Probable Cause #37: Approach Unauthorized
Although you won't find it as an official cause in any accident report, get-there-itis has been the root of many decisions that eventually led pilots down a wrong and dangerous path.
Sure, diverting to another airport is hardly ever a desirable option, but some pilots seem determined to avoid this at all cost, sometimes with fatal consequences.
On the afternoon of December 13, 2000, the owner pilot of a Piper PA-31 Navajo contacted the St. Petersburg, Fla., Flight Service Station for a weather briefing from Vero Beach, Fla., to Edenton, N.C. The pilot told the briefer he planned to leave in about half an hour and would eventually continue to the Boston area.
The briefer explained that there were numerous precautions in effect for turbulence below 15,000 feet, icing from the freezing level to Flight Level 220 and IFR conditions in North Carolina. This information prompted the pilot to remark that he wished he had a jet so he could get above all the weather conditions.
The briefer also told the pilot about an Atlanta Center weather advisory for isolated freezing rain from the surface to 4000 feet. Additionally, ceilings over eastern North Carolina were expected to drop below 1000 feet and visibilities to go below three miles as the afternoon and evening went on. Additionally, the icing level was expected to come down to the surface north of Atlanta.
Faced with this scenario, the pilot mentioned that he might cancel for the day. He said he needed to get to the Boston area, but he thought he would go up to Edenton and wait for the weather to move through. The briefer explained that there was a front lying across northern Florida and that it was receding to the north as a warm front. A low-pressure area was over Eastern Tennessee moving to the east and it was expected to take a couple of days for the whole thing to move through the area.
After a few more minutes of conversation with the briefer about the en route and destination weather and how long it might take to clear out, the Navajo pilot decided to wait it out in Vero Beach. The briefer told the pilot to enjoy the Florida weather and the briefing was concluded.
The following morning the pilot called FSS for another briefing. It was a short one this time, with the pilot telling the briefer that he had contacted the destination airport and had been told that it was 65 degrees up there. He then asked if there were any thunderstorms along the route in Florida and the briefer explained that there was some rain and a few thunderstorms over Central Georgia, but that if the pilot stayed along the coast he should be clear of all the weather. The pilot filed his IFR flight plan to Edenton for a 9 a.m. departure (all times are EST) and ended the conversation. No current or forecast weather was discussed, and the pilot took off soon after.
At 12:41 p.m. the pilot was handed off to the Washington Air Route Traffic Control Center. He was at 9000 feet in the vicinity of New Bern, N.C., about 60 nm south of Edenton's Northeastern Regional Airport (KEDE). Shortly after contact with the controller was established, the aircraft was cleared to descend to 4000 feet. Eight minutes later, the controller told the Navajo pilot that he had lost radar contact with his flight, not an unusual occurrence as Center radar coverage at lower altitudes is sporadic in the eastern part of the state. The pilot responded, "I'm in the soup."
The controller asked the pilot what approach he would like into Edenton, and the pilot said that he wanted to fly the GPS approach to Runway 1. A couple of minutes later the controller told him, "I'm showing that the RNAV Runway One is not authorized. That's printed on the publication that I've got." [Editor's note: The NTSB report did not explain why the controller's chart was marked as such.]
The pilot said, "OK. Well, I guess you can give me radar vectors. I don't know what the winds are down there."
The controller instead told him to plan on crossing the Edenton NDB (EDE), located on the field, presumably to allow the pilot to fly a full NDB approach to either Runway 5 or 19. "I can't direct you out there," the controller explained further. "I have nothing depicted, no form of approach course or anything depicted for you out there."
But the controller's intent seemed lost on the pilot, who responded, "I'm gonna try a straight-in for Runway 1. I'm three miles out."
At this point, the controller probably began to realize that the pilot didn't understand that a GPS approach to Runway 1 was not an option. He again asked what type of approach the pilot would like, adding that all he could offer was the NDB approach to either Runway 5 or Runway 19.
The Navajo pilot said, "I don't have any NDB equipment on board. I've got GPS, so I'll take just going in direct."
The controller instructed the pilot to descend and maintain 2000 feet and said that the aircraft was just over Edenton. He asked if the pilot concurred, but all he got was the acknowledgement of the descent.
The controller also contacted the Norfolk (Virginia) Approach controller and told them he had the Navajo over Edenton descending to 2000 feet. "He's trying to go to Edenton Airport, but he keeps telling me he doesn't have any NDB equipment, so keep an eye on him. I'm trying to get him into holding there. He's out of three for two," the Center controller told his counterpart, indicating his concerns about the pilot's actions.
Then he turned his attention back to the Navajo pilot. "N120JB, right now I'm showing you about four miles north of the airport. Fly heading of 270 (and) say your intentions, sir."
The pilot responded: "I'm trying to get down to 2000. I got to try to come around. Try to land on Runway 1."
"OK, sir," the controller said. "I don't have any authorized approach I can clear you into Runway 1 right now."
"Alright," the pilot responded. "Let me standby. Let me figure something out here."
A minute later the controller called the Navajo pilot twice with no response. Finally, the pilot came back and said, "I'm sorry."
But at that moment the controller was telling the Norfolk Approach controller, "That guy I showed you. I'm trying to get him to turn. He's disoriented. I'm not really sure what he's doing. He's trying to go into Edenton, but bear with me. I'm trying to get him out of your airspace."
"OK," the pilot was saying. "I'm gonna do a 180 here and see what I can do."
The controller then told the pilot to climb and maintain 3000 feet. "They need to get you up to 3000 or I'm gonna wind up losing you on radar. (Turn left) direct Edenton. Just let me know what you want to do when you get there."
"They've got three miles visibility," The pilot told the controller, "(and) a ceiling at 1000. I'm gonna try coming in on Runway 19. In the meantime I'm going to 3000."
The controller then said that he would clear the aircraft back to 2000 feet when it was closer to Edenton, but that was as low as he could allow it to descend. The pilot replied, "Thank you."
Once again the controller called Norfolk Approach to coordinate what he was doing, and as he was talking to the controller he noticed that the Navajo was back at 2000 feet. He called the Navajo pilot and asked what altitude he was at. The pilot responded, "2000."
"Roger, sir," the controller said. "Climb and maintain 3000. Are you experiencing any problems?" There was no response.
The controller called two more times with the same result. Then he asked the Norfolk Controller if he could still see the Navajo on his radar. That controller said he had lost him as well.
Better Weather Elsewhere
The aircraft crashed in a farm field near Belvedere, N.C., approximately 22 miles northeast of Edenton. The aircraft was found to have struck the ground in a nearly 90-degree nose-down attitude. The pilot, the only person on board the aircraft, was killed in the crash.
The 76-year-old pilot held a commercial pilot certificate with airplane single-engine land, airplane multiengine land and instrument ratings. He also possessed a second-class medical certificate that was issued five months before the accident.
The pilot's logbooks were never located, but on his application for his commercial certificate two months prior he reported that he had 617 total flight hours, 457 hours as PIC, 306 hours in the Piper Navajo, with 262 of it as PIC, and 129 instrument flight hours. The mechanic who maintained the aircraft estimated that the pilot had flown the aircraft 30 hours since he received his commercial license.
The engines, propellers and other components were removed from the wreckage and examined under the supervision of FAA personnel. No defects that may have contributed to the accident were found.
The weather at Elizabeth City, N.C., approximately 33 nm northeast of Edenton, was reported as winds from 260 degrees at 8 kts, visibility 10 sm, an overcast ceiling at 4600 feet, temperature 54 F, dew point 52 F and an altimeter setting of 30.26.
At 12:55 p.m., about eight minutes before the accident, the Edenton Automated Surface Observation Station (ASOS) reported the winds from 290 degrees at 10 kts, visibility 4 miles in drizzle, a broken ceiling at 1200 feet, an overcast ceiling at 1900 feet, and a pressure of 30.16.
Investigators studied recorded radar data from Washington Center as well as that from Norfolk Approach Control, which is approximately 55 nm northeast of Edenton. They noted that the aircraft descended from 3000 feet to 2000 feet at about the same time the controller was telling the pilot that he had no approaches that would get him into Edenton without the NDB. The aircraft maintained 2000 feet for about two-and-a-half minutes, then climbed to 3000 feet in 46 seconds. Half a minute later it began to descend again from 2800 feet to 2100 feet over 32 seconds. The flight maintained 2100 feet for 14 seconds and then descended to 1400 feet in 14 seconds while making a sharp turn to the left.
It then began a right turn while climbing to 2300 feet. The last radar return was recorded at 1:02 p.m. when the airplane was at 2000 feet, still in a right turn, and 0.09 miles from the crash site. The ground speed was seen to vary from 175 to 225 kts during the last portion of the flight.
Adamant About Edenton
It's clear that the pilot lost control of the airplane, but the question is why.
One of the biggest issues the NTSB report doesn't address is the pilot's apparent overwhelming desire to land at Edenton without considering other alternatives. Perhaps he had family or business connections there that he wanted to visit, which would explain why he was so eager to go there. Otherwise, Edenton, albeit a nice airport, offers no real compelling reason to take the risks the pilot took when better options were available.
Had he understood and accepted that without an NDB, he could not fly an approach into Edenton, he could have checked the weather at nearby Elizabeth City to learn that it was VFR and that he could have easily landed there.
The pilot told the controller that the weather at KEDE was 1000 feet and three miles -- basic VFR -- so he must have listened to the ASOS. Did he intend to fly below the 2000 feet altitude the controller could assign him in an effort to find the airport? Were the altitude deviations the result of the pilot becoming disoriented and confused, or was he trying to find a break in the clouds with the idea of descending visually? If it's the latter, he was in gross violation of the FARs.
The impression you get from reading the transcript of communications is that he wanted to fly over the airport, line up either with Runway 1 or 19 using his GPS, and make a descent to the airport, perhaps using the GPS to fly the unauthorized RNAV approach to Runway 1. It does seem that he was unwilling for quite some time to think of doing something else. This suggests either a lack of understanding or a lack of respect for the rules.
There are many other questions regarding this accident. Why did the airplane get so far north of the airport? When the pilot asked the controller to let him stand by while he "figured something out," the airplane was four miles north of the airport. The controller told the pilot to fly a 270-degree heading, but apparently he never did that and the controller didn't question him about it.
In the end he lost control of the airplane possibly due to mental overload. That could happen if he was trying to fly the airplane on instruments while looking out the window at breaks in the clouds trying to recognize the terrain. He may have also been trying to program his GPS to find another acceptable airport at which to land. He also probably was trying to determine what his next step should be.
Whenever you intend to fly into an airport that has no instrument approaches, or where there is some question about the availability of an approach, you need to do your homework. Always select an alternate airport in advance and keep tabs on it as your flight progresses. In fact, if you file an IFR flight plan to an airport that does not have an instrument approach, you must file an alternate airport.
When flying in instrument conditions, the more informed you are before and during the flight, the easier it will be to conduct the flight. Never focus on your destination at the expense of considering others. Perhaps the Navajo pilot had a reason for wanting to get to Edenton, but that is no reason not to be prepared to land somewhere else when the circumstances warrant it.