Lessons From the Crash

At a recent aircraft training course, the following material was presented by Steven Zaboji. Take a moment and read it through, it just might save a life namely yours. 
Reprinted with permission of Steven Zaboji and Aircraft Owners & Pilots Association.

There is no hope in aviation safety

By Steven B. Zaboji

The weather was terrible in the mid-Atlantic and the Northeast on the weekend of March 1, 2003. I was participating in my favorite biennial aviation event: the AOPA Air Safety Foundation’s Flight Instructor Refresher Clinic (FIRC). I remember the weather being so miserable that during the breaks, participants were calling their respective airlines to get the latest updates on flight delays or cancellations. For me, living only three miles from the Sheraton hotel where the FIRC was being held in Reston, Virginia, giving up a weekend under these weather conditions seemed almost fortunate in a serendipitous sort of way.

As a flight instructor who has an active day job, I always enjoy the FIRC experience as it immerses me in the world of flying for two solid days. I particularly enjoy the camaraderie among the 100 or so flight instructors, especially when it comes to anecdotal discussions as they relate to aviation safety issues. Little did we know that while we were discussing accidents and weather-related mishaps, the real world on the outside was a meteorological death trap for straying pilots?

The late winter weather, low IFR, and icing ensnared a number of pilots that weekend. One of the accidents occurred in Leesburg, Virginia, in nearby Loudoun County, where a Socata TBM 700 piloted by a prominent businessman and low-time owner pilot, along with a highly experienced co-pilot and an attorney passenger, succumbed to the perils of a low IFR approach.

News of the accident was especially fascinating to me, because as a former tenant and long-time user of Leesburg Executive Airport, I was aware of a number of low IFR approaches in recent years that ended in a fatality.

Given the sensationalist nature of the media, it was no surprise to see them pounce on the TBM 700 accident. Within the aviation community, the accident tugged at our collective heartstrings and conscience, as we once again needed to examine the compounds in that crucible known as a tragic, untimely, and unnecessary accident. Just what are the meteorological, mechanical, environmental, and emotional dynamics that dramatically destabilize a flight and overcome a pilot’s ability to survive?

Asking ‘why?’

This flight had every asset needed to complete its mission successfully. Yet in spite of a world-class turboprop aircraft equipped with state-of-the art avionics for guidance and situational awareness, a pilot with a Ph.D. level of education, and an insurance company-mandated qualified flight instructor pilot in the right seat, they lost it all. They lost the airplane, the pilot’s life, the co-pilot’s life, the passenger’s life, and the well being and stability of close and extended families. For everyone in the sphere of personal or business friendship, this accident represented a tragic and life-altering event. Even before the NTSB investigation began, the affected community’s chorus broke out in that old accident spiritual: “Why?”

Reconciling the “why factor” takes on a scope that involves safety interests, financial interests, engineering interests, legal interests, and even political interests among others; yet, as in most cases, the official NTSB conclusion was “pilot error,” and, although no one knows with absolute certainty what happened to the TBM 700, chances are more than likely that it was pilot error or maybe, more fairly, pilots’ error.

I don’t have a degree in aeronautical engineering, psychology, or any subject that could be considered relevant to this accident. But as a pilot, an occasional flight instructor, and a businessman with 46 years and more than 10,000 hours of flight experience, I don’t think I would be out of line in expressing a few thoughts about this tragic accident. But before I get into the subject of this calamity, I would like to share with you the reason that I felt compelled to write this article.

When I searched the Internet shortly after the accident, I stumbled across the Loudoun County Reader’s Forum, where one of the first postings read:

I Love You Dad (03/02/03 at 8:24 p.m.)

“This tragedy that has just occurred with my dad will never be explained. All I can keep thinking is why did it have to happen? There are so many emotions that I feel right now…denial, hurt, and frustration, to name a few. I had the best dad in the world, and something out of my control took him away from me. I feel like I am left with nothing. He was the one I looked up to, he inspired me, he gave me advice…he is half of who I am. It goes to show that you don’t know what you’ve got until it’s gone! I love you dad, you’ll be in my heart forever…I never thought I’d have to say these words so soon, but I know you’re shining down on me from heaven. Now I know who my true guardian angel is, I love you dad!!!”

This was written by teenager Emily Byrd. Her dad, an attorney, was the passenger on the ill-fated TBM 700. Her poignant message tore at my heart, because her tragic loss was totally avoidable. Her cry of “why?” needs answers loud enough so that perhaps others might hear, heed, and prevent another “pilot error tragedy” like hers.

For the official findings on this TBM 700 accident, you can go online and find the official report dated March 1, 2003. Rather than these details, I would like to discuss some factors that make up accidents. Perhaps when these are examined in the context of a tragedy such as the TBM 700 accident, we might—just might— change some of our emotional attitudes that portend in the process of any accident.

No room for hope

It has been said that every event in our lives is preceded by a process. A graduation is preceded by a process of study. A wedding is preceded by a process of courtship. A bankruptcy in business is preceded by a process of poor business judgments. You get the idea, and as a pilot, you also realize that a safe landing is an event that is preceded by a safe process of flight. Conversely, an accident is an event that is preceded by a process that departs a track of safety. The big question is, why do so many of us each year depart the track of safety? What tugs at us and makes us destabilize a flight, leading to utter destruction?

I would like to suggest that one of the major contributors to aviation accidents is hope. Our culture is one that continually markets hopefulness. Whether we are drawn to seek comfort in miracle medicines or wooed by the fortunes of Las Vegas or our state’s lottery, we default to hope and summarily dismiss logic and science. I am not arguing a fallacy in being hopeful, but what I am suggesting is that there is no room for hope in the cockpit of an airplane.

You might want to imprint the acronym HOPE on the logical part of your brain. In the context of aviation safety, HOPE might stand for Horrific Outcome Per Emotions. How many times have pilots gone to the performance charts when faced with a decision on takeoff performance in a high-density altitude environment? And how many times did the book say, “It won’t fly?” And how many of those pilots then turned to another page in the book listed under HOPE and found the performance figures on their virtual turbocharger? Aha! I think this takeoff will be okay! They default the takeoff to HOPE and away they go, all the way down the runway, until the next step in the HOPE process takes place and that is to pull up, and guess what? HOPE it’ll fly. By the grace of God most of us make it.

Why do airplanes run out of gas before reaching their destinations? Pilot error? Maybe. Pilot default to HOPE? Most likely. An airplane burns a certain number of gallons per hour, has a definite amount of fuel onboard, and travels just so many miles per hour. Winds add to or subtract from the airplane’s range. Oh, so many things to calculate and update, and besides, we would really like to avoid a stop for fuel and lose all that time that we are saving by flying this neat airplane. It looks like by calculations it’s going to be very, very close. Let’s see, maybe we can extend the range of the airplane by filling the extra virtual tank labeled HOPE! Yeah, that’s it; we are going to make it. And again, by the grace of God, most of us do.

If you want to become an accident statistic quickly, just mix your Hope Operating Manual and Procedures with weather. HOPE your way around a thunderstorm. HOPE your way below minimums on an instrument approach. HOPE your way through icing conditions. HOPE your way through the perils of VFR around obscured mountains. The NTSB files are full of HOPE-related accidents and most are labeled, “Pilot Error.”

But having said all that does not answer Emily Byrd’s question as to why her dad is no longer here for her. By now, the NTSB, FAA, insurance companies, and lawyers have probably worked through their respective post-crash processes, and for most of us, their findings are obscured by time. I am not, nor is anyone else for that matter, in a position to know exactly what happened on that fateful day in Leesburg, but from my perspective I think a number of HOPE components were involved.

The flight

As the TBM flight was moving along routinely toward Leesburg, the pilot certainly learned of the weather at Leesburg and understood that it was down to raw minimums if not actually below. A very simple and minimally inconvenient alternate would have been Dulles International Airport, a mere 9.2 nm away. This would be 20 minutes by car or about $30 by cab for an 11,500-foot runway, world-class lighting, ILS, and live controllers all the way to the tarmac. Having had a hangar at Leesburg, I know firsthand that getting in at your home airport is far more elegant than diverting to an alternate. I have been at that decision point many times when I flew into Leesburg, and I know what issues of completion, convenience, and machismo comes into play.

However, while it was perfectly legal to shoot the approach under the reported weather conditions, the ATP/ Flight Instructor rated co-pilot could have set an example of aeronautical humility by offering an example of using all available resources to complete the flight safely by choosing a rich alternate. Radar tracks confirmed the unstable approach, and I suspect that the crew resource management process was more under the guidance of HOPE than the truth of airspeed, altitude, attitude, and a sense of presence.

It is sometimes said that our strength can be our weakness, and conversely, our weakness can be our strength. In the case of the TBM 700 pilots, their strength was an aircraft equipped to handle IFR with tremendous technological assistance. But perhaps the false comfort of the high-tech features and a possible lack of technical proficiency detracted from the serious nature of their intended approach. Being wealthy enough to buy a sophisticated aircraft is a strength few enjoy; yet that strength can turn into a weakness when the aircraft can so easily get ahead of its pilot (as did John F. Kennedy Jr’s Piper Saratoga). Having the wealth to hire a co-pilot bodes well for perceived safety, but if the crew’s aggregate skill set is awkwardly galvanized, critical flight progress will be at the mercy of a fatally flawed HOPE guidance system.

Emotional responses

After 46 years of flying, I must confess that most of what I have learned has been at the cost of traversing the border of aeronautical science and a state of HOPE. As I review my close calls, clearly every incident involved leaning just a bit too far toward HOPE.

Do you remember the first time you went up on a three-meter diving board? I bet you did your homework by talking to friends who made the dive before you. Your desire and peer pressure advanced the idea of making the dive, thereby preparing you for a paradigm shift that would then include having jumped from a lofty diving board. Flying is a never-ending walk up the ladder to higher and higher diving boards, and for all of the Emily Byrds in the world, we need to be 100 percent sure that there is water in the pool.

I work in the consumer electronics industry where I have personally witnessed the digital revolution. Digital technology also lives in aircraft, and its capabilities have brought us unbelievable mechanical reliability, clarity in our radio transmissions, a keen sense of presence in our navigation, and a satellite view of weather that is rendered with stunning resolution. I believe today’s technology offers pilots an incredible amount of headroom for safety, but only if we don’t let emotions of HOPE get in the way.

Steven B Zaboji is an ATP, CFII, and MEI with more than 10,000 flight hours.

Reprinted with permission of Steven Zaboji and Aircraft Owners & Pilots Association.