Toss the Rulebook

By ignoring a few rules, pilot takes three friends to the bottom of a lake instead of a hockey playoff


For some reason, pilots tend to have love/hate relationships with rules. There sure are a lot of rules, and complying with some of them seems like a total pain. Many of them dont make any sense. Some even appear to contradict.

But having rules governing training, proficiency, maintenance and other aspects of flying does more than supply fodder for hangar gripe sessions. They provide the context in which aviation exists. Pilots have proven time and time again that, left to their own devices, the odds increase that they will make shortsighted decisions that are based more on their momentary convenience than their long-term benefit.

The phenomenon replays itself over and over, and is the genesis of the notion that the FAA is a tombstone agency. Behind almost every rule is an accident that prompted a bureaucrat or government lawyer to try to regulate away another one like it.

Still, pilots tend to pick and choose which rules theyre willing to follow, and which ones get relegated to the dustbin.

A Nevada pilot picked his own set of rules to play by, and found out the hard way why some of the rules are in place. The 280-hour private pilot joined a flying club in Reno on May 27 and checked out in the clubs Piper Warrior. The airplane had been modified via Supplemental Type Certificate to run a 180-hp engine, essentially turning the Warrior into an Archer.

The pilot and an instructor reviewed the airplanes performance specifications, at which time the instructor stressed that, due to density altitude considerations, the Warrior 180 should not be considered a four-person airplane if filled with adults. He said it was standard to fill the tanks only to the bottom of the tabs and not to top them off.

Because the pilot had never flown a Piper before, the instructor advised him that he would have to fly five hours locally before heading off on a cross-country. The pilot replied he had booked the airplane for most of the day two days later to fly off that time.

The instructor said the two then went on a flight of about an hour, during which time the air was very turbulent, with strong updrafts and downdrafts. Nevertheless, the instructor said, the pilots performance was satisfactory and at no time did he feel compelled to take control of the airplane for safety reasons.

At that point, the instructor showed the pilot how to access the keys from the clubs lock box and reiterated that he needed to fly five hours locally as part of his model transition training.

On His Own
Two days later, the pilot called the Reno Flight Service Station at 4:30 a.m. and requested a standard weather briefing for a 77-mile trip from Reno to Hawthorne, Nev., and an outlook briefing for Hawthorne to Denver – a distance of 650 miles.

The briefer described IFR weather to the east of his destination and thunderstorms to the south, but the storms were moving south and his destination in Denver was reporting VFR conditions. About two hours later, the pilot called the FSS again and filed a VFR flight plan to Hawthorne.

While filing the flight plan, the pilot made a number of mistakes that indicate he did not routinely file them. Interestingly, he listed fuel on board as 4 hours, 30 minutes, which would have required filling the tanks past the bottom of the tabs. He also listed the trip to Hawthorne as 1 hour, 30 minutes, despite the fact it was less than 80 miles away. He listed takeoff time as 7 a.m.

The Warrior took off at 7:26. There is no record the pilot opened his VFR flight plan. Theres no record he even landed at Hawthorne, nor did he file any amended flight plan. Investigators were able to turn up only one stop, in Meeker, Colo., which was 548 miles away and, given the winds aloft, at the very limit of the airplanes full-fuel range if flown at 55 percent power. Given the seven hours that elapsed between the time he took off from Reno and bought gas in Meeker, its almost certain the pilot made an undiscovered intermediate stop.

In Meeker, he bought 19.8 gallons of avgas, paying the tab at 2:48 p.m. At some point the pilot had been joined by three friends. Together, the four occupants weighed in at 760 pounds. Witnesses at Meeker said the airplane departed downwind and struggled to climb.

Investigators later estimated the airplane weighed about 2,436 pounds at takeoff, with a center of gravity at 91.88 inches aft of datum. The maximum certificated weight of the airplane was 2,325 pounds, but keep in mind the airplane had been modified with a 180-hp engine. The Archer is a virtually identical airplane as the Warrior, but has the 180-hp engine and a max gross weight of 2,440 pounds. The engine conversion STC does not allow for the gross weight change, but the performance of the Archer suggests the overloading of the Warrior was not necessarily a critical error.

However, Meeker lies at 6,421 msl, and the pilot was headed toward even higher terrain to the east. About 32 miles east, he came upon Upper Marvine Lake, a wilderness lake at about 9,300 feet, with even higher terrain in the area.

The Silence
Back in Reno, the flying club had become incensed at the pilots actions. He had taken the airplane early in the morning, much to the chagrin of another pilot who had scheduled using it from 6 a.m. to 8:30. As the day ticked on, another pilot got bumped. The accident pilot had reserved the airplane until 5:30 and another pilot planned to fly from 5:30 until 8:30.

The general manager of the flying club later told investigators the flight was unauthorized because it involved a cross-country trip without the pilot having flown off the local time.

Family members became concerned later that day when none of the airplanes occupants called them. The four apparently had landed tickets to a Stanley Cup finals game in Denver for that night, but never showed up to use them.

The FAA declared the flight overdue and issued an Alert Notice at 11:24 p.m. mountain time, by which time the airplane had been out of the air for some eight hours.

The Civil Air Patrol initiated an aerial search the next day, based on the sketchy – and possibly incorrect – information the pilot had supplied to the Flight Service Station briefer. The fate of the airplane and its occupants remained uncertain for several days.

On June 4, fishermen discovered debris floating in Upper Marvine Lake, which is in the Flat Tops Primitive Area of the White River National Forest. Motor vehicles are not allowed in the wilderness area, and the lake is a 3-hour horseback ride from the nearest road. Investigators got permission from the U.S. Forest Service to bring in salvage equipment and personnel by helicopter.

On June 6 a remote underwater camera found the airplane, lying on its left side in 43 feet of water. The wings and empennage had been ripped from the fuselage. Three days later, the wreckage was raised from the lake floor by helicopter and dragged to shore. All four occupants were inside, still wearing their seatbelts.

The Puzzle Pieces
The outboard section of the right wing displayed leading edge compression damage, and both wings showed damage consistent with separating on impact. Both sides of the fuselage showed compression damage, with the evidence strongest in the right front of the cabin.

Together, these signatures appeared to show the airplane hit right wing low and slightly nose down, at which point the wing sheared and the airplane cartwheeled. It does not support a controlled ditching. Investigators speculated the pilot might have been turning around when confronted with high terrain on the other side of the lake that the airplane could not out climb.

Much of the airplanes engine and accessories could not be tested, however it appeared the vacuum pump and gyros instruments were spinning at the time of the crash. The propeller did not exhibit the kind of bending consistent with a high-power impact, but the airplane been fueled only about 45 minutes earlier and there was some residual fuel in the fuel lines.

The airspeed indicator read 150 mph and the vertical speed indicator showed 2,000 fpm down, suggesting a high-speed spiral. Interestingly, both the fuel pump and the landing light were on.

Pathologists found no evidence of carbon monoxide, but they did find a troubling indication. The pilot showed high levels of methamphetamine, a powerful illegal stimulant. The levels found in the blood and urine suggest the pilot regularly used the drug and was perhaps addicted. He apparently had taken some shortly before the crash and was likely impaired by its effects.

In addition to the well-known stimulant effects of so-called crystal meth, it can also induce euphoria and increased self-confidence. Some users have experienced seizures or loss of consciousness, but pathologists did not consider it likely in this case.

The NTSB concluded the probable cause of the accident was the pilots failure to maintain clearance with terrain because of his drug-induced impairment, with the overloaded airplane being a factor. However, there are other factors that may have also played a part.

Other Factors
The density altitude at the crash site was calculated to be 11,515 feet at the time of the crash. Investigators noted that the service ceiling of the Warrior was 11,000 feet when operated in the normal category and 14,000 feet when operated in the utility category, which ends at 400 pounds less than the airplane weighed at the time of the accident.

The new engine had basically changed the Warrior into an Archer, and higher gross weight limit of the Archer suggests the overloading may have been more of a legal issue than an operational one. Terrain in the area tops out at 12,354 feet, however the above-standard temperature at the time would have made that terrain higher than the Archers service ceiling as well.

In fact, the airplane was likely cruising at about its maximum altitude, given the terrain and its loading. If the density altitude at the crash site was 11,515 feet, the pilot was likely operating at an altitude at which he would become hypoxic.

Recall the airspeed indicator reading 150 and the VSI showing 2,000 fpm down. Although the instrument readings are not necessarily accurate, given the crash sequence, they do not paint a picture of a course reversal.

Another issue lies in the position of a couple of switches on board. The electric fuel pump and landing lights were both on. This could reflect a pilot who does not use a post-takeoff checklist, because the Cessnas he was used to flying did not have electric fuel pumps.

While turning on the fuel pump could have been part of a power-loss emergency sequence, that would not explain why the landing light was on, unless one or both switches were thrown during the crash sequence.

In the final analysis, however, the exact details of the crash are largely irrelevant. But there are lessons to be learned from the unfolding of the doomed flight.

The legality of the aircraft loading aside, it was rather foolish of the pilot to demand the airplane operate at or near its service ceiling over towering terrain on a long cross-country flight when he had only one hour of experience in type. Baptism by fire works in some endeavors, but this isnt one of them.

The pilots alleged substance abuse is another matter. This is not strictly a flying issue, but a life issue. Flying demands sound judgment, but those who allow themselves to fall into a substance abuse trap are showing poor judgment. Legal or not, they should ground themselves until they work out the issue and can trust themselves to make the hard calls inherent in flight.

To a certain extent, the real cause of the accident was the pilots willingness to ignore the rules. Flight experience requirements based on insurance may seem arbitrary, but they are the result of loss experience that suggests its a prudent move.

If he had followed the rules on using oxygen or flight planning, he should have realized he was flirting with hypoxia and he also would have seen significantly lower terrain slightly south of his route of flight. The accident site is almost on a direct line between Meeker and Jefferson County Airport in Denver, and he had a hockey game to get to. The airplane was equipped with a GPS, so he chose to fly direct. But diverting only five miles south would have put him over terrain that was 2,000 feet lower.

In the end, its the rules of chemistry and physics – not those of the FAA or the insurance company – that keep airplanes in the air. And those are rules that dont take kindly to being broken.

-by Ken Ibold


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