I am friends with a few pilots who have been flying steadily more than half that time--theirs is, I feel, a very significant accomplishment. Significant in part, I am sorry to say, because I have a nagging perception they have beaten the odds.
But while the machines have become a proven factor, statistics indicate that flight, at least in light aircraft, has remained a risky proposition. Not as bad as the 1920s, certainly, but far worse than say, automobiles in the 90s. The problem? Flight training: instructors have had a hard time catching up. The sticking point? Judgment. Pilots regularly do stupid things that confound understanding.
Not you and I, of course, we're too smart. It's them.
A bit later in this piece, the subject of judgement will turn very serious.
Well, if you're a CFI, I hope you don't fall into any of those classes. If instructors abandon their efforts to teach judgement, flight training might as well grind to a complete stop. The truth is that judgement is the single most important element ever taught in flight training programs--technical skill and theoretical understanding fall in behind. The best instructors spend most of their time thinking about what their students don't yet understand, trying to imagine how it will become a problem. At its most successful, this approach actually equips students to anticipate and resolve situations before they ever become problems.
The FAA is bound and determined things like this will not happen: pilots are never supposed to have fuel problems in instrument conditions. To this end, the Feds have made the regulations for fuel reserves and alternate planning quite conservative. Nevertheless, here was a crash, with fuel management clearly the critical issue. Where there were problems with judgement, that's where the breakdown occurred.
Fuel exhaustion did not occur until after a 35 mile flight and three approach attempts at the alternate, suggesting the pilot may have carried the required minimum fuel at the time he arrived at the first airport of intended landing. On paper, then, he was legal, or close to it, at that point. And since the regulations do not attempt to control what pilots do after the first approach at the destination airport, there is no obvious violation of the FAR. The regs were accommodated.
However, the pilot must have been pretty close to the bottom of the tanks after that first missed--close enough, you would think, to have officially alerted ATC to his minimum fuel status. But perhaps at that moment fuel was just one more concern in a long list for a pilot dealing with fatigue, poor weather and an unexpected missed approach and diversion. It isn't difficult to imagine a line of thought predicated on a quick conclusion at the alternate: given less than fifteen minutes enroute and a successful approach, fuel would never become more than a mild concern,
Somewhere along the line, of course, the pilot's concerns about fuel had to changeperhaps sometime midway through the first approach at the alternate. Once he was into his last forty-five minutes of fuel, the pilot would have been hit by a do-or-die realization: it was either land soon or run out of gas in the clouds.
Then came the next missed, and still no declared emergency. By now, the tension in the cockpit would be a solid contributing factor to every decision madeand impending fuel exhaustion would soon become the number one priority. Somehow this urgency communicated to the controller, who asked about fuel status. The pilot acknowledged the emergency, stating he had virtually no time left.
At this point, it is difficult to know if there were any workable choices remaining. The plane carried a bit more fuel than the pilot estimatedinstead of running out immediately, it lasted through a third approach attempt and some portion of flight toward a second alternate. But whatever the exact quantity, it is clear the emergency was fully developed. And it also seems inevitable the pilot was aware of his status long before he made it known to ATC. He was at the bottom of his tanks by the end of the first attempt at the alternate, and if there was any help available, that had been the time to ask for it.
So was that the prime errornot asking for more help from ATC sooner?
WHAT WENT WRONG--COULD YOU DO BETTER?
So, when you get down to it, all we really know is that the pilot was involved in making approach attempts where the combination of his skills, the limitations of the nav aids and the weather conditions combined to prevent visual contact with the runway.
If it had been you, knowing all that you do now, where would you have broken out of this chain? Before the second attempt at the alternate, as suggested above? And gone where? It is likely that there would have been less than fifteen minutes fuel saved by that decision, hardly a reassuring quantity.
After the missed at the original destination? It is possible there was a better alternate choice than the one made, but that data is missing. Given what we have, that's second-guessing to no good effect.
So, what's left? What makes this accident so disturbing is that there is an inevitable quality to the unfolding events that makes it difficult to second-guess the pilot anywhere after the very first missed approach. Thus, the error was made earlier. This pilot should never have continued to the first airport of destination, knowing what he should have about his fuel and the reported weather. While it is true he didn't press his luck to the hairy edge, he did choose to arrive with minimum fuel in minimum weatherand that decision ended having teeth. His only certain guarantee of success would have been an early diversionone that made room for the possibility of failure all the way down the line--one made before the exits all closed.
Can judgement be learned? I found this accident very instructive--it's possible some of you out there did too.