The Human Factor: The Slippery Slope

(February 2012) At first glance the NTSB report seemed like a typical "non-instrument-rated pilot takes off into IMC conditions" accident. The pilot had accumulated close to 400 hours during the five years since he had earned his private pilot certificate, mostly in the accident airplane. He was eager to depart on a trip that he had been planning for six months, but the weather would not cooperate. Two days in a row the pilot had not been able to depart due to low stratus clouds that blanketed the New Jersey area. Finally, on the third day after his planned date of departure, the forecast held a glimmer of hope. Low stratus clouds still prevailed throughout the area, and the 300-foot overcast ceiling was below the published minimums for an instrument approach into the airport, but conditions were forecast to gradually improve later in the day.

The pilot was not alone in his desire to depart. The NTSB report states that several other pilots, including some who were instrument-rated, were either in the airport office or elsewhere on the airport waiting for the conditions to improve so they could depart. Shortly after 10 a.m., witnesses observed the pilot and his passenger fueling his airplane. At that point there was still a solid overcast at 200 to 300 feet, with no holes and no evidence of the sun starting to break through the overcast. Everyone assumed the pilot would return the airplane to the hangar after it had been fueled. However, a few minutes later the witnesses saw the airplane take off and quickly climb into the overcast. People in the maintenance hangar with a radio tuned to the local approach control frequency heard the pilot request traffic advisories from the controller.

For close to 10 minutes, people on or near the airport heard and occasionally saw the airplane flying in the vicinity of the airport, and reported that it sounded like the airplane was continually changing speed and direction. One individual who lived close to the airport was questioning the judgment of a pilot who would do aerobatics in the clouds, and he then sent his daughter into their house for safety when he observed the airplane fly over their neighbor’s house at a very low altitude. Eventually people in the area heard a loud thump and ran toward the sound to find the airplane wreckage and two bodies in the woods behind their homes.

Typically that is all we learn about an accident, but in this case, both the pilot’s wife and son had flown with him on multiple occasions. His wife told the NTSB that her husband “would only fly in the clouds if he could get out of the clouds immediately.” She said he “sometimes flew through clouds that were 1,000 to 2,000 feet thick” but that “he never kept me in the clouds for more than two minutes.” She also stated that the autopilot was functional, but that he rarely used it, and that he would hand-fly the airplane through the clouds. She also said she was “confused why he would have trouble in the clouds.”

I realized that this accident provides an amazing insight into the progression that is likely typical for many accidents that result from pilots breaking the rules and/or flying beyond their abilities. Perhaps his first experience of flying through a cloud layer was during one of his flying lessons, with his instructor providing an unfortunate example of how to not let a few clouds keep him from accomplishing the flight. Or maybe it happened later as a licensed private pilot, when he was ready to take off, but there was a thin layer of clouds between the ground and the blue sky above, and the pilot easily popped through the cloud layer.

On a subsequent flight the pilot was faced with a little bit thicker cloud layer, with no holes that clearly showed the thickness of the layer. However, since he was able to handle the previous situation with no problem, he went ahead and flew through this slightly thicker cloud layer. Step by step he progressed down this slippery slope until he was taking off when he knew he would have to fly for several minutes through thousands of feet of clouds, and would even request flight following from ATC to try to avoid colliding with an airplane on an instrument clearance. He also managed to convince his wife that this was perfectly safe.

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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