A Desperate Plea

Passenger left scrambling for answers after pilot passes out at the yoke


Not many people would justify the time and expense involved in being a proficient general aviation pilot without their spouse supporting the activity. While many spouses are pilots themselves, a great number are merely participants who enjoy the travel and other benefits of flying, without having been bitten by the flying bug itself.

These preferred passengers share a few traits. Theyre usually willing and able to help with some of the housekeeping chores like folding maps, watching for traffic and looking up frequencies. Some may take a pinch-hitter course or a bit of flight instruction in case the pilot someday gets a bad batch of oysters. Virtually all describe their pilot-in-command as a skilled, safe pilot who is a graduate of the conservative school of in-flight decision-making.

Such was the case with the owners of a Cessna 414 who departed Orlando, Fla., en route to White Sulphur Springs, W.Va. The pilot planned a cruising altitude of 25,000 feet. About 12 minutes after takeoff the pilot was cleared to 12,000 feet and was handed off to Jacksonville Center. Jacksonville almost immediately cleared him to 19,000 feet. Finally, 20 minutes after takeoff, the pilot was cleared to FL 250.

At that point, the flight began to unravel. The pilot asked for a routing change, and the controller cleared him as requested. When he entered it in the computer, however, the controller discovered that the airway route the pilot requested did not exist. At 7:51, the pilot said he would recheck his route.

Two minutes later, the controller amended the clearance, allowing the pilot to fly direct between the waypoints the pilot had thought were connected by an airway. The pilots acknowledgment of the clearance, however, never came.

Cessna 4MT, did you copy after Savannah direct Pulaski? the controller asked.

An unintelligible response filled the air.

OK, I got carrier only, no modulation. N414MT, if you have another radio please try it.

There was another unintelligible response, with the words mike tango perhaps at the end. Thirteen seconds later, a female voice replaced the male voice that had made all the previous transmissions.

This is 414MT, she said.

OK, all other aircraft standby one, the controller said, perhaps sensing what was to come. N414MT, say again.

We need help, came the chilling reply.

4MT, go ahead.

Mayday, this is 414MT.

N414MT, go ahead.

Jacksonville, mayday, mayday.

N414MT, this is Jacksonville Center. How can I help you?

Another pilot chimed in, Might stay off the frequency. Thats a mayday call from a four one four tango (sic).

OK, all aircraft radio silence, please. N414MT, Jax Center. How can I help you?

414MT. Do you hear me? the passenger of the Cessna asked.

N414MT, I hear you loud and clear. How can I help you? the controller asked.

… in trouble. The pilot is light-headed and fading. … hear me?

N414MT, yes I hear you loud and clear.

The pilot is … 414MT … is passing out. Do you hear me? 414MT pilot is passing out.

N4MT, roger. Can you fly the airplane? the controller asked.

At that point, the crew of a USAir flight broke radio silence to try to help the stricken flight. The pilot asked if there was oxygen on board, but the passenger didnt know how to get it. The pilot asked the planes altitude. The controller said it was at 26,000 feet and climbing. Over the radio came the passengers plea: The pilot is out. I dont know what to do.

Guessing that hypoxia was the problem, the USAir pilot told the woman to look for an oxygen mask and put it on the pilot. She said shed look around for it, but said shed have to leave her seat in order to do it.During this exchange, it appeared that the passenger could no longer hear the transmissions from Jacksonville Center, although she could hear the USAir pilots calls. The controller suggested asking her if she knew how to use the autopilot, but by then she had left her headset behind, searching for the oxygen mask.

Unfortunately, the controller and the USAir pilot, not knowing how the airplane was equipped, had her looking for a standard green oxygen tank with lines coming off of it. The Cessna, however, had an oxygen tank in the nose compartment and the masks plugged into fittings in the armrests.

Nearly four minutes crawled by. The passenger came back, saying nothing about the oxygen mask. She said she was trying to get the airplane to descend. Even as the USAir pilot and the Center controller implored her to get on oxygen, her labored breathing was clear over the airwaves.

… at 27,300 and (breathing) I seem to be level (breathing) and Ill do my … Im trying to uh go to … were at 27,400 uh and we seem to be level … uh, I am attempting to, uh, to go lower but Im having a hard time … at 27,600 now and Im trying not to climb but we are so tell me [how] to, uh, stop climbing. Im pushing, I am pushing on the wheel (unintelligible, breathing).

For the next four minutes, the passengers lonely battle was broadcast on the frequency. Apparently the mike transmit button was stuck on or she was inadvertently pressing the transmit button with her grip on the yoke trying to make the airplane descend.

The transcript of the transmission recounts her futile struggle to descend out of the thin air. The harder she pushed, the more the autopilot trimmed the airplane against her. The USAir pilot implored her to disconnect the autopilot and put on an oxygen mask.

Although the transcript is ambiguous, she may have finally found a mask and put it on. No oxygen was flowing, however, because a knob on the pilots side had to be pulled to start the oxygen flow. No one had told her about that.

By 8:08 the faint speech gave way to open air. The USAir pilot refused to give up. The airliner was vectored closer to the Cessna in an attempt to maintain communications. For several minutes he repeated the litany of autopilot disconnect, oxygen mask and descent. Sometimes he transmitted the obvious, begging her to release the transmit button so she could hear them.

Finally, at 8:13, the controller vectored the USAir jet back on its way.

Ten minutes later, a U.S. Marines F-18 that had been on a training mission nearby was routed to intercept the Cessna. Although it seemed hopeless, an open mike transmission popped up five minutes later, nearly 20 minutes after the last transmission. The controller grasped at the straw, repeating the earlier instructions about oxygen.

As the F-18 approached, the Cessna climbed past FL 330 and then, as the military pilots watched, the right wing dipped and it began to nose over. The plane descended erratically, dropping, leveling off, turning, straightening as it sought some kind of equilibrium. The descent indicated that the passenger had managed to disconnect the autopilot, but was not in control of the plane. At some points, the aircraft was in what the Marine pilots reported as an 80-degree nose down attitude. At 20,000 feet, the Cessna disappeared into the clouds below, and the F-18 broke off and headed for home.At 8:48, the airplanes ELT signal made clear the Cessnas ultimate fate.

Witnesses who lived near the point of impact said they heard the plane coming down, apparently flying in circles. One witness reported at least two orbits when the plane was in the clouds and another reported two very low level orbits, the last one at rooftop height. Both occupants of the airplane were dead at the scene.

Investigators discovered that the passenger had taken some flight instruction some six years earlier. She had accumulated about 73 hours in Cessna trainers and completed ground school. She never took the written test, however, and had never received a license.

In addition, the couples daughter discovered some notes written by her mother about emergency procedures for the airplane. The notes outlined the steps for dealing with a disabled pilot, including talking with controllers and descending on autopilot. There was no reference to supplemental oxygen.

The aircraft had a total time of about 3,900 hours and the 67-year-old pilot had accumulated about 1,550 of his 4,000 PIC hours in the airplane. He held a commercial license, although he was flying on a Class 3 medical, and had recently attended a refresher course at SimCom International.

The wreckage turned up evidence that a faulty cabin door seal may have been to blame for the loss of pressurization. Investigators could not determine why the pilot did not get a warning light showing the cabin altitude was above limits, however. Oxygen masks were found plugged into the outlets at the pilot and copilot positions, but the oxygen knob on the panel was shut off. The valve at the tank was open.

The same maintenance shop had been conducting annual inspections for the previous decade. The shop had not conducted 500- and 600-hour inspections of certain pressurization system components in the previous two years, and no records could be found that the checks had or had not ever been done.

The pilots structured training, the passengers flight training and pages of notes on getting down in an emergency show that the owners paid more than lip service to flight safety. The question, then, becomes how a relatively minor problem like a pressurization failure could result in such tragedy.

The oxygen system oversight is important, of course, but there are other factors as well.

Autopilot use has become routine for many pilots. The KAP 200 installed on the airplane is extremely capable in experienced hands, but learning it under duress was obviously beyond the passengers capability. It appears she did manage to disengage it, as evidenced by the eventual descent, but it was too little too late.

Pilots owe their routine passengers, such as spouses and adult children, a fighting chance in case of emergency. If you use an autopilot, make sure your right seater knows how to adjust altitude and heading, and disconnect it. Make sure they can operate a radio.

Obvious stuff, perhaps, when youre sitting in a living room thinking it through. But climbing in a panic through 30,000 feet is no time to be wondering how to turn on the oxygen.

-by Ken Ibold


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