Unfit to Fly

18 Feb 11 5 Comments

I read a lot of accident reports – most pilots do – in the hopes of learning more about flight and human factors and just maybe how to avoid ending up a statistic.

But there are some accidents that are simply sad, with no lesson to be learnt nor explanations that can help us to understand. This is, I think, one of those truly pointless accidents where, honestly, the pilot should not have been allowed to fly. I suppose at least he did not take anyone else with him. The primary information and blockquotes for this article are from the Air Accidents Investigation: Mooney M20B, G-JDIX.

The story starts in Austria in 2006 when Czech pilot Pavel Sedlacek learned to fly at Hohenhems in 2006 and received his Private Pilot’s Licence in June 2007. The PPL and his Class 2 medical certificate were valid at the time of the accident.

The pilot owned a Rallye (registration D-ECFX) which he kept at Hohenems in Austria near his home.

Photograph by David Moth of Old Buck Shots

In August 2009, Sedlacek purchased a Mooney M20B, registration G-JDIX, at Old Buckenham Airfield. Prior to the purchase, he flew the Mooney with a local pilot at Old Buckenham who was not happy with his approaches.

The pilot’s general handling was described as being of a quite low standard. Compared to the Rallye that the pilot was used to, the Mooney approached the runway at a higher speed and with less drag (even with flaps extended), requiring greater attention to speed control to avoid landing too fast. The pilot reportedly used an incorrect technique which consistently resulted in fast approaches and long landings that were also remarked upon by onlookers.

In addition, concerns were raised regarding his safety (he flew from Germany to Old Buckenham with incomplete charts and without over-water safety aids) and the fact that he generally appeared nervous and agitated. The accident report includes a rather British reference to the fact that he was happy to speak freely to strangers about his personal family life, which would arouse no suspicion in the American Southwest where I grew up. At any rate, his handling of the aircraft raised concerns.

Dismissing the suggestion that he should fly with an instructor to become more familiar with the Mooney, he flew the plane alone to Hohenems in Austria.

In November 2009, the 65-year old was on a journey in the Rallye on his way from Bad Endorf in Germany to Hohenems when he suffered engine problems. The engine cut out completely and he brought it in to land in a field in Doren, Austria. The nose wheel ripped off in the landing and the plane was scrapped although the pilot was uninjured. Local press at the time stated that the engine failure was caused by icing in the fuel line or the carburettor. The Austrian accident report does not appear to be online.

The portable GPS unit recovered from the crash site of the Mooney in May 2010 showed route data and logs dating back to November 2009.

There were four logs pertaining to flight. There were three flights in the above Rallye in November culminating in this forced landing at Doren. The only other flight was a flight from Hohenems to Biberach Airport in Southern Germany on the 27th of February in 2010.

An airfield operator there described him as appearing confused on occasions and stated that he approached the wrong runway and then descended to land wheels-up: the operator warned him before touchdown.

The next flight was planned from Biberach to Old Buckenham in order to have maintenance carried out on the aircraft. A later inspection of the logbooks showed that the aircraft had undergone a 50-hour inspection in August 2009 at the time of the sale. The aircraft’s Certificate of Airworthiness had expired in February 2010.

On the 9th of May 2010, he loaded the plane with 106 litres of fuel. He prepared a flight plan to Old Buckenham but didn’t file it, nor did he notify HM Revenue & Customs and the UK Border control with his flight details as required by the UK AIP. Staff at Biberach Airport later filed the flight plan on his behalf. The flight plan listed the flight as 3 hours 30 minutes with a fuel endurance of 4 hours 20 minutes.

He aborted his initial take-off attempt but took off successfully on his second attempt at 12:26.

Four hours later, at 16:20, he contacted Old Buckenham A/G to request airfield details.

About 10 minutes after his initial call, the pilot called ‘DOWNWIND’ and then ‘finals ’. When the aircraft had not landed some minutes later, staff checked with Tibenham airfield (4.5 nm to the south-east) and learnt that the aircraft had landed there unexpectedly. Recorded data from the aircraft’s GPS navigation unit, which was recovered from the accident site, showed that the aircraft had not in fact made an approach to Old Buckenham, but had landed at Tibenham after first orbiting briefly to the south of the airfield.

He never contacted Tibenham and landed on Runway 33, which was out of use, across the prevailing wind and covered with glider launch cables. He approached at high speed and bounced several times, using 1,100 metres (3,600 feet) of the runway’s 1,250 metres (4,100 feet) length.

After parking at the clubhouse, the pilot spoke to several club members. They described him as being in a highly agitated, even distressed, state. He was sweating profusely, with sweat-soaked clothing. He was also very voluble, and talked of a number of things, including personal family issues which were obviously a source of concern to him. He was given a hot drink but did not eat anything.

I like the fact that someone got him a cuppa to calm him down. He explained that he had landed at Tibenham because he was concerned about the short runway at Old Buckenham. He claimed to have concerns about the brakes but did not seek any engineering assistance nor would he consider cancelling the final leg of his flight to Old Buckenham.

People who met with the pilot were concerned and thought he should not fly again in his condition. They encouraged him to delay the last stage of his flight, but the pilot was clearly keen to continue.

One person who met the pilot reacted quite adamantly to the implication that more should have been done to stop him flying.

FLYER Forums • View topic – AAIB report – G-JDIX

WHOA. …I was in the clubhouse. He WAS advised not to fly and he WAS offered help.

He made a bit of a recovery and insisted on flying because he said the plane HAD to go to Old Buck. Short of physically restraining him and risking being arrested for assault there wasn’t much anyone could do. So please don’t be second guessing on public forums. We all feel bad enough about this business.

A later analysis calculated that he had slightly less than 5 US gallons on fuel on board, about 19 litres. This would allow for 30 minutes flight without reserves. He did not inquire about fuel at Tibenham.

He was told that Runway 03 was in use and that gliding operations were in progress. The instructions were to taxi for Runway 03 and then contact launch control before take-off, all very straight-forward.

Instead, he taxied to out-of-use Runway 33. He did not make any radio calls and he did not appear to carry out any engine checks. At 16:59 he departed Tibenham and disappeared into the distance at about 1,000 feet agl.

The pilot contacted the Old Buckenham frequency again. He expressed concern again about his brakes and stated something about returning to Tibenham. The controller did not hear further from the pilot and contacted Tibenham to find out if G-JDIX hand landed there again. It hadn’t.

Bystanders spotted the aircraft flying low around 500-700 meters away from the Old Buckenham threshold although clearly not on the standard approach path. The plane then turned away from the airfield. One witness said he saw the plane pass close enough for the pilot to be clearly visible. He believed the engine was at near idle power but then increased markedly just before the plane dropped a wing and disappeared from view.

The GPS data showed the flight at 120 feet above ground level for the last two minutes of flight, with groundspeed falling to about 60 knots over the final 80 seconds.

By the time anyone reached the field, the plane was on fire.

Witnesses alerted the emergency services and went to the scene of the accident, which was in a field of young crops, a few hundred metres from a road. A fire had broken out and was accompanied by one or more small explosions. Although some paper documents were on the ground outside of the cabin, the cabin door itself was closed and the pilot was seen to be lying, apparently deceased, across the front seats. The fire quickly consumed much of the cabin area.

The plane was damaged in the fire but no “technical defects” were obvious: the rudder, elevator and aileron systems all appeared to be in working order. The propeller was found two metres from the main wreckage with one blade buried in the ground and cuts in the soil, leading to the conclusion that the propeller was probably rotating on impact. The report concludes that the damage and ground marks are consistent with a spin to the left.

The left wing held 10 litres of fuel. There was no fault found with the brakes.

The AAIB conclusion is chilling:

From eyewitness accounts, it is probable that the pilot became distracted from the task of landing his aircraft at nearby Old Buckenham (if indeed it was his intention to do so), which could easily have been reached had the aircraft turned towards it, rather than away. Instead, the pilot allowed the aircraft to become dangerously slow at very low height. The source of distraction was not identified: the low fuel state perhaps presents the most likely reason, but this could not be confirmed.

Given the pilot’s questionable state of fitness to safely act as the pilot of an aircraft on the day in question, no further meaningful analysis was possible.


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Category: Accident Reports,

5 Comments

  • The people at Tibenham legally could not have done anything to stop him. Ultimately it’s up to the pilot to decide whether or not they are fit to fly. Maybe some people fail to develop the honest introspection necessary to assess their own fitness? They succeed in every other facet in their lives and refuse to accept they aren’t (at present) up to the required standard as their aviating peers?

  • I agree, Chris. The guy appears to have been in complete denial about his ability to handle the Mooney from day one. I’m pretty sure the whole “brakes are failing” issue was simply the low and fast approaches he continued to fly.

  • The biggest cause of general aviation accidents has always been pilot error. And the biggest cause of pilot error has always been various forms of egoistic behavior.

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