Category Archives: Thoughts on Investigation

How the investigative process works and why it’s important.

Looking for the Why

In trying to discover the fate of Amelia Earhart and Fred Noonan, our search naturally focuses on finding evidence of what happened. But, as an accident investigator, I’m just as interested in knowing why it happened. The point of all accident investigation, beyond determining cause and assigning blame, is the prevention of future accidents. My commitment to that goal began many years ago when I witnessed the worst disaster in air racing history.

T-6-Reno
T-6s racing at Reno, 2016.

In the summer of 1969 I was 21 years old, fresh out of college, and grabbing any flying job I could find to build time while waiting to go on active duty with the U.S. Army. By September I had scraped together enough money to buy a standby airline ticket to Reno, Nevada for the National Championship Air Races. By pure dumb luck I landed a place as gofer on the pit crew for Ed Snyder, a T-6 racer from Jacksonville, FL. Ed and his wife Jerri adopted the all-agog young pilot and, for a wonderful week, I was a junior member of the air racing fraternity.

Two years later, as a 2nd Lt. in Advanced Radio Systems School at Ft. Monmouth, NJ, I learned that there was to be an air race at nearby Cape May that included a T-6 class. Hoping to re-connect with old friends, I rounded up my fiancée and, with my brother and his wife, we made the pilgrimage. Sure enough, Ed, Jerri and the whole gang from Reno were there. We agreed to get together for dinner after the race, but horror intervened.

On the start, the seven-plane field came snarling past the stands, rounded the scatter pylon and banked left into the first turn. My friend Dick Minges and another T-6 were trailing behind the leaders. Dick didn’t see the other airplane flying tight with him at 3 o’clock low and when he rolled out of the turn, his right wing came down on the other guy’s canopy. Dick’s wing folded up like a fighter parked on the deck of a carrier. The other plane pulled up and away, the pilot lacerated by the shattered canopy but otherwise okay. Dick’s airplane did a complete roll on its way to the ground. He hit doing something over 200 mph, raising a huge cloud of dust but no explosion.

The other pilots, out ahead, had not seen the accident, but by the third lap the dust had cleared and the crumpled aircraft was visible. The three leaders, tight one behind the other, came around the turn, over the crash site, and headed down the backstretch.

Nobody seems to have seen what happened next. Everyone was focused on the emergency vehicles racing toward the wreck until a sound I’ll never forget snapped our eyes to the spectacle of three T-6s headed straight down like three fence posts. One of them was Ed Syder. They disappeared into the trees and were gone. Where a minute before there had been the deafening blat of R-1340s at full throttle there was now only the muted wail of the crash trucks.

Watching my friends die was a shattering experience. I grew up with airplanes. I learned to fly literally on my father’s knee. Aviation had always been a positive part of my life. I was, of course, aware that airplane accidents happened, but they were not something that touched me personally, until now. Aviation safety took on a new meaning and when I got out of the Army I chose a career as a risk manager for an aviation insurance company. I discovered that I had a particular talent for accident investigation.

Thinking back to that sad day at Cape May, there was no mystery about what had happened. Four midair collisions had resulted in four fatalities, but why? What went wrong? There were no known photographs or motion picture images of the race, but the cause of the first accident was obvious. Dick simply didn’t see the other plane.

The three-airplane collision is more difficult to explain. The FAA eventually determined that the second airplane hit the first airplane and the third plane ran into the debris of the first two. But why did number two hit number one?

Human factors are often behind the “why” of an accident. Ed Snyder was in the number two position. Dick Minges was his close friend. Flying in tight formation requires unblinking concentration. After Ed flew over the wreck of Dick’s plane he may have looked back over his shoulder to see if Dick was all right. That’s all it would take.

I left the insurance industry in 1984 and, with my wife Pat Thrasher, founded TIGHAR the next year. The cases are colder but the principles of investigation are the same. The research for my new book, Finding Amelia – The True Story of the Earhart Electra, makes it clear that human factors led directly to the tragic events of July 2, 1937. As in my first book, Finding Amelia- The True Story of the Earhart Disappearance, original contemporary sources tell a very different story than the popular legend.

Amelia Earhart was keenly aware that her record-setting flights were essentially publicity stunts. In the wake of her 1935 Honolulu to Oakland and Los Angeles to Mexico City flights she said, “My flights haven’t meant anything to the scientific advancement of aviation.”[1] It has become an article of faith that flying around the world was Amelia’s primary goal, but it is not true. The world flight was a financially motivated publicity stunt. Amelia’s first priority was to justify her fame to herself by making genuine contributions to the development of aviation.

Earhart’s husband’s original appeal to Purdue University for funding for a new airplane focused on her desire to make “certain flights as laboratory tests involving various scientific aspects of modern aviation.”[2] The airplane Amelia wanted was a Lockheed Model 10 Electra. After becoming “intimately familiar with the ship under all conditions” Amelia would establish some new transcontinental records, make a flight to Panama or Cuba, and undertake “detailed experimental work at various altitudes, including oxygen flight.” The scientific test flights would be followed by “the ultimate big flight, to be attempted only if and when everything proves out satisfactorily, to be around-the-world [emphasis in the original], starting at the Purdue airport and ending at Purdue. The plane could carry the name ‘Purdue’.”[3]

Reality intervened. Test flights do not make money. They cost money, and there was no money for scientific work. Record-setting stunt flights make money. Before the deal with Purdue was even completed, Putnam and Earhart had reversed the plan. The world flight would now take precedence over the experimental work, but there was a problem. The Lockheed Electra was the wrong ship for a trip around the world. Earhart’s technical adviser Paul Mantz felt that the safest choice for the world flight would be the new Sikorsky S-43 “Baby Clipper” amphibian. Putnam agreed, but Amelia was adamant – she wanted an Electra.

And so began a cascade of compromises fueled by human factors rather than prescribed by best practices. The tragic events of July 2, 1937 were not the consequence of misfortune, nor wanton negligence, but by a progression of poor decisions made in response to practical, emotional, and financial pressures. Finding Amelia – The True Story of the Earhart Electra will be the “prequel” that permits a new understanding of the events chronicled in Finding Amelia – The True Story of the Earhart Disappearance.

__________________________________________________

Notes

  1. Speech in Fort Wayne, Indiana, on March 21, 1935.
  2. “The Amelia Earhart Project,” memorandum from George Putnam to Purdue President Elliott, November 11, 1935.
  3. Ibid.
  4. Ibid.