Error Chain

Aeronautical decision making-it seemed like a good idea at the time.

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When a non-pilot asks me about flying, they are often surprised when I tell them it’s as much a mental exercise as a physical skill. Pilots know that flying is a constant game of assigning probability to “what if” scenarios and the search for potential outs if things go wrong. Nearing 1000 hours as a private pilot, I felt pretty adept at navigating this process. A recent flight has reset that assessment, however, and I want to share with you how, using logic and reason, I talked myself into a situation that nearly took two lives. This story involves equipment failure, but I hope that the slippery slope of poor decision making is what shines through as the true cause.

It Didn’t Look That Bad

The incident flight was planned from Destin, Florida (DTS) to Key West roughly following the coastline. The late December morning weather was IFR at DTS, with areas of low ceilings and light rain/mist with a few isolated patches of moderate/heavy rain. As the morning wore on, I watched this narrow system slide across the airport and move east. I compared the radar imagery on the iPad with what I saw out the window and decided that it wasn’t that bad, and I should be able to pick my way through and remain VFR.

VFR flight from Destin, Florida, to Key West. Estimated time en route was 2.8 hours.

DTS was VFR around noon, so my wife and I boarded our Harmon Rocket II, confident in the knowledge I could turn around and return if needed. The Rocket is a strong performer, but this particular example is not equipped for IMC with only a single EFIS as an attitude reference. This lack of redundancy was not a concern as I intended to remain strictly visual, and I’m not instrument rated anyway. Per procedure, I contacted ATC, received a squawk code prior to departure, and established radar contact immediately after takeoff. ATC asked for my normal cruise altitude and I responded, “7500 after I pass under the weather.” ATC acknowledged and instructed me to remain VFR. I engaged the autopilot and focused on managing the aircraft, traffic, and weather. Initial cruise under occasional rain showers was accomplished just as expected—slightly challenging, but VFR.

The panel included useful VFR instrumentation—but no real backups for IMC flight.

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EFIS and Pitot Problems

Eventually the cloud base lowered and rain became more frequent, bringing the first hint of trouble in the form of lost communication between the EFIS and the magnetometer located way back in the tail. Loss of magnetic heading indication was not an immediate concern to me considering the multiple GPS sources available displaying course and heading. I convinced myself that this was a temporary condition anyway, figuring that the magnetometer would come back after I found dry weather just a few miles ahead—so I pressed on. After continuing on a few more minutes, lower ceilings and isolated patches of low hanging clouds drove me to disengage the autopilot and maneuver slightly to remain VFR. While hand flying in the slowly deteriorating, but still VFR weather, the pitot tube apparently swallowed a slug of water as my airspeed and angle of attack (AoA) display suddenly lit up like a Christmas tree. Indicated airspeed was hovering around 500 knots, and the AoA (also driven off the pitot) was bouncing up and down the full scale. Though disconcerting and certainly unwelcome, I once again rationalized this away as a non-critical element, as I was in cruise, could see the ground, and had multiple GPS groundspeed displays. Finally, I was practiced and comfortable flying the airplane without reference to airspeed. Besides, I just need to go “a few more miles…”

An important factor I overlooked, however, was that this failure removed the autopilot function and, like it or not, I’d be hand flying from here on. A very effective tool (automation in inadvertent IMC) was gone, and I didn’t even give it a second thought. The situation was unraveling slowly, but like a frog in a pot of water warming up on the stove, I didn’t recognize how bad things were getting.

Fly under 90 miles of rain and marginal VFR.

Into the Clouds

I was in marginal but visual weather and down to a still relatively safe 1200 feet agl when things went from uncomfortable to legitimately bad in the blink of an eye—I plunged headlong into a cloud hiding in plain sight. Suppressing mild panic, I quickly weighed my options between a 180-degree turn and a climb straight ahead and convinced myself of a seemingly well-reasoned decision: Despite my lack of instrument training and extensive guidance that 180 is the thing to do, a straight-ahead climb for a “few more miles” seemed safer than a low-altitude 180 with obstructions. Decision made, I confessed to ATC that I was now IMC and starting a climb on course. As much as I feared an enforcement action, I feared a midair collision more.

ATC replied with the query, “Are you instrument equipped and trained?”

My reply was, “Negative.”

“Do you need assistance?”

“Not at this time, but keep an eye on me.”

My confidence that I was capable of hand flying in solid IMC turned out to be justified, as I made it up to 7500 feet and on course with little difficulty. Though my confidence in my own ability was still being proven, I never questioned the reliability of the modern electronic marvel on the instrument panel that was making it all possible. Single-point failure, yes, but I reasoned the possibility of a failure of the EFIS in the brief time I really needed it was remote at best.

My approach to risk management was about to change. I was still in hard IMC and about to level off when that incalculable random internal failure materialized: The EFIS screen flashed once and went dark, removing my only useful reference to the horizon. I have read enough accident summaries to know that my inner ear would betray me in seconds, and I would be powerless to prevent the inevitable. I froze all control input in an attempt to lock out any inner ear influence and hopefully maintain an even keel. My 1000-fpm climb rate continued, and I thought for a brief moment that I might just beat the odds. Reality struck quickly, however, when the VSI needle reversed direction, passed through zero, and settled firmly against the mechanical stop at 4000 fpm—all without any perceptible control input. I knew at this moment that I was going to be dead, and soon.

Sixty Seconds to Live

Recalling the adage to fly the airplane as far into the crash as possible, I jerked the throttle to idle and input a touch of left aileron (knowing this particular airplane to be slightly right wing heavy) while pulling back on the stick. It was a desperate and ineffective move as the altimeter continued to unwind at an alarming rate. As I stared at the instrument, confused by my inability to control the airplane, as well as accepting the stupidity of my actions, I came to the sobering realization that the unwinding altimeter was a graphic illustration of our time left to live:

7000…6000…5000…

Despite the closed throttle, the increasing wind noise howling over the airframe and stiffening controls were an unmistakable indication that airspeed was building quickly. A glance at the GPS groundspeed provided stark confirmation: 240 knots and climbing. I found cold comfort with the realization that death would be instantaneous and my innocent, trusting wife would not suffer. It is a bad day of flying when the best spin you can put on the situation is, “We’re going to die, but it won’t hurt.”

Completely due to my own actions, a simple VFR flight had quickly deteriorated to the point where I was now moments from death. I had a windscreen filled with featureless gray and a rapidly unwinding altimeter, yet all I could do was watch and wait for whatever was next. I did know that if I was going to break out, I’d better be ready for anything because it was going to be low.

4000…3000…2000…

With the end near, I strained to see through the murk and came to realize the walls of my vision were closing in. I was still unconsciously pulling the stick hard enough to initiate G-LOC (G-force induced Loss of Consciousness). Fighting the primitive instinct to survive by pulling up, I relaxed the back pressure, restoring my vision just as the featureless gray in the windscreen changed to vivid green forest, and I burst out the bottom at 1000 feet. A little aileron and 6 G pull took most of the available room between the clouds and trees, but there was no impact, the wings stayed on, and I was once again in visual, controlled flight. It seemed like an eternity, but the plummet from 7500 feet took less than 60 seconds.

Trapped

Elation quickly faded as we discovered we were now trapped in a small pocket about a mile in diameter. All around us the cloud base was sitting in the treetops while above, wispy tentacles hung from an unstable sub-1000-foot ceiling. Worse, below us was nothing but an unbroken carpet of 75-foot-tall pine trees growing three feet apart. Slowly orbiting in light rain at 300 feet agl, I had enough fuel to carry me through the afternoon and into darkness—both a blessing and a curse. I contemplated a scenario involving a radio call to dispatch a rescue team, followed by a controlled crash into the trees, but burning to death in twisted wreckage seemed a likely outcome. I was in no rush to exercise this option.

A few more minutes surveying my surroundings and the EFIS screen inexplicably came back to life—albeit still without heading or airspeed. Once again, with an incalculable swing of luck, my situation was suddenly improved with the addition of a second, yet equally frightening option: plunge back into the murk, trusting our lives to the attitude information presented on an instrument that would likely fail at any second. There could be no way to expect another miraculous recovery if the screen went dark again.

About this time ATC gave me a call and said he noticed I was “maneuvering” and asked if I was OK. I told him I was visual, in a small clearing, trying to find a way through. He next offered the location of the nearest airports and the direction of better weather —both pieces of information I had at hand thanks to the GPS and weather displays. I didn’t tell him about the failed attitude indicator or the fact that my plunge from 7500 feet moments before was not by choice. I also didn’t declare an emergency, though I’m certain he knew I was in trouble. I knew exactly where I wanted to go—I just couldn’t get there from here. The situation was clear—aside from traffic separation, the voice on the radio was not going to save me.

Simply flying through air doesn’t usually remove paint.

The horizontal tail shows evidence of high-speed precipitation impact.

No Good Options

Reduced to the choice between likely death in a forced landing or possible death in IMC, I chose the latter and announced to ATC that I was once again IMC and climbing. I plunged into the cloud wall climbing at 1000 fpm, strongly motivated to distance myself from the trees and towers below. My desire to climb was almost overwhelming as I focused intently on the EFIS screen, searching for any sign of failure, and praying to the Lord with every fiber of my being for the screen to stay lit. Climbing on course, I passed through light, dark, dry, heavy rain, a few lightning flashes, and moments of severe turbulence until things started to calm down around 9000 feet. Without an airspeed indication I focused on maintaining a 1000-fpm climb, and in my intense concentration, I overlooked the fact that even a 1250-pound airplane with 260 hp on the nose eventually runs out of climb performance. I was unknowingly trading airspeed for climb rate. At about 11,500 feet, the airplane shuddered and stalled hard. I immediately checked the stick forward to break the stall and stomped on the rudder to level the wings, but recovery was far too soon and I experienced an immediate post recovery stall. This scenario repeated twice more until on the final recovery I held forward stick until I saw 130 knots groundspeed on the GPS. Groundspeed now joined my rudimentary instrument scan, and I made sure to balance forward progress with climb rate from then on. Back in controlled flight I droned on through the gray in a shallow climb and apparently started to relax enough to notice a numbing cold. The canopy was fogged over on the inside, but what good would clearing it do? I couldn’t see past the wingtip anyway.

Icing in IMC

I continued up to 15,200 feet and wiped the canopy clear, hoping I could finally catch a glimpse of blue sky above. Instead I saw an opaque layer of ice on the windshield and also noticed the ailerons were becoming sticky. Not good: I’m flying a VFR airplane with no anti-ice capabilities of any kind in hard IMC, icing, and near the flight levels. I leveled off and pondered my next move when I heard a nearby IFR aircraft check in with ATC at 17.5. Hopeful for a positive report, I asked if he was “on top,” but he responded that he was still IMC. Realizing that I was going to have to drive out the side of the weather, I informed ATC that I was going to descend to 11.5 and headed for warmer air. Back at 11,500 I was still IMC, but I was at least dry, free of ice, and the EFIS was still bright. For the first time in more than an hour, I allowed myself the luxury of believing we might survive. A few more minutes of cruise and the solid mass enveloping us lightened, started to break up and slowly offered glimpses of the Gulf of Mexico below. After 1.2 hours in IMC, I now found myself nearing the coastline and finally in bright afternoon sunshine.

Recording instrumentation—and a radar shot—tells the harrowing tale.

Calling It Quits

Once again legitimately VFR, I hit my waypoint and turned southbound along Florida’s west coast. Taking stock revealed the airplane was performing well; we were not injured, and though the Keys were no longer in range, we still had plenty of fuel. A visual survey of the aircraft showed no damage, so we pressed on to Punta Gorda for fuel and a possible relaunch to the Keys. The landing and long taxi to the fuel pumps were anti-climactic, but were as welcome as the warmth of the Florida afternoon sun. Careful inspection of the airplane at the fuel pumps revealed no damage except for some missing paint, but power-on checks of the airplane presented a dark EFIS. This unwelcome sight provided the clarity to finally call it quits for the day. With a new appreciation for how quickly your “outs” can disappear, the choice to tie the airplane down and get a hotel room was an easy one.


Michael Robinson is a second-generation pilot, A&P, and was a U.S. Air Force aircraft technician for 10 years. He holds a private pilot certificate and currently flies his Harmon Rocket II and a friend’s RV-8, which he also maintains. Both aircraft are used for cross-countries, aerobatics, and a developing interest in formation work. And yes, an instrument rating is high on the agenda.

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