We finished our discussion of JC Williams’ “error producing conditions“(EPCs) just in time to remember the anniversary of this horrible tragedy anduse the events of that night to wrap up the lessons we learned using EPCs topredict the future. The takeaways from that crash are instructive even today topilots.
Let’s trace the events of the crash through Don’s lyrics tosee how the accident can really drive home just how predictable a tragedy can actuallybe. The song starts off recounting when it all happened “a long, long time ago, but I can still remember how.” It was wayback in 1959 but it was on the same night that I’m sitting here working on thisarticle, February 3. The lyrics go on telling more of the events that fatefulnight: “I can’t remember if I cried whenI read about his widowed bride, but something touched me deep inside, the daythe music died.” The accident indeed touched many people deep inside, andeven today it’s considered the first and maybe one of the greatest tragediesrock and roll has ever suffered. Modern music critics view Holly as “the singlemost influential creative force in early rock and roll” and Rolling Stonemagazine ranks him in the top ten on its list of the “Fifty Greatest Artists ofAll Time.” In a final tribute, Holly would become the first artist inductedinto the Rock and Roll Hall of Fame in Cleveland, Ohio. The opening lines alsorefer to Holly’s “widowed bride,” Maria Elena, who was six months pregnant atthe time of the crash. The “tragic news” about Maria Elena was that her acuteloss led to a miscarriage two days after the crash that would add a fifthvictim to the tragedy.
The lyrics go on, “Februarymade me shiver, with every paper I’d deliver. Bad news on the doorstep, Icouldn’t take one more step.” Holly and his band, The Crickets, were on a “WinterDance Party” tour that took them to twenty-four Midwestern cities in less thana month. It turned out to be really “bad news” for the guys in the band who hadto put up with long overnight travel in a rickety old bus that had a lousy heatingsystem, and with outside temperatures dropping to −25°F it made everyone “shiver.”The bus also had a nasty habit of breaking down several times between stops. Itgot so bad that drummer Carl Brunch was hospitalized for frostbite on his feet– he “couldn’t take one more step” and missed the rest of the tour (and theplane wreck). Buddy was fed up with the creaky old bus and decided to charter aplane to take them from Mason City, Iowa, to Fargo, North Dakota, for theirnext gig. The Big Bopper and Ritchie Valens were on the plane because of a coupleof odd twists of fate. Bandmate Waylon Jennings, who would go on to become afamous country music star, was scheduled to fly but gave his seat up to the BigBopper, who was suffering from the flu and didn’t want to ride the cold bus. GuitaristTommy Allsup flipped a coin with Ritchie Valens for the last seat – Valens won.All this had prompted Buddy to jokingly tell Jennings, “I hope your ol’ busfreezes up again!” Jennings shot back, “Well, I hope your ol’ plane crashes!” Itwas a prophetic statement Jennings said over and over in interviews that hauntedhim forever.
The band hired 21-year-old pilot Roger Peterson, who agreedto fly the guys to Fargo for $36 a person. Peterson was using a fork-tailed BeechBonanza 35, N3794N, that night but he hadn’t flown it much, having logged only128 hours as PIC. In the pitch-black darkness at 0100, Peterson taxied down Runway17 at Mason City Municipal Airport and took off. The flight lasted fourminutes. He flew into the dark night and directly into the blowing snow from anincoming blizzard. With visibility down to almost nothing, Peterson immediatelylost visual references to the ground, became disoriented, and flew down insteadof up. The plane plowed into a cornfield at over 170mph, instantlykilling everyone on board. The passengers were thrown from the wreckage and stayedthere for ten hours before they could be found as snowdrifts blew over thecrash site.
The crash resulted from a deadly co*cktail of error-producingconditions. The Civil Aeronautics Board (forerunner of the NTSB) determinedthat “the probable causes of the accident were the pilot’s unwise decision toembark on a flight which would necessitate flying solely by instruments when hewas not instrument certificated or qualified to do so. Contributing factorswere serious deficiencies in adequacy and communication of the weather briefing,and the pilot’s fatigue as well as unfamiliarity with the instrument that determinedthe pitch angle of the aircraft.”
So let’s find the lessons to be learned from this tragedy. Thefirst and also the most common EPC we talked about is fatigue. Not only was it 0100 when he started up the plane and tookoff, but Peterson had already flown for 17 hours that day. He agreed to fly thetrip anyway. We have already seen that fatigue incrementally increases the riskof error and certainly contributed to the crash by impairing Peterson’s pilotskills, thinking skills, and problem-solving skills. The next EPC in thistragic scenario is lack of experienceand unfamiliar circ*mstances. Peterson was a low-time aviator, having only accumulateda total of 711 flight hours. We don’t know how many hours of that was at nightor in IMC; it couldn’t have been much because he wasn’t instrument certified. Hislogbook was found in the wreckage and showed a total of only 52 hours of dual instrumenttraining. He obviously didn’t have the experience or skills to fly ininstrument conditions on a dark moonless night and snowy whiteout conditions. Itwasn’t that he hadn’t tried to get his instrument ticket, but Peterson failedhis instrument flight check nine months prior to the accident and didn’t liveto retake the test.
The next EPC is highrisk, low frequency circ*mstances. The limited instrument flight traininghe had was with a different kind of instrument panel than was on the Bonanza hewas flying. It was a common problem in the late ’50s that attitude indicators(AI) were not standardized; some had a fixed airplane symbol that the horizonbar moved around and others had a fixed horizon bar that the airplane symbolmoved over. The AI in N3794N was a Sperry F3 with a pictorial presentation ofpitch and bank angle using a stabilized sphere with free-floating movements ofthe airplane symbol. It presented its pitch information with sensing exactly oppositeof what he was used to in the AI instruments in the other planes he flew. It waslikely one of the reasons he flew the plane down into the ground instead of upinto the sky when he entered IMC. This was confirmed by the CAB crash inspector,who reported the “rate of climb indicator stuck at -3,000 feet/minute descent.”
Another EPC that is very commonly cited as a contributingfactor in NTSB statistics (it was one of the issues in the Tenerife tragedy wetalked about a whileback) is inadequate communication.Peterson had checked the weather but it was never communicated to him by theaviation weather briefer that there was a flash (Flash Advisory #5) weather advisory(forerunner of the “SPECI METAR” we have today) issued to take effect at 0040,just 20 minutes prior to his planned departure that warned of a “rapidly movingcold front with blizzard conditions, blowing snow, fog and visibility generallyless than 2 miles.” This lack ofcommunication of critical flight information also contributed to his tragicdecision to fly that night and possibly could have dissuaded Peterson from takingoff in the first place.
We started our deep dive into EPCs with that old CaseyStengel quote about how hard it is to predict the future. But it’s easy to seeafter picking apart the factors of this crash that predicting the future isn’thard or uncertain at all. Sure, we’re lookingat all of these EPCs after the fact, but it really shows how important it is tohunt down and identify these conditions before you launch on a flight. Thereare all kinds of checklists and templates around to help to develop this skill.The FAA has one they call the “FRAT” checklist that stands for “flight riskassessment tool” linkedhere. Pick one of these available tools or just print out Williams’list I cited last month and use it. Safely completing your flight requiresextra vigilance when faced with any of these common sets of circ*mstances. If RogerPeterson had done any kind of an error-producing conditions assessment as partof his pre-flight planning he might likely have just said to himself, “Tonight’snot the night to fly.” All of us need to do an honest evaluation of possible EPCs,a mental “pre-brief” identifying when bad outcomes are more likely to occur, aspart of our routine pre-flight assessment. By being on guard and anticipating timeswhen bad things are more likely to happen, they can be avoided, the future willbe right there to predict, and nobody will need to be lamenting, “Do you recall what was revealed the day themusic died?”
