People respond differently to stimuli
In the more northerly reaches of the country, far from the interstate highways, we frequently see similar behavior in the face of imminent hazard. In this remote setting, the road is usually a narrow, bumpy two-laner hemmed in closely on both sides by forest. The hazard is alces alces--the moose--and a good example can weigh 1,500 pounds and come loping out into the road at 30 or 40 mph, looking neither left nor right. Accidents occurring when moose and man converge are spectacular and lethal, but for many years the sole warning offered to motorists driving through the hot zones was a metal sign, with a cartoon-like image of a moose painted on it, mounted atop a wooden pole.
How did people react to this warning? By stealing the signs. And except for the "locals" who had seen their share of car/moose accidents or had experienced narrow escapes of their own, nobody slows down. Officials responded to the sign thefts by mounting the replacement signs higher than before, on stout metal bases. But the signs themselves conveyed no particular sense of urgency. (A sign showing a moose and a car about to collide might have more effect.)
Unfortunately, pilots sometimes act like drivers passing that "left lane closed ahead" sign, and this frequently ends up in the "probable cause" section of official accident summaries. Like the signs, sometimes the defied warnings are clear, as is illustrated in a case involving a pilot who on multiple occasions was determined to ignore recommended departure procedures from a high-elevation airport in mountainous country. Sometimes, the lack of caution is just one of various factors, along with training and pilot supervision, as another case shows. And some people just give in to persuasion.
The Big Bear City, California, airport sits at an elevation of 6,748 feet in a challenging environment. Bounded on three sides by peaks and high terrain, it offers good egress to the west, over a long lake and then descending valley terrain. A printed handout depicting the recommended departure is available to pilots. On April 6, 2003, a 150-hp Piper PA-28-140, not an ideal aircraft for high-density-altitude operations, struck a ridge five miles southwest of the airport during initial climb. Two aboard died. A passenger survived and called for rescue via a cellular phone.
According to the National Transportation Safety Board's online accident summary, "The pilot flew a southwestern departure route from the airport that crossed rugged mountainous terrain within five miles of the airport. This route was not the departure route recommended by the Big Bear City Airport; however, this pilot had recommended this route to at least one other pilot he had flown with in the past. The pilot misjudged the altitude required to cross these mountains and collided with terrain." The report made note of another matter of judgment, without assigning it causal importance: "Medical analysis indicated that the pilot may have been somewhat impaired by the effects of marijuana, but it is unclear what role such impairment might have played in the decisionmaking that set the stage for this accident."
The report also developed the question of the pilot's determination to fashion his own departure procedure. "An interview with a pilot, who had flown with the accident pilot in the past, revealed that the accident pilot had tried to fly a southwesterly departure out of Big Bear in the friend's airplane on March 20. The friend and owner of the airplane rejected the idea in preference to the standardized departure route over Big Bear Lake. According to the friend, the pilot was strongly urging the taking of the southwesterly route in order to save time." Included in the report was a brief passage bearing the heading "Information available to the pilot." It cited Aeronautical Information Manual discussions of accident causes involving an aircraft's pilot in command.
The day of the Big Bear City mishap happened to be the sixth anniversary of a fatal accident involving a student pilot on the second leg of a cross-country solo flight. Departing from Lake Tahoe Airport--another high-elevation California field--he did not follow the recommended departure path. "The student pilot was on an authorized round-robin cross-country flight with several intermediate landings. He had made one landing at the first airport, and three landings at the second airport, having a density altitude of about 6,700 feet. He then took off but did not follow the published (recommended) departure procedures for gaining altitude. He did, however, proceed along his flight plan route directly toward the next authorized landing site. The route was over terrain that required the airplane to climb at a rate that exceeded its published maximum performance. After climbing about four minutes the airplane collided with trees and impacted the snow-covered mountainside about 7,840 feet msl," the NTSB said.
The report added, "The CFI reported that he had personally authorized his student to make the flight, but told him to change the route from what the student had initially selected (accident route) to one over lower terrain. The CFI had not flown with the student in three months nor had he provided dual cross-country training in nearly six months. Also, the CFI had not provided his student with high-density-altitude flight training in the geographical area flown. Prior to the student's departure, the CFI had not reviewed with him the latest forecast weather conditions or ensured that the pencil line depicting the route of flight was drawn away from the higher-elevation mountainous terrain."
The report included the text of remarks describing departures from Lake Tahoe published in the Airport/Facilities Directory. It added this information about departure assistance available there: "Upon request, the Lake Tahoe airport director provides pilots with free information sheets containing an airport diagram and text which describes departure procedures. In pertinent part, pilots departing using Runway 18 are requested not to turn left (eastbound) until reaching 7,500 feet msl. No evidence was found indicating that the pilot had received this information sheet."
The report extensively detailed the pilot's training, noting the field elevations of other airports to which he had been authorized to solo by his 7,000-hour flight instructor. The highest elevation of one of those fields was 4,718 feet. However, "The Safety Board found no evidence indicating that the student had previously landed at Lake Tahoe, or that the CFI had provided his student with dual flight instruction regarding departure and climb-out procedures from Lake Tahoe, a high-density-altitude airport partly surrounded by higher mountainous terrain."
This in part was the reason for the determination of probable cause: "The pilot's collision with mountainous terrain due to his failure to follow published high-density-altitude departure procedures during climbout, and route selection which exceeded the airplane's maximum climb performance specifications. Also causal was the CFI's inadequate flight supervision and improper approval of his student's preflight preparation and route selection. Factors were the pilot's inadequate preflight planning, his lack of high-density-altitude training for the area flown, and the high density altitude."
There are many more examples of the pilot and the machine not being a match for the conditions in which they proposed to fly. Learn from them to reinforce your efforts to be pious about the virtues of caution. Another April 6 accident (in 1996) took the life of a pilot lulled into departing with two other aircraft on a dinner flight, despite his aircraft having an inoperative artificial horizon and other problems. The three aircraft encountered marginal weather conditions in the dark during the return flight, and the problem-plagued aircraft crashed in Barkhamsted, Connecticut, while diverting around the weather. Witnesses told investigators that an instructor-rated passenger in the accident airplane had encouraged the reticent pilot to make the trip.
Sometimes after an accident the argument is made that not enough warning of an obvious danger existed, and that the blame should be shared by those responsible for this shortcoming. At other times, the warnings were plentiful but went unnoticed by the pilot out of ignorance or indifference; training gets the blame. The third possibility is that the warnings were well presented to the pilot but then dismissed or challenged head on, like the driver speeding up to beat a highway lane closing. That impulse, which wells up inside a pilot from who knows where, is the most unsettling, inexplicable accident cause of all.
Dan Namowitz is an aviation writer and flight instructor. A pilot since 1985 and an instructor since 1990, he resides in Maine.
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