What was he thinking?What was he thinking?

Safety PilotSafety Pilot

AOPA Air Safety Foundation Executive Director Bruce Landsberg has rolled a number of aerobatic aircraft but never one in the Normal category.

All aircraft accidents are unfortunate, some are tragic, and a few defy any attempt to rationalize what happened. And as we go through this process, remember that bad judgment is not unique to general aviation. It happens on the highways daily, but as pilots we like to think we're above all that, if you'll pardon the pun.

It might be helpful to understand the thought process that led the pilot in the following mishap to fly as he did. The investigation is in preliminary status so there will likely be some changes, but circumstantial evidence is strongly pointing to some regrettable decision making. Accident investigation seeks to answer why something happened and how similar catastrophes might be prevented. That may prove to be a tall order.

The latest AOPA Air Safety Foundation Joseph T. Nall Report still ranks maneuvering flight as one of the top aircraft junk producers. The NTSB defines maneuvering as "aerobatics, low pass, buzzing, pull-up, aerial application maneuver, turn to reverse direction (box-canyon-type maneuver), or engine failure after takeoff and the pilot tries to return to the runway." A notable point is that the number of maneuvering accidents is down significantly from 1996: 135 to 80. Denominator calculations to determine rates are complex and measuring exposure accurately is almost impossible for GA, so pronouncements of doom, or unbridled success, should be weighed carefully.

The accident

On April 22, 2007, at 2:51 p.m. Eastern Daylight Time, a Beechcraft Baron BE-58, operating as an FAR Part 91 personal flight, broke up in flight in the vicinity of Hamilton, Georgia. Weather does not appear to have been a factor. The private pilot and four passengers were fatally injured. The flight originated from Gulf Shores, Alabama, at about 1 p.m. Central Daylight Time, headed toward Georgia under VFR.

A witness heard an airplane approaching that sounded as if it was performing aerobatic maneuvers. This is speculative since the witness could not see the airplane, but as the engine noise increased, the aircraft appeared and was descending very fast in a 45- to 60-degree nose-down attitude. A wing or part of the tail separated from the aircraft. A friend of the pilot told a police officer at the accident scene that the accident pilot's "flying skills were below his standards because the pilot was known for overstressing the planes he flew." The friend told other pilots that the accident pilot "would probably crash within the next year."

Another friend heard the accident pilot say, "I think I can roll this airplane." That same person noted, "The pilot had been at Sun 'n Fun in Lakeland, Florida, a few days prior to the accident and had observed an [airshow] performer rolling a Beech[craft] 18, and the deceased pilot just kept the rolling issue in his head." The accident pilot also had flown with a retired airline pilot in a Beechcraft Baron 55 who had rolled his airplane.

Another pilot was in the right-front seat of the accident airplane on April 19, 2007, on a return flight from Sun 'n Fun with two other passengers on board. The accident pilot stated, "I want to try something." He then banked the airplane to the left, then back to the right, and stated, "I believe it's possible to roll this airplane."

The pilot started a descent, and then pulled the aircraft up and rolled into a knife-edge attitude, according to the NTSB. The right-seat pilot told the NTSB, "It got me out of my comfort zone, and I could not handle it." The right-seat pilot grabbed the flight controls, leveled the airplane, and exclaimed, "I cannot do this." They descended to 7,500 feet and leveled off. A short time later, the pilot deliberately shut down the right engine and feathered the propeller, and they continued toward Griffin, Georgia, in cruise flight. He later restarted the engine, and they descended for a normal landing. Engine-out practice is essential in flying twins, but it's far better done in a simulator, if one is available, and it should never be done in an aircraft with passengers aboard.

Maneuvering accidents

There are more than 30 accidents dating back to 1983 that were classified as aerobatic maneuvering involving aircraft that were not approved for such. This is an imprecise estimate because of the complexity in sorting, but it shows this to be a relatively uncommon phenomenon. Aerobatic maneuvers in conventional multiengine aircraft were developed into a high art form by Bob Hoover, who performed for decades in the Shrike Commander. Hoover also has been called one of the greatest stick-and-rudder pilots of all time. He's flown his routine hundreds, if not thousands, of times and thrilled airshow crowds all over the world. Not many of us would try to emulate Hoover without a tremendous amount of specialized training.

Extreme unusual attitudes in twins are not always benign either. There have been some spectacular failures. A Partenavia twin was lost in the 1980s when the pilot was executing a high-speed pass over the runway at about 250 feet and then began a rapid pull-up, with the results captured on video. Both wings separated outboard of the engine nacelles. The investigation showed that the separation speed was 220 knots. VNE was 193 knots. The NTSB calculated that with an 8-degree nose-up pitch, the G load at the time of the wing failure was 8.3. Utility category limits are 4.4 positive Gs, so the predictable happened.

Perhaps the most famous multiengine roll of all time happened in August 1955 when the Boeing Dash 80, predecessor to the Boeing 707, was rolled by test pilot Tex Johnson. Boeing didn't fire Johnson but made it very clear that if he or any other company pilots ever did it again they would be out of a job and turned over to the Civil Aeronautics Administration.

Moot point

So, although properly performed aerobatics can be done in twins, they are illegal without an aerobatic waiver and carry a much higher risk than flight within the approved design envelope. The April 22 accident pilot, having had the Baron for only a few weeks, had neither the training nor the skill to do what he may have attempted to do. I also really have to fault the old airline pilot who, if true, felt compelled to show off and set a terrible example for an impressionable individual.

There is another aspect to the accident that will be thoroughly reviewed by the NTSB — the condition of the Baron, which reportedly had well more than 10,000 hours as a trainer. There were rumors of some pre-existing cracks in parts of the structure, which might have led to an earlier in-flight failure than may have happened in a lower-time machine. However, if the aircraft was being operated outside of the approved flight envelope, the point becomes moot. At this point we have no evidence one way or the other.

Now, let's assume the role of the NTSB and the FAA, which are charged with making recommendations. We can talk about aeronautical decision making (ADM) and lack of judgment, which appear to be the proximate cause of this tragedy. It's easy to analyze after the fact and to come to conclusions that are impossible to prove. The news media and the legal system are often experts in hindsight bias, so sitting in judgment should be done with some humility. It is my fervent hope that there is some other explanation to this accident than what appears to be the leading theory at press time.

We had another bad example of poor ADM with the recent loss of a Canadair regional jet on a positioning flight where the crew decided to climb to Flight Level 410 and got to horsing around at eight miles high. The crew flamed out both engines and then failed to follow the restart procedure. There were no passengers aboard. The pilots paid with their lives, the airline lost an aircraft, and insurance costs went up while the public's opinion of aviation went down.

Lessen the potential

If that can happen in the tightly controlled, highly regulated airline world, what chance is there to reasonably predict these fiascos in personal aviation? The sad truth and hard reality are that it's impossible. However, there are some things we can do to lessen the potential. It will take some of the wonderful spontaneity out of doing forbidden things in airplanes, but for the sake of your passengers, the reputation of GA, and a host of obvious financial reasons, consider these: Fly as if you had to explain every flight to an NTSB law judge. Fly as if the most valuable people in your life were aboard. Fly as if your eternal pilot reputation depended upon it. Or fly as if you had a winning $300 million lottery ticket in your wallet.

Try this on your passengers the next time you take to the sky: "OK, gang, I'm about to try a maneuver that I haven't practiced and have had no training in. The aircraft is prohibited from this type of maneuver, and it's never been tested by the manufacturer." (Depending on the type of maneuver, you can add, "We're going to fly really close to the ground and well below legal limits.") Then say, "There's also a good chance that we could all die if I mess this up, but if I pull it off it will be way cool! So, are you in?" Wanna bet what the reaction would be?

Most of us aren't nearly that good or paid well enough (as test pilots) to operate the aircraft outside the envelope. If another pilot asks you to "watch this," refuse, as did the pilot who may have saved the lives of the passengers on the earlier flight from Sun 'n Fun. If you know of someone who is consistently a bad actor — and I'm not talking about just the occasional bad landing or difference of opinion in the traffic pattern — try talking to him. If that's not possible, mention it to the airport manager, or if you know the pilot, send him a copy of this column or one of ASF's Safety Advisors, which are free and available online or as hard copy. Intervention sometimes works; sometimes it doesn't. Pilots don't need to show off since they're already part of an extremely exclusive group. Less than two-tenths of 1 percent of the U.S. population holds a pilot certificate, and we need you alive and flying for a long time.

ASI Staff

Bruce Landsberg

Senior Safety Advisor

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