A MOMENTARY LAPSE OF REASON ...
Acknowledgements: Thomas P. Turner/Mastery Flight Training Inc.
(Ed. Note: Condensed with our thanks from Tom’s excellent lesson this week We all KNOW, but do we always DO?)
“It’s commonly said that aircraft accidents result not from a single event or cause but are the culmination of a chain of events - an error chain. I prefer to think of it as a decision chain, because we make our decisions and it’s our decisions that make or break this chain.
Frequently these accidents happen to highly experienced pilots - they can happen to anyone. Often, it’s a fleeting decision that precipitates the end - you might call it a momentary lapse of reason. How can this happen? How can we detect ourselves making bad decisions in time to break the decision chain?
The solo pilot of a Piper Aerostar tragically perished in an apparent accelerated stall shortly after take-off. The stall, in turn, is linked to likely dual engine failure as a result of misfuelling the turbocharged piston twin with jet fuel. The pilot in this case was extremely experienced and a full-time flight instructor specialising in very high-performance twin-engine turboprops. This was no rookie making mistakes ...it was an expert somehow making bad decisions. Decisions, and mistakes, were made by ground personnel as well. From the NTSB’s early information, neither party was blameless, and neither party was entirely to blame ... According to the airport employee who fuelled the airplane, he asked the pilot [by radio] while on approach to the airport if he wanted jet fuel, and the pilot said "yes." He said the he asked the pilot if he wanted jet fuel because the airplane looked like a jet airplane. ... The employee fuelled the airplane with about 163 gallons of Jet A from the fuel truck ... An employee inside the Ops building heard the engines start. After the engines started, the engines sounded "typical." He said that he did not hear any radio transmissions from the pilot during his departure and did not hear an engine runup ... A pilot who received recurrent training from the accident pilot ... said the accident pilot visually checked the fuel tanks of the airplane and gave a "thumbs-up" ... He heard the engines start and "they sounded normal." ... He did not see the take-off ... A witness stated that the airplane made a "sharp left turn" to the east. The left wing "dipped low" and she then lost sight of the airplane but when she approached the intersection near the accident site, she saw the airplane on the ground. Post-accident examination of the airplane revealed the airplane wreckage ... displayed features consistent with an accelerated stall ... and revealed the presence of a clear liquid consistent in colour and order with that of Jet A in a fuselage tank and in the fuel lines leading to the fuel manifolds of both engines ...
CFIT: ... Another NTSB preliminary report newly posted this week suggests another series of decisions gone horribly wrong. This pilot also was highly experienced and considered an expert in type ... From the NTSB: A Lancair Legacy collided with the ground in a heavily wooded area ... The private pilot was fatally injured. Day marginal visual meteorological to instrument meteorological conditions existed near the accident site at the time of the accident, and no flight plan had been filed ... A witness located about 3 miles from the accident site ... noted the tops of the hills were obscured by mist and rain. Another witness located about 5 miles from the accident site said he heard an airplane making "whooshing sounds," like a "descending helicopter" ... The on-site wreckage examination revealed the airplane impacted the ground in a flat attitude ... Weather near the accident site at the time of impact was 800 overcast, visibility one mile ... I was at St. Louis that same weekend, and I recall the day of this crash being gloomy with intermittent low clouds and periods of thunderstorms with heavy rain showers all day ...
Another tragic event occurred last week and has been widely reported, although there is no NTSB investigative report yet and I don’t know the experience level of the pilot ... Police said: A passenger on a private flight ... stepped in front of the plane Saturday night at about 8:45 p.m. and was struck by the propeller, which severed one of her arms ... The victim was airlifted to hospital in stable condition ... The incident began when the pilot tried to taxi on the runway but the plane wouldn’t move. He got out while the plane was still running, to check to see if the plane’s tyres were still in the wheel chocks ... He told his wife to stay in the plane, but she got out. He then told his wife not to go to the front of the plane, but she did. She went to remove a chock from the plane’s tyres and came in contact with the propeller ...
It’s easy to dismiss reports like these, saying “I would never do that!”. But that’s too simplistic:
I bet the Aerostar pilot didn’t routinely sit in the airplane yet ignore the fuelling process, or (reportedly) confirm that he wanted “jet” fuel before fuelling began.
I’d wager the Lancair pilot didn’t usually fly visually in marginal-to-instrument conditions and possible thunderstorms.
I expect the pilot of the Cessna 172 knew not to get out of the airplane while the engine was running, or to try to remove a wheel chock behind a spinning propeller.
I suspect, in fact, that the people in these cases and the myriad others like them knew deep down they were violating the rules of safety:
We’re supposed to order fuel carefully and observe the fuelling operation, as a guard against those we expect to know why the jet-fuel nozzle won’t fit in the piston-fuel filler port.
We are trained to evaluate weather and plan flights to remain well clear of clouds and low visibility when flying VFR, to select minimum safe altitudes for each segment of flight, and to divert to clearer air and land if conditions cause us to descend below that safe limit.
From the very first FLYING LESSON we’re taught the potentially lethal danger of a spinning propeller.
Most of us know these things. It’s circumstance, and our reaction to it, that leads to violating our own sense of what’s right.
It may be that the Aerostar pilot was thinking about the business he was there to do, not on concluding his flight or preparing for the trip home. It may be coincidental that his business was to fly a turboprop, and that thinking became a factor in his lack of oversight. Focus on the reason for the trip, instead of the conduct of the trip itself, can negatively affect your normal routine.
It’s possible, because the Lancair pilot been away from home for several days, that he may have just wanted to get home that Sunday, perhaps to get to work Monday morning. I don’t know. Reports are also that it was his birthday - maybe there was additional external stress to get home. Get-home-itis is a well-known temptation, with a demonstrated history of tragic results.
It could be the pilot of the Cessna 172, making a nearly 9 pm departure on a weekend night, may have already been later than expected and felt rushed to get home. That might explain missing the chocks on his nose wheel in the first place, and the decision to jump out and remove them without shutting down the engine.
I recall years ago a FLYING LESSONS reader (flight instructor LeRoy Cook) making this salient point: “Beware finding yourself rushing toward an airplane.” Or, once in that airplane, rushing toward flight.
If it’s easy to say “I’d never do that,” while acknowledging that even highly experienced pilots sometimes make disastrous decisions, it’s even easier to take a fatalistic view that “accidents happen” and there is no avoiding the “one with your name on it.”
No, fate is not the hunter. Complacency, impatience and taking shortcuts probably presage most of the nearly 80% of accidents attributed to pilot decision-making. We are hunting ourselves.
How can we detect ourselves making bad decisions in time to break the decision chain? How can we avoid a momentary lapse of reason? I don’t have the ultimate answer. But if you find yourself feeling rushed, if you don’t have time to do things the way you know they should be done, or you are skipping checklist steps and other required actions because you don’t think they’re important or you simply don’t have time ... well, the above reports contain some definite clues”.
FLY SAFE!