On July 7, 2022, the NTSB released the final report on the Dale Snodgrass crash in Lewiston, Idaho, in July 2021. As many expected, it found that the crash was caused because the pilot failed to remove the control lock during his preflight and then failed to perform a full flight control check to catch the error. In this interview with NTSB Vice Chairman Bruce Landsberg, he reveals that the only thing unusual about the accident was the pilot was a high-time, accomplished military aviator with thousands of jet hours flown in high-risk environments. Unfortunately, we’ve seen this all too often before, and Landsberg also discusses a Gulfstream IV accident that killed seven in 2014. Same reason. Snodgrass’ legacy may be the positive one of shocking pilots into taking control checks seriously.
CLARIFICATION: Vice Chairman Landsberg said the aircraft didn’t burn after the crash. However, there was a post-crash fire that partially burned the wreckage, but not to the extent that hampered the investigation.
I remember a Scott Crossfield interviewed about his incredible complex test aircraft achievements and the interviewer noted that he like to fly his Cub and how that was probably nothing for a pilot like him to fly. Scott came back with the reply, “yeah, the Cub will only kill you a little bit”.
That statement has humbled me many times and probably saved my life several times. It reminds me that a checklist that I’ve read a thousand times needs to be read one more time.
And didn’t Crossfield fly into a thunderstorm with a Centurion?
Crossfield was guided into a thunderstorm by ATC while IFR, as I recall.
This isn’t a design problem this is a pilot was in a major rush to get airborne problem. All Cessna ag planes have a similar control lock and I have yet to read any issues on not unhooking it before flight. Face it Snodgrass screwed up.
“Face it Snodgrass screwed up.“ Human being’s have a tendency to do that now and then. Still haven’t found an antidote after all these years. We need another study of course.
I literally cannot get into my airplane unless the control lock is removed first.
No training whatsoever is required and no check list is required. As far as control locks are concerned it’s pretty much fool proof.
It is clear as day to me that design was and is the issue. An accident waiting to happen is an understatement. On the contrary, the accident was designed to happen just as a a gun is designed to discharge when you are playing Russian roulette. Eventually it’s going to happen with 100 percent probability.
There is a very simple and obvious fix that requires no training, no check list and literally costs nothing. How this is still an issue is beyond me.
Retired G4 pilot here.Thank you Paul for having and publishing the discussion with Bruce Landsberg. It’s a great public service on your part and that of AVweb.
If FSI did anything to teach me how to fly a G4, they convinced me of the imperative of flight control checks on a G4 regardless of the thrust lever interlock safety feature. And if there were any G4 flight control check doubters prior to BED 2014, there shouldn’t be now. In our department we did 3 control checks on the G4 prior to liftoff, the first one taking place prior to brake release while still on the ramp where we started engines. While I have always been enough of a flight controls check freak to make people think I’m trying to get airborne by flapping flight controls alone, I became even more of a freak as a result of flying the G4. My 120 gets a minimum of 3 visual flight control checks before every liftoff and it has no internal flight control lock. All that said, this conversation with Bruce Landsberg still gets my attention.
Yep. The seat belt has to be released from the yoke in early Cessnas LOL.
BUT..in tandem aircraft the “other” seatbelt can have the “stick” locked and not be noticed …UNLESS that FULL/FREE/CORRECT check is performed.
From day one student pilot:
Control Surfaces – Free, Clear and Correct.
Even on your own aircraft, absolutely on any rental even when rented everyday or even after a $200 hamburger.
When you turn your back on an aircraft it’s a different aircraft when you come back to it. You don’t know where or how it’s been.
Yeah, a Cub will only kill you a little bit, humbling thought.
I’m surprised that “complacency” was not brought up during this interview or report. I fear my own complacency. You do it over and over and complacency is inevitable. Brief the threats, and for high time folks, complacency is a big one.
A very sad accident.
I cannot understand how a pilot can start and taxi a tailwheel airplane to a runway for takeoff without ever having his hand on the stick. Even starting such an airplane such as this with the stick not back can cause serious consequences. I assume an autopsy eliminated medical issues. CFI 1419983
“I assume an autopsy eliminated medical issues.”
It did. The autopsy found no pre-existing medical conditions or drugs in his system that would have lead to the accident. The cause of death was “blunt force injuries”.
Many taildraggers can be taxied with the rudders locked…. because differential braking is a great-part of the method. No rudder movement is required in most designs.
“Snodgrass’ legacy may be the positive one of shocking pilots into taking control checks seriously”.
I agree. Thanks for taking the time to put this together.
The only thing that would have prevented this tragedy (or thousands of others) was the fourth factor, “engineering the problem” with a better control lock design. Every one of the other four failure chain factors (training, procedures, and supervision) can and will be missed or mitigated. I have a 1960 Cessna 172A and have never taken off with the control lock in place. I’ve never actually tried, because it’s very hard to taxi to the runway when the engine isn’t running.
There is a thin metal collar screwed to the panel where the control yoke column exits. Two holes are drilled on opposite sides of the collar which align with a hole drilled through the steel control yoke. A 3/16″ rod locks the yoke, and thus the control surfaces, into a neutral position. This sort of control lock is quite common, but could be forgotten when preflighting.
The elegant difference is that the other end of that rod has a red metal plate that completely covers the engine starter control. It is physically impossible to start the engine from the cockpit without removing the control lock.
The only possible failure mode would involve starting the engine and reinserting the control lock for some reason. Even then, there is a fail-safe: the locking ring is made of relatively thin aluminum. In 1996 when Hurricane Fran nailed KRDU while the plane was temporarily tied down on the ramp, that locking pin will rip right out of the ring simply from aerodynamic forces applied to the control surfaces, much less the muscles of a panicked pilot. THAT is proper design. It’s a little more elegant than using a seatbelt to tie the stick full-aft in my ’46 Champ, but just as effective.
Therefore, SIAI Marchetti is responsible for this accident, imho. All pilots forget control locks. When something designed to protect the aircraft depends on pilot wet-ware, both will be lost at some point.
If he forgot to put enough fuel in would SIAI Marchetti be responsible? What if he forgot to check the oil level and the engine seized for lack of oil? Is that the responsibility of Marchetti?
Chip, Bruce addressed the core problem here when he said, “We periodically will fish somebody out of the weeds because they used a bolt or a rusty nail in place of a missing or damaged control lock”. And, “…probably every year or so we’ll come across a crash where somebody used a makeshift control lock”.
Yes that design is poor, but even with the best designs the spectre of Personal Responsibility will still rear it’s ugly head somewhere along the continuum. That is until we have a fully automated aircraft that will take responsibility for removing the control lock for us, before doing all the flying for us.
So who is best placed to say that a given design is ‘too unsafe’ for us human pilots to use? And to decide what is ‘too unsafe’? My response would have been people of the calibre, knowledge and experience at the ‘coalface’ of the person in this accident. And if they can fail to recognise the hazard that (in this case) that control lock represented, then I think that’s cause for us all to be losing a little sleep. And to reinforce that the person who is ultimately responsible is as close as the nearest mirror.
Given that the cause of damn-near every aircraft accident can be placed on the pilot (“Did he really have to go flying that day?”) whose wet-ware is not nearly as reliable as fabricated control lock hardware, the control lock needs a failsafe for when the pilot fails.
My nosecowl plugs are attached by a strap that loops around the prop. Yes, I have had to retrieve them from the weeds. And yes, it’s embarrassing if anyone else sees it, but it’s a damn-sight better than wondering why the CHT’s are pegged on climb-out.
My point is that there are a lot of things that we can’t prevent, but a control lock designed to protect the _aircraft_ should jolly-well have a failsafe to protect the _pilot_ when (not ‘if’) it is overlooked.
And that responsibility lies with the manufacturer.
If the accident pilot was still in the military and this was a military aircraft, he would have been met by the plane captain who would have showed him that all the pins and locks had been removed. The pilot would then take directions from ground crew who will signal him/her to go through flight control checks several times up to and including just before take off. Not in the military, we as pilot have to make those checks ourselves and we need to do it all the time every time. Would a $15.99 “Remove Before Flight” tag with four feet of tether cord tied to the control lock and then draped across the control stick save a life here. Probably. Recognizing that the control lock is poorly designed is only the first step. Doing something about it (for less than $20) is the next step.
A sobering crash from such a well-known and highly respected aviator. So many things out of character from his normal method of operation, including time for preflight and using an intersection takeoff. Human factors along with a poor design of control lock is a hard pill to swallow on this one. Thanks for a great interview and a good, hard look at the factors.
Agree with Berto that the control lock is a bad design in that it is difficult to see when engaged from the pilot’s perspective. However, the inverse is also true- when the lock is NOT engaged, it is easy to see from the pilot’s perspective, laying on the cockpit floor. Before taking the runway, look at the floor to ensure the lock is clipped to the deck and not interfering with the controls in any way, then do your control checks. That lock needed to not just be verified as not engaged, but also confirmed to be clipped to the floor where it couldn’t foul the stick.
I was an Oceana based F14 driver when Dale was a VF43 bogey driver and later an XO/CO in VF33. Good stick, but over stressed many, many aircraft in training, causing tons of work for airframe and power plant crews. He had a lot of experience, but a unique attitude towards things like G and flap speed limitations that wasn’t prevalent amongst very many aviators. Mostly because he could get away with breaking airplanes, and the rest of us couldn’t.
Sad way to go. Had he had more experience in the aircraft, he likely would have had time to develop habits and flow patterns that included the control lock. He owned a Sportsman 2+2 previously, a great, forgiving, economic back country aircraft. Why he purchased this turbo prop, which had to have limited his flight time due to operational costs is beyond me. Lack of time in the aircraft was a contributing factor.
@Jack E. : Yes you are correct. He did display a “privileged” attitude which he (and any other commander) would not accept from a subordinate. This was quite evident in his auto-biographical Smithsonian presentation.
Still, I hate this happened to him.
New line item in checklist: “SNORT” check control surfaces, free, correct & clear….x 3. We should all remember him, by the final lesson he left us.
Do we know that Mr Snodgrass ever did the pre-flight before climbing into the cockpit. Although long time out of the military and commercial ops when the pilot never does more than a quick walk round. Had he therefore expected someone else to have pre-flighted the aeroplane and maybe they had or normally did. Of course, the simple full and free movement of the controls during taxiing ,even when late, causes no loss of time so this strikes strikes of complacency.
Some years ago when rock climbing from school our instructor emphasised self checks; “one mistake frightens the living day-lights out of you and you will never forget, two mistakes will require all you training and skills but three errors are unrecoverable”. that fact remains with me 60 years on. When has there ever been a serious accident with less than three elements.
If you read the report, you’ll see that he had a reputation for doing extended preflights.
Naval Aviators flying Tactical Jets did extensive preflights at all stages, followed by ground and flight deck crews giving the aircraft even more checks. On the F14, the pilot went one way, the RIO went the other, resulting in the aircraft getting two, discrete preflights by both crew members. There were multiple, detailed items to check, accumulator pressures, fasteners, pins, weapons, etc.
I met Snort at a performer’s party in Pensacola a few years back. He was holding court at the bar, talking with his hands, and knocked his glass of red wine all over my shirt. Without hesitating, he slapped a $50 on the bar top, which I tried to refuse, but he insisted. Instead of buying a new shirt, I used it to cover the next few drinks. He was a bit gregarious, but seemed a good guy.
Re: the accident, my take is “if he can make that mistake, we all can”. So how do I mitigate it in my flying? I check the critical items TWICE during my preflight. I move the flight controls during my preflight walk around, then again during my before takeoff check. I also give myself two chances to check the fuel level, fuel selectors, fuel shutoff valves, and trim.
The one thing I got out of that crash… I wonder if he survived.
The plane began to burn what seemed to be an eternity before anyone got to the plane.
He is a simple solution, and likely worth the $100 if you don’t like the idea of burning alive. A few companies make a fire ball fire extinguisher (look it up on YouTube) that only activates.when exposed to fire, not heat. If these were mounted forward of the firewall, when gas hits the hot manifolds and ignite… these explode, putting out the fire. The balls are harmless went the they go off. I’ve seen kids set them off in their hand. They are non toxic or corrosive… but most important, when you are unable to operate that little fire extinguisher in the cabin… the fire ball extinguisher can activate itself.
I don’t sell these yet… but I should.
The balls ARE heat sensitive (around 160 – 185 F), which is typically caused by flame. The flame, of course, provides the heat.
But what else sets them off? How well do they handle vibration? Or rough landings? And are ANY certified for use in a plane? What happens if it pops when you’re in cruise mode – will your engine be happy ingesting fire extinguishing dust?
And what happens during the crash? The G forces should be enough to set it off, even before the post accident fire is starting. Your firewall directs the powder dispersal forward of the plane, while your wing tanks are pouring fuel out behind – probably not a good outcome.
These look to be potentially useful for stable, static installations where the self-activation could be useful. But quite worthless for active fire fighting, as compared to regular, directable extinguishers.
“ The one thing I got out of that crash… I wonder if he survived.”
He did not. If you read the NTSB report it state: “According to the autopsy report, the cause of death was blunt force injuries.”
Thanks Paul, I learned more than I expected from this accident investigation.
In my experience, transitioning from one aircraft to another alters Operational Risk for each flight and / or transfer to alternate aircraft. Meaning, Experience in one aircraft does not imply experience another. Yes aircraft fly alike but pilot to flight systems interface and understanding are key elements to proper Safety Management of any flight. It is correctly observed that we all need fuel, oil, electrical power, instrumentation, frequencies, maps, weather planning, etc. All check list appropriate information.
My personal example is transitioning from a Cirrus (550 hrs) to a Columbia, both with Avidyne Instrumentation. My first year IMC with the Cirrus was a high awareness piloting process. Surprisingly my transition to the Columbia was also. They fly the same but both switches and systems work differently enough to cause pause between the thought and the assured correct action needed. In a way I was a test pilot for this new aircraft. For me the Check List was essential to operating the aircraft correctly. This included Check List phrases that were not common with the Cirrus.
While training for the Commercial, I recall that accident data surveys show early flight time pilots make silly / ignorant errors with mishaps (around 40 flight hours and above). As pilots approach 120 to 160 flight hours they get cocky with their capabilities and choose to make stupid decisions.
This human nature process to aircraft transition does not evaporate with thousands of hours of flight time. It represents a new test pilot school for flight systems. Even the CHECK LIST and functional locations in the cockpit.
I suspect that the FAA Safety Management System (SMS) guidelines does not consider flight in an unfamiliar aircraft as a specific issue to consider.
CHANGE is one of the human performance characteristics leading toward Human Error.
My daughter has earned her private pilot and is now transitioning to our personal airplane. Each takeoff is preceded by both hands on the yoke. Full right aileron and left thumb up and pointing at the up aileron. Then full left aileron and right thumb up pointing at the up aileron. Then full elevator up and then down. Then finally review of trim settings. I’m so happy as she does it without being told. She gets it.
Many years ago, flying the Jetstream 31, my fading memory recalls a parking brake style gust lock between the two pilot seats. Up was locked, down was unlocked. Simple, right? Unbeknownst to me, one time my first officer laid the aircraft logbook on the floor below the handle. Approaching the runway I lowered the handle and started to check control movement. The yoke only had partial movement! We moved to the side to allow traffic behind to takeoff while we troubleshot the problem. Thinking we might have to return to the gate I reached down to engage the locking handle. When I saw the logbook I instantly realized our problem. After moving the logbook to a better location, we went through the control checks again and they moved freely. Needless to say, a notice was put out to the pilot group to ensure nothing was ever placed on the floor below the control lock handle! One link in the mishap chain removed.
The discussion between Mr. Landsberg and Mr. Bertorelli was good. I wonder if either of them …or how many of us readers/listeners…noticed that the agreement between them about the poor design of the flight controls and how it likely contributed to the accident…was later ignored in the conversation about the “bolt or rusty nail” which sometimes has been used as replacements for OEM locks…and the subsequent comment by Mr. Landsberg and agreement by Mr. Bertorelli…. that substitution is a bad idea and that “original designs are better and shouldn’t be messed with” (words to that effecdt) …. are contradictory to the overall conversation.
I believe the adherence to STRICK DISCIPLINE and PROCEDURE…. with an eye toward CONSISTENCY OF PRACTICE ….is the KEY to this sort of accident avoidance.
I have experienced a near-disaster as a pretty-experienced pilot (13K+ hrs) in a HS-125. That airplane, like the Grumman, will not allow full throttle application of both engines unless the control lock is removed. The operator can advance each engine INDIVIDUALLY to full power for engine-checks…but Both Throttles are prevented by mechanical interconnect to prevent Both from being advanced beyond a “fast taxi”.
I was Chief Pilot/Captain for a year or so in that airplane and was introducing my F.O. to the left seat on a couple of corporate flights preparatory to sending him off to training for his Type Rating/Upgrad to Captain. We had taxied to the runway, were cleared for takeoff….and pulled onto the runway… slightly out-of-sequence because of the seat-swap…
The left-seat guy is taxying using throttles, brakes, and Tiller-Wheel steering…and pulling onto the runway, Mike began to advance the throttles for takeoff…when they would not allow further movement at about 60% power,… because the “claw” (control lock which is not easily in view from the right seat) was still engaged.
The DeHavilland/Hawker-Siddeley design saved us!
We had accidentally skipped thru the usual sequence of our taxi checklist due to the distractions of the seat swap…and missed the mandatory “Free/Full/Correct” flight control checks. (In that model it is typical for the Left seater who is taxying, should test rudder actions and announce “Lower” or “Rudders” and the right seater should respond “Uppers” as he operates the control column.)
Getting in a “hurry” to appear to passengers that things are “normal” (despite the seat-swap) for that particular takeoff is what I believe silently pushed us toward continuing off the taxiway and onto the runway for the takeoff.
It was a learning experience which taught me to ALWAYS use the same Sequence, Procedure, Technique WITHOUT DEVIATION.
I very much like Mr. Landsbergs’ remark about how we should view such accidents when committed by highly-regarded/experienced aviators. We should use them to reflect inwardly that “if that can happen to HIM (HER)…. it can happen to ME!
Thanks.
Sorry for my own “typos”. Once again…in a hurry…didn’t check my work! LOL(embarrased)
Ahem: on the video at 19:33, the NTSB guy says he doesn’t want to besmirch the name of the pilot and that’s why the NTSB doesn’t use the pilot’s name. Then, 23 seconds later at 19:56 in the video, he says this crash reminds him of Scott Crossfield, and how Scott Crossfield was a top-notch pilot, flew into a thunderstorm, etc.
Interesting.