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What went wrong? Breach of trust

Two CFIs make mistakes that cost a passenger’s life

A rough-water takeoff in a Lake Amphibian requires a deft touch. The Lake’s high thrust line near the center of gravity causes pitching action when full power is applied, which is exacerbated by choppy water.
What Went Wrong?
Illlustration by Brett Affrunti

The ensuing porpoising moments take considerable yoke action, properly timed, to counteract. It’s a skill that’s honed over hundreds of Lake Amphibian hours. Most experienced Lake pilots wouldn’t attempt a tailwind takeoff in rough conditions. Ignoring strenuous objections from an experienced harbor master; operating in rough water, downwind, without flaps, and at a heavy weight; and executing poor rough-water takeoff technique leaves almost no other outcome but disaster, which is exactly how a flight at the Oshkosh seaplane base in 2017 ended.

The airline transport pilot and CFI in the left seat, who owned the aircraft, had more than 33,000 flight hours, almost 900 of which were in single-engine seaplanes, although his time in the Lake Amphibian was more limited. Flying right seat was a commercial-rated, 2,400-hour CFI with more than 150 Lake hours, who had provided the pilot seaplane instruction. Joined by a nonpilot friend in the backseat, they departed for an afternoon at EAA AirVenture. They landed at Vette/Blust seaplane base (96WI) just after noon and requested a tow into the harbor because of a sagging float under the left wing.

After a couple of hours at AirVenture, the group returned to the airplane, but their plan to fly to Southwest Minnesota Regional Marshall/Ryan Field (MML) was upset by aircraft issues and water conditions. The pilot had to drain the left float of fuel and water, and then patch a hole on the underside of the wing. Because of choppy water, the harbor master did not recommend operations at the seaplane base.

Frustrated by the delays and probably worried about lodging during AirVenture week, the pilot grew more anxious to depart as the afternoon wore on. He was given a boat tour to appreciate the choppy water conditions, commented that they were too rough for departure, but upon arriving back on shore reconsidered and decided to depart. Hearing the pilot’s departure plan, the harbor master told him emphatically that he would never get a Lake airborne in these conditions, downwind with three passengers.

Impatience kindled irritation and haste. The pilot barked at volunteers trying to help as he attempted to taxi while still moored to the parking buoy. He was rebuked twice not to start the engine while still under tow. Ten seconds after tow release, he cranked and applied takeoff power. After a 60-second, no-flap takeoff run downwind, the Lake began porpoising, bounced off of the waves three times, lurched airborne, stalled, and cartwheeled. Only the right-seat CFI passenger survived.

So often poor decisions, easily identified in the aftermath, are camouflaged in the moment. Despite strenuous objections from credible onlookers, the highly experienced CFI pilot could not see the extreme risk of his departure plan. Perhaps the notion of getting stuck at AirVenture without lodging or transportation was so distasteful, it blinded him to clear reasoning. A proven enhancement to decision making is a second pilot on board, but it didn’t help in this instance. From the NTSB report, it’s difficult to determine what role the right-seat CFI played in the fateful decision to launch. At minimum, he acquiesced.

Impatience kindled irritation and haste. The pilot barked at volunteers trying to help as he tried to taxi while still moored to the parking buoy. He was rebuked twice not to start the engine while still under tow. Ten seconds after tow release, he cranked and applied takeoff power.
Committed to a poor decision, the pilot proceeded in haste, which usually invites mistakes and did so on this flight. Perhaps he was concerned about the left float and wanted to limit time on the water. Whatever his thinking, he forgot to lower the flaps in accordance with the Lake operating manual, a mistake compounded by the rough water. It’s the kind of mistake an experienced CFI usually corrects, but not in this case. Was the right-seat CFI passenger distracted, intimidated—or as statements to the NTSB could indicate, despite his 150 hours of Lake Amphibian time, did he mistakenly believe a no-flap takeoff was acceptable in rough water?

Neither the pilot nor the CFI passenger seemed deterred even after an elongated takeoff run. Bouncing through the rough water the pilot failed to properly counteract the porpoising, which should have been anticipated. Lake pilots match their experience level with “bumps” on takeoff run. After a single bump, inexperienced Lake pilots are encouraged to retard the throttle and regroup. After three bumps, even the most experienced Lake pilots are encouraged to abort. On this run, according to the NTSB, the pilot bumped off the waves three times, but continued the takeoff.

The Lake bounced airborne before it was ready to fly. Proper rough-water seaplane technique is to get airborne and out of the choppy water as quickly as feasible, then lower the nose to accelerate in ground effect. Photographs of the mishap flight indicate an excessive pitch angle out of the water. A high angle of attack, heavy weight, downwind without flaps resulted in a stall, dropped wing, and cartwheeling impact. With such a hasty departure, it’s unlikely the pilot and right-seat CFI paused to review their rough-water takeoff technique and talk about abort points. It’s difficult to understand why they would elect to stay with an alarmingly long takeoff run, beyond the “bump” thresholds recommended for any Lake pilot.

A CFI is always a CFI, even when not specifically operating as CFI or pilot in command. CFIs are entrusted to speak up, step in, and assert their judgment. This CFI passenger was in a tough spot, riding along with a stubborn pilot/owner who was also a CFI, but importantly had relied on the passenger CFI for instruction in the Lake Amphibian. Perhaps he felt intimidated by the pilot’s experience, some 30,000-plus hours more than he. Perhaps the passenger CFI also didn’t fully appreciate the demanding scenario building. Lake pilots do not consider 150 hours “experienced.” Or maybe he accepted the pilot’s determination to depart and thought the odds would improve if he stayed on board to assist.

Whatever the case, a high-time pilot and a CFI were complicit in a disaster that took the life of a passenger who couldn’t fully appreciate the risk they took on her behalf. A sobering breach of trust worth contemplating.

Web: airsafetyinstitute.org

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What Went Wrong?
Illustration by Charles Floyd

Richard McSpadden

Senior Vice President of AOPA Air Safety Institute
Richard McSpadden was appointed executive director of the AOPA Air Safety Institute in February 2017 and was promoted to senior vice president in July 2020. He currently leads a team of certified flight instructors and content creators who develop and distribute aviation safety material –free of charge— in order to advance general aviation safety industrywide. ASI distributes material through a dedicated YouTube channel, iTunes podcasts, Facebook, and a dynamic website. ASI material is accessed 12 million times annually. A native of Panama City, Florida, McSpadden started flying as a teenager and has logged over 5,000 hours flying a variety of civilian and military aircraft. McSpadden is a commercial pilot, CFII, MEI with SES, MES ratings and a 525S (Citation Jet Single Pilot) type rating. He taught his son to fly, instructed his daughter to solo in their Piper Super Cub, previously owned a 1950 Navion that was in his family for almost 40 years, and currently owns a 1993 Piper Super Cub. McSpadden holds a degree in Economics from the University of Georgia, and a Master of Public Administration from Troy University. He is a graduate of the U.S. Air Force Air War College. Prior to joining AOPA, McSpadden had a successful career in the information technology industry, leading large, geographically dispersed operations providing business-critical IT services. McSpadden also served in the Air Force for 20 years, including the prestigious role of commander and flight leader of the U.S. Air Force Thunderbirds flight demonstration team where he led over 100 flight demonstrations flying the lead aircraft. Additionally, McSpadden currently serves as the industry chair for the General Aviation Joint Steering Committee.

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