Helpless

By David Jack Kenny 

The initial reports of the break-up of a Beechcraft V35B Bonanza in May 2016 raised eyebrows when the radio transcript suggested that the controller hadn’t appreciated the significance of the pilot’s report of a vacuum system failure. The NTSB’s investigation of that accident is likely to continue into 2017 or beyond.  However, their finding of probable cause in the September 2015 crash of an A36 Bonanza took the unusual step of citing “deficient Federal Aviation Administration air traffic control training on recognition and handling of emergencies, which led to incorrect controller actions that likely aggravated the pilot's spatial disorientation” as a contributing factor.

The instrument-rated private pilot was moderately experienced, but new to the Bonanza. According to his primary instructor, he’d logged more than 800 hours that included “a lot of IFR experience in a Piper PA-28-180 airplane.” The instructor described his instrument flying as “very good and conscientious.” After he bought the Bonanza in August, the same instructor had provided transition training that included six hours in the airplane and about an hour and a half of ground instruction. In addition to earning his complex endorsement, the new owner got some practice loading approaches into the Garmin 530, though none of that was done “under the hood.” A close friend, also a Bonanza owner, reported that he had no prior experience with the Garmin 530/430 series or the airplane’s autopilot or flight director.

The checkout was concluded on Sept. 2 with the instructor’s recommendation that the pilot get more experience with the airplane before flying it in actual IMC. Two days later he and his wife, along with her father, flew from Pennsylvania to Florida to visit their daughter. Prior obligations kept his instructor from coming along, so the friend accompanied them and helped the pilot practice loading and flying instrument approaches. By the time they arrived, the pilot seemed to be “getting more comfortable” with the avionics suite and autopilot.

He’d need to be, because his friend wouldn’t be joining them on the flight home. It began early on Sept. 7 with a short IFR leg from St. Petersburg to Sarasota, where the pilot filed an IFR flight plan to Greensboro, North Carolina, and obtained his second weather briefing of the morning. Concern about a line of embedded thunderstorms approaching from the southwest led him to cut the briefing short, but not before the briefer had advised him of an airmet for IFR conditions covering “northern and central Florida, Georgia, South Carolina and North Carolina.” His flight plan listed an expected time en route of three-and-a-half hours with five hours of fuel on board.

They took off at 8:19 a.m., evading the advancing front, and the next three hours of radio communications were unremarkable. Checking in with Greensboro Approach at 11:33 a.m., the pilot was told to expect Runway 5R and asked whether he could anticipate a visual approach ... though after being told to expect the ILS, he confirmed having information Delta, which reported 10 miles visibility under a 1,100-foot overcast. During the next two minutes, he requested confirmation of runway and altitude assignments before accepting a handoff to the controller at the west radar position.

 

At 11:45 a.m., he was cleared to descend from 5,000 feet to 3,000 feet.  At 11:48 a.m., in response to a traffic advisory, he replied that they were “about to go IMC.” Radar-track data showed the Bonanza descending through 3,600 feet at that time.

After leveling off at 3,000 feet, the pilot read back heading assignments correctly but showed increasing difficulty following them. At 11:53 a.m., he asked the controller, “How do you like this route of flight?” The controller advised that he appeared to be right of the localizer and told him to turn left to a heading of 360. The pilot asked, “Turning left or right to 360?” and was told “Left.”

A minute later, the controller asked whether he was established and the pilot replied “Established if I could have vectors to final, please.” The controller asked a second time whether the aircraft was established on the localizer and the pilot replied, “I believe I am,” only to be told he’d just flown through it. The controller later told investigators that this wasn’t a rare occurrence, so he didn’t think much of it. He assigned the Bonanza a heading of 320 degrees for sequencing, then another left turn to 230 that the airplane never made. Asked to verify that he was flying a heading of 230, the pilot replied, “Negative, and 36HT is close to…”  The sentence wasn’t finished.

His transmissions became increasingly frantic during the last five minutes of the flight.  Asked for his heading at 11:59 a.m., he reported “166,” then added, “We need a descent, we are almost disoriented …2,700.” When he accepted the controller’s offer of a no-gyro turn to final, he was initially given a left turn, then, 33 seconds later, a right turn. Analysis of its radar track later showed that the Bonanza cranked through a full 360 degrees at a radius too tight to appear on the controller’s screen. It was not until 12:01 p.m., after a series of low-altitude alerts with the airplane at an indicated 2,100 feet, that the controller issued instructions to climb to 4,000 and offered a block altitude. Just before 12:03 p.m., the pilot made one more transmission to ask, “Is there a nearby field … ?”  Forty seconds later, “screams were heard on the frequency.”

Subsequent interviews with both radar controllers and their front-line manager determined that while they had coordinated effectively to enable the west position to concentrate on the accident aircraft, none had received refresher training on no-gyro approaches in “a very long time.” Neither radar controller could give a concise explanation of spatial disorientation or said he would automatically consider a VFR pilot in the clouds to be an emergency. Remedial measures including face-to-face briefings for all operational personnel were put into place by the airport’s safety committee.

But while quicker recognition of the urgency of the situation and simpler instructions issued earlier might have avoided catastrophe, the controllers didn’t create this emergency. Given his fuel supply and the forecast, the pilot knew (or should have) that he’d almost certainly have to rely on that unfamiliar panel to fly an instrument approach. Vectors to final for an ILS with good visibility under an 1,100-foot ceiling represented about the best possible case.

Once he realized he was having trouble capturing the localizer, decisive action was his responsibility. Diverting to a VFR airport probably wasn’t an option, but a straight-ahead climb—declaring an emergency if necessary—was. Once on top, vectors to final above the charted intercept altitude might have gotten him stabilized on the final approach course in VMC; and with the correct frequency tuned and the Garmin switched to VLOC, there’d be no need to load the approach. Keeping the wings level and the needles somewhere near crossed would have been a much simpler task, probably well within his abilities.

Or he could have just postponed the flight…