It's shortly after noon on May 3rd 2016
at the Grand Strand Airport in Myrtle Beach, South Carolina,
a pilot and two friends are preparing to fly home to Central Connecticut after a weekend getaway
66 years old, the ATP rated pilot has over
4,000 hours of flight time much of it in November 440 Hotel the Beech V35 Bonanza
he's owned for nearly 30 years
The extent of his recent flight experience is unclear, but given his conversation with flight service earlier in the day
There's no reason to think that today's flight will present any particular challenge
Flight Service: Good morning, flight service. Can I help you?
Pilot: Make the rain and the fog go away.
Flight Service: All right. We'll do our best
Pilot:Alright.
Flight Service: Basically you're traveling right along a stationary front that runs from the Mid Atlantic down into a
Mobile area there, and fairly widespread areas of rain showers and thunderstorms along that front and also widespread IFR
ceilings and visibilities.
Looking enroute here. You've got IFR, to
Low IFR conditions basically up across the bulk of that route of flight and then on into the Connecticut area all right
They're forecasting
1,500 to 2,000
Overcast tops and the flight levels visibilities three miles rain and mist that's good pretty much all day long
anyway, it looks like you're going to be in the weather the bulk of that.. uh. of the flight. Is there anything else I can get
for you sir?
Pilot: No. I'd just rather be on the other side of all those forecasts, is all.
Flight Service: I appreciate your call. Have a good day, sir.
The pilot files an IFR flight plan to Plainville, Connecticut listing Hartford
10 miles northeast as his alternate
The flight will take a little over three hours
At 12:40 p.m.
Bonanza 440H departs Myrtle Beach with five hours of fuel and is soon established in cruise at
7,000 MSL
For the first two hours and 20 minutes everything is routine, but shortly after 3:00 p.m., with the aircraft flying above an overcast
south of Long Island, the pilot calls New York TRACON with a troubling report.
Pilot: New York Approach, Bonanza 440H is with you 7000.
440H, New York ah Kennedy, altimeter is 2983
Pilot: 2983, Bonanza 440H, and sir, ah, we've, ah, we've lost our vacuum system for for our gyro
And 440H, What is the problem?
We've lost our vacuum systems our
ah gyros our partial panel. 440H We're VFR on top right now
We'd like the easiest approach to get down from the clouds and our destination, if possible.
Okay, sir you declaring an emergency now?
We're a partial panel, 40H
Okay, sir, do you want to declare an emergency or not?
And, 440H, descend and maintain 5,000
Sir we prefer to stay at 7,000. We're VFR right now. I don't want to go down into the clouds.
I thought you said you wanted
You want to stay at seven?
N440H, I might descend to the destination,
hopefully we're fairly clear going down into,
into my destination.
Okay right sir. And, uh, 440H, just to verify, you declare an emergency?
ah, yes, sir. 40H
And 40H, you want to continue onto his... you want to continue on to your destination?
Yes sir, I think, ah, the weather's better there than it is right here at my current location. Ah, I haven't been able to check. That, ah,
that far away yet. The Hartford area or the Bradley area, Bonanza 40H
Given the situation
The pilots initial response to the equipment failure was understandable
Less than an hour from his destination in the middle of a large weather system his focus was naturally on getting home
At the same time his desire to remain clear of clouds and his acceptance of emergency services
showed an awareness of the problem
What it didn't show was an understanding of just how much danger he faced.
Partial panel flying is a staple of instrument training, but after the check ride, it's a skill that tends to atrophy
It's also a skill that's rarely practiced under realistic conditions
During training gyroscopic instruments fail instantly - their face is covered by suction cups or post-it notes
But in the real world and especially in older aircraft
The tiny suction gauge on the far side of the panel quietly registers a decline and the instruments fail slowly.
In IMC it can be difficult to figure out what's happening before things go badly wrong.
And once things have gone wrong in a partial panel situation, it's almost impossible to recover
The pilot of 440H at least had the good fortune to experience his failure in VMC
He may have been able to cover the failed instruments. We don't know, but whatever the case it's clear
he didn't understand the gravity of the situation
It's now 3:29 p.m.
Just a few minutes after the initial exchange with ATC and the pilot is explaining his situation to a new controller
So November four four zero Hotel, New York, I understand you're an emergency.
Can you tell me the emergency nature of the emergency and you require any assistance?
Uh, we're partial panel, sir. We're fine. We're VFR over the top right now and we're just want to make sure that we don't have a whole bunch
of climb in the clouds partial panel to get down below the clouds.
N440H, I understand that you're not in dire need of extra service,
but you said, what, say again, the nature?
Partial panel, we've lost our vacuum system, sir
Partial or vac system loss, okay, thank you.
And you still want to continue to the destination, yes or no?
I believe the weather is better at my destination
So if I have a higher ceiling there then I would like to continue to my destination or to Hartford, Bonanza 40H
A few minutes later the pilot calls back with a request
Can you get me the current weather for Hartford Bradley area?
Hartford, stand by.
N440H, the weather at Hartford,
Observation is...
It's Auto-METAR, so it's one nine one three Zulu
The wind at zero two zero at six, visibility one zero, and it's 1,600 overcast.
Temperature is one two, dewpoint niner, and the altimeter is 2983 at Hartford
Bonanza 40H, roger.
40H, You're going to continue towards Hartford?
Uh, I'm not sure what I have for a better alternative, 40H
N440H, Looking at all the closest airports at this time, and it does look like
Hartford does have the best weather for the 1,600 overcast ceiling
Apparently assuming that his intended
destination has similar weather the pilot requests vectors to the Plainville airport, Four Bravo Eight
N440H, proceed direct Bridgeport, and we'll get you on course
40H, Roger. and we are IMC at this time sir, 40H
Just let me advise me if you need anything else.
clear skies would be good, 40H
I can't do that. I wish I could
The first item to note here is the pilot again explaining his situation to a controller who seems not to really grasp the problem
We can say two things:
First this seems to be a common issue with controllers,
many of whom are not pilots themselves and who may only rarely handle light aircraft
Second it's the pilots job to erase any doubt about the nature of the emergency.
This is no time to worry about technical descriptions
Just tell ATC what's going on and what you need.
For example, "I've lost critical flight instruments, and I need to stay clear of clouds"
Seen in that context the pilots report of entering IMC is troubling.
The controller doesn't offer a climb,
indicating that he still doesn't really understand the situation, and the pilot doesn't request one.
"Why", is hard to say.
The aircraft was still 70 miles from its destination.
It's conceivable that the pilot wanted to practice prior to the actual descent. But nothing was said about it.
More likely, he was resigned to the situation and just going along and in doing so, essentially choosing to make things worse
It's now 3:38 PM, and things are not going well
40H, Direct Bridgeport, Bravo Delta Romeo, please, Bravo Delta Romeo. It appears that you're southbound.
40H, New York
40H, Roger sir, I've lost a little bit more control over here.
Okay, 40H, turn left, left turning zero six zero
Turning left to zero six zero, 40H.
40H, would you like a lower altitude?
Bonanza 40H, how can I be of assistance?
Yes sir, we're working on it. We just lost more of our panel, that's all. 40H.
We're turning to 060, and we're trying to get back to 7000.
That's OK, just ah, if you need a block altitude, just keep me advised. I'll protect for you
40H, thank you.
Over the next two minutes
Radar shows the aircraft turning more than ninety degrees off course before correcting.
The controller volunteers conditions at nearby Republic Airport
And 70H, the Republic observation is 1853, the wind is 040 at 7, Visibility's 3 miles broken and 700 overcast.
Would you like to try to land at Republic?
By this time though, the aircraft has entered a steep spiral descending over 4,000 feet in 20 seconds
November 40 Hotel, radar contact lost
November 40 Hotel, low altitude alert 90 miles north-northwest of Republic, MVA is 1600
November 440 Hotel, New York Approach
There is no reply.
On the ground witnesses describe hearing a loud bang and seeing an airplane emerge from the clouds in several pieces
investigators find debris scattered along a path nearly a half mile long
Sometimes in emergency situations the entire outcome hinges on the pilots actions in the moment.
Think of Sully ditching in the Hudson River,
or the crew of United flight 232 whose quick thinking and never-say-die attitude, saved hundreds of lives in Sioux City, Iowa
In some situations though our fate is essentially sealed long before the emergency makes itself known
The loss of November 440 Hotel falls into that category.
In one sense, it was entirely avoidable
And yet for that pilot on that day and under those circumstances a tragic outcome was all too likely
But why?
The pilots proficiency was the most obvious factor.
We have no training records,
But the ATC radar track along with the fact that only three or four minutes elapsed between the aircraft entering
IMC and breaking up make it clear that whatever the pilots opinion of his own abilities,
he was woefully unprepared to fly the aircraft in a real-life partial panel situation
The next factor was the size of the weather system
When the vacuum pump failed, the aircraft had a little over two hours of fuel remaining
while the nearest conditions that might have allowed a VFR descent were roughly an hour and a half away
That would have been a stretch
but under the circumstances a long diversion to potentially better weather was clearly the better option and
also one the pilot was unlikely to choose
He obviously felt some degree of confidence in his partial panel skills and his actions
beginning with a selection of an alternate only ten miles from his primary airport
Show that his focus was on getting home and that potential problems were far from his mind
The vacuum pump was the next factor.
At the time of the accident the pump was 17 years old and had been in operation 373 hours.
A manufacturer's service letter called for replacement at 6 years or 500 hours, whichever came first.
Dry vacuum pumps are relatively fragile and their components do degrade with age alone.
An inconvenient fact that aircraft owners shrug off at their peril
The other aspect of vacuum failure was the aircraft's total lack of backup systems
Aircraft used for IFR typically have standby pumps and/or electrically powered attitude and heading indicators
Some have simple backups that pull suction from the intake manifold.
None of these were installed in 440H
We don't know how often the pilot flew IFR, but doing so without any form of backup was asking for trouble
The term "single point of failure" refers to a system in which the loss of a single component can by itself
lead to a catastrophic outcome.
In theory a vacuum pump equipped aircraft flown by a proficient instrument pilot is not such a system
Even without a secondary vacuum source or standby instrumentation,
there is still a backup: The pilot.
Too often though the pilot is not up to the task
When that's the case the vacuum pump becomes a single point of failure every time the aircraft enters IMC
It's a risk no passenger would knowingly agree to and one that we as pilots have an obligation to avoid.