Disciplinary action

Before takeoff they seemed to realize the potential hazards of the trip and agreed if things got dicey, they’d divert to Ralph C. Weiser Field (AGO) in Magnolia, Arkansas, along the route of flight. By design, plans are based on assumptions. Chief among these assumptions is the discipline to execute the plan.

According to the preliminary NTSB report, the two pilots departed one after the other. The second pilot said the weather was “sketchy” immediately after takeoff, with poor forward visibility. The pilots pressed on. After 20 minutes of scud-running at less than 1,000 feet agl, in poor forward visibility, and before reaching their planned divert point, the pilots entered instrument conditions. Although neither pilot was instrument rated, they decided not to divert, or turn back, believing the weather would improve farther north. They pressed on. Into rising terrain, into deepening IMC. The trail pilot noticed on his ADS-B In display that the lead pilot began a right turn off course. He received a 500 feet agl warning on ForeFlight, and began a full-power, straight-ahead climb in IMC to 3,500 feet msl, roughly 2,500 feet agl. He couldn’t raise the lead pilot on the radio and continued in IMC for another 15 to 20 minutes before finally getting visual conditions about 25 miles from their planned destination, Clarksville Municipal Airport.

According to the NTSB’s preliminary report, while the trail pilot was climbing, the lead pilot continued a slight descending right turn into the side of Trap Mountain at 1,095 feet msl. He did not survive the impact.

VFR-into-IMC accidents are a frustratingly tenacious problem. Given the advances in weather forecasting, and the affordability of in-cockpit satellite weather and moving maps, these accidents should be extinct. METARs, TAFs, radar pictures, and constantly updated ceiling heights and visibility are available to us now, refreshed every couple of minutes and color-coded for quick analysis. All that technology, though, is of limited use if we don’t establish the decision criteria to keep us safe, and then develop the discipline to execute our decisions. This seems to be the recurring theme in VFR-into-IMC accidents. We lack the discipline to say no, or to abort, or divert when we said we would. Every pilot who’s perished in a VFR-into-IMC accident thought they could handle it, thought they’d just turn around if it got too bad. That mindset seems to be a path to catastrophe.

We can learn from this tragedy in Arkansas. The pilots adopted technology to help them be safer pilots. A known enhancement to safety is verbalizing your plan, your concerns, and your options with a fellow pilot. They did that and devised a specific plan with options to retreat if conditions worsened. None of that helped in the execution of the plan, however. There’s a big difference between making a decision at zero knots with nothing on the line, and making a decision operating in three-dimensional space, with time racing and your sense of balance beginning to play tricks on you. This disconnect between our deliberate, rational mind and our anxious, stressed mind causes poor decisions airborne that lead to tragic consequences.

We can improve our airborne decision making by recognizing one important aspect of our human mental process that seemed to be at issue here. Once we go through the mental toil of making a decision, we are inclined to stick with it, and defend that decision (even to ourselves). We prioritize information, however insignificant, that supports our decision, and we dismiss information, however significant, that suggests we should reconsider. We’ve seen this too many times. Pilots who are on the verge of a go/no-go decision decide to go, explaining “we’ll go have a look.” When conditions worsen while they’re airborne, they rationalize pressing on.

The remedy is for all of us to be careful of our first decision, to be cognizant of just how difficult it will be once we’re airborne to change our momentum and reconsider. At several points in this accident, the pilots could have executed their plan and aborted or diverted: on takeoff, when the weather was worse than anticipated; at cruise, when they entered IMC; or at their planned divert point when weather was below their criteria. They kept pressing, justifying, rationalizing until they were in extremis. A plan has little value if we don’t have the discipline to execute it. This tragedy teaches us that once again.

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This analysis is derived from an NTSB preliminary investigation. The NTSB’s final report could add information that expands our understanding of this mishap.