Human Factors: Even a little crash can be deadly

More often than not, it’s the little things that kill you.

For instance, of all the myriad hazards of flying the bush in Alaska, death by pond taxi in the state’s third-largest city would seem so low on the list of possibilities as to be nearly impossible.

And yet…

The Accident

The official report is remarkably brief for a fatal accident. A haiku of an obituary.

It was late in the day in Fairbanks, Alaska, in October. The pilot of a float-equipped Cessna 185 loaded with more than 700 pounds of unsecured cargo was taking off from a pond. The first attempt didn’t play out. The aircraft didn’t get airborne before running out of water. The pilot aborted the attempt and was water-taxiing back to give it another go.

But something was desperately wrong. I don’t know if it was visible to the pilot or not, but witnesses reported the airplane’s floats were nearly completely submerged. The drag and suction of water surrounding the bulk of the floats no doubt caused the inability of the floats to “get on the step” and break free for takeoff on the first attempt.

The witnesses further reported that the pilot was taxiing with high power and that the pitch attitude of the aircraft was “unusually nose-low” in the water as it taxied back to reboot its takeoff run. So much so that when the pilot reduced power, the airplane pitched forward, rolled over on its back, and sank in a flash.

The Pilot

The pilot was a 74-year-old male. He was not technically a working Alaska bush pilot, as the flight was a Part 91 personal flight, and he held a private pilot certificate with a third class medical.

No summary of his hours was available, but according to the FAA airman registry, his certificate was issued in 2010, roughly 15 years before the accident. Maybe.

This could also simply be the date he got his plastic pilot certificate, as that’s the year all of us who originally held paper certificates had to convert, and the data base shows the issuance date of the plastic, not when we actually were certified.

His obituary stated that he was a “phenomenal bush pilot with several thousand hours in the backcountry.” He also apparently had owned a number of airplanes, including Super Cubs and other 185s.

But why so much cargo for a personal flight? Remember I said he was technically not a working Alaska bush pilot? He wasn’t, in the paid-to-fly sense, but in reality, things were more complex.

An overview of media coverage from Kathryn’s Report shows that the pilot was a long-time owner of a wilderness guide business in the Brooks Range, leading clients into the wilds since the 1970s. My guess is that the cargo was associated with his guide work.

Is that legal? Absolutely. It would fall under “incidental to business,” which is fully within the privileges of a private pilot.

Sadly, he was trying to sell the business at the time of the accident so that he could spend more time with his children, grandchildren, and great-grandchildren.

His obituary summed him up as a “longtime Fairbanks resident, pilot, veteran, wilderness guide, and guitar player.”

The Final Moments

The bush plane, tough little thing that it was, wasn’t actually damaged in the accident at all — a rare thing for a fatal airplane accident.

But during the pitch over on the water, all that unsecured cargo — 743 pounds of it in the cabin — slid forward, pinning the pilot and preventing his escape. He drowned in the cockpit before help could arrive.

But why did the airplane swamp? Was it overloaded?

Yes. Yes, it was, but not in the way you’d think.

Investigators inspecting the recovered and righted airplane discovered two unsecured holes in the floats that had allowed the floats to flood. That’s why witnesses saw them nearly submerged.

Like a pair of twin Titanics with holes in the bow, the floats were sinking ships. It’s possible that the takeoff attempt basically shoveled water though the holes, speeding their fill.

Oh. Right. Like the Titanic, floats have compartments. The NTSB investigators felt that the front compartments were likely completely flooded, causing the nose over. It’s a waterborne version of being out of the CG envelope in the sky.

The official probable cause was listed as improper maintenance of the floats, with the unsecured cargo being a contributing factor.

Aftermath

When the airplane was pulled ashore, witnesses reported “four large streams of water” coming out of the front of both floats.

The holes that water gushed from, investigators determined, rather sickeningly ironic, were caused by an attempt to do the right thing.

According to family members, when the airplane arrived in Alaska it did not have proper bumpers on the floats, instead having what appeared to be old tires rigged to the floats. The pilot had the proper bumpers installed, but in that process, the installer overlooked some of the holes that had been drilled for the previous modification.

Additionally, an FAA inspector reported patches on the bottoms of floats that did not appear watertight.

Why didn’t the thing sink at anchor? Apparently the pilot stored the airplane on dry land between flights.

Analysis & Discussion

So what was going through the pilot’s mind after the liftoff failure?

I checked the almanac and the flight happened about one hour before sunset. Could the lateness of the day, and the approach of sunset have prayed on the pilot’s mind? None of us are immune to the dangers of mission creep — gotta get this job done and daylight’s burning!

And what about the cargo being unsecured?

After the airplane was drug ashore, one witness described the fire department removing what turned out to be 690 pounds of the cargo load pinning the pilot’s body: “There was so much stuff on him. So much, so much. I couldn’t believe all the stuff.”

I’ve never flown freight or bush, much less freight in the bush, but from all the other sorts of flying I’ve done over the decades, I’ve always been impressed by how things I thought were well stowed had a way of moving around the cabin in flight.

But I don’t think our takeaway from this tragedy is about securing cargo. That was only one movement of the requiem. And the same is true for external pressures.

Sure, those were both elements — links in the chain of this accident — but I think our takeaway is in the basic pilot instinct to make a flight.

Or, more correctly, to take flight.

The Takeaway

How often does a takeoff not play out right and we essentially do a ground-based go-around? Just taxi back and try it again?

Airborne, the go-around is a most excellent landing tool. But it belongs squarely in the landing toolbox.

If things aren’t looking good on a landing — more often than not — a go-around is the safe and proper response. The only exceptions would be an extreme low fuel state (shame on you in the first place for that), some kind of one-way mountain strip, or some sort of desperate mechanical failure where a bad landing (even a crash landing) might be a safer bet than trying to navigate the crippled airplane around the pattern again.

But, like most tools, the best ones anyway, the go-around is designed for one job, and one job only: Landing.

A takeoff go-around isn’t such a wise thing. It’s using the wrong tool. It’s like using a power drill to open a can of peaches. The go-around is a fast-action tool. One to deploy quickly when time is of the essence. In fact, when there is no time to spare.

But if something didn’t work right on a takeoff, and the takeoff is successfully aborted, there’s plenty of time to spare. There is, I’d argue, fully enough time for a more reasoned response. Give it another go isn’t a reasoned response.

If the takeoff didn’t work the first time, an exact repeat isn’t statistically likely to have a different outcome. Isn’t one of the definitions of insanity doing the same thing over and over again and expecting different results? I think I read that somewhere.

Now in this case, sadly, I don’t think it would have made a difference to our guitar-playing wilderness guide pilot. He’d as likely capsized heading back to the dock as heading back to try the takeoff again but, that said, to me, the best takeaway from this accident is for us to think about second attempts following aborted takeoffs.

Hence my focus on the “go-around” takeoff.

If your takeoff didn’t work, you need to pull to the side of a taxiway, or to the side of the pond, and carefully go through what happened. Review your flow or your checklist. Did you possibly overlook, skip, or miss-set something that might have resulted in the unexpectedly poor performance?

If not, then something is probably wrong with your airplane. It’s not putting out the performance that it should for some reason.

At a minimum, it may take a shutdown and a more comprehensive preflight to get to the root of the issue or a mechanic might even need to get involved. But it beats a crash.

Because even a little crash can kill you.

The Numbers

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