Accident Case Study: In Too Deep

it's the morning of November 26 2011 at the Marion Indiana Airport a pilot his two college-age daughters and the younger daughter's boyfriend are preparing to depart in a cirrus sr20 it's Thanksgiving weekend and the plan is to fly the older daughter back to her College near Chicago's 2-page Airport then return home to Indiana the 47 year old private pilot has 207 total hours of flight time about half of it in this aircraft November two to three Charlie Delta which is owned by a local flying club he is not instrument-rated though he's apparently received some training how much is unclear his logbook shows a total of three hours of simulated instrument time and 29 hours of actual but because of issues with how the time was logged this probably overstates his true experience in IMC by approximately 8:30 a.m. the aircraft is fueled and the pilot departs Marion VFR at at Northwest the flight to de page will take a little over an hour on the day of the accident a low-pressure area centered over Wisconsin dominated the regional weather the system had brought IFR and marginal VFR conditions to much of northern Illinois it's unclear what weather information the pilot received prior to the flight but at the time of departure the area forecast for Chicago showed marginal VFR ceilings with light rain between 9:00 and 11:00 a.m. IFR conditions were expected thereafter likewise the terminal forecast for DuPage showed marginal VFR at the time of arrival broken clouds at 2,500 overcast at 3500 with six miles visibility 45 minutes after departure however that forecast would be amended to show an 800-foot overcast with five miles visibility and rain and mist it's not clear whether the pilot ever received the updated forecast in the aftermath of the accident a CFI at Marion reported that he and the pilot had briefly discussed the weather just prior to the flight the pilot was aware of IFR conditions in the area but pointed out that DuPage was forecast to be VFR at his time of arrival it's now 9:58 a.m. in the control tower a 2-page airport a call comes in from cirrus 2 to 3 charlie delta radar shows the aircraft two miles south of the airport at roughly 1500 AGL on the field the ceiling is 900 feet power 53 charlie delta what you - 3 charlie delta hf that's coming in let me see visual flight rules was wondering if we can be available for landing then through charlie delta the field is IFR same tension 30 seconds later the pilot calls again it may sound i college eyes i just go over your field I didn't realize I'm going that fast that's rich our Lee Delta IFR say your intentions I'm in IFR we're gonna move on now I was just checking that went down to that sit down and stay pretty well so I shouldn't leave you are available let's write out did you want to land at the page if possible that would be wonderful you have the field in Placer Terrace our Corning yeah do you have the field the DuPage airport in sight all right yeah we just flew past okay just son make a right 180 and land 2-0 right when to zero zero one five right 185th you're right two minutes later the pilot reports that he no longer has the airport in sight and is given a suggested heading however he seems to be having second thoughts about landing it to page three Charlie Delta say intentions I think I'm about tempted in the airport closet to have better visibility because I don't want to get in there and get stuck all day three Charlie Delta do you want to talk to Chicago approach they can help with vectors or you know I think I'm okay doing it either way but I was just do you have a later airport er I mean a report today three Charlie Delta Chicago executive the weather there is a we have visibility of one zero they're suing 1500 overcast they're VFR right now fire that what's their code we Charlie Delta Papa whiskey kilo Roger Papa with zero thank you again three choices are you familiar with the area at all I got my my what am I trying to say my training they're three Charlie Delta Roger would you like to talk to approach they can give you justice headings and help you get into Milwaukee a little better than I can I'm still trying to decide if I want to turn away anything page or not would you think that's a good idea or not the DuPage tower controller now seems to realize that something is amiss he asks about the pilots flight conditions and qualifications for IFR flight carried out there are you currently be afar right now three trade doctor you in the clouds are you clear the clouds I'm actually I am I made an out of the clouds right now we tried other you I have are qualified I'm Ania fire training and I let this get around me now more alert to the potential danger of the situation the controller calls Chicago TRACON and arranges to hand the aircraft off to them for help getting to a VFR Airport extra three to page three a CSV apart or approximately 1 0 miles north of under 2,200 using the clouds and he needs Baxter's either in to us or pillaji looks like they have a better ceiling and he's not IFR qualified can you give them to just headings to get him at least Milwaukee Wow what is go walkies whether they're showing it up feeling a fifteen hundred and ten for the visibility ok let me get right back to you right I think so much are you still there yeah you see about the 11 miles northwest of the page at two thousand there I'm not talking with that guide to page towers he says he he's not IFR qualified he's looking to go get vectors from tell rocky peak in VFR nice yeah so I'm just gonna tell the pages that I'm over T okay okay by the time the pilot contacted to page tower things clearly were not going well with his attention focused on the immediate problem of flying the aircraft in marginal conditions he was obviously having trouble staying on top of things it was the wrong time to be casting about for a plan B the fact that he ended up in such a bind says something about his priorities that day clearly the mission of getting his daughter back to school had taken on great importance but his determination not to get trapped by the weather shows that something else was competing for his attention getting there wasn't enough he also needed to get home and therein lay the problem given the weather succeeding in one mission meant failing in the other we can only speculate about what else may have weighed on the pilot's mind that day the wasted effort of a failed flight the potential embarrassment of turning back plans for later that weekend or perhaps simply the fact that he was a busy man who didn't want to end up stranded 200 miles from home whatever the case the end result was a pilot struggling with indecision seemingly looking to ATC for advice but not taking the kinds of action that would indicate he understood the true gravity of the situation it's now 10:08 a.m. and DuPage tower has told the pilot to contact Chicago TRACON which is expecting to hear from him the aircraft is now north westbound below the Class B airspace after five minutes without word from the pilot the new controller attempts to raise him November 2 3 3 charlie delta a chicago broach 53 charlie delta we are we're heading out of your area and going to get better visibility and number 2 to 3 charlie delta okay you're just going to continue westbound VFR Roger that on November 2 to 3 just Charlie Charlie Delta just for your information executive is showing an overcast at 1,500 feet while Keegan's and overcast at 1,400 you have the page and I'm looking up Rockford right now for you and Rockford at 700 feet over cap at this point there's no indication that the pilot is having trouble controlling the aircraft though his somewhat confused interactions with a controller indicate that he's under considerable stress I painted where we'd want to go but it seemed like it was lower than than 900 feet or thousand feet yeah the page right now is showing overcast at 900 feet Roger that if that's the case I think we'll just enter the page the page is IFR I Roger that but I apologize I think Jose had repeat if you have where was the closest one to see a barn and November two to three Charlie Delta the closest one I'm showin is executive and like I said that shown in overcast a 1500 feet Roger that will have sports executive I could you remind me at their call letters Papa whiskey kilo Roger Papa whiskey kilo number seven seven whiskey and climb and maintain two thousand four hundred Roger 2,450 we're at 2000 number seven seven with the affirmative two thousand four hundred for me please you're a deployed bar and I think someone else read back the two thousand four hundred that was four seven seven with he only from a two to three Charlie Delta November 3 Charlie Delta I just want to make sure that health tube restriction was not for you Roger 2400 and hold negative two to three Charlie Delta that altitude was not for you sir maintain VFR a few minutes later the pilot tells the approach controller that he's changed his mind about landing at Pojoaque Cirrus two to three Charlie Delta executive ATIS information Victor is current and let me know when you can navigate direct and what you like flight following at this point I don't want to mess with the weather I'm gonna get out and I don't want to get stuck in here there's two to three Charlie Delta okay so you're not you're no longer in bill to executive I know we've navigated out of your airspace yes two to three Charlie Delta frequency changes approved project maybe not help them by the time of this last exchange the pilot has turned left to a westerly heading possibly to continue the search for a VFR field possibly in preparation to head home a minute later he begins another turn this time to the right the turn becomes a descending spiral which continues until radar contact is lost at roughly 900 feet on the ground witnesses report hearing what sounds like an airplane doing aerobatics seconds later the doomed Cirrus emerges from the cloud bottoms in a 70-degree die as the onlookers watch helplessly it plunges to the ground and disintegrates instantly killing the pilot and his three passengers hey you guys remember that two to three Charlie Delta can you uh can scoffs find someone to talk to him and call me back really quick it's kind of important Charlie got a guy out of de Pays uses heavy problems and a new executive okay no he decided to go on his own last we saw me was about five north of Lake in the Hills northbound I lost radar on him he was like 1,800 feet the crash of Cirrus two to three Charlie Delta is a tragic but sadly typical example of the kind of accident that kills more pilots than thunderstorms icing and all other weather phenomena combined in a way though the accident is anything but typical what's different is not the proximate cause or weather and spatial disorientation but the fact that the pilot in his discussions with ATC so clearly articulated a mindset that contributes to far too many aircraft accidents they say it takes two to tango in training materials we read about the insidious qualities of low ceilings and poor visibility the ways they can lure a VFR only pilot deep into worsening conditions and in doing so make escape difficult or impossible but in reality of course we as pilots are almost always complicit in our own entrapment there's somewhere we need to be there's something we want to do there's some worried about disappointing friends or family about failing in the task we've set for ourselves with such thoughts we bind ourselves to a course of action and it's only at the end when the horizon suddenly tilts and the mind can't make sense of what the eyes are telling it that we understand the true gravity of the situation there is no single solution to the problem clearly a degree of respect for one's own limitations as a pilot and a corresponding respect for the unpredictability of weather is part of the answer the presence of mind to step back recognize a deteriorating situation and take action is another and perhaps a more honest acknowledgement of how much is at stake is part of the answer to in this case the price of failure was for lives but it was also the years of grief for those they left behind the nightmares of those who saw it happen and the doubts of those who will always wonder if they could have done more and no mission is worth any of that

Channel: Air Safety Institute

Views: 1,614,987

Rating: 4.8498197 out of 5

Keywords: radio, airplane, plane crash, airport, pilot, emergency, safety, radio communication, risk management, airplane crash, decision making, air crash investigation, flight plan, vfr, ifr, air traffic control, flight safety, safety tips, flight training, aviation safety, airplane accidents, general aviation, vfr into imc, accident, crash, analysis, ntsb, faa

Id: W0lWsqAwYwY

Length: 15min 6sec (906 seconds)

Published: Fri Mar 22 2013

Reddit Comments

[u/Senno_Ecto_Gammat]

VFR is visual flight rules and is what you fly under when you have good visibility around the aircraft and to the ground.

IFR is instrument flight rules and is used in bad weather or while flying through clouds or sometimes darkness, for example. Flying IFR is sometimes called flying "on instruments" because the you can't see anything out the window and have to rely on your instruments for all the information.

[u/Wilkinson_the_third]

A sad story that has been repeated to many times. I strongly recommend the book "The Killing zone" by Paul Craig, to any aspiring/new/somewhat seasoned pilots. It highlights the most common reasons for crashes as well as to whom it most often occurs!