Believe it or not

Strange tales of the accident investigators

October 1, 2010

When it comes to institutional humor, the NTSB is probably not the first organization that comes to mind—even if the competition’s limited to other government agencies. The Census Bureau, of course, is known for its sense of whimsy, and the Federal Reserve seems to love a good practical joke, but when talk turns to the NTSB, most people think of the somber face of the accident investigator standing in a field of twisted wreckage. Most sane, healthy people, anyway.

But spend enough time immersed in the details of NTSB reports, and it becomes clear that investigating GA accidents fosters a keen appreciation of life’s absurdities. While credit must be given to the pilots and passengers and backyard builders who supply the raw material, the official record contains descriptions that transcend mere narrative. (We’ve included the NTSB case numbers so you can see that, with apologies to Dave Barry, we’re not making this up. Enter them into the box marked “ NTSB Number” online].

This report makes a point of making a point: “The noncertificated pilot applied for a student pilot and third class medical certificate on November 4. The application was reviewed by the Airman Certification Division on December 8, February 4, April 19, May 19, October 2, and January 7. Additional information regarding the noncertificated pilot’s eligibility for medical certification was not provided by the noncertificated pilot. The noncertificated pilot reported on the application…that he had accumulated 13 total flight hours. A friend of the noncertificated pilot stated the noncertificated pilot had flown 100 hours in the airplane, and did not hold an FAA certificate or rating.”

—NTSB case number ATL04LA128

In all, the phrase “noncertificated pilot” and its close relatives appear 14 times in the full report, along with a couple more assertions that the pilot held no certificate. OK, I think we get it.

Some of the accident pilots write the best lines themselves. Their insights after the dust settles can be nothing short of dazzling: “The pilot flew on the right main fuel tank until the fuel was exhausted. He switched the fuel selector to the left main fuel tank…back to the right main fuel tank, then left main fuel tank, and back to the right main fuel tank. The engine did not start and the left main fuel tank gauge indicated low…. The pilot stated, “As far as I can tell, I landed without fuel.”

—NTSB case number MIA08CA120

Fuel management inspires a lot of belated enlightenment: “A Federal Aviation Administration inspector reported that there was no odor of fuel, no evidence of fuel spillage, and that the airplane contained less than eight quarts of fuel at the scene. The pilot stated, ‘Even though indications were that there was sufficient fuel for the return flight, getting fuel at [the departure airport] as a precaution would have prevented the accident.’”

—NTSB case number ERA09CA426

Other useful lessons are also learned just a little late. A Cessna 210 flew into the ground “in a near-level attitude” while the pilot tried to troubleshoot a gear-extension problem: “The nose gear was torn off, the propeller was damaged, and the left wing was substantially damaged…. The pilot stated in the Pilot/Operator Report that the accident could have been prevented if he had remembered to keep flying the airplane.”

—NTSB case number DFW08CA191

It’s hard to argue with that. Or this: “According to the pilot, he aborted the landing after two bounces. He applied full power, retracted the landing gear and the flaps, and the airplane settled to the runway. When asked how this accident could have been prevented, [he] explained that a positive rate of climb should have been established before the gear and flaps were retracted.”

—NTSB case number ERA09CA439

Some seek to establish new principles of aerodynamic theory: “The pilot reportedly touched down on the runway numbers, but inadvertently allowed the aircraft to balloon back into the air. After a few seconds, the aircraft touched down a second time, but then ballooned even higher. According to the pilot, when the aircraft touched down the third time, he ‘added some power to stay on the ground.’”—NTSB case number SEA03LA003. It didn’t work.

Other aerodynamic principles seem oddly familiar: “According to the pilot’s accident report, it was his intention to practice ‘fast taxi to see if I could keep the airplane straight down [the] runway. Apparently, when I reached takeoff speed, the airplane rotated and I was airborne.’”

—NTSB case number CEN09LA375

A witness described this last airplane as making “very steep naked turns.” Maybe that’s the answer to increasing the pilot population.

A few can take pride in their split-second decision-making: “A fire erupted at the engine. He reached back to get the fire extinguisher and when he looked back, he saw that his socks were burning and he exited the airplane.”—NTSB case number WPR09CA073. Good choice!

Some of the most remarkable passages were inspired by particularly imaginative members of the homebuilding community: “The FAA inspector conducted an examination of the airplane and reported that the aircraft was constructed primarily of plywood and fabric. The seat belts were out of a Chevy van and were held together with wooden screws. The shoulder harnesses were backpack straps. There was a coffee can welded to the exhaust with holes poked in it.”

—NTSB case number LAX98LA190

Another experimental airplane was the prototype for a kit design, but every bit as innovative: “According to representatives…the original pilot (left) seat in the airplane was replaced about a month prior to the accident with a six-way power seat from a 1980s’ Cadillac Cimarron. The seat incorporated three motors that facilitated the six-way movement of the seat. If one of the motors failed, it would trip the circuit breaker. If the breaker did not trip, the switch would fail. However, the motors could get hot before the switch failed.”

During the flight, “One of the pilots transmitted to the controller, ‘Is there anyone else at a lower flying airplanes, uh, complained of like the air stinking or anything is there a fire out, um, in the Everglades or something?’ The controller responded, ‘Nah, nobody said anything yet.’ The pilot stated, ‘We just want know if it’s the airplane that smells or the air.’”

—NTSB case number MIA03FA024. You can probably guess the answer.

A handful of accident pilots seem impervious to insight, or just about anything else. The people who designed and built their aircraft can take pride in having gone above and beyond mere certification requirements: “The airplane collided with a runway end identifier light control box. The pilot reported he felt a couple of ‘bumps.’ He then…taxied back to the runway and departed for Kenosha. He reported the airplane seemed to lack power during the flight. Damage to the airplane included buckling and puncture damage to the lower fuselage, engine cowling, and left horizontal stabilizer; firewall damage; the tip of one propeller was missing and the other propeller tip was damaged; and a section of the exhaust system was crushed.”

—NTSB case number CHI02LA053

You know the designer’s margin for error has to include a couple of extra feet of wing, right? “The left wing struck the runway distance sign marked 5, destroying the sign. The student ‘had no sensation of a collision,’ and conducted three touch-and-go landings and a full stop. The leading edge of the left wing was damaged from the landing light inboard for approximately three feet. The inboard end of the damaged area exhibited splintering and separation of composite finish, binder, and cloth layers. The underside of the wing had an approximate six-inch-diameter hole, which also exhibited splintered layers of composite finish, binder, and cloth material.”

—NTSB case number ERA09CA192

Friends of the pilots sometimes offer insights of their own. After a renter “inadvertently stopped the engine during flight” and made a successful forced landing in a field, the company owner, his director of maintenance, and an FAA inspector jointly determined that the Cessna 172 was still airworthy. The owner decided to fly it out of the field more than an hour after sunset, and a flight instructor who’d accompanied them described the results: “He was at full throttle the whole time. He pitched up, and never lowered the nose. He drug the tail the whole time. He was at full throttle and went up over a barn, hit a sign, went over the road, under the power lines, up an embankment, and down in the field.”

When asked if he had discussed and endorsed the pilot’s plan for takeoff, he responded, “No. We all discussed it, but he’s pig-headed, you can’t tell him anything. The FAA inspector told him not to do it, but he said, ‘It’s my airplane, and it’s airworthy. I’m taking off.’”

—NTSB case number NYC06LA026

Of course, the best insight, like so much of what’s best in general aviation, comes from the great state of Alaska: “The pilot reported that he was departing from a rough, 700-foot-long dirt-covered off-airport site with a load of caribou meat…and noted in his report to the NTSB that the accident might have been avoided if he had weighed the meat before takeoff.”

—NTSB case number ANC09CA101

The problem of weighing an airplane load of caribou meat out in the bush is just one of many that pilots in the Lower 48 rarely have to consider.

Reports from Alaska have a quality all their own. It really does seem to be different up there. In most of the country, talk of taking off “with everything you can stuff through the doors” is just a figure of speech: “The airplane was loaded with six 5-gallon (plastic) fuel containers of diesel fuel, a 150-pound iron stove, the mechanic’s tools, several bags of groceries, and a large cooler/ice chest. The…passenger felt uncomfortable because, ‘[the pilot] would never put a seat in for him.’ He would routinely be required to sit on a plastic bucket or a small ice chest during the flight to the remote lodge. The estimated gross weight of the airplane at the time of the accident was approximately 2,837 pounds, or about 287 pounds over the allowable gross weight.”

—NTSB case number ANC05FA116

A casual attitude toward weight, balance, and equipment is a common theme. This Cessna 185 carried three passengers and their gear: “The cargo…totaled 430 pounds. The combined weight of the pilot and passengers totaled 828 pounds. The fuel weight was calculated as 240 pounds. The airplane’s gross weight was 3,350 pounds. At the time of the accident, the airplane’s weight was calculated as 3,716 pounds. The accident airplane was equipped with two front seats, and was configured for the installation of two individual, second-row seats. No second-row seats were found in the airplane or at the scene. The attaching screws for the rear seats were found in a pouch behind the pilot’s seat.”

—NTSB case number ANC02FA107

And Alaskan aircaft aren’t just used for transportation in this world. They find unexpected new roles as vehicles of spiritual development: “After starting engines, the pilot was…surprised by the sight of the woman approaching the idling left engine. The pilot shouted a warning and closed the mixture controls; however, the woman turned and presented her buttocks to the propeller arc. The injured passenger said as she received first aid, ‘God told me to do this, I will not die!’”

—NTSB case number ANC93LA105

Sometimes an accident’s aftermath adds insult to injury: “The airplane was further damaged when it was dropped from a helicopter during the recovery flight.”

—NTSB case number ANC09CA106

If there were a Nobel Prize for NTSB literature, it would also have to go to Alaska. The case report for accident number ANC00FA052 begins with perhaps the best opening sentence ever written: “The pilot, the holder of an expired student pilot certificate, departed a remote village with a load of whale meat.” Eat your heart out, Herman Melville!

David Jack Kenny is manager of aviation safety analysis for the AOPA Air Safety Institute, an instrument-rated commercial pilot, and owner of a Piper Arrow. So far, his own contributions to the accident data have been purely administrative.