AOPA Pilot Magazine - March 2022 - 26

SAFETY SPOTLIGHT
Disciplinary
action
Bail out when you said you would
TWO FRIENDS DEPARTED Minden Airport in Louisiana (MNE),
in their respective aircraft in marginal VFR conditions. They
established a route of flight into slightly rising terrain to their destination,
Clarksville Municipal Airport in Arkansas (H35), 170 miles
north. 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
26
AOPA PILOT / March 2022
BY RICHARD MCSPADDEN / Senior Vice President
AOPA Air Safety Institute
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. richard.mcspadden@aopa.org
This analysis is derived from an NTSB preliminary investigation.
The NTSB's final report
could add information that
expands our understanding
of this mishap.
RICHARD MCSPADDEN
leads the AOPA Air Safety
Institute.
AOPA Pilot Magazine - March 2022

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