Thursday, December 24, 2015

"This Could Never Happen To Me"

Owing to their common depiction in popular media as roguish rule-breakers, the culture of safety that pervades the pilot community often comes as a surprise to non-aviators. A portion of that culture is the frequent review of aviation accidents. We do this not because it is fun reading (no rubbernecking or schadenfreude going on here), but to gain insight into what went wrong in an ongoing effort to learn and become safer pilots.

Blogger and professional pilot Ron Rapp recently posted a thoughtful discussion on pilot error focusing on a 2014 Gulfstream IV crash in Bedford, MA (see Ron's excellent post here: "Bedford and the Normalization of Deviance"). A point that Ron makes in his article is that, sometimes, the errors committed are obvious, even bordering on the egregious. The trap for any pilot reading such an accident report is to decide that they know better and dismiss the event as something that would never happen to them. Ron's point is that this is dangerous thinking because these things do happen to well-trained, intelligent pilots.

I confess that I have had these dismissive thoughts when reading accident reports, particularly when I was a less experienced pilot still in my first year of aircraft ownership. Then this happened:

NTSB Identification: CHI05CA144
14 CFR Part 91: General Aviation
Accident occurred Thursday, June 16, 2005 in Marcelles [sic], MI
Probable Cause Approval Date: 09/13/2005
Aircraft: Cessna 150M, registration: N9327U
Injuries: 1 Serious, 1 Uninjured. 
The airplane sustained substantial damage during a forced landing to a field after a loss of engine power. The certified flight instructor (CFI) reported that they had been flying for about one hour. The airplane was in cruise flight at 3,000 feet above mean sea level with the student pilot at the controls when the engine sputtered and quit. The CFI reported that he took control of the airplane and determined that the airplane was out of fuel. He executed a forced landing to a field. The inspection of the airplane revealed that the left fuel tank had about one gallon of fuel and the right tank was empty. The student pilot reported that he had conducted the preflight and walk-around of the airplane. The student pilot noticed that the airplane was low on fuel but failed to inform the CFI that the airplane needed fuel before takeoff.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
  • The total loss of engine power due to fuel exhaustion as a result of the CFI's inadequate supervision and inadequate planning/decision. The student pilot's inadequate preflight planning was a contributing factor.

Friends and long time readers might recognize the registration number of the accident aircraft. It was Two Seven Uniform, the 1976 Cessna 150-M in which I trained, soloed, and flew during my private pilot check ride.

Photo by Scott, June 29, 2003

They ran her out of gas over a field in Marcellus, MI and broke her back in the ensuing hard landing. Most important to this discussion, however, is that this happened to Bill, the instructor who taught me to fly. The airplane was the only true casualty of the accident, though it is my understanding that Bill never instructed again.

I was utterly baffled and unnerved by the accident. Bill drilled into me that I must always visually verify the fuel level in the tanks before launching. How could this happen to him? The answer is a simple one: complacency is insidious. It was a valuable realization to make as a young aviator.

Bill, Two Seven Uniform, and Me, September 23, 2002. Photo by John.

Since then, when I read accident reports and my inner smart ass pipes up with a disparaging opinion about the accident pilot's aeronautical prowess, I realize that I know better. Was the pilot inadequately trained or stupid? Not usually. If a fuel exhaustion accident could happen to Bill, who so successfully ingrained in me the pre-flight habit of visually checking the tanks every time, then it could happen to anyone under the right circumstances. Complacency creeps in through many vectors. Was Bill running late that day? Hurrying? Was he hungry or tired? Did the routine of so many instructional flights in the same aircraft, perhaps in the same day, lead to a loosening of standards? 

An important part of aviation safety is learning from the mistakes of others. But no learning happens when we fail to take the lessons seriously. There is no room for a "this could never happen to me" attitude. Bill taught me many things as he molded me into a certificated private pilot. This lesson, imparted two years after I completed my training with him, was by far his most important. Even with that valuable lesson well-taken, I still had a bout with complacency that grabbed my attention in 2009.

Complacency is insidious, particularly for those who believe that it can't happen to them.


  1. Chris,
    Great post. As we build hours we feel more secure in our procedures but can never get complacent. My CFI (Bill) always used real world events as a teaching moment, I still hear his voice in my head when I fly.

    I still perk up every time I hear 46Charlie on the radio. This was my PPL aircraft and holds many fond memories. I guess they are like our first car, we never forget them.

    1. Thanks, Gary. Merry Christmas to you and Mary!

  2. Nice post. Chris. When it's someone we know, it's jarring. In recent years, I have known three pilots who have had serious accidents: a gear up, a fuel exhaustion due to not switching tanks, and a fatal crash.

    When I started to learning to fly, I thought it was pretty darn morbid to read accident reports. Then I understood that it was a way to fill my bucket of wisdom and experience without taking anything out of my bucket of luck. This only works if we keep our inner smart asses in line.

    I also read Ron's excellent analysis, which got me thinking of my own slow creep. For example, I would forget to backup my startup flow with the checklist... And took off twice without flipping on the alternator switch. It is so easy to let these initially small lapses become the standard, and to allow further creep.

    1. Excellent comments. I think the best way to stop further creep is to shine a spotlight on it and to consciously determine that it's not OK. Being human, it happens to all of us. The best we can do is realize it and be vigilant rather than ignoring or shrugging off those small lapses.