Analysis of fatal accidents spanning the past 15 years has identified patterns of repeated rule-breaking prior to those accidents.
In one such accident, Safety Investigator Siobhan Mandich recounts a conversation she had with a witness as part of the post-accident investigation.
“He – the deceased pilot – was number two on my list”, Siobhan remembers the witness saying.
By 'number two', the witness meant the pilot was second on his list of pilots that he feared could die in an accident. Sadly, circumstances had proven his intuition correct.
“But if he was number two,” Siobhan asked the witness in bewilderment, “who is your number one?”
Months later, an investigation began into the witness’s ‘number one’.
Often, the challenge faced by accident investigators is the retrospective nature of their work. The bulk of safety-critical information starts flowing only after a catastrophic event. However, for Siobhan, this new investigation provided an opportunity to engage with a participant before their risky behaviour became a fatal accident.
“As we reviewed the files, a disheartening picture emerged – another ‘accident waiting to happen’ with a pattern of rule breaches against their name.”
Siobhan felt it was merely a matter of time before the pilot in question not only endangered themselves, but also potentially put passengers at risk.
The parallels between the recent fatal accident pilot (number two on the list) and the ‘number one’ were startling.
Siobhan highlights that early intervention from the CAA safety team often saves lives.
“If people have concerns about a pilot’s behaviour, they should report it. Taking early intervention, such as in this case, can potentially prevent fatalities.
“If you don’t say anything, then we cannot proactively improve safety,” says Siobhan.
From the files
CAA accident analysis has shown that pilots who repeatedly break the operating rules are statistically more likely to be involved in serious incidents or accidents.
“In one such example, a pilot was killed after crashing an aircraft for which he did not hold the appropriate pilot’s licence or medical certificate. He hadn’t received any dual flight instruction in that aircraft type, nor had flight hours been recorded in his log book.
“Sadly, this accident resulted in the death of not only the pilot, but his passenger,” says Siobhan.
Another example involving an Alpi Aviation Pioneer similarly shows how normalised rule-breaking can lead to tragedy. The pilot in question departed from Alexandra aerodrome for a group fly-in with other microlight enthusiasts heading to Stewart Island.
“Unfortunately, there wasn’t any adequate preflight planning conducted by the pilot. During the flight, he descended below 500 feet AGL, the minimum height for VFR flight in the area, and entered weather conditions below the required VFR meteorological minima,” explains Siobhan.
The investigation identified the cause of the fatality as controlled flight into terrain in poor weather conditions. The pilot was not instrument-rated, nor was his aircraft equipped for flight into IMC.
But Siobhan says the investigation also revealed a pattern of prior pilot rule-breaking.
“Video recordings retrieved from the pilot’s cellphone and tablet demonstrated unsafe flying practices, including low flying over water, and aerobatics. The pilot was not aerobatics-rated, nor was the aircraft approved for aerobatic flight.”
As the report states, “The conduct of these activities, which are in breach of the rules, is considered to demonstrate poor airmanship and reflects a propensity for risk-taking behaviour”.
Siobhan says the pilot had also been investigated several times by the CAA for alleged unsafe flying, ultimately resulting in his flying privileges being temporarily suspended.
“Additionally, witnesses said he had gone IMC within three months before the fatal accident.”
Human factors research has found VFR pilots who deliberately entered IMC tended to have experienced the conditions previously and possessed a comparatively greater tolerance of risk.
“In essence, pilots who get away with pushing the boundaries set by the rules tend to make that behaviour their new norm, until one day they push too far,” says Siobhan.
The rules are your safety guide
So how do pilots find themselves falling into a pattern of rule-breaking?
According to Safety Investigator David Oliver, one contributing factor could be a lack of personal ownership among pilots.
“Within our aviation culture, a number of pilots tend to absorb the rules through osmosis.”
By ‘osmosis’, David is referring to learning from your surroundings, particularly from seasoned pilots who you hold in high regard.
“Nonetheless, the onus is always on the individual pilot to take ownership of their knowledge and understanding of the rules.
“If another pilot, or even a person in authority, tells you anything rule-related that you’re not sure about, go away, sit down and have a look through the actual rules, or better yet, go through them together in person.
“The rules don’t come out of thin air, they are drafted carefully to ensure anyone following them has a built-in safety buffer. But remember, they are the minimum safety standard and you should be aiming higher.”
To create a safer flying environment, David underscores the importance of having open and honest communication between pilots about the rules.
“One time, after returning to New Zealand from a flying job in Papua New Guinea, I caught up with a good mate of mine, a fellow helicopter pilot, to discuss the rules and a time when I’d pushed the minima too hard.
“After telling him about my experience, he told me about a near-miss he’d had a few months before our catchup, where he’d mistakenly taken off with a long line still attached – he’d only just released it in time.
“I asked him why he hadn’t mentioned this to me earlier. He hadn’t broken any rules, but surely, I thought, he would have felt pretty sick if I’d done the exact same thing and killed myself, while he was keeping that experience to himself.
“It was only after speaking up and sharing my experience that he felt comfortable enough to share his. It’s through discussions like these that lessons can be learned and trust can be fostered.”
When asked about pilot opportunities to refresh on the rules and build their knowledge, David mentions the biennial flight review (BFR).
“You could complete your BFR with a new pilot or assessor so you can benefit from a diverse pool of experience and a fresh set of eyes.
“Your BFR is a golden opportunity to upskill and refresh over the rules. Rather than treating it as a two-yearly box ticking exercise, think of it as an upskilling opportunity.
“If you go into it with the mindset of looking for something new to learn and questioning yourself about the rules, you’ll get a lot more out of it.
Safety Investigator Peter Stevenson-Wright
“I’ve been to more than 30 aircraft accident sites, from sea level to mountain tops, aerodromes to dense forests (I recall once having to long-line 200 metres from a state highway into extremely dense bush – it was the only option).
When we first started doing accident investigations, the gear we had was minimal and training was mostly theoretical. Now we have a recurring training programme and all the tools necessary for accident site investigations, including survival training to help us help ourselves, if we get caught out by New Zealand’s rapidly changing weather in mountain or bush environments.
Safety is in my blood now. I truly believe the work the team does has meant more pilots educated as to what can happen when they break the rules, which, in turn, has led to the reduction in the number of fatal accidents over the last 25 years.”