Accident Probe: No Idea What’s Going On

All the bells and whistles of a modern bizjet won’t help us if we don’t learn their basic operation.

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No matter how successful we are in life, there’s always someone with a bigger house, a newer car and a better job to help keep us honest. That’s certainly true in aviation, where we’re often left to wonder how some pilots can get away with buying and flying more airplane than they can handle. You know the type.

Meanwhile, getting older in the cockpit can expose us to some basic realities about the aging process and how, while we might be physically fit for many activities, our cognitive abilities may not keep up, leaving us with slower reaction times and, often, difficulties in processing new information.

Of course, there’s no mandated retirement age for pilots flying non-commercial operations, nor should there be. But we can’t help wonder if those close to us and familiar with our kind of flying, and how well we do it, will step up and tell us when it’s time to retire the logbook. While the NTSB didn’t come out and say it in its report on this month’s accident, it seems likely from the record that declining abilities due to the aging process may have figured prominently.

Background

On March 24, 2017, at 1924 Eastern time, a Cessna 500 Citation collided with terrain in a residential neighborhood near Marietta, Georgia. The solo 78-year-old private pilot was fatally injured and the airplane was destroyed by impact forces, and a post-crash fire. Visual conditions existed near the accident site at the time of the accident. The flight operated on an IFR flight plan from Cincinnati, Ohio, to Atlanta, Georgia.

At 1851:36, with the airplane in cruise at FL230, ATC gave the pilot a revised clearance but it wasn’t until 1855:25 that the pilot correctly read it back. At 1859:04, the pilot told the controller he was having trouble with his GPS and requested direct routing to his destination, He was cleared direct with a descent to 11,000 feet. About three minutes later, the Citation’s cockpit voice recorder (CVR) recorded the pilot saying, “I have no idea what’s going on here.”

At 1911:02, the pilot told the controller that the airplane was descending as cleared but was experiencing a “steering problem” and that he could not “steer the aircraft very well.” The controller cleared the airplane to descend to 4100 feet and the airplane soon entered visual conditions. At 1915:44, ATC told the pilot he had descended to 3600 feet, which was 500 ft below the minimum vectoring altitude, and instructed the pilot to maintain 4100 ft. After he was given a frequency change, the pilot reported at 1918:26, that “I’m having a problem with my ah Garmin.”

At 1921:17, ATC told the pilot his destination airport was two to three miles on a heading of 177 degrees. The pilot responded that he “thought” he had a heading of 177 degrees but did not have the airport in sight. At 1922:09, ATC asked the pilot if he wanted to declare an emergency. The pilot said, “I’m not sure and I think I oughta declare an emergency just in case.” At 1923:44, the pilot said, “Well I’ve got my landing gear down but I don’t know.” This was the last communication from the pilot to ATC.

At 1923:55, the CVR recorded the pilot straining. At 1924:07, the Terrain Awareness and Warning System (TAWS) announced “sink rate, sink rate” followed by “pull up, pull up.” The CVR recording ended at 1924:19.

Investigation

The airplane impacted the front lawn of a private residence, and a post-crash fire ensued. Data recovered from the TAWS unit recorded the two warnings heard on the CVR. The sinkrate warning occurred when the airplane was at 4000 feet, on a 160-degree heading. The airplane’s descent rate increased from approximately 0 fpm to approximately 8500 fpm. About three seconds later, as the descent rate increased, the “pull up” warning was triggered at 2900 feet. The data ended approximately seven seconds later with a recorded descent rate of almost 12,000 fpm. Several witnesses observed the airplane make “a complete 360-degree roll” and a “barrel roll” before it rolled inverted and entered a nose-down dive.

The pilot held a type rating for the airplane, which was originally certified for two-pilot operations. The airplane had been modified for single-pilot operation, but there was no record of the accident pilot receiving training under the appropriate exemption. The NTSB concluded it was “unlikely that the pilot was properly certificated to act as a single-pilot.”

A Garmin GTN750 GPS navigator was installed about 3.5 years before the accident. A friend of the pilot trained him on how to use it and later said the pilot generally was confused about how the unit operated and struggled with pulling up pages and correlating data. The friend indicated that, if ATC amended a preprogrammed flight plan while en route, the pilot would be confused by the necessary procedures. The friend also said the pilot depended heavily on the autopilot and that he would activate the autopilot immediately after takeoff and deactivate it on short final.

The pilot also would not trim the airplane before engaging the autopilot because he assumed it would automatically trim the airplane. The friend added that the pilot was “constantly complaining” that the airplane was “uncontrollable.” A detailed post-accident examination revealed no evidence of any pre-impact deficiencies that would have precluded normal operation.

Probable Cause

The NTSB determined the probable cause(s) of this accident to include: “The pilot’s failure to maintain adequate airspeed while manually flying the airplane, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall. Contributing to the accident was the pilot’s inability [to] control the airplane without the aid of the autopilot.” According to the NTSB, the pilot “was consistently unable to manually fly the airplane.”

From the record, the pilot had his own way of doing things, from complying with single-pilot certification requirements to basic airmanship. His failure to understand operation of his navigation equipment suggests either the hazardous attitude of invulnerability or an age-related cognition problem for which his apparent devil-may-care attitude could have been covering. It’s a shame someone didn’t take his airplane keys away, but it’s a good thing no one else was harmed.


Aircraft Profile: Cessna 500 Citation I

OEM Engines: P&WC JT-15D-1B

Empty Weight: 6631 lbs.

Maximum Gross Takeoff Weight: 11,850 lbs.

Typical Cruise Speed: 357 KTAS

Standard Fuel Capacity: 564 gallons

Service Ceiling: 41,000 feet

Range: 1328 NM

VS0: 82 KIAS


Decisions, Decisions

The AOPA has amassed a wealth of material on how pilots change as we grow older. Among other challenges aging pilots may face, decision-making skills may not be what they once were, and a brief section on decision-making caught our eye. As AOPA notes, “You have grown older and gotten wiser through experience. However, aging can make it more difficult to handle the kinds of decisions that sometimes have to be made in the cockpit.” Remedies AOPA suggests are worth exploring include:

  • Spending more time doing preflight and contingency planning;
  • Have a realistic Plan B and be prepared to use it;
  • Get a thorough weather briefing and double-check Notams;
  • Be flexible in scheduling to combat pressure to “get there”;
  • Be realistic about your skills and proficiency; and
  • Fly when rested.

Jeb Burnside is the editor-in-chief of Aviation Safety magazine. He’s an airline transport pilot who owns a Beechcraft Debonair, plus the expensive half of an Aeronca 7CCM Champ.


This article originally appeared in the March 2020 issue of Aviation Safety magazine.

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16 COMMENTS

  1. This sounds like a situation where “taking the keys away” would have done little good since the PIC ignored any training requirements to maintain currency in the plane, and flew it anyway. Since there was no record of any training as a single pilot in the plane, what about the training received for the initial type rating? Did this person have a medical? No comments about these items in this article.

  2. Or…in the ’70s, a SAS DC8 flew into the Pacific about 5 miles or so from LAX. It was night, making a back course without glide slope, crew fatigued, FE looking into a gear issue. FO was fling. He said first time he noticed something not right was when he looked at the altimeter and it was just hitting zero. He advanced the throttles and rotated nose up. Too late to avoid the water but a pretty good attitude for a water landing. The Capt said he was sitting in his chair and the first time he became aware that something was wrong was when he felt a shudder and water got on his feet. Plane broke in half. Back half sand with those passengers. The front, wings forward forward until rescue arrived. But….yea….I just turned 78 and sold my last plane two months ago. It seemed time.

  3. Sounds to me like the typical ego trip: too much money and little brains. If you can afford to fly a personal jet, you can afford to hire a skilled pilot to go along. Similar to the JFK Jr disaster. He could have easily called a CFI to hold his hand on that night flight across the water.
    If you still want to go it alone then get the proper training and stay proficient. This guy did not seem to care about rules and regulations. Thank God he did not hurt anyone else. No sympathy here.

  4. Things are usually not all black or white. Take autopilots. Very useful. But should time on autopilot count toward logged flight hours? I think not.

    An example, a local pilot, older gentleman, with a son who is a CFI. Typical flights were take off, engage autopilot until time to land. Pilot went to his son for a BFR. No autopilot use. He could not hold altitude. His son would not pass him. His comment, “dad, you can’t fly”. This was an instrument rated pilot with plenty of logged hours. I’m thinking many of those hours should not have been logged as PIC.

  5. So the Garmin had been installed 3.5 years prior to the accident and he wasn’t able to get a handle on it, and he complained that the airplane was “uncontrollable” which presumably was perceived soon after he flew it for the first time which had to have been more than 3.5 years prior. I don’t think the pilot’s age was the major factor here, more like his inappropriate and deficient standard operating procedure(s) caught up with him.

  6. All good comments and the pilot’s inability to manually fly the airplane was a gross factor. But, he also was unable to use the Garmin 750 navigator. His training on it was inadequate. But, the human interface of the navigator was also a factor that made it hard to use. Better pilot interface design would have helped this pilot.

  7. I hope my comments are helpful to someone close to my age. I am 89. I have a CFII rating which I acquired many years ago but never used. I have 1800 hours in light twins. I sold my C310 five years ago because I felt I was getting too old to handle it. I switched to a C172 which I fly 60 to 70 hours a year. I am instrument current and either file instruments or ask for flight following when I take a short trip to visit family or friends. I will continue flying as long as I can pass my physical and get insurance. And incidentally I don’t have an autopilot but do go up with an instructor a couple of times a year to stay sharp.

    • You sound like someone I would love to fly with. In the Pt135 world I have seen both sides of this issue. I knew one person who eventually retired after he was unable to pass a pic checkride. I also knew a person who should have but would not admit that to himself and managed to squeak by a training provider check ride several times but no one wanted to fly with him. I have a few years to go before I reach 89, but hopefully I have the same wisdom as you do to realize my own limitations.

  8. Chronological age was not an issue in this accident. Flagrant disdain for proficiency, disregard for anyone else in his flight path, with the only age issue being his proclivity to violate virtually every required and common sense proficiency minimum requirement, flying this way for a long time prior to the accident flight. He did things his way all the time expecting someone else ( ATC), the airplane, or the avionics to help him out at his beckon call. Anything in between was too much bother for this airplane driver ( he was not a pilot in my mind). Amazing he could lose control within 2-3 miles of the airport in visual conditions, yet did not have the airport in sight ( he was in visual conditions from 19:15 to 19:24) finally to stall, roll, and then split S his way to oblivion ( not even knowing if he had the gear down or up). Looking outside did not seem to be a part of his normal flying habits.

    It would be interesting to determine if he had a medical, current BFR, when and if any recurrent training, or the airplane even had an annual. It would not surprise me, none of the above. Because regulations to this guy were meant to be broken, not adhered to. Another question in my mind was how often he flew, handled his average flying with ATC ( busted clearances, continuous or repeated help, requests for a phone call to the tower or center, etc), and the number of local people, including those within his inner circle of friends, family, and acquaintances who knew about his abhorrent, airplane driving behavior…but remained silent.

    I would surmise, there was a trail of evidence of non-compliance long before he became a smoking hole. Money has a way of potentially making folks look the other way or remain silent. But money cannot cover up basic lack of skills.

  9. Human Factors.. Early era “crew breakdown” accidents are not related, due to the lack of CRM skills, which was corrected later.. Single Pilot IFR, a category unto its own.. Is challenging to any pilot, let alone a pilot with declining cognitive skills.. Especially in a fast moving, “new fangelled contraption” equipped, 2 crew but flown by 1, aero plane.. At least the pilot didn’t drag his family along, into his follies..

    Completely Avoidable.. Check ..!!!!!