10 min read

Most “accident” reports should be labeled “lack of judgment” investigations

Like many of us, I spend a fair chunk of time reading accident reports; it’s something I’ve done for a long time. Even before I had my PPL, I was devouring hundreds of them. Of course back then, I knew that I wasn’t stupid enough to make the same mistakes as the unfortunate subjects of the AAIB [UK’s Air Accidents Investigation Branch, similar to the US’s NTSB] reports, I knew that it wouldn’t happen to me, I knew that I was better than that. I didn’t know that I was being an idiot. The innocence, ignorance and arrogance of youth, I guess.

plane break-up

Accident or lack of judgement?

This is about accident reports; it’s about pilots getting things wrong and, more importantly, it’s about the way that the rest of us learn from the mistakes of others, or rather–given the evidence–it’s about how we fail to learn from both our mistakes and from those of our peers. If you have ever lost a loved one in an aviation accident, you should probably stop reading this now. There’s every chance that what follows will upset you, and that’s not my intention.

I’m no longer a youth and I hope I’m no longer as ignorant as I once was, but it somehow took me far too long to reach the pretty bloody obvious conclusion that we’re all more than capable of making mistakes, and that being convinced that “It’ll never happen to me” makes screwing up more, rather than less likely.

It’s obvious to me, and presumably to everyone else, that pilots are the cause of most aircraft accidents, but what seems to be less obvious to some is that we–and yes, that includes you and me–are those pilots. And what’s more, I don’t think calling them accidents is doing us any favours, but more of that later. I want to look at a couple of examples.

Cameras & aeroplanes

Back in October 2010, a 28-year-old man by the name of Sipan Osman was flying a Robin 2160 in the skies over East Yorkshire. According to the AAIB report, which was based on an accident report submitted by the pilot himself, Osman flew some aerobatics at 2,500 ft before carrying out a practice forced landing. During the climbout from the PFL, the engine began to run rough and failed. During the real forced landing that followed, Osman reported that his options were limited because he was so low, but that at the same time he was too high for his chosen field. Consequently he planned to land in another that was on the other side of the River Derwent.

The aircraft made neither the first nor second field, and subsequently ditched in the river with Osman and his passenger able to vacate the aircraft and reach the bank uninjured. A friend of Osman’s, fortuitously filming the aerobatics from the riverside, was on hand to help with the rescue. Serendipity? I think not.

During the investigation, the AAIB were made aware that the same aircraft, flown by the same pilot, had previously been seen making low passes at the same place along the same river while someone on the bank took photographs. The AAIB report concluded, “The accident area, being generally flat and agricultural, would appear to offer much better alternatives for a forced landing than the River Derwent. The pilot described being forced to overshoot his intended field in favour of the next field, beyond the river. There would presumably have needed to be some positive manoeuvring in order to align the aircraft’s track with the river, which would appear inconsistent with being unable to reach the field immediately beyond.”

You could read between those lines even if you were blindfolded in the dark. Mixing cameras and aeroplanes often increases risk factors, and perhaps influenced by the presence of a camera, one of Osman’s low passes was just that bit too low and the inevitable happened. Luckily for him, on this occasion only the aircraft suffered any damage.

It’s too easy to put this crash into the “it’ll never happen to me” category, but even if you know that you’ll never do anything as plain dumb as Osman there are plenty of smaller lapses of judgment, with similar or worse consequences, that we’re ALL capable of making. We ignore those lessons at our peril, but that doesn’t seem to stop us.

I was going to try to make my point by asking if anyone wanted to bet their house that another pilot wouldn’t run into the water while low flying ever again, but earlier this year the body of David Riggs, a US pilot with a history of maverick stunts, certificate suspensions and an aviation-related prison term, was pulled out of a lake in China. Riggs had been trying to water-ski a Lancair 320 on the lake in bad weather when he crashed. Killing yourself by doing something dumb is one thing, but when Riggs crashed, his 18-year-old Chinese translator was also killed. Accident or murder?

Riggs and Osman were unbelievably stupid, but if we think we’ve got nothing to learn from them, we’re plain dumb too.

In the 12 months that followed his Derwent ditching, Osman added another 70 hours of flying experience to his logbook bringing his total hours up to about 340. Not hugely experienced, but no novice either. A year after his water-skiing incident, Osman flew to Neuchâtel in Switzerland in a rented PA28-140. It was a flight he’d made once before earlier that year, but this time, the return flight, which had been due to take place on 10 October, was delayed due to bad weather.

Osman’s wife, who was to have flown back with him, returned to the UK on a scheduled flight.

Lake Neuchatel

The mountains around Lake Neuchatel are not the place to mix VFR and IMC.

Four days later, on 14 October, Osman was at Neuchâtel preparing for the return flight with a non-pilot friend who’d decided earlier in the morning to accompany him. Just after 10:35 the pair took off for Amiens in France where Osman had planned a fuel stop. The conditions at the airport and along the lake were good, and he flew the PA28 along the shore of Lake Neuchâtel for about ten miles before turning inland where the ground rose and the peaks were covered in cloud. During this time Osman was in contact with Geneva Flight Information Centre and 20 minutes after takeoff the controller heard Osman interrupt a transmission from another aircraft with the words, “…out of the clouds, of, Heu.”

The controller called Osman, who replied: “…I’m just in clouds, cannot see anything.” Twenty-three seconds later, and just over 20 minutes after taking off, Osman’s PA28 disappeared from radar. Five-and-a-half-hours later, the wreckage was found along with Osman and his friend, both dead.

It seems the aircraft had first hit trees about 6 to 8m above the ground with a rate of descent of at least 2,000 fpm. It was nose down and banking at about 45° to the left, the engine screaming at 3,200 rpm. Witness marks on the ASI suggest the PA28 was travelling at 188 mph; the wreckage trail extended for 60m, with the seats and both dead bodies ending up 35 metres ahead of the initial impact point.

Hillsides & bad weather

The remarkably thorough Swiss accident report combines very matter-of-fact reporting with a chilling paragraph containing the final analysis:

The last seconds of flight probably unfolded as follows: the pilot flew into cloud; he tried to avoid it by making a tight left turn. Deprived of any external visual reference, the considerable load factor encouraged him to release pressure on the elevator controls and the aircraft assumed a nosedive attitude. The spiral dive began. The pilot ceased to perceive that he was turning but observed a significant loss of altitude on the altimeter. To combat this, he was tempted to pull on the stick and increase engine power. The airspeed and the turn radius increased until impact with the ground occurred.

It’s true that there were issues found with the aircraft—the ARC had expired by 44 days, there was a discrepancy over a 150-hour check, some of the records relating to an overhauled engine were incomplete, there was corrosion found in parts of the engine and the surviving spark plugs weren’t exactly factory-fresh. In short, the report doesn’t paint a pretty picture and it is easy to imagine a very tired (the airframe had amassed 14,614 hours) rental PA28, but none of this caused the accident. That was a result of the pilot’s decision to mix VFR, IMC and mountains, a combination that rarely has a happy outcome.

Another crash that we can put in the “it’ll never happen to me” category? It’s tempting, particularly if you knew about Osman’s water-skiing before reading the Swiss report, but the crash that killed Osman and his passenger isn’t rare. There are too many examples of UK pilots killing themselves along with their families and friends, by flying into European mountains.

Are you reading this and enjoying the comfort of thinking that it could never happen to you? I can see how that’s tempting (been there, done that), but while Osman was a VFR-only pilot in an old aeroplane, in mountains, in bad weather, there have been two recent accidents involving British pilots flying into hillsides in bad weather. Except in these cases the pilots were instrument rated and flying well-maintained, well-equipped, privately-owned, twin-engined aircraft.

One of these took place in the south of France and killed a well-respected and popular couple when they flew their Twin Comanche into rising ground. There has been, and continues to be, some discussion over the role that ATC played in the accident; the UK representative added an appendix detailing the ATC action that may have led to a misunderstanding. That, however, was dismissed and the BEA [French version of the NTSB] report concluded that, “The accident was due to the pilot’s decision to continue the flight under VFR in instrument meteorological conditions and at an altitude that was lower than the high ground in the region.”

The other accident, for which the report has not yet been published, took place in Italy where an apparently intact Beech Baron flew into terrain in fog.

To dismiss these or Osman’s crash would, I think, be to miss an opportunity. I hope none of us would really think that teaching yourself water-skiing or playing hide-and-seek in the mountains is a good idea, but the pilots’ decisions that lead to the deaths were almost certainly smaller and far more subtle in isolation.

There’s always an opportunity to look, learn, think, consider and work out how we might screw up, and more importantly what we can do to avoid it. While it’s always reassuring to think that some kind of malfunction or system failure caused an accident, the unavoidable truth is that it’s almost always me, you and our peers who get it wrong, and, when we do, it’s almost always a lack of judgment rather than skill that does it. Perhaps we’d think differently if every month we read lack of judgment reports rather than accident reports.

Mostly we get away with it, occasionally we pay dearly for our mistakes. Those we leave behind get to pick up the pieces and to read our “lack of judgment” reports. The wise look hard for the learning points, while those burdened with the ignorance and arrogance of youth, regardless of age, are happy in the sure and certain knowledge that it’ll never happen to them.

Read the full accident reports:

Ian Seager
Latest posts by Ian Seager (see all)
22 replies
  1. Peter
    Peter says:

    This so close to what I have been sprouting for years, I do love reframing, accident to Lack of judjement as this does hit home. My brother crashed my aircraft, survived and was dissmayed that He the Master of Aviation crashed, in his word “I thought I would Crash an aeroplane”, to which i replied “F… Me, I never thought that wouldn’t”. I like to fly knowing that I am very venerable!

  2. Peter Lovett
    Peter Lovett says:

    I dislike the word “accident” when it comes to aircraft crashes as it presupposes that there was something that took the matter out of the control of the pilot, something that so rarely happens to be statistically non-relavent. Further, I don’t like the thought of something being outside of my control as a pilot.

    Throughout my aviation career I have always been guided by 2 adages; the first is that you should learn from the mistakes of others as you won’t live long enough to make them all yourself; and the second is that experience is what you have just after you needed it. It is the second that has given me pause for thought recently.

    When we gain a PPL many are told that it is a licence to learn. It certainly does not equip you to take on all that the elements or conditions may throw at you. The same can be said on attaining an instrument rating or commercial licence. A wise person takes a cautious approach to their flights gradually building experience so that they can take on more challenging flights as that experience builds. However, there comes a point where the experience level has reached a point where some very challenging conditions may be contemplated.

    Now heres the rub. The tipping point between what may be taken on and what may lead to disaster becomes very close and often cannot be seen clearly. There are very many skilled and careful pilots who have come a cropper due to falling over that point, not due to recklessness or stupidity but that what appeared to be doable on initial examination has turned out to be a degree too far in reality. Some examples off the top of my head; the MD80 at Little Rock, Arkansas; Air France A340 at Toronto; the DC10 at Dallas.

    In my own flying I am required to fly to a challenging airstrip on an island that is often beset by strong winds. When those winds are blowing the approach to the runway is a low level curving approach due to a range of hills that impedes the approach path. When the winds are from the other direction they are not strong but bring in low cloud/mist/sea fog and the runway does not have an instrument approach.

    Recently, I went there when the wind was gusting between 30 and 40 knots, thankfully almost straight down the runway but with considerable turbulence on the low-level circling approach. The thought struck me as I started the approach that this was getting very near my competence level. While I have plenty of experience in handling the aircraft, the conditions were such that if something was to go wrong (or the wind/turbulence was to increase suddenly) then there would be very little time to try and correct the situation and if one couldn’t then the result would most likely be a crash. We didn’t.

    However, the whole incident got me thinking about how many pilots have suddenly found themselves in a situation which they thought they were going to be able to handle but inadvertently found themselves in over their heads. Food for thought.

    • John Zimmerman
      John Zimmerman says:

      Wonderful comments, Peter. I think this is the eternal challenge – how do get good utility out of an airplane without going too far? It’s not a question we will ever resolve; just something to keep working on.

  3. RobertL
    RobertL says:

    “how do [you] get good utility out of an airplane without going too far?”

    Once you move from GA for enjoyment to GA as a transportation tool, the realistic mission profile which is within reasonable limitations (i.e. a good margin of safety) for GA SE piston single pilot operations (IFR current) is around 300~400nm in light IFR with no SigWx warnings. Integrating this in flight planning and personal SOPs would go a long way in reducing the risk profile of the sector. The inference being that all transport missions should ideally be on an IFR plan.

    A better pre disposition to precautionary landings, and an aircraft tough enough (FG, low stall speed) to carry them out, would help the VFR into IMC threat for VFR pilots. Richard Bach had a good story in praise of precautionary landings, which should carry more emphasis in training.

  4. Geoff Semler
    Geoff Semler says:

    Excellent article Ian. I do think the use of the word accident is misguided, indeed it is no longer used by those “in the know” in road parlance, as it implies no real blame where mostly there clearly is. We always like to avoid “blaming the pilot” and go to great length to do so, but perhaps it is time to change that culture. There will always be great debate in some cases (the Chinook hitting Mull comes to mind) but in most cases, it is blatantly obvious yet we pretend it was just an “accident” and that leads to a false sense of security which can only contributes to further “accidents”.

  5. Gyro47
    Gyro47 says:

    Thanks for this great article indeed ! Isn’t “Accident vs Lack of Judgment” comparable to “Consequence vs Root cause”? This is probably the reason why BEA, the French organization similar to AAIB, SAIB or NSTB decided to change their name from “Bureau Enquete Accident” to “Bureau Enquete Analyse” (enquete in French means investigation).
    All the best for this new year and lots of safe flights !
    Gyro47 (Marmande, France)

  6. Don R
    Don R says:

    Great article. I think the incidents that drive this home the most are when an aviator we know of, who is widely considered “a great pilot”, with many years and hours of experience, stuffs it. Don’t ever think it can’t happen to you.

  7. Michael Gray
    Michael Gray says:

    I’m not a qualified pilot but keep a lifelong interest in aviation alive. I frequently read accounts of pilots losing orientation, as in this account of Mr Osman’s demise and even commercial pilots making the same mistake. Can somebody clarify for me why the artificial horizon doesn’t tell the pilot that he’s not flying level and the altimeter doesn’t tell the pilot he’s dangerously low for the area he’s flying in? ie. in this case mountain terrain!

    • George Welch
      George Welch says:

      If these instruments are not operational due to electrical or vacuum pump failure, they will indeed indicate attitude and altitude information to the pilot. Of course most of these accidents are not due to mechanical failure, but rather the pilots stress level increasing to the point of panic in trying to react to physical body forces rather than disciplined reaction to the instruments. Thus the need for proper instrument training and staying current.

    • Larry Coleman
      Larry Coleman says:

      Michael, the attitude indicator does indeed tell the pilot whether or not they’re level, but it takes a trained, current, and competent instrument pilot to use it. The sensations of flight without visual reference are sneaky liars, and the body will tell you things that contradict the instruments. It takes just as much training (40 hours) to get an instrument rating as it takes to get a license in the first place (40 hours), which gives you some idea how much work it takes to drill it in you that if your butt and your instruments disagree, TRUST your instruments. It’s easy to sit on the ground and tell someone that, but more often than not, the first time I take an instrument student into clouds, all that goes out the window. It’s one of those things where 1000 pages of explanation don’t compare at all to 10 minutes in actual IMC.

      Pilots don’t get into a cloud and then immediately bank 90 degrees. It starts slowly and subtly, with a bit of a turn. The turn causes the inner ear to get confused, so the non-instrument pilot makes a “correction”. That correction didn’t fix it because what they were fixing wasn’t the problem, so they try more “correction”. That didn’t fix it, they try more, and so on and the figurative downward spiral gradually ends up being a literal one. At that point, the instinctual part of the brain can be overwhelming when spatial disorientation kicks in and often causes the pilot to do exactly the wrong thing. Richard Collins says it very well in http://airfactsjournal.com/2013/12/ice-gotcha-heartbeat/ when he says there is a “theoretical” recovery procedure for the graveyard spiral. It’s only a theoretical recovery because if the pilot let it get to that point in the first place, they probably don’t have enough skill left in the tank to get out of what they put themselves into.

      As for the standard sensitive/barometric altimeter found in most GA aircraft, it only reads height above sea level. It has no idea how high above ground level it is. It will quite happily indicate 8000 feet when a pilot crashes 500 feet below the top of an 8500-foot mountain. It’s the pilot’s job to know the terrain, because the altimeter has no way of doing it for them. (After several crashes just like that one, the FAA started requiring airliners to have radar altimeters, but you’re unlikely to find one in a rental aircraft. However, some newer GA planes use GPS altitude combined with a terrain database to make a system that provides a level of terrain awareness.)

  8. Dave Tonks
    Dave Tonks says:

    As the pilot of an ultralight (Drifter) here in Oz I will never experience spatial disorientation from losing ground reference – I’m a fair weather flyer anyway, and I’ve read a lot of stories of the “20 seconds to live” variety. What astounds me is that VERY experienced pilots still make the same mistake – I won’t.
    What I don’t understand is this – in situations where commercial pilots ‘lose’ their instruments due to incorrect information being sent to the flight computer by, e.g. the ARDUs (air reference data units) OR by human error (e.g. taping over pitot sensors during aircraft cleaning, and ‘forgetting’ to remove the tape) – why is their not a GPS backup instrument in the cockpit to give accurate information to the flightcrew?
    These incidents usually happen at night over uninhabited areas, so no visual reference with the ground usually means the flightcrew are bombarded with a myriad of alarms and conflicting information from the flight instruments, particularly with respect to the two things they need to know to keep the aircraft flying – airspeed and altitude. The GPS in my mobile phone tells me that !!!!!
    Looking forward to replies,

  9. Marc Rodstein
    Marc Rodstein says:

    Boleropilot, nearly every plane today carries at least a portable GPS that can show the pilot a close approximation of airspeed and altitude. I say a close approximation because GPS derived altitude is often off by 200 or 300 feet due to the limitations of the GPS syatem, and a GPS actually shows groundspeed and cannot determine airspeed. But your question really misses the point that is crucial in the vast majority of VFR into IMC accidents.

    In the vast majority of these cases the instruments are telling the pilot everything he needs to know, but the pilot is unable to process and act on it properly. It takes a lot of training, experience and constant practice to safely bring together all the information from all the charts and instruments, interpret it properly, and control the airplane safely all at the same time. The “accident” happens when the pilot is not up to the task described above, and this happens all too often.

    • Dave Tonks
      Dave Tonks says:

      G’day Marc – I agree with your comments re. VFR into IMC incidents/accidents wholeheartedly, but I am not missing any points – what I am suggesting is that INDEPENDENT GPS information should be made available for commercial flights as a backup for the standard computer-provided information to the flightcrew, specifically when that information is flawed.

      I understand that ground speed and height above sea level is not ideal, but in a situation when the flightcrew are going nuts trying to cope with all the alarms and incorrect indications (and deep stalling the aircraft all the way to terra firma) that information is better than what they are currently being given by the flight computer and may give them an opportunity to recover the aircraft.

      • Marc Rodstein
        Marc Rodstein says:

        Dave, I missed the fact that you were referring to air carrier operations and not GA. Your point about independent GPS for commercial aircraft is very sensible but it goes against the grain of the airline industry today. They want the plane to fly itself and the pilot to just sit there and warm the seat. I like your approach much better.

        I thought that GPS signal degradation was halted many years ago, making the GPS signal the same for civilian and military uses. Both can locate an aircraft (or your car or cellphone) within about 2 meters of its exact location on earth, but this is based on lateral measurement. When it comes to vertical measurement (altitude) my understanding is that the accuracy is limited by the physical limitations of the satellite geometry, and would therefore be limited for all users, military or civilian. I could be wrong though. I was wrong once before.

        • Dave Tonks
          Dave Tonks says:

          yeah m8 I’ve been wrong lots of times – I was under the impression that “combat area access” to GPS is still governed by military decisions, but I wasn’t aware that non-military degradation had been canned – learn something new every day…

          Cabin Announcement after take-off – “welcome to the very first fully computer operated aircraft flight – there are no flightcrew on this aircraft – but you don’t have to worry, because nothing can go wrong – go wrong – go wrong – go………” – followed by a lot of yelling and screaming from the passengers….

    • Duane
      Duane says:

      Actually, Rod, WAAS GPS accuracy on altitude is much better than mechanical precision altimeters are capable of producing. If you see your WAAS GPS altitude varying from your altimeter reading by 200 or 300 feet, the imprecision is mostly due to errors in your altimeter.

      The standard precision requirement to achieve category I performance for WAAS GPS is plus or minus 4 M (about 13 feet) in the vertical axis and plus or minus 16 M (52 feet) laterally, and it is entirely unaffected by ground level atmospheric pressure or temperature.

      To pass an FAA altimeter accuracy test an altimeter needs to read within +/- 80 feet at 10,000 ft MSL simulated altitude. Additionally, in operation the altimeter must be set to the correct local altimeter setting otherwise it introduces additional error. It is impossible to obtain a continuously updated altimeter setting as the aircraft travels cross country, at best it will be just whatever the nearest reporting station may have per ATC, ATIS, AWOS, etc. And even that local altimeter setting may not be fully updated, especially on ATIS or on Sat-Wx. Temperature also affects altimeter readings too, with lower than standard temperatures providing an altitude reading that is higher than the actual aircraft altitude.

      These issues become especially important when flying across frontal zones, and thus the aviator’s saying, “From high to low, look out below”.

  10. Dave Tonks
    Dave Tonks says:

    Sorry, forgot to mention that “military grade” GPS info is incredibly accurate – no reason why that technology can’t be made available to commercial aircraft…

  11. Ross Bond
    Ross Bond says:

    Hi Ian, great article! I agree with everything that you say, but no amount of logic or common sense (which, sadly, is not all that common) can keep some idiot of the “Hey Y’all, watch this!” variety from killing themselves and those with them. I have been to my share of aviation funerals for this type of idiot over the years and I am sure many of your readers have too.

    Back when I was instructing I used to require that my students watch a video entitled “178 Seconds To Live” (https://www.flightsafetyaustralia.com/2016/01/178-seconds-to-live-vfr-into-imc/ ) which detailed rather graphically the steps leading to loss of control due to VFR into IMC – the title says it all from there. They had to watch this video and discuss it with me before I would let them start their VFR Nav training, which would eventually have them operating out in the Big Wide World away from the airfield, and it sure seemed to do the trick, even the more ‘self-assured’ (read ‘arrogant’) ones got the message very quickly.

  12. Joel Godston
    Joel Godston says:

    What a GREAT article Ian. As a pilot for 50+ years…trained and flew Piper cub, T-28, T-33 and B-47 aircraft in the US Air Force; T-33, F-84 and F-86h in Mass, Air National Guard.and finally owning and flying a Cessna 182 in the civilian sector; your ‘parting’ comment says it ALL, ” There is ALWAYS an opportunity to Look, Learn, Think, Consider, and Work Out how we might screw up, and more importantly what we can do to avoid it.” Thank you, THANK YOU, for what you are doing for the Aviation Community, our nation, and the World. PLEASE do keep up with what you are doing.

  13. David Ward Sandidge
    David Ward Sandidge says:

    I subscribe to the monthly NTSB Reports. I think it’s incredulous, dumbfounding actually, the number of low time VFR-only pilots who are killed each year by deliberately flying into IMC weather – many of those at night. There are one or two in every monthly issue. When you compare VFR (VMC) daytime flying with IFR (IMC) nighttime flying it’s like trying to compare overfed, de-clawed house cats with starving in-the-wild lions. When will people learn?

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