by Marc Norton
There are words no one wants to hear in the cockpit, especially during an approach in instrument conditions. Those include certain two-word phrases beginning in Oh and ending with an expletive of some sort.
But if youre flying into Somerset, Ky., on instruments, theres a five-word phrase youll be better off not hearing: Cleared for the SDF approach.
On Jan. 18, 2000, the pilot of a King Air requested and received that clearance. The turboprop twin crashed, killing the pilot and his three passengers.
In what truly could be called a shocking revelation, the National Transportation Safety Board determined that the SDF RWY 4 approach to Somerset had been out of service for more than four years before the crash.
The pilot had requested an approach published in current charts. He had been cleared to fly that approach. But the approach simply did not exist any longer.
Now, fast forward to 2003. More than three years after the crash, that same simplified directional facility approach was still in the approach books – still just as imaginary as it was more than seven years ago and still an accident waiting to happen.
The Haze Layer
The FAA has well-defined procedures to determine when an airport qualifies to get an instrument approach procedure. But Brad Rush, assistant manager of the FAAs National Flight Procedures Office, says, There is no real specific guidance on removing an approach chart from publication.
In general, an approach will continue to be published unless it is decommissioned by the authority controlling the approach equipment, Rush says. In many cases, that means airport management or local government rather than some branch of the FAA.
If the equipment is out of service but the approach is not officially decommissioned by its owner, the chart will continue in publication. And, as the NTSB pointed out in the Somerset crash, the FAA is not required to put any out-of-service notice on the chart.
Gremlins are at work here in the form of strong incentives against decommissioning an approach. First, time and money were invested to set up and certify the procedure. Businesses, including FBOs, may depend on having an IFR airport.
Indeed, regional economies and economic development efforts are often tied to having a good airport. So there is natural reluctance to decommission, knowing that if the equipment is subsequently repaired, the approach certification process must start from scratch.
Still, the owner of approach equipment is obliged to maintain it and notify the FAA when it is not operating. Repairs sometimes take a while, in part because sometimes it takes the owners of the equipment time to find out about the outage. And in an era of tight public budgets, bureaucrats tend to defer what they dont see as critical.
Once the FAA knows an approach is out of service, it issues a Notam. Under the Notam process, approach equipment can be repaired and come back on line quicker and at much less expense than recertifying the entire approach.
The NTSB found that, at Somerset, the Notam on the localizer-like SDF approach was active for one 56-day publication cycle and then the information was transferred to the Airport/Facility Directory. If the approach had been returned to service, a Notam would have been issued until the out-of-service note could be removed from the A/FD.
The out-of-service information was in the A/FD when the King Air crashed, the NTSB found, but the point is sobering if somewhat obvious: What you see in an approach book is not necessarily what you get. Phantom approaches can hang around in approach books for years.
The King Air pilot got two FSS briefings before flying from Columbus, Ohio, to Somerset on an icy day with ceilings running about 500 broken and forecasts of as low as 100 feet. He was asked if he wanted Notams and replied that he already had them.
The pilot obviously didnt know about the SDF problem. Had he accepted a fuller briefing from FSS, would he have found out?
Dont bet your life on it.
A call to the Louisville Flight Service Station in April to request a briefing for an instrument flight into Somerset yielded good information about IMC en route and at the airport. And FSS provided Notams that the airports rotating beacon and pilot-controlled runway lighting were out of service and that the AWOS-3 wasnt making ceiling measurements. But there was no mention of the SDF approach being inoperative.
During in-person visits, briefers were specifically asked if the approaches were working. Because Somerset is in their coverage area, the briefers knew about the SDFs checkered history and hauled out the A/FD to check its status. The out-of-service notice was no longer there.
When asked to check further, they dug into the thick book of published Notams. The notice was there, not really hiding but not in plain sight either.
We cant give you all this stuff over the phone, one briefer explained.
A DUATS briefing for the 85-mile flight from Louisville to Somerset brought up 27 Flight Data Center Notams. These included temporary flight restrictions in Indiana, Arkansas and Alabama and a laser light show in Dayton, Ohio. None of these pertained to the route of flight, but the last Notam in the list was important: Somerset, SDF 4 NA.
The Chain Gang
Its aviation gospel that accidents typically stem from a chain of errors rather than a single mistake. And its easy to see how this error chain developed.
The approach is in the book. The approach outage is missed because it takes some digging to find. Most pilots will assume theyve fulfilled both the spirit and the letter of the law regarding all available information before they stumble on the truth. During descent in rugged weather the pilot requests the approach that yields the best navigation guidance and lowest minimums. And Air Traffic Control mistakenly issues the clearance.
That approach outage was briefed among controllers at every shift change at Indianapolis Center, Rush says. The NTSB found that a status information sheet circulated throughout Indy Center mentioned the outage.
The controllers were following procedures, working as always to assure safety, and the error at Indy Center was just one of the last links in the chain.
If we could back up, could we break the chain? Could we keep that King Air out of trouble? Lets look at some of the links:
Approach owners: The Somerset SDF approach languished for four years before the crash. If the approach owners (Pulaski County, Ky., in this case) had waited two long years to decommission the approach, it would still have been two years before the crash. With the approach decommissioned, there would have been no approach chart aboard the King Air and thus no request to fly that approach.
If the owners of the equipment knew it was unlikely to be repaired in a timely manner, does it not make them, as Rush contends, negligent to a certain degree for not simply having the approach decommissioned?
Certainly, this is serious business. The FAA mandates that pilots refrain from careless and reckless operations that could endanger the lives and property of others. For the air navigation system to have integrity, approach owners must hew to the same standard of safety.
If an approach goes out, its owner should be zealous about notifying the FAA. And if repair efforts falter, the approach should be decommissioned through the FAA.
The FAA: Notice that an approach is out of service presents the FAA with a data management issue.
As it stands, approach outage information is easy for FSS briefers and pilots to miss. One possible answer is to put the information in many places rather than just one. One suggestion: Keep the information in the unpublished Notams and also put it in the Airport/Facility Directory and in the published Notams. Maybe a new listing of inoperative approaches is needed. And perhaps most important, put a note on the approach chart – something as simple as Approach reported INOP. Check Notams.
If that note had been on the SDF chart, the King Air pilot almost certainly would have double-checked before attempting the approach at Somerset.
One briefer at the Louisville FSS admits, Honestly, the system we have now is not very good.
With everything on the same 56-day cycle, these steps – and perhaps more innovative ones – seem very possible.
There are several schools of thought about what to do. Right now, we Notam the procedure NA, Rush says. If they (the owner of the facility) have not fixed it within 224 days, then we start action to remove the procedure from publication.
The pilot: A host of failings often bring pilots to the error-chain party: lack of knowledge, complacency, over-confidence. But there are ways to throw off your chain.
Make sure your FSS briefer knows you plan to file instruments. Ask for both published and unpublished Notams concerning the destination airport – especially if that airport is out of the way with no FAA presence. If you get a DUATS briefing, dont overlook the FDC Notams at the bottom of the report. And whenever possible, check the A/FD.
For an uncluttered check of airport Notams, go to www.notams.faa.gov. Typing in the airport identifier, such as KSME for Somerset, brings up an easy-to-read list.
As you near an out-of-the-way airport, ask the controller if other aircraft have used the approach today.
Always identify approach components by the Morse code ID. Removal of the Morse code is a warning that the component is undergoing maintenance and may not be reliable.
If youre flying an NDB approach, keep station volume audible. A loss of audio is your only sure warning should the beacon stop working.
If you have a GPS receiver or even a LORAN, use it to monitor your progress on the approach. Many GPS receivers draw the approach course on a moving map. If you think youre on the approach course and the GPS doesnt confirm it, consider terminating the approach to sort things out.
Alter your personal approach procedures. Remember that while youre off touring on the procedure turn, a farmer tending the corn that surrounds the airport could plow down some of the approach equipment. Or the electricity could go out. Some pilots make callouts on approach, such as 1,000 feet (above minimums), 500 feet, approaching minimums (100 feet to go) and minimums. Let those callouts be a signal to also make sure youre still receiving approach guidance.
If you find outages, false courses or other problems with any navaid, be sure to alert ATC or a Flight Service Station.
And, of course, when there is doubt, dont descend.
In the Somerset crash, the King Airs radar-plotted course did not fit any of the airports four approach procedures. Yet the plane descended to an altitude that approximated minimums and struck a guy wire of a communications tower.
The last transmission from the flight was, Ah, Indy, four charlie charlie.
Rush of the FAA believes that by this point, the pilot realized things were going sour in a hurry. An error chain that stretched unbroken across four years was ending horribly on a hilltop in eastern Kentucky.
Marc Norton, a newspaper editor in Louisville, Ky., is a commercial pilot with a multi-engine rating and also an instrument flight instructor.