2003-05-I.M.-S.A.F.E

THE VINTAGE INSTRUCTOR I.’M. S.A.F.E. DOUG STEWART NAFI MASTER INSTRUCTOR few days ago, a Piper Cherokee Six crashed into a mountainside about 6 miles east of the Great Barrington Airport (GBR), which is my home base. This particular accident made it into the national news for the next two days. The accident was newsworthy because a family of seven had been on board the aircraft. The crash occurred at night, and the temperatures had dropped to below zero, while the winds gusted more than 25 knots. Miraculously, four of the seven on board survived the crash. The pilot (father of all five children) and three children were still alive when a New York state police helicopter finally found the wreckage about 17 hours after the airplane crashed.

For the next few days reporters called the airport seeking answers to numerous questions. Every one of them wanted to know what had led to this tragic accident. Most of the questions were of a technical nature. What is the difference between IFR and VFR? What does ice do to aircraft performance? How does a pilot turn on the runway lights from his aircraft? On and on the questions came, but few, if any, of the reporters looked at the real issues. To me, the important question was why this pilot was flying at night, over mountainous terrain, in horrific weather, with his entire family on board? I can answer the technical questions, but unfortunately, I cannot answer the last question.

Let’s first review what is known, as of now, about the flight, the weather, the aircraft, and the pilot.

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The flight originated in Lakeland, Florida, shortly after midday. The family had been in Florida for a vacation, and was now returning to its home near Keene, New Hampshire. Predicated on the forecast weather, the pilot originally filed for Utica, New York, where his wife had family. The plane made a fuel stop in Silver City, North Carolina.

At some point after departing Silver City the pilot amended the flight plan, making Keene the new destination.

On and on the questions came, but few, if any, of the reporters looked at the real issues.

About 40 miles north of the Stewart International Airport, in Newburgh, New York, the pilot reported to Air Traffic Control (ATC) that the plane was starting to pick up ice. He requested to descend from 7,000 feet to 5,000 feet and divert to Barnes Municipal Airport in Westfield, Massachusetts. He was cleared to 5,000 feet, but when he subsequently requested to descend lower, the MEAs (minimum en route altitudes) prevented that. He then canceled his IFR and said he would descend and fly visually to Great Barrington, Massachusetts.

His last communication with the

Bradley TRACON (Terminal Radar Approach Control) was at about 6:30 p.m. A credible witness (a pilot of more than 30 years experience), who lives about 1 mile east of the threshold to Runway 29 at GBR, reported to us that she had heard a plane do what sounded like either a go-around or a missed approach somewhere between 6:30 p.m. and 7:00 p.m. Another airport neighbor to the west of the airport reported that she too had heard an aircraft in the pattern at about the same time period. Sometime shortly after that, the airplane crashed on the heavily wooded flank of Mt. Wilcox at 1,700 feet MSL (mean sea level).

The summit of Mt. Wilcox is 2,100 feet. The crash site lies 3 degrees to the east of the direct course line from GBR to the Chester VOR (omnidirectional radio range) and 6 miles to the east of Great Barrington Airport.

What was the weather like in the Berkshires that evening? A very strong arctic cold front had passed through the area earlier that afternoon, pushing a coastal low-pressure area out into the North Atlantic. The temperatures were plummeting, and the wind had started to howl. The ceilings were ragged, and the nearest reporting airport (Pittsfield, about 15 miles to the north) had reported overcast ceilings at about 1,900 feet MSL. Several other aircraft had already filed pilot reports of icing in the area. This region overlying, and to the east of the northern Appalachians is somewhat notorious for the gnarly weather that the mountains can create, and most

pilots treat the weather, at all times of the year, with cautious respect.

The airplane was a Piper Cherokee Six, which is well known as a load hauler. In addition to the seven people on board, there was the requisite luggage that a family of that size would take for a vacation, including a television. The aircraft was filled with fuel in Florida, and then took on 48 gallons in North Carolina. Even with full fuel it still could have weighed less than maximum gross weight, since most of the children were small. The youngest of the children was 2 years old (found alive outside the wreckage sitting in a creek), with the oldest being 12. The others were 5, 7, and 10. If the aircraft had been laden with ice, however, it might not have been capable of climbing.

What I know of the pilot is sketchy. He was a relatively lowtime pilot, with less than 400 hours of total time; however, he had made the New Hampshire-to-Florida roundtrip “dozens of times since 1997.” He had acquired the plane in a business deal and then learned to fly. As of this writing there is no evidence that he participated in the FAA’s Pilot Proficiency Award (Wings) Program, but he did have a current biennial flight review.

Whether he was instrument current or not is not currently known.

That is what I know of the facts surrounding this accident. I have many more questions that might give insight into what led to this crash. As many of us pilots know, most accident chains start forming before the aircraft ever takes off. As events unfold, that accident chain gets bigger and stronger until it finally reaches a point where the accident is unavoidable. If we can break that chain at any point prior to the accident, then the accident can be prevented.

My first question is, What time did this pilot’s “duty day” start?

What time did he get up that Sunday morning? Had he had a good night’s sleep, or had he tossed and

turned all night worrying about the weather? When did he make his first call to flight service to get a weather briefing and file his flight plan? The accident occurred sometime around 7:00 p.m. The Florida departure was between 12:00 p.m. and 1 p.m. But when did this pilot first start “working” on this flight?

When we think of the I’M SAFE (illness, medication, stress, alcohol, fatigue, emotion) checklist, how much of a part did fatigue play in this accident?

“F” could also symbolize food. I can’t help but wonder when this pilot last had a square meal. We all joke about the “pilot food” that is typically found in those honor system boxes at many airports, and I have yet to find anything in those boxes that could be termed nutritious. But when the chips are down, and the proverbial yogurt has crept up above the eyeballs the ability to

We have to ask ourselves if we can pass the I’M SAFE checklist. make proper, rational decisions becomes more and more difficult. If we haven’t sufficient “fuel” in the body, that ability to make the right decision might become impossible.

So I ask, when did the pilot last eat a nutritious meal?

The effects of stress could have also played a large part in this accident. When did the stress first start affecting the pilot? Was there knowledge of the poor forecast weather the night before the flight? If there was, it might very well have prevented a good night’s sleep. Then again, the stress of feeling the need to get home by Sunday evening might have been what prevented the pilot from making the correct decisions.

When three, or perhaps four, of your children have to be in school

the next morning, a pilot can feel tremendous pressure to get home.

Even though the weather is going down the tubes, many pilots have killed themselves and others with them as they press on into deteriorating weather, suffering from that dread “get-home-itis.” There is no doubt in my mind that this played a very large part in the pilot making the decision to continue into poorer weather, rather than making a 180-degree turn and retreating to an airport with better weather where the whole family could spend the night.

The human factor issues known as “hazardous attitudes” also need to be addressed. These attitudes are anti-authority, macho, invulnerability, impulsivity, and resignation.

None of us will ever know if any of these played a part in this accident, but again I have to ask these questions. The forecast was for a chance of icing in precipitation and clouds.

The FARs dictate that the IFR pilot cannot fly into those areas where icing is forecast. Was the pilot exhibiting an anti-authority attitude, if he indeed had obtained a forecast of possible ice? The macho attitude is best described as one that makes pilots think they are capable of anything. Traditionally, pilots with 300 to 500 hours fall into this category.

They have logged just enough time to think that they are capable of flying in any condition, but nowhere near enough time to understand that they really can’t. Is it quite possible that the macho attitude played a part in this accident?

Did the pilot think that he was invulnerable? Did he believe that icing events only happened to other pilots, or that a Cherokee Six was capable of carrying large amounts of ice? We’ll never know. Was his decision to divert to Great Barrington an impulsive one? Great Barrington was, at this point in the flight, the nearest airport, but it lies in a valley and is surrounded by rising terrain in all quadrants. Was the continued on page 26 Vintage Airplane

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decision to divert and descend well thought out, or was the pilot just doing something…anything to try to address the ever-increasing problems?

I also wonder if at some point, late in the chain of events, resignation came into play. I have seen students of mine give up when the workload of flying became too great. Is it possible that this pilot, after trying to make an approach into Great Barrington and not being able to complete it, either because he couldn’t find the airport, couldn’t turn on the runway lights because he didn’t have the correct frequency, or couldn’t see the runway well enough to land because the windshield of the airplane was completely covered with ice, is it possible that he stopped flying the airplane? Is it possible that he gave up, resigned to his fate?

None of these questions will ever be answered. Although the pilot did finally make it to the Great Barrington ramp, he was on a gurney being transferred from the ambulance to a helicopter, and then he went into cardiac arrest. He died a few hours later, after efforts to save him at the local hospital failed. His wife and two sons were already dead. As of this writing, his three sons are in serious condition at a hospital in Albany, New York, but they won’t be able to answer my questions. Only the pilot can explain his decision to continue into deteriorating weather, with his entire family on board, to the point that escape from the weather and the opportunity to break the accident chain that had been forged throughout the day became impossible.

I certainly don’t have the answers, but in presenting my questions I hope that it makes you question whether you would have done differently in the same situation. Every one of us, as pilots, has to ask ourselves some very important questions prior to each and every flight. We have to ask if the flight is necessary, and if the weather is suitable for our aircraft and our skills. We have to ask ourselves if we can pass the I’M SAFE checklist. We have to ask ourselves if we have any hazardous personal attitudes, and if we do, do we know how and when to apply the appropriate antidotes to these attitudes. If we cannot answer these questions, or if the answers dictate that we not fly, will we have enough sense and discipline not to fly? Having the right answers is not enough. We have to take the right action in response to our answers. Doing so will aid in our transition from being good pilots to being great pilots.