Human Factors: Déjà vu all over again

Wait a second, I think I’ve read this fatal accident report before. More than once, in fact.

Only… huh… there are a couple of details here that I’m not recalling. OK, I guess I haven’t read this particular one before, it’s just déjà vu from the fact that — over the decades — I’ve read so many cases of blood on twisted metal that share the same root cause.

People don’t seem to be getting the memo.

The Flight

The accident flight started at Machias, Maine — located on the extreme eastern coast of the state, where it bulges out toward Nova Scotia — bound for Palatka, east of Gainesville, Florida. According to the NTSB report, the pilot was flying from Maine to Florida to meet friends at the 2023 SUN ‘n FUN Aerospace Expo.

It’s a long flight by GA standards in a 161-horse Piper Warrior, over 1,500 miles as the crow flies. Only that would put the crow over the Atlantic Ocean nearly the entire flight, even using a great circle route. Following the coast line, it’s a fair bit longer. In fact, it’s pretty much as long a flight in a north-south direction as you can make in the continental United States.

But even though it was a long trip, this wasn’t the pilot’s first rodeo. In an interview with the pilot’s widow, she told authorities that the pilot had traveled to SUN ‘n FUN “on numerous occasions” and was familiar with the route.

In a memorial announcement on the Facebook page of his home airport, posted shortly after the crash, the individual posting noted that the pilot was making his “annual trip” to the event.

That said, this time the trip wasn’t going according to plan.

On Day One the pilot took off from Maine a bit after 8 in the morning. He made two fuel stops and then put down for the night at Tarboro-Edgecombe Airport (KETC) in Tarboro, North Carolina — more or less half way.

But it had been a 10-hour day in the air. He slept that night (or tried to, at any rate) in the FBO’s pilot lounge at the airport. Dinner came via Uber Eats. According to the pilot’s widow, sleeping at the airport was her husband’s normal modus operandi, adding that he carried camping equipment and guitars for such occasions.

The next morning, he took off again a little after 8 a.m. and flew to Conway-Horry County Airport (KHYW) in Conway, South Carolina, landing about a quarter to 11 in the morning.

An FBO employee at Conway reported that the pilot looked tired, telling the accident investigators he could see “fatigue in his eyes.”

The pilot told the employee he was SUN ‘n FUN bound, but had been fighting a strong headwind the whole trip. He took his shoes off and had a cup of coffee. He checked the AWOS and told the employee he might spend the night to wait out approaching weather.

But then he apparently changed his mind. Next thing the employee knew, the pilot was walking out to his airplane to takeoff again. It was just before noon. Less than an hour later, the pilot would be dead.

The Pilot

Public records don’t tell us much about the pilot. He was a 66-year-old male with a private pilot certificate and a third class medical. Based on his last medical application, he had over 740 hours of flight time, and he was the owner of the airplane.

He didn’t file a VFR flight plan, but was taking advantage of flight following services. Upon takeoff from Conway he leveled off at 1,600 MSL which, that close to the coast, is around 1,500 AGL.

At 1243 a controller asked if he wanted to climb higher, and the pilot reported he wanted to stay low to maintain VFR “due to any clouds up ahead.”

The controller acknowledged saying “maintain VFR, altitude your discretion.”

The Final Moments

At 1251 the controller noticed on his radar screen that the Warrior was starting a right descending turn. The controller radioed the pilot and asked if he was maneuvering to stay below the clouds.

The pilot responded: “Mayday, Mayday… in the clouds… I’m going down.”

That was the last communication from the pilot.

The Accident

A witness doing yard work heard the Warrior’s engine and looked up to see the airplane descending “straight down, nose first, at a high rate of speed.”

It hit a nearby marsh and mud flew up in the air. The witness said the weather was overcast, with low clouds, “like when it rains.”

A second witness, launching a boat, heard a high-pitched whining noise and looked up just in time to witness mud flying up in the air from the impact. He described the sound of the engine as what he had heard from old World War II movies with the dive-bomber’s engines whining at a high pitch.

He quickly launched his boat and headed toward the crash site to render aid. He beached his craft at the edge of the marsh and made his way on foot toward the scene of the crash. It was tough going due to deep, thick mud.

As he closed in on the shattered wreckage he realized there was nothing he could do. He noticed the water was covered in fuel and the smell of fuel in the air was strong. He made his way back to his boat and directed first responders to the scene.

The NTSB found the airplane embedded in thick mud, water, and vegetation. The wreckage “disposition” was consistent with a high-speed, nose-low impact.

The airplane sustained extensive damage from impact forces from nose to tail, or quoting the NTSB’s Final Report, “Both wings, including the flaps and ailerons, the fuselage, and the entire tail section exhibited impact damage. Both wing fuel tanks were breached. The fuselage and cockpit area were crushed.”

The NTSB

The NTSB added this accident to its long list of VMC into IMC crashes — a catalog of tombstones that rivals the size of any decent military graveyard. Yep. One more non-instrument-rated pilot suffering spatial disorientation in the clouds, then losing control of the aircraft.

Although, that said, this one wasn’t quite your typical case of disorientation, because the pilot knew he had lost control. In his final radio call he said “I’m going down.” He knew he was disorientated.

It’s chilling.

Then the NTSB called out fatigue as a major factor in this accident. And there’s no denying that the pilot was burning the candle at both ends.

Based on what we know about his challenges on his final cross-country, his trying to get a night’s sleep in a FBO, and a witness who could plainly see that he was fatigued, there’s no doubt about that. He also apparently didn’t maintain his normal communication protocols with the home front on this trip, something people sometimes skip when they are tired.

But to me, while a factor, fatigue is way down the list of what really caused this crash.

Analysis & Discussion

What really caused this crash, in my opinion, was his desire to make it to SUN ‘n FUN as planned, an example of our old nemesis, external pressures.

Despite embedding awareness of its corrosive effects at all levels of pilot training, despite repeated showcasing of it in accident case studies, and despite countless articles, webinars, and talks, people just aren’t getting the memo: The quickest way to kill yourself in an airplane is to pressure yourself to fly beyond your capabilities — whether those capabilities are weather, equipment, certification, experience, or simply how much energy you have left over from the day before.

A second pilot-induced gremlin might also have come into play here too and that’s expectation bias, a tendency of the human mind to expect operations to go the way we experienced them previously.

As this was an annual trip that he had apparently done many times before, his mind may not have been optimally primed to deal with a major change. There was no flight plan filed, but based on what he told the FBO staff, it sounds like he was not making the progress he had expected. He even talked about waiting out the weather, but changed his mind and took off, apparently without a weather briefing.

Pity. He had the camping gear and the guitars to make waiting out the weather a joyful diversion.

Fatigue, external pressure to meet friends at an event, and expectation bias…that’s an unholy trinity of interfering factors when it comes to quality aeronautical decision-making if there ever was one…well, three…

Some colder folks will say, “well at least the only person he killed was himself.”

And while that’s strictly true — at least from the inside-the-airframe point of view — we are social creatures and no one passes without leaving grieving loved ones behind.

And in this case, fate was even crueler. Apparently the pilot and his wife had an ADS-B receiver in their home, and the pilot’s wife was actively tracking him at the time of the accident.

The NTSB, in the summary of its interview with her, reported that she “watched the accident in real-time and knew that he had crashed. In fact, she is the one that called 911.”

The Takeaway

So with SUN ‘n FUN 2025 right around the corner — it kicks off April 1 and runs through April 6 — and with pilots far and wide planning that annual pilot pilgrimage, it seemed like a good time to re-issue the old memo: You can’t have fun in the sun if you kill yourself — literally — trying to get there.

We must temper our excitement with good judgment. We must not let pressure to complete the mission — either from ourselves or others — cloud good judgment.

And when things go wrong, we need to roll with the punches, not bull ahead. Leave early, give yourself time for the unexpected, and remember that the journey, when it comes to GA, should be as much fun as the destination. Pack your guitars.

The Numbers

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