The emotion in Sheriff Billy Garrett was clear as the 40-year veteran officer described the task of breaking the news. “It’s horrible . . . it hurts an old man’s heart to hear a young girl cry like that.” It had been a stressful couple of days for the Sherriff, culminating in the duty to make that call. First responders had to call off the search during the previous evening, due to dark and poor weather conditions. When the search resumed the following morning, they found the crash site; a horrible debris field containing the remains of an aircraft and two occupants; a son and his mother.

The NTSB report describes an accident sequence starting with a descent from 7500 feet, but in fact, the links in the accident chain started months or even years prior and provide important lessons for both pilots and instructors.

In October of 2016, Charles was visibly excited. Accompanied by his girlfriend, he attended a neighborhood picnic at the airpark where he was buying a home. Meeting his new neighbors, he declared his intention to become a pilot. As a friendly, outgoing person with a career in sales, it didn’t take long for him to make the acquaintance of several of his new neighbors in this tight-knit community. Those contacts led to numerous conversations about how to obtain training and fly safely.

However, as the months went on, some of the conversations reflected a worrying pattern. On one occasion, a Baron was landing on the runway. Wide-eyed, Charles declared: “That’s the airplane I’m going to get. It’s a Seminole, isn’t it?”

“No. It’s a Baron. However, you should probably plan to get your license and build experience in a simpler aircraft first. A high performance twin isn’t a good place to start”.

“I don’t care. I can buy one. I’m going to get one,” he replied.

“Starting with a simpler airplane with one engine will help you build the skills necessary before stepping up to something with twin engines”.

“I’ve driven cars, motorcycles and boats and I’m good at it. Airplanes will be no problem for me,” he said.

Charles asked a neighbor where he should go to learn to fly. The neighbor outlined a few options, but suggested that it would make things faster and cheaper for him if he spent some time reading texts on flying; it would allow him hit the ground running when his real training started. The neighbor offered to recommend some titles.

“I don’t need to do that,” Charles replied. “I don’t read stuff. That’s the instructor’s job; to tell me what I need to know”.

Upon learning that one of his neighbors was an instructor, Charles approached him to ask if he would teach him to fly. The neighbor refused. When Charles asked why, the neighbor explained that over the months he had gotten to know him, Charles had displayed a number of traits that the instructor felt would not be consistent with the ability to fly safely. The neighbor clearly stated that if he continued down his current road, Charles would have an accident in an airplane and the instructor didn’t want to facilitate it.

Charles dismissed the concern as the neighbor having it “out” for him. With this in mind, he relayed the conversation to another neighbor, who stated his respect for the instructor’s experience and opinion and suggested Charles should take those concerns to heart. He didn’t.

Fresh from these events, Charles approached another neighborhood instructor, who also refused to take him on as a student for the same reasons as above. He then went to another airport and over the following several months went through several instructors. In each case, the instructors flew with him a few times and then refused to continue, even though they continued to fly with other students in the area.

Charles was running out of options. The manager of the local flying club said he did not wish to continue renting to Charles, but he was undeterred and in August of 2019, found a way to work around this latest obstacle by buying his own airplane: A well equipped Piper Turbo Lance. He also found another instructor outside the club who was willing to work with him in the new airplane.

Over the following months there were a number of events involving the new Lance, including several near misses in or near the traffic pattern at local airports, some involving nonstandard pattern entries and limited or no radio calls. On one occasion, patrons at an airport restaurant watched in disbelief as the Lance took off, just barely visible through ¼-mile visibility in driving rain as a thunderstorm passed through the area.

By sometime in 2021, Charles had accumulated over 100 hours of time in his new airplane as evidenced by his logbook, his frequent movements around the airport and by social media postings showing him flying his airplane, surrounded by smiling passengers. There was only one problem: He still didn’t have a certificate. In fact, he had not even passed his private license written exam. One of his pilot friends offered to sit down with him and help him study, but Charles wasn’t interested.

At some point, the new instructor accompanied Charles on a dual cross country from Houston to Murray, Kentucky, where Charles had family; a distance of over 500 nautical miles. Sometime thereafter, a solo-cross country followed along the same route.

Around the middle of April, 2021, Charles lost his job. A family event in Murray beckoned, plus his father was in ill health and Charles wanted to see him. As the owner of an airplane, he probably assumed that flying would be the natural way to make the trip. The instructor apparently agreed and even though the private solo cross country requirements had already been met, he approved another solo cross country along the same route as flown before. However, this flight would be different.

For one thing, it was delayed and Charles elected to make it a night flight. For another, his mother was on board. This may not have been the first time she had flown with him; witnesses recount other occasions in which a female passenger was seen and thought it odd, given Charles’ known instructor was a man.

The NTSB final report summarizes the rest of the facts; a night flight into known deteriorating weather conditions, which most probably became night IMC, leading to spatial disorientation, loss of altitude, airspeeds approaching 300 knots and the death of both people on board.

As pilots, we are taught to recognize the hazardous attitudes: Macho, Impulsivity, Invulnerability, Anti-Authority and Resignation. In this case, there was a pattern of behavior that illustrated at least three of these. We are also taught to self-assess our fitness for flight with a PAVE check (Pilot, Aircraft, enVironment and External pressures).

No doubt, Charles was feeling external pressures, with a sick family member, a passenger relying on him to get her to the destination and the desire to demonstrate his ability. However, how good are we at recognizing these behaviors and pressures in ourselves or in others, and when recognizing those conditions in others, to what degree is intervention justified? Certainly each person must take responsibility for their own actions, but at what point does concern for innocent passengers or passers-by take precedence?

In Charles’ case, there were many people who anticipated the events of April 20, 2021. Several of them tried to directly warn him with frank conversations, to no avail.  However, the person most directly connected to the situation was his instructor.

As instructors, we have a number of responsibilities. Chief among them are keeping the student safe while they acquire skills and knowledge sufficient to keep learning on their own. However, shouldn’t the responsibility to keep a student safe also extend to being comfortable that the future passengers and passers-by of a new pilot will be in good hands? It is our responsibility to ensure a productive learning environment while the student acquires those skills and we assess their ability to leave the nest on their own. Until that time comes, the objectives of flight should be education, not transportation.

The private pilot license requires a solo cross country flight of over 150 nautical miles with full stop landings at three airports and one segment of a minimum 50 nm.  Typically, this involves a flight of up to 75 nm from the home field; sometimes less if a triangular flight path is followed. It allows for the student to experience navigating through potentially unfamiliar terrain to potentially unfamiliar airports while still remaining within a time and distance in which the conditions are unlikely to change significantly after review with their instructor.

Increasing the time or length of cross country beyond these requirements contributes little in terms of educational objectives at this license stage, but increases significantly the risk of encountering unforeseen weather as time and distance increase. By endorsing a multi-state, multi-day solo cross country, an instructor risks leaving the insulated, controlled learning environment and steps into the realm of facilitating transportation, something that should be reserved as a privilege of the private certificate itself.

In addition, part of an instructor’s responsibility is to supervise their students. This means reviewing the weather and conditions prior to launch, being aware of when launch occurs and then monitoring conditions during the flight, up to the point at which safe arrival is confirmed. In this case, the cross country was approved as a day cross country, but according to the NTSB report, the instructor was unaware that the student had delayed departure to the point where it became night. It is difficult to supervise a student’s flight if the instructor does not know when or if the pilot departed.

Another instructor responsibility is not only ensuring that a student knows about things like hazardous attitudes and external pressures, but helping the student cultivate an awareness of those things in themselves. This is done over multiple flights, reviewing PAVE checks together and loaning the instructor’s experience as a guide to the student as they develop their own judgment. An instructor who is aware of significant hazardous attitudes has an obligation to help the student recognize and address them, or alternately stop facilitating flight, as several of Charles’ previous instructors had done.

The pre-requisites for first solo or for first solo cross country do not include completion of the written exam, but perhaps they should. There is a material chance that a student on a solo cross country might need some of the knowledge contained on that exam. I’m aware of a number of instructors who require that their students complete the written exam before those events.

At the end of the day, the responsibility for the safe conduct of a flight rests with the pilot in command. After 130-plus hours in the cockpit, the students assuming the duties of pilot in command should know what they’re doing and the risks they’re taking and exposing their passengers to. There is a chance that Charles was going to do what he wanted, regardless of any outside intervention; he had certainly displayed significant resistance to outside opinion in the past.

However, as bystanders and instructors, perhaps we should question the degree to which we might have influenced the behavior, or missed an opportunity to take some action that might have broken a link in the chain and prevented the outcome that led a Sherriff to make a heartbreaking call on April 21, 2021.

David Forster is an instructor and experienced homebuilder who contributes to AVweb’s sister publication, KITPLANES. He lives in Texas.

The post The Most Difficult Call: Intervening to Stop the Inevitable Accident appeared first on AVweb.

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