“Oh, $%*@# !….” Waking up to the news that he had lost another friend to an aviation accident was not a good way to start the day for Tom Bush (CDR, USN, ret.)
This latest tragic mishap claimed pilot number 21 in his own necrology of civilian and military pilots he had known over the years. Bush’s friend, former airport neighbor, and fellow Mooney driver had flown into trees in pre-dawn fog in Norfolk, Virginia, killing the pilot and two passengers onboard.
Bush’s aviation safety analysis training kicked in almost before the morning’s coffee, and he pored over weather charts, ATC tapes, and the Mooney’s flight path tracings toward his old Tidewater, Virginia, stomping grounds.
It began to look very much as if his friend’s accident was the last link in a distressingly long chain of questionable decisions.
The pilot had borrowed the 1975 Mooney M20F, a plane he had flown often, from a friend at the Suffolk, Virginia, airport (SFQ). With two friends accompanying him, he left Virginia’s miserable winter behind for a week of tropical relaxation aboard his sailboat in the Florida Keys. Too soon, surely, it was time to go home.
The men departed Key West (EYW) on the evening of March 3, 2015. After refueling in northern Florida, they took off for SFQ. The Florida weather had been excellent, and they had a fine tailwind northbound, but by the time they reached eastern North Carolina, much of the coast was blanketed with chilly fog, drizzle, low ceilings, and gusty winds.
The poor Atlantic seaboard conditions that night had spread, leaving no good alternates within the pilot’s fuel range. Home beckoned most powerfully, though.
If he was like many confident IFR pilots, he might have figured there was a good chance they could slip in under those IFR weather conditions at his familiar home field, and still get to work on time. If not, he may have reasoned, nearby Norfolk (ORF) had an ILS good down to 200 and a half.
Bush knows risky flying when he sees it. He had a 25-year career of flying the Navy’s hottest jets. He’d flown F-14s and F/A18s in combat over Iraq and Afghanistan. He and his fellow Navy fighter pilots routinely landed on aircraft carriers, flew mere feet apart from each other in formation flights faster than the speed of sound, and screamed low over enemy territory dodging missiles and anti-aircraft fire.
“While the flying we did in the military — especially in combat —was inherently very dangerous, out of the 21 pilots that I consider friends who have died over the years, you want to know how many were lost in combat? Not a single one,” he grimly notes.
According to Bush, the same stuff that kills civilian pilots kills some of the world’s best military pilots, flying some of the world’s best airplanes. They ran into each other. They flew into terrain under controlled conditions — otherwise known as CFIT. They suffered from spatial disorientation. They got into weather they couldn’t handle. They made decisions to continue in spite of poor conditions — sometimes pressing ahead despite extreme manifestations of mental or physical fatigue. Only rarely were the fatalities due to equipment failure, and even when they were, those failures were almost always traceable to a human source.
For these reasons, Bush is angry. He’s angry because the initial indications regarding the loss of his friend strongly suggest that the mishap was totally preventable, like so many others he has seen or investigated. He’s angry because one simple decision to abort and land short of the destination in more favorable conditions could have prevented it. He’s angry because he’s lost another friend.
The NTSB report is months from being published, and what follows is, Bush warns, entirely unofficial conjecture by a grieving friend. There could have been factors not in evidence that led to the crash, he points out.
“The pilot could have had a cardiac event, he could have had induction system icing, he could have run out of fuel,” he readily admits. “But with the basic information available in the immediate aftermath of the crash, it looks more like a series of regrettable decisions than any of those possibilities.”
As a Naval Aviator, Bush has conducted many accident investigations. His civilian career now involves not only lots of corporate flying, but advising his oil and gas industry employers and colleagues on maximizing safety in a risky field, so he knows whereof he speaks. He ticks off the items of concern over his friend’s last flight one by one:
The pilot had a late departure after dark, embarking on a single-engine flight over an 80 nm stretch of water and a sizable chunk of the inhospitable Florida Everglades. While this, in itself, did not contribute to the mishap, to Bush it is indicative of the pilot’s level of risk acceptance for this particular flight, perhaps serving as a telltale sign of “get-there-itis.”
“While I might have found the risk level associated with flying my own, well-equipped and maintained airplane over that amount of water acceptable during day VFR conditions, I wouldn’t even begin to consider it at night, as you’re simply out of options if something goes wrong,” he said.
They passed many VFR fields, but were headed toward airports with conditions ranging from IFR to Low IFR, with temperature/dew point spreads in the destination area within one degree of each other.
His fuel reserves were tight, considering the widespread worsening conditions forecast for their destination and what would be brutal headwinds on the approach.
By the time the pilot expected to be landing at SFQ, he was doubtless very tired. His circadian rhythms were probably at their lowest ebb, just when he needed to be at the top of his game.
Bush’s stint in the Navy taught him that fatigue is the second-most prevalent causal factor associated with Naval aviation mishaps, second only to spatial disorientation.
By the time the Mooney arrived in the SFQ terminal area, automatic weather observations were reporting conditions below approach minimums, but the pilot decided to take a look anyway. He reported to ATC that he was having difficulty intercepting the final approach course for the RNAV 22, was experiencing moderate turbulence, with loose articles flying around the cockpit, and was having trouble reading his approach plates.
On the missed approach, the Mooney continued to Norfolk (ORF) for the ILS 23. Once again, he had trouble intercepting and staying on the final approach course, describing a flickering localizer needle and turbulence that made it feel like “flying in a washing machine.”
With excessive lateral deviation on his first ILS approach into ORF, ATC cancelled his clearance, directing him outbound for another try. The pilot described a badly precessing Directional Gyro (DG) to ATC, and also revised his earlier estimate of an hour and a half of fuel remaining to perhaps a half-hour. He turned inbound for his second attempt at the ILS at about 10 miles northeast of the airport over the Chesapeake Bay.
Winds were so severe from the southwest at altitude that at one point, he told ATC, “I’m indicating 105, but only showing 30 knots ground speed.” ATC confirmed this. Due to his previous report of a precessing DG, he was offered and accepted no-gyro vectors from ATC.
Flight Aware tracks indicate the pilot did an excellent job of maintaining course along the localizer up until about 1.8 nm from the runway. From there, a series of lateral deviations resulted in his being issued a few course corrections by ATC. With weather reported just moments earlier as “200 feet overcast,” the pilot called the runway in sight from a position that appeared to correspond to less than a half-mile final.
This would be the last radio call he made, with ATC losing contact with the aircraft from a position northwest of the field. The aircraft came to rest in the woods of the Norfolk Botanical Garden, 1,800 feet to the right of the final approach course and perfectly abeam the approach end of Runway 23.
“It sounded as if he fully realized that he’d flown himself into a situation for which there were but two remaining options: Break out of the clouds and land at Norfolk, or flame out due to fuel exhaustion and land off airport. He didn’t have the fuel to reach anywhere else with better weather.”
Saddest of all, by that afternoon, the sun was shining.
In this case, the classic stages of grief — denial, anger, bargaining, acceptance, moving on — had stalled, for Bush, at anger. The sad outcome was so avoidable, it seemed.
There were many links in the accident chain before they were in real trouble. If any one of those had prompted a no-go call, the pilot and his passengers would likely still be alive and a nice-enough Mooney would still be flying.
In his career flying fighters in dangerous places, being shot at, landing hot airplanes on pitching aircraft carrier decks at night, and betting his life on all of his fellow aircrewmen doing their jobs perfectly, Bush understands better than most that “stuff” happens. When it did, he grieved. He cried. He prayed. He donated to surviving children’s college funds.
As a military mishap investigator, he studied the accident scenes, analyzed data, and wrote reports hoping, as he sifted through the clues, to come up with ways to understand it so that they could prevent the next one.
This GA accident offered only perplexity. Bush can’t help but wonder, what was this competent and experienced IFR-rated pilot thinking? He had chance after chance that evening to survive his flight. He and his passengers could have spent the night somewhere along the way and, with an early start the next morning, they would have arrived at their destination after the fog lifted.
He could have refueled a second time at the last VFR airport along the way to add a healthy cushion of time for a much better Alternate Plan B, or a retreat to the better conditions they’d overflown.
“The reason I get mad is that I can see all these factors that were stacked against him that he, and he alone, created,” Bush said. “Now, I admit, I have absolutely done some stupid things. I’ve been low on gas, I’ve iced up, I’ve flown when I was tired. So far, I’ve lived to tell about it.”
“There were so many chances to stop this chain of events, though, before it killed three people,” he continued. “Perhaps I am not so much mad at my friend in particular, but mad at the very fallible human condition that causes us pilots to do things that defy logic and good sense — things I’ve done myself and fortunately got away with, but that I don’t do anymore because I’ve learned.”
In dealing with grief, we all go through predictable stages. After we get past the aghast denial, the anger at preventable tragedy, we then move to bargaining, and we resolve not to make those errors ourselves. In acceptance, and moving on, we might help others learn from horrible accidents. Bush is doing all those things, but he’s still mad.
Because the story didn’t have to end that way.
The aviation clichés are there for a reason. They’re truths distilled. You really would rather be down there wishing you were up here than the other way around, when everything turns to worms.
Flying at night can be beautiful, smooth, clear, and unforgettable. It can also be the worst ride of your life, with far fewer options for landing safely if something goes wrong, and there’s much less margin for error.
Understand the risks of pushing the limits: Yours, the weather, and the airplane’s. Cemeteries are full of people who couldn’t be spared at the office. Arriving on time, but dead, isn’t a good option.
One of those three most useless things is fuel already burned, with too little left when it is most needed. Minimum fuel required is just that — absolute minimum of 45 minutes beyond a very good alternate. Did the pilot even have an alternate? Based on existing and forecast WX conditions, one would have been required.
Simple physiology: Flying at night, after a long day, when your body really expects to be recharging for the next day doesn’t usually lead to superior decision-making skills, excellent night vision, or outstanding eye-hand-brain coordination. If you’re in this situation despite your better judgment, if you have oxygen on board, hook up the nose hose. It’s dramatic how much better you can see and think with better O2 saturation.
“If something doesn’t feel right, stop right there and check it out, even if you’re already on the runway,” Bush urges. “Pay attention to your hunches.”
It’s easy to brush that little nagging concern off as preflight tension and press on, but more often than not, there’s a reason for your second thoughts.