Aftermath: A Question of Judgment

After 11,000 hours, an ATP makes a rookie mistake.

airline pilots
Is every pilot capable of making a dangerous blunder, or is this fate reserved for a headstrong few?Pexels

The privately operated Phenom 300, arriving from Milan’s Malpensa Airport with a single ­pilot and three passengers aboard, overflew the Blackbushe aerodrome, southwest of London, before circling to a left downwind for Runway 25.

Blackbushe is not a controlled airport, but it once was, and it still has an old-fashioned tower with a glass-enclosed cab, within which is a person called the AFISO, or aerodrome flight information service officer. His function is to advise aircraft of things like wind conditions and traffic, but not to issue instructions or clearances.

Ahead of the Phenom on the downwind leg, more than half a mile closer to the runway and well below the jet’s altitude, was a high-wing, two-seat microlight aircraft — what in the United States is called a light-sport aircraft, or LSA — flown by an instructor and a student. The jet pilot had seen the LSA, then just taking off, as he first crossed over the field, and he reported traffic in sight to the AFISO. The LSA instructor likewise reported visual contact with the jet.

After a short discussion with the AFISO, with whom he was on a first-name basis, the LSA instructor, who intended the landing to be a touch-and-go, said he would extend his downwind leg to let the jet turn inside him and land first. At the same time, a transient aircraft, flying north to south at 2,300 feet, crossed east of and above the jet as it turned base.

In order to remain well clear of the LSA, the jet’s pilot had stayed higher than normal. On the base leg, he was more than 1,400 feet above and 1.4 miles from the runway threshold, and still well above approach speed. Once certain that he was clear of all traffic, the jet’s pilot selected full flaps and dived for the runway with 13 degrees of nose-down pitch and a descent rate of 3,000 fpm. He crossed the threshold at 151 knots, 43 knots above the target final approach speed.

In the tower, the AFISO watched with growing alarm as the Phenom floated for two-thirds of the 3,500-foot runway. When the jet finally touched down, it was doing 134 knots across the ground with just 1,100 feet of ­runway remaining — and 1,437 feet to the end of the pavement. The AFISO, certain that the jet would not be able to stop on the runway, alerted emergency responders.

When the jet finally touched down, it was doing 134 knots across the ground with just 1,100 feet of ­runway remaining — and 1,437 feet to the end of the pavement.

The pilot applied maximum braking. Decelerating at a steady 0.45 G, the Phenom was still doing over 80 knots when it went off the end of the runway. It rode up a low berm, became briefly airborne, and crashed into an auto auction company’s parking lot. The wing ­separated from the fuselage, which rolled over once and came to rest nearly upright. Fire immediately engulfed the airplane. The occupants, who survived the impact but ­apparently could not open the cabin door, perished before help could arrive.

The UK’s Air Accidents Investigation Branch, unlike our NTSB, does not assign a probable cause to accidents. If it can, the NTSB pins blame on some person, place or thing. The AAIB merely lays out the facts, discusses them and speculates about what may have taken place.

In this case, one result of the AAIB’s approach is that the pilot’s inflight decision-making — which in an NTSB analysis of such an accident would have been the first mentioned among probable and contributing causes — is seen, instead, as the outcome of external ­circumstances. The approach is presented as having been unusually stressful and confusing for the 57-year-old, 11,000-hour ATP, even though the weather was fine, the traffic was light, and he was familiar with the airport, having flown into it on at least 15 previous occasions.

The Phenom had overflown Farnborough, a few miles south of Blackbushe, in contact with ­Farnborough ­approach control. When the pilot switched from ­Farnborough to Blackbushe radio, he kept the audio up on the Farnborough frequency, presumably to stay aware of local traffic. The cockpit voice recorder, which was recovered after the accident, recorded a number of aural announcements and warnings from various sources ­besides the two communications radios, including the airplane itself (e.g., four autopilot messages after the ­pilot disconnected the autopilot on the downwind leg), the TCAS and the TAWS, which was triggered by the high descent rate on final approach. The AAIB counted 36 aural inputs during the two minutes and 19 seconds preceding the turn to base, plus an additional 30, or almost one every two seconds, between then and when the jet crossed the runway threshold.

Not all aural inputs carried the same weight with the pilot, but they could certainly cause cognitive dissonance if, for example, when he was climbing to ensure clearance from the LSA, the TCAS recommended descending. A pilot’s instincts are one thing; a computer program’s algorithms are another. “It is possible in these circumstances,” the AAIB says, “that the pilot ... [was] fixated on ... [landing] and lacked the mental capacity to recognize that the approach had become unstable ...”

Accident analysts regularly struggle to invent locutions that create the impression of understanding. “Fixated” is right, but I think that “lacked the mental capacity” seems to imply that circumstances grew in complexity beyond the normal capacity of an ordinary pilot to process them. It would be more accurate to say that the pilot’s mental capacity shrank until obvious alternatives became invisible to him.

The pilot was in the grip of that strange phenomenon we call “fixation” and had lost the ability to change his mind.

Having overreacted, perhaps, to some traffic warnings, the pilot found himself too high and fast on the base leg. A calm assessment would have counseled a go-around, but for some reason — deference to his passengers, reluctance to admit an error, mistaken beliefs about what the airplane could do — he decided to continue the approach. That decision quickly became a commitment. He cannot have failed to perceive that he was crossing the threshold at a vastly excessive speed — a pilot senses high speed over the runway without even having to look at the airspeed indicator — and he knew that the runway was short and he was leaving more and more of it behind him. The AFISO saw the situation sufficiently clearly to alert the emergency vehicles. But the pilot was in the grip of that strange phenomenon we call “fixation” and had lost the ability to change his mind.

It is standard practice to go around if an approach is not stabilized at a certain height above, and distance from, the runway. The criteria being different for IFR and VFR approaches. The pilot was certainly familiar with the conventions of a stabilized approach and with his employer’s rules and practices. Some pilots, ­however, probably think themselves the best judges of when an approach can be unstabilized and still be safe. In perfect VFR weather, it is particularly tempting to improvise.

Is every pilot capable of straying into this kind of suicidal blunder? Or is this fate reserved for a headstrong few? If the Phenom pilot could read the report of his own accident today, he would perhaps roll his eyes in disbelief, as we do. Before he made his fatal mistake, he probably never dreamed that he could do such a thing. But he did.

Could you? Could I? With a little luck, and reasonable caution, we will never find out.