Accident report: aviate, navigate, communicate

The phrase is so overused that it’s become a cliche: aviate, navigate, communicate. The clear suggestion is that flying the airplane is much more important than messing with the GPS or telling Air Traffic Control about your problems. But while all pilots hear this advice from day one of flight training, the accident record shows that it’s hard to do when something goes wrong.

JetProp
The JetProp Malibu is a high performance airplane, and demands the pilot’s full attention.

That “something” doesn’t have to be a serious emergency, as a 2003 fatal accident shows. In this case, a relatively minor abnormality quickly became a disaster because the pilot seemingly didn’t maintain his focus on flying the airplane. The Piper Malibu, which had been modified to include a turboprop engine (a JetProp conversion), departed the Hilton Head Airport in South Carolina, but crashed after attempting to return for a precautionary landing.

Two pilots were at the airport and saw the accident sequence, which means the eyewitness accounts may be a little more trustworthy than usual. The first witness reported that the pilot and his passenger arrived at the airport and loaded up without doing a preflight inspection (the FBO had fueled the airplane prior to their arrival). Both witnesses reported a normal takeoff and initial climb, but soon a “vapor trail or smoke” was seen coming from the left wing. The pilot reported on CTAF that he was returning to the airport and mentioned something about a “cover off.”

Witnesses reported that the airplane was flying erratically, at one point descending very low over the trees on downwind, then climbing again. The pilot’s wife could be heard on the radio as well, and the overall scene appeared to be one of great confusion and stress. As the airplane turned from base to final, the airplane banked very steeply then pitched up. The result was predictable and tragic: the JetProp crashed and killed both occupants.

Examination of the wreckage found no issues with the engine, propeller or flight controls. The left inboard fuel cap, however, was not found at the accident scene. A ground search eventually located the fuel cap in the grass next to runway 21. While the NTSB report goes into detail about the type of fuel cap and whether the FBO employee remembers tightening it, it doesn’t matter too much. The cap most likely departed on takeoff and the white trail from the left wing was fuel venting overboard.

Fuel dipstick
It’s great to check the fuel quantity, but make sure the cap is on before you start up.

That may have started the accident chain, but it hardly caused the crash. The venting fuel would have been a distraction, but the airplane was fully controllable and the weather was excellent. There’s virtually no chance the plane actually ran out of fuel, since the right wing cap was on and the engine was turning at impact.

The NTSB concluded the accident was caused by “The pilot’s failure to maintain control of the airplane during a VFR pattern for a precautionary landing, which resulted in an uncontrolled descent and subsequent collision with terrain.”

How could such a minor problem turn fatal? The private pilot was reasonably experienced, with just over 2500 hours total time and 186 hours in the JetProp. It’s hard to know for sure, but this doesn’t sound like a case of a pilot whose bank account was ahead of his experience. Weather was not a factor, either.

The most likely scenario is familiar and depressing. The pilot was so concerned about the missing fuel cap that he lost his focus. Aviate, navigate, communicate became: troubleshoot, communicate, aviate. That loss of focus spelled disaster.

Beyond the basic lesson, though, there are two other points to consider: single pilot emergencies and the role of spouses.

There’s no doubt that an airplane like the JetProp Malibu can be flown safely by a single pilot, and it’s done every day in airplanes from Cirrus SR22s to Citation Jets. But when something goes wrong in a high performance airplane, the lack of a co-pilot – even just to read the checklist or work the radio – can put the pilot a step behind. That doesn’t have to be fatal, but it certainly demands good training and quick attention. The margins are simply lower.

In place of a fully-rated pilot, many of us fly with our spouses in the right seat. This can be a fun and rewarding experience, but we also have to be realistic about it. A panicked non-pilot can be a hindrance, not a help, in situations like this. A good start is to have a frank discussion about your own flying procedures and crew resource management, on the ground before an emergency happens. Talk about what you’ll do and what you expect from your right seat companion. Beyond that, a disciplined pilot has to be able to block everything else out – to the point of being rude – when the chips are down.

In other words, when something goes wrong, “fly the f*&^%$# airplane!”

14 Comments

  • I think that instead of having a frank discussion with the non-pilot passenger (spouse or otherwise)before takeoff, it is better to just downplay the situation; like the airlines do. “Oh dear, it looks like I forgot to tighten the fuel cap cover, we’ll just go back and tighten it”. This method tends to:
    a) Not alarm the passenger.
    b) Calm yourself down.

  • I was lucky. While I was still a relatively newbie student, just taken off from the local airport, instructor in the right seat, my door popped open, (not wide, as the airstream was keeping it close to me,) and I told my instructor what had happened. He asked me what I wanted him to do. Asked him if he could reach around and secure the door, as I was too busy trying to fly the plane. He reached around me, and secured the door. When we finally got back on the ground, we had a very good debrief session. He finally asked me what I learned from that, and I gave him the stock answer, “Aviate, Navigate, and communicate.” Just glad I had him as my primary instructor – no panic, calmness, and confidence, along with a good understanding of how to handle his student’s nerves, as well as the capabilities of that airplane.

  • When I was still instructing back in the late 70s and 80s, one of the things I always did was have my students experience an opened door. Part of the reason was so that they wouldn’t fail to fly the airplane if a door popped open, and the other part was to show that indeed the airplane would still fly just fine with the door open, so unless it could be closed and latched safely, just fly it that way until after landing.

    This paid dividends one day. My student was an older man who had some air-sickness issues early in training, so his solo was delayed. Once we got past that, he did pretty well, but he tended still to get pretty nervous whenever we tried something new. On the day of his solo, one of the last things I said as I got out of the airplane was to latch the passenger door of the 172. But due to his nervousness, that was the one thing he didn’t do. It was closed, but not hard-latched. He taxied out, took off, and the door popped open as he lifted off. But he flew around the pattern, came in, landed nicely, taxied off, and I could see him reach across and open the door farther to slam it and latch it. Then he taxied back and did a couple more circuits. We talked afterwards, and he said when the door popped open, the words that went through his mind were “fly the airplane, forget the door”.

    Most of the time, doors and windows that open, gas caps that come loose, oil caps which come loose, all of these are distracting, but they’re not nearly as serious as failing to maintain control. At best, they’re an annoyance; at worst, they may require returning to land to fix the issue. I agree that the worst part of them is placating a nervous passenger, so long as the pilot continues to safely fly the airplane.

  • My wife is a non-pilot, but very aware of flying details. One flight, our engine quite as we were flying over Duluth Intl. I quickly did the expected control fiddling (carb heat, etc), trimmed the airplane, and turned downwind for the runway, told tower what was happening and they said the airport was mine. We had a totally uneventful dead stick landing and rolled out on a diagonal taxiway to the waiting fire crew. All the while, my wife sat on her hands and said nothing but “We’re going down aren’t we.” I am forever thankful for her help in keeping me focused on flying the plane and not being a distraction. The reason for the engine quitting was fuel starvation, and the reason for that is another whole story.

  • Thanks for sharing guys.
    It’s been a while since I had a simulated emergency. (Open door is always popular ) I’m Gona schedual some time with Bob (CFI) to do some wet runs… It will be good for me :/)

    Liad

  • I failed to follow my checklist; missed one item, to latch the door on my Cherokee. It popped open on takeoff. It was winter in SC and below freezing. I was really cold but elected to continue on to my destination airport about 15 miles away. Luckily I remembered a story; of a guy trying to put a blanket in the opening that got sucked out and wrapped around his elevator and resisted the temptation to put my winter coat by the door.

  • It’s really “tempting” (if that’s the word for it) to let yourself be distracted by minor mishaps like an open door (been there, done that) or missing fuel cap, or a pitot tube cover not removed during pre-flight (a friend did that once when I was a passenger).

    Yet the discipline involved in being an intelligent and attentive pilot-in-command SHOULD easily overwhelm any such distractions and allow the pilot to fly the airplane. However, we pilots being human beings and having lives and concerns that sometimes transcend (in our minds) the act of piloting an aircraft, really dumb actions are sometimes the results of losing concentration on the act of flight.

    Our minds are restless things, sometimes due to overwhelming real life concerns, relationships with those who might be sharing the seats in the aircraft, worries over the immediate future, or the proverbial attacks of “get-there-it is”. Calming a restless mind can sometimes be a big challenge.

    It helps a great deal, as one approaches the pre-flight planning, the trip to the airport, the pre-flight inspection and fueling, and any other flight preparations, to make sure we also conduct the following check:

    A pre-flight inspection of ourselves and of our mindset.

    Before punching that throttle, take a deep breath, focus solely on the task at hand – a successful, safe flight – then mentally walk through the list of “what I will do if the engine quits on takeoff” or “how I will transition to instruments after takeoff” … and do our utmost best to force every other single thing to the back burners of our minds.

  • As a student pilot renting Musketeers from old Andy Anderson at KRST in Minnesota, one day I went to practice short-field work at a little duster strip maybe 10 miles off. My first landing on the short strip was a “dropper,” and I went around after the first bounce. But as I started to climb out, a LOUD banging sound began and scared me to instant sweat. Control was fine, engine was fine, just this banging. Avigate, navigate, communicate! I turned toward home, told the tower I had a problem and was returning; I’m sure they heard the noise and cleared me to land, any runway. As I leveled off and reduced power, the banging became less noisy, now clearly coming from the right side. The proverbial light bulb appeared over my head, and I reached for the passenger seatbelt. !#*?! It was hanging outside, under the door. I let the tower know I was okay, and landed. The Musketeer had two doors, and I’d missed the dangling right seatbelt on preflight. The seat belt tang had banged up the finish quite a bit. I brought Andy out and showed him the damage, expecting a tongue-lashing. He looked, shrugged, and said, “Everybody does that at least once,” winked, and walked off. I was always suspicious that he put that belt out on purpose, but he’s gone now, and I’ll never know.

  • I was one of the witnesses to which John Z refers.

    As I stood there beside our C-210 staring numbly at the ugly black cloud of smoke rolling upward from behind the tall pine trees just northeast of the threshold of Runway 21, it was difficult coming to grips with the fact that two people who less than ten minutes ago had stood within a few feet of me were now absolutely, completely, utterly, totally and forever DEAD.

    How could this happen? How could an experienced pilot fail to follow the Golden Rule of flying (aviate, navigate, communicate, in that order)under any circumstance, much less in the relatively minor event of venting fuel from an uncapped tank when the engine is running perfectly and you are within easy reach of an acceptable runway?

    Let me build the pre-accident scene a little for you. It was a hot, but good VFR Labor Day weekend afternoon. I went to KHXD intending to fly our 210 which was tied down on the line. But a dead battery nixed that plan.

    I was, ironically, sitting in the shade of the left wing on my little square stool that I carried in the plane to step up on to check fuel levels and security of gas caps waiting for the mechanic to arrive to install a new battery. The accident airplane sat next to me on my left. Soon a car pulled up in front of the accident aircraft and four people got out.

    While the pilot’s wife stood talking with the other couple by their car, the pilot loaded the luggage into the airplane. I was sitting on my stool, so I could not see everything that the pilot did on the left side of his airplane. He might have checked the errant fuel cap. I don’t know. My impression was that everything he did was done in a hurry. One thing for sure, he did not come to my side of his airplane. I remember thinking, “I’ll wish him ‘a good one’ when he comes to this side of the plane on his preflight.” But he never came over to my side of the plane.

    When he was ready to get in the airplane, he returned to his wife and the other couple still standing by the car. They said their goodbyes and the pilot escorted his wife to the plane. She sat down in the cabin on the right side; not in the co-pilot’s seat. I watched her buckle up.

    The cockpit windows were at about my eye level. The pilot climbed in, sat down and took a towel and wiped his face. I could see him sweating profusely. The sun had heat-soaked the interior.

    As they taxied away, I thought, “I’ll watch him takeoff and see if he’s one of those who wants to impress his friends by sucking up his gear fighter-pilot style right after breaking ground.”

    They took off. I was relieved to see that he didn’t prematurely retract his gear. I didn’t notice anything trailing from the airplane. The takeoff, initial climb out and left turn toward the beach looked and sounded entirely normal.

    I lost sight of him behind the tall pines at that point and returned to my seat in the shade. But I could hear his engine. It sounded like he had climb power, which of course would be normal. I though I might catch a glimpse of him above the tree line as he climbed out on the downwind, but I didn’t.

    The sound of his powered-up engine started to fade as he went north over the beach, but then it started to get louder again. He was below the tree line. I couldn’t see him. The engine sound kept getting louder, and then suddenly stopped. A second later came a low-pitched whoomp, and a great ball of black smoke rolled up.

    When I recovered some of my senses, I walked over to the FBO office and let them know that I was a witness to the tragedy. I heard people saying they heard a woman screaming on the frequency about the plane being on fire.

    So let’s take stock of the pilot’s possible situation. It’s very hot in the cockpit. The pilot is in a hurry. His mind set is, “I’m late”. Suddenly his wife starts screaming, possibly that the plane is on fire. He might have been able to see his left wing enough to realize that he was trailing fuel; that he was not on fire. Or maybe his mind was so concentrated on his screaming wife at that point that he is not sure whether his problem was a missing fuel cap or fire.

    In any event, his wife is screaming in fear. He has to immediately switch mental gears from hurrying to get home to getting his wife on the ground, the sooner the better. He might have tried to calm her by yelling over his shoulder at her, but the effectiveness of that attempted communication would be problematic at best with the engine noise.

    Then he got himself in that steep low altitude left turn to final. He may have chosen the moment to put in flaps and lower the gear. Maybe he also have a touch of top rudder. End of story.

    Lessons to me:

    1. Never be in a hurry in or around an airplane. We sometimes have to do things with studied dispatch (engine out shortly after takeoff comes to mind), but never hurry for the sake of hurrying.

    2. If and when the moment comes, say aloud, “Aviate, navigate, communicate.” Then keep repeating, “Aviate…aviate…aviate.”
    It is the most basic of all basic rules. Please place your left hand on your computer, raise your right hand, and swear that you will never, ever forget it.

    • Dave,

      Thanks for your detailed recitation of what you witnessed that day.

      A couple of points:

      1) I think that if the pilot’s wife was screaming that the plane was on fire – a clear panic response – it would be very difficult for him to focus on aviating. Not impossible, but very very difficult. Mustering your pilot’s focus on the task at hand with a loud, panicked person in the cockpit, who also happens to be your significant other, in a low altitude maneuvering situation would be more than many people, no matter how good a pilot, to overcome.

      2) If the spouse was screaming and panicking at what is after all a very minor flight anomaly, that seems to suggest that she, and maybe her husband-pilot too, were already predisposed toward a bad response emotionally. The fact that the pilot seemed in a definite hurry, along with her quick panic response, suggests that there may have been a strong case of “get-there-itis” involved .. or possibly an argument, or pre-existing emotional thing going on (anger due to some conflict or argument not yet settled, or fear – such as fear of flying). Emotion is a very big factor in causing people to behave in an otherwise uncharacteristic way.

      We talk a lot as pilots about being well prepared to fly, and the need for pilots to do the proper pre-flight due diligence, on the weather and the aircraft.

      But any time the pilot (or a passenger) is in an emotionally agitated or fragile state, that represents a very big and possibly dangerous risk factor that must be addressed before you go wheels up. If the cockpit is full of anger, fear, distrust, or agitation, don’t go.

  • I have had the baggage door on my Mooney come open after take off with my non-pilot wife as passenger. All I said was were landing, she asked why and I told her the door was not latched and came open. She said ok, we entered the downwind and landed uneventfully. She was calm and cool the entire time.
    Lesson: Latch and lock the door every time

    I have made a hard landing once and said SH##, to which I received a lecture later on how I made her nervous.
    Lesson: Be a duck: calm and cool on the surface but kick like hell underneath.

  • All these comments are good and valid, and they make you think about procedures and practices. I appreciate them all. Also, I truly believe flight instructors can and should go further in introducing “emergencies” to their students in order to test and temper reactions and stress levels. Remember the chapter in ‘Fate Is The Hunter’ when Captain Ross put Ernest Gann to the test during a ‘range’ approach in actual conditions at Newark? He kept waving lighted matches under his nose and around his head all the way down to touchdown in order to teach his charge to stay calm under pressure and continue to focus on the task at hand. It was a lesson that proved invaluable later on in the book.

  • Funny (sort of) door opening…. I was flying a famous sculptor friend on a cold winter’s day several years ago of a trip to see a piece being fabricated. On the return flight, the door opened. I didn’t panic or get upset, but it did get cold in the Mooney, so I cancelled IFR (it was great VFR at the time) and prepared to land at an airport below us (couldn’t remember procedure to close door and this seemed the easiest solution). As I tried to line up for the runway, the plane behaved very strangely… I had never experienced anything like it. I couldn’t get it to fly straight and level. I abandoned the approach, and did a go around with a really big pattern. Again the plane behaved strangely but I managed to get it on the ground. Only then did I realize that my 6’4″ friend, who was bracing himself to keep the door as closed as he could, had his foot firmly planted on the right rudder pushing as hard as he could. One more thing to think about….

    • Very good point re. the rudder pedals.
      As part of my pre-flight briefing with any passenger, experienced or not, I’ve always made a point to tell them to keep their feet back and well clear of the rudder pedals… going so far as telling them what it could cause, especially on take-off or landing. That gets their attention and they always keep their feet back the whole flight. I’d recommend anyone to add that to their passenger briefing.
      As happened in your situation, it can be a natural reaction of a passenger that’s nervous for any reason much like they would in a car.

Leave a Reply

Your email address will not be published. Required fields are marked *