AOPA Pilot Magazine - April 2020 - 26

SAFETY SPOTLIGHT

Lessons from a tragedy

BY RICHARD MCSPADDEN
Executive Director
AOPA Air Safety Institute

Speculation versus hard truths

AOPA Air Safety
Institute Executive
Director RICHARD
MCSPADDEN

has flown more
than 5,000 hours
in a variety of civilian and military
aircraft.

26 | AOPA PILOT April 2020

DON'T SPECULATE. This is a common rebuke directed
at those discussing a recent aviation accident, and it's
been drilled into our culture. We've learned that the root
cause of an accident can be quite different than what
may seem obvious. It's a sensible posture that has kept
us (and some public agencies) from acting on erroneous theories with ineffective or even counterproductive
remedies. Often, though, the "don't speculate" principle
is misapplied to mute all discussion until an investigation is fully complete, thereby delaying an opportunity
to reinforce important learning.
Speculation is forming a theory without firm evidence.
A person who happens to see an airplane crash near a runway is speculating when he or she says, "The aircraft must
have stalled." It's not speculation to piece together known
facts such as weather, winds, aircraft state, flight path, and
air traffic control communications, and deduce a likely
cause. The distinction is important. Informed analysis
based on facts and experience can be helpful in emphasizing lessons learned while the event is still fresh.
The helicopter crash that killed nine people, including
L.A. Lakers basketball star Kobe Bryant, is a case in point.
The NTSB advised it would be more than a year before
the investigation is complete (absurd, but the NTSB has
recently promised reforms to reduce investigation timelines). Meanwhile, enough facts have been determined to
ascertain what likely happened and summarize lessons
learned that are beneficial for pilots to consider now.
According to investigators, the Sikorsky S-76 was
flown by a single, experienced pilot under VFR per the
operator's Part 135 limitations. The pilot departed in
marginal VFR conditions over flat terrain, traversed
busy airspace, and-in worsening weather and visibility-followed a prominent highway into rising terrain.
He climbed to avoid a cloud layer, began a left turn, and
then made a sharp descent that peaked at 4,000 fpm. A
witness observed the helicopter emerge from the mist
descending at high speed and roll sharply left a few seconds prior to ground impact. NTSB experts found no
evidence of engine or flight control problems. It's not
speculation to deduce that this is likely a spatial disorientation accident. Several lessons from this tragedy
will remain relevant, regardless of additional findings.
1. Flying VFR into instrument meteorological conditions is dangerous, regardless of your experience
and ratings. A third of these accidents happen to

experienced, IFR-rated pilots and they are usually
lethal. Falter into IMC and you are likely to die.
2. The gray area between flying on instruments and flying by visual reference is far more challenging than just
flying on instruments. This hybrid arena, often borne of
indecision, can provoke visual illusions. Pilots anxious
to gain visual context can convince themselves of visual
recognition that isn't present. The consequences are exacerbated at low altitude by reduced opportunity to recover.
3. Low visibility in hilly terrain is especially treacherous. False horizons from multiple illusory effects can
occur. Tiers of sloping cloud decks against rolling, layered hillsides are insidiously disorienting. Lights from
cars, houses, or other sources can add to a misperception of aircraft attitude. Recognition is slow and often
too late.
4. Fog, and in particular coastal fog, is unpredictable
and can move in dense waves. Fog hinders depth perception, so it's difficult to determine where it gets worse.
It can seem tolerable, then thicken quickly into hard IMC.
5. Flights, conditions, and decisions must be assessed
more conservatively when operating single pilot.
There is no one to cross-check a decision, and no help
to alleviate task saturation, an especially perilous state
when operating a helicopter at low altitude in hilly terrain with limited visibility amid busy airspace. This
flight was extraordinarily demanding for a single pilot.
6. The most important decision pilots will ever make
is made every time they fly, and that is whether or
not to fly. We often talk of advancing skills in terms of
knowledge and stick-and-rudder skills. We rarely think of
advancing our skills relative to decision making, yet pilot
decision making is a part of most fatal accidents. Decisionmaking skills need just as much work and continued
development as stick-and-rudder skills. It only takes one
lapse in judgment on one flight for a tragic ending.
We don't need to wait a year or more (actually, 22
months on average) for the NTSB to finish its full investigation to emphasize some important lessons from the
tragedy in Calabasas, California. It's not speculation to
analyze an abundance of facts, determine what likely
happened-with a caveat that we're not completely
sure-and emphasize promptly some important lessons that may prevent a future tragedy.
AOPA
EMAIL richard.mcspadden@aopa.org

AOPA Pilot Magazine - April 2020

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