What REALLY caused John Denver's death?

Here’s a nice example of a SNAFU waiting to happen:

The North American T6 Texan was operated in various countries as the T6 Harvard. The Harvards that made their way to New Zealand (and other Commonwealth countries I imagine), had a fuel mixture control where fully aft was rich mixture, and forward was lean. Other Harvard/Texans had the standard mixture control, forward = rich, aft = lean. The problem is that putting the mixture to lean when you want rich will kill the engine. Of course in today’s Warbird loving aviation society there’s no guarantee that a Harvard you fly in NZ will have the mixture layout you’re familiar with! Generally you figure it out when the aircraft engine won’t start, but it could still be a problem in an emergency situation.

Or how about the Beech Baron which has the propellor and throttle controls reversed as well as the flap and gear levers. It’s not a good look when you retract the gear instead of the flap on the ground.

Or the Spitfire which requires you to swap hands on the flying controls to retract the gear.

Unfortunately aircraft manufacturers don’t put nearly enough thought into Human Factors as they should.

Human factors - I love this stuff. The John Denver crash is a perfect example of this. Something that looks fine and dandy while you are standing on the tarmac becomes a nightmare when airborne.

I’ll share two personal human factors stories - one bad, one good.

The bad one is from an older airplane, the venerable 727. I sat sideways on that thing flying the panel for 18 months, and I can assure you that human factors never trickled down to the 727 FE panel. It was obvious that every system (fuel, hydraulics, electrics, pneumatics, etc) was designed by a different person. On one system (fuel) an illuminated light indicated that something was NOT working (ie a boost pump). On a different system (anti-ice) an illuminated light meant that the system WAS working. And for fuel crossfeed, the light FLASHED ONCE after you activated the switch. Before and after activation it was not illuminated. Multi-position switches also were not consistent. For fuel, a normal flow had all knobs vertical. For electrics, a normal flow had all knobs horizontal. In addition, every system used one of three colors of lights in a different way - an illuminated blue light was good for anti-ice, but bad for fuel. Overall, a human factors nightmare. The only way to overcome it was repitition, repitition and more repitition in the simulator. And even after that guys still screwed things up. If you promise not to sue, I’ll tell you the story of one poor soul:

Fresh out of training and flying the line, he forgot to turn on ANY fuel boost pumps on taxi-out. Not a problem while taxiing and while flying at lower altitudes, because the engines can suction-feed the fuel. As the 727 climbed, he never noticed that the boost pumps were off. Passing 30,000 feet everyone figured it out as all three engines flamed out due to fuel starvation! :eek:

Now for the good. On newer airplanes, and even older ones that we acquire from other airlines, some human factors lessons are applied. For example, on the MD-80s every switch on the overhead panel has it’s “ON” position as forward. In this case “forward” means the same direction you push the throttles to accelerate. So no matter what system you are reaching for, to turn it on you move the switch forward. To turn it off, move it backward. Same thing on the forward console panels - up is on, down is off. Always. Some airplanes came to us with different switchology, but they were modified to our standard before they came on the line. Consistency like this is a VERY good thing, because you do not have to think about which way to throw any switch to get the desired effect.

Human factors design in airplanes is a constantly evolving process. Airplanes made today have learned many lessons from the past - gear handles are shaped like a small wheel, flap handles look like a flap, etc. But the new problems are occuring where advances are being made - namely automation. The phrase “why is it doing that?” has been uttered countless times in simulators and aircraft across the globe. Different philosophies about automation (the most notable being between Airbus and Boeing) result in vastly different methods for accomplishing the same task. The current strive for common automation practices is similar to past battles fought for common mechanical practices. Lessons will be learned (often in blood), and a standard will eventually appear.

Of course these standards would never be required for a homebuilt like the Long-EZ, but you always hope that people are learning SOMETHING from other people’s mistakes.

Talking to a Southwest pilot I know, it is my understanding that, not only does Southwest fly only 737’s, but when they buy another one they do whatever is required to make the cockpit of the new 737 conform the the layout of all their other 737’s. Which means no matter which of this guy’s employer’s airplanes he sits down in, he knows exactly where everything is and how it works. And the reason is… human factors.

(Also, cheaper to only have to train people to work on just one type of airplane, keep parts for only one type of airplane, etc.)

If the NTSB started a “human factors” category distinct from “pilot error”, I wonder how many accidents now labeled “pilot error” would fall partly or wholly into the new category?

pilot141, as a complete non-pilot, I have a question about your “bad” example: is it possible to re-start the engines in that situation, or did you learn about what happened from the flight recorder?

Sam Stone: I agree with you. I didn’t mean to imply that it was solely pilot error, and not a human factors error. The placement of the fuel selector was extremely poor. As we all know, crashes are usually not caused by a single mishap, but by a string of events.

The aircraft in question was powered by a Lycoming O-320-E3D, which has a higher rate of fuel consumption than the Lycoming O-235 or Continental O-200 for which the aircraft was designed. Still, Denver flew several types of aircraft and would have been familiar with the fuel consumption on this type of engine.

Denver knew that he would be unable to easily reach the fuel selector handle, even with the addition of a pair of vice-grips.

In my opinion, Denver made a serious error when he failed to get fuel. Had he refueled before taking the aircraft up, (according to the NTSB) “the pilot’s [attention would not have been diverted] from the operation of the airplane and his inadvertent application of right rudder that resulted in the loss of airplane control while attempting to manipulate the fuel selector handle.”

Since Denver knew the burn rate on the engine, and he knew approximately how much fuel was remaining, and he knew that he could not easily manipulate the fuel selector, I think his decision not to refuel was “pilot error”.

But you are absolutely correct that the placement of the fuel selector is a human factors issue.

Not at all. I know this is frowned upon, but I’m going to do a driveby (flyby?) post. I think that sometimes congratulating a job well done is more important than resting the hamsters.

Great work Sam Stone and Broomstick. Thorough and informative posts. I, for one, greatly appreciate the effort you took to write them.

The engines are easily restarted once you turn the boost pumps on. They lost some altitude, got the engines restarted and continued to their destination. We learned about it from a company-wide message that said “DON’T do what these guys did!”

Broomstick, sorry about that, next time Ill try that nifty spoiler box thing. I hope I don’t find some of those extra parts laying around when I’m surfing. I have surfed that spot since the plane incident, however. That link also has some interesting info on the plane, but not much more than has already been written here.

There wouldn’t necessarily have to be water in his lungs even if he did drown.