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“Those who fail to learn from the mistakes of their predecessors are destined to repeat them.”. (Paraphrase) – George Santayana, 1905. v ermontflightacademy. org. v ermontflightacademy. org. “What WAS That Guy Thinking?”. Case # 1 - Burley, ID.

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those who fail to learn from the mistakes of their predecessors are destined to repeat them

“Those who fail to learn from the mistakes of their predecessors are destined to repeat them.”

(Paraphrase) – George Santayana, 1905

case 1 burley id
Case #1 - Burley, ID

Pilot: 42 y.o. PP with 480 hours TT and 160 in make/model

Aircraft: 1979 Cessna P210

Environment: Runway elevation 4154’, temp 91° (DA 7,116 feet), aircraft at gross weight, 6 to 10 knot tailwind on departure. Sky clear

Other: Non-towered field, plane had been re-positioned to this airport after an alternator failure, pilot and passengers were driven to airport by other family members

case 1
Case #1

NTSB Accident Description:

“Witnesses reported that during the takeoff, the airplane lifted off about three-quarters of the way down the runway. The landing gear was retracted and almost immediately, about 75 feet above ground level, the airplane entered a left turn and began to descend. The left descending turn continued to ground impact.”

Probable Cause:

The pilot's failure to attain sufficient altitude and maintain aircraft control during a turn shortly after liftoff while operating at maximum gross weight, with a tailwind, and in high density altitude conditions.

case 11

Comments from Other Pilots

“This guy took off from an airport that was 4,100 feet MSL in August with an airplane stuffed to the gills. You talk of hindsight, I say it shouldn't have taken a lot of foresight to foresee the end result here. I agree that not everything is simple, but this was.”

“I in no way think this couldn't happen to me if I were to stuff an airplane full of people, fuel and things, not check W&B, and try taking off from an airport 4,100 feet MSL in the middle of August. But that's not a mistake I'm going to make.”

“I know what the bad decisions were, and I'm smart enough not to make them myself.”

“I know you can't fix stupid, but at the same time I find it hard to believe people knowingly do things they know (or ought to know) are very dangerous . . .”

Case #1
case 12

Typical Comments from Friends and Family

“He was an excellent pilot.”

“He took his flying very seriously, and was always thinking about safety.”

“He had excellent aeronautical decision making and was not the kind of pilot who would take risks, especially with his family on board.”

Case #1

NTSB Aviation Database


NTSB Aviation Database


NTSB Aviation Database

from the full narrative
From the “full narrative”

“wind from 030 degrees at 03 knots”

“taxied to the approach end of runway 20 (4094 paved)”

“lifting off at a location that was about three-quarters of the way down the runway”

“Based upon the 4,000 pound estimated weight, the temperature of 91 degrees F, and the tailwind of 6 knots, the expected takeoff ground roll was determined to be 2,412 feet”

Father – similar takeoff once before, in winter. Aircraft turned shortly after getting airborne so the “passengers could keep the family members on the ground in sight ”

so what do we conclude
So what DO we conclude?

The takeoff under those conditions was well within the performance capabilities of the aircraft.

The immediate turn for the benefit of the passengers was not.

Density altitude and wind direction DO matter if you plan to make a non-standard departure at low altitude.

People who think that “pilot stupidity” for taking off in those conditions is what actually caused the accident are “falsely immunizing” themselves from making the same mistake.

false immunity
“False Immunity”

The incorrectly applied assumption that simple pilot stupidity or simple “poor judgment” caused a particular accident and that since you are smarter and use better judgment you are immune from experiencing the same situation or event.

We ALL make mistakes!

“Phew” landings!

the faa looks at adm
The FAA looks at ADM

Pilot’s Handbook of Aeronautical Knowledge

Chapter 17 – Aeronautical Decision Making

p a v e

Pilot-in-command (PIC)



External pressures

p a v e1

Pilot-in-command (PIC)



External pressures

Identify risks, then use T.E.A.M approach:





p a v e2

Pilot-in-command (PIC)



External pressures

Or apply the C.A.R.E. method:




External Factors

i m s a f e

Illness—Am I sick? Illness is an obvious pilot risk.

Medication—Am I taking any medicines that might affect my judgment or make me drowsy?

Stress—Am I under psychological pressure from the job? Do I have money, health, or family problems? Stress causes concentration and performance problems. While the regulations list medical conditions that require grounding, stress is not among them. The pilot should consider the effects of stress on performance.

Alcohol—Have I been drinking within 8 hours? Within 24 hours? As little as one ounce of liquor, one bottle of beer, or four ounces of wine can impair flying skills. Alcohol also renders a pilot more susceptible to disorientation and hypoxia.

Fatigue—Am I tired and not adequately rested? Fatigue continues to be one of the most insidious hazards to flight safety, as it may not be apparent to a pilot until serious errors are made.

Eating—Have I eaten enough of the proper foods to keep adequately nourished during the entire flight?

3 p s perceive process perform
3 P’s – Perceive, Process, Perform
  • • Perceive the given set of circumstances for a flight.
  • • Process by evaluating their impact on flight safety.
  • • Perform by implementing the best course of action.






chapter 17
Chapter 17


PAVE, IMSAFE, 5P’s, 3 P’s, CARE, TEAM, OODA, and DECIDE models

BUT . . .

. . . circumstances and conditions change, and sometimes quickly and unexpectedly.

Not all decision making can be processed through checklists or algorithms.

how and what do we learn from the mistakes of others

HOW and WHAT do we learn from the mistakes of others?

Remember, it’s risk MANAGEMENT not risk elimination.

case 2
Case #2

Pilot: 39 y.o. PP with 310 hours TT and 36 in make/model, no instrument rating (JFK, Jr.)

Aircraft: Piper PA-32R-301, Saratoga II

Environment: Night, haze

Other: Delay in departure time, refused CFI’s offer to go along for the flight, planned to drop his sister-in-law off at MVY then fly to HYA for a wedding the next day

case 21
Case #2

NTSB Accident Description:

The non-instrument rated pilot obtained weather forecasts for a cross-country flight, which indicated . . . clear skies and visibilities that varied between 4 to 10 miles along his intended route. The pilot then departed on a dark night. . . descended from 5,500 feet to 2,200 feet . . . right turn . . . climbed to 2,600 feet . . . left turn . . . Descend 900 fpm . . . right turn . . . airspeed increased and descent increased to 4,700 fpm . . . struck water.

Probable Cause:

The pilot's failure to maintain control of the airplane during a descent over water at night, which was a result of spatial disorientation. Factors in the accident were haze, and the dark night.

case 22

Case #2

Comments from Pilots:

“It was certainly a bad decision to launch in those conditions, period, and I'm not going to try to defend it.”

“Proof once again that the best avionics in the world cannot save you from poor aeronautical decision making.”

“I would never fly over an unpopulated area at night.”

“There are pilots who shouldn't be flying. Which is why JFK Jr. is a horrible example as to why IMC is "deadly" to VFR pilots.”

“Or he more likely he made an impulsive decision, maybe he was Pis%$# that his sis in law was late..whatever it was a sad accident that should not have happenned.”

“In a rush, delayed, nagging women, Less then 3 miles in haze, barely min's, scudd running most of the way, over water without a reference and non instrument rated."

from the full narrative1
From the “full narrative”

55 hours night experience (9.4 in the Saratoga)

35 prior legs along that route of flight

The CFI who prepared the pilot for his private pilot check ride stated that the pilot had "very good" flying skills for his level of experience.

DPE affirmed JFK’s ability to recover from unusual attitudes

The CFI stated that the pilot's basic instrument flying skills and simulator work were excellent.

from the full narrative2
From the “full narrative”

The CFI further stated that he had talked to the pilot on the day of the accident and offered to fly with him on the accident flight. He stated that the accident pilot replied that "he wanted to do it alone."

the pilot, or someone using his user code, made two weather requests from WSI's PILOTbrief Web site on July 16, 1999.

observations indicated that visibilities varied from 10 miles along the route to 4 miles in haze at CDW. The lowest cloud ceiling was reported at 20,000 feet overcast at PVD.

MVY tower: "The visibility, present weather, and sky condition at the approximate time of the accident was probably a little better than what was being reported. I say this because I remember aircraft on visual approaches saying they had the airport in sight between 10 and 12 miles out. “

so what do we conclude1
So what DO we conclude?

Weather conditions and weather forecasts were for VFR conditions along the entire route of flight. There were NO AIRMETS or in-flight advisories for the route issued by the NWS.

The pilot had experience in make and model, night VFR, use of the autopilot, and had many prior trips along his route of flight. He had checked the weather twice prior to departure and felt confident enough to make the trip that he turned down a CFI’s offer to fly with him.

It appears that during the descent he became spatially disoriented and lost control of the airplane.