• Cessna 172 Wire Strike

    CEN18FA011
    Ramsey, MN October 13, 2017
    Fatal: 2

    Analysis:

    After takeoff, the pilot proceeded south until reaching the Mississippi River when he proceeded to fly along the river at a low altitude. As the airplane approached a bend in the river, the pilot entered a shallow left turn to follow the river. The airplane subsequently struck power lines spanning the river that were located about 200 yards beyond the bend. Ground-based video footage and witness statements indicated that the airplane was at or below the height of the trees lining both sides of the river shortly before encountering the power lines. One witness initially thought that the pilot intended to fly under the power lines due to the low altitude of the airplane. Several witnesses also noted that the sound of the engine seemed normal and steady before the accident. A post-recovery examination of the airplane did not reveal any anomalies consistent with a preimpact failure or malfunction. The power lines were below the level the trees on either side of the river. Red aerial marker balls were installed on the power lines at the time of the accident. Weather conditions were good at the time of the accident; however, the sun was about 9° above the horizon and aligned with the river. It is likely that the position of the sun in relation to the power lines hindered the pilot's ability to identify the hazard as he navigated the bend in the river at low altitude. In addition, the location of the power lines relative to the river bend minimized the reaction time to avoid the lines. FAA regulations prohibit operation of an aircraft less than 500 feet above the surface in uncongested areas unless approaching to land or taking off, and at least 1,000 feet from obstacles in congested areas. They also prohibit operations in a reckless manner that endanger the life or property of another. Based on the available information, the airplane was less than 100 feet above the river and within 400 feet of the residences located along the river during the final portion of the flight. The pilot's flight instructor described the pilot as "reckless" because of his habit of low-level flying. While the location of the bend in the river and the position of the sun relative to the power lines may have hindered the pilot's ability to see and avoid the lines, it was the pilot's decision to operate the airplane along the river at a low altitude contrary to applicable regulations and safety of flight considerations that caused the accident.

     

    Probable Cause

    The National Transportation Safety Board determines the probable cause(s) of this accident to be: The pilot's decision to fly along the river at a low altitude contrary to applicable regulations and safety of flight considerations which resulted in the impact with the power lines. Contributing to the accident was the pilot's inability to see the and avoid the power lines due to their proximity to a bend in the river and the position of the sun at the time of the accident.

     

    Lessons:

    Low-level flying is hazardous and should be avoided unless it is absolutely necessary. This accident illustrates the increased danger of striking objects such as wires. Additional hazards associated with low-level flying include increased bird activity and greater susceptibility to wind shear and other thermal anomalies. Flying at a higher altitude also provides more options to deal with an emergency situation.

     

    As noted in the photo, if low-level flying is necessary, be aware that wires are nearly invisible from the airplane. Watch for poles or transmission towers. Assume that there are wires running between them.

    The photo above shows the propeller blade with a visible gouge and evidence of electrical arcing.

    NTSB Photo

     

    Click here to see the entire NTSB report

  • Beech Bonanza - Decision Making After Power Loss

    WPR15FA222
    Riverside, CA July 26, 2015
    Fatal: 1

    Analysis The official NTSB accident report states, “The private pilot was receiving vectors for an instrument landing system approach during daytime visual flight rules conditions when he advised the controller that the engine had lost power and that he needed to land at a nearby airport located northeast of his position. The controller responded with the distance and direction from the airport and asked the pilot if he had the airport in sight, which he acknowledged. The controller advised the pilot to proceed inbound to the airport, told him that he could land on the runway of his discretion, and asked him to tell him which runway he was going to use; however, the pilot only responded that he was going to land into the wind. The controller repeated that the runway was at his discretion and the pilot repeated that he was going to land into the wind. Shortly after, the controller provided the pilot with the current weather conditions at the airport, which included wind from 280° at 12 knots gusting to 18 knots, and he then cleared the pilot to land on runway 27. Subsequently, the pilot responded that he was not going to make it to the airport. No further radio communications were received from the pilot.”

    The radar plot of the flight indicated that the airplane was at about 1,644 feet above ground level and on a heading of 094 degrees when the pilot reported that engine power was lost. The approach end of Runway 34 was only 1.65 nm northeast of the airplane’s position. The approach end of Runway 09 was 1.74 nm northeast of the airplane’s position. The approach end of Runway 27, the pilot’s choice for the landing was 2.3 nm to the northeast. The pilot had about a 12-knot headwind to reach any runway, but a landing on Runway 34 would have required only about a 90-degree turn to line up, while Runway 27 would have required about a 180-degree turn to line up. However, the pilot did not attempt to fly directly toward either of the runways, but flew what appears to be an attempt at a normal left hand traffic pattern for Runway 27.

    Also, the pilot operating handbook for the F35, section III, Emergency Procedures, page 3-6 states in part:

    "MAXIMUM GLIDE CONFIGURATION
    Landing Gear – UP
    Flaps – UP
    Cowl Flaps – CLOSED
    Propeller – LO RPM
    Airspeed – 105 Knots/121 MPH

    Glide distance is approximately 1.7 nautical miles (2 statute miles) per 1,000 feet of altitude above terrain."

    The NTSB determined that the flaps were extended to about the 20-degree position and that the landing gear was down. This configuration would have significantly decreased the glide distance.

     

    Probable Cause

    The National Transportation Safety Board determines the probable cause(s) of this accident to be:“The total loss of engine power for reasons that could not be determined during postaccident examination of the airplane and engine. Also causal to the accident was the pilot's decision to attempt to reach the farthest runway and land into the wind instead of conducting a crosswind or downwind landing at a closer runway following the loss of engine power.”

     

    Lessons

    This is an example of the need for rapid decision making. There was not a lot of time to ponder the decision, but a few seconds could be spent on analysis. It seems obvious that the pilot had a strong bias toward landing into the wind regardless of circumstances. That bias was evident in his initial response to the controller that he would land into the wind. Once he made that decision, confirmation bias apparently set in and he did not do further analysis of the situation. He most likely could have reached a runway crosswind runway, Runway 34.

    Rapid analysis requires us to draw on our training and experience to help us make a good decision. We do not know how long it had been since the pilot had been presented with a simulated engine-out situation. Recurrent training can help us make better rapid decisions. Had this pilot participated in recent recurrent training that included power loss scenarios, it seems likely that he would have known to head for the nearest runway and the recommended procedure for this airplane, including best glide speed and the need to leave the flaps and landing gear retracted.

     

  • Piper PA28-140 Deficient Maintenance

    CEN17FA139
    Stonewall, TX March 25, 2017
    Fatal: 1

    Analysis The airplane owner and a mechanic completed the airplane's annual inspection the morning of the accident. The mechanic did no work but returned the airplane to service with an endorsement that the annual inspection/airworthiness requirements had been met based on his determination that the engine runup was satisfactory. The airplane departed but returned to the airport shortly after the departure. During the return, a witness said that the airplane was "way too high," and its approach was "pretty steep." The airplane touched down about halfway down the short-grass runway and was "going way too fast." The airplane overran the end of the runway and into a pond where it became submerged. Postaccident examination of the runway revealed the presence of skid marks from the airplane main landing gear wheels along the last 300 ft of the runway.

    The propeller exhibited rotational signatures but with some loss of torque. Postaccident examination of the airplane revealed numerous unairworthy maintenance items and/or lack of maintenance to the engine and accessories; further the engine and various accessories surpassed their manufacturers' recommended time for overhaul/replacement. The exhaust manifold was blocked with internal fractured pieces that would have resulted in power loss. The condition of these pieces was consistent with a failure that had been preexisting. The induction hose to the carburetor was the wrong part for the installation. The hose was collapsed and would have restricted airflow into the carburetor resulting in power loss. Both magnetos were no longer serviceable and would have produced minimal ignition. The engine timing was not set to the engine manufacturer's specification. Had the mechanic conducted a proper annual inspection, he would have identified many of the issues found during the airplane's postaccident examination.

    Based on the evidence, the pilot likely returned to the airport due to a loss of engine power. It could not be determined which of the many discrepancies led to the loss of engine power. Further, the pilot did not attain a power-off approach glideslope that would have led to a proper touchdown point near the approach end of the runway.

     

    Probable Cause

    The National Transportation Safety Board determines the probable cause(s) of this accident to be:
    The pilot's failure to attain a proper touchdown point following a loss of engine power and his inability to stop the airplane on the short, soft runway. Contributing to the accident was the inadequate maintenance of the airplane by the owner and the mechanic and the improper annual inspection by the mechanic.

     

    Lessons

    Unfortunately, this is a much more common practice than we would like to think. I have been personally aware of pilots who knew somebody who held an IA rating on his/her mechanic certificate who would provide a sign-off to an annual inspection without actually checking the airplane. We all know that quality aircraft maintenance is expensive. But what price do we put on our own well being and the well being of our family and passengers? If the money for quality maintenance is not available, it is time to reconsider aircraft ownership. There are some excellent flying clubs available and an aircraft partnership may provide a solution.

    NTSB Photo (White rectangle is protecting identity of recovery personnel)

     

    Click here to see the entire NTSB report

  • Beech Bonanza Wake Turbulence

    WPR16FA172
    Sparks, NV August 30, 2016
    Fatal: 2

    NTSB Analysis

    The 73-year-old commercial pilot was on the fourth and final leg of a 950-mile round trip same day flight. As the airplane neared the airport, the pilot was told by the air traffic controller to

    expect runway 25 for landing. After the controller informed him of a delay for that runway, the

    pilot stated that he could accept runway 16L; the pilot was told to proceed for runway landing,

    but the runway was not specified, an instruction which he acknowledged. Shortly after

    establishing contact with the tower controller, who instructed the pilot to continue for runway

    25, the pilot reported that the airplane was on a downwind leg for landing on runway 16L. The

    controller acknowledged and, rather than correcting the pilot, instructed him to continue

    inbound for 16L. At the time, runway 16R was being used for landing by two Boeing 757 (B757)

    airplanes in sequence, separated from each other by about 7 miles. The controller advised the

    accident pilot that a B757 was on a 9-mile final for runway 16R and cautioned him about wake

    turbulence, then cleared the accident airplane to land. Shortly thereafter, the pilot reported

    that he had "the airliner" in sight. At this time, one of the B757s was on a short final approach

    for 16R, about 4.5 miles ahead of and below the accident airplane. The other B757, which was

    the potential conflict, was about 5 miles away from the accident airplane at its 2-to-3-o'clock

    position. Given that the pilot's attention was likely focused toward the runway during this

    portion of the approach, it is likely that he misidentified the ATC-reported traffic as the B757

    on short final, which landed soon after and likely resulted in the pilot relaxing his vigilance in

    looking for traffic. Shortly thereafter, the controller issued an all-aircraft advisory that the wind

    was from 250° at 17 knots with gusts to 20 knots. Although these wind conditions met or

    exceeded the airplane's maximum demonstrated crosswind capability for a landing on 16L, and

    the airplane was still well-positioned to revert to an approach to runway 25, the pilot continued

    toward 16L.

    About 70 seconds after the pilot reported sighting the traffic, just after turning the airplane

    onto the base leg of the traffic pattern, the B757 passed about 1 mile ahead of and about 100 ft

    below the accident airplane. The investigation was unable to determine whether the pilot saw

    that B757, or if he did, whether he was cognizant of the potential for a wake vortex encounter

    and the flight path alterations necessary to avoid such an encounter. The pilot made no radio

    communications or flight path adjustments to indicate that he saw the B757 or tried to avoid its

    wake.

    According to witnesses, the airplane's flightpath appeared normal as it approached the runway

    for landing. When the airplane was on about a 1/2-mile final approach, at an altitude of less

    than 200 ft above ground level, it suddenly rolled and descended to the ground. Ground scars

    and debris distribution was consistent with a near-vertical descent and impact. Examination of

    the wreckage did not reveal any evidence of pre-impact mechanical deficiencies or

    malfunctions that would have precluded normal operation. A wake vortex analysis study

    revealed that the airplane most likely encountered the wake vortices that were generated by a

    B757 landing on the parallel, upwind runway. The vortices were of sufficient size and strength

    to radically upset the airplane at an altitude too low to recover.

    Had the controller informed the pilot that there were two B757s on final approach for 16R, it is

    likely that the pilot's traffic situational awareness would have been more complete. The pilot

    likely would have altered his traffic scan or questioned ATC further to ensure that he had

    identified the correct B757. The pilot's radio communications did not indicate any doubt about

    whether he had properly identified his traffic, and in postaccident interviews, the controller

    stated that he was certain that the pilot had correctly identified it. Had either the controller or

    the pilot specified the location of the traffic once the pilot reported it in sight, that information

    would have significantly improved the likelihood of detecting the pilot's identification error.

    The safety of the approach sequence was dependent on assured separation of the airplane from

    the B757 and its wake. In this case, because both airplanes were being controlled by ATC in a

    radar environment, aircraft and wake turbulence (vortex) separation was the responsibility of

    the controller until explicitly transferred to the accident pilot. Although ATC requirements to

    apply pilot-based visual separation had been satisfied and it was the controller's intent to have

    the accident pilot maintain visual separation from the B757, the controller relinquished his

    separation responsibility without explicitly transferring that responsibility to the accident pilot.

    As a result, no separation services were being provided by the controller. The accident pilot's

    likely misidentification of his traffic, the controller's lack of awareness of that apparent error,

    and the controller's failure to monitor, detect, or intervene in a situation conducive to a wake

    vortex encounter enabled the accident to occur.

    At the time of the accident, the pilot had been awake about 14.5 hours and had flown about 8.5

    hours that day. Given the pilot's experience level, it is unlikely that he was not aware of the

    effect of either the extreme landing crosswinds or wake vortex behaviors and hazards, but for

    reasons that could not be not determined during the investigation, the pilot nevertheless

    continued his approach to land on 16L. Investigators were also unable to determine the effect

    of the pilot's long duty day on his mental acuity or explain the reasons behind several of his

    actions and decisions, including his vague communications with ATC regarding the landing

    runway, his decision to forego landing on a runway more favorable to the wind conditions, and

    his misidentification of the conflicting traffic.

     

    NTSB Probable Cause

    The pilot's selection of a landing runway which, given the wind and traffic conditions, was

    susceptible to high crosswinds and the translation of wake turbulence across its approach path,

    and the controller's and pilot's failure to ensure separation from the B757 and its wake, which

    resulted in a low-altitude encounter with wake vortices that the pilot was unable to recover

    from.

     

    Lessons

    Wake turbulence is sneaky. It is there and it is a very real hazard but it is invisible. Any pilot who routinely flies into air carrier airports has heard the warning, "caution wake turbulence" many times. Those who have never had an encounter with wake turbulence and have lived to tell about it tend to become complacent. Whether or not complacency played a role in this accident, we will never know. The pilot did acknowledge seeing one large airliner landing and apparently mistook that airplane for the airplane that posed the real threat. Was he confident that the threat had passed or did complacency prevent him from questioning whether that was airplane in question? In any case, he did not have the necessary situational awareness. Maintaining situational awareness when landing at a busy airport with large airplanes is not easy. In this case, the pilot was most likely to suffering from some fatigue which is detrimental to good situational awareness.

    We can learn from this that wake turbulence is a very real threat and we must never allow ourselves to be complacent about it. I was once rolled 360 degrees at altitude by the wake of a B-52. On another occasion, I was rolled 45 degrees or more in the traffic pattern by the wake of a large airplane. Obviously, I was able to recover in both instances, but either of them could have ended badly for me. For more information, view my YouTube video, "Wake Turbulence Essentials."

    Another lesson is that we need to avoid fatigue when we fly. This pilot was on the final and fourth leg of a 950 mile round trip same day flight. That is a lot of flying for one day for a single pilot. Fatigue has an adverse effect on many of our abilities, including the ability to maintain situational awareness. The only remedy for fatigue is sleep. Coffee and other products can help mask it which might actually increase the danger.

  • Grumman AA1 Fuel Exhaustion

    ERA17FA299
    Portland, TN August 29, 2017
    Fatal: 2

    Analysis The private pilot and the passenger were making a local personal flight in the airplane. According to witnesses, the airplane was flying "low" in the vicinity of the runway when it collided with trees and impacted terrain in a nose-down attitude. Examination of the airplane revealed that the fuel selector was in the left tank position; there was no fuel in the left tank or in the fuel lines, and there was less than 1 teaspoon of fuel in the electric boost pump. Therefore, it is likely that the engine lost power because of fuel exhaustion.

    At an unknown time, the airplane's original 108-horsepower engine had been replaced with a 150-horsepower engine. An updated pilot operating handbook or operating handbook supplement that would have provided fuel consumption figures for the higher horsepower engine was not located. When the accident occurred, the airplane had been flown about 2.23 hours since it had been fully fueled. Based on the estimated fuel burn rate of between 8.8 and 10 gallons per hour provided by the engine manufacturer for the 150-horsepower engine, the airplane likely would have consumed its entire usable fuel capacity of 22 gallons about the time of the accident.

     

    Probable Cause

    The National Transportation Safety Board determines the probable cause(s) of this accident to be:

    The pilot's improper fuel planning, which resulted in a total loss of engine power due to fuel exhaustion.

     

    Lessons

    The big question here is why the pilot did not put more fuel in the airplane. The NTSB cites the lack of accurate fuel consumption data available. Perhaps, but the pilot had owned the airplane for about nine months prior to the accident. It seems like he should have had a good estimate on the fuel burn. In any case, the full NTSB report states that the airplane had been flown about 1.4 hours prior to this flight. That would indicate that the accident flight lasted only about 0.8 hours. A visual check of the fuel quantity should have revealed a low level. The lesson here is simple. Always know how much fuel you have and know the expected rate of fuel consumption. And, of course, always do a visual check of the fuel quantity.