Check Yourself

Last summer I found myself rebooting my flight training at KDXR through Arrow Aviation with Duke Morasco as my instructor.

Things were going pretty well.  I was ~15 flight hours into the process and Duke thought I was about ready to solo.  I felt confident and capable and in control.  “PP-ASEL, here I come!”, or so I thought.

I found myself out for a lesson with Duke on Thursday 10 August 2017 and…  it was an outlier of a lesson.  I wasn’t sure what was up, but it was our worst lesson together.  I had the sense that Duke was agitated and abrupt, out of character from all of our earlier flights, but I reserved substantial probability mass for it having been my fault, the result of some rust having accumulated from a couple of weeks out of town.

I hoped that it was a fluke and scheduled another lesson with Duke on Saturday 12 August.  That lesson would never take place.

On Friday 11 August I received a call from Arrow Aviation.  Duke had been killed in an accident while up in N1727V with another student.


I found myself in shock, confused, and light on information.  For a long time I had little to go on, just an assortment of news articles and a preliminary NTSB report.  Was it during take-off or landing?  Was there a mechanical failure or operator error?

Somewhat insensitively Arrow asked if I wanted to schedule with a new instructor on Sunday.  I told them I need some time to reflect.  Insanely, Arrow had just lost another plane on 30 July during a failed take-off, and I did not feel like tempting fate.

For over a year I found myself wondering what had happened.  At last the NTSB has issued a final report.

Most notably…

According to GPS data, the airplane landed on and then took off from a grass airstrip, climbed about 150 ft, then collided with terrain about 1,000 ft past the end of the runway.

… and furthermore…

An examination of the wreckage did not reveal any evidence of a preaccident mechanical malfunction or anomaly. An examination of the flight controls revealed that the wing flaps were in the fully extended (40o) position at impact. The airplane’s operating checklist stated that normal and obstacle clearance takeoffs are performed with wing flaps up, and flap settings greater than 10o are not recommended at any time for takeoff. Upon landing on the grass runway, the flaps should have been retracted as part of the after-landing checklist, then confirmed up as part of the before takeoff and takeoff checklists. It is likely that the flap setting at the time of takeoff resulted in an aerodynamic stall and loss of control during the initial climb.

Well, shit.

The student pilot was apparently pretty green.  And it seems like nobody realized that the aircraft was in an excessively high-drag wing configuration prior to take-off.  This, in concert with the natural resistance of a grass-field airstrip, and in conjunction with some nasty trees beyond the threshold, presumably led to a late rotation and inadequate rate of climb that culminated in a panic, stall, and crash.


So preventable.

Take your time.  Run your checklists.  Don’t get complacent.

And be wary of relying on “experts”.  They get over-confident or overwhelmed and make mistakes just like everyone else.

This is doubtless good advice in many contexts, professional and recreational.  If what you’re doing is complicated and dangerous, take the time in a calm and quiet moment to codify how you want to operate in every circumstance.  Your future stressed-out self will thank you.

And it’s not just about the operation’s procedures.  It’s about assessing you, the operator. Every aircraft comes with a comprehensive checklist for every stage of flight.  And yet pilots are further counseled to run the IMSAFE checklist against themselves before getting behind the controls.  The risks of illness, medication, stress, alcohol, fatigue, and emotion are all too real.  And some of those items are extremely difficult to gauge.  It’s pretty straightforward to avoid getting into a cockpit while sick, medicated, or drunk.  But how stressed, fatigued, or emotional is too much?

I wonder how to navigate these circumstances when the impacts are less dramatic and more ambiguous than crashing a plane.  How many times have I driven a car when exhausted and distracted?  How many times should I have waited to share an opinion or make a decision until I had attained a better mind-state?

Choices and consequences.


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