Most “accident” reports should be labeled “lack of judgment” investigations

Like many of us, I spend a fair chunk of time reading accident reports; it’s something I’ve done for a long time. Even before I had my PPL, I was devouring hundreds of them. Of course back then, I knew that I wasn’t stupid enough to make the same mistakes as the unfortunate subjects of the AAIB [UK’s Air Accidents Investigation Branch, similar to the US’s NTSB] reports, I knew that it wouldn’t happen to me, I knew that I was better than that. I didn’t know that I was being an idiot. The innocence, ignorance and arrogance of youth, I guess.

This is about accident reports; it’s about pilots getting things wrong and, more importantly, it’s about the way that the rest of us learn from the mistakes of others, or rather–given the evidence–it’s about how we fail to learn from both our mistakes and from those of our peers. If you have ever lost a loved one in an aviation accident, you should probably stop reading this now. There’s every chance that what follows will upset you, and that’s not my intention.

I’m no longer a youth and I hope I’m no longer as ignorant as I once was, but it somehow took me far too long to reach the pretty bloody obvious conclusion that we’re all more than capable of making mistakes, and that being convinced that “It’ll never happen to me” makes screwing up more, rather than less likely.

It’s obvious to me, and presumably to everyone else, that pilots are the cause of most aircraft accidents, but what seems to be less obvious to some is that we–and yes, that includes you and me–are those pilots. And what’s more, I don’t think calling them accidents is doing us any favours, but more of that later. I want to look at a couple of examples.

Cameras & aeroplanes

Back in October 2010, a 28-year-old man by the name of Sipan Osman was flying a Robin 2160 in the skies over East Yorkshire. According to the AAIB report, which was based on an accident report submitted by the pilot himself, Osman flew some aerobatics at 2,500 ft before carrying out a practice forced landing. During the climbout from the PFL, the engine began to run rough and failed. During the real forced landing that followed, Osman reported that his options were limited because he was so low, but that at the same time he was too high for his chosen field. Consequently he planned to land in another that was on the other side of the River Derwent.

The aircraft made neither the first nor second field, and subsequently ditched in the river with Osman and his passenger able to vacate the aircraft and reach the bank uninjured. A friend of Osman’s, fortuitously filming the aerobatics from the riverside, was on hand to help with the rescue. Serendipity? I think not.

During the investigation, the AAIB were made aware that the same aircraft, flown by the same pilot, had previously been seen making low passes at the same place along the same river while someone on the bank took photographs. The AAIB report concluded, “The accident area, being generally flat and agricultural, would appear to offer much better alternatives for a forced landing than the River Derwent. The pilot described being forced to overshoot his intended field in favour of the next field, beyond the river. There would presumably have needed to be some positive manoeuvring in order to align the aircraft’s track with the river, which would appear inconsistent with being unable to reach the field immediately beyond.”

You could read between those lines even if you were blindfolded in the dark. Mixing cameras and aeroplanes often increases risk factors, and perhaps influenced by the presence of a camera, one of Osman’s low passes was just that bit too low and the inevitable happened. Luckily for him, on this occasion only the aircraft suffered any damage.

It’s too easy to put this crash into the “it’ll never happen to me” category, but even if you know that you’ll never do anything as plain dumb as Osman there are plenty of smaller lapses of judgment, with similar or worse consequences, that we’re ALL capable of making. We ignore those lessons at our peril, but that doesn’t seem to stop us.

I was going to try to make my point by asking if anyone wanted to bet their house that another pilot wouldn’t run into the water while low flying ever again, but earlier this year the body of David Riggs, a US pilot with a history of maverick stunts, certificate suspensions and an aviation-related prison term, was pulled out of a lake in China. Riggs had been trying to water-ski a Lancair 320 on the lake in bad weather when he crashed. Killing yourself by doing something dumb is one thing, but when Riggs crashed, his 18-year-old Chinese translator was also killed. Accident or murder?

Riggs and Osman were unbelievably stupid, but if we think we’ve got nothing to learn from them, we’re plain dumb too.

In the 12 months that followed his Derwent ditching, Osman added another 70 hours of flying experience to his logbook bringing his total hours up to about 340. Not hugely experienced, but no novice either. A year after his water-skiing incident, Osman flew to Neuchâtel in Switzerland in a rented PA28-140. It was a flight he’d made once before earlier that year, but this time, the return flight, which had been due to take place on 10 October, was delayed due to bad weather.

Osman’s wife, who was to have flown back with him, returned to the UK on a scheduled flight.

Four days later, on 14 October, Osman was at Neuchâtel preparing for the return flight with a non-pilot friend who’d decided earlier in the morning to accompany him. Just after 10:35 the pair took off for Amiens in France where Osman had planned a fuel stop. The conditions at the airport and along the lake were good, and he flew the PA28 along the shore of Lake Neuchâtel for about ten miles before turning inland where the ground rose and the peaks were covered in cloud. During this time Osman was in contact with Geneva Flight Information Centre and 20 minutes after takeoff the controller heard Osman interrupt a transmission from another aircraft with the words, “…out of the clouds, of, Heu.”

The controller called Osman, who replied: “…I’m just in clouds, cannot see anything.” Twenty-three seconds later, and just over 20 minutes after taking off, Osman’s PA28 disappeared from radar. Five-and-a-half-hours later, the wreckage was found along with Osman and his friend, both dead.

It seems the aircraft had first hit trees about 6 to 8m above the ground with a rate of descent of at least 2,000 fpm. It was nose down and banking at about 45° to the left, the engine screaming at 3,200 rpm. Witness marks on the ASI suggest the PA28 was travelling at 188 mph; the wreckage trail extended for 60m, with the seats and both dead bodies ending up 35 metres ahead of the initial impact point.

Hillsides & bad weather

The remarkably thorough Swiss accident report combines very matter-of-fact reporting with a chilling paragraph containing the final analysis:

The last seconds of flight probably unfolded as follows: the pilot flew into cloud; he tried to avoid it by making a tight left turn. Deprived of any external visual reference, the considerable load factor encouraged him to release pressure on the elevator controls and the aircraft assumed a nosedive attitude. The spiral dive began. The pilot ceased to perceive that he was turning but observed a significant loss of altitude on the altimeter. To combat this, he was tempted to pull on the stick and increase engine power. The airspeed and the turn radius increased until impact with the ground occurred.

It’s true that there were issues found with the aircraft—the ARC had expired by 44 days, there was a discrepancy over a 150-hour check, some of the records relating to an overhauled engine were incomplete, there was corrosion found in parts of the engine and the surviving spark plugs weren’t exactly factory-fresh. In short, the report doesn’t paint a pretty picture and it is easy to imagine a very tired (the airframe had amassed 14,614 hours) rental PA28, but none of this caused the accident. That was a result of the pilot’s decision to mix VFR, IMC and mountains, a combination that rarely has a happy outcome.

Another crash that we can put in the “it’ll never happen to me” category? It’s tempting, particularly if you knew about Osman’s water-skiing before reading the Swiss report, but the crash that killed Osman and his passenger isn’t rare. There are too many examples of UK pilots killing themselves along with their families and friends, by flying into European mountains.

Are you reading this and enjoying the comfort of thinking that it could never happen to you? I can see how that’s tempting (been there, done that), but while Osman was a VFR-only pilot in an old aeroplane, in mountains, in bad weather, there have been two recent accidents involving British pilots flying into hillsides in bad weather. Except in these cases the pilots were instrument rated and flying well-maintained, well-equipped, privately-owned, twin-engined aircraft.

One of these took place in the south of France and killed a well-respected and popular couple when they flew their Twin Comanche into rising ground. There has been, and continues to be, some discussion over the role that ATC played in the accident; the UK representative added an appendix detailing the ATC action that may have led to a misunderstanding. That, however, was dismissed and the BEA [French version of the NTSB] report concluded that, “The accident was due to the pilot’s decision to continue the flight under VFR in instrument meteorological conditions and at an altitude that was lower than the high ground in the region.”

The other accident, for which the report has not yet been published, took place in Italy where an apparently intact Beech Baron flew into terrain in fog.

To dismiss these or Osman’s crash would, I think, be to miss an opportunity. I hope none of us would really think that teaching yourself water-skiing or playing hide-and-seek in the mountains is a good idea, but the pilots’ decisions that lead to the deaths were almost certainly smaller and far more subtle in isolation.

There’s always an opportunity to look, learn, think, consider and work out how we might screw up, and more importantly what we can do to avoid it. While it’s always reassuring to think that some kind of malfunction or system failure caused an accident, the unavoidable truth is that it’s almost always me, you and our peers who get it wrong, and, when we do, it’s almost always a lack of judgment rather than skill that does it. Perhaps we’d think differently if every month we read lack of judgment reports rather than accident reports.

Mostly we get away with it, occasionally we pay dearly for our mistakes. Those we leave behind get to pick up the pieces and to read our “lack of judgment” reports. The wise look hard for the learning points, while those burdened with the ignorance and arrogance of youth, regardless of age, are happy in the sure and certain knowledge that it’ll never happen to them.

Read the full accident reports: