The Most Difficult Call: Intervening To Stop The Inevitable Accident


The emotion in Sheriff Billy Garrett was clear as the 40-year veteran officer described the task of breaking the news. “It’s horrible . . . it hurts an old man’s heart to hear a young girl cry like that.” It had been a stressful couple of days for the sheriff, culminating in the duty to make that call. First responders had to call off the search during the previous evening, due to dark and poor weather conditions. When the search resumed the following morning, they found the crash site: a horrible debris field containing the remains of an aircraft and two occupants, a son and his mother.

The NTSB report describes an accident sequence starting with a descent from 7500 feet, but in fact, the links in the accident chain started months or even years prior and provide important lessons for both pilots and instructors.

In October of 2016, Charles was visibly excited. Accompanied by his girlfriend, he attended a neighborhood picnic at the airpark where he was buying a home. Meeting his new neighbors, he declared his intention to become a pilot. As a friendly, outgoing person with a career in sales, it didn’t take long for him to make the acquaintance of several of his new neighbors in this tight-knit community. Those contacts led to numerous conversations about how to obtain training and fly safely.

However, as the months went on, some of the conversations reflected a worrying pattern. On one occasion, a Baron was landing on the runway. Wide-eyed, Charles declared: “That’s the airplane I’m going to get. It’s a Seminole, isn’t it?”

“No. It’s a Baron. However, you should probably plan to get your license and build experience in a simpler aircraft first. A high-performance twin isn’t a good place to start.”

“I don’t care. I can buy one. I’m going to get one,” he replied.

“Starting with a simpler airplane with one engine will help you build the skills necessary before stepping up to something with twin engines.”

“I’ve driven cars, motorcycles and boats and I’m good at it. Airplanes will be no problem for me,” he said.

Charles asked a neighbor where he should go to learn to fly. The neighbor outlined a few options, but suggested that it would make things faster and cheaper for him if he spent some time reading texts on flying; it would allow him to hit the ground running when his real training started. The neighbor offered to recommend some titles.

“I don’t need to do that,” Charles replied. “I don’t read stuff. That’s the instructor’s job, to tell me what I need to know.”

Upon learning that one of his neighbors was an instructor, Charles approached him to ask if he would teach him to fly. The neighbor refused. When Charles asked why, the neighbor explained that over the months he had gotten to know him, Charles had displayed a number of traits that the instructor felt would not be consistent with the ability to fly safely. The neighbor clearly stated that if he continued down his current road, Charles would have an accident in an airplane and the instructor didn’t want to facilitate it.

Charles dismissed the concern as the neighbor having it “out” for him. With this in mind, he relayed the conversation to another neighbor, who stated his respect for the instructor’s experience and opinion and suggested Charles should take those concerns to heart. He didn’t.

Fresh from these events, Charles approached another neighborhood instructor, who also refused to take him on as a student for the same reasons as above. He then went to another airport and over the following several months went through several instructors. In each case, the instructors flew with him a few times and then refused to continue, even though they continued to fly with other students in the area.

Charles was running out of options. The manager of the local flying club said he did not wish to continue renting to Charles, but he was undeterred and in August of 2019, found a way to work around this latest obstacle by buying his own airplane: a well-equipped Piper Turbo Lance. He also found another instructor outside the club who was willing to work with him in the new airplane.

Over the following months there were a number of events involving the new Lance, including several near misses in or near the traffic pattern at local airports, some involving nonstandard pattern entries and limited or no radio calls. On one occasion, patrons at an airport restaurant watched in disbelief as the Lance took off, just barely visible through ¼-mile visibility in driving rain as a thunderstorm passed through the area.

By sometime in 2021, Charles had accumulated over 100 hours of time in his new airplane as evidenced by his logbook, his frequent movements around the airport and by social media postings showing him flying his airplane, surrounded by smiling passengers. There was only one problem: He still didn’t have a certificate. In fact, he had not even passed his private license written exam. One of his pilot friends offered to sit down with him and help him study, but Charles wasn’t interested.

At some point, the new instructor accompanied Charles on a dual cross-country from Houston to Murray, Kentucky, where Charles had family, a distance of over 500 nautical miles. Sometime thereafter, a solo cross-country followed along the same route.

Around the middle of April, 2021, Charles lost his job. A family event in Murray beckoned, plus his father was in ill health and Charles wanted to see him. As the owner of an airplane, he probably assumed that flying would be the natural way to make the trip. The instructor apparently agreed and even though the private solo cross-country requirements had already been met, he approved another solo cross-country along the same route as flown before. However, this flight would be different.

For one thing, it was delayed and Charles elected to make it a night flight. For another, his mother was on board. This may not have been the first time she had flown with him; witnesses recount other occasions in which a female passenger was seen and thought it odd, given Charles’ known instructor was a man.

The NTSB final report summarizes the rest of the facts: a night flight into known deteriorating weather conditions, which most probably became night IMC, leading to spatial disorientation, loss of altitude, airspeeds approaching 300 knots and the death of both people on board.

As pilots, we are taught to recognize the hazardous attitudes: Macho, Impulsivity, Invulnerability, Anti-Authority and Resignation. In this case, there was a pattern of behavior that illustrated at least three of these. We are also taught to self-assess our fitness for flight with a PAVE check (Pilot, Aircraft, enVironment and External pressures).

No doubt, Charles was feeling external pressures, with a sick family member, a passenger relying on him to get her to the destination and the desire to demonstrate his ability. However, how good are we at recognizing these behaviors and pressures in ourselves or in others, and when recognizing those conditions in others, to what degree is intervention justified? Certainly each person must take responsibility for their own actions, but at what point does concern for innocent passengers or passers-by take precedence?

In Charles’ case, there were many people who anticipated the events of April 20, 2021. Several of them tried to directly warn him with frank conversations, to no avail. However, the person most directly connected to the situation was his instructor.

As instructors, we have a number of responsibilities. Chief among them is keeping the student safe while they acquire skills and knowledge sufficient to keep learning on their own. However, shouldn’t the responsibility to keep a student safe also extend to being comfortable that the future passengers and passers-by of a new pilot will be in good hands? It is our responsibility to ensure a productive learning environment while the student acquires those skills and we assess their ability to leave the nest on their own. Until that time comes, the objectives of flight should be education, not transportation.

The private pilot license requires a solo cross-country flight of over 150 nautical miles with full stop landings at three airports and one segment of a minimum 50 NM.  Typically, this involves a flight of up to 75 NM from the home field, sometimes less if a triangular flight path is followed. It allows for the student to experience navigating through potentially unfamiliar terrain to potentially unfamiliar airports while still remaining within a time and distance in which the conditions are unlikely to change significantly after review with their instructor.

Increasing the time or length of cross-country beyond these requirements contributes little in terms of educational objectives at this license stage, but increases significantly the risk of encountering unforeseen weather as time and distance increase. By endorsing a multi-state, multi-day solo cross-country, an instructor risks leaving the insulated, controlled learning environment and steps into the realm of facilitating transportation, something that should be reserved as a privilege of the private certificate itself.

In addition, part of an instructor’s responsibility is to supervise their students. This means reviewing the weather and conditions prior to launch, being aware of when launch occurs and then monitoring conditions during the flight, up to the point at which safe arrival is confirmed. In this case, the cross-country was approved as a day cross-country, but according to the NTSB report, the instructor was unaware that the student had delayed departure to the point where it became night. It is difficult to supervise a student’s flight if the instructor does not know when or if the pilot departed.

Another instructor responsibility is not only ensuring that a student knows about things like hazardous attitudes and external pressures, but helping the student cultivate an awareness of those things in themselves. This is done over multiple flights, reviewing PAVE checks together and loaning the instructor’s experience as a guide to the student as they develop their own judgment. An instructor who is aware of significant hazardous attitudes has an obligation to help the student recognize and address them, or alternately stop facilitating flight, as several of Charles’ previous instructors had done.

The prerequisites for first solo or for first solo cross-country do not include completion of the written exam, but perhaps they should. There is a material chance that a student on a solo cross-country might need some of the knowledge contained on that exam. I’m aware of a number of instructors who require that their students complete the written exam before those events.

At the end of the day, the responsibility for the safe conduct of a flight rests with the pilot in command. After 130-plus hours in the cockpit, the students assuming the duties of pilot in command should know what they’re doing and the risks they’re taking and exposing their passengers to. There is a chance that Charles was going to do what he wanted, regardless of any outside intervention; he had certainly displayed significant resistance to outside opinion in the past.

However, as bystanders and instructors, perhaps we should question the degree to which we might have influenced the behavior, or missed an opportunity to take some action that might have broken a link in the chain and prevented the outcome that led a sheriff to make a heartbreaking call on April 21, 2021.

David Forster is an instructor and experienced homebuilder who contributes to AVweb’s sister publication, KITPLANES. He lives in Texas.

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  1. Steve Fossett, Scott Crossfield, Dale “snort” Snodgrass and now Charles whats-his-name in this story.
    Don’t do what they did.

    • I read that Snodgrass was the “greatest living fighter pilot”. I don’t see how that title can be applied to a man that was a surely a great pilot, but was brought down by an item that is taught you on you’re first day of flight instruction – ensure all controls are free and correct. Steve Fosset getting caught in a boxed canyon or Crossfield flying into a thunderstorm are demonstrations that nobody is immune from screwing up BIG TIME in an aircraft, even a simple single-engine CESSNA.

  2. At first I thought of Thurman Munson, but after reading more JFK jr would be a better description. Some people just have more money than brains.

  3. Perhaps an ASRS-like system that anonymously allows instructors to report to the FAA characters like this. Not punitive, but more like a stage-check. If the pilot doesn’t pass check, then his ticket gets pulled until remediation and further instruction. Then reassess and if no improvement then a complete ban. This guy would have failed and perhaps lived longer. And his Mom would be alive

    • Sure – i would assume you would support doing that with your drivers license. A regular citizen could anonymously report your poor driving and your license gets pulled with no way to recover it. That sounds like a great idea. CFI’s and training facilities are not the FAA police.Nor should they have the power to pull a certificate. I have seen instructors do some really dumb stuff and they have been killing themselves for decades all in the name of safety and training.

      Letting the government fix it. No thank you.

      • Actually you can, by providing LEO with a license plate number, never pull someone over, or providing them with your neighbor who is constantly drunk and observed driving. They will put those individuals on the radar scope. (Reserve cop here.)

    • You and many politicians erroneously think that people can be controlled. This guy already did NOT have his “ticket” but he still flew (when he wasn’t supposed to). Ban? What would a “ban” do? Nothing. Declaring that he is not allowed to fly would do nothing to prevent him flying. Despite some declaration, he can still get in the plane, turn the key, and take off. Part of life is that bad things happen. In many cases, at least, not much can be done about it. Parents and friends can help shape others (like this guy’s instructors or would-be instructors tried to do), but that’s about it.

      • If someone had dropped a dime to the FAA and they ramp checked him, the fine might have been enough to straighten him out. Unlikely though.

      • Mmm…not entirely. I know of at least one case where the Agency did all the normal sanctions (revocation, civil penalties, etc.), all to no avail. In a last ditch effort, the legal department got a federal judge to issue an injunction against the “pilot” enjoining him from coming within 100 feet of a GA aircraft. That worked. There are many things in life that are never a good idea: one of which is to piss off a federal judge.

        • I’m with Eric J. As instructors, we have a duty to others (potential passengers, other pilots in the airspace, etc) to speak to the FAA about someone whose actions are so illegal and unsafe as to constitute a hazard to safety. The FAA is required to investigate any such complaint, and they will surveille that person’s activities — which with a guy like “Charles” won’t take long to nail.

  4. As a long time instructor I stopped two characters early. One was outright too dumb, lacked, except for money, any form of talent or willingness to learn.
    The other self made and succesful businessman was already on a rocket track with his company, living his own dreams but with a total disregard for other people, who handed him good advice.
    In general I waited 5-6 flights before making a decision. Because some people get the message after a few flights and are good students from there on. Plus slow starters that need a few lessons because the flying sets them off in a for them hostile environment and did not perform in the beginning.
    In other cases in which for one or the other reason I would suspect a (much) higher number of hours needed, I would say so around that time also. That prevented discussions after the minimum flight hours for the test was well passed.

  5. There have been more-money-than-brains Charles-type around the local airport since I started flying in 1956.

    Why doesn’t the FAA do something similar to what California does with motor vehicle sales? No airman’s certificate, no sale. Not perfect, but a step in the right direction.

    • Can you elaborate?

      I’ve lived in California for over forty years, have gone through numerous cars, and the only time I’ve ever had to show my license was if I was paying by check. But never in order to simply buy, register, or title them.

    • I have to laugh every time I hear the suggestion that the FAA should “do something.” After 44 years of flying and over 21 years as an Aviation Safety Inspector, I’ve been around long enough to remember the howls of protest every time we even thought about “doing something.” “The FAA is knee-jerking,” they’d say, or the FAA is “heavy-handed and inept.” I was once called a Nazi because I had the temerity to expect a flight instructor to know some of the stuff in the Flight Instructor’s Handbook during a reexamination I conducted after he failed to properly supervise a student. I once had a pilot I knew from a previous job call me up at the FSDO to tell me that I should “go after” some other guy that he “just knew” was flying in the clouds without a clearance because he heard him on the radio on a day when there was no way anyone could be VFR—like I’m some kind of attack dog you can sic on an annoying neighbor. When I asked him if he’d be willing to submit a detailed written complaint as evidence?…oh, no, he didn’t want any part of THAT!

      It’s in everyone’s interest to see that nimrods like the one in this article are kept out of the airspace that we all share. But if, as a CFI or as a knowledgeable and responsible member of the aviation community, you’re unwilling to step forward and file a formal complaint—testifying to names, dates, and specific acts that you have personally observed—then you need to go back in the hangar, close the door, turn off the lights and contemplate what you’re doing in this business. In the words of JFK, “If not us, who? If not now, when?”

  6. According to the accident report, the aircraft type was a Piper PA-28RT-201T which is a turbo Arrow and not a turbo Lance. In any case, it was a completely avoidable accident.

  7. In a free society it is difficult to prevent people from killing themselves and others because of their arrogance, stupidity, impulsivity, etc. The system isn’t really set up to stop them until they have a serious accident or worse, and that is often too late to prevent a tragedy.

  8. Well, he was observed routinely violating regulations, carrying passengers, etc. He posted about it on social media. A call to a FSDO might have brought enforcement action and loss of his student certificate. That probably wouldn’t have stopped him, though. It’s unfortunate that any CFI was willing to work with him. Kudos to those who refused. They aren’t responsible for the fact that he ultimately found his way into the pilot’s seat.

  9. We all have met people like this . I know of one out of TOA who we seen flying with
    a passenger without his PPL but was only a few day past his long cross country in a high performance complex aircraft. I told our shared instructor who talked to the original witness and the pilot in question who gave him a big deal old man everything was fine answer. (The Old man is a well known local instructor). He continued to do so and the instructor basically fired himself and would no longer fly with him. The pilot shopped some more and finally was caught by the FAA is a few of us decided the FAA needed to know. His Student flying rights were suspended. there were other serious consequences of his action i cannot share.

    The problem with a personality like this is that they do not accept that their decision making is flawed. the goal of earning a pilots certification is to learn correct decision making and thought processes.

    I have 240 hrs in my training and after the death of my son in law afew days before my private checkride, (as per usually mid life students i had money but no time), my son in law died leaving my daughter pregnant. I did this grounding as my emotions did not allow me to sit in a car for my usual LA commut without thinking of Mike. I would get a bit upset and teary he was like a son, a very good and loved man. I became my grand daughters dad for a few years, my second daughter took that over and eventually my daughter wed a fantastic man who has been a very good father. it has been 11 years and I want to fly but in all reality it may not be the best idea. I may give soaring a shot. I have too many responsibilities with grandchildren and an upcoming wedding to a wonderful woman to put this added risk into my life. and at 64 years old one gets very good at risk analysis and sober thought.

  10. I’m sure for instructors it’s a tough call on when & how to escalate on their misgivings, whether on the basis of skill or judgment.

    I sold my own first airplane, a Tri-Pacer, to a co-worker who wanted to become a pilot. He had two different instructors, with the first eventually suggesting to my friend that he try the second. Ultimately the Tri-Pacer came to grief during a go-around, fortunately with injuries limited to bumps and bruises for pilot & instructor; at the time he had accumulated something above 40 hours of dual and had not yet been signed off for solo (and had not done so, to the best of my knowledge). The friend did give up the idea of becoming a pilot, which made me happy even though he never finished paying me for the airplane.

  11. Instructors have a special obligation to not train students that exhibit personality traits not conducive to safe flying. I have fired several students over the years that I deemed unsuitable.

    However the situation is often not as cut and dried as the example given. I am still haunted by a Multi Rating I did 30 years ago. The guy had a lot of single engine bush time and had excellent hands and feet. He also unfortunately had a “bush flying “ attitude with respect to checklist discipline, Emergency procedures SOP’s etc etc. Despite making a point of following SOP’s and emphasizing their importance his performance was consistently uneven. I had the distinct impression that he was just going through the motions and not taking the training seriously. But like I said his hands and feet were really good and so his aircraft control was excellent.

    I recommend him for the flight test despite my reservations and he passed.

    3 Months later the engine on the piston twin he was flying failed right after takeoff. He crashed killing himself and 8 passengers. I can’t help but think that despite an inconclusive accident report he wasn’t mentally ready to be flying more complex aircraft and I should not have passed him to the examiner for the flight test.

  12. Unfortunately it seems this was an accident waiting to happen, all the links in the chain were there and he would not let anybody break them..kind of like arguing with a drunk, no matter what facts, statistics, and evidence you tell them you are always wrong and they are always right.

  13. An instructor can be up against it, knew an instructor who was ex military F-111 working for a school who advised a student he didn’t have what it took to be a pilot, owner of the school went ballistic because of the loss of revenue. Money talks.

  14. This reads like a “Find 50 Things Wrong in This Story” exercise. To me, that includes him shopping around until he found an instructor who was kind enough/desperate enough to take him on. Of course the instructor bears fault for approving the X-
    C, but this is one where I am very sure the “pilot” would have found a way to do it regardless.

    You can’t fix stupid. Or as an aerospace engineer told me, “You can make things foolproof, but you can’t make them damn-fool-proof.” And the damn-fool took his mother with him…