March 1, 2003
By Bruce Landsberg
Bruce Landsberg is the executive director of the AOPA Air Safety Foundation.
Psychology plays an important, if generally subtle, part in flight safety. Why does a professional pilot with a perfect flight record make a critical and deadly mistake at his home airport? When does enforcement cease to become an adjunct to safety and become a major hindrance? Is it possible to have too many additional assignments to function safely as a professional pilot? The overlapping effects of external life events are shown again to lead to a catastrophic failure in the cockpit.
Everyone knows not to fly when emotionally distressed or highly fatigued. We're also legally required to ground ourselves when taking medication that would make us unable to pass a flight physical. Yet many pilots decide to just "tough it out." It's hard to admit when we're over the edge — physically and especially mentally. It is also somewhat unusual for the NTSB to cite external pressure as an accident factor and identify the federal agency charged with enforcing and promoting aviation safety as the source of that pressure.
The Cessna CitationJet (CJ) with five passengers, including one pilot-rated in the right front seat, and the pilot in command departed Lambert-St. Louis International Airport on December 9, 1999, for a one-hour flight to Point Lookout, Missouri. The weather was foggy and the pilot filed an IFR flight plan. He also called the operations manager at M. Graham Clark Airport in Point Lookout 20 minutes before departure, inquiring about the destination weather. The manager replied that the weather was lousy, and the pilot said he'd call on the CTAF (common traffic advisory frequency) for an updated weather observation when the flight was about 10 minutes out.
A departing Cessna 421 gave a pilot report that the cloud bases at Point Lookout were about 1,200 feet mean sea level (msl). The airport elevation is 938 msl. The CJ pilot radioed the airport manager that the flight was diverting to Springfield, Missouri. At 2:47 p.m. the CJ contacted Springfield Approach Control and was told to expect the ILS Runway 2 approach into the Springfield-Branson Regional Airport.
At 3:01 p.m., after some vectoring to position the flight on the localizer, the pilot asked to try an approach to Point Lookout, saying, "The weather doesn't look that bad there now, and then, if we miss, we'll come back up with you ...."
Springfield cleared the flight for the GPS 11 approach to Point Lookout with a descent to 3,000 feet. At 3:07 p.m. the flight crossed the RAWBE waypoint at 3,000 feet, turned to a heading of 116 degrees magnetic, and began a descent seconds later. A minute later radar showed the flight level at 2,500 feet.
At 3:08 p.m. Springfield called, "Citation Five-Kilo-Lima, change to advisory frequency approved. Call me back with your cancellation or your miss." The CJ responded and reported RAWBE inbound. At 3:09 p.m. radar showed the flight descending out of 2,500 feet. The last radar hit occurred 47 seconds later, 5 nm from M. Graham Clark Airport on a 296-degree radial from the airport, at 2,100 feet.
The GPS 11 initial waypoint, RAWBE, is located 10 nm west of the runway with a crossing altitude of 3,200 feet. After crossing RAWBE, the minimum altitude is 2,500 feet until crossing GARYY (it has since been raised to 2,600 feet), the final approach fix, located 5 nm from the end of the runway. There is a 2,000-foot step-down fix until reaching 3.2 nm from the end of the runway with a minimum descent altitude (MDA) of 1,460 feet msl.
The weather for Springfield, 38 miles north of Point Lookout, at 3:12 p.m. was 2,200 feet broken, 6,000 feet overcast, two and one-half miles visibility, with light rain and mist. The weather for M. Graham Clark Airport at 2:50 p.m. was 300 overcast, rain and mist, and three-quarter-mile visibility. The landing minimums for the GPS 11 approach require a ceiling more than 500 feet above ground level and one mile visibility.
The crash site was 4.3 miles from the airport, at about 1,240 feet msl, some 200 feet below the MDA for the approach and about 760 feet below the minimum segment altitude. There were no survivors.
The pilot held an airline transport pilot certificate and a flight instructor certificate (CFI) with single- and multiengine land and instrument privileges. Additionally, he was designated by the FAA as a pilot examiner for private, commercial, airline transport pilot, and flight instructor certificates in single- and multiengine instrument airplanes. Flight experience was reported at more than 10,000 total hours with 328 hours in the CitationJet.
The pilot-rated passenger held a commercial pilot certificate with single- and multiengine land, and instrument ratings. He also held CFII privileges in single- and multiengine, airplanes. Total flight time was 965 hours with 75 hours in the CJ. The autopsy showed that he had used marijuana between two and eight hours before the accident.
Toxicology tests from the pilot detected the drug doxepin hydrochloride, marketed and prescribed under the commercial name Sinequan. The 1998 Physicians' Desk Reference states that Sinequan is particularly effective in treating "anxiety, tension, depression, somatic symptoms and concerns, sleep disturbances, guilt, lack of energy, fear, apprehension, and worry." Precautions include drowsiness, and patients are advised not to drive a car or operate dangerous machinery while taking the drug. The physician who prescribed the drug to the pilot said that it had been around for 40 years and did not possess many "mood-elevating properties." He noted that the drug is also used to treat other conditions, such as "irritable bowel." The pilot's gastroenterologist noted a few months before the accident, "Patient...started on doxepin 25 mg at bedtime...."
Would it have made a difference if the right-seat pilot had advised the pilot that they were below minimums? It might have been enough to break the accident chain. Granted, he was not a required crewmember, but there are good reasons why mind-altering substances, recreational or prescription, should not be used on the flight deck.
The pilot served as the director of aviation science at a small college. His duties included curriculum development and implementation, oversight of the college's maintenance school program and Part 61 flight school, counseling and advising students, and managing the department's faculty and staff.
As the airport manager he oversaw the parking and servicing of transient aircraft, facilities management, hangar rentals, car rentals, fueling of aircraft, rental of the college's airplanes, the aircraft repair station, weather observation, and fire and emergency operations. He also managed the airport staff and special airport projects, and was responsible for the aviation science and airport operations department budgets. Prior to the accident, he was involved in contract negotiations to move and extend the airport's runway. As a designated pilot examiner, he administered all of the student check flights. Finally, he was the only person at the college type-rated to fly the CJ. According to the NTSB, "Interviews with college staff, faculty, and st(dents revealed that everyone was aware of the pilot's workload. They described it as the pilot having 'a full plate.'"
The pilot was also the subject of an alleged bogus enforcement and harassment action by the Kansas City Flight Standards District Office (FSDO). Harassment charges were substantiated by an independent Department of Transportation Inspector General (IG) audit conducted at the request of Missouri Rep. Roy Blunt (R). The relationship with the FAA was reportedly positive prior to the change of office managers at the FSDO, about a year earlier. However, others not directly involved in the case acknowledged that the pilot had never cared for FAA oversight. In the nine months prior to the accident, the pilot had responded to an enforcement action taken against the college's repair station. An enforcement action also was taken against one of the school's mechanics.
In March 24, 1999, the pilot received a letter from the FSDO stating, "On March 10, 1999, an inspector from this office reviewed the maintenance records of several aircraft under your control. The results of this review give reason to believe that a re-examination of your airman competency is necessary...." The pilot appealed to the FAA Regional Headquarters questioning why his pilot competency was in question when the problems purportedly existed on the maintenance side of the house. In April 1999, the FSDO rescinded the action.
Fifteen days prior to the accident, the pilot received another letter from the Kansas City FSDO, claiming that he had administered two multiengine practical tests without the appropriate authorization and asking for the pilot's logbook(s). There is a difference of opinion as to whether the pilot was authorized.
The pilot contacted an aviation attorney and began drafting a response to the FAA's action. The pilot's wife said that in the days prior to the accident, her husband "was distressed by the FAA harassment.... He was concerned about the disgrace that this could bring to the college, as well as to himself.... There were a lot of sleepless nights."
On the evening before the accident one of the college's Cessna 172s, piloted by a student, was involved in an accident resulting in minor injuries to two passengers. A witness reported that this also weighed heavily on the pilot's mind.
On the morning of the accident several witnesses at the airport reported the pilot to be "unusually calm" given the weather. One witness said, "I spoke with him briefly; he was jovial. It was unusual. He would not have been that calm with the way the weather was."
A corporate pilot friend said that he met the pilot in St. Louis while he was waiting for the passengers on the return flight and said that the pilot "wasn't himself that day." The pilot said he hadn't slept for three days, and worried that a supervisor in the Kansas City FSDO "is trying to destroy me." He was visibly upset and antsy, and his face showed the lack of sleep.
The obvious probable cause of this accident was the pilot's failure to follow the published approach procedure resulting in a descent below minimums. But as we look at why a good professional pilot made such a disastrous mistake, overwork, emotional distress, and bureaucratic harassment show some systemic flaws that should have been addressed. However, this absolutely does not relieve the pilot in command from his responsibilities, and he must be held accountable for not following procedures, not grounding himself after taking medication, and flying while extremely fatigued. But there are many lessons from this tragedy for everyone who flies.
A footnote to the NTSB's investigation is the role that FAA flight standards played. FAA management appears to have participated in a cover-up, not only in this case but in several others as well, according to the IG. Overzealous and wrong-headed enforcement creates an atmosphere of distrust and concern for integrity that should not be tolerated as we cooperatively work toward the highest levels of safety.
Safety and Education,
Department of Transportation,
Pilot Training and Certification,
FAA Information and Services
The silence on the approach control frequency is broken as the controller speaks your N number and advises, “Traffic, two o’clock, westbound, type and altitude unknown.”
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