May 1994 Volume 37 / Number 5
No second chances
The importance of arriving at point B can assume monumental psychological proportions, and pilots are admonished that they should "just say no" when the weather is not flyable.
How easy to say "no" when you're discussing a hypothetical situation. You don't have the pressures from family, business associates, and, perhaps most important, yourself. Sometimes the risk is very high, but the reward is also very high. In gambling, this is known as betting the farm. For pilots, the next step frequently is buying the farm.
Suppose that being late for work would involve a reprimand and that you were advised to "take the necessary action to prevent a recurrence" by your boss, in writing. Would something like that affect your decision making? For most of us, it would.
The 20,000-hour pilot was a DC-9 captain for a major airline who lived near Fort Myers, Florida. He was scheduled to report at 7:20 a.m. to crew a flight departing from Tampa, some 90 miles from his home.
The evening before the flight, the pilot received a weather briefing and filed an IFR flight plan. He planned to fly his Piper Apache from the fly-in community in Fort Myers to Tampa International.
Tampa's terminal forecast called for scattered clouds at 500 feet with visibility of 3 miles in fog, occasionally a ceiling of 300 broken and a half-mile in fog. Conditions were scheduled to improve after 9 a.m. to 10 a.m. to scattered and 5 miles in haze.
The forecast was revised later that evening, after the pilot had gotten his briefing. The second amendment, issued at 4:20 a.m. and valid for 5 a.m. to 9 a.m. local time, called for considerably worse conditions: ceiling 100 obscured; visibility an eighth-mile in fog; occasionally partial obscuration with a ceiling of 300 feet and visibilities of 1.5 miles.
According to the pilot's wife, he awoke at 5 a.m. and was airborne at 6:12 a.m. in VFR conditions. There was no evidence that he called for any pre-departure briefing, which would have alerted him to the low visibility. A good alternate plan would have been to drive to Tampa, although an earlier departure would have been necessary. The other alternative was to call the dispatcher and explain the circumstances.
Immediately after takeoff, the pilot contacted the Fort Myers FSS and received the current Tampa weather: indefinite ceiling 0 obscured, a sixteenth-mile in fog...winds light and the Runway 36L RVR 1,000 feet variable to 1,600. The decision height for the Category I ILS approach to Runway 36L at Tampa is 200 feet, and the minimum visual range is 1,800 feet. It was well below landing minimums.
At 6:14 a.m., the pilot picked up his IFR clearance from Miami Center and flew toward Tampa.
An Airborne Express DC-9 and a Cessna 172 attempted approaches at Tampa just ahead of the Apache. The DC-9 was certified to conduct Category II approaches with minimum RVR of 1,200 feet.
The Airborne Express captain said that during the approach, he caught a momentary glimpse of the approach lights. But upon reaching the decision height of 100 feet, no lights were visible, and he diverted to an alternate.
The Cessna 172 pilot spotted the approach lights at 300 feet, but at the Category I decision height of 200 feet, he was "on solid instruments." That flight also diverted to an alternate airport. The time was 6:40 a.m.
At 6:41 a.m., the Apache pilot contacted Tampa Tower and was cleared to continue the approach. It is likely that he would have heard the Cessna 172 receive missed approach instructions from approach control.
The visibility continued to deteriorate, and at 6:45 a.m., the controller advised the Apache that the touchdown RVR was 600 feet and rollout RVR was 800 feet. This was one-third the visibility required to land.
At 6:47 a.m., the pilot declared a missed approach. When asked his intentions, he replied, "Like to go back and try it again." As the Apache was on the downwind leg, being vectored for a second attempt, Tampa Approach reported that the touchdown RVR had improved to 800 feet and the midfield RVR had improved to 3,000 feet. This may have been due to a departing airliner stirring up fog near the RVR sensors, but this was not mentioned. The pilot commented, "That 3,000 sounds better I hope," and the approach controller responded, "Yes it does."
As the Apache was cleared for a second ILS at 7:03 a.m., the pilot was advised that the touchdown RVR was back down to 600. He acknowledged, and that was the last transmission.
At this time, a Boeing 727 was taxiing for takeoff on the parallel taxiway to Runway 36L. The captain noted "pockets" of fog where the runway edge and centerline lights were visible, about 400 feet away.
The captain saw the Apache coming out of the fog on a head-on collision course. The captain immediately turned the Boeing to the right to lessen the impact. He estimated the time from when he first saw the Apache until impact was about 2.5 seconds. The Apache's left engine struck the lower nose area of the Boeing. Fuel from the Apache's ruptured fuel tanks ignited, and the wreckage slid under the wing of the 727. It continued past the wing and burned on the taxiway. The Boeing stopped a little farther down the taxiway, and the captain called for an evacuation. There were three minor injuries during the evacuation from the 727. The Apache pilot was fatally injured.
Five years earlier, the Apache pilot had been given a letter by his airline's chief pilot, reprimanding him for being late. This thought was almost certainly weighing heavily on the pilot's mind.
A second attempt after a flawless but fruitless first approach is evidence of desperation.
Given the weather conditions, it's obvious that there was to be no substantial improvement in RVR. The density of the fog, as reported by flight service, right after the Apache's departure from Fort Myers, was unlikely to change during the ensuing 30-minute flight.
Weather texts tell us that fog will tend to form at sunrise and can thicken shortly afterward as the sun's early rays evaporate surface dew and put more moisture into the air. Light winds provide a gentle mixing and can thicken the fog layer. The wind at Tampa that morning was easterly at 3 knots. The pilot had no reason to expect improving weather during the short time prior to arrival at Tampa and between subsequent approaches. In conditions like this, it could take up to several hours to improve to Category I landing minimums.
Timing and circumstances play a major role in our decision-making process. Certainly the pilot, in his airline role, had faced similar weather before and had diverted to alternates without hesitation. This flight, however, did not include the professional detached environment of an airline operation that leads to consistently safe decisions and superb safety records.
This was personal, and the pilot had put himself in a high-stress, high-stakes environment. Once airborne, his only option other than making the approach to fog-bound Tampa was to divert to an alternate and take the consequences of being late. In hopes of pulling off a grand slam, the pilot took the ultimate risk of descending below minimums on the second approach. Professionally, he knew the gamble. Emotionally, he was desperately hoping for a miracle. History has shown this to be a poor way to fly. The only salvation is to be perfectly honest with ourselves.
See also the index of "Safety Pilot" articles, organized by subject. Bruce Landsberg is executive director of the AOPA Air Safety Foundation.