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APRIL, 2003


We are coming close to the centennial of powered flight--100 years of successful escapes from gravity. Over the next year, as we approach the magical date--December 17, 2003--that marks the precise anniversary, you will no doubt read scores of uplifting and inspirational pieces celebrating the enormous personal and technical accomplishments that have marked our 100 year journey.

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.

The first powered aviation fatality followed quickly on the heels of the first flight. It was hardly surprising: the airplanes were unstable, the engines unreliable and the art unknown. Most of that changed dramatically: airplanes rapidly became stable and engines reliable. Measured against every other aviation accomplishment--space flight, wide bodies, mach speeds--the development of reliable and safe airplanes has to be seen as the single most important milestone of the first century.

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.

Some say judgement can't be improved. I'm proof they're wrong. Mine isn't the best, but it's better than when I started. Others acknowledge the possibility of change, but believe judgement only modifies as a consequence of unpleasant personal experience: "I learned about flying from that…" Then there is a third group that simply doesn't give the matter much thought at all.

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.

There is a lot to long-term survival in aviation–even with good training and good equipment, there is the undeniable element of luck. But beyond those three elements, consistent success means making the right decisions almost all the time, sometimes under unexpected and trying circumstances. So, hats off to the survivors--those aviators with more than a half century behind the controls. They have obviously been doing it right. Seen in the reflection of the light they cast, it is chilling to read accounts of some who haven't been as successful. Follow along with me and see if you don't agree; here's a instance where judgement failed:

After more than four hours of IFR flight, three of them on the last leg, a pilot attempted and then aborted a non-precision approach at his destination. After the missed, he elected to fly approximately 35 miles to an alternate that offered an ILS. There he made two approach attempts, both unsuccessful. Conditions were reported to be 300' overcast with reduced visibility. After the second miss, queried as to fuel status, he admitted to emergency conditions–perhaps only minutes of fuel remaining. ATC provided vectors to a third attempt, a surveillance approach, but the pilot was again unable to conclude successfully. He gave up, and enroute to a third airport ran out of gas and landed off field.

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.

So far, you have only a condensed description of the events; you have to read a lot between the lines to get glimpses of what the full picture might have been. Keep in mind, what follows is mostly speculation.

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 change–perhaps 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 second missed–the first at the alternate–and an incomprehensible decision: still nothing said about fuel. The pilot had apparently never gotten established on the localizer, and that fact had all his attention. So instead of confronting what had now become a raging fuel emergency, he concentrated instead on what had gone wrong and how to get back for a second try, where it appeared he was hopeful he could overcome whatever difficulties occurred the first time. Confidence may have transitioned into wishful thinking.

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 made–and 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 estimated–instead 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 error–not asking for more help from ATC sooner?

While we don't know anything about the pilot's instrument background, it would be genuinely foolish to assume that weak technical skills were the cause of the four missed approaches. A reported three hundred foot ceiling coupled with mist and low visibility can be enough to give problems to even seasoned pilots–success wasn't a sure thing. On the surveillance approach–the last attempt–where we are assured solid course and altitude guidance were provided by the controller, the pilot was unable to see the runway from 300' above and one mile short of the threshold, a position confirmed by ATC. The weather was poor.

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 weather–and that decision ended having teeth. His only certain guarantee of success would have been an early diversion–one 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.

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