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Unaccountable lapses, part twoUnaccountable lapses, part two

“Unaccountable lapses, part one” (July 12, 2016, Flight School Business) discussed flight instructors’ responsibility to make sure so-called “off days” don’t compromise their students’ chances to learn, much less their physical safety.

In 2014 a 51-year-old student pilot flight-planned for a dual night cross-country, only to have the instructor change the plan to another destination on the day of the proposed flight. No updates or revisions were made to the original flight plan.

The CFI and student took off at sunset in a Cessna 172S equipped with analog instruments instead of the G1000-equipped 172 that had been reserved, but was not available. They practiced a bit of pilotage and some VOR tracking, and made two or three stop-and-go landings at the airport en route. By the time they left it was completely dark, the moon still below the horizon.

The instructor had the student level off at 3,000 feet and hold a heading of 240 degrees. Knowing they were near the hills, the student asked about elevations in the area. The CFI “replied that he did not know the specific terrain elevation because the aircraft did not have the G1000.” The student further recalled that they didn’t have any paper charts open in the cockpit, though a copy of the Washington, D.C., Sectional was folded up inside his flight bag.

A glance at that sectional wouldn’t have been a bad idea. Their cruising altitude was well below the maximum elevation figures (MEF) in the area, which ranged from 3,600 to 4,400 feet. But it wouldn’t have helped with arrival planning, as their destination airport was on the adjoining Cincinnati Sectional. It sits on top of a ridge at nearly 3,800 feet above sea level—800 feet higher than the altitude at which they were flying toward it.

The CFI began a series of autopilot demonstrations, making turns at 20- and 30-degree banks and then setting up a constant-rate climb. With the airplane pitched to climb at 500 feet per minute, the student noticed its airspeed decaying and asked whether he should add power. Just after the instructor opened the throttle, the airplane crashed into a hillside 300 feet below its summit. The MEF in that quadrant was 5,100 feet. The instructor was killed; his student survived and was rescued the next afternoon. Their decision not to file a flight plan meant that the airplane was not reported missing until morning, and searchers didn’t know its route. Moreover, air traffic control failed to follow up on several reports of the Cessna’s ELT transmission.

The official record of the accident investigation offers no insight into the reasons for the instructor’s uncharacteristic behavior. In retrospect, it seems plain that his mind wasn’t on his work that evening: The abrupt change of destination without fresh flight planning and his failure to add power for an autopilot climb both suggest some deep distraction whose cause was never elucidated. He probably should have cancelled the lesson, but he didn’t.

Answers are easier for those of us pondering how to guard against this type of single-point failure, however. Requiring all cross-country flights to operate on active flight plans at least guarantees that search-and-rescue will know where to look and when to start if an aircraft never arrives—and the briefing that accompanied the filing might have pointed out an en route altitude of 3,000 feet wasn’t going to reach an airport situated at 3,800.

David Jack Kenny is manager of safety analysis for the AOPA Air Safety Institute.

Read Unaccountable lapses, part one

ASI Staff

David Jack Kenny

Manager, Safety Analysis
David Jack Kenny analyzes GA accident data to target ASI’s safety education programs while also supporting AOPA’s ongoing initiatives and assisting other departments in responding to breaking developments. David maintains ASI’s accident database and regularly writes articles for ePilot, Flight School Business, Flight Training, CFI-to-CFI, and other publications.

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