quote:

Originally posted by Balzé Halzé:
In other words, the pilot fucked up. Wondering aloud how someone as skilled and experienced as Dale Snodgrass is could make that mistake isn't unreasonable and isn't disrespecting the man. Shit happens even to the best of us.

Every professional pilot knows any of us are capable of making errors. As a check airman at my airline I was involved in debriefing and retraining pilots who found themselves in an "undesirable state". These were intelligent, well trained professional pilots in a crew environment operating modern airliners. Yet circumstances led to an incident, and sometimes it almost seems fated.

Many times the quiet discussions in the crew lounge are "man, that could have happened to anybody!".

Just like the layers of an onion in security, aviation safety requires multiple layers of procedures, checks, and physical systems.

It is necessary and valuable to question what happened, and how someone like Dale Snodgrass could make this kind of a mistake.

quote:

Every professional pilot knows any of us are capable of making errors.

Just need to watch Air Disasters on Smithsonian Channel if you want examples of this truth...

Most aviation crashes seem to be a result of 'cascading errors' rather than one giant fuck up. For example, take a look at Santa Barbara Flight 518.

Experienced Captain, flying with lesser experienced First Officer. They lose track of time in the terminal while drinking coffee, rush out to the aircraft and do a quick start to make up time and get back on schedule, skipping a few items on the checklist in order to do so, including a failure to align the automatic heading equipment. Captain doesn't think it's a big deal because he's done without it before and anyway, they can do it when airborne if they need it. They take off and instead of following the authorised departure track, follow an unpublished airline specific track that takes them towards high ground - again, the crew have used this track before and it's always been okay. After take off, they enter cloud and turn onto what they think is the correct heading, but it isn't, they get overloaded by the situation and self created problems and fly into terrain and kill themselves and all the passengers.

At any time, a correct procedural action would/could have saved them, but the culmination of the many mistakes they made ultimately forced them into a position that they could not escape from.

SB 518

It's quite possible that Snodgrass had something similar - bad morning, not feeling on top of his game, in a rush, who knows?

(I am not a licensed pilot)

quote:

Originally posted by Pyker:
Most aviation crashes seem to be a result of 'cascading errors'

(I am not a licensed pilot)

Dogs are "licensed"
Pilots are "certificated"

ATP w/4 jet type ratings

Snort's wife said he typically does his preflight in the hanger, then rolls the aircraft out and does a final walkaround, fires it up, does in place checks, taxis to runup, then departs.

She stated this takes him and hour to two hours depending on the aircraft.

This time he was less than 1/2 an hour.

The gust lock is a long U shape device that "flips" up, (like those hotel door "security locks" that go sideways). It is painted red, and when flat on the floor is locked in with a spring clip. It takes some willful effort to pull the lock up and pin it.

When in use, it hinges on two pivots where the "top/opening" of the "U" would be the pivot point on the floor, and the "bow" of the "U" has a hole in it. The bar is rotated up and engages a pin that is on the control stick to "hold" the stick, and keep the ailerons and elevators from being blown against their stops from winds or blast from other aircraft.

It also impedes the rudder pedals from the tubes of the "U" being up against the back inboard side of each pedal.

You can taxi and since the aircraft is so light, it may not have required much deflection to operate steering and braking.

If he did not "stir the stick" and being a Navyator, that is always done, and "self observed". He would have missed the lock not permitting stick movement.

The findings show the trim motor was driven full nose down, so he must have tried that when he realized he had not pitch or roll control.

The even happened so fast, that unless he was very familiar with the lock (similar to someone who always uses a parking brake and someone who never uses one and the extra time it takes the second to release it, vs the person that always does, being faster instinctively to release it when they realize it is engaged.

Since he had no rudder authority, the aircraft is going to yaw and roll due to engine torque and the inclination of the prop thrust being slightly off centerline, and greater effect at full power and slow.

He really had no options, even pulling power, as he as in a stall about the time he would realize he had no controls.

Aircraft crashes have always been hard to deal with. To many up close and personal encounters, and all of them leave lasting damage to people. Not that the tragedies are any greater than car crashes, and so many other accidents, they simply seem to be more intense to deal with.

The chain is invisible, until something happens to reveal it, and then it is there to see forever. Everything else broken, but the links in that chain. I always try think about the chain and break every link I can find.

quote:

Originally posted by skywag:

quote:

Originally posted by Pyker:
Most aviation crashes seem to be a result of 'cascading errors'

(I am not a licensed pilot)

Dogs are "licensed"
Pilots are "certificated"

ATP w/4 jet type ratings

Whatever. My meaning was clear.

Most has been said, not much to add.

I will say, he seemed kinda rushed getting out & off on this flight. I watched some ground video, listened to the comms. There wasn’t much time between the initial call for taxi, and then the fatal takeoff. I think he even called for takeoff on the ground control frequency, not normally done.

I didn’t see the length of time the plane was at that airport, if just a fuel stop, extended time, or if any maintenance was done.

I think when the incident occurred, I recall he had recently acquired the aircraft, flew it (about 20 hours) and he arrived with the purpose of ferrying it to his newly built cabin for permanent base. So it was just being based there temporarily.

My checklists are about things that are much less important than a pilot’s, but I have found that the more I use them the more likely it is I’ll unthinkingly skip over something. Familiarity breeds contempt: “Yeah, yeah, I know what’s on it and I don’t have to read it every time.” It’s especially likely I’ll skip something if I’m in a hurry. I must force myself to read every line, and not only read it, but think about it as well.

I don't speak pilot so, Juan helps explain things. All indicators are it was pilot error....it happens, even to the best of them. Snort by all indications was one hell of a pilot however, I have no idea if he was a high-tempo kind of guy prone to short-cuts or, was known to hurry through processes, don't know. It's a bummer he's no longer with us.

It may sound unrelated, but one can compare to some aspects of firearms handling & basic safety protocols. Those could be as basic as opening the action & checking the chamber & magazine before handling, cleaning, or passing a firearm to another.

One can become overconfident, then thinking they are ‘beyond the basics’ with experience.

I own a light aircraft that I fly regularly. I flew to the Salt Lake area earlier this Spring. One safety tenet I have is, ‘have more ability than overconfidence’. In other words, be better than you think you are.

I know two killed in a Piper Cub years ago, no the pilot didn’t intend to crash. He was screwing around in the pattern in front of family, very familiar and comfortable with the plane. They both died right there.

Thanks for posting up those two videos. They were thorough and very helpful in understanding just what exactly happened here.

I found it interesting that in each of those videos they used the words "careless" and "complacent".

quote:

Originally posted by Bassamatic:
Thanks for posting up those two videos. They were thorough and very helpful in understanding just what exactly happened here.

I found it interesting that in each of those videos they used the words "careless" and "complacent".

Yup, double thanks Corsair for posting both of those videos. I had just finished watching the Blanco video and was doubling back to this thread when I noticed you had already posted it.

Juan did his usual excellent job of breaking down this tragic crash. For those that want to see the control lock in question or to better understand the NTSB report I'd suggest watching it.

I noticed you later edited the post to include the AVweb video interview with the NTSB rep and that was an interesting discussion, as it went into both the details of this crash as well as complacency in general that can be applied to other catastrophic incidents. I found it particularly interesting that they agreed with me that this specific control lock design is a bad one, both because it doesn't fully lock the rudder even though it is designed to do that, but also because this control lock design obscures the pilot's view of its status from the seated flying position.

No question about it, this ultimately lands squarely on the pilot's shoulders as a classic example of complacency that leads to tragedy...BUT, this particular control lock design is a bad one that is unforgiving of complacency or carelessness.

quote:

Originally posted by Modern Day Savage:
I found it particularly interesting that they agreed with me that this specific control lock design is a bad one, both because it doesn't fully lock the rudder even though it is designed to do that, but also because this control lock design obscures the pilot's view of its status from the seated flying position.

No question about it, this ultimately lands squarely on the pilot's shoulders as a classic example of complacency that leads to tragedy...BUT, this particular control lock design is a bad one that is unforgiving of complacency or carelessness.

I think that's the big take-away here from this investigation:
1) Pilot error. Most people think that when an investigation finds that pilot error is the primary cause of an accident, it's assumed the pilot is grossly negligent, incompetent, reckless, etc. The reality is fault can be found with every single operation, you'd have to be autistic in order to be flawless. One of things I know pilots have to deal with and train on is flight deck or, cockpit management; being able to prioritize the workflow and processes as things are happening. This is one of the leading causes of flight school failure.

2) Design failure. Paul in AvWeb points this out, the location of the Flight Control Lock is simply an invitation for an accident.

That was the point I was trying to make. All accidents due to complacency are pilot error. All accidents due to pilot error aren’t necessarily because they were complacent. If a Dr accidentally cuts the wrong artery while performing surgery it doesn’t necessarily mean he was complacent. He made a mistake.

Pilots hate accidents caused by pilot error because they are avoidable. Pilots hate accidents due to complacency more because they were avoidable and the pilot was being a jackass.

Conflating the two is disrespectful. You can still learn from this accident through the facts, the fact being it was pilot error. Complacency? We will never know which is why that word doesn’t appear as a causal factor in the report. Not adhering to a checklist does.

quote:

Originally posted by pedropcola:
If a Dr accidentally cuts the wrong artery while performing surgery it doesn’t necessarily mean he was complacent. He made a mistake.

True, but not a good comparison. A more appropriate one would be a surgeon forgetting to put on sterile gloves. That's not an accident nor a mistake. It is complacency.

It is puzzling why you seem to have such difficulty calling this incident complacency when all of the experts agree that it was. It seems to be the very definition of complacency and it is not disrespectful to call it that. It happens to a lot of people...even the best pilots out there apparently.

I have been told I like to argue, so there is that.

I disagree with your characterization though. The experts said it was pilot error. They didn’t say it was complacency. I pointed out there is a difference whether anyone wants to acknowledge that or not. Telling me internet experts said it was complacency doesn’t hold much. The report correctly says it was pilot error. Saying it was complacency is a distinction that can’t be accurately made. You guys think it can. I disagree.

Is it an error of the pilot to have a moment of complacency? I think it’s semantics, and splitting hairs.

In the video above they said the reason for the accident was clear, one relatively simple item. Sadly that forgotten item was very critical.