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Good judgment comes from bad experience

By Jeffrey Madison · December 20, 2018 ·

I was a freshly minted fixed-wing private pilot with some five total hours of simulated IFR training logged visiting an airport friend at Van Nuys Airport (KVNY) in Southern California.

KVNY was CAVU, but to the west, the marine layer had started a slow creep from the beach in towards Santa Monica Municipal Airport (KSMO). I had to return the tiny, rented Grumman Tiger to KSMO right away. So I bid my friend goodbye after a cursory preflight and taxied to 16L.

Full fuel tanks and my weight combined to put that plane at gross weight, making my climb rate anemic. I vectored toward the Cahuenga Pass. If I couldn’t gain enough altitude in time to cross over the Santa Monica Mountains, I could at least slip through the pass over the 101 Freeway. I flew through the cut and was abeam the Hollywood Bowl when I saw it: The marine layer had gone from creeping to galloping.

Grumman Tiger

Being the hotshot 60-hour fixed-wing pilot I was, I decided to call ATC and get a Special VFR clearance into KSMO. I told them I could stay clear of clouds, I could maintain visual contact with the airport, and I had at least a mile visibility. They granted it. First time on a Special, so I was feeling pretty smug. Just for backup, I dialed in the frequency for KSMO VOR Runway 21 and tracked the 033 radial inbound.

I descended from 2,500 down to 1,400. I remembered something about that being the minimum descent altitude near Century City. Century City is east of KSMO, with a pair of 900′ twin towers on the approach path.

Just east of Century City, several things happened. Approach switched me over to Tower, and I lost contact with the airport when I ran into a thick cloud bank. Plus, I lost sight of the airport, and also Century City.

So I bailed. I told Tower I was breaking off my approach, and I cranked the yoke over to turn back toward KVNY. I cranked so hard over, I got vertigo. The plane began a rapid descent. The clouds cleared and I could see the roofs of the Century City twin towers filling my windshield.

I yelled, “Not today!” and pulled the yoke full aft, kicked right rudder and firewalled the throttle. I avoided crashing, but it took several seconds to regain altitude, recover my attitude and get on a good heading.

Tower called me a few times before I responded. They asked if I needed help. I took a long breath before I told them I was okay and didn’t need help but was going to return to KVNY since KSMO had just gone IFR.

When I landed, my friend was still in the parking lot. He drove me the 16 miles back to KSMO. I explained my situation to the FBO owner. My friend drove me back to KVNY the next day, and I flew the Grumman back to base.

Back then I didn’t know about reports to NASA’s Aviation Safety Reporting System reports, so I didn’t file one. Too bad. It might’ve made good reading for somebody.

Each holiday season I endeavor to present a Christmas gift to you, great readers, in appreciation. This year my gift to you is another pilot’s NASA report, (mostly) in his own words. His report is the embodiment of “Good Judgment Comes From Bad Bad Experience.”

This pilot’s one flight is so chockful of misfortune, misadventure and near mishap, you have to read it to believe it. Enjoy and be thankful this wasn’t you.

The pilot was flying a Piper Arrow. He landed, fueled the aircraft and filed an IFR flight plan to his final destination.

Piper Arrow (Photo courtesy Wikimedia Commons, Tomas Del Toro)

“I had already flown approximately 2.5 hours that day solo and put in five hours instructing before this final leg,” he wrote in the report. “The scheduled leg was to be approximately 2.5 hours, and I felt fine to push on with no hint of fatigue.”

His problems began one hour into the flight, just as night fell. His first issue was that the audio panel began to “take control” of his aircraft. He had a PMA 450, he wrote, “which when transmitting and seeing the transponder on my 650, shut down my communication radios multiple times. I reset it and made it unable to transmit or receive ATC calls.”

“When I had the chance, I notified ATC of my issue. They helped me by asking me my plan to land at airports within 50 miles of my course with instrument approaches. But I lost comms with ATC for three mins because of the bad transmitter.”

The pilot then made a plan in case he was unable to reestablish radio contact. He began looking for any suitable airport reporting VFR conditions. He continued to troubleshoot his radio problems and discovered if he turned off his primary communication radio, his backup worked. He recontacted ATC, and all was right again.

Then, “about 1.5 hours into the flight, ATC warned me of a track deviation. I did my instrument scan. Turns out I had a bad AI (attitude indicator). I looked at the suction gauge, but it was within limits, 4.8″-5.2″. Somehow, I HAD PARTIAL PANEL failure! As an instructor and as a former student instructor who taught partial panel regularly in simulated conditions, both in sims and VFR flight, I felt that I could continue this flight.”

So he did. Just 45 minutes from landing, the pilot reported hearing “a loud WOOSH!!!” The baggage door on his Piper had unlatched and was open. His backpack was hanging partway outside the aircraft.

“I lost control of the aircraft for a few seconds and made a sharp turn left off course because I became distracted,” he wrote.

He called ATC and told them he needed a lower altitude immediately and vectors to the nearest airport.

“I regained control and was now focused on one task, flying the aircraft. My second task: Not let my baggage fall out of the aircraft, and if so, not hurt people down below. I kept the aircraft in a side slip to reduce airflow on the side where my door was open.”

ATC gave him vectors and asked him to state the number of souls on board and fuel remaining. He regained aircraft control about 35 nm from the field. ATC gave him clearance down to 8,000′, then down to 5,600′ — the Minimum Vectoring Altitude for that area.

“ATC set me up for the VOR approach,” he wrote.

Then they told him it was not authorized at night. The pilot asked for vectors for the GPS approach, 15 nm from the field. At five miles from the Final Approach Fix, he told ATC he was 3,000′ high. He asked to intercept the GPS and perform a 360 descent to finish the approach.

“ATC denied me and said unless I see the runway, I cannot descend.”

Photo courtesy FreeImages.com/Cee Lee

The field was reporting 5.5 miles visibility, few clouds and haze. The pilot still couldn’t see the field. At that point, he thought his landing and navigation lights had failed.

They hadn’t. He’d forgotten to run his landing checklist.

“I turned the strobes and landing light on…I was in the soup and visibility was zero.”

He told ATC he couldn’t see the field and asked again to descend.

“ATC said he needed to vector me 10 miles out for the GPS approach. This was not going to work with me given the nature of the situation. I needed to get down ASAP!”

“What I did next was exercise my privileges under 91.3B and disobeyed ATC by descending on the course to 5.4 10 miles from the airport, and I was able to pop out of the clouds and see the field.”

The pilot reported to ATC that he could see the airport but couldn’t hear ATC well. He relayed to a nearby aircraft that he was okay and that he would call ATC when he landed.

The pilot then descended in a left-hand spiral over the airport “to keep my luggage in the plane.”

“Fortunately for me, fatigue never became an issue. After a whole day of flying, it’s good to keep a calm head when mistakes occur.”

He added that when flying single pilot IFR at night, it’s essential to maintain situational awareness and think about what can be done with what there is, not dwell on what you want there to be.

“In hindsight, after the comms issue, I should have decided to turn back, but my desire to make it to my destination made me underappreciate the issue of the partial panel failure. The door open and near-loss of my luggage was a sure reminder of how bad flights can go in an instant. I should not have disobeyed the ATC instructions and stayed higher, but in my mind, getting down ASAP was the only solution at the time.”

“I am filing this report since I disobeyed ATC but am glad to say that I made it back safely and flew the remainder of the flight VFR no problems.”

About Jeffrey Madison

Jeffrey Madison, a pilot since 1995, is an ATP CFI/MEI. He has over 1,000 hours dual given. He has flown into more than 250 GA airports throughout most of the Lower 48. He is a former Part 121 and Part 135 airline captain. You can reach him at [email protected]

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Comments

  1. Robert Hartmaier says

    December 22, 2018 at 12:31 pm

    Jeffery, the expression is:

    Good judgement comes from experience
    Experience comes from bad judgement.

    Another that may also be appropriate is:

    Experience is something that is happening to you that you wish was happening to some else!

    Thanks for sharing your experience. It is valuable food for thought and hopefully will cause folks to think twice and then three times when making the go/no go decision.

    Bob

    • Jeffrey Madison says

      January 4, 2019 at 9:30 am

      Happy New Year, Bob! Thanks for the clarification. I really appreciate the feedback.

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