Terry,

My sympathies to you, and everyone affected by this incident.

Just for reference, I am a 10k+ hr CFI, CFII, MEI, ASC, and have
studied for many years the human factors answers to the questions you
are asking.

I have had several experiences similar to yours over 17 years of
flying. I know how it hurts to see this happen--as you properly
say--needlessly.

In cases like this, we will never truly know the whole answer, as we do
not get the priviledge of interviewing the decisionmaker. However, we
can deduce the most likely scenario based on many similar experiences.

Here we have a non-IFR rated pilot departing into instrument
conditions. As often happens, they literally do not make it off the
airport property. If the aircraft was in flight for one minute, as you
say, then it is likely that the maximum alititude reached was less than
500 feet. This is almost certainly a spatial disorientation accident;
I will offer a prediction that the eventual NTSB report will determine
that, and state that no faults were found with the aircraft or engine.

Year after year we lose several hundred people to this or similar
scenarios; 40% of the light aircraft fatal accidents in the NTSB
database include "continuation of flight into weather for which the
pilot was not qualitied" as the proximate or a contributing cause.

I and other Accident Prevention Counselors across the country have been
fairly shouting this from the rooftops for years, yet we see the same
accident over and over again. Presumably everyone with a license has
been told that flying in such conditions without an instrument rating
is foolhardy. Hence your question: why does this happen?

I think you are close to the answer. Every time I hear about one of
these, I silently ask myself "Where was the time pressure coming from?"

Why does someone consider something they know is a bad idea, and then
decide to do it anyway? Why not just cancel the flight, head for a
restaraunt, and have lunch. You can wait for the weather to get
better, or schedule for another day.

But, no, she decided to do it now--when the evidence is all around that
we should *not* do it now. Visibility less than 1/4 mile? They do not
even allow us to complete an *instrument* approach in that kind of
weather. (Cat I ILS minima are 1/2 mile visibility or greater.)

Here is a person who, in your words, 'always used good judgment.'
Unfortunately, that is obviously not true. She did not use good
judgment on this day. I suspect that this was not the first time,
either, but you may never get to know that.

The bad news is that most people tend to make decisions on emotional,
rather than rational, criteria. That is most certainly true of this
pilot on this day. She allowed her emotional desires to drive her
decisionmaking instead of compying with a rational decision process.
Very likely she did not want to disappoint the passengers. Or maybe it
was to comply with some time constraint established by the parents. It
really doesn't matter which form the time pressure came in; what is
important is the PIC's failure to resist it.

Very often I get asked the question 'What does it take to become a
pilot?' People think it is great motor coordination, or math skills,
or good eyesight, or some such. I tell them, no, all you need is
average skills in those areas. What it takes to be a good pilot is
ultimately the *will to say no.*

You have to pre-define what your personal safety margins are; and then
you have to say no to yourself, and/or whomever else, no matter what
the emotional cost, when continuing will take you into that grey area
beyond those personal margins.

You have to say no when everyone will be mad at you. You have to be
able to say no when its going to cost you money you didn't plan on.
You have to say no when everyone else is doing it. You have to be able
to say no when they are all going to call you a 'wimp.'

I was interviewed for a fifteen minute segment on a TV show after John
Kennedy's accident. We went up in a Saratoga and demonstrated spatial
disorientation to the reporter. As we taxied back in, I told her that
the real thing that killed JFK Jr was not weather or lack of instrument
skills or spatial disorientation; all those things contributed. But
the real cause of these kinds of accidents is an inability to say 'no'
to yourselft--when you know youve done it before and it worked, you
know no one will see you and it will be easy to get away with doing
what you 'want.' But it is over the line, and you know where the line
is. You have to say no, anyway. If you can't do that, you need to
take up basketweaving or chess, but get out of aviation.

You have no right to put your passengers in this kind of a situation.
When they get in the airplane, they have no way of knowing the level of
risk you are taking. They are literally trusting you with thier lives.
You job as PIC is to honor that trust by maintaining wide safety
margins, by not even remotely approaching the 'edge.' It is not fair
to shave off the safety margin just so you can show off, or save a
buck, or have a thrill or whatever. Once you let your emotional needs
become more important than maintaining wide safety margins, you have
violated a sacred trust.

Your passengers deserve better, and so did the little girl in this
accident.

John Kennedy Jr died because he failed to say 'no' to himself when the
margins closed in. Same thing happened in this situation.

The FARs are 'written in blood;' for every paragraph in there, somebody
died to prove to us we needed that rule. I wish that no one will ever
again have to give their life to teach us something; but they do it
anyway.

I just wish that if someone insists on making the ultimate sacrifice to
teach us something, would they please try at least to pick something we
don't already know?

Sincerely,

Gene Hudson
CFI-IA, MEI, ASC