AOPA Pilot Magazine - January 2021 - 26

GUEST EDITORIAL

Aftermath

BY BRUCE LANDSBERG

It doesn't have to be this way

BRUCE LANDSBERG
is vice chairman
of the National
Transportation
Safety Board and
former president
of the AOPA
Foundation and the
AOPA Air Safety
Institute.

26 | AOPA PILOT January 2021

WITH LIGHT WINDS AND CLEAR SKIES, the weather
could not have been better as I flew out to the crash
site. Twenty hours earlier, a 500-foot overcast and heavy
rain obscured the view. Yesterday's forecast was wrong;
it was supposed to be much better. A VFR pilot chose to
continue into instrument conditions. Flying is not inherently dangerous, but the environment is unforgiving of
error-especially judgment regarding weather.
Here in the heartland, the roads run in orderly fashion to cardinal compass points. Farms and homesteads
are neatly kept in the wide-open spaces punctuated by
lines of trees. It would have been a reasonably safe place
to make a precautionary landing, if chosen.
The NTSB investigator was alone in the bean
field when I joined him. We walked quietly around
the wreck, mud sticking to our boots with the ground
still damp from last night's rain. The conversation was
clinical, not wanting to dwell on how these people had
died. The aircraft hit steeply nose down, left wing low,
at more than 180 knots according to the airspeed indicator-coming to an instant and violent stop. No one
walked away from this one.
The engine was partially buried with one curled
propeller blade visible. Oil seeped into a crater filled
with muddy water. The cockpit was crushed, a mass
of shredded, jagged aluminum, upholstery, plastic
parts, and avionics. Side forces ejected the right-side
door and a few other parts about 20 yards. The windows had fragmented into hundreds of small pieces and
were strewn about. Personal effects-a coffee cup, a pair
of glasses, and a small bottle of hand lotion-were poignant reminders of human tragedy.
The first responders had removed the two occupants last evening before the investigator arrived. The
site was a brutal reminder of the forces involved and
required some mental processing for those of us not
experienced with this environment.
The engine and airplane manufacturer representatives arrived. This team had worked together too many
times and, after some pleasantries, started methodically measuring and documenting. Landing gear,
flap, and trim tab position. Check. Control continuity.
Check. Gyros? The case was damaged but looked normal otherwise.
The aircraft recovery crew arrived to load the
wreckage onto a flatbed and move it to a nearby hangar. Next morning the wreck was pressure washed to

clean it up as much as possible. Personal protective gear
is always worn by teams as they perform recovery tasks;
it's often uncomfortable but essential.
Was the engine running normally? It looked OK,
with some superficial damage, but nothing is left to
chance. The valve covers were pulled, and the mangled prop spinner cut away to see if the crankshaft
could be rotated, looking for drive train continuity. A
reciprocating saw-a tool not usually associated with
aviation-shattered the morning calm as it ripped
through an unrecognizable wing to inspect gear and flap
actuators. Forty-eight hours ago this aircraft was someone's pride and joy. Now, it was just evidence in a fatal
crash investigation and would eventually be discarded.
From interviews and available evidence, it wasn't
this pilot's first encounter with weather. He wasn't
trained or certificated to fly in the clouds. Past flight
tracks showed the horizontal and vertical meanderings
of someone who wasn't used to taking no for an answer
even when clouds, prudence, and regulation strongly
advised against a trip.
What did we learn? Nothing new, sadly. Visual pilots
must stay out of clouds, forecasts aren't always accurate,
and sudden stops are lethal. What's missing from this
essay is the raw emotion of the families and friends, the
massive complexity of transferring property, the legal
fights, the empty holidays, and the dread that will come
every year as the anniversary approaches.
It's so easy to be critical after the fact; the psychologists call it hindsight bias. None of us would fly in these
circumstances if there was a chance it would end this
way. But there's almost always a history of success that
emboldens. My hope in relating this tragedy is to revisit
the realities of physics, aerodynamics, and human limitations. Would we bet our entire net worth-home, cars,
aircraft, life savings, all future earnings-on a card game
where winning merely meant arriving at a destination
on time? When put in those stark terms, few would take
that bet. The risk just isn't worth the reward. Why gamble, then, with something so much more precious?
Icing, a descent below minimums, clouds, or a thunderstorm encounter-there isn't a weather condition out
there that cannot humble the best pilot. The phenomena
may vary, but the outcome will be the same. Sadly, NTSB
will investigate a similar scenario again in a few weeks,
and the process will begin anew. We should pause to
remember that it doesn't have to be this way.
AOPA

AOPA Pilot Magazine - January 2021

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