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Risk Management Handbook

FAA-H-8083-2A Version 2022

Appendix C: Accident Case Studies

The pilot had only one hour of night flight experience in the previous 11 months and did not possess an instrument rating. Witnesses to the accident stated the area around the airport was dark or “very dark.” The pilot was taking a disqualifying drug that can cause drowsiness, although the NTSB did not assert this as a factor in the accident.

The surviving passenger stated that the pilot was in a hurry to return home and spend time with his daughter.

Risk Identification, Assessment, and Mitigation

At least three of the four risk categories in the PAVE checklist may relate to this accident. The pilot had minimal night currency for this flight. In addition, aeromedical factors may have affected the pilot’s perception of the environment.

The airport environment hazard contributed to the risk present at takeoff. The 50-foot trees near the takeoff zone resulted in a normal takeoff and climb that did not provide safe clearance during climb out. A hovering takeoff and climb also might have been hazardous at night in a dark environment.

External pressures relate to the pilot’s desire to return as soon as possible. Perhaps this caused him to rush through the start-up and liftoff with reduced situational awareness of the airport environment.

The collective risk severity level for this accident was catastrophic. The risk likelihood was at least occasional, producing a high overall risk level. Avoiding nighttime operations at this particular airport could have been a key mitigation.

Accident Profile 4: Fatal Turbojet-Powered Airplane Accident

The following details pertain to this accident:

  • Location: Cleveland, OH
  • Date: 12/29/2016
  • NTSB Defining Event: Loss of control in-flight
  • NTSB Case File Number: CEN17FA072

NTSB Probable Cause

Controlled flight into terrain due to pilot spatial disorientation. Contributing to the accident was pilot fatigue, mode confusion related to the status of the autopilot, and negative learning transfer due to flight guidance panel and attitude indicator differences from the pilot’s previous experience.

NTSB Factual Summary Excerpts (edited)

The pilot and five passengers flew to the Burke Lakefront Airport (BKL) earlier to attend a sporting event. They arrived back at BKL around 2230 for the return flight to Columbus, Ohio. Although BKL was VFR, the ceiling was 2300 feet and the departure took place in full darkness. Within two minutes after takeoff, the single pilot lost control of the aircraft. The radar track showed the aircraft climbing through its assigned altitude and then flying erratically before plunging into Lake Erie with a descent rate of about 6,000 feet per minute.

The pilot had been awake for 17 hours at takeoff. He had recently transitioned from another small jet and completed aircraft and simulator training, resulting in a single-pilot type rating only three weeks before the accident. According to his instructors, he had been taught to operate using the autopilot most of the time. He may have suffered from mode confusion regarding the configuration and status of the autopilot in the new aircraft, and may not have verified autopilot engagement. He may also have experienced external pressure to return to Columbus that evening.

Risk Identification, Assessment, and Mitigation

Several categories on the PAVE checklist may apply to this accident. The pilot may have been fatigued. It is likely that his expectation and that of the passengers was to return to Columbus immediately after the event. After departure, he may have unconsciously applied procedures appropriate to his previous experience. The nighttime environment and departure over the lake required the pilot to both monitor the flight instruments and deal with the automation.

The catastrophic consequences associated with this accident, when combined with at least occasional likelihood, created a high-risk level for loss of control. In hindsight, having a second pilot or “mentor pilot” for this flight may have reduced the likelihood of loss of control. In addition, remaining overnight in Cleveland would have provided needed rest for the pilot and allowed for a departure during daylight, which also could have reduced the likelihood of loss of control.