Accident report: learning to say no

Editor’s note: Richard Collins started a healthy debate when he argued that reviewing accident reports should be part of any safe pilot’s routine. Since then, many Air Facts readers have written to echo Richard’s thoughts, and to encourage us to periodically discuss accidents that offer a lesson for pilots. With that in mind, we will be offering a regular series on accident reports.

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A short flight, but the pilot never made it to his destination.

The checkride is always a stressful time for student pilots, as months of preparation culminate in a big test and hopefully a new certificate. It’s also a time of transition, when new pilots go from the clearly defined instructor-student relationship to the much fuzzier examiner-applicant relationship. Who’s in charge? The simple answer is the applicant, but an accident from late 2013 shows how tricky this question can be in real life. It also offers some lessons for all pilots.

The 36-year old student pilot wasn’t going far in his rented Cessna 182, just 20 nm east to a neighboring airport. Here, he planned to meet a designated pilot examiner for his Private Pilot practical test. Unfortunately, the weather wasn’t cooperating this morning, with a 600 ft. overcast and 4 miles visibility at his departure airport (KAJZ). The pilot called the examiner to discuss the weather, and the NTSB report describes the conversation:

According to the DE, the student pilot called him on the morning of the accident and informed him there was a cloud deck at KAJZ. The DE told the student pilot the cloud deck was likely a thin layer that would burn off and to fly to 99V after the weather cleared up.

How this was interpreted by the pilot, we’ll never know. But a short time later, surveillance cameras at the airport show the 182 departing on runway 3. The airplane flew just two miles on runway heading before crashing and killing the pilot. Examination of the airplane did not show any mechanical malfunctions or pre-impact failures. It appears to be a simple VFR-into-IMC accident.

Unlike some of these scenarios, the pilot didn’t stumble into ever-worsening weather. It was clear from the ground that weather conditions were not good, and the pilot knew this (as demonstrated by his phone call to the examiner). So why would a student pilot launch into weather that was obviously unsafe for VFR flight?

The NTSB report makes note of the pilot’s “go-go-go” personality and his motorcycle racing background, suggesting he was not afraid of some risk. He was clearly a successful, goal-oriented person who viewed aviation as a way to support his business, and perhaps expected too much from a pilot’s license. His flight instructor apparently warned him about not trying to “push too hard” to complete a trip and “not getting over his head.”

On the surface this sounds like simply a reckless pilot who did not recognize his limitations. That may be part of it, but other details suggest this is an oversimplification. According to the CFI, the pilot was clearly feeling pressure, both personal and business, to complete his flight training. There was even a discussion about trying to schedule the checkride before the airplane had to be taken down for its annual inspection.

The pilot’s personality and the pressure he felt set the table for a potentially unsafe flight. With that context in mind, the examiner’s comment about the cloud deck burning off seems like the final straw. Here is a much more experienced pilot suggesting that the clouds are not a major problem, since they will not last long. While the examiner very clearly said he should not fly over to 99V until after the weather cleared up, the student pilot may have taken that as encouragement to make the trip. He may have heard what he wanted to hear. And it was only a 20 mile flight.

Regardless of the pilot’s thought process, this accident is a reminder for all pilots that only the person sitting behind the yoke is pilot in command. That authority cannot be outsourced to anyone else, whether it’s ATC or a more experienced pilot. Learning to say no, even to implicit pressure or harmless suggestions, is hard. But it’s a life-saving skill.

This happens to pilots of all experience levels. When the controller says there’s a gap in the weather, but you’re not sure, do you give into that subtle pressure? When the mechanic says the airplane is ready to go, but you have your doubts, do you have the backbone to push back? When a flying buddy says the weather is good enough to go, but it’s below your personal minimums, do you stand firm?

These are all hard decisions, and the right answer is not necessarily to cancel every flight at the first sign of trouble. But there is only one vote that counts in the go/no go decision: the PIC. Guard that power jealously.

15 Comments

  1. John in Texas says:

    I had a very close call on my checkride in my conventional geared Cessna 140A when the older check pilot had his own idea of how to do a wheel landing (in a heavy crosswind). Grabbing the controls from me, he forced the tail down at a high speed and we took off at a high, nose up angle and nearly stalled at about 20-30 feet. I went full power and shoved nose down as we were being blown towards nearby hangars. I did a go around.

    We didn’t even do my checkride landings at his home one-runway airport due to wind. I told him I wouldn’t have landed there at that later time, and would have left him at other multi-runway airport. When I got to his airport earlier, the wind wasn’t so bad. Even then, the other instructors were surprised we were flying. That bothered me.

    I just about quit flying that day. He came close to killing us. And he didn’t pass me. My instructor, who was a crop duster and also flew a Cessna 180, was furious. I went back a week later and the same checkride pilot passed me after doing one full stall landing.

  2. Stephen Phoenix says:

    I can’t resist a good healthy debate…
    So, I can see a prospective flyer picking up a magazine, with this type of article, while waiting at the doctor’s office and thinking, “Gee, here is a guy that didn’t even make it 20 miles to get his license. I’ve heard that little planes are dangerous, but wow”.

    But let’s assume that the price of scaring new people away is small compared to the knowledge we gain by endlessly publishing accident analyses in the monthly aviation magazines. So what knowledge do us “real pilots” gain from this particular analysis?

    I would suggest that we get almost nothing. What, “just learn to say no” or “don’t learn to fly if you’re a motorcycle racer” or “don’t take off in bad weather”. This doesn’t seem too useful to me.

    The useful knowledge would be the background of pressures and rationales that the pilot used to begin this flight. Why was it so important to make the flight? Did he have a later appointment that would prevent waiting out the weather? If the weather didn’t clear, did the DE suggest that the next available appointment would be weeks away; after the airplane annual expired?
    Why did he think he could make it? Was the weather clear at the destination and so indicating only a short ride to clear weather? Did he think the three hours of hood time that his instructor and the FAA assured him would allow dealing with “inadvertant” cloud encounters give him confidence to proceed?

    The useful knowledge in this accident (as with most) went down with the ship and cannot be recovered and used. So why publish it?

    • John Zimmerman says:

      Stephen, we love a good debate, so thanks for your comment. I think you make a perfectly fair point, and we certainly do not know all the details (this is based solely on the NTSB report). But I still think there’s enough information here to learn from. For me, it’s to be sensitive to external pressures that may force you into making a bad decision. Just being aware that such pressures might exist is a huge step. Learning how to think about decision-making and learning to recognize traps is something we can all do better at as pilots.

      • Stephen Phoenix says:

        John, no argument about the need to learn about decision making and the effects of external pressures. But my point would be, do we have to read specific accident cases (every month for most major magazines) to learn these things?

        I always felt that Richard Collins’ format of describing a flight that he actually made and the decisions that went into that flight, were a much more useful learning experience than the accident analyses format. And I would further subscribe that the “real flight by an experienced pilot” format does not have the possibility of scaring new people away.

        • John Zimmerman says:

          I too love Richard’s trip reports, and you can learn a lot. But to me, it’s like MBA students doing case studies on bankruptcies or failed product launches. NASA is famous for their thorough reviews of accidents.

        • Duane says:

          Stephen – If I were an aspiring pilot and only read “happy talk” about flying in the aviation journals, I’d lose interest in those journals very quickly.

          If I remember correctly I’ve seen you comment rather often here before that motorcycle and auto racing enthusiasts don’t dwell on accident reports in their publications, so why should the aviation rags do so.

          But that’s easy to explain – any idiot (literally) can drive a motorcycle or a car real fast on a road or track, and there’s little to nothing mysterious about it … because just about everybody in America drives a motor vehicle of some kind.

          But aviation is NOT something that the average person intuitively understands … it’s a mystery to most why airplanes don’t fall out of the sky. Let a civilian spend ten minutes in the front seats of an aircraft with the headset on, and being assaulted by rapid-fire ATC instructions and aviation gibberish, and watching the pilot manipulate this control and that, and read this instrument or chart and that, and this experience quickly reinforces the complex mystery of flight. So most people understand that flying is complicated and requires a much greater degree of skill and understanding to perform safely than does driving an automobile or motorcycle. What most civilians DO understand intuitively is that screwing up in an airplane can easily kill you, so there’s a strong motivation for learning how NOT to screw up.,

          Maybe it’s just me, but I certainly like to understand and manage the risks that I’m taking in life, including aviation risk. I think that the most intelligent people, the ones most likely to be good pilots, think similarly.

  3. Cary Alburn says:

    While not all of the specific facts of this accident would be relevant to everyone, certainly some of them are really relevant. Taking off into potential IMC, whether by a student, an experienced VFR-only pilot, or even a rusty non-current IR pilot, is dangerous–period. The vast majority of VFR into IMC accidents are fatal. That’s the lesson of this accident–and others like it. Yet that lesson is not ingrained in enough pilots, because GA continues to have such accidents every year.

    So it this drum needs to be beaten more and more, by publishing various accident scenarios over and over, then do it. Meanwhile, watch this 178 Seconds to Live video, if you haven’t already, or even if you have: http://www.aopa.org/AOPA-Live.aspx?watch=%7BCCA30EA1-A94D-4E45-ABCD-3AD4074403E0%7D

    Cary

  4. SaferAviator says:

    While I can see Stephen’s concern about scaring away potential pilots, I think other considerations outweigh the risk of running off those with only a passing interest rather than people with a passion for flying:
    1) A big reason commercial and military (including me) is safer than GA is we talk about our mistakes and accidents. To paraphrase a famous quote, if we don’t take the time to learn from our mistakes, we are doomed to repeat them.
    2) If we do not learn from mistakes, the GA accident rate will remain high and people will have a valid reason not to pursue flying as recreation or business.

    Something very important Stephen raises is the depth of analysis needed. Despite the media driven belief accidents are caused by one silver bullet, every accident has multiple factors, whether you call them links in the chain or holes in the cheese.

    • Liad B. says:

      Please don’t take this the wrong way, but the reason commercial flying is safer has little to do with the pilot and more to do with all the 100 computers on board that are making sure u guys don’t screw up.

      If this student had an AP with a flight computer and auto-everything working to keep him safe in the air, he would have made it out of the IMC without a scratch.

      Liad.

      • Duane says:

        Liad – SaferAviator is correct in saying that being full time professional aviators, the guys who fly for a living and who on average fly many times more hours, with more professional and demanding recurrent training requirements, and check pilots looking repeatedly over their shoulder, and usually flying as part of an at least two-person flight crew, are naturally safer pilots than the 50 hour/yer private pilot flying single pilot.

        You’re also correct that if the student pilot had a autopilot on board and knew how to use it (which is rather doubtful for the typical 60-70-hour student pilot) he might have survived his trip through the thin layer of low clouds .. but he didn’t.

        Technology is great – I love the modern technology of today, use it in my airplane, and look forward to much more of it in the future. But this pilot died almost entirely because he made a bad decision to take off as a VFR pilot in IMC. Technology can’t save us from ourselves.

        • John Zimmerman says:

          I agree with you Duane. Autopilots are great (and I think everyone should use them), but that’s not the only difference between GA and airlines. The training, the SOP manuals, the two pilots – there are so many checks. In the end, the pilots don’t have to decide, they just follow rules. I don’t mean that as a put down, but it’s the way the system works – don’t make the pilots decide. It’s black and white. GA doesn’t work that way.

  5. Duane says:

    John,

    Thanks for the article. I am not with Stephen in worrying that this kind of analysis and discussion scares away too many pilots. We pilots have always been “the few, the brave” (or the “foolhardy” – take your pick!), never more than a small fraction of one percent of the general public. We have always been the risk takers or we simply wouldn’t be pilots.

    As for this accident, what it says to me more than anything is the same thing that the accident stats have always said – the group of pilots most susceptible to aviation accidents, as measured in accidents per flight hour, is the low-experience pilot (under 200 hours). Insurance rates reflect that fact.

    What this stat tells me is that our flight training regime does not do a very good job of training pilots to fly safely and manage risks.

    It only takes a handful of dual hours to train most pilot trainees to manipulate the controls, and after that it’s mainly a matter of building time and honing stick and rudder skills. It’s when the student pilot or recently-certificated pilot starts having to balance stick and rudder with all the other risk-management-oriented tasks, such as flight planning, fuel management, weather flying, avoiding other air traffic, “get-there-itis” and such, that pilots mess up and crash their airplanes.

    Even many of the stick-and-rudder related accidents such as the stall-spin in the base-final turn are not solely due to lack of stick and rudder skills, but rather are part of the infamous “accident chain” where other factors (such as weather, traffic in the pattern, get-there-itis, etc.) serve as distractions leading to a loss of concentration on flying the airplane.

    The FAA is in the process of revising and superseding the current “Practical Test Standards” with an explicit approach to teaching pilots how to identify and manage flight risk. Many of the old dogs have complained bitterly about this change – they always bitterly complain about every change, it seems! – but it is long past time that we teach pilots how to manage flight risk. The new instruction standard will not be a magic bullet, and pilots (even the old dogs like me) will continue to make errors in judgment.

    But it should never be acceptable to any of us that the pilots most likely to kill themselves are often just like the fellow in this accident report.

  6. William "Pete" Hodges says:

    I am glad you printed this article. I may not agree with all the points you made but I do agree that reviewing accident reports is vital to promote flying safely. We as pilots, and potential pilots, need to remember that one bad decision could be our last.

    When my wife and I were taking flying lessons in 04, she read the NTSB reports published in AOPA Flight Training every month and we discussed and analyzed them together. She was fearful of flying in small planes and wanted to know why so many were involved in severe accidents. Over time we became aware that most of the severe accidents either involve weather or fuel… then followed by “stupid pilot tricks” that are usually ground related, non-fatal and often humourous in one way or another. Now I’m not suggesting that airplane accidents are funny, but you gotta at least smile when you read about a Pilot who tried to take off with a cinderblock tied to the tail!

    The point I’m trying to make is If reading about airplane accidents scares off a potential new pilot, isn’t that better than bringing in a pilot who might ignor safety with diasterous results? It appears to this reader that is what happened to the pilot in this article, but we will never know for sure because he is no longer alive to tell us. In aviation you ignor safety and your own personal minimums at your own peril. THAT will never change.

  7. Steve Lackscheide says:

    As a newly minted (4 days ago) private pilot, my question regarding this incident would be where was the instructor in all this? Before my check ride last Friday, we checked the weather for the hour’s flight to my destination and the forecast for the trip back.

    I have no doubt that my instructor would have put the kibosh on making a trip around the patch, let alone fly a cross-country trip (however short) with a 600 foot ceiling! After all, he signed off for me to make the trip.

    • Brent Reddick says:

      As a student pilot (only about 30 hours) I would assume that the CFI was there on an “as needed basis”. When I started flying my local solos a few weeks ago I couldn’t help but have the desire to call my CFI and say “Hey I know it’s a blue bird sky with no wind… you think it’s ok to fly”? It’s really hard to make myself by the PIC from decision #1 (go / no go). On several occasions my CFI has allowed me to make less than perfect decisions (speaking of dual stuff btw) and I have begun to understand why… It’s the decision making stuff that will kill me first. My stick and rudder skills are great and getting better. I perform very well under pressure and feel pretty confident that I could safely land my Cherokee 180 in a field if my engine failed, today. My instructor knows that and he’s not going to hold my hand so that the first time I get to make a dumb decision is the day of my check ride.

      Another example… This past Saturday I took my wife up for the first time in our plane. CFI in the right seat and she was nearby in the backseat. The winds were pretty rough and although the flight was somewhat pleasant there would have been better days to choose for this “first flight”. But you see we have busy lives and 3 children. There were several days prior to this where we had to scratch our plans due to no babysitter, etc. Saturday we were out of excuses except for the 20mph winds. It wasn’t a matter of safety as it was a direct wind with our airport with very little cross component but never the less it was BUMPY!

      The next day my CFI said, “I can’t believe you took your wife up in that rough air!” I looked at him in confusion and replied, “But I asked you if you thought the winds were acceptable to fly…” His response, “well you’re a good enough pilot to safely fly in these winds and that’s where I got my answer. The decision to take your wife… That’s on you!”

      My CFI has been teaching for long time and he is a very safe pilot/teacher. I do think he’s figured out that one of the most difficult things to teach is the decision making process… and that’s why he will not hold my hand.

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