Departure Deviation

Failing to climb and fly the initial leg of a published departure procedure has predictable results.


Pilots and non-pilots alike fret about and measure a flights quality by the landing. Yes, landings are important to get right, but takeoffs and initial climb procedures can be just as critical. In fact, I worry about takeoffs more than landings. One of the reasons is a takeoff involves more variables and uncertainties than a landing.

As an example, the airplane weighs more than it will the rest of the flight and exhibits its worst performance. For another, were accelerating, not slowing down. In fact, were trying to go as fast as we can in as short a distance as possible. A third thing is the relatively unknown status of the airplane: How will it feel? Is it loaded correctly? Is it trimmed correctly? Will it perform as expected? What about the local wind and weather-is it what we expected from our preflight briefing and personal observations? If there are obstacles, will we be able to clear them if something goes wrong?

These factors plus others combine to make the instrument takeoff and departure even more interesting. Not only will we find answers to the previous questions, we get to transition immediately from a visual maneuver-the takeoff itself-to obtaining our aircraft attitude and performance information from the flight instruments. As we clean up the airplane-retract landing gear and flaps, if any, and set power-pitch changes can occur, elevating our workload. Along the way, well verify the local weather observation, if any, plus determine whether our flight instruments are working properly. Well also soon discover whether our navigation equipment is correctly set up and working as expected. By comparison, the average landing can be a piece of cake.

As a consequence of all these unknowns and variables, the instrument takeoff and departure is probably the busiest time well spend in a cockpit when everything is operating as it should. Add in our need to immediately begin navigating and monitoring our progress toward our first fix while communicating with ATC, and the instrument takeoff/departures workload might convince us to wait for better weather.

An instrument takeoff/departures high workload should be manageable, especially with some practice. Heres an example of one that apparently wasnt.


On August 5, 2009, at 0431 Pacific time, a Cessna 182S Skylane impacted hilly terrain shortly after departing the Napa County Airport in Napa, Calif. The solo commercial pilot was killed; the airplane was substantially damaged. Instrument conditions prevailed. Prior to takeoff, the pilot received an IFR clearance and correctly read back the following: cleared Napa to Bakersfield via the LIZRD3 departure, CROIT transition, on V108 and as filed, climb and maintain 7000 feet.

A construction crew was pouring concrete the morning of the accident about a mile south of the airport and about two miles west of the accident site. The crew recalled witnessing an airplane pass directly over their work site at about 0430, flying at a very low altitude. They said the area was foggy, but could not determine the cloud layers height. They witnessed a fire plume in the distance shortly after the airplane passed over them. The accident occurred before dawn, with civil twilight beginning at 0546, and sunrise at 0615.


The accident site was located about 3.25 nm southeast of the departure end of Runway 18R. The first identified points of ground contact were at an elevation of 425 feet msl and on a magnetic heading of 165 degrees. The aircrafts cabin was completely consumed by fire; control continuity was established from the empennage control surfaces to the control cables found within the thermally destroyed area of the fuselage but the remainder of the wreckage was too damaged to verify continuity to the respective cockpit controls.

No anomalies were noted with the engine that would have precluded normal operation. The propeller remained attached to the crankshaft flange. One of the three propeller blades was separated from the propeller hub. The remaining two propeller blades exhibited chordwise striations, trailing edge “S” bending, torsional twisting and leading edge damage.

Archived weather information recorded by the Napa ASOS between 0420 and 0435 that morning depicted an overcast cloud layer at 600 feet agl with 10 miles visibility. The recorded temperature and dewpoint were 55 deg. F. According to FAA records, the pilot received a standard preflight weather briefing from the Prescott AFSS by telephone at 0310 the morning of the accident.

Recorded radar data covering the area of the accident was supplied by the FAA. The target was first identified at a Mode C altitude of 100 feet msl. During the next minute, the data depicted a gradual climb to 1000 feet msl, or about 960 feet agl. The last two returns show an altitude of 900 feet msl and a slight change of direction to the south. The last radar return was located about 0.5 miles north of the accident site.

The pilots flight instructor told investigators he performed the pilots instrument proficiency check a few days prior to the accident. During it, they thoroughly discussed taking off in IMC at an uncontrolled airport and specifically the departure procedures the pilot was executing on the day of the accident.

Probable Cause

The NTSB determined the probable cause(s) of this accident to include: “The instrument-rated pilots loss of situational awareness and failure to follow the prescribed instrument departure clearance/procedure, which resulted in an in-flight collision with the terrain.”

According to the FAA Advisory Circular AC 61-134, General Aviation Controlled Flight Into Terrain Awareness, CFIT “…occurs when an airworthy aircraft is flown under the control of a qualified pilot, into terrain (water or obstacles) with inadequate awareness on the part of the pilot of the impending collision.”

Yes, this clearly is a CFIT accident, but placing it into that category is something of a disservice. For some reason, the pilot apparently elected to try remaining VFR below the cloud layer after takeoff and failed to follow a departure procedure he and his CFI had specifically discussed only days earlier. Will we ever know why pilots deviate from well-known and -understood procedures?


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