Human Factors: A change of mind…or two

The whiteout is so complete that the pilot can’t tell where the hazy sky stops and the snow-covered frozen lake begins. One of the passengers aboard the 6-seat Cessna U206F Stationair later said that the view out the window looked like a “white sheet of paper.”

Closer to the frozen surface of Alaska’s Lake Iliamna than the pilot realizes, and in a gentle bank to divert to the second alternate airport of the day, he flies his airplane right smack onto the ice.

The Accident

If there’s anything lucky about this crash, it’s that the ice on the frozen lake is deep enough, and the impact angle shallow enough, that the airplane doesn’t punch through and sink into the murky depths of the 1,000 foot-deep lake.

But the snow covering the ice does little to cushion the blow — the bush plane is torn to pieces, the wreckage scattered across the frozen surface of the lake. The engine separates from the airframe, the windscreen blows out, the tail is snapped nearly off, and the wings are bent in opposite directions.

The pilot is seriously injured, as are three of his four passengers. Only one escapes with minor injuries, pulling the others from the mangled, twisted wreckage to await rescue.

A wait that, bleeding out on the ice, will be a long one.

Alaska State Troopers are alerted to the wreck about 30 minutes after the accident, thanks to the airplane’s ELT activation. Word quickly spreads, and despite the whiteout conditions, local pilots scramble to search for the downed airplane.

The reports don’t make it clear who found the wreck first, but as soon as it’s known that there are survivors out on the ice, both the Alaska Air National Guard and the U.S. Coast Guard send helicopters to the rescue. But, due to the poor weather conditions, neither chopper makes it through.

Now, if the Coast Guard can’t make it, pilots like you and me should be sitting in the hangar drinking beer. Just sayin’….

It’s not until 6 p.m., almost six hours after the crash, that the rescue choppers arrive on the scene and are able to airlift the survivors out.

The Flight

The March 5, 2022, flight wasn’t an overly long one, about 100 nautical miles from Levelock Airport (9Z8) northeast to Port Alsworth’s Wilder Runway Airport (PAKX), home base to the pilot and his four passengers. But the weather at Port Alsworth was no bueno as departure time approached.

The pilot hatched a Plan B. He’d fly about two-thirds of the way, and put down at Iliamna Airport (PAIL), as an alternate. Iliamna was only a hair off course to the south and, at the time of departure, was still reporting MVFR conditions.

The plan was to head there and wait for things to improve at Port Alsworth.

Other than that, there was no other plan. No flight plan was filed, but the pilot did ask a buddy to keep watch over the flight using an online service.

This may be par for the course up north, I don’t know. Please chime in via comments, Alaska fliers.

As the pilot and his passengers approach Iliamna, conditions deteriorate. The pilot reaches out to Kenai Flight Service, through a remote communications outlet (RCO), to coordinate a Special VFR clearance into the uncontrolled airport. He circles outside the boundaries of the Class E while waiting for the clearance, which he quickly receives and reads back.

But at this point he has a change of heart. He decides he doesn’t like the look of things and decides to divert a second time, to Igiugig Airport (PAIG), about 40 nm south-southwest, on the far side of the lake, back in the direction he came from.

He is six miles from the Iliamna Airport, which is reporting IMC, mist, and one mile visibility — right at the minimum. The temperature/dewpoint spread is a chilling (literally and figuratively) 0°, with the temperature 0℃ and the dewpoint also 0℃. The pilot estimates the ceiling is 700 scattered and 1,700 broken, with snow and haze.

He’s traveling easterly, terrain to the left, lake to the right. He makes a shallow turn to the right, the terrain disappears behind his tail, and he enters a world of white-on-white.

The Pilot

The pilot is a 52-year-old male, holding a single-engine land commercial pilot certificate, with an instrument rating (the NTSB report erroneously states he had no instrument rating).

For his age, his hours are on the low side, suggesting a second career, although he’s not listed as an occupational pilot on the NTSB 6120 form.

He had a total time of 620 hours at the time of the accident, all but 55 of them as Pilot in Command, indicating that he was a quick study, and got his certificates without undue dual instruction. He had 219 hours in make and model.

That said, somewhat alarmingly, he only had four hours in the last 90 days, and only one hour — presumably the accident flight — in the previous 30 days.

He had a special issuance Class 2 Medical, the reason for the special issuance being redacted from the record, as it should be. Lord knows if it’s good enough for the FAA medical branch, it’s good enough for the rest of us. Special issuances on upper-class medicals are not granted lightly.

His last flight review was nearly a year before in the same airplane. About a year after the crash he was issued an A&P certificate.

The Final Moments

Diverting to Igiugig, the pilot executes his shallow 20° right turn out over the frozen, snow-covered lake. The terrain, probably only barely apparent with one mile visibility, disappears and he’s in the evil twin of the blackhole approach: The whitehole departure.

He “notices” that he’s losing altitude, pulls back on the yoke, throttles up, and “switches to instruments,” but…it’s too late.

The Stationair becomes a stationary object as it — still in a turning attitude — smacks into the ice-covered lake.

The NTSB

The NTSB, per the usual play book, throws the pilot under the bus. Well, under the station wagon, in this case.

Cessna chose the name Stationair to suggest “Station Wagon of the Sky.” Other models of the 206 are variously named Skywagon, Super Skywagon, and Skylane.

But back to the NTSB, who declare that the probable cause of the accident is the pilot’s “decision” to continue a visual flight into an area of instrument meteorological conditions, loss of visual reference, yada, yada, CFIT, blah, blah, blah.

But I’m not sure. Was it the decision to continue or the indecision on continuing that resulted in the accident?

And arguably, he wasn’t continuing — although cleared to do so — he was retreating.

Analysis & Discussion

Of course, there’s no excuse for getting 1,000 feet too low. Granted, the visibility sucked, but he still had ceiling, so there’s no reason to fly a pattern so low that you smack into a frozen lake seconds after noticing that you are losing a little altitude.

So we have to ask: Was he scud-running?

Given that he was righteous enough to call for a Special VFR clearance into an uncontrolled airport, I find that doubtful.

So, unless he was crazy low to start with, what explains a loss of altitude sufficient to cause the accident? He stated he made a gentle 20° bank turn. But in the white-on-white world, did he overbank without realizing it, shifting lift from the vertical to the horizontal components, resulting in a descent?

And what if he’d turned to the left, keeping the shore line in sight, instead of turning to the right? Would the accident even have happened under those circumstances?

Perhaps, most importantly, did his changing of plans — not once, but twice — cause sufficient mental churn to trigger a lack of focus? Or was there a pre-existing lack of focus that led to the changing of plans? Or was it good airmanship that just happened to end badly?

Setting aside the decision to launch towards MVFR, flying VFR to a destination that’s IFR, how were the rest of his decisions?

On one hand, we tell pilots to stay flexible as things change, but I have to wonder in this case if there were too many changes. Would he have landed the Stationair in one piece if he’d just flown his Special VFR on in and landed at Iliamna?

The director of the missionary outfit that operated the airplane filled out the NTSB 6120 form and shared some interesting thoughts in the “Owner/Operator Recommendations” section. He said that pilots get routine training flying under the hood, but added that such training should also reinforce strategies to avoid inadvertent flights into IMC.

Going further, he says that awareness of the risks of spatial disorientation over snow-covered terrain “cannot be stressed enough.”

But his most interesting thought had to do with personal minimums.

“Having and adhering to personal weather minimums (especially for the geographical area that the pilot is often flying and can potentially feel overly confident in) is important, and should be included and re-evaluated every year during training,” he wrote.

The Takeaway

OK, I know what you are thinking: What’s interesting about the advice to have and adhere to personal minimums and to re-evaluate them every year? Not a thing.

It’s the thought between those two thoughts that perked me up — the thought that we could be more at risk on our home turf than we are when we are strangers in a strange landscape.

On the face of it, when you are flying in your backyard, a looser set of minimums would seem to be in order. You know where every cell tower, wind farm, and tall tree is. You know the games the terrain plays on the wind. You know how, where, and when fog forms, ice builds, and clouds appear. You should be safer at home, and therefore not need minimums that are as stringent.

But perhaps the opposite is true. Perhaps our personal minimums need to be higher at home than they are when we are the visiting team. While we know our own backyard, can that intimacy, as the director suggested, make us “overly confident?” Never a good thing for an aviator.

Maybe the takeaway from this accident is the need for two layers of personal minimums: The basic ones and more stringent ones for closer to home.

The Numbers

Want to read more? Download the NTSB’s final report here or view the items on docket here.