We sure can learn from this accident

[Erlanger]

I found the report about this accident very interesting. The part to read is the "Analysis" part. While the crew is ultimately responsible, the controller sure could of prevented this one.

http://www.ntsb.gov/publictn/2006/AAB0605.pdf

 

[avbug]

How could the controller have prevented this event? The crew didn't initiate or make contact with ATC, didn't obtain a clearance, and departed VFR into rising terrain. The crew didn't follow proceedure, and appear to have been tired at the time of the event.

The controller tried to make contact, was unable, and initiated SAR. Where did ATC fail?

Perhaps you're thinking of the statement by the controller in which he was asked if knew about the rising terrain. He said he was. He was asked why he didn't notify the crew, and stated that the crew was VFR. This is correct, and the controller acted properly. One migh ask why the crew didn't contact ATC.

Think about it. Does ATC initiate contact, or does the crew? The crew. That's a pilot responsibility.

The controller saw the flight departing toward Tijuana's airspace and notified Tijuana about a possible handoff or possible aircraft, and by the time he came off the landline and viewed his screen, the aircraft display had gone into coast status.

When an aircraft departs VFR, ATC isn't under any responsibility to contact the aircraft and apply control, particularly when ATC doesn't know who is up there, their callsign, what frequency they might be monitoring, etc.

The pilots made mistakes, and paid for it with their lives. Pure and simple.

 

[A Squared]

I found the report about this accident very interesting. The part to read is the "Analysis" part. While the crew is ultimately responsible, the controller sure could of prevented this one.

I suppose it's tempting to say that the controller could have prevented this, but it was 17 seconds from the time the radar recognized the assigned squawk code and the last return radar return (4 sec. between returns). That's 17 seconds to identify the airplane, identify the problem and communicate corrective action in time for it to be applied.


If you take off at night in low ceilings in mountainous terrain, ignore the published departure procedure (which calls for an approaximately 180 degree turn), level off at 1700 ft AGL and just maintain runway heading toward your destination, you effectively lose your right to complain about poor service from ATC. THis is sort of a soapbox issue for me, but don't ever depart from an airport at night or in instrument conditions (especially an unfamiliar airport) without a good solid plan for not hitting mountains, a review of the Obstacle departure procedure, or solid confirmation of the lack of an ODP. ATC is there to keep you form hitting other planes. Period. If you are counting on ATC to keep you out of the rocks on an IFR Departure, you've abdicated a big part of your responsibility.

 

[Erlanger]

avbug,

My point is that there is a mentality that the FAA has bread. Just as the PIC and dispatcher are responsible and are accountable, a controller should also be too. Maybe this accident could of been prevented if only the controller was involved. The LEX accident with Comair may of been prevented if controllers are also held responsible for a flight. No doubt that controller would not have turned and went off to do other things.

It's just like the read back. The FAA says that if a controller gives you instructions and you read it back in error, the controller is not responsible to correct you. That's freakin' B.S. We're all in this together. Safety is number 1, right! I'm sure most controller go above and beyond what they're suppose to do.

The FAA broke their own rules in not having 2 controllers in the tower. How many other things have they done that we don't know about. They can do whatever they hell the want to do and not be held accountable. FUBAR!

 

[avbug]

How is the dispatcher accountable? The pilot(s) departed under known conditions, failed to accomplish all that they could have or should have, and paid with their lives for their errors.

Pilots love to blame others. It was management. It was the mechanic. It was someone else. However, in the cockpit, the PIC holds ultimate responsibility. Once we have identified ultimate responsibility, we can stop the blame game. We need only blame ourselves.

ATC has bred exactly what atmosphere? The atmosphere of doing exactly what they were supposed to do in this case?

You had an ulterior motive for this thread; there's nothing here to indict ATC. You're trying to dredge up examples of ATC failure to provide a soapbox to whine about the Comair event.

The media has a hayday with the number of controllers on duty, their duty times, the color of the taxiway, the number of morning doves in Kentucky on a Sunday morning, and the price of fry bread. But the bottom line is that the one person who held ultimate responsibility for the safe outcome of that flight is dead...because both pilots failed to do their most basic duties and ensure that no harm came. The aircraft didn't have a mechanical failure. The controller didn't assign the wrong runway. The crew failed to line up on and use the runway they announced they would use, failed the most basic of runway checks and cross checks, and subsequently killed everyone.

The why's and wherefore's haven't been addressed yet; the accident investigation is still in it's early stages. I don't intent to speculate on the details surrounding the event, and I don't intent to argue the merits of an irrelevant and unrelated accident for whatever political reason you feel like beating your chest today. Fact is that regardless of whom ever else may have been in error, the pilot can and should blame nobody but himself.

ATC didn't fail the Learjet by having too few controllers. ATC didn't fail the Learjet by failing to provide critican information. The Learjet wasn't participating in the National Airspace System, and as I said before, one cannot expect the controller to know what frequency the Lear might be using, or if they might be listening...or even the Lear's callsign, for that matter. How is he to know who has departed?

Is a controller responsible for failing to catch an incorrect readback? According to the FAA, no. Cry about it all you will, but the message is clear, as it always has been; you're the PIC, YOU'RE responsible.

You might try thinking about it like this. You make a mistake, you don't get to go home. The controller makes a mistake, the controller gets to go home. You make a mistake, you get buried under earth and cement. The controller makes a mistake, he gets buried under paperwork. Who has the most to lose?

You have the right of way as a pedestrian. Therefore you exercise your right by walking in front of a semi-rig as it barrels down on you. You die. But at least you were in the right. Show the world Teach them. Prove who's boss. Who has ultimate responsibility for your safety? Does it really matter, as you're the one with the most to lose?

Don't you worry about what the other guy is eating. What he's drinking. With whom he's sleeping. Worry about yourself. Don't point your finger. Don't look about greedily and seek someone to blame. As the PIC, you know full well who to blame. YOU. You. You. You. You're always to blame; you're the pilot in command, and you hold the full privilege and weight of that responsibility. Don't try to pawn it off on someone else. Once ou've found the source of ultimate responsibity, you can stop your search. It's all about you.

 

[Axel]

While the controller's actions may have been cited, it was not the controller who decided to depart under those circumstances.

http://www.ntsb.gov/ntsb/GenPDF.asp?id=DCA92MA011&rpt=fi

http://www.ntsb.gov/ntsb/GenPDF.asp?id=DCA94GA010&rpt=fi

 

[mtrv]

While the controller's actions may have been cited, it was not the controller who decided to depart under those circumstances.

http://www.ntsb.gov/ntsb/GenPDF.asp?id=DCA92MA011&rpt=fi

http://www.ntsb.gov/ntsb/GenPDF.asp?id=DCA94GA010&rpt=fi

So, when it comes right down to it, every flight into terrain accident listed in this thread, including the takeoff on the wrong runway; and I'll even throw the Hendrick Motorsports King Air flight into rising terrain-----

Could now probably be prevented with todays GPS technology and MFD's such as the 15" center unit in the new Cessna Mustang, or the Avidyne unit you'll find in the Piper Mirage.

With MFD's such as these, terrain features and terrain warnings both visual and audio are rather hard to miss; even if the pilot is somewhat confused, dissorented, or not paying real attention. And detailed airport diagrams with your airplane symbol overlayed on the ramp/runway are available too, even for hand-helds.

Does anyone care to argue this point in favor of old school navigation? Last time I brought up GPS moving maps, someone attempted to use the Hendrick MotorSports accident as a case where GPS was in use, and did little good.

Yea right, sure was a GPS, except it was a small screen Bendix/King KLN90B that's from the stone ages. Very little (if any) useful terrain information to be gotten from that unit.

Since it's been brought up in this thread, that it's ultimately the pilot who is responsible, then the more info the pilot has, then the better! At least that's my thoughts on the subject.

 

[avbug]

Does anyone care to argue this point in favor of old school navigation?

I won't argue that point, but I do disagree that there's such thing as "old school navigation." If basic navigational skills are out of style, I certainly haven't heard of it.

GPS and other cockpit innovations over the years from LoRaN to FMS and all the bells and whistles we enjoy today are proverbial tools in the toolbox. I've had them all fail at various times, and have merely used other tools that were available. Where the ground is visible, I still look down and follow along on the ground, even from FL410, even though an FMS may guide the way through an autopilot. Conversely, I had a discussion with a pilot regarding ground prox and terrain mapping, and when the discussion didn't supply all the answers, we made a low flight in the airplane to verify what it would do. At one point in the flight, he pointed to the terrain display and told me that we could exit the area we were flying through a pass ahead. I crossed the canyon he had found on the moving map at a right angle, and showed him that it was a box canyon. The map was wrong, and had he relied on the map information to get him out of a situation, it would have killed him. Staying visual, using the water principle (flows downhill, and so do we) in terrain and using basic pilotage skills was the order of the day on that flight.

I don't consider any navigational skill to be old school, regardless of what is in the cockpit. Take everything that's available, old and new, and use it to your advantage. One skill or piece of equipment compliments another. The most important navigational skills are still those taught to student pilots...what is taught to the ATP merely enhances and adds to it. The basics are never replaced.

I met a pilot this year who was working in one geographical area. He had made multiple trips to a particular point, and his GPS failed. He grounded the airplane. He said he couldn't be expected to continue without his GPS. The company had to spend time and effort and money, and take a revenue loss for the downed airplane, because this pilot couldn't navigate over the same route he'd been using all day, without his GPS. I flew his airplane a couple of days later and brought my own charts. He didn't have any on board. Not good.

I've used electronic flight bags, but still prefer paper. I've never had a paper chart fail me, but I've had more EFB failures that ranged from display problems to computer problems to corrupt data bases to power failures, than I can count. Old School? No. I'll use the EFB. When it's working. School is never out.

 

[satpak77]

Erlanger

You are sadly wrong. ATC has run "double shifts" for 30 years now, and Comair goes to the wrong runway and it is ATC's fault? Sure, two controllers might have prevented it, maybe so, and maybe not.

It was a unfortunate accident...Captain probably taxied to wrong runway, while FO is heads down on the box and looking at charts and paperwork. Captain reaches the end of the incorrect runway, tells FO, "your plane", who looks up and applies power, with tragic results. Thats prob what happened, but I do not know. Lets wait for the NTSB report.

As far as the Lear crash, that crew

1) Did not fly the recommended DP
2) Did not obtain IFR clearance and departed in hilly terrain at night, VFR.
3) Forgot that under VFR, terrain and collision aviodance is 100% the pilots responsiblity, even under positive radar contact and control, such as flight following. The PIC still MUST monitor the controller and flight.
4) Did not brief the departure nor terrain in the area. Worst case scenario, they takeoff from the other direction and that makes it safe(r).

Not to second guess two dead guys, God rest their souls, and like you said, lets all learn from this. Me personally, I am more concerned with physical terrain avoidance then I am about busting a stratus layer while still under VFR control. I know how to fly by instruments.

I have seen more accidents because pilots were wrapped up in "we don't have an IFR clearance yet" and scud runned until they got one, when they could have just orbited up and above the airport until above the MSA. Of course the preference is don't fly into IMC without a clearance. But if you are gonna launch, don't get killed if you don't really have too.

The NTSB report stated the bases were 2100 at the airport. The MSA circle for the SW quadrant is 2500 feet

http://myairplane.com/databases/approach/pdfs/05814VGA.PDF

Airport elevation is 524, putting the turbine traffic pattern at 2024, or basically in the bases. Cognizant of an airborne IFR pickup, one alternative would be to depart RWY 26, headed toward flat terrain, and flown a 1000 foot pattern, while waiting on ATC. You would wake up the neighbors, but at least you aren't headed towards the mountains at night.

Again, we could second guess and say "I would have done ____" to these now-dead fellow aviators all day long.

With that said, if you insist on departing VFR into IMC, have a gameplan to deal with it, and that does not mean scud-running. It it means busting a cloud layer to avoid granite rock, well, I know choice I would make....

 

[satpak77]

FYI

I believe the Hendricks crash airplane had a "VFR only" GPS installed. Again, as pilots were are scared that the FAA is around every corner and might violate us, so since we are flying a IFR approach, of course we cannot "use" the VFR only GPS, right?

Of course not, don't be silly. The primary nav is VOR, but the VFR only GPS can provide supplemental advisory information. Such as, you just flew over the airport numb-nuts. That might trip a red flag in our brains that our VOR data is wrong or we are misinterpreting it.

Etc etc

 

[mtrv]

FYI

I believe the Hendricks crash airplane had a "VFR only" GPS installed. Again, as pilots were are scared that the FAA is around every corner and might violate us, so since we are flying a IFR approach, of course we cannot "use" the VFR only GPS, right?

The Hendricks aircraft was equipped with a Bendix/King KLN 90B, but the database was not current for use with IFR approaches.

According to the in depth article on this subject in the Sept. 06 AOPA magazine under "Safety Pilot", the GPS was installed between the seats, which required the pilot or co-pilot to look down and almost 90 degrees away from the panel & instrument scan.

And as I previously mentioned, what you get on a KLN 90B's screen isn't much information compared to today's moving map GPS's. Once passing the airport, all the screen displayed was a black line from the aircraft's symbol, back to the airport.

I set this same scenario up on my Garmin 296 hand-held with a color moving map & terrain/terrain warning features. Instead of a missed approach and climbing right turn, I continued on the runway heading beginning at 1,400' msl., waited for five miles plus another minute, and then began a straight ahead climb to 2600'.

And here is the point; while their old style GPS is showing no more than a black line, my terrain warning box has already came on with a yellow field (terrain within 2000' altitude) of warning X's followed by a red field, meaning terrain is approaching within 100' of my current altitude.

At the same time, my moving map is also showing the airport's locatiion, relative to the aircraft's, as well as terrain shading, plus the fact that the runway center line arrows would depict the airplane as outbound from the airport.

While it appears that the crew was confused regarding the fact that they had already passed the airport and overflew the missed approach point, and possibly have been relying on the GPS's annunciation lights instead of other nav instruments; they were in fact confused, or just didn't realize their real location. Just the same way, the Comair crew apparently didn't realize that the aircraft was pointed down the wrong runway.

Now, I'm not saying to replace paper charts with just electronic boxes, or to depend solely on GPS as a means of navigation. The title of this thread, has to do with what we can learn. I don't believe it's the controllers problem, as stated in the original thread. However, I'm well aware of how far GPS has improved in the last 15 years. And from what I've seen, even my hand-held Garmin will display in your face information at the exact second (as well as before) that the confused pilot apparently needs, even if he/she doesn't yet know it. And a 15" center panel mounted moving screen MFD is even going to show a lot more detail than my hand-held including high resolution airport/runway diagrams.

Since flight into terrain accidents still happen month after month, after month (I've kept track since Frank Sinatra's mother's plane crash a long time ago); I'm quite sure that these newer high tech screens, especially the future models with synthetic 3D terrain imaging, should help in reducing terrain collusions in IMC.

 

[avbug]

Yes and no...if one immediately rotates skyward and climbs like an exceptionally healthy bat, yes. But if one is spending time amid terrain, such as an approach in mountainous terrain, then the terrain informaton offered on moving maps, displays, enhanced ground prox, gpws, and the like aren't particularly useful.

As in the example I cited above, during particular types of flying I've had to silence the devices because I got sick and tired of "terrain! Pull-Up! Pull-Up!" I wasn't going to pull up; that wasn't part of the profile, and on the moving map of display on some units, I had boxes appearing which obliterated the screen, showing me different obstacles that were apparently the prominant terrain features in the area.

I was visual. Flying on instruments in those circumstances is beyond stupid. Yet pilots do it. In the example cited above, a pilot had told me at great length that he trusted the device to do just that, and closely monitored terrain while flying into mountainous airports. He told me he felt that with an instrument failure, he would catch it on the terrain display. Perhaps he would, but I made the point that perhaps he would not by having him select a cayon that would allow us out of the valley, before he could see the canyon, based on the terrain display...and then flying him to the canyon to show him what would have been the result. He was very quiet after that.

Certainly if the only purpose of these devices, displays, and equipment is to indicate that *something* big is out in front and that you must pull up, then great...but predicating terrain avoidance upon them, rather than upon standard approach proceedures, is wrong.

A crew that can't tell if they've passed the MAP or not needs only do one thing. Climb. Like a ruptured duck. Loss of situational awareness is bad. Very bad. I'm not familiar with the Hendricks crash to which you're referring, so I can't address the details. I can say that chances are the crew was far more at fault than the controller, which is the theme established by the person who started this thread...blame the controller. In the cockpit w(h)eather we are situationally aware or not, our fate is in our hands. The pilot needs to know what safe altitude will get him back out, the terrain into which he's flying, the timing involved, and all other basic aspects of the approach if he's to survive. Flying blind toward the ground at high rates of speed with terrain all around you is NOT a natural act, and it behooves on to take the full brunt of responsibility in backing ones self up sixteen ways from sunday to remain situationally aware, lest one marry the terrain.

 

[Waldom]

I hope what Erlanger and mtrv learned from this accident report is not to perform an instrument departure without a plan for terrain avoidance and not to abdicate their responsibility for situational awareness whether or not radar contact.

 

[mtrv]

I hope what Erlanger and mtrv learned from this accident report is not to perform an instrument departure without a plan for terrain avoidance and not to abdicate their responsibility for situational awareness whether or not radar contact.

I'm interested in what the future is bringing, and what's already here on a limited bases.

Synthetic 3D vision that will be presented on a HUD or MFD. Using built in topography databases, the screen projects an out the window VFR representation of mountains, nearest terrain , and the runway. It also uses a "highway in the sky" mode, that can be used for flying exacting IFR approaches, as well as holding patterns, even if an approach plate isn't used.

I'm not advocating (nor is anyone else) doing away with the approach plates, but for testing purposes, they were not used, to see how well the system can be flown. The right seater observers who see nothing but IMC are amazed just how perfect the approach is flown; either by hand or auto-pilot.

Reports on different systems being developed by NASA, Chelton and a few others, are very positive. Pilots who have flown these systems, feel that moving maps representing topography from above, such as the Garmin 1000 glass panel, now seem somewhat antique.

One can see just how good sythetic vision terrain databases are getting, by just looking at Microsoft's new FSX flight simulator, that uses newer high resolution topography databases from Space Shuttle topography mapping. X-Plane also has global terrain mapping available.

 

[Axel]

Old school:

Wait for your clearance, depart IFR and fly the DP. A little patience goes a long way.

 

[Publishers]

Avbug brings a great deal more experience to the table than a black box. While the new tech is great, recently I have had the chance to look at both the Garmin and Avadyne systems in slow piton pounders. Frankly, admitting I am an old guy, It almost became more confusing than old school. Looking all over and checking all things,,,,, oh yeah, I am supposed to be flying this thing. That is all at 100 knots not 400.
This whole thing is a bit like the DUI accident--- the bartender should have stopped me, my friends should have taken my keys, the parking lot guy should have noticed I was drunk. In the end, it was my stupidity.

 

[A Squared]

Old school:

Wait for your clearance, depart IFR and fly the DP. A little patience goes a long way.

Exactly, and even if you can't be patient and get a clearence, use the DP and don't just blindlyfly reunway heading toward mountains.

I think the point that mtrv is missing here is the guys completely dropped the ball on any sort of terrain awareness, they apparenty didn't review the departure procedure (or if they did review it and flew runway heading anyway, the gene pool is better off without them), they didn't make any attempt to figure out what the terrain was around the airport ... if they are so unconcerned about hitting a mountain that they don't do the bare basics, what makes anyone think that they wiould have correctly set up and used the terrain display if it was available. Seems to me that given thier casual attitude toward terrain, they would have had the MFD set up on the "nearest ARTCC frequencies" page as they plowed into the same mountain.

 

[mtrv]

if they are so unconcerned about hitting a mountain that they don't do the bare basics, what makes anyone think that they wiould have correctly set up and used the terrain display if it was available. Seems to me that given thier casual attitude toward terrain, they would have had the MFD set up on the "nearest ARTCC frequencies" page as they plowed into the same mountain.

Then happily, thanks to new technology as designed,

The terrain warning box will pop up, no matter what page your reviewing. Even my Garmin 296 hand-held forces me to acknowledge the fact that I'm possibly about to die, if I don't do something about it. If VFR, and low to terrain, such as putting out fires, then ignore it or don't use it, as Avbug has suggested.

I'd be willing to bet, that on those moonless nights or in IMC conditions, that a synthetic 3D topography image on the pilot's PFD or HUD will become a matter of routein, when available. Who would not use one, if it was there in front of you?

 

[satpak77]

technology will never beat a sectional chart and knowing how high the terrain is

(but yes, it helps)

 

[mtrv]

Avbug brings a great deal more experience to the table than a black box. While the new tech is great, recently I have had the chance to look at both the Garmin and Avadyne systems in slow piton pounders. Frankly, admitting I am an old guy, It almost became more confusing than old school. Looking all over and checking all things,,,,, oh yeah, I am supposed to be flying this thing. That is all at 100 knots not 400.
This whole thing is a bit like the DUI accident--- the bartender should have stopped me, my friends should have taken my keys, the parking lot guy should have noticed I was drunk. In the end, it was my stupidity.

I'm an old guy too.

And sure, it's somewhat more confusing than old school. But find someone who has actually used these new systems, and learned how to use them, instead of just a flight or two with the glass setups; and then see how many prefer to go back to the six pac setups. I have found no one! Not one single soul.