Experienced Eyes

Veteran pilot with a host of qualifications but little time in type puts Baron on path to loss of control during night IFR approach


By Ken Ibold

Can one of aviations most popular mantras be wrong? Proficiency, pilots are told, is the Holy Grail to which all should aspire. Maintain currency. Fly it. Log it. In short, practice makes perfect.

But can it be that the opposite is also true, that after a point experience adds nothing except added exposure to risk and a certain ennui when it comes to addressing vital safety issues that the less experienced take more seriously? Been there, done that. Bring on something new.

Certainly this question is something of a rhetorical one, since piloting involves the mental discipline of gathering experience while still vigilantly ensuring you can detect variations from the routine. In this complex interaction of cause and effect, and man and environment, there are plenty of chances for things to go wrong.

The question then becomes elementary: Can you defeat the problem before it defeats you?

One pilot who faced that test was flying a Beech E55 Baron from Sulphur, La., to Joplin, Mo., on a July night in 2001.

With five passengers and full fuel, the Baron – nearly 300 pounds overweight and with the center of gravity behind the aft limit – took off from Southland Field at about 10:30 pm for the flight. They expected to get in around 12:30 in the morning.

With full fuel, the airplane had an expected endurance of around four hours. The weather was decent and the 6,800-hour pilot did not file an instrument flight plan, not even a VFR flight plan. He was well-qualified, with 1,440 hours in multi engine airplanes and instrument instructor tickets for both singles and multis.

Where You Headed
Despite the overweight takeoff, the flight proceeded normally until the Baron approached its destination. The pilot had made contact with Kansas City Center and advised he was going to start a slow descent toward the airport.

The controller asked if he had the current weather for Joplin, which the pilot said he did not. The controller gave the weather as winds 050 at 7 knots, visibility 10 miles, ceilings of 800 feet broken and 5,000 overcast.

On this news, the pilot realized he would need to fly an instrument approach and asked for an IFR clearance. The controller cleared the flight direct to the airport and told the pilot to maintain 4,000 feet.

About six minutes later, the controller asked, Are you heading toward Joplin now?

The pilot replied his on-board GPS showed they were heading direct to Joplin on a heading of 042 degrees. The controller said he had inquired because it looked like you were heading to the north there. Looked like you were heading straight north.

A few minutes later, the pilot asked, What kind of approach we gonna make? The airport was served by ILS approaches into runways 13 and 18; GPS approaches into 13, 18 and 36; a localizer into 31 and an NDB into 13.

Itll be the approach of your choice. Theyve got ILS, theyve got back course, uh, just let me know what you can do. I can vector you for the ILS if you want.

Ive got the approach plate out now for the ILS 18, the pilot replied.

All right, turn 15 degrees left vectors ILS … uh, you say you want to do ILS 18?

I guess thatll do.

OK. They got vectors … uh … theyve got the ILS 13 or 18. Itll be your choice, the controller said, apparently nudging the pilot to consider that the winds were from 050.

I guess well … uh, let me see if Ive got that one approach plate.

A few minutes later, the pilot checked back in to say that he now had the approach plate for the ILS Rwy 13 approach and the controller began supplying vectors that would eventually lead to intercepting the final approach course eight miles from the final approach fix.

A minute later, the controller asked the pilot if he was on the localizer inbound, to which the pilot replied he doesnt show it on. The controller gave him vectors to rejoin, and 30 seconds later the pilot said, We show on the localizer now.

Just after that exchange, the pilot reported a flag on the localizer signal and glideslope and said, I guess I ought to go over there and try that 18. The controller said he would give the pilot vectors and asked the pilot to climb to 4,000 feet, up from the 3,000 feet used to intercept the glideslope at the final approach fix. The controller verified the airplane had sufficient fuel for the maneuver. You say you still got plenty of fuel? You say you got two hours of fuel there?

The pilot was unequivocal: Yes, sir.

The controller provided vectors to 13 miles north of the airport and cleared the pilot for the approach. When the controller said radar showed him right on the localizer, the pilot corrected that he was about a needle width to the right of course – hardly a disparity most pilots would point out.

During the approach, radar contact was lost as the airplane descended through 2,500 feet and the controller cleared the pilot to change to the advisory frequency. A minute later, this interchange:

If youre still with the center and can hear me, I show you just about over the airport, 2,400 feet.

Were going to make a missed approach and try it again. Never could get the runway lights on, I dont think, the pilot replied.

The controller supplied climb instructions and vectors for another try. A few minutes later, more indications of trouble. The controller called once. No answer. The controller called again. This time the pilot responded.

Were having a little problem here. I think weve lost an engine. Im trying to get leveled off here and get back up to 4,000 feet.

Roger, the controller said. Just keep me advised.

Forty five seconds later, the airplane descended below the minimum safe altitude and crashed 3.4 miles east of the airport.

Witnesses reported hearing the airplane flying back and forth, with the sound changing on the last pass so that it sounded like a single-engine airplane. Several witnesses saw the airplane in a nose-down counterclockwise roll into a residential area. All six occupants were killed, but no one on the ground was hurt.

First Flights
One of the passengers on the airplane was a businessman who had bought the airplane only two weeks earlier. The airplane had flown only 7 hours, including the accident flight, in the previous eight months. The seller said the pilot had been checked out in the airplane five days before the accident flight began, but the pilots logbook showed his last flight in a multi-engine airplane had been nearly eight months earlier, and that was in a Cessna 337, which has centerline thrust.

The 70-year-old pilot had a history of heart disease, including coronary bypass surgery, but had regained a second class medical more than two years earlier.

After the crash, airport officials checked the runway lights shortly after 1 a.m. and determined that they were operating correctly. Standard procedure at the airport calls for turning the runway lights on when it gets dark and leaving them on until morning. The airport also is equipped with a medium-intensity approach lighting system with runway alignment indicator lights and sequenced flashing lights; as well as with a precision approach path indicator system. Both are connected to a pilot-controlled lighting system that operates on the common traffic advisory frequency of 119.8 – the same frequency used by the tower when it is open.

An FAA inspection at 4 a.m. found all airport lights and approach equipment operating correctly.

Post-crash inspection of the propellers showed both engines were apparently producing power at the time of impact. No anomalies could be found that may have caused the pilot to report possible engine failure, but the extensive damage limited the amount of information that could be gleaned from the wreckage.

The airplanes previous owner said she had met with the current owner to discuss operating techniques. She said the owner told her he was running the main tanks empty, then switching to aux tanks to complete the flight and land. He also asked, on behalf of the pilot, whether the fuel gauges worked.The previous owner said she reminded the buyer of POH stipulations that the airplane use main tanks for takeoff and landing. She told him her technique was to take off on the main tanks and operate for 1.5 hours, then switch to the aux tanks. When they were empty, she would go back to the main tanks.

Paltry Leads
With no single smoking gun, several human factors may be considered for their potential role in this accident: the aircraft loading, the pilots low time in type, and the pilots flight planning.

Although the airplane took off overweight and with an excessively aft center of gravity, it did cruise for several hours. When it arrived for the approaches, it was no longer overweight, but the aft cg was exacerbated by the trip. In the E55 Baron, the center of gravity moves aft as fuel is burned.

The load and the CG puts some question into the airplanes endurance. Raytheon officials told investigators the airplane would likely have burned more fuel than the POH suggests, given the weight, CG and the pilots lack of experience in the airplane, but they could offer no definitive answers as to whether the airplane was having fuel problems. The POH stipulates about 4 hours endurance at normal cruise power. With both propellers showing damage consistent with a power-on crash, it seems unlikely the airplane ran out of fuel.

The pilots low time in type also raises questions. The 1973 model he was flying was equipped in the Beech style of the day, with the flap and gear switches opposite what other manufacturers used at the time. In addition, the throttle quadrant was different, with the prop controls on the left and throttle in the center, rather than the conventional arrangement of throttles on the left and props in the center.

Perhaps the most telling aspect was the pilots apparent lack of preparation for the flight. His fuel management procedures that ran counter to the POH and his quick request for a downwind instrument approach when a better alternative was available are symptoms.

Consider also that the airplanes radios may have been suspect. He got warning flags on an operating localizer and glideslope, perhaps due to radio malfunctions. Its unclear whether he identified the station before starting the approach, but it seems like if he had – and the station was inop – he would have mentioned it earlier.

He could not activate the lights, although the airport manager could with a handheld an hour later. Perhaps he was trying on the Unicom frequency rather than the CTAF, or perhaps the radios were malfunctioning.

Finally, and most seriously, was the pilots inability to maintain control of the airplane. One can imagine the end result being from a Vmc rollover when the pilot was trying to climb on one engine when his multi-skills were rusty. One can imagine that suspected power failure stemming from the unconventional throttle quadrant the Baron sported.

All of that is supposition, of course, but its a clear indicator of a veteran who looked at a night IMC approach with the jaded eyes of one whos seen it all.

Also With This Article
Click here to view “Aircraft Profile: Beech E55 Baron.”


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