Why It Went Wrong

Why do pilots come to make blatantly bad decisions? Can we catch those bad choices before its too late?


Mishaps happen for a number of reasons, but all too often theres a “what were they thinking?” element to an NTSB accident report. In the calm, clear skies of retrospect-or a motionless easy chair-its easy to condemn a bad decision and move on. But its not usually a single bad decision that causes tragedy. Pilots dont take off intentionally choosing to put themselves in a no-win situation; they dont mean to kill themselves, their families and friends.

How do pilots come to make blatantly bad decisions? When can a decision made on the ground, perhaps weeks or months before the accident flight, be recognized for its potential contribution to a mishap? How can we catch our own bad choices before its too late? Maybe by examining some particularly egregious examples, we

Plane Crash


can find some insights into how these bad decisions are made and how to prevent them in our own flying.


Our first example involves a single-engine retractable that impacted trees and terrain short of the intended runway during a night IFR approach. In the aftermath, two were dead, two more had serious injuries and one was left with minor injures. The airplane was destroyed

The flight originated IFR with a clearance to VFR conditions on top. Reaching visual conditions, the 1300-hour Instrument-rated pilot canceled IFR but continued receiving VFR flight following. The ceiling at destination was 400 feet overcast with 10 miles visibility, creating dark night conditions beneath the clouds. Available approaches (NDB and GPS) had MDAs of 700 and 500 feet agl, respectively. Although the pilot did not obtain a new IFR clearance, a surviving passenger said she “thought the pilot was performing an IFR approach and it was a normal approach.” She saw the runway lights before the airplane “hit something.” Two survivors both report hearing a “rumbling sound” and the pilot saying, “Its not working, its not working.” The airplane then solidly impacted trees and terrain -mile short of the runway, left of centerline.

The NTSB attributes the crash to “the pilot not maintaining altitude/clearance from the trees during an approach on a dark, low overcast night, the pilots improper use of an IFR procedure without clearance, and the pilots improper in-flight decision to attempt an IFR approach without clearance. Factors were the local weather being below published minimums, the trees and the dark night.”

On investigation the following was found:

The installed GPS was inoperative, but a non-aviation handheld GPS was in the cockpit.

The installed communications radio was inoperative, but a handheld comm radio was in the cockpit.

The aircrafts ADF was “off.”

A can of automotive starting fluid was found in the aircraft.

The fuel selector valve, spring and screen were coated with a brown material.

Expired instrument approach plates were found in the cabin.

The airframe logbook contained a two-year-old annual inspection entry stating the required transponder check was overdue.

Several over-the-counter medicines commonly used for cold or allergy relief were found in the pilots body, some carrying warnings they induce drowsiness and dizziness.

An airport commissioner had sent the pilot a letter asking for a copy of the airplanes airworthiness certificate since he had “been observed spraying a [starting] fluid into your aircraft and this presents a safety problem at the airport.”

A local avionics technician had advised the pilot his comm radio and GPS were inoperative and not repairable. The technician reported the pilots only working radios were portable units.

The FBO manager reported the pilot “did not perform preflight inspections before departure.”

The A&P/IA who signed off the airplanes last annual reported a months-long exchange with the pilot/owner regarding various discrepancies. These included an inoperative fuel pump (hence the need for the starting fluid since he couldnt prime the engine); both main fuel tank sump drains corroded shut despite the pilots assurance he drained them before every flight; the airplanes starter had failed and “he had to prop it the last couple of trips”; and a missing fuel cap was “never replaced, but the opening was covered with duct tape.” All these issues were eventually addressed prior to the annual inspection.

Theres an axiom in general aviation that pilots tend to buy the most airplane they can barely afford. If thats the case, and unplanned expenses or the natural results of use crop up, the owner may not be able to afford to make repairs.

People dont suddenly decide to fly IFR without radios and with made-up approach procedures-that the pilot obtained a clearance to VFR conditions on top suggests he did not expect to need to fly an approach.

Instead, pilot/owner economic workarounds start small: Use a handheld radio when the primary starts to become unreliable. Then, a little bit at a time, the pilot finds himself flying an unairworthy airplane, most likely too embarrassed to admit it to a mechanic (e.g., skipping the 24-month transponder check because the technician might find the inoperative radios). And each time a pilot successfully works around a problem, the more reinforcement he/she has that the workaround is safe. In reality avoiding an accident is usually just a matter of luck…and time.


Another example of what we might call a blatantly bad decision involves a destroyed single-engine fixed-gear airplane and two fatalities. The 200-hour, non-Instrument rated Private pilot failed to obtain a weather briefing before taking off at night on a cross-country flight through an area where low ceilings and visibilities were becoming widespread.

After departing Class D airspace, the pilot flew about 35 minutes at 8000 feet (roughly 3000 feet agl), then descended to about 700 agl and changed heading several times, including multiple 180-degree turns. At one point, he maneuvered to within about four miles of an airport. Eventually, however, the airplane impacted hilly terrain. According to the local sheriff, area weather at the time of impact included “blizzard conditions,” with winds “gusting to 65 mph” making “it hard even for surface vehicles to maneuver.”

The NTSBs “probable cause” finding cites “the pilots VFR flight into instrument meteorological conditions, and his subsequent failure to maintain terrain clearance, which resulted in an in-flight collision with terrain. Contributing factors were the pilots failure to obtain a weather briefing, low ceilings, snow, high winds and dark night light conditions.”

Additional items discovered during the investigation include:

The accident flight was a return trip that began at the intended destination that morning. On the morning flight the pilot obtained a telephone preflight briefing and conditions for the trip were good VFR.

On departure, the pilot taxied to an intersection instead of the end of the runway as cleared by ground control. When questioned by the controller, the pilot requested and was granted an intersection takeoff.

After departure, the pilot needed prompting to turn on his transponder.

The pilot tested positive for marijuana.

Have you ever taken off without a weather briefing? (Be honest). Do you sometimes short-change the briefing and preparation for the return portion of a one-day trip? Even before late 2001, when temporary flight restrictions (TFRs) became a common “hazard,” fast-changing weather was the biggest danger to safe flying (the cited mishap occurred in 2000).

Showing Off

Having an inflated view of our piloting skills is another characteristic common to many pilots. Too often, this has led to getting in over our heads and doing really stupid things. Few examples, however, compare to a recent accident involving a piston twin that left five dead and destroyed a perfectly good airplane.

The airplane broke up in flight while maneuvering at low altitude in day visual conditions. The accident site was en route between the departure point and intended destination, near the home of a friend of the accident pilot. The NTSB has not yet released a probable cause finding on this mishap.

The preliminary investigation turned up these facts:

Witnesses report the airplane “sounded as if the pilot was performing some aerobatic maneuvers.”

The aircraft was observed to be “high and descending very fast in a 45-to-60-degree nose-down attitude” when “a wing or part of the tail separate[d] from the airplane.”

The friend of the pilot informed police he was “planning on purchasing an airplane from the pilot” and the pilot was “going to use the money [from that sale] to purchase” the accident airplane.

The friend continued by saying the pilots “flying skills were below his standards because the pilot was known for overstressing the airplanes he flew.” The friend said he had told a third person about three weeks earlier he had flown with the accident pilot and expected the pilot would “probably crash an airplane within the next year.”

That same friend reports the accident airplane had attended a major airshow and saw an aerobatic performance in a non-aerobatic certified airplane from the same manufacturer. Following that performance, according to the friend, the accident pilot “just kept the rolling issue in his head.”

Returning from the airshow featuring the cited aerobatic performance, according to a passenger on that trip, in cruise flight the pilot said “I want to try something.” He then “rolled the airplane to the left side, and then back to the right side” and commented, “I believe its possible to roll this airplane.” The pilot then “pushed down on the control yoke, initiated a descent and turned the airplane to the left, pulled back on the control yoke, and the airplane went up and over to the right like a spiral until the airplane was in a knife-edge attitude. The friend of the pilot stated he did not know what airspeed they [at]tained while the pilot was performing this maneuver and stated, It got me out of my comfort zone, and I could not handle it. The friend…grabbed the flight controls, leveled the airplane, and stated to the pilot, I can not do this. The pilot replied, I believe it is possible to roll this airplane. The pilot…leveled off in cruise flight, and there was no further discussion about rolling the airplane. A short time later, the pilot pulled the power back on the right engine, feathered the propeller, and they continued towards [home], in cruise flight. The pilot [later] started the engine, and they made their descent and landing….”

Its irresponsible to defend any of this pilots decisions. But hangar talks and Internet chat lines are full of pilots of non-aerobatic airplanes cavalierly discussing their airplanes rolling or looping characteristics, or its ability to carry loads outside the weight and balance envelope, or tips for spraying the wings or filing the propeller to fly non-ice certified airplanes in icing conditions. Maybe some of us are a little closer to this pilots thinking than wed like to admit.

Known Deficiencies

The first accident I described involved willfully ignoring maintenance requirements over a lengthy period of time. Thankfully, thats pretty rare. More common, however, is deferring repair of a system with a redundant back-up. Sometimes its a gray area, helped along by the rather looser rules of Part 91 when compared to other, stricter operations. Most of the time, however, theres a reason everything on the airplane should e working.

The final example involves a single-engine retractable sporting a standby vacuum system to power gyros in the instrument panel. Shortly after a hand-off and while in or above clouds at 8000 feet, the airplane descended to 7400 feet, climbed to 8500 feet for about a minute, then leveled at 8100 to 8200 feet for another minute. The airplane then made a descending turn to the right at vertical speeds up to 16,000 fpm. Its tail separated shortly before impact and the left wing spar was bent downward. NTSB cites as cause “the pilots loss of control, and his subsequent overstress of the airplane after a vacuum system failure during flight in instrument meteorological conditions. Factors included the instrument meteorological conditions, [and] a sheared coupling on the vacuum pump….”

The investigation revealed:

The airplane was equipped with a vacuum-powered attitude indicator and directional gyro, as well as a standby vacuum system using differential pressure between ambient and that in the induction system to spin the instruments gyroscopes. This system requires the pilot reduce power significantly to obtain sufficient pressure differential to be effective. Its likely the standby systems annunciator light was illuminated on impact.

The vacuum pumps flexible coupling failed, leading to loss of vacuum and instrument failure. The gyroscopes did not have evidence of rotational scoring-they were not spinning on impact.

The failed component was installed 26 years before the failure occurred. The manufacturer recommends replacing the coupling every six years. The recommendation is not mandatory for Part 91 operators.

The NTSBs probable cause statement continues: “…the pilot/owner’s failure to ensure the coupling was changed per the manufacturer’s recommendations, a lack of regulatory requirement to ensure compliance with the manufacturer’s recommendations, and a lack of regulatory requirement to ensure installation of a suitable backup system.”

The pilot of this airplane was flying under circumstances many of us fly in every day. The airplane was FAA-legal. He (or a prior owner) had added a back-up vacuum system. The failed couplings manufacturer has a recommended replacement schedule, but such is not mandatory for privately flown U.S. civil aircraft (see the sidebar on page 19). Certainly the pilot was thinking he and his family were safe, flying in compliance with regulations and with a backup safety system in place for emergencies. But put in the retrospective context of a crash that killed off an entire family, simply complying with the FAAs minimum standard of safety is harder to justify.

Theres no excuse for flying approaches without equipment or clearance, or taking off on a night cross-country without a weather check, or performing aerobatics in a normal-category airplane full of passengers. And its hard to justify IFR flight with a 26-year-old vacuum pump. The record shows even “good” pilots sometimes make bad decisions…often repeatedly, until one day its too late.

Next time you read a mishap report and think, “I would never do that,” consider the decisions many of us make every flight could lead to a slippery slope of similar patterns and occurrences. Consider also: Those reading about it later will wonder what you were thinking.

Tom Turner is a CFII-MEI who frequently writes and lectures on aviation safety.


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