What Really Happened to John Denver

On October 12, 1997, John Denver, popular folk singer and amateur pilot, at the controls of a newly-purchased experimental aircraft, died after crashing into Monterey Bay, in California. He died in an aircraft that had already done its best to kill two previous pilots, an aircraft with a human interface flaw so fundamental, so profound, that it finally managed to kill.

The Long EZ is a kit aircraft designed by Burt Rutan, one of the world's greatest aerospace designers. Rutan was responsible for the Voyager, the first aircraft to circumnavigate the globe without refueling. He is currently working on a reusable spacecraft for commercial and tourist operations that can fly into space in the morning, be checked out and refueled over lunch, and fly again that very afternoon. One of his Long EZ planes, similar to John Denver's, holds the altitude record for conventional aircraft. It is a brilliant design, and is well respected in the aviation community.

Experimental aircraft kits, however, need not be built as the designer intended. Indeed, the flaws that led to Denver's death were the work of the builder, and had nothing to do with Burt Rutan. These flaws led from the builder's sincere desire to improve on Rutan's work, a goal that could actually be said to have been accomplished from an engineering perspective, even if it did kill the pilot.

Background

Aircraft are designed to be as safe as possible. This sounds pretty obvious, but if you look back to the history of the motorcar, you can see quite a contrast with aviation. The car companies required government intervention before adding, while still kicking and screaming, such esoteric safety equipment as headlights, windshield wipers, and seat belts. The aviation community, on the contrary, from the beginning made safety their primary goal. Car fires are a common enough occurrence along America's freeways. A gas line breaks under the hood and soon the engine is engulfed in flames. The cure? Pull over, get out, find a long stick, and start roasting marshmallows.

That same fire in an aircraft at 10,000 feet is a far more serious affair. It can take several minutes to "pull over," during which time that fire can be pouring inky black smoke into the cockpit, blinding the pilot, making a crash inevitable. As a result, aircraft have fuel shutoff valves in the cockpit. Flip the valve and find a nice, friendly field somewhere below where you can safely land your plane. These shutoff valves, on most aircraft, serve a second purpose, letting you choose between the tank located in the left wing and the tank located in the right wing. (I prefer flying aircraft that also have a "Both" position, so all this gas selection can be avoided).

The Bad Interface

John Denver's aircraft had a fuel selection valve with only three positions: Off, Left, and Right. Burt Rutan's design called for that valve to be placed on the front panel of the aircraft, making it easy to switch among the options. The builder of the aircraft, however, elected to place the valve back behind the pilot's left shoulder. He did so with the best of intentions. By placing the valve behind the pilot's compartment, on the other side of the back firewall, with only a long rod leading to the handle behind the pilot's left shoulder, he avoided running the gas lines through the passenger compartment, eliminating any possibility of a gasline rupture occuring inside the compartment.

He did so, however, at a terrible cost to the human interface, because the only way to switch tanks was to let go of the controls, twist your head to the left to look behind you, reach over your left shoulder with your right hand, find the valve, and turn it. As the National Transportation Safety Board (NTSB) discovered, it was difficult to do this without bracing yourself with your right foot-by pressing the right rudder pedal all the way to the floor. And that's what killed John Denver. His plane was seen veering to the right and plunging into the ocean from only a few hundred feet up, consistent with the NTSB's reconstruction.

Making things worse

The fuel: Denver had three ways to ensure he had enough fuel. Evidence suggests he made use of two of them:

He had fuel gauges in the rear of the aircraft, behind the pilot, and a mirror (!) used to look at them. However, the fuel gauges were not linear and had no markings to indicate that apparently half-full was really close to empty. He dipped a rod into the fuel tanks while pre-checking the plane before flight to test the fuel level. He may not have been aware, however, that, because of the way the Long-EZ rests, the fuel tends to slosh toward the fuel tank filler port, giving a highly-optimistic reading.

The third method is adding fuel to the tanks, which Denver failed to do. Because the Long-EZ has very large tanks, the common practice is to add an amount of fuel suffient for the flight, plus a healthy margin. It may be John Denver was told not to fill the tanks, but was not told of this partial-filling practice.

The valve: The builder not only placed the valve in a non-standard location, he also rotated it in such a way that turning the valve to the right turned on the left fuel tank. This ensured that a pilot unfamiliar with the aircraft, upon hearing the engine begin missing and spotting in his mirror that the left fuel tank was empty, would attempt to rotate the fuel valve to the right, away from the full tank, guaranteeing his destruction.

Lessons to be Learned

John Denver learned the biggest lesson of all, even if he only had a few seconds to appreciate it: Let the User Beware! And, indeed, the NTSB, as per its long history of setting aside findings, human factors or otherwise, that might conflict with a verdict of pilot error, ruled that the responsibility for this crash lay with the pilot. The interface was relegated to a mere "factor." Had John Denver fueled his aircraft in spite of evidence indicating he had sufficient fuel, had he somehow managed to thoroughly familiarize himself with the idiosyncrasies of this uniquely-assembled experimental aircraft sans manual, he would be alive and well today.

However, to those of us versed in even rudimentary human factors, it is easy to see that the design of this fuel system was a disaster waiting to happen, as was borne out not only by what Denver experienced, but by incidents reported by two previous pilots of this same plane who almost met death under the same circumstances. Presumably, they had a bit more altitude when their fuel starved out and, therefore, a bit more time to react.

With all of aviation's emphasis on safety, the human factors of small planes and the environment in which they fly would be laughable, if it weren't so dangerous. Why? Because the whole thing is awash in "macho." Just as with Unix, just as with DOS, the more confounding everything is, the better it is, because it helps separate the men from the boys-and the girls, who aren't really invited. Until that changes, general aviation will continue to experience both a high fatality rate and a continuing drop in new pilots.

Author unknown

Name? Richard Koch

Age? 55

Personal qualifications?

As a relative newcomer to aviation, I helped establish a type club for the Musketeer line of Beechraft planes built from the 60s to early 80s. We are the Beech Aero Club, www.beechaeroclub.org, established in July of 2004. We have 500 members and are continuing to grow.

Flying qualifications?

Private Pilot (~360 hrs, trying to juggle work and flying times to allow for starting my instrument training).

Do you own an aircraft? If not, what do you fly?

I own a 1978 Beechcraft Sundowner C23. It’s a 180 HP, low wing, comfortable airplane. It is part of the Musketeer line built for strength and durability. While it’s a wonderful airplane, it’s also a member of the “low and slow” club.

What is your day job?

Graphic Designer/Web and Interactive Developer

Why did you choose flying as a career/sport?

It was a boyhood dream. I started flying in high school in the late 60’s. I managed only eight or so hours before running out of money. Six years ago my adult son said he was going to begin pilot training and I decide to join him to fulfill my own dream. We started a month apart and got out tickets a month apart � 9 months later. Training with my son made it even more special. I tell people it took me about 30 years to get my license!

What irks you about aviation?

Continually rising costs.

Can anybody learn to fly? Yes. Can anybody learn to be a pilot? No. It takes a unique mindset, commitment and dedication to the “art of flying”. Half of my enjoyment of being a pilot comes from totally immersing myself in all things flying. There’s a thrill in continuing to learn and in advancing my skills. Studying and training in other areas of my life seldom yield interest or satisfaction anywhere close to that of flying and owning my airplane.

Describe your most memorable flight?

Probably my first long cross country trip. It was ~1500NM roundtrip and required a lot of preparation. I had it planned to the max and seeing it unfold just that way was awesome.

Your closest call/most anxious moment? Preparing for an oil change, I made a few laps around the pattern to warm things up. Just as I touched down to taxi back to my hangar, the oil cooler ruptured and covered the windscreen with oil. The cause is a long story but as I replayed the event over and over in my mind I could only shudder to think what the outcome might have been had the problem occurred airborne.

Your most admired aviation personality?

Besides the obvious pioneers like the Wright Bros. et al, I’m inspired by Mr. William Bower, one of only two pilots still alive, who flew the Tokyo Raid mission with Jimmy Doolittle in WWII. He lives near me and I had the great opportunity to hear him recall his mission and ask him questions about his experiences. His story is phenomenal.

Barely 18 years old, and jumping into the cockpit of his Mitchell-B25 bomber, he took off from the decks of an aircraft carrier far too short for a normal B25’s takeoff roll. They used celestial navigation and a lot of guts to guide them to the mainland of Japan with only enough fuel to complete the mission and then head toward China to either crash or bail-out in the dark of night. All 16 planes and crews successfully completed their missions. One man was killed on bail-out. Two men drowned as a result of crash landing in the water off China’s coast. Eight men were captured. Three were executed by firing squad. One died from beri-beri and malnutrition while in prison. Four survived 40 months of prison, most of which was in solitary confinement.

Despite two enemy fighters that trailed them inland, and a series of barrage balloons over their target, Lieutenant Bower and his crew of Plane #12 completed their mission. Bailing-out over China was Bower’s first and only parachute jump. After a day or two on his own he made his way to a Chinese village and there he was reunited with most of his crew. With the help of local villagers, the entire crew traveled to join up with Lieutenant Joyce's crew from the 10th aircraft. Both crews reached Chuhsien four days later.

He and pilots like him are true heroes to me.

What is your ultimate goal in aviation?

Well, I’m too old to make aviation a career so I guess achieving my instrument and commercial ratings, possibly multi-engine as well, will be my goal(s).

What aircraft would you still love to fly?

I would love to go up in a jet and take the controls to feel what it must be like, but for everyday flying, a big rotary engine Beaver or even a 200HP Aviat Husky would be awesome. Someday I would like to experience bush flying, setting down on a gravel bar or a shimmering lake deep in the woods somewhere. Since my home state of Colorado, USA doesn’t allow any water landings of any type, anywhere � it may be a dream that never comes true.

Is flying really safe, and why?

I’m one who believes there is inherent danger in flying simply because of height above the ground. But with a commitment to flying safely, following the Regulations and continuing to learn about flying until you “hang it up” it becomes as safe as it can be.

What direction do you think aviation will take in the future?

I’m afraid that more “pay as you play” types of situations will face pilots in the coming years. Here in the United States, we’ve enjoyed free services that others have paid for, for years. Those days could be numbered. I also worry about the possible elimination of 100LL. The purely recreational pilot will likely be subject to an evolving general aviation that could put a death grip on many pilots’ flying.

What is the most important single item of advice/suggestion that you would wish to pass on to your fellow aviators?

With only 360 hours to my credit, I could only advise low time pilots. To them I would say, do your best to eliminate pilot error. Always carry out the most complete preparation for even the most basic, simple flights. Be careful that as your experience level grows, it doesn’t breed complacency. Make flying education a lifetime commitment.

Do you read Aviation & Safety Magazine?

Here in the States, I read your electronic email newsletter.