Learning From Mistakes

ASRS reports are treated confidentially. After a report has been logged in, the section of the form containing the submitter's name, address and other identifying information is removed and returned to the submitter as proof of submission in case the FAA asks for it.

ASRS reports often tell of life-threatening situations with happy endings, very much unlike typical NTSB accident-investigation files. For example, ASRS recently released a number of reports sent in by pilots who inadvertently flew into instrument meteorological conditions.

The pilot of a single-engine Piper Cherokee flew in marginal VFR conditions when the ceiling suddenly dropped. The pilot reported that he "flew into an area of lower clouds. I did a 180-degree turn and got out of it." He then used the "nearest airport" function on his GPS receiver. He turned to fly toward the airport, but "faced a steep hill with the clouds almost touching it. I went over the hill and into the clouds and realized I didn't know what would be below me if I descended." Fortunately, the pilot broke out between layers and flew parallel to a ridge line with more clouds below. He eventually got to the airport, descended below the reported ceiling and landed. ASRS summed up the report by commenting that the pilot "used up all the options, but one---luck."

In another report to ASRS, the pilot of a Cessna 172 told about a flight during which the weather became worse than was forecasted "at an alarming rate." He had to descend to maintain VFR, but, then, wound up having to climb up to 5,000 feet. When he turned the aircraft around, he found that the area behind him had also closed up. With assistance from air traffic control, which dedicated a radio frequency to handling only his airplane, he set up for an approach, descended through the clouds, broke out at 1,400 feet and landed.

Unfortunately, another pilot of a Cessna U206G, who flew into adverse weather conditions, was not one of those who was able to submit a voluntary report to ASRS. The NTSB recently finished investigating his weather-related accident.

On March 8, 2001, at 2:20 p.m., that single-engine Cessna U206G, registered to a Canadian aviation company and flown by a Canadian-certificated airline transport pilot, was destroyed when it hit trees and terrain five nautical miles east/northeast of Mica, Wash. The pilot, who was the sole occupant, sustained fatal injuries. Instrument meteorological conditions prevailed and a VFR flight plan had been filed and activated. The personal flight originated from the Renton Municipal Airport, Renton, Wash., at approximately 11:07 on the morning of the accident. Radio contact was lost with the aircraft at 2:20 and a search was initiated. The wreckage was located two days after the accident.

According to personnel at an FBO located at Renton Municipal Airport, the fueler arrived at the FBO earlier than the usual opening time of 7:30 to service an outgoing medivac flight. Upon his arrival at the FBO, he encountered the pilot of the accident airplane, who reported that he had been there since 3:00 a.m. The fueler allowed the pilot to sleep on the FBO's couch and reported that the aircraft departed around 11:15.

The pilot's first known contact with the Seattle Automated Flight Service Station (AFSS) was at 08:23 for a telephone preflight weather briefing for a flight from Renton (RNT) to Calgary (YYC), Alberta, Canada, with an estimated departure time frame of 9:30 to 10:00. The briefing included three separate routings from: 1) Seattle, Wash., to Vancouver, British Columbia (BC), and, then, to Calgary; 2) Seattle to Spokane, Wash., and, then, Calgary; 3) Seattle south toward Portland, Ore., then, east along the Columbia River toward The Dalles, Ore., and, then, via Spokane to Calgary. The briefer recommended against VFR flight and the pilot chose to delay the departure about an hour and then recheck the weather.

There was a second call to the Seattle AFSS at 9:44, during which the pilot received an updated weather briefing for a flight from RNT to Spokane (GEG). The briefing included routings from: 1) Seattle to Spokane direct over the Cascade Mountains; 2) Seattle to Spokane via a routing south toward Portland, east along the Columbia River toward The Dalles and, then, Spokane. The briefer recommended against VFR flight on the direct routing and indicated that the southerly route was better. The briefer also advised the pilot that the recently transmitted terminal forecast for the Spokane area indicated VFR conditions with intermittent periods of overcast at 2,500 feet and three miles visibility due to moderate rain showers and mist. The pilot stated that he would call back in about 10 to 15 minutes to check on conditions on a direct routing.

At 10:29, the pilot telephoned the Seattle AFSS and received an updated weather briefing. The briefer advised of an AIRMET for IFR conditions in the Seattle area, as well as mountain obscuration and icing for the direct routing, concluding with "certainly, VFR wouldn't be recommended at this time." The pilot, then, filed a VFR flight plan with the briefer for the southerly route.

At 11:06, the airplane received clearance for takeoff from Renton and, at 11:09, the Renton local controller attempted to contact the pilot to advise him that his transponder was not being received. At 11:14, the pilot contacted the Renton local controller, requesting a frequency change, and was advised of his lack of a transponder signal and, at 11:15, the pilot activated his VFR flight plan. At 12:37, the pilot radioed Seattle flight watch and provided a pilot report from the vicinity of The Dalles and was advised, "We still show along the route for mountain obscurement and icing."

At 1:52, the pilot radioed the GEG air-traffic-control tower, stating that he was "15 south" and requested the current weather. The controller responded, "Visibility five, light rain, mist, few clouds at 700, our ceiling, 1,100 overcast," and the pilot responded, "We have a lower ceiling where we are at this altitude." The pilot indicated that he wanted radar vectors to land at GEG and was, then, switched to Spokane Approach Control.

Just before 1:54, the pilot contacted Spokane Approach Control, indicating he was "12 south." He, then, requested vectors to land and, when given a discreet transponder code of 0345, advised approach, "We're having some transponder trouble here." The pilot, then, radioed that he was 12 miles south of the airport inbound on 350 degrees at an altitude of 2,700 feet, orbiting "just on the bottom edge of the clouds."

At 1:57, the controller advised the pilot, "I won't be able to pick you up at that altitude, so, therefore, I can't give you radar vectors to any type of approach or to the airport" and the pilot, then, inquired as to the weather at Coeur d'Alene (COE), Idaho. The controller responded with the 1:30 p.m., COE weather, reporting, in part, "Visibility reported seven miles, few clouds at 100, ceiling of a 2,000 overcast" and the pilot radioed back, in part, "I'm going to see if I can work my way over to Coeur d'Alene or go back south and pick up a small airport" and stated that he was presently on the 347-degree radial of the GEG VOR inbound.

At 14:02, after several inquiries from the controller, the pilot radioed that he was 21.7 miles out from the airport and on an inbound track of 352. At 2:03, the controller inquired as to whether the pilot was still navigating toward GEG or going to try for COE. No response was received until 2:17:29, when the pilot radioed, in part, "On a heading to Coeur d'Alene of 020 and we're 22 miles out."

At 2:19:54, the pilot radioed the controller, "Spokane Center, could you give me the last weather for Coeur d'Alene?" This was the last known radio transmission from the pilot. Thirty seconds after the initiation of this last radio call, Spokane Approach Control received a brief ELT transmission coming from the airplane.

A witness traveling in his automobile east on a highway about a mile southeast of Freeman, Wash., reported seeing a Cessna aircraft between 2:00 and 2:15 p.m., on the afternoon of the accident. He reported the aircraft as being about 300 feet above the elevation of the highway and heading northeast. He reported that the aircraft was under the fog line and, then, it disappeared into the fog.

The NTSB determined that the probable cause of this accident was the pilot's continued flight into instrument meteorological conditions. Contributing factors were fog, low ceilings, drizzle and mist, rising terrain and the non-availability of a functioning transponder.

Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.