There comes a time in every pilots career when they get ready to launch on a flight they really shouldnt make.
The warning signs are there. Maybe the pilot isnt feeling up to snuff. Maybe the mechanical health of the airplane is suspect. Maybe the weather is either threatening to go bad or already is below the pilots or legal minimums.
This is the stuff of flying. Forget about stick and rudder. Forget about IFR radio technique. Forget about navigation. Think instead about the C that comes with being PIC. Command. It implies the skill to measure the likelihood of a favorable outcome and the wisdom to know if the risk is worth the outcome. In short, its the competition between judgment and ego.
Theres no doubt that pilots with superb skills can dig themselves out of a pile of misfortune. Its also true that pilots with mediocre skills can merely avoid the misfortune by staying far away from it. That, of course, is easier said than done.
A low-time private pilot decided to take his wife and adult son on a Thanksgiving weekend trip from Tallahassee, Fla., to Key West in a brand-new Commander 114B that had just been purchased by the company he owned.
The new 114B was everything the 172s in which the pilot had learned to fly was not. Loaded with avionics, the 114B was bigger and more complex than anything he had flown before, right down to the air conditioning every pilot in the Southeast wishes for in the dog days of summer.
The Long and Short of It
The pilot had started on the road to his license in 1993, when he flew a single introductory flight in a Cessna 152. He didnt fly again for 10 months, at which time he took another three flight lessons. Nearly another year passed, then three more lessons in the space of three weeks. Then, more than three years after the initial lesson, the pilot got serious. He flew eight lessons in a little over a month, then headed out of town away from the distractions of business and family life. He took 12 lessons in six days, returned to work for a couple of weeks, then returned to the flight school and flew seven lessons in four days.
During the frenzy of activity he logged his first solo, after 37.5 hours of often-interrupted training. He went three months in which he only flew once. Then he returned to the flight school again and flew 17 flights in 13 days, including passing his private check ride. He had more than 95 hours in his log book. He made a few cross country flights and logged a little actual instrument time with an instructor. As cooler weather approached, he took the plunge into aircraft ownership.
In November he took delivery on a brand new airplane. The custom N-number linked the airplane to his company. Inside, it was loaded with IFR GPS, an HSI, Argus moving map, WX 1000 Stormscope and KFC 200 autopilot. Total time aircraft and engine: 3.7 hours.
He launched into the aircraft checkout with the same intensity that earned him his license. In less than a week he logged nearly 31 hours of ground instruction and 19.6 hours of flight instruction at the factory in Oklahoma. With his aircraft checkout in hand, he returned to Tallahassee. The next day, the Monday before Thanksgiving, he took his son for what he logged as a look see in the new plane. Thanksgiving day, the family took off on a holiday trip in their new pride and joy.
Upon arriving in Key West, the pilot couldnt wait to show the plane off to some friends who were meeting them for the holiday weekend. The salesman from Commander Aircraft was in town for the holiday as well. One of the sumps had developed a minor drip, but it wasnt serious and the airplane was under warranty. Nothing could spoil this trip.
Saturday morning, the family assembled and set out for home. Their friends had already left, heading out early on the 600-mile drive back to Tallahassee. At the airport, the pilot got his first weather briefing of the day. VFR flight was not recommended because of low IFR conditions along the pilots proposed route of flight up the west coast of Florida. The pilot asked for weather up the east coast of Florida. He got it, then hung up, saying hed call back with a new plan.
A half-hour later he called back and proposed a flight up the east coast from Key West to Orlando. He got a standard weather briefing in which VFR flight was not recommended. He filed a VFR flight plan. Forty minutes later, he left Key West and headed north.
He never activated his flight plan, although he did participate in flight following. His actual route of flight more closely resembled his initial suggested route than the one he filed in his flight plan.
At just after noon, controllers asked the pilot to verify that his intended destination was Orlando Executive Airport. He responded that he would like to change his destination to Cross City, Fla., 114 nm closer to his destination. Controllers briefly lost him as he ran through the intersection of three facilities airspace. He never made it to Cross City, however. The Commander ended up on the ground in Crystal River, some 54 miles short of Cross City and 54 miles north of Tampa. Frustrated by poor weather, the family spent the night in a hotel, determined to get back home the next day.
Briefing, Anyone?
At 7:30 Sunday morning, the pilot called Flight Service to get a weather briefing for making the 55-minute dash home. Tallahassee reported ceilings at 100 feet and instrument conditions prevailed along the route. He was given two Airmets, one that forecast IFR conditions over the whole state until evening and another that warned of moderate turbulence below 10,000 feet.
At 9:15 he called again and found that conditions had not improved. In fact, some convective activity was popping up over the Gulf of Mexico and into the Florida panhandle.
At 10:20 he called again. The weather at his destination had improved somewhat, but the weather en route has deteriorated. Rain and low ceilings had cropped up through the middle of his route, stretching far east and west and virtually impossible for him to circumnavigate. During this briefing, however, a seed was planted. The briefer mentioned that the forecast for Tallahassee to improve to 1,500 scattered in about two hours, and then quickly added that the en route portion would not be as good. The pilot seized on what little good news there was.
Well, thats OK. I can just blast through most of that, he told the briefer. But, um, alright. Well just have to hold off then. If theyre still IFR Im still stuck.
At 11:20 he made his fourth call of the day. The Airmet for IFR conditions was still in force. Tallahassee was still IFR. The pilots frustration was beginning to show. As the briefer went through the weather reports, the pilot appeared to be listening half-heartedly. Some of his readbacks were incorrect. He expressed no interest in conditions anywhere along the route of flight.
At 12:08 he called for the last time. He asked only for Tallahassee weather, which had improved to 700 scattered and 1,500 broken. As soon as the briefer called it marginal VFR the pilot ended the briefing and asked to file a VFR flight plan. He said he be in the air in 20 minutes.
The pilot contacted Jacksonville Center at 12:37 as he was climbing out of 2,300 feet. The controller verified that he was VFR and asked him what his cruising altitude was going to be.
Were going to try for 5,500, but well just remain below this cloud level here, the pilot said.
The controller told him that he had talked to several aircraft going through the area within the past 20 minutes. He said pilots at 4,000 feet, 6,000 feet, 8,000 feet and 10,000 feet reported there were no VFR conditions. The accident pilot replied that he was level at 3,000 feet and that visibility was 15 to 20 miles. Then he requested to leave the frequency to open his flight plan. The controller approved the frequency change, but the flight plan was never opened.
In less than 10 minutes, the pilot indicated that the ceiling had begun to lower, but he apparently wasnt worried. The controller advised him to switch frequencies to another sector. When the pilot checked in there, he asked for flight following into Tallahassee but was told flight following was unavailable due to the high volume of IFR traffic. The pilot advised that he would monitor the frequency and contact Tallahassee Approach as he got closer to the destination. There was no further recorded conversation with the pilot of the Commander.
Radar showed the airplane continued on its heading for another 10 minutes, level at 3,200 feet. It then climbed 500 feet and began a left descending turn. In the next minute it lost 2,100 feet and turned 270 degrees. Its last radar return was from 1,600 feet at 1:03 p.m.
The Unseen Solution
The flight was not reported missing for three days. On the fourth day, the wreckage was located in a remote swampy area that was part of a hunting club. All aboard had been killed on impact, so there was no blame to be laid at the feet of the inactive flight plan or the destruction of the ELT antenna.
Ironically, the brand new bird that carried the three people to their deaths could also have been their salvation. The band of weather that apparently disoriented the pilot was not that wide nor that severe. VFR into IMC is a killer, no doubt, but if the pilot had thought to use the autopilot when he blundered into the clouds the flight might have had a drastically different outcome.
The KFC 200 that was installed included an altitude hold feature. The autopilot was switched off at the time of the crash, and there was no indication of any pre-crash malfunction that would have led the pilot to disconnect it if he had been using it. Coupling the autopilot to the GPS or the Tallahassee VOR signal and engaging altitude hold would have allowed the airplane to punch through the band of weather to the marginal VFR conditions on the other side. That would have taken only a few minutes.
Although its impossible to say for sure, the pilots training history appears to show an individual consumed by purpose. He plunged through his training with a vengeance when time permitted. After he bought his airplane, he blew through the transition training with an intensity many people could not have matched.
Somewhere along the way, however, he didnt learn an important lesson. He didnt learn how to put a flight in perspective. He didnt learn the fine art of judgment. He may have even forgotten how to use the autopilot.
The fact that an inexperienced pilot was flying a complex, well-equipped airplane deserves part of the blame for the last flight of the Commander 114B. The taste of instrument flying he had gotten after passing his private checkride must have made it seem easy, this keeping upright in the clouds. Recall his statement to the weather briefer that he could blast through most of that bad weather.
Perhaps he meant his plane could. Because his plane was certainly up to the task. Its just that the brain operating the aircraft came up a little short.
The ability to realistically assess ones own skills is a key measure of a safe pilot. Unfortunately, thats one thing that can only be taught by experience, and experience has proven to be a very unforgiving teacher.
-by Ken Ibold
