On the tightrope without a net
| No matter how much support is available to you on a flight, treat the mission as if it were you, and you alone, who must carry it off safely. |
What do a student pilot taking off on the wrong runway and a ground fog encounter during a night landing have in common? Both flights seemed to have plenty of support during their accident phases, yet things still went wrong.
The official probable causes of these two accidents were complex, more so than the immediate circumstances would suggest. Fail-safe mechanisms that the pilot was counting on to keep the flight safe didn't function. The safety net might have been as simple as a glance out a tower window, or the reassuring presence of a second pilot selected specifically for the occasion. Still, the backup didn't actuate. Accidents did.
That's a lesson for all of us. What fail-safe mechanisms do you rely on when you fly? It might be a basic strategy such as picking routes or destinations that give you that safe, confident feeling. Do warning lights flicker in your mind when those support systems aren't available, or don't seem to be fully functional? Backup systems even have a drawback: the seductive lure of complacency. But even absent that problem, accident chains don't have to be made of many links for a momentary failure of the safety net to have destructive results.
On February 6, 2008, a solo student pilot in a Piper PA-28-161 attempted to take off on the short remainder of a runway in St. Augustine, Florida, ending up in the Intracoastal Waterway. He had not seemed entirely sure about his position on the airport, having gone to some lengths to clarify his taxi route, including asking for progressive taxi instructions. Nor did the tower controller who cleared him for takeoff on Runway 31 observe the errant departure sequence on intersecting Runway 6. The controller was occupied with preparing hourly weather-a task meriting a lower priority than monitoring the takeoff that had been authorized, as the National Transportation Safety Board was to point out.
The student had arrived in St. Augustine from Deland, Florida, and had asked to return to the active runway for departure. Uncertain about complying with taxi instructions he had received, the pilot, now at a runway intersection, requested detailed instructions. He was advised, "You're fine where you're at. Are you ready to go?" The online National Transportation Safety Board accident summary gives his account of what happened next. "The air traffic controller told me that I was good there and gave me clearance to depart 31. I understood that to mean I was on [Runway] 31 and clear for departure so I completed my pretakeoff checklist and began my ground roll. Then I noticed I was on the wrong runway and tried to stop, but was too late and the momentum carried me into the marsh."
Anyone who has taxied on a complex or unfamiliar airport should study this case, further summarized by the NTSB: "The controller instructed the pilot to make a left turn on B2 then taxi to Runway 31 via taxiway B, and hold short of Runway 31 at taxiway B4. The pilot acknowledged the clearance. The pilot taxied past taxiway B4 and went onto Runway 6/24. While on Runway 6/24 and short of Runway 31, the pilot requested progressive taxi instructions from the tower controller. The controller advised the pilot, 'You're fine where you're at. Are you ready to go?' The pilot stated that he was ready to depart. The controller instructed 'Zero-Foxtrot-Tango, Runway 31 at Runway 6 intersection, cleared for takeoff left turn southbound.' The pilot read back 'cleared for takeoff.' "
According to the preliminary report, the tower controller observed the aircraft make a turn onto Runway 31 at the Runway 6 intersection and then returned to administrative duties (the hourly weather). The pilot had departed straight ahead on Runway 6 from the intersection of Runway 6/31 with approximately 200 feet of runway remaining. The pilot was not injured when the aircraft ran off the runway and into the water.
Take a pilot who is out of practice with night flight. Give him a mission to fly to an airport, pick up passengers, drop them off at another location, and return home. A good idea before heading off is to bring another pilot along. The owner of a Mooney M20F did that, hiring an instructor to accompany him on the three-leg, dark-night VFR flight in California on February 16, 2006, as described in an NTSB report. "According to the pilot's written statement, he hired the CFI to assist in the night flight, as he was not current in night operations. The pilot and CFI flew from Lampson Field, Lampson, California, to Sacramento to pick up two passengers. The passengers were to be dropped off at Willits [Municipal Airport] and the pilot and CFI were to return to Lampson. The pilot obtained a weather briefing before making the uneventful flight to Sacramento. After picking up the passengers, the flight proceeded to Willits. After reaching the vicinity of Willits, the pilots activated the pilot-controlled lighting over the common traffic advisory frequency. They entered a right downwind for Runway 34, which was lit by runway edge lights."
At this point the hazard made its appearance. "As the pilot flew the airplane onto final approach at 80 knots, he entered a low-lying area of ground fog and temporarily lost sight of the runway. The airplane descended too low and the CFI applied full power, but the airplane impacted a tree on short final with its right wing. Two of the aircraft occupants were seriously injured, the other two suffered minor injuries."
Fog wasn't the only risk factor for a dark-night approach to this airport: "The Airport/Facility Directory (AFD) for Willits indicates that trees were present on the approach end of Runway 16 and 34 and medium intensity runway lighting was available. The pilot indicated that some of the runway edge lights were inoperative. The airport was not equipped with a visual approach slope indicator or a precision approach path indicator," the NTSB summary noted.
In such cases, assigning a probable cause is a balancing act. What is causal, and what is a "contributing factor" in an accident? In the case of the student pilot who ran off the end of the runway in St. Augustine, the NTSB found the probable cause to be "the pilot's failure to adhere to the controller's takeoff instruction," but "contributing to the incident was the controller's failure to properly monitor the flight, and the controller's decision to perform lesser duty priorities during the takeoff roll."
The cause of the night-landing mishap, said the NTSB, was "the pilot's failure to maintain visual contact with the runway at night, which resulted in a descent below the proper glide path and a collision with a tree." Also causal was "the flight instructor's inadequate supervision of the flight."
No matter how much support is available to you on a flight, treat the mission as if it were you, and you alone, who must carry it off safely. Errors or omissions will often be caught by back-up systems, human and mechanical, on board or on the ground. But not always. Often there's no warning light on the panel to tell us that our backup has gone off line or missed a cue. Nor is there a warning light or buzzer to sound a complacency alert after a pilot misplaces his focus, or bites off more than he can chew.
Dan Namowitz is an aviation writer and flight instructor. A pilot since 1985 and an instructor since 1990, he resides in Maine.
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