"I'm not doing that"

I’ve covered these three case studies before, but it wasn’t until the crash of Cessna 680A N8JR that I made the connection: when we condition ourselves to accept these excuses, we make it more likely we will accept those excuses for ourselves. “I’ll do ____, which I know is wrong, because ____ told me to.” The sad thing is we almost always get away with it, making it easier to stretch our limits even further. Three case studies, in particular, come to mind:

1 — Cessna 680A, N8JR, August 15, 2019, Elizabethton Municipal Airport, TN

2 — Southwest Airlines 1455, March 5, 2000, Burbank Airport, Burbank, CA

3 — Learjet 45XR, N279AJ, January 3, 2009, Telluride Regional Airport, CO

I think in each case, the results would have been different had the pilot flying the jet simply said:

4 — Tell Yourself: “I’m not doing that”

On August 15, 2019, two pilots managed to come very close to killing themselves, professional race car driver Dale Earnhardt, Jr., his wife, and his daughter. The series of mistakes along the way to destroying their aircraft were so obvious, I once called this the “I don’t under this accident” case study because the National Transportation Safety Board (NTSB) accident report covered the “what” but not the “why.” Thanks to Earnhardt himself, we now have the “why.” But let’s cover the “what” first.

The flight originated at the aircraft and aircrew’s homebase, Statesville Regional Airport (SVH), Stateville, NC. The destination was Elizabethton (OA9), Tennessee, an airport nestled in a valley.

The aircraft was a four-year-old Cessna Latitude, N8JR.

The crew.

The PF was a 56-year-old pilot with 5,800 hours total flying time, 765 in type, with three type ratings, the accident aircraft being the largest. He had 2-1/2 years with the company. The PM was a 52-year-old pilot with 11,000 hours total flying time, 1,165 in type, with six type ratings, the accident aircraft being the largest. He was the flight department’s Director of Operations and had 14 years with the company. We often hypothesize about an authority gradient when the PM has double the PF’s experience and I think that would be correct looking at the Cockpit Voice Recorder (CVR) transcript. That authority gradient was verified in a post-crash interview with the owner, who referred to the PM as “my A pilot” and the PF as “the B pilot.” Note: I’ll refer to each pilot this way because I think it will help to understand the “why.”

The accident flight.

They departed under Visual Flight Rules (VFR) without filing a fight plan or using air traffic services. They did announce their position on the Common Traffic Advisory Frequency (CTAF) for a visual approach to runway 24.

Reading between the lines, the B-pilot asked permission to go around, the more senior A-pilot told him he could not.

Mr. Earnhardt and the B-pilot attempted to open the overwing exit but it wouldn’t budge. The main cabin door was partially blocked, but all five occupants were able to exit.

Of course the approach was wildly unstable but the [B-pilot] didn’t feel compelled to go around and simply “asked permission.” The [A-pilot] didn’t hesitate to veto the idea with a simple “no.” The NTSB tells us what happened but not why:

Seven years later . . .

Seven years later, Dale Earnhardt, Jr, provided additional clues in an extraordinary interview: YouTube. I’ll quote him a few times, but preface this with that he attempts to accept full responsibility and in effect exonerate both pilots. This provides a clue to the “why” but not the “why” itself.

“Two great pilots” would not have conducted this flight in the manner planned by Pilot-A and executed by Pilot-B. Among the mistakes:

1. They should have filed an IFR flight plan to help deconflict their route with other aircraft and to stack the odds in their favor looking for the airport.
2. It appears they chose Runway 06 to reduce flight time, but it was the more challenging runway because of terrain. An RNAV(GPS) was available to ensure terrain clearance and to help locate the runway. They ended up too fast partly because they were unsure of distance remaining. The instrument approach would have greatly increased their situational awareness.
3. If a visual approach was a priority, the opposite runway was generally clear of terrain.
4. Pilot-A clearly realized they were unstable: “we’re really fast.” Pilot-B said as much in his post-crash interview and “asked” if a go around was necessary. But the fact the approach was unstable did not result in a go around.

Why did this crash happen? In my opinion, the owner directed, implied, or made the pilots feel that getting from Point A to Point B was the most important objective and the need for standard operating procedures or outside oversight was either discouraged or ignored. As the flight department continued under the A-pilot’s leadership, the A-pilot was either prone to or grew to accept a normalization of deviance. The cause of this crash was not the decisions that “came from the top,” but the decisions made by the pilots. The A-pilot’s procedural intentional noncompliance which may have been a part of his philosophy when hired or may have been normalized with his inability to tell the owner “I’m not doing that.” Either way, Pilot-A’s attitude led to this nearly fatal crash.

"There I was . . .""

If you’ve been a successful commercial pilot for more than a few years, you are bound to have a few stories about when decisions made at the top ran contrary to safety. For example:

Things were going smoothly for the first several months after I took over a flight department when the mechanic passed along a message from the CEO that she was in a hurry and to have the engines running when she arrived. I told the mechanic, “I’m not doing that.” He said, “nice knowing you, the last two chief pilots were fired for less.” She arrived and asked why the engines weren’t running. “I’m not doing that.” “Why not?” “It’s too risky and not safe.” She never asked again.

The management company mandated the order of airports for a month long trip through Africa, including having to depart a small airport in the southern part of the continent for France, a long-distance flight for our Gulfstream GV. I let them know the order of airports had to be changed because the aircraft’s weight, when loaded for the long flight, exceeded the airport’s pavement classification number. They ordered me to do it anyway. I said no. They called the aircraft owner who called me, saying a half-million-dollar charter was at risk and that I should play ball. “I’m not doing that.” He backed down, the management company backed down, and the charter customer said it wasn’t a big deal to change the order.

These things happen in the military too. I had just started engines in our C-20A (Gulfstream III) for a trip into Sarajevo back when there was a shooting war going on. We were the only noncombat rated aircraft authorized in. After we began our taxi, the base’s command post ordered us to return to parking to pick up several aircraft lead acid batteries for a stranded C-130. “I’m not doing that.” “This order is coming from Alpha (the wing commander).” We took off. I heard after the fact that Alpha went ballistic until someone pointed out that the HAZMAT rules for our C-20 were substantially more strict than for the C-130.

Over the years I’ve had more than a few of these orders from “the top” and a few times someone mentioned my job was at risk. I said I’d rather be fired than dead, or have my license pulled. I know this seems overly dramatic, but in this particular case study, it seems the aircraft owner was quite reasonable. I think had Pilot A at some point said he was uncomfortable cutting corners, I think that would have carried the day.

Air Traffic Control put the crew in an almost impossible situation. I say “almost” because each pilot had several opportunities to say, “I’m not doing that.” Had they done so, the case of Southwest Airlines 1455 wouldn’t have become a standard chapter in many aviation safety textbooks.

If you were to place yourself in the situation these pilots faced at the conventional stable approach gate, passing 500 feet above runway elevation, the need to go around would be obvious. But if you rewind the clock to the first ATC instruction that set all this up, you probably would think nothing of it. “We can do that,” we think in an effort to help speed things along. Had these pilots taken their stable approach rules more seriously, they would have avoided the mess about to happen. But they had more than one opportunity well before that. As is often the case, we can read the NTSB accident report to understand what happened. But we won’t understand why it happened unless we go deeper.

The crew.

The 52-year-old captain was a U.S. Air Force pilot from 1970 to 1975, back when the commitment for pilot training was only four years. From there he went on to fly Gulfstream and Convair turboprops and then the Boeing 737 with Wien Air Alaska. He flew for a time on the program known to many as “Janet” out of Las Vegas, said to be a shuttle service to and from Area 51. He was hired by Southwest Airlines in1988 and upgraded to captain five years later. He said he had a total of 11,000 hours, of which 9,870 hours were with Southwest, and 5,302 were as pilot-in-command. This implies he only flew 1,130 hours during his previous 18 years. [DCAOOMA030, Accident Brief and Interview Summaries]

The 43-year-old first officer was also an Air Force pilot, having spent 12 years on active duty flying the F-15, followed by time with the Air Force Reserves flying the F-16. He was hired by Southwest in 1996. He said he had just over 5,000 hours, of which 2,522 were with Southwest. [DCAOOMA030, Accident Brief and Interview Summaries]

The captain’s entire Air Force experience after pilot training was at Mather Air Force Base, near Sacramento, California. That implies that he either flew the B-52 bomber or the KC-135 tanker, both with the Strategic Air Command. The third choice at that base was the T-43 navigator trainer but I don’t think new pilots were eligible for that assignment. The first officer’s entire Air Force experience was in Air Force fighters. The F-16, of course, is single seat. Most F-15s back then were also single seat.

In my opinion, from what we know about their backgrounds, both pilots started their careers with Southwest with scant experience in robust Crew Resource Management (CRM) cultures.

The airport.

The Burbank Airport (KBUR) is about 3 miles northwest of Burbank, California, at an elevation of 775 feet, nestled at the end of the San Fernando Valley, between the San Gabriel Mountains and the Pacific coastline. The airport has two grooved asphalt runways, 8/26 and 15/33.

Runway 8 is 6,032 feet long and 150 feet wide, is configured for precision instrument landings. A precision approach path indicator (PAPI) is located 1,520 feet from the approach end of runway 8 on the left side of the runway. Runway 8 is the favored arrival runway because of the terrain on the opposite end. Runway 26 is only used when the tailwind on Runway 8 exceeds 10 knots and is from the northwest.

Runways 15/33 are longer than 8/26, but unfavored for arrivals. Runway 15 is the favored departure runway but rarely used for arrivals because of noise considerations over populated areas. Runway 33 is unfavored for arrivals because of terrain.

The configuration at the time of the accident was for the approaches to Runway 26 and 33, because the winds were fairly brisk, and Runway 15 for departures. The crew received early ATIS reports of winds at 260/18G26, but the last report they got from tower, just seconds before landing, was 210/6.

The accident flight.

Imagine yourself in one of the pilots’ seats for this scenario. The airport was busy and there was a steady stream of airplanes ahead of you. Everyone was making it in without problems. See the accompanying ground track chart.

Note: the chart that follows is extracted from two diagrams in the NTSB report and the CVR. The elevation of the runway is given as 727’ MSL but I’ve used 700’ because the other altitudes are approximated as well. I’ve used this to compute an approximate Above Ground Level (AGL) but it is really the height above the runway elevation.

1802:25 – [8,000’ MSL, 7,300’ AGL, 33 track miles to go] The crew was handed over to SOCAL approach where they checked in and were told ATIS PAPA was current and to expect an ILS to Runway 8. The crew said they would get PAPA and were then given a frequency change.

1802:41 – [8,000 ‘ MSL, 7,300’ AGL, 31 track miles to go, 235 ft/nm] The crew checked in on the new frequency and were given clearance to 6,000’ and instructions to turn left heading 190. The first officer handed off radio responsibilities to the captain, presumably to get the ATIS.

The ATIS was: "Burbank airport information papa, 0153 Zulu, wind 240 at 6, visibility 19, few clouds at 6,500, ceiling 9,000 overcast, temperature 9 dew point 1 altimeter 29.65, ILS runway 8 approach in use, arriving and departing runway 8 and runway 15."

1804:02 – [Descending through about 7,500’ MSL, 6,800’ AGL, 28 track miles to go, 243 ft/nm] The crew was instructed to “maintain two thirty or greater till advised please.” The first officer returned and took ATC responsibilities; the captain relayed the 230 or greater instruction.

1805:54 – [6,000’ MSL, 5,300’ AGL, 22 track miles to go, 241 ft/nm, 230 knots] The crew was instructed to descend and maintain 5,000 and “if you would like the visual approach you will be following company right now at your one o’clock and twelve miles turning onto final out of forty-six hundred.”

The captain said to the first officer “I want to get through these clouds but I think the visual will be fine.” They may or may not have realized that their company traffic was turning onto a longer final, since from their heading that aircraft was at their one o’clock position.

1807:43 – [5,000’ MSL / 4,300’ AGL, 13 track miles to go, 330 ft/nm, 230 knots] The crew was instructed: “descend and maintain three thousand, company’s over Van Nuys at three thousand.” The first officer acknowledged the clearance and added “lookin’ for company over Van Nuys.”

The pilots agreed that a visual approach was desirable but knew they had to spot company traffic first to make that happen. At this point they were only slightly above the optimal 3° (318 feet per nm) descent and about 30 knots faster than what many pilots shoot for at this distance from the runway.)

1808:18 – [Descending through 4,500’ MSL / 3,800’ AGL, 11 track miles to go, 345 ft/nm, 230 knots] The crew reported, “company in sight.”

1808:19 – [Descending through 4,400’ MSL / 3,700’ AGL, 10 track miles to go, 370 ft/nm, 230 knots] The crew was instructed, “Cross Van Nuys at or above three thousand, cleared visual approach runway eight.” The crew acknowledged.

Once cleared the approach, the previous speed restriction is deleted, as noted in the Airman’s Information Manual: “Approach clearances supersede any prior speed adjustment assignments, and pilots are expected to make their own speed adjustments as necessary to complete the approach. … previously issued speed adjustments will be restated if that speed is to be maintained….”

There is a fair amount of speculation “out there” that the crew didn’t realize their speed restriction had been removed. I disagree, because after the clearance was issued the aircraft decelerated to 220 knots, presumably to meet the 230 VFE for flaps five, and the captain asked for and the first officer selected flaps five. The NTSB notes that they could have asked for the speed restriction to be removed sooner, but they didn’t.

1809:29 – [3,000’ MSL / 2,300’ AGL, 5.5 track miles to go, 418 ft/nm, 220 knots] The aircraft reached 3,000 ft. At this point they were beyond Van Nuys and the 3,000 ft restriction no longer existed, but they were faced with also needing to slow down.

1809:38 – [3,000’ MSL / 2,300’ AGL, 5 track miles to go, 460 ft/nm, knots] The crew was handed off to Burbank Tower. Their configuration was flaps 5 and the gear was up.

1809:48 – [3,000’ MSL / 2,300’ AGL, 4 track miles to go, 575 ft/nm] The landing gear was selected down and the autopilot was disconnected.

1809:53 – [2,900‘ MSL / 2,200’ AGL, 3 track miles to go, 733 ft/nm] The crew checked in with Burbank tower and were cleared to land.

1809:58 – [2,800’ MSL / 2,100’ AGL, 2.9 track miles to go, 724 ft/nm] The crew began their descent to the runway, it appeared to be about a constant rate from this point on.

The math of their situation shows they needed a 6.8° descent angle and that is pretty close to what they did. From what I’ve heard, a Boeing 737 can make that descent, provided they start that descent on speed. What makes it impossible is the fact they were carrying an extra 50 knots.

1810:24 – The first of a series of GPWS “sink rate” and “whoop whoop, pull up” alerts were sounded. Between these, the pilots continued the checklist. At one point, the first officer said, “need any help?”

The captain told Safety Board investigators that he remembered hearing the “sink rate” warning from the GPWS but that he did not react to the warning because he did not feel that he had to take action. He stated that he did not remember any other GPWS warnings during the approach. The first officer indicated in a postaccident interview that he heard both the “sink rate” and the “pull up” GPWS warnings but that he believed that the captain was correcting. [Aircraft Accident Brief DCA00MA030]

At 1811:20, the cockpit area microphone (CAM) recorded impact sounds. The airplane departed the right side of the runway about 30° from the runway heading, penetrated a metal blast fence and an airport perimeter wall, and came to a stop on a city street off of the airport property. An emergency evacuation ensued, and all crewmembers and passengers successfully exited the airplane. [Aircraft Accident Brief DCA00MA030]

1811:46 – The captain says, “Well, there goes my career.”

Southwest terminated both pilots after the accident. The first officer was subsequently reinstated through the grievance process; the captain’s termination was also overturned, but he was permitted to retire.

The NTSB was quite critical of the air traffic controller, saying his actions “positioned the airplane too fast, too high, and too close to the runway threshold to leave any safe options other than a go-around maneuver.” [Aircraft Accident Brief DCA00MA030]

Understanding the Southwest “we can do that” culture.

The crew had to have known they were being pushed into a corner, but all those airplanes in front of them seemed to deal with it, no problem. And some of those were not even Southwest Airlines! If lesser airlines could handle this, surely it would be no problem for them! But they didn’t know their vector was well inside normal and they had far less room to lose speed than any of the aircraft before them. Still, the idea of going around never seemed to cross their minds. Why?

We pilots understand that being expeditious in the air will get us on the ground sooner and when we do this, we also speed things up for other aircraft. We feel a kinship with our air traffic control partners and if we can help them, we will. But we professional pilots also understand that there comes a time when “we can do that” needs to change to “unable.” That is a word I’ve used many times over the years and only twice did that result in a directed “go around” call from ATC. I was fully prepared to divert both times but got good service for the second approaches. Easy. But, as we know, some pilots are more accommodating than others.

I once got a tour of a busy airport tower – back in the days when towers welcomed no-notice visits from pilots – and noted that all aircraft were approaching from a runway equipped with an ILS, but some were asked after they checked in to circle to another runway. It seemed the aircraft were typically right at 500 feet, but that is just a guess on my part. After a while I realized the only aircraft getting the circle were Southwest flights. I asked why and was told, “because they’re the only ones who agree to do it.”

Several of my Air Force squadron mates ended up flying for Southwest Airlines and I asked a few about this “can do” mentality. They told me the pilot culture at Southwest encourages the idea that Southwest pilots are a cut above all others and if it can be done, they can do it. Is this true? I don’t know but it might explain what happened to Southwest Airlines Flight 1455. Chris Manno and I investigate this idea in our book, “Whiskey Air,” available at Amazon and other fine book sellers.

"There I was . . .""

The only time I got into a debate on the radio over an “unable” call was about 30 years ago when we rarely talked about stable approach rules. We were cleared for a visual approach and I set up for a two-mile final, knowing that would get me wings level on runway extended centerline no later than 500 feet. Here is what happened next:

ATC to us: “Aim for the numbers, please.”

Me to the PM: “I’m not doing that.”

PM to ATC: “Unable.”

ATC to us: “Why not?”

PM to ATC: “Our SOP requires us to be wings level at 500 feet.”

ATC to us: “After you land I need you to give me a call, ground control will give you my number.”

PM to ATC: “Wilco.”

ATC to us: “Cleared to land.”

After we landed, we didn’t get a phone number and asked. Ground control told us to disregard the request. These days, I think most air traffic controllers are well schooled in the need for stable approaches and the “unable” call isn’t needed as often. And when we pilots say “unable” in that situation, I think most controllers understand immediately.

Before we dive into this case study, two questions: What is your aircraft’s approach category? Does approach category apply to straight-ins as well as circling approaches?

Is there room for debate? When I first flew the Challenger 604, the manuals clearly stated the aircraft was Category D, end of discussion. A year after I was typed, that statement was removed. Being a Cat D aircraft doesn’t sell airplanes that are used for getting in and out of small airports. The numbers clearly demonstrated the aircraft was Cat D, but pilots started assuming the aircraft was Cat C. I’ve had the debate at the simulator. Cat C airplanes sell.

According to 14 CFR 97.3, “Aircraft approach category means a grouping of aircraft based on a speed of VREF, if specified, or if VREF is not specified, 1.3 VSO at the maximum certificated weight.” My Challenger instructors argued that the maximum landing certificated weight didn’t apply to their aircraft, since VREF was not specified. In 2012, the FAA issued a memorandum saying the maximum certificated weight does apply to aircraft using the 1.30 VSO provision. More about this: Approach Categories.

What about that second question? Do approach categories apply to straight-in and circling approaches, or just circling approaches? The answer is in AIM 5-4-7, which lists the applicable categories and speeds and then says: “VREF in the above definition refers to the speed used in establishing the approved landing distance under the airworthiness regulations constituting the type certification basis of the airplane, regardless of whether that speed for a particular airplane is 1.3 VSO, 1.23 VSR, or some higher speed required for airplane controllability. This speed, at the maximum certificated landing weight, determines the lowest applicable approach category for all approaches regardless of actual landing weight.”

The phrase “all approaches” should end the debate. So those two questions answered, on to the case of “tell the other pilot I’m not doing that.”

“I mean we could almost circle and do it. Wanna try?”

For many of us, circling is one step away from an emergency procedure. Even if that isn’t true, “almost circling” ought to be. The correct answer is “no, I’m not doing that.” But that wasn’t the answer in this next case study.

An “off-runway landing”

The sequence of events leading to the crash make little sense to most professional pilots, since pilot actions seemed contrary to good airmanship. It will be helpful to look at both pilots before looking at what happened.

The Pilot in Command (PIC) was the Pilot Monitoring (PM) in the right seat. He had 4,800 hours total flying time of which 1,038 hours were in type. He held three type ratings: CE-525, LR-45, and LR-JET. He was 42 years old. The Second in Command (SIC) was the Pilot Flying (PF) in the left seat. She had 3,520 hours total flying time of which 831 hours were in type. She held two type ratings: LR-JET and LR-45. She was 36 years old.

There doesn’t seem to be a great deal of difference between pilots that cause the term “authority gradient” to pop out. The PIC/PM wasn’t much older or senior in terms of experience. But the SIC/PF’s actions indicated a deference greater than I would expect. The NTSB failed to dive deeper into this and there is no record of the PIC/PF also having a position of authority over the SIC/PM.

An Instrument Approach “for reference”

The fact the PIC/PM was careful to state they used the approach “for reference,” tells us he was aware their approach category made this approach unusable as an instrument procedure. If they really were flying under Visual Flight Rules I think the PIC/PM would have called for a go around and not a missed approach, but that is probably too fine a point at this point. (But there is more to come.)

The Learjet 45 AFM for N279AJ shows a VREF of 123 KIAS at sea level to 6,000 ft, 124 KIAS at above that. It is a Category C aircraft. It appears the PIC/PM knew that.

Authority Gradient: PIC/PM’s perspective

The fact the PIC/PM referred to the SIC/PF as the copilot, when he was in the copilot crew position, tells us that he didn’t really invest in her the authority of the pilot flying the airplane.

Runway Contamination

The PIC/PM’s recollection about “1” of snow on the runway” is interesting, indicating he downplayed the actual report:

I have a copy of the Learjet 45 AFM dated 2004, but do not know if that was current for the 2009 date of this accident. That AFM, Section V, says “A runway is considered to be contaminated when more than 25% of the runway surface (whether in isolated areas or not) within the required length and width being used, is covered by more than 1/8 inch (3 mm) of standing water or by slush or loose snow, equivalent to more than 1/8 inch (3 mm) of water.” The AFM gives correction factors for up to 1.5 inches of loose snow, but no actual limitation. I think the PIC/PM knew they were operating at the edge of the aircraft’s capabilities.

What the PF/SIC said happened during the “approach” and landing

What the SIC/PF and PIC/PM actually said

The CVR labels the PIC/PM as HOT-1 and the SIC/PF as HOT-2, which I think is opposite convention but might be an indication that the NTSB knew who was really “running the show.”

On the second attempt they were at the MDA and had this exchange:

The MDA was 2,039' above the runway; they would have needed to spot the runway at 6.4 nm to have a normal 3° glide path. The FAF was 500' higher than the MDA but only 6.5 nm from the end of the runway. A stable instrument approach was impossible from the FAF at the published FAF altitude. As is typical with many approaches in mountainous areas, you need to spot the runway well before the final approach fix. This should be part of the approach briefing; you don't want to find yourself at minimums approaching the missed approach point and having to figure this out.

Even if their aircraft’s category allowed for a circling approach, which wasn’t the case, they did not brief a circling approach. The SIC/PF’s “I don’t” would have been better phrased, “I’m not doing that” to end the debate. But she begrudgingly went along.

The flight data recorder indicates the bank angle reached 45° at several points.

As they rolled out the PIC/PM spotted the runway . . .

In her post accident statement, the PF said she spotted the runway prior to landing. It is evident here she did not see the runway while below the MDA.

Authority Gradient: SIC/PF’s perspective

The NTSB did not appear to investigate the steep authority gradient evidence by the PIC/PM to the SIC/PF. The SIC/PF started to assert herself with her “I don’t” statement but she gave up on that when the PIC/PM followed immediately with “circle this way.” I think his statement just prior to the crash exhibits a type of aggression typical with this sort of relationship: “I know you don't want to listen to me.”

Probable Cause

Actual Cause

I think the NTSB failed to give this accident enough attention to get it right. Yes, both pilots failed to positively identify the runway. But why did this happen?

I took my first course in Crew Resource Management (CRM) in 1986 and within a year I was an advocate. It spoke to the safety officer in me, as well as the fallible pilot I knew I was. The more help, the better! By 2009, when this accident took place, every aircraft initial and recurrent course I ever attended included at least a brief discussion about CRM. I’ve been a standards pilot, evaluator pilot, or check airman off and on (mostly on) since before that first CRM course. Even before I heard the term, the crew’s ability to communicate was one of my frequent critique items. No doubt about it, by 2009, CRM was a mainstream idea.

We can make the same statements about situational awareness, stable approaches, threat error management, and so forth. Just adjust the dates a little but you get the idea. All these buzz words are just that, buzz words, unless you are paying attention. Then they become tools for your arsenal to make flying easier and safer.

I suspect that with both pilots in this case study, all those courses were just “eye wash” for the course, agenda items to make the course syllabus look good, the instructors look smart, and the students appear well trained. But none of this does any good unless everyone involved takes the lessons themselves seriously. The PIC/PM may have answered all the questions correctly in the CRM test, but he failed out in the field when ignorning the SIC/PF’s reservations about circling. The SIC/PF might be able to spout out the idea that she has to be on course, on glide path, on speed, fully configured at 500 feet, but that hardly matters when she wraps the aircraft into 45° of bank on a base turn that probably rolled out just one or two hundred feet off the deck.

Let’s say you were in her position, as the pilot flying in the left seat with somebody senior to you in the right seat. Let’s say that person is your boss who signs your paycheck and can get you fired for the least offense. Now that person wants you to do something you know is wrong. Saying, “I’m not doing that” can have several results. It could be your last flight with that operation. It could be that saying no is just what the senior person needs to shake off the target fixation – what the CRM gurus call continuation bias – and will win you newfound respect. Or it could be something between those two extremes. I would argue any of those results are better than finding out the next day you didn’t actually land on the runway.

“There I was . . .”

One of the advantages of being thrown into a large pool of pilots, as happens in the Air Force, the Navy, and many large airlines, is that you get exposed to a broad cross section of peers. You learn that some are good, some are bad, and most sit someplace between. You learn that just because someone senior to you says a course of action is the only option, that is probably not true. If you’ve spent your career in small pilot pools, you might not realize that the boss might be the worst pilot of the bunch. For me, the most poignant lesson came when I was a 23-year-old lieutenant, flying in the right seat of a KC-135A, saying “yes sir” to an aircraft commander who out ranked me (he was a captain), who was older than me (he had just turned 30), and was my boss (he signed my performance reports.) There we were, returning from air refueling B-52s somewhere over the Atlantic, and we were faced with a thunderstorm between us and our base. The navigator spotted the buildup on his monochromatic radar: “it’s a big one.” I looked out the window and spotted it. It went higher than we could climb, but I thought we could fly around it with no more than an additional 15 minutes of flying time.

“Recommend left or right, 30 degrees,” the navigator said.

“Let’s go right,” I said, “upwind, more better.”

“Nah, I don’t want to have to explain the extra flight time,” the aircraft commander said. “It’ll be fine.”

Captain Don Leishman was a pleasant enough fellow, but he had been in trouble a few times with the squadron for what I heard were all bad judgement calls. Since I was assigned to his crew, he seemed hyper interested in flying everything exactly as published. No deviations allowed.

“You aren’t going to fly through a thunderstorm, are you?” I asked.

“Just watch me,” he said.

“I’m not doing that,” I said. “Not only that, I’m not going to let you do that.”

“Listen, lieutenant,” he spat out, and then fell silent. Our radar repeater up front was a smaller version of the nav’s. It was monochromatic as well, just showing green stuff where it was bad, nothing where it was good. The green blob in front of us grew larger and we approached. Don sat and thought. “Okay,” he finally said. “We’ll fly underneath it.”

“I’m not doing that either,” I said. “The vertical gusts from that thing will make mincemeat out of us.”

Don sat and thought some more. “If I get hauled in to see the squadron commander, you’re coming with me.”

“My pleasure to do just that.”

Of course, that never happened. In fact, another tanker behind us took some damage flying through the same build up. “Can you believe that!” Don said to one of his fellow aircraft commanders. “What an idiot, trying to fly through a thunderstorm!”

Through these examples we see that there is pressure from the boss, from air traffic control, and even from our fellow pilots to do something we might not want to do. In most cases, the initial requests are innocuous in themselves. Extend the duty day just a little? No problem. Hold a higher speed for just a little longer to help out the aircraft behind you? Of course! Assume the checklist is done to help speed things along? Why not!

Even if the first requests are perfectly harmless and something you’ve done a hundred times before, there comes a time when request after request piles up and you realize that you are venturing into unchartered territory. If your inner monologue says, “I’m not doing that,” it is probably time to give those silent thoughts some volume.

I recommend you take the next request from the boss that stretches your personal safety boundaries and go on record. Some things are nonnegotiable for safety because the environment is fluid and even the best pilots can be bested by aircraft problems, conflicts with other aircraft, or frailty of the system itself. I’ve heard a few variations of this: “Why can’t you do this? Joe does it all the time.” My answer: “Joe has a higher risk tolerance than me. It could be he has more relevant experience or it could be just the opposite. My experience tells me this incurs an unacceptable risk.”

You should realize that in a war of wills between you and air traffic controller, you will never lose so long as you are complying with regulations and favor the more conservative approach. You might have to go around, and you might have to make a phone call. But as long as you can say your actions were safer than the alternative, you cannot be faulted.

Finally, when dealing with your fellow pilots, as soon as they realize you are one of those aviators who always tries to follow the rules, they will stop asking you to bend those rules. As with that case where we were asked to aim for the numbers, making a stable approach impossible. My cross-cockpit oath, “I’m not doing that,” didn’t need a translation. The other pilot knew instantly and issued our “unable” with an air of finality.

The irony in all this is that I suspect those who push us into these corners gain respect for us when we say, “I’m not doing that.” What seems traumatic to us at first, might actually be the best thing we can do. Or it may be a nonevent. Either way, it is a better outcome.

Cessna 680A, N8JR

NTSB Aircraft Accident Docket, CEN09LA116

NTSB Aircraft Accident Narrative, CEN09LA116

Southwest Airlines 1455

NTSB Aircraft Accident Brief, DCAOOMA030, Southwest Airlines Flight 1455, Boeing 737-300, N668SW, Burbank, California, March 5, 2000

NTSB Specialists Factual Report of Investigation, DCA00MA030, Cockpit Voice Recorder, April 20, 2000

NTSB Operational Factors Group Chairman's Factual Report, Interview Summaries, DCAOOMA030

Learjet 45XR, N279AJ

NTSB Aircraft Accident Docket, CEN09LA116

NTSB Aircraft Accident Narrative, CEN09LA116

NTSB Group Chairman’s Factual Report of Investigation, Cockpit Voice Recorder, ERA19FA248, NTSB Record of Conversation, ERA19FA248, Aug 16, 2019