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Autopilot mode mix-up sends pilot into ridgelineAutopilot mode mix-up sends pilot into ridgeline


Understanding proper IFR procedures and carefully programming key avionics are two important aspects of safe flight. When taking off from an unfamiliar airport at night, in marginal weather, with rising terrain nearby, these aspects become critically important. Ignore one, and the flight is in jeopardy. Fail at both, and tragedy is all but inevitable.

On the night of March 14, 2008, the pilot of a Cirrus SR22 took off westbound from Front Royal-Warren County Airport in Front Royal, Va. Rapidly rising terrain required an immediate climbing right turn to the northeast. The pilot entered the appropriate waypoint into the airplane’s GPS but failed to set the autopilot to the correct GPS steering mode. The aircraft climbed straight out, impacting a ridgeline four miles west of the airport. The pilot and his passenger were killed.

Related Links

IFR Insights: Charts” interactive course

GPS for IFR Operations” interactive course

Your airplane is watching: Flight data recorders are here” April 2009 AOPA Pilot article

Air Safety Institute Accident Database

The pilot had flown from Baltimore, Md., earlier in the evening to pick up his son. At 11:24 p.m., he telephoned Potomac Clearance Delivery for an IFR clearance back to Baltimore. The clearance included initial instructions to fly direct to the COGAN fix, climb and maintain 4,000 feet, and expect 5,000 feet 10 minutes after departure. COGAN is located about 13 nautical miles northeast of Front Royal Airport.

Shortly before midnight, the pilot departed Runway 27. Marginal visual meteorological conditions prevailed at a nearby reporting station: visibility three miles in rain, broken ceiling at 2,400 feet agl. The wind was from 340 degrees at 4 knots.

Recorded data from the airplane’s primary flight display (PFD) showed that the Cirrus climbed straight out to the west, maintaining roughly runway heading for the duration of the 80-second flight. A 2,400-foot ridgeline is located about four miles west of the airport. Data showed that the airplane reached an altitude of 2,200 feet msl before making a steep left turn. The bank angle reached 95 degrees during the last-ditch evasive maneuver and the nose pitched down. The airplane struck terrain and burned.

PFD data indicated that, prior to takeoff, the “desired course” parameter was set to about 050 degrees, consistent with a magnetic course from the airport to COGAN. Just after the airplane began its takeoff roll, a GPS waypoint of COGAN was selected. The primary navigation source was set to GPS No. 1, while the horizontal deviation source was set to GPS No. 2. The airplane flew straight out after departure rather than turning toward COGAN, consistent with the GPS steering mode of the autopilot system not being selected.

According to the NTSB, the probable cause of the crash was the pilot’s failure to maintain clearance from rising mountainous terrain, and his failure to turn toward his assigned course during initial climb. Contributing to the accident were the low ceiling, reduced visibility, dark night conditions, and rising mountainous terrain.

There was no record of the pilot previously departing the airport at night. It’s unclear whether he was familiar with the takeoff minimums and obstacle departure procedures for Front Royal Airport, but all pertain to Runway 9. The notation for Runway 27 is simple and direct: “NA-obstacles.” With a light, four-knot wind that was nearly perpendicular to the runway, the pilot should have departed in the safer direction—eastbound off Runway 9.

Whenever the airport is unfamiliar, the conditions are less than ideal, and the surrounding terrain is hostile, it’s important to understand the procedures that will ensure a safe departure. And if you’ll be relying on an autopilot to fly those procedures for you, the time for button pushing shouldn’t be the takeoff roll. Program your avionics well before taxiing to the hold-short line, when you can focus entirely on the task at hand. Dividing attention can lead to mistakes—errors that can turn tragic if they send you headlong into rising terrain.