Risk Management — Repeat Performance

Very recently, in the dark of night, six persons aboard a piston twin died near Joplin, Missouri. The instrument-rated pilot departed under Visual Flight Rules (VFR) but picked up a clearance for an Instrument Flight Rules (IFR) approach when he discovered the weather was “ceiling 800 overcast, visibility 10 miles” at the planned destination. Around one o’clock in the morning the pilot flew the instrument approach procedure for Joplin but for some reason “missed” — despite the reasonably good reported weather he didn’t conclude the approach with a landing, but instead climbed away on the prescribed missed approach procedure.

The pilot requested and was granted another shot at the same approach, only to “miss” a second time. The same thing happened on a third attempt — except that, during the third run through the missed approach procedure, the airplane disappeared from radar and radio coverage about three miles from the airport. It had crashed into a garage, bursting into flame; the two occupants of the adjacent house at first thought the explosion was from a natural gas fire and were fortunate to survive without injury. All aboard the airplane perished.

So goes a distillation of the FAA Preliminary Report and local press coverage of this recent, tragic event. Most assuredly there were a number of factors that added up to the apparent loss of control and descent into the ground. All too often, reports of accidents in Instrument Meteorological Conditions (IMC) include reference to flying the second, third, fourth or even fifth (the most I’ve ever seen in a report) attempt at flying the same approach before ending up in the mishap record.

Under the Gun
One possible conclusion is that flying the same procedure over and over again leads to complacency. Another theory is that, under stress, the temptation is to try to go “just a little bit lower” or “a little bit longer” on each subsequent attempt. In this scenario, risk increases with each failed attempt — another case of “get-there-itis.” Certainly, in this case, after a three-hour flight … with six people aboard … at 1:30 in the morning, the pilot may have been under significant pressure to make a landing. Fuel was likely running short, VFR alternate airports may not have been available and, with the airplane’s seats full, the airplane may have been harder to control. The aircraft was a Beech Baron — as fuel burns off, the center of gravity moves progressively aft (see Back and Forth on Weighty Issues). We don’t know (yet) what caused this airplane to go down, but history tells us that multiple, unplanned instrument approaches, can bring distractions and deteriorate a pilot’s judgment. These factors were likely contributors to the crash.


Should I Stay or Should I Go?
How can pilots better manage the risks and temptations of flying multiple instrument approaches? First and foremost, you must commit to flying precisely and “by the book.’ Plus, remember that complacency and temptation nearly always accompany multiple attempts at an approach in “actual” conditions. There are three simple rules to follow.

If you must “miss” an instrument approach, do not attempt the same approach a second time UNLESS:

  1. You have good reason to believe that the weather conditions that required you to “miss” were temporary and that they’ll improve in time for your second attempt; or
  2. You can identify a specific technique or part of the procedure you flew incorrectly, which caused the “miss,” and which you can honestly say you’ll get right the next time; or
  3. You’re facing a true emergency and because of your planning or unforeseen weather conditions you have no better options within your remaining range and you must try again before running out of fuel, entirely.

If none of the conditions above apply and you attempt a second approach, anyway — you’re wasting time and the fuel you need to get somewhere with better conditions or lower approach minimums.

After the Second Missed
If you thought the weather would improve, or you thought you’d fly the approach more precisely the next time, but ended up flying a missed approach a second time — go somewhere with better weather or lower approach minima. DO NOT FLY A THIRD APPROACH unless you’re truly in a fuel emergency, and you’ll have to continue the descent below minimums for a landing somewhere to avoid having to dead-stick it down in IMC. History shows that multiple attempts at the same approach tempts pilots to violate safe altitudes, or distracts them from flying proper procedures. The results are often fatal.

Lessons Gone Bad
Instrument instructors (and I am one of them) may be guilty of reinforcing this behavior. Consider a typical instructional instrument flight — take off, fly multiple approaches, “missing” the approach over and over again until finally flying a final approach (usually the same approach you just missed), “breaking out” at minimums and landing. Are these habits teaching our students that if they try over and over again they’ll eventually be successful? Are the relatively few times we “miss” an approach “for real” enough to counter this landing expectation?

BOTTOM LINE: It’s very hard to envision what we’d do when tired … flying a planeload of passengers … facing unexpected IMC after a long flight … in the dark … with fuel running out … in a squirrelly-handling airplane. We may never know precisely what event, or combination of events, caused this piston twin to descend fatally to earth. The “multiple attempts at the same approach” does, however, appear — repeatedly — in actual-IMC crash reports. Perhaps a personal Standard Operating Procedure for flying “repeat performance” approaches can protect us from the distractions and temptations of flying in this stressful situation. There are many uncertainties in flying IMC approaches, but one thing’s for sure — think twice before flying it twice.