Snap Decisions

I have always thought it was extremely unfortunate when a professional pilot or crew carefully plans a flight, expertly follows the flight plan, and then suddenly makes a snap decision that undoes all their careful planning and execution. An accident at the Ellen Church Field Airport (CJJ) in Cresco, Iowa, in July 2006 illustrates how easy it is for the human mind to suddenly latch on to a certain course of action and vigorously pursue that course of action without carefully assessing the risks involved.

Starting in Gulfport, Mississippi, the crew had flown the Cessna 560 Encore to Destin, Florida; Meridian, Mississippi; and then Oxford, Mississippi, where they had lunch with the passengers. The left seat pilot had not actually completed the company Part 135 training and check ride yet, but he was hardly inexperienced, with 11,607 hours total time and type ratings in the CE-500, G-1159, HS-125 and CE-560XL. In the right seat was the company's chief pilot. He had logged over 13,000 hours and also had multiple type ratings. Neither pilot had any record of previous accidents, incidents or enforcement actions.

After lunch they departed for Rochester, Minnesota, with the chief pilot flying from the right seat. They had filed an IFR flight plan with no alternate as no serious weather was forecast for the destination. However, as they approached Rochester after a routine flight, the NTSB report stated that there were "two

areas of organized echoes, one over northeastern Iowa and the second over southeastern Minnesota into western Wisconsin. Both systems merged in the general vicinity of the accident site and appeared as a bowing line with an intense leading edge."

By the time the crew was transferred to Minneapolis Center, they were deviating around weather but still direct to Rochester. They informed the controller, "we're just gonna' keep kinda' heading this direction, stay on the west side of the weather 'til we get north of Rochester and then turn around and take a look at it." Soon they were transferred to another controller who informed them, "It's heck of a bow hook we got going on there." He told them they would have to go 100 miles north or 80 miles south to get around the storm, and they decided to try to "pick their way" through the storm.

About 10 minutes later they checked in with the Rochester approach controller, who informed them that the wind was 343 degrees at 6 knots with gusts to 24. While that favored the ILS to Runway 31, he said they were showing weather echoes along the final approach course, followed by, "Say your intentions." The left seat pilot replied that they would continue for another 20 miles on their present heading of 240 and then take a look at it on the radar. The pilot flying in the right seat told the other pilot, "probably what I'm going to do is go here to this hole then work my way up around that way," and the other pilot agreed with this.

It is almost always a bad sign when a controller says, "Say your intentions." There is nothing wrong with taking a look as long as you have a good out in case things don't work out as planned. However for some reason this crew had been pushing on in the face of mounting evidence that Rochester was not a good place to be headed to at that moment, and as they twisted and turned trying to follow perceived "holes" in the echoes, they were getting further and further into a storm with no good way out.

As they continued towards the airport, the controller informed the pilots the winds were now 320 at 29 with gusts to 39, visibility one-half mile in a thunderstorm with heavy rain. The crew's discomfort is evident when the right seat pilot says, "couldn't get there at a worse time." They also seem confused about a blinking red area on the radar screen, saying, "We're gonna know here in a minute. I'm gonna go this way," telling the controller they are going to turn further to the south.

All of a sudden, just when the pressure was getting intense, the left seat pilot saw an airport in their vicinity on the moving map with the identifier CJJ. "This little airport right here C-C-J-J, don't see it on the map here." The right seat pilot asked, "What airport is that?" The left seat pilot replied, "I'm gonna have to look it up." As the altitude alerter went off, the right seat pilot spotted the airport, "I've got that airport right there." The left seat pilot asked how long the runway looked, to which the other pilot replied, "I'm guessing 5,000 feet at least."

The left seat pilot asked the controller about the airport, and he informed them it was Cresco, Iowa. The right seat pilot stated, "I guess worse case scenario we could set here until it clears." The left seat pilot replied, "yeah." The right seat pilot asked, "What do you think?" The left seat pilot responded, "Cresco, yeah, I mean I'm okay with that." The right seat pilot said, "Let's do that," tells the controller of their intentions, and is cleared for a visual approach to Cresco.

This professional ATP rated flight crew with years of experience and a combined total of 10 type ratings and almost 25,000 hours had just committed to land at an airport they knew nothing about in the teeth of an approaching thunderstorm. The right seat pilot asked the other pilot to see if he could get "some numbers for the thing at all or, well, the landing numbers would be okay." As he did a 180 and started an aggressive descent, the left seat pilot got the correct spelling of the airport name and the CTAF frequency from the controller.

The left seat pilot then radioed in the blind, "Creston [sic] Iowa traffic, Citation 636SE we're checking in for a, we're turning final landing to the ah north," to which the right seat pilot replied, "whatever runway it is," and the left seat pilot joined in with "improvise" as they laughed. They did a hurried checklist and briefing and approached the runway with the Ground Proximity Warning System calling "terrain, terrain" and "pull up, pull up" throughout the precipitous approach.

On short final the left seat pilot pointed out that the runway looked wet, and that it was "pretty short." After they touched down, the left seat pilot said, "I'd go full reverse. You got 110 knots," followed shortly by a call for a go-around and a frantic call from the right seat pilot for "full power, full power," and then the sounds of the impact. Both pilots were killed, but the two passengers survived with serious injuries.

This landing was doomed from the start. The wind was actually from the south at Cresco, not from the north as it was at Rochester. At its estimated landing weight of 13,500 pounds, it was determined that a Cessna 560 landing on a wet runway with a 10-knot tailwind would require 4,284 feet to stop. The runway at Cresco is only 2,949 feet long. On a dry runway landing into the wind they might have made it. With a wet runway and a tailwind they didn't stand a chance.

Jets are flown by the book. The one thing you never do is "improvise." Airports and conditions must be carefully analyzed, and a stable approach is critical to a successful landing, especially in difficult conditions. Why did two professional pilots with spotless records suddenly do something that was so out of the norm? Even with the voice recorder, we will never know what they were thinking, but there are several traps of human nature that can lead to that type of a situation.

Almost everyone experiences a certain level of mission-itis, the desire to get the job done, to get to the destination. With the original forecast, there was no reason for them not to think that they would land at the destination on schedule. If the weather had been forecast to be bad from the start, they would not have had that expectation, and would have been planning for alternates, but in their case, they had a clear expectation of success, and there was no information during the course of the flight to lead them to begin planning an alternate course of action.

As they approached Rochester, the controllers tried to warn them with comments about the bow hook, the weather echoes along final approach, and the request to "say your intentions." That should have been enough to set off alarms in their heads and cause them to look for somewhere else to go to wait out the storm. However, by now they are so close to their destination it is like the tractor beam on Star Trek, pulling them in (Proximity Rule). I am sure that by that point they were having some doubts about proceeding, but with two very experienced pilots who didn't know each other very well, it is possible that each hesitated to show any weakness to the other pilot or question his recommendations or decisions (Excessive Professional Courtesy/Copilot Syndrome).

Just as it was becoming obvious they needed a different course of action, a false hope appeared in the form of the Cresco airport. If they had stopped to consider for even a few seconds, there were other options available. Waterloo, Iowa, with three runways up to 8,400 feet long, was only 50 miles to the south. But like drowning men grasping for a life ring, they latched on to the airport they could see right below them and proceeded to break every rule in the book to try to get to that perceived safe haven.

The scary thing about life in general, and especially about flying, is that you can do everything right for many years, but all it takes is one foolish decision to destroy all that you have accomplished. The best way to deal with the traps of human nature that can ruin a career or end a life is to get them out in the open. Before every flight, assess the crew dynamics. Commit yourself and any crewmembers to speaking up about any concerns, and to taking the conservative response whenever there is any doubt. If you are starting to get nervous, say so. Even if you are alone in the cockpit, it is much more effective to state out loud to yourself that you are not comfortable with the current situation, or even to say "This is stupid!" Be especially wary of a sudden change in plans. That is usually when our minds are racing, and under those conditions it is really easy to screw up and really hard to catch our mistakes until it is too late.

This article is based on the National Transportation Safety Board's report of the accident and is intended to bring the issues raised to the attention of our readers. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.


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