Probable Cause #40: Too Much Baggage

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This article originally appeared in Aviation Safety, July 2005.

Probable Cause

Stuff happens. Despite our best, most conscientious plans, once we get airborne things can change. Weather forecasts turn to lies, passengers change destinations and a well-maintained aircraft can break. It can get lonely up there. When the landing gear fails to extend, do we calmly and professionally run the manual-extension checklist and fly the airplane to a safe, otherwise-uneventful landing that doesn't make the evening news? When one of our two engines fails, do we secure the dead engine and safely divert to the nearest suitable runway? When our single engine fails, do we manage our kinetic energy to arrive over a farmer's field at the key point necessary to ensure a safe off-airport landing at touchdown speed? How we handle the changes in plans is the measure of our skill, experience and professionalism. Excitement should be avoided -- often, the greatest compliment to a pilot can be for passengers to be bored into getting some sleep for most of the flight. Even among the combinations of confusion, fear and anxiety an in-flight emergency or sudden change in plans can bring to the cockpit, we still have to fly the airplane. We still have to execute a safe landing, remembering to put down the landing gear or to switch on the fuel pump. We may still have to brief, prepare for and fly an unfamiliar instrument approach to an airport we hadn't planned to visit. Leaving out one or more of these critical elements to handling an in-flight emergency, dealing with a sick family member or diverting for weather can turn a simple challenge into a catastrophe. It shouldn't be that way.

Background

Cessna 421

This month's example of how not to handle an in-flight emergency occurred on July 3, 2003, at about 1600 Alaska time. A Cessna 421C was destroyed when it collided with terrain about three miles north of Sitka, Alaska, during an instrument approach to the Sitka Airport (SIT/PASI). The airplane was on an IFR flight from Prince Rupert, B.C., to Anchorage, Alaska. The Commercial pilot and the four passengers aboard the pressurized twin were fatally injured. While en route near Sitka, the pilot reported to ATC that a forward baggage door on the right side of the airplane's nose had come open, and he was concerned baggage could be ejected into the right engine. He requested and received a diversion to the nearest airport -- Sitka. The airplane was cleared for the GPS Runway 11 approach, which the NTSB says is a "straight-in, nonprecision instrument approach, which necessitated the airplane flying past the airport, intercepting the instrument approach course, and approaching the airport from the northwest." During the approach, the pilot used the Sitka Flight Service Station (FSS) Airport Advisory Service frequency to report the airplane inbound on the approach. When the airplane did not arrive, a search was initiated. Searchers located the wreckage of the airplane on a steep, heavily wooded hillside the next day three miles north of the airport at an elevation of 1100 feet. The accident airplane was co-owned by four pilots, three of whom were aboard during the accident. Due to the severity of the crash and post-impact fire, it could not be definitively determined who the flying pilot was at the time of the accident. A seating chart created by the Alaska State Troopers, who recovered the occupants' remains, indicates that the left front pilot's seat was occupied by the individual who filed the accident IFR flight plan. The NTSB considered him the flying pilot, although no personal flight records could be located. The FAA's records show he held a Commercial certificate with ratings for airplane single-engine land, airplane multi-engine land, helicopter and instrument airplane. According to the most recent medical certificate application, the pilot had accumulated 9200 total flying hours. The airplane was well-equipped, including recent upgrades involving two Garmin color moving map/GPS/NAV/COM, GNS-530 navigation systems. According to the surviving owner, the system was loaded with the latest Jeppesen databases, and certified for IFR operation. The airplane was also equipped with a fully coupled S-Tec autopilot during the installation.

Investigation

Excerpt from RNAV/GPS Rwy 11 Approach at Sitka, Alaska (click here for larger version -- 88 KB).

The Sitka weather observation included 10 miles of visibility, wind from 200 degrees at 10 knots, an overcast ceiling at 2600 feet, temperature 12 degrees C, dewpoint 11 degrees C, and an altimeter setting of 29.83 in. Hg. A DC-9 had just executed the instrument approach, and its crew reported breaking out at 400 feet MSL, one and one-half miles out, and that conditions were deteriorating. As a result of the unsecured baggage door and the deteriorating weather, the pilot may have felt great pressure to execute the approach procedure and get the airplane on the ground as soon as possible. Radar coverage was available for the entire approach. According to radar data, the airplane was approaching Sitka from the southeast, tracking direct to TIPEH, the final approach fix. On reaching TIPEH, the flight failed to follow the published procedure, turned toward rising terrain and began a descent. The next day, searchers located the airplane's wreckage on a steep, heavily wooded hillside. A post-crash fire had consumed most of the fuselage. The accident site was inside the final approach fix, about three miles prior to the missed approach point, and about 1.5 miles north of the course centerline. Elevation at the accident site was about 1100 feet msl. The right baggage compartment door was intact, broken off at the hinges. The latches on the right door, and latching devices on the right nose section were undamaged. Evidence at the accident site indicated the landing gear was down; due to the post-crash fire, flap position and control continuity could not be confirmed. No preimpact mechanical anomalies were found with the engines. All the propeller blades showed significant torsional bending and twisting. The propeller spinners were crushed, and showed rotational shredding and scoring.

Probable Cause

[IMGCAP(4)] The NTSB determined the probable cause(s) of this accident to be "The pilot's failure to follow IFR procedures by not following the published approach ... which resulted in an in-flight collision with terrain. Factors contributing to the accident were a low ceiling, and the pressure induced by conditions/events (the open baggage door)." That's an accurate summary of what happened, but the NTSB's report refuses to speculate on why the pilot turned away from the published final approach course and began his descent. With two other owner/pilots aboard, surely one of the three should have realized the flight was not following the published procedure. Why the aircraft turned right -- into the open nose baggage door -- is also a mystery, since a turn to the left would have taken the airplane out over open water where it would have avoided the rising terrain and seemingly would have helped prevent any baggage from departing the airplane. Regardless, the in-flight "emergency" seems to have overridden an experienced pilot's professionalism, perhaps coupled with real or perceived peer pressure from the other owner/pilots aboard, and led him to cut corners on the approach. His attempt to get the airplane on the ground in a hurry created too much baggage for him to carry.
More accident analyses are available in AVweb's Probable Cause Index. And for monthly articles about safety, including accident reports like this one, subscribe to AVweb's sister publication, Aviation Safety.