Despite warning signs of course excursions, controllers failed to give a pilot the extra attention he obviously required while shooting an approach in a technically advanced aircraft.
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In response, the pilot requested and received vectors to "around OZNUM," which is the final approach fix (FAF) for the GPS Runway 31R procedure into RHV.
The GPS Runway 31R approach procedure was a fairly new procedure, and was not directly depicted on controllers' display terminals. In order to determine the proper course, controllers had to visualize
a line between the airport symbol, and the OZNUM and ECYON waypoint symbols.
After this clearance was given and acknowledged, radar data indicates the airplane turned almost 90 degrees to the right and tracked on a course consistent with proceeding direct to PAO. The
controller noticed the course deviation, and queried the pilot. The controller provided no specific headings, but told the pilot to make a right turn to avoid traffic associated with San Jose
International Airport, and to proceed to OZNUM. The pilot acknowledged and made a right turn of approximately 270 degrees, briefly tracking on an approximately southbound course, which did not appear
to be aligned with any relevant navigational fix. After approximately three miles on that course, the pilot turned left to a heading consistent with proceeding direct to OZNUM, flying overhead RHV, on
approximately the reciprocal of the final approach course, i.e., aligned with RHV, and the fixes OZNUM, then ECYON.
The first controller to handle the flight in the RHV vicinity (L1) later said he became aware of the aircraft when he overheard the previous controller (Saratoga) correct the pilot's course to OZNUM.
The L1 controller said he believed the pilot required extra attention and intended to provide what assistance he could. The pilot had no further clearance to follow, since the Saratoga controller had
cleared him direct to OZNUM with the expectation that L1 would provide vector service.
At that point, L1's initial instruction was for the pilot to proceed direct to ECYON; the pilot's response was to question the fix. According to L1's statements, he recalled that the airplane was in a
position coincident with a downwind leg, and the turn toward
ECYON would work out to be the same as a vector to final. Shortly after this exchange, L1 noted the airplane appeared to begin a left turn towards OZNUM, but he instructed the pilot to turn right
toward ECYON in order to remain clear of a higher terrain area. At this time, OZNUM was directly behind the airplane, and ECYON at about the four o'clock position. The pilot completed a right turn,
briefly flying a course headed to OZNUM, but then made a slight left turn and flew a course consistent with the published segment between ZUXOX and ECYON. L1 said he observed the pilot on this course
and issued clearance for the approach.
At this point in its discussion of the accident sequence, the NTSB chose to quote FAA Order 7110.65, the "bible" for controllers, by noting that it specifies that standard approach procedures "shall
commence at an Initial Approach Fix or an Intermediate Approach Fix if there is not an Initial Approach Fix. Where adequate radar coverage exists, radar facilities may vector aircraft to the final
approach course [by assigning] headings that will permit final approach course interception on a track that does not exceed 30 degrees."
Compounding the apparent confusion in the controlling facility -- and probably fostering it in the cockpit -- a controller change occurred as the flight flew between ECYON and OZNUM. As part of the
changeover, L1 advised the second controller (L2) that the aircraft was on the approach and the only remaining task was to issue the frequency change to RHV tower.
During the pilot's initial conversation with the RHV tower, the airplane began a turn to the right approximately over the JOPAN waypoint. The airplane's course had diverged almost 90 degrees from the
final approach course.
Shortly after the pilot made initial contact with RHV tower, the Minimum Safe Altitude Warning System (MSAW) alerted. The RHV tower controller cleared the pilot to land then said, "low altitude alert,
check your altitude immediately." Based on the radar data, the airplane's projected
track was diverging away from the centerline of the approach, and toward higher terrain. At the time of the alert the airplane was at about 1900 feet, and the minimum altitude for the final segment
is 1440 feet. About 30 seconds later, the tower controller notified the pilot that he appeared off course. The airplane had clipped power lines and came to rest approximately 032 degrees from the
first identified point of contact.
The NTSB determined the accident's probable cause to be the pilot's failure to "maintain the course for the published approach procedure due to his diverted attention. The distraction responsible for
the pilot's diverted attention was the ... the confusion surrounding the ATC clearances to get established on the final approach course, which likely involved repeated reprogramming of the navigation
system. Factors in the accident include the failure of ATC to provide the pilot with a timely and effective safety alert concerning the deviation from the proper course ..." According to the NTSB, an
additional factor was the nonstandard method of providing approach clearance, which likely may have exacerbated pilot task overload.
There's no question that modern cockpits can demand high workloads of solo pilots when a series of missteps by controllers require their time and attention. And, as we have reported in the past, the
proliferation of GPS approaches has left many controllers unsure how to handle them at times.
In this instance, both parties -- controllers and the pilot -- should have taken a deep breath and started from scratch by positioning the airplane south of RHV for a straight-in approach. But, pride
goeth before a fall, and both ends of the transaction probably believed things were salvageable. Unfortunately, neither gave the flight the extra time and attention it obviously deserved.
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Gather 'round, boys and girls. It's time for your annual smug fix, wherein we harvest the perplexing and peculiar from a year's worth of NTSB accident reports.
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truck, the pilot took his eye off the ball to copy down a phone number to call about an en route airspace violation. The pilot's bent ego was then joined by bent airplane when his left wing hit a
metal pole, crunching four ribs back to the spar. With that much bad luck in one day, we hope he stayed away from the slots.
Unmanned Aerial Vehicles can be a really good thing in a war zone. They're not as swift in the civilian context.
Consider, if you will, the California chopper jock who'd just ferried an organ harvesting team to a hospital helipad. During preparations to depart, he noticed a door unsafe indication. After setting
the brake and idle for the Sikorsky S-76A, the pilot left the cockpit and attempted to secure the door. Returning to the cockpit to leave, the unsafe indication persisted. He went back and forth
several times, becoming increasingly frustrated. The pilot didn't recall retarding the throttles to ground idle before he left the cockpit the last time. The helicopter started moving on its wheels
toward the edge of the pad. The pilot tried to get back in, but a witness reported that the chopper did a quarter turn and then rolled on its side.
Then there was the Tennessee Hiller UH-12E light utility helicopter doing fertilizer bucket dumps. When the bucket stopped dispensing, the pilot landed and stepped out of the aircraft in an effort to
read the hydraulic gauge. During exit, the pilot slipped and bumped or grabbed the collective to the full-up position. The unmanned helicopter lifted off and climbed to about 500 feet in a right spin.
The bucket was still attached, of course, and its gyrations eventually caused the main rotor to sever the tail boom.
You know all those stories about talking the non-pilot passenger down? Consider for a moment how much additional fun it would be for that passenger if the thing had already crashed once. A temperature
shift caused a Colorado balloon to land much harder than intended, which tossed the pilot athwart the basket. A second bounce ejected her completely. One of the passengers then jumped ship. Although
the pilot tried to hang on to the vent line, the sudden decrease in weight sent the balloon skyward once again with a single non-pilot passenger still aboard. After a bit of an unscheduled jaunt, the
crew chief was able to talk the passenger through landing the balloon. We assume that there was no
extra charge for the additional flight time.
As in life, aviation cures are sometimes worse than the disease. Witness, for example, the Minnesota mechanic with a bit of a follow-through problem. It seems that he started an oil change and then
noticed a problem with the nose gear.
After notifying the owner of same, "I abandoned all work, as I had no safety wire with me. And I didn't have a new crush washer for the drain plug." Which begs the question why he'd started the oil
change in the first place, but we digress. "I then closed and locked the hangar. That's the last time I saw the aircraft."
Six days later, a second mechanic showed up to fix the nose gear. Everybody and his first cousin saw that the safety wire to the oil filter had been cut, but nobody noticed that the drain plug was
gone. Safety wire installed, the airplane was ground run for a minute. Predictably enough, there weren't any leaks. Apparently the subsequent flight commenced without checking the dipstick, which is a
bad idea any time, of course, but is certifiably insane before launching into an 800-foot overcast right after maintenance. The engine seized a few minutes after takeoff and two very lucky people came
to a survivable stop in a cornfield.
A similar fate befell a Texas RV-3. The pilot reported spending most of the day waxing the airplane and decided to take it for a single turn around the pattern. Apparently some of that waxing time
should have been spent checking the dipstick. The post-accident investigation determined that a mechanic had drained the oil and then left the aircraft unattended, at which point Mr. Clean showed up.
But it looked really nice in the accident pix.
In the realm of "trust, but verify" was the Cardinal RG starting a post-maintenance test flight in Washington State. The date was April 21, but it probably should have been 20 days earlier. On the
first takeoff following replacement of the wings, the aircraft rolled left. Right roll inputs just made it worse. Upon reaching approximately 80 degrees of roll, the 177 descended onto the runway
surface. You're ahead of us here, aren't you? Yep, the ailerons had been rigged backwards, and neither the mechanic nor the pilot caught it on the walk-around.
Then there are the folks who are overly solicitous of the hardware. Perennial entrants in this category are the pilots who stop the engine to save the props and
whatnot. The occasional laudatory Film-At-Eleven notwithstanding, every year yields another crop of those who tried to save the engine and wound up balling up the whole airplane. The lucky ones
didn't break bones while they were at it.
Along these lines was the Kansas P-206 jump-plane driver who apparently sustained a backfire during the March startup. Unbeknownst to him, the air intake hose had blown off. Although sluggish, the
Cessna made it to 11,000 feet, dropped its human cargo and started back down, at which point the pilot couldn't close the cowl flaps. At 6,000 feet, the manifold pressure started fluctuating, so the
pilot intentionally shut down the engine "to prevent further damage." All of which might actually have worked out OK, except non-standard maneuvers by another aircraft in the pattern delayed the turn
to base and put the field out of reach for what was now a rather large and heavy glider. The subsequent off-airport landing substantially damaged the aircraft.
We close this year's sojourn through mechanical mayhem with a remarkable performance turned in by that venerable draft horse, the Cessna 182. In June of 2001, a Missouri commercial pilot doing aerial
photography had a close encounter of the guy wire kind. Climbing through 800 feet AGL, the pilot felt a "jolt." As the pilot reported, "After regaining control of the aircraft, I noticed a section of
my left wing was missing." Not just a tip faring or some such, mind you. More than three feet of the left wing was now lying on the ground beneath the tower. Nevertheless, the sturdy old girl carried
her pilot to an uneventful on-airport landing.
This year's iteration of the bent and bizarre inaugurates a new award category: Creative Excuses. We don't mean the ever-popular but pedestrian wind shear in the flare or even "the dog ate my
preflight" from our last entrants.
Contestants in this category must demonstrate exceptional ingenuity and panache in constructing reasons for the accident. A straight face during execution is a definite plus.
The first contestant in this new genre is the Illinois student pilot who balled up a 152 during a January landing. According to the student, "After [the first] landing I felt that conditions were too
windy for flying without an instructor, however, the Hobbs time indicated that I still had time for a few more touch-and-goes, so I went ahead and flew two more." After the third touchdown, the
Cessna's spinner wound up buried in an adjacent snow bank. We
assume that any remaining Hobbs time expired with the aircraft.
Honorable Mention goes to a second Illinois C-150 pilot for his forced landing to a snow-covered field one week later. "I have been flying this aircraft for the past 19 years, and the ending of every
flight was a stop at the fuel pumps to top up the tanks." The pilot didn't report actually looking in the tanks. Rather, he "perceived that the fuel gauges indicated full." In fact, "They are always
full ... My conclusion: Someone, between my last flight and this, someone entered my hangar and removed 76 percent (17 gallons) of the useable fuel from my airplane." Why the putative thief left
behind the other few gallons wasn't addressed.
A second Honorable Mention is awarded to the California pilot who trashed yet another two-seat Cessna. The pilot was tooling just offshore on a bright March morning when, as he reported to the
responding deputy sheriff, some loose items on the seat "struck the engine controls" during turbulence, causing an engine shutdown and a ditching 20 yards offshore.
Somebody ought to do a research paper on the phenomenon, since we've never previously heard of turbulence that could pull a mixture control, turn an ignition key or otherwise shut down a 150's engine.
We're absolutely certain that it couldn't possibly have been that he was just flying way too low over the water and got bit. By the way, the pilot's certificate had been revoked some 18 months earlier
following another accident.
Another finalist is the Missouri PA-34 driver who lost power to one engine due to fuel exhaustion in IMC during an early morning December cruise. The second engine went dry on short final, bringing a
very nice airplane to an inglorious stop 500 feet short of the runway. The pilot reported that he didn't visually verify the fuel quantities because there was "standing water in the fuel caps and
moderate rainfall at near-freezing temps and I didn't want to contaminate my fuel." The pilot didn't indicate why it was better to take off with an uncertain fuel load rather than locate a couple of
paper towels to wipe off the caps.
You know how they always tell you to be familiar with the systems before flight? Occasionally, that's more easily said than done, particularly in older aircraft with time-worn labels.
An instructor and private pilot were tooling around in a C-172F, a substantially older model than those with which they were familiar.
Colorado can turn a bit nippy in February, so our intrepid aviators eventually began a search for the cabin heat control.
An illegible but prominent white knob on the panel appeared a likely candidate. Things proceeded normally for a while, albeit without any noticeable heat. Then the instructor noticed that the left
tank was showing empty. Shortly after switching to the supposedly full right tank, the engine stopped graveyard dead.
The subsequent investigation determined that the white knob was actually the fuel strainer knob, from which the closing spring was missing.
Loss of directional control on landing normally is just too routine for our annual roundup of the ridiculous, but a Bellanca pilot proved an exception to the rule.
On landing in New Mexico, the aircraft departed the runway, the situation made worse by an attempted go-around. "The more I added right rudder, the more it went left." During the subsequent
investigation, the pilot sat down in the airplane to demonstrate what happened.
It was then that the FAA inspector noticed that the pilot was sitting in the left seat at an angle and had placed his right foot on the co-pilot's left rudder pedal. What makes this even more bizarre
is that the same pilot had the same sort of accident in the same aircraft type just six months before.
And The Envelope, Please
As always, it was hard picking the cream of the ... er ... crop, but our esteemed panel of judges have conferred the 2001 Stupid Pilot Trick Of The Year on the Yogi Berra moment of a pilot ferrying
The single-engine aircraft struck trees during takeoff. One erstwhile jumper reported a very high angle of attack and the pilot "winding the wheel on the lower right side of the chair clockwise,
The pilot said that he originally suspected a "possible flap disconnect," then a dust devil. Subsequent examination revealed, however, that the aircraft was 1,100 pounds over max gross and nearly 10
inches beyond aft CG.
When asked why there were 22 people on board an aircraft placarded for a maximum of nine passengers, the pilot stated that this limitation didn't apply since the "jumpers are not considered
It wasn't reported what the passengers considered the pilot.
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