Aftermath: A Short Hop

Thunderstorms are where you find them.

It is reasonable to suppose that if you were flying to an airport that was flanked by thunderstorms, you might turn on your weather radar and glance at your Nexrad display, especially if you were technically sophisticated.Pexels

On a stormy afternoon in August 2015, a Cessna 310 crashed in the Indian River, near the Kennedy Space Center in Florida. The accident occurred as the airplane was executing a missed approach in extremely heavy rain. The pilot, who was alone in the airplane, was killed.

According to his brother, who was interviewed after the accident by a local journalist, the pilot, 59, a retired Navy captain and active electrical engineer, had been flying for 20 years, had owned several airplanes, was instrument rated and “could fly anything except a jet.” He had about 1,000 hours, including 300 in the Cessna 310, but the extent of his actual instrument experience could not be determined. The pilot was “always very cautious,” his brother said. “He wouldn’t have gone up flying if he knew there was going to be inclement weather.”

Relatives and loved ones commonly paint a somewhat rosier picture of a pilot’s skill and caution than the circumstances of a fatal accident appear to warrant. On the other hand, the circumstances themselves often appear more clear-cut in retrospect, and especially in light of the fatal outcome, than they did to the pilot at the time.

On the day of the accident, he was flying from Orlando to Space Coast Regional Airport (TIX) at Titusville, a distance of only 28 nm. At around 3:45 in the afternoon, he had gotten a weather briefing and filed an IFR flight plan. The briefer told him that the route was clear, but that there were thunderstorms north and south of TIX. He suggested the pilot call again for an update before taking off, but the pilot was airborne just 11 minutes later and did not do so.

When the flight was halfway to TIX, the approach controller told the pilot that the airport was reporting 3 miles visibility and a broken ceiling at 1,000 feet, with thunderstorms and rain in the vicinity. The Runway 36 ILS was in use. The controller said the intensity of the rain increased 8 nm south of the airport, so he would vector the 310 onto the ILS closer in to keep it clear of the heavy weather. At the time the controller was speaking to the pilot, his radar display actually showed extreme precipitation — rainfall rates of 4 inches an hour or more — directly over the airport. Later, during interviews with National Transportation Safety Board accident investigators, the controller was unable to account for his failure to mention this fact to the pilot.

Radar showed the 310 completing 180 degrees of a climbing turn before descending into the river.

Shortly after this conversation, the approach controller was replaced by another one, who vectored the 310 onto the ILS inside the final approach fix and about 4.4 nm from the runway — a nonstandard procedure, but not especially hazardous in itself. Assuming that the previous controller had provided up-to-date weather information, he added none himself, and in due course instructed the pilot to switch to the tower frequency. The pilot flew the ILS accurately, but did not see the runway and told the tower that he was going to miss it. The local controller handed the flight back to approach, who gave the pilot a right turn to 210 (the published missed approach calls for a left turn, but the controller thought the weather echoes looked weaker to the right). The airplane was in heavy precipitation, the pilot said. Radar showed the 310 completing 180 degrees of a climbing turn before descending rapidly into the river.

Why did the airplane suddenly descend? Investigators recovered only part of the wreckage, severely fragmented by the violence of the crash. No indication was found of any mechanical malfunction — not that such evidence would necessarily have survived — and it was impossible to tell whether any of the breakup occurred before the airplane hit the water. Vertigo, disorientation, extreme turbulence, a microburst — there are several ways to account for such an event, all speculative.

The NTSB concluded that the causes of the crash had been the pilot’s decision to fly into convective weather conditions and, secondarily, the controllers’ failure to provide him with “timely and accurate” weather information — which might have included the interesting fact that the tower cab had been struck by lightning shortly before the pilot began his approach. (During a 45-minute period around the time of the accident, more than 1,100 lightning strikes occurred within a 15-mile radius of TIX.) Furthermore, although the official weather report for TIX near the time of the accident was of 2-mile visibility in moderate rain, airport surveillance showed that shortly before the accident intense rain reduced visibility to a few hundred feet.

The 310 was equipped with weather radar as well as a Garmin 496 GPS receiver with weather depiction. The pilot also had a tablet computer with ForeFlight and another weather-display app. “The extent to which the pilot may have used any of these devices during the flight,” the NTSB said, “could not be determined.” But it is reasonable to suppose that if you were flying to an airport that, according to your briefer, was flanked by thunderstorms, you might turn on your weather radar and glance at your Nexrad display, especially if, like this pilot, you were technically sophisticated.

It appears that his desire to make the trip, combined with the generally encouraging tone of the preflight briefing and the first approach controller’s report of “moderate” rain at the airport, convinced the pilot that the flight was safe and an ILS approach was feasible. He had no reason to anticipate extreme conditions at TIX, and since the surrounding convective weather was patchy, he would have felt that he could always return to Orlando if he had to.

When you are flying in bad weather, it often seems that improvement is as likely to lie ahead as behind.

Assuming that he was using his radar and Nexrad displays, why did the pilot begin the approach when echoes of extreme intensity were appearing right over the airport? Because the controller said otherwise? The Nexrad depiction might have been out of date by several minutes, but his onboard radar was real-time. If the pilot’s onboard weather-depiction equipment was working — and it’s hard to imagine that all three devices weren’t — then his passivity in not questioning controllers about the weather he saw ahead was matched only by theirs in not accurately informing him of the hazards displayed on their own radar screens.

One factor influencing the pilot could have been that, as many pilots have learned from experience, it is easier to continue with a course of action, once embarked upon, than either to embark upon it in the first place or exchange it for the uncertainties of a new one. When you are flying in bad weather, it often seems that improvement is as likely to lie ahead as behind. When the rain pounds more and more loudly and a viscous darkness descends around you, your concern about the worsening conditions is balanced by the belief that your wheels will soon be touching the ground or that the sky will brighten a few miles ahead.

Not long ago, the NTSB began including in its reports a section titled “Preventing Similar Accidents.” My first reaction was to suspect that this well-intentioned new “product” would become a dumping ground for threadbare governmentspeak boilerplate.

I am happy to report that this seems not to have happened; at least not yet. The “preventing” section at the end of this accident report — the number is ERA15FA325, Google it — is a useful, clearly written collection of practical advice about flying in convective conditions and making use of ATC services to help you do so safely. It particularly emphasizes the differences in perspective between pilots and controllers, and the assumptions, sometimes faulty, that each may make about the other. This is valuable stuff, and it deserves to be widely disseminated.