Links in the Chain

Risk involved in some short flights prove accident chain doesnt have to be long


The vast majority of aviation accidents have a chain of events that lead up to tragedy. It may be long or short, but seldom is it a single catastrophic event that strikes without warning.

Sometimes the events that chain the airplane to the accident are subtle. Only by playing Monday morning quarterback can you spot the links. In examining those accidents you may silently wonder if you would have spotted the potential for disaster in time to avert it.

Other times, the accident chain smacks you across the face. How, you wonder, could anyone have been so foolish?

One December night three acquaintances decided to go flying. They drove to a private airstrip west of Ocean City, Md., and parked outside the hangar there. The pilot had about 600 hours on a private license.

No anomalies were found during the preflight, and at about 10 p.m. the pilot loaded his two friends, fired up his fathers 1965 Piper Cherokee Six and taxied to the end of the grass strip.

A man who lived across the street from the airport heard the airplane taxiing down the runway, the engine surging as if the airplane was having trouble driving through the wet grass.

The pilot got to the end of the runway and turned around. He pushed the throttle forward and got the 260-hp Lycoming wound up. At about 10:09, with the engine singing loud and strong, the neighbor lost sight of the airplane as it took off into the night sky.

No flight plan had been filed. There was no record of the pilot obtaining a weather briefing. If he had checked with a Flight Service Station he would have found several nearby airports reporting a temperature of 43, dewpoint 41 and an overcast ceiling only 400 feet off the ground.

The direction of flight was unknown. The pilot did not contact any air traffic facility and radar does not provide coverage below 2,500 feet in that area.

Less than 30 minutes later, another witness about 10 miles south of the airport reported that he heard a low-flying aircraft with a high-pitched sound fly directly over my house. The sound was followed by a dull thud. The witness first thought it came from his baby, asleep in another room in its crib.

At about the same time, the owner of the airplane was driving past the airstrip on his way home. The hangar had no power, but he noticed a light there. He drove in and found his sons pickup truck parked there with a rear light illuminating the bed. Inside the hangar, he discovered the Piper missing. The father contacted another son, and they attempted to reach the airplane by portable radio, but got no response.

Early the next morning there was still no word from the pilot. The pilots brother was up early, calling friends and family to see if anyone had heard from the pilot. The family called nearby Salisbury Airport and Ocean City Municipal to see if the airplane had landed there, but came up empty.

Homing In
The Civil Air Patrol detected a weak ELT signal within minutes of the thud reported by the witness, but could not start a search mission until first light. Shortly after 11 a.m. the next morning the CAP found the first debris; shortly after noon they found the main wreckage and the bodies of the three victims. The two passengers were brothers in their early 40s, less than a year apart in age.

Investigators found no evidence that the aircraft had malfunctioned. With the help of the Maryland State Police, they begin retracing the steps of the doomed fliers.

The 37-year-old pilots last day had been a busy one. Between 3:45 and 4:00 p.m. on the Thursday evening he walked into a bar in town. The bartenders knew him, and recalled that over the next 2 hours he drank five bottles of beer. He left that bar and went to another, where he ordered another beer. He wandered around talking to friends and left half an hour later without finishing his sixth Ice House.

The pilot apparently then went home, showered and changed clothes. At 8 p.m. he arrived back at the first bar. He ordered another beer but was told the bar was out of his favorite brand. He changed his order to a mixed drink. Forty-five minutes later, he ordered another.

The pilot was seen in the company of the other two victims during this trip to the bar. At about 8:30 one of the other victims approached a female acquaintance and said the three of them were going flying. He invited her to come along. She said she could not tell if the pilot had been drinking, but declined the offer nonetheless. She did take their picture. Sometime around 8:45 to 9:00, the three left the bar, saying they were going flying.

Risk? What Risk?
The pilot was seen drinking between seven and eight drinks within the six hours before the flight. Toxicology reports after the accident showed a blood alcohol level of 0.102 percent and a urine alcohol level of 0.221 percent.

Joyriding in a car after a stint at the bar is dangerous enough. Joyriding in an airplane under the same conditions is foolhardy.

In this case, you can run out of adjectives describing just how futile this pilots effort was. Alcohol, night flight, VFR pilot in times of low ceilings … all of the cards stacked the deck against the safe landing of the Cherokee Six.

Its not enough to smugly concede that he flatly should have stayed on solid ground. Making the call to postpone a flight because of marginal weather takes a stiff backbone when friends are involved. The alcohol adds to the likelihood that mortality will be ignored.

One lesson that all pilots can take away from this tragedy is that the pressure to complete a flight – even a local flight – can come from unlikely places. A show-me flight is a tempting time to take shortcuts, because you know it will probably be short. This pilot didnt count on just how short his flight would be.

Length Doesnt Matter
A short flight doesnt necessarily mean a safe one. Sometimes it only takes a short piece of chain to reach up and swat you out of the sky.

Consider another tragically short flight, that of a Piper Aztec that crashed in Carson City, Nev., on Thanksgiving Day in 1997.

Although the NTSB has released its final report, the report itself raises several questions. Many of the facts of the case, however, are clear.

The Aztec was loaded with full fuel, three passengers and a small amount of luggage. Although the initial calculations showed the center of gravity dangerously aft, investigators later discovered an error in the paperwork and concluded that the aircraft was well within weight and balance requirements.

Although the W&B miscalculation was not a factor in this case, it does show that the pilots operating the rental plane were less than fanatic about running weight and balance calculations. If they were, the error would have been discovered earlier.

The airplane took off from runway 27 and began climbing in what several witnesses called an unusually nose-high attitude.

Within a few seconds it began rolling to the left, went inverted and spun to the ground. The Aztec smashed into a T-hangar containing a Cessna T210. The resulting fire incinerated the two planes and the occupants of the Aztec.

One witness reported that, as the plane rolled, he could see the nose baggage door open and folded back over the windshield. Despite a search, investigators could not find any luggage near the runway, even though one victims husband put bags in the nose compartment personally. The man said he did not work the doors to the compartment, only placed the bags there. The wreckage showed that the door was unlatched at the time of the post-crash fire.

One witness, a 7,000 hour corporate pilot with a CFII-MEII rating, reported that the airplane was about 300 feet when it made the most tragic Vmc demonstration I could ever have imagined. The airplane was at about midfield on the 5,900-foot runway when the engine sounds changed. The witness reported hearing a few pops and the airplane pitched up slightly.

It became obvious that an engine had lost power, and a lot of it, he said.

Answers Elusive
Certain aspects of the NTSB investigation seemed to bear this out. The engines were badly damaged by the fire, so it is difficult to be certain of any conclusions drawn from their examination. However, the plugs in the Nos. 1, 3, and 5 cylinders of the left engine were black with oil, while the other plugs were normal.

Analysis of the propellers was difficult because both sets were badly damaged. The cockpit controls were gone, but the actuator arms of both governors were in the low-pitch position.

If there was an engine failure, as the highly qualified witness described, the pilot did not react properly in securing both engines and landing on the remaining runway. He didnt even feather the prop of the dead engine.

However, in its report the NTSB did not assign any blame to engine problems, perhaps because the fire damage made assigning blame to mechanical problems risky.

In making that determination, however, the Board discounted the testimony of a highly qualified observer who was very close to the scene and watched the entire episode unfold. It simply blamed the pilot for failing to maintain airspeed because he was distracted by the open baggage door, resulting in a spin.

The board further put the blame on the pilot by saying his preflight inspection was incomplete because he did not adequately secure the baggage door after a passenger put luggage there and because he had little experience in the make and model.

Assigning blame in any accident is a often a no-win situation, and this is one of those times. However, the Aztecs last flight, like that of the Cherokee Six, shows that diligence is crucial.

Murphys law says that the moment you let down your guard some challenge will arise to test you. Such complacency may be reflected in thinking you can fly safely when you clearly cannot; it may also come when a holiday outing is on your mind instead of the nuances of slipping the imperious bonds of earth.

-by Ken Ibold


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