CFIT kills two

This January 2010 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

Aircraft: Piper Cherokee Six. Injuries: 2 Fatal. Location: Honolulu, Hawaii. Aircraft damage: Destroyed.

What reportedly happened: The 81-year-old pilot, who had logged about 5,900 hours, was on the return leg of his regular 63-nautical-mile commute between two islands. He was cleared for a VFR arrival, which entailed passing over a VORTAC, continuing over a golf course, and then following a freeway before entering the traffic pattern. The controller told the pilot to proceed to the VORTAC, but the pilot replied that he wanted a vector.The controller provided a vector and the pilot said that he did not have the island in sight. The controller told the pilot to resume his own navigation. The airplane flight path crossed over the VORTAC and proceeded north into mountainous terrain instead of the cleared arrival path. While the pilot said that he was over the golf course, radar data indicate that he was actually about 2.5 miles to the east of that location. About 1 minute 20 seconds later, he said that he was inbound for landing, and the controller told him that he was heading toward the mountains. The pilot immediately requested a vector for landing. The controller told the pilot to make either a left or right turn southbound to a 180° heading. The airplane was substantially off course for almost 90 seconds before impact.

Despite the pilot’s two radio calls suggesting disorientation during the flight’s final 90 seconds, the controller did not issue a safety alert to the pilot. Although the responsibility for flight navigation rests with the pilot, FAA Order 7110.65, paragraph 2-1-6, directs controllers, in part, to “Issue a safety alert to an aircraft if you are aware the aircraft is in a position/altitude which, in your judgment, places it in unsafe proximity to terrain, obstructions, or other aircraft.” The investigation concluded that the controller had sufficient information to determine that a low altitude alert was necessary, as evidenced by her attempt to turn the airplane. A timely low altitude alert may have enabled the pilot to climb and avoid the accident. When the controller recognized that there was a problem with the airplane, she concentrated on correcting his lateral track rather than helping him immediately climb to a safe altitude.

Probable cause: The pilot’s continued flight into instrument meteorological conditions at an altitude insufficient to ensure adequate terrain clearance. The air traffic controller’s failure to issue a safety alert after observing the pilot’s navigational deviation toward high terrain was a factor.

For more information: NTSB.gov. NTSB Identification: WPR10FA1074

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