Pushing training back to basics
The Human Factor
Ultimately, the investigators turned their attention to the pilot. He held a private pilot certificate with single-engine and multiengine land airplane and instrument airplane ratings. According to his logbook, the pilot had accumulated a total of 438 hr. Of that total time, 28.7 hr. were in multiengine airplanes and 17.5 hr. flown in the Beech 58. The logbook also showed that he had flown 30.1 hr. within the preceding 90 days, 20.1 hr. within the preceding 60 days and 8.7 hr. in the previous 30 days.
The pilot had logged 50 hr. of simulated instrument time and 11 hr. in actual instrument conditions. He passed an instrument proficiency check five months prior to the accident but had logged only 0.7 hr. of instrument time between that check and the accident. The pilot also successfully completed a check flight for a multiengine airplane rating on Feb. 18, 2011. An autopsy was performed on the pilot. Toxicology testing of samples taken from him were negative.
investigators also looked at the high-workload approach sequence. A review of the ATC services provided to the pilot by the Kansas City Center indicates that the controller issued “incorrectly phrased instructions” to the pilot when the controller transmitted “N580EA is 6 mi. south of UJASA, fly heading 340, intercept the Topeka 129 radial for the back course Runway 31 approach.” The pilot responded that he'd intercept the Topeka 129 for the back course for Runway 31.
The 30-deg. intercept angle met the proper approach course intercept standards required byprocedures; however the “129 radial” phraseology is more typically used as part of an ATC instruction related to VORs. The Topeka VOR was located 5 mi. northeast of the airport. The TOP VOR 129 radial was parallel to the localizer back course, but 5.5 nm northeast of it.
Investigators said the Topeka VOR and the TOP 129 radial were not used to define the final approach portion of the localizer back course 31 procedure, but the VOR is used as part of the missed approach procedure. Radar data showed that upon the pilot accepting the approach clearance, the airplane continued on the 340-deg. heading across the localizer back course. The airplane then turned to approximately 309 deg., the inbound heading for the back course localizer procedure on reaching the vicinity of the TOP VOR 129 radial and well north of the final approach course for the localizer.
At that time, the controller noted the pilot's apparent deviation from the localizer procedure and instructed him to fly a heading of 280 deg. “to intercept the 129 radial for the back course.” The heading took the airplane back to the correct final approach course. The pilot intercepted the correct course at POACH, the final approach fix for the approach located 3.9 nm from the runway. The airplane at that time was at 2,900 ft. MSL. The published crossing altitude at POACH was 2,200 ft. The pilot executed the missed approach shortly afterward.
The Safety Board had yet to issue a determination of probable cause as we went to press. Certainly, decision-making, workload considerations and airplane handling will all be factors — in short, all the elements of airmanship regardless of how we define it.