When Trained Pilots Make Dumb Mistakes

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There are various dividing lines in the world of aviation, none more stark than that drawn between avocational pilots and professionals—the airline and military community. Although we should know better intellectually, those of us across the fence from the professionals tend toward surprise when the better equipped, better trained and more experienced pilots who fly for a living make dumb mistakes.

Example: One theory circulating on the Colgan crash in Buffalo is that its cause will be a mundane stall/spin, nothing more or less. "I just can't believe," wrote one reader, "that a trained airline pilot could do that." Well, a trained airline pilot can. The NTSB will decide if he did.

On Tuesday, the U.S. Marines found themselves explaining how a Marine pilot flying an F/A-18 that was already in extremis—he had shut an engine down--decided to pass up an easy overwater approach to San Diego's Naval Air Station North Island in favor of an approach to MCAS Miramar, that's landlocked by dense urban development. When the other engine tanked, he ejected and the aircraft crashed into a neighborhood, killing four people on the ground.

How could an expensively trained Marine aviator allow this to happen? For the same reason that a trained airline pilot can lose control of a perfectly good airplane: They, like the rest of us, are all too human and more than capable of making that single decision or a chain of decisions that end in a smoking hole.

Try as we might, even the best training can't reduce human variability to that point where every pilot will make the same decisions when faced with like circumstances. When that variability results in things turning out right, we call it judgment. When it turns things sour, we call it a mistake.

In their press conference Tuesday describing the F/A-18 accident, the Marines were painfully blunt. The aircraft had known deficiencies and shouldn't have been in the air. The pilot, for reasons unknown, flew right past a perfectly situated military air field and continued on to one in a congested area and lying under an overcast. If you listen to our podcast here,the point-of-no-return will be glaringly obvious. Also obvious is that the pilot had help making the choices that got the airplane airborne and pointed at Miramar.

What conclusions can be drawn from this tragedy? Two in my view. The first is that this particular Marine unit and perhaps the service in general still struggles with cultural issues related to safety in decision-making. In this regard, their training may actually be a hindrance, emphasizing as it does the need to complete a mission at all costs in ways that don't necessarily mix well with civilian environs. The officers conducting the press conference alluded as much. With so many members of our armed services in harm's way, it's unreasonable for us to assume civilians living near bases don't share some risk. But it's just as reasonable to expect the military to do better than this in reducing risk to themselves and others.

But the larger issue for all of us is to well understand that any of us can be sucked into this kind of dark vortex of bad judgment at any time during our flying careers. All it takes is a bad day, a little fatigue or an innocent oversight. And there aren't enough training dollars and hours on the planet to change that. If that sounds like another version of "it could happen to anybody," I guess it really is. As for that Marine pilot, I don't cut him much slack because he's a highly trained aviator, but because he's human.

Comments (34)

In the F/A-18 accident, had the pilot passed up a close-by urban airport for one in an open area and crashed, there would have been little said. Like so many other situations in aviation, this should have been hard wired before the pilot even left the ground. "in the event of critical failure you will land at the closest appropriate airport, period. The only exceptrion is if there is some overiding consideration that would make another action preferable." In health care, the vast majority of medical errors are process based, not competency based. The solution is to hardwire the action to be taken unless there is an exceptional overiding onsideration. Like engine failure on take-off, land straight ahead, unless there is a rock solid reason to do otherwise.

Posted by: Richard Montague | March 5, 2009 8:07 AM    Report this comment

Training, Experience. Two different things. The military has outstanding training not replicated in the civilian world. Show me a civilian trained pilot with over 6 million dollars of training in 3 years. They do this and spend huge sums because they have to. They cannot find people with the experience they must have so they put out the money for training.

In the civilian world not even a fraction of that money is spent on training so usually what they lack in training they make up for in experience. Years of experience is an excellent teacher.

Ideally the airline Captain flying the airplane you are about to board will have a combination of training and experience that equal enough of the "Right Stuff" to safely get the job done.

A very sad situation happens when the pilot is short on both training and experience. Even if the FAA minimums are met this combination will often prove deadly when thrown a curve ball.

Very sad since the experience is out there. The reason it happens is to save money. Experience in any field always demands more money. As an employer if you want to minimize expense you hire the lowest experienced pilot and train him/her to the FAA mins.

Posted by: Unknown | March 5, 2009 4:17 PM    Report this comment

"In the F/A-18 accident, had the pilot passed up a close-by urban airport for one in an open area and crashed, there would have been little said."

So far so good...

"Like so many other situations in aviation, this should have been hard wired before the pilot even left the ground. 'in the event of critical failure you will land at the closest appropriate airport, period. The only exceptrion is if there is some overiding consideration that would make another action preferable.'"

The overriding tenet of a military pilot is to subordinate the well-being of his aircraft and himself to the safety of civilians below. Pilot Neubauer egregiously violated this fundamental character trait.

"In health care, the vast majority of medical errors are process based, not competency based. The solution is to hardwire the action to be taken unless there is an exceptional overiding onsideration. Like engine failure on take-off, land straight ahead, unless there is a rock solid reason to do otherwise."

One would expect that, whether in medicine or aviation, we would not want martinets making life or death decisions that directly affect us. We want professionals who will make the right decisions, based on their intellect and judgment. (The requisite skill set is a given.)

Posted by: bug menot | March 6, 2009 4:31 AM    Report this comment

This sounds like the all too common binary selection error. Choice A, choice B. Weigh options. Select choice A. Execute choice B. We make that mistake when heavily distracted (like by a rapidly failing aircraft). The brain stops thinking and with no decision input, goes autopilot. Ever put the keys in the freezer while you were thinking about something else? More of an error of non-judgment than an actual decision here, I would believe.

Posted by: Unknown | March 9, 2009 5:27 AM    Report this comment

Does an F18 lose all control when both engines shut down? If so, nobody has mentioned it. That's the only excuse I'd accept for that pilot's behavior. Even a lowly student pilot in a Cessna 152 would have been committed right up to the last moment to prevent injury to those on the ground.

Training or not, mistakes or not, I hold military aviators to at least the same standard as I would that student pilot. Access to an ejection seat does not excuse a military aviator from his duty to protect innocents on the ground. If four people have to die from an airplane falling on their house, there had better be a fifth casualty found strapped in the cockpit with his fingers still clutching the stick. The grieving survivors deserve at least the small comfort that he did all he could.

I was happy and relieved that the Marines did not try to cover up their hand in the negligence. Apparently, one corner of the world still exists where honor means something. But I was very disturbed that Neubauer has not stepped forward to take personal responsibility for his actions. I could excuse the act itself -- under pressure and panic, his training probably overrode his judgement and it was just easier to pull the lever. But his failure to face up to the result tells me it was an act of pure cowardice. I wouldn't want that guy on my wing in combat.

Jon Baker

Posted by: JON BAKER | March 9, 2009 7:33 AM    Report this comment

Monday Morning quarterback on this tragedy is just wrong. A fighter pilot does not think about those on the ground and it is not an overriding tenant as some have suggested. Even an airline pilot thinks about self first. If you have never flown a fighter it is difficult to understand the help you get. The flying supervisor more than likley influnced or clouded his judgment. One gets a lot of help from supervision and yes the guy driving the jet is responsible for it ones mind plays tricks. You think there is something you have done wrong, someone else is providing direction. Once I was inexperienced and almost got into the same problem. The term "coward" is plain unjust. The John Wayne attitude is just stupid. It was an accident plain and simple.

Posted by: Jim Bruchas | March 9, 2009 8:51 AM    Report this comment

Lets not forget that this is a young aviator who was on his first mission out to the ship for carrier qualifications. He's returning and his superiors, who have all since been relieved of duty, are ordering him to return to Miramar.

Yeah I know the pilot of the final authority blah blah blah, but if you were a young pilot limping home on one engine and someone who is supposed to be much wiser, and is your superior, orders you to come on home and not land at some aux field what would you do?

Remember this is the military: Follow orders - good, Don't follow orders - loose your wings.

You are flying back from the ship, warning lights are flashing, alarms are going off, the plane seems to be flying OK, you have plenty of altitude, the order to return seem logical, busy flying the plane, no time to really think, base is calling on one radio, ATC is asking questions on the other, gotta check the weather, decide on a runway, monitor the good engine, worried about making it but the commanders on the ground seem confident.

Yeah, it's pretty easy to say the pilot screwed up and ultimately, he did. But you cannot lay all the blame on him once you consider the facts. I submit that if he had landed at North Island after being ordered to land at Miramar he would have been finished as an Aviator in the Marines.

Posted by: Ed Snow | March 9, 2009 9:23 AM    Report this comment

No excuse for passing up NAS North Island. He likely didn't go in there without the knowledge and consent of his chain of command back on the ship. They are likely in as much trouble as the pilot. It's too bad, but when mistakes are made of this magnitude, it can't get dismissed as an unfortunate incident. It isn't Monday morning quarterbacking when a more suitable divert was knowingly passed up in favor of returning to home base which is located in a populated area. If Miramar had been closer than North Island and he had chosen Miramar because of the engine failure, then second guessing his choice would be MMQB. Not so in this case. We hopefully learn from others' mistakes by studying these types of accidents.

Posted by: Mark Davis | March 9, 2009 9:36 AM    Report this comment

As with any accident/incident, the morning after will come with all the other options painfully clear. Having had to face the dragons (investigations) due to being the Air Unit Commander of pilots involved in an accident and/or decisions made, it can be daunting. As with any accident chain, there is the denial factor and can always be a part of stastical odds of a double engine failure. I do not know which aerodrome was home, but having a second engine in this case just created the problem. The only difference between the civilian pilot and the military one is the exit-rocket option under the seat. This places the civilian decision process further into the crash as to what he/she wants to hit...I have little doubt that the pilot didn't have time to estimate the trajectory of the arching, now powerless aircraft on final (he was trying to stay high). But I bet he had practiced one engine landings, which was his original intent. As for the mistakes further up the chain as to how he got there, I will let those that are in the position to play Monday morning quarterback to sort out. It was a sad day for all involved and will have an impact on future policy that is all too often written in blood.

Posted by: Chuck West | March 9, 2009 10:02 AM    Report this comment

I probably don't know what I'm talking about but that's never stopped me before. So here goes: The hottest airplane I've ever flown is the B727. But, the FA-18 seems like a wonderful airplane and I would imagine its single engine performance is superb what with the engines being so powerful and having almost center-line thrust. Also, considering the power available, it would seem to me, one of the uninitiated, to assume that single engine flight in that airplane is a piece of cake. IF that is true, then continued flight with one engine out seems no more dangerous that flying the F-16 with only one engine to start with.

If my assumptions are correct, I don't consider continueing flight with one engine out in the FA18 as being hazardous at all. It is important to note here that I have no idea what other systems were lost with the loss of that engine.

If I would assign the blame on anyone, it would be on the real estate developers who insist on surrounding every airport with wall to wall homes. All airports should be provided with an adequate safety buffer zone no matter how many tax dollars the local pols are unable to collect.

Posted by: Wilmer Richards | March 9, 2009 10:38 AM    Report this comment

Somewhere in the Marine report someone had said "landing at North Island would have been inconvenient".....obviously referring to logistics of repairing the plane off it's home base....more likely, but unstated is "Marine planes only land at Marine bases"...so I think it boils down to a cultural issue.....if safety was the overriding concern, then no question you land at North Island, but this took a back seat to Marine culture......so that is really an issue for the higher up generals who propagate this attitude, the squadron officers and OIC are only executing what they are taught.....not enough accounting came out of this whitewash....if this report was considered highly candid about the Marine Corps, I'd hate to see the reports where they are not candid........

Posted by: Richard Morrison | March 9, 2009 11:58 AM    Report this comment

Richard Morrison thinks that an attitude of, "Marine planes only land at Marine bases" was a contributing factor in this crash and that it is probably a cultural attitude imposed from high up in the USMC chain of command. As a former Marine Aviator, I can tell you that Marine Aviation is part of Naval Aviation and that Marine and Navy aviation units often operate together and deploy on ships together. In my entire career I never once heard a comment that reflected an attitude such as that described by Richard Morrison.

Posted by: Jeff Kreinbring | March 9, 2009 1:31 PM    Report this comment

I would not consider the USMC as a factor here. The pilot was A Naval Aviator, flying from an aircraft carrier. I'm a LCDR USNR Ret, and a TWA Captain retired. We are all cut from the same cloth. The only time I see the difference is in the O'Clubs in Uniform after a few drinks. I'm 77 now, and consider myself to be just plain lucky. I was not an outstanding pilot, but I managed to log between 15,000 and 20,000 hours, no accidents, incidents, scratched wingtips etc.. There IS such a thing as "LUCK".

BTW, I'm Irish.

Posted by: Ed Toner | March 9, 2009 1:36 PM    Report this comment

As the owner-pilot of a single engine jet warbird, I concur with most of the observations posted above, including the thought that normally, loss of one engine in an F-18 would not be considered excessivewly hazardous. Of course if there was concern about the integrity of the remaining engine, the hazards escalate exponentially. We used to lose an engine/month in T-38's at Randolph AFB due to bat ingestion, and thought nothing of returning to a final approach low over Universal City. In retrospect, probably not a great idea with Seguin (no maintenance there) being available as a rural alternate, but those were the orders.

I do not concur that the pilot was a coward for having ejected: What good would come of his committing suicide? How would he know which house was occupied and which wasn't? How much control would he have had in choosing the exact crash site in that area? If he was going for carrier qual, how much flight time did he have - couple hundred hours total, maybe? I don't know, but I do know that in his training it was beaten into him that "delayed decision to eject" is the #1 cause of pilot mortality, and that it's a stupid thing to do. So his extensive training trumped his lack of experience - just like it was supposed to. You can bet that young man will be hard enough on himself, and there's no one in the world who wishes more than he that those people hadn't perished. Five dead isn't better than four dead in my opinion.

Posted by: warford johnson 11 | March 9, 2009 1:36 PM    Report this comment

It's been 20+ years since I was involved in Naval Aviation having worked in simulators in a training environment at North Island. So my memory may be wrong or changes made in procedures. Having said that, in any emergency situation the flight crew performs the memory items from the appropriate emergency checklist, then consults the checklist to verify the memory items are executed and the balance of the checklist is completed. Somewhere on that checklist, regardless of the emergency, there will be a statement when to land. I have no background with the F/A-18 but I would bet that with one engine down and fuel control issues on the remaining engine, NATOPS says "Land As Soon As Possible". To me that would have meant North Island, not Miramar. Reading/following the checklist should have taken the decision out of the hands of those on the ground, and for that matter out of the PICs hands as well.

Posted by: Mike Wills | March 9, 2009 2:03 PM    Report this comment

Remember the guy who dead-sticked an F-16 into San Antonio International 12 or 13 years ago? He saved the plane, but it didn't go over too well with some since some of the externals he jettisoned went into a house, and he had to come back over part of the city to get into the airport. I was on his side at the time, but that situation had a much different result. Tough decision.

Posted by: Mike Holshouser | March 9, 2009 3:14 PM    Report this comment

As a former Naval Aviator (27 years on active duty), I can unequivocally state that there is no culture, attitude or mentality within Marine Aviation that suggests "Marine planes only land at Marine bases."

Posted by: William J. Smith | March 9, 2009 6:04 PM    Report this comment

This crash fits well with the idea that accidents happen due to a chain of events--change a link in the chain and the accident doesn't happen. Review of this accident may lead (we all hope) to changes to procedures that will break the chain the next time. I don't have the whole story, but relying on commnents posted:
1. He ejected because that is what he is trained to do.
2. If people on the ground told him to continue to Miramar, then that's what he would do. He is trained (we all are) to follow orders and respect the direction given by those more experienced. Checklists, training and standard procedures will usually be ignored by most of us if we are trained to listen to and follow directions given by authority figures.
Change any factor in this incident, and you will probably get a different (better) outcome. Let us not forget that there are probably scores of incidents like this that we never hear about because the airplane keeps flying to the chosen airfield.

Posted by: Russell Smith | March 9, 2009 6:49 PM    Report this comment

What about FAR 91.3b? Look it up. I suppose it doesn't apply to millitary logic. Somehow I am not surprised...

Posted by: Patty Haley | March 10, 2009 12:44 AM    Report this comment

It all boils down to exercising good judgement on the firing line now,doesn't it? Who can say? Da nes nyude? Pues kin sabe?

This thread has been very interesting.

Posted by: Ed Toner | March 10, 2009 2:58 PM    Report this comment

It is eazy to secound guess the reaction of a person after the fact, Monday quarter backing it's call. The pilot is already beating self up over it and has to live with the menory. Best thing to do is learn from the mistake and move on. Nothing is going to fix what has happened or change the past, live and learn. I was at Miramar when it was NAS, VF-194 had a F-8 fly into a hanger, pilot was on a maintanence flight lost hydraulics then the engine. He punched out appoximatly 3 miles from the runway, the A/C glided those 3 miles into 194's hanger. Killed 19 people. So things happen, just hope you got all your poop in one bag and you can bail yourself out.

Posted by: Larry Schuling | March 11, 2009 1:15 PM    Report this comment

This pilot was a student! His decisions were made by the sof/supervision. period. He did what he was told to do. period. get it? Lets see-they are all relieved of duty/fired for their decision making....

to imply that riding the jet into the ground somehow makes it right is absurd! He has chosen a career that puts his life on the line to protect us. This was a horrible accident but one more life doesnt make it right. The Father/husband understands that! I saw the interview with him.
Get him back in the air and continue his training. We as a nation need more like him! Hammer the supervision--leave the young man alone--

Posted by: Dave Guanell | March 12, 2009 2:02 PM    Report this comment

Thanks, Dave. You are so right.

Posted by: Russell Smith | March 12, 2009 2:19 PM    Report this comment

The SOF is relying on the pilots (student or whatever) assesment and info about the aircraft condition to make plans and decisions. when the pilot checked in with atc he knew he had a questionable only remaining engine. The pilot either failed to impart that to the SOF or lacked the stuff to say "this is a bad decision." "Just Following Orders" doesn't even come close!

Posted by: David Friedman | March 13, 2009 1:00 PM    Report this comment

Strange, but my wife had checked out the movie "The Great Santini" from the library right when this accident happened. The climactic scene from that movie involves the title character being faced with a very similar situation, an in-flight emergency over a populated area in his jet fighter. In the movie, the main character, in spite of his personal flaws, actually makes the right decision, and that scene is on of the two scenes that make the movie into a truly heroic tale.

Posted by: MARK BOBERG | March 24, 2009 8:13 AM    Report this comment

The student is not allowed to say--"this is a bad decision"!!! He tells the sof what he has and the sof tells him what to do--thats how it works.
His staying with that aircraft would not have made that crash any less tragic!!! Makes for a good movie though.

Posted by: Dave Guanell | March 24, 2009 3:41 PM    Report this comment

This has been an interesting discussion. None of us has the complete picture of who did what, who had what responsibility, what standard procedures were in place, who had what information at their disposal, etc. Investigating boards are convened to gather all that and make determinations. So, despite all our opinions, experience and discussions, none is in a position to make a call. I'm sure the Marine
Corps will, though.

Posted by: Russell Smith | March 24, 2009 4:08 PM    Report this comment

Nuremberg shows us beyond any doubt that when people disengage their brains and or their conciences in favor of "just following orders" they will be held responsible, period. A bad decision is just bad, No Excuses.

Posted by: David Friedman | March 26, 2009 6:06 AM    Report this comment

My comment is not so much about this F/A-18 accident, but about one "Dumb Mistake" that has apparently been made recently by the Colgan Air crew in Buffalo, the 737 crew in Amsterdam, and the Pilatus pilot in Montana: approach stall! Now information is sketchy on the Pilatus crash, but his position makes investigators think he may have tried a tight turn at low speed while heavily loaded and possibly with some ice on to get back on the approach. If that was the case and he still had a bit of fuel on board, all I can say is "Never be too proud to go around!" I'm sure commercial flying has a high cockpit workload near landing and yada, yada, yada. But seriously! I'm just a lowly private pilot and it was beaten into me: You've gotta watch your airspeed! Sheesh!

Posted by: Steve Brady | March 26, 2009 1:59 PM    Report this comment

Hindsight shows that there were many bad decisions that snowballed. Classic aviation accident. It's easy to say what you would do from the comfort of your office -studying history...the kid did his best within his authority.

Posted by: Dave Guanell | March 26, 2009 3:14 PM    Report this comment

Steven Brady - Gear down but NO FLAPS.

I believe this was the fatal error.

Posted by: Ed Toner | March 26, 2009 3:44 PM    Report this comment

Ed: I think you're referring to the Pilatus accident? I don't know what the POH says for that model, but sometimes the admonition is to use no flaps during landings with ice accumulation. Yes, if flaps were ok'd with ice they would have helped avoid an accelerated (turn) stall in the approach, but it still sounds like an approach stall to me. Perhaps I should have said more technically, "You've gotta watch your angle of attack!", but that translates to an airspeed for a given configuration.

Posted by: Steve Brady | March 26, 2009 4:10 PM    Report this comment

This has been an interesting thread with a lot of founded opinions. As for the Pilatus, the one thing that I have learned in 26 of flying is that a reason behind the accident may be some time coming and even then fuzzy, in this case. The gathering of physical evidence is going to be difficult at best. From the physical state of the pilot and aircraft to direction of energy and flight charactistics prior to the crash. At least when an aircaft starts feeling strange on base to final, this unfortuate event may surface from the sub-conscience to remind us that the laws of physics are strictly enforced...

Posted by: Chuck West | March 26, 2009 4:29 PM    Report this comment

I do want to say one more thing: Chuck is right that we don't know the facts in the Pilatus accident. I don't know it was an aproach stall. The 737 was, and it now sounds like the Dash-8 was. It is tragic when pilots mess up and kill themselves, but it's immensely moreso when they take a plane-load of passengers with them. Approach stalls should not happen.

Posted by: Steve Brady | March 26, 2009 4:43 PM    Report this comment

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