That Well Known Chain

N. W. Miller
© 2008 WordWise Publications LLC

It's practically a cliché: Every accident results from a chain of events, and if that chain had been broken at any point, the accident would have been averted.

  We know a pilot who assembled such a chain recently, though fortunately the final link was never forged. It started out with a forecast that had gone sour--the weather had turned out better than forecast. That's right--better. The original plan had been to depart from the small Washington strip to which he had flown six days earlier, and where there was no fuel, cross the Columbia River, and land at Astoria airport in Oregon to gas up.

  The forecast had been for cloud cover, with ceilings in the neighborhood of 1000 feet. This would have allowed the fuel hop across the water under VFR; then an IFR departure would have put the flight on top of the clouds for the trip south, with full tanks (50 gal.), where the weather would clear up entirely. But clear skies over the Columbia made it possible to climb out VFR and get on top of the broken clouds. Why not just head on south?

  As for fuel, that would be available further along, in central Oregon. A related factor, as they say in NTSB reports, was the price of gas: $5.60/gal at Astoria, but only $4.99 at Lebanon (which also had auto gas), some 100 miles to the south. Forty gallons times $ .60--well, it's lunch for two (and if the cheaper auto fuel satisfied the requirements of his STC, the difference would be lunch for three--almost real money).

Link Two

The next link in the chain was failure to follow the advice given in General Information, on page 3, under "Reach Out," where we read, "Convenient and inexpensive insurance against an unpleasant surprise can accrue from a phone call to your destination airport. Calling is an excellent way to ensure that the field is open. . . ."

  The pilot had a cell phone and (of course) a Flight Guide. A call would have been easy. But he didn't make it. And in fact, his selected destination airport was torn up for reconstruction. Two minutes to make a phone call would likely have disclosed this relevant fact.

  So would have a pre-flight briefing. But the complacent pilot had checked the NWS weather via computer, and he had received an outlook briefing from Flight Service the previous evening. Besides, he knew the route well. So he skipped the briefing, which, even more surely than a call to the destination, would have revealed its closure.

Link Three

The pilot was not familiar with Lebanon airport, not that that matters: He had his Flight Guide and a Sectional chart-and a handheld GPS that had served him well for several years. He confidently keyed in the coordinates--latitude and longitude--for S30 and considered his preparations adequate.

  But the master link in the lengthening chain of events was a mistake made at this critical juncture. Lebanon's longitude is 122° west (plus minutes and seconds), but our intrepid aviator inadvertently entered 121°. Lesson: Always re-check your data when entering a waypoint. The GPS cannot tell you whether the numbers are right or wrong.

  Now the fact that the field was under construction would have become apparent in due course, and the error in entering the coordinates into the GPS would have become obvious after 10 or 15 minutes' flying--but for the cloud cover.

Link Four

The broken cloud deck below afforded good visibility of the ground through numerous holes, some quite large, but it prevented any view of the landscape ahead; a carpet of cloud-tops paved the route for a hundred miles. Thus it was not possible to use pilotage--comparing the terrain against the chart to gauge the flight's progress. The course commanded by the GPS overrode all. So instead of discovering visually that his progress was too much easterly, the pilot complacently followed the GPS.

Link Five

It was not very far into the flight that he noticed a large airport to the left; it had two runways, and he could even read the runway designators. But this airport did not correspond with any field that lay on his intended route. Flipping through the Oregon section of his Flight Guide, he determined that the only airport with this configuration of runways was Hillsboro Field in Portland. Problem: Portland wasn't on the intended route; it lay well to the east.

  Instead of sleuthing out the reason for this discrepancy, the pilot rationalized that he wasn't all that far off, that there had been some drifting owing to the substantial wind aloft, that his destination was further inland than he normally flew, and so on. As philosopher James Harvey Robinson has noted, "We like to continue to believe what we have been accustomed to accept as true, and the resentment aroused when doubt is cast upon any of our assumptions leads us to seek every manner of excuse for clinging to them. The result is that most of our so-called reasoning consists in finding arguments for going on believing as we already do"[italics sic].

  This pilot clung to his belief that he was headed where he intended. What trumped everything was the GPS: He was on course as far as it was concerned. He never even considered the possibility that it was not taking him where he thought it was. He pressed onward, mile after mile.

Inhospitable Terrain

And yet, as he peered downward, repeatedly, through the breaks in the clouds, expecting any minute to see flat terrain, city structures, and an airport or two-by now he was supposed to be only 15 or 20 miles out-all that appeared were forested hills: no sign of humanity, no place to land. Fuel had dropped below 10 gallons, activating a red warning light on the fuel-flow "totalizer," and one thing was beginning to stand out above all else: He needed to land pretty soon. There was, in addition, a growing and disquieting sense that, given the terrain below, he wasn't where he thought he was.

  It dawned on him abruptly. I have a problem.

Cliffhanger

Well, we've run out of space. We'll have to leave our friend aloft, cruising southeasterly at 7,500 feet in smooth air over a lovely deck of scattered-to-broken cumulus clouds, with a tailwind to boot-but heading for a point some 45 miles east of where he wanted to go, a point deep in the thickly forested hills of central Oregon. The fuel that would have been adequate was now possibly insufficient. But we'll have to save the rest of the story for next time.

[Story is concluded in Part 2, below]

Part 2

Headwinds

We left our pilot low on fuel and perhaps lost in the bargain. But even with the obvious lack of correspondence between what he did see below and what he should have been seeing, still he had some difficulty accepting the notion that he wasn't where he had expected to be. But he had begun to suspect that something was amiss with respect to his GPS course.

  Taking his GPS unit in hand he quickly--we won't say "feverishly"--entered coordinates for the Corvallis VOR (already tuned on his nav radio). CVO was close to the intended destination, and there were a couple of other airports besides Corvallis Municipal in the same neighborhood. A course directly to CVO was already set on the OBS. The GPS, at least in its role as a tool for navigation, had, for the moment, lost its allure. Still, only it could give the distance, which is what the pilot now sought. Punching "GO TO," the bad news that until now had been only suspicion became substance on the LCD; what ought to have been about a dozen miles was in fact--fifty-three miles. Suddenly an additional forty miles separated him and his dwindling gas from a place to refuel.

  The stark truth of the situation sank in.

  It wasn't only that 53 miles intervened between emptying tanks and needed fuel: Turning westerly would transform the previously friendly tailwind into a quartering headwind, cutting his groundspeed substantially, and increasing the likelihood of running out the clock. The situation that a moment ago seemed potentially worrisome now appeared something approaching dire.

Communicate

The novice pilot, particularly one who has blundered into IFR conditions, is (or at least, used to be) adjured to "Climb, Communicate, and Confess" (pundits seem to believe that alliteration makes an aphorism more memorable). Climbing would be of no value here: Our pilot was above the "weather" and plenty high enough to enable radio contact with ATC. But clearly it was time to confess (which is ipso facto to communicate: the redundancy is apparently accepted in service of the alliteration).

  Selecting 122.0 and keying his mike, the pilot called Flight Watch. His exact words are lost to history, but the gist of the message was "I'm low on fuel, uncertain of my position (somewhere east of Corvallis), and need to know what frequency to use to call ATC for help."

  "Stand by." There was silence for a few seconds--which of course seemed much longer. Then the specialist came back with two frequencies, one for Cascade Approach (operating out of Medford) and the other for Seattle Center. Our pilot thanked him and reached for the radio again.

Link Six

Let us pause to reflect on yet another link in what could have become a fatal chain (if not, perhaps, literally). Focused on where he ought to have been (somewhere to the east), the pilot gave no thought at all to the possibility that something might lie ahead (to the south), on the course he had been mistakenly following.

  The terrain below (no forward visibility of the ground, remember) was clearly inhospitable. But in fact, as later examination of the chart would show, Sisters, Ore. was only about 25 miles away--closer than Lebanon (although without fuel)--and it was, moreover, downwind. Just 12 or 14 miles beyond Sisters, at about the same distance as Lebanon, lay Redmond, a controlled field with services. Why did the preoccupied pilot fail to consider these?

  The Seattle Sectional that he was using cuts off just south of his position; Sisters lies across the break, on the Klamath Falls chart. The pilot did not have that chart open at this point. After all, he was going to be landing before leaving Seattle's coverage and wouldn't need it. . . .

  Do not let an emergency give you tunnel vision. Consider all your options. It's easy to be sucked into fulfilling the original plan simply because that's what's foremost in your mind. But continuing a mistaken, unplanned flight track might turn out to be the wisest course.

Help from ATC

By now the pilot had already turned westerly, toward CVO, and was beginning to descend slowly. He selected 119.0 on the radio. Again, the words are but an approximation: "Cascade Approach, Piper [tail number]. I'm low on fuel and need vectors to the closest airport." The controller gave a surprising instruction.

  "Piper zero-two Romeo, roger. Squawk 7-7-0-0." Well, that was a first. After years of assiduously avoiding that combination of digits, the pilot now set the emergency code. Seconds later, Approach advised "Radar contact." And it was about this time that the engine quit.

  The pilot broadcast some comment to that effect, though what other remarks might have passed between him and the controller he does not remember. (He does recall thinking that it might be useful to document the exhaustion of one tank for the FAA's ATC tape recording.) The fuel totalizer at this point was showing about seven gallons remaining as he reached reflexively for the fuel selector and changed to the right tank. After a few more seconds of silence, the engine resumed its accustomed purr.

  Unusable fuel in the Cherokee is published as 2.5 gallons per side, or five in all. There could thus have been as little as two gallons of usable fuel remaining aboard the airplane. Fortunately, with the power back for descent, consumption was much lower than at cruise.

Link Seven?

The controller was suggesting that, given his location, Seattle Center would be a better choice to handle the emergency. Switching to 125.8, the pilot called Seattle Center and again stated his problem. The controller came back with the name of the nearest field, some seven miles north, noting that it was a private, unattended turf strip. The pilot did not catch the name, but he did a quick assessment of the essentials: He could gamble on making it to his original destination, where there would be fuel, or take a sure thing and land at a remote grass strip where he would end up safe and in one piece on the ground--but be unable to leave without considerable hassle in getting gas. He'd be trading one problem for another, admittedly less severe.

  Was it a good trade? He imagined himself on the grass strip miles from aviation fuel. How would he get fuel to the airplane? How many hours--or days--would it take? These thoughts occupied mere seconds. His decision: Continue west--there's got to be enough gas . . .

  Should we identify this decision as yet another link in the lengthening chain? The pilot had evaluated the odds and inconveniences and made a choice. Would it turn out to be the wrong one? He announced to Seattle his intention to continue to his original destination. And what field would that be, Seattle wanted, not unreasonably, to know.

  "Lebanon."

  "That field is NOTAMed closed." The controller betrayed no emotion. It was a laconic statement of fact. (Of course he probably wondered why the pilot did not know this.)

  "This just keeps getting better!" thought the increasingly frazzled pilot. He was beginning to heap recriminations on himself for having failed to make the phone call before he took off. Center wanted to know his intentions. In his sketchy flight planning, the pilot had considered another field which, at six or seven miles northwest, was close to Lebanon. "I'll go for Albany." Never mind the unattended grass strip just to the north.

  The controller asked, in what was perhaps a legalistic gesture (think "Millionaire," when the host asks, "Is that your final answer?"), "You're going to Albany then?" He was neither making a judgment nor expressing an opinion. He just wanted to clarify, for the record, one suspects, that the pilot himself had made this decision, that it was his elected course of action.

  "Yes."

  It was right about this point that the GPS blinked off. The batteries had been used for the eight or nine hours it had taken to fly north to Washington six days earlier; now, like the gas in the left tank, they had run out. The pilot was not unprepared for this eventuality, however. Opening his briefcase on the right seat, he retrieved fresh batteries and swapped them for the depleted double-As. It didn't take long, but it was an unwelcome distraction. It intensified a growing sense of concatenated calamities: Would the flight end in a field? With bent aluminum?

  Center was giving a vector to Albany; the course required only a small change in heading. But as Albany was slightly farther away than Lebanon, fuel was now going to be even tighter.

Out of the Clouds

The aircraft had been steadily descending, mostly in breaks between cumulus clouds, and now it was close to the level of their bases. The terrain below had smoothed from hilly to mostly flat. Though clouds blocked forward visibility, there was an excellent view of the ground below and to the sides. It was a really pretty day, with clean, smooth air. It would have been great for an introductory flight to help persuade a novice of the joys of aviation.

  The controller now described for the pilot how the town of Albany lay with respect to the freeway. Unable to see any distance ahead, and in fact flying through a cloud or two (despite the lack of a clearance), the pilot reasoned that, after all, he was in radar contact and was obviously alone in the neighborhood. Presently, he flew out of a cloud and into the clear; he enjoyed considerable relief as he spied Albany, lovely Albany, nestled alongside the Interstate amid green fields, just five or six miles away. And the engine was still running.

Inbound With Low Fuel

At first he could not isolate the airport in the urban environment, but drawing a little closer, suddenly he discerned the north-south runway just where the chart showed it to be. Only a few more miles. He called the controller to say that he had the field in sight and would now change to Albany's advisory frequency. The controller acknowledged; then he gave him a phone number: "Call me when you're on the ground so that I'll know you're OK." The pilot copied the number to his pad, thanked the controller for his help, and promised to call.

  The power was reduced, of course, and fuel consumption was about half that of cruise. But the numbers on the totalizer suggested that his remaining fuel could be exhausted at any second. Keeping rather higher than usual, he approached runway 16/34 from the east and slightly north, intending to land on 16. He announced his position and intention on the CTAF, mentioning his fuel situation and requesting priority. Only one other airplane was on frequency, a pilot on the ground who was taxiing for takeoff on 34. But he responded that he would hold short until our pilot had landed.

  Making a high left-base entry, the pilot intercepted final well above the normal glide angle; finally, when a glide to the runway was more than assured, he reduced power, added flaps, and even slipped a bit to give up the last of his altitude, taking no chance of coming up short should the engine quit in the last seconds before touchdown.

  The landing was long--there was only a slight tailwind, but final-approach speed had been well above normal--and the Piper floated considerably; another factor was the nearly complete lack of fuel in the tanks. Touchdown was somewhere near the middle of the 3000-foot runway. As he rolled out to the south end, the pilot noticed the Cessna awaiting takeoff. Its pilot waved, and he returned the salute. Safe!

  The engine continued to operate as he taxied to the self-service pumps at the south end of the ramp. He braked to a stop and reflected briefly on the adventure, surprised at how quickly life could return to normal after such emotionally intense events. Here he was, taxiing for fuel as he had done two hundred times before, and now shutting down normally, as he had done five hundred times before. All three wheels were on asphalt; nothing was bent.

  According to the totalizer: 3.9 gallons remained in the two tanks. Unusable fuel, as noted above, is 5.0 gallons for the Cherokee. Thank heaven for smooth air--and for a left turn from base to final!

  After sitting a few more moments to reflect on the events of the last forty-five minutes, the pilot climbed out, walked a safe distance from the airplane, and took out his cell phone. He then called Seattle Approach to report his safe arrival and to thank the controller for his help.

Lessons

Several lessons emerge from this story. First, make that call ("Reach Out"). Second, an outlook briefing the night before, by itself, is insufficient. Third, if it doesn't look right, check it out; find out why.

  There are other, less general lessons, too. When the view ahead is a carpet of clouds, cross-check your position with the VOR. If your destination lies near the edge of your aeronautical chart, have the next chart open and glance at what lies ahead. Should you nevertheless find yourself with an emergency that requires quick landing, consider alternatives other than simply completing the original plan. Last, and certainly not least, carry a Flight Guide in case you end up somewhere you didn't expect to. (See Oregon, page 3 for Albany.)

Postscript

In case you're wondering, filling the left tank--the one that ran dry in flight--to capacity took 23.9 gallons of fuel. The right tank needed 22.5 gallons. With just 2.5 gallons remaining on the right side, and if we assume, by analogy to the left tank, that 1.1 gallons would have been unusable, then there was a grand total of 1.4 gallons of usable fuel--and maybe less--remaining on the airplane. That's about nine minutes in level cruising flight at 7500 feet. Had the decision to check location been deferred even a couple of minutes longer; or had the air been rough, unporting the fuel line sooner; or had the turn to final been toward the right tank; the outcome of this flight could have been . . . unpleasantly different.

  In other words, there exists another chain besides the chain of mistakes; that is a chain of--what shall we call them--mercies, perhaps?

  One hopes that this pilot can say, as Flying magazine entitles its monthly feature, "I Learned About Flying From That," or, as AOPA's Pilot magazine puts it, "Never Again."