CAA Aircraft Accident Report and Summary
This discussion contains extracts from the SACAA’s accident report. It is compiled in the interest of aviation safety and is not to establish legal liability.
Aircraft registration: ZS-JTW
Date and time of accident: 6 February 2014 1920
Type of aircraft: PA-25-250 Pawnee
Type of operation: Agricultural
PIC license type: Commercial
Licence valid: Yes
PIC age: 52
PIC total hours: 5346
PIC hours on type: 47
Last point of departure: Parys, Free State
Intended landing: Parys, Free State
Meteorological information: 090/10. Viz good. 20˚C. Cloud 4/8 at 1000’ AGL
POB: 1
People injured: 1
People killed: 0
Synopsis
The pilot took off from Parys Aerodrome with the intention of completing crop spraying 30 nm away. According to the pilot, he carried out the pre-flight and the chemical loading, started the aircraft and warmed up the engine for approximately five minutes. He then taxied to the runway and back-tracked on runway 06, as the wind was approximately 090° at 10 kt.
During line-up and application of full power on the runway, the pilot checked static RPM and continued with the take-off. The aircraft rotated at 70 mph and accelerated to 80 mph, which is the best rate of climb speed. At approximately 100 feet above ground level he experienced turbulence and the indicated airspeed remained at 80 mph.
The aircraft began to lose height and the pilot turned the aircraft to the right into the wind to a heading of approximately 080˚. The aircraft continued to lose height while heading towards high ground: the pilot turned to the left to avoid impacting the high ground.
The aircraft continued to lose height, with full throttle and fuel pump ON. It crashed into an open field approximately 800 m from the threshold of runway 06.
It is possible that a nearby thunderstorm brought about windshear. This could have caused the airspeed to decay, which in turn would have caused the aircraft to lose altitude and crash into the ground.
Thunderstorms are associated with windshear. The official report of the SA Weather Service revealed that there were thunderstorms in the area at the time of the accident.
Probable cause
Downdraught associated with a thunderstorm.
Jim’s Analysis
I just have to shake the turnip in horror when I think of this guy setting off to do crop spraying, amongst thunderstorms, at night, with no moon (I checked).
Oh, and he also took off into a black hole – away from the town’s lights. This is an act which has killed many pilots, both experienced and raw.
Taking off into a black hole is about the most dangerous thing you can do in a light aircraft.
As your wheels leave the runway you lose all outside reference – you are surrounded by blackness. You have no time to settle down on instruments, but you must instantly fly extremely accurately because you are only feet from the ground.
Your airspeed is changing, which means the aircraft is not properly trimmed. And if that’s not enough you will be suffering from acceleration illusions, and the AH will be telling you the same lies as your body.
Here’s how it works. When you are flying straight and level your body agrees with the AH, and reality. When you climb your body gets pushed into the back of the seat, and the AH shows a nose-high attitude.
But when you accelerate during take-off, your body and the AH both react as if you are climbing. Your natural reaction is to lower the nose – which is exactly what you can’t do just after lift-off.
Either that, or you drop a wing, due to fuel imbalance, turbulence or rudder bias, and start a graveyard spiral.
Typically, you lose control before you reach 100 feet. I wonder if that happened to this guy.
It would either be a botched instrument take-off, or a downdraught associated with the thunderstorms.
But what got into his head, all of a sudden, to do something so suicidal – actually almost worthy of a Darwin Award? He was not a wild youngster; he was a mature 52-year-old who had over 5000 hours.
I suspect the answer is nothing. It didn’t happen all of a sudden. He built up to this level of over-confidence, progressively over the years. At first he got away with minor corner-cutting and rule-breaking – and each time he did so it boosted his confidence so that he began to think he was invincible.
Let’s side-track for a moment to give you an idea how this "normalisation of deviance" happens.
In January 1986 some will remember watching the horrendous footage of the Challenger Space Shuttle flight that went so desperately wrong just 73 seconds after lift-off?
The flight captured the attention of the world’s media largely because it carried the first civilian passenger, Christa McAuliffe, a 37-year-old school teacher from Concord, New Hampshire. This was to be the start of Ronald Reagan’s programme to raise awareness and promote interest in space exploration amongst young people.
There were six other crew members who all died in the disaster. In the photograph you can see the remains of the orbiter and tank which leave thin white contrails as they fall 46,000 feet toward the Atlantic. It’s particularly horrendous because it’s likely that all on board were alive and conscious throughout.
So the connection between the crash of the humble Pawnee, and that of the space shuttle Challenger, would seem to be an erosion of standards. A deviation from safety levels that both operators were aware of but chose to ignore because it had always proved OK in the past.
NASA chose to repeatedly fly the space shuttle despite knowing about a design problem with the booster rockets’ O-rings and their behaviour in cold weather.
The “group think” that lead NASA to accept the risk was the defining case for normalised deviance. The rocket carrying Challenger aloft had a known defect which had given no trouble up till now.
Management and human factors within NASA permitted critical safeguards to be ignored.
What once seemed wrong starts to feel normal, and outcomes that may be mostly due to good luck start to feel more like skill. In aviation, rationalising can result in disaster.
Many years ago when I was building 43 Air School, I had a really excellent guy in charge. Hennie was a bricklayer, plumber, carpenter, electrician and foreman.
One Monday morning he didn’t turn up at work – it wasn’t long before we got the news that he and his wife had been killed when one of the front tyres of his ute had blown out and caused them to crash.
How had this happened? Hennie knew the tyres were in poor shape, but he had got used to it and kept thinking that level of wear was okayish and the tyres would last another month.
Every time you accept a slightly lower standard you are making that the norm, and you are decreasing your safety margins.
So it’s easy to see how Hennie had killed his wife and himself, and orphaned their children. His worn tyres had become acceptable. Our crop spraying pilot had got away with low standards for years – why not this night?
Now turning to Challenger, the problem of eroding standards was addressed by Dr Diane Vaughan in her book The Challenger Launch Decision. She coined the term, the “normalisation of deviance”, which she defined as, “the gradual process through which unacceptable practice or standards become acceptable. As the deviant behaviour is repeated without catastrophic results, it becomes the social norm for the organisation.” 
What Can We Learn?
The best way to avoid the slide into the normalisation of deviance, is to stay forever uneasy. This means having a sceptical and questioning attitude about our own competence and discipline.
It’s not easy to detect this gradual drift in yourself because we humans are really good at rationalising. If you find yourself trying to justify some action, the chances are you are on a slippery slope towards normalising that behaviour.
Watch out for the word “because”. Here are some examples.
- I didn’t bring a map because I know this route so well. Yes, and how does that help when we have to divert for weather?
- I didn’t check the tyres for flat-spots because I never brake hard.
- I didn’t check the tanks for water because she lives in a hangar.
- No need to check the oil because I have only flown a couple of hours since the MPI.
- We don’t need to do fuel calculations for this trip – because she always uses around 25 gallons.
- I’m sure we will be within CoG because she is a four-seater.
Jim Davis is a natural teacher with a passion for flying training, believes in learning through enjoyment. His book is refreshingly un-textbookish yet thoroughly covers its subject clearly. With over 15,000 hours, including 10,000 in flying instruction for civilian and military pilots, Jim founded South Africa’s largest and most respected flying school, 43 Air School. He is also an author of multiple books on flying training and has contributed numerous articles to flying magazines across two continents. https://www.jimdavis.com.au