Safety Pilot: A deadly invincibility

AOPA Summit

AOPA Foundation President Bruce Landsberg is a featured speaker at AOPA Aviation Summit 2010, November 11 through 13 in Long Beach, California. He will present “What Went Wrong?” on November 12. Visit the website for more information.

One of the necessarily frustrating things about NTSB reports is that they generally do a good job of telling us what happened, but the why is often left to interpretation and the imagination. This month’s “Landmark Accident” fits that description perfectly and leaves us to wonder why the pilot made the decisions he did.

The pilot rented a 1969 Cessna 172K at Seaside Municipal Airport (56S) in Gearhart, Oregon, on August 4, 2008. He told the aircraft owner that he was making a business trip to Klamath Falls, Oregon, in the morning. Although the aircraft was not equipped with flight data recording devices, a Garmin 296 handheld GPS survived the next day’s accident and gave a reasonably clear indication of the flight path. The pilot did not file an IFR flight plan—nor did he obtain any official weather, according to the NTSB. But the problem goes much deeper than checking bureaucratic boxes or meeting regulatory requirements.

According to the NTSB report, “The Automated Surface Observation System (ASOS) at the Astoria Regional Airport, located eight miles north of the Seaside Municipal Airport, reported that the weather conditions at 6:55 a.m. were calm winds; 2.5 miles visibility in mist; 300-foot overcast layer; temperature 12 degrees Celsius (C); and the dew point 12 degrees C.” A former airline pilot who lived on the beach in Gearhart reported surface visibility was less than 80 feet at 6 a.m. on the day of the accident.

The GPS recorded the takeoff from 56S at 6:44 a.m. The Cessna climbed to about 412 feet msl on a northerly heading (about 400 feet above the ground) and entered a climbing left turn that tightened into a spiral over the beach. The last calculated velocity was 136 mph groundspeed with a course of 220 degrees true. The climbing turn constantly reduced in radius, creating a path consistent with an inward spiral. At 1,350 feet msl the airplane entered a rapid descent of approximately 3,885 feet per minute. The spiral started at 6:46:31 a.m. and the last GPS data point was recorded about eight seconds later. It was a very short flight.

The pilot and passenger were killed, and what made the event especially tragic was the aircraft hit a beach cottage about one mile northwest of the airport. Three occupants were killed, and three more seriously injured as a post-impact fire destroyed the house. This GA mishap killed and injured more innocents on the ground than any other in recent memory.

Pilot and aircraft

The 36-year-old pilot held a commercial certificate with single-engine land and instrument airplane ratings. Additionally, he held a flight instructor certificate, issued on August 4, 2006. His second class medical certificate was current and at the time of issuance, two months prior to the accident, a total flight time of 1,650 flight hours was reported. The aircraft owner gave the pilot a flight review in June 2008 that covered Cessna 172 operations, engine failures, GPS familiarization, and crosswind landings, but they did not fly any practice instrument flight. The NTSB could not verify any recent instrument flight experience or currency.

The 1969 Cessna 172 received an annual inspection on April 1, 2008. At that time the total time on the airframe was 3,650 hours, and the engine’s total time since overhaul was 1,198 hours. A week prior to the accident, the operator had flown an instrument proficiency flight with another pilot and noted no instrument abnormalities.

The investigation revealed no instrument or engine malfunction. The vacuum pump rotor was intact. The attitude gyro rotor shaft was in its journals with two very light score marks observed on one interior side of the external gyro case. That indicates that the gyro was probably spinning. However, because of fire and physical damage to the engine and cockpit area, the vacuum system integrity could not be determined.

The accident reconstruction from the Garmin 296 GPS unit was extremely helpful in determining the accident sequence. According to the NTSB, “Downloaded tracklog data included the following parameters for each recorded data point: index, date, GPS time, GPS altitude, distance from previous update [leg length], time since last update [leg time], average groundspeed during period since last update [leg speed], average course during period since last update [leg course], and latitude/longitude position at the time of the update. Leg length, leg time, leg speed, and leg course information are all calculated by the download software and are not directly calculated and recorded within the GPS unit itself.”

Because virtually all new aircraft are delivered with GPS equipment and a few have dedicated flight log recorders, our knowledge of what happened will be significantly improved for future accidents—assuming the equipment survives the ordeal. However, this extra data still won’t address the pilots’ thought process—or lack thereof.

Analysis

Given a moderately experienced pilot in an easy-to-fly light aircraft, it’s reasonable to think there might be some overconfidence in this situation. The instrument rating confers a skill set that erodes with disuse, often faster than we realize, which is why the FAA requires either some recent experience or an instrument proficiency check. The level of degradation is probably not linear, nor does it affect all of us equally. Some pilots are more equal than others and maintain their skills longer, but it is impossible to know in advance how this will affect any one of us.

There can be no question regarding the weather. This wasn’t a situation where clouds suddenly enveloped the aircraft in flight. Nor was it the case of a dubious forecast along a distant route where poor visibility might not materialize. The airport was clearly covered in fog. So why would the pilot launch knowing that he was breaking the rules by not having an IFR flight plan or being current? Rhetorical question! The desire to complete the trip overpowered any concern about the weather. Did the pilot have a history of pushing the envelope on regulations? We’ll never know. My speculation is the pilot was neither current nor proficient on instruments but somehow felt confident enough to escape a localized fog condition. Perhaps the thinking was that a collision with another aircraft was unlikely and that he could maintain control to get up and on this way. He did not apparently feel confident enough to file IFR.

This pilot and his passenger paid the ultimate price, along with the beach house vacationers. General aviation and the local airport paid a high price, too. It will probably take a generation before Seaside residents forget that morning in August 2008. Image campaigns and PR efforts won’t easily erase this stain—it’s not the legacy any of us wants to leave, and we can do better.

Summary

• Pilot flying Cessa 172 departs airport in foggy conditions without IFR flight plan.
• Aircraft climbs to about 400 feet before entering climbing left spiral.
• Aircraft hits a beach cottage, killing three occupants and seriously injuring three more.