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When a high performance airplane crashes in IMC, the self-proclaimed experts on social media quickly spin elaborate theories about autopilot failure, in-flight icing, structural failure, carbon monoxide poisoning, or some other incredibly rare cause. It makes for good entertainment (“hit that subscribe button!”) but the reality is usually much less interesting and much more depressing. When the NTSB report comes out a year later, it’s almost guaranteed the cause will be “the pilot’s spatial disorientation and loss of airplane control.”
In fact, if you hear about a general aviation airplane crash and you know nothing else, you should assume it’s pilot error—even if there are tantalizing clues that suggest otherwise. After all, if 70-80% of accidents are due to pilot error, why would you jump to in-flight breakup or heart attack instead? This is a classic case of base rate neglect, a fallacy where we ignore the general prevalence in favor of exciting details. To put it in aviation terms, if I told you Bill is a doctor, you might assume he’s flying a V-tail Bonanza. It’s possible (the stereotype isn’t totally unfounded), but it’s much more likely he flies a Skyhawk. Why? For the simple reason that Cessna has delivered five times more 172s than Beechcraft has of their distinctive V35.
First impressions
There are plenty of recent examples of this phenomenon. One of the most shocking is the crash of a Pilatus PC-12 off the coast of Beaufort, North Carolina, in 2022 that killed eight. The instant online analysis, based mostly off FlightAware data, suggested a flight control issue or medical event, and plenty of speculation raged across forums and Facebook groups. The actual cause ended up being far more mundane, as the NTSB lays out in excruciating detail: the pilot simply lost control of the airplane, got too slow, and never took decisive action to save the airplane.
The airplane was out of control, but not because of any equipment failures.
In fact, the entire flight was an exercise in frustration for the pilot, as he struggled to work the avionics in marginal VFR conditions. Even at the end, as the right-seat passenger pointed out “we’re sideways,” the pilot was thinking only about the panel, saying “it’ll navigate” and “activate vectors.” There was absolutely nothing wrong with the airplane—it just needed a pilot in command to be in command. It’s one of the worst accident reports I’ve read in years.
V-tail Bonanzas, as mentioned above, seem to attract particularly wild speculation. Tail failures, the favorite theory when commenters don’t know any better, have indeed happened, but not nearly as often as most people think. In any case, most Bonanzas have been modified to increase strength, and even the ones that aren’t modified usually crash because the pilot ends up in a spiral dive well beyond Vne. The tail failing is simply the final straw.
The crash of a V35 in Tennessee last month has brought this topic up yet again, because witnesses on the ground “heard a pop” as the airplane descended rapidly, a classic sign of in-flight breakup. The NTSB report is still preliminary, but—remembering the base rate—I would bet on loss of control. The airplane clearly came apart, but it was probably after the airplane went through redline on the airspeed indicator and was coming down at 4000 feet per minute. Weather was a factor here, with radar images showing the Bonanza clipping the edge of a developing thunderstorm. That may have set the accident chain in motion, although I’d be surprised if it actually pulled the airplane apart.
The airlines are not immune to this fallacy either. Both the Colgan flight 3407 and Air France flight 447 accidents seemed to be caused directly by weather or equipment failure, but were in fact simple human error.
Contributing factors
This article is not meant to be an attack on pilots. We all make mistakes or simply have bad days, and even if an accident is due to pilot error that does not mean nothing can be done. On the contrary, airplanes can be designed to be more fault-tolerant, avionics can be made easier to use, ATC can offer more help, and instrument procedures can be simplified. Pilots shouldn’t have to be superheroes to fly safely.
That level button is pretty handy, but have you ever tried it?
Having said that, if we pilots are looking for quick wins, we should admit that we in the left seat have the biggest impact on safety. Our commitment to training, our everyday flying habits, and our honest evaluation of proficiency are within our control—and those probably matter more than fancy technology or new FAA rules.
I’ve written before about the importance of basic attitude instrument flying, and I would reiterate the importance of that fundamental skill. If you can’t reliably hand fly in IMC, then you should find a flight instructor immediately. But don’t stop at practicing hand flying—the accidents above demonstrate the importance of two related issues, avionics and weather.
The PC-12 accident is a lesson in how not to manage automation. The pilot probably should have scrubbed the flight when he couldn’t load the flight management system before takeoff, but instead he took off VFR into decidedly marginal conditions. When things started to go south, his instinct was to go head-down and try to “fix” the autopilot, instead of stepping down a level and hand flying.
This is a procedure that should be part of every instrument proficiency check: just like old school unusual attitudes, the flight instructor can use the autopilot to put the airplane in an unstable state, then tell the pilot “your airplane.” The instant reaction must be to push the red autopilot disconnect button and hand fly. Troubleshooting can wait until later, when the airplane is stable. When in doubt, fly the airplane!
Newer autopilots like the Garmin GFC 500/600 are better at this scenario, since they won’t just kick off when the airplane gets too slow; they will warn you and push the nose over. There’s even a Level button that can fly straight and level no matter what you put in the GPS. This is a great feature, but if you’ve never seen it in action then it doesn’t really matter—you are not proficient in the airplane.
The Bonanza accident points to weather as another key factor. There were obviously some building storms in the area that day, but the weather wasn’t terrible, something that may have actually lulled the pilot into complacency. ATC had the Bonanza pilot on a vector, and it’s quite possible the pilot was hesitant to ask for a deviation. The subtle pressure of an ATC clearance can lead us into danger.
Just go around—all the way around.
But the lesson is clear: just go around anything that looks ugly, and be quite insistent with ATC if you must. If you feel like a wimp for deviating, just remember that even the big boys do it. The screenshot at right shows a recent airline flight from Washington, DC, to Columbus, Ohio, taking a massive detour through South Carolina and Georgia instead of flying through a line of weather. If it’s good enough for the airlines, with two jet engines and two professional pilots, it’s good enough for us.
This lesson, one I’ve learned dozens of times in my career, was reinforced yet again on a recent flight. A line of storms was draped across our flight path, and while there was a fairly good gap in the middle, I wasn’t exactly sure how fast it was developing or whether that gap would close up. After hesitating for a few minutes, the other pilot and I took the easy option and just deviated all the way around the line. This added a good 60 miles to the flight, but on a 1000-mile trip, who cares? We fly to have fun and this made the flight a lot more fun, because we weren’t worried about a potential sucker hole.
If the lesson with automation is fly the airplane, with weather the lesson is take the sure thing. That’s a good way to ensure you don’t have to use your great hand flying skills to save the airplane when you get bounced around.
One more thing
In the interest of intellectual honesty, I should mention one more tricky subject: impaired pilots. In reading NTSB reports over the last few years, I have noticed an increasing number of comments about drugs (either over the counter or illegal) and even alcohol. The PC-12 pilot, for example, had used a number of powerful drugs recently, including oxycodone and hydroxychloroquine. This accident from 2022 is even worse, seemingly caused directly by alcohol: “it is likely that [the pilot’s] impairment due to alcohol consumption contributed to his loss of control.” Even marijuana is starting to show up in some accident reports, especially as laws loosen up in the US (at the state level, that is—not with the FAA!).
I don’t want to overstate this trend—it’s hardly an epidemic, and just because the autopsy finds an antihistamine or THC doesn’t mean it caused the accident—but it’s hard not to wonder whether social norms have changed ever so slightly. In my opinion, this subject should be pretty simple: pilots seem to struggle with single pilot IFR as it is, so any handicap is just asking for trouble. “Zero” is easier to manage than “a little bit” when it comes to drugs and flying. And yes, that means spring allergy season is rough for me.
The final takeaway from this research is personal: I miss Richard McSpadden, the leader of AOPA’s Air Safety Institute who died in a plane crash last year. His calm, level-headed accident analysis videos were a master class in how to learn from tragedy while sticking closely to the facts. There are some great YouTube channels today (blancolirio is a personal favorite), but no one can quite match Richard’s compassionate style. As many have said, we honor his legacy when we fly safely.
- Weather flying means learning to read clouds - November 11, 2024
- What’s wrong with the teardrop pattern entry - September 25, 2024
- What matters for VFR proficiency: better landings - August 26, 2024
True as it may be, there is not a lot of satisfaction in the usual “the pilot’s spatial disorientation and loss of airplane control” type explanation from the NTSB.
I think what a lot of these outlets try to do, and I agree with you that most of it is pure speculation, is try to figure out “the specific holes in the swiss cheese” that led up to pilot spatial disorientation as a group learning exercise. How useful that really is? Debatable.
Always enjoy your articles John and we all miss the Richard’s, McSpadden and Collins. Both were excellent writers and level headed aviators with a keen ability to cut to the chase with compassion and care. Thanks for stepping into that gap and keeping things clear and unbiased.
On youtube I really like Dan Gryder. He really took Richard McFadden to task for fixating on the runway landing with a partially failed engine when many open fields were available right in front when failure manifested during takeoff climb. Gryder always says what needs saying.
This article is literally about Dan Gryder…He is a pompous, obtuse, and disgusting man who jumps to the wrong conclusions. He has a history of slander and defamation and recently lost a court case and has to pay over $1M at 5% interest after being found guilty. He’s also a thief having stolen evidence in an NTSB investigation from the accident in Burley, ID.
Dan Gryder was not in the airplane with Richard McSpadden and has absolutely no idea what was going on at that time. He has a history of premature, wild, and inappropriate speculation about aviation incidents.
At the same time, he has been involved in a number of crashes, and run-ins with the law, showing a very anti-authoritarian attitude. He is most recently accused of stealing evidence from the crash scene of the Cessna 208 crash in Burley Idaho.
Please stop giving him attention. Instead, check out Martin Pauly or CitationMax’s YouTube channel if you want to see someone doing it right every time. And if you want to learn about accidents watch the AOPA Air Safety Institute accident case studies. Dan Gryder is the opposite of all those.
I think Gryder is one of the “self proclaimed experts” that John is referring to. Gryder may end up charged for what he did with C208 accident in ID that took the young woman’s life. Disgraceful.
Your article is much appreciated John. As stated above, we miss our mentors. Richard would be proud!
I think Pilot Debrief with Hoover is excellent.
I agree, Liz. Another excellent analyst Is Mentour Pilot (I don’t know his real name) who primarily analyzes airline accidents, but does so in a well-considered way that always has something applicable to us GA types as well.
The reason why Mentour Pilot is so good is because he waits for the investigation to finish and then presents all the facts in an informative and entertaining way giving his insights as a fellow pro-pilot. Imagine if Mentour Pilot made content a few hours after a crash? It would be a lot different.
I agree, Liz. Hoover is compassionate, sticks to the facts, and presents all information concisely.
What bugs me the most about the “self-proclaimed experts on social media” is most often their analysis and determination of the cause is based on 2 min. local news report or a 30 sec. video clip. In the next breath they complain about how long it takes the NTSB’s final report to be issued. Rather than acknowledge the mountains of evidence that needs/should be gathered and analyzed to determine what “really” happened. They pander to viewers wants/needs for QUICK answers (fast doesn’t equal accurate) to get those “Likes and Subscribes”.
I agree that Blancolirio does an excellent job offering balanced information based on his knowledge/experience and technical research. He also always leaves the door open for the NTSB’s final report.
Juan and Hoover give the best preliminary insight and Fly Wire goes deep into the basic causes.
I’ve met Martin and he is just as pleasant in person as in his videos. We should all approach aviation with his same inquisitiveness.
And yah, Gryder is a disaster!
Richard McS’s tagline was “go fly” it wasn’t a throw away line, it emphasized the most important safety investment you can make is in yourself…before spending on the latest safety widget, figure out how many flight hours won’t be flown while acft is down or fuel budget is crimped…by all means do all the above if $$/time is no object, but for most of us mere mortals avgas is the best safety investment.
Couldn’t agree more John, look in the mirror for most of the problem, a perfect flt never happens…trng helps on the day when the holes start lining up.
Thank you for this article, it is so tempting to watch these “expert” preliminary reports. I’m my heart I know they know nothing, but it is so tempting.
Their sensationalism seems to be an ego trip for them. I know more than you kinda crap.
They all need their channels yanked.
I’m in full agreement—YouTube will not replace the NTSB anytime soon. I do like some of the YouTubers—Juan Browne of Blancolirio, Hoover of Pilot Debrief for example—but neither of them seemingly tries to second guess, or I should say, pre-empt the work of the NTSB. After watching a few of Gryder’s videos, though, I stopped—I don’t have much use for pompous know-it-alls who leap to conclusions prematurely. And I’ve been flying long enough (51 1/2 years and about 3000 hours) that I know that none of us is immune from making mistakes—or for that matter, doing stupid pilot tricks. So I don’t like it much when some self-proclaimed expert sounds off about others’ errors in a way that says, “I’m so perfect that I would never do something so ignorant.” I know full well, as we all should know, that I am as capable of doing something just as dumb—and so are you, and you, and you.
Gretaa article. I had a good friend die in his Turbo Commander back in the early 90s. It took the NTSB a year and change to submit the final report to the public. the detail of that report was eye opening. I used this as a lesson in failure diagnostics in my career in aerospace materials engineering. (Note the cause of the accident was pilot error combined with engine failure on take off. there were many other factors which i do not wish to repeat here.) The take away to my manamgers was..If I do not do the FD correctly and we have a second failure can i used management schedule pressure as an excuse to keep from getting canne? the answer was of course no. The NTSB may seem very harsh but in reality the person holding th stick is usually the reason for the accident either through action or nonaction.
HOWEVER on a separate note my ground school instructor was piloting a cessna 206 with others on board and crashed into the ocean. in his case the NTSB determined that this mid 50s healthy man who passed his medical weeks before died of a massive heart attack while flying. He had a very rare condition which usually shows it first symptom with death. a terrible tragedy. So again it takes time to know what happened and for the most part speculation should be left out of the discussion.
As a VFR pilot, on my cross country trips, I usually flight plan it over, around, or near other airports. Both as a navigation aid, as well as having an out due to weather or a mechanical issue.
This has saved my hide many a time. Don’t get in, hit the GPS direct, and follow the course.
I don’t really agree with the premise. I watch the YouTube channels that cover crashes, and they almost always identify the cause as pilot error.
Even though i think there is a lot of value in the group discussions inspired by all the various channels mentioned in this thread, the fact is none of them have all the information needed to do a thorough investigation (and the good ones admit that). So saying “it’s the pilot” is not that satisfying either outside cases of gross negligence, i.e., taking an IFR clearance without an instrument rating.
At the end of the day though, I think the real value in “accident investigation channels” is to provide an open venue to discuss GA safety and how to improve it.
I think you’re right – there is value in an open discussion. But I wish the open discussion was more around final NTSB reports, not instant reactions to 12-hour old accidents. I think there’s value in reading through all the details from the investigators, and I find many lessons there. But a lot of the stuff I see is more like detective work, where the host is trying to use ADS-B data to “solve the problem” instead of learning about how we could avoid the same fate.
Anybody want to start a YouTube channel where we do instant analysis of the final report?
You know John, you jest, but I think that would be a great channel! I totally agree that most of these channels (including the good ones) would be better off waiting for the NTSB report to come out and then go into the nitty gritty. At least by then, you have way more facts than the post 12-hour (even sooner) report. Think the incredible ASI video series – the gold standard, but quality takes time.
What’s sad is the overwhelming majority of channels mentioned in this thread fall victim to the social media trap and try to produce “content” as fast as they can after a crash. And as a result, ALL of them have made mistakes in their reporting – serious ones – which undermines their whole endeavor in the first place.
But again, what other public venue exists to really talk about GA safety in the context of an accident, i.e., a recent case study, using high-quality video? YouTube has filled that vacuum – for better or worse.
One of the reasons Richard was so good was that he didn’t say what happened, he said what the NTSB will look at and why. That is what provides the most value to pilots and what is sorely missing from a lot of the YouTube content I see. Put simply, more Dr. Watson, less Sherlock Holmes.
I agree with you. Aviation accidents are usually a result of two or three things that go wrong. Dan Gryder does his best to figure them all out. He isn’t perfect at that and even admits it. Everyone has a right to be wrong. Even the NTSB.
Echoing Scott Z’s comment, I strongly disagree with the theme of the article. Overwhelmingly the YouTube analysts (whether they deserve the term or not) come to a conclusion of pilot error. There’s often the context of other factors including equipment issues, but the overwhelming message Is the accident chain starts early. In nearly every case there is something the pilot might have done differently, including deciding not to fly for emotional, physical, mechanical, wx or other reasons. These videos have been an extraordinary resource, condensing what back in the day would have required many years of personal and hanger flying, or reading monthly aviation magazines, into a far shorter period of understandable, accessible, engaging learnings. Of course you need to be a careful media consumer, but the time I’ve put into watching these has absolutely made me a more thoughtful, safer pilot. I think it’s dangerous to suggest that pilots focus solely on recurrent training and their own air experience – which are of course foundational to safety – but without recognizing the significant additional learning available right from a pilot’s sofa. So perhaps if the article was titled “avoid crappy sensationalist YouTube pilot videos but spend lots of time watching high quality accident investigations” I’d be on board.
I think you’re watching the higher quality ones. I can assure you there are some truly awful analyses out there (especially off YouTube – don’t go browsing TikTok). If you stick to the higher quality ones, I agree there is great value in analyzing accidents. The key question is, “what would I do differently?”
So every accident is pilot error. That sure saves a lot of time and money on investigations. Let’s not dig into why it was pilot error. Just another uninformed blogger spewing his BS.
I think you missed the point. We absolutely, 100% should dig into why it’s pilot error. But that is what the NTSB does, in a systematic way (and some good YouTubers). Wild speculating and self-serving rants do not achieve that goal.
Funny and ironic that you call John Zimmerman uninformed. He is the president of Sporty’s Academy, recently editor of AirFacts that you are reading now, etc. One of the most reasonable and insightful aviation writers. One of the lessons of this article is to know the reputation of the person you are watching on youtube or reading.
And don’t overlook Scott Perdue at Flywire. He’s content to wait on the prelim report & actually does either detailed science based chalk talks or in-flight demonstrations (his latest graveyard spiral in a Bonanza was eyeopening; how quickly the speed & forces build up in a slick plane), while leaving the door open for correction by the final report.
Thank you John, this is a very well written, helpful article!
This article is “No truer words have been spoken”.
We need the reminder every now and then.
I was involved with several mishap investigations for the Air Force during my civilian aero career. One thing that most people don’t recognize is that the investigation looks at ALL facets of what could have caused a particular mishap and then by process of elimination eliminates those that didn’t or couldn’t. What is left is probable or contributing causes. Using fault tree or fish bone analysis takes time, and the NTSB or other mishap investigations bodies use them and do a great job. Guys like Gryder jump to what appear to be possible causes to fit “the facts” and then come to their conclusions versus eliminating ALL potential causes. Quite a difference in approach.