NTSB's Bruce Landsberg Discusses Snodgrass-Lewiston Accident
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- เผยแพร่เมื่อ 21 ส.ค. 2024
- On July 7, 2022, the NTSB released the final report on the Dale Snodgrass crash in Lewiston, idaho in July 2021. As many expected, it found that the crash was caused because the pilot failed to remove the control lock during his preflight and then failed to perform a full flight control check to catch the error.
In this interview with NTSB Vice Chairman Bruce Landsberg, he reveals that the only thing unusual about the accident was the pilot was a high time, accomplished military aviator with thousands of jet hours flown in high-risk environments. Unfortunately, we've seen this all too often before and Landsberg also discusses a Gulfstream IV accident which killed seven in 2014. Same reason. Snodgrass' legacy may be the positive one of shocking pilots into taking control checks seriously.
CLARIFICATION: Vice Chairman Landsberg said the aircraft didn't burn after the crash. However, there was a post-crash fire that partially burned the wreckage, but not to the extent that hampered the investigation.
In 2010, AVweb interviewed Snodgrass about his preparation and planning for a jet airshow. • Ride Along with Dale S...
You can the accident report at this link. There's also a link to the full investigation docket.
s30121.pcdn.co...
All those Bruce Lansberg columns in AOPA Pilot about what goes wrong. But I read them. All those similarly themed analyses I've read or seen by Paul Bertorelli over the years. But I read them. I watched them. And, for five decades, all those checklists I followed religiously, occasionally hating myself for doing so because it often felt...dumb to do so. But I did them. Every time. Is that why I'm still here? No one can say. But one thing for sure - they didn't shorten my life.
No one is immune to a momentary lapse of discipline.
The way I look at something like this is the more sophisticated the aircraft the more disciplined pilots might be. The younger the pilot the more disciplined they might be. After years and years of beating the odds and coming out unscathed it might be human nature or easy to let your guard down especially during a less sophisticated simplistic situation. This is how I feel based on my life experiences. I will take it to heart and try to be more aware and disciplined.
Thank you! Yours is one of the very best comments about this tragic accident. My little contribution is that, what I will call "High Skill Complacency" to summarize your comment, could have been further complicated by the fact that in the final report it is mentioned that Mr. Snodgrass had heart disease. While the heat disease was NOT the immediate cause of the accident (as in a heart attack or stroke), it is medically known that heart disease can cause momentary, temporary lapses in judgment and other equivocations even in people as highly trained and lifelong careful as Mr. Snodgrass (search: "mental impaiment in heart disease").
The tragic part is that these momentary incidents are usually dismissed as not important. Sadly, this may have happened to him and I bring it because we pilots (and everybody else) must take regular medical care because we literally feel with the brain, hear with the brain, see with the brain, etc. and FLY with the brain, so the body and brain must be kept in top shape. May he rest in peace and may we rest in uncompromising diligence and self-care.
I'll take experience over youth any day. Been around it 72 years.
@@watchgoose When experience becomes complacent and over-confident, it loses its amazing value and it stops being experience and becomes carelessness mixed with a superiority attitude. Experience retains its amazing value by remaining very hungry for more learning and training, never compromising safety to satisfy our ego and welcoming corrections with a smile and open arms.
Humility should be an absolute requirement for a pilot because it keeps us lightweight, if not we are like an elephant trying to fly in a Cessna 150 and gravity tragically always wins. It's not about being chronologically old or young, it's about staying young in the mind and the heart by constantly fighting the biggest enemies of flying: complacency, overconfidence, not being a life-long learner and PRIDE. Pride is the enemy, not youth or anything else.
@Captndarty
There’s an old adage. If you “try” to feed the dog…the dog will die.
Think about it. Not intended to be personal.
@@watchgoose until your body betrays you from sheer age. Your brain ages, your memory weakens, your eyesight degrades.
I am reaching the end of my forties and already notice a significant performance degradation in comparison to the late twenties. Of course knowledge and experience gives me the edge over my younger self. Sometimes it is just the confidence that I know I can do this or that.
On the other hand becoming older is real. I don't think that "experience over youth" is the right contraposition.
The older and the younger should team up and have each others' backs and make the most of both experience AND youth.
I have great respect for the NTSB so I _really_ appreciate Mr. Landsberg and Paul having this discussion. Thanks to you both (and the rest of the crew, of course).
Paul, a word of encouragement: There very well could be at least one pilot out there who would have done something risky and died, but didn't due to having been informed and warned by you...but you'll never know about it. How many lives were saved? We'll never know. It's hard to study and quantify things that never happened.
There are things I do because I've read about a crash or someone like Paul has done a video on it. You're absolutely right in that we can never know how many people have benefited from Paul's videos.
It's one of those weird knowledge things. I recently did work to arrest minor flooding in a basement--but I can never know if I solved the problem, only that I haven't.
Paul can never know who he helped--he can only know who he didn't, and that (presumably) by reading about a crash that is similar to this, e.g.
Locks and safeties like this control lock need to be very inconveniently located so that the damn thing is 'in the way' before you can operate the airplane. To get it out of the way, it has to be stowed and safe. The control lock design in this airplane was terrible.
That's why many pilots use their seat belts around the control stick as a control lock. It's effective and completely in the way if you want to fly.
@@abel4776 I’m pretty sure this control lock was locking the yoke shut.
Very true, but I guess pre flight checks take an element away from needing to make the lock visible enough, it's unknown why this pilot didn't move the stick around to check full movement before starting out, a natural thing he'd done in all other flights
Amen!
yeah.. not just visible, but really in your way. I recall the Cessna 172's control lock was just too much in your way for you to fly with it.
That reminds me of working at an FBO in the 80’s and doing a major overhaul and service on a Twin Otter. When it was released back to the corp owners pilots they took it and did a complete pre flight and then spent about an hour on a run up pad doing checks. When they went to take off did the same, pitch up into a deep stall and crashed nose down on airport grounds. They hadn’t removed the control locks. These are incredibly complicated set of pins and red metal flags that are right in front of the pilot. You literally can’t grab the yoke without hitting a pin flag. I have no idea how they missed this.
It is important to emphasize the full motion control check in our checklists isn’t just about controls locks left in place, it is about any discrepancy in the free movement of the controls before we attempt a takeoff. As a flight instructor I use the example of tragic known accidents due to missed control locks left in place to make a point, but is is also about frayed cables, physical obstructions (a big purse in someone’s lap), failed pulleys… etc. any number of unforeseen scenarios that can contribute to the lack of full control when necessary that can be detected before we take the runway. All of us who use written checklists miss items from time to time. It would be disingenuous and false to say otherwise. It is the long established disciplined use of well thought out checklists that we must instill to safeguard our humane fallacies in flying. We morn our compadres who remind us sometimes of our simple human failing as aviators. May we honor their lives in our own reflections in how to conduct our future flights and interactions with our with our peers.
well stated---for sure we all miss an item on a written or memorized checklist from time to time. Our minds drift, especially when we are doing a task so familiar from multiple interactions daily
This one time.. A full control check was done and I saw all the flight controls moved as expected. Then I asked the student, did you do a walk around? He said no. I found a rusty external control lock installed on the rudder and was bent from the peddle movements during control checks.
How about another approach? Do whatever you want with the a/c’s checklist BUT train yourself that at ever turn onto the active runway you check three basics: CONTROLS FREE, SEAT LOCKED, FUEL ON.
Most of the other stuff, trim set, door closed, wife happy, etc is survivable or fixable before you crash.
Attribution bias is a real issue. I'm in the medical field, and any time I hear about a medical error by a colleague, I try to learn from it rather than saying "I could never do that". I have changed protocols and procedures because of errors I have read about
hear hear
One phenomenon I find interesting is how surgeons have been so resistant to implementing checklist in operating rooms.
I think it is rude when people blame other people for whatever mistakes they've made. It is probably lack of compassion, or maybe a cultural thing as common phrases are repeated over and over again.
Here's a simple solution for this situation, and others like it. When you activate the lock, run a bungee cord from the control lock to something across the seat, so that you have to release it to get in the seat. When you stow the lock, wrap the bungee around it so that you'll remember to use it when you activate the lock. Simple, but effective!
This is why I bit the bullet and bought the genuine Beechcraft control lock for my Bonanza which has an integrated engine controls cover, making operating the engine without removal of this control lock impossible. I see people often using homemade solutions for control locks to save few bucks but I think this is an area where you should not skimp on if you can use a control locks that also locks out the engine controls.
This, 100%! any control lock should at a minimum prevent taxi by locking the rudder pedals too and preferably also prevent starting the engine. That's the failure here, not the missed checklist item. Humans gonna human and make mistakes, aircraft designers can *easily* make it very difficult if not impossible for a pilot to attempt takeoff with the control lock in place. Here the control lock not only allowed taxi and takeoff, it's not even readily noticeable to the pilot that the lock is on place.
@@ulbuilder out of site out of mind ☹️
I have to admit one time I was in a hurry, and did a very quick walk around and saw that there was no damage to the aircraft because it was just flown an hour early jumped in it and flew. All of a sudden I realized I was not getting any air speed and looking around. I then noticed out the window that I forgot to take the pitot tube cover off. Sometimes complacency or doing things repetitiously without paying attention, leads to you, believing you did something that you did not actually do.
You should always check your control movement because you don’t know if another aircraft or something on the ramp bumped into one of the control surfaces and caused it to be deformed. I often do a reverse control check first. This is as I am looking at both sides of the aileron, rudder or elevator I carefully move the control surface at the pushrod location and look into the cabin to see the movement and direction of the yoke. Then as part of my pre-takeoff checklist, I’ll do a full free and clear movement with the yoke and verify the control surfaces I can see from the cabin.
The airplane like a chainsaw analogy is quite fitting.
This brings to mind a thing I learned as a woodworker for using a band saw. When not in use, we take the tension off a band saw blade to keep it from stretching or ruining the wheels. If the band saw gets turned on without re-tensioning the blade, it could jump off the wheels and break or otherwise cause an issue, so to be sure that doesn’t happen, we clip a carabiner on the blade. For a flight procedure like this where it’s a known issue, it would be a good practice to put a coffee cup over the stick with a message written on it in black marker saying CONTROL LOCK!
Great discussion, serious and somber. I watch many of these small plane crashes from multiple sources, for the main reason is that it serves as a repeated, regular reminder that mistakes can be made by any of us. I have an old C172 which is among the simplest and most forgiving planes that has never caused me exceeding worry. But I keep in mind especially as a common example, the many stall-spin crashes on that base-to-final turn that catches people banked, to slow and to low to recover in time. If I am ever in a situation that the instinct/urge is to just "pull up!!!" I hope I've seen enough of these scenarios that are in my memory at the time that I will remember NOT to do that...As an example. Thank you.
This is so sad, this accident is going to stick in my mind each time i preform a preflight check in my Mooney...
😎 Thanks AV ⚓️ As a Mariner, I have to thank the aviation industry for all the positive changes to our safety culture…. The oil companies got tired of paying for pollution & blown up barges… and looked to the aviation industry for some sound practices. I am a direct beneficiary. ⚓️
Paul,
Great video and interview - thank you! Im not a pilot and your explanations make understanding these aviation issues easier to understand. Much respect for NTSB Vice Chairman Bruce Landsberg as well.
Paul (in MA)
One thing I have found at the ripe age of 73, it is possible to simply miss something, or forget a step in a procedure. So the big mistake is attributing proficiency of an experienced 30 year old, to someone performing a task at the age of 73. When you get over 70, simply due to the brain's blood flow plumbing, you will not be as good handling multiple tasks, especially, if you try to compress your schedule and do them quickly. (You can read about this online. It is a well documented challenge for seniors). A senior will drop the ball when trying to do something complicated in a time compressed manner. Besides that fact, a senior's vision may not be as stellar as it was during their younger professional years. This is not to doubt the accomplishments and talent of the pilot in this accident. But perhaps an additional factor might be overconfidence in your own ability to perform task management as you age into your senior years. The lack of awareness of your own abilities as you age, might also have been a contributing factor. Perhaps It might be important for senior aged pilots (even accomplished former Navy Pilots) to not be in a hurry, and have a buddy as a second set of eyes during pre-flight.
Nail on the head. Bravo.
Same goes for the unfortunate past-retirement age B-17 captain. All the training and experience in the world aren't always sufficient to get out of an extremely precarious situation. Maybe nobody could have. But still...
Anybody can make a mistake.
My little RV-12 has no internal gust locks, just a PVC pipe U shaped rudder lock and the seat belt around the stick. After "burping" the Rotax for the oil check and sumping the fuel, the next part of the preflight before ever getting into the cockpit is a walkaround which includes moving all of the control surfaces by hand and checking the integrity of the fittings. I box the controls right after startup and right before taking the departure runway and watch them to make sure they move correctly. Years ago, I heard something that I've never forgotten: A mechanic A&P/AI friend related something his father (a FAC in Laos during Vietnam) told him when he said he wanted to learn to fly: "Son, remember. No one is exempt."
There was more than one error. A full exterior preflight inspection, with the flight control surfaces checked for free movement, most likely was not performed by the pilot in command. And the final error was the lack of a pre-takeoff flight control check. Amazingly simple, and routine. And the omission of these standard checks proved to be amazingly fatal.
Exactly, it's the free movement of travel he obviously didn't do that gets me, people comment about the 'stupid' control lock being hidden from view, if he'd checked control movements he'd have known
Thanks Paul! I will be talking about Attribution bias and the correlation with normalization of deviance and complacency at the next meeting with our pilots. This is so important as it shows that if this can happen to the best of us, it can happen to any of us.
Excellent interview! Many thanks for the thoughtful analysis and lessons learned!
I appreciate the comparison of airplane and chainsaw: every airplane - simple, complex, piston, jet or rocket- that's worthy of the name (and some that aren't) can still take you to a height from which you cannot safely fall. Heck. I've slipped off icy wings on the ground. . So adhering to a pretakeoff procedure that works and covers all the killer items is just as essential in a J3 as it is in an F35. While I have always, without fail, boxed the controls to make damned sure they are free and correct, I have committed other pretakeoff sins that could easily have ended badly. Not catching the mixture control pulled aft to keep the plugs clean as I taxied a long, long way on a hot summer day is one of those. I have also experienced (mainly post-maintenance) the sins of others. A bent aileron trim tab comes to mind.
Controls free and correct. Instruments in the green. Gas? On the mains and boost pump as required. Altimeter set. Runup. Trim for takeoff. Interior (doors and windows closed and checked). Propeller for takeoff.
If you only check these things - without fail, without allowing anyone or anything to interrupt you - I think you have pretty good odds of flying airplanes long enough for it to become habit forming.
Well said Robin. Very well said. The surprising thing about this mishap is the..... end of runway freedom of movement drill. As was said.....inexplicable that he did not accomplish it. Hard to even think about.
Once I was taxiing an A320 and the controller cleared us to cross a runway. We were nowhere near the runway. My partner and I were both inexperienced at driving the plane. I looked at my partner and said, That's not right. He said, I know, I know....we'll just look before we cross. OK, the situation was discussed and "briefed." We make our way over to the runway in question and as we get closer and closer it becomes apparent to us non pilots that a FedEx 727 is approaching our runway for landing. I say, "Do we have time? We won't make it" Partner says, "GO....JUST GO!"
We crossed the crown of the runway surface going pretty fast and felt the plane noticeably bounce as it crossed. We had to brake hard to make the turn and turned hard. Just as we made the turn the 727 blew past us on the runway. I was livid. You know who I was mad at? The controller? My partner? Nah.....I was mad at ME ! I swore like Scarlet O'Hara.....as God is my witness I will never let others rush me ever again.
Thanks Paul and Bruce for a great interview and video on such an important topic. I'm wondering if we need refreshers on human factors just as much as we need Biennial Flight Reviews. As GA pilots who often fly alone, we need to have a healthy fear of the aeroplane and a healthy fear of our own fallibility EVERY time we go to fly. There is no room for complacency when you're a solo pilot. God bless my wonderful flight instructor who taught me to put my own mental status assessment as part of my preflight checklist. I hope I never let him down.
Excellent interview, thank you for your great content.
Thank you for a very good discussion about this simple, but catastrophic, crash and its implications. The points about more experienced pilots and “Murphy’s Law” are particularly relevant.
It was once summarised to me as: the inexperienced pilot is surprised when the aircraft does not take off; the experienced pilot is surprised when it does!
Trim is a big one. On my Comanche it’s up above your head and out of your field of view. I once had it incorrectly set way trim up (for landing) and did a taxi back. On the takeoff roll I was trimmed too far back and had to abort takeoff. Big big wake up call
This has been the very best summary of this accident. Thank you Paul and Bruce.
The control lock on this aircraft type is a poor design / engineering so how was it approved during the type certificate process? Was it an FAA oversight?
The FAA has little to no opinion on most safety related items. They care more about minimum performance targets and stability and control. And that all components are "certified". They don't care how the product actually functions for the customer in reality, and they prevent anyone from making changes no matter how bad the initial design.
1. Scott Crossfield came to mind right away for me. 2. A Ford Tri-motor went down in Fullerton, Ca. airport, at a airshow of all things, due to a control lock not removed. 3. One of the best ways is to keep up to date on all accidents and know that you could be that person given the right circumstances My dad used to say, "a fool doesn't learn from his mistakes, the average man does, but the wise man learns from the mistakes of others."
A very good discussion, only have one thing to add, we always do full and free control checks just before entering the runway, the last thing before checking for traffic, this because of a number of accidents where something has blown up or been taxied over and jammed a control surface in-between the start up and run up.
Things wrong with the design of the gust lock: 1) It was hard to see when installed because you are looking along it's length. 2) It locks the elevators up when it should rather tend to keep the aircraft on the runway. An overrun would be better than what happened to this mishap aircraft. 3) The gust lock should cover the engine ignition key slot or in some other way keep you from starting the engine. Any other practical ideas for the gust lock?....short of a Rube Goldberg design?
You're barking up the wrong tree. Pilots, especially naval aviators, due a control check even in their most rushed moments. Controls free, gauges in the green, knobs forward. The gust lock is an important safety item (ask any airline mechanic about those recurring inspections.)
@@flyingjeff1984 I don't get what you're saying. So you are perfectly fine with the design of this gust lock and it's all on the pilot?
@@flyingjeff1984 "The gust lock is an important safety item (ask any airline mechanic about those recurring inspections.)"
What does an airline mechanic's experience with recurring inspections have to do with a pilot's preflight gust lock removal ?
Thank you Mr.Paul.... you're doing a world of good sir - for those of us in the sky as well as those of us past the end of the runway - don't let anybody tell you any different. I think mr.Dale would be proud of the way you represented his incident, mr.Dale was a giver, as proven by his lifetime of military service, and while the final chapter was unfortunate for friends and family and community, mr.Dale went out giving, giving us something to think about that might just keep us safer in the future.
I just wanted to say, without you and others, there would be 100s if not 1000s of more crashes.
I think I can safely speak for all of us that are not narcissistic, your work is invaluable! Do not feel like you are not making a difference, you most definitely are, and if you give up, it will result in many more crashes!
Thank you so much for what you do, PLEASE keep it up for our sakes!
Luv you bro!
I've had a fair amount of accident analysis and accident investigation training and experience (not in the aviation world). Something that we were told in one of my early courses that has always stuck with me: "If you can imagine it, it can happen."
In US Navy that is said "whatever can happen, will happen" and the corollary "shit happens"
We have far too many of these senseless crashes. I read a report about an RV-6 that ended up on its back just after takeoff from a fly-in - the pilot was alive and talking to the crew that was trying to rescue him, but he ended up burning. Seat belt around the passenger stick, with obviously no "free and correct" check before flight. That's the guy I think about every time I take the runway and do my 3rd "free and correct" check. I also do it before startup after raising the flaps, and before taxi. A bit pedantic, but I want to honor that guy's memory by not repeating his mistake. There is also a video of an RV-8 with control locks in place. And now Snort. RIP my brothers.
I've almost done that before in my Citabria... 5 point harnesses, use the back seat one to lock down the controls when parked outside. Just the stick, not the rudder pedals. So you could taxi all the way to takeoff without noticing. Skipped the control check. Taxiied a little distance, and then turned around to toss a small bag I had up front with me over the back seat. That's when I saw it. That Hooker Harness that was minutes away from attempted murder. Never again have I failed to do a proper control check. Hell nowadays I do about 5 of them. Having a close call like that can be the best training on earth. As long as I live I'll never forget that particular thing again. Unfortunately in aviation, those kind of lessons are often accompanied by no longer being alive. So you can't learn from them. Chuck Yeager said "I'd rather be lucky than good any day" I got lucky, once. Which means my chances of getting lucky again have to be incredibly low. So now I'm hyper vigilant about everything.
The difference between an accident and a crash….. well said. Scott
As a former “Birdfarmer” on CVs I just want to say that SAFETY ON THE CARRIER and especially on the ROOF is never, never, never a one person job. There are always multiple Airedales looking and checking everything and making sure it is done correctly. They don’t call it THE NAVY WAY for nothing! Having said that - me, one simple guy, endured FOUR crashes on my ships, and shared each time in the heartache involved…RIP ‘Snort’!
That was really great Paul - Thanks. Just what we needed to hear as the Summer goes on and we do those lazy Summer's eve flights just bimbling around in the pattern.
So easy to miss - Controls Free And Clear.
I’m not a pilot but a long time aviation enthusiast. While checklists are an absolute necessity, there is a certain psychology of repetitive tasks that can trip up humans. Otherwise Intelligent, good parents will forget their kid is in the car seat because some event will interrupt a routine and everything seams completely innocuous up to that point in time that their sleeping kid is trapped in a hot car.
I studied Math at university, and in studying statistics it gave me an appreciation for seeing how easy it is to be trapped into so many situations without express mindfulness in following an exact procedure every single time - for which there is not a person alive who does.
The human brain is exceptionally good at certain things, like abstract reasoning and art. But makes for a terrible computer or machine thats job is to just do repetitive processes.
Yeah there really isn’t too much to talk about this an experienced pilot flying an airplane that he’s only had maybe 20 to 25 flights and forgot to takeoff the Gus lock and tragedy happen. It’s very simple all the pictures from the NTSB have stated and seen the gust lock was still in place not bent up but still in place which was restricting the movements of your controls. He did not do a proper pre-check and did not do a proper run up I think because at that time when you do the run up is you would have noticed that you do not have full use of your controls. It was an honest mistake that caused the man his life. The lesson to be learned here is DO YOUR PRE CHECKS!!
I think it comes down to reasoning by induction... I've done this a million times, nothing bad has happened, let's go.
I just joined a flying club that has all Pipers. You can’t get in the seat until you take the seatbelt off the yoke. The ultimate visible control lock
Very good discussion, and a useful and important reminder why checklists and procedures are so important in aviation.
- Martin
I've been waiting on the edge of my seat for you, Paul!
I’m getting a bit older. It has not happened in preflight, but in work. I’ll do the right thing in checking everything and go ahead only to have looked right at something that was not correct and not realized it. Very strange and lousy. Thank you for all that you gave us Dale Snodgrass. Sure wish you didn’t give us this last lesson though. He was a legend. To bad it turns out he was human.
Godspeed Dale Snodgrass.
My dad told me a story of getting ready to check fly a Cessna single with his boss (the FBO owner), he boxed the controls and a control cable popped off a pulley! His boss went white-faced. The plane was taken back to the hanger and re-rigged correctly.
How about making the control lock breakable? Maybe when applying a force of 20 kg on the stick which you most likely could do when in panic.
They can. Frangible links, shear pins, very small bolts. But making it to have a part blocking the seat or throttle or starter is better. Also, nobody mentions the aircraft had a lateral departure from controlled flight, it stalled and rolled. This can be easily rectified with leading edge droop/extensions. So the crash would be straight ahead and level, not partially inverted face-plant.
It is inexcusable, to me, that something designed to keep an aircraft stable, from wind,parked on the ground, would not be up in your face, literally, so you would SEE it to take it off! How freaking hard would it be to extend part of that steel structure of the "lock up" in your face near the control stick.
It only takes one fatal mistake....
Some mistakes are worse than others. Leave your fuel cap open and down the road you'll have an engine failure due to fuel exhaustion, land your new glider now. Add full take off power, roll down the runway and take off with a control lock in place and learn about it in the air, this like getting in a car with the throttle stuck all the way down.
it amazes me that a gust lock was installed with the airplane in a hangar
@@GeneCash it certainly brings the question when was the lock installed and who installed it. Ground handling an airplane is just as serious as doing maintenance. In the good ole days we just tied the stick back with the seat belt and went home.
We can speculate forever as to how this happened but here's my two cents. He skipped the runup. I think if he had done the runup checks, the control checks are a normal part of that process and he would have caught the control lock. So, he missed the control lock during the preflight. My guess is he skipped the runup. Also, he called for takeoff on ground control. Three pretty major mistakes. Not sure where is mind was that morning but it's clear to me that it was somewhere else.
*WHY* in the hell wasn't there a "Lanyard" that wraps around the controls in such a way that its obvious, *with a Huge "Remove Before Flight" Tag* to keep you from doing this!
When checking controls, move both ways. I had a cable tie end get caught in a PA28 chain and gear when moved in one way only, which was forward and right. It jammed. OK in any other motion such as forward left, or back left right.
There is no better safety device than a checklist. I'm willing to bet that checklists have saved orders of magnitude more people than every other safety device combined. Yet I'm willing to bet that every pilot has skipped checklists at some point. I have. I remember one time in particular. I was flying a Cherokee 140 out of an airport I rarely fly to. They had an automated, unmanned fuel pump. I had never fueled here before. I topped the plane up after I landed and took off into a beautiful morning the next day.
The flight home would take me over very heavily forested, rising, remote, terrain. About half way home...I realized that I hadn't sumped my tanks. Sure...odds are...any water would have made its way thru the fuel system by now...but 'odds are' isn't the same as 'absolutely sure'.
What started out as a beautiful, relaxing, flight...became an hour and a half of stress and worry. Snodgrass's crash proves once again, that everybody can and will screw up.
He gave us the final lesson.
Ten thumbs up for Bruce Landsberg's differentiation of crashes from accidents!
@23:23
This accident proves beyond doubt, no matter how good you are, no matter how much experience you have, you are never immune to doing something stupid.
Aviation is inherently dangerous. Most people are content with not knowing what they don't know. Or skipping steps to save time. Or not thinking about contingencies.
I box the controls in Flight Simulator. You can never be overly cautious.
Thank you for your thoughtful and well produced videos. I hope to be a pilot in the future and have very much enjoyed your videos. I wish there were more informative and well produced series like yours!!! Thanks again.
Bypassing check list seems to be common in general aviation I seen it done. When questioned the response I got was "We do them in our head I have the checklist memorized".
GUMPS!
@@TheJustinJ Gas, Undercarriage, Mixture, Pumps, Switches nothing about control locks, or control checks. Maybe that is all he used.
A great 27 minute safety briefing
Muy buena entrevista 👌 no importa la cantidad de horas de vuelo, o la formación aún así puede darse una cadena de eventos que terminen de esta manera. Muchas cosas por aprender. Gracias por compartir esta información. Saludos desde Argentina.
“Aviation in itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity, or neglect”. RIP Snort
Hi Baaa. Agreed. Unforgiving is the word and I am in complete accord. On the other hand I see other comments floating around that are making my blood boil so maybe it's time for bed. RIP Snort.
I respectfully disagree. Aviation is inherently dangerous. But so is driving. If you adopt the idea that its not inherently dangerous, why bother to perform checklist or really try to dot your i on everything?
What Killed "Snort" was letting down his gaurd flying little prop puddle jumpers. If he strapped in like it was an F-14 about to pull several Gs over its limit load in front of spectators, he would have been more vigilant.
One factor that nobody seems to be considering is early onset dementia that could have certainly impacted memory and contributed to the accident.
72 years old. Wouldn't even be that "early"
Exactly why we should not raise the retirement age of airline pilots beyond 65.
yes but the point is, if you are using a checklist, Memory is irrelevant.
@@eansugarman4675 being momentarily confused about what you are doing is the problem. But i don't think dementia is a major medical factor for most GA pilots.
Great video! I bought an old 172 midway into my PPL training with a bolt for a control lock. I spent the money ($70) on a proper one because it looked better, but immediately realized it obstructs my ignition and master switch, so I can’t even start the plane with the lock installed.
Fast forward a year and one of the old grumpy pilots at my airport is approaching me smoking mad… I thought I had cut him off in the pattern or something… but he’s mad because he saw me taxi onto the runway without moving my ailerons. “That’s your last chance to check your controls. Always cycle your controls one more time as you taxi to position. Point your thumb up, it will point at the aileron that should go up.” Now that’s what I do,, and look at the pitot, and confirm my runway and instruments match my clearance.
I saw a cross control first hand. Homebuilt airplane cartwheeled on takeoff, luckily the owner walked away. I heard he did his own annual inspection and declined any help, even after a mechanic and a couple of his friends offered to check if everything had gone back together correctly.
#164👍Thanks Paul! This is a reminder to all of us we are only one mistake away from disaster. Whatever the checklist; always use one!
ERAU 80 CFIA&I ret.
The control lock was a horrible design, but I don't think it was the root cause of the crash. If one focuses solely on the design characteristics of the airplane trying to make it impossible for a pilot to make a simple error, you will end up playing an infinite game of Whack-A-Mole with a never-ending series of edge cases. The fact of the matter is that we are human beings and we are constantly developing bad habits, even when we have a lot of experience. I am in a situation where I find myself flying with an instructor every few months. Each time I consistently find myself amazed at the new bad habits I pick up.
My guess is that somewhere along the line Snort picked up a bad habit. Who knows when the last time was where he flew with someone who felt as though they had the experience to point out a mistake that he made. That bad habit aligned with some as-of-yet unknown pressure that led him to essentially skip the entirety of the Before Takeoff checklist. The rest is, unfortunately, inevitable. The battle against bad habits doesn't stop until we quit flying or flying forces us to quit the hard way.
But yeah, that control lock is a horrible design.
You're right that we can't engineer every simple mistake out of the equation. But I feel the root cause is a design flaw. If the lock had been more noticeable or completely locked rudder pedals or prevented engine start this accident would not have happened. When I get around to designing a control lock for the airplane I'm building I'll certainly be thinking of this accident.
Success…….Complacency……..Failure. Sometimes you survive the failure from complacency. Sometimes you don’t.
Please forgive me for speculating, but his age (72) could have been a factor. Mental faculties deteriorate over age and they do so insidiously. This is not to say that this is what caused him to skip checking free movement of the flight controls, but it is something that has to be suspected, and investigated.
My good example to make a lock more apparent. I have a sportbike with a double disc front brake that has drilled rotors. I have a very robust lock that uses a pin to go though one of the holes and stop the thief from rolling your motorcycle away. Well if you forget to remove it it can damage your carbon fiber fender. I found someone who invented a simple plastic coated steel cable that wraps around the lock and up to your throttle grip. Never again forgot to remove the lock with the not easy to miss yellow cable under your grip. Something like that could be used on planes too.
In the USN the ground/flight deck crew will drive the preflight control checks (along with many others).
Fantastic content. A cold reminder of the importance and understanding of each ground control check.
The human being is fallible. Simply, directly, and to the point.
The aircraft is a tailwheel.
In the process of taxiing to the runway, the pilot should hold full aft-stick in a no-wind or into the wind situation. When taxiing with a tailwind which is stronger than idle thrust across the tail surfaces, he should hold neutral or down elevator to prevent the tail being raised. He should also "bank" into the wind when taxiing crosswind. The tailwheel and rudder are a given, you cant even turn on the ground if they are locked.
The saying is "Climb into/Dive away from the wind" Even if its a 5kt breeze, it still helps to practice that every time there is a little steady breeze, just to ingrain ground handling into your sub conscience.
In my experience, based on the above, if performing these actions, its not really possible to unintentionally takeoff with control surfaces locked.
This scenario can actually be eliminated by proper engineering. Edit* It appears from reading that is was inside the cockpit. Control locks can still be engineered in a manner to prevent this, either by having frangible links/shear pins or by automatically disengaging above a certain threshold. Or by being so obtuse that the pilot cannot physically enter the cockpit until removed. Or the lock should prevent gripping the controls.
This lock seems to be worthless. If the lock doesn't prevent motion of the controls that are sufficiently locked to cause the pilot to be unable to taxi, then why are they locked in the first place? Its a pilot mistake for sure, but an engineering oversight as well.
Also, that accident would probably not have been fatal if the aircraft was not susceptible to lateral departure from controlled flight. That is, leading edge cuffs. Wuld prevent it from rolling over and ploughing headfirst, it would allow it to remain substantially level, where the pilot would have control with throttle.
Landing a jet with gear up is not some inconsequential oversight - it's a really big deal.
This was a great discussion Paul. I'm glad the NTSB joined you to share thoughts on this accident. It's disheartening to see that a simple engineering mistake proofing step (poka-yoke) could have prevented this. I'm sure folks are looking at their interlocks to find a way to make it more visible when activated.
I like Mike Patey’s design, where the presence of the locking pin in the locked position triggers a switch, giving both a warning light and a lockout on the starter. Also, another switch requires the presence of the locking pin in the stowed position to cancel the warning and lockout. Involved maybe, but definitely keeps you from inadvertently leaving things locked.
All of these mindless mistakes can pretty well be engineered out. Automobiles had several major waves of failures along the way also, unfortunately aircraft are produced in far fewer numbers, so there is less improvements directly transferred to the next product. Many engineers retire having only one or two major projects under their belt. Companies go bankrupt. And aircraft are all radically different than each other.
The control lock on the Citation XLS is excellent....with the lock on the engines cannot even be started.....However the parking brake design could use some work
As an experienced aviator, he was understandably not as stupid as the control lock. Every time we see these imbecilic devices, we are reminded of the utter stupidity of the non-pilot aircraft designers. The seat belt works fine.
Gentlemen, the lock does block elevators, meaning it does lock the stick at least one way of moving. Otherwise snort would be able to land again.
Apparently it did not prevent the plane form taxiën with the aid of rudder.
I wonder how Snodgrass was able to forget about they massive red lock. And didn’t check control movement before takeoff.
a string at the stick would prevent forgetting it.
It's even more boggling in a tail dragger where it's SOP to get the tail up early in the takeoff roll using forward stick. That would have been a good time to notice the stick isn't going forward and abort. As stated, "shock waves" -- indeed.
I am not familiar with that aircraft - but "SOP lift the tail" is not standard on some planes. So that might not have caught it. But more to the point - stick in pit of stomach while taxiing and fly the plane on the ground for the wind directions. But - if you read the report - there was no wind.
@@graemejwsmith if you are holding the stick during taxi you would notice it doesn't move. if you aren't holding the stick with gust lock removed, it would be flopping around. either way is out of place. here's my probable cause. he was in a hurry, taking all the short cuts. consciously left the lock in to hold the stick while he taxied and dialed in the radio's and other knobs. Then forgot to remove the lock during pre-takeoff. Maybe he and is wife did have a fight and that flustered him into making the mistakes or he just wanted to get to the destination before she did. Note: That kind of effect doesn't happen on an aircraft carrier. It happens to us normal pilots. Don't fly under stress.
@@warped-sliderule that wife thing you mention touches a nerve, "shines a light on the unknowable possibilities" behind this specific event, so to speak.
p.s. The exact background does not matter, except to identify for us on the left half of the bell curve what in the world might cause one on the right tip of the curve to get knocked off their pace.
@@77thTrombone yes, ntsb mentioned possible heated wife discussion. looked at emotional situation as possible factor. some factor, if it dragged the best of the best down to levels of us mortals. sad that all we left is lessons from this awesome pilot...
@@warped-sliderule well said.
from one who has hurled a cell phone across a parking lot. (Not a stat to be proud of, but we can't pick all our stats.)
Cheers.
Good discussion on how we get into checklist complacency. Case in point when you audible the last second acronym before entered runway before takeoff and note a missed setting of flaps. We love aviation that requires our full attention and discipline.
Thank you, Paul, for this deeper look into this unfortunate accident (crash).
How can a noted aviator who flew an F-14 Tomcat about 5000 hours, and landed it on an aircraft carrier about 2000 times, end up crashing a simple Marchetti? A factor that I've not seen discussed at all regarding Snort's crash is the SETTING in which he flew. On an aircraft carrier and otherwise when flying for the military, there were likely relatively few distractions that would militate against his piloting acumen; whereas on the morning of the fatal crash, he had just had a contentious verbal exchange with his wife, according to a reliable witness. Considering his possibly lingering agitation from that exchange, and adding in the factor that the pilot was now 72 years old, I venture to postulate that the environment in which he was living may have been a factor that placed him in a perilous state of mind on that fateful morning.
I tend you agree with you on possibly some lingering agitation as a contributing factor. I honestly believe he wasn't in the best frame of mind! In 1985 LCDR Snodgrass was my boss as the QAO when I was running the Quality Assurance Division of VF-143, World Famous Pukin' Dogs. His desk was 5 feet from mine. In 1986 (I believe) he was selected as COMNAVAIRLANT Fighter Pilot of the Year. He was the best of the best, hands down! He could fly that F-14 like no other. He was so meticulous in his preflights. I worked for him again when he was COMFITWINGONE. I'm 73 now, so I know how your mind sometimes wonders. It's really hard for me to accept that he just forgot to do his Pre-flight! I greatly appreciated your comment. Thanks!
RIP Captain!
I agree the gust lock was poorly designed. However, the plane’s design was 50-60 years old, and the customer was military.
Why I like the pilot's seatbelt as a control lock!!
This was an excellent discussion. Thank you for posting this.
If your hand is on the control stick, you literally can't see the control lock at all. The control lock needs to be extended up and OVER the control stick, that way there is absolutely no way you can miss it. I still think this is easily avoidable by using checklists, but why not make the control lock more visible, especially when it's so easy to make a better design.
This was a very impressive and thoughtful interview. When my flying days were over I became a computer programmer which further supported my suspicion that the human element was the weakest component of any system. As skeptical as I am of AI (AI as in heuristic algorithms not the populist recursive search engines), I believe its greatest promise is in removing the unreliable human brains from critical systems. RIP Snort.
Paul, Thank you for this video. I have forwarded it to my flying circle. Valuable content.
This happened with a Dehaviland Buffalo years ago,sad video
His age got him
That ain't the control locks fault. Dude, didn't even cycle his controls. Both ailerons could have been detached with the control lock off and the same thing would of happened. Bro, I don't trust anyone, and my biggest fear is a flight control surface being locked, or pinched, or detached, you gotta check that shit first and ALWAYS. People talk about engine failures, well, that ain't shit compared to a flight control failure. Your engine fails you can still fly it to the ground, even if you're going 90mph as long as you don't smash straight into the surface of the Earth you're going to come to a stop relatively quickly, but if you can't control your airplane no amount of engine power is going to save you. How in the fuck did this guy get all the way to the runway without cycling the controls, that's literally the first thing you do!!!
Thanks capt obvious.
As an old OV-1 mechanic , you ALL WAYS check EVERYTHING , without fail.
I am (obviously) not a pilot, but I have a question: Why on earth would there be any kind of, "lock all the controls to where they're unusable"??? What possible scenario could one be protecting against ..... with the possible exception of the flaps lapping as a hurricane approaches (or something a lot more 'pilot-intelligent')?
I'm assuming it has a key....why would you not want the controls to work...ever?
You have actually called out the main reason for the control locks. It’s to prevent damage to the flight controls due to them moving in the wind. It’s for any gusts not just hurricanes
"Gust locks," as they're often called, are devices designed to mechanically immobilize the control surfaces. The main reason for this is when you have a big sheet of metal designed to deflect airflow, and you get some air flowing from some other direction than would be expected in flight, it can catch those big surfaces and push them, and the applied force can be quite impressive. Many times, it's just impractical to design all the hardware associated with the elevators, for example, to withstand a sudden rapid transit through its range of motion to the stop, with several times the force that a human could apply to the controls. Even in surprisingly light winds, unrestrained control surfaces could break hinges or mounts or stops, damage cables or pulleys or unseat lines, or just experience unexpectedly high metal fatigue. Don't want an elevator pulling off like a soda can tab in flight, because it's been overflexed too many times.
Or locking nose-down like happened here, probably because a privately-owned MD-87 was parked for almost a year without gust locks in place:
www.avweb.com/aviation-news/jammed-elevators-cited-in-houston-md-87-overrun/
It's an easy thing to overlook, and it can be hard to imagine the forces involved until you've actually seen one of those hinges popped, or seen a rudder slam over in a little gust of wind, that kind of thing.
Gust locks are required to prevent damage to controls and control surfaces when aircraft are parked.
Pilot rolled the plane out of the hangar. It was inside. Why would anyone have locked the controls to prevent damage from wind gusts when the aircraft was parked inside?
Excellent explanation. Thanks
It's so easy to be in a hurry when alone and nobody there to keep you accountable. I have personally made simple mistakes on the ground that could have been deadly had I made it into the air before finding my mistake. The Checklist is critical no matter how many thousands of hours you have.