Safety Pilot Landmark Accidents: Attitude or altitude?

Just because you can doesn’t mean you should

March 1, 2010

Pilot attitude is, perhaps even to a greater degree than skill, an accurate predictor of an unhappy outcome. This month’s Landmark Accident is a testament to the adage that haste makes waste, and that the laws of aerodynamics apply equally to all pilots, regardless of their station in life.

Lousy day to fly

On a snowy February morning in 2008 the pilot called the Augusta, Maine, FBO and requested that her Cessna CitationJet (C525) be fueled and moved into the hangar, presumably to keep it out of the snow and ready for a late-afternoon departure. A local air carrier cancelled its afternoon flight because of weather and the CJ was moved out of the hangar at 4 p.m. to make room for the carrier’s airplane.

Around 5 p.m. the pilot called Flight Service, received a standard briefing, and filed an IFR flight plan to Lincoln, Nebraska. The briefer advised of icing, fog, mist, precipitation, and turbulence—from the surface to the requested cruising altitude of Flight Level 380—along the entire route of flight. The pilot commented that the weather was “just cruddy.”

The official weather observation taken just after the accident at Augusta, six miles northeast of the crash site: winds from 020 degrees at 3 knots; visibility 3 statute miles; freezing rain; haze; overcast clouds at 1,800 feet; temperature minus 6 degrees Celsius; dew point temperature minus 6 degrees C; altimeter 30.32 inches of mercury.

According to an NTSB weather study, at the time of the accident the area cloud bases were 2,100 feet with cloud tops at 10,000 feet; below the lowest cloud base, in-flight visibility was six miles in mist; there was light freezing rain with moderate mixed/clear icing below 5,000 feet, and light to moderate turbulence below 10,000 feet. A sigmet for occasional severe mixed/clear icing in clouds and precipitation was in effect for the accident area.

The pilot arrived at the airport around 5:15 p.m. and although the ground was covered with snow and ice, she declined to have the airplane deiced when asked by the FBO representative. Witnesses reported that freezing rain had been falling for the past 90 minutes and cars in the parking lot had a one-fourth-inch coating.

Confusion on the ground

At 5:31 p.m. the pilot contacted an air traffic controller at the Portland, Maine, Jetport for an IFR clearance. After the readback the pilot advised that she would be departing from Runway 17 in about five minutes. At 5:36 p.m. the pilot mistakenly used the clearance delivery frequency to advise that she was taxiing to Runway 17, and then stated she was taxiing for Runway 35.

Although it was dark, the pilot did not use the common traffic advisory frequency (CTAF) to activate the pilot-controlled taxi and runway lights. With the taxiways invisible, witnesses noted the jet had travelled off the taxiway and onto an adjacent grass area. The cross-country odyssey continued when the engines were heard to spool up as the CJ powered through a ditch on its way to the runway. The post-accident investigation found that the left main tire broke through the ice and became stuck in the ditch.

The pilot announced that she was departing from Runway 35 and an FBO employee turned on the runway and taxiway lights. Then she announced she would depart from Runway 17 instead and made her way to the other end of the airport. At 5:41, the pilot advised the controller that she was ready for departure and was given an IFR release with clearance to 10,000 feet. At 5:43 p.m. the pilot announced she was departing from Runway 17.

Short flight

At 5:44 p.m. the pilot reported climbing out of 1,000 feet for 10,000 feet. One minute later the departure controller instructed the pilot to identify, and radar contact was established two miles southwest of Augusta. The flight was cleared direct to Syracuse. At 5:46 p.m. the pilot declared an emergency, reporting, “We’ve got an attitude indicator failure.” The controller requested the pilot’s intentions. At 5:47 p.m. the pilot stated she wasn’t sure which way she was turning. The transmission abruptly cut off mid-sentence, radar contact was lost, and an emergency locator transmitter (ELT) was then received on 121.5 MHz.

Boston Center radar showed the CJ departing Runway 17 at Augusta and entering a climbing right turn to a track of about 260 degrees. It maintained that track for 38 seconds, while accelerating and climbing, before the pilot declared an emergency and reported an attitude indicator failure. Radar confirmed the jet at 3,500 feet and 267 knots. Thirteen seconds later, the pilot radioed that she did not know which way they were turning; radar data showed the airplane in a tight, rapidly descending left turn that continued until radar contact was lost.

The impact occurred in a wooded area with heavy snowfall immediately after the accident. The aircraft struck the ground approximately 80 degrees nose down at high speed, making component identification and recovery extremely difficult—especially after the post-crash fire. The pilot and her 10-year-old son did not survive. The engines were determined to have been producing power, but there just wasn’t much else left to analyze.

Pilot and aircraft

The pilot, age 45, held a private pilot certificate, with airplane single-engine land, multiengine land, and instrument ratings, and Cessna 525S and Cessna 500 type ratings. Her medical certificate was issued in December 2004 and would have been valid for five years if issued before she turned 40; an aircraft insurance application reported that a third class medical was issued in November 2007, although the FAA apparently had no record of the later medical certificate. The insurance application noted total flight experience of 3,522 hours at that time. The last recurrent training for the C525 was completed at FlightSafety in December 2005.

Since her logbook was not recovered it is unknown what flight reviews or other training she had received in the interim. In jets requiring more than one crewmember, an annual proficiency check in type is required for the PIC but not for single-pilot operators, so it appears that more than two years had elapsed since she had received any documented training. The pilot was scheduled to return to FlightSafety International in March 2008.

The CJ, serial number 525-0433, was manufactured in 2001 and certificated for single-pilot or two-pilot operation. It was equipped with a Rockwell Collins Pro Line 21 Integrated Avionics System and was approved for flight into known icing conditions. There were three pitot static systems and three separate attitude indicators (pilot, co-pilot, and standby), each powered from separate and unique attitude and heading reference system (AHRS) units. Additionally, there was a standby airspeed indicator, altimeter, and compass.

The pitot static and venting system heat was controlled by one switch, and the circuit of all six elements was rigged so that any failure would trigger an annunciator light. The pitot static heating system is not automatic and should be turned on just prior to takeoff.

No flight data recorder was installed, nor was it required. According to factory service center records the aircraft was properly maintained and airworthy.


The factual information presented here by the NTSB is straightforward but inconclusive and the probable cause has not yet been issued. There are several obvious factors and a few that might be surmised. It’s a safe bet that the aircraft’s performance may have been degraded by ice-contaminated wing and tail surfaces. It’s been proven too many times that not deicing on the ground is dangerous.

If the autopilot was used it may have masked the aircraft’s compromised handling and handed an out-of-trim and marginally controllable aircraft back to the pilot, which can be extremely disorienting. For this reason autopilot use is not recommended in icing conditions. There was no way to determine if the anti-ice or deice systems were in use. As noted, pitot heat is not automatic and failure to turn it on also could lead to some very confusing indications.

Jets do fly in tough icing conditions regularly but everything has to work and the pilot(s) must not stay in areas of supercooled liquid droplets for any extended period. Fortunately, jets have the power to move through those layers quickly and the clearance to 10,000 feet in this case provided no ATC impediments.

The odds of total flight instrument failure seem unlikely, although a malfunction of the flight data computer or pitot heating systems might be possible—especially given the off-taxiway excursion prior to takeoff. Still, to have more than a single system fail is extraordinary. Cessna’s C525 emergency procedures cover both dual and single attitude reference failures but it may have been some time since the pilot had had an opportunity to practice these rare but critical actions. According to the FAA, “It may take as much as 35 seconds to establish full control after loss of visual reference by qualified pilots. The spatial disoriented pilot may place the aircraft in a dangerous attitude, which can lead to a rapid, uncontrollable, near-vertical descent.”

The pilot’s apparent mindset may have been more important than any of the speculative technical issues, if you’ll indulge some armchair psychology. The pilot was an extremely well-known and successful entrepreneur. A business partner described her “as fearless in her pursuits, both professional and personal.” The Boston Post reported that the pilot “was named the wealthiest woman in the country under the age of 40 by Fortune magazine in 2001, and was reported having a net worth that year greater than Tom Cruise and Tiger Woods.” This is admittedly stereotyping, although it seems at least plausible that she was used to having things done on her terms.

The NTSB noted that the pilot was in Maine for a week while her son attended a skiing academy. A family member “did not recall any mention from the pilot with respect to being upset or concerned with time restraints; however, the pilot did mention that the [area] was boring on several occasions.” An FBO employee noted that the pilot “looked like she wanted to get out of here. She was in a hurry.” The failure to deice, the taxi debacle, and the decision to change runways in this context all point to distracted thinking at the least.

The pilots’ paradox is that the attitudes of some economically successful people may occasionally be at odds with successful piloting. As I’ve written before, ignorance or arrogance can be problematic in flying and a substantial amount of either one is often lethal—regardless of the pilot’s net worth. The NTSB will publish the probable cause shortly.

Bruce Landsberg is president of the AOPA Air Safety Foundation.