Safety Pilot: Landmark Accidents

Some accidents aren’t really accidents, since the definition of “accident” includes the adjectives “unforeseen” or “unexpected.” Here is a rare FAA overindulgence to tolerate those who don’t measure up. The pilot’s history is punctuated by an incredible series of miscues and mishaps by one who was, shall we say, financially gifted but aeronautically challenged. Normally I tend to be somewhat charitable toward pilots—see if you think that is warranted here.

History of the flight

On May 12, 1998, a turbine-powered Beech Bonanza A36 departed from Buffalo Niagara International Airport in Buffalo, New York, at 9:38 a.m. Eastern Daylight Time on an IFR flight plan to Moore County Airport in Pinehurst/Southern Pines, North Carolina. The aircraft carried the pilot and three passengers. Everything was routine until 10:54 a.m. when ATC called traffic to which the pilot replied, “I’m in the clouds.” A minute later the altimeter setting was given and acknowledged. At 10:58:43 a.m., the pilot was asked to recycle the transponder, but there was no reply. The Bonanza sustained an in-flight breakup with the wreckage scattered over a one-mile area of hilly terrain at an elevation of about 3,000 feet. The impact occurred near Davis, West Virginia, and there were no survivors.

Summary

A pilot suffers spatial disorientation in a turbine Bonanza in IMC. Icing may have been a factor. Four fatalities. Pilot had one accident and multiple incidents prior to his final crash. He consistently failed checkrides and requalification checks. The FAA’s oversight is in question.

The radar plot showed the Bonanza in level flight on a southerly course, at 13,000 feet, with a groundspeed of about 200 knots. At 10:57 a.m., it began a right turn and the last transponder signal was received about 23 seconds later, at an altitude of 11,800 feet. Subsequent radar contacts consisted of primary returns only with no altitude readouts. The returns were spread over a 16-square-mile area around the crash site.

The primary radar returns ceased at 11:00:31 a.m. The NTSB notes, “The scattering of primary returns is consistent with the in-flight breakup of an aircraft. The signals occur as the radar beam is reflected off aircraft parts, which may reach the ground much later than the primary wreckage.” A loss of 10,000 feet in three minutes predicts a vertical speed of something more than 3,000 feet per minute in descent. With small pieces fluttering slowly down and still providing a radar target, it’s probable that the fuselage’s final plunge was much faster. The radar-estimated groundspeed was between 242 knots and 253 knots.

Meteorological information

The weather was typical for mid-spring with scattered to broken clouds and the possibility of moderate icing aloft. The Buffalo forecast until 9 a.m. included scattered clouds at 1,000 feet, a broken layer at 2,500 feet, and temporary conditions of five miles visibility in light rain and fog. Greensboro, North Carolina’s forecast from noon until 4 p.m. included scattered clouds at 3,000 feet, broken at 7,000 feet, and an occasional broken layer at 3,000 feet.

Temperatures were forecast to be minus-4 degrees Celsius at 12,000 feet over Buffalo. At Raleigh-Durham, the temperature was predicted to be just below freezing at 12,000 feet until 2 p.m. The NTSB noted airmets for Pennsylvania and West Virginia that called for occasional moderate rime/mixed icing between 10,000 feet and Flight Level 180. The freezing level was 8,000 to 10,000 feet slightly to the north of the flight path. The winds aloft at 12,000 feet were generally east to northeast, and no thunderstorms or significant turbulence were reported in the accident area.

The aircraft

The Bonanza had a modified Allison turbine engine. It had no pressurization system, but supplemental oxygen was installed. It was equipped with engine icing protection, which included engine inlet anti-ice, a heated inlet fairing, propeller deice, and continuous ignition. The airplane also had a TKS weeping fluid airframe anti-icing system with windshield anti-ice. There was no indication that any TKS fluid was aboard the aircraft. Despite all this, the aircraft was not approved for flight into icing conditions, and the pilot’s operating handbook was very clear that the engine anti-ice system must be used any time the temperature was below 5 degrees C (41 degrees F) when in visible moisture. The deice and anti-icing switches were found off, but this was inconclusive because of the possible effect of impact forces.

The pilot

The 65-year-old pilot’s dossier is poor. Total flight time at the time of the mishap was approximately 1,500 hours. Time in type was not reported. In June 1994 the pilot failed the private pilot checkride but passed in July. In February 1995, the pilot did not pass the instrument practical test but was successful in March 1995.

In the summer of 1996 the pilot attended turbine Bonanza training at FlightSafety International but nearly didn’t survive the trip. The pilot told his flight instructor that while en route to the training site, he’d encountered a thunderstorm. With hail damage and a 6,000-foot loss of altitude, he attempted to reverse course, but wound up in a 60-degree bank, so he leveled the wings, put the landing gear down, reduced power, and “decided to plow through it.” The pilot then landed at the wrong airport and ran off the runway into the grass. He was cleared to land on Runway 36, but landed on Runway 18 with a quartering tailwind of about 15 knots. The hail damage included “some dings on the stainless-steel wing leading-edge deice system, and holes in the radome.”

It gets worse. The pilot said one reason he wanted to take the training was to learn more about turbine engines. He had previously exceeded the engine temperature limits during start, and had to have the engine hot section replaced.

FAA accident/incident records noted a gear-up landing in August 1996 when the pilot executed a missed approach and failed to put the gear down on the second attempt. In September 1996, the FAA requested a reexamination, to “consist of Private/Instrument procedures with emphasis on rejected landings, missed approach procedures, and emergency operations.” The pilot failed the evaluation three times. In April 1997 the FAA sent the pilot a letter stating he lacked the qualifications to be a private pilot. But in September 1997 he managed to complete a reexam. The success was short-lived.

Less than a month later, after making a night landing, the pilot taxied off the active runway onto the grass between the runway and the taxiway. The pilot then “turned the aircraft 180 degrees, and taxied back onto the active runway without a clearance or notifying the tower of his intentions.” As a result, a Boeing 737 on short final had to go around. The FAA again requested a reexamination. The pilot failed, but the FAA gave him a temporary certificate anyway! The pilot completed his reexam in April 1998.

There is considerable documentation in the pilot’s medical file regarding a possible neuropsychological condition, and much of it argued for his not being issued a medical certificate. There may have been an element of professional courtesy since the pilot was a radiologist and his medical was never revoked. In an Aeromedical Certification Division staff comments sheet dated May 12, 1998—the date of the accident—the following was written: “Psychology report recently received… does not indicate pathology.”

Analysis

The NTSB’s probable cause was, “The pilot’s spatial disorientation, his subsequent loss of control of the airplane, and his overload of the horizontal stabilizer during a recovery attempt. Factors include the pilot’s continued flight into icing conditions, his lack of airspeed control, and the lack of an airmet advisory from the weather briefer.”

A potentially icy air mass at the flight’s cruise altitude could be expected with a northeast flow off the ocean in springtime. A change to a lower altitude would certainly have solved any icing problem at the expense of some fuel. Why would the aircraft not have been on autopilot? Perhaps the icing was such that the autopilot disconnected or the pilot was hand-flying.

The NTSB’s probable cause dwells on the technical aspects and completely misses the root cause—a total meltdown of the enforcement process. Here was a pilot who clearly had difficulty in processing the demands of high-performance cross-country flying. FAA oversight was lacking—yet, in too many cases, the agency tends to overreact to minor infractions with pilots who otherwise have excellent records.

Psychology is an imprecise science and to state, with certainty, that someone is psychologically unfit must be done with care. The observable operational evidence here is undeniable—this individual had no business flying. Sadly, three innocent lives were lost because of both an individual and systemic failure. Thankfully, this situation is rare.