Aviation Safety Letter 3/2004

When Night VFR and IFR Collide

The aircraft struck the frozen surface of the lake, bounced, and became airborne again.On January 29, 2003, a Beech 99 with two pilots and three passengers on board was departing Pikangikum, Ontario, at 18:38 central standard time (CST) on a night visual flight rules (NVFR) flight to Poplar Hill, Ontario. The captain, who was the pilot flying (PF) and sitting in the right hand seat, completed a normal takeoff. The flight took off from Runway 27, over a lake. About 400 ft above ground level (AGL), the PF began a climbing right turn en route. During the turn, the PF had difficulty seeing the artificial horizon and concentrated on the aircraft's bank angle. The first officer called that the aircraft was in a 2 000 feet per minute descent and took control. The aircraft struck the frozen surface of the lake, bounced, and became airborne again. The first officer retained control, and the captain attempted to feather the damaged right propeller. The first officer, believing that both propellers had sustained damage, force landed the aircraft on the lake surface. The aircraft sustained substantial damage. No one was injured. This synopsis is based on the Transportation Safety Board of Canada (TSB) Final Report A03C0029.

The original first officer for the flight became ill and the operator sent a relief pilot as a replacement. On arrival, the relief pilot became the aircraft captain, based on seniority within the company. The original captain, who was now to act as the first officer, had flown the first series of scheduled flights in the left seat, and the cockpit was configured to accommodate him. When the new captain arrived, it was convenient for the new captain to fly from the right seat. The operator's Operations Manual (OM) permits a left seat qualified pilot who receives annual right seat training to operate the aircraft from the right seat. However, the captain had never received right seat training as a captain with the company.

Both held valid airline transport pilot licences and their pilot proficiency checks and required training were current. The captain had accumulated about 4 800 hr of flight time in nine years of flying and had been a Beech 99 aircraft captain for two years. The first officer had been flying for eight years and had about 4 200 hr of flight time. The first officer had also been a Beech 99 aircraft captain for two years.

After the crew change, the flight continued to Pikangikum in night visual meteorological conditions (VMC). During the flight, the first officer, the PF for this flight, adjusted the cockpit instrument lighting for both crew members. The captain, the non flying pilot, found the lighting selection too bright and re adjusted the instrument lighting on the right side of the cockpit to a lower setting. The flight landed at Pikangikum, and passengers and baggage were offloaded. Three passengers and baggage were loaded for the flight to Poplar Hill. During this time, the crew were working in the brightly lit area of the ramp. After the aircraft was loaded, the crew took their positions, with the captain, the PF for the departure from Pikangikum, in the right seat. The PF did not change the lighting selection on the right side of the cockpit from the selections made during the flight into Pikangikum.

The PF taxied to the runway, executed a normal takeoff, and established the aircraft in a climb at 1 500 feet per minute. After the first officer called positive rate, the PF called for the landing gear to be selected up. Approximately 15 seconds after takeoff, the first officer made the required 400 ft call. The PF called for flaps up and, after the first officer confirmed that flaps were selected, called for climb power and the after take off checks. The first officer acknowledged, and the captain indicated starting a turn toward Poplar Hill.

The first officer was setting climb power as the PF started the turn. The PF intended to establish the aircraft in a bank angle of 20° to 25°. However, the PF was unable to see the artificial horizon clearly. Although the aircraft was banked to one of the marks on the artificial horizon, the PF was uncertain of the bank angle that was reached. The PF concentrated on the artificial horizon, even leaning forward trying to identify the bank angle displayed. The PF was completing the roll out of the turn when the first officer told the PF that the aircraft was descending at 2 000 feet per minute. The PF pulled back on the control column. When the first officer saw the frozen surface of the lake approaching rapidly (visible because one landing light was still on), the first officer also grasped the control column and pulled back. However, the combined effort of both pilots did not prevent the aircraft from striking the frozen surface of the lake. The aircraft struck the frozen surface in a wings level attitude with the landing gear retracted and bounced airborne. The aircraft was equipped with a belly pod, which absorbed a large amount of the impact forces during landing. The frozen surface of the lake was covered with a layer of snow about two feet deep, which also reduced the force of the impact.

The captain noted that the right propeller was slowing and attempted to feather it. The crew agreed that the best option was to land immediately on the frozen surface, and the first officer completed a forced landing about 1.5 nautical miles (NM) from the departure end of Runway 27. The aircraft slid to a stop in about 300 ft on the frozen, snow covered surface. The crew used the aircraft radios to contact company staff at the airstrip, and the passengers and the crew were transported to the terminal in a short period of time.

Damage was confined to the engines and the propellers and to the underside of the fuselage, wings, and flaps. Inspection of the airframe, flight controls, and engines revealed no pre impact anomalies. There was no internal damage in the cockpit or the cabin. The flight instruments from both sides of the instrument panel were removed and tested. No unserviceablities were found.

Canadian Aviation Regulation (CAR) 602.115 requires, for NVFR flight in uncontrolled areas, that "No person shall operate an aircraft in VFR flight within uncontrolled airspace unless, (a) the aircraft is operated with visual reference to the surface." The 18:24 CST special weather report for Red Lake, Ontario, 46 NM south of Pikangikum, was as follows: wind 210° at 15 kt, gusting to 25 kt; visibility 12 statute miles (SM) in light snow and drifting snow; ceiling 2 500 ft broken; and temperature 15°C. The weather at Pikangikum was reportedly similar. The moon was in the last phase of waning, and there was no moonlight; it was a very dark night.

Analysis — The takeoff and departure were initiated in accordance with the company's standard operating procedures (SOPs). The aircraft captain, the PF, had completed currency requirements for the left seat but had not completed the required annual right seat training to operate the aircraft from the right seat. Consequently, the aircraft captain was not current to operate the aircraft from the right seat.

The ramp was brightly lit, and there was no problem seeing the instrument panel, so the captain did not adjust the lighting illuminating the artificial horizon before taking off. However, once the aircraft was airborne, the lighting was too dim to allow the captain to see the artificial horizon clearly. The PF concentrated on the bank angle, but did not cross check the climb angle or other instruments, and a high sink rate rapidly developed. When the first officer called the descent, the captain was unable to re establish situational awareness, and the first officer correctly took control. The damage to the propellers and the engines was such that a forced landing on the lake surface was the only option.

The aircraft took off over a lake, and there were no ground lights under or around the aircraft after it left the airport area. The lack of ground and celestial lighting created conditions that made flight with visual reference to the surface very difficult, if not impossible. With adequate outside visual references, a pilot, unsure of the aircraft attitude, would certainly look outside to regain their situational awareness. The ambient (outside) lighting conditions after takeoff on the accident flight would have provided little or no help to this crew in orienting the aircraft. It is highly probable that the PF was referencing only the aircraft instruments, and they were not bright enough to ascertain the aircraft attitude. In essence, this flight was not being conducted in accordance with VFR.

The TSB determined that the captain chose to fly the aircraft from the right seat during a night departure when not current to operate the aircraft from the right seat, and that the captain did not set the instrument lighting correctly for the night takeoff and was unable to use the artificial horizon effectively, resulting in the loss of situational awareness after takeoff and the subsequent loss of control of the aircraft. The TSB also determined that the flight was filed as a VFR flight whereas, in essence, it was operating under IFR conditions.

The mixing of VFR and IFR procedures can be deadly in NVFR operations. Had the crew planned for an IFR flight to begin with, they would likely have configured the cockpit for the appropriate illumination, and they would likely have noticed any deviation from a controlled IFR climb before it was too late. Permissive NVFR regulations come increasingly under attack after such accidents; pilots must recognize when NVFR becomes IFR and plan accordingly. Furthermore, the conditions under which the original captain was re-assigned to first officer duties upon arrival of the relief pilot may have contributed to the chain of events — particularly with the "convenience" of letting the original captain stay in the left seat. Experienced pilots, such as the two involved here, are used to change seats all the time, and this would have taken at most a few minutes. Of course, there is nothing inherently wrong with having the captain in the right seat; the argument rather is the judiciousness of performing a right-seat takeoff under these circumstances. Right-seat flying skills are valuable under controlled conditions such as VFR flight, dual training, and during an emergency. With the fine line between NVFR and IFR having been crossed, the appropriateness of the decision to perform a right-seat takeoff was proven strikingly wrong. — Ed.

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