Real Pilot Story: Hidden Hazard

it's a cold February evening at duth International Airport with temperatures in the weather briefing reporting -12° C the Pilot's trip began earlier that day when he flew from Winona municipal airport his home airport to thunderbay Ontario via duth for a meeting before heading back home the roundtrip totals approximately 630 nautical miles well within the capabilities of both the pilot and instrument rated CFI with over 2100 hours of logged flight time and his aircraft a 1969 m20c Ranger it's equipped with a Garmin 530 GPS and ANC 30 autopilot which includes altitude hold heading hold and GPS steer among other functions after clearing customs at duth International Airport the pilot files an IFR route direct to Winona municipal airport and is cleared as fire 49 you ready to go you need a few more minutes yet yeah we're just about ready to go 49er Victor turn left 2 40 Runway 27 clear for takeoff all right left uh 240 clear for takeoff go during climb out the pilot pitches the airplane to climb at an air speed of 105 knots and sets his trim to hold that attitude at his current heading approximately 195° after a few Transmissions with duth Tower the pilot switches to departure frequency good afternoon departure M1 49er Victor uh climing through 4,300 49 Victor 49er Victor departure R contact turn left direct wona maintain Niner th000 left direct wona up to ner that was the last thing I remember of the flight and that was only about 4 and 1/2 minutes after I took off you see uh sols and fuel remaining I don't know how much fuel I got but I thought I got at least one or two [Music] quarts you had two choices to give up or fight for your life told him I loved them and I put the nose of the plane down into the canyon the Mooney flight track shows the airplane maintains its heading and stops climbing at an altitude of 12,500 ft considerably higher than the Pilot's filed altitude of 9,000 ft Bo ner4 ner Victor if you hear duth contact Minneapolis Center 12.05 and let them know what altitude you're climbing to 95 minutes after takeoff at 12,500 ft MSL the Mooney's engine stops due to fuel starvation Flight Aware data stops reporting the Pilot's location at 7:53 p.m. 72 nautical miles west of his intended destination at an altitude of 2,300 ft MSL Rescue Services are dispatched to the aircraft's last known location the next thing I know is I'm waking up and I I I think I'm flying and I want to tell ATC I fell asleep so I started keying the mic and trying to raise ATC and as I'm doing this I'm looking forward and I started to kind of get happy because my window was so clear I was like this is really nice I kind of paused I'm like this looks really good and then I remember Reaching Forward to touch it kind of and it was gone there's some pictures after the accident and you can see the glare Shield and there's a hand streak coming back through my condensation that was all over the the panel and that was from me Reaching Forward and pulling my hand back and as I was doing that then I noticed that there were some trees off to my left and that I was in kind of a field and that's when I I started to realize I wasn't flying anymore I arrived out at the airport I'm not a huge morning person and so I didn't get up early enough to have any sort of breakfast or any sort of coffee and coffee was pretty common for me and I didn't have any that that morning I took off on Runway 30 out of Winona and I'm in the climb and something got caught in my eye and it irritated my left eye I do remember that uh and I started rubbing it and I was trying to trying to get it out and figure out what it was and then I thought to myself oh this could be carbon monoxide cuz it's the winter and I'm running the heat on full so I turned the heat off off and to see if it would clear up and I did get whatever it was out of my eye and got my eye clear but then I thought that has nothing to do with carbon monoxide um it was just something caught in my eye and it was getting really cold so I turned the heat back on and continued on and that was the last time I thought about carbon monoxide the entire day I always have a pulse oximeter with me and if I'm cruising at 5,500 ft or 175 I'm always checking it and seeing where I'm at so I have a good idea and a good Baseline of where I'm supposed to be on this particular flight I was at 10,000 ft I put it on I don't remember the reading but I remember the reading was several points higher than normal and it was in the morning and it was beautiful and I had several points higher than normal and I thought this is going great I'm doing really well and I took it off and that was the last time I used it um but it was also another little tidbit on what was happening to me so the pulso symmetry works on color the blood and the the carbon monoxide colors the blood in the way that it increases your O2 saturation on a pulse oximeter so I thought I was doing better but really I was seeing that I was being poisoned by carbon monoxide and I was I had much much lower O2 sets so for 2 and 1 half hours I had the heating system on full 10 to 15 minutes before I landed I started to get a slight headache and I immediately thought about the coffee I didn't have and I just assumed I I was having a caffeine headache which was at that time in my life was really common if I cut out C caffeine I was that kind of addicted to it so it didn't it didn't set off any alarm bills at all I taxied into the ramp and I called the Canadian customs CU that was the procedure I was to call them on the phone and let them know what time I landed and the Customs agent asked and I told him I landed at 9:5 just a few minutes ago and he was kind of confused and there was some fumbling around and he then gave me a clearance code and I wrote it down and uh I think he said have a nice day or something to that that like and I got out of the airplane secured it I plugged it in and I sprinted into the FBO building and when I got in there I found out that Thunder Bay in the winter time was on Eastern Time Zone not Central Time Zone and I had no idea Chicago Central Time Zone that's Far East compared to Thunder Bay I immediately thought about my conversation with the Customs agent and that's why he was confused it was really 10:15 it wasn't 9:15 and I arrived outside of my plus or minus 30 minute window by 45 minutes I had this anxiety feeling I thought I was in trouble I thought that maybe the Customs would come breaking in and I would I would get locked up or who knows I I had no idea this anxiety feeling I had I've never experienced before uh I've never experienced since but I attributed it to anxiety and so I thought that um the way I was feeling was because of what happened with customs and I didn't think there was any other influence on it so up until this point I had the higher pull socks and I had the slight headache and I had anxiety which isn't normal for me so then I went and got lunch I got some coffee and I my headache started to go away started to feel a little bit better uh and I went back to them after lunch and had the meeting with them and and everything went went well with the meeting uh but my headache would come and go it would it would be kind of strong but then it would get go away and it would kind of come back and it would go away Thunder baited Deluth the entire flight I didn't have any physical symptoms I felt good it was just a nice ending to the day so I landed duth and I felt great I taxi up I shut the plane down and the second I stood up on the wing outside of the airplane so I open the door and I stand up and I got a splitting headache it was almost as if someone hit me in the face and it it was that abrupt and quick and what I was attributing it to was my my daughter was sick that week leading up to this and I assumed I was getting whatever she had um and that was how I Justified it this time and the other thing that was interesting was that symptom didn't come in the airplane it came when I got out of the airplane and so I never connected the way I was feeling with the airplane itself I go and finish the Customs so I ran out jumped on the plane got it started and as I was idling then I got my iPad and I filed my IFR Flight Plan back to Winona as I was waiting for that to be in the system because the tower wouldn't know I have an IFR flight plan I organized the cockpit I put hat and gloves on the seat next to me I put my headlamp on that I always wore at night I put my headsets on obviously uh I had the flashlight next to me once I got uh notice that it was in the system then I called the ground and got my clearance I'm going Victor where over here here at the FBO with uh information here we're ready to copy R Moody 49 Victor clear the onea airport as filed maintain 6,000 expect 900,000 one0 minutes after departure depart Frey 1 12545 SC 4250 clear on file 6,000 expect 9,0 minutes 12545 departure and 4250 49 Victory you back correct by the time I got my clearance uh I had already been sitting in the cockpit with the heat full on trying to stay warm for between 10 and 20 minutes at this point I knew I didn't feel well but I was just an hour from home and so I just wanted to get home and not feel well there uh on the taxi out there was a moment where I had that anxiety for me come back and it hit me really hard uh but it was only 15 to 20 seconds long and once that went away the headache went went away I mean it's quick as quick as I explained it it just went from headache to all of a sudden I feel fine and I got to the runup area and I don't remember if I was repeating the flow or if I did the flow and was repeating the checklist but either way I was kind of locked into some sort of uh check it and then go through it again and then go through it again again again and I sat at the runup area so long that the tower had called me and asked if I was ready to take off I didn't ask for takeoff Moody 49er B you ready to go you need few more yet yeah we're just about ready to go I don't even remember saying that this is from the ATC feeds but then uh about 45 seconds later the tower just clears me for takeoff and I didn't ask I just all of a sudden was like okay how I'm going to go now I really wasn't driving the bus at this point I didn't know what was going on so the airplane would was full power full Rich mixture I had it trimmed for a climb of at about 120 mph or 105 knots was my trimmed climb speed and the S 30 autopilot had altitude hold but that was it once you get to altitude you hit altitude hold it tells you to retrim it if it needs to and then it maintains altitude so it was just tracking a heading and climbing uh with the trimmed air speed that I had set fortunately I had full Rich mixture uh a lot of times I would Lean by the time I was at uh 3,000 4,000 ft I'd start to lean for the climb unfortunately I didn't in this case because I would have went higher for longer and uh more than likely that would have been fatal for sure when I was maybe 100 or 200 ft up I went to put the landing gear up and when I put the landing gear up that butterfly feeling came back really really intense again and it lasted only 15 or 20 seconds and then it went away and I had no idea what that was um they told me that they cleared me to turn left to heading 2 40 and up to 6,000 ft so I thought I was doing that the flight track shows that I turned further than 240 I think what it was is I never set the DG right so even though I ran through the checklist multiple times I didn't set the DG correctly and then they gave me the handoff to departure Moody 914 Victor contact departure 12545 Victor I really slurred the reback of the frequency and I didn't hit flip-flop and I called departure but it was the tower and they told me to flip it and then it took quite a while for me to flip it and talk to departure and departure then cleared me direct to Winona up to 9,000 ft the next thing I know after I get my direct to clearance um I enter it in the 530 and I didn't hit my GPS steer button that whole time I remember thinking something was really a miss something was wrong and I had my thumb hovering over uh the autopilot disconnect and thinking I got to hit this I got to tell them I have to come back and land um that was kind of my last thoughts now if I did that if I disconnected the autopilot I wouldn't be here uh so fortunately I lost Consciousness without any inputs from the pilot the air craft miraculously crashed into a field in such a way that it was survivable it isn't often we get to hear from a pilot who has experienced carbon monoxide poisoning in flight this is partly due to the low number of occurrences in general aviation and this is partly due to the Fatal nature of Co related accidents according to the NTSB 77% of Aviation accidents involving carbon monoxide poisoning are fatal but these accidents are worth looking at because they are so preventable carbon monoxide is a colorless odorless gas and due to the cognitive effects Co has on the brain without a detector in the cockpit a pilot and their passengers have little chance of becoming aware of a leak a functioning carbon monoxide detector in the cockpit is the only way to know if Co is present for increased safety and maximum Effectiveness the FAA recommends the use of an electrochemical sensor-based CO detector placed on or near the instrument panel with an alarm threshold of 35 parts per million or lower it's really important that people have at least two um because these these digital devices we don't really know if they're working right or if they fail what are they going to do when they fail and so it's really good to have two and make sure they're both uh telling similar information um now if you have two detect tors and one's saying 10 parts per million the other one's saying five it doesn't really matter it just matters that we know we're getting Co well what I found out after was Co doesn't go away quickly it goes down slowly and so the morning flight it would built up I would had a break during the day where it came down but it certainly wasn't to zero yet and then the next flight it would have built up again before the the third flight when they talk about symptoms of carbon dioxide poisoning they talk about the physiological I'm going to get a headache I'm going to get dizzy Etc and they the way they build it in their symptom chart is a linear progression and if you got a partial headache now you're clearly going to have a much worse headache later not it'll go away and it'll come back and it'll go away that's one thing but the other thing that I haven't seen talked about is that as you're getting those symptoms your cognitive ability is going down and so by the time you have the strong headache to make the connection on why you're not as smart as you were before it all started so that's the problem the m20c has a 4 into one Muffler and a single exhaust pipe and the muffler right in the center uh developed a crack right right over on the top side and that's underneath the heater shroud so the heat of the airplane comes in goes around that gets heated up by the hot exhaust and then goes into the cabin so it was leaking hot exhaust directly into the heating system the flight before this day of flights I took my wife and kids down to Rushford Minnesota to get some ice cream weird thing to do in January in Minnesota but we did it and uh when we were leaving I was starting up down there and my airplane backfired and my wife was kind of like what was that and so that was rare but I said don't worry about it and it the after my accident the FAA asked me have you had any backfires recently so that could have caused the crack or made it worse or it didn't help that's for sure I hate to say it but there was almost like an innocence to Flying before this before this I didn't really I didn't know anyone who perished in an airplane crash I didn't know really that many people that have crashed and then now through my my telling the story I've made a lot of friends and I know lots of people that have crashed and I know people that have perished in crashes and so it's taken an innocence kind of away from flying flying used to be man I used to fly at night all the time and I loved it and now I fully expect my engine to quit every time I go flying so it's it's changed it's it's not as relaxing to fly but I still love it um but I'm always looking for a place to land I'm always worrying about what's going to break next every flight has a multitude of factors to consider some are out of our control and others are not fortunately carbon monoxide poisoning is one of those controllable factors one we can all work toward preventing in our own cockpit and eventually bring the occurrence rate of coop poisoning down to zero

Channel: Air Safety Institute

Views: 163,318

Keywords: institute, aopa, aviation, pilot, fly, flying, flight, plane, airplane, airport, air, safety, asi, air safety, training, aircraft, owners, pilots, Aeromedical, Emergency, Icing and Cold Weather Ops

Id: 6ebhig-vr9o

Length: 19min 25sec (1165 seconds)

Published: Thu Nov 16 2023