Human Factors: The second decision

The loud bang on takeoff wasn’t a good sign, but it was the cell phone call that really ruined the pilot’s day. That’s when he learned his nosewheel was lying on the grass strip 1,000 feet below, the towbar still attached.

We all make mistakes although, granted, this one was a doozy.

But it’s what you do in the moments after a mistake that makes the difference between whether the NTSB writes about your bad day or — as in this case — you get to author your own misadventure in the form of an Aviation Safety Reporting System (ASRS) report, known to its friends as the “NASA report.”

Before the Incident

What could be nicer? A quick flight to a private grass strip to spend some time with your son, then a flight back to your home base for dinner with your daughter, all in the same day. The pilot’s ride is a Cessna Turbo 182 Skylane RG, and he described the weather that day as “severe clear.”

After landing at the grass strip, he puts his airplane into an air conditioned hangar (it must be one heck of a nice grass strip).

After visiting with his son, the temperature has reached 95° Fahrenheit, so he sensibly chooses to pre-flight in air-conditioned splendor.

Then, in his own words, “Upon completion of my preflight, I went to retrieve my bag and briefcase while my son opened the hangar door and moved the airplane to the end of our taxiway.”

The Pilot

Because this is a NASA report, we don’t know as much about the pilot as we do in the case of NTSB reports, but he reported that he was multiengine-rated with a total time of 3,685 hours, including a very respectable 420 hours in type.

But it is worth noting, he’d only flown six hours in the previous three months.

The Bad Decision

Our hero continues his story: “I walked out to the airplane and put the gear in the backseat. I gave my son a hug while standing under the shade of the wing and got into the airplane.”

He did not, he reports, do a final walk around. Which is too bad, because if he had, he might have noticed that his son had neglected to remove the towbar.

The bar does not impede the initial takeoff roll, but as he lifts the nose at V1 it drops down, digs into the turf, and snaps the nosewheel clean off the airplane.

“I heard a loud bang and vibration. I assumed I had hit an obstruction,” he wrote in the report.

The Next Decision

We could spend all day talking about delegation, trust, verification, PIC responsibility, or adding the stupid towbar to the checklist. Let’s not. Instead, let’s just chalk the towbar up to a mistake, the first link in a chain that could have just as easily ended in tragedy, instead of bent metal.

And make no mistake, a mistake can happen to any of us. It’s what happens next that deserves our attention.

“The controls were functioning, and the airplane was stable, so I continued my climb to clear trees at the end of the runway. At 1,000 feet I reduced power and began circling to troubleshoot.”

Had he chosen to abort the takeoff, it could have ended badly. His first decision, skipping a final walk around in the heat, not so great. His second, trusting that the airplane felt right so he kept flying, much better.

More Decisions

He reaches his son on his cell phone, “who told me the nosewheel had been severed from the airplane. Apparently, he had not removed the towbar when he moved the airplane from the hangar.”

Wouldn’t you just love to hear a recording of that phone call?

Regardless, here is our pilot, orbiting the grass strip at pattern altitude, with no nosegear and a difficult decision to make: Now what?

So, a quick word on NASA reports, if you haven’t read many. Remember, it’s an anonymous system — that’s the point — so airport names are replaced with Zs, and when there are several airports being discussed, numbers are added. This keeps the reporting party’s identity safe, but it can sometimes make it difficult to piece together some of the details.

But in this case the pilot rejects both landing back on the grass he took off from and also ZZZ2 — presumably the next closest airport — due to the lack of emergency equipment there. In the end, he decides to return to his home field. He also calls a pilot/mechanic he knows who is an expert in Skylanes for tips on how to best land the lame beast.

His plane continues to function properly, with good oil pressure and “solid control function,” he reported.

He contacts approach, requests priority handling, and gives them the 4-1-1 on his situation. He’s cleared direct, and asks the tower to roll the fire trucks.

“Once I had the runway made,” writes the pilot, “I pulled the mixture, turned the fuel selector to off, turned the master off and turned the mags off. I used soft field technique, touching down on the mains at about 45 knots and holding the nose off until I couldn’t anymore. The airplane settled and skidded less than 50 feet.”

Following one bad decision, a chain of good ones.

He then double checks that the airplane is secure, and exits where, he reports, he is “greeted by the local fire men.”

The Outcome

“There was no fuel or oil spill nor any debris on the runway. The airplane suffered a prop strike and lower cowling damage, but was removed from the runway in about 30 minutes.”

But, he confesses, “the incident could have been avoided with a simple, final walk around the aircraft after having ‘ground personnel’ (my son) move the airplane out of the hangar.”

We don’t know if he made the dinner with this daughter and, if so, what was said about her brother.

Analysis & Discussion

So he made a bad decision. A mistake. An oversight. You choose.

But then he made a long series of good decisions in the aftermath.

• Consider: What could have happened if he’d aborted the takeoff?
• Consider: What could have happened if he didn’t confirm he’d lost the nose gear?
• Consider: What if he had returned to the grass strip and attempted to land?
• Consider: What if he’d gone to the nearest paved airport that didn’t have emergency equipment?
• Consider: What if he didn’t call an expert for tips?

The Takeaway

I think that it’s very easy, after making one bad decision, to make another. And following two bad decisions, not only is your reservoir of luck running low, your options have just been significantly narrowed as well. At three bad decisions, you might as well just call the NTSB yourself to save a bystander the trouble.

So that, I think, is the takeaway. When you make a bad decision — and you will — it’s only the next decision that matters.

Back in the day, pilots were taught that when something went wrong, the first thing they should do was wind their watches. (This was before watches had batteries.) Of course, in an emergency, you don’t generally need to worry about timekeeping. The point was to force a moment of inaction. To take a breath to maximize your chances of making a good follow-up decision.

Because, in an emergency, there is a human tendency to do something, anything, right away. But rushing into the next decision, following a bad one, is a good recipe for making a second bad decision.

Now in this case, the pilot’s second decision — abort the takeoff or keep going — was split second. There was no time to wind his watch. But after that second decision, each decision he made was well considered before it was executed, and he always kept focused on the next step, instead of beating himself up (too much) about the original bad decision.

We all can learn from his example. When you make a bad decision, let it go. Let it go and move forward. But move forward clear-headed, open eyed, and cautiously. Because your next decision is more critical to the final outcome than the bad decision that started the wheels in motion.