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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.
- Ignore the YouTube crash detectives—it’s usually pilot error - June 24, 2024
- Why learning to fly can be good for your mental health - May 15, 2024
- What a difference a decade makes: the GA boom in statistics - April 15, 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.