A Baron pilot flies into Lake Ontario on an approach in foggy conditions, proving that CFIT accidents can happen in the flattest of places./p>
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Years ago I used to fly into the Toronto City Centre Airport (CYTZ), although in those days it was called the Toronto Island Airport, because it was
built on an island in Lake Ontario.
Back then, the only instrument approach that was available was an NDB approach over Lake Ontario towards the city and all of its buildings. It was scary when you knew that the CN Tower, which hails
2,056 feet into the Toronto skyline, was less than a mile northeast of the airport. But the beacon was on the airport property, so if you paid careful attention to your track, it worked out fine.
Not As Forecast
In July 2003, the pilot of a Beech B58TC Baron departed Lansing, Ill., for an instrument flight to Toronto City Centre where he was to take part in a business meeting. At 5:12 a.m. (all times are
EDT), when the pilot called for his briefing, the forecast for City Centre had yet to be issued. However, the forecast for the Lester B. Pearson International Airport (CYYZ), located on the northwest
side of the city, indicated that the lowest ceiling that was expected that morning was 2,000 feet overcast with a visibility of two miles in thundershowers and mist. The actual weather was consistent
with the forecast at the time the pilot received his briefing. With no other indications that suggested otherwise, the Baron pilot probably thought he was in for an easy flight.
About 30 minutes later, the CYTZ forecast was issued and it, too, suggested a similar forecast as that provided for CYYZ. However, beginning with the 6 a.m. AWOS for CYTZ, the ceilings were reported
occasionally as low as zero feet and the visibility deteriorated to one mile between 6 and 7 a.m. At 7:24 a.m., an amended forecast was issued that indicated a temporary reduction in visibility to one
mile in light rain and mist with scattered clouds at 200 feet until 10:00 a.m. The Baron pilot received this forecast when he checked the weather while enroute at 8:25 a.m.
At 9:46 a.m., a new forecast was issued that indicated ceilings of zero feet and a visibility of 1/8-mile, improving to two miles visibility in mist and an 800-foot broken ceiling between 10 a.m. and
noon. By this time, the pilot was about to enter a hold to wait his turn for the approach and it is believed that he never received this forecast.
Tower controllers at City Centre noticed some improvement beginning at about 9:30 a.m. when the RVR was 2,800 feet and the top of the CN Tower was visible. At that time the aircraft ahead of the Baron
began its approach to the airport. The crew later told investigators that they had visual contact with the surface of the lake when they were holding approximately 15 miles southeast of the airport at
3,000 feet. At 3.0 DME the crew noted that a lighthouse protruded through the fog layer, indicating that the fog depth was about 50 feet. At 2.2 DME the crew could see buildings and trees through the
fog and some of the city's features.
The approach in use was the Localizer/DME-B Approach, which only has circling minimums of 760 feet and two miles. The crew stated that as they began their turn to final approach, the precision
approach path indicator (PAPI) was briefly visible, the mid-portion of the runway was briefly visible, but both ends of the runway were obscured by fog. As a result, the crew elected to execute a
At that time the tower controllers stated that conditions on the surface appeared to be "almost VFR," with an RVR of 6,000 feet. The AWOS at 9:44 a.m. reported the ceiling was unlimited with a few
clouds at 8,800 feet, but that the visibility was still 1/4 mile.
Over The Water
The Baron's flight from the Chicago area to Toronto was uneventful. The pilot had filed for and flew at 13,000 feet until reaching London, Ontario, where he began a descent to 7,000 feet. He was later
cleared to 4,000 feet and told to hold at the TILEL initial fix, located 15 miles east-southeast of the airport on the localizer. At 9:48 a.m. the Baron entered the hold at TILEL and the pilot was
given an expect further clearance (EFC) time of 10 a.m. because the other aircraft ahead of him was still on the approach.
At 9:50 a.m. the first flight crew declared their missed approach and they indicated to the controller that only part of the runway was in sight. The Baron pilot acknowledged hearing the report and
the controller issued the 9:44 a.m. AWOS report. The pilot told controllers that he would like to fly the approach and he was cleared to do so with the stipulation that he cross TILEL at 3,000 feet.
As the Baron passed TILEL inbound, the pilot was instructed to contact the City Centre Tower controller. The frequency change was accomplished and the Tower controller instructed the pilot to report
the runway in sight or the missed approach. He was given the option of landing on Runway 8, 26 or 33.
The pilot acknowledged the landing clearance and was not heard from again. After passing VOKUB, the final approach fix (FAF), the aircraft continued inbound on the localizer and descended below the
minimum descent altitude (MDA) of 760 feet until it struck the water at approximately 3.6 DME, 1.6 miles short of the missed approach point.
Several hours later, the Metropolitan Toronto Police Marine Unit located floating debris in the water. Using a side-scanning sonar, the aircraft was located the following day, but it would take
another two weeks until it was recovered from Lake Ontario.
No Sign Of Distress
The private pilot was originally licensed in 1960 and possessed multiengine and instrument ratings. He had approximately 700 hours of flight time in the Baron that he had owned for 11 years. He had
undergone a biennial flight review and instrument competency check two days before the accident occurred. During that flight he flew two ILS approaches and one GPS approach in VFR weather conditions.
The instructor told investigators that the pilot hand-flew the aircraft throughout the approaches and his handling of the aircraft was normal.
Records indicate that the pilot flew 15 hours in the 90 days preceding the accident. He did not log any instrument time or any actual or practice approaches. Looking back to the beginning of 2002, the
pilot flew three non-precision approaches in instrument conditions to his home field in Lansing. He also flew two training flights about 10 months before the accident occurred. Two ILS approaches were
flown near his home airport and two non-precision approaches to Lansing were made.
There is an ILS/DME Runway 8 approach into City Centre Airport, but it is not available if CYYZ is landing on Runways 23 and 24, as they were that morning.
The investigation revealed no discrepancies with the aircraft or onboard equipment. The altimeter was found to be correctly set and the pilot flew all altitudes accurately, with the exception of
descending below the MDA. The flight path of the aircraft was steady throughout the flight and it appeared that the pilot correctly flew the localizer inbound. The aircraft struck the water in a
wings-level, nose-level attitude, suggesting that the pilot was in control up to the point of impact. The landing gear was extended and the flaps were set to what would be considered the approach
setting. There was no indication of pilot incapacitation.
Investigators with the Transportation Safety Board of Canada turned their attention to "controlled flight into terrain" (CFIT). They identified several factors in this accident that are seen in many
CFIT accidents. They are:
- Non-precision approach;
- Poor visibility conditions;
- Transitions from instrument to visual flight conditions and vice-versa;
- IFR-rated general-aviation pilot over the age of 50; and
- Low annual flying hours and limited recent experience in actual IMC.
The weather was considered as well because it was below what had been forecast when the flight began and significantly below the revised forecast for the two-hour period when the aircraft arrived in
the Toronto area. A new forecast was issued just before the pilot began his approach, but there is no evidence that the pilot ever received it.
But would it have made any difference if he had? When the crew of the aircraft ahead of the Baron passed along that they had sporadic ground contact, the Baron pilot might have assumed that conditions
were improving and that he would have a better chance of locating the runway than the first crew did. At that point the forecast itself probably would not have mattered, especially considering that
the weather had not done what it was forecast to do anyway.
Also, the RVR was indicating that the visibility on the runway was more than a mile, although the AWOS was still reporting a visibility of 1/4 mile. When the other crew reported seeing parts of the
runway, it might have bolstered the pilot's impression that conditions were improving enough that by the time he got to the runway he'd be able to see it well enough to complete the landing. After
all, the AWOS was reporting no ceiling.
Based on the report made by the other crew, the fog itself was not very thick. It's entirely possible that the Baron was in and out of the clouds during the approach, and that the pilot was shifting
his focus between scanning the instruments and looking outside the aircraft for evidence of the airport and the city.
It's also possible the pilot was rushed as he began his approach. When he received his approach clearance, the aircraft was positioned close to TILEL at an altitude 1,000 feet above his cleared
altitude. Radar indicates that he began an immediate descent with his airspeed increasing, so the aircraft's gear and flaps would probably have still been retracted.
The aircraft passed TILEL 500 feet above the cleared altitude and soon afterward it leveled off and the speed decreased before the descent was resumed. The pilot probably extended the flaps and
landing gear during this period and should have completed his before-landing checklist at this point.
The aircraft then continued its descent, with a relatively high speed and rate of descent, eventually decreasing to what would be expected, about 120 kts and 700 fpm. They remained at those rates for
about one minute. Had the pilot maintained this airspeed and rate of descent, he would have crossed the FAF at about 1,300 feet. It also would have placed the airplane at MDA at 3.0 DME, one mile from
the missed approach point.
But that's not what happened. Two miles before the aircraft reached the FAF, the rate of descent and the airspeed began to increase, and the aircraft crossed VOKUB at 1,000 feet, which is the minimum
crossing altitude. But the 1,200-fpm rate of descent continued beyond VOKUB, which was greater than that needed to cross the 2.0-DME fix at the MDA of 760 feet. This rate continued until the aircraft
struck the water.
So, why did the aircraft fly into the water? We don't know if the pilot was monitoring his instruments during the final part of the descent or if he was looking out the window for the airport. It is
likely that he saw the downtown buildings and possibly had some visual contact with the ground or water.
Perhaps the water and the fog combined to create an optical illusion, presenting a false horizon that led the pilot to believe he was straight and level when he was instead descending towards the
lake. The visibility above the very low-lying fog layer was probably good. It's possible that the aircraft's rate of descent was such that by the time the pilot realized he was in the fog bank, it was
too late to look back at his instruments and arrest the descent before hitting the water.
This accident points out the need for pilots to follow procedure when flying an instrument approach. One has to resist the temptation to look outside for the airport or runway too early when
visibility is marginal or obscured. Optical illusions and the risk of spatial disorientation are real threats that have claimed numerous lives.
More accident analyses are available in AVweb's Probable Cause Index. And for monthly articles about IFR flying including accident reports like this
one, subscribe to AVweb's sister publication, IFR Refresher.
In this second chapter of the career of Carl Moesly, he goes to Long Beach to ferry brand-new aircraft all over the country.
Click here for the full story.
Our class of 51 sergeants, with newly sewn stacks of chevrons on our sleeves and silver wings pinned to our shirts, arrived in Long Beach, Calif., the
heart of aircraft manufacturing facilities. We were to ferry these aircraft to modification plants scattered around the country and then catch an airliner or an Army aircraft shuttle service back to
Long Beach. It may have been a poor place to get a promotion, but it was a hell of a good place to learn about the latest aeronautical designs coming off the production lines! The aircraft included
models from Lockheed, Douglas, North American, Consolidated, Boeing and Vultee, plus the modification factories.
Each manufacturer had its strong points and weak points. Our day-to-day work gave us a real education in aeronautical design, engineering, and craftsmanship. I had set a goal to be the best pilot I
could be and to not pass up any chance to learn. We had Link Trainers for instrument flying, which I used at every opportunity. I also posted maps across the windshield when cross-country flying with
a co-pilot in a twin-engine or four-engine aircraft, as I felt instrument flying might someday separate the men from the boys.
Learn from the White Hairs
I knew that, by comparison, I was a novice pilot and I searched out a few old-timers to question. I found that very little of their experience could be applied to the types of aircraft and equipment
we were now flying. However, I did learn from their mental approach to aviation problems, which usually centered on remaining calm and using common-sense solutions backed up with technical knowledge,
plus -- of course -- the skills needed to perform the necessary task.
One beautiful day, another pilot and I took off on a trip from Long Beach to Oakland, each of us in a P-38. These were the latest fighter planes off the production line. We took our planes into the
clouds, dancing in and out at tremendous speeds and enjoying the capabilities of these high-performance machines.
After we landed at Oakland, my fellow pilot motioned me into the hangar. He pointed toward the iron beams of the ceiling where, suspended from cables, was a wood-and-fabric contraption with a wooden
pusher propeller and a skimpy seat way out in front from which the foolish pilot would control this conglomeration of sticks, wires, and fabric. The pilot next to me softly said, with a whimsical
smile on his face, "I used to fly one of these." I looked at my pilot friend and saw a pudgy figure with a weather-beaten face and long, white hair that had blown about in many a prop wash. I looked
once more at the early bird contraption and then again at the sleek, metal fighters we had just flown. This was a man who had already lived a tremendous life through many changes in aviation history.
I stood next to him and realized how I envied him and his experiences.
Reunited with Jeanne
About this time, I was missing that blonde I had left in Florida. Jeanne and I had grown up together -- being a couple through junior and senior high school -- and everyone knew that someday we'd
marry. That time had come for me, and I invited her to California to get married. She agreed to forgo an elaborate wedding in Fort Lauderdale and flew out to the West Coast, where we had a simple
ceremony with a few of my classmates standing by. Jeanne was a slender 5-foot 3-inches tall, with long, flowing hair and an easy smile that would always make you feel welcome in her presence.
After our wedding, my bride found a one-room apartment with a pull-down bed for us on the ocean side of town. When we were together, everything was peaceful and wonderful. But during those years, my
life was hectic; I was flying on many missions and was frequently away for weeks at a time. We never had enough time to spend with each other. Eventually, Jeanne got a job in a doctor's office that
always allowed her time off when I was in town. Over the following few years, the doctor lost his sons in the war.
New Planes, New Challenges
Our class of pilots was being pushed hard to cope with powerful, new aircraft, the new terrain of desert and Rocky Mountains, and long-range navigation. But the factories that built these aircraft
were also under tremendous strain. The assembly lines were staffed with ex-housewives, plasterers, plumbers, and bartenders. Where did the designers and engineers come from? President Franklin D.
Roosevelt said the country would build 10,000 aircraft a month, and that was close to accurate. I could not guess how many ships were built at the same time. I was constantly amazed by the number of
aircraft I flew and how few problems we had. I gained a lot of respect for the men in charge of production.
I flew a Hudson Bomber from Lockheed to the Canadian border in Michigan to be delivered to the British. This plane didn't have any controls for a co-pilot, and it loved to ground loop in a crosswind.
There was also the B-34 -- a larger, more powerful and faster sister ship of the Hudson -- but its hearty appetite for fuel made it suitable only as a short-range bomber for the British to use against
targets across the English Channel. The B-25 was my first tricycle gear-plane and made it easy to make a good landing. (Lt. Col. James Doolittle would later use B-25s on his 1942 Tokyo raid.) We also
had Boeing B-17s that were to be used for bombing German terrain, and B-24s made by Consolidated that were used to fight the enemy all around the world. We pilots would compare every aircraft against
the others with our constant hangar talk, and sometimes bar talk.
As a staff sergeant pilot, I would sometimes be outranked by my co-pilot, and a couple of times by my crew chief. There was never any trouble with rank and understanding who was in command. Skill and
knowledge created its own ranking system. My promotion to flight officer and later to second lieutenant helped ease the social strain for me.
Fun with Fighters
Getting into the fighters was a lot of fun. It was a great pleasure to drive the twin-boom P-38, with its service ceiling of 42,000 feet and its long-range capability, which was made possible by its
wing tanks. The P-38 could carry the same bomb load as the four-engine B-17. After flying from the Pacific coast to Dallas nonstop at 38,000 feet, I was met at the modification plant by the chief
pilot, who announced a celebration at the plant and also at the Lockheed plant in California for setting a new speed record. (Of course, we knew speed records of this sort indicated only how good a
tailwind was blowing.) This particular time I had flown the F-5, a reconnaissance version of the P-38 without the guns and armor. It was lighter and faster than its heavier sisters. This plane also
had improved engines, and I was guilty of pushing it a little bit.
The marvelous P-51 single-engine fighter was another craft in our fleet. In 1943 I was flying one of these when I bounced it against the compressibility of the sound barrier by going to high altitude,
rolling it over onto its back, and pointing the nose down. I really had no knowledge of what could or might happen, but I figured I would learn something. This was years and years before we heard
about the sound barrier or broke through it.
One day I and a crew flew a B-17 down the Grand Canyon at about sunset -- a breathtaking sight that made me appreciate some of the wonders of this great country. I had also flown a small, trainer
plane inside the lip of a huge meteor crater near Winslow, Ariz. The crater was about 450 feet deep and three-quarters of a mile across. Later, I was able to view a large fragment of the meteor in the
lobby of a hotel nearby. It consisted of a huge piece of black iron with a once-molten surface honeycombed like a block of Swiss cheese.
Trust But Verify
Not everything that happened, however, was pleasant. A combat crew in a B-24 heading for Australia came to Long Beach needing a command pilot to fill out the crew for an overseas trip. Operations
assigned me to the task. The crew had been put together in a training station and were pretty green. I asked operations for a test flight with the full crew, fuel load, and complement of equipment
before going to Fairfield, Calif. Fairfield was to be our jump-off point for Honolulu, a leg of about 2,450 miles -- a critical distance in terms of fuel.
My request was granted and on the test flight the plane flew like no other B-24 I had flown. It seemed to crab sideways through the air, and it failed to achieve the speed I expected. The cowl flaps
were not rigged uniformly, and there were various other discrepancies from optimal performance conditions. It was far preferable to make these corrections in Long Beach than to send the plane overseas
to be fixed under difficult conditions. The ailerons were re-rigged, which improved performance, and the plane was cleaned up mechanically. The engines were shut down individually and the props
feathered to check their operation. When all seemed to check out fine, we finally took off for Fairfield.
I was really looking forward to seeing Australia again, but mainly the islands between here and there. On the route to Fairfield, I became physically ill, developed a fever, and was barely able to
handle the controls for landing. Upon landing, I had to be helped out of the aircraft. Shortly thereafter, I vomited on the runway and, feeling weak, decided to check in at the small base hospital.
The doctor could find nothing wrong, but he decided to keep me overnight and said he would send a specialist to see me. That evening, a pompous specialist arrived and started asking outlandish
questions: "Are you afraid of flying over the Pacific Ocean? Do you like your crew? Is your wife making your life difficult?" It didn't take me long to realize he was a "shrink."
I slept well that night and woke up feeling OK, but then I looked at myself in the mirror and noticed a lot of little red bumps had appeared. The riddle was solved: I had chicken pox. I was placed in
isolation. I called Long Beach and told them I was to be hospitalized for a while.
After a few days, a classmate named Ken was sent to take my place. We talked, as much as the doctors would allow, about the condition of the aircraft and crew.
There But For the Grace of God ...
The plane was scheduled to take off in a couple days, headed for Honolulu. When the time came for their departure, I looked out into the dark night through the hospital windows and silently wished Ken
and the crew well, for I knew the plane would be heavily loaded.
The next morning, I was awakened early by a clamor of commotion and conversation in the hallways. There had been an aircraft accident, and the hospital staff was bustling to take care of the injured
and the dead. I asked about the survivors and was told that two were OK and a third was in critical condition. The two survivors visited me and, as I recall, one was a gunner and the other a flight
engineer. As their story unfolded, I learned their takeoff was fine, but the climb out was very slow because of the heavy fuel load, a full crew of 11 men and their baggage, plus a lot of overseas
mail. They must have been less than an hour out when an engine failed and the propeller refused to feather, thus becoming a huge aerodynamic drag for the other three engines to overcome.
The pilot tried to stretch his glide back to the field, constantly losing altitude. Realizing he could not make it to the runway, he gave the order to bail out. For many, it was too late. I can only
imagine the confusion and decisions that must have transpired in the cockpit. The two men standing in front of me had parachuted out, getting in one or two swings before hitting the ground. The plane
had hit the marshland a short distance away and was in a ball of flame. Running to the crash site, they had been unable to find anyone other than the radio operator, a very stout man, who was attached
to his chute, buried to his waist in the soft marsh and unconscious, the marsh grass on fire around him. They pulled him away from the fire and waited for rescue crews.
While waiting for my quarantine to be lifted, I received word that Ken's wife had requested that I accompany her husband's body to Amarillo, Texas, for burial. I was uncomfortable meeting her and the
rest of Ken's family, because he had taken my place during an untimely illness. If I had been in the cockpit, would I have handled things differently? Would the outcome have been the same? I will
The funeral and burial went with military efficiency, and I met some very fine people who remained my friends for many years. Thereafter, I often stopped at the ranch Ken's family owned to visit or to
go hunting, and to remember Ken through the pictures of him in uniform that hung on the walls.
I returned to Long Beach to continue building up flying experience with my classmates. After we had finished our primary, basic, and advanced flight training and had our silver wings ceremoniously
pinned on, we felt like "hot stuff," but actually we were woefully inexperienced. Fortunately, wiser heads prevailed and tried to keep us from killing ourselves. They wanted us to learn the basics of
getting to Point B from Point A in any kind of weather, over any distance and any terrain. To learn about the different kinds of aircraft, we did a lot of useful work moving aircraft about.
I was soon ordered to fly to Homestead, Fla., for special courses in instrument flying. Could it have been because of my pestering operations for Link training and local flying under the hood? When I
arrived at the school, I found I was the lowest-ranking man to be assigned as a student. They used C-54s, C-87s, B-24s, and C-60s for instrument training, all of which I had considerable flying time
in except the C-54, which flew the way a four-engine plane should fly and handle. Of course, there also was the ever-present Link instrument trainer. The instructor and I took a C-60 to Santiago,
Cuba, giving me over six hours of flying under the hood. Ostensibly, it was a training flight, but we loaded the aircraft with rum and other bottled goods for the officers club and some friends.
After my checkride under the hood in a C-54, a very rough test that included feathering two engines, the check pilot pulled me aside and asked questions about my flying background. I was a bit nervous
during our conversation, until he told me I had done better than the others. But then he also cautioned me that due to my rank, it would be better for us not to talk about it. I never did.
I had a couple of days after the training classes before I needed to report back to Long Beach. As Homestead was only about 50 miles from my hometown, I decided to take a bus to Fort Lauderdale and
then a taxi to the foot of my parents' driveway. I took a leisurely walk up to my former home, savoring every minute of it. The home we had built looked much smaller now, and the river looked narrower
than it did on the day when I had pulled out a young lad to save him from drowning. Dad looked older and had been coaxed out of retirement to operate the mill at the navy station. Mom was the same as
ever and insisted on baking me an apple pie. My older brother was on a seagoing tug in the Aleutian Islands. For a period time, he was believed to be dead after a German sub had sunk the Liberty ship
he was towing in the Caribbean and the abandoned raft had washed ashore. The family was elated to hear his tug had managed to escape and he was actually still alive. My younger brother was a
paratrooper, location unknown. Getting news to and from even family members was quite impossible, due to the security of our country and not releasing information on the troop movements.
For the past year, I had had my head into flying, focusing on aircraft, production lines, and the new technology coming in aviation. Little did I know, or even think, about the lives of civilians and
how they were changing during this turbulent time, or about how a war could bring such changes to a small town. There were missing people, rationing of food and other products, and restricted travel,
along with other quiet, determined sacrifices by everybody in hopes of bringing about a victory. We had been a close-knit family: three brothers separated by only a few years, growing up as boys do,
in and out of trouble and constantly on the lookout for a new adventure. But now we were separated and scattered by the winds of war.
After my return to Long Beach, I was transferred to Palm Springs, Calif., about 100 miles east of Long Beach. This was a good staging area for aircraft. A mountain range separated us from the Pacific
coast, cutting us off from dense fogs and smog. Its desert location meant the temperatures would reach 120 degrees in the shade; you could fry an egg on the wing of an aircraft. Jeanne had bought an
old Plymouth coupe to move our belongings to Palm Springs and rented a trailer for us to live in. It was so small that we had to leave my suitcase in the car. Fortunately, a small house soon became
available and we moved right in, but we missed our old apartment on the beach and our occasional drives down the coast to rent a sailboat for the day. Nevertheless, life in Palm Springs was good for
the few days I was home.
It was not long before orders came for me, along with about a dozen of the pilots who had completed the instrument flying course with me, to report to Hickam Field in Honolulu. Due to the extended
duration of this assignment, Jeanne drove back to Miami to live with her parents.
[To be continued ...]
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