Probable Cause #62: Lucky, Or Good?

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By Joseph E. Burnside | August 4, 2008

This article originally appeared in Aviation Safety, June 2006.

Probable Cause

There's something about the typical experienced-pilot's personality that is antithetical to safety. I'm not an expert in analyzing personalities -- though I know what I like -- but it seems the very traits that make someone a "good stick" also make that same skilled pilot a safety risk. Maybe it's the so-called "God complex" often attributed to surgeons who have risen to the top of their specialty. Maybe it's a blasé sense that, having seen and done everything in an airplane that's possible to do, nothing "bad" can happen. Maybe it's just an overdeveloped confidence in one's ability, the basic elements of which are almost mandatory for a pilot to possess. Maybe it's just luck. Regardless, too often the very self-reliance on which pilots can depend is also the trait that gets us into trouble. Those whose role it is to analyze aviation accidents and how psychology and human behaviors contribute to them sometimes boil all this down to "overconfidence." In turn, overconfidence can result from facing the same challenges before and emerging unscathed. Once the first corner is cut, pilots are truly on a slippery slope, unable to stop the slide to whatever fate awaits them. Over a period of time -- whether counted in years or flight hours -- overconfidence can breed contempt for rules, inevitably leading one to bend or break them. After surviving a few bent-rule flights, the idea that they don't really apply to you -- because you're so good, of course -- becomes the new norm. But what if all that skill and derring-do you believe got you through the earlier close calls was really just a dollop of luck? What happens when your luck bucket runs dry? Are you really that good, or just that lucky? There's no way to know how much luck we've been graced in our aviation careers. One thing's for sure: If we depend on it to complete flights, sooner or later our luck will run out. In the meantime, we can always draw on skill and judgment. On which would you rather depend?

Background

Beech King Air 200

On June 13, 2004, at about 0830 Eastern Time, a Beech Model 200 Super King Air was destroyed when it impacted Big Mountain, near Rupert, W.Va. The Airline Transport pilot and Commercial co-pilot were fatally injured. Instrument conditions prevailed near the accident site. The flight departed the Summersville (W.Va.) Airport (SXL) at about 0815, destined for the Greenbrier Valley Airport (LWB) in Lewisburg, W.Va., a great-circle distance of 31.6 nm. The flight's purpose was to position the aircraft to meet passengers for a Part 135 on-demand charter flight from LWB to Charlotte, N.C. An instrument flight plan was filed for the short flight, which was flown under Part 91, and an IFR reservation had been obtained for the arrival at LWB. This was necessary due to the FAA establishing a Special Traffic Management Program in conjunction with a large event at a nearby resort. The flight plan was never activated and no radar data was recorded for the accident flight. Instead, the crew was scud running its way to LWB, probably to avoid the lengthy process of obtaining an IFR clearance, climbing to a minimum IFR en route altitude and flying the approach procedure. Both crew members were experienced. The pilot-in-command had 10,400 hours, with 1500 hours in the same make and model and 2700 hours were in IMC. The co-pilot had accumulated 2910 hours, with 400 in the King Air 200; he had 175 hours in IMC. Lewisburg's field elevation is 2302 feet msl. The airport's reported weather, at 0822, included a ceiling at 2000 feet, placing the overcast at 4302 feet msl. At 0838, LWB's ceiling was at 1800 feet agl, placing the cloud bases at 4102 feet msl.

Investigation

Sectional Chart Excerpt - Vicinity of Accident Site

The King Air's wreckage was found at an elevation of about 3475 feet msl. A debris path extended about 500 feet, beginning with tree tops all sheared off at the same height, about 60 feet above ground. All major components of the airplane were accounted for at the scene and the wreckage was unremarkable. Research into the King Air's operator uncovered three previous "events," two of which involved Cessna 310s and resulted in fatalities. In the third, the NTSB found the accident King Air had been repaired for "... some damage when it contacted a tree while in flight ..." apparently while it was being flown by the accident pilot. The NTSB's report on this accident notes that the FAA inspector overseeing this Part 135 operation was aware of these prior events. However, the inspector failed to initiate any enforcement actions since, according to the NTSB, "... all of the accidents occurred under ... Part 91," and not when operating under Part 135. Regardless, a few months after this accident, the FAA suspended the operator's Part 135 certificate.

Probable Cause

The National Transportation Safety Board determined the probable cause of this accident as, "The pilot-in-command's improper decision to continue VFR flight into IMC conditions, which resulted in controlled flight into terrain. Factors were the FAA Principal Operations Inspector's inadequate surveillance of the operator, and a low ceiling." It's clear from the record that both the operator and the accident pilot had cut a few corners in their time. It's also clear that FAA surveillance and oversight of this particular Part 135 operator was inadequate. Whether by luck or design, no paying passengers were involved in any of the resulting accidents. Obviously, the history of this operator's and this pilot's apparent scud-running, and other questionable operations -- whether under Parts 135 or 91 -- calls into question their collective judgment. From the NTSB report, we can't tell if this corner cutting resulted from financial and competitive pressures or if this kind of pilot behavior was simply part of the operator's culture. We can, however, discern a clear willingness to bend and break various basic flying rules. What led to this kind of behavior? Was it overconfidence, some variation on the "God complex" or just a bad attitude? Could it have been a sense of entitlement, leading this operation to think it was well-skilled when in reality it simply had a bucket of luck from which it took too much? On your next flight, you get to be the judge.
More accident analyses are available in AVweb's Probable Cause Index. And for monthly articles about safety, including accident reports like this one, subscribe to AVweb's sister publication, Aviation Safety.

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