We don’t know how many times he successfully climbed in IMC to get to VFR over the top, but each time he became more comfortable with doing so, and that made it much more likely that some time in the future he would push his luck too far. That moment arrived when the pressure to complete a long-planned trip came up against entrenched low ceilings. When he realized he could not take off the day of his planned departure, he grew more determined to depart the following day. When he could not depart the second day, the pressure became even more intense. Finally, on the third day, the forecast held out the hope of gradually improving conditions later in the day. In a phone call just before he departed, he told his wife he “saw a sunbeam where the clouds were thinner” and that there was a break in the clouds. He also told her that “if I’m not in blue [sky] right away, I’m coming back,” which seems to indicate that somewhere in his pilot brain he realized this was a low-probability exercise.
When he took off, he was probably shocked at how quickly he entered the clouds and how dark and thick the clouds were, and realized he would not be in “blue sky” any time soon. At that point the only viable plan was to climb straight ahead, engage the autopilot and tell ATC what had happened. With full gas tanks, the controllers likely could have helped him to get on top and then to find an area where he could land visually, perhaps after a short descent through the clouds.
Unfortunately he stuck with his original commitment to return to the departure airport if he didn’t break through the clouds right away, even though there is no way he could have done so with such a low ceiling. The GPS in the airplane recorded a chilling sequence of tight turns with a radius of between 400 and 1,000 feet. Because the left wing was located about 1,000 feet from the main wreckage, the NTSB determined that the wing separated from the airplane in flight.
This accident emphasizes a couple of important points. First, it shows how easy it is for someone to make a completely illogical decision under the pressure and frustration of a delayed departure. But more importantly, it illustrates how we can start down the slippery slope toward an accident with a seemingly minor deviation, and then gradually slip farther down the slope as we get used to taking bigger and bigger risks. While each incremental increase in risk may be small, over time they can lead us into a situation in which there is no longer any way to recover.
There are other “slippery slopes” pilots need to be alert for:
• Taking off over gross weight or out of CG — just a few pounds the first time, then a few more pounds the next time, until the hot day at a high-elevation airport where the airplane can’t clear the trees at the end of the runway.
• Going below minimums — just a few feet the first time, then a few more feet the next time, to the point that the pilot no longer worries about minimums but just descends until the runway is visible, until the day the airplane crashes short of the runway.
• Not having a current medical or biennial flight review — I seem to be noticing more accidents (including this one) in which the pilot did not have a current medical and/or BFR. Once you break one rule, it is easier to break others.
• Flying low — the first time at 800 feet, then 500 feet, then 300 feet, until a wire or other obstruction ends the flight.
It is amazing how this process can gradually dull our senses to the risks we face. If you asked the pilot in this accident just after he got his private pilot certificate if he would ever consider taking off VFR into thick stratus clouds with a ceiling of 200 to 300 feet, he would undoubtedly have responded, “Do you think I’m crazy?” And yet after several years and many occasions when he took off knowing he would have to fly through the clouds at least for a minute or two, under the pressure of a delayed departure that is exactly what he did. The most dangerous aspect of this process is that we are usually not aware it is happening, so it would be a good idea for all of us to examine our flying to see if we have started sliding down that slippery slope to an unacceptable level of risk.
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