Adding to the judgment bucket—a flight that never should have happened

A pilot’s life progresses in phases, represented by various combinations of aeronautical knowledge and skill, experience, and judgment. These phases can be roughly defined by the number of hours in the pilot’s logbook, but this varies widely from one individual to another. Each phase also carries with it a component of risk.

Skill and confidence develop more rapidly than judgment. This often leads pilots into taking on situations that the more seasoned would normally avoid. Scud running or taking off into marginal weather conditions are examples. When bad decisions are made based on lack of experience or poor judgment, skill often saves the day. This was the old-fashioned method of mastering risk management. Mistakes were made, skills were put to the test, and experience was gained. Occasionally, if the mistake was serious enough or the skills were inadequate, people didn’t survive.

But if luck held, there were two possible outcomes. If the episode didn’t end in disaster, it could possibly reinforce poor judgment and the behavior would be repeated until the inevitable bad outcome occurred. Preferably, the participant would learn from the experience and in the process become immune from making the same mistake again. It is ironic that experience gained in this way required the exercise of poor judgment to start with.

Logbook
One way to learn judgment is to fill up a logbook. Is there a better way?

Establishing the principles of risk management began with both the airlines and the FAA. At some point, they realized that a systematic approach to aeronautical decision making and risk management would help to improve the safety record, and they were right. For the airlines, it centered on the concept of crew resource management. Through the application of strict rules and procedures, the major airlines have managed to achieve an outstanding safety record, safer than any other form of human transportation. The FAA decided that if it could work for the airlines, it could work for general aviation as well.

To illustrate the advantages of learning risk management over the time-honored method of letting fate take its course, I offer the following episode. It happened on a soggy, overcast, and misty day in 1967 in southern Louisiana. I was in my dangerous phase.

Having been involved as a passenger in an accident that occurred a few years previously, I had redoubled my efforts, helped along by a diverse host of instructors and mentors at the local airport. It was a lively group. It included a former WWII B-24 pilot, an ex-Navy Crusader jockey, and the usual assortment of hangar bums and aerial swashbucklers who enthusiastically contributed to my store of aviation knowledge and skill. In true barnstormer tradition, any thought of risk was disdained and deemed not worthy of real aviators.

In this heady atmosphere, I piled on the ratings and developed an impressive swagger consistent with the grand total of 587 hours in my logbook. I was 26 years old, and naturally I knew everything there was to know about flying. Ironically, my performance skills as a pilot were actually nearing their peak even though my judgment was sadly lacking. I had also just completed an FAA Part 135 check ride as pilot-in-command (PIC) for a local air taxi operator (the experience requirement in those days was 500 hours).

It was one of those gray days. The conditions made it difficult to determine ceiling and visibility due to the lack of prominent visual landmarks. The country was flat as a pancake, surrounded by waterways, lakes, and bayous. It was thus that I set off on a charter flight in a Piper Twin Comanche. The weather reporting in that neck of the woods was sparse to non-existent. The “look and see” method was most often used to obtain a weather briefing. My first big mistake was the decision to take off.

I had gotten the call on a Sunday morning. A young gentleman, a family friend of the airport owner, was anxious to travel to Jackson, Mississippi, to pick up his girlfriend and return to Morgan City. I conducted my pre-flight (minus weather briefing) and pulled the Twin Comanche out of the hangar, fueled and ready to go. I got my passenger securely belted into the right seat and started the engines. We were operating out of a privately owned 4000-foot grass strip in Amelia, Louisiana. There was no instrument approach procedure. The runway was still shedding an abundance of water from recent downpours that had passed through the area. The winds were calm.

My plan was based on, what proved to be in retrospect, wishful thinking. I would climb to a VFR maneuvering altitude, establish contact with ATC, request IFR clearance to Jackson and be on our way. On the return trip, I would fly an instrument approach to a nearby airport, then scud run back to Amelia.

The runway was aligned north and south, so I taxied to the south end, lined up with the runway and advanced the throttles for takeoff. The Comanche quickly became airborne. At about the time the gear was fully retracted, one thing became abundantly clear: there was no way we would be returning to Amelia that day. At about 150 feet, the forward visibility was about ½ mile and any further climb would have resulted in solid IMC conditions. I thought about the possibility of a night away from home in a cheap motel in Baton Rouge, Lafayette, or New Orleans. My young passenger would have had his girlfriend, but I didn’t even have a toothbrush.

With those thoughts rushing through my mind, I made a split-second decision to abort the mission. This was my second mistake, and the one that could have easily been the last mistake I would make, that day or forever.

clouds
Is it VFR or IFR? One way to find out—a bad way—is to take off and see.

Most pilots appreciate the elegant symmetry of ground reference maneuvers. Turns about a point, S-turns across a road, and rectangular patterns are all things of beauty when executed precisely, just as when they are drawn on paper with compass and protractor. One maneuver you won’t find in the Airplane Flying Handbook is one that I will refer to as the “90-270.” It is a course reversal that puts the aircraft on the exact same ground track, except on a reciprocal heading. It’s regularly performed at low altitude by crop dusters, but it’s not the kind of maneuver you should demonstrate to paying air taxi passengers.

Why a 90-270? Because a simple 180 would have caused me to forever lose visual reference to my beautiful 4000-foot grass runway and put me on final approach for nearby Bayou Boeuf. I had never practiced 90-270s at any altitude, let alone 150 feet AGL. With limited forward visibility and teasing the bottom of a layer of solid IMC, this somehow instantly occurred to me as the best course of action in my ace-pilot brain.

I immediately rolled into a 30-degree bank turn to the right. Precisely maintaining altitude and a constant angle of bank was critical to make this maneuver come out right at the end. I anticipated the roll-out at 90 degrees and continued the roll to the same bank angle to the left. I was being helped along by adrenaline. I maintained the bank angle, scanning the gauges with intermittent glimpses of the ground appearing not far below. The heading indicator progressed slowly towards the ultimate goal. And there it was, the runway threshold, beautifully displayed right in front of me and with perfect alignment.

Get the gear and flaps down and try to get this thing slowed down. I have 4000 feet of runway ahead of me, so not to worry.

But the fun wasn’t over. I touched down on the sodden grass runway fast and gingerly tried the brakes. The seat of my pants reported that we were developing some serious divergence in the yaw axis. The aircraft was hydroplaning, just slip-sliding away. I countered the increasing yaw with the throttles and asymmetric thrust, first one engine, then the other, as the aircraft careened down the runway through a few ungraceful semi-pirouettes. With about 1000 feet of runway behind us, positive control was finally established, and I managed to get the airplane settled down and headed for the hangar.

My passenger had been very quiet, staring straight ahead throughout all of this. He now turned to me wearing a “what the hell just happened” look and began to voice his displeasure in no uncertain terms. Blissfully unaware that we had come inches away from being wrapped up in a large ball of aluminum, his disquietude stemmed from the fact that we were back on the ground and not headed for Jackson, Mississippi. Apparently, attractive girlfriends can have a profound effect on male reasoning. I explained in my best pilot-in-command voice how the weather was not acceptable for the flight and we had to return to the airport, leading him to believe that the fiasco he had just witnessed was standard operating procedure in the air taxi business.

As my erstwhile passenger departed the airport for the long drive to Jackson, undoubtedly calmed by the thought of his girlfriend’s waiting embrace, and I was left to ponder the totally unnecessary risk I had taken with our lives. There could be no doubt in my mind about the seriousness of my mistakes. I had surely used up my allotment of good luck for at least the next ten years. I was thankful that there were no other witnesses to the debacle. This lesson has stayed with me, resulting in a permanent decrease, if not complete elimination, in my swagger. But it was a good trade. I had also added a small quantity of judgment to the bucket.

And that is why the FAA requires the incorporation of risk management and all its components in today’s pilot training curriculum.

Editor’s Note: This article is from our series called “I Can’t Believe I Did That,” where pilots ‘fess up about mistakes they’ve made but lived to tell about. If you have a story to tell, email us at: editor@airfactsjournal.com.

1 Comment

  • February 2000, after several weeks working with Peterson AFB Flying Club at Colorado Springs, I wanted to go home. The Mooney M20F was ready as was I, except for the
    0/0 weather on this Friday Morning. “It will burn off by 8 AM, 9AM, 10Am, maybe after noon”. Did not happen so back to the guest house. Saturday, Wx was 0/0 again at 8Am,
    9 AM, and then a bright light came on. I called ATC for another briefing finding that the tops were 8000 ASL, and destination at Salina KS was 2000 Ft broken. I filed IFR and the lady control said, “Have a nice day!”. Finally found the runway, Power up, try to stay on the center line, I could see one stripe at a time, off the ground and clean it up. Pure white for about 45 seconds, then poof, on top. Denver Departure got me on course and
    it seemed that I was the only one flying. 9000 Ft, direct with my Loran and a nice discussion with the Denver Center controller. As I switched to Kansas City Center the
    controller asked if I had heard from a Cessna 195, if not please listen since he was
    over due. THAT was when it really dawned on me what a chance that I had taken. The
    “what if” that I always preach to my students came home to roost. Any time in that first minute of flight, with any kind of mechanical or electrical problem would have been fatal. Just was not my day, but even if I were to stay grounded another week, I would not have done this again. In my younger days I did a lot of scud running. It was a very common practice in the 50s and 60s. Now with all the power lines and cell towers it just does not pay. Thank the Lord for my time on earth and time flying but I do not take chances like that any more. I guess at 80, it is time to reflect and offer better advice to my students and all that will listen. Stay healthy, fly safe, keep the greasy side down and please consider, what to do with the fuel left behind, the altitude above and of course, runway behind. Just an old pilot with ideas that may save another. Later

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