Monday, October 10, 2011

NTSB Report CEN11CA516

It took a little digging but here is the information I’ve been able to find about the aircraft that crashed into Lake Huron -- where the pilot had to tread water for 18 hours awaiting rescue.

From the NTSB: CEN11CA516

”The pilot stated that while crossing Lake Huron at an altitude of 3,000 feet, the engine began to lose power. The pilot contacted flight watch and informed them of the situation. He moved the fuel selector handle and enriched the fuel mixture to no avail. The pilot stated he applied carburetor heat, moved the throttle, and fuel selector switch again, but by this time he was about 100 feet above the water and 15 to 17 miles off shore. He contacted flight watch again to provide a position update and to tell them he was ditching in the lake. The pilot stated that engine power was regained just prior to the airplane contacting the water; however, by that time he was unable to avoid the ditching. The pilot exited the airplane which sank soon after contacting the water. The pilot was able to tread water for approximately 18 hours prior to be picked up by a pleasure boat. The pilot was hospitalized for several days following the accident. The airplane remains at the bottom of Lake Huron in about 210 feet of water. The outside air temperature was 73 degrees Fahrenheit and the dew point was 57 degrees Fahrenheit. According to the FAA Icing Probability Chart, these conditions were conducive for serious icing at glide power. The pilot reported he did not recognize the symptoms of carburetor ice and that he should have applied the carburetor heat sooner.”

The aircraft was a C-150, N3050X.

I found a blog post that fleshed things out a little better.

”"Our agencies have come to the consensus that Lockheed Martin Flight Service played a major part in the lack of response to this incident," referring to the Federal Aviation Administration's move to subcontract flight services to Lockheed Martin, who then consolidated services and closed the Lansing Flight Service. ”

That’s the sheriff being quoted and I’m not sure what agencies “our agencies” refers to.

Just to show you how this goes, I listened to the tapes (okay, mp3 files) available at the previous link, and until you look at a map, you don’t have any idea about the level of confusion. Unless, of course, you have local knowledge. (Just in case the important point escaped you.)

(From Google Maps)

“B” is Harbor Beach, MI. N3050X crashed in Lake Huron a dozen or so miles from there. I believe he was headed for Bad Axe, MI (“A” on the map), not “Big Axe” as heard on the tape. (I can’t find a “Big Axe” in Michigan.) Regardless, the FSS guy heard “Lansing” and that got stuck in his brain. On the tapes, you continually hear him reference the pilot’s initial position report when talking to other ATC facilities trying to locate the aircraft: “29 miles east of Lansing.” As you can see on the map, Lake Huron is over a 100 miles east of Lansing, MI.

Once again, I see the same old errors at play that I see in every incident or accident. And the greatest of these is communications. Start at the very beginning. The only correct way to declare an emergency is with one simple word repeated three times -- “Mayday, Mayday, Mayday”.

AIM 6-3-1. Distress and Urgency Communications

”c. The initial communication, and if considered necessary, any subsequent transmissions by an aircraft in distress should begin with the signal MAYDAY, preferably repeated three times. The signal PAN-PAN should be used in the same manner for an urgency condition.”

If you can’t get your mind wrapped around that fact, then get your mind wrapped around the fact that your communication errors will likely help kill you should you ever encounter an emergency. I’m not talking about procedures for the sake of procedures. The words in-of-themselves aren’t important. Getting your mind wrapped around the fact that the wrong words can contribute to your demise is what is important. Okay, I’m going to stop before I go on a full-blown rant about phraseology.

Don Brown
October 10, 2011

No comments: