"Get-Home" Syndrome Leads to CFIT

The pilot and three passengers had just spent a weekend at a Florida "Sun ‘n’ Fun" fly-in, and woke up at 07:00 Eastern Daylight Time (EDT) on Monday, in preparation for the 11:00 EDT departure for the return trip. They landed in Hamilton, Ontario at approximately 21:40 EDT to clear customs, and departed for Brampton, Ontario at approximately 22:15 EDT. Shortly after departure, the pilot contacted the Toronto terminal radar service area (TRSA) and requested an instrument flight rules (IFR) clearance because he had encountered deteriorating weather conditions. While flying the instrument approach to Brampton Airport, the aircraft struck the terrain and crashed. Two of the three passengers were seriously injured and the pilot was killed.

In Final Report A93O0115, the Transportation Safety Board of Canada (TSB) determined that the pilot descended below the final approach fix (FAF) altitude before he had established the aircraft on the final approach radial and before he had reached the FAF. The aircraft continued to descend below the minimum descent altitude (MDA) until it struck the terrain.

The VOR/DME A approach flown into Brampton was new and became effective on April 1, 1993 — 18 days before the occurrence. After being cleared for the approach, the aircraft flew through the final approach radial and the air traffic controller issued the pilot with a vector to re-intercept the final approach radial. The radar showed that, although the pilot flew the new vector to re-intercept, the aircraft remained east of the final approach radial and, once the descent started, the aircraft maintained approximately the same rate of descent until it disappeared from the radar screen.

Among its findings, the TSB said that fatigue may have played a role in the accident. The group had been awake for 16 hrs at the time of the accident, and the pilot had assumed the entire workload for the trip. The customs agent at Hamilton later reported that the group appeared tired. The 16-hr day that the pilot had already endured and the unplanned flight into instrument meteorological conditions (IMC) requiring him to fly a new instrument approach procedure surely resulted in a much heavier workload. The pilot had relatively little instrument flight experience, having accumulated only 54 hrs in actual IMC.

The "get-home" syndrome — We all know what that is, and most of us have experienced it. Somehow it is hard to ignore or conquer. The self-induced pressure to make it back home as planned is very powerful, and it has killed more people than we dare to count. Did it play a role in this accident? Most likely. The group was almost home, it was relatively late at night, and the prospect of spending the night in Hamilton was probably not even discussed, as there was no evidence found that the pilot had requested any weather information or filed a visual flight rules (VFR) flight plan for the flight from Hamilton to Brampton.

In the end, the TSB was unable to determine officially why the pilot descended below the FAF altitude before he had established the aircraft on the final approach radial and before he had reached the FAF. However, the most probable cause is pilot error owing to a combination of the following contributing factors: fatigue, heavy workload in demanding environmental conditions, limited instrument experience in actual IMC, and the "get-home" syndrome.