Human Factors: Feeling trapped

The right wing hit first. Clipping the top of a 30-foot-tall tree on Trap Mountain, Arkansas, ripping the lower right skin right off.

But the Cessna 182 was going fast enough it hardly mattered. It smacked into the rocky ground a hundred feet further on, the momentum carrying a 12-foot chunk of the left wing yet another 144 feet from the crash.

The NTSB described the wreckage as “highly fragmented.”

In fact, only the tail — embedded in a tree above the debris field — gives any evidence at all that you are looking at the wreckage of an airplane.

Careful analysis of the little bits and pieces that remained revealed that the airplane was operating correctly — in the mechanical sense — prior to the crash.

The probable cause of the fatal accident? “The non-instrument rated pilot’s improper decision…”

Yeah. I’ve read that line too many times to count. It’s the classic VFR into IMC killer that’s been stalking pilots for decades. But while VFR to IMC is the “defining event,” I’m more interested in the thought process of the pilot well before that event defined his fate.

And in this particular case, there is a lesson in pilot culture that I think we can all benefit from. But first, let me set the stage.

The Mission

It was a long day on deck. The pilot, who owned a maintenance shop, and a second pilot, had left their Clarksville, Arkansas, home base early in the morning and flown south deep into Louisiana. They made two stops.

At the second one, they picked up a “nice-looking” Cessna 182 that had suffered cosmetic sheet metal damage in a hurricane. The mission was to ferry the 182 back to Clarksville for repairs as a flight of two.

The Pilots

The owner of the maintenance shop was a 55-year-old male. He received his private ticket in 2004 — 17 years before the accident — and his A&P certificates the next year, in 2005. Earlier in the year of the accident, he obtained his Inspection Authority. He did not have an instrument rating. He was the leader of the flight.

At the controls of the Cherokee, the chase plane, was another private pilot. We don’t know much about this person other than the fact he also did not have an instrument rating.

The Flight

The flight of two stopped at Minden, Louisiana, for food and fuel, about 200 miles short of their final destination. Night was setting in, and the weather wasn’t good.

The FBO had already closed for the night, but the pilots huddled and studied the weather, which the chase pilot later described to the NTSB as looking “very sketchy.” Their destination was reporting 1,500 scattered and 2,000 overcast.

Despite this, the accident pilot advocates for taking off, climbing to 1,500 feet, and reportedly stated that they “could always land at Magnolia (slightly off route, and about 40 miles into the 200-mile flight) if the clouds were too low.”

The chase pilot concedes, and the accident pilot takes off first in the 182. The chase pilot follows in the Cherokee.

On takeoff the chase pilot describes the weather as “already sketchy.” The clouds are patchy. He can see the ground if he looks to the side, but has no forward visibility. Within 20 minutes they are in solid IMC. But they fly on.

No instrument flight plan. No instrument ratings.

In his interview with the NTSB, the chase pilot says that the two pilots were talking to each other on 123.45, the unofficial, but widely used air-to-air frequency.

As they approach the proposed alternate, the accident pilot tells the chase pilot that he thinks the weather will clear up and that they should push ahead. The chase pilot reportedly tells the lead that he’s feeling that he’s in over his head, but the lead’s response is to coach him on how to keep his wings level.

They are in almost non-stop communication. The chase pilot later told the NTSB that the accident pilot appeared more worried about the chase pilot than what was going on with the flight.

At this point, the only thing the chase pilot can see is the rotating beacon of the lead plane.

Seconds before the accident, the chase pilot glances down at his phone “to check his flight path” on ForeFlight, and sees the track for the lead airplane is coming back toward him. He keys the mike to ask the lead pilot what he’s doing. There is no response.

Then the lead airplane disappears from the ADS-B feed on ForeFlight. About 30 seconds later, the app issues an altitude alert for 500 feet.

The chase pilot pours on the coals, pulls back hard on the yoke, and climbs to 3,500 feet. He’s still in solid IMC, but feels safer now that he’s higher. He remains in IMC for over an hour. When he gets close to Hot Springs, Arkansas, about two-thirds of the way through the flight, he considers diverting, but finds the ceiling is 300 feet, overcast.

He proceeds on toward his home base and, luckily for him, 10 miles out the weather clears and he’s able to land. As soon as he touches down, he calls the lead pilot’s cell phone.

There is no answer.

The chase pilot told the NTSB investigator that he knew there had been an accident.

He also blamed himself for the accident, saying that the accident pilot became complacent because he was trying to keep him (the chase pilot) safe, and not paying attention to the altitude they were at, compared with terrain elevation.

Analysis & Discussion

At first blush, that sounds like a case of survivor guilt to me.

And while we only have one person’s side of the story here, it feels like the accident pilot was putting a lot of pressure on the other pilot: Overriding the chase pilot’s worry about “sketchy” weather, ignoring his statement that he’s in over his head, and by-passing the agreed-upon alternate.

On the other hand, there was nothing stopping the chase pilot from saying, “you go ahead, I’ll catch up with you tomorrow” while they were still on the ground at Minden. Or turning around and landing again once he saw there was no forward visibility on takeoff. Or heading for the alternate on his own. He was part of a flight of two, but he was Pilot in Command of his own aircraft.

As to their battle plan, it was theoretically doable. Their destination has a field elevation of 481 MSL. With the clouds at 2,000 AGL, their cruise altitude of 1,500 MSL put them 1,019 feet above the field and 981 feet below the clouds. But of course, the clouds were lower en route.

And while the route was mainly flat, there are at least three areas of elevation very close to, or higher than their cruising altitude, including the mountain the lead pilot hit, which was just off the direct route to the west.

I think that, had they been able to maintain VFR, it would have been ok-ish, but of course they both illegally flew — for a considerable time — in the soup.

The fact one survived, and the other survived as long as he did, suggests to me that they did this kind of flying on a regular basis — especially the lead pilot who was coaching the other.

What kind of person not only flies IFR without an instrument rating, but encourages someone else to do the same?

His obituary says he was a “good Christian man with a generous spirit.” He was described as a hard worker with a passion for flying and could fix “just about anything.” It says he took great pride in the aviation business he had built and truly loved what he did. The splash page of his obituary at the funeral home’s website is a photo of him getting his shirt tail cut off after his first solo.

But there is a darker side to him, as well. The FAA Forensic Sciences Lab detected Seroquel in his body, an antipsychotic prescribed to treat schizophrenia, manic-depression, and bipolar disorders.

The Aircraft Owners and Pilots Association’s FAA Medication Database shows Seroquel as a prohibited medication. The NTSB notes that the medication’s side effects include sleepiness and that it may impair mental abilities.

That said, plenty of VFR pilots NOT on Seroquel have flown VFR to IMC and killed themselves, so I’m not inclined to blame the drug. But, as it’s on the “no fly” list — along with the pilot’s illegal IFR flying — it does tell us something about his personality.

But even all of that isn’t what jumped out at me about this crash. What jumped out at me was that not one but two pilots made a series of really bad decisions.

The Takeaway

For decades, having two pilots has been considered to be a “proven” safety enhancement. And in the airline transport world that is certainly true, but it may not be true in other areas of aviation.

A recent research project carried out by my Luna College Skunk Works team (for presentation at the 2023 NAFI Summit in Florida) found that in loss of control on ground crashes — which are one-quarter of all flight-training accidents — instructors giving advanced training to other pilots were twice as likely to be in an accident than instructors training new students.

Maybe because that’s still fresh in my mind, I can’t help but wonder if this tragedy doesn’t have similar roots: That maybe in GA, a pair of pilots isn’t a safety enhancement, after all.

I can’t help but wonder if either pilot would have continued into the “sketchy” weather had they been completely alone, rather than in a peer-to-peer environment.

I’m guessing the lead pilot would have, given his other behaviors. But I think the chase pilot, if making the go no-go decision on his own, would have hunkered down in the mist and waited for the next day.

But peer pressure — either subconscious or conscious — won the day, with tragic results.

So, what can we do to combat peer pressure in these kinds of situations?

Would something as simple as a secret ballot be better than a discussion? After reviewing weather together, should each pilot write “go” or “no-go” on a sheet of paper, then compare? That might work, but it only combats verbal peer pressure. If you feel you have to write the answer someone else expects, it won’t work.

But any tool that slows down the decision-making process, even by a few minutes, gives time for thought, and confidence in that thought.

Aside from that, if you are the more experienced, older, or more certified pilot in flights of two or more, you need to do your best to reset your caution meter to the lowest common denominator. Be sure you are being respectful of others’ comfort levels. Just because you can do it doesn’t mean someone else can, or should.

If you are a junior pilot you need to develop absolute confidence in only one thing: It’s your call to make, and no one can — or should — make it for you. Allowing yourself to be swayed outside your comfort zone is a trap.

And if you start feeling trapped, just remember what happened on Trap Mountain, Arkansas.

The Numbers

Want to read more? Download the NTSB’s final report, CEN22FA058, here or view the items on docket here.