Breaking Solemn Vows

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How inviolate are the personal rules that we set for ourselves when we find them inconvenient for a specific occasion?

While having extensive experience in a given type, like this Cessna 310R, is a valuable commodity, it shouldn’t give us license to deviate from basic precepts.

Flying is often a convenient and valuable means of travel. But it can also be lethal if we fail to abide some simple guidelines designed to keep us safe. Many of these rules, procedures, and limits were explained to us by our instructors, and then followed up by a request that we make a vow such as... “Promise you’ll never go below minimums, and that you will divert instead,” may have been one of those made, when first learning to fly instruments.

We may have also been asked to promise never to fly impaired. Not just from alcohol, but also when we’re feeling under the weather, or taking medications that may affect our ability to think clearly. When we were asked to make this promise, we certainly would have thought to ourselves, “Of course. That makes total sense. Why would I do that?”

Most of us took these types of oaths seriously. After all, our instructors knew best. They had experience, we didn’t.

But as the years went by, and we gained experience, we may have bent a few pledges, every now and then (just a little) because in the end there is a fine line between being too conservative and operating an airplane for business. A built-in conflict exists between using an aircraft as a reliable form of transportation, while remaining 100-percent safe. And if we have a lot of experience with a particular airplane or familiarity human factors with airport, it is easy to fall into the trap of bending a rule or two because we have done it before without consequences.

Pilot Experience

The 50-year-old pilot was the co-owner of a charter operation, which at the time of the accident, had been in business for 22 years. The pilot held an airline transport pilot certificate with rating for airplane single and multi-engine land. He had a total time of 19,600 hours, of which 17,000 were in multi-engine aircraft, and 15,300 hours were in the Cessna 310. He had more flying time in a single type aircraft than what most general aviation pilots can ever hope to accumulate in a lifetime. The accident aircraft was a Cessna 310R, a venerable aircraft used extensively by charter operators, and part of the pilot-owner’s fleet. The pilot was certainly experienced with both the airplane and with charter operations.

The pilot’s charter company was based at Portland Municipal Airport (KPLD), in Portland, Indiana. After the accident, investigators interviewed the charter company’s chief pilot. According to him, the purpose of the flight was to take a geotechnical engineer to review some field work near Pikeville, Kentucky. The chief pilot mentioned that the accident pilot should have been familiar with the Pike County Airport (KPBX) since he had flown the engineer to the airport a number of times previously.

The chief pilot also mentioned the charter company promoted weather safety. One example he gave was the cautions the company made to their pilots about making proper weather decisions. The company even kept a van at the nearby Fort Wayne International Airport (KFWA) for their pilots in case they were unable to land at the company’s home base, KPLD, due to weather.

IMC Conditions Prevail

The route of flight certainly presented few problems and was well known to the pilot. Familiarity breeds contempt.

An hour before departure, the NWS Surface Analysis Chart depicted an area of low pressure in Eastern Kentucky. There was a developing stationary front southwestward into Tennessee, and the Radar Summary Chart indicated light precipitation over Eastern Kentucky. The closest weather station, Julian Carroll Airport (KJKL) 36 miles west, was reporting calm wind, four miles visibility in light rain and mist, with ceilings of 800 feet broken, and 1,600 feet overcast.

The relevant TAF at KJKL was forecasting winds out of the north-west at three knots, six miles visibility in light drizzle and mist, a broken ceiling at 500 feet and an overcast sky at 1,500 feet. Nineteen minutes later, the KJKL TAF was amended to winds variable at four knots, visibility at six miles, in light drizzle and mist, with a lowered ceiling forecast of 300 feet.

The Cessna 310 left KPLD at 1100 local and uneventfully traveled the short distance to Day ton Wright Brothers Airport (KMGY). The plan was to pick up the sole passenger at KMGY, then fly to KPDX, wait for the passenger to complete his business in the Pikeville area, and then return to KMGY. Once the pilot arrived at KMGY, he filed an IFR flight plan via phone, with flight service. The plan was for a direct flight to KPDX at 7,000 feet. The estimated time enroute was one-hour, and the 310 would have four hours of fuel on-board. The flight departed KMGY at approximately 1148 local.

There was no mention of weather during his conversation with Flight Service, but that does not suggest the pilot did not have weather information. He may have simply self-briefed, and it was not noted or discovered by the NTSB. Additionally, the chief pilot stated, the Cessna pilot “would have picked up two approach plate books that would cover Indiana, Ohio, and Kentucky.”

Low IMC Approach

Did the pilot choose the less desirable approach because it was more convenient to saving time?

As the aircraft approached KPBX, two critical communications occurred. Unfortunately, it is impossible, based on the available NTSB reports, to determine which radio call was made first by the pilot—a call to the airport’s CTAF frequency, or the call to the controller requesting a clearance to fly the RNAV GPS RWY 9 approach?

This may be significant, since it could have determined the pilot’s choice for the better approach into the airport. The RNAV approach was more expedient based on the direction of flight, but the ILS to Runway 27 would have allowed for significantly lower minimums. The RNAV RWY 9 approach had minimums of 506 feet AGL and one-mile visibility. The ILS to runway 27 had minimums of 200 feet AGL and one-mile visibility.

However, according to the relevant factual provisions, noted in an order arising from a lawsuit, it appears the pilot may have requested a clearance for the RNAV approach prior to receiving weather information directly from an airport employee/observer on the ground.

This airport employee recalled the pilot reporting being 20 miles out on the CTAF frequency and requesting weather conditions. The airport employee reported the AWOS as one and one-half mile visibility with a 200- to 300-foot ceiling. The airport employee also told the pilot the weather conditions were worse than reported. During the investigation, a city employee mentioned visibility was so bad and fog so thick he could not see more than thirty feet ahead, and a worker located 200-300 feet below the approach end to runway 9 reported thick clouds at treetop level.

The Cessna was flying the approach as published until the last three ATC radar returns. At approximately 1248 local, the radar returns showed the Cessna 310 aligned with the runway at 1,900, 1,800, and 1,700 feet MSL respectively, with the last plot being one-half mile from the runway end. The MDA for the approach was 1,960 feet MSL.

Individuals at the worksite below the approach end of the runway saw the 310 appear, from beneath the clouds, on top of a ridgeline and roughly in line with the runway. The 310 then hit trees 1,100 feet right of the runway centerline.

Contributing Factor

Terrain is a primary consideration when briefing the approach. Unless you have access to a better topographical chart than the sectional, you might not have the proper perspective.

A toxicological exam of the pilot revealed night-time cold medication above therapeutic levels. The NTSB agreed that the self-medication by the pilot may have resulted in his impairment and listed it as a contributing factor to the probable cause of the flight “Descending below published approach minimums.” The unanswered question is “why.”

The FAA document worth refreshing ourselves on the basics of meds and flying is a short two-page pamphlet:

When asked by investigators why he thought the pilot descended be-low minimums, the company chief pilot said “...the pilot may have seen the terrain below the clouds as he approached the airport, but didn’t realize that the terrain rose as it approached the airport.” He also stated “...descending below approach minimums was out of character for the pilot,” and added “The only thing I can think of is that he was running a little late.”

Look Back To Our Training

So many of the accidents I have reviewed could have been avoided by following the simple maxims given to us by our primary and instrument instructors—and of course by the FAA. We have all been guilty of bending a few rules, but before we make the mistake of doing so again, we should remember the promises we gave to our instructors—and ourselves.

Armand Vilches is a commercial pilot and instructor who lives in Brentwood, TN. His extensive background in risk management and insurance allows him to bring a unique perspective to aviation and flight instruction.

This article originally appeared in the February 2018 issue of IFR Refresher magazine.

For more great content like this, subscribe to IFR Refresher!


Comments (1)

Thanks for sharing this very helpful and instructive reminder.

Posted by: Mike Sweeney | August 8, 2018 1:28 PM    Report this comment

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