Premium on Safety - Issue 45, 2022 - 8

ASI MESSAGE
Learning Works If We
Change Our Behavior
BY RICHARD MCSPADDEN
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 is so obvious in hindsight. We scratch our
heads 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 admire 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
non pilots 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.
Accident Case Study:
Faulty Assumptions
Let's learn these lessons and fly like the pilots our family and friends
believe us to be.
Fly safe!
Richard G. McSpadden, Jr.
Senior Vice President, AOPA Air
Safety Institute
8
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