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Deciding Factor

It's nearing midnight. A damp fog rolls lazily off the Gulf of Mexico, thick clouds blurring the lines between earth, sea and sky. Lights pierce less than a mile through mist and fog under a 100-foot overcast. Dark silence envelopes the salt marshes of the Florida panhandle. Suddenly an otherworldly shriek shakes the trees and swamp, a wail punctuated with a dull thump, the squawking of birds, then a return to silence. An airplane lay mangled in the steaming marsh, its pilot dead at the controls. Why?

It's nearing midnight. A damp fog rolls lazily off the Gulf of Mexico, thick clouds blurring the lines between earth, sea and sky. Lights pierce less than a mile through mist and fog under a 100-foot overcast. Dark silence envelopes the salt marshes of the Florida panhandle. Suddenly an otherworldly shriek shakes the trees and swamp, a wail punctuated with a dull thump, the squawking of birds, then a return to silence. An airplane lay mangled in the steaming marsh, its pilot dead at the controls. Why?

This is a dramatization, as accurate as the facts at this point allow, of a mishap that needlessly took the life of a pilot and destroyed a fine airplane. The purpose of this article is not to point fingers or assign blame, but instead to show how a chain of decisions can end in a gnarled heap. The hope is that readers, faced with making similar decisions themselves, will remember this pilot's mistakes and honor his life by using his experience to save themselves.

"I'M LOSING IT!"
"I can't. I'm losing it." The last transmission received from the accident airplane hints at the despair, the terror that must have entered the pilot's mind as his airplane began its final, out of control plunge. Air Traffic Control (ATC) was trying to vector the airplane, operating on an Instrument Flight Rules (IFR) flight plan and clearance, to the localizer of the southbound Instrument Landing System (ILS) approach. The weather was worse than the minimums allowed by Federal regulations, and both the pilot and controller both knew it. But the incident had already devolved into a de facto emergency -- although the pilot never declared a formal emergency, ATC was giving the flight priority over other traffic. In fact, this was the pilot's fourth unsuccessful attempt to line up on the approach inbound to the airport. ATC had provided the flight vectors three times previous, but each time the pilot had been unable to intercept the localizer and glideslope. Repetitive failure heightened the anxiety which finally overpowered the pilot, that midnight over the swamps.

"...A FUEL SITUATION...."
Fifty-one minutes earlier the pilot was cruising at 6000 feet in Instrument Meteorological Conditions (IMC), en route from east-central Florida on a filed non-stop to Louisiana. Thirty miles southeast of Pensacola the pilot advised ATC he was "having a fuel situation and (he needed) to get this taken care of." The pilot requested a change of destination to Pensacola, which was granted. While being vectored for the ILS 17 approach ATC asked the pilot his fuel state, and he replied "I have fuel in a tip-tank and I can't get to it." The pilot clearly thought there was something wrong with a fuel valve or fuel transfer system, or was not properly managing fuel flow. But halfway into a planned cross-country, presumably with adequate fuel and reserves for the entire night, IFR flight, the airplane should have had a significant amount of fuel still on board -- even with one full tip tank inaccessible. Pensacola was at his 12 o'clock position and open well past dark, so Pensacola it was. The pilot seems to have committed himself to landing there at all costs.

"LOW ON FUEL"
It seems, though, that the pilot was aware of his fuel state even earlier. At first contact near Pensacola he told ATC his flight plan needed to be "amended" because he was "low on fuel and needed to land at Pensacola." Had he departed for this maximum-range flight without sufficient fuel? Did he not realize until he was airborne that his endurance did not match his planned range? Did something happen after takeoff that reduced the fuel load, such as a loose fuel cap or a leaking tank? Regardless of cause, the reported low fuel state turned into an unplanned descent into below-minimums weather.

FILING IFR
It was a damp, rainy night along the Gulf Coast, with widespread marginal cloud and visibility conditions dipping to Low IFR (ceiling below 500 feet, visibility below one mile) along the coast. Temperature and dew point both hovered in the mid-50s; the natural cooling of night meant ceiling and visibility were likely to go down even more. The pilot had filed an IFR flight plan but there is no record of an official weather briefing. The flight departed about two hours and five minutes prior to the pilot's first "low fuel" report (perhaps this time frame only coincidentally correlates with the endurance provided by a single main fuel tank on this type of aircraft). The pilot flew another 51 minutes after that first low-fuel radio call. A thorough briefing might have revealed improving conditions to the north, with all-night stations like Ft. Rucker, Alabama, well within that range.

THE FINAL STRAW?
A night IFR flight. Lowering weather, with below-minimums ceilings near the coast. A low fuel state. None of these, singly or in concert, should have led to the inability to intercept the ILS approach from radar vectors (which, frankly, is one of the easiest things an IFR pilot is ever called upon to do). Certainly they do not provide cause for loss of aircraft control.

So what was the final straw? We may never know -- but one thing discovered in the National Transportation Safety Board's (NTSB's) preliminary investigation is that the pilot did not hold an instrument rating. Currently, no mechanism exists to cross-check pilot qualifications with the type of flight plan being filed. This pilot slipped through that crack, filing and flying a flight he was neither trained nor qualified to fly. Undoubtedly he'd done it before, considering his apparent ease with the process and lack of tell-tale difficulties prior to the need to divert. He must have assumed he'd merely overfly the bad weather and, when faced with a change in plans, fell into the trap of aiming for the most convenient, not necessarily best alternative. His decisions cost him his life.

THE BOTTOM LINE: The NTSB's final report, expected about a year following the crash, will likely list "spatial disorientation" as the primary cause. The "deciding factor" in this mishap, however, may have been the anti-authority attitude exhibited by a pilot that so obviously flaunts the rules, and the complacency many of us have about overflying adverse conditions, hoping we won't have to descend into them. The common decision to land at the closest, most convenient airport, instead of seeking a better alternative perhaps more distant and off the planned route, was another factor. It robbed the world of another pilot, a family member, and from what I've heard, a teacher; it also added to the bad press personal aviation desperately today desperately needs to avoid. For all the damage done, please don't let the positive lessons be lost. At the very least, remember that the consequences of our decisions range far beyond the personal risks we choose to accept. Even when flying alone.

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About This Author:
Tom Turner is a widely published author and regular forum speaker at EAA's Oshkosh/Airventure and American Bonanza Society. Tom holds an M.S. in Aviation Safety with an emphasis on pilot training methods and human factors. He has worked as lead instructor at FlightSafety International, developed and conducted flight test profiles for modified aircraft and authored three books including: Cockpit Resource Management: The Private Pilot's Guide and Instrument Flying Handbook (both from McGraw-Hill). His flight experience currently spans 3000 hours with approximately 1800 logged as an instructor. Tom's certificate currently shows ATP MEL with Commercial/Instrument privileges in SEL airplanes.
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