BREAKING the CHAIN to DISASTER
GA Accident Analysis
PLAN AHEAD!
In today’s newsletter, we will be examining a GA crash that was (in my opinion) 100 percent avoidable. If you’re interested, here is a video in preparation for discussing the lessons we can learn from this crash https://youtu.be/fLlWf-Fk_YM I will caution you with a “trigger” warning, as the video is difficult to watch without recognizing the mistakes made by the pilot and the knowledge this crash could have been avoided.
On January 13, 2013, a Piper Arrow collided with trees during an emergency approach to Delaware’s Dover Air Force Base. An examination of the flight makes it abundantly clear the accident was the culmination of many factors—these “Links in the Chain to Disaster.” What can we learn from this pilot’s mistakes?
Let’s begin by saying it as simply as possible: Pilots must plan ahead and the most important planning we can do happens ON THE GROUND before we take off!
First, we need to look at the BIG PICTURE for the flight. We must know the weather forecasts, and what to expect. What approaches are available and what are the approach minimums at each airport we may use? Are there any NOTAMS affecting approaches we plan to use? A precision approach consists of localizer for lateral, and a glide slope for vertical guidance, such as an ILS or PAR (FAR AIM, Precision Approach Procedure). Plan on landing with at least 30 minutes of fuel remaining, make this a personal minimum! Utilize the “Pilot’s No Go/Go Safety Chart” (above) to assist in the decision-making process for a safe, successful flight.
What errors can you spot with regard to this flight? Here are some to consider:
The first approach was abandoned prior to reaching minimums descent altitude,
The second approach with a missed approach off the localizer and higher above minimums,
The pilot did not look for another approach at destination. Perhaps a full ILS Precision approach (with lower minimums) might have given a better choice for avoiding the crash.
What are some of the other errors you spotted? Each bad decision made after take-off added more Links on the Chain, burning precious fuel as the flight continued. The “NO GO/GO Safety Chart” will clearly show where the pilot could have broken the chain to disaster, and reduced the level of risk leading to the final outcome.
Pressure to GO! Was the pilot physically and mentally prepared? A Human Factor.
Long Day: He checked weather at 1000 hrs. eastern time. Departure time 1300 est.
TER destination 3:46, FOB 5:30,
Weather marginal IFR in destination area.
Alternate airports were marginal,
Missed approaches, thought his equipment was not working properly, Human Factor possible fatigue beginning,
Failed to declare an EMERGENCY! Could have accepted a PAR approach to Dover AFB.
RED: What were the pilot’s Personal Minimums? Was the pilot aware of the fuel condition? Were there AIRMETS out for the North East US?
YELLOW: Was the pilot fatigued? Was “pressure TO GO” a factor? Was the pilot aware of the minimums on the instrument approaches? Why did the pilot not advise ATC of his fuel situation?
GREEN: Was the Auto Flight (auto pilot) flying the approaches?
OVERALL: Why did the pilot FAIL to DECLARE an EMERGENCY?
Careful planning is almost always the key to any successful endeavor. As a pilot, plan ahead for every flight VFR or IFR, know what is going on, look over the approach plates and know all the points and altitudes and minimums before you start your descent. A safe pilot will be ahead of the aircraft at all times, and Always give yourself a safe out! FUEL MATTERS!
Fly Safely Plan Ahead STAY COOL When in doubt
DECLARE THAT EMERGENCY
Until next time,
Captain Will Rondeau