There’s this great cartoon drifting around the internet. A little boy and his father are walking past an airliner and the child asks: “Dad, why are there always two pilots?”
The father replies, “One has to prevent the other from doing stupid things.” To which the boy then asks: “Which one is doing the stupid things?”
To everyone’s surprise, the NTSB recently released a report that answers that question: Both pilots.
The Accident
Following an avionics calibration flight in the early afternoon of Aug. 27, 2020, a trike-model Van’s RV6-A crashed in a soybean field near Milton, Delaware. The aircraft cartwheeled, bending the tail, damaging both wings, snapping the prop off the crankshaft — and then flipped inverted, tearing the canopy off.
It ended its 25-minute flight a sad little pile of twisted two-tone blue aluminum amidst shredded dark green soybean plants.
Amazingly, both certificated pilots aboard escaped serious injury, no doubt thanks, in part, to the Hooker Harness 4-point restraints installed.
More amazingly, as it would turn out, neither pilot was flying the airplane.
The Flight
The day that ended in the soybeans started off simple enough. The owner of the airplane and a second pilot who had installed some glass panel avionics for the owner took to the sky to calibrate the new system.
The installer pilot was in the left seat and he handled the takeoff and the flight to 1,500 feet AGL. At that point, the owner took the controls and made a series of maneuvers so the installer pilot could calibrate the avionics. After the first set of calibrations, the installer took the controls again to demonstrate a function.
Shortly after that, the first link in the accident chain was forged.
The owner assumed that the installer retained control of the plane, while the installer assumed it had reverted back to the owner, so the installer went on to the next calibration task. The two pilots did not verbalize a positive exchange of controls.
At this point, one of them noticed that the alternator wasn’t functioning, and they made the joint decision to return to the airport before the battery crapped out.
Then fate intervened.
While the installer was head down continuing additional calibration entries and the owner was head down admiring his new glass — both assuming the other “had the flight controls” — the aircraft made a gentle uncommanded turn, reinforcing each pilot’s belief that the other had control, and had turned back to the airport as agreed.
It wouldn’t be until after the crash that either one of them would have any clue that no one was flying the plane.
The Pilots
I’m sure at this point you want to know more about the two pilots.
The owner of the aircraft, who was seated in the right seat for the flight, was 55 years old at the time of the crash. He had a private certificate with an instrument rating.
The left-seat installer pilot was also a certificated private pilot, aged 38.
The owner had 2,140 hours, with 135 in make and model, while the younger pilot had 296 hours total time, 79 in make and model.
Some of the documents associated with the case say the owner had no flight time in the last 90 days, while other documents list 15.1 hours. The second pilot reported only three hours of flight time in the previous three months. Both were current on their medicals and flight reviews.
They had known each other for four or five years, but only talked to each other about once every six months or so, and had only flown together one time previously.
The Final Moments
In the final minutes there were yet more links in our accident chain, because the crash was one of those “third time’s the charm” kinda things, at least if you believe in unlucky charms.
That’s because before the final bellyflop into the soybeans, the airplane — not once, but two times — nearly smacked into the ground.
What on earth were the pilots thinking? They were each thinking that the other guy really sucked as a pilot.
Quoting the NTSB report, “both expressed discomfort with how the other was flying.” Of course, neither of the men were flying. The NTSB goes on, “But neither communicated their concerns to the other in a way that was understood, nor did either confirm who was flying the airplane.”
In fact, the younger pilot later said he thought the older pilot was “messing with him” or showing off “hotshot piloting,” while the older, more experienced pilot probably thought the young pup just wasn’t a very good stick.
The NTSB
The NTSB classified this misadventure as a CFIT or Controlled Flight Into Terrain.
I’m not sure that’s a fair characterization, given that no one was in control of the airplane.
The official probable cause finding is: “The pilot and owner’s failure to adequately communicate and establish an understanding of who was flying the airplane, and their failure to take timely action to avoid a collision with terrain.”
Additionally, there are a pair of “personnel issue” findings: Lack of Communication and Delayed Action on the part of both pilots.
Analysis and Discussion
Many people, quite fairly, ask how such a crash could happen with a side-by-side seating configuration.
Of course, the answer to that was that both pilots were head down with other tasks, in the happy delusion that the other was flying. The owner was checking out his pretty new glass, and the installer was finishing up some other settings. I’ll give them a pass on that. But only so far. Because as both men expressed discomfort with how the other was “flying,” why did they allow themselves to remain head down in such a circumstance?
Of course, we already know that being head down is dangerous, especially close to the ground. And we should also know by now that we need to speak up when we aren’t comfortable with someone else’s flying.
But it was the seating arrangement, and mythology around the left seat that is our learning moment — our key human factors takeaway — from this accident.
The Takeaway
Speaking to the NTSB air safety investigator assigned to the case, the owner pilot said that as he occupied the right seat, he considered himself the passenger — even though he was the owner and the more experienced pilot.
Interestingly, the younger, less-experienced installer pilot also felt the same way, telling the investigator, that as the pilot in the left seat, he should have taken more responsibility.
Really? The left seat is not the Throne, and sitting there doesn’t make you King or Queen. If it did, every student pilot would be Pilot in Command on every training flight, and we know that’s not the case.
The fact is the Pilot in Command can be in either seat, as suits the mission.
Which is why we have the whole positive exchange of control ritual in the first place. That: “You have the flight controls.” “I have the flight controls.” “You have the flight controls” thing. I actually prefer “you have the airplane” over “you have the flight controls” because it signifies a larger responsibility, but that’s neither here nor there.
This accident clearly demonstrates that a positive exchange of flight controls isn’t just a student pilot/flight training thing, but rather, a critical safety procedure any time two pilots share a cockpit.
The owner told the Investigator that his RV was “a wonderful airplane” and it was flying perfectly before the impact. Had the pair simply followed the flight control exchange ritual, the wonderful airplane would still be flying perfectly.
So do you practice the exchange ritual when you fly with other pilots? If not, will this incident change that?
The owner pilot also said one other thing that any pilot flying with another pilot needs to think about. He told the NTSB investigator that, “In my mind, when I’m in the right seat, I am the passenger. I am in passenger mode, and not thinking about flying.”
What do you think? Can we, as certificated pilots, ever be in passenger mode?
Want to Know More?
Want to read more? Download the NTSB’s final report here or view the items on the docket here.
“Looking at his new glass.”
His new glass what?
From my days as a working pilot:
Preflight briefing to include who is PIC, maneuvers to be performed as well as emergency procedures, etc, etc.
Transfer of controls example:
PIC-“I have the controls”
SIC-“You have the controls”
PIC- “I have the controls”
SIC- Holds hands up in view of PIC
Term “controls” used instead of “aircraft” to avoid confusion with pointing out traffic.
Ironically, this is a case where the accident would never have happened had there been only one pilot instead of two.
We changed to “I have the flight controls, you have the flight controls, etc.” with the airline I flew for because “You have the airplane, Roger, my airplane, etc.” can be wrong when the copilot says it.
Because everyone knows in every situation,
It’s the Captain’s airplane!😎
well, every now and then I read an accident article and think ‘what goombahs’. this is one of those.
I recall in the mid 80’s as a military pilot a UH-1 Huey was taxiing out of departure at a 2 foot hover and at a fast walking speed. The pilot flying said “I need to look up the frequency for center”, needed after departure. The non flying pilot said ” I have them”. Moments later the helicopter was on its side with part and pieces all over the place. The first pilot assumed the other pilot meant he had the controls and released them without visually confirming in order to look up the frequency. The second pilot meant I have the frequency not the controls.
Maybe it’s just me, but I don’t typically fly around at 1500 agl. I like to have some air under me.
The fact that both survived means credit must go to the designer of a stable, well-behaved, strong airplane! The second credit goes to the pilot builder for building it correctly.
But in the end, being onboard for destruction testing is not recommended!
On multi-manned test flights, having a test card or an outline of the proposed tasks helps in two ways, team coordination and divvying up the responsibilities. Both keep the vital part of flying in perspective, always someone flying the plane!
Excellent article! I’d add from experience that the risk of such incidents are greatly increased with tandem seating and/or with two CFI’s on board. Obviously, tandem seating, eliminates the opportunity to see directly whose hand in on the stick. Less obvious is that instruction involves walking a line between being a passive observer and taking action. When both become observers or both take action, bad things happen and our rather large glider club has a collection of broken gliders to prove it.
Starting next season, our club will formalize the PIC question by instituting “tow cards” to be filled out before each flight, listing the pilot in charge (and the one responsible for damages). If nothing else, the card will force a conversation that should happen before every flight but is often skipped over.
Lucky for them, the airplane knew how to fly itself into the soybeans.
Dang, that’s messed up. I’ve caught myself being a little absorbed in something other than flying before. We’ve all done it.
You would think that one of them would have looked outside at some point during the descent and pulled up. Glad to hear there was no fatalities.
I wish it had been that simple. Both of them were judging the other guy was flying poorly while somehow not noting no one was in control. That sounds like an ego problem too. I’m a student pilot and these stories stand as the best example of what not to do.
The takeaway is the spelling of ‘assume:’ Makes an Axx out of You and Me.