NTSB's Bruce Landsberg Discusses Snodgrass-Lewiston Accident 

All those Bruce Lansberg columns in AOPA Pilot about what goes wrong. But I read them. All those similarly themed analyses I've read or seen by Paul Bertorelli over the years. But I read them. I watched them. And, for five decades, all those checklists I followed religiously, occasionally hating myself for doing so because it often felt...dumb to do so. But I did them. Every time. Is that why I'm still here? No one can say. But one thing for sure - they didn't shorten my life.

No one is immune to a momentary lapse of discipline.

The way I look at something like this is the more sophisticated the aircraft the more disciplined pilots might be. The younger the pilot the more disciplined they might be. After years and years of beating the odds and coming out unscathed it might be human nature or easy to let your guard down especially during a less sophisticated simplistic situation. This is how I feel based on my life experiences. I will take it to heart and try to be more aware and disciplined.

Paul, a word of encouragement: There very well could be at least one pilot out there who would have done something risky and died, but didn't due to having been informed and warned by you...but you'll never know about it. How many lives were saved? We'll never know. It's hard to study and quantify things that never happened.

That reminds me of working at an FBO in the 80’s and doing a major overhaul and service on a Twin Otter. When it was released back to the corp owners pilots they took it and did a complete pre flight and then spent about an hour on a run up pad doing checks. When they went to take off did the same, pitch up into a deep stall and crashed nose down on airport grounds. They hadn’t removed the control locks. These are incredibly complicated set of pins and red metal flags that are right in front of the pilot. You literally can’t grab the yoke without hitting a pin flag. I have no idea how they missed this.

I have great respect for the NTSB so I _really_ appreciate Mr. Landsberg and Paul having this discussion. Thanks to you both (and the rest of the crew, of course).

Great discussion, serious and somber. I watch many of these small plane crashes from multiple sources, for the main reason is that it serves as a repeated, regular reminder that mistakes can be made by any of us. I have an old C172 which is among the simplest and most forgiving planes that has never caused me exceeding worry. But I keep in mind especially as a common example, the many stall-spin crashes on that base-to-final turn that catches people banked, to slow and to low to recover in time. If I am ever in a situation that the instinct/urge is to just "pull up!!!" I hope I've seen enough of these scenarios that are in my memory at the time that I will remember NOT to do that...As an example. Thank you.

It is important to emphasize the full motion control check in our checklists isn’t just about controls locks left in place, it is about any discrepancy in the free movement of the controls before we attempt a takeoff. As a flight instructor I use the example of tragic known accidents due to missed control locks left in place to make a point, but is is also about frayed cables, physical obstructions (a big purse in someone’s lap), failed pulleys… etc. any number of unforeseen scenarios that can contribute to the lack of full control when necessary that can be detected before we take the runway. All of us who use written checklists miss items from time to time. It would be disingenuous and false to say otherwise. It is the long established disciplined use of well thought out checklists that we must instill to safeguard our humane fallacies in flying. We morn our compadres who remind us sometimes of our simple human failing as aviators. May we honor their lives in our own reflections in how to conduct our future flights and interactions with our with our peers.

Locks and safeties like this control lock need to be very inconveniently located so that the damn thing is 'in the way' before you can operate the airplane. To get it out of the way, it has to be stowed and safe. The control lock design in this airplane was terrible.

The airplane like a chainsaw analogy is quite fitting.

Attribution bias is a real issue. I'm in the medical field, and any time I hear about a medical error by a colleague, I try to learn from it rather than saying "I could never do that". I have changed protocols and procedures because of errors I have read about

Paul, Great video and interview - thank you! Im not a pilot and your explanations make understanding these aviation issues easier to understand. Much respect for NTSB Vice Chairman Bruce Landsberg as well. Paul (in MA)

This is why I bit the bullet and bought the genuine Beechcraft control lock for my Bonanza which has an integrated engine controls cover, making operating the engine without removal of this control lock impossible. I see people often using homemade solutions for control locks to save few bucks but I think this is an area where you should not skimp on if you can use a control locks that also locks out the engine controls.

😎 Thanks AV ⚓️ As a Mariner, I have to thank the aviation industry for all the positive changes to our safety culture…. The oil companies got tired of paying for pollution & blown up barges… and looked to the aviation industry for some sound practices. I am a direct beneficiary. ⚓️

Excellent interview! Many thanks for the thoughtful analysis and lessons learned!

This brings to mind a thing I learned as a woodworker for using a band saw. When not in use, we take the tension off a band saw blade to keep it from stretching or ruining the wheels. If the band saw gets turned on without re-tensioning the blade, it could jump off the wheels and break or otherwise cause an issue, so to be sure that doesn’t happen, we clip a carabiner on the blade. For a flight procedure like this where it’s a known issue, it would be a good practice to put a coffee cup over the stick with a message written on it in black marker saying CONTROL LOCK!

Here's a simple solution for this situation, and others like it. When you activate the lock, run a bungee cord from the control lock to something across the seat, so that you have to release it to get in the seat. When you stow the lock, wrap the bungee around it so that you'll remember to use it when you activate the lock. Simple, but effective!

Thank you for your thoughtful and well produced videos. I hope to be a pilot in the future and have very much enjoyed your videos. I wish there were more informative and well produced series like yours!!! Thanks again.

Excellent interview, thank you for your great content.

That was really great Paul - Thanks. Just what we needed to hear as the Summer goes on and we do those lazy Summer's eve flights just bimbling around in the pattern. So easy to miss - Controls Free And Clear.

I've been waiting on the edge of my seat for you, Paul!

I have to admit one time I was in a hurry, and did a very quick walk around and saw that there was no damage to the aircraft because it was just flown an hour early jumped in it and flew. All of a sudden I realized I was not getting any air speed and looking around. I then noticed out the window that I forgot to take the pitot tube cover off. Sometimes complacency or doing things repetitiously without paying attention, leads to you, believing you did something that you did not actually do.

Paul, Thank you for this video. I have forwarded it to my flying circle. Valuable content.

Thank you, Paul, for this deeper look into this unfortunate accident (crash).

This was an excellent discussion. Thank you for posting this.

One thing I have found at the ripe age of 73, it is possible to simply miss something, or forget a step in a procedure. So the big mistake is attributing proficiency of an experienced 30 year old, to someone performing a task at the age of 73. When you get over 70, simply due to the brain's blood flow plumbing, you will not be as good handling multiple tasks, especially, if you try to compress your schedule and do them quickly. (You can read about this online. It is a well documented challenge for seniors). A senior will drop the ball when trying to do something complicated in a time compressed manner. Besides that fact, a senior's vision may not be as stellar as it was during their younger professional years. This is not to doubt the accomplishments and talent of the pilot in this accident. But perhaps an additional factor might be overconfidence in your own ability to perform task management as you age into your senior years. The lack of awareness of your own abilities as you age, might also have been a contributing factor. Perhaps It might be important for senior aged pilots (even accomplished former Navy Pilots) to not be in a hurry, and have a buddy as a second set of eyes during pre-flight.

Fantastic content. A cold reminder of the importance and understanding of each ground control check.

Thanks Paul! I will be talking about Attribution bias and the correlation with normalization of deviance and complacency at the next meeting with our pilots. This is so important as it shows that if this can happen to the best of us, it can happen to any of us.

Thanks Paul and Bruce for a great interview and video on such an important topic. I'm wondering if we need refreshers on human factors just as much as we need Biennial Flight Reviews. As GA pilots who often fly alone, we need to have a healthy fear of the aeroplane and a healthy fear of our own fallibility EVERY time we go to fly. There is no room for complacency when you're a solo pilot. God bless my wonderful flight instructor who taught me to put my own mental status assessment as part of my preflight checklist. I hope I never let him down.

Thank you Mr.Paul.... you're doing a world of good sir - for those of us in the sky as well as those of us past the end of the runway - don't let anybody tell you any different. I think mr.Dale would be proud of the way you represented his incident, mr.Dale was a giver, as proven by his lifetime of military service, and while the final chapter was unfortunate for friends and family and community, mr.Dale went out giving, giving us something to think about that might just keep us safer in the future.

I appreciate the comparison of airplane and chainsaw: every airplane - simple, complex, piston, jet or rocket- that's worthy of the name (and some that aren't) can still take you to a height from which you cannot safely fall. Heck. I've slipped off icy wings on the ground. . So adhering to a pretakeoff procedure that works and covers all the killer items is just as essential in a J3 as it is in an F35. While I have always, without fail, boxed the controls to make damned sure they are free and correct, I have committed other pretakeoff sins that could easily have ended badly. Not catching the mixture control pulled aft to keep the plugs clean as I taxied a long, long way on a hot summer day is one of those. I have also experienced (mainly post-maintenance) the sins of others. A bent aileron trim tab comes to mind. Controls free and correct. Instruments in the green. Gas? On the mains and boost pump as required. Altimeter set. Runup. Trim for takeoff. Interior (doors and windows closed and checked). Propeller for takeoff. If you only check these things - without fail, without allowing anyone or anything to interrupt you - I think you have pretty good odds of flying airplanes long enough for it to become habit forming.

Very good discussion, and a useful and important reminder why checklists and procedures are so important in aviation. - Martin

You should always check your control movement because you don’t know if another aircraft or something on the ramp bumped into one of the control surfaces and caused it to be deformed. I often do a reverse control check first. This is as I am looking at both sides of the aileron, rudder or elevator I carefully move the control surface at the pushrod location and look into the cabin to see the movement and direction of the yoke. Then as part of my pre-takeoff checklist, I’ll do a full free and clear movement with the yoke and verify the control surfaces I can see from the cabin.

This is so sad, this accident is going to stick in my mind each time i preform a preflight check in my Mooney...

Thank you for a very good discussion about this simple, but catastrophic, crash and its implications. The points about more experienced pilots and “Murphy’s Law” are particularly relevant. It was once summarised to me as: the inexperienced pilot is surprised when the aircraft does not take off; the experienced pilot is surprised when it does!

Muy buena entrevista 👌 no importa la cantidad de horas de vuelo, o la formación aún así puede darse una cadena de eventos que terminen de esta manera. Muchas cosas por aprender. Gracias por compartir esta información. Saludos desde Argentina.

Anybody can make a mistake.

I just wanted to say, without you and others, there would be 100s if not 1000s of more crashes. I think I can safely speak for all of us that are not narcissistic, your work is invaluable! Do not feel like you are not making a difference, you most definitely are, and if you give up, it will result in many more crashes! Thank you so much for what you do, PLEASE keep it up for our sakes! Luv you bro!

Trim is a big one. On my Comanche it’s up above your head and out of your field of view. I once had it incorrectly set way trim up (for landing) and did a taxi back. On the takeoff roll I was trimmed too far back and had to abort takeoff. Big big wake up call

Good discussion on how we get into checklist complacency. Case in point when you audible the last second acronym before entered runway before takeoff and note a missed setting of flaps. We love aviation that requires our full attention and discipline.

Excellent explanation. Thanks

My little RV-12 has no internal gust locks, just a PVC pipe U shaped rudder lock and the seat belt around the stick. After "burping" the Rotax for the oil check and sumping the fuel, the next part of the preflight before ever getting into the cockpit is a walkaround which includes moving all of the control surfaces by hand and checking the integrity of the fittings. I box the controls right after startup and right before taking the departure runway and watch them to make sure they move correctly. Years ago, I heard something that I've never forgotten: A mechanic A&P/AI friend related something his father (a FAC in Laos during Vietnam) told him when he said he wanted to learn to fly: "Son, remember. No one is exempt."

There was more than one error. A full exterior preflight inspection, with the flight control surfaces checked for free movement, most likely was not performed by the pilot in command. And the final error was the lack of a pre-takeoff flight control check. Amazingly simple, and routine. And the omission of these standard checks proved to be amazingly fatal.

A very good discussion, only have one thing to add, we always do full and free control checks just before entering the runway, the last thing before checking for traffic, this because of a number of accidents where something has blown up or been taxied over and jammed a control surface in-between the start up and run up.

This has been the very best summary of this accident. Thank you Paul and Bruce. The control lock on this aircraft type is a poor design / engineering so how was it approved during the type certificate process? Was it an FAA oversight?

The difference between an accident and a crash….. well said. Scott

Paul this is a great video ,I am a very strict person about safety ,, keep the good work

I think it comes down to reasoning by induction... I've done this a million times, nothing bad has happened, let's go.

Great video! I bought an old 172 midway into my PPL training with a bolt for a control lock. I spent the money ($70) on a proper one because it looked better, but immediately realized it obstructs my ignition and master switch, so I can’t even start the plane with the lock installed. Fast forward a year and one of the old grumpy pilots at my airport is approaching me smoking mad… I thought I had cut him off in the pattern or something… but he’s mad because he saw me taxi onto the runway without moving my ailerons. “That’s your last chance to check your controls. Always cycle your controls one more time as you taxi to position. Point your thumb up, it will point at the aileron that should go up.” Now that’s what I do,, and look at the pitot, and confirm my runway and instruments match my clearance. I saw a cross control first hand. Homebuilt airplane cartwheeled on takeoff, luckily the owner walked away. I heard he did his own annual inspection and declined any help, even after a mechanic and a couple of his friends offered to check if everything had gone back together correctly.

#164👍Thanks Paul! This is a reminder to all of us we are only one mistake away from disaster. Whatever the checklist; always use one! ERAU 80 CFIA&I ret.

When checking controls, move both ways. I had a cable tie end get caught in a PA28 chain and gear when moved in one way only, which was forward and right. It jammed. OK in any other motion such as forward left, or back left right.

We have far too many of these senseless crashes. I read a report about an RV-6 that ended up on its back just after takeoff from a fly-in - the pilot was alive and talking to the crew that was trying to rescue him, but he ended up burning. Seat belt around the passenger stick, with obviously no "free and correct" check before flight. That's the guy I think about every time I take the runway and do my 3rd "free and correct" check. I also do it before startup after raising the flaps, and before taxi. A bit pedantic, but I want to honor that guy's memory by not repeating his mistake. There is also a video of an RV-8 with control locks in place. And now Snort. RIP my brothers.

Great discussion with good points, thank you. Stick to your routine and check lists even if that takes time, like you brush your teeth and turn off the lights before bedtime! RIP Snort

I've had a fair amount of accident analysis and accident investigation training and experience (not in the aviation world). Something that we were told in one of my early courses that has always stuck with me: "If you can imagine it, it can happen."

This was a great discussion Paul. I'm glad the NTSB joined you to share thoughts on this accident. It's disheartening to see that a simple engineering mistake proofing step (poka-yoke) could have prevented this. I'm sure folks are looking at their interlocks to find a way to make it more visible when activated.

My dad told me a story of getting ready to check fly a Cessna single with his boss (the FBO owner), he boxed the controls and a control cable popped off a pulley! His boss went white-faced. The plane was taken back to the hanger and re-rigged correctly.

There is no better safety device than a checklist. I'm willing to bet that checklists have saved orders of magnitude more people than every other safety device combined. Yet I'm willing to bet that every pilot has skipped checklists at some point. I have. I remember one time in particular. I was flying a Cherokee 140 out of an airport I rarely fly to. They had an automated, unmanned fuel pump. I had never fueled here before. I topped the plane up after I landed and took off into a beautiful morning the next day. The flight home would take me over very heavily forested, rising, remote, terrain. About half way home...I realized that I hadn't sumped my tanks. Sure...odds are...any water would have made its way thru the fuel system by now...but 'odds are' isn't the same as 'absolutely sure'. What started out as a beautiful, relaxing, flight...became an hour and a half of stress and worry. Snodgrass's crash proves once again, that everybody can and will screw up.

Ten thumbs up for Bruce Landsberg's differentiation of crashes from accidents!

Things wrong with the design of the gust lock: 1) It was hard to see when installed because you are looking along it's length. 2) It locks the elevators up when it should rather tend to keep the aircraft on the runway. An overrun would be better than what happened to this mishap aircraft. 3) The gust lock should cover the engine ignition key slot or in some other way keep you from starting the engine. Any other practical ideas for the gust lock?....short of a Rube Goldberg design?

I’m not a pilot but a long time aviation enthusiast. While checklists are an absolute necessity, there is a certain psychology of repetitive tasks that can trip up humans. Otherwise Intelligent, good parents will forget their kid is in the car seat because some event will interrupt a routine and everything seams completely innocuous up to that point in time that their sleeping kid is trapped in a hot car. I studied Math at university, and in studying statistics it gave me an appreciation for seeing how easy it is to be trapped into so many situations without express mindfulness in following an exact procedure every single time - for which there is not a person alive who does.

*WHY* in the hell wasn't there a "Lanyard" that wraps around the controls in such a way that its obvious, *with a Huge "Remove Before Flight" Tag* to keep you from doing this!

1. Scott Crossfield came to mind right away for me. 2. A Ford Tri-motor went down in Fullerton, Ca. airport, at a airshow of all things, due to a control lock not removed. 3. One of the best ways is to keep up to date on all accidents and know that you could be that person given the right circumstances My dad used to say, "a fool doesn't learn from his mistakes, the average man does, but the wise man learns from the mistakes of others."

We can speculate forever as to how this happened but here's my two cents. He skipped the runup. I think if he had done the runup checks, the control checks are a normal part of that process and he would have caught the control lock. So, he missed the control lock during the preflight. My guess is he skipped the runup. Also, he called for takeoff on ground control. Three pretty major mistakes. Not sure where is mind was that morning but it's clear to me that it was somewhere else.

Thanks for focusing on this "landmark accident/crash " that puts lessons into such direct view. I believe the "normalization of deviance" phrase came out of the Challenger explosion investigation, another landmark accident/crash.

I just joined a flying club that has all Pipers. You can’t get in the seat until you take the seatbelt off the yoke. The ultimate visible control lock

Yeah there really isn’t too much to talk about this an experienced pilot flying an airplane that he’s only had maybe 20 to 25 flights and forgot to takeoff the Gus lock and tragedy happen. It’s very simple all the pictures from the NTSB have stated and seen the gust lock was still in place not bent up but still in place which was restricting the movements of your controls. He did not do a proper pre-check and did not do a proper run up I think because at that time when you do the run up is you would have noticed that you do not have full use of your controls. It was an honest mistake that caused the man his life. The lesson to be learned here is DO YOUR PRE CHECKS!!

It only takes one fatal mistake....

As a former “Birdfarmer” on CVs I just want to say that SAFETY ON THE CARRIER and especially on the ROOF is never, never, never a one person job. There are always multiple Airedales looking and checking everything and making sure it is done correctly. They don’t call it THE NAVY WAY for nothing! Having said that - me, one simple guy, endured FOUR crashes on my ships, and shared each time in the heartache involved…RIP ‘Snort’!

How about making the control lock breakable? Maybe when applying a force of 20 kg on the stick which you most likely could do when in panic.

It is inexcusable, to me, that something designed to keep an aircraft stable, from wind,parked on the ground, would not be up in your face, literally, so you would SEE it to take it off! How freaking hard would it be to extend part of that steel structure of the "lock up" in your face near the control stick.

A great 27 minute safety briefing

AV WEB,,Hello PAUL, thanks for this discussion ,with BRUCE LANDSBERG, whom I know, from AOPA seminars in TRI STATES, NTSB, is right up alley, as he did many crash investigations years before. THE CASE INVOLVED WAS A TRAGIC OUTCOME, BUT ODDBALL SYSTEM. RIP, TO SNODGRASS ! 🇺🇸🇺🇸🇺🇸🇺🇸

I box the controls in Flight Simulator. You can never be overly cautious.

In the USN the ground/flight deck crew will drive the preflight control checks (along with many others).

My good example to make a lock more apparent. I have a sportbike with a double disc front brake that has drilled rotors. I have a very robust lock that uses a pin to go though one of the holes and stop the thief from rolling your motorcycle away. Well if you forget to remove it it can damage your carbon fiber fender. I found someone who invented a simple plastic coated steel cable that wraps around the lock and up to your throttle grip. Never again forgot to remove the lock with the not easy to miss yellow cable under your grip. Something like that could be used on planes too.

Bypassing check list seems to be common in general aviation I seen it done. When questioned the response I got was "We do them in our head I have the checklist memorized".

This was a very impressive and thoughtful interview. When my flying days were over I became a computer programmer which further supported my suspicion that the human element was the weakest component of any system. As skeptical as I am of AI (AI as in heuristic algorithms not the populist recursive search engines), I believe its greatest promise is in removing the unreliable human brains from critical systems. RIP Snort.

This accident proves beyond doubt, no matter how good you are, no matter how much experience you have, you are never immune to doing something stupid.

This happened with a Dehaviland Buffalo years ago,sad video

He gave us the final lesson.

The human being is fallible. Simply, directly, and to the point.

The control lock on the Citation XLS is excellent....with the lock on the engines cannot even be started.....However the parking brake design could use some work

it amazes me that a gust lock was installed with the airplane in a hangar

Success…….Complacency……..Failure. Sometimes you survive the failure from complacency. Sometimes you don’t.

The control lock was a horrible design, but I don't think it was the root cause of the crash. If one focuses solely on the design characteristics of the airplane trying to make it impossible for a pilot to make a simple error, you will end up playing an infinite game of Whack-A-Mole with a never-ending series of edge cases. The fact of the matter is that we are human beings and we are constantly developing bad habits, even when we have a lot of experience. I am in a situation where I find myself flying with an instructor every few months. Each time I consistently find myself amazed at the new bad habits I pick up. My guess is that somewhere along the line Snort picked up a bad habit. Who knows when the last time was where he flew with someone who felt as though they had the experience to point out a mistake that he made. That bad habit aligned with some as-of-yet unknown pressure that led him to essentially skip the entirety of the Before Takeoff checklist. The rest is, unfortunately, inevitable. The battle against bad habits doesn't stop until we quit flying or flying forces us to quit the hard way. But yeah, that control lock is a horrible design.

It's so easy to be in a hurry when alone and nobody there to keep you accountable. I have personally made simple mistakes on the ground that could have been deadly had I made it into the air before finding my mistake. The Checklist is critical no matter how many thousands of hours you have.

The aircraft is a tailwheel. In the process of taxiing to the runway, the pilot should hold full aft-stick in a no-wind or into the wind situation. When taxiing with a tailwind which is stronger than idle thrust across the tail surfaces, he should hold neutral or down elevator to prevent the tail being raised. He should also "bank" into the wind when taxiing crosswind. The tailwheel and rudder are a given, you cant even turn on the ground if they are locked. The saying is "Climb into/Dive away from the wind" Even if its a 5kt breeze, it still helps to practice that every time there is a little steady breeze, just to ingrain ground handling into your sub conscience. In my experience, based on the above, if performing these actions, its not really possible to unintentionally takeoff with control surfaces locked. This scenario can actually be eliminated by proper engineering. Edit* It appears from reading that is was inside the cockpit. Control locks can still be engineered in a manner to prevent this, either by having frangible links/shear pins or by automatically disengaging above a certain threshold. Or by being so obtuse that the pilot cannot physically enter the cockpit until removed. Or the lock should prevent gripping the controls. This lock seems to be worthless. If the lock doesn't prevent motion of the controls that are sufficiently locked to cause the pilot to be unable to taxi, then why are they locked in the first place? Its a pilot mistake for sure, but an engineering oversight as well. Also, that accident would probably not have been fatal if the aircraft was not susceptible to lateral departure from controlled flight. That is, leading edge cuffs. Wuld prevent it from rolling over and ploughing headfirst, it would allow it to remain substantially level, where the pilot would have control with throttle.

Why I like the pilot's seatbelt as a control lock!!

His age got him

Gentlemen, the lock does block elevators, meaning it does lock the stick at least one way of moving. Otherwise snort would be able to land again. Apparently it did not prevent the plane form taxiën with the aid of rudder. I wonder how Snodgrass was able to forget about they massive red lock. And didn’t check control movement before takeoff. a string at the stick would prevent forgetting it.

How can a noted aviator who flew an F-14 Tomcat about 5000 hours, and landed it on an aircraft carrier about 2000 times, end up crashing a simple Marchetti? A factor that I've not seen discussed at all regarding Snort's crash is the SETTING in which he flew. On an aircraft carrier and otherwise when flying for the military, there were likely relatively few distractions that would militate against his piloting acumen; whereas on the morning of the fatal crash, he had just had a contentious verbal exchange with his wife, according to a reliable witness. Considering his possibly lingering agitation from that exchange, and adding in the factor that the pilot was now 72 years old, I venture to postulate that the environment in which he was living may have been a factor that placed him in a perilous state of mind on that fateful morning.

As an experienced aviator, he was understandably not as stupid as the control lock. Every time we see these imbecilic devices, we are reminded of the utter stupidity of the non-pilot aircraft designers. The seat belt works fine.

I agree the gust lock was poorly designed. However, the plane’s design was 50-60 years old, and the customer was military.

Fascinating stuff. One almost might say Snodgrass' reputation killed him. He should have lost his license when he forgot to put the landing gear down on the jet in 2006. Instead he was allowed to keep on until age, heart trouble, and just plain forgetfulness did him in.

Landing a jet with gear up is not some inconsequential oversight - it's a really big deal.

One factor that nobody seems to be considering is early onset dementia that could have certainly impacted memory and contributed to the accident.

The conceptual phrase I like use to remind myself that aviation requires constant diligence is “The slowest airplane that can kill you is Piper Cub?” There is no intrinsically safe airplane.

It's even more boggling in a tail dragger where it's SOP to get the tail up early in the takeoff roll using forward stick. That would have been a good time to notice the stick isn't going forward and abort. As stated, "shock waves" -- indeed.

These gentlemen are enablers.

I'm about to have my first lesson on Sunday here in Australia. This story has solidifed in my mind that I am determined to try and avoid the little voice in my head that says "you can take a safety shortcut here" whenever I am doing something that requires skill but is repetitive (like driving). I had the thought that pilots, as they get more experienced, might decide for themselves which parts of the checklist they follow to the letter and which they feel they can skip over because the checklist is really only for the noobs. I am very happy to know that I can be a goody-two-shoes check-everything-by-the-book sort of a pilot forever, and if any gung-ho jock type that smirks at me can come and watch this video. I am taking the "chainsaw" analogy with me on Sunday. Wish me luck.