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Posted: 7/7/2022 8:47:35 PM EDT
Sadly, as many involved in aviation know too well, even the best of the best are not immune to human error and complacency.
R.I.P. Snort

AvWeb - NTSB Cites Failure To Remove Control Lock In Snodgrass Crash
By Kate O'Connor - Published: July 7, 2022
The NTSB has cited the pilot's failure to remove the flight control lock as the probable cause of the crash of a SIAI-Marchetti SM-1019B that killed respected airshow performer and retired naval aviator Dale "Snort" Snodgrass in July 2021. In its final report, which was published on Wednesday, the Board noted that "the control lock and its retaining clip were essentially undamaged, and the lock was found raised off the floor," indicating that it was engaged at the time of the crash. Investigators also reviewed high-resolution footage from airport security cameras and determined that "deflections of the elevator and ailerons were either zero, or so small that they could not be seen."

"The pilot was reported to be extremely thorough about performing preflight checks, and according to his wife, the expected duration of his normal preflight activities would not have allowed him to depart when he did," the NTSB wrote in its report. "The pilot had limited experience in the accident airplane, which could explain why he did not remove the control lock during the preflight inspection. There was no video evidence to provide insight into the duration and scope of the pilot's preflight inspection; however, omission of the preflight control check was uncharacteristic given his extensive flight experience, and the reason it was not performed could not be determined."
View Quote
Complete story is linked at title.

Here's a link to the NTSB Report and Materials: Project Summary: Aviation Investigation - 25 Docket Items - WPR21FA283 - Date of Accident: 24-July-2022

Here's Juan Browne's YouTube video discussing the released report:
YouTube - blancolirio: NTSB Docket and Final Report Dale 'Snort' Snodgrass

NTSB Docket and Final Report Dale 'Snort' Snodgrass

Link Posted: 7/8/2022 9:14:10 AM EDT
[#1]
Sadly, he won't be the last do do that Stupid Pilot Trick.

I know of one locally that left the control lock in his 152, but was able to abort when he realized it.
Link Posted: 7/8/2022 9:44:57 AM EDT
[#2]
Is that why I see light GA pilots walk around and move the control surfaces pre-flight?
Seems that would be so ingrained in one's mind as to be nearly impossible to forget.
Link Posted: 7/8/2022 11:15:02 AM EDT
[#3]
Discussion ForumsJump to Quoted PostQuote History
Quoted:
Is that why I see light GA pilots walk around and move the control surfaces pre-flight?
Seems that would be so ingrained in one's mind as to be nearly impossible to forget.
View Quote

It is somewhat incomprehensible. All pilots in aircraft of any size also move the controls around inside the cockpit as part of a "controls free and correct" pre-flight checklist item. Or at least almost all pilots

Link Posted: 7/8/2022 2:45:12 PM EDT
[#4]
I had about 13,000 hours when I had an airplane finally have issues with a flight control check.  I'd never done a flight without doing one, so they become rather routine.  You just don't expect a problem.  This particular aircraft actually failed the check on its second flight of the day as well.
Link Posted: 7/8/2022 5:41:43 PM EDT
[#5]
Discussion ForumsJump to Quoted PostQuote History
Quoted:
Is that why I see light GA pilots walk around and move the control surfaces pre-flight?
Seems that would be so ingrained in one's mind as to be nearly impossible to forget.
View Quote

Yep. And why military pilots like Snodgrass always "wipe out" the controls in the full range of motion to make sure there's nothing interfering with their movement. Well… almost always. It's always the one time you forget to do it that you needed to do it most.
Link Posted: 7/8/2022 11:24:38 PM EDT
[#6]
Discussion ForumsJump to Quoted PostQuote History
Quoted:
Is that why I see light GA pilots walk around and move the control surfaces pre-flight?
Seems that would be so ingrained in one's mind as to be nearly impossible to forget.
View Quote


Sort of, on the walk around on GA airplanes I moved the control surfaces to look and make sure the hinge pins were not damaged or missing. Once back inside the cockpit you should again check for full range of motion on the controls and also check for no resistance or improper rigging.
Link Posted: 7/9/2022 8:21:21 AM EDT
[#7]
A friend of mine caught himself on a takeoff roll with a KA100 a very long time ago. Luckily it only cost 4 main tires and rescheduling. He decided to go home for the day after that.

Beech has a manditory service bulletin for the KA gust lock inspections. When assembled correctly it's about 4' of chain with the yoke pin connected to a pedestal levers clamp and the rudder pin.
Link Posted: 7/9/2022 6:17:27 PM EDT
[#8]
As noted above, moving the control surfaces during the walk around is primarily to get a good look at the hinge pins and connecting cables or push rod ends, although secondarily it also verifies they actually move through a normal range of motion with no unusual binding.

Once in the cockpit, checking for free and proper control movement is also almost always a formal checklist item. An issue here is sometimes the “proper” part of the check.  Pilots like other people often see what they spect to see and when something unusual happens they can miss it.

I preflighted a V-35 Bonanza once for a post annual check flight and once in the cockpit the control movement was free but when I rolled the yoke to the left, the left aileron went down.  Something about that see,Ed wrong so I did it again slowly and then thought about what that meant.  It meant the aileron cables had been connected incorrectly and the aircraft would have rolled right, when the pilot commanded a left roll, and vice versa for a right roll.  On takeoff that kind of reverse response can often be unrecoverable as the pilot doesn’t figure out what is happening before the aircraft crashes.  

That’s also occurred on swept wing military aircraft where the pilot can’t always visually see the control surfaces but instead relies on a crew chief or aircraft marshaler giving him signals for control movements and verifying they move in the correct direction.  If he screws that up and misses the improper movements the odds are high it will end in a crash.


——-


Formal checks aside, most pilots will do an abbreviated memory item checklist before takeoff based on a memonic like CIGAR.

For me that breaks down to:

Controls  - free and proper movement (and based on my prior near death experience there is an emphasis on “proper”) This involves moving the stock and rudders  through their full range of motion.

Instruments - checking to see that the altimeter and DG are correctly set, and the oil pressure, oil temp, EGT and CHT are in normal ranges

Gas- checking to ensure the fuel gauges are showing amounts that match the amounts you verified were in the tank(s) with a calibrated stick, that the fuel selector is correctly set, that the mixture is set to full rich, and the fuel pressure is normal.

Airplane stuff - checking to ensure the door(s) are closed and locked, you and any passengers are properly strapped in, the trim is set, the carb heat is set and the prop pitch is set.  I’ll also do a final visual check of the parts of the airframe I can see looking for anything out of place, like fuel dripping off the trailing edge or a remove before flight flag still in place.

Radios - the radios are properly set including com frequencies, transponder, and nav radios.


It’s a second/last chance to verify all the key items are ready for flight.

——

In Dale Snodgrasses, case he had something north of 5000 hours in the F-14 plus other military time, plus 6500 hours of civilian flight time.

The control lock on that particular aircraft is in the cockpit and can be removed in flight, but it’s narrow and easy to miss on a quick visual sweep.   He also only had about 20 hours and 20 flights in that aircraft so he was still very new to the type and that’s always a risk factor as familiarity Is low,  task loading is correspondingly high, and the pi,ot doesn’t hallways have the key items committed to memory.

Still, wiping the cockpit with the stock should be second nature,

——

There may also have been one other factor.  I had the privilege of meeting with Bob Hoover in Phoenix in 1983 or 1984 and one of the things he said to me stuck.  He stated he that anytime he is interrupted during a pre flight inspection, he starts over from the top of the checklist (written or memorized) to ensure he doesn’t miss or skip an item..  He stated it was one of the practices that had kept him alive throughout his career.  

Even as a nobody knows me at all pilot over the years there have been times I’ve had to politely ask people to be quiet, stand over there and not disturb me while a I complete the pre flight.  For a well known and or famous pilot that people want to meet and talk to the interruptions are no doubt much more frequent, and there is probably a much greater temptation to attend to an admiring public rather than stay focused on the pre flight. I have no idea if this was an issue in this crash or not, but if I was assigned to the investigation it’s something I’d have looked at closely in terms of both his normal practice and on that particular day.

Link Posted: 7/9/2022 10:20:05 PM EDT
[#9]
Discussion ForumsJump to Quoted PostQuote History
Quoted:
Is that why I see light GA pilots walk around and move the control surfaces pre-flight?
Seems that would be so ingrained in one's mind as to be nearly impossible to forget.
View Quote


I ALWAYS do a flight control check on taxi even in jets.  Saved my ass in a King Air years ago
Link Posted: 7/12/2022 10:37:18 AM EDT
[#10]
Yet another reminder that skill and experience provides no immunity to errors in judgment or decisionmaking.

We all have to remember -- every day -- that "it can happen to me."
Link Posted: 7/12/2022 12:24:26 PM EDT
[#11]
Discussion ForumsJump to Quoted PostQuote History
Quoted:
Yet another reminder that skill and experience provides no immunity to errors in judgment or decisionmaking.

We all have to remember -- every day -- that "it can happen to me."
View Quote

+8

Every time I fly I'm scared I forgot something simple that will cause an NTSB report, or worse. This is the reason I don't wear fun morale patches. I don't want the photo of a hat that says "We Die Like Real Men" in the docket
Link Posted: 7/12/2022 12:41:04 PM EDT
[#12]
Discussion ForumsJump to Quoted PostQuote History
Quoted:
I had about 13,000 hours when I had an airplane finally have issues with a flight control check.  I'd never done a flight without doing one, so they become rather routine.  You just don't expect a problem.  This particular aircraft actually failed the check on its second flight of the day as well.
View Quote



It happens.  I remember reading an early airliner (50s or 60s era prop job) that had an in air control systems failure.  I forgot which surface was effected but I think it was the elevator.  Was still of the cable control design and iirc some pulley wheel came off in the belly and the cable was sawing into the aluminum framework.   Pilots didn’t know what it was and were damned afraid of severing the cable by horsing on the stuck controls.  I forget how the worked around it but they landed it.
Link Posted: 7/14/2022 10:48:22 PM EDT
[#13]
Discussion ForumsJump to Quoted PostQuote History
Quoted:
Is that why I see light GA pilots walk around and move the control surfaces pre-flight?
Seems that would be so ingrained in one's mind as to be nearly impossible to forget.
View Quote


That and "controls free and correct" are(or should be) checklist items.
Link Posted: 7/18/2022 3:16:50 PM EDT
[#14]
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Quoted:
That and "controls free and correct" are(or should be) checklist items.
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Checklists only work if you use them.

That being said, there are segments of the professional aviation world that are not as checklist-based as others. As a USAF fighter/trainer pilot, I rarely ever pulled out the actual checklist and used it to accomplish tasks.  If it was used, it was a verification only of items already accomplished...and the vast majority of the time it was not.
Link Posted: 7/19/2022 4:45:19 PM EDT
[#15]
I watched the summation of the NTSB report and can't help but wonder how on earth did he not notice his control stick was locked. Am I correct in that the lock physically attaches to the control stick and locks it in place? I mean sometime between setting takeoff power and rotation he had to have moved that stick and notice it was not responding as it should.
Link Posted: 7/20/2022 6:27:40 AM EDT
[#16]
Discussion ForumsJump to Quoted PostQuote History
Quoted:

Checklists only work if you use them.

That being said, there are segments of the professional aviation world that are not as checklist-based as others. As a USAF fighter/trainer pilot, I rarely ever pulled out the actual checklist and used it to accomplish tasks.  If it was used, it was a verification only of items already accomplished...and the vast majority of the time it was not.
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Discussion ForumsJump to Quoted PostQuote History
Quoted:
Quoted:
That and "controls free and correct" are(or should be) checklist items.

Checklists only work if you use them.

That being said, there are segments of the professional aviation world that are not as checklist-based as others. As a USAF fighter/trainer pilot, I rarely ever pulled out the actual checklist and used it to accomplish tasks.  If it was used, it was a verification only of items already accomplished...and the vast majority of the time it was not.



Were you a successful pilot?
Link Posted: 7/20/2022 9:31:23 AM EDT
[#17]
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Quoted:
Were you a successful pilot?
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Not sure what you're asking or getting at here.

Is this an attempt at criticism of my comment that in the USAF fighter/trainer slice of the industry that physical checklist use as a routine is rare?

If you're implying that you're skeptical that it is possible to be a "successful pilot" with such a culture, then that's exactly why I posted it in this thread.  Yes, it is entirely possible to do that, and I did, just like the thousands of others who did and do in that piece of the profession daily. That wasn't a culture I created or just started participating in out of the blue; it was the culture of the community, and the expectation of how we learned the job initially and performed the job once we were out in the operational world.

The point in posting that is that there are many different segments of the flying world in which there are many different cultural standards and expectations that constitute good airmanship. Most of us only know the cultural definitions of good airmanship and decisionmaking that we, personally, are brought up with, and are mostly unaware of what things are like in other segments of the profession. As such, we tend to parochially think that our way is the best/only way, even if it isn't.

What constitutes good airmanship while flying an A-10 in Afghanistan is strikingly different than what constitutes good airmanship aboard a 757 in Georgia, or flying a Beaver in Alaska, a Cirrus in California, or a B-29 in Texas.

There are a lot of folks who have a certain view about when/how it is appropriate to use a checklist, and they mostly believe that their view is a Universal Truth. Unfortunately, regardless of which particular view on the practice they have, it isn't.
Link Posted: 7/20/2022 10:35:49 AM EDT
[#18]
Discussion ForumsJump to Quoted PostQuote History
Quoted:

Not sure what you're asking or getting at here.

Is this an attempt at criticism of my comment that in the USAF fighter/trainer slice of the industry that physical checklist use as a routine is rare?

If you're implying that you're skeptical that it is possible to be a "successful pilot" with such a culture, then that's exactly why I posted it in this thread.  Yes, it is entirely possible to do that, and I did, just like the thousands of others who did and do in that piece of the profession daily. That wasn't a culture I created or just started participating in out of the blue; it was the culture of the community, and the expectation of how we learned the job initially and performed the job once we were out in the operational world.

The point in posting that is that there are many different segments of the flying world in which there are many different cultural standards and expectations that constitute good airmanship. Most of us only know the cultural definitions of good airmanship and decisionmaking that we, personally, are brought up with, and are mostly unaware of what things are like in other segments of the profession. As such, we tend to parochially think that our way is the best/only way, even if it isn't.

What constitutes good airmanship while flying an A-10 in Afghanistan is strikingly different than what constitutes good airmanship aboard a 757 in Georgia, or flying a Beaver in Alaska, a Cirrus in California, or a B-29 in Texas.

There are a lot of folks who have a certain view about when/how it is appropriate to use a checklist, and they mostly believe that their view is a Universal Truth. Unfortunately, regardless of which particular view on the practice they have, it isn't.
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It is called “normalization of deviance” and is the subject of many flight safety articles and accidents.
Link Posted: 7/20/2022 10:40:28 AM EDT
[#19]
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Quoted:
It is called “normalization of deviance” and is the subject of many flight safety articles and accidents.
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Good attempt, but no.
Link Posted: 7/20/2022 10:47:20 AM EDT
[#20]
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Quoted:

Good attempt, but no.
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That is exactly what it is.  You can pretend its something else, doesn’t change things.
Link Posted: 7/20/2022 10:51:11 AM EDT
[#21]
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Quoted:
That is exactly what it is.  You can pretend its something else, doesn’t change things.
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Exactly the point I'm making above about individual experiences and our tendency to parochially view our personal perspective.
Link Posted: 7/20/2022 12:12:11 PM EDT
[#22]
FWIW: my first instructor, a guy who was already crusty way back in the '80's when I first learned to fly, always said "It's a check list, not a do list." AFAIK they didn't have the concept of "flows" back then, at least not in the formal way it seems to be now. But you did your flow, then you whipped out the checklist and reviewed your flow.

I've always lived by that method since. I recently read an article (sorry, I forget where) that espoused that method as being superior for single pilot op's where there is nobody else to do challenge/response/check for you.

I have tried to use digital checklists on my tablet (Garmin Pilot, it's effectively the same in Foreflight). It works perfectly well, but I find I'm much more comfortable, and much more efficient, using the flow/printed checklist method.

I've also got certain items highlighted in my mind that I see as flight critical and Must Not Be Missed. On the R44 these are mag's on BOTH, hydraulics check, and low RPM horn check. Pretty much everything else will give you a second chance, but those three items definitely won't.

Link Posted: 7/20/2022 12:49:49 PM EDT
[#23]
Discussion ForumsJump to Quoted PostQuote History
Quoted:
FWIW: my first instructor, a guy who was already crusty way back in the '80's when I first learned to fly, always said "It's a check list, not a do list." AFAIK they didn't have the concept of "flows" back then, at least not in the formal way it seems to be now. But you did your flow, then you whipped out the checklist and reviewed your flow.

I've always lived by that method since.
View Quote

Yep, that's basically my methodology in single-seat GA and warbird flying, too.

The greater point I was moving toward regarding Snort's crash is that he spent his entire professional flying career (both Navy and his civilian airshow and Draken flying) in a single-seat, fighter culture world. And, even though there are different cultural standards inside a fighter cockpit than in a GA aircraft, there is this sneaky little human factors bugaboo called "negative transfer". I'm sure Snort had some deeply ingrained habit patterns that worked well for him over his decades of high performance flying...but, as mentioned before, errors in judgment or decisionmaking (especially being rushed, or distracted, or other things that can upset habit-based behaviors) don't care how much skill or experience you have.

Add to that little things like how you can move the rudder pedals enough to taxi with the control lock engaged in this Marchetti, and you have all the swiss cheese holes required for disaster.
Link Posted: 7/20/2022 2:06:43 PM EDT
[#24]
There was a fatal GIV crash that involved failing to box controls prior to takeoff as well.

Since that accident, I always box during the taxi. Since reading about Comair 5191, I always call out runway numbers and verify that I read the number. Since hearing about numerous fueling incidents, I always sump. Since losing 6qts of oil on one leg of a flight, I always check my oil. Since having a friend have fuel stolen out of his Baron, I always look in the tanks.

The two biggest killers of pilots are complacency and the FAA.
Link Posted: 7/20/2022 2:35:18 PM EDT
[#25]
Discussion ForumsJump to Quoted PostQuote History
Quoted:
There was a fatal GIV crash that involved failing to box controls prior to takeoff as well.

Since that accident, I always box during the taxi. Since reading about Comair 5191, I always call out runway numbers and verify that I read the number. Since hearing about numerous fueling incidents, I always sump. Since losing 6qts of oil on one leg of a flight, I always check my oil. Since having a friend have fuel stolen out of his Baron, I always look in the tanks.

The two biggest killers of pilots are complacency and the FAA.
View Quote


Those Gulfstream guys didn’t think they needed checklists either.
Link Posted: 7/22/2022 8:15:39 AM EDT
[#26]
My instructor always had me check for freedom of controls and correct movement.
Move the yoke to the left and point your right thumb in the air.  That left aileron should be pointing up.
Move the yoke to the right and point your left thumb in the air.  The right aileron should be pointing up.
I do the same thing with a control stick.
It only takes seconds to do, and it's difficult to understand why some people don't do it.
But we know the results when they should have done it.  That's my lesson right there.
Link Posted: 7/24/2022 3:23:03 AM EDT
[#27]
Quoted:
Sadly, as many involved in aviation know too well, even the best of the best are not immune to human error and complacency.
R.I.P. Snort

AvWeb - NTSB Cites Failure To Remove Control Lock In Snodgrass Crash
By Kate O'Connor - Published: July 7, 2022
The NTSB has cited the pilot's failure to remove the flight control lock as the probable cause of the crash of a SIAI-Marchetti SM-1019B that killed respected airshow performer and retired naval aviator Dale "Snort" Snodgrass in July 2021. In its final report, which was published on Wednesday, the Board noted that "the control lock and its retaining clip were essentially undamaged, and the lock was found raised off the floor," indicating that it was engaged at the time of the crash. Investigators also reviewed high-resolution footage from airport security cameras and determined that "deflections of the elevator and ailerons were either zero, or so small that they could not be seen."

"The pilot was reported to be extremely thorough about performing preflight checks, and according to his wife, the expected duration of his normal preflight activities would not have allowed him to depart when he did," the NTSB wrote in its report. "The pilot had limited experience in the accident airplane, which could explain why he did not remove the control lock during the preflight inspection. There was no video evidence to provide insight into the duration and scope of the pilot's preflight inspection; however, omission of the preflight control check was uncharacteristic given his extensive flight experience, and the reason it was not performed could not be determined."
View Quote
Complete story is linked at title.

Here's a link to the NTSB Report and Materials: Project Summary: Aviation Investigation - 25 Docket Items - WPR21FA283 - Date of Accident: 24-July-2022

Here's Juan Browne's YouTube video discussing the released report:
YouTube - blancolirio: NTSB Docket and Final Report Dale 'Snort' Snodgrass

https://www.youtube.com/watch?v=9LY4dngI17c
View Quote


Nobody is bigger than the program... I don't care if you flew F35's    follow your check lists...
Link Posted: 8/4/2022 4:15:29 PM EDT
[#28]
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