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Three strikes and you're out: A good rule of thumb to avoid being the star of your own 'never again' story


  •  By Dan Sobczak
     September
     2019
  • Editor's note: This content does not constitute flight instruction. Consult a certified flight instructor in your area for proper flight instruction.


Edit, September 18, 2019:

Two days ago, 'Draco', a highly modified backcountry turboprop high-wing airplane, was destroyed in a takeoff accident where strong winds were a factor in the accident. Thankfully, Draco's pilot Mike Patey and his two passengers walked away unharmed.

Shortly after the accident, Patey began filming a video of himself in which he explained what happened and noted the sequence of events that lead up to the takeoff attempt.

"I kind of asked tower if I could kind of crab a little bit to the runway and takeoff a little bit to the wind because it was a direct crosswind of the runway we were departing from. And, it kind of felt like I was doing something wrong, kind of even asking or turning to the wind, and in my head I kept thinking, this wind's so strong, I ought to just turn at 90 and takeoff. I don't want to get the tower mad at me. And if I didn't want to get the tower mad at me, and I felt that there was something wrong with that, I should have just taxied back."

Patey's description of the decision points leading up to the accident progressed similar to what our blog post here described below -- three strikes and you're out -- which was published eight days prior to Patey's accident. Thanks to Patey's openness and his description of the decision points in his accident, all pilots can learn from his experience.

Original article below, published September 8, 2019:

Recently, I came across a blog post and podcast by two different authors on two different stories in aviation. Yet I was surprised at how connected these two unrelated piloting stories were.


The blog post: "Three Strikes"


The blog post was entitled Motivational Speaker on Safety: The Chain of Events Leads to the Scene of the Accident, written by Anthony "AB" Bourke, CEO & Founder of Mach 2 Consulting.

With more than 2,700 flight hours, Bourke is a highly experienced F-16 fighter pilot who flew tactical missions all over the world. Bourke tells the story of a mission he flew in the F-4E Phantom which nearly led to catastrophic results.

A U.S. Air Force F-4 Phantom flies with the 82nd Aerial Targets Squadron over White Sands Missile Range. By USAF - holloman.af.mil, public domain.
  • A U.S. Air Force F-4 Phantom flies with the 82nd Aerial Targets Squadron over White Sands Missile Range. By USAF - holloman.af.mil, public domain.

Prior to takeoff, Bourke had a series of events occur during his mission assignment, and then during preflight and taxi to takeoff, that caused him to remember the briefings of various accident reports he'd sat in on during his U.S. Air Force pilot training classes:

"I started to remember the accident briefings in my U.S. Air Force pilot training classes, and the words of my wise instructor pilots who reminded me that airplane accidents were never the result of one single incident; rather they always occurred at the end of a sequence of events that many pilots should have seen would ultimately lead to a mishap... In every case, the popular expression during these briefings was "three strikes and you're out," which essentially means that the pilots and the squadron leadership should have seen many accidents coming well in advance because the sequence of events was leading them down that path."

As he sat waiting for takeoff, Bourke recognized the strikes he was accumulating, and made a decision that ultimately may have saved his and his backseater's life later in the mission.


The podcast: "Never Again"


The podcast was a story from AOPA's Never Again podcast, titled "Never Again: A murky Michigan trip" (by Tom Kern), which caught my attention for its similarities to Bourke's F-4 Phantom mission experience.

Tom Kern had spent a great deal of time flight-planning a VFR flight from Blue Ash, Ohio to Traverse City, Michigan, checking weather and NOTAMs to ensure he had the most current information. The night before his flight, Kern said the weather forecast for the next morning along his entire route was perfect with high ceilings and unlimited visibility.

However, before he even got to the airport the next morning his strikes began.

The Piper Archer Kern planned to use was out of service, and he had to use another Archer, which only had a basic VFR panel with a single NAV/COM radio.

A photo of a Piper PA-28-181 Archer II. (For the sake of clarity, this is not the same aircraft involved in the podcast story mentioned in this blog post.) Photo credit: Frank Schwichtenberg. Used with permission under the Creative Commons Attribution 3.0 Unported license.
  • A photo of a Piper PA-28-181 Archer II. (For the sake of clarity, this is not the same aircraft involved in the podcast story mentioned in this blog post.) Photo credit: Frank Schwichtenberg. Used with permission under the Creative Commons Attribution 3.0 Unported license.

Upon checking the weather one last time before takeoff, Kern found that the forecast for weather at his destination was changing from the promising forecast he got the night before.

Kern later admits at the end of his story there were several warning signs he chose to ignore -- three strikes, if you will, which came in in the form of specific decision points Kern faced. The experience Kern had was the catalyst he needed to start his instrument training soon after his incident.


Different stories, same lessons


The lessons learned from both of these separate yet similar stories comes in two parts:

Lesson #1: As Bourke summarizes in his F-4 Phantom story, training is critical. When a crisis hits, even though you may not know what happened, muscle memory from your training will go into overdrive. You may even hear your instructor's words of wisdom that she or he taught you during your student pilot or instrument training lessons, all of which can boil down to a single phrase: aviate, navigate, communicate. These three steps will help guide you in your effort to recover from a life-threatening situation.

Lesson #2: Be aware enough of your situation -- and the decision points along the way -- to recognize those strikes when they start adding up. They just may be telling you to slow down and "wind your watch." As Bourke's instructors taught him, once you have the initial situation under control, it is always best to take a minute to "wind your watch and analyze the situation before taking further action." Take a deep breath to try and figure out what is going on (assuming you have time and altitude in which to do so).

Stay sharp!
The Flight Chain App team



Flight Chain App and its companion blog www.AheadOfThePowerCurve.com are committed to reducing general aviation accidents, helping improve aviation safety, and growing the pilot population.




  • Dan Sobczak is the founder of www.FlightChainApp.com, a mobile app that helps pilots learn from accident chains by making NTSB reports more convenient and easier to digest. Dan received his private pilot certificate in 2003.

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