Tapestry of Disaster: An Accident
By Parvez Dara, MD, FACP, ATP, CFII, and MEI
Reprinted with permission of
"FAA Aviation News"
When we commit an error it is generally an isolated one, and we get
away with it. This getting-away mentality reinforces the behavior as
being okay. But start stitching a series of these scenarios together,
and a tapestry of disaster unfolds
in his most reflective moments, he would extol the many virtues of
flying; the splendor of sights, of new places but mostly of its
freedom. He was 60 on his last birthday, a Vietnam veteran with an
artificial leg flying with a 2nd class medical certificate and a
Statement of Demonstrated Ability (SODA).
flew with precision, dedicated to his hobby and mode of
transportation. Every flight was enriching to him. He carried his task
of flying with zeal, from checklist to checklist, double-checking
while motoring one to two miles above terra firma.
that cold, rainy night in October, when I got the news of his plane
crash, it scared me, then chilled me, and finally numbed me. He was,
in my mind, going to be an old pilot, for he was never bold. He flew
this immaculately dressed Mooney 201. But the crashed plane was a
apparently flew it with the gust locks still attached!
plane had taken-off, gained 500 feet and then, predictably, plowed
into the woods. This man, in life a stickler for checklists, in death
was now the object of a storm of controversy and was leaving a legacy
of stuff that he would not have been proud of.
tried to piece together the shattered dreams of his mind and the
associated features of the ill-fated flight on that rainy night in
October. 'Accidents don't just happen,' said the aviation counselor
from the FAA, 'Planes don't just fall out of the sky.' There is some
truth to this, if you were to evaluate the cumulative vapor trail that
eventually condenses into the big splash, multiplicity of factors have
look at the so-called 10-17 percent catastrophic engine failures in
piston aircraft. I am not a betting man, but I can wager that most, or
all of them, gave plenty of warning signals and hence, could have been
averted. The gremlins may have shown up in a previous flight, in the
pre-flight, or in the intuitive feel. The oil analysis may have
revealed the chewed metal in the filter, maybe the need for more oil,
a blob of oil on the ground, or discordant magnetos. In flight, it may
have been a change of the aircraft's behavior, in its speed, sound,
dynamics, the hum, and all of the subtle noises that we are attuned to
in the cockpit. This subtle vapor trail of metal, sound, feel, and
dynamics is there for us to recognize.
we commit an error it is generally an isolated one, and we get away
with it. This 'getting away' mentality, unfortunately, reinforces the
behavior as being okay. But start stitching a series of these
scenarios together, and a tapestry of disaster unfolds.
Imagine a series of cards with random holes in it reflecting the
error-prone deficiencies of human beings. Each little hole reflects an
act of omission or commission (failing to check the trim, or the fuel
quantity, and so on; you get the point). Once in an unfortunate while,
when those holes line up in sequence, an accident occurs.
first priority to safety remains trying to patch the holes in each of
those successive cards. Learning the art of flying, practicing it,
constructing a practical checklist for all possibilities, and never
taking flying for granted. For instance, every time before I fly into
an airport, I look at its layout to see on departure where a
straight-in engine out on take-off or landing would save my bacon. Not
much but it keeps your guard up.
Consider the big boys who dream of flying Mooney's but are stuck with
the Boeings. They, too, can have a bad day. The flapless take-off in
Detroit, Michigan, led to hundreds dead'a minor mistake that led to a
major tragedy. A Continental aircraft was about to land gear-up at the
Newark airport until advised by an American pilot on the ground to put
the wheels down. Mistakes from shoddy cockpit behavior, taking things
for granted, or having the attitude that 'I am the greatest' will
in low overcast without the prerequisite experience or attempting a
crosswind landing beyond your abilities speaks volumes of the male
gender. Some of the newly minted and even long-time pilots with little
weather experience who venture into the gray unknown of an overcast
day just for a rush or, better, stupidity. How can you justify that
with anything but the remark, 'idiots?'
are preconditions for these unsafe acts [as per the Office of
Aerospace Medicine's technical report, The Human Factors Analysis and
Classification System (Shappell & Wiegmann, 2000)]:
Substandard Conditions of Operators
We have discussed
some of them above.
Substandard Practices of Operators
Management and Personal Readiness
former is not flying with adequate charts, plates, or lack of their
utility, etc. The latter is when your instinct tells you, 'It is not
good to go even on severe clear and a million,' so heed it.
I'll get back to the story. My veteran aviator would occasionally
drink beer but cognizant of the regulations, he would wait eight hours
before flying. He mostly flew his Mooney, where his checklist was
always dangling from the mixture control knob and he never allowed
himself to rush.
fateful night, he had consumed alcohol nine hours before, but he also
had taken an over-the-counter mediation for allergies, which it turns
out, decreases the alcohol metabolism in the body (slows the breakdown
of alcohol, hence the effects of alcohol are prolonged in the body).
He was flying an aircraft that he was not totally familiar with, and
all his tell-tale readiness checklists were not present to help him
where they usually presented themselves before flight, and he was in a
rush to pick up his friend from an airport only 20 miles away before a
line of thunderstorms came through (that friend owned the Cherokee)
careful, analytic mind reduced in alacrity, unencumbered by the weight
of his previous knowledge through the harmful effect of persistent
alcohol in his body, failed to see the cues of impending disaster.
Having found none of the patterned elements that had kept him safe all
along, his clouded brain edged him on that day and sought to play its
own game of chance.
are many lessons to learn from this story. My own guidelines are as
follows; add on to them as you please:
Know your limits
habits - use checklists
Rectify a 'getting
away' scenario; do not amplify it
critical of each flight
Even the best
pilots make mistakes - minimize the number and break the chain
Always think about
where is the possible error
If intuition tells
you something is wrong, prove the intuition to be wrong before
proceeding. Intuition is mostly right.
Alcohol, with or
without medicines, is dangerous
voluntarily if you need to for any medical reason. Death is not an
periodically practice safe flight with an instructor
If flying a
different aircraft, become thoroughly familiarized with it before
Do not violate the
rules; they are the products of previous tragedies
Good decisions are
born of good judgments, and good judgments are born of prepared,
rested, and alert minds
safe - always.
Dr. Dara is an aviation medical examiner who specializes in hematology
and oncology in Toms River, N.J.; he is also a pilot with the ratings
of Airline Transport Pilot, Certified Flight Instrument Instructor,
and Multi-Engine Instrument with more than 2,400 hours in the air. He
is a director of the Mooney Aircraft Pilot Association and a frequent
speaker at ground and flight safety seminars.
This article originally appeared in the Fall 2002 Federal Air