What would you do if you thought that you had an electrical system failure and a vacuum system failure at the same time in a single-engine airplane? The chances of that happening are pretty slim, but the pilot of a Cessna T210 was convinced that he had both failures at the same time while flying in the clouds. Controllers attempted to help the pilot by supplying no-gyro vectors, but the pilot lost control of the airplane and it crashed, killing both aboard.
There are some disturbing aspects to this accident that occurred during April 1997. It will become obvious that the pilot was not familiar enough with the systems of his airplane, and he was on a flight home from taking a recurrent simulator course. He had failed to meet the course requirements for IFR proficiency.
The pilot had a current flight review, though that was completed in a Cessna 172 nearly six months before the accident. There was no indication of instrument time logged during that flight. He also had 1,373 total hours logged, 934 hours in the T210 and 254 hours of total instrument time. He possessed a private pilot certificate with an instrument rating.
AIRMET For IFR
The pilot was on the second leg of a flight from Wichita, Kansas, to Las Vegas, Nevada. He had stopped for fuel at Las Vegas, New Mexico, after which he picked up his IFR clearance for the night flight to the North Las Vegas Airport in Nevada. He departed at 1750 MST. When the pilot filed his flight plan out of Las Vegas, New Mexico, he checked the weather. There was an AIRMET for IFR conditions along the route of flight through northwestern Arizona, another for turbulence along the entire route and a third for mountain obscuration over the northwestern third of New Mexico and the northern half of Arizona.
And Thunderstorms
The radar showed level two and three embedded thunderstorms in the vicinity of the Las Vegas, New Mexico, airport that were moving to the northeast. There were rain showers along the route of flight, with scattered level three and four thunderstorms northwest and north of Las Vegas, Nevada. The pilot told the briefer that he had picked his way through similar weather on the first leg of the flight from Wichita using his StormScope. The briefer remarked, If you can do that, then you ought to be able to get through.
No current weather was provided to the pilot, and only one forecast was read. It was for Las Vegas, Nevada. It called for an occasional five miles visibility in light rain showers with a ceiling of 2,000 broken. The winds were forecast to be from 350 degrees at 10 knots.
Trouble Begins
The flight was routine until the pilot reported to the Los Angeles Center controller, at 1956, that he had lost his alternator. At that time the airplane was about 20 miles east of the Grand Canyon Airport at FL190. Two minutes later, the pilot asked the controller for lower, saying, "We’re in the clouds, but we cant seem to have any lights on at all." The controller cleared the flight to 15,000 feet and issued the Grand Canyon altimeter setting. He also told the pilot that the Grand Canyon Tower was about to close but that the tower controller had agreed to stay if he wanted to land the T210 there. The pilot agreed to try to locate the airport.
The Grand Canyon Tower controller told the Los Angeles Center controller that the weather consisted of a ceiling at 3,700 broken and another broken layer at 5,500 feet. No visibility was given at that point, though a special was issued at 2013 for the airport that said, "snow began at 1959 and ended at 2013."
Panel Problems
The T210 pilot called the center controller and said, "Seven Two Charlie’s got problems up here, sir."
Center, 2002:13: "Seven Two Charlie, you want to go to Grand Canyon Airport, sir? It’s only about ten miles away."
72C, 2002:17: "Yeah. Vector me there, sir. I’ve got — all my gauges are all messed up."
The controller advised the pilot that the Grand Canyon Airport was at 240 degrees and eight miles away. The pilot said, "Well see what we can do, sir."
The pilot obviously was having problems controlling the airplane, and that became apparent to the controller with the next couple of transmissions.
Center, 2003:44: "Seven Two Charlie, is your compass working okay?"
72C, 2003:46: "Negative. She’s — everythings out, sir."
72C, 2003:52: "I dont even know if I [can] fly straight and level, sir."
The controller told the pilot to roll out on a steady heading and then offered no-gyro vectors. Then he told the pilot to turn left. The pilot acknowledged the instruction, then said, "Looks like we’re descending pretty bad, sir."
"A Funny Smell"
The controller issued a stop turn instruction. The pilot repeated it and said, "We’re — we haven’t even got an altimeter working here, sir."
Center, 2004:19: "You say you do not have an altimeter?"
72C, 2004:21: "Negative. Not that Im trusting. I’m smelling something strange up here."
Center, 2004:26: "All right. You checked your heat on your pitot tube?"
72C, 2004:30: "Heat’s on the pitot tube, but like I say, weve got a funny smell up here, sir."
Center, 2004:38: "All right, sir. I’m showing you at eighteen thousand four hundred feet. You might start a shallow descent here and let’s see if that’s working."
72C, 2004:46: "Thank you, sir."
Remember, the pilot had reported an electrical failure. He said that he had no lights, and that would include panel lights. It’s likely that power from the battery was exhausted, especially if the pitot heat had been left on after the failure occurred. The standby electric power would not power it. Since the radios still were working, it is likely that he was on standby power. More on this later.
The controller attempted to issue no-gyro vectors again. The pilot reported that his altimeter was working again. At one point the controller warned the pilot to make shallow turns. He could see, even on the radar, that the pilot was making very tight turns. No-gyro vectors demand that the pilot make standard-rate turns.
The controller confirmed that the airplane was maintaining 17,000 feet, the altitude that he was seeing on his radar. Then he told the pilot to descend to 15,000 feet and that he thought that he had him pointed "pretty much at the airport."
Control Problems
At 2009:17, the pilot said, "Were IMC, sir. I think we lost the vacuum pump. We smelled something burn up. We’re on standby. We don’t know where we’re at."
Center, 2009:40: "All right, Seven Two Charlie, turn right."
72C, 2009:43: "Right. Seven Two Charlie."
Center, 2010:46: "All right, Seven Two Charlie. Stop the turn now, sir. Hold it straight and level if you can."
72C, 2010:50: "We’ll try to hold it straight and level. The bank indicator says one thing, the DG says one thing [and] the HSI says another thing."
Notice that the pilot did not say anything about the attitude indicator, though he may have been referring to it rather than the turn-and-bank indicator when he used the term "bank indicator."
72C, 2011:07: "[The] magnetic compass is walking all over the place so I know Im turning."
The controller became concerned about the high terrain around the 6,600-foot airport and the reported ceilings.
Center, 2012:11: "Seven Two Charlie, the minimums at Grand Canyon — I don’t think you’re going to be able to get in there. I’m not going to be able to get you down low enough to cancel."
72C, 2012:20: "How about trying to get me a shot straight to North Las Vegas or something, sir?"
Center, 2012:25: "All right. Why don’t you steady out on your present heading? [It] looks like you’re in a little left turn there."
72C, 2012:37: "(unintelligible) a pretty good descent."
Center, 2013:08: "Seven Two Charlie. You’re pointed right at North Las Vegas. If you can just try to hold it steady or straight and level now."
72C, 2013:14: "We’ll try that, sir."
Center, 2014:22: "Seven Two Charlie, you’re showing one six thousand, sir."
72C, 2014:25: "I’m showing all kinds of stuff. We’re gonna lose this baby after all."
Center, 2014:35: "All right, sir. The Grand Canyon [Airport] is about fifteen miles due south of your position. You wanta get [a] vector over there?"
72C, 2014:41: "We’ll try something. These gauges are just going all over the sky, sir."
Center, 2014:45: "All right. Is the airplane still flying okay?"
72C, 2014:48: "[The] airplane’s flying okay, but I can’t control it because it — one gauge says one thing, another gauge another thing. I can’t even get the compass to stay on this sucker, sir."
Several more times the controller urged the pilot to maintain straight-and-level flight. The airplane continued to turn left though the pilot said that he would turn it to the right. Then the last transmission from the airplane came at 2015:44. The pilot said, "I’ll try to pull her up, sir. Jeez, we’re gonna die. Oh, Honey, no!"
In-Flight Breakup
The search for the aircraft was impeded by weather. It was located four days later by the National Park Service in wooded mountainous terrain at 8,800 feet. There were five or six feet of snow at that elevation. The pilot and his wife were found near the wreckage. The aircraft had come apart in flight. Twice the pilot told the controller that he had switched to the standby generator, but investigators found the guarded switch in the off position in the wreckage.
Even if he had turned the switch on, however, only the landing gear warning system, stall warning system, fuel quantity indicators, turn coordinator, engine oil and cylinder head temperature indicators, numbers one and two nav/coms, transponder and encoding altimeter would have been powered.
The accident occurred about 20 minutes after the pilot first advised the controller that he had lost his alternator. The aircraft’s battery may have powered the aircraft that long if it was in good condition. The pilot reported that he had no lights. His radio was working, however, so chances are that the airplane was being powered by the standby generator and that the battery had completely failed.
The NTSB included a copy of the airplane’s radar track in the accident report. It indicates that the pilot had little control of the aircraft after the failure was recognized. There were at least five tight turns to the left with short periods of what appear to be shallow left turns.
Failed Proficiency Flight
During the proficiency course, the pilot flew the simulator for seven hours of instrument flight and .9 hours of VFR flight. His record is annotated, "Training completed to visual flight rules standards only." His instructor told investigators that throughout the course, the pilot’s performance was not up to par. The instructor sat up front with him in the simulator and gave him all of the assistance that he could. By the third day, the instructor said that he did "a fair job on the ILS approach that I had radar vectored him to. However, on the other approaches he had considerable altitude and course deviation."
At that point, the student told the instructor that if he could not sign him off for an instrument competency check, he was wasting his time. He added that he had no trouble flying his airplane on the autopilot using VOR and his Loran. He indicated that he only did ILS approaches and did not need to do the non-precision approaches. The instructor explained that he had to be capable of flying the airplane on the other instruments in case one of them failed. The pilot decided to go home at that point.
The instructor told investigators that "the full benefit of emergencies in the simulator was not conducted because most of the simulator time was devoted to basic IFR training. I gave him 1.9 hours more than he purchased in an attempt to solve his problems with conducting instrument flight."
Airplane Trouble Too
What about the alternator failure that caused the accident sequence to begin? Investigators found that the alternator circuit breaker was open. The alternator was sent to an appropriate facility for examination, and the technician’s report indicated that it had failed from normal wear and tear. According to the pilot’s son, a repair had been made to the unit, but investigators could find no logbook entry or yellow tag that confirmed it. The aircraft’s vacuum pump did not appear to have failed. The drives, vanes and rotors all were found to be intact. This aircraft was not equipped with a flight director, according to the NTSB report, but it did have an HSI. It appears that the HSI was electric because there was a standby directional indicator, according to the pilot’s remarks in the transcripts. It would appear that the altimeter and attitude indicator were not electric, and they should have worked properly throughout.
It’s possible that the pilot did not understand which instruments were powered by the electrical and vacuum systems. Investigators could find no reason for the pilot’s report of a "funny smell up here." It’s possible that the pilot smelled the alternator burning up before the circuit breaker opened, though that would have been several minutes earlier than when he mentioned it to the controller. Another possibility is that the standby generator was overloaded and that it too was in the process of failing. If the pitot heat was drawing a large load from the battery, it may have generated a heat smell before it ran down.
Lack Of Proficiency
It’s likely that the pilot was having a hard time flying the airplane because of his lack of instrument and partial-panel proficiency, the fact that the turn coordinator probably was not working due to the battery condition, and the lack of adequate lighting, which meant that his wife probably was using a flashlight to illuminate the instruments. This would square with his statement to the controller that the instruments were all reading differently. What probably occurred is that the pilot was overcontrolling the airplane so much that he couldn’t make any sense of any of the instruments.
The pilot’s report that his compass and altimeter were not working probably was the result of his inability to make the airplane fly straight and level. Once he was able to hold altitude for a short period of time, he reported that the altimeter was working again. One problem with flying partial panel is that the pilot often becomes distracted by the instruments that are not working, even if he knows that they are inoperative. When the pilot is not able to sort out what is working and what isn’t, that is a recipe for disaster.
What To Do
You can prevent this type of accident from happening to you by doing several things. First, make sure that you are proficient at flying in the clouds with the full panel as well as a partial panel. Learn how to differentiate between those instruments that are working and those that aren’t if you should have a failure. Make sure that you know which instruments are powered by the electrical system and which are powered by the vacuum pump. If you own your own single-engine aircraft, decide on a life limit in hours for the alternator and vacuum pump, and have both replaced when you hit the limit. Do not attempt to repair a failed unit if the failure occurs within the last half of the life limit that you establish. It should be overhauled or replaced at that point.
The ironic part of this accident is that the pilot’s wife was not fond of flying, yet she attended the simulator sessions with him in order to take a "confidence-building course." She repeatedly told her instructor that she had no desire to learn to fly and was afraid of flying, but she was taking the course because her husband wanted her to.
