Accident Probe: The Zero-Zero Takeoff

Taking off in conditions below approach minimums doesn’t afford us much of a margin for error.

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One challenge all instrument-rated pilots face from time to time is the zero-zero takeoff, one in which the ceiling and visibility are at or near nil values. While such an operation can be completely legal under FAR Part 91, it poses obvious risks, not least of which is the need for precise aircraft handling when on the runway and during initial climb. Another risk is the probable impossibility of an immediate return to the departure airport if the need arises. When confronted with a zero-zero takeoff, the smartest choice a pilot can make often is to remain on the ground until conditions improve.

While this magazine doesn’t advocate zero-zero takeoffs, we also don’t wag our fingers at pilots who execute them. Over the years, we have published articles discussing how and how not to perform zero-zero takeoffs, as well as discussions of why they can be a really bad idea. This is not one of those articles. Instead, we’re simply going to use a particularly sad accident to explore how zero-zero takeoffs whittle down the margins for error to razor-thin size, demanding near-perfect performance from pilot and aircraft alike.

Background

On December 24, 2017—Christmas Eve—at 0717 Eastern time, a Cessna 340 impacted terrain after takeoff from Bartow, Fla. The 70-year-old instrument-rated private pilot and four passengers—the pilot’s two daughters, his son-in-law and a family friend—were fatally injured.

The airplane was destroyed. Instrument conditions prevailed; an IFR flight plan had been filed. The flight’s purpose was to spend the day and night in Key West, Fla., then return on Christmas Day. Employees at the FBO later told investigators the pilot requested that the airplane be towed from the hangar to the ramp, “so that he did not have to taxi next to the other hangars because of reduced visibility and dense fog.” At about 0645, the five occupants boarded the airplane while it was parked in its hangar and the FBO employees towed it to the ramp.

The engines were started and the FBO employees watched as the airplane taxied very slowly to Runway 9L. Fog limited their visibility to about 400 feet and they soon lost sight of the airplane. Subsequently, they heard an increase in engine noise consistent with a run-up and then heard—but could not see— the airplane take off.

The engines “sounded strong and [were] operating at full power.” The employees heard two tire “chirps”—consistent with the airplane settling back to the runway with a side load during the takeoff—then sounds consistent with a climb. They then heard an explosion on the east side of the airport and drove toward the explosion to find the airplane on fire.

Investigation

The accident site was on airport property about 190 yards east-northeast of the departure end of Runway 9L. The debris path was about 230 feet long and oriented northeast. According to the NTSB, “ground impact marks and wreckage distribution were consistent with the airplane rolling left over the departure end of the runway and impacting the ground inverted in a nearly vertical, nose-low attitude.”

The fuselage was mostly consumed by fire while the empennage was mostly intact. The nose landing gear had separated, and was found about 200 feet from the main wreckage. The landing gear actuator, and the left and right main landing gear, were in the retracted position. The flight controls did not reveal any pre-impact anomalies. Wing flap position could not be determined.

All three vacuum-pump-driven gyros—two attitude indicators and one directional gyro—plus the electric turn-and-bank indicator exhibited rotational scoring inside their housings, an indication they were functioning at impact. The airframe, engines and cockpit instrumentation did not present evidence precluding their normal operation.

The airplane had been flown for approximately 30 minutes since its fuel tanks had been topped off. Five were aboard, and the airplane was 105 lbs. (1.6 percent) over its maximum gross takeoff weight of 6390 lbs., and outside the top of the CG envelope. Weather at the departure airport included visibility of less than ¼ mile in fog, plus an overcast at 300 feet.

The area forecast included widespread shallow fog and an advisory for dense fog was in effect for the area. A center weather advisory for low ceilings and visibility also was in effect, as was an AIRMET for IFR conditions. According to the NTSB, “There was no evidence that the pilot obtained a preflight weather briefing from a recorded source.” The airplane’s 24-month pitot/static and transponder certifications had expired.

Acquaintances of the 1600-hour pilot provided a mixed picture of how he managed the risk of flying the airplane. His mechanic stated the pilot always flew with his feet flat on the floor and not on the rudder pedals, but he “never flew dangerously or recklessly.” The pilot’s personal assistant told investigators “that everyone she talked to described him as a good pilot and diligent with his pilot duties.”

An acquaintance who also was the pilot’s flight instructor in 2002 scrubbed a flight with the accident pilot due to weather, which included about ¼-mile visibility and 100-foot ceilings in dense fog. The accident pilot was ready to take off into that weather. A local airplane mechanic stated he flew with the pilot one time and then refused to fly with him again, saying he was not a safe pilot and took unnecessary risks.

Probable Cause

The NTSB determined the probable cause(s) of this accident to include: “The pilot’s loss of control due to spatial disorientation during takeoff in instrument meteorological conditions.”

Lots of things are going on with this accident, but it appears mechanical failure isn’t one of them. Similarly, the weather itself wasn’t dangerous; there were clear skies above the low-lying fog, and calm surface winds. Once above the fog, weather wouldn’t have been a problem.

The pilot clearly knew it was foggy—he didn’t want to taxi near buildings—but apparently not too foggy to take off. The tire chirps may indicate a shallow angle of attack at liftoff, or perhaps the heavy airplane settling back to the runway. What happened next is anyone’s guess. But there was no margin for error. And that’s the problem with zero-zero takeoffs.


Zero-Zero Takeoffs

The FAA’s Instrument Flying Handbook, FAA-H-8083-15B, lists some common instrument takeoff tips that reduce the risk of any instrument takeoff:

  • Perform an adequate flight deck check before the takeoff. This includes locked controls, pitot tube covers, etc.
  • Start the takeoff roll on the centerline at the end of the runway with the nosewheel or tailwheel straight. Anything less risks directional control problems.
  • Apply power smoothly and continuously to achieve the takeoff setting within approximately three seconds.
  • Incorrect seat or rudder pedal adjustment, with feet in an uncomfortable position, can lead to poor directional control.
  • If the pilot reacts to seat-of-the-pants sensations as the airplane lifts off, pitch control is guesswork.
  • Fixations—and not crosschecks—are likely during trim changes, attitude changes, gear and flap retractions, and power changes.

Aircraft Profile: Cessna 340

OEM Engines: Continental TSIO-520-N

Empty Weight: 3730 lbs.

Maximum Gross Takeoff Weight: 5975 lbs.

Typical Cruise Speed: 210 KTAS

Standard Fuel Capacity: 102 gallons

Service Ceiling: 26,500 feet

Range: 1258 NM

VS0: 71 KIAS


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 December 2019 issue of Aviation Safety magazine.

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10 COMMENTS

  1. As both a military and a Part 121 pilot, I have made countless lo-vis takeoffs in both the sim and the aircraft. Such procedures are not to ever be treated lightly. I will note that I always had the distinct advantage of multiple, independent systems and the invaluable advantage of a qualified and current co-pilot looking at those independent systems. The key point that applies here is that I always had a good reason to make the takeoff in those conditions. Sorry if this offends anyone’s sensibilities but this pilot had absolutely NO overwhelming reason to attempt this departure. His determination to “go” killed him and his passengers for absolutely no valid reason what-so-ever. A companionable breakfast and an extra cup of coffee at the local eatery would have been the proper choice.

    • I agree given the details in the article that this pilot probably should have waited for better conditions. I disagree that “need” played any part in his decisions — or yours. As a professional pilot, I’d hope your “need” to complete a revenue flight would never overrule your assessment of the risk of doing so. Unless you’re launching to defend your country in battle or fleeing an earthquake about to swallow the runway no one needs to launch into conditions they deem to be unsafe. It appears (because we don’t actually know for sure) to have been the pilot’s judgement about his flying skills that was the problem, not his need to go to the beach.

  2. I agree with David C… As a current and qualified CAT IIIc, and Low Vis TO, Part 121 Captain. All while using the Super Jet equipped with a HUD/FLIR, that makes you look good.. I think of all the training and procedures that brought me to this point.. Yes, the Part 91 caveat, that is well known, and omits TO minimums, is a “fools game” for any average Part 91 pilot to attempt. This completely avoidable accident, exemplifies this point.

  3. As a CFII, I instruct the student to never take off from an airport they can’t land at.

    “Yes, it’s legal. Is it safe?”

    The concept of Personal Minimums should be emphasized here – things to establish at home, at leisure, and without mission pressure – and a dedication to adhering to them. These PMs must also come with explicit evaluation – at the time of execution – of things like “IMSAFE” and currency/competency for the maneuver being contemplated.

    I also teach the philosophy of “Do dangerous things if you want, but don’t endanger others.” It might’ve been (marginally, depending on the likelihood of injuring or killing people on the ground) ethical to attempt this takeoff solo, but to do so with unwitting passengers is unconscionable. For example, I love to do aerobatics with passengers, but we have a long preflight briefing that focuses on “we might break the airplane today”. This gets real for them when I strap them into a parachute and discuss with them emergency egress procedure, including how to do it if I’m unresponsive. Assuming they still get in the plane, they are not an unwitting passenger…

  4. Smh, this was easily avoidable by not taking off and waiting for better weather. An excellent pilot made a rash decision to take off in his wonder plane in high gusting cross winds after a day of meeting other stol a/c. As skillful as he is in stol with a highly modified a/c, he wasn’t prepared to deal with the gusting winds suddenly changing. A/c was totaled but he and his wife walked away. Admitting to full responsibility of failure to maintain control. he could have waited until winds died down. In both cases was it too much a/c and too little pilot?

  5. And if you do, definitely add a little to your normal rotation speed. The “chirps” could indeed have resulted from a less than positive liftoff. Zero viz is no time to be finessing less than positive handling (and climb rate).

  6. In 121 operations we need at east 600′ visibility. Which isn’t much, barely enough to steer the plane on the centerline of the runway. Any less than that and a safe takeoff is impossible. Then it’s just a matter of if the guy can get the plane off the ground and climbing before he exits the side of the runway or hits something.
    The guy in the C-340 used terrible judgement taking off and not waiting for it to burn off some. Air carrier limits should be used by all as a minimum. Not sure why the FAA regs don’t have a minimum takeoff visibility for even part 91 operators. It’s not safe to allow part 91 pilots to takeoff in 0-0 conditions, as they can hit objects in or outside of the airport. A glaring loophole that needs to be closed.

  7. I haven’t heard anyone mention back-taxing to ensure a clear runway, danger of animal crossing or worse, aborted takeoffs. Many pilots have troubles with them in good conditions; reduced visual conditions can make them exciting to say the least.

  8. Jeb writes a good article. No excessive judgment contained. Without mechanical faults with the airplane, it comes down to pilot proficiency and currency, and the way it is evaluated by the passengers, the PIC, and the CFI. It’s a tough situation for all. As a career Professional Pilot and 35year CFI, I can tell you that there seems to be a profile for proficiency & ADM decay that the insurance companies have certainly taken note of, and that the rest of us need to wake up to. If this pilot was using a statistically relevant FRAT (Flight Risk Assessment Tool), it might have questions like this:

    Has the PIC been flying more than 20 years, but not professionally?
    Is the PIC financially successful in business other than active flight operations?
    Has the PIC’s Instrument currency been recorded in a reliable and available form?
    Is the PIC more than 65 years old?
    Is the flight to be conducted with an instrument-current SIC rated in category and class?
    Is the flight to be conducted in a multiengine aircraft that seats more than 4 persons?
    Are the weather conditions at both the departure point and destination forecast to be less than basic VFR?
    Was the PIC’s last Flight Review conducted in a simulator at a 14CFR 142 training center?
    If answer to previous question is NO, was the Flight Review conducted by a CFII in same category and class?
    Are PIC’s immediate family and potential passengers kept somewhat informed of 14 CFR 61.51 requirements?
    Are PIC’s immediate family/potential passengers kept somewhat informed of Aircraft Insurance requirements?