• Cessna 172 Wire Strike

    CEN18FA011
    Ramsey, MN October 13, 2017
    Fatal: 2

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    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

  • Piper Arrow

    CEN19CA017
    Hobbs, NM October 27, 2018
    Uninjured: 3

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    Analysis The official NTSB report states, "The pilot reported that he entered a left traffic pattern for runway 30 during night, visual meteorological conditions. Although the pilot thought he had sufficient altitude during the initial phase of the final approach based on his altimeter indication, shortly after turning to final approach, the airplane impacted terrain."

     

    "The airplane sustained substantial damage to the right wing and fuselage, and the three occupants were not injured.:

     

    "Postaccident examination of the airframe and engine revealed no evidence of preaccident mechanical failures or malfunctions that would have precluded normal operation. The examination did reveal that the altimeter had an incorrect setting, which resulted in an altimeter indication error of +800 ft mean sea level. The pilot stated that he must have had the incorrect altimeter setting for the destination airport."

     

    Probable Cause

    "The pilot's incorrect altimeter setting during the night visual approach, which resulted in a controlled flight into terrain"

     

    Lessons

    Though this accident resulted in only property damage, different terrain could have provided a tragically different outcome. The obvious lesson is easy to state but more difficult to accomplish. We need to be attentive to the details, especially the ones that we have done hundreds of times before. Whether it be setting the altimeter, reading an altitude from a chart, switching fuel tanks, or any one of the many small tasks we accomplish as part of a flight, attention to detail counts.

     

    All that being said, I must confess that I once flew an instrument flight with my altimeter set 1 in. Hg. in error causing me to fly precisely 1,000 feet lower than my clearance. Ironically, I was enroute from Utica, New York to Albany, New York, to take my instrument flight instructor checkride with the FAA. The weather was IFR in Utica but clearing in Albany. I filed my IFR flight plan for the lowest possible altitude, (MEA) 3000 feet, because the flight was less than 100 miles and the terrain below as relatively flat. The airplane had been in the hangar for about a week due to a long stretch of nasty weather. There had been a large change in barometric pressure during that time. As a very active flight instructor, I was not accustomed to flying airplanes that had been sitting for long periods. The altimeter setting usually only needed a very slight adjustment before takeoff. I apparently set the last two digits and ignored the first two, causing me to be flying 1,000 feet lower than I thought. ATC had no means of knowing my altitude back then. They relied entirely on what the pilot reported. Since I had gone into clouds soon after departure, I was not aware of the error until I broke out of the clouds while still at my cruise altitude. The trees below appeared to be much nearer than they should have been. I keyed the mic and asked for the current altimeter setting. My error was quickly confirmed and I climbed up to where I was supposed to be. I did not mention anything to ATC about my error. I was probably fortunate that I had filed for the lowest possible altitude, 3,000 feet. There was no opposite direction below me. Had I decided to fly at 5,000 feet for my easterly heading, I would have actually been at 4,000 feet and might have met up with a westbound airplane flying the reverse direction on the same route.

     

    Click here to see the entire NTSB report

     

  • Cessna 172 Night CFIT

    New Orleans, LA August 27, 2016
    Fatal: 2

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    The official NTSB Accident report states in part, Shortly after sunset, the pilot with two passengers departed on a local sightseeing flight of the city. The flight flew around the city, then proceeded back to the airport after civil twilight. The final portion of the flight and the landing approach were conducted over a lake. A review of radar's last return revealed the airplane about 0.6 miles from the airport at an altitude of 100 ft agl. The surviving passenger reported everything appeared normal during the flight, and as they neared the airport, it started to rain, and visibility was poor. The pilot pointed out 4 four red lights ahead of the airplane and stated to the passengers that was the airport. The passenger added that she could see out the side window and the airplane was about 4-6 ft. above the surface of the lake. Shortly thereafter, the airplane impacted the lake.

     

    Postaccident examination of the airplane did not reveal any anomalies that would have

    precluded normal operation. A review of weather information noted the presence of

    thunderstorm activity and isolated rain showers in the area at the time of the accident.

     

    The pilot's toxicology report was positive for ethanol and clomipramine. Due to a delay in the

    recovery, it is likely that most, if not all, of the ethanol was from postmortem production.

    Clomipramine is a tricyclic antidepressant used to treat symptoms of obsessive-compulsive

    disorder. Clomipramine is not considered impairing. Additionally, the pilot's actions and

    communication with the passengers also indicate that the pilot did not experience a seizure or

    incapacitation, so a reaction to his medication was not likely.

     

    With reduced visibility due to rain and night conditions, it is unlikely the pilot could see the

    water. The four red lights, consistent with the runway's precision approach path indicator

    (PAPI) that the pilot pointed out to the passengers, reflected the airplane's low approach path.

    The accident is consistent with the pilot continuing the descent, while already below a normal

    approach path to the airport, which resulted in the controlled flight into terrain.”

     

    The NTSB Docket includes a “Memo for Record” of a phone conversation between the FAA inspector and the NTSB inspector. The contents of the memo includes:

     

    Narrative:

    During the initial call, the inspector made the following points:

    • People said that he had the habit of flying too low [ on the approach]
    • Passenger reported the pilot said  four red lights – “that’s the runway” 

     

    During a follow-up email, the inspector reported a conversation with a individual:

    • Said pilot always flew low on the approach 
    • Pilot did not use flaps for landings 

    NTSB probable cause: “The pilot's improper decision to continue a descent during a night visual approach a for landing which resulted in controlled flight into terrain. Contributing to the accident was the reduced visibility and pilot's disregard of the PAPI indications that the airplane's approach

    path was excessively low.”

     

    For our analysis of this accident I must say that I find it puzzling. The flight was conducted as an air tour flight with paying passengers. The pilot held a commercial pilot certificate with an instrument rating, current flight review and a current medical certificate. On his application for his medical certificate about three moths prior to the accident, he reported having more than 9,000 hours total flight time with 170 hours in the previous six months. The report does not indicate how much flying the pilot had done in the previous 24 hours so we can neither include nor eliminate fatigue as a factor.

     

    It was a dark night. According to information from the United States Naval Observatory, at the time of the accident, both the sun and the moon were more than 15° below the horizon. Those conditions are tricky for an inexperienced pilot, but this experienced pilot should have known to do two things. First, know the elevation of the lake, add a comfortable margin (200 feet for me) and do not go below that altitude until landing is assured. Second, the PAPI was clearly indicating that the pilot was dangerously low. Seeing four red lights should be a cause for an immediate go-around regardless of distance from the airport.

    Of course, the pilot was instrument rated and the Pilot/Operator report states that the airplane was instrument equipped. Had the rain showers and the associated reduced visibility been an issue, the option to request and instrument clearance was an option. It was supposed to be a sight seeing flight and going IFR does not fit that mission, but disappointing passengers is always preferable to killing them. There was no information provided as to whether the pilot was instrument current. If he was not, that might have been his reason for remaining VFR.

     

    There are several lessons that can be learned from this.

    1. We cannot allow ourselves to become complacent regardless of how fat our logbook has become.
    2. Each flight must be carefully planned, including an alternate course of action if things are not going as expected, such as rain showers reducing visibility.
    3. Night VFR flights are much more challenging and require more planning than day VFR flights.
    4. Never fly lower than what is reasonable and necessary. Altitude is our friend.
  • Cirrus SR22 Spatial Disorientation - Impaired

    WPR15FA082
    Tooele, UT January 9, 2015
    Fatal: 1
     
    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.
     
    Analysis The official NTSB accident report states, "The noninstrument-rated private pilot departed during the late afternoon and flew over the southern portion of the Great Salt Lake. According to data recovered from the airplane's avionics system, which did not capture altitude, the duration of the flight was about 9 minutes. During the final minute of the flight, the airplane conducted a gradual left turn at an engine power setting of about 2,200 rpm. Shortly thereafter, the airplane impacted the lake. Postaccident examination of the airplane revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation."
     

    "Local meteorological observations indicated that restricted visibility and fog were forecast throughout the area about the time of the accident. It is likely that the pilot encountered these conditions inflight and lost visual reference to the ground and/or horizon. Given the pilot's lack of an instrument rating and of recent instrument flight experience, the loss of visual reference likely resulted in spatial disorientation."

     

    "Toxicological testing on the pilot revealed the presence of bupropion, an antidepressant; hydrocodone, an opiod analgesic; and diphenhydramine, a sedating antihistamine. The investigation was unable to determine if the use of bupropion or the cognitive effects of any underlying depression contributed to the accident. Because the hydrocodone was found in the urine but not the blood, it no longer caused systemic effects and played no role in the accident. However, it is likely that the effects of diphenhydramine impaired the pilot's cognitive and psychomotor performance at the time of the accident, and contributed to his spatial disorientation."

     

    Probable Cause

    "The non-instrument rated pilot's decision to depart into low visibility conditions, which resulted in spatial disorientation and a loss of control. Contributing to the accident was the pilot's impaired performance due to his use of the sedating antihistamine, diphenhydramine."

     

    Lessons

    This pilot, like so many others have done, apparently overestimated his ability to fly the airplane low visibility conditions. The NTSB full report indicates that the pilot did not have an instrument rating, though he did begin instrument training a couple of years earlier. His last instrument training flight occurred about 18 months prior to the accident flight.

     

    As stated in the NTSB accident report, "However, it is likely that the effects of diphenhydramine impaired the pilot's cognitive and psychomotor performance at the time of the accident, and contributed to his spatial disorientation." The cognitive impairment may have contributed to the pilot's decision to begin the flight in the low visibility conditions. The pilot was a medical doctor and most certainly was aware of the impairing effects of diphenhydramine. The NTSB has recommended that a pilot not fly for a minimum of 60 hours after the last dose of diphenhydramine. Yet, the pilot decided to fly. Perhaps his decision making was so heavily influenced by his impairment that his medical knowledge was simply overpowered. We cannot know what influenced his decision, but we must be aware of the negative effects of flying while impaired. In case you are not familiar with diphenhydramine, it is the active ingredient in many OTC cold and allergy medications.

  • Luscombe 8F Hand Propping

    Vicksburg, MI March 20, 2017
    Fatal: 1

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path..

    The NTSB roport includes the following: "On March 20, 2017, about 1644 central daylight time, the pilot of a Luscombe 8F, N2007B, was struck by the airplane's propeller as he attempted an engine start at Thrall Lake Airport (7MI3), Vicksburg, Michigan. The commercial pilot was fatally injured, and the airplane did
    not sustain damage. The airplane was registered to a private individual and operated by the
    pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight.
    Visual meteorological conditions prevailed for the flight that was originating when the accident
    occurred, and no flight plan was filed.


    According to the local police report, on the afternoon of the day of the accident, the pilot's wife
    called a friend of the pilot to inquire about the whereabouts of her husband. After attempting
    to contact the missing pilot, the friend drove to the airport where he observed the pilot lying on
    the grass under the nose of the airplane with a fatal head injury. The friend reported the
    accident to the police about 1844.


    The airport owner responded to the airport at the request of the police; he thought the pilot
    was attempting to start the airplane by hand propping it when he was injured. The magneto
    switch was in the "Both" position; the throttle was at idle; the primer was in the unlocked
    position; and the fuel tank selector "was in the 'ON' position." Additionally, the owner stated
    that it appeared that the pilot was intending to fly the airplane given that the airplane was
    refueled, and the left tire was chocked as the pilot always did when preparing for a flight.
    According to the airport owner, the accident occurred after his employees left the airport about
    1600.


    The owner of the airplane stated that the pilot had been flying the airplane for about 15 years.
    He believed that the pilot "had extensive knowledge of the use and precautionary measures
    needed" to hand prop the engine, which was the normal starting procedure for the airplane.
    According to the owner, there were no known malfunctions or failures with the propeller,
    airframe, or engine that would have precluded normal operation.


    The Federal Aviation Administration's (FAA) Airplane Flying Handbook states that hand
    propping an airplane "is a critical procedure never [to] be attempted alone. And propping
    should only be attempted when two properly trained people, both familiar and experienced
    with the airplane and hand propping techniques, are available to perform the procedure." The
    handbook describes the recommended procedure and communication/commands to be used
    when hand propping.


    The Department of Pathology, Western Michigan University, Kalamazoo, Michigan, performed
    an autopsy of the pilot and determined that the cause of death was craniocerebral injuries. The
    FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed
    toxicology testing on specimens from the pilot. The toxicology results were negative for ethanol
    and drugs."

     

    NTSB Probable Cause: "The pilot's inadvertent contact with the propeller while hand propping the engine, which resulted in a fatal injury."

     

    The lesson here is simple, but sometimes difficult to follow. Hand propping an airplane is extremely dangerous, but sometimes it is necessary. In the case of this pilot, the airplane was an antique that was normally started by hand propping. If he wanted to fly, somebody had to hand prop the airplane. The procedure probably seems strange to many, but when I learned to fly in the Piper Cub and in the Piper PA17 Vagabond, that was the only to start the airplane. I have hand propped many other airplanes over the years because of dead batteries.

     

    But all that being said, it is a very dangerous operation. The risk can be mitigated substantially by following a few simple rules and being trained by someone who is experienced in the procedures. Preferably, a qualified pilot is at the controls holding the brakes while someone else who is qualified spins the prop. It is also preferable to have the airplane tied down just in case the brakes don't hold, the surface is slippery allowing the tires to skid, or a foot slides off a brake pedal at a bad time. It is never a good idea to attempt this as a solo operation. As I look back, I did not always follow those rules which means I was very lucky. I would not violate any of those practices today.

     

    Here is something else to think about. In the case of a dead battery, there may also be a problem with flying an airplane with a compromised battery. For example, a retractable landing gear system often requires battery power in addition to alternator power to operate.

     

    Click here to see the NTSB report on the NTSB website.

  • Piper Malibu Improper Fueling

    Spokane, WA Feb. 22, 2015
    Fatal: 1

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    The NTSB accident reports includes the following, “The pilot was conducting a cross-country flight from Canada to California and had landed to clear customs into the United States and to refuel his airplane. The pilot then departed to continue the flight. During the initial climb after takeoff, the engine experienced a total loss of power, and the pilot attempted to make an off-airport forced landing. The right wing struck railroad tracks at the top of a hill, and the airplane continued down an embankment, where it came to rest adjacent to the bottom of a railroad bridge.

     

    Postaccident interviews revealed that, when requesting fuel from the fixed-base operator (FBO), the pilot did not specify a grade of fuel to be used to service the airplane. The refueler mistakenly identified the airplane as requiring Jet A fuel, even though the fuel filler ports were placarded "AVGAS (aviation gasoline) ONLY." The fueler subsequently fueled the airplane with Jet A instead of aviation gasoline. Additionally, the fueling nozzle installed on the fuel truck at the time of the refueling was not the proper type of nozzle. Jet A and AvGas fueling nozzles are different designs in order to prevent fueling an airplane with the wrong type of fuel.”

    NTSB Graphic showing fuel placard

    “Following the fueling, the pilot returned to the FBO and signed a receipt, which indicated that the airplane had been serviced with Jet A. There were no witnesses to the pilot's preflight activities, and it is unknown if the pilot visually inspected or obtained a fuel sample before takeoff; however, had the pilot done this, it would have been apparent that the airplane had been improperly fueled.”

    NTSB Graphic Excerpt showing fuel receipt

    The NTSB probable cause states, A total loss of engine power due to the refueler's incorrect refueling of the airplane. Contributing to the accident was the fixed-base operator's improper fueling nozzle, which facilitated the use of an incorrect fuel, and the pilot's inadequate preflight inspection.”

     

    What lessons should we take away from this accident? Don’t dismiss this being unrelated to your flying just because you may not fly an airplane that can be confused with a turboprop. Incorrect fueling can take several forms. Fueling with the incorrect type of fuel is only one. Water or other contaminates can be in the fuel provided by an FBO. This is not common, but it does happen on occasion. There have been accidents caused because a fueler topped off the wrong airplane and the pilot did not check the fuel level before departure. Another accident was caused because a pilot ordered a “top off” but the fueler was confused with another order and only added five gallons per side. On the other side of that, there was an accident in which a fueler topped off an airplane that was only supposed to receive a few gallons per side due to weight restrictions. The pilot did not detect the error and ran off the end of the runway while attempting an overweight takeoff. And of course the classic and much more common error is to either leave off the fuel cap or not properly secure it. It is a good idea to always specify the type and quantity of fuel when placing the fuel order.

     

    Personally, I have had several problems related to fueling over the years and yet I am still here running my mouth and keyboard about safety. I am not smarter than most pilots, just a bit more paranoid. I always personally observe the fueling and I always visually look in the tanks and I always sample the tanks after fueling. Also, I always make time to allow the fuel to settle for a few minutes so that if any water is present, it will show itself by having at least a few drops reach the fuel tank drains. Of course this all takes extra time and sometimes other things are pressing. But when we fly, our primary job is to be as good a pilot as we can be and everything else must be secondary.

     

    Click here to see the accident report on the NTSB website.

  • Beech Bonanza - Decision Making After Power Loss

    WPR15FA222
    Riverside, CA July 26, 2015
    Fatal: 1

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    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

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    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

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    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

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    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.