On a warm day in late spring, four professional helicopter pilots rented a Cirrus SR20 in North Las Vegas, Nevada, for a fishing trip to Bryce Canyon, Utah. Of the four, only one had an airplane rating.

After taking off from North Las Vegas Airport (KVGT) and flying 60 miles, they landed at Mesquite, Nevada (67L), where they added 10 gallons of fuel. The pilot with the airplane rating, who had flown the first leg, now ceded the left front seat to one of his companions, evidently with the idea of giving him some flight instruction. He moved to the right seat, and they performed several touch-and-gos before continuing toward Bryce Canyon, 105 miles distant.

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The terrain rises from around 4,000 feet msl near Mesquite to around 7,800 feet at Bryce. Between them is a pass at 8,500 feet. Shortly before reaching that pass, and still below 8,000 feet, the Cirrus stalled, flipped inverted, and crashed into a mountainside, killing all four men. The Cirrus was equipped with an Avidyne solid-state primary flight display that stored an array of flight and engine data. The memory module was undamaged, and investigators were able to reconstruct the flight in detail. The story it told was surprising.

To start, the airplane was about 225 pounds over gross weight when it left Mesquite. The air temperature on the ground near the accident site was 80 degrees, and the density altitude over 9,000 feet. At the time of the accident, the airplane was just a few hundred feet above the surface, barely climbing, and only 4 miles away from the 8,500-foot pass. Its indicated airspeed was around 70 knots, and for the three minutes before the loss of control, the stall warning had been sounding almost continuously. All the while, its 210 hp Continental engine was turning at a leisurely 2,300 rpm.

• READ MORE: Only Assumptions Can Be Made About What Took Down a Curtiss C-46 in Alaska

So many things are wrong with this picture that I hardly know where to begin. But let’s start with general mountain flying principles. The wind was from the southwest, so the airplane would not expect to encounter downdrafts in the pass. Nevertheless, because in mountainous areas winds close to the surface are unpredictable, it’s chancy to fly toward rising terrain with the idea that you will just make it over the next ridge. Better to circle and climb, and not approach the ridge until you have the altitude to safely clear it, and approach it at a 45-degree angle, in order to have room to turn away if you don’t have enough altitude. The Cirrus, which had reached as high as 7,847 feet, had actually begun to lose altitude, probably because of its very low airspeed, before the stall occurred.

Even overloaded, and despite the high density altitude, the Cirrus had sufficient power to climb at 375 fpm. But to do so would have required increasing the rpm to 2,700, the rated maximum. It would also have required maintaining the best rate-of-climb speed, which was 93 kias. At 2,300 rpm, the calculated rate of climb at 93 knots would have been 22 fpm. At the stall speed, it was zero or less.

As a helicopter professional, the airplane-rated pilot—he was legally the pilot in command, and we assume he was the pilot flying—may have felt comfortable flying from the right seat. But the instrument cluster was on the left, making it difficult for him to see the airspeed indicator. Still, the stall warning should have been airspeed indicator enough.

He was a very experienced pilot, with more than 5,600 hours. Only 160 of them, however, were in fixed-wing airplanes, and only 17 in the SR20. He had originally gained his airplane rating in an SR20 but then began renting an SR22, which has the same airframe but 100 more horsepower. He had not flown an SR20 for 18 months before this trip and used it only because the SR22 he usually rented was not available.

Two major errors, which are immediately obvious to a fixed-wing pilot, are the failure to fly at the best rate-of-climb speed and the failure to increase rpm to make use of all the power available. The low speed may possibly be explained by the pilot wanting to use the best angle-of-climb speed, or by the fact that the best rate-of-climb speeds of helicopters are generally lower than those of fixed-wing airplanes, usually around 60 or 70 knots. As for the rpm, main rotor rpm is not normally used in setting power in a helicopter. Rotor rpm is set at a customary value and remains there, while power is controlled by throttle and, in both turbine and most modern reciprocating-engine helicopters, some type of automatic correlation or linkage with the collective, which controls the average pitch of the main rotor blades. It’s not hard to imagine that fixed-wing power-setting practices might be eclipsed by the ingrained habits of a helicopter pilot with limited fixed-wing experience who flies helicopters daily but airplanes only seldom.

• READ MORE: A Night Flight Leads a Pilot to a Tragic End

That the stall warning could have been allowed to sound for several minutes also seems incredible, but helicopters do not stall. Perhaps the pilot imagined that he could safely fly at what he believed to be the best angle-of-climb speed and that the stall warning was a mere unavoidable nuisance.

The National Transportation Safety Board (NTSB) blamed the accident on the “pilot’s failure to maintain sufficient airspeed and airplane control,” to which his assumed lack of experience operating heavily loaded airplanes in a high-density-altitude environment contributed. The NTSB made no effort to explain the egregious failure to use an appropriate speed and all available power, to circle to climb, or to stay well clear of the terrain. The agency did, however, report that the pilot had previously been admonished for overloading an airplane, gone out of his way to conceal his overloading of this one, and was prone to “try to circumvent things” with employees of the rental firm. The NTSB may think that imperfect morals predispose pilots to accidents, but in this case the cause was not overloading by a few percent nor the intent to deceive the renters about it. It was the blatantly faulty management of the airplane.

I used to visit Robinson Helicopter Co. in Torrance, California, from time to time, and founder Frank Robinson, always very cordial and hospitable, would send up one of his pilots with me for a little jaunt to administer CPR to my four-decade-old, but seldom used, helicopter rating. Once he flew with me himself and cautioned me against a too-abrupt forward push on the cyclic. He said this was an error to which fixed-wing pilots were prone when startled, for instance, by the sudden appearance of conflicting traffic. It was harmless in a fixed-wing airplane but dangerous in a helicopter, because the main rotor blades could strike the tail boom. He preferred that helicopter pilots learn to fly in helicopters and not come to them polluted by fixed-wing habits.

It works both ways.

Note: This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This column first appeared in the January-February 2024/Issue 945 of FLYING’s print edition.

The post Fatal Cirrus Accident Shows That Some Knowledge Doesn’t Translate appeared first on FLYING Magazine.

According to a recent report from Alaska Public Media, that state’s rate of fatal general aviation accidents was about twice that of the rest of the country until 2016 when, for unspecified reasons, it began to decline. It still remains higher than elsewhere. The gist of the article—which was motivated by the death of Eugene Peltola, husband of U.S. representative Mary Peltola, in a Piper Super Cub—was that the main problem for Alaskan pilots was lack of weather information, since the density of automated weather reporting stations in the state is half that of other parts of the country.

Actually, it would be difficult to define the main problem for pilots flying in Alaska. There are so many of them. And there is an additional problem that is created by the sheer existence of all the other problems: a certain style of flying and acceptance of risk arising from the combination of urgency and improvisation that backcountry operations entail.

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In December 2000, a Curtiss C-46 called Maid of Money—a twin-engine World War II-era transport similar to, but larger than, a DC-3—collided with a mountain ridge. It was destroyed and its two pilots killed. The airplane was returning from a round-robin trip out of Kenai delivering fuel to Big River Lakes and Nondalton. It left Nondalton, empty and light, at about 15:40 local time, bound for its home base 113 nm distant. The flight would take it eastbound across the Alaska Range and then across Cook Inlet, a body of water about 30 miles wide. The winter sun was setting, but darkness was still far off, so the flight would take place in the lingering Alaskan twilight.

• READ MORE: A Night Flight Leads a Pilot to a Tragic End

There are two ways to fly from Nondalton to Kenai. One, through Lake Clark Pass, follows a river and allows low-altitude VFR flight under an overcast, preferably in stable weather. (The crew may have used the Lake Clark Pass route to fly from Big River Lakes to Nondalton.) The other is the straight line over the Alaska Range, whose highest peak, Mount Redoubt, an intermittently active volcano, rises steeply to more than 10,000 feet. Most of the terrain in the area, however, although quite rugged, is lower than 4,000 feet.

The pilots, both of whom had logged more than 600 hours in the C-46 in just the past five months before the accident, must have known the route intimately. They had briefed the weather for the out-and-return flight and were aware of an AIRMET for turbulence and mountain obscuration. Nondalton and Kenai were VFR, but as they prepared to depart, the pilots must have seen that the weather was rapidly worsening. Shortly after they left, snow began to fall, and the surface wind picked up to 50 knots. A person living 30 miles south of the accident site described the storm as the worst he had seen in 25 years. The conditions were not ones in which the Lake Clark Pass would have been a good choice, so the C-46 took the straight shot over the mountains instead.

The crew did not file an IFR flight plan. Its transponder failed to deliver any Mode C information, but Air Force radar evaluation specialists concluded that the airplane had climbed to a maximum altitude of 10,800 feet msl and subsequently descended. The last altitude that could be determined was 8,800 feet. The National Transportation Safety Board’s report does not say where along the route these altitudes were measured.

We don’t know what the pilots saw or did along the way. They may have circled to climb, or they may have had a strong easterly headwind, because when the accident occurred, around 16:20, they had gone only 70 nm in 50 minutes. Mount Redoubt would have been abeam as they approached the accident site, and so if they climbed to 10,800 feet and didn’t stay there, it may be that they were on top and could see the tip of the peak and the clouds dropping away ahead of them. It is also possible, however, that they were in cloud, on the Kenai 227 radial, and uncertain how far they had come. The NTSB report states that the airplane was equipped for IFR flight but does not say whether it had GPS or DME. Still, the Homer VOR, 50 miles away on their right, could have provided cross-track guidance.

• READ MORE: Something Happened: Wind Shear Takes Down a Grumman Trainer

One thing that seems obvious is that the crew must have been in cloud when it hit the ridge at 2,900 feet msl. To judge from the condition of the wreckage, the pilots were at cruising speed, and if they had been a few yards higher, they would have cleared the ridge without ever knowing how close they had come. They were under a Victor airway, but all the minimum safe altitudes in the area were above 12,000 feet, and so they may have felt that the risk of meeting someone else in the clouds was negligible. The fact that the transponder was not reporting altitude is suggestive, but who knew that some Air Force boffins in Utah could somehow extract posthumous altitude information from raw radar returns?

That they descended so low—2,900 feet—when they were still 43 miles from Kenai is hard to explain. They evidently didn’t know their position. Kenai was reporting 2,000 scattered. Perhaps they wanted to get below clouds covering the western side of the inlet so that they could make a plausible case, in the event that someone asked, that they had been in VMC all along. Perhaps they misread the radial from Homer that would mean they were safely over water. Perhaps they did not consult a sectional and forgot that there was one more little ridge before the shoreline. Perhaps they had flown this route so many times before, in so many kinds of weather, that they had lulled themselves into a feeling that nothing could go wrong and began the descent after a certain time had elapsed, as they had countless times before, without checking the Homer radial at all.

In all flying, we rely on certain assumptions: Engines will keep running, weather will be as reported or forecast, and insurgents will not have seized the runway. Gradually, pilots who fly certain routes over and over again develop a sense of what to expect. As “old hands,” they have a sixth sense about what lies beyond the next mountain ridge or bend in the river. Assumptions begin to take the place of up-to-date information.

Lacking CVR records, we cannot know what the C-46 pilots were thinking or saying to one another, or whether they even discussed the question of when to start the descent. But it’s not too hard to imagine a pilot glancing at his watch 40 minutes into what would normally be a 50-minute flight and saying, “Let’s start down.” After all, who ever heard of a C-46 making a groundspeed of only 84 knots?

Editor’s Note: This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This column first appeared in the December 2023/Issue 944 of FLYING’s print edition.

The post Only Assumptions Can Be Made About What Took Down a Curtiss C-46 in Alaska appeared first on FLYING Magazine.

Around 7 in the evening on September 4, 2020, the Muskogee, Oklahoma (KMKO), pilot-owner of a Cirrus SR22 telephoned his flight instructor to report he was going to fly to Pickens, South Carolina (KLQK), that night. His instructor advised him to wait until morning. Instead, the pilot fueled the airplane, loaded his father, wife, and child aboard, and took off at 8:27 p.m. for the four-hour flight.

As you will have guessed, since you are reading about this in Aftermath and not in I Learned About Flying From That, the flight did not end well. About 25 minutes after takeoff and shortly after crossing the Arkansas border, the 31-year-old pilot, whose in-command time amounted to 75 hours, lost control of the airplane and went down in a remote woodland. All aboard perished.

A few minutes before the impact, as he was climbing to 9,500 feet msl, the pilot contacted ATC and requested flight following. The weather along his route—which, notably, he had last checked with ForeFlight 17 hours earlier—was generally VFR, with a chance of scattered convective activity. There was, however, one patch of rainy weather just to the left of his course, and the controller advised him to turn right to avoid it.

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On the controller’s display, the target of the Cirrus crept eastward just below the edge of the weather. Radar paints rain, however, not cloud. The flight was over a remote area with few ground lights and the harvest moon had not yet risen, but its hidden glow may have faintly defined an eastern horizon. In the inspissated blackness of the night, the pilot, whose instrument experience was limited to what little was required for the private certificate, probably could not tell clear air from cloud.

As the Cirrus reached 9,500 feet, it began to turn to the left toward the area of weather. Perhaps the tasks of trimming and setting the mixture for cruise distracted the pilot from his heading. The controller noticed the change and pointed it out to the pilot, who replied he intended to return to Muskogee. He now began a turn to the right. Rather than reverse course, however, he continued the turn until he was heading northward back into the weather. The controller, who by now sensed trouble, said to the pilot that he showed him on a heading of 340 degrees and asked whether he concurred. The pilot, whose voice until this point had betrayed no sense of unease, replied somewhat incoherently that “the wind caught me, [but now] I’m out of it.”

With a tone of increasing urgency, the controller instructed the pilot to turn left to a heading of 270. The pilot acknowledged the instruction, but he did not comply. Instead, he continued turning to the right. At the same time, he was descending at an increasing rate and was now at 6,000 feet. “I show you losing serious altitude,” the controller said. “Level your wings if able and fly directly southbound…Add power if you can.”

It was already too late. In a turning dive, its speed increasing past 220 knots, the Cirrus continued downward. Moments later, its radar target disappeared.

In its discussion of the accident, the National Transportation Safety Board (NTSB) focused upon the pilot’s preparedness—in the broadest sense—for the flight. A former Marine, he should have been semper paratus—always ready—but his history suggested a headstrong personality with a certain tendency to ignore loose ends as he plunged ahead.

He had failed his first private pilot test on questions related to airplane systems; he passed on a retest the following week. But this little glitch tells us nothing about his airmanship. His instructor reported he responded calmly and reasonably to turbulence, and was “good” at simulated instrument flight. He had enrolled in Cirrus Embark transition training shortly before acquiring the airplane. He completed all of the flight training lessons, but—again, a hint of impatience with tiresome minutiae—may not have completed the online self-study lessons. The flight training was strictly VFR and did not include night or instrument components.

The airplane was extremely well equipped for instrument flying, but it was a 2001 model, and its avionics were, according to the Cirrus Embark instructors, “old technology” and “not easy to use.” In other words, it did not have a glass panel, and its classical instruments, which included a flight director, were sophisticated and possibly confusing to a novice. The airplane was equipped with an autopilot, and the pilot had been trained in at least the elements of its use.

The airplane was also equipped with an airframe parachute, but it was not deployed during the loss of control. In any case, its use is limited to indicated speeds below 133 kias, and it might not have functioned properly in a spiral dive.

• READ MORE: Dissecting a Tragedy in the Third Dimension

An instructor familiar with the pilot and his airplane—whether this was the same instructor as the one whom he called on the night of the fatal flight is not clear—wrote to the NTSB that the pilot had made the night flight to South Carolina at least once before, and he had called her at midnight before departing to come help him fix a flat tire. She declined and urged him to get some sleep and make the trip in the morning.

“I told him he was starting down the ‘accident chain,’” she wrote. “New pilot, new plane, late start, nighttime, bad terrain, etc….To me, he seemed a little overly self-confident in his piloting skills, but he didn’t know enough to know what he didn’t know.”

He fixed the tire himself and made the trip safely that night. Undoubtedly, that success encouraged him to go again.

We have seen over and over how capable pilots, including ones with much more experience than this pilot, fail to perform at their usual level when they encounter weather emergencies. A sudden, unexpected plunge into IMC—which, on a dark night, can happen very easily—opens the door to a Pandora’s box of fear, confusion, and disorientation for which training cannot prepare you.

There are two clear avenues of escape. One is the autopilot. Switch it on, take your hands off the controls, breathe, and count to 20. The fact the pilot did not take this step suggests how paralyzed his mental faculties may have become.

The other is the attitude indicator. It’s a simple mechanical game. Put the toy airplane on the horizon line and align the wings with it. That’s all. It’s so simple. Yet in a crisis, apparently, it’s terribly hard to do. The fact that so many pilots have lost control of their airplanes in IMC should be a warning to every noninstrument-rated pilot to treat clouds—and, above all, clouds in darkness—with extreme respect.

This column first appeared in the November 2023/Issue 943 of FLYING’s print edition.

The post A Night Flight Leads a Pilot to a Tragic End appeared first on FLYING Magazine.

On a cloudless April afternoon a Grumman AA-1B Trainer lined up on Runway 16 at Dodge Center, Minnesota (KTOB), for takeoff. The wind, 27 knots gusting to 34, was coming from the right, 50 degrees off the little airplane’s nose. Three people had seen the pilot board the airplane and taxi out. One of them watched as it took off.

When the airplane was, he thought, 500 feet above the ground and three-quarters of the way down the 4,500-foot runway, he returned to his work. A few minutes later, one of the others, who had not watched the takeoff but perhaps heard an impact, alerted him to what turned out to be the wreckage of the Trainer in a farm field not far from the end of the runway.

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The instrument-rated commercial pilot, 61, was killed. The National Transportation Safety Board’s report on the accident does not mention whether he had obtained a weather briefing for the flight, which was bound for an airport only 40 nm away. An AIRMET was in effect for occasional moderate turbulence below 12,000 feet, with a potential for low-level wind shear below 2,000 feet over an area that included both the departure and destination airports. But the pilot could have guessed as much while walking out to the airplane.

More cautionary, perhaps, would have been two pilot reports that unfortunately came too late. A pilot who landed at an airport 22 miles south of the accident site reported an indicated airspeed drop of 20 knots, caused by wind shear, 150 feet above the ground. The runway orientation at that airport was almost the same as at the accident site. A little later, a Northwest Airlines DC-9, scheduled to land at an airport 16 miles to the east, turned back because the steady crosswind component of 31 knots exceeded company landing parameters. As if a 31-knot crosswind component were not enough, the tower reported a 42-knot gust while the DC-9 was on approach.

The two-seat Grumman was a bit of a hot rod. Originally equipped with a Lycoming O-235 of 108 hp, it had been re-engined with a 160 hp O-320. The engine power is significant because, although its gross weight was less than 1,600 pounds, the stock Trainer, with a 24-foot wingspan, was never a strong climber, as it could do no better than 600 to 700 fpm at sea level. The more powerful engine adds credibility to the witness report of the airplane being at 500 feet well before the end of the runway.

The airplane, manufactured in 1973, was not equipped with the electronic recording equipment that now allows us to anatomize some accidents with second-by-second precision. We do know, however, the pilot had logged 2,400 hours, but fewer than 22 of them had been in the Grumman, which he had acquired less than a year earlier.

The takeoff roll would have been short—probably under 400 feet—but tricky, with a 20-knot crosswind component pushing the airplane to the left. The pilot would probably have wanted to get the wheels off the ground as early as possible. He was light, so, say he rotated at 60 knots, then turned 15 degrees into the wind to maintain runway heading and accelerated to 75 knots. The airplane could certainly climb at better than 1,000 fpm, which is 17 feet per second, and its ground speed along the runway was about 55 knots, or 92 feet per second. In the 30 seconds needed to gain 500 feet, it would have progressed about 2,800 feet along the runway. Add 400 feet for the takeoff roll and you get 3,200 feet. The witnesses’ report was only a guess, and the small size of the airplane might have made it appear higher up than it was, but there is nothing physically implausible about it being at 500 feet three-quarters down the runway. We know, at the very least, that it was not close to the ground.

The NTSB’s “probable cause” was bizarre: “the pilot’s failure [to] maintain climb and his failure to maintain clearance from the terrain during initial climb after takeoff.” Only a bureaucrat bored to distraction would describe an abrupt fall from 500 feet as a “failure to maintain clearance from terrain.”

The wreckage lay 100 yards west of the runway and 300 yards short of its end. Whatever happened must have happened mere seconds after the witness who watched the takeoff turned away. It can’t have taken long. The airplane’s path must have been more vertical than horizontal, since the wreckage rested not far from where the airplane was last seen. The orientation of the 150-foot-long ground scar leading from the point of initial impact to the main wreckage was 10 degrees. The reversal of direction would be consistent with a stall and incipient spin. It may also be significant that the destination airport was to the north-northwest. The Grumman could have been beginning a right turn to on course. Banking steeply would raise the indicated airspeed at which a stall could occur.

Strong, gusty winds produce constantly fluctuating airspeed and vertical speed. The pilot who reported an airspeed loss of 20 knots at 150 feet was descending from a zone in which he had a headwind of a certain velocity into one where it was suddenly 20 knots slower. Assuming that a comparable shear might have existed at the accident site, it would have manifested itself as a similar airspeed loss to an airplane climbing on a downwind heading.

• READ MORE: The Down-Low on Wind Shear

An airplane does not instantly recover airspeed lost in a wind shear. That takes time, and it takes a particularly long time when all excess power is being used for climbing. Assuming that in a 30-degree bank the Trainer’s stalling speed was 60 knots, the difference between that and the best rate of climb speed was around 20 knots. The airplane would not stall instantly if those knots suddenly disappeared because its angle of attack would not instantly change. But its nose would drop, and a pilot trying to maintain a constant pitch attitude in turbulence might react to that by instinctively pulling back on the yoke.

It’s common practice in gusty conditions to add some knots to your normal approach or climbing speed. Those knots are often said to be “for grandma”—probably because she was always urging us to be careful—and they seem to come in multiples of five. To be logical about it, we should add airspeed in proportion to the reported gust or wind shear fluctuations. When those numbers are of the same magnitude as the difference between the airplane’s climbing speed and its stalling speed, grandma would become justifiably nervous, and it might be best to honor her by remaining on the ground. If that isn’t possible, favor airspeed over climb rate and, if the nose and airspeed drop at once, push, don’t pull.

Editor’s note: This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This column first appeared in the October 2023/Issue 942 of FLYING’s print edition.

The post Something Happened: Wind Shear Takes Down a Grumman Trainer appeared first on FLYING Magazine.

On a December evening, a turboprop Piper Meridian climbed out of Cody, Wyoming, for a 300-mile flight to Steamboat Springs, Colorado. The flight must have been a pleasant one for the private pilot, 42, an orthopedic surgeon who lived in Steamboat Springs. He had a 40-knot tailwind at 25,000 feet and made a groundspeed of more than 300 knots. When he left Cody, Steamboat was reporting 4,500 broken and 7 miles. Every reporting station along the route was VFR. The forecast for his arrival called for VFR conditions with some light snow in the vicinity and some mountain obscuration to the east.

It was dark when he approached Steamboat Springs. Cleared for the RNAV (GPS)-E approach for Runway 32 at Bob Adams Field (KSBS), he began his descent 20 minutes out, turned eastward at the initial approach fix, HABRO, and then northward at MABKY intersection.

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The design of the approach brings you up a valley between high terrain to the east—where a number of peaks rise above 10,000 feet—and 8,250-foot Quarry, aka Emerald Mountain, to the west. The final approach fix (FAF), PEXSA, is aligned with the runway; the 5.4 nm leg from MABKY to PEXSA, however, is oriented at 353 degrees and requires a left turn of 30 degrees onto the 4.6 nm final approach course.

The field elevation at KSBS is 6,882 feet. Category A minimums are nominally 1,300 and 1¼ with a minimum descent altitude of 8,140 feet. The missed approach, begun at the runway threshold, calls for a climbing left turn back to HABRO at 11,300 feet.

The descent profile specifies crossing altitudes of 9,700 feet at the FAF and 8,740 feet at an intermediate fix, WAKOR, 2.4 nm from the FAF. From WAKOR to the threshold is 2.2 nm. Once passing WAKOR, the pilot could step down to the minimum altitude and start looking for the runway.

The Meridian tracked the ground path of the approach with electronic precision. The profile was not so perfect. The airplane crossed the FAF at 9,100 feet, 600 feet below the required altitude. At WAKOR it was 540 feet low and for all practical purposes already at the minimum allowable altitude for the approach.

At WAKOR, rather than continue straight ahead toward the runway, the Meridian began a left turn, similar to the turn required for the missed approach but 2 miles short of the prescribed missed approach point. The ground track of the turn, executed at standard rate, had the same machine-like precision as previous phases of the approach—but not the profile. Rather than immediately climb to 11,300 feet, as the missed approach required, the Meridian continued to descend, reaching 7,850 feet, less than 1,000 feet above the field elevation. It then resumed climbing but not very rapidly. One minute after beginning the left turn at 8,200 feet and on a heading of 164 degrees, it collided with Quarry Mountain. At the time of impact, the landing gear was in the process of being retracted.

When the Meridian arrived in the vicinity of Steamboat, the weather had deteriorated to 1,200 feet overcast and 1 mile visibility—below minimums for the approach. The National Transportation Safety Board limited its finding of probable cause to the statement that the pilot had failed to adhere to the published approach procedure and speculated that he had become aware of the below-minimums conditions only during the approach. Indeed, he would have become aware of the low ceiling by the time he reached WAKOR because he was already practically at the minimum descent altitude there.

He was apparently unprepared for this unexpected development.

The Meridian was equipped with a lot of fancy avionics that recorded every detail of the approach, and the accident docket includes extensive graphic depictions of those records. (These are not included in the published report.) What is striking about them is the contrast between the undeviating steadiness of headings and the large random fluctuations in airspeed, vertical speed, and altitude, which are evidently being controlled by the pilot. During the last two and a half minutes of the flight, the Meridian’s airspeed fluctuated between 89 and 110 knots and its pitch attitude between minus-5 and plus-10 degrees. Approaching WAKOR, its vertical speed was zero. Crossing WAKOR and beginning the left turn, the vertical speed first dipped to 1,500 fpm down, then, 10 seconds later, corrected to 1,300 fpm up. Ten seconds after that, it slumped again to zero before shooting back up to 1,500 fpm, holding that rate momentarily and then dropping again. The impact occurred a few seconds later.

The pilot’s logbook, which recorded 580 hours total time with 43 hours of simulated instruments and 45 hours of actual, contained four instances of this same GPS approach in the month preceding the accident. In some of those log entries, no actual instrument time was recorded, and at least two of them ended with a low approach but no landing. In some, if not all, of those approaches, the pilot was evidently practicing in VMC. Plots of two of those approaches, one a month earlier and the other a week earlier, display the same precision in ground track as the one that led to the accident, so it appears that he was relying on his autopilot for horizontal navigation.

• READ MORE: When VFR Turns into IFR

Being based at KSBS and having repeatedly flown the approach in good weather, the pilot would have been aware that the terrain below him never rose above 7,000 feet. He might therefore have believed, consciously or unconsciously, that as long as he didn’t get much below 8,000 feet, he wasn’t going to collide with anything. That idea could have factored into his starting the missed approach 2 miles short of the runway. Or perhaps he simply forgot about Quarry Mountain. Or, possibly, he made the decision to miss at WAKOR and began the turn without even reflecting that an important element of any missed approach is the location at which it starts.

His unsteady control of airspeed and pitch attitude, and his failure to retract the landing gear until a full minute after beginning the miss, suggest a pilot unaccustomed to balked approaches and now struggling with a novel situation. Anticipating VFR conditions, he had not filed an alternate and would now have to make a new plan and execute it in the air.

The difference between simulated instrument flying and the real thing—compounded, in this case, by darkness—is difficult for novice instrument pilots to imagine. It is not just a matter of the complexity of the required actions. It is the effect that anxiety, uncertainty, or surprise may have on your own capabilities. What looks like a dry script on a piece of paper can become a gripping drama—comedy or tragedy—when the human protagonist steps onto the stage.

This column first appeared in the September 2023/Issue 941 of FLYING’s print edition.

The post Dissecting a Tragedy in the Third Dimension appeared first on FLYING Magazine.

On June 30, 2019, a Beechcraft King Air 350 twin turboprop, leaving Addison Airport (KADS) near Dallas on a flight to Florida, crashed into a hangar beside the runway. Either the impact or the ensuing explosion and fire killed all 10 people aboard.

The catastrophe was recorded by a number of surveillance cameras, some located not far from the point of impact. Video showed the airplane airborne, initially drifting left, then yawing left to an extreme sideslip angle before rapidly rolling into an inverted dive. The sequence took just a few seconds. Once the left wing had dropped, the low altitude made recovery impossible.

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The crew had not reported any trouble to the tower. National Transportation Safety Board (NTSB) investigators reconstructed the event by analyzing surveillance videos and the sound spectrum of the engines captured as background noise by the cockpit voice recorder, as well as extracting data from the airplane’s ADS-B and terrain awareness warning systems. They concluded the critical left engine had spooled down for some reason, and the pilot had reacted by pressing on the left rudder pedal rather than the right. Only the combination of asymmetric thrust with added rudder, the NTSB found, could bring the airplane to the extreme yaw angle observed in the videos, as asymmetric thrust alone would not have been sufficient.

The only communications between the two pilots recorded during the accident sequence were an exclamation of “What in the world?” by the pilot flying and the copilot’s statement, three and a half seconds later, that “You just lost your left engine.” (The King Air is a single-pilot airplane. The copilot frequently flew with the pilot to gain experience, but was not permitted to touch the controls when passengers were aboard.)

The NTSB suspected the spooldown of the left engine might have been caused by a faulty friction setting on the left power lever, which could have allowed it to creep backward during the takeoff roll. This is a known susceptibility of King Airs; the power levers are spring-loaded toward idle, each has its own friction knob, and they rely on positive friction to keep them from drifting. The power quadrant was too badly damaged in the post-crash fire to allow investigators to tell anything about the position of the left power lever or the friction settings. Uncommanded power rollbacks on the PT6-series engines can have other causes, however, which would not necessarily be detectable in a severely burned wreckage, and so the attribution to the friction setting remained speculative.

The quadrant frictions are a checklist item, but the CVR recording disclosed no pre-takeoff briefing and none of the expected checklist or V-speed callouts. According to other pilots who had flown with him, the pilot, 71, a 16,450-hour ATP, was “not strong on using checklists” and “just jumped in the airplane and went.” He was, on the other hand, “super strong” on knowledge of the airplane, in which he had logged 1,100 hours. According to the pilot who administered his most recent proficiency check, he had performed well on the simulated engine failure on takeoff. The check ride took place in the airplane, however, not in a simulator, and so as a safety precaution the engine cut, which had been briefed in advance, did not occur until the airplane was safely airborne and climbing. A successful performance under such controlled circumstances did not guarantee success in exigent ones.

The NTSB’s reconstruction of the takeoff showed the pilot had rotated at 102 kias, slightly below the V1 (go/abort) speed of 106 kias and 8 knots below the calculated rotation speed of 110 knots. The airplane was fully airborne at 106 kias and was at around 110 kias when the power began to roll back. The airplane drifted left, reaching a maximum altitude of 100 feet. Three seconds later, it was at 70 feet and the airspeed was 85 knots. One second later, it plunged through the hangar roof.

The standard procedure for loss of an engine in the King Air 350 is to establish a positive rate of climb with a pitch angle of 10 degrees, retract the landing gear, and feather the propeller on the inoperative engine while maintaining V2 (minimum safe climb speed with an engine out) to 400 feet agl. Above 400 feet, the airplane is allowed to accelerate, the flaps are retracted, and the climb continues at 125 kias.

None of this happened, however, because the pilot, in spite of his lifetime of flying experience and countless successful proficiency checks, stepped on the wrong rudder pedal.

• READ MORE: Objection Overruled

There was a time when the NTSB often cited fatigue as a contributing factor in accidents, but at some point it must have become obvious that plenty of well-rested pilots crashed too, so unless a pilot literally fell asleep at the wheel, fatigue could never be proved to have been a link in a causal chain. In this case, the pilot had a history of severe sleep apnea. To the extent that the FAA was aware of it, the agency had taken no action, although in principle the condition could have been disqualifying. The NTSB turned its back on this opportunity to invoke fatigue. “No evidence,” the agency wrote, “indicates that the pilot’s medical conditions or their treatment were factors in the accident.”

I would have expected the NTSB’s finding of “probable cause” to be something like “…the pilot’s inappropriate reaction to a loss of power in the left engine, which resulted in loss of control.” Instead, it blamed “the pilot’s failure to maintain airplane control,” which seems rather vague and generic. Among the contributing factors, “failure to conduct the airplane manufacturer’s emergency procedure” is a little misleading, since he did begin to execute the procedure but bungled it. The agency added his “failure…to follow the manufacturer’s checklists during all phases of operation,” even though the only link between checklists and the crash was the hypothetical faulty friction setting for which there was no material evidence. Two King Air pilots with whom I discussed the accident were skeptical of the friction theory because they said matching torques on two PT6s during takeoff involves enough fiddling with the power levers that it would be impossible for the pilot to be unaware of a sloppy-feeling lever.

I suspect the NTSB wanted to blame the accident on the pilot not being a by-the-book kind of person. None of his associates the NTSB interviewed suggested he was reckless or incompetent—quite the opposite. The problem with pinning the accident on a personality trait of the pilot is that the mistake of stepping on the wrong rudder pedal is not connected in any obvious way to that. It seems more like one of those random human mistakes we all sometimes make—but hope we will never make at a critical moment.

Note: This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This column first appeared in the August 2023/Issue 940 print edition of FLYING.

The post King Air 350 Accident Proved to Be Fatal Misstep appeared first on FLYING Magazine.

“I’ve been watching the Weather Channel, so I probably can use an abbreviated brief,” said the pilot. He had called Flight Service for a trip from Diamondhead, Mississippi (66Y), to St. Louis Regional Airport in Illinois (KALN).

“You’ve been watching, and you still want to go?” the briefer asked.

“Baby needs a wash,” joked the pilot, 66, a recently retired judge who was known for his “well-honed” sense of humor.

“Oh, he’s going to get a wash job,” the briefer said. “We do have a lot of rain and convective activity. It’s becoming pretty solid. I can’t see you doing much dodging trying to get around.”

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“It looks like it subsides as it goes east,” the pilot suggested, and then added, “Question mark.”

“Well, yeah, question mark,” said the briefer. “If you take a line drawn directly north, it’s heavy precipitation until you get over to about Bowling Green (Kentucky), and that’s when the thunderstorms start again. But all this is moving northeast about 34 knots, so you head east as it is heading east, and then you get blocked off, and it’s building behind so…you have to go today?”

“Well, maybe not.”

“We will have some rain tomorrow, but at least it will break up enough and begin to move to where, you know, that Arkansas and Missouri area won’t be getting so smashed.”

“I might just go up and take a look at it and see what it looks like out of the windshield,” the pilot mused. “I don’t have anything better to do today.”

“Well,” said the briefer, “think of a good reason to go.”

He issued the required “VFR not recommended” warning—under the circumstances it was hardly necessary—and the pilot filed an IFR flight plan, estimating 2 hours and 15 minutes for the 520 nm trip.

His airplane was a Lancair Legacy, a small, very fast two-seat retractable homebuilt with a 310 hp engine. After climbing VFR to 6,000 feet, the pilot contacted Memphis Approach at 9:50 a.m. The controller asked whether he wanted to continue on his present heading of 356 degrees or deviate eastbound to try to go around the weather. The pilot said he would like to avoid the weather, and the controller gave him a vector of 060. The pilot, however, asked to continue on his present heading for a couple of minutes, and the controller agreed.

A minute later, the pilot came back. “The route ahead, as far as I can see, looks VMC. I can’t be sure on that, but I’d appreciate your input.”

“All right,” the controller replied, “stay on course and let me know if that weather starts to become a problem for you.”

Four minutes later, the controller said, “You are just going to run into about a 10-mile-wide band of showers that’s crossing in front of you. The quickest way through the weather, if you want a direct 90-degree cut, is about a 330 heading. There’s a lot of rain for about 10 miles, and then it should clear up on the other side.”

“All right, thanks,” replied the pilot. “We’ll go to 330, and we’ll slow down a little bit.” Two minutes passed.

“Looks like you are getting an updraft there,” the controller said. “I don’t have any targets around your altitude. Do what you can to hold it, but just take care of yourself through that weather. You’ve got another 10 miles before you’re going to clear it up a little bit.”

“Thank you, sir,” the pilot said.

Twenty seconds later, the controller asked the pilot whether he was OK. There was no reply. The controller’s transmissions became increasingly urgent.

“You’re going through a heavy area of weather, sir. If you can hear me, you, climb, altitude whatever, deviate, reverse course is also approved, sir…Radar contact is lost 30 miles northeast of Memphis, sir…You’ve got another 15 or 20 miles in that weather. If you can hear, sir, suggest a heading northwest bound to get through the weather. You’re in a level 4 and level 5 cell in that area, sir.”

The controller was not long in guessing what had happened. “I think he might have crashed,” he told a colleague.

Three hours later, searchers in a helicopter spotted fragments in a rain-soaked field. The recovery team found the engine and propeller buried almost 9 feet below the surface.

About an hour before the flight took off—but after the pilot’s conversation with the weather briefer—the National Weather Service had issued a SIGMET for the area through which the flight would pass. It warned of severe thunderstorms with tops to 38,000 feet, possible 50-knot gusts and 1-inch hail. The pilot most likely never saw the SIGMET. A retrospective analysis of Doppler weather radar recordings confirmed that at the time of the crash the pilot was just crossing the leading edge of a level 5 storm.

The National Transportation Safety Board limited its finding of “probable cause” to the trivial insight that the pilot had lost control of the airplane. A factor in the accident, it added, was “insufficient information” provided by the controller, who did not convey the storm’s intensity level to the pilot until he was already in it. Exactly how and why the loss of control occurred was not discussed. The wreckage was too badly fragmented for forensic analysis, and significant portions of it were not recovered at all. It did not appear that the airplane had broken up in flight, however. The wreckage was confined to a small area among plowed fields where more widely scattered debris would have been easy to find.

• READ MORE: The Road Not Taken

This accident occurred in 2004. In the intervening years, the NTSB has moved away from mechanistic analyses such as “loss of control” and toward more judgment-oriented ones signaled by the phrase, “the pilot’s decision to…” Today, I think, the finding of probable cause would put more emphasis on decision-making on the parts of both the pilot and controller, although the board’s investigations seldom satisfactorily dissect the nuances of decisions made by two people unconsciously influencing one another. The pilot’s assertion that it looked like VMC ahead probably affected the controller’s interpretation of his own weather display. The controller’s mention of 10 miles of “showers”—two and a half minutes in the Legacy—probably alleviated the pilot’s concern about the storm.

At the risk of venturing into groundless speculation, I am inclined to note that, as a judge, the pilot was accustomed to being the final arbiter of complex questions. As the builder-pilot of a beautiful—the word he used when filling in the “color” field in his flight plan—high performance airplane, he also probably experienced a little of the feeling of untouchable power that comes with fast airplanes and fast cars. The weather briefer hinted, warned, cajoled—but his objections were overruled.

This review first appeared in the July 2023/Issue 939 print edition of FLYING.

The post Objection Overruled appeared first on FLYING Magazine.

Alaskan flying entails decisions and improvisations that pilots in the contiguous U.S. seldom contemplate. Remote locations, rugged terrain, and harsh weather on one hand, and, on the other, the urgent human needs that airplanes fulfill, create a press-on-regardless mentality. It takes a hardy pilot to survive.

In June 2000, near the Yukon River in the state’s southwestern corner, a Cessna 337 crashed shortly after takeoff, killing one such pilot.

The airstrip near the remote town of Marshall then consisted of 1,940 feet of hard gravel surface, 30 feet wide, 90 feet above sea level. The wind was calm, the sky clear, the landscape illuminated by the late-evening twilight of the Alaskan midsummer.

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There was one witness, not of the crash itself, but of the events that preceded it. The starter motor on the rear engine had failed. The pilot’s companion offered to fly him somewhere to get a replacement, but the pilot, who had logged 600 hours in the 337 and said that he had done single-engine takeoffs in it before, was determined to take off using just the front engine. The pilot and his companion paced out a distance on the runway, and the pilot said that if he was not airborne by that point, he would abort the takeoff.

His companion then watched from beside the runway as the Cessna accelerated. Its nosewheel was lifting off as it passed the abort point. The airplane climbed to about 50 feet, the wings rocked slightly, and it then disappeared behind a low hill. Satisfied that the pilot was safely on his way, the other man left the airport. An hour later, he learned that the pilot had not arrived.

The airplane and the pilot’s body were later recovered from a small lake not far from the runway. The landing gear was retracted, the flaps set at the 1/3 position.

The 337 was equipped with a Robertson STOL kit. The handbook for the conversion recommends a special maximum-performance takeoff procedure. It is to set 2/3 flaps, lift the nose at 44 kias, climb at 56 kias to clear obstacles, then accelerate to 87 kias before reducing the flaps to 1/3 and retracting the gear. Blue-line—that is, single engine best rate of climb—speed is 87 kias at gross weight, and is the same for the Robertson conversion and the stock 337.

The airplane was relatively light. The National Transportation Safety Board calculated that it weighed 3,462 pounds, but that included an implausible allowance of 108 pounds for oil, evidently the result of confusing quarts with gallons. The likely actual takeoff weight would have been below 3,400 pounds.

The Cessna manual gives single-engine rates of climb, at a weight of 4,000 pounds, of 425 fpm with the front engine out and 340 fpm with the rear engine out. (When the rear propeller is not operating, there is excess drag due to separated flow on the relatively blunt rear cowling. The Robertson kit includes some aerodynamic mods to reduce that drag.) Cessna’s rate of climb figures apply at the blue line speed and assume a feathered prop on the dead engine. The propeller of the accident airplane was not feathered, however, because in order for a propeller to feather, it must be windmilling, and it’s pretty certain that the airplane never got to windmilling speed.

The single-engine rate of climb diminishes rapidly at lower than blue-line airspeeds. If the airplane climbs 340 fpm at 87 kias, it will climb only 200 fpm at 60. That is why one is well advised to accelerate promptly to the blue-line speed when taking off in any multiengine airplane.

Neither Robertson nor Cessna published any data or recommendations concerning single-engine takeoffs; in fact, the FAA eventually forbade them. POH guidance for engine-out emergencies assumes that the engine failure occurs after the airplane becomes airborne. The Cessna manual, however, does provide this admonitory note:

“The landing gear should not be retracted until all immediate obstacles are cleared, regardless of which engine is out… Airplane drag with the landing gear doors opened and the gear partially extended is greater than the drag with the gear fully extended.”

The manual cites a 240-fpm reduction in blue-line climb rate with the gear in transit and a dead rear engine. It does not specify what the penalty for a stopped, unfeathered propeller would be. But it is very probable that with the gear in transit, a stationary unfeathered prop, and a low airspeed, the vertical speed would be reduced to zero or less.

We don’t know at what indicated speed the pilot rotated, only that he lifted the nosewheel at the agreed abort point. Presumably he then became airborne. By establishing an abort point on the runway, however, the pilot had, in effect, set up the conditions for a short-field takeoff. Such a takeoff implied a low rotation speed and possibly quite a lot of flaps.

With only half the expected power available, however, the short-field strategy was not ideal. A higher rotation speed and a cleaner configuration would have been preferable. An airplane airborne out of ground effect at low speed accelerates with difficulty. Obviously, the problem is far worse when half the installed power is missing. The way to avoid that situation is to delay rotation until you have plenty of speed and to use little or no flaps, because flaps add drag. At sea level, a 3,400-pound airplane with a 210-hp engine and a constant-speed prop can comfortably get airborne without flaps in 1,900 feet; there was no need to use the special capabilities conferred by the Robertson conversion. In fact, it would have been better to delay rotating until almost the end of the runway.

The NTSB concluded that the accident had been the result of an inadvertent stall, citing as well the “improper retraction of the landing gear” and the pilot’s “overconfidence in the airplane’s ability.” It seems likely that a stall occurred, since, if the airplane had merely failed to climb, the pilot might have ditched it under control in the lake and very possibly survived. (The pilot seemingly did survive the impact, although with serious injuries; the official cause of death was drowning.)

In my opinion, the pilot’s confidence in the airplane was not misplaced. Very probably, it could have made the takeoff successfully if only the pilot had used the full length of the runway and then delayed retracting the landing gear until he reached the blue-line speed. The terrain ahead was low and flat; any rate of climb at all would have been sufficient. By setting an abort point, as if the main concern were the possibility that the front engine would fail, the pilot had inadvertently stacked the deck against himself.

This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This column first appeared in the June 2023/Issue 938 edition of FLYING magazine.

The post A Skymaster Taking Off on One Engine? appeared first on FLYING Magazine.

It has often been said, never more so than by FLYING’s erstwhile editor, Richard Collins, that a single-engine airplane is a better bet than a twin if an engine fails right after takeoff, because the chance of the pilot of a twin successfully handling the emergency is so small. This paradox applies, to be sure, to recips, with their meager surplus power. Turbines have it easier. Still, the single-engine pilot has only one task: land. Twin-engine pilots have their hands full.

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We generally don’t hear about the successful engine-out emergencies unless in private conversations; most of them don’t come to the attention of the authorities. Maybe there are more than we think. We hear about enough unsuccessful ones, however, to suggest that the challenge can be overwhelming.

Expectation plays a role. Twin pilots expect to save both the airplane and themselves. Their object, consequently, is to execute the go-around correctly, not to find a smooth place to crash. If they make a mistake,their situation is worse than that of the single-engine pilot. The single-engine pilot begins the emergency landing in control; the main requirement is to avoid stalling. The twin pilot does not even entertain the idea of an off-airport landing until things have gotten out of control. By then, it may be too late.

The crash of a Piper Twin Comanche in 2004 illustrates how quickly things can go wrong even when the pilot appears to be in a relatively good position as the engine failure occurs.

The airplane, manufactured in 1966, had a number of STC modifications, including tip tanks, 200-hp IO-360 engines in place of the stock 160-hp IO-320s ,and a STOL kit that increased its gross weight from 3,600 pounds to 3,800 and lowered its single-engine minimum control speed from 78 to 70 knots. Although only two people were aboard, baggage and fuel brought the airplane to just a few pounds under gross. The National Transportation Safety Board, obliged to call attention to every discrepancy, noted that the tip tank STC required that any weight above 3,650 pounds be carried symmetrically in the tip tanks, but, in fact, the tip tanks were empty. Only if the crash had been due to a failure of the wing structure, however, would that fact have mattered. It had no bearing on the loss of control.

The weather was clear, the wind from 300 degrees at 16, gusting to 22. The pilot, who had a total time of around 600 hours and 150 hours in the Twin Comanche, took off from Runway 26. Witnesses reported that the airplane became airborne, climbed to 200 or 300 feet, and briefly banked left. One witness reported a sputtering sound, similar to that of a power reduction to idle, just before the first left bank. The airplane then leveled out and appeared to be flying stabilized before it again banked left and descended until it hit the ground, still within the confines of the airport, having turned more than 180 degrees. Data retrieved from a recording engine monitor showed an abrupt EGT drop on all four cylinders of the left engine. The magnitude of the drop, vastly in excess of that observed in an engine tested at the Lycoming factory by suddenly shutting off both fuel and ignition, baffled the NTSB’s technical analysts. (Whether the EGT thermocouples on the accident airplane were of the same type as those used in the Lycoming test is not revealed.) The NTSB dwelt at length on the possibility of water or some other contamination in the fuel, but finally conceded that the reason for the loss of power could not be determined. In any case, the fact that the engine quit—dead—was never in doubt.

From the witness reports, it seems likely that the airplane was still on the runway heading when the engine failed. When it began its final left turn, its ground speed was 77 knots. Assuming that the headwind component of the quartering 16-to-22-knot wind was at least 10 knots, the airplane would have been indicating 87 knots or more and had a margin of at least 17 knots over VMC, the single-engine minimum control speed. In theory, it should have been in good shape.

The good engine, on the right, was the “critical engine,” that is, the one with the more powerful destabilizing tendency. But that did not matter because the pilot failed to accomplish an essential step. He did not feather the left propeller. 

The flight manual procedure for power loss involves several steps—the same steps as apply, with variations in detail, in all engine-out situations in reciprocating-engine airplanes. The first was to fully open the throttle of the operating engine to maintain altitude and an airspeed of at least 84 kias, that being presumably the single-engine best rate of climb speed. The next steps were to close the throttle of the inoperative engine, pull the mixture to idle cutoff, and pull the prop control into the feather position. (Closing the throttle increases the drag of the windmilling propeller slightly, but if the prop is promptly feathered, it’s not for long.) When the airplane turned 180 degrees, its ground speed was 92 knots; it was 84 at the last recorded data point before impact. Subtracting rather than adding the wind component now, it appears the aircraft did not accelerate. The windmilling propeller was the probable culprit, although it’s possible, if the pilot failed to feather the prop, that he also failed to command full power from the good engine. The fact that he turned from upwind to downwind was not hazardous in itself, but close to the ground, it can produce a distracting sense of flying sideways at excessive speed.

Why does the pilot of a twin-engine airplane, when he has one good engine and the necessary airspeed, fail to cope successfully with the emergency? Lack of time is one reason. At 200 or 300 feet, the whole sequence—identify the failed engine, correct yaw, control airspeed, feather, and bank into the good engine—must be executed swiftly and flawlessly. Another could be mental or physical paralysis produced by the airplane’s failure to respond to the controls. He wanted it to turn right, but it kept turning left. People freeze. Thought stops. Panic takes the reins.

When a twin with an engine out slows and cannot be controlled, there is still one life-saving strategy left to the pilot: to power down the good engine and land straight ahead. It is the potential for loss of control that Collins thought made a single safer than a twin. But rational thoughts are fleeting in an emergency, and it might be hard to remember that minimum control speed applies only when the good engine is developing power. Power is good, altitude and speed are good, but nothing is as good as control.

This article is based on the National TransportationSafety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This article was originally published in the May 2023, Issue 937 of  FLYING.

The post Twin-Engine Troubles appeared first on FLYING Magazine.

American Airlines Flight 311 departed New York on the evening of October 7, 1947, bound for Dallas and Los Angeles. Three pilots, all qualified captains, were aboard. The airplane was a Douglas DC-4 Skymaster, military designation C-54, the first of the series of four-radial-engine Douglas transports that ended with the DC-7. With a wingspan of 117 feet and room for as many as 80 passengers, it was a big airplane for its time. Unlike later models, however, it was not pressurized.

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After the stop in Dallas, the airplane took off a little before dawn and climbed to its cruising altitude of 8,000 feet msl, or about 4,000 feet above ground level. Captain Charles Sisto was in the left seat, but after leveling off he relinquished it to Captain John Beck, who had come along to familiarize himself with the DC-4. In the right seat was Captain Melvin Logan, flying as copilot. Captain Sisto now took the jumpseat, which was behind and between the two pilots’ seats.

Almost two hours after takeoff, a little west of El Paso, Beck noticed that the airplane had begun to climb. He rolled in some nose-down trim, but the climb persisted. He rolled in more trim, and, to his surprise, the rate of climb increased. Puzzled by the failure of pitch trim to produce the expected result, he turned to Sisto and asked him whether the automatic pilot was on. Sisto replied that it was not. Beck then considered the possibility that the gust lock, which was actuated from inside the airplane, had inadvertently become engaged. He began to roll the trim back to its neutral position, but before he could do so, the airplane pitched violently downward.

Beck and Sisto, who did not have their seat belts fastened, were thrown to the cockpit ceiling. On their way up, one of them accidentally struck the prop controls, feathering both propellers on the left side of the airplane and the outboard one on the right. Logan, whose belt was fastened and held him in his seat, perceived that the airplane had performed a half outside loop and was now flying inverted a few hundred feet above the ground. He half-rolled it to the left—aided by the functioning number 3 engine—unfeathered the other propellers, turned around and headed for El Paso, where the airplane landed uneventfully 15 minutes later. Remarkably, while 30 of 49 passengers and five of the six crew received minor injuries from being thrown around, no one was seriously hurt.

In initial statements made the following day to the Civil Aeronautics Board, which investigated the bizarre incident (the National Transportation Safety Board did not yet exist), the three pilots said that the autopilot had been engaged just before the upset. CAB investigators accordingly examined the autopilot on the ground, and, finding nothing wrong with it, bravely took the airplane up for a test flight. No malfunction or evidence of demonic possession was found in the autopilot or any other part of the airplane.

A week later, the pilots, presumably having worked out what happened among themselves, withdrew their previous testimony. It now appeared that the autopilot had not been in use at all. What had happened was that Sisto, perhaps intending to test the alertness of Beck or maybe just because he was fun-loving, had silently engaged the elevator gust lock. After Beck asked him whether the autopilot was engaged, but before Beck had time to neutralize the trim, Sisto released the lock. The elevator trim tabs, still deflected upward, forced the elevators down, and the airplane tucked. The accidental feathering of the propellers, which removed thrust from three engines, was fortuitous—the CAB was of the opinion that if the engines had all continued to deliver cruising power, the airplane would certainly have struck the ground.

The mechanics of what happened are straight forward but maybe not obvious except in retrospect. The unexpected initial climb was probably a random effect of the engagement of the gust lock, which must have slightly changed the elevator incidence. When Beck trimmed the airplane nose down, the elevator trim tabs deflected upward. Normally, the tabs would push the elevators downward, but with the elevators locked, the tabs became ersatz elevators and pushed the entire tail down instead, causing the airplane to climb. Releasing the control lock restored the normal function of the tabs, which were now trimmed for a steep dive. It was perhaps thanks to the period of climbing before the upset, as well as to the accidentally feathered props, that the airplane avoided hitting the ground. Finally, the same powerful nose-down pitch trim that caused the bunt in the first place held the airplane’s nose up when it was inverted, and gave Logan time to assess the situation and see the way out of it.

The CAB’s report does not mention Beck pushing the controls forward to arrest the climb, but probably when he asked Sisto whether the autopilot was engaged it was because he had tried to apply a nose-down correction and found that he could not move the wheel. When Sisto said that the autopilot was not on, Beck’s thoughts turned next to the gust lock. We don’t know whether he visually checked the gust lock handle, but we do know that he realized that if the gust lock were engaged, he would have to neutralize the pitch trim before disengaging it.

Evidently, the same thought did not occur to Sisto.

This bizarre incident occurred before airplanes carried flight data recorders, and the reconstruction of the accident was based on the testimony of the pilots. The CAB commended Logan for “his immediate recognition of the situation and for taking proper corrective action so promptly.” Beck emerged blameless. However, the misadventure ended the airline career of Charles Sisto. In a decision handed down a year after the incident, the CAB found that he had “demonstrated a disregard for the principles of air safety [and] lacked the discretion and good judgment necessary for the holder of an airman certificate with an airline transport pilot or commercial rating…” Sisto’s commercial certificate was revoked, but he eventually regained his private one. My friend and fellow scribbler Peter Lert, who called my attention to this curious story, heard it from Sisto himself sometime in the 1970s, when Sisto had a hangar at Santa Paula in southern California.

It’s a rare Aftermath that ends without at least one fatality. I’m not sure what edifying lessons can be drawnfrom this story, but I thought it was too good to leave untold. And it does equip us with a bit of aviation trivia that may come in handy on some rainy afternoon in a hangar. Q: How much space does a DC-4 require for a diving outside loop? A: Less than 4,000 feet.

This article is based on the Civil Aeronautics Board’s report of the incident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This article was originally published in the April 2023, Issue 936 of  FLYING.

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IFR and lower ceilings with reduced visibility will be common through much of the period across central and southern AR terminals. Northern AR terminals are more likely to remain VFR…

National Weather Service Area Forecast

On December 3, 2021, two pilots—call them Jack and Ken—left Clarksville, Arkansas, in a Piper Cherokee 235. They flew south to Louisiana, where Jack, who operated an airframe repair shop in Clarksville, picked up a Cessna 182 that had suffered some sheet metal damage in a hurricane. They then flew the two airplanes to Minden, Louisiana, where they stopped for food and fuel before continuing to Clarksville, 175 miles to the north.

Ken, the Cherokee pilot, had checked the weather and considered it “very sketchy.” Neither pilot had an instrument rating. But Jack said they would climb to 1,500 feet to stay below the clouds, and they could land at Magnolia, 40 miles north of Minden, if the clouds turned out to be too low.

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It was already dark when they took off. Jack was leading in the 182, and they were communicating on 123.45. The clouds were broken or scattered and the ground was visible, but the forward visibility was poor. Ken could see the icon of the 182 ahead of him on his ForeFlight traffic display. By the time they reached Magnolia, Ken thought they were in IMC, but Jack was confident that the weather would clear ahead and decided to continue.

They were at 1,600 feet msl—about 1,350 agl—and cruising at 140 knots, heading more or less due north. All Ken could see ahead of him now was the 182’s rotating beacon. He knew that he was in over his head and said so to his friend; but Jack, who seemed more concerned about Ken than about the weather, continuously coached him to keep his wings level. After some time, Ken tore his eyes from the attitude indicator to glance at his ForeFlight screen. He saw, to his surprise, that the 182 had turned toward the southeast and was backtracking toward him. He asked Jack what he was doing but got no response. Moments later, the 182 vanished from the screen.

Half a minute passed, and then ForeFlight issued a low-altitude alert. Alarmed, Ken pushed the throttle forward, hauled back on the yoke and climbed to 3,500 feet. Still in IMC, he turned eastward toward Hot Springs, but on learning that the weather there was 300 overcast he turned back northward toward Clarksville.

It turned out that Jack had been right about the weather farther north. The clouds cleared, and Ken was able to land at Danville, 25 miles south of Clarksville. Once on the ground, he tried again and again to call Jack’s cell phone, but there was no answer. He was sure there had been an accident. Perhaps, he thought, Jack had become so preoccupied with trying to keep him, Ken, safe that he had lost track of his own heading and altitude.

ADS-B data showed the 182 cruising northward at 1,600 feet until a mile and a half south of Trap Mountain, where it began a gradual descent and then a shallow right turn. Searchers found the wreckage of the 182 on the north slope of the mountain at an elevation of 1,070 feet. Trap Mountain is a narrow, steep wedge rising 500 feet above the surrounding terrain. Its charted height is 1,095 feet; the 182’s initial point of impact was the top of a 30-foot tree, just below the ridge.

The original plan had been to fly at 1,500 feet, as this would keep them in uncontrolled airspace, below the floors of airways and a couple of military operations areas, but clear of all terrain between Minden and Clarksville. (The terrain was a few hundred feet higher north of Trap Mountain than south of it, but since Jack expected the weather to improve to the north, he probably thought they would be able to climb a little higher there if they needed to.) We can’t know why the 182 strayed from its intended path, but the NTSB blamed “the non-instrument-rated pilot’s improper decision to continue visual flight rules flight into instrument meteorological conditions, which resulted in spatial disorientation and a subsequent impact with terrain.” Spatially disoriented pilots, however, typically make rapid, random changes of heading and altitude. The gradual descent and turn are more suggestive of distraction or instrument failure than spatial disorientation.

What is noteworthy about this accident is that we have a narrative of the events leading up to it—not, admittedly, from the point of view of the accident pilot himself, but at least from that of a bystander. Conditions in the air can look different to different pilots, however, especially to ones with varying amounts and kinds of experience. Jack had 2,500 hours and came from a family that had long been immersed in aviation. In his work he probably flew many types of airplanes, and in a variety of weather conditions. (Considering his relatively high time and the fact that he was an aviation professional, his lack of an instrument rating is puzzling, but, as I have learned in 60 years of flying, not everyone follows the beaten path.) 

I suspect—this is just a guess—that Ken was the less experienced pilot of the two; at least, he seems to have been less at ease than Jack was in, as he repeatedly put it, “sketchy” conditions. It may be significant that while Ken’s narrative repeatedly uses the phrase “in IMC,” it does not use the words “in clouds”; to Jack, that distinction may have made all the difference.

The condition of forward visibility, or lack of it, that Ken perceived as IMC could have appeared to Jack as night VFR minimums. In the dark, how are you to know whether a cloud is 2,000 feet away or whether the dim light you discern through the haze ahead is one or three miles away? The weather outlook was ambiguous, as it often has to be. Reduced visibility and ceilings—as opposed to straight-up IMC—would be common in the area, but not general. Better weather to the north was likely, but not certain. To a pilot used to scud running, words like “common” and “likely” are open doors. One of the oddities of the FARs is that they classify as VFR certain nighttime conditions that absolutely require reliance on the gauges. It’s possible that the same conditions that were IMC to Ken looked like unpleasant-but-legal VMC to Jack.

One could question the wisdom of Jack’s pressuring Ken to make a flight with which he clearly felt uneasy. Ironically—or perhaps not—it was the confident Jack who came a cropper and the hesitant Ken who got home safely.

This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This article was originally published in the March 2023 Issue 935 of  FLYING.

The post The Road Not Taken appeared first on FLYING Magazine.

On December 3, 2021, a student pilot, 23, went from his home in Katy, Texas, to Cincinnati, Ohio, to take possession of a Piper Cherokee 140 that he had purchased. Surveillance video at West Houston Airport (KIWS) recorded that on his return, his fiancee and a third person emerged from the airplane with him. The next day he put 40 gallons of fuel into his airplane, and the day after that he flew it in the traffic pattern for 20 minutes.

On December 6, he called his flight instructor, with whom he had hitherto flown only in Cessna 172s, to ask whether his training could continue in the Cherokee. The instructor agreed, contingent on his looking over the airplane and its maintenance logs.

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On the evening of the 8th, after dark, the young man arrived at the airport with a female companion. The pilot mentioned going to Pearland (KLVJ), a short distance to the southeast. The pair climbed aboard the 140 and took off, heading southward.

On the following day, the pilot’s fiancée came to the airport. She had been trying without success to reach him by phone. His car, she found, was still in the airport parking lot. The airport manager reviewed surveillance camera video and found the pilot and his companion—that must have been an uncomfortable moment—arriving and taking off a little before 8:00 p.m. He brought up the online ADS-B tracking information for the 140’s N-number, and saw the short track of the flight heading south, then turning left and terminating over an undeveloped area a short distance south of Interstate10. The airport manager and safety officer took off and spotted the 140 in the woods two and a half miles from the airport. Responders found it demolished; its two occupants were dead.

The tracking information publicly available online uses longer time intervals between ADS-B hits than the FAA’s radar does. The higher-resolution FAA track revealed movements that clearly pointed to pilot disorientation. First, there was a descending left turn with increasing groundspeed, followed by a climbing right turn, followed by another descending left turn to the northeast, then a hard right descending turn back toward the southwest. The airplane descended more and more rapidly. Radar contact ended 700 feet above the ground. Most likely, the pilot had strayed into clouds and then, descending over an unlighted area, he could not reorient himself in time to avoid the crash, or perhaps stalled in an attempt to pull up.

The pilot, who had logged 38 hours of flight time over the past year, had completed his solo and night requirements and was close to his private check ride. He had not yet done the simulated instrument part of the training. His instructor described him as friendly and a good pilot, one who intended to make flying his profession. 

His final flight was—to put it mildly—ill-advised. In addition to it being dark, there was a layer of stratusclouds 500 feet above the ground, and so, although the visibility below the clouds was good, the weather was officially IFR. The entire route to Pearland lay beneath the 2,000-foot floor of Houston Class B airspace, and it involved a dogleg to the south to avoid Hobby (KHOU). Along the way were some obstacles so tall that they poked through the TCA floor. In short, the proposed flight,although short in miles, was long in complications.

It was also illegal. The pilot’s student status precluded his carrying passengers. He had already demonstrated his willingness to ignore that restriction, but whether his nonchalance was due to an exaggerated sense of entitlement—not every 23-year-old student pilot can afford to buy his own airplane—or just youthful high spirits and resentment of restraint, we can’t guess. It seems likely, however, that one thing that entered into his choice to make that particular flight at that particularly inopportune time was the desire to impress. He was a young man; his passenger was an attractive young woman. What else needs to be said?

The desire to impress is almost, but not quite, a universal human trait. A few people are free of it. I myself know one, and I’m not even sure about her. When I began flying—I was not yet 20—I did a number of stupid things, most of them in order to impress certain women (at that time, I would have said “girls”). I still cringe today over one in particular that backfired so badly that in the mind of the woman in question, who atleast is still my friend, that flight eclipses all others that I have made since, and that I will make in the future. Since then, my need to impress has somewhat dwindled and now manifests itself mainly in a harmless proclivity for using fancy words. But I remember how I used to be, and so, while I deplore his judgment, I cannot but empathize with the young pilot who took off, impressively he thought, into that Houston night.

The quality of judgment that we pilots are expected to possess—and that is supposed to protect us and our passengers from actions that in retrospect will appear rash or completely idiotic—comes under the broad heading of “maturity.” It requires an ability to separate emotion from reason. That sounds easy, but the decisions that we consider rational are often influenced by biases, desires,and calculations of which we are barely—or not at all—aware. In theory, at least, we gain maturity from time and experience; some get a lot, some none at all.

One kind of situation presents a particularly obvious risk of ego-driven misjudgment. When we fly with another person whose esteem we crave, we may experience a sort of stage fright or “performance anxiety.” If that person is a pilot whom we perceive as our superior inexperience or native ability, the fear of doing something stupid, or just appearing awkward or flustered, flusters us and makes us awkward and stupid.

A poet I slightly knew in college once imagined a psych class called “Interpersonal Relations in the Group of One.” That would be a good class for pilots to take because, in addition to our desire to impress others, we may entertain a similar need to impress ourselves. Self-esteem is a powerful motive, and it affects pilots in both good and bad ways. On the credit side, it makes us work hard, try to perfect ourselves, and approach our flying with that attitude we call “professionalism.” On the debit side, it drives us to take unnecessary risks and to continue into worsening situations in order not to feel that we have “chickened out.”

As in finance, credit and debit in flying form a continuum. The hard part, sometimes, is to know which side of zero we’re on.

This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This article was originally published in the February 2023 Issue 934 of FLYING.

The post The Fatal Desire to Impress appeared first on FLYING Magazine.

Ever since Luke Skywalker plunged into the mesial groove of the Death Star, flying through canyons has seemed to be a supreme test of airmanship. Military pilots practicing terrain following love to thread the so-called “Star Wars Canyon” into Death Valley at 500 knots. When the new Top Gun installment came out, it was all about negotiating canyons, both geological and interpersonal.

It’s fun, and it’s dangerous. In fact, it’s fun because it’s dangerous. 

And that’s why three ex-Air Force pilots set off on a December morning in three Van’s Aircraft taildraggers to practice flying through a canyon in southern Colorado.

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The flight leader, 70, who had been a captain with United Airlines after leaving the military, had 20,000 hours. He was flying a tandem two-seat RV-4. The two other airplanes were an RV-8, which is a slightly enlarged redesign of the RV-4, and a single-seat RV-3. As they neared the canyon, the flight leader descended and called for a change from echelon to trail formation. The airplanes moved into single file, several hundred feet apart.

The RV-3 was in the last position and remained above the canyon rim. From that vantage point, the pilot could observe the No. 2 airplane ahead of and slightly below him, and the leader’s RV-4 descending northeastward into the canyon. After a few seconds, they encountered one of the challenges that make canyon flying exciting: an S-turn requiring a 120-degree heading change to the right immediately followed by a 180-degree turn to the left, both within a space about 1,300 feet wide.

The leader’s RV-4 was completing the second turn in a steep bank at high speed when its left wingtip snagged the scree below the canyon’s eastern wall. The airplane cartwheeled and disintegrated—the pilot must have died instantly.

If this accident had involved a 100-hour pilot in a Piper Cherokee 140, we could write it off to ignorance and rashness. But the pilot was of the highest caliber and qualifications and most likely had flown this canyon or ones like it before, and so it is worth pondering why this outing ended the way it did. 

(For readers who use Google Earth and wish to better understand what happened, a view of the canyon is helpful. The wreckage came to rest at latitude 37.792822,longitude -104.57616; the first impact occurred a few hundred feet south of that point. And “left wing tip” is not a misprint. Although the crash occurred on the right side of the canyon, it was the steeply-banked airplane left wing that first struck the ground.)

In the portion of the S-turn leading up to the accident site, the rims of the canyon are about 500 feet apart and the canyon bottom is 200 feet below the surrounding plain. The second turn, the 180-degree one, must be completed with a radius of about 400 feet. The radius of the first turn is a little smaller—about 350 feet—but it’s not a full 180 degrees.

Turn radius in still air is a function solely of true airspeed and bank angle. This is true for every airplane, Piper J-3 through SR-71. Bank angle is limited by the G tolerance of the airplane and the pilot. The RV-4 is a 6-G airplane, corresponding to an 80-degree bank angle, but the greatest G loading an airplane can maintain continuously—without losing altitude—depends on the power available. In the case of a 200 hp RV-4 at, say, 1,300 pounds, it would be around 3.5 G or 73 degrees of bank. The required turn radius of 400 feet could be achieved at 120 knots. But, of course, the speed can change during the turn. You could enter at 160 knots with a 6-G, 80-degree bank, and, if you haven’t grayed out, gradually reduce the bank angle.

The skilled pilot, like an outfielder judging where the pop fly will fall, uses the instinctive calculus that millions of years have bred into us to solve this problem in many variables. The slower you go, the easier it is, but the fun is in going as fast as possible. At high speed, however, small errors in timing, bank angle, and path selection nibble away at the slender margins of safety that are the spice of the exercise.

There is one additional element that is invisible and defies intuitive calculation: the wind.

Traveling at 120 knots, the RV-4 makes a 180-degree, 3.5-G turn in about seven seconds. During those seven seconds, a 20-knot wind blowing across its track carries it 210 feet downwind; 30 knots, 315 feet. So much for the calculated turning radius.

The RV-3 pilot and the leader had discussed the wind before taking off. Strong winds and a possibility of moderate to severe turbulence were forecast for the area. The leader was not concerned. Nearing the canyon, the RV-3 pilot’s EFIS reported a 30-knot, south-southwest wind 2,000 feet above the surface; its direction was such that an airplane emerging from the S-turn would have been pushed toward the right canyon wall. But there was no way to know how the wind would behave down inside the canyon. The canyon itself might provide some shelter. On the other hand, it added the risk of up- and downdrafts, and its meandering topography could produce unexpected changes of wind direction and velocity.

Something in the situation must have made the second and third pilots reluctant to descend below the canyon rim, despite the cultural tendency to stay with the flight lead. Perhaps they had not flown this canyon before and intended to watch the leader fly it before doing so themselves. The statements they provided to accident investigators did not touch on their own motivations, beyond the RV-3 pilot stating that he remained above the rim “to assess potential turbulence.” The leader alone went deep into the canyon. It was the RV-8 pilot,following him through the turns in second position, who reported that the lead aircraft was flying at “high speed” when he clipped the talus slope.

The most likely explanation for the accident is that the southwest wind poured into the portion of the canyon aligned with it and carried the RV-4 toward the eastern rim. The fact that the airplane was steeply banked at a point where it should have been rolling out of the turn, and when most of the energy available from excess speed would have been used up, suggests a desperate attempt to remedy a miscalculation. It almost succeeded.

Because many people perceive it as dangerous, aviation is obsessed with safety. It is practically obligatory, after an accident like this, to deplore the pilot’s decision-making. The NTSB does. But aviation can also be an extreme sport. The pilot knew what he was doing, and how to do it. He made a mistake, and paid the highest price. Let’s leave it at that.

This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This article was originally published in the December 2022/January 2023 Issue 933 of FLYING.

The post Windy Canyon Dangers appeared first on FLYING Magazine.

An hour before midnight. The stillness of a northern Minnesota lake. Ripples on pebbles exposed in the water, reboantic loons. Darkness. Starlight.

Then suddenly, close by, the incongruous snarl of an airplane engine. Red and green lights race into view, swooping and plunging. The airplane disappears behind trees, reappears, turns, seems to aim straight for the startled stargazers on the shore. It veers away, zooms upward. Its lights become momentarily hazy and diffuse. The airplane again turns, dives, disappears behind trees. Then a dreadful sound, part boom, part thud, for which there is no name. And then silence.

Moments later, shouts and footfalls, the unlimbering of boats, clatter of oars and outboard motors, lights and voices out on the water, searching. Clouds have moved in; the stars are extinguished. The wreckage of the Lancair ES rests 25 feet down, on the bottom of White Iron Lake. The pilot, 58, who had hoped to reach his cabin near Grand Marais that night, sleeps there as well.

From Ely, Minnesota (KELO), where the Lancair took off, to Grand Marais (KCKC) is only 58 nm, more or less due east. The kitbuilt four-seater would make the trip in 20 minutes. But on the night of the accident there were complications. It was dark and moonless. The area between Ely and Grand Marais is a wilderness completely devoid of lights. An AIRMET warned of possible IFR conditions in mist and fog. The Aviation Forecast Discussion issued from Duluth a few hours before the accident talked of a chance of “fog at all terminals,” as evening temperatures fell. However, conditions were expected to improve to VFR everywhere the next morning.

Between Ely and Grand Marais is the southern edge of a prohibited area, P-204, in which flight below 4,000 feet msl is prohibited to help preserve the primeval quality of the Boundary Waters Canoe Area Wilderness, where no motorized vehicles of any kind are permitted. The weather at Ely, where the pilot had landed earlier in the day and was now waiting for fog at Grand Marais to

lift, was VFR with clouds reported at 3,200 scattered, 4,100 broken, with unlimited visibility. Uncomfortably, there was a space of only a few hundred feet between the ceiling of the prohibited area and the base of the lowest clouds. The distribution of cloud cover—whether it was clearer to the east, or the scattered clouds became broken or solid—was impossible to know.

After taking off, the pilot flew northeast, making a somewhat unsteady track along the western edge of White Iron Lake. This made no apparent sense, as he was not going toward his destination. But perhaps it made sense in that there were habitations and lights in that direction, and his first instinct was to orient himself using those lights.

He was airborne for just four minutes before crashing into the lake near its north end.

Often, National Transportation Safety Board accident investigators interview friends and relatives of pilots to find out whether the route on which they lost their lives was one they had successfully flown before. They examine logbooks to see how much experience the pilot had in conditions similar to those of the accident flight. In this case, the accident docket includes no such information. We don’t even know if the airplane had a functioning autopilot—such airplanes usually do—or whether the pilot was in the habit of using it.

What we do know about the pilot is that he had 400 hours. From the FAA aircraft registry, it appears he may have acquired the airplane from its builder five years earlier. He had begun working on an instrument rating and had logged about 15 hours under the hood. His instructor told investigators that he was not ready for flight in IMC (instrument meteorological conditions) and “nowhere near ready for a check ride.”

It’s clear that the pilot became disoriented. Possibly he experienced some degree of vertigo. The zooming and plunging motions described by witnesses are not uncommon when a pilot becomes disoriented, panics, and begins to fly not smoothly but with a series of violent over-corrections. That’s where an autopilot comes in handy. With a flick of a switch, the rattled pilot can let go of the controls and try to calm down.

We don’t know what weather sources the pilot had consulted, or when. We don’t know how much night flying experience he had. We do know, however, that he lived in the Minneapolis area, and so it’s possible that most of his night flying experience had occurred in places with lots of ground lighting. It’s significant too that a flight from Minneapolis to Grand Marais never leaves ground lights, and so it may be that he had flown that route at night but did not realize how different the experience would be if the flight started from Ely.

The NTSB blamed the accident on the pilot’s “improper decision to attempt flight into instrument meteorological conditions.” The phrasing strikes me as imprecise, in that “instrument meteorological conditions” usually suggests fog and clouds, not just a dark night. There’s no way to know whether the pilot strayed into an unseen cloud or whether the lack of any horizon or ground lights was sufficient to disorient him, but I think it’s very unlikely that he made a deliberate choice to fly into IMC. He cannot have forgotten the difficulties he experienced flying under the hood. He may or may not have entered clouds—the radar record of his track suggests that he stayed below them—but in total darkness it makes no difference whether you’re inside a cloud or not.

It’s customary, when discussing pilots’ decision-making, to assume that a pilot is a “rational actor.” Rationally, the pilot’s choices were three. He could stay the night at Ely. He could follow Highway 1 down to Lake Superior and then hug the shoreline up to Grand Marais, a dogleg that would add 30 nm to his trip but keep him over some lights. Or he could try the short, direct flight. Knowing the outcome, we realize that the option he chose was distinctly the worst. But with VFR conditions at Ely, and after waiting hours for Grand Marais to go VFR, he may have ceased to think of what lay between.

He may have had no idea what total darkness—the proverbial “inside of a cow”—would be like. He probably also did not know how he would react to becoming disoriented, alone and in the dark, or how easy it would be for that to happen once the terrain ahead of him ceased to have any lights, or had so few, and those so small and faint that they could not be differentiated from stars.

But really, it was just a 20-minute flight. The terrain was flat, the clouds were thousands of feet up. How hard could it be?

This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

The post Flying Into Total Darkness, Inside the Cow appeared first on FLYING Magazine.

It was a snowy late-November morning at Chamberlain, South Dakota (9V9). A Pilatus PC-12 had sat out on the ramp during a night of intermittent snowfall and freezing drizzle. Its passengers, who had flown in from Idaho Falls the previous day to hunt pheasants, planned to return home that day.

While the rest of the party was out shooting, the private pilot, 48, and one companion got some isopropyl alcohol de-icing fluid from a hardware store, borrowed a ladder from the hunting lodge at which they had stayed, and spent three hours chipping snow and ice from the wings. The ladder was not tall enough to allow them to reach the upper surface of the T-tail, but the pilot was satisfied that the rest of the airplane was sufficiently clean.

Video of the Pilatus taxiing out showed snow falling heavily and white clumps adhering to parts of the fuselage and vertical tail. A couple of inches of snow (and presumably some ice) lay on the top of the horizontal stabilizer. The takeoff was recorded as well. The Pilatus roared down Runway 31, lifted off, banked to the left, and faded from sight in the snow and mist.

No one at the airport knew it at the time, but it crashed less than a mile from the runway. Of the 12 people aboard, three survived with serious injuries. The pilot was among the nine dead.

Thirty years ago, it would have looked like an open and shut case. Whatever residue of ice remained on the wings must obviously have triggered a premature stall. But we live in a different era now, with flight data and cockpit voice recorders in wide use. They tell accident investigators not what must have happened, but what really did.

The National Transportation Safety Board’s probable cause finding made no mention of snow and ice. It attributed the loss of control after takeoff and the ensuing stall to “the pilot’s improper loading of the airplane, which resulted in reduced static longitudinal stability.” Another contributing factor was “his decision to depart into low instrument meteorological conditions”—although that seems unfair, since the whole point of having an instrument rating and a powerful airplane equipped for flight in known icing is to be able to do exactly that.

The cockpit voice recorder picked up the sounds of passengers boarding the airplane, stomping snow from their shoes, clicking their seat belts. One passenger commented on how many pheasants they had bagged. Another recited a prayer of gratitude for various blessings—it was Thanksgiving weekend—and went on, with eerie prescience, “Father in Heaven, we ask for a special blessing now that we take off in this not-so-great weather and that [Thou wilt] watch over and protect us. Impress upon the mind of [the pilot] that he might know how best to travel this course that we are about to do, and we are thankful for this airplane and ask that You will watch over and protect us.” A collective “Amen” followed.

The pilot and the right-seat occupant radioed the airport manager, who was plowing the runway, to ascertain its condition. Their exchange was somewhat acerbic. The manager frankly told the pilot he must be crazy. The pilot good-naturedly replied that the snow berms on either side of the plowed portion of the strip were not a concern. As it turned out, he was right.

The pilot back-taxied to the approach end of Runway 31 and succeeded in turning the airplane around. The power came up, the Pilatus accelerated, and after 30 seconds it rotated. The pitch angle increased to almost 20 degrees, then eased back to about 10. Practically from the moment of liftoff, the stall warning sounded and an automated voice intoned the word “stall” over and over, no fewer than 19 times. Eleven seconds after rotation, a porpoising motion began, increasing in magnitude and rapidity. The bank angle increased to 64 degrees; the stick pusher actuated and, at a height of 380 feet, the Pilatus stalled.

With granular information from the flight data recorder, the NTSB conducted simulations to ascertain whether the airplane had been controllable and whether the accumulations of snow and ice remaining on it could have been a factor in the accident. The conclusion was that the airplane should have been controllable, and that the snow and ice had not significantly degraded its performance, though they may have affected the elevator control forces.

READ MORE: Classic Aftermath

The data recorder stored a number of previous flights, and the NTSB noted that the pilot, who had 1,260 hours in type, habitually rotated somewhat abruptly, tending to slightly overshoot the desired pitch attitude and then correct. Another pilot who regularly flew the airplane used a gentler, more gradual rotation, which the board found made speed control easier.

The board compared the accident flight with the previous day’s trip from Idaho Falls to Chamberlain. The cabin loading had been similar, and there were pitch oscillations after takeoff on that flight as well. The crux of the matter, in the NTSB’s view, was the combination of heavy weight—the airplane was 107 pounds over gross—and the CG location, several inches behind the aft limit, that resulted from 12 people, none of them lap children, and a great many dead pheasants occupying a 10-passenger airplane. An aft CG is associated with diminished stick forces and weak speed stability, conditions that may be difficult to manage on instruments.

The stall warnings that were heard practically from the moment the airplane rotated were due to the design of the Pilatus’s ice protection system. When ice protection is on, the triggering speeds for both the stall warning and the stick pusher increase considerably. According to the flight manual, the target rotation speed at max gross in icing conditions was 92 knots. The pilot rotated at 88, possibly because he wanted to get clear of snow build-up on the partially plowed runway. When the actual stall occurred, however, the indicated airspeed was only 80 knots. 

One can speculate about what passed through the pilot’s mind during the few seconds between the liftoff and the stall. The aural stall warning must have taken him by surprise. Since he had just spent hours removing snow and ice, his first thought may have been that it was caused by some lingering contamination on the wings. But now he was in near-whiteout conditions, and too low to risk pushing the nose down decisively. The airplane may not have responded to a gentle push on the yoke. Pitch oscillations made speed control difficult. There was little time to analyze or adapt—only enough for an exclaimed “Oh no!”

The pilot was the kind of person whom you would expect to follow rules. Yet he ignored the CG limits. Did he feel undue pressure to get his passengers back home? Probably not. There is no indication that he hesitated or considered the takeoff dangerous; in fact, he seemed less concerned than his prayerful passengers were. Did he understand how the extreme aft loading could affect the airplane’s flying qualities? He had made a similar flight the day before. Did he begin this one thinking it would be exactly the same? 

Sometimes you don’t know how near the edge you are until you go over it.

This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

The post A Wing and a Prayer appeared first on FLYING Magazine.

In August 2016, Le Rêve Bleu, a replica of the prewar Bugatti-de Monge 100P racer, crashed on its third flight. The pilot, 66—a 10,000-hour ex-U.S. Air Force pilot holding an ATP (airline transport pilot certificate), who had devoted years to the recreation of the fabled airplane—died.

The original airplane, now in the EAA museum, was built in the late 1930s. It was stored, incomplete, when World War II loomed, and it never flew. Intended to compete in the Coupe Deutsch de la Meurthe races, it had a drastically tapered, forward-swept wing (with an aspect ratio of 3.3), a minimal empennage, and contra-rotating tractor propellers driven by two Bugatti supercharged straight-eight engines of 450 hp each, mounted amidships, one behind the other. Racing speeds in those days were around 300 mph—the dominant competitors in Europe were carefully streamlined, but conventional Caudron monoplanes with six-cylinder inverted, inline engines of around 300 hp. Clearly, the Bugatti, if it worked, would be faster. Besides, some people thought it was the most beautiful airplane ever.

Bugatti’s aeronautical engineer, Louis de Monge, packaged the pilot, the engines and their cooling radiators ingeniously, wasting nary a cubic centimeter of the fuselage’s slender, perfectly streamlined spindle. The modern replica used two Suzuki Hayabusa motorcycle engines, 1.3-liter straight-fours, nominally rated at 175 hp at 9,500 rpm. Their integral gearboxes were retained, set in sixth gear. Hydraulic clutches, intended to protect against harmonic resonance during start-up, connected the engines to slender drive shafts that ran forward on either side of the pilot to a speed reduction unit driving the two fixed-pitch props. Thus, the two engines and propellers were almost entirely independent of one another. The only potential point of failure common to both was the lubrication system for the nose gearbox.

Unusual for an event involving a single fatality and a unique airplane, the National Transportation Safety Board (NTSB) produced a detailed analysis. The circumstance was clear: the aircraft stalled during initial climb from the 13,500-foot runway at Clinton-Sherman Airport (KCSM) in Oklahoma. The airplane was equipped with half a dozen GoPro cameras that recorded its demise in granular detail. Using those recordings, the NTSB could dissect the accident/flight second-by-second, and reconstruct a test flight from a year earlier.

The first flight of Le Rêve Bleu—the name, conferred by the pilot, means “The Blue Dream”—took place in August 2015. The runway hop, intended to check stability and control, was successful, although during the rollout a brake pedal failed and the elegant airplane ended up nosed over in rain-soaked ground beside the runway. The second flight, in October, was a single circuit of the airfield. The airplane lifted off at 80 knots with both engines turning at about 6,000 to 6,500 rpm—presumably propeller-limited and well below their speed for maximum power. At 500 feet agl, it leveled out and slowly accelerated to about 110 knots. As it turned final, the engines continued to turn at around 6,000 rpm, although the throttle levers had been backed off considerably—behavior consistent with a propeller pitched for climb. 

Although the second flight was without incident, it was not the flight expected of a 2,800-pound, 350-hp airplane in the hands of a pilot fully confident in its performance. It suggested, in fact, an airplane with barely sufficient power. In any case, the pilot’s impressions were not made public. I have not found among the reports on various aspects of the project that are posted online any discussion of what took place or what changes, if any, were made during the 10 months that elapsed between the second and third flights.

The third flight was announced to be the last. The airplane was destined for a museum in the U.K. This must have been a disappointment to the many people who had contributed money, time, and effort to the project, hoping some day to see it—on YouTube, at the very least—roar past them at speed, a blue streak out of the past.

The pilot accelerated gradually, as if feeling out the airplane anew. He rotated at a little above 80 kias after having rolled nearly 8,000 feet. He retracted the gear immediately. The airplane climbed, but its attitude seemed somewhat nose-high. Then the angle of climb seemed to diminish, the right wing dropped, then came back up. A moment later the other wing dropped and the nose sliced to the left. The airplane was only 100 feet in the air when the stall occurred, and it was impossible to recover.

In-cockpit video revealed that about 30 seconds after the airplane became airborne the left engine’s rpm began to drift upward, approaching the redline. (“Left engine,” here, means the engine controlled by the left throttle lever.) The pilot pulled the left throttle back to idle and that engine rolled back to 7,000 rpm. He pushed the right lever fully forward but the rpm of the right engine did not change, but that of the left engine, surprisingly, surged upward again, briefly reaching 9,500 rpm.

During this sequence, which lasted 20 seconds, the indicated airspeed, which had never exceeded 85 knots, gradually bled off, and the angle of attack—displayed on a conspicuous digital indicator at the top center of the instrument panel—steadily increased, eventually reaching 18 degrees. The NTSB found that the probable cause of the crash was “the pilot’s failure to maintain airspeed during an engine anomaly…the reason for which could not be identified during post-accident examination.” Although the NTSB declined to say so, the “engine anomaly” was certainly a slipping clutch on the left engine.

Aviation usually avoids complex drivetrains. Each non-rigid transition from one component to another involves losses, and no matter how well engineered the separate components may be, their potential interactions are difficult to foresee. There was always a possibility, even a probability, that Le Rêve Bleu might suffer a failure of one of its engines or drives. With an empty weight of over 2,500 pounds, it was extremely heavy for its size. Its large wing area, 223 square feet, gave it a comparatively low wing loading, but its 27-foot span was a liability at low airspeed. So was the extreme taper, which would predispose it to a wing drop at the stall. Running at 7,000 rather than 9,500 rpm reduced the raw horsepower available from the engines by between 15 and 20 percent. The two-stage reduction gearing took away a few more percentage points, as did the inevitable inefficiency of a fixed-pitch propeller at an off-design airspeed. According to a 1945 NACA report on the interactions of contra-rotating propellers, the windmilling front prop could have peeled off another 10 percent of the thrust available from the other one.

It was foreseeable that the airplane would have trouble climbing at low speed; its drag was at a minimum at around 110 kias, which was the “blue line” speed marked on the airspeed indicator for single-engine flight, and so at 85 kias, it was “behind the power curve.” The single most important action the pilot could take at the first sign of engine trouble would be to get the nose down, even if this meant belly landing in the rough. He certainly knew this and most probably rehearsed the proper response in his mind.

So why, when he lost power on one engine, did he fail to maintain airspeed? Nobody knows. But the fact a 10,000-hour former fighter pilot, intimately familiar with his airplane and able to plan for the scenario, failed to execute the indispensable response is a caution to us all. We may not react as well as we imagine.

This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

The post An Aircraft Built for Speed Loses Power appeared first on FLYING Magazine.

On a freezing January evening in 2016, a Cirrus SR22T approached Greene County Regional Airport (I19) near Dayton, Ohio, its home field, after a 100 nm IFR hop from Indianapolis.

Conditions at the airport were VMC, with a 1,700-foot ceiling, 10-mile visibility and a 9-knot wind gusting to 14 and varying from 240 to 330 degrees. The sun had just set, and the temperature on the ground was 32 degrees Fahrenheit.

The 2,000-hour airline transport pilot, 33, descended from his cruising altitude of 9,000 feet and used the GPS approach for Runway 7, intending to circle to Runway 25. Passing through 4,000 feet, he switched on the anti-icing system, which on the Cirrus consists of a porous metal leading edge from which an ethylene glycol fluid with a low freezing point, called TKS, bleeds onto the wing surface. Six miles from the airport, in the clear just below the clouds, he canceled IFR and switched anti-ice off. Passing the final approach fix, he slowed, selected half flaps and began a descent.

The Cirrus entered a left downwind leg for Runway 25. Witnesses mentioned that it appeared unusually low and unusually close to the runway. It turned base, then final. The wings leveled only briefly between turns. On the base to final turn, the Cirrus stalled and spun, crashing 100 yards from the runway threshold and killing the pilot.

The airplane was equipped with a data-logging device. It showed that in the seconds preceding the loss of control, the angle of bank approached 50 degrees and the indicated airspeed was between 87 and 90 knots.

The National Transportation Safety Board noted that, according to the airplane handbook, at 60 degrees of bank the stall speed with half flaps was 95 knots, and could have been even higher had any ice been present on the wings. It attributed the accident to “the pilot’s failure to maintain adequate airspeed while turning from the base leg to final, which resulted in the wing’s critical angle of attack being exceeded and a subsequent aerodynamic stall.”

It is difficult to know the precise stalling speeds of particular aircraft, but we can assume that the full-flaps stall speed of the SR22T at gross weight is no more than 61 knots. This airplane was not at gross weight, however; it was on a positioning flight, and therefore probably carrying no cargo, and the pilot had messaged ahead that he would be requiring 48 gallons of fuel. The actual weight of the airplane was likely around 3,100 pounds, so its full-flaps stall speed would have been 57 kcas. The stall would probably occur at around 63 kcas, or 65 kias, with half flap. The maximum angle of bank recorded did not exceed 50 degrees, which corresponds to a level-flight G-loading of 1.56 and a stalling speed of 81 kias. The NTSB’s mention of 95 knots is a mere rhetorical flourish, irrelevant to the accident.

In cases involving a spin out of a turn — a fairly common type of approach-to-landing accident — the NTSB almost always alludes to the increase in stalling speed that occurs when an airplane is banked, but never mentions that it applies only when altitude is maintained. It is obvious when you perform a wingover turn, for instance, that you can put an airplane into a 90-degree bank and still not stall it. I’m not sure whether the problem is that the NTSB accident analysts don’t know this fact — which would be hard to believe — or that they merely feel that their analysis is more forceful if they omit to mention it.

In any case, the airplane did stall. Why?

The gusting wind could have been a factor. It was not very strong to begin with. Groundspeed and indicated airspeed tracked each other closely in the logged data, and the airplane would in any case have been turning into the wind. However, a sudden 14-knot gust from 330 degrees when the airplane was banked 50 degrees could conceivably have increased the wing’s angle of attack by a couple of degrees and caused it to stall. A gusty right crosswind is a little-recognized hazard on the base-to-final turn of a left-hand pattern.

From one of the witness statements included in the accident docket, some inferences can be drawn about the state of mind of the pilot. He had a busy schedule flying the Cirrus. According to the line supervisor at I19, who knew the pilot, “the goal for him” was to get back to I19 before the FBO closed, which was at 8 p.m. in summer and 6 p.m. in winter. The accident took place at precisely 6 p.m. It’s likely, therefore, that the pilot was trying to get down as expeditiously as possible. The facts that the airplane was low and close-in on the downwind leg — he had to turn right to widen out the approach before he turned left from downwind to base — and that the turn to final took place very close to the end of the runway are consistent with that theory.

It’s probable that, beginning from an unusually low downwind and having to make steeply banked turns because he had flown the downwind leg so close to the runway, the pilot found himself sinking and increased the angle of attack in the final turn to arrest his descent.

Ice remains a possible, but unknown, factor. The effect of ice on the stalling behavior of wings is difficult to predict, but it is well-known that very small amounts of ice can sometimes have disproportionately large effects. The pilot selected half flaps two and a half minutes before landing, but he did not begin to slow down until a minute later. He may have been in the habit of getting the airplane configured for landing well in advance of arriving at the runway — the essence of a “stabilized approach” and a staple of Cirrus standardized training — but it is also possible that he was concerned about ice and thought it would offer an extra margin of safety.

The fact that the pilot used anti-ice during his descent suggests that he saw some airframe icing; this would be consistent with the weather conditions and with pilot reports. That he turned off the TKS bleed upon emerging from the clouds is logical: In the clear, with no precipitation, no further icing would occur. It was unclear from witness accounts which wing stalled, although one witness stated categorically that the airplane rolled to the right. It is possible that the pilot turned off the TKS when the left wing appeared satisfactorily clean to him, and that he overlooked some residue on the right wing.

It’s often said that accidents arise from the combination of multiple factors that are harmless enough by themselves. Here you had a well-trained professional pilot, very familiar with his airplane, making a traffic-pattern approach to his home field in VMC. You could hardly imagine a less threatening situation. And yet it ended with an accident. To understand how that could happen, you cannot ignore all of the elements of the approach that were slightly unusual: that it was flown close in and low, that the banks were unusually steep, that the plane had been through icing conditions and that the pilot was most likely hurrying to get to the FBO. To this add the fact that the pilot was very familiar with and perhaps overly confident in the airplane, and you have a glimpse of how what should have been a completely ordinary maneuver could turn into a disaster.

This article was originally published by FLYING on March 7, 2018.

The post A Skilled Pilot, a Routine Approach, an Unexpected Catastrophe appeared first on FLYING Magazine.

Late in August 2015, a 55-year-old Pennsylvania lawyer bought a 1981 A36 Bonanza. A private pilot with an instrument rating and around 800 hours of flight time, he had, according to a friend, “a lot” of IFR experience in a fixed-gear, fixed-pitch Piper ­Cherokee. The Bonanza, however, equipped with a Garmin 530 EFIS navigator and a flight director, was more airplane than he was used to.

He quickly obtained a “complex” checkout—six hours in flight and an hour and a half of ground instruction—from an instructor whom he knew. The instructor showed him how to set up the Garmin for IFR ­approaches, but the approaches they flew ­together were in VMC, without a hood. The instructor cautioned the pilot not to fly in actual IFR conditions until he had more experience with the airplane and its equipment.

A few days later, the pilot, accompanied by his wife, her father and a friend who owned a similarly equipped A36, flew to ­Florida to ­visit a daughter. The friend remained in Florida; on ­September 7, the others ­began the return trip north.

Just before the leg from Sarasota to Greensboro, North Carolina, the pilot filed an IFR flight plan—190 knots at 8,000 feet must have been a gratifying change for someone used to a PA-28—and got a telephone weather briefing. He cut the briefing short because thunderstorms were approaching and he wanted to get away before they ­arrived. The just-under-four-hour flight in VMC from Sarasota to Greensboro was uneventful. At the destination airport, ­Piedmont Triad (KGSO), however, he found an 1,100-foot overcast. The cloud layer was 1,500 feet deep.

The pilot asked the approach controller whether he should expect a visual approach. The question implies that he had seen breaks in the overcast, but the controller told him to expect the ILS to Runway 5R, and he did not demur. Presumably, the pilot attempted to set up the Garmin unit for the approach, as he had practiced, but he must have quickly become mired in confusion. The 530 is intimidating to a novice, with 20 knobs and buttons on its face and a seeming infinity of menu choices. The pilot’s distraction was such that he had to be told three times that his runway was 5R, not 5L.

The approach controller assigned a heading of 020 to intercept the localizer. The Bonanza was then 9 miles from the initial approach fix, PAGAN intersection. About two minutes later, the pilot asked the controller, “How do you like this route of flight?” The controller took the unconventional question in stride, replying that the airplane seemed to be a little to the right of course; he amended the heading to 360, a 20-degree adjustment. Surprisingly, the pilot asked, “Turning left or ­turning right for 360?” Nonstandard phraseology and illogical questions are often the first signals that a pilot is headed for trouble.

A little later, the ­controller asked, “Are you established on the localizer?”

“I believe I am,” the pilot said.

But the Bonanza had flown through the localizer. The pilot ­requested “vectors to final”—by which he possibly intended something like the ­virtually ­obsolete GCA (ground-controlled approach), in which the controller guides the airplane all the way to the runway. Instead, the controller canceled the ILS clearance and vectored the Bonanza back around for another try. While the controller was talking to ­another facility on a ­l­andline, the Bonanza ­pilot called again asking for vectors. His voice was “strained,” and the controller ­noticed that he was at 2,500 feet rather than the ­assigned 3,000.

Finally, the pilot said, “We need a descent; we are almost disoriented.”

The controller now realized that the pilot was in trouble. He decided to simplify matters by giving him no-gyro turns rather than vectors. He had his radar screen set to so large a scale, however, that he did not discern that the pilot was ­actually flying in circles, first to the right, then to the left. The Bonanza continued to lose altitude.

Finally, the controller told the pilot to climb and maintain 4,000 feet, above the overcast. “I’ll block altitude for you.” He thought that once in the sunshine above the clouds, the pilot would be able to collect and reorient himself. But the Bonanza did not climb. It continued to descend, whether deliberately or inadvertently. The terrain below was relatively flat, and the airplane emerged from the clouds in one piece. But that was not to be the end of the story. Witnesses on the ground saw the airplane maneuvering erratically and banking steeply. It “looked as if it were a trick airplane practicing stunts, or else someone trying to stabilize the airplane but continuing to overcorrect …”

Surprisingly, although he was now in good VFR conditions below the overcast, the pilot never regained control. Perhaps panic or vertigo had become too extreme for him to fight his way back. The A36 stalled and spun before crashing 7 miles from KGSO, almost exactly beneath the Runway 5L ILS. No one survived.

The National Transportation Safety Board’s finding of probable cause exposes the difficulty the board sometimes has with the concept of “cause.” The cause of the accident, the NTSB says, was spatial disorientation. Certainly, this is true. But the pilot’s inflight decision-making, which put him in the position of having to make an ILS approach, against the advice of his instructor and with still-unfamiliar equipment, is not mentioned, even though the narrative strongly suggests that the pilot became disoriented, at least partly, because he was overwhelmed by his new equipment.

The NTSB criticized the FAA for failing to train controllers “to recognize and effectively respond to disorientation scenarios.” The NTSB objected that no-gyro turns in both directions may have worsened the pilot’s disorientation and was scandalized that most controllers at the facility were unfamiliar with the concept of a standard-rate turn. The exact rate at which a pilot turns during a no-gyro approach is, however, of only marginal importance to a controller.

Something to notice about this accident is how a pilot’s ability to cope deteriorates over time, to the point that he can no longer even avail himself of the seemingly elementary expedient of climbing back above the clouds in a straight line.

It is important for pilots, and particularly low-time pilots, to understand that the very stress of trying to solve a problem erodes one’s power to solve it. Unlike most other ­challenges in life, those which are encountered in airplanes may be life-threatening. In menacing circumstances, the brain seems to become blinkered, abandoning rational analysis in favor of raw impulse or, worse, total paralysis.

You may overlook the ­obvious and make unreasonable choices. You may find yourself unable to interpret the readings on your instruments. You will not perform as well as you expect, and certainly not so well as you did in the same situation on a check ride or in a simulator. This is why it is so important not to skirt risk closely, but to give it a wide berth.

A different lesson, and one of broad application in life, may also be drawn from this story. However much you love it, don’t go into the clouds with your new EFIS until you’ve really gotten to know it.

This article was originally published by FLYING on March 9, 2017.

The post More Than He Could Handle appeared first on FLYING Magazine.

According to the pilot’s own account, he and his lady friend were on a weekend jaunt to Saline Hot Springs, a tiny, rather charming clothing-optional oasis located in the middle of nowhere on the eastern edge of Death Valley in California. He approached the 1,350-foot gravel and rock “Chicken Strip” at 60 knots in his Grumman Yankee, landing uphill, as recommended. Something went wrong, and the Yankee came to rest upside down at the far end of the strip. The pilot broke out what was left of his side of the canopy, and he and his friend crawled out, uninjured. The airplane, however, was a total loss.

That happened in June 2016. Seven months later, the pilot flew his other airplane, a Mooney M20, into a mountainside in southern California.

The pilot, 56, an electronics engineer, commuted three times a week from his home in Tehachapi, California, to the company in Los Angeles where he had worked full time prior to his semi-retirement in 2015. He would land at Torrance (KTOA), a large GA airport 10 miles south of Los Angeles International (KLAX).A colleague would meet him there and they would drive to work together. The straight-line distance from Tehachapi (KTSP) to Torrance is about 95 statute miles.

Tehachapi lies in a valley ringed on three sides by mountains, and overlooks to the east the Mojave Desert, NASA Armstrong Flight Research Center, Edwards Air Force Base, and the Mojave Spaceport of Burt Ru-tan and SpaceShipOne fame. The natural route from Tehachapi to Torrance would be to fly eastward out of the valley, then turn south. You would probably cruise at 5,500 or 6,500 feet, depending on wind conditions, to cross the mountains on the south edge of the desert—home, incidentally, to the portion of the San Andreas Fault which is said to be preparing a cataclysmic temblor for Los Angeles.

You would fly over Van Nuys Airport (KVNY), staying above Burbank’s Class Charlie airspace, drop down to 3,500 feet to thread the VFR corridor through the Los Angeles Class Bravo—don’t forget to change your transponder to 1201, the required squawk code in this corridor—and then call Torrance.

These are the published VFR procedures. And it appeared, from the tracks stored in his Garmin GPS, that the pilot, who had more than 2,500 hours and an instrument rating, usually did make the trip VFR. The Garmin stored records of 35 trips, beginning about a month before the fatal accident. Of these, 17 were be-tween KTOA and KTSP. In a few cases, the pilot had taken off but eventually turned back, presumably be-cause of clouds over the mountains. It was winter, when Los Angeles would be free of the morning coastal stratus of the spring months but prone to frontal passages and lingering clouds over the mountains to the north.

Between the Garmin and ATC radar, the final, fatal flight was precisely documented—and perplexing. After emerging from the Tehachapi basin, the pilot had flown straight toward the Lake Hughes VOR, which is located on a 5,800-foot peak in the mountains that mark the south edge of the desert. The track was west of all the other stored routes, and differed from them in being absolutely straight. The airplane was obviously on autopilot, whereas it had also been obviously hand-flown on all the previous trips.

KTSP is at an elevation of 4,000 feet. The Mooney had initially climbed to 7,500 feet, then turned toward Lake Hughes VORTAC and immediately returned to 6,500. It stayed there for a short time, then descended to 5,750 feet, where it remained until it struck the mountain just 70 feet below the summit and a stone’s throw from theVOR antenna.

National Transportation Safety Board accident investigators could find no explanation for the altitude of 5,750 feet. The hemispheric rule called for 6,500, since the heading was 210. Fox Field (KWJF), 10 miles or so east of the Mooney’s track, was reporting overcast at 2,400 feet, or 4,750 feet msl. It is extremely probable that a similar ceiling prevailed over the mountains and the ridges were obscured. The pilot was not in contact with air traffic control, and the NTSB determined that he must have, at some point, entered IMC.

The reason for the 5,750-foot altitude, which the pilot maintained quite accurately, can probably be inferred from his previous tracks and altitudes. Although he sometimes flew at 6,500 or 7,500 feet, on three occasions he had crossed the mountains at 5,700. Even at that height, he still had 1,000 feet of ground clearance, because the mountains east of Lake Hughes are only3,500 to 4,500 feet high. Only a couple of isolated peaks rise to 5,200 or so. On one occasion he had passed about a mile and a half east of Lake Hughes, but he was thenat 7,000 feet and would not have formed a definite ideaof the height of the VOR.

He knew that he could drop down below the overcast once he had crossed the initial group of ridges. He was low enough to be out of the way of IFR traffic—hence the odd, neither-here-nor-there altitude—but high enough to get safely over the mountains. To ATC radar, he would look like scud-running VFR traffic. The hemispheric rule does not apply to traffic flying less than 3,000 feet above terrain.

The elevation of the Lake Hughes VOR is indicated in tiny, faint characters on the sectional—much less conspicuously than the heights of charted obstacles. But it is unlikely that the pilot consulted a sectional chart. He was improvising and believed that he was so familiar with the terrain that he had no need of a map.

But there was a critical difference between this flight and the others. This time he was navigating by the VOR, not by pilotage, and the VOR turned out to be a trap. Two aspects of this accident are worth reflecting upon. One is the role of habit and the sense of security that it brings. Familiar tasks frequently repeated dull alertness. The pilot probably felt no threat from these low, forgiving hills.

The other is the pilot’s evident willingness to impro-vise, to take chances, to shrug off norms and regulations. Most pilots would not consider a Yankee, with its high approach speed and small tires, a good candidate for a rugged desert strip a third the length of the typical GA airport. He tried it anyway.

The willingness to take a chance and the optimism about likely outcomes that took him to Saline in the Yankee were also, perhaps, in play when he decided to fly blind across mountains within—he thought—a few hundred feet of them. Perhaps they also made him reluctant to subject himself to the regimentation, scrutiny, and delays of an instrument flight plan.

Adventurousness is not a vice, even in pilots. Which of us has never done an unwise thing, taken a chance, or broken a rule? Proverbially, there are no old, bold pilots, but in fact, there are plenty. The trick is to strike a balance—to know when to be rash and when to draw back.

This accident represents the convergence of a psychological willingness to behave unconventionally and a confident lack of concern born of habit. Unfortunately, it is not always in our power to recognize our mistakes as we are making them. That’s why we fall back on rules and procedures: They insulate us from our own frailties. One may feel a grudging admiration for bold nonchalance—but really, all things considered, he should have filed.

This article appeared in the Q2 2022 issue of FLYING Magazine.

The post Improvisation Is Not a Flight Plan appeared first on FLYING Magazine.

Familiarity in flying has several components. There is the foundational element of general familiarity with airplanes and how to fly them. There is familiarity with systems; this may be of a general kind (knowing how to lean the mixture or adjust a constant-speed propeller, for instance) or specific to a particular airplane or type (such as knowing to use the left main tank of an old Beech Bonanza for takeoff when both mains are full because all return fuel from the injection pump goes to the left tank).

There is familiarity with handling characteristics: whether, for example, a certain type pitches up or down with flap deflection. There is muscle memory, knowing how much effort will be required to pitch or roll, and where to reach to lower the gear or switch fuel tanks. There is knowledge of cruising performance, clean and dirty descent rates, quality of stall warning, and post-stall behavior.

Although FAA regulations set quite precise requirements for familiarity and currency—becoming more rigorous for more complex and higher-performance airplanes—it is really hard to tell how much familiarity is enough and, for that matter, whether there is such a thing as too much familiarity. A pilot may know an airplane very well but usually fly a different type. Habits acquired from the more recently flown, or more familiar, airplane might be unconsciously applied to the other. The key word is “unconscious.” Familiarity is the thing that allows you to act without thinking. “Without thinking” is commonly a reproach, but instinctive, unconscious flying is also the hallmark of a natural and skilled pilot. There is a middle ground to be found between too much thought and too little.

How to make the first flight in a homebuilt airplane is a subject of ongoing debate, with one school arguing for short runway hops, reasoning that a few feet is not very far to fall, and another for immediate up-and-away flight, in order to get far from the rocks and hard places as quickly as possible. The impatient purchaser of a Lancair 235 tried to have it both ways.

What Happened

The pilot, 81 years old, had not flown in six months. He had about 450 hours total time. He had no experience whatsoever in the Lancair, which was turned over to him by a broker who asked him not to fly it until he had found someone with experience in the type to fly with him. The pilot promised he would not; however, he wanted to taxi-test the airplane. On his second taxi run down the runway, as the surprised broker looked on, the airplane took off and flew away.

Most likely, the pilot did not intend to break his promise to the broker, who was his friend. The airplane probably became airborne unexpectedly, and he thought it best to get familiar with it before attempting a landing.

He was gone for an hour. When he finally returned, the pilot made two landing approaches, each time going around. A witness observed that the pilot was having trouble with pitch control: “Nose up, nose down…nose up, nose down.” On the third approach, he landed long, bounced twice, climbed to 100 or 150 feet, stalled, and spun.

The National Transportation Safety Board identified the pilot’s lack of familiarity with the airplane as a contributing factor, the cause of the fatal accident being simple failure to maintain flying speed. It’s possible, however, that the pilot was not only unfamiliar with the Lancair 235 in particular but also with airplanes in general that are flown with fingertips rather than a fist. An extremely sensitive airplane is difficult for an inexperienced pilot to cope with because anxiety makes you more ham-handed and likely to overcontrol.

Some airplanes have design quirks that set them apart from others. One is the Piper Comanche, whose manual pitch trim—like that of the Ford Trimotor—consists of a crank handle in the ceiling. Early Comanches did not have electric trim, the operation of which is intuitive: forward button means nose down/go faster. Vertical trim wheels are similarly natural. The overhead crank, however, has built-in unfamiliarity.

The 3,000-hour pilot of a Comanche 250 was observed adjusting the overhead trim control as he taxied out to depart. During the takeoff roll, the propeller struck the runway surface. After breaking ground, the airplane pitched up, stalled and crashed vertically, killing all three aboard.

In principle, it should be impossible to strike a prop even with a flat nosewheel tire and a fully compressed nose strut. However, the nose-strut drag links and torque link were fractured “as if the nose gear had been forced rearward while extended.” Whether this damage arose from the crash or preceded it could not be determined; what was determined, though, was that the pitch trim was set in the full nose-down position, which would have the effect of lifting the tail as the airplane gained speed.

• READ MORE: Previous editions of Peter Garrison’s ‘Aftermath’

Another Comanche crashed somewhat similarly, although the fragmentation of the wreckage was such that the trim setting could not be determined. It was the 700-hour pilot’s second solo flight in the airplane, which he had bought two weeks earlier. He had taken the precaution of getting 15 hours of dual in it in the meantime. A witness reported the pilot appeared to intend to perform a short-field takeoff: He ran up to full power before releasing the brakes. The airplane seemed to rotate prematurely, and the witness, who was an experienced pilot, judged that it looked slow. Rather than level out to gain speed, however, it kept climbing “steeper and steeper” until it stalled and spiraled to the ground.

Although this was an early Comanche, manufactured in 1959, it was equipped with electric trim. The overhead trim is faster-acting, however. The inexorable increase in pitch angle is suggestive of an airplane that was either mistrimmed in the first place or whose pilot is inadvertently applying trim in the wrong direction while trying to get the nose down.

Fuel systems, especially ones in low-wing airplanes, which do not have a “both” position, can be a source of trouble. There are many instances of pilots using an empty tank for takeoff when there was fuel in another. Opportunities for confusion multiply as tanks become more numerous.

A 1,300-hour commercial pilot, flying a single equipped with aftermarket tip tanks, crashed while trying to return to land immediately after taking off. The pilot, who had only a few hours in the airplane, had taken off with the fuel selector on a tip tank, although use of the tip tanks was limited to whatever is meant by “level flight.” The NTSB’s report on the fatal accident does not provide information about the pilot’s previous experience, but the fact that he took off with a tip tank selected suggests he probably landed on his preceding flight with that same tank selected—also forbidden—and his previous experience may have been in airplanes, such as high-wing Cessnas, that do not require so much attention to tank selection.

Mistakes breed in the shadowy land between the systematic and the instinctive. Only by forcing our actions up into the realm of conscious procedure—for instance, by methodical use of checklists and each crewmember’s critical attention to the actions of the other—can we reduce our reliance on instinct and the unconscious errors that come with it.

This story originally published in the December 2019 issue of Flying Magazine

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