Probable Cause #6: Experience Can Kill You

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A time-ridden cliché in aviation is, ''Learn from your mistakes so you don't make them again.'' Of course, if what you learn is that you can press on in a bad situation and survive, someday you might not.

This article originally appeared in Aviation Safety, February 2004.

Probable Cause

At various points in the careers of most pilots, there come times when the pilot attains mastery of the airplane and, therefore, mastery of the air. Sometimes those episodes are fleeting, beaten back into submission by some kind of learning experience that convinces the pilot that he has not seen it all or that she has not "been there, done that." Armed with a new humility, the pilot adds another notch to the pole of experience and soldiers on.

As the hours mount, that pole gets filled up, even as old experience helps keep away new quandaries. This is the value of experience. The pilot becomes armed with the ability to detect trouble spots before they become critical and to avoid them. That ounce of prevention, then, becomes far more valuable than a pound of cure.

There is, however, that minority of pilots for whom the lessons of experience backfire. Rather than allowing the pilot to breathe a sigh of relief and resolve never to push the envelope so far again, the successful resolution of a problem simply emboldens them to go further the next time. These are the kinds of pilots for whom risk management is a game to win rather than an exercise in improving safety. They manage risk by taking shortcuts rather than circumnavigating. All too often, those shortcuts take them past the point of no return.

A pilot who flew eight passengers from Tooele, Utah, to Mesquite, Nev., to do some skydiving found the shortcuts he planned fell far short of what he needed to complete the return flight.

Not VFR

The pilot called the Reno Flight Service Station at 3:26 p.m. and filed a VFR flight plan for the return home. He filed an airway route, defined by VOR stations, that would take 1 hour, 23 minutes in the King Air A90 he was flying. The pilot estimated a true airspeed of 214 knots and filed for an altitude of 13,500 feet.

After filing the flight plan, he requested a standard weather briefing. There was an AIRMET for moderate rime or mixed icing in the clouds. There was also an AIRMET for IFR conditions north of a line from the south edge of the Great Salt Lake due west to Lovelock, Nev.

"You can make an IFR approach, I presume?" the briefer asked.

"Yes, sir," the pilot replied.

"You need to," the briefer said, giving the pilot the current Salt Lake City weather, which was below VFR minimums.

The pilot departed Mesquite at about 4:15 p.m. There were no radio communications with the airplane, and the pilot never activated the flight plan. He did not follow the route of flight he filed, either. The radar track showed he flew direct from Mesquite to Tooele at altitudes that varied from 4,800 feet MSL to 15,400 feet.

The weekend manager of the Tooele Valley Airport and the husband of one of the passengers heard a twin turboprop pass over the airport and assumed it was the King Air returning. Radar data showed a VFR target assumed to be the accident flight passed directly over the airport at about 3,400 AGL and proceeded about five miles north of the airport.

A witness about three miles northeast of the airport heard the airplane fly overhead, outbound from the airport. He estimated the airplane was about a half mile west of his position, between pattern altitude and 500 feet AGL on the runway centerline course. The witness, an instrument-rated private pilot, described the weather conditions as indefinite ceiling, a quarter-mile visibility in haze and fog, snow and "almost dark."

The nearest official weather information came from Salt Lake City International Airport 35 miles northeast. At the time of the accident, the station reported visibility a half mile, light snow, mist, ceiling 500 feet broken, 900 feet overcast, and temperature and dewpoint both -1 degree C.

North of the airport, over the lake, the airplane began a descending left turn, losing 2,000 feet in 60 seconds, according to radar data. The airplane crashed into the lake at about 5:30 p.m. The water temperature was 20 degrees F. Everyone aboard perished from either the impact or the frigid water.

The wreckage was found in water five feet deep, about a half-mile offshore and 2.5 miles north of the airport on the extended runway centerline to Runway 17.

Smoking Guns

The airplane had been stripped to accommodate skydiving operations. The cabin seats had been removed and replaced by vinyl-covered cushions with seatbelts mounted to the seat tracks. There was no evidence the seatbelts had been used by anyone on board the airplane, including the pilot.

The instrument panel had been stripped, with the only avionics consisting of a single transceiver and a portable GPS unit. The airplane was neither approved nor equipped for IFR flight.

Two other skydivers who had flown with the pilot on previous trips reported separate instances in which the pilot approached VFR, descended when a hole presented itself, and then flew at low altitude the rest of the way using familiar landmarks.

Over the pilot's 15 years of flying, he had accumulated an ATP certificate and 5,150 hours total time, including 321 hours in the King Air. His logbook was recovered with the wreckage, and in it investigators found some telltale signs of the pilot's lack of familiarity with the rules.

His logbook recorded his most recent biennial flight review in a Boeing 737 simulator. But because he was not type-rated in the 737, the BFR was not valid under the regulations. The pilot had logged 1.2 hours of night flying in the previous 90 days, but he had not logged the number of landings, so his legal currency for night operations is unknown. He had not logged any instrument time in the previous six months, making him ineligible to fly IFR even if the airplane had been properly equipped.

Furthermore, the toxicology screening on the pilot revealed the presence of pseudoephedrine, phenylpropanolamine and ephedrine. Although all are found in over the counter medications and are not disqualifying for flight, they are also found in the herbal supplement ephedra, which is marketed as an energy booster but banned in several states due to health concerns.

Alone, none of the irregularities that showed up in the pilot's lifestyle or logbook is particularly damning. Mistakes happen. Paperwork is sometimes inaccurate. Good intentions sometimes go awry. And, yes, sometimes pilots land after dark when they're not night current. But taken together, these items paint a picture of a pilot who had learned a lot of lessons in his career, but not all of them were, shall we say, in the Aeronautical Information Manual.

Experience is a great teacher, but how you apply that experience influences whether the lessons you learn work to your advantage or merely provide you with new avenues to disaster.



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