NTSB report on accident offers lesson in combating pilot complacency

When pilots gain more experience, some let their guard down—to chilling effect.

Earlier this year, the NTSB determined that the cause of an accident in Addison, Texas, in June 2019, was the result of pilot error. Specifically, the report noted that the pilot of Beechcraft King Air 350 experienced a left engine failure on liftoff, and responded with left rudder input, the very opposite of what was needed. The pilot, his co-pilot and eight passengers on board were killed.

According to the report, if the pilot determined the need for right rudder and used that instead, the airplane would have been controllable.

I was keen to read this report because during my time introducing engine failures to students in multiengine airplanes, I would review the harrowing video of said crash, which was taken from multiple cameras around the airport, showing the airplane’s final moments. My goal in using it wasn’t to scare them, but frame by frame to examine the engine failure, and discuss the corrective actions that should have been taken.

We would discuss the mechanics of flying through the engine failure after liftoff—the tested “dead foot, dead engine, identify, verify, feather” method. However, this report now points out a swiss-cheese series of lapses that lead to this outcome. I think all these things are compounded by the fact that the pilot flying had 16,000 hours, according to the report. It seems sadly ironic that while I’ve used this incident to instruct new students, there is a trend worth exploring where more experienced pilots find ways to create and mismanage emergencies.

I suspect that at the root of these incidents is complacency.

The irony of gaining more flight experience is that pilots let their guards down. On the other hand, no one wants to constantly be on the edge, so it seems that the best hedge against complacency comes from putting up systematic guard rails to keep us in line. Larger flight departments and airlines obviously have robust safety management systems and recurrent training programs to do this, and this should be a sign to GA pilots how consequential the lack of these structures can be.

Here are some observations and lessons from the accident that more experienced pilots should consider.

Startle… Again

When the NTSB reviewed the audio from the cockpit voice recorder, they discovered that the crew had not discussed an emergency brief prior to departure, and during the emergency, the pilot was startled, and failed to run any checklists. The report noted that “the pilot’s confused reaction to the airplane’s performance shortly after takeoff supports the possibility that he was startled by the stall warning that followed the propeller speed divergence, which may have prompted his initial, improper rudder input.”

When I wrote about combating the startle effect, one thing I encouraged was slowing down as a way to hedge against our initial instincts. Despite having enough time for the point of initial failure to impact—17 seconds—the report noted that it would have been possible to maintain directional control of the airplane after the loss of thrust in the left engine if the pilot used the right rudder instead of the left rudder.

Don’t Skip the Pre-brief

The cockpit recorder also revealed that the pilot and co-pilot did not go over preflight checklists or discuss emergency procedures. “As a result, they did not have a shared understanding of how to respond to the emergency of losing thrust in an engine during takeoff,” the report says.

Briefings are low-cost, high-leverage elements that hedge against complacency because they refocus the mind to the possibilities ahead. Briefings simply put you in the frame of mind of what to expect for the next phase of flight and help root out the invulnerability of “it could never happen to us.” Furthermore, the extra time they require, especially on the ground, is nothing any pilot in distress wouldn’t trade off for being ready for any likely emergency.

If you’re a GA pilot operating independently, or flying solo, I encourage you to come up with a standardized briefing framework per phase of flight. This will improve both the quality and safety of your missions.

Good Pilots Use Checklists

Another hedge against complacency? Checklists.

Throughout the report, investigators pointed out a series of events—ranging from the airplane’s improper configuration to recovery procedures—that checklists would’ve aided. In my own experience conducting check rides, if I quizzed the applicant on abnormal scenarios and they began guessing the right things to do, I would generously remind them that someone—the manufacturer—probably anticipated the scenario in question and wrote steps down for them to follow. This would prompt them to finally consider the checklist.

Who’s flying? Who’s monitoring?

The breakdown—or lack—of crew resource management in the incident is important to mention.

The report pointed out that the 28-year-old co-pilot, despite some experience in the airplane, was not allowed to operate the airplane with passengers on board, which might be reasonable for various reasons. This may have contributed to the breakdown in crew dynamics that could have provided the pilot flying the support he needed when things went awry.

More chilling, the CVR recorded the co-pilot correctly identifying that the left engine had failed, but it is likely he didn’t take over, possibly because of the pilot’s practice of being the sole operator of flight controls with passengers.

Relating back to the briefing tip, it would be beneficial for crews to identify who the pilots flying and monitoring are, and how the crew will work together when things go wrong.

In training, I would discuss on the ground with my student the exact verbiage we would use to practice engine failures for each phase of flight, and we would rehearse the task that each of us would be expected to complete. This is something you could do as well if you operate independently.

Help on the way: Smart Rudder Bias

While it’s sad to see findings of this incident, I am encouraged by recent technology advances that will hopefully eliminate accidents like this in the future.

With Garmin’s recent release of their Smart Rudder Bias technology, it seems the industry is thinking about these incidents more broadly.

“Smart Rudder Bias provides additional assistance against hazardous effects of a one-engine inoperative (OEI) event when appropriately equipped,” according to Garmin. “It also provides pilots assistance in maintaining control of the aircraft while determining the next course of action, simultaneously reducing workload in a high-stress and time-critical flight environment.”

Perhaps more advanced technology might be the ultimate hedge against complacency. flyingmag.com