Too little, too late

March 1, 1996

One of the worst feelings in flight is knowing that the fuel is going to run out before the runway is under the wheels — and that the emergency is entirely of your own making. Fuel exhaustion claims slightly more than one aircraft a week, typically under VFR conditions where the rules require only 30 minutes of reserves for day VFR.

When a pilot is operating under IFR, the regulations are far more conservative. There must be enough fuel to fly to the destination, make a trip to the alternate, fly an instrument approach there, and have at least 45 minutes after that to seriously contemplate landing. These requirements come into play if the weather is forecast to be less than 2,000 feet and three miles for an hour before arrival to an hour after arrival. These are the minimums and, depending on conditions, prudent pilots will carry much more fuel to ensure that the engines keep running for as long as needed.

A recent accident serves to illustrate the wisdom of these rules. The private pilot had been flying for almost eight years and had logged 1,041 hours. Not quite two years prior to the accident the pilot had earned an instrument rating and a year later added a multiengine rating with a VFR restriction. Total logged instrument time was 60 hours and an estimated 177 hours in twins.

The Beech 55 Baron was purchased in September 1993. At the time of the accident in November 1994, the transponder, pitot-static system, and altimeter were all overdue for their required checks by some 16 months and thus were illegal for instrument flight.

The pilot obtained preflight weather briefings at 9:06 a.m. and at 12:16 p.m. from automated flight service stations in Pennsylvania. On the first call the pilot asked for weather from Perkasie, Pennsylvania, to Covington, Georgia, which is about 30 miles east of Atlanta. Covington has no weather reporting facility. The synopsis showed a warm front overlying the southern portion of the route, with low ceilings and visibilities. The first several hundred miles of the trip were VFR.

The Athens, Georgia, hourly sequence showed 500 broken, 1,500 overcast, with the visibility at four miles in rain and fog. Other nearby stations were not as good, with 500-foot ceilings and one-mile visibilities. The forecast was considerably better for the late afternoon, when the flight was to occur — showing 2,500 scattered, 4,000 broken, and visibility better than seven miles, with a possibility of 1,500 broken and three miles. There was some discussion about low-level icing, and the pilot said that he would check again later in the day.

On the second briefing, the weather had deteriorated in Atlanta, with 100 feet indefinite obscuration and visibility one-eighth mile in fog. Some surrounding stations were hovering at minimums between 200 and 300 overcast and visibilities of a mile or less. The briefer volunteered that, despite the forecast improvement for later in the day, the weather sure wasn't improving as fast as expected — then followed up with, "They're definitely looking for improvement by the time you get down there."

In addition, the Baron would be slugging into headwinds beginning at 25 knots and increasing to 40 knots as the flight moved south. An IFR flight plan was filed for an 1800 Zulu departure time, estimating 3.5 hours en route with 4.5 hours of fuel on board. The alternate was listed as Dekalb-Peachtree Airport, which is about 30 miles from the destination airport.

It does not appear that the pilot checked the weather en route until arriving in the Atlanta area around 2200Z. The flight was cleared for the VOR/DME approach to Covington and provided with missed approach instructions. The pilot indicated that he would go to Fulton County (FTY), about 40 miles away, if he could not land at Covington. The controller provided the FTY weather as 300 overcast and three-quarters of a mile in fog. (Landing minimums were 270 feet agl and three-quarters of a mile visibility.)

At this point the pilot may have begun to have some doubts, because he queried the controller about arrivals at FTY. The controller replied, "Three-Three-Mike, there doesn't appear to be any difficulty landing into Fulton County Airport. At this time there are numerous aircraft that missed at Peachtree and went to Fulton County to land." The pilot responded that he would make one pass at Covington and then head for FTY.

The pilot then asked the controller for his position, stating a disagreement on his VORs, and departed the frequency. He was back in two minutes, announcing a missed approach. The flight was handed off to two subsequent controllers as it moved toward FTY.

After checking on with the FTY approach controller at 22:35, the pilot asked, "How many you got ahead of me into Fulton County?" ATC responded, "There's five of them right now."

The following ATC transcript records the events. Non-pertinent remarks and routine communications have been removed. ATC is Atlanta Approach Control, 33M is the Baron, and Tower is the Fulton County Tower. The time is shown in Zulu.

2235:13 33M: "OK, I'm getting nervous about my gas."
2235:14 ATC: "Three-Three-Mike, roger. Turn left heading 230. We'll shorten it up for you a little bit."
2241:17 ATC: "November-Three-Three-Mike, ah, if you have time, give me, ah, the souls on board the aircraft and any fuel you have remaining in time."
2241:26 33M: "Ah, one soul, and the fuel I've got is about, ah, 15...20 minutes."
2242:33 ATC: "Three-Three-Mike, due to your emergency situation, I'll turn your final to join at the marker."

At 2248 the ATC satellite coordinator (SAT) called FTY tower on the land line with, "Three-Three-Mike looks like he's a little left of the final."

2248:44 FTY: "He's correcting."
2248:51 33M: "Tower, what's my distance off the field now?"
2249:36 FTY: "Baron Three-Three-Mike, show you half-mile final."
2250:01 33M: "Tower, I'm...I haven't got it and I'm disoriented. Can you give me another pass here?"
2250:42 FTY: "Baron Three-Three-Mike, roger. Climb and maintain 3,000, left heading 320."
2250:47 33M: "I haven't got the gas for that! Can you give me another go-around?"
2252:32 FTY to SAT: "Three-Three-Mike does not have the gas to go back around...he's circling on short final."
2252:40 SAT to FTY: "Okay, we can give him a surveillance approach if you put him right back on us, 132.55...we'll turn him short final, give him a surveillance approach."
2253:09 ATC: "November-Three-Three-Mike, you're radar contact, maintain 3,000."
2253:13 33M: "I don't know how far I'm going to get without any gas here."

For the next three minutes ATC provided vectors for an ASR approach.

2257:21 ATC: "Three-Three-Mike, turn left heading zero eight zero. Start your descent, two miles from the airport."
2257:36 33M: "Zero eight zero. Lost my...I lost my left engine."

ATC provided vectors which brought the Baron right over the airport, but the pilot was unable to land. On the missed approach the decision was made to try again for Runway 8.

2302:33 33M: "I just lost an engine (unintelligible). Let me try zero eight zero."
2302:37 ATC: "What heading are you going through right now?"
2302:51 ATC: "Three-Three-Mike, what is your heading right now?"
2303:03 ATC: "Three-Three-Mike, radar contact lost."

Atlanta Approach tried several more times to contact the Baron, without success. The wreckage was located 1.5 miles west of the airport. The pilot did not survive. Several other aircraft landed at FTY both before and after the accident, with pilot reports of ceiling and visibility close to minimums.

There were many factors in this accident chain. First, the pilot was not very experienced in IFR operations. With a total of 60 instrument hours logged, at least 35 to 40 hours of that was in training for the rating, so his actual IFR experience in the cross-country environment was extremely limited.

Secondly, the pilot had a casual regard for regulations. Neither he nor his aircraft was legal for this flight. This pilot was not rated to fly twins in the clouds, and the aircraft was overdue on pitot-static and altimeter checks. Were these factors in the accidents? It certainly is open for discussion.

There was no planning done when the circumstances dictated considerable caution. The pilot had made this trip on many occasions and estimated the time en route at 3.5 hours, as filed in the flight plan. This corresponded to a no-wind condition. On this day, using forecast headwinds aloft, the actual time en route was much closer to 4.2 hours. There was not enough fuel to fly legally in daytime VFR conditions, let alone into a warm front, approaching darkness, and clouds to minimums.

It is unclear from the accident report whether an amended forecast was issued, but we have to deal with the weather as it is, not hopeful forecasts. Within an hour or two after departure it was obvious that the forecast was in error and that the actual weather would be low IFR.

The pilot's skills and judgment were far below those needed in this environment. His ILS approach to FTY, which needed to be flown perfectly for survival, was not. This was in evidence by the localizer wanderings noticed by ATC and by the fact that other pilots were not missing the approach. The ASR approach was a desperate attempt by ATC to take some of the load off the rattled pilot, even though the minimums were much higher than the ILS.

This will be categorized as a "weather accident," but there was nothing accidental in the scenario. All of the decisions were consciously made to place the flight into an untenable situation. In listening to the ATC tape you can hear the tension and rising concern in the pilot's voice. It robbed him of the concentration and the one chance needed to escape the trap he sprang upon himself. The psychology of fear and its debilitating effects are not to be taken lightly. By the time he realized there was too little fuel, it was too late.The AOPA Air Safety Foundation will re-create this accident and several other dramatic VFR/IFR learning situations in a new national seminar series, Never Again, which will be coming to a location near you. Watch your mailbox or contact ASF at 800/USA-AOPA.


See also the index of "Safety Pilot" articles, organized by subject. Bruce Landsberg is executive director of the AOPA Air Safety Foundation.