It was about 1 o’clock in the morning. The air on the surface was warm and humid. If he checked the weather—there was no evidence that he did—he would have expected to find widespread but patchy cloudiness over the route of flight and at the destination. In some places clouds were broken or scattered with tops at 3,000. Elsewhere buildups climbed into the flight levels. Ceilings and visibilities under the clouds were good, at worst 700 feet and 5 miles. The temperature and the dew point were only 3 degrees apart, however, and there was a slightly increased risk of fog formation owing to, of all things, particulate pollution from dust blown in from the Sahara.

During the short flight, he climbed to 3,600 feet, probably to get above some cloud tops. It was pitch-dark as the crescent moon was far below the horizon. As he neared his destination he descended to 1,500 msl, 1,300 feet above the terrain, and reduced his groundspeed from 175 knots to 100 knots.

The airstrip at which he intended to land was 3,500 feet long, 40 feet wide, and had a light gray concrete surface oriented 4/22. Other than a hangar on an apron at midfield, there were no structures on the airport and no edge lights along the runway.

The only lights were red ones marking the runway ends. The surrounding area was largely dark. Sam Rayburn Reservoir sat close by to the north and east, a vast region of uninterrupted black. Parallel to the runway, about half a mile north, was State Highway 147, lighted only by the headlamps of infrequently passing cars.

• READ MORE: Two Fatal Cases of the Simply Inexperienced

For almost an hour, the pilot flew back and forth over the airstrip, tracing a tangled path of seemingly random right and left turns. His altitude varied between 350 and 1,100 feet agl and his groundspeed between 65 and 143 knots. His ground track, as recorded by ATC radar, suggested no systematic plan, but it was broadly centered on the northeast end of the runway.

The last return from the Saratoga, recorded 54 minutes after it arrived over the field, put it 9,700 feet from the northeast end of the runway on a close-in extended left downwind leg for Runway 22 at a height of 350 feet agl and a groundspeed of 94 knots. The Saratoga was below radar for the remainder of the flight.

Its burned wreckage was found at the southern edge of the clear-cut area surrounding the runway, several hundred feet short of the threshold. A trail of parts led back across the clear-cut to its north side, where the airplane had clipped a treetop at the edge of the woods. From the orientation of the wreckage path, it appeared that the Saratoga may have overshot the centerline on base and was correcting back toward the approach end lights when it struck the tree.

In the course of the accident investigation, it emerged that the airplane was out of annual, its last inspection having occurred in 2017, the registration had expired, and the pilot’s medical was out of date. The pilot had 400 hours (estimated) but did not have an instrument rating and, in fact, had only a student certificate. The autopsy turned up residues of amphetamine, methamphetamine, and THC (the psychoactive component of cannabis), but investigators did not rule out the possibility that the drugs could have had a therapeutic purpose.

• READ MORE: Three-Mile Limit: Novice Pilots Succumb to the Perils of Total Darkness

The National Transportation Safety Board’s report on the accident declines to speculate on whether the drugs impaired the pilot in any way. In fact, the NTSB report concedes that “the pilot’s aircraft handling was not deficient relative to his limited experience of flying in night instrument conditions and the prolonged period of approach attempts.” The finding of probable cause cited only the pilot’s “poor decision-making as he attempted to land at an unlit airstrip in night instrument conditions.”

The pilot bought the Saratoga in 2016 and then took flying lessons, but he stopped short of getting the private certificate. His instructor said he had never given him any instrument training. The pilot’s wife said that he “normally” flew to the airport at night and circled down until he could see the runway.

The airport was in Class G airspace. What the cloud conditions were we don’t know—the nearest automated reporting station was 24 nm away—and so we don’t know whether the Saratoga was ever in clouds and, if so, for how long. Maneuvering around at low level for nearly an hour in darkness and intermittent IMC would be taxing even for many instrument-rated pilots, and so it seems likely that if the pilot was in clouds at all, it was only for brief periods.

• READ MORE: Fatal Cirrus Accident Shows That Some Knowledge Doesn’t Translate

Two things strike me about this accident. First, how close it came to not happening: If the pilot hadn’t clipped the tree, he might have made the turn to the runway successfully and landed without incident, as he apparently had done in the past. Second, that he had ever managed the trick at all. I can only suppose that the contrast between the runway clear-cut and the surrounding forest was discernible when there was moonlight and that he was able to use GPS and the runway’s end lights to get himself to a position where his landing light would illuminate the runway.

Rugged individualism being, supposedly, an American virtue, I leave it to you to applaud or deplore the nonconformist aspects of this pilot’s actions. Perhaps a certain amount of freelancing is inevitable in an activity like flying. But I deprecate his persistence. One of the essential arrows in every pilot’s quiver should be knowing when to quit. He set himself a nearly impossible goal, and after flying half an hour to his destination, he spent an hour trying to figure out how to get onto the ground.

If it was that difficult, it wasn’t worth doing. There were other airports—with runway lights—nearby.

At the time of the crash, the pilot was awaiting the decision of a Houston court in a wrongful  termination lawsuit that he had filed against a former employer. Five months later, the court found in his favor to the tune of $143 million. Thanks to a terminal case of “get-homeitis,” however, he wasn’t there to enjoy it.

Note: This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This column first appeared in the May 2024/Issue 948 of FLYING’s print edition.

The post A Cautionary Tale About Pilot Freelancing appeared first on FLYING Magazine.

Both pilots were in their early 30s and were Polish nationals. Both held FAA private pilot certificates based on their Polish certificates. They were relative novices, with 210 hours total time between them, only 130 as pilot in command (PIC). Neither was instrument rated, and only one was legally qualified for night VFR flying. (Their FAA certificates required them to comply with the limitations imposed by their Polish ones.)

After having dinner in town, they returned to Key West International Airport (KEYW) around 8 o’clock. It was dark, the sun having set an hour and a half earlier. The moon, new two days before, was now a smiling sliver on the western horizon. By the time they boarded the airplane, it too had set.

Presumably because he was the one who had done the rental checkout, the less experienced pilot of the two, with 30 hours of PIC time, took the left seat, and his companion took the right. It was the pilot in the right seat, however, who held the night qualification.

• READ MORE: Fatal Cirrus Accident Shows That Some Knowledge Doesn’t Translate

They began their takeoff roll at 8:33 p.m. When they were airborne, the tower instructed them to make a left turn northbound, remain clear of Navy Class D airspace, and contact Navy tower for transition. “Navy” meant Naval Air Station Boca Chica (KNQX), whose airspace abuts that of KEYW.

The tower frequency for KNQX is 118.75, but the pilot read back only 118.7, followed by a pause and then the last three digits of the Cessna’s call sign, “five eight niner.” The “five” was ambiguous, but it is possible that the pilot handling the radios missed the final “five” in the Navy tower frequency. In any case, that acknowledgement was the last communication heard from the Cessna.

In the early afternoon of the following day, some pleasure boaters noticed an object floating in the water. They thought it might be a manatee and approached it cautiously, only to find that it was a human body. The water was shallow, just 7 feet deep, and perfectly clear. Parts of an airplane could be seen resting on the bottom. The site was less than 3 miles from the Key West runway. 

Accident investigators found that an airport surveillance camera had recorded the airplane’s lights as it departed. Its flight path was erratic, descending, leveling off, descending again, leveling off, and then disappearing from view.

A witness, who had been fishing from a nearby bridge and read about the accident in the newspaper the following day, reported having seen what he thought at the time was a firework but now realized might have been a red light on the airplane descending rapidly toward the water.

• READ MORE: Only Assumptions Can Be Made About What Took Down a Curtiss C-46 in Alaska

The National Transportation Safety Board (NTSB) attributed the accident to “the non-night-qualified pilot’s improper decision to depart in dark night meteorological conditions, which resulted in his subsequent spatial disorientation…”

A direct line from Key West to Miami bears about 055 degrees, and about half the trip is over open water. On a dark night, the danger of disorientation is great. The brightly lighted line of the Keys recedes on the right, while the dark Everglades lie ahead. Miami is a pale glow beyond the northeastern horizon. The two pilots having just returned from the Bahamas, flying over open ocean in a single-engine airplane evidently held no terrors. (They had, nevertheless, taken the precaution of wearing life jackets.)

Most likely, however, they had no idea that the main danger of a night flight over open water was not that they might have to ditch after an engine failure, it was that they would lose the horizon and fly into the water before they even realized that something was wrong.

The fact that one of them was legally qualified for night flying meant only that he had logged a certain number of hours and takeoffs and landings at night with an instructor, not that he had any experience flying at night in this particular kind of environment. In any case, the pilot with the night qualification was sitting in the right seat, and to the extent that he might have made better use of the attitude indicator, he was not in a position to do so.

This is not an unusual kind of accident. I have written in this column about many similar ones, including two Barons and a Citation that flew under control into Lake Erie immediately after taking off from Cleveland Burke Lakefront Airport (KBKL); a Lancair 550 and a Cessna 210 that crashed immediately after taking off on moonless nights in desert terrain; and a Piper Cherokee, on another island of the Florida Keys, that went into the water a couple of miles from the runway from which it had just taken off.

Note the recurrence of the phrase “taking off.” The airplanes that took off over a pitch-dark lake or desert invariably climbed only a few hundred feet before they began to bank, then the bank grew progressively steeper, and the climb became a dive. The pilots were unaware that anything was wrong. Once the lights disappear, the rest lasts a matter of seconds, or at most 2 or 3 miles.

The two Polish pilots did fine at first, while they were over the lights of Key West. It was only when they left the lights behind that the insidious effects of darkness beset them. Neither pilot had instrument flying experience beyond the hood work required for the private certificate, which bears more resemblance to an arcade game than the real sensations, physical and emotional, of piloting an airplane in total darkness.

In pilots’ careers certain dangers are bound to arise for which it is very difficult for an instructor to prepare them. Many of those dangers are associated with loss of a visible horizon, whether because of fog, clouds, or darkness.

Warnings to believe the instruments, not bodily sensations, may be memorized, emphasized, and faithfully repeated, but they are never so persuasive as the sensations themselves. One must work hard to develop the discipline to level the tilting wings of the attitude indicator despite an overwhelming impression that the instrument has failed and the airplane is still in level flight.

Unfortunately, not every airport has an ocean or large lake handy with which to impress upon the student pilot the perils of total darkness—and Warsaw is far from the Baltic Sea.

Note: This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This column first appeared in the March 2024/Issue 946 of FLYING’s print edition.

The post Three-Mile Limit: Novice Pilots Succumb to the Perils of Total Darkness appeared first on FLYING Magazine.

As you will have guessed, since you are reading about this in Aftermath and not in I Learned About Flying From That, the flight did not end well. About 25 minutes after takeoff and shortly after crossing the Arkansas border, the 31-year-old pilot, whose in-command time amounted to 75 hours, lost control of the airplane and went down in a remote woodland. All aboard perished.

A few minutes before the impact, as he was climbing to 9,500 feet msl, the pilot contacted ATC and requested flight following. The weather along his route—which, notably, he had last checked with ForeFlight 17 hours earlier—was generally VFR, with a chance of scattered convective activity. There was, however, one patch of rainy weather just to the left of his course, and the controller advised him to turn right to avoid it.

On the controller’s display, the target of the Cirrus crept eastward just below the edge of the weather. Radar paints rain, however, not cloud. The flight was over a remote area with few ground lights and the harvest moon had not yet risen, but its hidden glow may have faintly defined an eastern horizon. In the inspissated blackness of the night, the pilot, whose instrument experience was limited to what little was required for the private certificate, probably could not tell clear air from cloud.

As the Cirrus reached 9,500 feet, it began to turn to the left toward the area of weather. Perhaps the tasks of trimming and setting the mixture for cruise distracted the pilot from his heading. The controller noticed the change and pointed it out to the pilot, who replied he intended to return to Muskogee. He now began a turn to the right. Rather than reverse course, however, he continued the turn until he was heading northward back into the weather. The controller, who by now sensed trouble, said to the pilot that he showed him on a heading of 340 degrees and asked whether he concurred. The pilot, whose voice until this point had betrayed no sense of unease, replied somewhat incoherently that “the wind caught me, [but now] I’m out of it.”

With a tone of increasing urgency, the controller instructed the pilot to turn left to a heading of 270. The pilot acknowledged the instruction, but he did not comply. Instead, he continued turning to the right. At the same time, he was descending at an increasing rate and was now at 6,000 feet. “I show you losing serious altitude,” the controller said. “Level your wings if able and fly directly southbound…Add power if you can.”

It was already too late. In a turning dive, its speed increasing past 220 knots, the Cirrus continued downward. Moments later, its radar target disappeared.

In its discussion of the accident, the National Transportation Safety Board (NTSB) focused upon the pilot’s preparedness—in the broadest sense—for the flight. A former Marine, he should have been semper paratus—always ready—but his history suggested a headstrong personality with a certain tendency to ignore loose ends as he plunged ahead.

He had failed his first private pilot test on questions related to airplane systems; he passed on a retest the following week. But this little glitch tells us nothing about his airmanship. His instructor reported he responded calmly and reasonably to turbulence, and was “good” at simulated instrument flight. He had enrolled in Cirrus Embark transition training shortly before acquiring the airplane. He completed all of the flight training lessons, but—again, a hint of impatience with tiresome minutiae—may not have completed the online self-study lessons. The flight training was strictly VFR and did not include night or instrument components.

The airplane was extremely well equipped for instrument flying, but it was a 2001 model, and its avionics were, according to the Cirrus Embark instructors, “old technology” and “not easy to use.” In other words, it did not have a glass panel, and its classical instruments, which included a flight director, were sophisticated and possibly confusing to a novice. The airplane was equipped with an autopilot, and the pilot had been trained in at least the elements of its use.

The airplane was also equipped with an airframe parachute, but it was not deployed during the loss of control. In any case, its use is limited to indicated speeds below 133 kias, and it might not have functioned properly in a spiral dive.

• READ MORE: Dissecting a Tragedy in the Third Dimension

An instructor familiar with the pilot and his airplane—whether this was the same instructor as the one whom he called on the night of the fatal flight is not clear—wrote to the NTSB that the pilot had made the night flight to South Carolina at least once before, and he had called her at midnight before departing to come help him fix a flat tire. She declined and urged him to get some sleep and make the trip in the morning.

“I told him he was starting down the ‘accident chain,’” she wrote. “New pilot, new plane, late start, nighttime, bad terrain, etc….To me, he seemed a little overly self-confident in his piloting skills, but he didn’t know enough to know what he didn’t know.”

He fixed the tire himself and made the trip safely that night. Undoubtedly, that success encouraged him to go again.

We have seen over and over how capable pilots, including ones with much more experience than this pilot, fail to perform at their usual level when they encounter weather emergencies. A sudden, unexpected plunge into IMC—which, on a dark night, can happen very easily—opens the door to a Pandora’s box of fear, confusion, and disorientation for which training cannot prepare you.

There are two clear avenues of escape. One is the autopilot. Switch it on, take your hands off the controls, breathe, and count to 20. The fact the pilot did not take this step suggests how paralyzed his mental faculties may have become.

The other is the attitude indicator. It’s a simple mechanical game. Put the toy airplane on the horizon line and align the wings with it. That’s all. It’s so simple. Yet in a crisis, apparently, it’s terribly hard to do. The fact that so many pilots have lost control of their airplanes in IMC should be a warning to every noninstrument-rated pilot to treat clouds—and, above all, clouds in darkness—with extreme respect.

This column first appeared in the November 2023/Issue 943 of FLYING’s print edition.

The post A Night Flight Leads a Pilot to a Tragic End appeared first on FLYING Magazine.

It was dark when he approached Steamboat Springs. Cleared for the RNAV (GPS)-E approach for Runway 32 at Bob Adams Field (KSBS), he began his descent 20 minutes out, turned eastward at the initial approach fix, HABRO, and then northward at MABKY intersection.

The design of the approach brings you up a valley between high terrain to the east—where a number of peaks rise above 10,000 feet—and 8,250-foot Quarry, aka Emerald Mountain, to the west. The final approach fix (FAF), PEXSA, is aligned with the runway; the 5.4 nm leg from MABKY to PEXSA, however, is oriented at 353 degrees and requires a left turn of 30 degrees onto the 4.6 nm final approach course.

The field elevation at KSBS is 6,882 feet. Category A minimums are nominally 1,300 and 1¼ with a minimum descent altitude of 8,140 feet. The missed approach, begun at the runway threshold, calls for a climbing left turn back to HABRO at 11,300 feet.

The descent profile specifies crossing altitudes of 9,700 feet at the FAF and 8,740 feet at an intermediate fix, WAKOR, 2.4 nm from the FAF. From WAKOR to the threshold is 2.2 nm. Once passing WAKOR, the pilot could step down to the minimum altitude and start looking for the runway.

The Meridian tracked the ground path of the approach with electronic precision. The profile was not so perfect. The airplane crossed the FAF at 9,100 feet, 600 feet below the required altitude. At WAKOR it was 540 feet low and for all practical purposes already at the minimum allowable altitude for the approach.

At WAKOR, rather than continue straight ahead toward the runway, the Meridian began a left turn, similar to the turn required for the missed approach but 2 miles short of the prescribed missed approach point. The ground track of the turn, executed at standard rate, had the same machine-like precision as previous phases of the approach—but not the profile. Rather than immediately climb to 11,300 feet, as the missed approach required, the Meridian continued to descend, reaching 7,850 feet, less than 1,000 feet above the field elevation. It then resumed climbing but not very rapidly. One minute after beginning the left turn at 8,200 feet and on a heading of 164 degrees, it collided with Quarry Mountain. At the time of impact, the landing gear was in the process of being retracted.

When the Meridian arrived in the vicinity of Steamboat, the weather had deteriorated to 1,200 feet overcast and 1 mile visibility—below minimums for the approach. The National Transportation Safety Board limited its finding of probable cause to the statement that the pilot had failed to adhere to the published approach procedure and speculated that he had become aware of the below-minimums conditions only during the approach. Indeed, he would have become aware of the low ceiling by the time he reached WAKOR because he was already practically at the minimum descent altitude there.

He was apparently unprepared for this unexpected development.

The Meridian was equipped with a lot of fancy avionics that recorded every detail of the approach, and the accident docket includes extensive graphic depictions of those records. (These are not included in the published report.) What is striking about them is the contrast between the undeviating steadiness of headings and the large random fluctuations in airspeed, vertical speed, and altitude, which are evidently being controlled by the pilot. During the last two and a half minutes of the flight, the Meridian’s airspeed fluctuated between 89 and 110 knots and its pitch attitude between minus-5 and plus-10 degrees. Approaching WAKOR, its vertical speed was zero. Crossing WAKOR and beginning the left turn, the vertical speed first dipped to 1,500 fpm down, then, 10 seconds later, corrected to 1,300 fpm up. Ten seconds after that, it slumped again to zero before shooting back up to 1,500 fpm, holding that rate momentarily and then dropping again. The impact occurred a few seconds later.

The pilot’s logbook, which recorded 580 hours total time with 43 hours of simulated instruments and 45 hours of actual, contained four instances of this same GPS approach in the month preceding the accident. In some of those log entries, no actual instrument time was recorded, and at least two of them ended with a low approach but no landing. In some, if not all, of those approaches, the pilot was evidently practicing in VMC. Plots of two of those approaches, one a month earlier and the other a week earlier, display the same precision in ground track as the one that led to the accident, so it appears that he was relying on his autopilot for horizontal navigation.

• READ MORE: When VFR Turns into IFR

Being based at KSBS and having repeatedly flown the approach in good weather, the pilot would have been aware that the terrain below him never rose above 7,000 feet. He might therefore have believed, consciously or unconsciously, that as long as he didn’t get much below 8,000 feet, he wasn’t going to collide with anything. That idea could have factored into his starting the missed approach 2 miles short of the runway. Or perhaps he simply forgot about Quarry Mountain. Or, possibly, he made the decision to miss at WAKOR and began the turn without even reflecting that an important element of any missed approach is the location at which it starts.

His unsteady control of airspeed and pitch attitude, and his failure to retract the landing gear until a full minute after beginning the miss, suggest a pilot unaccustomed to balked approaches and now struggling with a novel situation. Anticipating VFR conditions, he had not filed an alternate and would now have to make a new plan and execute it in the air.

The difference between simulated instrument flying and the real thing—compounded, in this case, by darkness—is difficult for novice instrument pilots to imagine. It is not just a matter of the complexity of the required actions. It is the effect that anxiety, uncertainty, or surprise may have on your own capabilities. What looks like a dry script on a piece of paper can become a gripping drama—comedy or tragedy—when the human protagonist steps onto the stage.

This column first appeared in the September 2023/Issue 941 of FLYING’s print edition.

The post Dissecting a Tragedy in the Third Dimension appeared first on FLYING Magazine.

“You’ve been watching, and you still want to go?” the briefer asked.

“Baby needs a wash,” joked the pilot, 66, a recently retired judge who was known for his “well-honed” sense of humor.

“Oh, he’s going to get a wash job,” the briefer said. “We do have a lot of rain and convective activity. It’s becoming pretty solid. I can’t see you doing much dodging trying to get around.”

“It looks like it subsides as it goes east,” the pilot suggested, and then added, “Question mark.”

“Well, yeah, question mark,” said the briefer. “If you take a line drawn directly north, it’s heavy precipitation until you get over to about Bowling Green (Kentucky), and that’s when the thunderstorms start again. But all this is moving northeast about 34 knots, so you head east as it is heading east, and then you get blocked off, and it’s building behind so…you have to go today?”

“Well, maybe not.”

“We will have some rain tomorrow, but at least it will break up enough and begin to move to where, you know, that Arkansas and Missouri area won’t be getting so smashed.”

“I might just go up and take a look at it and see what it looks like out of the windshield,” the pilot mused. “I don’t have anything better to do today.”

“Well,” said the briefer, “think of a good reason to go.”

He issued the required “VFR not recommended” warning—under the circumstances it was hardly necessary—and the pilot filed an IFR flight plan, estimating 2 hours and 15 minutes for the 520 nm trip.

His airplane was a Lancair Legacy, a small, very fast two-seat retractable homebuilt with a 310 hp engine. After climbing VFR to 6,000 feet, the pilot contacted Memphis Approach at 9:50 a.m. The controller asked whether he wanted to continue on his present heading of 356 degrees or deviate eastbound to try to go around the weather. The pilot said he would like to avoid the weather, and the controller gave him a vector of 060. The pilot, however, asked to continue on his present heading for a couple of minutes, and the controller agreed.

A minute later, the pilot came back. “The route ahead, as far as I can see, looks VMC. I can’t be sure on that, but I’d appreciate your input.”

“All right,” the controller replied, “stay on course and let me know if that weather starts to become a problem for you.”

Four minutes later, the controller said, “You are just going to run into about a 10-mile-wide band of showers that’s crossing in front of you. The quickest way through the weather, if you want a direct 90-degree cut, is about a 330 heading. There’s a lot of rain for about 10 miles, and then it should clear up on the other side.”

“All right, thanks,” replied the pilot. “We’ll go to 330, and we’ll slow down a little bit.” Two minutes passed.

“Looks like you are getting an updraft there,” the controller said. “I don’t have any targets around your altitude. Do what you can to hold it, but just take care of yourself through that weather. You’ve got another 10 miles before you’re going to clear it up a little bit.”

“Thank you, sir,” the pilot said.

Twenty seconds later, the controller asked the pilot whether he was OK. There was no reply. The controller’s transmissions became increasingly urgent.

“You’re going through a heavy area of weather, sir. If you can hear me, you, climb, altitude whatever, deviate, reverse course is also approved, sir…Radar contact is lost 30 miles northeast of Memphis, sir…You’ve got another 15 or 20 miles in that weather. If you can hear, sir, suggest a heading northwest bound to get through the weather. You’re in a level 4 and level 5 cell in that area, sir.”

The controller was not long in guessing what had happened. “I think he might have crashed,” he told a colleague.

Three hours later, searchers in a helicopter spotted fragments in a rain-soaked field. The recovery team found the engine and propeller buried almost 9 feet below the surface.

About an hour before the flight took off—but after the pilot’s conversation with the weather briefer—the National Weather Service had issued a SIGMET for the area through which the flight would pass. It warned of severe thunderstorms with tops to 38,000 feet, possible 50-knot gusts and 1-inch hail. The pilot most likely never saw the SIGMET. A retrospective analysis of Doppler weather radar recordings confirmed that at the time of the crash the pilot was just crossing the leading edge of a level 5 storm.

The National Transportation Safety Board limited its finding of “probable cause” to the trivial insight that the pilot had lost control of the airplane. A factor in the accident, it added, was “insufficient information” provided by the controller, who did not convey the storm’s intensity level to the pilot until he was already in it. Exactly how and why the loss of control occurred was not discussed. The wreckage was too badly fragmented for forensic analysis, and significant portions of it were not recovered at all. It did not appear that the airplane had broken up in flight, however. The wreckage was confined to a small area among plowed fields where more widely scattered debris would have been easy to find.

• READ MORE: The Road Not Taken

This accident occurred in 2004. In the intervening years, the NTSB has moved away from mechanistic analyses such as “loss of control” and toward more judgment-oriented ones signaled by the phrase, “the pilot’s decision to…” Today, I think, the finding of probable cause would put more emphasis on decision-making on the parts of both the pilot and controller, although the board’s investigations seldom satisfactorily dissect the nuances of decisions made by two people unconsciously influencing one another. The pilot’s assertion that it looked like VMC ahead probably affected the controller’s interpretation of his own weather display. The controller’s mention of 10 miles of “showers”—two and a half minutes in the Legacy—probably alleviated the pilot’s concern about the storm.

At the risk of venturing into groundless speculation, I am inclined to note that, as a judge, the pilot was accustomed to being the final arbiter of complex questions. As the builder-pilot of a beautiful—the word he used when filling in the “color” field in his flight plan—high performance airplane, he also probably experienced a little of the feeling of untouchable power that comes with fast airplanes and fast cars. The weather briefer hinted, warned, cajoled—but his objections were overruled.

This review first appeared in the July 2023/Issue 939 print edition of FLYING.

The post Objection Overruled appeared first on FLYING Magazine.

In June 2000, near the Yukon River in the state’s southwestern corner, a Cessna 337 crashed shortly after takeoff, killing one such pilot.

The airstrip near the remote town of Marshall then consisted of 1,940 feet of hard gravel surface, 30 feet wide, 90 feet above sea level. The wind was calm, the sky clear, the landscape illuminated by the late-evening twilight of the Alaskan midsummer.

There was one witness, not of the crash itself, but of the events that preceded it. The starter motor on the rear engine had failed. The pilot’s companion offered to fly him somewhere to get a replacement, but the pilot, who had logged 600 hours in the 337 and said that he had done single-engine takeoffs in it before, was determined to take off using just the front engine. The pilot and his companion paced out a distance on the runway, and the pilot said that if he was not airborne by that point, he would abort the takeoff.

His companion then watched from beside the runway as the Cessna accelerated. Its nosewheel was lifting off as it passed the abort point. The airplane climbed to about 50 feet, the wings rocked slightly, and it then disappeared behind a low hill. Satisfied that the pilot was safely on his way, the other man left the airport. An hour later, he learned that the pilot had not arrived.

The airplane and the pilot’s body were later recovered from a small lake not far from the runway. The landing gear was retracted, the flaps set at the 1/3 position.

The 337 was equipped with a Robertson STOL kit. The handbook for the conversion recommends a special maximum-performance takeoff procedure. It is to set 2/3 flaps, lift the nose at 44 kias, climb at 56 kias to clear obstacles, then accelerate to 87 kias before reducing the flaps to 1/3 and retracting the gear. Blue-line—that is, single engine best rate of climb—speed is 87 kias at gross weight, and is the same for the Robertson conversion and the stock 337.

The airplane was relatively light. The National Transportation Safety Board calculated that it weighed 3,462 pounds, but that included an implausible allowance of 108 pounds for oil, evidently the result of confusing quarts with gallons. The likely actual takeoff weight would have been below 3,400 pounds.

The Cessna manual gives single-engine rates of climb, at a weight of 4,000 pounds, of 425 fpm with the front engine out and 340 fpm with the rear engine out. (When the rear propeller is not operating, there is excess drag due to separated flow on the relatively blunt rear cowling. The Robertson kit includes some aerodynamic mods to reduce that drag.) Cessna’s rate of climb figures apply at the blue line speed and assume a feathered prop on the dead engine. The propeller of the accident airplane was not feathered, however, because in order for a propeller to feather, it must be windmilling, and it’s pretty certain that the airplane never got to windmilling speed.

The single-engine rate of climb diminishes rapidly at lower than blue-line airspeeds. If the airplane climbs 340 fpm at 87 kias, it will climb only 200 fpm at 60. That is why one is well advised to accelerate promptly to the blue-line speed when taking off in any multiengine airplane.

Neither Robertson nor Cessna published any data or recommendations concerning single-engine takeoffs; in fact, the FAA eventually forbade them. POH guidance for engine-out emergencies assumes that the engine failure occurs after the airplane becomes airborne. The Cessna manual, however, does provide this admonitory note:

“The landing gear should not be retracted until all immediate obstacles are cleared, regardless of which engine is out… Airplane drag with the landing gear doors opened and the gear partially extended is greater than the drag with the gear fully extended.”

The manual cites a 240-fpm reduction in blue-line climb rate with the gear in transit and a dead rear engine. It does not specify what the penalty for a stopped, unfeathered propeller would be. But it is very probable that with the gear in transit, a stationary unfeathered prop, and a low airspeed, the vertical speed would be reduced to zero or less.

We don’t know at what indicated speed the pilot rotated, only that he lifted the nosewheel at the agreed abort point. Presumably he then became airborne. By establishing an abort point on the runway, however, the pilot had, in effect, set up the conditions for a short-field takeoff. Such a takeoff implied a low rotation speed and possibly quite a lot of flaps.

With only half the expected power available, however, the short-field strategy was not ideal. A higher rotation speed and a cleaner configuration would have been preferable. An airplane airborne out of ground effect at low speed accelerates with difficulty. Obviously, the problem is far worse when half the installed power is missing. The way to avoid that situation is to delay rotation until you have plenty of speed and to use little or no flaps, because flaps add drag. At sea level, a 3,400-pound airplane with a 210-hp engine and a constant-speed prop can comfortably get airborne without flaps in 1,900 feet; there was no need to use the special capabilities conferred by the Robertson conversion. In fact, it would have been better to delay rotating until almost the end of the runway.

The NTSB concluded that the accident had been the result of an inadvertent stall, citing as well the “improper retraction of the landing gear” and the pilot’s “overconfidence in the airplane’s ability.” It seems likely that a stall occurred, since, if the airplane had merely failed to climb, the pilot might have ditched it under control in the lake and very possibly survived. (The pilot seemingly did survive the impact, although with serious injuries; the official cause of death was drowning.)

In my opinion, the pilot’s confidence in the airplane was not misplaced. Very probably, it could have made the takeoff successfully if only the pilot had used the full length of the runway and then delayed retracting the landing gear until he reached the blue-line speed. The terrain ahead was low and flat; any rate of climb at all would have been sufficient. By setting an abort point, as if the main concern were the possibility that the front engine would fail, the pilot had inadvertently stacked the deck against himself.

This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This column first appeared in the June 2023/Issue 938 edition of FLYING magazine.

The post A Skymaster Taking Off on One Engine? appeared first on FLYING Magazine.

We generally don’t hear about the successful engine-out emergencies unless in private conversations; most of them don’t come to the attention of the authorities. Maybe there are more than we think. We hear about enough unsuccessful ones, however, to suggest that the challenge can be overwhelming.

Expectation plays a role. Twin pilots expect to save both the airplane and themselves. Their object, consequently, is to execute the go-around correctly, not to find a smooth place to crash. If they make a mistake,their situation is worse than that of the single-engine pilot. The single-engine pilot begins the emergency landing in control; the main requirement is to avoid stalling. The twin pilot does not even entertain the idea of an off-airport landing until things have gotten out of control. By then, it may be too late.

The crash of a Piper Twin Comanche in 2004 illustrates how quickly things can go wrong even when the pilot appears to be in a relatively good position as the engine failure occurs.

The airplane, manufactured in 1966, had a number of STC modifications, including tip tanks, 200-hp IO-360 engines in place of the stock 160-hp IO-320s ,and a STOL kit that increased its gross weight from 3,600 pounds to 3,800 and lowered its single-engine minimum control speed from 78 to 70 knots. Although only two people were aboard, baggage and fuel brought the airplane to just a few pounds under gross. The National Transportation Safety Board, obliged to call attention to every discrepancy, noted that the tip tank STC required that any weight above 3,650 pounds be carried symmetrically in the tip tanks, but, in fact, the tip tanks were empty. Only if the crash had been due to a failure of the wing structure, however, would that fact have mattered. It had no bearing on the loss of control.

The weather was clear, the wind from 300 degrees at 16, gusting to 22. The pilot, who had a total time of around 600 hours and 150 hours in the Twin Comanche, took off from Runway 26. Witnesses reported that the airplane became airborne, climbed to 200 or 300 feet, and briefly banked left. One witness reported a sputtering sound, similar to that of a power reduction to idle, just before the first left bank. The airplane then leveled out and appeared to be flying stabilized before it again banked left and descended until it hit the ground, still within the confines of the airport, having turned more than 180 degrees. Data retrieved from a recording engine monitor showed an abrupt EGT drop on all four cylinders of the left engine. The magnitude of the drop, vastly in excess of that observed in an engine tested at the Lycoming factory by suddenly shutting off both fuel and ignition, baffled the NTSB’s technical analysts. (Whether the EGT thermocouples on the accident airplane were of the same type as those used in the Lycoming test is not revealed.) The NTSB dwelt at length on the possibility of water or some other contamination in the fuel, but finally conceded that the reason for the loss of power could not be determined. In any case, the fact that the engine quit—dead—was never in doubt.

From the witness reports, it seems likely that the airplane was still on the runway heading when the engine failed. When it began its final left turn, its ground speed was 77 knots. Assuming that the headwind component of the quartering 16-to-22-knot wind was at least 10 knots, the airplane would have been indicating 87 knots or more and had a margin of at least 17 knots over VMC, the single-engine minimum control speed. In theory, it should have been in good shape.

The good engine, on the right, was the “critical engine,” that is, the one with the more powerful destabilizing tendency. But that did not matter because the pilot failed to accomplish an essential step. He did not feather the left propeller. 

The flight manual procedure for power loss involves several steps—the same steps as apply, with variations in detail, in all engine-out situations in reciprocating-engine airplanes. The first was to fully open the throttle of the operating engine to maintain altitude and an airspeed of at least 84 kias, that being presumably the single-engine best rate of climb speed. The next steps were to close the throttle of the inoperative engine, pull the mixture to idle cutoff, and pull the prop control into the feather position. (Closing the throttle increases the drag of the windmilling propeller slightly, but if the prop is promptly feathered, it’s not for long.) When the airplane turned 180 degrees, its ground speed was 92 knots; it was 84 at the last recorded data point before impact. Subtracting rather than adding the wind component now, it appears the aircraft did not accelerate. The windmilling propeller was the probable culprit, although it’s possible, if the pilot failed to feather the prop, that he also failed to command full power from the good engine. The fact that he turned from upwind to downwind was not hazardous in itself, but close to the ground, it can produce a distracting sense of flying sideways at excessive speed.

Why does the pilot of a twin-engine airplane, when he has one good engine and the necessary airspeed, fail to cope successfully with the emergency? Lack of time is one reason. At 200 or 300 feet, the whole sequence—identify the failed engine, correct yaw, control airspeed, feather, and bank into the good engine—must be executed swiftly and flawlessly. Another could be mental or physical paralysis produced by the airplane’s failure to respond to the controls. He wanted it to turn right, but it kept turning left. People freeze. Thought stops. Panic takes the reins.

When a twin with an engine out slows and cannot be controlled, there is still one life-saving strategy left to the pilot: to power down the good engine and land straight ahead. It is the potential for loss of control that Collins thought made a single safer than a twin. But rational thoughts are fleeting in an emergency, and it might be hard to remember that minimum control speed applies only when the good engine is developing power. Power is good, altitude and speed are good, but nothing is as good as control.

This article is based on the National TransportationSafety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This article was originally published in the May 2023, Issue 937 of  FLYING.

The post Twin-Engine Troubles appeared first on FLYING Magazine.

On December 6, he called his flight instructor, with whom he had hitherto flown only in Cessna 172s, to ask whether his training could continue in the Cherokee. The instructor agreed, contingent on his looking over the airplane and its maintenance logs.

On the evening of the 8th, after dark, the young man arrived at the airport with a female companion. The pilot mentioned going to Pearland (KLVJ), a short distance to the southeast. The pair climbed aboard the 140 and took off, heading southward.

On the following day, the pilot’s fiancée came to the airport. She had been trying without success to reach him by phone. His car, she found, was still in the airport parking lot. The airport manager reviewed surveillance camera video and found the pilot and his companion—that must have been an uncomfortable moment—arriving and taking off a little before 8:00 p.m. He brought up the online ADS-B tracking information for the 140’s N-number, and saw the short track of the flight heading south, then turning left and terminating over an undeveloped area a short distance south of Interstate10. The airport manager and safety officer took off and spotted the 140 in the woods two and a half miles from the airport. Responders found it demolished; its two occupants were dead.

The tracking information publicly available online uses longer time intervals between ADS-B hits than the FAA’s radar does. The higher-resolution FAA track revealed movements that clearly pointed to pilot disorientation. First, there was a descending left turn with increasing groundspeed, followed by a climbing right turn, followed by another descending left turn to the northeast, then a hard right descending turn back toward the southwest. The airplane descended more and more rapidly. Radar contact ended 700 feet above the ground. Most likely, the pilot had strayed into clouds and then, descending over an unlighted area, he could not reorient himself in time to avoid the crash, or perhaps stalled in an attempt to pull up.

The pilot, who had logged 38 hours of flight time over the past year, had completed his solo and night requirements and was close to his private check ride. He had not yet done the simulated instrument part of the training. His instructor described him as friendly and a good pilot, one who intended to make flying his profession. 

His final flight was—to put it mildly—ill-advised. In addition to it being dark, there was a layer of stratusclouds 500 feet above the ground, and so, although the visibility below the clouds was good, the weather was officially IFR. The entire route to Pearland lay beneath the 2,000-foot floor of Houston Class B airspace, and it involved a dogleg to the south to avoid Hobby (KHOU). Along the way were some obstacles so tall that they poked through the TCA floor. In short, the proposed flight,although short in miles, was long in complications.

It was also illegal. The pilot’s student status precluded his carrying passengers. He had already demonstrated his willingness to ignore that restriction, but whether his nonchalance was due to an exaggerated sense of entitlement—not every 23-year-old student pilot can afford to buy his own airplane—or just youthful high spirits and resentment of restraint, we can’t guess. It seems likely, however, that one thing that entered into his choice to make that particular flight at that particularly inopportune time was the desire to impress. He was a young man; his passenger was an attractive young woman. What else needs to be said?

The desire to impress is almost, but not quite, a universal human trait. A few people are free of it. I myself know one, and I’m not even sure about her. When I began flying—I was not yet 20—I did a number of stupid things, most of them in order to impress certain women (at that time, I would have said “girls”). I still cringe today over one in particular that backfired so badly that in the mind of the woman in question, who atleast is still my friend, that flight eclipses all others that I have made since, and that I will make in the future. Since then, my need to impress has somewhat dwindled and now manifests itself mainly in a harmless proclivity for using fancy words. But I remember how I used to be, and so, while I deplore his judgment, I cannot but empathize with the young pilot who took off, impressively he thought, into that Houston night.

The quality of judgment that we pilots are expected to possess—and that is supposed to protect us and our passengers from actions that in retrospect will appear rash or completely idiotic—comes under the broad heading of “maturity.” It requires an ability to separate emotion from reason. That sounds easy, but the decisions that we consider rational are often influenced by biases, desires,and calculations of which we are barely—or not at all—aware. In theory, at least, we gain maturity from time and experience; some get a lot, some none at all.

One kind of situation presents a particularly obvious risk of ego-driven misjudgment. When we fly with another person whose esteem we crave, we may experience a sort of stage fright or “performance anxiety.” If that person is a pilot whom we perceive as our superior inexperience or native ability, the fear of doing something stupid, or just appearing awkward or flustered, flusters us and makes us awkward and stupid.

A poet I slightly knew in college once imagined a psych class called “Interpersonal Relations in the Group of One.” That would be a good class for pilots to take because, in addition to our desire to impress others, we may entertain a similar need to impress ourselves. Self-esteem is a powerful motive, and it affects pilots in both good and bad ways. On the credit side, it makes us work hard, try to perfect ourselves, and approach our flying with that attitude we call “professionalism.” On the debit side, it drives us to take unnecessary risks and to continue into worsening situations in order not to feel that we have “chickened out.”

As in finance, credit and debit in flying form a continuum. The hard part, sometimes, is to know which side of zero we’re on.

This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This article was originally published in the February 2023 Issue 934 of FLYING.

The post The Fatal Desire to Impress appeared first on FLYING Magazine.

Then suddenly, close by, the incongruous snarl of an airplane engine. Red and green lights race into view, swooping and plunging. The airplane disappears behind trees, reappears, turns, seems to aim straight for the startled stargazers on the shore. It veers away, zooms upward. Its lights become momentarily hazy and diffuse. The airplane again turns, dives, disappears behind trees. Then a dreadful sound, part boom, part thud, for which there is no name. And then silence.

Moments later, shouts and footfalls, the unlimbering of boats, clatter of oars and outboard motors, lights and voices out on the water, searching. Clouds have moved in; the stars are extinguished. The wreckage of the Lancair ES rests 25 feet down, on the bottom of White Iron Lake. The pilot, 58, who had hoped to reach his cabin near Grand Marais that night, sleeps there as well.

From Ely, Minnesota (KELO), where the Lancair took off, to Grand Marais (KCKC) is only 58 nm, more or less due east. The kitbuilt four-seater would make the trip in 20 minutes. But on the night of the accident there were complications. It was dark and moonless. The area between Ely and Grand Marais is a wilderness completely devoid of lights. An AIRMET warned of possible IFR conditions in mist and fog. The Aviation Forecast Discussion issued from Duluth a few hours before the accident talked of a chance of “fog at all terminals,” as evening temperatures fell. However, conditions were expected to improve to VFR everywhere the next morning.

Between Ely and Grand Marais is the southern edge of a prohibited area, P-204, in which flight below 4,000 feet msl is prohibited to help preserve the primeval quality of the Boundary Waters Canoe Area Wilderness, where no motorized vehicles of any kind are permitted. The weather at Ely, where the pilot had landed earlier in the day and was now waiting for fog at Grand Marais to

lift, was VFR with clouds reported at 3,200 scattered, 4,100 broken, with unlimited visibility. Uncomfortably, there was a space of only a few hundred feet between the ceiling of the prohibited area and the base of the lowest clouds. The distribution of cloud cover—whether it was clearer to the east, or the scattered clouds became broken or solid—was impossible to know.

After taking off, the pilot flew northeast, making a somewhat unsteady track along the western edge of White Iron Lake. This made no apparent sense, as he was not going toward his destination. But perhaps it made sense in that there were habitations and lights in that direction, and his first instinct was to orient himself using those lights.

He was airborne for just four minutes before crashing into the lake near its north end.

Often, National Transportation Safety Board accident investigators interview friends and relatives of pilots to find out whether the route on which they lost their lives was one they had successfully flown before. They examine logbooks to see how much experience the pilot had in conditions similar to those of the accident flight. In this case, the accident docket includes no such information. We don’t even know if the airplane had a functioning autopilot—such airplanes usually do—or whether the pilot was in the habit of using it.

What we do know about the pilot is that he had 400 hours. From the FAA aircraft registry, it appears he may have acquired the airplane from its builder five years earlier. He had begun working on an instrument rating and had logged about 15 hours under the hood. His instructor told investigators that he was not ready for flight in IMC (instrument meteorological conditions) and “nowhere near ready for a check ride.”

It’s clear that the pilot became disoriented. Possibly he experienced some degree of vertigo. The zooming and plunging motions described by witnesses are not uncommon when a pilot becomes disoriented, panics, and begins to fly not smoothly but with a series of violent over-corrections. That’s where an autopilot comes in handy. With a flick of a switch, the rattled pilot can let go of the controls and try to calm down.

We don’t know what weather sources the pilot had consulted, or when. We don’t know how much night flying experience he had. We do know, however, that he lived in the Minneapolis area, and so it’s possible that most of his night flying experience had occurred in places with lots of ground lighting. It’s significant too that a flight from Minneapolis to Grand Marais never leaves ground lights, and so it may be that he had flown that route at night but did not realize how different the experience would be if the flight started from Ely.

The NTSB blamed the accident on the pilot’s “improper decision to attempt flight into instrument meteorological conditions.” The phrasing strikes me as imprecise, in that “instrument meteorological conditions” usually suggests fog and clouds, not just a dark night. There’s no way to know whether the pilot strayed into an unseen cloud or whether the lack of any horizon or ground lights was sufficient to disorient him, but I think it’s very unlikely that he made a deliberate choice to fly into IMC. He cannot have forgotten the difficulties he experienced flying under the hood. He may or may not have entered clouds—the radar record of his track suggests that he stayed below them—but in total darkness it makes no difference whether you’re inside a cloud or not.

It’s customary, when discussing pilots’ decision-making, to assume that a pilot is a “rational actor.” Rationally, the pilot’s choices were three. He could stay the night at Ely. He could follow Highway 1 down to Lake Superior and then hug the shoreline up to Grand Marais, a dogleg that would add 30 nm to his trip but keep him over some lights. Or he could try the short, direct flight. Knowing the outcome, we realize that the option he chose was distinctly the worst. But with VFR conditions at Ely, and after waiting hours for Grand Marais to go VFR, he may have ceased to think of what lay between.

He may have had no idea what total darkness—the proverbial “inside of a cow”—would be like. He probably also did not know how he would react to becoming disoriented, alone and in the dark, or how easy it would be for that to happen once the terrain ahead of him ceased to have any lights, or had so few, and those so small and faint that they could not be differentiated from stars.

But really, it was just a 20-minute flight. The terrain was flat, the clouds were thousands of feet up. How hard could it be?

This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

The post Flying Into Total Darkness, Inside the Cow appeared first on FLYING Magazine.

While the rest of the party was out shooting, the private pilot, 48, and one companion got some isopropyl alcohol de-icing fluid from a hardware store, borrowed a ladder from the hunting lodge at which they had stayed, and spent three hours chipping snow and ice from the wings. The ladder was not tall enough to allow them to reach the upper surface of the T-tail, but the pilot was satisfied that the rest of the airplane was sufficiently clean.

Video of the Pilatus taxiing out showed snow falling heavily and white clumps adhering to parts of the fuselage and vertical tail. A couple of inches of snow (and presumably some ice) lay on the top of the horizontal stabilizer. The takeoff was recorded as well. The Pilatus roared down Runway 31, lifted off, banked to the left, and faded from sight in the snow and mist.

No one at the airport knew it at the time, but it crashed less than a mile from the runway. Of the 12 people aboard, three survived with serious injuries. The pilot was among the nine dead.

Thirty years ago, it would have looked like an open and shut case. Whatever residue of ice remained on the wings must obviously have triggered a premature stall. But we live in a different era now, with flight data and cockpit voice recorders in wide use. They tell accident investigators not what must have happened, but what really did.

The National Transportation Safety Board’s probable cause finding made no mention of snow and ice. It attributed the loss of control after takeoff and the ensuing stall to “the pilot’s improper loading of the airplane, which resulted in reduced static longitudinal stability.” Another contributing factor was “his decision to depart into low instrument meteorological conditions”—although that seems unfair, since the whole point of having an instrument rating and a powerful airplane equipped for flight in known icing is to be able to do exactly that.

The cockpit voice recorder picked up the sounds of passengers boarding the airplane, stomping snow from their shoes, clicking their seat belts. One passenger commented on how many pheasants they had bagged. Another recited a prayer of gratitude for various blessings—it was Thanksgiving weekend—and went on, with eerie prescience, “Father in Heaven, we ask for a special blessing now that we take off in this not-so-great weather and that [Thou wilt] watch over and protect us. Impress upon the mind of [the pilot] that he might know how best to travel this course that we are about to do, and we are thankful for this airplane and ask that You will watch over and protect us.” A collective “Amen” followed.

The pilot and the right-seat occupant radioed the airport manager, who was plowing the runway, to ascertain its condition. Their exchange was somewhat acerbic. The manager frankly told the pilot he must be crazy. The pilot good-naturedly replied that the snow berms on either side of the plowed portion of the strip were not a concern. As it turned out, he was right.

The pilot back-taxied to the approach end of Runway 31 and succeeded in turning the airplane around. The power came up, the Pilatus accelerated, and after 30 seconds it rotated. The pitch angle increased to almost 20 degrees, then eased back to about 10. Practically from the moment of liftoff, the stall warning sounded and an automated voice intoned the word “stall” over and over, no fewer than 19 times. Eleven seconds after rotation, a porpoising motion began, increasing in magnitude and rapidity. The bank angle increased to 64 degrees; the stick pusher actuated and, at a height of 380 feet, the Pilatus stalled.

With granular information from the flight data recorder, the NTSB conducted simulations to ascertain whether the airplane had been controllable and whether the accumulations of snow and ice remaining on it could have been a factor in the accident. The conclusion was that the airplane should have been controllable, and that the snow and ice had not significantly degraded its performance, though they may have affected the elevator control forces.

READ MORE: Classic Aftermath

The data recorder stored a number of previous flights, and the NTSB noted that the pilot, who had 1,260 hours in type, habitually rotated somewhat abruptly, tending to slightly overshoot the desired pitch attitude and then correct. Another pilot who regularly flew the airplane used a gentler, more gradual rotation, which the board found made speed control easier.

The board compared the accident flight with the previous day’s trip from Idaho Falls to Chamberlain. The cabin loading had been similar, and there were pitch oscillations after takeoff on that flight as well. The crux of the matter, in the NTSB’s view, was the combination of heavy weight—the airplane was 107 pounds over gross—and the CG location, several inches behind the aft limit, that resulted from 12 people, none of them lap children, and a great many dead pheasants occupying a 10-passenger airplane. An aft CG is associated with diminished stick forces and weak speed stability, conditions that may be difficult to manage on instruments.

The stall warnings that were heard practically from the moment the airplane rotated were due to the design of the Pilatus’s ice protection system. When ice protection is on, the triggering speeds for both the stall warning and the stick pusher increase considerably. According to the flight manual, the target rotation speed at max gross in icing conditions was 92 knots. The pilot rotated at 88, possibly because he wanted to get clear of snow build-up on the partially plowed runway. When the actual stall occurred, however, the indicated airspeed was only 80 knots. 

One can speculate about what passed through the pilot’s mind during the few seconds between the liftoff and the stall. The aural stall warning must have taken him by surprise. Since he had just spent hours removing snow and ice, his first thought may have been that it was caused by some lingering contamination on the wings. But now he was in near-whiteout conditions, and too low to risk pushing the nose down decisively. The airplane may not have responded to a gentle push on the yoke. Pitch oscillations made speed control difficult. There was little time to analyze or adapt—only enough for an exclaimed “Oh no!”

The pilot was the kind of person whom you would expect to follow rules. Yet he ignored the CG limits. Did he feel undue pressure to get his passengers back home? Probably not. There is no indication that he hesitated or considered the takeoff dangerous; in fact, he seemed less concerned than his prayerful passengers were. Did he understand how the extreme aft loading could affect the airplane’s flying qualities? He had made a similar flight the day before. Did he begin this one thinking it would be exactly the same? 

Sometimes you don’t know how near the edge you are until you go over it.

This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

The post A Wing and a Prayer appeared first on FLYING Magazine.