Accident Probe: Oshkosh Or Bust II

Combining anti-authority attitudes with "get-there-itis" is a bad idea when heading off to an air show.

18

Editor’s note: For our July 2021 Accident Probe, Oshkosh Or Bust, we explored an accident involving a non-instrument-rated pilot who took off into dark night IMC and crashed into an open field near the airport, killing himself and his passenger. This month’s accident is eerily similar, except both occupants were instrument-rated commercial pilots. The underlying reasons for both accidents differ somewhat, but they share a common goal: flying to Oshkosh, Wis., for the annual air show. Get-there-itis is a real thing.


The FAA’s Pilot’s Handbook of Aeronautical Knowledge (PHAK, FAA-H-8083-25B) discusses five hazardous attitudes pilots may harbor. It defines “attitude” as “a motivational pre-disposition to respond to people, situations, or events in a given manner.” A hazardous attitude, meanwhile, “can interfere with the ability to make sound decisions and exercise authority properly,” according to the PHAK. As we’ll see, this month’s accident has the “anti-authority” hazardous attitude interwoven throughout.

But it also has the “get-there-itis” mentality, wherein pilots ignore normal procedures and/or adverse conditions in an attempt to begin or complete a planned flight. We’re sure this is more common than the accident record reflects, thanks in part to some combination of luck and skill allowing completion of the mission without the need to make an NTSB report.

And there’s a fine line between skillfully negotiating the many challenges a flight may present and doing it irresponsibly, with possible tragic consequences. The accident record tells us that line is often crossed.

To me, the real trick in all this is a pilot’s ability to recognize when he or she is getting in over their head, and making decisions only with the mission in mind, instead of soberly considering the possible adverse outcomes. Here’s an example of the former.

Background

On July 24, 2019, at about 0550 Eastern time, a Cirrus SR22 was destroyed when it impacted terrain near Americus, Ga. The pilot and the pilot-rated passenger were fatally injured. Night instrument conditions prevailed; no flight plan had been filed. The pair was heading to Oshkosh, Wis., for the
annual air show.

Radar data consisted of six targets over a span of one minute, depicting a 180-degree arc to the left. The first target located the airplane about 1700 feet beyond the departure end of the runway at 900 feet MSL/432 feet AGL. The last target showed the airplane at about 1100 feet MSL.

A resident of the farm where the airplane crashed heard its engine at about 0550. He noted it was cloudy and still dark outside, and that the noise sounded like the airplane was turning and the engine was “whining really loud.” Then he heard an explosion.

Investigation

The airplane came to rest at an elevation of 477 feet; all of its major components were accounted for at the scene. The wreckage path was about 400 feet long, oriented on a southerly heading. Initial contact was a tree strike about 34 feet above ground; a ground scar began about 50 feet beyond the tree strike.

The airframe and flight control surfaces were highly fragmented, including the rudder pedals and sidesticks, but control cable continuity was confirmed from the cockpit to associated bellcranks, and to their overload breaks and cuts by first responders. This was an early, non-glass SR22: its gyro instruments displayed rotational scoring, indicating they were operating at impact.

The oil filter was dated July 7, 2017. It was disassembled; no metallic debris was noted. The propeller had separated from the airplane; all three propeller blades remained attached to the hub. Each displayed similar twisting, bending and chordwise scratching, indications the engine was running at the time of impact. The Cirrus Aircraft Parachute System’s activation handle still had its safety pin attached, including its “Remove Before Flight” banner.

According to the airplane’s logbooks, the most recent annual inspection was completed April 3, 2018. The last three annual inspections were completed about every other year.

“There were no anomalies noted with the airplane that would have precluded normal operation,” the NTSB said.

The 0550 recorded weather observation at the departure airport, about two miles south of the accident site, included an overcast ceiling at 500 feet and wind right down the runway at five knots. Visibility was 10 miles. At 0445, an updated AIRMET Sierra was issued, advising of IMC with ceilings below 1000 feet and visibility less than three statute miles, with precipitation and mist. Weather satellite data indicated the approximate cloud-top height over the accident site was 6500 feet MSL. Civil twilight was to begin at 0619, with sunrise at 0646. There is no record of the flight’s pilots receiving a weather briefing through Leidos or ForeFlight. It’s not known if they obtained weather information from any other sources before the accident flight.

The pilot/owner (male, 69) held a commercial certificate and an instrument rating. (An early version of this NTSB report stated he had 22,000 total hours, something dropped from the final.) The pilot-rated passenger (male, 63) also held a commercial certificate with an instrument rating.

Probable Cause

The NTSB determined the probable cause(s) of this accident to include: “The pilot’s decision to depart in dark instrument meteorological conditions, which resulted in spatial disorientation and subsequent loss of airplane control. Contributing to the accident was the pilot’s and pilot-rated passenger’s self-induced pressure to complete the flight and the pilot’s anti-authority attitude.”

Given the pilot/owner’s failure to obtain a weather briefing, file an IFR flight plan or regularly inspect his airplane, the NTSB says “it is likely that he had developed an anti-authority attitude, as evidenced by the disregard for several rules and regulations.” In addition, the NTSB noted, the pair may have experienced “get-there-itis” in attempt to get to the air show.

The sidebar below highlights some details about both the anti-authority hazardous attitude and “get-there-itis.” Acknowledging you may be experiencing one or both, or other emotional distractions, is the real key to avoiding the bad decisions that result.


‘Effective Risk Management Takes Practice’

According to the NTSB, “By identifying personal attitudes that are hazardous to safe flying, applying behavior modification techniques, recognizing and coping with stress, and effectively using all resources, pilots can substantially improve the safety of each flight. Remember that effective risk management takes practice. It is a decision-making process by which pilots can systematically identify hazards, assess the degree of risk, and determine the best course of action. Pilots should plan ahead with flight diversion or cancellation alternatives and not be afraid to change their plans; it can sometimes be the difference between arriving safely late or not arriving at all.”


Aircraft Profile: Cirrus SR22

Not accident aircraft. Image: Alan Wilson/Flickr.

OEM Engine: Continental IO-550-N

Empty Weight: 2250 lbs.

Maximum Gross Takeoff Weight: 3400 lbs.

Typical Cruise Speed: 175 KTAS

Standard Fuel Capacity: 81 gal.

Service Ceiling: 17,500 feet

Range: 1049 NM

VS0: 59 KCAS


This article originally appeared in the July 2022 issue of Aviation Safety magazine.

For more great content like this, subscribe to Aviation Safety!

Jeb Burnside is the editor-in-chief of Aviation Safety magazine. He’s an airline transport pilot who owns a Beechcraft Debonair, plus the expensive half of an Aeronca 7CCM Champ.

18 COMMENTS

  1. This is a great article. The article identifies the essence of aircraft crashes since O met W at the bike shop.

    Crashes are not accidents. Most crashes are, and were, preventable. Accidents by definition are unexpected and unintentional. Likewise crashes are the result of willful misconduct because the resulting consequences were somewhat predictable and could be anticipated. “The two pilots took off into night IFR but were not IFR rated”. Because the consequences are predictable means they are also expected and intentional. Willful misconduct is not an accident.

    Predisposition to “get-er-done” is inherent in the Mars grouping of pilots. Let’s label this a fact and not and not bad thing. It’s in our Mars genes to get-er-done. This is who we are as humans. Because this fact will be with us for ever we simply need to understand ourselves and then deal with it.

    The stats speak for themselves. 6% of the pilot population is female yet the Venus group accounts for only 2% of crashes and accidents. Almost never fatal. Let this sink in.

    We don’t need more regulations to prevent crashes. We just need to look in the mirror and make the appropriate adjustments.

    God bless.

    • Can you tell me what data source you are referencing that suggests female pilots are safer, or where that 2% comes from?

      There are several studies I see that show different conclusions
      For instance the Hopkins study “Characteristics of general aviation crashes involving mature male and female pilots”, authored by women it turns out, reviewed NTSB reports for 432 GA crashes (287 males, 144 females) and showed for Pilot Error (which is 90% of pilot deaths):
      Misused Rudder M: 4.9% F: 11.8%
      Improper Flare M: 3.5 F: 10.4
      Poor Response to Bounce M: 6.3 F: 17.4
      Could not recover stall M: 10.5 F 12.5

      Outside of GA, women, being less than 5% of the industry, accounted anecdotally to a way way more than 5% of the Pt 121 crashes in the previous two decades.
      Another study “Comparing pilot-error accident rates of male and female airline pilots” in the peer reviewed journal Int’l Journal of Mgm’t Science states: “The study found that females employed by major airlines had significantly higher accident rates than their male counterparts overall.”

      Back in the day, my primary CFI was a great pilot, teacher, mentor, motivator, and woman, and that’s the order I find important. I know female heavy iron captains , aerobatic, and F-16 pilots who are hands-down better pilots than me, so it’s nothing to do with gender ability. They are good pilots. period.

      But there appears to be numerous peer reviewed statistical analysis of accident rates and types based on gender, and none I see suggest they women are on the whole, safer pilots.

      • Carl R.
        Very interesting stats regarding a selection of presumably frmale and male pilots. I wonder if a followiing post might include citations for these studies. A discussion of methodology for each of the studies as welll as a dive into contributing psychological factors would perhaps be enlightening.

    • are we all on the same page? QUOTE; The pilot/owner (male, 69) held a commercial certificate and an instrument rating. The pilot-rated passenger (male, 63) also held a commercial certificate with an instrument rating.

  2. It is hard to imagine someone who didn’t follow regulations regarding maintenance and inspection of his aircraft. Even harder to imagine someone launching off at night into those conditions without knowing. I think this was intentional, the pilot probaby was going to just fly VFR altitudes on the AP. I feel sorry for the families and the right seat occupant but not the pilot, this was just suicide whether he intended it or not.

  3. Working in this LoB, I always take any government narrative with a grain of salt, and these one-investigator GA accident investigations always read as trying to making stew from lean meat. He did a day of interviews, spend two years, and like a kid with a term paper due tomorrow morning, it seems like they try to try to cram and embellish facts that could clearly stand on their own if they made more effort. Every day at my own fed job I see colleagues, in good faith, take weak signals and amplify them to the point of low fidelity or even distortion. Yes, the general conclusions of the report are probably correct, but the report repeatedly assume facts not in evidence.

    “get-there-itis” for “final few days” of Air Adventure? This was the very early hours of the third day of the 7 day event. The whole thing is a few days, but this didn’t happen near one of the “final” ones. They list this as a contributing cause but caution: Hyperbole Alert!

    “did not obtain an official weather briefing” – this is one we have to retire as a concept. It’s not 1997, we don’t call 1800 WX anymore where the 8-track records your Morse Code briefing for posterity. They go on to say they did not use Leidos or Foreflight. Ok, I use the “official” sources in Garmin Pilot for every flight, but if I skipped typing my password, (but still review the 30 pages of wx), I am now an anti-authoritarian scofflaw. Show me in the regs where I am required to have a notarized receipt that I have reviewed all available info for my flight.

    “was flying the airplane after the annual inspection was due” – again, most probably true, but they based this off not finding a log book entry. Both owner and pilot were A&Ps, so they would know that you can read 14 CFR all day in vain for where it says the annual has to be recorded in a log book. Spoiler alert, there’s no such reg. Yes you have to keep a record, and yes you have to make it available to FAA or NTSB for inspection, but just because you couldn’t find it after they died, doesn’t make it so. You can have it on a Post-It on the fridge if you want, there is no reg requirement for the format

    “The last three annual inspections were completed about every other year.” Again, very probably, but you have no idea if that’s a fact. Again, both guys are A&Ps and when I went to A&P school the hardest class was regs, but you end up learning that stuff cold. Regs require you to keep records of inspections for one year or until they’re superseded. Yep, everybody “normal” keeps this stuff in a log book, but you’re not required to, you can throw out the records for last year’s inspection once you get a new one

    Ok ok, yep the big picture is absolutely correct, these guys blatantly ignored risks, and the report does provide info to support this conclusion (not filing, leaving “remove before flight”). And I sound like a nit-picking wingnut (which I may have turned into), but where I’m from, when you write a report, you stick with what you can actually prove as a fact.

    • I would agree with you that it can be argued that the annual(s) may not have been recorded in the log books and the plane was maintained; but that argument is moot when they found a 4 year old oil filter installed. Nobody and I mean nobody thinks that an oil change is not job 1 on routine maintenance (or would have been overlooked during the last 3 annuals).

  4. Agree with Carl R. NTSB and Aviation Safely is making an awful of assumptions without backing them up. Makes me question their credibility. If this is what “Aviation Safety “ is about then I don’t want anything to do with it.

  5. I certainly wouldn’t have done this myself. But if I would have showed up as the passenger and the 22K hour commercial pilot said “Shhhh, I got a fish finder so I am not gonna bother filing a flight plan to get to VFR on top” I doubt I would have expected getting on board the plane to be a death sentence.