The Accident Chain: The Insidious Gamble

How can people be so stupid? I sometimes wonder, when hearing of flying accidents. There were so many things wrong with that flight, it's a wonder they got as far as they did. I recently got a glimpse at how such things can happen. Fortunately, the final links in the chain didn't occur, and the flight was "uneventful" but it got me thinking alot about the psychology and peer pressure that can occur in a cockpit. First I'll describe the events, then I'll provide a few thoughts at the end.

Free Ride

A friend of mine, David (one of the 300 or so that we have at the flying club), a pilot, is interested in getting a plane. He contacted the nearest Mooney representative in Massachusetts, and they agreed to fly a new Mooney Encore down to Ithaca so he could test fly it. He told me, if I wanted a free ride, there'd be an extra seat in the back. Having never seen a turbocharged plane before, let alone a brand new $350,000 one, I quickly agreed.

The plane arrived in Ithaca just before 10am; aboard were the salesman and a pilot named Bob. The salesman was, of course, very positive about the plane. Bob was too, but he seemed to have a sort of attitude. When David asked about draining fuel, since the tanks have anti-siphon devices, Bob dismissed the concept. When David asked about the flow-rate on the cockpit fuel drain control, Bob said that it would be very bad planning on the pilot's part if he were going to fly over gross max weight (ignoring the fact that it's common to top the tanks after you fly, before you know who will be on your next flight)). He later admitted to have flown the plane "dozens of times" over max gross weight and said the plane's performance was good, even outside the performance envelope.

Eventually, having been shown all the features of the planes, they were going to go out for the demonstration flight. David would be in the left seat, Bob in the right, and myself in the back.

Kick the Tires, and Light the Fires

While we had looked at the plane, we hadn't performed a preflight inspection on it. They checked the oil upon arrival, and that was about it. David asked Bob about the checklist. I could almost envision a Mexican Bandito sitting in the right seat of the plane saying, "Checklists? We ain't got no checklists! We don't need no checklists! I don't have to show you any stinking checklists!"

In reality, Bob said that they didn't use checklists, and that it's the same as the M20J that we had at the club. Starting the engine would be the same, only that any changes to the power controls should be very smooth (they had vernier knobs, allowing for very fine adjustments). The plane started very easily. Bob then showed some of the features of the IFR GPS unit, and how easy it is to program in a flight plan. In addition, the unit can provide all of the necessary frequencies.

Bob dialed up the ATIS frequency to get the weather. <CLICK>...ormation Romeo<CLICK> Having heard the designator for that hour's weather ("R" as in "Romeo") he turned it off and didn't bother listening to the rest of it. He could call the tower and report that he had "information Romeo" but hadn't bothered to get the wind, altimeter setting, nor any of the other information that could be on the ATIS. He calls and receives a clearance to taxi and we proceed.

At the end of the runway, Bob tells David that the most important thing to check is that the controls are free and correct. We do the engine run up, and are ready to take off.

Outside the Cockpit

The weather at Ithaca was a marginal VFR day. They were calling it 7000 scattered and hazy, but the ragged clouds were closer to 3000' with probably between 3 and 5 miles visibility. We took off and climbed out to about 2500 and departed the traffic pattern to the north.

David asked if that's as high as we'd go. Bob said, "Oh, I think it's just the visibility" and set the altitude preselect on the flight director to 12,500'. As we started climbing, he set the radio to Elmira and called them up, reporting that we had just departed Ithaca, were at 3500, climbing to 12,500' and wanted a squawk code. After a few read-backs, we finally got the code and we continued the climb. Bob made some comment about how ATC should get better radio equipment.

At this point, we were around 5 or 6 thousand feet, and from the back seat, it's pretty obvious to me that we're in solid IMC. Bob asks David if he's a VFR pilot, and he says that he is instrument rated. We break out somewhere around 8 or 9 thousand feet, and to the north, the clouds become broken and we can maintain ground contact from 12,500'. Elmira tells us that we are leaving their airspace, to squawk VFR, and frequency change approved. And then adds that they never had radar contact with us. Bob tells us that the transponder probably wasn't working, as it's had problems.

The Return

The air tank in the plane was not filled, so we are unable to go up to the flight levels (or above 12,500'). After doing various maneuvers, using the speed brakes, and IFR GPS, we head back to Ithaca. This time David makes sure that the descent will keep us clear of clouds. Bob suggests descending to 2,500'. David keeps us a little higher, and mentions the fact that there are towers in the area (to the west of us, between Syracuse and Ithaca is a tower that's 1000' tall, and there are various 300' tall towers all over the area). We make it in and do two touch-and-gos and one full-stop landing back at Ithaca without incident.

The Summary

Any pilot who read the above sections should be appalled and think things like: What in the hell were they doing? How could responsible pilots, one a professional, and the other two instrument rated, allow themselves to do such things? They're damn lucky they didn't wind up as an NTSB accident report! While we're casting aspersions, why don't we quote some of the FARs (Federal Aviation Regulations) that were violated (all in Title 14 CFR, Part 91):

In non-technical terms, there were a LOT of problems. The worst offense was flying in the clouds without a clearance from Air Traffic Control. Coupled with that was the fact that the inoperative transponder rendered us invisible to Elmira's radar, which means they can't direct planes to avoid us. In addition, any collision avoidance devices on airliners would be useless, since they rely on the transponders in the other planes. But it went beyond that. There was, in general, very little regard for the regulations and things were played in a very loose and fast manner and in marginal VFR weather. The question is why, or perhaps how did it happen?

What Went Wrong

It's too easy to just cast blame at someone and not address the real issues. All of us fell prey to a form of peer pressure involving a fear of action, coupled with a form of get-home-itis. Let's start from the backseat and work our way up.

It's easy to sit back, as a passenger, and assume the people in front are "in charge" and therefore "must know what they are doing." We do it every time we fly in an airliner. However, as an instrument- rated pilot, plugged into the intercom, able to hear the pilots and talk to them, as well as see what is going on, I can not hide behind ignorance. Certainly the ultimate authority and responsibility for the safety of the flight rests with the PIC (pilot-in-command), however that does not mean you must stay silent if you don't like something. Airliners teach CRM (cockpit/crew resource management, also heard other explanations of the acronym), that encourage input from other crew members in the cockpit. The captain has the final say, but that doesn't mean he's always right. The worst they can do is say "shut up" and if there is a safety concern, it's hardly a risk.

It's an incredibly awkward situation to be in the left seat of a plane, acting as the "sole manipulator of the controls" (which allows you to log the time as PIC), but are not acting as the Pilot In Command. Students and instructors face this situation every time they fly, but the parameters of the situation are known ahead of time. In this case, David is flying someone else's brand new $350,000 plane. He's familiar with the basic model, but not that particular type (hasn't flown with a turbocharged engine before). He knows he's not the expert here, and in addition, in the right seat is a pilot who has logged countless hours in this make and model of plane, including flying with the test pilots during its development. It's an extremely intimidating situation to be in, even for David who normally is not easily intimidated. And to top it off, the right-seat pilot is going to be heavily promoting the plane, which has the reputation of being fast and sports-car like. Do you dare question him, possibly show your own inexperience, or inability to handle such a thing? It's a ridiculous question, but nevertheless, it's in the back of your mind in such a situation.

When a relatively inexperienced pilot flies as PIC with an experienced pilot in the right seat, you get a similar situation, where the left seat pilot might defer to the right seat's judgement, even though the non-PIC does not realize he is "in control" and in essence is deferring to what he thinks is the judgement of the PIC. The solution is the same for both situations in the left-seat: you must take the initiative of PIC and refuse to do something that you don't like, whether it be something that violates an FAR, or something you don't feel comfortable doing like flying in marginal weather that are close to your personal minimums.

Finally, there was the right-seat pilot. He found out the night before that he had to take this plane, first thing in the morning, to Ithaca. The O2 tank wasn't recharged, which precludes any high altitude flying, and the transponder was having problems, which doesn't render the plane unairworthy, and in fact ATC will grant waivers if a transponder is not working. There's over 1/3 of a million dollars on the line here, as far as the sale goes. Do you want to tell your customer that your solid, reliable transportation that you're trying to sell him isn't up to snuff and can't handle these conditions? Again, it's a matter of perspective. Most pilots respect safety, and if told the chief demo pilot felt that the weather conditions prevented him from being able to conduct the demonstration flight safely, I think most would understand. David told me that had they said they'd have to reschedule, or that they would want him to come to them, so be it. The $300 of travel money is not terribly significant if you're looking to spend 1000 times as much money.

Lesson Learned

So the wrap up: I think we all got some insight as to how a situation can get out of hand. It's very easy to go with the flow and avoid making waves or decisions that might be unpopular. It is vital, however, to make such decisions and take control of the situation. The description of the flight sounds like a typical NTSB accident report: no weather briefing, no checklist, no flight plan, no clearance, in the clouds in an unfamiliar plane. It was an accident chain waiting to happen. And fortunately, no other links were added to complete it...this time. But had we, any of us in the plane, acted in a way to change the way things were headed, we could have the satisfaction of knowing we made a safe choice, instead of now, reflecting on how lucky we were that there were enough things in our favor that the gamble worked, for no other reason than dumb luck...this time.

However, I think we all learned enough to make sure this situation won't arise again, next time.

Written on August 17th, 1998.