NTSB's Bruce Landsberg Discusses Snodgrass-Lewiston Accident

Hello everyone, Paul Bertorelli, reporting now on avweb and elsewhere. I'm sure you've seen the final report on an

accident

that said it shocked general aviation and especially the air show and Warburg communities. It was shocking because the pilot was 72 years old. Snodgrass, a retired naval aviator of enormous accomplishments, came of age in the F-14 Tomcat and was by far the longest serving pilot in that aircraft. Grumman's famous piston cats were well known and respected. I interviewed him in 2010 and I'll put a link in the description. This

accident

was a simple find. The pilot took off in a turbine-powered tandem with the control. locked in place and apparently without having performed a standard flight control check, the plane banked sharply, left controlled flight and crashed near the runway, the disconnection here is painful, how could something like that happen to a such an experienced pilot?

This is the most mundane cause of accidents. If you know anything about naval aviation, you know that their safety culture is unique because you have to operate planes from aircraft carriers, it's one of the most dangerous flights imaginable and the navy is good at it because it instills in pilots a disciplined approach to procedures before from a the plane launches with that jack bump, you get full control from all angles every time the navy puts several eyes on everything, films a lot and checks it for possible deficiencies, something we do little of in general aviation as product of that culture, captain.

Snodgrass had a reputation for being careful about preparation and prefighting, but he wasn't without sin either: He landed an F-86 in 2006 during air show practice and was once disciplined by the Navy for flying too aggressively, even so it did not. I won't survive so many years of high-risk flying by being consistently careless, which is why the crash drew so much attention, including the eyes of NTSB Vice President Bruce Landsberg, who sent me a note after the discovery and we scheduled the interview. We're about to see a word on the plane: it was a CMR Kitty 1019B, which is essentially a Cessna L1901 equipped with an Allison 250 turboprop.

About 90 of them were built for the Italian Air Force in the late 1960s, during our conversation, vice president

landsberg

will I do not mention Captain Snod Grass by name, which is an

ntsb

custom; instead the crash is referred to by the location which was Lewiston, Idaho and in some ways the name doesn't really matter as

snodgrass

could be said to represent an archetype of a highly experienced pilot who dies in a crash due to an inexplicable oversight if you are expecting some hidden problem here, something you have never heard or seen or something new and different, forget it, the simple conclusion for those of us who are not first level graduates and perhaps even those who What is it that nothing It imposes more discipline than a checklist, even for pre-flight, of all the accidents we deal with.

Know? It's bad news for someone and some of it is, while most of it is stuff we've seen before. and this one falls into that category, what makes it unique is the nature of the pilot and, you know, I think everyone would agree that he was an exceptional pilot, so we looked at this and one of the things in

ntsb

is that Talk about the attribution bias, are you familiar with that? Yes, but go ahead and explain it, because it's something that I think everyone who, by their very nature, would deny having had, but will recognize it when it's described, of course, in an attributional way.

Prejudice is a fancy way of saying, "I would never do something like that. If it happens to me, it's bad luck. If it happens to you, it's because you're a fool, and in this case I think it's going to be a pretty long stretch for anyone." Of us can make that claim based on the pilot's qualifications, and as you and I have discussed now, the military is very good at preparing people to work in high-risk environments, not that we would necessarily consider flying in a high-risk environment, although it certainly can be and the fact that this incident occurred under what I think most of us would agree are benign circumstances, you know, then you start to think, okay, so how I'm vulnerable in all of this and you know there are four different ways?

What can be addressed, the problems, first is with training and we all understand that the pilot was superbly trained. Next, we talked about the procedure on our planes, which is. Follow the checklist and do everything a certain way, the same way every time. make sure we don't miss anything the third element is monitoring and in general aviation we generally don't have that when you have a multi-pilot crew so you can have one pilot monitoring and one pilot flying and then the last element which is I think It is very effective, but it cannot stand on its own.

It's designing the problem out of the system, that's what has given us all our automation and the tremendous technological improvements we enjoy in our airplanes. In this case, we had three of those. elements, there was a checklist of procedures to follow, there was absolutely training, although in this case the pilot was new to the plane, if I remember correctly, he had about 20 hours in this particular plane, now you would think that this It is a very simple airplane compared to what He has flown throughout his career and that is true, but simple airplanes can be as dangerous or even more dangerous than the more sophisticated ones because they do not have all the systems of airplanes. passengers and in commercial chess, we have takeoff configuration alarms and things like that that will not allow you to reach this point in general.

Hold that thought because we'll come back to it in just a minute. So, as I say, that brings us to the engineering side of things and how control. The crash of this plane was designed so that when we get down to analyzing the case and the wreckage, one of the biggest challenges that our investigators always face is not to jump to conclusions because it's very, very easy to say, "Oh, yeah, I've seen this." before we know what happened, that's not how we like to conduct investigations because a lot of times you'll miss something that will make the result completely different from the path you started on, so here our people started looking at the things we have in mind. video they made.

It was much easier for us to see what was happening with the plane and fortunately it was high definition so we were able to look very closely at the control surfaces and the lack or near lack of movement during the accident sequence, which which gives us a pretty clear image. One of the things our investigators will look at is the continuity of the flight controls and one thing that helped tremendously in the investigation was the fact that the plane did not burn, that gives us a lot more to work with, so they were able to establish the continuity of the flight controls and then observe the wreckage itself and the way the plane landed on the floor of the plane.

It was horribly deformed due to the forces of the impact and if the control lock had been locked to the floor, as it would be in flight condition, i.e. not activated, the control lock would have suffered significant damage along with the rest of the floor that is. What they found, they found that the control lock was in almost perfect condition and had only been turned about 90 degrees as a result of the movement of the rudder pedals because it connects to the rudder pedals on the control stick, but if you look in the file and for people who like to study accidents, you know that most of us just read the accident report, but if you really want to dig into things, you go to the file and there are some pictures in there that show exactly how it was placed this control lock and I'll put those pictures up as you talk here, yes, absolutely, so if you look at the pictures, you can see how when the control lock is locked, in its position, it's not close to the floor, so it doesn't get damaged in the crash sequence and secondly, what is of great interest to me from a human factors perspective is that it is perfectly aligned with the control stick, so if you didn't look closely you wouldn't even see it now .

You know every plane I know is on the checklist, if you have a checklist, I'm thinking of your pup Paul and my days in j3 flying, there's not much checking, but the check is free and correct, it's one of those. absolutely essential things that we use every time and hopefully you do it before you start the engine or immediately after you start the engine, set the controls, that is, move them to their full extent to make sure everything is as it should be and Ah By the way, it would be good to look out the window to see that the ailerons are going the way they're supposed to and that the elevator is doing what it's supposed to do, especially after maintenance, because sometimes there's a chance things can break down. . the other way around, if you will, one point of the statement here that I think is important is that some of the early speculation from people familiar with this airplane said that when the control lock is installed, it locks the stick and it also locks the throttle pedal. rudder so that he couldn't taxi with the control lock in place, so it couldn't have been a control lock, but in fact that wasn't true, our people also looked at that and apparently it certainly wasn't, so you already know.

We get into all the technology of all this and so on, and what it brings to mind is that there are certain things that we have to do procedurally every time we fly and that's what caught my attention because I was thinking, you know , I fly quite a bit these days and you know I feel comfortable on my plane. I spend a lot of time on it, but the thing to remember is that any plane can create a serious problem for you in a very short time. Note that most of the time we have a chain of events that happen, in this case the chain was very short and manifested very quickly, so there are a few things about setting the fuel in the wrong tank, having the airplane adjusted incorrectly or get out of control. lock in place that will take you off the end of the runway very, very quickly if you look at the report and I don't remember if the report or the file uh, investigators interviewed another pilot who said the same thing happened to him, not really. he saw the lock in place and flew and suddenly realized that this is bad and luckily he was able to disconnect it before the plane hit the ground so this is not completely unknown to an engineer. perspective, I would say you know it would be nice if we made those control locks a little more visible, well, originality, go ahead, you probably can't say this as VP of ntsb, but I can, the design of that control lock is It's horrible, almost it is a preparation for this type of accident and I will show the picture again when you look down, from where you are sitting you can't see unless you are really looking for it and the and the ends of the control lock that engage with the rudders would be far away of their feet, so they wouldn't necessarily feel it and the rudders would work enough to be able to taxi.

I can't tell, I think it's a bad design. and yes, it works when everything fits exactly into its place, but we have to design things to bring out the human factor in them. You know the chain of events from the accident and you know I like to say you design these things for the bottom we should design airplanes for the bottom half of the bell curve we can't say this about this pilot he was at the top of the curve, right, so that doesn't apply, so I think you know what's there. There are some real takeaways, one other thing, but while we're discussing control locks and I don't want to let the opportunity slip by, you may remember that a few years ago a Gulfstream G4 went off the end of the runway in Bedford Massachusetts.

Because the control lock was left in place and the crew was pretty bad, they never checked it on the checklist we had, that we had a cockpit voice recorder and a flight data recorder that survived the crash and they never, ever checked the free controls and Now, admittedly, Gulfstream had designed the airplane so that if you didn't disengage the control lock, you could only advance the throttles or push the sticks to a fast taxi level, not I would get enough power to make the plane move a lot. quickly, unfortunately, the interlock failed, so you know, the security system failed.

What are the chances of that happening? The other thing we find going forward, well, it's one of those, beyond 10 to at least nine, isn't it? I'm sure Gulfstream engineers said this couldn't fail, how could it fail, but it still did. We've seen a lot of other engineering failures that I think we're all familiar with here that people were pretty sure couldn't happen. uh and they did um I'm a firm believer in Murphy's law uh in that sense so the other thing we do remember is thatwe're talking about the procedure uh in the Bedford accident uh we went back and looked at the flight data The recorder and this particular recorder was recording literally hundreds of flights.

This crew got into the habit of not checking the control lock, so the term is deviation normalization, I guess, or accepting, you know the fact that yeah, we don't need to do that. This is just a waste of time and stuff, and what I see in all of this is that there is a reason we have the procedures we do and 999 times out of a thousand it won't make any difference. You're wasting your time, don't bother and that time it will make a difference and save your life. That leads to the natural question. You and I both looked at this, the summary of the accident.

Now I have looked at the file in detail, looked at the probable cause and there is really no doubt that the probable cause is a human failure accident or a human factor accident for the type of pilot you would least expect it to happen to. a naval aviator traps thousands or hundreds aboard aircraft carriers and the navy has a good safety record and they do this by having a very consistent disciplined safety culture so this guy would be the last person you would expect to happen. but it happened to him, so where do we go from there to really instill the idea that the basic safety checks that you do as part of the pre-fight and the pre-fight period, wherever you do it?

Do you also always have to include that control? Check because I'm sure in my aviation career I took off without a checkpoint. I'm sure it is. You know, I can't remember it specifically, but it's the kind of thing it should be. Basic survival instinct, how is it built? Yes, I think you know that none of us want to show the pilot's memory better here and, as you know, we don't, we don't mention the pilots by name because we don't want to. Attributing more value to a person or another life for us is important, but I think the bottom line for me and it also reminds me a little bit of the Scott Crossfield accident, uh, involving thunderstorms and of course Scott Crossfield was a you know in that top 0.05 percent of aviators and crashed in a storm in his uh 210. and what is the last act in which these pilots served as an award if you want to look at it that way to remind the rest of us in the 99 lower of the bell curve that can happen and there is a reason why things are set up the way they are and people who don't study this as much as you and I and as ntsb does, I don't think I fully appreciate that, we see it. regularly and you say, oh my gosh, how did this happen and how could this person have done this and I know I will never look at a control lock check or make sure the control is free and correct.

Likewise, well, that may be the lasting positive legacy of this accident. um if people remember the details of this accident and the details here are minimal, they are absolutely minimal, this is not a complicated situation here, it's a very simple situation. a poorly designed control lock that was easy to miss, so if you remember that, maybe that will refresh your memory to check for control locks and remove them and then do the control check anyway, but you just reminded me something else, um, periodically I'll pull someone out of the weeds because they used a rusty bolt or nail instead of a missing or damaged control lock and I think we can all agree that sometimes new equipment is pretty expensive to replace , but again I won't.

Discuss the price of these things, but I will say that you have to have a good control lock that will make it very difficult to miss. There's a reason why equipment is designed the way it is and when you start. work independently on some of this stuff and say oh I'm better than that, I don't need to do it, like I say, we grade, I wouldn't say regularly, but probably every year or so I'll come across an accident where someone used an improvisation. control lock and you think you know cost-benefit analysis just doesn't work well, that's aviation for you, I mean I admit it, I'm very disheartened by the details of this accident and others because this is not something that doesn't has happened before we address this, I mean, I've been writing about safety topics for 35 years, we've covered this topic before and a lot of times there's nothing that's been particularly inventive about any of the accidents.

I'm seeing that, oh there's one we haven't seen before, we've seen almost everything before and this is just another version of that, maybe you can encourage me to make the distinction between crash and accident. This is something I learned when I came to the board and when you ask people they think they are generally synonymous with it's not an accident it's something that is unforeseen and unpredictable an accident is something we know what happened, we know why it happened and we know how to prevent it and in all the modes that we investigate, highway, railway, marine, aviation, 99 of what we investigate are accidents, we have seen it before, we know how to prevent it, I suppose it would also respond to your frustration, uh, in fact We always have new people coming in, we talk about the old bold pilot.

Old pilots, with a few exceptions, have generally learned, either indirectly or directly, that things can go wrong and they can go wrong pretty quickly, which is why it unfortunately has to come to this point. some of the things we see on YouTube and some of the things the local airport attendant says. Oh yeah, you know, no, you don't have to worry, it's not a problem and you have young drivers who are susceptible to that. impressionable and they think, oh yeah, I can get away with this. I'm too good for this to happen. That's the attribution bias we talked about at the beginning.

Yes, of course, this cake was not one of those types that it was not. That's maybe the point, that's the creepy part in a way because, you know, but by the grace of God, I mean for sure, I interviewed him and in the introduction to this I'll give his name. I realized that the board. doesn't do that, but I will lay out the details of this accident and uh he was very well known, very respected and I think he has really sent shockwaves through the aviation community and especially the air show community if Can you know take a huge pile of lemons here and turn them into lemonade?

I would say the message is that there is a reason why we train one, two, why we have procedures and we have to follow them and, unfortunately, the engineering in the plane that we choose The fly is practically built in, so when you take it it's your baby, which means that the training and the procedure really has to start and you have to be pretty focused on all of this and that's another thing we talked about is not flying when we're distracted or whatever it is and we get complacent. Planes are easy once you've learned the basics of what's going on, but I like to think of a plane as a kind of chainsaw and not many people misunderstand the risk of a chainsaw and I think we need to see our planes as chainsaws. , with that interesting analogy, we'll wrap it up, vice president

bruce

landsberg

of the national transportation safety board, thanks for the information and thanks for reaching out, thank you.

Thank you very much Paul and safe flights to you. The same to you.