HELICOPTER PROFESSIONAL PILOTS SAFETY PROGRAM
VOLUME 7 * NUMBER 1 * 1995
IT WON'T HAPPEN TO ME
This letter was submitted to us by the pilot involved.--Thanks, Editor
"Ive just recieved your Human AD and was immediately drawn to your article on fatigue.
In October of 1984, I was flying a twin-engine Navajo on a short haul, night scheduled flight when I inadvertently flew my aircraft into the ground.
I was attempting an unpublished non-precision IFR approach and busted my own minimums. It was an action I was unable to explain properly, either to myself or to the subsequent trials and inquiries.
Transport Canada had prepared an in-depth report on my fatigued condition as a possible explanation, but this was dismissed when it was learned I had had a day off prior to the accident.
That night I alone elected to operate an aircraft on a night IFR flight with only a single pilot and no working auto-pilot. This route was only approved for VFR, but a passing snowstorm with its accompanying icing segments reled this out. It gets worse, but I still felt compelled to attempt the flight. We were competing with a larger carrier operating Dash-7 aircraft, and our management wanted us to arrive before them.
Under your article's "Effects of Fatigue", you listed:
This last one really hit home. My biggest concern that night while I was descending was the build-up of snow on the runway that was reported to me by the morning pilot.
Because I was late, the company radio operator had left his station to attend to passengers waiting in the terminal, and I was therefore unable to learn the runway conditions, nor the fact that the weather had dropped to 600 obscured.
This particular runway was approximately 1000 feet shorter than the recommended takeoff-stop distance required. I was also operating approximately 400 pounds over gross as we were not permitted to refuel enroute, and I chose to carry my required IFR fuel reserves-fewer passengers wasn't an option.
This was only my fifth week of employment with this carrier and I'd already lost over 20 pounds. We were on call 24 hours a day for medevacs, and were expected to fly one scheduled flight a day, plus charters, if any. I had only 160 hours on type and had just renewed my IFR rating for this job, after a two year lack of employment. I later learned this outfit had fired over 40 pilots in a one year period-almost all for refusing flights.
I had allowed this to affect my no-go decisions and when we checked the weather, we were even challenged by management.
IFR flight was generally discouraged due to required fuel and pilot needs, since a second pilot meant one less passenger. That night I was told I had nine passengers, and my co-pilot was bumped. I still decided to fly IFR and cancel when overhead my destination.
In my descent I failed to level at a safe beacon crossing altitude and continued down to my preplanned circling altitude. Unfortunately, I was not overhead, and we struck a 2900 foot hill 20 miles south of the runway.
I had left a job 2 years earlier after losing an ongoing battle over safety problems, and here I was in a worse situation and needing the hours more than ever.
That night, I had no less than five adequated reasons to cancel or postpone my flight, but I chose to go; it was Friday night and all my passengers wanted to go home as well.
The "snowball effect" ws at full speed. At the time I should have been leveling off (or diverting), but I was more concerned with schedules and bad weather ahead. I had convinced myself I ws almost overhead and it was only a "minor" shortcut.
To this day, I still cannot believe how I allowed myself to deteriorate to such a level that I was incapable of flying safely. It cost six passengers their lives and ended my career. This was a decision I must still live with.
I have tried speaking to student pilots about my accident, but had often been met with the "It'll never happen to me" response that I now recognize all too well.
I don't know all the answers but your article helped explain some of my actions that night. I would be more than pleased if you can use my accident to further educate pilots of all types that are faced with these pressures.
To date, there has been little "good" to come from my experience. I have met a pilot who studied my accident in his commercial training, but I felt that he didn't think it could happen to him. I learned that he too pushed the weather and almost didn't make it.
I am including a copy of the Department of Transportation's Safety Letter which summarizes the Accident Board's Report quite accurately.
The only changes that I would add to it would be my list of snags that were uncomfirmed; none of the pilots were allowed to write up snags, and didn't want to testify that they flew aircraft in this condition."
The HELIPROPS editor and administrator is Jim Szymanski,C/O Bell Helicopter Textron, P.O. Box 482, Fort Worth, Texas 76101.