ePilot ASF Accident Reports -- Don't let bad decisions box you in

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AOPA Air Safety Foundation

Don't let bad decisions box you in

From the time we arrive at the airport until we shut down the engine at our destination, every decision we make can affect the outcome of our flight. Early in our training we are taught to always have an "out" or a failsafe option that ensures a safe outcome. On December 9, 2004, the pilot of a Piper Saratoga descended below the minimum altitude for the Runway 33 GPS approach at Glenwood Municipal Airport (GWH) in Glenwood, Minnesota, and subsequently crashed. The pilot and his passenger were killed. The decisions this pilot made, well before the accident, left him "boxed" between two bad choices that ultimately lead to this tragedy.

On the morning of the accident, the pilot called flight service to file three IFR flight plans. The first was from Florida to Georgia, the second from Georgia to Illinois, and the third plan was from Illinois to his final destination in Glenwood, Minnesota. He received a briefing that covered the first two legs of the flight but declined information related to the third leg. There was no record of any additional information being provided to the pilot at any flight service station along the route of flight.

At 1:42 p.m., the pilot contacted Kansas City Center and reported that they had departed Mount Vernon, Illinois, en route to GWH. He was cleared to GWH at an altitude of 10,000 feet msl. At 3:50 p.m., the flight was handed off to Minneapolis Center, and at 4:37 p.m. was instructed to descend and maintain 6,000 feet. Five minutes later, another descent to 4,000 feet was issued by ATC. The pilot responded by asking to remain at "6,000 feet to stay out of the clouds here [until] the last minute [due to] possible icing." ATC replied that the flight could stay at 6,000 feet and issued a clearance to descend to 4,000 at the pilot's discretion.

Shortly thereafter, the pilot reported accumulating a "fair amount" of rime and mixed ice at 6,000 feet and requested a climb to 7,000 feet. When questioned, the pilot characterized the icing intensity as "light" and that the cloud tops were at 6,200 feet.

The pilot was being given vectors to the Runway 33 GPS approach course, and radar recorded the aircraft intercepting the course at an altitude of 6,000 feet at 5:03 p.m. ATC then cleared the flight for the approach, and requested the pilot report when established. The pilot acknowledged the clearance, and reported established on the approach. A frequency change was approved, and there was no further contact with the pilot.

The MDA for the approach was 372 feet agl. A witness to the accident said she heard a low flying airplane, spotted its lights, and then saw it dive down and hit the ground. It was completely dark at the time with mist and fog. The AWOS at GWH reported a ceiling of 200 feet agl overcast and visibility of 1 and a quarter statute miles in mist shortly before the accident—almost 200 feet below the approach minimums.

The NTSB determined the cause was the pilot's failure to execute a missed approach and his failure to maintain sufficient altitude and clearance from terrain. Contributing factors included the pilot's failure to obtain a weather briefing, the pilot's icing concerns, and ceilings below the MDA for the approach.

At the time of the accident, the instrument-rated private pilot had accumulated more than 700 hours of total time, with 19 hours at night, and 85 hours of instrument experience.

A descent through nearly 6,000 feet of clouds with known icing conditions could result in a significant amount of ice accumulation. The accident aircraft was not equipped for flight into known icing. The further the pilot chose to proceed in this flight, the fewer choices he had. By proceeding with the approach into GHW he was left with two choices: Go missed and pick up more ice or go below minimums and try to land the aircraft. He chose to land. If he had chosen to divert before executing the approach, the results would have been dramatically different.

For more information about icing and its dangers, see the AOPA Air Safety Foundation's newest Safety Hotspot, Aircraft Icing. To learn how to make better decisions, both in flight and on the ground, plan to attend the foundation's newest Safety Seminar, " Do the Right Thing—Decision Making for Pilots," which will start touring nationally in January 2006.


Accident reports can be found in ASF's accident database.


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