In the Cockpit, Are Two Heads Better Than One?

Sometimes the multiplication of eyes and minds does not prevent fatal airplane accidents.

To hold the controls of an airplane is easy. To snatch them from another pilot, literally or figuratively, is one of the hardest things a pilot might have to do. [Credit: Adobe Stock]
To hold the controls of an airplane is easy. To snatch them from another pilot, literally or figuratively, is one of the hardest things a pilot might have to do. [Credit: Adobe Stock]
Gemini Sparkle

Key Takeaways:

  • Two general aviation accidents, one in Alaska and another in Oregon, were caused by pilots continuing visual flight rules (VFR) into instrument meteorological conditions (IMC) or attempting to land in dense ground fog.
  • Both accidents are notable because they involved multiple experienced, pilot-rated individuals on board, yet critical errors were not prevented.
  • The article suggests that the absence of a formal crew structure in these situations led to negative social dynamics, where pilot-passengers were reluctant to question the pilot in command (PIC), became overly passive, or the PIC felt pressure, ultimately undermining safety and good decision-making.
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The scattered wreckage of the 1948 A-model Bonanza was identified by comparing photos, taken from a circling Cessna, with ones of the formerly pristine polished-aluminum airplane. It had fallen and slid more than a mile after flying, under control and at cruising speed, into the sheer cliff that formed one face of a 12,000-foot mountain.

There it remained. The terrain was too hazardous to permit recovery of the wreckage.

This Article First Appeared in FLYING Magazine

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The pilot, 78, had been a colorful figure in his hometown of Haines, Alaska. He was a “true aviator,” according to a fellow pilot, “who possessed an ‘innate’ understanding of all aspects of flight from philosophical to mechanical,” and there were “very few, really a small few” other pilots with his level of knowledge of the area. His logbook recorded more than 28,000 hours, but he had evidently become tired of detailing every flight. The last entry was for 243 hours, ostensibly representing flights between Haines and Juneau, a distance of 75 miles, in 2022 and ’23. 

The purpose of the accident flight was to take a man and woman from Juneau to Yakutat, where they operated a flying service. Whether the woman passenger was pilot rated is unclear from the National Transportation Safety Board (NTSB) report on the accident, but the man, 53, held, like the Bonanza pilot, an ATP license. Both pilots were therefore instrument rated, highly experienced, and thoroughly familiar with the area of southeast Alaska over which they were flying. 

That part of Alaska, colloquially called the Panhandle, is a mountainous coastline dotted with hundreds of islands and riddled with channels and fjords. Airplanes are the only means of reaching places, other than very slowly. Yakutat is 210 miles from Juneau. Between them lies Glacier Bay National Park and a mountain range misleadingly called Fairweather, whose ridges generally rise to 5,000 or 6,000 feet above sea level. A single pyramidal peak, Mount Crillon, towers above the rest of the range.

On the day of the flight, the METAR report called for clouds and mountain obscuration. ADS-B data showed the Bonanza, which left Juneau in midafternoon, initially tracking northwestward toward Yakutat. After flying in that direction for 72 miles, it turned to a slightly south of westerly heading for another 30 miles, then turned due westerly, cruising at 141 knots at 10,875 feet. Presumably these course changes were made to circumnavigate clouds. But at some point they must have flown into cloud, because otherwise the Bonanza’s ADS-B track would not have abruptly ended at the east face of Mount Crillon.

Let us leave the demolished Bonanza for a moment and pan six months back and hundreds of miles to the southeast to Independence, Oregon, where a private pilot is returning from practicing instrument approaches in a 172 at McMinnville (KMMV), 25 miles distant. It’s not yet 5 o’clock, but it’s mid-December and the sun has set.

On the ground at McMinnville, the pilot, 35, received a call from his instructor telling him that fog had moved into Independence, ground visibility was 500 feet, and that he should not try to return. The pilot replied that he had ample fuel, so he would fly down and have a look. If he couldn’t land at Independence (7S5), he would use one of several nearby
alternates.

Approaching Independence from the north, the 172 flew a left downwind leg for Runway 34. A mile and a half past the threshold, it reversed course and then descended toward the runway. It crossed the extended centerline, passing 500 feet west of the threshold. Now flying parallel to the runway, it struck a power line tower at 69 feet agl, crashed inverted, and burned. All three occupants of the airplane died.

The men in the airplane were Afghan refugees, and all three had formerly been pilots in the Afghanistan air force. The pilot flying the 172 had logged 150 hours in the U.S., on top of 1,200 flying Cessna 208s in his native country. All three had instrument ratings, but, despite their considerable flying experience, they had to start again from scratch to earn American pilot certificates.

This accident and the one in Alaska were different in most ways, but the NTSB’s findings of probable cause were nearly identical: “The pilot’s decision to continue the visual flight rules flight into instrument meteorological conditions, which resulted…” in Alaska, in “controlled flight into terrain,” and in Oregon, in “collision with an obstacle while landing.”

That the Alaska pilot flew into instrument conditions is unproven, but it’s a safe assumption, because if he could have seen the mountain he certainly would not have flown into it. That there was fog at Independence was well established, but the quality of the problem it presented was different. The sky above was clear; the fog was on the ground. The pilot had triggered the landing lights, and so could probably see them and the nearby town lights quite clearly from above.

But ground fog is deceptive. From above it’s transparent, because you’re looking through a shallow layer. But when you descend into it, you’re looking obliquely through it, and it’s as opaque as any cloud. Most likely the pilot believed that he would be able to see the runway to land and only at the last moment lost forward visibility.

Apart from the obvious elements the NTSB identified, these accidents had something else in common. The pilots weren’t alone. In Alaska, at least two pilots, both highly experienced and
intimately familiar with the environment, were in the airplane. In Oregon, there were three pilots.

Why did the multiplication of eyes and minds not prevent the accidents?

The answer, I think, may have something to do with the absence of a formal crew structure. Members of a crew understand that one of their roles is to monitor and, if necessary, question the actions of their colleagues. In principle, at least, personal relations shouldn’t matter.

Without a crew structure, the presence of several pilots creates a social situation that can undermine rather than reinforce safety. The PIC may feel that they have something to prove. Conversely, the pilot may feel doubts about how to proceed but interpret the silence of the others as approval and encouragement.

Pilot-passengers may hesitate to offend the PIC by questioning their judgment or may be reluctant to appear anxious or unsophisticated. Or they may find their own discomfort alleviated by the apparent confidence of the other.

Or, in the simplest and perhaps the commonest case, they may feel so confident in the pilot flying that they simply subside into passivity. To hold the controls of an airplane is easy. To snatch them from another pilot, literally or figuratively, is one of the hardest things a pilot might have to do. 


This column first appeared in the February Issue 967 of the FLYING print edition.

Peter Garrison

Peter Garrison taught himself to use a slide rule and tin snips, built an airplane in his backyard, and flew it to Japan. He began contributing to FLYING in 1968, and he continues to share his columns, ""Technicalities"" and ""Aftermath,"" with FLYING readers.

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