From our first days as student pilots, we’re taught to trust Air Traffic Control (ATC). And why not? The voice on the other end of the radio seems to hold great authority, an all-knowing expert who has the big picture right in front of him.
This isn’t just a student pilot problem. Even many experienced pilots get complacent when they’re in ATC’s warm embrace, assuming that terrain, weather and traffic concerns are being handled by someone else. It’s hard to stay paranoid.
But a chilling accident report from 2010 offers an important reminder that controllers can make mistakes, and that only the pilot in command (PIC) can make the final decision about a flight. Reading the blow-by-blow account should make us all a little more paranoid.
The accident
The pilot of the Mooney 201 was anxious to get home–that much is obvious. After attending a family event in Jackson Hole, Wyoming, the pilot and his three sons planned to fly back to Minnesota on Sunday, October 24, 2010. Bad weather forced them to cancel, so the pilot booked a commercial flight for the next day. After this plan fell through (due to mechanical issues it appears), the pilot again planned to make the flight in his Mooney, and called twice for a weather briefing on Monday.
The route the pilot expected (top) and the route he was cleared (bottom) were quite different.
While not completely unflyable, the weather certainly wasn’t great, with a 1,000 ft. broken layer and 1 mile of visibility in snow showers. AIRMETs were issued for turbulence, icing and mountain obscuration. The tops weren’t too high, but higher than the Mooney could get to. Overall, it was a late Fall IFR day in the mountains: an easy trip in a King Air perhaps, but a challenge for a normally-aspirated Mooney with no deice.
Adding to the risk was the pilot’s relatively low instrument experience. He had just completed an Instrument Proficiency Check a few days before the Wyoming trip, after more than a year off. He had a total of 3 hours of actual instrument time in the accident airplane.
Nevertheless, the pilot launched out of Jackson Hole on an IFR clearance. Significantly, the clearance was quite different from what he had filed. Instead of a departure to the north, via airways, the controller cleared the Mooney on a south departure, off-airway and at an altitude 5,000 ft. higher than filed. This would turn out to be a critical change.
After climbing to the south, the pilot turned east and soon reported light turbulence and icing at 14,000 ft. At this point, the airplane was on an off-airway route, below the minimum instrument altitude for the area, at gross weight, over the mountains, in the clouds. Due to technical issues, the Mooney was also out of radar contact. Neither the controller nor the pilot recognized how bad the clearance was, but when the airplane appeared again on radar, the controller instructed the pilot to climb to 16,000 ft.
This was the final straw. The airplane, desperately trying to climb, stalled and spun into the ground. It’s possible the airplane encountered a downdraft (the pilot reported “severe mountain wave” just before the crash), but it’s also possible the pilot was disoriented and simply stalled the airplane (he reported to ATC that he might not be able to make it to 16,000 ft. and his groundspeed was getting slow). In any case, it’s clear that the airplane and the pilot were operating on the ragged edge.
Causes
As usual, the final cause of the accident was fairly basic: loss of control. But the sequence of events leading up to this final mistake offers a number of lessons for both pilots and controllers. In many ways, this accident fits the classic “Swiss cheese” accident model–no one mistake was instantly fatal, but the combination of being at gross weight, lack of IFR currency, bad weather, time pressure and a bad ATC clearance all conspired against the pilot. There is plenty of blame to go around.
The Mooney crashed just after passing a mountain range.
In particular, it’s interesting that the NTSB final report lists both ATC and the radar systems as contributing factors in the accident. While the controller certainly did not cause this accident, it’s fair to say that he didn’t help either. The pilot’s filed route was over lower terrain, with a Minimum En Route Altitude (MEA) of 14,000 ft. and a Minimum Obstruction Clearance Altitude (MOCA) of 13,500. The flight was certainly not a cinch on this route, but it was perhaps possible (the airplane did make it to 14,000 successfully). Taking the pilot off-airway required a minimum altitude 2,500 ft. higher, which turned out to be too much. In addition, the portion of the flight at 14,000 was actually conducted in Class G airspace, since it was below 14,500 ft.–certainly a non-standard procedure.
The JAC tower controller was actually the one who amended the route, not the Salt Lake Center controller. But the center controller never seemed to question the route–he was reacting more than proactively planning.
Technology didn’t help either, as a complicated radar situation meant the Mooney was out of radar contact for almost 10 minutes. When radar contact was reestablished, the Minimum Safe Altitude Warning system immediately triggered, which initiated the clearance to 16,000. In fact, the airplane should have been at 16,000 from the start.
Notwithstanding the ATC errors, it all comes down to the pilot. FAR 91.3 spells it out in black and white:
The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft.
The pilot of this flight didn’t seem to take his “final authority” as seriously as he should have. For one, his original flight plan altitude was 9,000 ft., at least 4,000 ft. below the lowest MEA in the area. This was just one of many signs of wishful thinking–there is simply no way out of Jackson Hole at 9,000 ft.
Richard Collins has often argued that safe flying is all about having margins built in. Look at the various margins that were thinned down or completely eliminated on this flight:
- The airplane was taking off from a high altitude airport near maximum gross weight.
- The required cruising altitude was at least 14,000 ft., near the realistic ceiling of the airplane.
- The terrain in the area is some of the highest and most remote in the Western US.
- The weather was fairly low on takeoff, and weather aloft included possible ice and turbulence.
- The wind at the pilot’s destination was forecast to be 27 knots, gusting to 40 upon arrival.
- The pilot was barely instrument current.
- There was self-imposed pressure to get home on this day.
- There wasn’t much planning for oxygen. The Mooney did have a 2-place portable oxygen system on board, and FBO records at JAC show the pilot had the bottle filled. But at 16,000 ft., the lack of oxygen for each passenger was illegal.
All of these factors shaved the safety margins for this flight down to just about zero. If ATC had cleared him on his filed route, it’s possible that, in spite of all these mistakes, the pilot may have made it to his destination. But he didn’t get that route, and that’s exactly the problem with having non-existent margins: if one thing goes wrong, there is no chance to recover.
Besides the decision to fly that day, the pilot’s biggest mistake was to accept a clearance that was simply impossible–between the potential for icing, the lack of oxygen and the required rate of climb, it wasn’t going to happen on this day. This was “get-home-itis” of the worst kind.
Lessons
Trust but verify – a good attitude when it comes to Air Traffic Control.
Contrary to what some pilots may think, ATC really is on our side and is there to help. Most controllers I deal with are knowledgeable, friendly and professional. But that doesn’t mean we should blindly follow their every direction. They are human and they do make mistakes, as this accident shows.
Weather in particular is something only a pilot can judge. The controller may have good intentions, but his butt isn’t moving at 150 knots, looking at the buildups out the front window. It is well within your rights as a pilot to refuse a vector into bad weather. It’s also within your rights to declare an emergency if you find yourself backed into a dangerous corner. The controller may not be happy, but that can be sorted out after you get on the ground.
Taxiing around an airport is another time to be paranoid. Just because the controller cleared you to cross an active runway does not mean you can blindly wander across the yellow line–remember to look both ways and verify a jet isn’t barreling down the runway towards you (it’s happened to me). The same goes for line up and wait instructions–if you’ve been sitting on the runway for longer than 30 seconds, don’t assume the controller sees you. Be paranoid.
Finally, this accident scenario drives home the reminder to be especially wary if the plan changes at the last minute. If you get a clearance that is significantly different from what you were expecting, slow down and think it through. There could be serious consequences down the road that aren’t immediately apparent. And if that clearance simply won’t work, it’s your right–and your duty–to refuse it. You are the PIC.
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John — A good summation of a familiar story. Not much to add here other than to point out the obvious glaring gap in the flight training environment. The flight instruction community needs to get serious about incorporating the large body of knowledge about risk awareness, assessment, evaluation, and mitigation together with limitations of aircraft and pilots into the flight training curriculum so that pilots have a better idea about what they’re facing if thess types of accidents are to be reduced.
Knowledge about flying and piloting comes in two flavors: (1) that which is based on learning by reading, listening to others who purport to know, studying and the like — otherwise known as beliefs; and (2) knowledge based on experience, the “been there done that” type where reality provides the lessons and examinations. Most real learning, knowledge and understanding, the kind that sticks for a long time, is based on experience and reality, the stuff of “Never Again” articles.
The current flight training environment is mostly about imparting beliefs with a little low risk experience included in sufficient amounts to enable passing witten examinations and checkrides. The real learning begins as pilots venture forth on their own and begin to sample the real world where natural forces are the referee. In the case of the Mooney pilot, it is doubtful if he had ever attempted a similar flight under those conditions and therefore would not have had any reality based experience for guidance. If he had, it’s a good bet that he would not have attempted such a flight on that day under those conditions in that aircraft.
Where there is no previous experience-based knowledge, beliefs guide the way such as the service ceiling of my airplane is higher than the terrain; the weather is often better than forecast; the winds aloft will be mostly a tailwind; we can climb above any icing encountered; it’s important that we go today, and I think we can make it!
In the absence of relevant experience in similar conditions, pilots are provided with a regulatory environment where the boundaries of good practice are spelled out in a series of “may nots.” Going through the NTSB accident report, there were a number of FAR violations that should have been sufficient to keep the airplane on the ground that day — all of which went unheeded. But, what the pilot was likely unaware of as he made the fateful decision to fly that day, is that while FAR compliance is voluntary and discretionary (PICs are the the final authority!), violations of the boundaries of good practice are patrolled, defended and enforced 24/7 by the Forces of Nature, and the penalties for blatant violations typically involve extinguishing (destroying) the aircraft and its occupants as was the case here — without apology, remorse or appeal!
The flight training community needs to do a better job imparting knowledge and understanding of risk awareness, assessment, evaluation and methods of risk mitigation in the flight environment together with the rather finite limitations of aircraft and pilot capabilities. As you pointed out John, this trip would have been much more likely to end well in a King Air (assuming, of course, a competent, well trained pilot with appropriate preflight preparation, briefing, planning, loading and fuel on board). There would have been a decent chance of success in such a King Air; there was virtually no chance in a Mooney as the record shows.
Accidents such as this are very easy to avoid if pilots adopt an attitude of compliance with the regulatory environment, pay attention to and respect the boundaries of good practice, but there is little the aviation industry can do to prevent such incidents, as the record shows, in the absence of an attitude of compliance. It appears that most pilots do have an attitude of compliance since only a relative few crash and burn each year. If the GA accident record is to be improved, it will likely come through better and more thorough flight training as outlined above, or by screening out pilots who cannot or do not display the proper behaviors.
I am not sanguine about either prospect given the deeply entrenched bureaucracies that govern this arena. Indeed, the industry seems comfortable with the current level of accidents and fatalities since we allow it to continue. Under the current system, the error prone are systematically eliminated, but it is their innocent passengers who bear the burden, and there’s not much to be done about that except through the tort liability system — the price of freedom!
A very thoughtful analysis, Keith. I don’t disagree with anything you’ve said. I’m a big believer that humans are pretty bad at making rational decisions (there’s an awful lot of scientific studies that support this). So the way to combat this is A) try to recognize those situations when you are most likely to be at your worst (like schedule pressures) and B) recognizing that you’ll still mess up, always have those margins built in. Like I said in the article, even with a lot of bad decisions, this pilot almost made it. If he would have had a few more margins–weather, routing, schedule–he might have made it.
It is implied here that although the basic cause was listed as loss of control, it was really a lot of thin margins that piled up. But isn’t loss of control truly the basic element here? If you don’t lose control then the next element to worry about is CFIT, but if you do lose control you don’t even get to worry about that. I would also propose that taking off was not necessarily the bad idea of the day. It is mentioned that the tops were not too high; maybe below 14000′? If so, it might have been worth a look as long as there was a plan in place to return if things did not look favorable (in this case there probably was no such plan).
It’s easy to armchair a flight and say the pilot “obviously” shouldn’t have taken off. But if a pilot does not stick his nose in it now and then, no experience takes place and he will be no better off the next time a questionable situation arises. By definition I don’t believe it is possible to teach experience as that is a very personal sense. So the next best thing perhaps, is to teach how to gain experience without busting one’s behind. Maybe that is all that was lacking here; beyond basic control of the airplane of course.
Steve, I’m a big believer in “sticking your nose in it” from time to time–it’s a great way to learn. As I’ve written before, some pilots cancel far too quickly: http://airfactsjournal.com/2012/04/do-you-cancel-too-many-flights/
Having said that, the critical part of gaining experience is to always have an out (or two). I don’t see many outs on this flight–high terrain, marginal (at best) weather, not many en route alternates, low experience, passengers on board and pressure to get home. If this was home base and the pilot was willing to turn around, I’d say it was a calculated risk. To me, this looks like the pilot was determined to go no matter what. That’s when we should be nervous.
This event and others like it are indeed very sad, but Dirty Harry said it best; ” a man’s got to know his limitations”.
I continually see in these columns, the failings of flight instruction dragged in as contributing factors. Well, I have to disagree pretty intently on that point.
Flight instruction cannot make reckless people cautious or irresponsible people responsible; that’s what parents and peer pressure and life experience are supposed to do. And if all that hasn’t succeeded, what chance does a flight instructor have? Once you obtain a license to fly (or drive, or captain a ship, or whatever) you have the personal responsibility to do it, not just to the best of your ability, but to do it right (true “accidents” notwithstanding).
This wasn’t a simple runway incursion, an altitude oops or momentary lapse; this pilot intentionally placed himself and his family into a dangerous situation all on his own, by the apparent lack of planning, awareness, knowledge and prudence. ATC didn’t help matters but once we enter “the system” we are assumed competent and capable until we say or prove otherwise, and I think we’d all prefer it that way.
We pilots all have the personal responsibility to continue learning our craft and expanding our knowledge base, on our own, without heavy handed rules and regulations. And it’s never been easier with all the videos available (FAA.gov, AOPA/ASI, Air Facts and What You Should Know series as examples). There is simply no valid excuse for failing to be informed and exercising good judgment when commanding an aircraft in flight. Every time we line up and push the throttle forward we, and nobody else, are responsible for being fully prepared and adequately capable for what lies ahead.
The pilot obviously made several bad decisions, including accepting the ATC non-standard departure clearance … and ultimately as PIC he was responsible.
At the same time, it’s curious, if not rather startling, that a local JAC controller would issue an off-airway departure over extremely high terrain. The NTSB did not explain in its final accident report why the controller issued an essentially illegal DP. Surely the local controller was aware of both the high terrain and of the applicable requirements for IFR flight.
Terrible situation for the family, yet completely avoidable with competent piloting. Just like all too many other GA accident scenarios.
An ODP clearance is a viable option for pilots competent to fly it, in aircraft able to fly it, with weather where it can be flown. ATC can authorize departures with the ODP, and it’s up to the pilot to accept or decline.