TSB Report C177 loss of control ILS 07 YOW Dec 14/11

[RatherBeFlying]

http://www.bst-tsb.gc.ca/eng/rapports-r ... 1o0239.asp

The report details the PIC's difficulties with the ILS on renewal rides.

I will add that you can get and renew a rating in severe VFR.

How many IFR instructors have their students file and fly in IFR conditions in Canada?

[Rookie50]

This is a brutal accident I have rather strong opinions on. I don't care if the guy had passed 10 renewal rides in actual IMC.

Conditions on several levels were totally inappropriate for a low time pilot in a single engine piston aircraft.

Night IMC to Cat 1 minimums in potential icing conditions in a Cardinal; is way beyond my level. Those who disagree.....

Edit -- when this accident occurred it was reported the ceiling was 100 feet, in mist, and the freezing level was at the surface to boot.

This accident should be required reading for every IFR PPL.

[ReserveTank]

I always filed IFR with my IFR students. They had much better command of the airplane and did well on their flight tests. It seems as though FTUs aren't doing this and I can't figure out why. In my opinion, this pilot should not have been out in these conditions. On the other hand, he should have been trained well enough not to dump the airplane on an ILS.

[Big Pistons Forever]

Sadly IFR instruction is usually almost wholly geared to passing the flight test and is often taught by instructors who have little or no real world A to B IFR experience, themselves.

This is't so bad if the newly minted IFR rated guy/gal is going to be acting as copilot with an experience Captain to show how things work in the real world and can bail him out if he gets in over his head, but it can be an absolutely deadly for a PPL intending to go out and fly single pilot IFR on their own.

Passing the IFR flight test does not IMO mean you are qualified to actually go out an fly for real IFR. For PPL owner pilots it is absolutely mandatory that they have an experienced IFR pilot fly with them to mentor them until they are competent. In addition maintaining the skills to be a safe IFR pilot, when it is not your full time job, means you need to have a serious program of recurrent training and practice often.

[Rookie50]

Sadly IFR instruction is usually almost wholly geared to passing the flight test and is often taught by instructors who have little or no real world A to B IFR experience, themselves.

This is't so bad if the newly minted IFR rated guy/gal is going to be acting as copilot with an experience Captain to show how things work in the real world and can bail him out if he gets in over his head, but it can be an absolutely deadly for a PPL intending to go out and fly single pilot IFR on their own.

Passing the IFR flight test does not IMO mean you are qualified to actually go out an fly for real IFR. For PPL owner pilots it is absolutely mandatory that they have an experienced IFR pilot fly with them to mentor them until they are competent. In addition maintaining the skills to be a safe IFR pilot, when it is not your full time job, means you need to have a serious program of recurrent training and practice often.

BP a big + 1 to the above. I am a classic statistical risk -- a low time IFR CPL who files and flies IFR irregularly in a SE piston. I fly more often than many Ppls, but no where near the Recency of a real commercial pilot. So how do I mitigate the risks? Partly through recurrent training and practice, and partly through my personal policies:

1) functioning AP is required for IMC flight, but so is my human factors capacity that day to hand fly.
2) No night IMC. A personal choice.
3) my minimums for a precision approach are non - precision minimums. Non precision minimums and alternates are respectively considerably higher.
4) No actual approaches in remote areas, with no precision approaches or alternates nearby. So weather has to be at least marginal vfr to good vfr.

How I started, as a new ppl IFR: ( and recommend others )

1: departure good VFR, hand flew (high) broken cruise IMC, landed good VFR, a few flights.

2. Departure IFR -- really in marginal VFR -- climb and cruise in solid to broken IMC, or on top, a few flights, Hand flying part of every flight to keep sharp. High workload phases, use AP or be ready to instantly use it, if hand flying for currency and get behind. Know your AP well.

3. Begin to fly IMC in all phases, begin to do actual approaches to conservative minimums ( like really conservative!) I've had relatively few real approaches and no really low approaches in 3 years of IFR
flying. Not easy to get. I have taken off lately in fairly low conditions, but won't take off unless I can return to the same airport immediately to my minimums --so I want like a 400 + ceiling to take off in, at least -- some places I want 800. Conservative, yes.

I now have about 45 hours IMC -- that's actual. If its 0.4, it's 0.4 on a 3 hour flight. Not many real approaches though outside of training -- maybe a dozen, and none anywhere close to minimums. So I remain careful.

As BP says, if you are going to go out and do this on your own, you can but must be very careful and thoughtful. Few instructors IMO have actual experience. I've been able to complete flights that would be much more difficult without an IFR rating, but the ability to compete those flights means the flight planning an decision making is much more serious. Icing and thunderstorms become major concerns.

Hope my experience helps someone reading. Fly safe all.

[grimey]

This is a brutal accident I have rather strong opinions on. I don't care if the guy had passed 10 renewal rides in actual IMC.

If he had passed 10 renewals in actual, he probably would have had the sense to put down in Watertown when he got this:

The latest actual weather at CYOW at the time that the flight plan was filed was issued at 1600, and described conditions as wind 090 at 8 knots, visibility 3 sm in mist, and ceiling overcast at 700 feet.

At 1812, while cruising at 5000 feet, 29 nm south of Watertown International Airport (KART), the pilot requested a weather update for KART and CYOW from Boston Flight Watch (BFW). The BFW specialist reported conditions at KART to be visibility 10 sm and overcast ceilings at 9500 feet, and conditions at CYOW to be visibility 3 sm in mist and overcast ceiling at 200 feet. The specialist repeated the AIRMET previously described, and the PIC indicated that the crew would check for updates once the aircraft was across the border.

[RatherBeFlying]

The weather reports in the TSB report do not mention temps below 0C or any icing pireps.

Possibly icing was not happening Dec 14 at night. If the OAT was operational and showing >0C -- and Kingston was good -- I would not fault the decision to continue.

Bottom line in my book, the pilot could not stay on the localiser.

[pdw]

Fairly gusty at 19:12 (20kts+ when higher, 2-3miles out) in a right crosswind.

At 1900 it was Zero degrees Celsius in mist at the surface.

[Maynard]

The pilot examiner noted on the flight test report that the candidate let the localizer deviate to ½-scale deflection upon interception. Notes written on a separate piece of paper during the flight test described the localizer deviation as ¾-scale. Had the most recent instrument-rating renewal flight test not been completed, the PIC would have had to rewrite the INRAT written exam.

If they would have failed him, he'd probably still be around. How can one with such a bad record,(and knowing it), have the confidence to safely fly an ILS to mins?

[pelmet]

This is an example of what happens when we have pilots with poor judgement who really should not be flying. They don't know their limitations.

I had a instrument rating way back when and was probably on a similar level to this guy in terms of little real experience. One time on a VFR flight, my destination was not VFR as forecast but perhaps 800 feet with some hills around. I had a valid rating but little real world experience. I got an IFR clearance and was cleared for a localizer approach. The approach did not go well due to chasing the needle although I made it in.

So, I decided not to do that sort of stuff until I had more experience. The only real way was to get a job flying which I did and got some real experience. Years later when I was in a high wing Cessna and faced with the same almost the situation as the Cardinal(except 200 feet overcast), it was all quite easy doing an approach single pilot to minimums with what seemed like all kinds of time and a nice relaxed procedure done with plenty of time.

Bottom line, I knew I wasn`t really up to it prior to getting my experience on the job and avoided such situations. Know your limitations. It is not an overly long drive from Watertown to Ottawa. And there are even closer alternates.

As well, while icing probably had little to do with the accident, flying a plane like this into what could easily become significant ice with weather below minimums is a very poor idea.

[Doc]

200 feet, at night in a C177 is well below my personal limits. An aircraft like this, flown IFR, in weather along the line of the old sliding scale for VFR, would work. What was that now? 700/3. 800/2. 900/1?
An IFR rating for a PPL should be used to get on top for a smooth trip if the destination is as mentioned above.....not for hard IFR. Just my take on it.

[KAG]

An IFR ticket is a license to learn, not take your friends up in hard core IMC.

[Kzanol]

Not that it has anything to do with the accident itself, as I agree he shouldn't have been flying an ILS with his past history of ILS performance. However if we look at the forecast for YOW, the lowest ceilings were at 3000' with a tempo of 900'. This would have been plenty to get into YRP and no problem at all to get into YOW, even marginal VFR for you PPL guys with your own personal limits. Alternate mins for YOW would be 400-1 I believe for two ILS approaches, and if winds were an issue you would at least have 600-2 for the ILS 07 at YOW. Where in the f**k did the 300' and 3sm come from environment canada/navcanada? I even remember this night and I seem to recall that the wx at YOW was even below this at times down to 1mile and 100'. This guy had no idea what he was taking off into, of course he got the wx during the flight, but if he had known that it was going to be ILS mins, would he have taken off in the first place? I put some blame on the overpaid weather forecasting assholes that put out forecasts like this and then just amend then when they are wrong. If i was wrong in my job as much as a wx forecaster is, I'd be a big smoking hole in the ground.

[grimey]

Not that it has anything to do with the accident itself, as I agree he shouldn't have been flying an ILS with his past history of ILS performance. However if we look at the forecast for YOW, the lowest ceilings were at 3000' with a tempo of 900'. This would have been plenty to get into YRP and no problem at all to get into YOW, even marginal VFR for you PPL guys with your own personal limits. Alternate mins for YOW would be 400-1 I believe for two ILS approaches, and if winds were an issue you would at least have 600-2 for the ILS 07 at YOW. Where in the f**k did the 300' and 3sm come from environment canada/navcanada? I even remember this night and I seem to recall that the wx at YOW was even below this at times down to 1mile and 100'. This guy had no idea what he was taking off into, of course he got the wx during the flight, but if he had known that it was going to be ILS mins, would he have taken off in the first place? I put some blame on the overpaid weather forecasting assholes that put out forecasts like this and then just amend then when they are wrong. If i was wrong in my job as much as a wx forecaster is, I'd be a big smoking hole in the ground.

This has more to do with changes in policy and reduction in WX stations than the forecaster making errors. Prior to the FICs coming into place, you could get a weather briefing from the local specialist, with local knowledge. I don't know that it would have made a difference in this case, but at the stations I worked at there was definitely local phenomena that the forecaster couldn't reasonably be expected to be aware of. It's below zero, the ski hill doesn't have much snow, and the wind is from the northeast? Yea, snowmaking ops are going to screw up YTH for a bit throughout the day. I don't recall the morning fog out of the valley in YPE being routinely forecast either, but we could see it coming up out of the valley on mornings when it occurred. A guy at the FIC, unless he has a TON of experience, probably won't know about it for a wx briefing either, and certainly won't be able to look out the window to get more info. We've been losing manned observation posts for years now too. AWOS doesn't cut it when a bird shits on the ceilometer. The problem isn't overpaid forecasters, it's a lack of observers, and an inability to get local wx briefings.

And in this case, the pilot got up to date info that should have warned him off before he crossed the Canada/US border. It's not as if he started on the ILS expecting to break out between 3000-900'

[captcrunch2013]

Dr. Barry Stratton was loved and respected, his passenger Jacques Domey was also well known although I'd never met or heard of him before the crash.

So, What would Barry want us to say now?
I would hope some honesty.

Doctors are professionals in their area and its very easy for such highly educated and skilled people to
develop the god complex that it won't happen to them.

His training record shows a gross lack of respect for the standards required
and on the day of the flight, he took off into known icing conditions.

There is no record if he called any of his mentors prior to the flight.
The investigators could have and should have commented on that possibility.
Did anyone tell him that he was ok to go?

most probably not but it was a point worth looking at.

There is no mention of his training records, of interviews with the instructors who trained him,
What happened to the instructors?

My god, if a student of mine later crashed on an ILS, I'd hold myself responsible until I learned otherwise.

The trail of failed flight tests, and a 3/4 scale deviation written on a separate piece of paper is
damming.

"On 31 October 2011, the PIC completed an instrument-rating renewal flight test, which was assessed as a pass.
The PIC received a mark of 2 on 4 exercises, including Arrival, Holding, RNAV Approach, and ILS Approach. "
Then there was the fact that he was almost at the end of two years which would require the rewriting of the Inrat exam.

Back on on 11 December 2009 the flight test never got off the ground due to his lack of knowledge but he was not required to rewrite the Inrat exam or apparently is there any note of having to satisfy the knowledge requirement to a practical standard if the legal standard did not apply.

This report is again, another politically correct report that is designed not to offend the least number of people
and to hold the least number responsible.

Then there is the lack of night recency and IFR recency on top of flight into known icing conditions.
Take those factors alone and there existed before take-off a real probability that the flight would end
in a fatal accident.


There were a host of factors that were not mentioned in this report and
one wonders what happened to the monitoring of the instructors who did his IFR training
and the person who signed off his latest IFR renewal when his skills were not that
of the most basic required for a single pilot IFR who was not going to have a lot of
currency in the future.

The psychological factors are that the pilot saw what he wanted to see and
ignored anything and everything that showed he should not have even taken off that evening.

With these sorts of standards, the reality is it is only a matter of time before we will be reading about
another almost identical fatal accident.

The moral is, instructors and flight test officers cannot be trusted 100% to maintain standards.
Everyone, passengers, fellow owners, all have a responsibility to prevent such tragedies.

[Rookie50]

Not that it has anything to do with the accident itself, as I agree he shouldn't have been flying an ILS with his past history of ILS performance. However if we look at the forecast for YOW, the lowest ceilings were at 3000' with a tempo of 900'. This would have been plenty to get into YRP and no problem at all to get into YOW, even marginal VFR for you PPL guys with your own personal limits. Alternate mins for YOW would be 400-1 I believe for two ILS approaches, and if winds were an issue you would at least have 600-2 for the ILS 07 at YOW. Where in the f**k did the 300' and 3sm come from environment canada/navcanada? I even remember this night and I seem to recall that the wx at YOW was even below this at times down to 1mile and 100'. This guy had no idea what he was taking off into, of course he got the wx during the flight, but if he had known that it was going to be ILS mins, would he have taken off in the first place? I put some blame on the overpaid weather forecasting assholes that put out forecasts like this and then just amend then when they are wrong. If i was wrong in my job as much as a wx forecaster is, I'd be a big smoking hole in the ground.

Anyone committing to complete a flight based on any TAF ------ What of an ATIS? I try to pick mine up 50 + miles out, then often a second time close in. He checked wx on route, which should have led to diverting, then should have -- maybe did -- check ATIS again. Lots of time to change destination. Waterdown was not far away and VFR.

Not all of this can we either blame poor instructors. As a low timer, No one told me how to properly decision make. I thought about it a lot, asked (and still ask as a low timer ) a ton of questions, and have developed my personal routine and minimums accordingly. And yeah, I've made mistakes in my decisions IFR, but I've also always planned an out, and dealt with the mistake promptly. Still learning.

I think fatal accidents, often develop from a multitude of mistakes or refusal to correct the intial mistake. Seems to be the case here, adding up the risk factors. Sorry if that sounds insensitive,

On another note, I sure hope I don't see a post from anyone stating they can, so anyone should, land perfectly every time in 100 feet, 1 mile, mist, rain, hail, ice, whatever, so it's no big deal. Much higher minimums need to be held based on weather, experience, Recency, aircraft, night vs day, and aptitude.

[pelmet]

I put some blame on the overpaid weather forecasting assholes that put out forecasts like this and then just amend then when they are wrong. If i was wrong in my job as much as a wx forecaster is, I'd be a big smoking hole in the ground.

There is a saying...``only a poor craftsman blames his tools``. The weather forecast is irrelevant in terms of the decision making failure in this accident, which would be....if you don`t have the skills to do this properly, don`t do it. It could just have easily been 800 overcast and a dark night or vectors or a procedure turn to an airport over dark terrain.

Weather has always been fickle and the reality is that if you are going to crash well before reaching minimums, it has little to do with the weather being below minimums.

[Big Pistons Forever]

There is no such a thing as a "guaranteed easy" approach, especially at night. My last night ILS had an 10 minute old METAR of few at 300 overcast 1200. Piece of cake right ? Well of course the "few" clouds were parked exactly on the ILS so I was in cloud, out of cloud, in cloud and broke out at maybe 250 feet.

The bottom line is you have to be able to bring you A game to the job on every flight

[Doc]

Weather has always been fickle and the reality is that if you are going to crash well before reaching minimums, it has little to do with the weather being below minimums.

I've been doing this for a long time, and I've yet to see anybody crash "well before reaching minimums"? Most folks crash only "after" reaching minimums.....
Perhaps there is trickery afoot?

[RatherBeFlying]

Yep, there's a difference between doing the bare minimum to obtain and keep your rating and maintaining proficiency.

Maintaining proficiency means flying under the hood with a safety pilot -- or going up on those days where you can do approaches in actual. You can takeoff on a nice day and fly to where you can do approaches in actual. If you find yourself deviating, it's time to call a miss and head back to VFR -- And arrange some more hood time in VFR.

Oh yes, it's not quite right to take anybody but a rated pilot with you into actual until you really are proficient.

Some folks have an IFR as a backup plan, but don't maintain proficiency. That's OK if you use it to keep right side up until you get back to VFR while keeping ATC in the loop.

A few decades ago, a pilot died enroute over Ontario. The non-rated pilot in the right seat managed the descent through cloud and made a safe landing.

[pelmet]

Weather has always been fickle and the reality is that if you are going to crash well before reaching minimums, it has little to do with the weather being below minimums.

I've been doing this for a long time, and I've yet to see anybody crash "well before reaching minimums"? Most folks crash only "after" reaching minimums.....
Perhaps there is trickery afoot?

The pilot lost control well before reaching minimums. Minimums are at 200 feet on the approach, he never got close to that point on the published approach.

[PositiveRate27]

Weather has always been fickle and the reality is that if you are going to crash well before reaching minimums, it has little to do with the weather being below minimums.

I've been doing this for a long time, and I've yet to see anybody crash "well before reaching minimums"? Most folks crash only "after" reaching minimums.....
Perhaps there is trickery afoot?

The pilot lost control well before reaching minimums. I should think that this is easy to understand. Minimums are at 200 feet on the approach, he never got close to that point on the published approach. I fail to understand your difficulty with this. How long did you say you have been flying?

I think what Doc was getting at is that when you hit the ground you are at 0 feet AGL, 200 feet below minimums.

If we are arguing semantics I assume what you meant by "well before reaching minimums", was losing control of the aircraft and crashing before reaching decision height, on profile.


While on the topic of semantics, I think it was BPF who mentioned about always bringing your A game to every IFR flight. I agree with needing to bring a high level of proficiency to every IFR flight, but if you need to be throwing your ace to make it down safely, you don't have enough proficiency to be doing it. If you are exerting every ounce of skill on a standard approach to minimums, what happens when things to sideways? Your B game should be at a level where you can still safely execute the approach. Your A game should be reserved for greasing it on in RVOP/LVOP conditions, and dealing with emergency scenarios. If you are a weekend warrior and feel like you're gonna have draw on the A game, you should automatically be thinking diversion to alternate.

[Doc]

Agreed. But yourA game should always be in your quiver...just in case. C game should work most of the time though.

[Big Pistons Forever]

In context of PPL, SEP, IFR, flying good judgment should mean that you always flight plan for relatively benign conditions where there is plenty of margin for less than optimal flying. But unfortunately Mother Nature doesn't always play fair. Therefore you still have to have those "A" game skills and the personal confidence that comes with lots of training and practice, ready for use on the day when things go for shit.

[captcrunch2013]

ok, you are the refueler, dispatcher, engineer and you find out that
a pilot got home last night in known icing conditions below minimums
when he was out of IFR currency and night currency.

The odds are that not a sole will say a word because he is an aircraft owner.

Or, you notice that a fellow instructor or examiner gives a green light
to recommend an accident going to happen for an IFR ride?

Or an examiner gives a PPC or IFR to a pilot you know is an accident going to
happen.

The problem is that while such accidents are supposedly rare, they cost
every aircraft owner and operator with increased premiums based on a percentage of "hull"
that goes up or down with the accident rate.

Investigators are public servants and historically provide a political report and not
a report that results in the changes that are necessary.

As a first step, Investigators need to have confidence of being able to
write reports that address the real causes of the accident and not
just a white wash.

In this case, the pilot's errors of judgment and skill were so damning that
they could not be left out.. Everything else was.