Friday, March 07, 2008

Speak Up

On February 1, 2008, about 1748 eastern standard time, a Cessna Citation 525, N102PT, crashed in a wooded area in West Gardiner, Maine. The private/instrument-rated pilot and one passenger received fatal injuries; the airplane was destroyed. The flight was operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Instrument meteorological conditions prevailed and an instrument flight rules flight plan was filed for a flight from Augusta, Maine to Lincoln, Nebraska. The flight had originated from the Augusta State Airport about 1745.

When I heard the news about this crash and learned the pilot hailed from the Bay Area, I was fairly certain I had seen the pilot and her aircraft. And it turns out I was right.

A Citation piloted by a woman regularly departed Oakland on runway 33 and every time I saw her depart, I shook my head and wondered "Why?" Not only is Runway 33 only 3,372 feet long, a jet departing that runway violates the airport's noise abatement procedure which requests that all jet aircraft depart runway 29. But runway 29 is a much longer taxi from the North Field and one can only assume that this pilot wanted as little delay as possible. Runway 27R or 27L would require only a minute more of taxiing, they are significantly longer, and they would have been better, slightly more quiet, and certainly safer choices.

Since this pilot departed runway 33 regularly, more than once I thought about saying something to her over the ground frequency. But I regret to say I never did.
Representatives of the fixed base operator (FBO) at Augusta State Airport stated that the airplane was fueled and moved from the ramp into the FBO's hangar earlier that morning at the pilot's request. However, the hanger is utilized by a part 121 operator that provides service for that area. The operator canceled its 1630 flight due to the weather conditions and needed the hangar to house its airplane. The Citation was taken out of the hangar and moved back to the ramp area about that time. The pilot was informed of this possibility at time of the request and she stated that she understood that the other customer had priority over the hangar space.

Freezing rain and a cold-soaked aircraft are a deadly combination that pilots need to take seriously. It seems like departing without any ground de-icing in weather conditions that have resulted in a part 121 flight being cancelled would be unthinkable.
A person identifying herself as the pilot of N102PT called a flight service station at 1701 to file an instrument flight plan from Augusta, Maine to Lincoln, Nebraska, The pilot received a standard weather briefing for the flight at that time. Witnesses stated that the pilot arrived at the airport about 1715, at which time she and the passenger loaded their personnel effects into the airplane, returned a rental car, and paid for the fuel. She and the passenger then boarded the airplane. Shortly after, about 1730, the airplane's engines were started and the airplane was observed taxing. The FBO representative heard the pilot's announcements over the radio in the FBO. He also noticed the airplane was not on the taxiway, but on the grass area on the south side of the asphalt taxiway. At that time the ground was covered with snow and ice.

For the past hour and a half, the weather condition had turned from light snow to freezing rain, and ice was observed covering the cars in the parking lot. The FBO representative noted the pilot did not activate the airport's taxi and runways lights via the common airport frequency radio channel. It was observed that the airplane taxied through a ditch, which was covered with ice and snow. The airplane's engines were heard at a high rate of power about this time. It was later discovered that the airplane's left main tire broke through the ice and became stuck in the ditch. The airplane continued on the grass area after the high engine power was heard. The FBO representative heard the pilot announce the wrong runway (runway 35) that she was planning to depart from. The FBO representative turned on the runway and taxi lights after hearing the incorrect runway announcement. The pilot later announced a change of departure from runway 35 to runway 17, while the airplane was observed back taxing on runway 26 onto taxiway "C" Charlie. About 1745 the announcement for departure from runway 17 was heard; the FBO representative observed the departure at that time.

Any pilot who has flown for very long has experienced a bad day and some pilots have a three strikes rule. It goes something like this: You arrive to find something wrong, say your aircraft has a dead battery. Strike one. You have a mechanic replace the battery, but now you find that the weather is worse than forecast. In fact, the forecast seems to be way off. Strike two.You're ready to call Clearance Delivery when you realize that the GPS database in your plane is out of date. Strike three. You choose to cancel the flight.
After takeoff, the pilot contacted the Air Traffic Controller (ATC) and reported that she was at 1,000 feet, climbing to 10,000 feet. ATC requested the pilot to squawk ident on the transponder. Radar contact was made with the airplane when it was about 2 miles southwest of the Augusta State Airport. About one minute later, the pilot declared an emergency and stated, "We've got an attitude indicator failure". About seven seconds later, the pilot announced over the frequency they were not certain which way they were turning. Radar contact was lost shortly after that.

About 1749, local authorities received several 911 calls from residents reporting a possible airplane crash. A short time later, the airplane wreckage was located about 6 miles south-southwest of the Augusta State Airport. One witness stated to local law enforcement authorities that he saw an airplane fly overhead at a low altitude and moments later observed a large explosion off in the distance.

Let's say you are about to take flight, but you find yourself deep in the count. Maybe you are so committed, so determined to go, that you can't stop yourself. Maybe there's another pilot who's observed your situation, they key the mic and suggest "It looks like it's not your day. Why don't you delay your departure until the weather improves?"
Maybe that other pilot is you.


Greybeard said...

Here is a face and article to make cold statistics more personal.

Ron said...

There is a corollary to the "speak up" mantra, and that's "listen up".

I believe the reason many pilots don't speak up is because they don't want to be told to shut up by the person they're trying to help.

So it's incumbent upon each of us to be receptive to suggestions and ideas coming from other aviators. They're taking the time to talk to us for a reason. We'd best listen.

Hamish said...

I had the same reaction as you when I heard the news about the accident: "I bet I know who that was...". Like you, unfortunately, I discovered I was right.

I remember watching several times as her Citation departed VFR on KOAK's runway 33, very loud and (once) barely airborne by the end of the runway (I even mention seeing it somewhere in my blog). At the time I don't think I ever thought of it as a safety issue so much as just another yahoo intent on saving a few minutes' taxiing at the expense of pissing off the neighbours in Alameda.

Anonymous said...

I think that it never hurts to speak up, but (and I hate to sound harsh) do you think she would have listened? If she continued to ignore the noise abatement procedures then that says a lot about her character.

Anonymous said...

Is there any kind of reprecussions for violating noise abatement procedures? It would seem to me that if this person in particular repeteadly violated noise abatement procedures by taking off on the wrong runway, why the tower would continue to grant takeoff permission for that plane. Why can't they say "sorry, that would violate noise abatement, go to runway 27"?


John said...

Several comments have suggested that there are times when pilots don't listen, so listen up!

Below are some excerpts from the Oakland Airport's noise abatement policy. The policy does not even envision someone departing runway 33 in a jet, but I'm fairly certain this pilot was contacted by phone or by mail for her non-compliant departures. There are no fines or penalties that I know of, unless you count a guilty conscience.

"Pilots in command make the final decisions relative to runway use; therefore, pilots may request to use any available runway. Neither the Airport nor the Federal Aviation Administration (FAA) Air Traffic Controllers (ATC) may restrict a pilot’s access to an available runway. ...

"Although air traffic controllers instruct jet aircraft pilots to taxi to Runway 29 for departure for noise abatement, FAA regulations allow pilots to request departure from Runways 27R/L. Occasionally, pilots may request departure from Runways 27R/L during their request to taxi or initial contact with air traffic control. Requests for departure from Runways 27R/L are normally granted. ...

"Air Traffic Control (ATC) may instruct a pilot to depart from Runways 27R/L in order to maintain the flow of air traffic and to avoid delays on the South Field during operational peak-times.

"If a pilot chooses to depart from Runways 27R/L, the Noise Abatement Office will contact the aircraft owner via written correspondence or telephone. To effectively reach business jet airlines, their staff will be contacted by phone or by e-mail after their pilot(s) deviate from the procedure.

"If ATC does not instruct a pilot to use the South Field runways for the above operations, the radio conversation recording system will be reviewed to determine the reason for the non-compliant operation. Airport staff will work with the FAA to ensure that this noise abatement procedure is the standard instruction given to pilots whenever feasible."

You can read more at:

Teller said...

The 121 carrier for which her airplane was displaced...well that was my airplane. Your evaluation of the situation is spot on...she was well past three strikes, but just didn't listen. Both the Augusta plane and the Bar Harbor plane canceled our last round trips of the night, before it even started raining at the surface. The FBO employee that night, a friend of mine, tried to speak up, but she wasn't having any of it. He asked her multiple times if she wanted to deice. She declined every time. He asked if she was sure she wanted to go, and she was. It took him a couple weeks to get over this, wondering what he could have done differently. I think Ron's corollary, that is to listen up, is the easily forgotten weak link in this tragic story.

John said...


Thank you for fill in that important information, though I guess knowing more only serves to deepen the tragedy.

My motivation for writing this was my wondering if, had I called her on the non-compliant departures, would it have had some impact on her whole aviation decision-making gestalt. In retrospect, I doubt that it would have, but the lesson for me is to speak up, even if I suspect the message will go unheeded.

I can easily imagine how that line guy felt, but he would have felt much worse had he not given her ample opportunities to change her mind.

Scott Schappell said...

Not to sound callous, but my regret is for the passenger more so than for the pilot that pushed herself beyond her ability.

I don't want to sound like a jerk, but something tells me given what she had done in her professional life she could do no wrong and probably wouldn't have listened anyway. I suspect she had a bit of a cavalier attitude.

Putting yourself in danger is one thing, but putting another life at risk is inexcusable, period.

Colin Summers said...

There is a pilot at my field who does not have situational awareness. He cannot read a map. Given a VOR, radial and DME reading he could not tell you where the plane was. Given a heading, told the position of his plane, and a radial to intercept off the VOR he could not tell you what the next step was. Right turn? Left turn? Go straight? Need to 180?

He just passed his IFR check ride. I haven't spoken to him directly, but I believe the practical took him three tries.

The school that gave him the sign off for PP refused to sign him off for IFR, so he switched schools. Three more times. I guess the last one eventually gave in and signed him off.

On a VFR day he flew at 2,500 MSL south down the shoreline from Ventura and right into the Class B for LAX while trying to find SMO. Take a look at a chart. It's impossible.

He should never ever fly in the clouds. If anyone can get disoriented, it's this fellow. I spoke to the FAA examiner that signed him off for PP and he said there was nothing he could do, that the guy did everything he was meant to do by the rules.

He couldn't find the originating airport after the steep turns, but all the rest of the test was complete. Apparently that was not one of the tasks.

If he winds up killing himself and passengers, it will not surprise me. I've spoken as strongly as I can to him, and anyone else who has taught or flown with him. All the instructors agree.

I think I even have a pretty strongly-worded letter I wrote to him about instrument training and currency posted on my blog.

I hate that the Citation pilot killed her ten year old and I hope her daughter grows up knowing how stupid and stubborn her mother was.

Detail Medic said...

I came to you by way of Greybeard and I'm glad he sent me to this post. My situation is a little different, but similar enough to make me think I'm ABSOLUTELY doing the right thing...

My partner is a reckless driver and tomorrow I have to put it in writing for him to be disciplined. I've tried again and again to get him to slow it down. I have to draw the line at driving 75 mph in fog (about 5' visibility) down country roads with no lighting!