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Summary
On December 14, 2011, a privately owned Cessna
177A Cardinal departed Wilkes-Barre Wyoming Valley
Airport (KWBW), Pa., USA, with two persons on board, on
an IFR flight plan to Ottawa/Carp Airport (CYRP), Ont.
Approximately 44 NM from destination, because of low
visibility and ceilings at destination, the aircraft diverted to
its filed alternate of Ottawa/Macdonald-Cartier International
Airport (CYOW), Ont. The aircraft was then cleared for an ILS
approach to Runway 07. At about 19:12 (all times quoted are
EST), while flying the approach in instrument meteorological
conditions (IMC) at night, the aircraft collided with the ground
approximately 1.9 NM west of the threshold of Runway 07. The
aircraft was destroyed, and both occupants were fatally injured.
There was no fire. The 406 MHz ELT activated on impact.
Wreckage of Cessna Cardinal 1.9 NM west of the threshold of
Runway 07at CYOW
History of the flight
The aircraft was returning to CYRP from a 12-day trip to
southern Florida and the Bahamas. Both persons on board
were licensed pilots and generally shared the flying duties
throughout the trip.
On December 13, 2011, the two pilots checked out of their
hotel at 07:00 and departed Marsh Harbour International
Airport (MYAM), Bahamas, at 09:57 for Newport News/
Williamsburg International Airport (KPHF), Va. The flight
consisted of three stops and 10.5 hr of flight time, arriving at
KPHF at 00:16 on December 14, 2011. The pilots checked
into a hotel at 00:55.
At 12:15 on December 14, 2011, the aircraft departed KPHF and
arrived in Wilkes-Barre Wyoming Valley Airport (KWBW), Pa.,
at 14:51. At approximately 17:07, after civil twilight, the
aircraft departed KWBW on an IFR flight plan destined for
CYRP. At 18:40, approximately 44 NM south of CYRP, the
pilot-in-command (PIC) requested a diversion to CYOW for
a Runway 07 ILS approach. CYOW is located 15 NM east of
CYRP. An ILS approach is unavailable at CYRP.
At 19:06, Ottawa Terminal ATC cleared the aircraft for the ILS
approach to Runway 07 and issued radar vectors to intercept
the final approach course. The aircraft intercepted the localizer
approximately 8 NM from the threshold, and the terminal
controller instructed the aircraft to contact the Ottawa tower
controller. The tower controller informed the aircraft that it
was number one in the landing sequence. At approximately
4.5 NM from CYOW, while on the ILS approach, the aircraft
began to deviate north of the localizer. The tower controller
informed the pilot of the deviation. The pilot acknowledged
the information and informed the tower controller that they
were trying to get back on track. A minute later, as the aircraft
was approaching the centre of the localizer, the tower controller
cleared the aircraft to land. Shortly after receiving the landing
clearance, the aircraft began to deviate northbound again; the
controller informed the pilot of the deviation. There was a
brief, unrecognizable transmission on the tower frequency, but
it could not be confirmed that it came from the Cessna 177.
Eighteen seconds later, the controller instructed the aircraft to
pull up and go around. There was no response.
At approximately 19:12, the aircraft entered a steep right turn
with a rapid descent, and struck power lines before impacting
the ground 1.9 NM west of the threshold of Runway 07. Radar
data show that, while on the approach, the aircraft twice deviated
significantly from the localizer to a point that would have caused the
localizer indications on the aircraft instruments to go to full deflection.
Airspeed on the approach was maintained above 100 kt until the
loss of control (Figure 1).
Figure 1—Aircraft’s flight path showing its deviations from the localizer
during the final approach.
Weather and flight planning
At 16:21, while on the ground at KWBW, the PIC filed an IFR
flight plan with Williamsport flight service station (FSS). The
flight was planned to depart at 17:00 and cruise at 5 000 ft, and
was estimated to take 2 hr and 10 min to CYRP. The alternate
airport for the flight was CYOW; the forecast weather was
within alternate limits at the time of filing.
When the pilot called the FSS to file the flight plan, a weather
briefing was not requested. It could not be determined if the
pilot accessed the latest weather reports on the Internet prior
to the flight-plan phone call. The flight service specialist asked
if the pilot wanted information relating to icing and proceeded
to inform the pilot of an AIRMET that forecast moderate
icing between 3 000 and 14 000 ft on the flight route. The
pilot asked about the area around Watertown, which was on
the flight route, and the flight service specialist indicated that
there were no pilot reports, but that they might encounter some
showers as indicated by the AIRMET.
The latest forecast weather available for CYOW at the time that
the flight plan was filed was issued at 15:38. Forecast conditions
at 18:00 were visibility greater than 6 SM, scattered cloud at
1 500 ft and broken ceiling at 4 000 ft. Between 18:00 and
20:00, the conditions were forecast to deteriorate temporarily
to visibility of 2 SM in mist and ceiling at 900 ft overcast. At
20:00, conditions were forecast to improve to visibility greater
than 6 SM in light snow and rain showers with overcast ceilings
at 3 000 ft.
The latest actual weather at CYOW at the time that the flight
plan was filed was issued at 16:00. It described conditions as
wind 090° at 8 kt, visibility 3 SM in mist and ceiling overcast
at 700 ft.
At 18:12, while cruising at 5 000 ft, 29 NM south of
Watertown International Airport (KART), the pilot requested
a weather update for KART and CYOW from Boston Flight
Watch (BFW). The BFW specialist reported conditions at
KART to be visibility 10 SM and overcast ceilings at 9 500 ft,
and conditions at CYOW to be visibility 3 SM in mist and
overcast ceiling at 200 ft. The specialist repeated the AIRMET
previously described, and the PIC indicated that the crew would
check for updates once the aircraft was across the border.
At 18:34, while crossing the Canada–USA border near
Gananoque, Ont., the pilot requested a weather update for
CYOW from Montréal ATC. The weather relayed was the
same as previously reported by BFW. Six minutes later, the
pilot asked to change the destination to CYOW.
At 19:06, before clearing the aircraft for the ILS approach,
Ottawa Terminal ATC issued the latest weather to the pilot:
ceiling at 200 ft AGL, visibility 3 SM in mist and wind 100°
at 10 kt gusting to 15 kt.
The aircraft
The aircraft was certified, equipped and maintained in accordance
with existing regulations. Examination of the aircraft wreckage
determined that there were no signs of pre-impact damage or
defects that would have precluded safe flight. The aircraft was
not certified for flight into known icing conditions and did not
have any anti-ice equipment other than a heated pitot tube.
The aircraft collided with the ground with the flaps selected
up. In this configuration, the Cessna 177A stall speed is listed
in the owner’s manual as 57 kt.
The pilot and passenger
The PIC held a private pilot licence, a valid Category 3 medical
certificate and a valid Group 3 instrument rating. The pilot’s
personal logbook, last completed prior to the return trip,
contained the following totals (hr):
- Total flying time 429.1
- Night flying as PIC 30.3
- PIC on the accident aircraft 28.7
- Actual instrument 44.1
- Simulated instrument (hood) 40.9
- Simulator 41.8
While the logbook showed a total of 44.1 hr of actual instrument
time, the TSB determined that this column was being used to
record time spent flying on IFR flight plans rather than time
spent in actual IMC. Analysis of the departure, arrival and en
route weather of these recorded flights suggests the pilot had
experienced very little, if any, actual flight in IMC.
Canadian Aviation Regulation (CAR) 401.05(2)(b)(i)(B) requires
a pilot who is carrying passengers at night to have completed
five night takeoffs and five night landings in the preceding six
months. Records indicate that the PIC had completed only one
takeoff and two landings at night in the prescribed time period.
The passenger held a private pilot licence and a valid Category
3 medical certificate. Records indicate that the passenger had
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approximately 330 hr of experience, including 58 hr at night
as PIC and 5.9 hr under simulated instrument conditions. The
passenger did not possess an instrument rating.
Flight tests
Flight tests in Canada are evaluated using a 4-point marking
scale. A detailed explanation of the marking scale is outlined in
the Flight Test Guide—Instrument Rating published by Transport
Canada (TC), but the following applies in general:
- 4 – Performance is well executed considering
existing conditions.
- 3 – Performance is observed to include minor errors.
- 2 – Performance is observed to include major errors.
- 1 – Performance is observed to include critical errors,
or the aim of the test sequence/item is not achieved.
The PIC had attempted 5 flight tests since beginning flight
training in 2003.
On May 5, 2005, the PIC completed a private pilot flight test,
which was assessed as a pass. On Exercise 24A: Instrument
Flying—Full Panel, the PIC received a mark of 2. The pilot
examiner noted that the candidate was “chasing the needle”,
referring to a series of over-corrections in an effort to regain
the desired track.
On October 26, 2007, the PIC completed an instrument-rating
flight test, which was assessed as a pass. On Exercise 8: ILS
Approach, the PIC received a mark of 2. The pilot examiner
noted that the candidate let the glideslope deviate to ½-scale
deflection inside the outer marker, because he was trying to read
the pre-landing checklist. The PIC was granted an instrument
rating valid to November 1, 2009.
On December 11, 2009, the PIC attempted an instrument rating
renewal flight test, which was assessed as a fail. On Exercise 2:
IFR Operational Knowledge, the PIC received a mark of 1.
The pilot examiner noted that the candidate was unable to
explain the approach ban and showed an unacceptable level
of knowledge. The flight test was stopped on the ground after
this exercise was failed.
On October 7, 2011, the PIC attempted an instrument
rating renewal flight test, which was assessed as a fail. On
Exercise 8: ILS Approach and Exercise 9: Missed Approach,
the PIC received a mark of 1. The pilot examiner noted that
the candidate let the glideslope deviate to full-scale deflection
and let the course deviation indicator deflect fully en route
to the missed-approach waypoint.
TC’s Flight Test Guide—Instrument Rating describes the aim,
description and performance criteria for each exercise to be
completed on the flight test. For Exercise 8 (ILS or LPV1
Instrument Approach [Precision Approach]), the Performance
Criteria section, (i), states that assessment will be based on the
candidate’s ability to, “on final approach course, allow no more
than ½-scale deflection of the localizer or glideslope indications”.
CAR Standard 421.49(4)(b) requires applicants renewing an
instrument rating that expired more than 24 months before
the date of application to rewrite the instrument-rating
written examination (INRAT). The original instrument rating
held by the PIC would have been expired for 24 months on
November 1, 2011.
On October 31, 2011, the PIC completed an instrumentrating
renewal flight test, which was assessed as a pass. The PIC
received a mark of 2 on 4 exercises, including Arrival, Holding,
RNAV Approach and ILS Approach. The pilot examiner noted
on the flight test report that the candidate let the localizer
deviate to ½-scale deflection upon interception. Notes written
on a separate piece of paper during the flight test described
the localizer deviation as ¾-scale. Had the most recent
instrument-rating renewal flight test not been completed, the
PIC would have had to rewrite the INRAT.
Factors affecting pilot decision making
The PIC had several work appointments that were scheduled
for the day following the accident. In addition, the pilot also
had personal commitments to attend to later that week.
In the Operators Guide to Human Factors in Aviation2 (OGHFA),
the Flight Safety Foundation (FSF) describes the phenomenon
of making a decision to continue to the planned destination
or toward the planned goal even when significantly less risky
alternatives exist. This phenomenon has been variously referred
to as “press-on-itis”, “get-home-itis”, “hurry syndrome”, “plan
continuation” and “goal fixation”3.
The FSF states that the following are some of the reasons that
aircrews may be susceptible to “press-on-itis”:
- They have a personal commitment/appointment at the
completion of the flight, or they may simply want to get to
the destination.
- They want to “just get the job done” (excessive commitment
to task accomplishment) and are influenced by organizational
goals such as on-time arrival, fuel savings and passenger
convenience.
- They focus solely on aircraft flight path control, due to
turbulence and other distractions.
- “We are almost there, let’s just do it and get it over with.”
- They become task-saturated.
- They are fatigued.
- They lose situational awareness and are not fully aware of
the potentially perilous situation.
- They have not set performance limits and trigger gates that
require a go-around.
- They are not fully aware of their own limitations and/or the
aircraft’s limitations.
Analysis
The PIC was appropriately licensed and instrument rated.
However, the most recent, and other, flight test reports showed
signs that the PIC had continued difficulty conducting ILS
approaches. In addition, the PIC was not current in night-flying
operations, and had very little, if any, experience in actual IMC.
Most of the PIC’s instrument-flying experience was acquired
during training in simulated IMC and in the simulator.
2 European Advisory Committee, Operators Guide to Human Factors
in Aviation. Flight Safety Foundation (2009), available at http://www.
skybrary.aero/index.php/Portal:OGHFA (last accessed 25 October 2013)
3 European Advisory Committee, “Press-on-itis” (OGHFA Briefing
note), Operators Guide to Human Factors in Aviation, Flight Safety
Foundation (2009), available at http://www.skybrary.aero/index.php/
Press-on-itis_(OGHFA_BN) (last accessed on 25 October 2013)
This experience may not have presented the PIC with an
accurate representation of the conditions and pressures faced in
actual conditions.
The PIC chose to depart KWBW into forecast icing conditions
despite the fact the aircraft was not certified for such operations.
While en route, the pilot was informed of deteriorating
conditions in the Ottawa area but chose to continue. This
decision and the previous day’s long flying schedule, combined
with work and personal commitments, suggest the PIC may have
been susceptible to the phenomenon known as “press-on-itis”.
While on the ILS approach into Ottawa in unfamiliar night
IMC, the pilot had significant difficulty maintaining the
localizer. During the approach, the tower controller twice advised
the pilot that the aircraft was deviating from the approach
course. During the second attempt to regain the localizer,
the pilot most likely made a steep right turn, which quickly
developed into a rapid descent and loss of control.
Airframe icing could not be completely ruled out as a possible
contributor to the loss of control, but the high airspeed (> 40 kt
above the stall speed) that was maintained until the loss of
control suggests that it was unlikely. Icing likely did not
contribute to the aircraft’s repeated deviation from the localizer
and over-correction.
Finding as to causes and contributing factors
1. During an attempt to fly the precision approach at night in
weather conditions unfamiliar to the pilot, control of the
aircraft was lost and the aircraft collided with the ground.
Findings as to risk
1. If pilots possess limited currency and experience at night
or in instrument flight conditions, the risk of a loss of
control is increased when operating an aircraft in marginal
weather conditions.
2. Non-recognition of the effects of the phenomenon known
as “press-on-itis” can lead to increased risk that a decision
will be made to depart or continue a flight when significantly
less risky alternatives exist.
Other finding
1. The pilot did not meet the recency requirements for night
flying with passengers.
This particular accident has created a lot of discussions in pilot lounges
as well as on various online aviation blogs. Thought-provoking issues
are addressed, challenged and debated. Such issues include the realities
and challenges of IFR training, IFR qualification for commercial
pilots as opposed to private pilots, giving and taking check rides,
passing and failing those check rides, the need for actual IMC time,
mentorship, IFR theoretical knowledge, pressure and the insidious
effects of fatigue. While briefly mentioned in the report under “Factors
affecting pilot decision making”, one has to wonder whether fatigue
could have been a contributing factor in this accident. Read again
the pilots’ schedules described in the report for December 13 (over
17 hours) and December 14 (close to 8 hours). Combined with very
poor weather and the pressing desire to get home, the cumulative
effects of fatigue may have played a role in this accident. Want to
learn more from this accident and others? Hit the blogs, but check
your feelings at the door. —Ed.
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