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Analyzing pilot error

It shouldn’t matter, but it does

In the title lyric of his recent ballad, John Mayer croons, “It shouldn’t matter, but it does.” The line resonated as I began the unpleasant task of another fatal accident review.

Analyzing accidents requires an objective mind. Look hard at the facts; have the honesty to go where they lead and the discipline to ignore emotions. Emotions shouldn’t matter. They corrupt conclusions and lead to elisions that conceal lessons we must glean from these tragedies, or we’re more likely to repeat them. The emotions felt by family and friends from what these accident analyses reveal are difficult to put aside.

When families hear pilot error as the cause of an accident that took their beloved pilot and others, they often respond with disbelief, then denial and anger: The NTSB is wrong. The pilot the family knew and who flew them safely was exceptional. A great, knowledgeable pilot. If only we had flown with them, we’d understand something else had to cause the accident. A problem with the airplane; some unexplained weather phenomenon or a controller mistake, anything but pilot error. Not their pilot.

The shock and grief of surviving loved ones is the price we pay for publicizing lessons from our tragedies. I hate it for the families. I know their emotional reaction shouldn’t taint our drive for a full and accurate understanding of the accident. It shouldn’t matter, but it does. The only justification is that I’m certain a public analysis saves lives and prevents others from similar emotional wreckage.

The incredulity of family and friends faced with the fallibility of their pilot exposes the trust our loved ones place in us. A recondite trust. They cannot comprehend the risk calculations we make on their behalf, nor the knowledge required to make those calculations. Every passenger we fly offers us their life, all they’ve worked for, and the emotional health and well-being of those who love them. The latter impact on our own families—when our flying skills lie naked, fissures exposed through a harsh public critique—seems especially camouflaged to us.

Poor decision-making is often the catalyst for general aviation accidents and the ensuing heartache. Looking back is easy. We spend hours gathering near-perfect awareness of a situation a pilot experienced clouded in mental duress. Sometimes, the pilot makes a premeditated bad decision. Other times, the error comes with only minutes or seconds to take action. In both cases, the error is so clear. The right path so obvious in hindsight. We scratch our head and ask, “What were they thinking?” If the pilot were sitting beside us, comfortably, at zero knots and 1 G, with no pressure and all the information we have, they’d nod their head and agree: “What were they thinking?” That rhetorical question is better reframed, “Why were they thinking that?”

Asking “why” prevents us from dismissing a poor decision by thinking I’d never do that. I read about accidents with an assumption the pilot was skilled, knowledgeable, and bringing their best to the situation, but something derailed them. Something corrupted the decision-making that has served them so well in their lives up to that point. My paradigm comes from experience. In my lifetime of flying I’ve known skilled, professional pilots who made a costly bad decision. Something clouded their head-work so that what is so logical in hindsight eluded them in the moment. If it could happen to them, it can happen to me. So, I study their mistakes, and I learn.

An experienced pilot takes off in zero-zero conditions with the people they adore most. A VFR-only pilot takes their child into instrument conditions. A friend takes off over-loaded on a hot day for a joyride. A pilot anxious to keep a holiday promise launches in a winter storm. These flights ended tragically, under control of an experienced pilot who had flown safely for decades and earned a reputation with family and friends as an excellent pilot, a safe pilot. The point is not to dispute the convictions of those family and friends, rather to appreciate the innocent faith nonpilots place in us.

In his ballad Mayer laments: “Shoulda done more. Shoulda learned a lesson from the year before.” Let’s heed his regrets. Lessons are only learned when we change behavior. Unless we change behavior, it’s simply a lesson observed. We owe it to the pilots who’ve perished and their families who endure the painful analysis to learn as much as we can from these tragedies and change our behavior in response.

Let’s learn these lessons and fly like the pilots our family and friends believe us to be.

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Richard McSpadden

Senior Vice President of AOPA Air Safety Institute
Richard McSpadden was appointed executive director of the AOPA Air Safety Institute in February 2017 and was promoted to senior vice president in July 2020. He currently leads a team of certified flight instructors and content creators who develop and distribute aviation safety material –free of charge— in order to advance general aviation safety industrywide. ASI distributes material through a dedicated YouTube channel, iTunes podcasts, Facebook, and a dynamic website. ASI material is accessed 12 million times annually. A native of Panama City, Florida, McSpadden started flying as a teenager and has logged over 5,000 hours flying a variety of civilian and military aircraft. McSpadden is a commercial pilot, CFII, MEI with SES, MES ratings and a 525S (Citation Jet Single Pilot) type rating. He taught his son to fly, instructed his daughter to solo in their Piper Super Cub, previously owned a 1950 Navion that was in his family for almost 40 years, and currently owns a 1993 Piper Super Cub. McSpadden holds a degree in Economics from the University of Georgia, and a Master of Public Administration from Troy University. He is a graduate of the U.S. Air Force Air War College. Prior to joining AOPA, McSpadden had a successful career in the information technology industry, leading large, geographically dispersed operations providing business-critical IT services. McSpadden also served in the Air Force for 20 years, including the prestigious role of commander and flight leader of the U.S. Air Force Thunderbirds flight demonstration team where he led over 100 flight demonstrations flying the lead aircraft. Additionally, McSpadden currently serves as the industry chair for the General Aviation Joint Steering Committee.

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