15 minute read
Jim Davis - ACCIDENT REPORT
BONANZA VFR INTO IMC
AIRCRAFT ACCIDENT REPORT
• This report is to promote
aviation safety and not to establish legal liability.
• The CAA’s report contains
padding, repetition, poor
English and incompetence.
So, in the interest of clarity and readability, I have had to correct and paraphrase extensively
ACCIDENT REPORT:
Time of Accident: ±1517Z Date of Accident: 13/09/2012 Aircraft Registration: ZS-TVR Type of Operation: Private flight Type of Aircraft: Beech F33A Pilot-in-command License Type: Private Pilot Age: 64 License Valid: No Pilot-in-command Flying Experience:
Total Flying Hours: 1 047,4 Hours on Type : 984,9
Last point of departure: Pietermaritzburg Next point of intended landing: Newcastle Location of the accident site: Ophatha, near Cato Ridge
(GPS position; 29° 38.679’ South 030° 42.236’ East, elevation 1 574 feet)
Mete.: Surface wind 130°/10 kts; Temp 15°C, Dew
point 12°C, Overcast
Number of people on board: 1+2 No. of people injured: 0 No. of people killed: 1+2
Briefly
The pilot and two passengers, took off from Newcastle on Thursday morning, 13 September 2012 on a private flight and landed at Pietermaritzburg at 0523Z. The aircraft was parked and the occupants attended a conference in the city. That afternoon they returned for their intended flight home. At 1507Z ATC cleared them for takeoff on runway 16 under special VFR. Approximately ten minutes after takeoff a witness heard an aircraft flying above the clouds, and seconds later he saw it descending through the clouds and spiraling down. It remained in a spiral until it impacted in dense bush and mountainous terrain. Following impact it was consumed by fire. All three occupants were fatally injured.
Weather Pilot history
The satellite and radar data indicated broken to The pilot took over 80 hours to get his PPL, 63 overcast low-level clouds in the FAPM area. In the being on Cessnas and 20 on a Beech 85. He only area of the accident site thundershowers and poor flew the Beech 33/35 after obtaining his PPL. visibility prevailed. In 2000, the year his PPL The captain of a domestic flight, Link 741, stated “I advised was issued, he retracted the landing gear instead of the that they had to enter into a holding pattern for the student flaps on a V-tail Bonanza at Newcastle. And ten years approximately 20 minutes to the north of FAPM where to fly without later, also at Newcastle, in the accident aircraft, he forgot to they waited for thunderstorm activity to move away to the east before they could start the approach for Runway 16. autopilot more regularly“ lower the undercarriage. Ten years before the fatal accident he flew 13 hours of IF and 3 hours of night The weather was IMC. Link dual in order to get his night 741 broke cloud at 2 200 feet AGL in haze with rating. There is no mention of night solo. The night limited visibility for the approach. The pilot told rating instructor wrote, “I advised the student to ATC he would not advise a VFR departure. The fly without autopilot more regularly in order to pilot of ZS-TVR, however, opted to continue with improve accuracy”. the takeoff regardless. He had not obtained a weather briefing.
Oblivious to advice, the pilot took off and headed east into the thunderstorms.
The aircraft was well equipped with Bendix avionics including two nav/comms, DME, marker beacons, ADF, transponder, stormscope, radar altimeter, ELT and a two axis auto pilot.
Communications
The pilot requested takeoff clearance, but ATC advised him that the CTR was in IMC. The communication between the pilot and ATC lasted approximately 20 minutes. At 1508Z ATC cleared the aircraft for takeoff under special VFR. The transcript indicates that the pilot was agitated by ATC asking him what his intention was several times.
No mayday call was picked up.
Wreckage and impact information
The aircraft crashed in dense bush in mountainous terrain16,2 nautical miles east of FAPM. It was in a vertical trajectory during impact. The wreckage was contained at one location, without any debris field. The landing gear was retracted. The empennage remained intact and both elevators and the rudder control surfaces were still attached at their hinging points. The cabin and both wings were consumed by fire. The manifold pressure and fuel flow indicator was the only gauge that presented a readable display. It showed 28,5 inches, and 11 to 12 US gallons per hour. These were both within the expected range.
Flight Planning
The pilot did not file a flight plan. Improper flight planning played a major role in this accident. During communication with ATC the pilot requested to fly via Greytown, 36 nm north-east of FAPM, and then to climb above cloud and fly
Manifold and fuel pressure were within normal limits. The pilot had not throttled back.
direct to Newcastle.
The aircraft crashed 16,2 nm east of FAPM. The pilot’s decision to take this route took him directly into thunderstorms.
When ATC issued the pilot with a special VFR clearance, they were very specific that he should remain clear of cloud and in sight of ground at all times.
The pilot displayed an over eagerness to get home.
Next red flag, perhaps also smallish, ten years later he lands with the gear During this investigation it became apparent he is getting up. Another old saying, “There are those pilots who that the pilot was very dependent on the autopilot. impatient with have done it, and those who are going to.” And one It is believed that, due to thunderstorm turbulence ATC more, “It can happen to anyone.” the auto-pilot probably Sorry, I don’t buy any of it. disengaged, forcing the Things didn’t just happen pilot to fly manually. By the time the pilot became to you – baring mechanical failures – you cause aware of the situation, the aircraft had most things to happen. There are tens of thousands probably entered an unusual flight attitude from of pilots with a lifetime of flying who have never which he needed to recover without any visible landed gear up. Those who have done it didn’t horizon. have their finger out at a critical phase of the flight. The first time the pilot became aware of the ground was probably when the aircraft came out of the clouds in a nose down-spiral with a high rate of descent. The pilot was unable to start recovery prior to impact.
JIM’S COMMENTS
There’s quite a bit going on here - it’s more than a simple VFR into IMC. If I knew the pilot’s history there’s no way I would have sat in the back of that aircraft. Some of the red flags are small and may seem unimportant - but they are there nonetheless, while others are huge things being waved in your face - like marshals at a grand prix. Let’s run through them. A smallish one to start with. The pilot only started flying when he was 52. In my book this is great. Older pilots often take a little longer to learn, but they generally learn better - they are inclined to remember what they learn. Unfortunately this guy wanted to run before he could walk. He bought a Bonanza while he was still training. Hmmm, this brings to mind the old saying “more money than sense”. As a general rule converting to a 210, a Bonnie, a Mooney or a Comanche before you have 200 hours is pushing it. And so it turned out in this case – before the ink had dried on his license he crashed it by pulling up the gear, instead of the flaps, after landing.
The next little red flag is a night rating. Yep, a good thing if you are working towards a com. Or if you plan to do a fair amount of night flying. In this case my intuition tells me that he is just one of the many pilots who claim they want the rating just in case they get home half an hour after dark. This is generally bull. The more honest ones say just in case I get caught out with bad weather. But no one admits that it will make them feel more comfortable doing illegal auto-pilot IF - which is often the bottom line.
His instructor suspects that to be the case, and advises him to practice hand-flying on instruments instead of using the auto pilot. I suspect that his limited exposure to instrument flying may have given him a false sense of security around clouds. Are you starting to feel perhaps you also wouldn’t want to be in the back with this guy in dodgy weather? It gets worse. He has a serious case of get-home-itis. He is in a hurry, he hasn’t obtained a met report, he hasn’t
filed a flight plan, he is getting impatient with ATC, he won’t listen to the advice of an airline pilot who has just flown in that very weather. And worst of all, he hasn’t done any flight planning apart from telling ATC that he plans to get on top of the weather. Really…with thunderstorms? And how does he plan to get there with no instrument rating? Auto pilot of course. You still want to fly with him? Let’s have a closer look at the weather. The system was moving rapidly eastwards – but the pilot elected to divert to the east - slap into it. Had he waited half an hour, or diverted slightly to the west, he would have been in clear air all the way home.
During the final graveyard spiral the pilot must have been paralyzed by fear – he didn’t even throttle back.
Allow me a little rant because I am tired of repeating the same old story of a pilot who ignores the weather and takes off against competent advice. If you think this is an unduly brutal attack on a pilot who is no longer around to defend himself – you are right. And some of it is based on conjecture because we don’t have all the facts. But we do know that he killed two trusting pax. Perhaps the final red flag is the fact that the pilot’s license was not valid. Although this may not alter his physical handling of the controls, or even his decision making, it points to his attitude which is a major safety concern. Also no license can invalidate his insurance, and possibly the life insurance of his passengers. I wonder if he had told them he didn’t have a valid license.
This is not a legal debate - it’s a flight safety article and if it keeps just one pilot – perhaps you – out of trouble, then I have done my job. Rant over – just as the thunderstorms were soon over.
The Bonanza impacted almost vertically.
TAKE-HOME STUFF
• Never buy, or fly, more aeroplane than you can handle. Baby steps first. • If you start losing control in IMC Beech recommend chucking out the gear. • A night rating is not an invitation to stick your nose into cloud. • An autopilot is also not an invitation to stick your nose into cloud. • The met office is there to give you a safe and comfortable flight - use it. • Plan the flight and then fly the plan. • If what you are doing sounds like the start of an accident report, perhaps it is – slow down and take stock. • Flying without a valid license is illegal, it’s not fair to your passengers or your family. • Please don’t give me reason to write about you.
APPENDIX
Disorientation (from POH)
Disorientation can occur in a variety of ways. During flight, inner ear balancing mechanisms are subjected to varied forces not normally experienced on the ground. This, combined with loss of outside visual reference, can cause vertigo. False interpretations (illusions) result, and may confuse the pilot’s conception of the altitude and position of his airplane. Under VFR conditions, the visual sense, using the horizon as a reference, can override the illusions. Under low visibility conditions (night, fog, clouds, haze, etc.) the illusion predominates. Only through awareness of these illusions, and proficiency in instrument flight procedures, can an airplane be operated safely in a low visibility environment. Flying in fog or dust, cloud banks, or very low visibility, with strobe lights or rotating beacons turned on can contribute to vertigo. They should be turned off in these conditions, particularly at night. All pilots should check the weather and use good judgement in planning flights. The VFR pilot should use extra caution in avoiding low visibility conditions. Motion sickness often precedes or accompanies disorientation and may further jeopardize the flight. Disorientation in low visibility conditions is not limited to VFR pilots. Although IFR pilots are trained to look at their instruments to gain an artificial visual reference as a replacement for the loss of a visual horizon, they do not always do so. This can happen when the pilot’s physical condition will not permit him to concentrate on his instruments; when the pilot is not proficient in flying instrument conditions in the airplane he is flying; or, when the pilot’s workload of flying by reference to his instruments is augmented by such factors as turbulence. Even an instrument rated pilot encountering instrument conditions, intentional or unintentional, should ask himself whether or not he is sufficiently alert and proficient in the airplane he is flying, to fly under low visibility conditions and in the turbulence anticipated or encountered. If any doubt exists, the flight should not be made, or it should be discontinued as soon as possible. The result of vertigo is loss of control of the airplane. If the loss of control is sustained, it will result in an excessive speed accident. Excessive speed accidents occur in one of two manners, either as an inflight airframe separation or as a high speed ground impact; and they are fatal accidents in either case. All airplanes are subject to this form of accident.
For years, Beech Pilot’s Operating Handbooks and FAA Approved Airplane Flight Manuals have contained instructions that the landing gear should be extended in any circumstance in which the pilot encounters IFR conditions which approach the limits of his capability or his ratings. Lowering the gear in IFR conditions or flight into heavy or severe turbulence, tends to stabilize the airplane, assists in maintaining proper airspeed, and will substantially reduce the possibility of reaching excessive airspeeds with catastrophic
The pilot's decision to fly east is evident in the location of the wreckage.
consequences, even where loss of control is experienced. Excessive speed accidents occur at airspeeds greatly in excess of two operating limitations which are specified in the manuals: Maximum manoeuvring speed and the “red line” or “never exceed” speed. Such speed limits are set to protect the structure of an airplane. For example, flight controls are designed to be used to their fullest extent only below the airplane’s maximum manoeuvring speed. As a result, the control surfaces should never be suddenly or fully deflected above the maximum manoeuvring speed. Turbulence penetration should not be performed above that speed. The accidents we are discussing here occur at airspeeds greatly in excess of these limitations. No airplane should ever be flown beyond its FAA approved operating limitations.j
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This brief reminiscence brings to an end the series of anecdotes from Doc Mark Holliday reflecting on his many outlandings experienced during thirty years of competitive gliding.
MY VERY FIRST SA NATIONALS competition my crew Thomas Burki’s relationship with was back in the good old days in Vryburg. I Jackie, who he eventually married. What could had leaking waterbags, so I launched an hour be more conducive to intimate conversation than after the field had started and had an enjoyable driving hundreds of kilometres across the South flight going from storm to storm watching the a massive African landscape with the biggest sky in the world as lightning viciously strike through the lightly raining areas. storm cut us off your theatre? One afternoon a massive storm cut us off and I When you are that close remember Dave Mortimer to lightning, it looks different and the sound of and I sat in our ASW20s on the Delareyville thunder seems more muted. Since that day airfield after dark, balancing our wings as the I have always felt quite safe going near to lightning danced all around us. It was only later lightning as long as I stay out of the rain. The that I thought that we were high points on the late start worked in my favour as I won, and I ground and could have easily been struck. wasn’t to win another day at the Nationals for 11 years. j That night however still remains a beautiful and enduring memory. That competition saw me land out many times and I am sure that the long retrieves cemented
