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.
Text and Photographs © 2008 Gremline & Hill House
Publications, unless otherwise stated.
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