Aftermath: Failure to Land

The 600-hour, instrument-rated pilot of a Piper Arrow left Georgia early on a Sunday afternoon for Delaware, where he was scheduled to perform a surgery the following day. The forecast weather at the destination and nearby airports was near minimums; the pilot filed Baltimore/Washington International (BWI) as his alternate.

As he approached his filed destination of Summit Airport (EVY) in Middletown, Delaware, he got a call from the Dover Air Force Base approach controller who was working him.

“Philadelphia Approach just informed me that a guy went missed approach out of Summit and was unable to land at Wilmington, had to divert out of Philadelphia’s airspace.”

“All right, I guess I’m going to have to divert,” the pilot said. BWI, his official alternate, had gone down considerably, and after reviewing his options he requested the weather at Salisbury (SBY). The controller gave him 400 overcast, 8 miles. “I wanna try Salisbury,” the pilot said.

Darkness was approaching as the Arrow pilot checked in with the Salisbury local controller and was cleared for the GPS Runway 14 approach at 5:19 p.m. The Arrow was equipped with a Garmin 430 GPS and an S-TEC 30 autopilot coupled to the GPS for horizontal, but not vertical, navigation. The minimum descent altitude was 306 feet agl, but the pilot broke off the approach 1.7 miles from the runway while still more than 500 feet above the ground.

He went around for another try. This time the Arrow veered to the right while almost 900 feet above the runway, completely reversing course while continuing to descend to 480 feet agl before again aborting the approach. “For some reason, my GPS is not working right,” the pilot told the tower. He said he would come around for another attempt. He did not request the ILS Runway 32 approach, with 200-foot minimums, nor did the local controller suggest it.

Rather than try a third time at SBY, the pilot decided to go to nearby Sussex County (GED), where the reported ceiling was 700 feet. He was cleared for the approach to GED at 6:01. Along with the clearance came bad news: The latest weather report was 300 overcast, 5 miles in mist — roughly the minimum descent altitude for the GPS Runway 22 approach.

This time, the pilot flew the approach to a GPS altitude of 250 feet, somewhat below legal minimums. He still did not catch sight of the runway and called the missed approach at 6:26. He had now been airborne for almost five hours. The Arrow holds 50 gallons of fuel and uses between nine and 10 gallons an hour, not counting a few extra gallons for taxi, takeoff and climb. His fuel gauges must have been indicating very close to empty. When the controller cleared him to climb to 3,000, the pilot replied, “I’m running pretty low, how ’bout two?”

“Advise if you’re gonna need an alternate airport to land,” the controller said.

“Well, do you have anything that is easier than this?”

The Dover approach controller offered Delaware Airpark (33N), 5 miles north of Dover AFB, with a VOR approach and 500-1 ­minimums. When the pilot inquired about the weather at 33N, the controller replied, “They go off our weather, which is currently 10 mile visibility, ceiling of 500 feet overcast, little bit better than Georgetown [GED].”

A couple of minutes later, the pilot said to the Dover controller, “Ma’am, I don’t suppose there is any chance I can land at Dover?” — meaning the Air Force base.

“Negative sir, unless it’s an emergency, there is no way you can land here.”

The pilot replied, “OK,” and continued on his way to the IAF for the approach at 33N.

This conversation took place at 6:31, five hours after the Arrow took off. Five minutes later, Dover Approach cleared the Arrow for the VOR 27 approach into 33N. “So it’s a VOR approach, correct, ma’am?” the pilot said. “Affirmative,” replied the controller. “Sorry about that.”

Another five minutes passed, and the approach controller got a frantic call from the Arrow pilot. “Ma’am, I’m declaring an emergency here, I’m out of fuel. I’m out of fuel and going down!”

“Roger,” replied the controller.

“Give me vectors please,” said the pilot.

The Arrow was abeam the Smyrna VOR, about 6 miles north of Dover AFB, and northbound. The controller, who evidently thought the pilot must be exaggerating, instructed him to turn right to a 010 heading to intercept the ILS 19 final approach course for Dover. The pilot had the good sense to ignore this vector and made a tight right turn while simultaneously slowing from 150 to 67 knots.

The controller amended the heading to 360.

“I’m out of fuel and going down!” cried the pilot. He was now 1,700 feet above the elevation of Dover’s runway and 6 miles away from it.

There was confusion among various Dover controllers about what was going on. Only the clearance delivery position seemed at first to understand that the Arrow was literally out of fuel. The approach controller continued to issue routine vectors as though nothing unusual were happening, inquiring whether the pilot had the field in sight — which was highly unlikely, given the weather — and at one point offering the completely misguided advice that “wheels should be down” before superfluously advising him to contact the tower on 126.35.

“What was that, 126 what?” was the pilot’s final transmission. He did as good a job of gliding as could have been done, but the Arrow inevitably crashed a couple of miles north of Dover. There was no fire, but the airplane was demolished and the pilot died.

The National Transportation Safety Board blamed the crash on “the pilot’s failure to land the airplane at multiple airports that were equipped with adequate instrument approach procedures … and his delay in declaring a fuel-related emergency.”

The reference to “failure to land” is somewhat confusing, since one can quite blamelessly fail to land because of unexpectedly low ceilings. I think it is intended to mean that the pilot chose, for unknown reasons, not to use the ILS approach at SBY, even though its minimums were lower than those of the GPS approach. Perhaps he had become so comfortable with his Garmin GPS that he felt more capable flying an approach with it than with the ILS. But by not choosing the ILS, he only made things more difficult for himself.

The question of his delay in declaring an emergency is more clear-cut. No pilot wants to declare an emergency when the situation he finds himself in is of his own making, and this reluctance was perhaps reflected in the hesitant phrasing of his question to the Dover approach controller: “I don’t suppose there is any chance I can land at Dover?” The reason for the discouraging tone of the controller’s reply — “Negative sir, unless it’s an emergency, there is no way you can land here.” — is a little harder to fathom. After all, the Arrow had been flying around for the last hour and a half in wretched weather, trying in vain to land. It was a tiring and stressful situation. It was dark. The pilot might well need a little help. Suppose she had said, “Yes, sir. Dover is available in an emergency. What is your present fuel state?” He would still have had to declare an emergency, with all the hassle that entails, but a more welcoming tone might have reconciled him to it.

In the final analysis, however, it’s the pilot’s responsibility, not the controller’s, to decide what to do and when to do it. It was an emergency. As the song says, “You got to know when to hold ’em, know when to fold ’em.” It was time to fold ’em long before he did.

_This article is based on the NTSB’s report of the accident and is intended to bring the issues raised to our readers’ attention. 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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Peter Garrison taught himself to use a slide rule and tin snips, built an airplane in his backyard, and flew it to Japan. He began contributing to FLYING in 1968, and he continues to share his columns, "Technicalities" and "Aftermath," with FLYING readers.

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