Get-Out-of-Here-Itis
Thirty minutes before planned departure, the Cessna 525 pilot acknowledged the “just cruddy” weather conditions to her briefer by phone as she drove to Maine’s Augusta State Airport (AUG). Filing a flight plan while driving in the bad weather one intends to fly through? I could probably write an entire post on the problems I see with this alone. Upon arrival at AUG, the pilot learned the plane had been moved out to the ramp about 4:00 PM. A commercial passenger flight had been cancelled due to weather and the airline had priority for the hangar. Precipitation had changed from light snow to freezing rain in the hour plus since then. De-icing was offered and declined. Between that time and engine start, the pilot indicated they were glad to be leaving the area and hurried the passenger along during preparations to board the aircraft.
(Forgive me if I’ve used this anecdote before) An instructor I served with had a personal rule: If three things go wrong before the flight, cancel. My personal rule is to try another day if things get too hard. Pretty subjective, I know. It’s more of a risk-benefit approach. Our story’s pilot now has 1) bad weather 2) is in a rush to beat worse weather and 3) probable ice on the plane. (One-quarter inch of ice had been observed on cars in the parking lot.) Looks like 3 strikes to me, not mention the airline had given a hint by canceling their flight for weather.
Our pilot-in-a-hurry boarded with the single passenger, started the engines, and announced intent to taxi. The Fixed Base Operator (FBO) attendant noted the taxiway lights had not been activated via Common Traffic Advisory Frequency (CTAF). Strike 4. He also saw the Cessna had begun to taxi, but over ice and snow covered grass instead of on the taxiway. Strike 5. No doubt fascinated by this series of events, the attendant continued watching and heard the twin FJ 44s go to high power, apparently because the aircraft had become stuck in a ditch. Is this part of Strike 5 or does it count as Strike 6? I say stuck in a ditch follows a decision to stay in the grass. Strike 6.
Apparently determined to continue, the pilot taxied on the grass toward Runway 26 and announced on CTAF they were headed for Runway 8. Strike 7. Are you confused,yet? I’m almost as confused as this pilot. Perhaps feeling embarrassed just watching this unfold . . . The FBO attendant turned on the lights. Shortly thereafter our soup sandwich of a pilot began to back taxi on Runway 26 and announced taxi to Runway 35. Soon, a new transmission indicated a route to Runway 17 via Taxiway C. Strike 8. Finally . . . About 1745, the attendant heard the call for departure from Runway 17, followed by takeoff.
The flight was short. Over a 3 minute span, the pilot checked in with Air Traffic Control (ATC), acknowledged a small change to routing, declared an emergency due to attitude indicator failure, and crashed the plane.
Cessna 535 N102PT crashed February 1, 2008, 6 miles from Augusta State Airport. The aircraft was destroyed. Pilot and passenger were both killed. The report does not explicitly state, but it can be inferred and other sources report, the passenger was her young son.
The Brief of Accident indicates this aircraft had 3 independent attitude indicators available to the pilot and no post-crash evidence was found pointing to any system failures on board. Conditions and radar tapes point to spatial disorientation as causal.
I don’t think I’ve ever launched with so many things telling me it was a bad idea. I didn’t even count the cancelled commercial flight and there were 8 items on the list. Is Augusta, Maine, “boring” enough to justify the risk taken by this pilot?
While I’ve chosen to focus on the pre-takeoff part of this accident, there are also lessons to be learned from the 3 minutes of flight. I will only say this: partial panel practice is critical. It provides an informed crosscheck of the attitude indicator, makes for a better and more comfortable attitude indicator failure response, and makes you a more skilled IFR pilot.
What sort of risk management do you practice before you fly?
Findings in Brief of Accident MIA08MA051
(Different format than older reports):
OCCURRENCES
- Enroute-climb to cruise – Loss of control in flight
- Uncontrolled descent – Collision with terr/obj (non-CFIT)
FINDINGS
- Psychological-Perception/orientation/illusio-Spatial disorientation-Pilot – Cause
- Action/decision-Action-Incorrect action performance-Pilot – Cause
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Brief of Accident MIA08MA051
(Both Factual and Probable Cause reports used.)
Search for “MIA08MA051″ in the accident number filed at
http://www.ntsb.gov/aviationquery/index.aspx
Risk Management Resources
AOPA Flight Risk Evaluator