Safety Publications/Articles

December 2010 Volume 53 / Number 12

Safety Pilot Landmark Accidents: Overloaded, unbalanced, unable 

A winter wallop that a pilot ignored

Overloaded and unbalancedThis tragedy serves as an excellent case study on what not to do. It’s hard to understand this pilot’s thought process because of the number and magnitude of errors. We are left to speculate why.

On January 30, 2009, the VFR private pilot and five passengers, members of a Chicago-based aero club, boarded a 1975 Piper Seneca at Lake in the Hills Airport (3CK), Illinois. The purpose of the flight was to look at aircraft for sale in Raleigh-Durham, North Carolina, and Clearwater, Florida.

A friend of the pilot and club member was at the airport as the passengers were boarding. The subject of weight and balance came up, and he asked why six people were going instead of the planned five. Three of the passengers weighed 190 pounds or more. The pilot assured him that everything was in order. According to the NTSB, “The friend further advised the pilot to obtain a weather briefing and file a flight plan before departure. The pilot assured his friend that he would obtain a briefing and file a flight plan from the airplane using his cellular telephone. The friend then left for a hangar, and when he returned at 8:45 a.m. Central time, the airplane was gone.”

Fueling records show the airplane was “topped off” with 68.3 gallons prior to departure.

Overloaded and unbalanced

Summary

A VFR private pilot flies a Piper Seneca into a snowstorm in West Virginia. Overloaded and nearly out of fuel, he calls ATC in a desperate attempt to land at Huntington, West Virginia. The controllers provide vectors and a no-gyro ASR approach, but the pilot loses control. Sadly, there are five passengers aboard.

The NTSB computed the takeoff weight at 4,902 pounds and the center of gravity at 98.4 inches aft of datum. The manufacturer’s aft center of gravity limit at maximum gross weight is 95.0 inches aft of datum. The maximum allowable gross weight was 4,570 pounds with a proper zero fuel weight (ZFW) of 4,343.9 pounds.

ZFW is not something that most single-engine pilots have to deal with, but it’s an important limitation for some twins. FAA Advisory Circular 120-27D defines it as, “The maximum permissible weight of an aircraft with no disposable fuel and oil.” The passengers, baggage, and aircraft can only weigh that much—everything above that must be carried as fuel. The Seneca was about 558 pounds over the allowable ZFW and 332 pounds over maximum takeoff weight. The CG at the time of the accident was not published in the NTSB factual report—but looking at the physics, as the fuel burned off, the CG would move farther aft. It is probable that the Seneca’s handling was “squirrelly” at best, and the climb lethargic, but it flew.

Weather—unsuitable

The National Weather Service issued an area forecast about 3:30 a.m. the morning of flight predicting snow in the eastern half of Ohio, the northeastern part of Kentucky, and all of West Virginia.

The direct routing would take the Seneca about 10 miles northeast of Huntington (HTS), West Virginia, and the terminal area forecasts (TAF) were not promising for VFR flight. The 6:24 a.m. EST TAF projected marginal VFR with occasional IFR conditions. Beginning at 7 a.m. EST, 1,400 feet overcast, six statute miles visibility, with light snow showers and mist was expected, with conditions temporarily lowering between 7 and 9 a.m. to 800 overcast, four statute miles visibility in light snow showers and mist. A gradual improvement after noon included a broken cloud layer at 3,000 feet and visibility in excess of six statute miles.

The TAF issued around 10 a.m. showed overcast skies at 2,000 feet, six statute miles visibility, and light snow showers and mist—occasionally dropping to 1,500 feet broken and one-half statute mile visibility in snow showers.

It’s possible that the pilot received weather from an unofficial source, but the fact remains that this was clearly not a VFR operation. Remember that TAFs are based on a five-mile radius around the airport, and Huntington (elevation 828 feet msl) sits in the middle of the Appalachian Mountain chain. The maximum elevation figures surrounding the airport range from 1,600 feet to 2,300 feet, so mountain obscuration was a foregone conclusion.

The actual weather was worse than forecast: At 6:51 a.m. Huntington reported overcast skies at 900 feet, one and one-half statute miles visibility in snow and mist. At 7:51 a.m.: 900 feet overcast, two and one-half statute miles visibility in snow and mist; at 8:51 a.m., 2,000 broken and one and one-half statute miles visibility in light snow. Throughout the morning the actual observations showed the forecast to be optimistic.

The forecast and weather observations at the intended destination, Raleigh, were reportedly good but, oddly, that data was not included in the NTSB’s factual report. This may have led the pilot to believe that he could proceed VFR over the top and not have to deal with the poor weather over the mountains.

Unable to maintain control

The Seneca showed up on Huntington’s radar about 12:44 p.m. EST squawking VFR at 9,700 feet msl, about 50 nm southwest of Huntington. It proceeded to the northeast and, approaching Huntington, turned southeast—then east.

The pilot contacted air traffic control at 1:05 p.m. with a Mayday call, and notified the controller, “I’m flying VFR...low on fuel, and need a place to land. I’m, like, seven miles from you.” The controller confirmed radar contact eight miles southeast of Huntington, and that the Class D airspace was, “IFR at this time…ceiling one thousand broken, visibility two miles with light snow.” At 1:08 p.m., the controller directed a turn to 360 degrees, which the pilot acknowledged and reported level at 2,600 feet. The controller asked if the pilot was, “capable of IFR flight,” and the response was, “Yes.”

The controller provided an IFR clearance and cleared the flight to 3,200 feet. Radar now showed the aircraft at 2,100 feet. It then climbed to 2,700 feet, descended to 2,000 feet, and climbed back to 2,700 feet. Whether this was because of the pilot’s inability to fly instruments, the instability because of aft CG, or perhaps a combination of the two is unknown.

There were numerous transmissions over the next 10 minutes with the controller providing headings and altitudes that the pilot was unable to follow. At 1:19 p.m. the controller attempted a surveillance approach: “To Runway 30, this will be a no-gyro approach. I’ll just give you turns, the published minimum descent altitude I’ll give you momentarily, when you’re able turn ah left, make stan—ah, half standard rate left turn.”

There was considerable vectoring, again, with the pilot progressively unable to follow, and at 1:25 p.m. the pilot asked, “Could you get me back to the airport?” The controller responded, “Affirmative, fly heading zero three zero and if able, maintain VFR at your current altitude, if you have ground contact. If not, climb and maintain two thousand five hundred.” The pilot responded that he had ground contact.

The controller advised that the landing runway was 30, the altimeter setting was 30.06, winds were calm, and that the runway did not have approach lights, but was brushed and plowed. “You’ll see the dark strip in the snow and the runway lights are all the way up.”

The airport surveillance radar was unsuccessful despite considerable guidance from ATC, and at 1:30 p.m. the controller stated, “Two miles southeast of the airport, heading is three, three—correction—three, two, zero.” The controller subsequently called headings of 310, then 300, but there were no acknowledgements from the pilot.

The Seneca was now tracking northeast, and the controller advised the pilot that he was going the wrong way with the airport behind him. This was followed by several large heading changes but no acknowledgement.

A witness near the crash site was outside sleigh riding in heavy snow, as “a small airplane passed overhead. It…made a quick fly-by at [the] treetops next to the tallest power lines.” Ten minutes later, at 1:31 p.m. EST, he heard “the familiar sound of an airplane taking a nosedive” as the Seneca descended through the trees and into terrain. The pilot and five passengers were killed.

Pilot and aircraft

The aircraft, owned by the pilot, was a 1975 Piper PA-34-200T—N8047C—with about 4,300 hours noted on the engine tachometers. No maintenance logbooks, records, or inspection history could be found.

The pilot’s history was similarly not documented, with the only information coming from a recent second class medical certificate application showing approximately 2,200 hours total time. The pilot did not hold an instrument rating.

Analysis

This flight began badly and ended worse. Start with poor fuel planning: Based on standard tank capacity of 93 gallons useable, normal consumption would predict dry tanks at about four hours, just slightly more than the no-wind ETA at Raleigh. The Seneca was airborne approximately three hours, 45 minutes—so the dire fuel situation probably pressured the pilot to try for a landing at Huntington, still 234 nm from his destination. He may have planned to overfly the snow areas in the mountains with an escape option of letting down sooner if fuel got tight. Any reasonable assessment of the weather would have shown that to be a non-starter. There was no discussion by the pilot or ATC regarding icing, but that may have compounded any controllability problems.

Weight and balance transgressions have already been discussed, and this was no minor oversight. Pushing on VFR into instrument conditions is, unfortunately, nothing new for mission-focused pilots, and in an average year there will be 25 to 30 fatal accidents in this category. Do we never learn?

Lessons Learned

  • Operate within weight and balance.
  • Carry at least one hour of reserve fuel.
  • Get a weather briefing and have a realistic alternate plan.
  • Aircraft maintenance logs and pilot logs are not required to be kept aboard, nor should they be.
  • No mission is so critical that lives should be put at risk.

A flying club certainly has some management responsibility to the members, to keep reasonable records of both pilots and aircraft to ensure compliance with FARs and club rules. It appears that the club did not store the valuable documents relating to this flight, at least, in a safe place. That indicates a somewhat casual attitude toward safety.

Finally, we are left questioning why this happened. Overconfidence and complacency, based on the pilot’s moderately high flight time, is one guess. Layer on the importance of the mission and the large number of people who would be inconvenienced if the flight were delayed or canceled. The NTSB has not provided probable cause at this writing.

The Air Safety Institute recreated this accident, using the actual ATC recordings, on the website.