Probable Cause #17: Commander's Last Call

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This article originally appeared in IFR Refresher, June 2005.

Probable Cause

Remember the old saying, "Fly the airplane first?" Your flight instructors probably mentioned it to you when you were dividing your attention among several things that were going on in the cockpit at the same time. If you allow your attention be drawn away from monitoring the airplane and insuring that it continues to do what it is supposed to do, disaster is not far away.

Very often pilots get caught up in the communications trap. Usually, a controller will ask them something at a critical time during the flight, and instead of telling the controller to stand by, they allow themselves to become distracted in order to answer the controller or provide the requested information.

I remember a friend I used to fly with as a safety pilot many years ago in his Cherokee 140 while he practiced his instrument work. He never put his microphone down. He would hold it between the palm of his hand and the control wheel, the microphone dangling over the outside of his hand on its chord. It was like he was sitting at attention just waiting for the controller to ask him to do something. He wanted to be able to answer the controller immediately.

Controllers are important and in most cases when they ask you for some information there is a reason why they want it. But never should you allow the safety of flight to be compromised in order to answer a controller. Let's look at an accident that may have occurred for that reason.

Missed At KHUT

Commander 114TC

The pilot was flying a Commander 114TC from Oklahoma City's Wiley Post Airport (KPWA) to the Hutchinson Municipal Airport (KHUT) in Hutchinson, Kan. It was nighttime and the weather was not good.

Transcripts of the pilot's communications with ATC indicate that the flight was perfectly normal as it neared Hutchinson. At 6:14 p.m. the pilot contacted Wichita Approach Control and received instructions to prepare for an ILS approach to Runway 13. The controller also gave the pilot the grim news: Hutchinson was reporting winds from 040 degrees at seven knots, 1-1/4 mile visibility with mist, an overcast ceiling at 200 feet and a temperature and dew point of six degrees Celsius. The wind direction was variable between 010 and 080 degrees.

It is interesting to note that when the Approach controller contacted the Hutchinson Tower to inform the other controller of the inbound aircraft, the Tower controller acknowledged the information by saying, "Wish him the best of luck." Apparently, he felt the weather was not good enough for the ILS approach.

The touchdown zone elevation (TDZE) for Runway 13 is 1,524 feet, while the decision altitude on the ILS is 1,724 feet, a difference of 200 feet. The visibility requirement for the approach is 2,400 RVR or half a mile. Did the controller's comment indicate that the actual weather at Hutchinson was worse than what the ASOS reported? Remember, the ASOS may be located anywhere on the airport property and its reports are generally representative of that location and not necessarily for the runway environment.

In the event of a missed approach, the Approach controller instructed the pilot to fly the runway heading and climb to 4,000 feet. This was different than the published missed procedure, which called for a right turn to the Hutchinson VOR. The pilot acknowledged the transmission.

For the next several minutes the controller vectored the aircraft to the final approach course and at 6:39 p.m. he issued the approach clearance for the ILS approach. He instructed the pilot to inform him when he was established on the localizer and about a minute later the pilot did so. He was then cleared to switch to the Tower frequency.

The Tower controller cleared the Commander to land when contact was made and then told the pilot, "We are showing the visibility 1-1/4 miles, ceiling 200 overcast. I do not have any bases or tops reports available."

At 6:45 p.m. the Commander pilot called the Tower to report that he was going missed. The Tower controller told him to fly the runway heading and climb to 4,000 feet. Then he said, "I take it you didn't get the runway lights or anything else at all." The pilot responded, "Right over the runway now. I just got them too late."

The pilot was then instructed to switch back to the Approach controller. That controller acknowledged his initial transmission and asked what he intended to do. "What's the weather look like in Wichita right now," the pilot asked.

The controller read the Wichita weather, which was reported as 2,700 feet overcast and 10 miles visibility. The pilot never responded to that transmission and he was not heard from again.

It took some time to locate the aircraft. It had crashed off the left side of Runway 22 on airport property. The Tower controller did not see the aircraft from the tower cab. At first, he thought the crash had occurred off the property. He told the crash truck that was trying to locate the Commander that he had seen a strange light to the southeast of the airport. Approximately 20 minutes after the crash the fire truck found the wreckage and reported it to the Tower. That would indicate that the surface visibility was something less than 1-1/4 miles. The pilot was the only person on board and he was killed in the crash.

The Commander pilot had a total of 887 flight hours, all of which were in single-engine airplanes. He had logged 829 hours as PIC, and had 752 hours in the accident aircraft make and model. He had flown 76 hours in the previous three months and 24 hours in the month prior to the accident. He had logged 23.9 hours in actual instrument conditions and 43.9 hours in simulated instrument conditions. 7.1 hours of his actual instrument time had been flown in the six months prior to the accident. He had been an instrument rated pilot for nearly two years.

The Final Minutes

Missed Approach

Investigators were able to obtain the radar tapes and study the aircraft's track. The tapes showed that the pilot intercepted the final approach course but drifted slightly to the right, possibly because of the winds being from the north. The aircraft passed abeam the outer marker on the right side of the localizer, corrected to the localizer centerline about halfway between the outer marker and middle marker, then drifted off to the right again.

The lowest altitude reported by the radar track showed that the airplane was at 1,600 feet, 124 feet below the DH, and that occurred when the aircraft was off to the right of the localizer and inside the middle marker. The Commander then began a climb and made a 90-degree turn to the left over the airport. Then the airplane climbed to 1,900 feet, began another left turn, and continued the climb to 2,000 feet. The plot shows that it maintained 2,000 feet for about 12 seconds before beginning the descent to the ground still in the left turn.

The radar plots show that he may have maintained 1,700 feet beyond the missed approach point. Was he trying to look for the runway? He told the tower controller that he saw the runway from directly over it, but saw it too late to land.

He was also aware of the revised missed approach instructions, which were to continue on the runway heading and climb to 4,000 feet. He began the climb but started a turn to the left. We can only speculate as to why he did that.

If he spent more time looking for the runway than flying the airplane, that may have contributed to the accident. Many pilots who are involved in instrument approach accidents spend so much time looking for the runway environment that they simply fly the airplane into the ground. While the Commander pilot did not fly the airplane into the ground by a continual descent during a straight-in approach, he did lose control of his airplane shortly after he commenced the missed approach.

Did he become disoriented in the transition back to the instrument panel after he spotted the runway below? That is not too difficult to do under the circumstances, especially if he inadvertently began the turn to the left while he was looking out the window. He may have looked back at the instruments fully expecting to see that the airplane was flying straight ahead but found the instruments indicating it was in a turn. This "conflict" could have led to the beginnings of his disorientation. It's obvious he lost his attitudinal awareness sometime after the missed approach began, and perhaps his positional awareness as well.

The communications between the controllers and the pilot give us an indication that he might have become distracted not only by spotting the runway below him, but by the controllers' questions. He responded to the Tower controller's question about seeing the runway lights with the remark that he was just over the runway. Perhaps at that point he was looking out the window as well as talking on the radio. Then he was given the frequency change to Approach control.

There were only seconds between the transmission to the tower, the frequency change, and then the short conversation with the Approach controller about what the pilot wanted to do next. During that entire period the airplane was in what the radar plot depicts as a steady left turn away from the course the aircraft was supposed to fly. Why didn't the pilot realize that he wasn't doing what he was instructed to do?

Often, if the pilot is not current or proficient we see large deviations from the localizer and glide slope on the radar plot. The radar plot shows the Commander favoring the right side of the localizer, but staying within acceptable limits. The glide slope profile shows the airplane staying within acceptable limits until it reached DH. Then it went below the 1,724 feet authorized on the approach plate to 1,600 feet before beginning a climb.


Foggy Tower

There are several potential distractions on every instrument approach we fly. Anything that does not concern flying the gauges on the instrument panel is a distraction. The biggest one of all is looking out the window for the runway.

If the reported ceiling is 200 feet there is no point in looking for the runway before that on an ILS approach. Sure, you could break out sooner, but if you start searching for the approach lights or runway too soon you are not flying the airplane. If you have someone in the right seat let him or her look for the lights or the runway. Concentrate on flying the approach until MDA or DH. When the ceiling and visibility are very low it is important to keep the airplane on the localizer and glideslope to the decision altitude if you are going to have a chance at spotting the runway environment.

Where did the Commander pilot become disoriented? It's hard to say, but the radar plots indicate that it may have occurred after the pilot declared the missed and before the left turn began. That's when the Tower controller questioned the pilot on what he saw. At that moment the airplane was passing abeam the runway and the pilot said that he was over it, and that he had seen the approach lights too late. That's also when the Tower controller told the pilot to change frequencies.

Since no frequency was mentioned in the instruction to change to the approach controller, we can assume that the pilot changed to the frequency he had used when inbound. Since the airplane was built in 1995 it was probably equipped with digital displays where the pilot only had to reach over and push a button that would flip the frequency to the one last used. It seems like an innocuous thing to do, but when coupled with everything else that was going on at the time, it was just one more thing to add to the workload.

The missed approach procedure requires concentration. Just like flying the airplane down the localizer and glideslope, during the missed you cannot afford to become distracted by anything. While communicating with ATC is a normal function during any approach, there are some things that need to be said and others that can wait.

Remember the friend of mine who always had the microphone in his hand? He had it in his mind that he had to communicate with ATC before he did anything else and he wanted that microphone handy so he could do just that. Remember, the rule is to always fly the airplane first. Everything else is secondary. Aviate, Navigate, Communicate.

If the Commander pilot had followed that rule, he would not have said anything to the Tower controller, except perhaps that he was on the missed approach. But even that can wait while the airplane is put into a climb attitude and cleaned up. According to the transcripts and radar plots, the pilot was talking while he should have been climbing straight ahead and reconfiguring the aircraft.

Any pilot has two magic words he can say if he does not want to talk. They are the same ones controllers use for the same reason: "Stand by." Use them whenever necessary. The controllers can wait until you are sure that the airplane is doing exactly what you want it to do and you have the time to communicate.

More accident analyses are available in AVweb's Probable Cause Index. And for monthly articles about IFR flying including accident reports like this one, subscribe to AVweb's sister publication, IFR Refresher.