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Poor situational awareness leads to CFIT

By NTSB · November 17, 2006 ·

These November 2004 Accident Reports are provided by the National Transportation Safety Board. Published as an educational tool, they are intended to help pilots learn from the misfortunes of others.

Aircraft: Piper Saratoga.

Location: Santa Barbara, Calif.

Injuries: 3 Fatal.

Aircraft damage: Destroyed.

What reportedly happened: Prior to takeoff on the instrument night flight on a moonless night, the pilot informed the air traffic controller that he had checked the weather. A broken sky condition existed with layers at 5,500 and 7,000 feet msl. When the pilot climbed from 4,900 to 5,200 feet he requested information from ATC about the elevation of the clouds. He stated that he was in and out of the clouds. The flight continued and the airplane tracked near the centerline of Victor Airway 183, which had a published course of 195°. Family members said the pilot was familiar with the route between Santa Barbara and his destination, Bakersfield. The pilot was receiving radar flight following service from a controller at the Los Angeles Air Route Traffic Control Center. According to the mode C transponder read out, during the last few minutes of the flight the pilot was cruising at 6,500 feet. The controller observed the airplane and was aware that the minimum en route altitude for airplanes on instrument clearances along the airway was 9,000 feet. Both the controller and the pilot had aeronautical charts with them that depicted a 6,840-foot msl mountain peak along the flight route. The controller did not issue a terrain-related safety alert, as required by an FAA order. The pilot’s course and altitude did not vary as he approached and hit the mountain.

Probable cause: The pilot’s failure to select and maintain an adequate terrain avoidance cruising altitude. Contributing factors were the dark conditions, the rising mountainous terrain and the controller’s failure to issue a terrain-related safety alert.

—

Aircraft: Cessna 210.

Location: Lomita, Calif.

Injuries: 1 Fatal.

Aircraft damage: Destroyed.

What reportedly happened: The purpose of the night flight was to reposition the aircraft at the request of the aircraft owner. The pilot, who had an estimated 13,000 hours and held multiple certificates, was in a hurry as the plane was one of three that was supposed to be repositioned that night. It was not determined if the pilot did a preflight inspection of the aircraft. Friends of the pilot revealed that he was supposed to have repositioned the airplane a few days earlier and that the owner had expressed his disapproval that the job had not been done yet. Prior to the airplane’s departure, the owner of the aircraft noted that the fuel gauges were reading about 1/4 tank each. About two weeks before the accident, the owner and the accident pilot refueled the other two airplane’s that were to be ferried that night but did not refuel the accident airplane. The accident airplane held a total of 40 gallons. The total flight time since the last refueling of the accident airplane was 2.1 hours. Fuel calculations based on charts in the Cessna Pilot’s Operating Handbook indicated that approximately 30 gallons would have been used during the 2.1 hours. The duration of the repositioning flight was 12 minutes. The aircraft was on short final for the runway when the engine lost power. The plane did not have sufficient altitude to glide to the airport. It collided with trees, power lines and a house that lay in the final approach path to the airport. Investigators determined the right fuel tank contained about eight ounces of fuel. The left fuel tank had one gallon. The fuel selector was positioned to the right tank.

Probable cause: A loss of engine power due to fuel starvation as a result of the pilot’s mismanagement of fuel and inadequate preflight inspection.

—

Aircraft: Taylorcraft BC12-D.

Location: Wasta, S.D.

Injuries: 1 Fatal.

Aircraft damage: Destroyed.

What reportedly happened: The student pilot was returning to land at his farm field. The sun had gone down and the aircraft did not have any cockpit lighting. A witness reported seeing the airplane’s wings “wobble” when it was at an altitude of about 300 feet above the ground. The aircraft then pitched down sharply and crashed. Investigators found the push-pull type fuel shutoff valve was pulled to the off position. An Airworthiness Directive to install a safety cover to prevent the accidental activation of the fuel shutoff valve had been complied with, however the cover was bent so that it did not cover the valve.

Probable cause: The pilot inadvertently pulled the fuel shut off valve resulting in fuel starvation and a subsequent loss of engine power.

—

Aircraft: Cessna 172.

Location: West Columbia, S.C.

Injuries: None.

Aircraft damage: Substantial.

What reportedly happened: The student pilot was practicing touch and goes. On the first touchdown the airplane bounced. The pilot increased engine power in an attempt to control the bounce, but his efforts failed and the airplane became more difficult to control. The airplane then veered to the left and off the runway onto a grassy area. The student applied right rudder and brakes, but was unable to avoid hitting a runway sign.

Probable cause: The student pilot’s improper landing flare, inadequate recovery from a bounced landing and failure to maintain directional control during rollout.

—

Aircraft: Beech Musketeer.

Location: New Market, Va.

Injuries: None.

Aircraft damage: Substantial.

What reportedly happened: The pilot was attempting to take off at night. As he began the rotation, a deer ran on to the runway and hit the left stabilator. A portion of the stabilator separated from the airframe. The pilot continued the takeoff, then circled the airport and performed an emergency landing. During the landing, the nose gear collapsed and the airplane came to rest in a grassy area beyond the end of the runway.

Probable cause: A collision with a deer during the takeoff roll.

—

Aircraft: YMF-80.

Location: Arcola, Texas

Injuries: 1 Serious.

Aircraft damage: Destroyed.

What reportedly happened: The airplane had been undergoing restoration. The accident flight was the first flight since it was reassembled. Shortly after takeoff, the airplane entered a nose-high attitude and stalled at an altitude of 500 feet, according to a witness. The plane entered a spin. The pilot was unable to recover and the plane hit the ground nose first.

Probable cause: The pilot’s failure to maintain airspeed sufficient for flight, resulting in an inadvertent stall/spin during takeoff initial climb.

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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