Gremline Flight Safety Report: The Darwin Awards - Piper PA-28 Cherokee. Fit to Fly? - Bombardier Challenger 604.

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the gremline digest — the darwin awards & fit to fly?

The Darwin Awards for Aviation — An Honourable Mention

Readers are probably aware of the Darwin Awards that “salute the improvement of the human genome by honouring those who accidentally remove themselves from it by an act of outstanding stupidity.” To recognise the achievements of those who do not actually manage to kill themselves, but have exhibited outstanding stupidity, there is a lesser category of Darwin Award known as “Honourable Mentions.” These are awarded to recognise cases where “the stupidity displayed by the participants stops short of the ultimate sacrifice, but deserves a salute to their spirit and innovation.”


It seems that the time is ripe to institute a special category of Darwin Awards to recognise those involved in aviation, just as there are various categories of Nobel Prize awards. We will start with an Honourable Mention for the pilot involved in the following accident. Given time, we suspect he may well qualify for a full-blown Darwin Award.


A Bungled Beginning ...

The 45 year old holder of a Private Pilot’s Licence had bought himself a Piper PA-28 Cherokee some two weeks before this accident. He had accumulated a total experience of some 145 hours flying with about 7 hours on type and had flown about 6 hours in the previous 90 days. On November 1 he decided to fly a passenger from the UK to an airfield near Antwerp in Belgium This was to be his first international flight and he purchased a new GPS unit to assist his navigation. The aircraft, with two on board, departed the aircraft’s base at 0630 hrs (sunrise about 0650 hrs) and landed at Cambridge at 0702 hrs.
      They refuelled the Cherokee, filed a VFR flight plan to an airfield near Antwerp in Belgium, and set off again at 0747 hrs. They encountered low cloud as they approached the UK east coast so they flew over the North Sea at an altitude between 300 and 500 feet. The sea temperature was about +13C. Neither pilot nor passenger was wearing a survival suit. The aircraft carried lifejackets but no life raft or emergency locator beacon. The pilot did not make radio contact with anyone during the sea crossing. When approaching Antwerp he requested radar vectors to his destination, where they landed at about 1040 hrs after a flight of about 3 hours.
      The destination airfield is a private airfield and is not a recognised Port of Entry for Belgium. There was further confusion as the pilot had not requested the necessary prior permission to land there. The local flying club provided sufficient fuel (about 40 Imperial gallons) to fill the aircraft tanks. The pilot and his passenger wanted to visit the local town but no public transport was available as it was a public holiday in Belgium. They decided to walk into town. This delayed the pilot’s return to the airfield and he recognised that some of his return flight would be in darkness. He said he asked someone to file a VFR flight plan to Coventry before getting airborne as quickly as possible at about 1350 hrs. This departure time meant that he could not arrive before sunset at 1650 hrs. No flight plan was filed.


Carrying On Regardless ...
The weather over the North Sea had improved enough to allow the aircraft to maintain an altitude between 500 and 1,000 feet for the crossing. The pilot did not attempt to make any radio contact until he reached the UK coast when he called London Flight Information Service (FIS). London FIS heard the call but could not establish two way communication with the aircraft. The pilot reports that at around sunset the GPS unit lost its waypoints. The recorded GPS data indicates that this happened about 15 nm south-east of Cambridge. The pilot also reported that while his left fuel gauge appeared to be registering as expected, the right gauge was still indicating full. He thought he has been using fuel equally from both tanks so he concluded that the right gauge was defective. He spent 20 minutes circling while he tried to sort out the GPS unit. He was now unsure of his position and having difficulty reading the aircraft instruments because of the dim internal lights. He does not mention attempting to adjust the cockpit lighting level. After circling for 20 minutes he continued towards Towcester.
      The pilot was now so concerned about the fuel state that he decided it safer to land back at his base rather than fly to Coventry. The base airfield is unlit so he used his mobile telephone to ask his son to position his pick-up truck at the threshold of the runway. This truck had additional rear facing spot-lights and the pilot briefed his son to use the headlights to illuminate the undershoot and the rear spot-lights to illuminate the runway.



A Sticky End
On reaching what he thought was the airfield area he began circling until he saw what he took to be his son’s vehicle. He made an approach down to 50 feet above the ground before he realised that the vehicle he was approaching was actually a farm vehicle working in a field some distance from the airfield. He overshot and then saw more lights in what he took to be the right area, so he made another approach.

      Meanwhile, some members of the resident flying club were preparing for night flying. They were near their hangar that had two illuminated security lights on the front door, positioned about 6 feet apart. They saw an aircraft flying so low that they assumed it was trying to land, despite the runway being unlit. They had a vehicle loaded with runway lights for the planned night flying, so they drove towards the runway with the intention of getting the aircraft to hold until they positioned the runway lights. They attempted to contact the aircraft on the air to ground frequency but received no reply. They saw the vehicle parked on the threshold of Runway 06 and asked the driver if he had any communication with the aircraft that was trying to land.
      The pilot had now decided to land and he selected 30 degrees flap. He says that just prior to touchdown he saw the shadow of a fuel bowser ahead so he applied full power and pulled back on the control yoke. The aircraft’s left flap struck a rotating beacon on the top of the bowser’s cabin roof and scraped along the top of the bowser. The aircraft landed heavily on its nose some 30 metres beyond the bowser. The nose gear collapsed and the right wing struck the ground. The aircraft pitched forward coming to rest with the nose and propeller on the ground and the tail in the air. The pilot received a minor cut on the chin before he switched off the electrics and vacated the aircraft.
      The aircraft fuel tanks contained sufficient fuel for about one hour of flight.
      The lessons to be learnt from this truly amazing catalogue of errors and bad decisions, abysmal airmanship and sheer stupidity are too numerous to list. This pilot had many opportunities to break the sequence of events leading to the crash in the dark that could so easily have cost him his life. We can only hope he recognises at least a few of his errors and seeks further training and supervision of his flying until he develops a safer attitude.



It’s a No-Brainer!
Perhaps a few questions about this flight will help others to think about ALL the traps this pilot blundered into.
      What was so urgent about this flight that, at the basic planning stage, it must have been obvious that the daylight hours available in November and the total elapsed time of the flight made the whole idea marginal?
       The pilot had very few hours on type and was not totally familiar with the Cherokee, otherwise he would have at least known how to adjust the cockpit lighting before setting out on a flight that was going to end in darkness. How many night hours did he have on type? Was he night qualified?
      How familiar and competent was he in the operation of his new GPS system?
      How much flight planning did he do before setting out? Was he relying on GPS to provide all the navigation information required?
      Had he checked the weather en route and at his destination? The weather over the North Sea alone should have caused the flight to be cancelled.
      Had he checked the airfield details for his destination in Belgium and decided to ignore PPR and Entry Point requirements?
      Had he consciously decided to hazard his life and that of his passenger by flying across the North Sea at low level without the required survival aids and without any position reports? Had he given any thought to an engine failure? Does he know his likely survival chances in the sea?
      Carrying life jackets in the cockpit is just stupid, especially so at low level over the sea. Ever tried to don a life jacket while sitting in an aircraft seat after an engine failure at 300 feet?
      Why did he not make any radio contact while en route?
      Why did he decide to risk his life instead of spending a night in Belgium?
      Why did he not call on 121.5 MHz when he knew he was lost and suspected he was short of fuel?
      How did he avoid an interview regarding illegal entry to Belgium, landing a passenger there without entry permission and re-entering the UK without clearance?
      Does he realise that he has already used up a whole lifetime’s worth of luck?



Fit To Fly?

The standards required on the flight deck of a business jet are just as high as those required on a large passenger aircraft – and the workload on a bizjet is likely to be higher than on a scheduled flight.
       Bizjets do not always have the support of an operations and planning department to reduce the pre-flight workload on the crew. I suspect that not all bizjet crews exercise rigid limitations on their own duty hours and rest periods, especially when operating away from their home base and perhaps under pressure to complete a flight on time.

 A Bombardier Challenger 604 rolled inverted immediately after takeoff from Birmingham International Airport (England) shortly after midday local time and struck the ground, catching fire. Both pilots, an observer and both passengers died in the crash.
      The Challenger was based at Atlanta, Georgia, USA and was being operated by a crew of two experienced pilots with another pilot (unqualified on type) on board for experience. The crew began duty at Atlanta at 04.00 local time on the day before the fatal accident. They departed from Atlanta at 05.15 local time and flew to Fort Myers and then to West Palm Beach, both in Florida, to pick up a passenger at each airport. The aircraft departed West Palm Beach at 07.59 local (12.59 UTC) for a trans-Atlantic flight to Birmingham that lasted 7 hours and 40 minutes, landing at Birmingham at 20.39 UTC. The crew then checked in at a local hotel and had a meal and some alcohol before retiring at about 2330 UTC, some 14 hours and 30 minutes after beginning their duty period on that day. The handling pilot for the return trans-Atlantic flight the following day made a phone call to the USA at 02.00 UTC, so obviously did not immediately go to sleep on retiring.
      On the following morning the handling pilot and the observer arrived at the airport about 20 minutes before the other pilot (the commander), who arrived at about 11.00 UTC (Local time). The aircraft was refuelled so that it was some 364 pounds below its maximum takeoff weight at takeoff. The CofG could not be calculated accurately as the seating of the passengers and the positioning of the baggage could not be determined after the accident. The temperature overnight had fallen to a minimum of –9C (16F) and various witnesses had seen frost and ice on the wing surfaces of the Challenger. Other aircraft were defrosted, with reports of severe to moderate ice accumulation. The Challenger was not de-iced before departure.
      Before engine start, the commander questioned the handling pilot about the frost on the wings of the aircraft. The cockpit voice recorder (CVR) recorded the following interchange between the two pilots:

Commander: ‘Got a **** frost on the leading edge, on there, did you-all look at it?’

Handling pilot: ‘Huh?’

Commander: ‘D’you **** that frost on the leading edge – wings?’

Handling pilot: ‘Did I feel ‘em?’

Commander: ‘Yeah, did you-all check that out?’

Handling pilot: ‘Yuh.’

The commander was 51 years old, the director of operations for the operating company and held an FAA ATP with a total of about 10,000 hours and 800 hours on type. The second-in-command was 58 years old, held an FAA ATP with a total of about 20,000 hours and 800 hours on type.
      The aircraft began its takeoff run at 12.07UTC (Local time) and this appeared normal until immediately after liftoff when the aircraft began to bank to the left. Two seconds after liftoff the bank angle had reached 50 degrees and the heading had diverged about 10 degrees to the left. The left bank continued to increase rapidly despite the crew’s application of full opposite aileron and rudder control. Progressively more nose up elevator was applied as the aircraft continued to roll rapidly to the left. The aircraft struck the ground, inverted, adjacent to the runway. The accident was not survivable.



Post Mortem Analysis
The post mortem examinations detected the drug diphenhydramine in both pilots. This is a sedative antihistamine used in cold medication, allergy medication and in sleep aids. The handling pilot’s bag contained a quantity of ‘Excedrin PM – aspirin free.’ This medication contains 500mg of acetaminophen (pain/fever reducer) and 38mg of diphenhydramine per tablet.
      Research by the pathologist who conducted the post mortems and by a psychologist indicated that the pilots’ judgement and decision making likely were impaired by the diphenhydramine, jet lag and fatigue.
      The pathologist said that diphenhydramine can cause drowsiness, blurred vision, dizziness and nausea, and can impair short-term memory and attention. The effects of diphenhydramine are amplified by alcohol, in common with most other antihistamines. He said the reason for both pilots taking diphenhydramine was open to speculation but that, in his opinion, the most likely explanation was that they took the drug to aid sleep.
      The psychologist said that the five-hour time difference between Atlanta and Birmingham would have affected the quality of rest obtained by the crew on the night before the accident. He said that the overall effect on the morning of the accident is likely to have been a considerable degree of fatigue that could have impaired judgement or reasoning.
      This condensed report is based on UK Air Accidents Investigation Branch (AAIB) Aircraft Accident Report 5/2004 (EW/C2002/1/2) which source is gratefully acknowledged. That Report contains several recommendations regarding FAA documentation and others regarding the dangers of self-medication.


Lessons for Every Pilot
The lessons to be learnt from this unfortunate accident apply not only to pilots of business jets. They are equally pertinent to every pilot of every aircraft type.

      Ice or snow on the flying surfaces of any aircraft will degrade the performance of that aircraft. The degradation of performance may well be catastrophic, as it was in this accident. Modern business jets with supercritical aerofoil sections are particularly sensitive to the effects of icing on the upper surfaces and this is exacerbated by the fact that supercritical wings typically do not stall symmetrically. A high rate of roll develops at the stall and ailerons are ineffective in controlling the roll until the wing is unstalled. It is possible that the hot exhaust from the Challenger’s APU that was running during the refuelling prior to start may have reduced the amount of ice on the right wing. This could have led to the left wing stalling first after takeoff.
      The second lesson from this accident is contained in a piece of advice given during my training at the Royal Air Force Institute of Aviation Medicine many years ago. That was, “
He who prescribes for himself has a fool for a physician.” If you are not fit, you are certainly not fit to fly.

      Finally, the report said that the judgement and concentration of the flight crew, who were aware of the ice contamination on the wings but did not have the aircraft de-iced before departure, might have been impaired by the combined effects of the drug taken, jet lag and fatigue.

FACT: Controlled Flight Into Terrain (CFIT) is a leading cause of fatal business jet accidents worldwide. Inadequate crew coordination and monitoring were cited in the majority of business jet accidents.



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