Hughesair (Inflection Point)

Retired physician and air taxi operator, science writer and part time assistant professor, these editorials cover a wide range of topics. Mostly non political, mostly true, I write more from experience than from research and more from science than convention. Subjects cover medicine, Alaska aviation, economics, technology and an occasional book review. The Floatplane book is out there. I am currently working on Hippocrates a Fanciful History of Medicine and Death of the Middleclass. Enjoy!


Wednesday, March 22, 2017

Fatal Crash Ketchikan

NTSB reports the 2015 crash in South East that killed 9 sight seers from Holland American Lines as controlled flight into terrain, indeed it was controlled flight first into instrument conditions.  There was plenty of blame all around. The pilot age 64 had 1200 Alaska hours and a reputation for caution. but flew an Otter into the mountainside near Ella Narrows, Misty Fjords and Ketchikan.

There were several issues. This was a part 135 operation. The mantra for part 135 is 500 and 2, that is 500 feet clear of clouds or terrain and 2 miles visibility. There was no way given the photograph and fatal outcome that this basic regulation, meant to insure minimum passenger safety, was even partially followed. The radar altimeter was found to be shut off, with the explanation that pilots frequently disable the device because it makes a frequent noise that frightens passengers. If the warning device was set at 500', that alone would confirm the disregard of the basic flight limitation for this level of commercial flying. Ah, but this is Alaska, home of the dare devil bush pilot where Lodge pilots, not limited by the Part 135 restrictions routinely brag about flight where overcast is "down to the grass." At 64, the pilot was a bit of an oddity with only 1200 Alaska hours, maybe he was a retired airline pilot. Airline pilots are accustomed to fling high, fast, in the system and on auto pilot. Mountain flying, low and slow under the scud is new to them. That may account for reports of his poor adaptation to down drafts and "misty conditions." More than anything this was a human factors disaster on multiple levels. Additionally 1200 hours may be a time when pilots gain some elementary level of confidence about Alaska flying which can easily turn into relaxation and over confidence. Then one sees others doing it, and one is tempted too. So much for the pilot, he paid the price. This was his third flight of the day, flight time and fatigue may have played a role as well.

Unfortunately, the blame does not stop there. The weather reports are not much better than in the 1940s. NWS still reports weather in the acronyms and hieroglyphics understandable only by themselves and pilots in a flight service briefing or on the ground. Add to that the US compliance with international weather terminology reports temperature and due-point in Centigrade whole numbers, numbers representing a wider value than Fahrenheit. NWS should report the temperature due-point spread with a decimal point to the tenth, so as to more finely describe the amount of visible moisture in the air. Furthermore, and for the same reasoning, WS reports low clouds and fog as mist, with a criteria that offers an excuse to fly into mist considering mist not to violate the 500 and 2 rule. In this tragic fatality weather service bears a significant blame due to its own reporting criteria.

Not to be left out, the FAA bears a significant responsibility. For one, they have left Alaska in the dark ages of aviation with primitive third world airfields, little or no support for float or seaplane operation, and in their twice a year inspections, the PI fails to contain the local convention of routinely violating the most basic part 135 rules. Furthermore, FAA is blind to the need for Alaska pilots flying in conditions prone to whiteout and sudden precipitation of fog over a massive area to be IFR certified and current whether their aircraft is or not. The FAA approaches IFR for air taxi operations is just say no. By saying no, as if saying no the FAA will eliminate the high likelihood that 135 pilots will encounter unintended and unavoidable instrument meteorological conditions.  When mist turns into a solid fog bank or suddenly dense cloud cover, there is no way to go except up, way up. Just last week a young  man failed to survive his vertical landing near Nome because he was not instrument capable. Instrument flying is not rocket science, in fact it is very basic.

Not so basic is a particular advanced IFR maneuver from the RAF. The Chandelle will get you turned around given enough maneuvering room; however, the Ella Narrows are apparently extremely narrow, severely limiting the pilots ability to just turn around. In discussing this issue this morning with another retired 135 pilot, I recalled having learned an IFR maneuver that was perfected by the British for bombing German installations at the head of Norwegian fjords. The Brits made use of twin engine Spit Fire bombers to run in low under the cloud cover targeting the enemy facility at the head of the fjord right in the face of the steep glacier wall. The pilots would drop their bombs and immediately climb up into the cloud cover, full power, steep to the stall point, then executing a coordinated turn to the left - always to the left, still full power, dropping off to a reciprocal heading while remaining in clouds, thus executing a 180 with minimum lateral displacement, IFR in the clouds until out of anti aircraft range. I was taught this maneuver (IFR) in an A36, by one of the owners of the aircraft as a safety measure for dealing with accidental controlled flight into instrument conditions in the mountains. The maneuver somewhat resembles the lazy 8 but much steeper and a bit more abrupt, scary in concept but easy to do, at least in the A 36, I don't know about an Otter. The stall characteristics might be a bit less forgiving -- would sure scare the passengers.

The FAA once allowed 15 minutes of IFR if visual flight rules when VFR could be had within the 15 minutes on departure and the same upon arrival in event weather changed in-rout. It now requires an extensively equipped aircraft, more extensive than needed when used only for emergency or potential emergency.

The operator in Ketchikan must be saddened, but cannot claim complete innocence or ignorance. One hopes there was not a financial motive for pressing the limits. The report mentions some significant training shortcomings and surely dispatch has a duty to red-line flights due to weather if indeed the owner or chief pilot is not available. The ultimate responsibility rests with the pilot but in a multi pilot operation, there needs to be a chief.

Time spent on the ground due to weather is not counted against your life.  Please consider these comment as generic and thought provoking, I have no personal knowledge of the incident nor the terrain in question and defer any judgement to the NTSB and their superb capability and analysis.




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