Anyone who has passed through the U.S. gauntlet of pilot training lately to come out the other side with a certificate knows about the FAA’s emphasis on risk management. The topic is an underlying reason for the airman certification standards, it has its own FAA handbook (FAA-H-8083-2) and is woven into all aspects of our training and evaluation.
A principle of risk management is self-awareness. If we’re not honest about our fitness for a task or if we convince ourselves it’s okay to ignore obvious shortcomings, our self-awareness cannot be complete. There will be gaps—blind spots. Most of the time, the blind spots are of little impact, but they can and do interfere with our ability to realistically assess our risk exposure.
As part of its risk management training, FAA materials include a discussion of the hazardous attitudes it says affect the quality of our decisions. It adds that recognizing “hazardous thoughts is the first step toward neutralizing them.” Which raises a question: If I have little or no self-awareness, how can I recognize my own hazardous attitudes?
One thing we can do is review the FAA’s five hazardous attitudes, summarized in the table below, along with recommended solutions and antidotes. Let’s explore a textbook example of how hazardous attitudes are, well, hazardous.
Background
On November 3, 2022, at about 1009 Eastern time, a 1977 Beech A36 Bonanza was destroyed when it impacted a ravine short of the Runway 08 threshold at the Tucker-Guthrie Memorial Airport (I35) in Harlan, Kentucky. The solo instrument-rated private pilot (male, 56) was fatally injured.
The pilot was a physician and frequently flew into the accident airport to see patients. The airplane’s ADS-B data show it departing Knoxville, Tennessee, at 0932 and proceeding via what the NTSB said were user-defined waypoints to I35. Its ADS-B altitude data was unreliable throughout.
Beginning at about 0958, the airplane flew a series of apparent approaches and teardrop turns over and near the airport environment. At about 1005, the airplane flew over Runway 26 on a longer extended centerline before it made another left 180-degree teardrop turn to intercept an extended centerline course for Runway 08. This was its third and final approach to the airport. The last ADS-B data point, at 1009:54, showed the airplane about 0.1 nm from the Runway 08 threshold. The airplane impacted a ravine and steep rock wall about 50 feet below runway elevation and 375 feet before the threshold.
Investigation
A pilot-rated witness heard the accident airplane complete two approaches to Runway 08 but could not visually observe it due to the fog and low clouds. The first approach seemed to be high, and the second one sounded “really low.” The airplane’s engine noise was steady, with no power changes noticed. After the second pass, the noise faded out and the witness did not hear the accident airplane again.
All major portions of the airplane were located at the accident site. Flight control cable continuity was established from the elevator, rudder and elevator trim tabs to the fire-damaged forward cabin area. The left and right aileron control cables were traced from the forward cabin area to the outboard wing areas where they were separated in tensile overload.
A post-impact fire consumed a majority of the cockpit, fuselage and portions of the left wing. Due to the impact and fire damage, the position of the flaps, landing gear and fuel selector could not be determined.
The attitude indicator’s gyro and housing exhibited rotational scoring, indicating it was operating at impact. The vacuum pump was partially disassembled; its gears were intact and the unit appeared normal. No pre-impact mechanical malfunctions of the engine or airframe were found.
Review of the pilot’s electronic logbook revealed he did not meet the recent experience requirements for instrument flight on the day of the accident. In the three months before the accident, the pilot landed at I35 at least 15 times. Matching up commercially available flight track data for the accident airplane with Metar observations revealed the pilot routinely landed at I35 when the airport was reporting instrument conditions.
The NTSB found that the pilot routinely flew VFR to the accident airport and conducted circling maneuvers to land into IMC. According to the NTSB, “The approaches were likely conducted under VFR and into instrument meteorological conditions (IMC), given that the altitudes and flight track flown were not consistent with the published instrument approach procedure.”
For example, on September 27, 2022, the pilot flew to I35 and landed at 0950. Automated observations at I35 published nearest to the time of the landing recorded a broken ceiling at 100 feet agl and 10 sm of visibility. The flight track data show the flight completed a circling maneuver pattern similar to the accident flight but landed successfully.
The I35 airport has a published RNAV (GPS)-A approach procedure. The flight tracks varied, but multiple flights were not consistent with the GPS-A instrument approach procedure. The procedure’s circling minima allow for a minimum descent altitude 1356 feet above the field elevation. Weather observations around the time of the accident included visibility of less than ¼ sm and an overcast at 200 feet agl.
There was no record that the pilot received a weather briefing before the flight, nor did the pilot file an IFR flight plan.
Toxicology testing was positive for methamphetamine and phentermine, neither of which are allowed under FAA medical certification rules. A third substance, chlorpheniramine, is allowed but only after 60 hours have elapsed since a dosage. Insufficient samples were available to toxicologists to determine if any of the three substances were present in therapeutic levels.
Probable Cause
The NTSB determined the probable cause(s) of this accident to include: “The pilot’s visual flight rules flight into instrument meteorological conditions during an approach to land at an airport in mountainous terrain, which resulted in controlled flight into terrain. Contributing to the accident was the pilot’s hazardous anti-authority attitude.”
According to the NTSB, “The pilot’s repeated VFR flight into IMC, his decision to fly an approach that was not consistent with the instrument approach procedure published for the airport, and lack of instrument currency demonstrated an anti-authority hazardous attitude, in which he repeatedly disregarded regulations and demonstrated poor judgment. It is possible that the pilot’s decision to conduct the flight was in-part influenced by his scheduled appointments with his patients, which would have increased the external pressures to complete the approach to landing.”
There’s an old cliché that doctors flying Bonanzas are a danger to themselves and their passengers. It has a kernel of truth. This guy appears to have been a textbook case for both the anti-authority and invulnerability hazardous attitudes. The truth kernel? The cliché doesn’t apply only to Bonanzas and successful professionals, but also to the rest of us.
