Accident Case Study: Final Approach

and hopefully without declaring you have a heavy to extreme sell at your 1 to 2 o'clock reports the pilot of the plane may have been doing aerial acrobatics just by no stretch of the imagination are we healed and we may never be it's 6:45 p.m. on January 13 2013 a gloomy overcast evening on the mid-atlantic coast three miles from the end of runway one for a Dover Air Force Base a piper arrow glides silently through the clouds propeller wind milling in the slipstream its pilot searching desperately for the glow of runway lights through the gloom just a few hours earlier such a dire situation is almost unthinkable in Sandersville Georgia the arrows pilot an orthopedic trauma surgeon is preparing for a routine aerial commute to Delaware summit Airport he's scheduled to perform surgery and nearby Dover the following morning it's 10:00 a.m. when he requests a Duarte's briefing for an afternoon flight the verdict is mixed IFR conditions prevail over a large swath of the mid-atlantic and terminal forecasts call for ceilings of 3 and 400 feet with visibilities of two miles and mist and light rain starting around 4:00 p.m. however conditions are expected to improve significantly with visibility increasing to 6 miles and ceilings rising above 1,000 feet it's not an ideal forecast but given the pilots qualifications it's hardly a showstopper the 600 hour private pilot is instrument-rated and current with nearly 80 hours of actual IMC log he sloane 30 hours in the previous 90 days and his airplane has a wass enabled garmin 430 and an S tack 30 autopilot timing his arrival in Delaware to coincide with the expected break in the weather the pilot files for a 1:30 p.m. departure and chooses Baltimore where the weather is forecast to improve more dramatically as his alternate at liftoff arrow four Niner seven five Sierra is carrying an excess of five hours of fuel plenty it would seem for a three-hour 45-minute flight 3 hours and 20 minutes pass before the first hint of trouble by this time the pilot is on initial approach to summit airport but ATC has troubling news and if ember sometimes here Philadelphia approach just informing a guy with mr. proton summit was unable to I had a remington headed over to had an event to add a film about the user space okay he did not land itself and if ever said perhaps you sure he was unable a that limited as well alright I guess I'm gonna have to divert and let's look for an airport that I can do it in to Salisbury Airport 53 miles south apparently seems a promising candidate and the pilot asks the controller for the latest weather there Salisbury lymph I have a correction Salisbury to and to 9zu observation as a scene Thunderfoot overcast at 8 miles visibility I want to try Salisbury and there were 7000 oh you're cleared via lectern direct maintain 5,000 by the time the pilot diverted to Salisbury it was clear that the earlier forecast of rising ceilings was if not wrong then at least mistimed what's less clear is whether the pilot could have been aware of this earlier in the flight we don't know whether he called for updates and route but in any case there likely were no meaningful updates the relevant forecasts had not been revised and his earlier briefing had led him to expect conditions to improve only late in the flight the decision to divert was another matter given the reported weather and the aircraft's fuel status Salisbury was not an entirely unreasonable choice despite being 25 minutes away nevertheless from a broader perspective it does point to a couple of worrisome issues first much like his selection of Baltimore as an alternate the pilots choice of salisbury seems to indicate a lack of big-picture weather awareness given that similar conditions prevailed over the entire area the odds of the weather being significantly better at any nearby airport were slim second his conversation with Dover approached hints at a somewhat passive attitude toward ATC hearing the news about the other aircrafts failed approaches the pilot simply took it for granted that he wouldn't be able to land at his destination at no point did he inquire about the approaches flown or the actual weather conditions together such lapses set the stage for much greater difficulties ahead half an hour after the pilots initial exchange with Dover approach November 7 5 Sierra is 11 miles out on the Arnav runway 1/4 approach to Salisbury passing hiders overview on a GPS 2 1 4 7 5 0 1 for the Arnav approach to runway 1 4 has a decision altitude of 300 6 feet AGL when flown to lpv minimums lpv requires a wass enabled GPS and provides both horizontal and vertical guidance much like a traditional ILS for reasons that are unclear however the pilot discontinues the approach while still nearly 300 feet above decision altitude 7 5 she was going missed seven last year object approach shortly thereafter approach control calls Salisbury Tower to let them know that the pilot is attempting the RNAV approach again rather than switching to the ILS from the opposite direction alas the second attempt goes even worse with the aircraft deviating from the final approach course and declaring a missed approach 200 feet above decision altitude and tower for some reason my my GPS is not working right let me pull up and we'll try it again after being handed off to approach however the pilot decides he's had enough of Salisbury he queries the controller about weather at Georgetown Delaware 22 miles back to the north upon learning that the reported ceiling there is 700 feet he sets a course for airport number 3 together the attempts to land at Salisbury raise one of the central questions of the flight why after two failed GPS approaches with the pilot not avail himself of the ILS approach to the opposite runway the wind was calm the ILS offered significantly lower minimums and programming would have been a snap we'll never know for certain but there are a couple of potential explanations it's possible for example that the pilot was simply uncomfortable with ILS approaches it seems more likely however that the option was simply overlooked it was dark the pilot was flying solo and IMC things were not going well and fatigue was likely setting in it was a situation ripe for mistakes it was also a circumstance in which ATC might have been able to help the airport wasn't busy and the controllers knew the pilot was having trouble with the RNAV approach under the circumstances a simple suggestion to try the ILS might have made a real difference whatever the case by the time November 7 5 Sierra headed back north having burned an hour of its fuel reserve the situation had become vastly more serious it's now 6:01 p.m. roughly an hour past the pilots original ETA and he's just been cleared for the RNAV runway two to approach at Georgetown Delaware sympathia I got the Georgetown to confine for dual observation wind is estimated a one eight zero seven five miles visibility was missed ceilings overcast at 300 feet thank you sir the the ceiling is 400 feet lower than reported just ten minutes earlier it's also slightly below minimums for the approach but the pilot ops to proceed anyway this time he descends a hundred feet below minimums but the end result is the same sober I gotta go around to get it set aside here similar to popular concept and my selfish time is for interesting let's try that again please so make them touch the advisors funny things sometimes now however there's a new concern fuel it's 626 p.m. 4 hours and 55 minutes into the flight I want a pretty well how about to that be ok sometimes I'll see a hundred thirty thousand two million thousand seven hundred so much for those busy for the win well if you have anything that's easier to do most American travelers really wonderful house is the weather better air and sometimes there's a fire lever which apparently cannot listener be positive we overcast little bear those are shown all right rapido couple thank you as the aircraft nears Dover Air Force Base and rude to three three November the pilot asks a logical question about suppose there's a chance I can land ass over so many popular letters for emergency there we go have you ever okay yeah but it is an emergency ten minutes later and eight miles north of the base there's a frantic call from the pilot of seven five Sierra Sam I'm declaring an emergency here I'm out of fuel I have out of fuel and going down by the time the pilot asked over approach about landing at the base he'd been airborne for five hours from his flight planning or failing that his fuel gauges he must have known that he had precious little time left and he still had more than ten miles to go before commencing a non-precision approach in marginal weather how could any pilot consider that anything other than an emergency the most likely explanation sadly is that he was ashamed to confess his predicament and all too aware of the fact that he was talking to a military controller about landing in an air force base those factors coupled with the controllers strong if appropriately qualified statement about landing at the base our likelihood kept him pushing on in silence despite the dire situation and ultimately what caused him his life ma'am I'm declaring an emergency here I'm out of fuel I have out of fuel and going down if he vectors please similar to the later few hours and nonpolyposis over the next few minutes confusion reigns as the approach and tower controllers attempt to vector the stricken aircraft for landing at Dover and out of fuel and going down somewhere some Barfield away from total six months keep talking to me please no my things I feel lighter I am going down so myself I swear you had the same effect negative negative negative Pamela Theresa I still heading in the right direction seven five Sierra there since I hear a thunder side beyond hit letting pinion in my collection expected mm mm for services a charm force right now on course but out of energy shortly thereafter the aircraft collides with trees two miles off the end of the runway and crashes to an abrupt fatal halt the crash of November 7-5 Sierra is something of an enigma while it's easy to see how a pilot of modest experience could find himself suckered in by marginal weather and an inaccurate forecast the mistakes that turned a bad luck into tragedy are harder to understand in the end though what matters is what we can learn and this is a case with no shortage of lessons the first and most obvious is that weather can be a deal breaker and when conditions argue for a change of plans safe pilots listen forecasts can be wrong and it's particularly important to be wary when conditions are expected to improve if you decide to go always leave yourself and out and get updates and route weather is dynamic and our decision-making process needs to be equally dynamic likewise avoid focusing too narrowly on the destination Airport zoom out and look at the whole region legal doesn't always equal safe and in a large weather system the only realistic alternates may be far away which means carrying plenty of extra fuel even if it requires a stop in route a good rule of thumb with large systems is to start with twice the fuel required to reach your destination even then it's still critical to have a viable plan B and if that falls through to speak up about your situation in the clearest possible terms don't be afraid to expand your options by using the e word had the pilot instead of saying quote I'm running pretty low declared an emergency and told the dover approach controller that he had less than 20 minutes of fuel he'd probably be alive today that points to another issue military airfields are fair game in emergency situations there may be some explaining to do after you land but it's a small price to pay to ensure a safe outcome awareness of approach options and the ability to exercise those options is also important a diversion in low weather at night is no time to be hesitant GPS programming or unaware of an ILS approach to your alternate finally there's the matter of decision making it can be tempting to hope that one more try will fix things but in truth you're usually just digging the hole deeper try something different don't let plans and expectations become blinders that keep you from seeing better options the crash of November 7 5 Sierra was a tragedy not only for the pilot his family and friends but for the medical community as well it seems safe to say that had the accomplished surgeon faced a crisis during an operation he would have availed himself of every resource to save his patient in a case with many ironies the fact that he was unable to extend the same level of care to himself is perhaps the saddest you

Channel: Air Safety Institute

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Keywords: Aviation (Industry), Aviation Safety (Literature Subject), Aircraft Owners And Pilots Association (Membership Organization), AOPA, acs, accident, case, study, plane, ASI, airplane, crash, GPS, Final approach, final, analysis, Insurance, Wings credit, piper, arrow, collision, collided, Delaware, Dover, Air Force, disaster, ntsb, faa, investigation, accidnet, fatal, student, pilot, training

Id: fLlWf-Fk_YM

Length: 16min 49sec (1009 seconds)

Published: Tue Jun 30 2015