WHEN DO WE MAKE THAT CALL? We all have been there before — running late, weather worse than expected and an urgency to get off the ground. Many of us have committed the same unsafe acts that cause mishaps, but had luck on our side. Not all pilots do. Such was the case of a Sikorsky Aircraft UH-60 flight that ended in seven fatalities just south of Waco, Texas.
At 0629 local on Nov. 29, 2004, the Black Hawk departed VFR from Fort Hood, Texas, en route to Texarkana, Ark., with three crewmembers and four passengers, including a general officer. The aircraft immediately encountered lower-than-expected ceilings and visibility. The flight crew "hunted and pecked" their way for 15 min. It was evident from many sources that from the start the crew was in marginal VFR weather. It worsened as the flight progressed.
The aircraft flew VFR at altitudes (according to radar images) as low as 16 ft to avoid bad weather. Shortly before the impact, the crew finally asked Waco Approach Control for an IFR clearance. At 0648, while in instrument meteorological conditions (IMC), the aircraft struck the guy wire of a large TV antenna at about 900 ft agl about 20 nm southwest of Waco. The fuselage separated in flight and crashed onto adjacent fields, killing all onboard.
The weather en route was worse than forecast: a 600-ft ceiling and visibility 2 mi. The dew point/temperature spread was only 1C. Conditions deteriorated to 200 ft and 2 mi. Witnesses indicated the visibility was less than 0.5 mi and the ceiling less than 100 ft at the accident site.
How could this mishap occur? Why would two qualified and experienced pilots try to fly VFR and "scud run" instead of filing IFR? It happened because a series of unsafe acts and decisions aligned to produce catastrophic results.
As Frank Bird of the International Loss Control Institute noted in his 1974 "Domino Theory," mishaps "are the end result of a series of errors made throughout a mission profile." If one domino is taken out, "the mishap would not happen."
Risk management aims to continually assess the conditions prior to and during a flight. This begins at mission conception and continues until a flight is completed, and requires pilots to apply the process with the goal of eliminating hazards where possible and reducing residual risks to acceptable levels.
Let’s examine this crew’s decisions. Looking at pre-mission planning, there was no evidence the aircrew ever discussed the notice to airmen (NOTAM) for out-of-service lighting on an antenna tower directly in the route of flight. The VFR route was planned at 1,500 ft directly over this 1,763-ft antenna. The minimum sector altitude was 3,600 ft.
There was no indication the pilot was aware of the temperature/dew point spread of 1C, which would indicate fog or impending fog. There was no evidence that the copilot was involved in pre-mission planning, particularly the analysis of current and forecast weather. There was also no evidence that the pilot obtained weather information from other sources to aid his decision to attempt this mission as required by Federal Aviation Regulations Part 91.103.
There was evidence of an urgency to not cancel or alter the profile. The flight originally was scheduled for Nov. 22 but cancelled for poor weather. The crew was behind schedule the day of the mishap because Flight Operations opened late.
Finally, the crew chose to file VFR vs. IFR in weather that was unsafe for VFR flight. The crew’s actions were a direct result of attention failures, decision errors, and procedural errors. The pilot in command allowed himself to be overwhelmed with the circumstances surrounding this mission. This led to his lack of attention to detail; he overlooked many areas of pre-mission planning. The crew was forced to enter IMC because they left themselves no way out.
There were ample opportunities to remove a "domino." The crew should have initially filed IFR, but could have turned around, landed, or filed for an IFR clearance much sooner than they did when they began to run into marginal VFR weather.
Unfortunately, accidents like this happen regularly in both civilian and military operations. When trained instrument pilots are flying IFR-capable aircraft, they should have no hesitation to file IFR when the circumstances demand it.
The problem many instrument-rated pilots face when deciding to fly IFR vs. VFR is proficiency and confidence. Like many U.S. Army helicopter pilots, most civilian ones do not fly IFR enough to become comfortable and proficient. When a situation may require flying in IMC, many decide to fly VFR and hope they can stay out of the bad weather.
So what can we do to prevent accidents like this? Always practice good risk management. Don’t get overwhelmed by the circumstances. Plan your flight and fly your plan. Obtain current and forecast weather information from several sources. Don’t let the urgency or importance of the flight influence your decision-making process. File IFR as much as you can. Utilize simulators more often. Conduct good pre-mission planning so you always have a backup plan to execute a flight. Finally, if the weather is bad enough, cancel or adjust the flight profile. If pilots do all of the pre-mission tasks properly, they will have the satisfaction of a good flight that was well executed.