Guest Blog: Lessons Well Learned And Too Often Ignored

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Tuesday, November 14th, 2023, three pilots took to the skies in what appeared to be a sightseeing flight of the nearby mountains. Allegedly having completed a similar flight (or flights), it appears as though this one may have started out routine. Good weather, airplane in generally good condition, and a few friends not too terribly detracted from anything on the IMSAFE checklist. Somehow, only one of the three pilots still walks about, while sadly the other two perished in a tragic accident that bears an uncanny resemblance to thousands just like it.

Publicly available downloads of their fateful flight shows an aircraft being flown with an abundance of bravado straight off the runway in Spanish Fork directly into Slate Canyon. No observations into the canyon prior to entry, no overhead observation, no circling to gain altitude. Straight into the canyon. Three pilots. One hundred and forty-five horsepower. Zero chance.

A wise professor of mine once told me (and every class he taught) that “if you want to be the best pilot in the world, kill yourself in a plane crash. They’ll all be saying it at your funeral.” As if he’s lived through these tragedies in his own life, the Facebook posts, news article comments, and (likely) eulogies echo similar sentiments.

What drives me to my oft-worn journals this evening is not any sort of “I told you so” but rather an important takeaway that as pilots we continue to do the same dumb stuff over and over and for some reason we sit and wonder why it continues.

At first the community thought the three were careless pilots and took unnecessary risks. Friends and classmates speak on the contrary, and while investigations into their past will surely find something off the beaten path, I believe that we can become more than our past, and an absence of risqué social media content from the three lead me to look elsewhere for any causal factors.

Weather is always something brought up in these discussions. While there are some repositories available for investigative weather analysis of reported and forecasted conditions, the absence of instrumentation in Slate Canyon (and a general lack of abilities to predict weather in the mountains) rules weather out as the sole reason they went down. Even on a good day, a well-loaded and underpowered airplane would have had difficulty completing the apparent mission. I could only imagine what may have transpired if any downdrafts or turbulent air were experienced.

Having been an accident in the mountains, cries for mountain flying training are the next loudest voices in this space. As a proponent of pilots seeking instruction and experience prior to flying in the mountains, I start to see myself joining on the bandwagon. Then a voice inside my head starts increasing in volume. “Rule books are paper. They will not cushion a sudden meeting of stone and metal.” Captain Gann seems to always have the right words in these situations.

I’ve known many pilots who took that first step in seeking this wisdom from the elder statesmen (and women) in the backcountry. Thousands of dollars invested in books, guides, dual instruction, and fly-out jamborees later, those hours spent either in the same cockpit or off the wing of those who literally wrote the books on mountain flying are sometimes proven worthless with twisted wreckages of CarbonCubs and human bodies across the mountains. Even the proverbial patron saint of mountain flying, Sparky Imeson, author of the Mountain Flying Bible, was found dead inside his Skywagon days after one hunter observed him flying recklessly in the mountains.

More than completion certificates, more than the dual given and CFI signatures in our logbooks, what we need more than anything is to start making better decisions before, during, and after flying. Experience means nothing when experience doesn’t influence your decision making process for the better, and while we all (yes, all) contend with a lack of experience, the only tool left on our belt is time.

Looking back at the flight path of the accident, it appears there was no consideration of time. In less than the time it takes to read this, they took off from Spanish Fork, flew abeam Provo’s Class D airspace, and made a hard 90° turn to the right and met their demise. Tragically finding themselves likely out of airspeed, altitude, and ideas, the plane came to rest between near-vertical granite outcroppings, truly the least ideal situation the three (and their loved ones) ever envisioned.

Certifications, hours in the logbook, experience in the airplane, the local area, mean nothing when they’re not put to use. If Imeson taught us anything outside his books, it’s that same sentiment that Captain Gann immortalized in his classic Fate is the Hunter.

If there’s anything we can learn from yet another tragic CFIT story, it’s that we need to be making better decisions. We laugh when we read about the threats of flying perfectly good airplanes into mountains in the manuals, then cry when we have one happen right in our backyard. Between the two tragically infinitely-repeating events is where we must grow. That time that I spoke of earlier is on our side, even during a flight like this one. Moments spent surveying the canyon, the weather, and the current state of the aircraft may have shallowed out that fateful turn to the east and started the development of a more favorable outcome.

The time is now to not only hold ourselves accountable for making better decisions, but those we associate ourselves with. Even the ringleader of the Flying Cowboys, the ones who brought careless and reckless into the mountains, agrees that he too was lucky his dumb decisions didn’t kill him, and now finds himself not only saying no to taking chance with fate, but telling his friends they shouldn’t either.

One thing we can all agree on is that between takeoff and tragedy there was ample time for the three pilots to speak up and make better decisions. Another thing we can agree on is that no flight is worth risking our lives for. Thorough reviews of our intended flights, careful consideration of the potential threats that may be experienced, the mitigation strategies to overcome them, and mustering the fortitude to tell our friends, our loved ones, and even ATC “no” are things we need to start putting into practice to put the brakes on this never-ending accident cycle.

Whether it be ourselves, our communities we find ourselves in, or the revered mentors we confide in, much like the wisdom of Smokey Bear, only you (the PIC) can prevent CFIT accidents. Take that first step today to start making better decisions on the ground so we can enjoy better memories in the air. My heart breaks for these young men and their families.


34 COMMENTS

  1. A tragic loss, for sure.

    However as long as people choose to fly (and we certainly do!) there will always be accidents of this nature. No amount of red-tape, rules, training, or experience will ever reduce the accident rate to zero.

    Flying has inherent risks. As pilots we ought to know and understand them. But there have been several examples in recent times of highly respected and capable pilots making their final, tragic flights.
    Sometimes it’s just a misjudgement with serious consequences.
    Perhaps a misunderstanding of the aircraft situation.
    A genuine error (to err is human).
    An unexpected weather effect.
    And sure, the odd rule bender/breaker (“we need more rules!” they clamor).

    Flying isn’t inherently unsafe. But the environment is inherently unforgiving – the wrong kind of small mistake in the wrong circumstances can kill you very quickly.
    None of us are immune from making mistakes. Thus the great care taken in aircraft design, pilot training, and (hopefully) flight planning. But the risk cannot and should not ever be reduced to zero – that would be the day we stop flying entirely.

    • > But the risk cannot and should not ever be reduced to zero – that would be the day we stop flying entirely.

      Risk can never be reduced to zero no matter the endeavor. People have drowned in their own bathtubs. But we can and should make every attempt to reduce the risk as much as we are able, and sometimes that means we don’t fly.

  2. It’s all about rational planning and sound decisions vs misplaced optimism, isn’t it?
    A typical Sunday sundown outdoors tinkering with my wingless Luscombe at semi-abandoned Downtown Airport [S. Park and I-10, Tucson] except it was atypically overcast and sprinkling in the desert. I was surprised to see a Piper 140 glide out of the grey onto our unlit sandy scrubby sort of runway. Guy and wife and 2 kids fighting headwinds all day from Midland [TX] heading to Whiteman [CA]. “I have to be at work tomorrow. Is there fuel here?” “No, and there’s worse weather, empty desert, and then the Sierras the next couple hours west of here.” “What do you think I should do?” “Let me take you to TIA.” Either there were no flights or they couldn’t afford them because he came out and asked me to take them back to the plane. “I guess we’ll have to give it a try.” “No, you don’t.” I told him to wait a minute, called my Squadron Commander, Jack Francisco [a respected even beloved leader and skilled pilot whether in combat with F-105’s or flight testing Learjets], explained the circumstances, and got his immediate OK to help them out and take a short notice leave Monday.
    “I’ll take you back to the plane, you guys bring only essentials, and I’m gonna drive you. I don’t want to hear about you on the news tomorrow.”
    Crammed them all into my little German V-6 stick Capri and got them to Pacoima before dawn. I met him at the bus the next weekend and he ferried it the rest of the way.
    How many THOUSAND souls have pressed on aloft into the murky night and never arrived since that fortunately NOT fateful evening in 1975?

    • I commend you for your genuine concern for this pilot and his family and for your generous and non-judgmental decision to take action on their behalf. I also commend the pilot for his willingness to accept your generosity.

    • Your kindness reminded me that in a sometimes uncaring world, there are still special people who spread goodness. Thanks for making a positive impact on others’ lives.

    • There was some comments online that one of the passengers expressed their concerns about the flight, and that those concerns were not addressed, however the flight continued. Most of them likely having heard Mike Patey’s speech on the perils of peer pressure prior to takeoff, these supposed remarks are hard to hear.

      • I was an instructor at Spanish Fork airport for the Woodhouse family that had owned the airport since 1927. Tom and Allen were excellent mechanics and pilots and l learned a lot in my nearly 20 years flying from Provo and Spanish Fork airports as a CFI. I also took lessons from Sparky. I taught mountain flying in 20 different single and multi GA airplanes in Utah. I have seen my share of accidents in my years teaching in that area.
        I have flown that very route over a 100 times. Why this airplane crashed l dont know, nor will l speculate. I don’t think there are many ‘lessons to be learned” either. After 55 years flying and 40 years as a instructor I have read many speculations about why a accident happens. I am a former Crime Scene investigator also. Why do people get murdered? There is no definitive answer to that either.
        I taught pilot students what the dangers were, various avoidance techniques, etc. Never had a pilot crash that l trained. Not because lm a good teacher l will tell you. Allen Woodhouse would just say, “The plane crashed because it hit the ground when it wasn’t supposed to.” That is in reality all we know. Is there a lesson in this, not really. Do your best as a pilot. The mistake pilots make is they think they are totally in control and can get out of any situation. You aren’t and you can’t. Why does the human mind make good and poor decisions? This is what this accident is really all about. Why does someone decide to murder? I appreciate what your article is trying to say however. I spent 10 years as a mental health professional in Utah working with every mental illness known. Yet, very little is known about decision making in any walk of life.
        How does the brain process known knowledge and make a decision, vs decision making on the spur of the moment? Whats the chemical process involved that causes decisions like this. How is the decision implemented, is it the conscious or subconscious that is the main influence? These are questions that science is still trying to figure out.
        Why did the brain of the pilot flying make the decision ro fly up the canyon that particular moment. That is the real issue, and one that cannot be fully understood by science at this point.
        All I know is they didn’t intend to die when they took off, but they did anyway, despite all the experience and knowledge and training they had.
        Gann book title says it perfect, Fate is the Hunter.

    • An old timer once told me, “ They haven’t found a new way to crash a plane in 50 years” ( that would be 80 now).

      The “good” instructors get their students through in the minimum time and use every loophole in the regs to do so. They figure they can pick up judgement somewhere along the way. Maybe.

      Add in irresponsible YouTube showboats and their worshippers and you wonder why it’s not raining aluminum every day.

      • You hit the nail on the head. That old timer sounds like the guys that used to hang out at our airport. Thank God they died of old age and not “almost made it”.

    • From this article: “Even the proverbial patron saint of mountain flying, Sparky Imeson, author of the Mountain Flying Bible, was found dead inside his Skywagon days after one hunter observed him flying recklessly in the mountains.”

      As I recall this was a suicide flight following a failed attempt the week before…..a suicide for reasons that don’t need to be brought up herein….

      I also think I remember a training accident this “proverbial patron saint” did in a Husky. He told the pilot to turn and the pilot turned (sorta the same turn as the subject of this feature article)….but the wrong way. They ended up on a mountain side and as I recall Sparky Imeson had a broken leg.

  3. Every single one of these plane crash stories all start with the same sentence, “It started out as a routine flight”. Whenever you strap on an aircraft there is nothing “Routine” about it, nothing is the same as the last flight. This is the mind set you must take when flying. This aircraft has the potential to KILL you every single flight………period. This is treating it with respect, not just another walk in the park.

  4. All replies from a lot more experienced pilots than me, for sure. I have had three close calls with “fate” and was able to realize what was going on or was able to take corrective action and there was no accident. In all three events it was a pilot who saved me when they took the time to admonish me about certain dangers in a classroom, hangar, in flight training or just a burger run. #1 was my first flight with my wife who I “promised”. I thought I would show her a National Park in our local mountains. About a third of the climbing up the valley I heard a voice in my brain from a local doctor and EAA mountain safety officer “controlled flight into terrain is a common pilot error.” Flying up a valley in mountains can be a one way flight into a crash. And I immediately started a turn back towards the valley behind us. I was surprised how tight that turn was and how close the canyon wall seemed, my hands gripping the stick and applying power as the airplane completed the turn. It was only then that I realized that I was only a minute or two into a crash or stall. #2 was violating my preflight which I was told “even if you taxi out for an engine test make sure you do a complete pre-flight from your list”. This was from an airlines Captain buddy with 34,600 hours when he helped me test flight the Vans RV-12 that I built. He had insisted that I always fly the “numbers” especially in the pattern and to cross reference speed with rpm, climb rate, attitude etc.. I decided to do an engine run up after re-pitching my prop, simple enough. After the run up the weather was perfect so I decided to take her out over the valley and record the performance numbers. As I was climbing out I realized that I was so focused on the RPM and FPM that I had not seen I had no airspeed indicated on the G3X. I forgot to take off the pitot cover! With sweaty hands I remembered that I had RPM numbers for the pattern memorized plus ground references he made me use. I landed, no problems but embarrassed and taxied back to the hangar. #3 could have ended with serious consequences. My retired Navy pilot and airline Captain (airline captain #2) Was concerned that I had not pushed myself doing more stalls, and maneuvers that displayed the performance envelope of my RV-12 and that flying my wife to California over the Mojave desert and Tehachapi mountains was serious flying and you’re going to be at gross weight. Let’s go up over the valley away from everything, get some altitude and see how she behaves.” Really? It’s just a light sport, I thought. As we went through the first of these stalls, steep turns and climbs I watched the AOA that I had installed when I built her. You can look at the AOA but I want you to “feel” what she’s doing. He was really adamant about me “feeling” her at these critical points. Then he said, we’re going to perform some “deep” stalls. I didn’t understand. He explained the maneuver and then told me, Use rudders, NO ailerons! Why? I asked. Think about it, one up and one down, what’s she going to do? ROLL! And in a full stall you will be on your back in a split second. I put her into that high angle of attack and we were dropping from 8,500′ at 1,500 fpm when the nose moved a bit to the left. Looking up into the blue sky and without thinking I pushed the stick to the right and instantly she rolled and I immediately pushed the stick back and then down and she recovered. He told me my eyes were the size of coffee cups. He was laughing. “You won’t ever do that again, will you? Then he had me do two perfect deep stalls and keep the airplane on a straight path with the rudder. How this relates to our flight to Sacramento was that having topped off the tank at 29 Palms I climbed to 9,500′ and headed for Gila Bend. My wife was asleep while I was handling thermals North of Blythe. A few thermals lifted us up to 10,500′ and I was focused on that. The airplane felt funny, almost like those deep stalls. I looked over at the AOA and the chevrons were moving up and down but not into the red. But the airplane felt familiar. I looked out at the wings and the angle looked OK but then I remembered I was at gross weight and that “soft” feel might be something to be concerned about. I put the nose down slightly and descended slowly and magically the airplane felt more stable/solid. 8,500′ might be more turbulent and other airplanes were talking to ATC about this but my RV-12 just seemed more solid there. I believe that my RV-12 was at the edge of it’s envelope with the 100+ ground temps and 10,500 even though it was 60F up there. We made it back to Libby field with no issues but I was very grateful that I have pilot friends who are willing to speak their opinion and keep me and those I love safe. What if I had touched the ailerons? Sorry about the length of this. Just wanted to pass it on.

  5. I can see it – three good friends, all trusting one another. One says “Hey, what’s up that canyon?” Hey, we do it with cars, right?

    I wonder if a glass cockpit with its sea of red would have kept them from taking that turn?

  6. For the “what on earth was the pilot thinking !?” crashes like this one, my observation as a general comment, not specifically directed at this one; is that many pilots who knew the victim probably not that surprised.

    Human factors researchers have done a lot of work on analyzing risk taking behaviours. When combined with impulsiveness it can often be an innate personality trait and very hard to alter.

    This was not an “accident” as there was nothing accidental about what happened. So what to do ? Well ultimately flying allows incredible freedom to make choices, good and bad. The kind of regulation that would have prevented this pilot from making those choices would destroy aviation.

    Ultimately I think we can only be our brothers keeper and offer some advice when we see things that reduce flight safety. If that advice is ignored there is not a lot left to do.

    I was at an airshow and I saw a great example of this. One of the performers saw some low passes in a warbird that were flown in a way that concerned him. He took the pilot aside and had a respectful private conversation with some pointers on how he could make his flying safer and provide a better show. It was accepted in the spirit it was intended and he adopted the suggestion. I truly believe a future accident was avoided here.

    These kind of interventions are hard to do but can make a profound difference. Choosing to accept the message is a choice, but then flying is ultimately all about the choices a PIC makes and nothing will change that.

  7. “What drives me to my oft-worn journals this evening is not any sort of “I told you so” but rather an important takeaway that as pilots we continue to do the same dumb stuff over and over and for some reason we sit and wonder why it continues.”

    Because we are humans.

  8. “Another thing we can agree on is that no flight is worth risking our lives for.”

    I can not and do not agree. Every flight I have ever made has had some degree of risk in it. I chose to accept that risk and hopefully manage whatever problems came my way.

    • There are many levels of risk.
      A planned flight with a good plane, pilot in good condition, good fuel, good weight, good terrain, good weather, good traffic and good flight planning will have a much lower level of risk than one that lacks one or more of these.
      And one feels they must fly with a high risk in any of those factors, it’s much better to manage the risk before the problems arise rather on the fly.
      Even if the pilot can get out of a jam one or more times, “past performance is no guarantee of future results”.

  9. “One thing we can all agree on is that between takeoff and tragedy there was ample time for the three pilots to speak up and make better decisions.”

    Each of the three with a bit of testosterone. Each not wanting perhaps to be seen as the weaker of the other two?

  10. “Another thing we can agree on is that no flight is worth risking our lives for.”

    I’ll add the words of a respected instructor

    “There is no civilian mission that’s worth taking calculated risks.”

    • The mission of getting out of bed is a calculated risk. Hopefully, I’ll be taking that mission for a long time to come as long as I mitigate the risks inherent to my flying and driving missions as much as possible.

  11. How any able-minded human adult the slightest familiar with flying in areas with vertical earth projections can call this crash an “accident” with a straight face is far beyond my ability to understand.

  12. The bottom line is: Was this “accident” preventable? From what I understand and from the comments, it was not really an “accident”. It was an outcome caused by poor judgement and flawed decision making. It was definitely preventable on several levels. The fact is… it was a series of decisions creating a fateful “mistake”. The greater question is: When will the NTSB start classifying (a majority of) airplane crashes as mistakes instead of accidents?

    • This is why in the safety field, we speak of mishaps, not accidents. Most mishaps in the workplace (80 – 85%) are due to unsafe acts by the workers. NOT accidents. Only about 1% are unpreventable, “acts of God,” or accidents.

  13. I can make a mistake and not have an accident.

    I can make the same mistake that results in an accident.

    Clearly there was an accident following the pilots mistakes.

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