Questions

[kenimpzoom]

Gents,



I am a newby and only registered to start a dialogue about what might have happened in the crash of my uncle’s plane. If this is not appropriate, then mods you may delete it, but I would really appreciate your help. I know the NTSB will be very slow, so any and all ideas as to what you think might have happened are welcome. Please be brutally honest if you have to, don’t sugarcoat.

I know a lot about flying, and the mechanics of it all.



My uncle was killed in San Antonio on Nov 14th. He had 40 years of flying experience. He had an air freight business for 15 years, and owned 6-7 planes. He had tons and tons of flying experience. I thought I had heard he had 45,000 hours, but not sure. For the last 5 years he had been retired, but still flew a corporate plane for his “retirement” job. He had flown out of that airport most of his life, so he knew it like the back of his hand. He was the nicest guy you could know. He was very meticulous, I remember flying with him several years ago, and he made sure he had the weight distribution correct, and that we were not overloaded.



What I am asking is, for yall to speculate as to what might have happened.



Here is a newspaper story that includes all the details:

A senior investigator with the National Transportation Safety Board said today that the small airplane that crashed late Sunday afternoon veered off its approach course before the fatal accident and that the pilot did not declare an emergency.

Five people died late Sunday when the Piper Navajo crashed near an apartment building on San Antonio's North Side.

Alex Lemishko of the NTSB told reporters today that investigators will focus on the weather, aircraft maintenance records and why the pilot may have turned off course. He said that although no cause has been ruled out, fuel starvation is not considered likely because a flash fire started when the plane hit the ground.

“In this type of investigation, we don’t have a lot to go on,” he said.

Lemishko said he believes the plane crashed nose-first and that its engines are buried.

Air traffic controllers asked the pilot his altitude on approach and were told 2,500 feet, Lemishko said. They asked him to climb to 3,000 feet but got no response.

The last radar contact showed the plane at 1,300 feet. Lemishko said the drop from 2,500 to 1,300 feet was rapid.

Cloud cover was only about 400 feet, he said, meaning it’s not likely the pilot could have been aware of his surroundings before the crash. The plane’s wing struck the roof of an apartment with a resident inside, punching a hole in the building, but no one on the ground was injured.

It's likely the small, private plane did not have a “black box” that would have recorded flight data and the pilot's voice in the moments before the crash.

Frank McGill, a senior investigator with the NTSB, said that years of investigating plane crashes should help determine what led to Sunday's fatal incident.

“We've been doing this a long time,” said McGill, who is not investigating this accident. “You start off by going through the weather. Then he'll cover the training this pilot had, his amount of flying time. And then there is the airplane itself — the fuselage and the engine.”

NTSB, which is the lead agency in charge of the investigation, should have a preliminary report issued within four or five days, McGill said, but warned that it would not contain much information. A final report will take more time to be issued.

“Sometimes it doesn't take long at all,” he said. “Sometimes it takes months.”

A spokesman for the Federal Aviation Administration said both the plane and the pilot had clean records. The plane was manufactured in 1980 — modern by aviation standards.

“You see a lot of airplanes from the '60s and '70s and they're up-to-date and totally flyable,” said spokesman Roland Herwig. “It has no prior incidents or accidents.”

The pilot, Jerry W. Oyler, didn't have any reports of accidents, incidents or enforcements from the FAA, Herwig said.

The plane, which flew here from Dodge City, Kan., narrowly missed an apartment building for seniors in the 3800 block of West Avenue.

 

[kenimpzoom]

If it was mechanical failure, the only thing I could think of, is the instruments failed. I doubt they could fly all they way from Kansas, only to have an engine or control surface fail right there. Plus it was a twin engine. There was plenty of gas.

I am thinking the level flight gauge failed, he pulled up, went into a stall, and was too low to pull out.

Thanks for any replies.

Ken

 

[KeroseneSnorter]

Not much to go on there. It could be anything from pilot incapacitated by some medical problem, to mechanical problems, or he just screwed up.

If I were you I would wait for the NTSB to at least see if the airplane was functioning correctly. They can normally rule out, or find mechanical failure pretty quick by sifting through the wreckage.

 

[kenimpzoom]

Yea, I dont know about medical problems. Hopefully the autopsy will help. He was very fit, but other than that, I dont know.

One other question, the way I have read NTSB reports there are only two causes. Mechanical failure or pilot error. Is this correct? In other words, if the pilot flys into bad weather, it is pilot error?

Thanks, ken

 

[KeroseneSnorter]

If it was mechanical failure, the only thing I could think of, is the instruments failed. I doubt they could fly all they way from Kansas, only to have an engine or control surface fail right there. Plus it was a twin engine. There was plenty of gas.

I am thinking the level flight gauge failed, he pulled up, went into a stall, and was too low to pull out.

Thanks for any replies.

Ken

The Navajo has duel vacuum systems, and many are equipped with duel attitude indicators. Even if it was only equipped with one A/I and it failed, your uncle should have been able to fly it by using the other systems. A pilot is not supposed to crash just because he lost one instrument.

If it was because of an A/I failure then your uncle will be faulted by the NTSB for the accident with a contributing factor being the instrument failure.

 

[KeroseneSnorter]

Yea, I dont know about medical problems. Hopefully the autopsy will help. He was very fit, but other than that, I dont know.

One other question, the way I have read NTSB reports there are only two causes. Mechanical failure or pilot error. Is this correct? In other words, if the pilot flys into bad weather, it is pilot error?

Thanks, ken

Unless the airplane comes apart around a pilot for no good reason, the pilot is normally faulted for any loss of control or errors in judgment (ie. flying into thunderstorms etc...)

Let me add that I am not an accident investigator in any way. I am taking a best guess at what the NTSB might say in the situation that you described.

 

[kenimpzoom]

Thanks a lot for your insite Kero.

I would also think that even if all gages fail, a person with his experience would not pull up enough to cause a stall. I know spacial disorientation is very real, and in fact, once while flying with my uncle, I experienced it. But I doubt it in this cause cause he would certainly hear the engines lugging with a steep climb.

One other question, what would be the normal flaps setting for landing, If you go around to attempt another landing (as my uncle did), do you put flaps back in the "normal flight" position, or do you keep them in the "landing" position. What about the landing gear?

Ken

 

[avbug]

Ken,

No useful information is presently available. Most sincere condolences to your family for the loss. Speculation is a futile effort in aviation events such as this; heaven knows the media does enough, and usually gets most everything wrong.

This crash was listed on this site, with no replies at:

http://forums.flightinfo.com/showthread.php?t=43042

I realize that you feel a need to have answers. Sometimes the answers are clear, sometimes they're not. Sometimes they're never known. I do know that having the answers never makes the loss easier, only more understandable in cold, mechanical term. In dwelling on what has happened, I'd urge you to concentrate more on how the person lived than how they passed away. Those answers will come in time.

For now, rest in the knowledge that those who have died are hardly gone, just gone from our own sight. They still hear, they still see, they are still they...we just must wait a little while before we join them. Until then, there are memories and feelings, and they must suffice. I'm sorry for your loss.

The National Transportation Safety Board investigates these events. A preliminary report has not yet been published on what happened. You can check at the following site to see it when it is published. You should remember when you do see it that it's preliminary in nature only, and may contain errors or omissions. To see the NTSB database query, go here:

http://www.ntsb.gov/ntsb/query.asp

 

[KeroseneSnorter]

Thanks a lot for your insite Kero.

I would also think that even if all gages fail, a person with his experience would not pull up enough to cause a stall. I know spacial disorientation is very real, and in fact, once while flying with my uncle, I experienced it. But I doubt it in this cause cause he would certainly hear the engines lugging with a steep climb.

One other question, what would be the normal flaps setting for landing, If you go around to attempt another landing (as my uncle did), do you put flaps back in the "normal flight" position, or do you keep them in the "landing" position. What about the landing gear?

Ken

It has been a while since I flew a "jo" but normally it would be full flaps for landing and in the case of a missed approach the routine would be "Full Power(or take off power), Flaps to take off position (Whatever that may be) positive rate of climb, and then gear up"

The report did not mention what the temperature was at the time of the accident. IF, and I stress if, his pitot static probe (or probes) iced over that might explain the altitude deviation from the assigned 3000 ft. That could be either he forgot to turn on the P/S heat or it failed. However this is pure speculation since the is so little info to go on.

If I were you I would spare yourself all of the what if's and wait to see what the NTSB has to say after they inspect and test the wreckage and components.

 

[kenimpzoom]

Avbug, thanks for your reply and kind words.

I would like to say that the local media has actually done a pretty good job. They had interviews with people that spoke highly of my uncle. They did of course have to say "... it could have been weather, mechanical failure, or pilot error". But I knew it was coming, they have to do it for ratings. Still I think 90% of the media is a bunch of idiots.

I understand that speculation is futile. But I also know my family will begin to speculate, and I would like to be somewhat informed as to the aircraft specs and such.

Everytime they start to speculate, I try to tell them not to, but I know it will continue.

Ken

 

[kenimpzoom]

I thought of icing too, I think the temp was in the 50s. I know ice can form in weird conditions, but I would think that this would be a little too hot, also considering they were flying pretty low.

I found this info:

Cloudy drizzle enveloped the plane as it approached the airport. Federal investigators said it was about 2,500 feet high at the last contact and was headed to Runway 3.

Controllers reported it veered off the path, and they told Oyler to go up to 3,000 feet, but on the next radar contact, the plane quickly had dipped to about 1,300 feet.

By the time it cleared the clouds, at about 400 feet, the plane was heading down. About three miles from the airport it slammed into the ground outside a senior citizen apartment complex on West Avenue, narrowly missing a building, and burst into flames.

There had been no distress call from the plane.

 

[flyifrvfr]

First let me join those who sent condolences. I know this will sound idiotic but I have been pretty good at speculating causes of accidents in the past. With the lack of information contained in the newspaper, even I wouldn't specualte the cause of this accident. There simply isn't enough info to work with.

The article doesn't hint that the pilot made any distress calls. Witnesses are highly unreliable, and missing in this case. I would wait until the investigation is complete and more information becomes available. The one thing that keeps coming to mind is perhaps your uncle became incapacitated. Unfortunately, even people who are in great physical shape can suffer from heart attacks and such. Wait for the medical examiner to give a report.

 

[kenimpzoom]

Fly, thanks for your input. I agree there is very little to go by.

There were no distress calls, witnesses reported the plane was flying low, and then hit a tree. There was no reports of the plane being inverted, etc.

Here are some quotes from the newspaper.

Two teens playing basketball at a church nearby said they saw the tail end of the aircraft after hearing what seemed like a sputter.


The aircraft appeared to hit a tree and then the teens lost sight of it, until they saw flames.


"It sounded like a car backfiring but way louder," said Aaron Alvarez, 15, one of the teens. "I was hoping everyone got out all right."


More and more signs point to my uncle becoming incapacitated. We havent had the nerve to ask if there is enough left to determine if he had a heart attack.

I have also learned that there was someone sitting in the co-pilots seat. There was also a hunting dog on board.

It was a very hard hit, engines buried 6 feet in the ground.

I plan to talk to my uncles neighbor and get the facts. Appearently, the neighbor is a pilot also, and has the NTSB investigators contact info.

Ken

 

[kenimpzoom]

The pilot of a private plane that crashed near an apartment complex, killing all five people aboard, did not indicate he was in trouble as he dramatically veered off his approach to the San Antonio International Airport, officials said Monday.

A probe has begun into Sunday's plane crash on West Avenue that killed all five on board. Investigators from the National Transportation Safety Board and representatives from Piper Aircraft Inc. examined the wreckage Monday.


A lack of clues, coupled with the mangled plane body that left a crater more than five feet deep by six feet wide, hampered investigators as they dug through the wreckage of the deadliest crash in San Antonio in more than three decades.

"This is a complicated scene," said Alex Lemishko, lead investigator in the case for the National Transportation Safety Board.

"There was no declaration of a specific kind of emergency to give us an idea of where to look first, and then there's the sheer destruction of the aircraft."

While investigators continued to pick through the rubble at the Walnut Manor complex in the 3800 block of West Avenue on Monday, they began to paint a picture of the doomed flight's final minutes before it crashed nose-first into the earth about 5:20 p.m. Sunday.

Pilot Jerry W. Oyler; radiologist David McMurray and his son Ben McMurray; and Stewart "Skeet" Johnson, a general surgeon, and one of his twin sons, Hugh Johnson, were returning from a pheasant hunting trip and left the Dodge City, Kan., airport at 1:45 p.m.

They had been the guests of Ron Hermann, who owns Columbia 300 Inc., a local bowling ball manufacturer. Hermann's son, David, is vice president of Dash Air Charter Inc., which owned the plane.

Another plane returning hunters from the same trip arrived in San Antonio without incident about 30 minutes earlier.

Oyler, who was using instruments to land the Piper Navajo, suddenly veered off course, turning left. In his last communication with air traffic controllers, he reported he was at an altitude of 2,500 feet and climbing to 3,000 feet. Shortly afterward, radar indicated he was at 1,300 feet and descending.

The plane's right wing then clipped the apartment complex, coming through the roof of a second story unit. The craft then hit a tree and dove nose-first into the ground.

"There was a large amount of energy. The impact was forceful enough to create a large crater," Lemishko said. "No distress calls were heard. He didn't declare an emergency."

Among other factors, weather conditions will be studied. The sky was thick and overcast, and the conditions were appropriate for an instrument landing, Lemishko said.

"He would have been in the clouds during the entire approach," he said. "It's possible to become disoriented in the clouds."

After the impact, the plane's internal fuel bladders burst, causing a flash fire.

On Monday, the Bexar County medical examiner's office continued to recover bodies at the scene and was beginning the official identification process, which is expected to take several days and involve dental records. However, family, friends and officials confirmed the names of the dead.

Today, the plane's wreckage is to be moved to a warehouse in the Dallas area, where it can be scrutinized. While a preliminary report is expected this week, a final report may take three to six months or longer, Lemishko said.

"There's not a whole lot to look at," he said. "There's a lot of studying to be done."

It's likely the plane did not have a flight data recorder or a cockpit voice recorder, also known as "black boxes," that would have provided answers to investigators.

Oyler was a veteran pilot with 8,700 flying hours and was licensed to fly a variety of planes, Lemishko said.

"He had all the proper credentials to make this flight," he said. "He was qualified."

Both the plane, which was manufactured in 1980, and the pilot had clean records, according to Federal Aviation Administration records.

FAA spokesman Ronald Herwig said the Piper Navajo is a respected aircraft and, though the plane was 24 years old, it is considered modern.

"You see a lot of airplanes from the '60s and '70s and they're up-to-date and totally flyable," he said. "It has no prior incidents or accidents."

Lemishko said the fact the plane — which wedged tightly between a carport and the apartment building — didn't seriously hurt anyone on the ground was "a miracle."

The resident of the apartment where the wing crashed through the ceiling was in her kitchen at the time of the accident.

"From looking at the wreckage and the proximity to where people were living, it certainly is a godsend that no one was hurt," he said.

"I'm just amazed by the resiliency of the apartment residents — certainly it was traumatic."

On Monday, residents greeted each other warmly inside the building, hugging and kissing each other, and praying. Outside, one of the families that lost loved ones came by the scene to say a prayer.

James Couch stood outside his apartment complex, awed by the site of the crash that left little of the plane visible.

"That doesn't even look like an airplane," the 81-year-old said. "It's just a stack of junk.

"You don't see seats, you don't see a propeller, you don't see an engine. Coming down on a small space like that and no more damage was done — that's unbelievable."

 

[kenimpzoom]

Here is the preliminary NTSB report. Does it have any clues?

The way I read it (I am not a pilot), he was on approach, and was 1.3 miles left of the proper approach line, and then was told "looks like you lost the localizer, turn left heading two seven zero, climb and maintain three thousand five hundred". On the climb out and turn, something went wrong. He went into a hard left turn, and then who knows.

Do I have that correct????


I can think of two scenarios.

1) He lost all instruments and radio, and was dipping below cloud cover to try to gain a reference point, he became disoriented in the clouds, stalled it, and crashed.

2) He became incapacitated, and the person occupying the co pilots seat tried to take over, but was unable to fly. From what I have heard, the person in the co pilots seat had some basic knowledge of flying.

Any other possibilities?

Thanks, Ken


On November 11, 2004, approximately 1718 central standard time, a Piper PA-31-350 twin-engine airplane, N40731, registered to and operated by Dash Air Charter Inc., of San Antonio, Texas, was destroyed when it impacted a multi-unit residential building and the ground following a loss of control while on an instrument approach to runway 3 at the San Antonio International Airport (SAT), San Antonio, Texas. The commercial pilot and four passengers were fatally injured. Instrument meteorological conditions (IMC) prevailed, and an instrument flight plan was filed for the Code of Federal Regulations Part 91 personal flight. The cross country flight originated from the Dodge City Regional Airport (DDC), near Dodge City, Kansas, approximately 1345, and its final destination was SAT.

According to information provided to the NTSB investigator-in-charge (IIC) by friends and family members, the passengers on board the aircraft were returning home after a hunting trip. Preliminary information provided by the FAA and weather reporting services revealed that the en route portion of the flight from Dodge City was flown in instrument meteorological conditions. There were no reports of problems from the aircraft during the approximate 3 1/2-hour en route portion of the flight. As the aircraft neared its destination of San Antonio, the pilot established communications with San Antonio Air Traffic Control Tower (ATCT) and maneuvered to execute the Instrument Landing System (ILS) Runway 3 approach. The following are excerpts of radio communications between the pilot of the aircraft (N40731) and approach controllers (ATCT) in the minutes prior to the accident. In the excerpts, ATCT controllers identify the aircraft as "Navaho seven thirty one."

ATCT: Navajo seven thirty one, turn left heading zero nine zero
N40731: Left turn, zero nine zero
ATCT: Navajo seven thirty one, descend and maintain, disregard, just three thousand five hundred for
Navajo seven thirty one, heading zero nine zero
N40731: Three thousand five hundred, zero nine zero
ATCT: Navajo seven thirty one, is three miles from RESOC, turn left zero six zero, three thousand five
hundred till RESOC, cleared I L S runway three, maintain max forward speed
N40731: Ok, left zero six zero, join localizer, maintain three point five till RESOC
ATCT: Navajo seven thirty one, San Antonio
N40731: Yes
ATCT: Navajo seven thirty one, looks like you lost the localizer, turn left heading two seven zero, climb
and maintain three thousand five hundred
N40731: Left turn two seven zero, three thousand five hundred
ATCT: Navajo seven thirty one, say altitude.
N40731: Climbing to three thousand
ATCT: Say altitude now
N40731: Two thousand five hundred
ATCT: Navajo seven thirty one, looks like you are in a left turn northeast bound, traffic one o'clock and a
mile, hard left turn now, heading three zero zero, hard left turn
ATCT: Seven thirty one, maintain three thousand five hundred, I show you at one thousand eight hundred
ATCT: Navajo seven thirty one, I lost your transponder

No further communications were received from the aircraft.

The ILS RWY 3 approach can be initiated via a radar vector to intercept to the final approach course at 4,000 or 3,500 feet msl depending on the location of the vector. The initial approach fix for the approach (RESOC) has a designated altitude of 3,500 until established on the 3.00 degree glide slope. The final approach fix (FAF) for the approach is located 5.4 miles from the runway threshold. The decision height for approach was 986 feet msl (200 feet height above touchdown) and is based on flying the full ILS with a fully operational ILS receiver. The published missed approach procedure for the approach is to climb to 1,700 feet msl, then execute a climbing left turn to 3,500 feet msl, heading 025 degrees, then proceed outbound via the SAT R-040 to SHEPE Intersection/SAT 18.4 DME and hold.

Preliminary radar data received from the FAA showed that the aircraft remained initially left of the localizer course line before turning right of the localizer approximately 2 miles before the final approach fix (FAF). Radar then showed the aircraft turn to the left of course line. When the aircraft was abeam the FAF, it was approximately 1 mile left of the course line. As the aircraft closed to approximately 1.5 miles from the runway threshold, the aircraft had veered about 1.3 miles left of the course line (at which time ATCT instructed the pilot to turn left to a heading of 270 degrees). The aircraft continued to turn left through the assigned heading and appeared to be heading back to the ILS course line. According to the radar, another aircraft was inbound on the ILS course line and ATCT instructed the pilot to turn left immediately. Thereafter, the aircraft went below radar coverage (approximately 1200 feet msl).

A witness, located approximately 1.25 miles northwest of the accident site, reported to the NTSB investigator-in-charge (IIC) that he heard a very loud noise, and then observed a small white airplane flying toward a building, approximately 60 feet in height. The airplane pitched up approximately 45 - 90 degrees just before the building and disappeared into the clouds. A second witness located approximately 1 mile northwest of the accident site reported to the IIC that he heard a low flying aircraft, and then observed a white twin-engine airplane banking left out of the clouds. The airplane leveled out, and flew into the clouds again a few seconds later. The witness added that he "saw no indications of problems, smoke, or visible damage to the airplane." The witness stated that the airplane was at an altitude of 100-200 feet above the ground. A third witness located adjacent to the accident site reported that they heard the sound of a low flying airplane in the distance. As it became louder and louder, they looked up and observed the airplane in a near vertical attitude as it impacted trees and the side of an apartment complex.

At 1732, the automated surface observing system at SAT reported wind from 050 degrees at 9 knots, visibility 4 statute miles, cloud condition overcast at 400 feet, temperature 54 degrees Fahrenheit, dew point 51 degrees Fahrenheit, and an altimeter setting of 30.29 inches of Mercury.

 

[flyifrvfr]

Just speculation but it sounds like the instruction for a hard left turn to avoid traffic one mile away may have caused your uncle to crash. When we fly on instruments, we are taught not to make more than a standard rate turn while in the clouds. The standard rate is 3 degrees per second and the bank angle varies with the airspeed. Your uncle probably should have been no more than 30 degrees of bank.

The instruction for a hard right turn to avoid traffic while in the clouds is probably enough to make any pilot bank over to 45 degrees or more to miss an invisible aircraft. This can and does lead to loss of control of an aircraft in the clouds. I can't stress enough to you that this is pure speculation, but reading the report offers a few clues to the possible cause which in my untrained opinion was loss of control as a result of attempting to comply with ATC's hard left turn instructions to avoid a collision while in the clouds ( IMC ).

 

[kenimpzoom]

Thanks for your speculation.

I would have to agree with you 100% except that a witness has the plane nearly missing a building, pulling up, and going back up into the clouds. Perhaps he caught the loss of control, and then lost control again.

One other item, was ATC telling him to turn hard left, or was he merely stating what he was seeing on the radar? The way it reads, it is difficult to tell.


"A witness, located approximately 1.25 miles northwest of the accident site, reported to the NTSB investigator-in-charge (IIC) that he heard a very loud noise, and then observed a small white airplane flying toward a building, approximately 60 feet in height. The airplane pitched up approximately 45 - 90 degrees just before the building and disappeared into the clouds. A second witness located approximately 1 mile northwest of the accident site reported to the IIC that he heard a low flying aircraft, and then observed a white twin-engine airplane banking left out of the clouds. The airplane leveled out, and flew into the clouds again a few seconds later. The witness added that he "saw no indications of problems, smoke, or visible damage to the airplane." The witness stated that the airplane was at an altitude of 100-200 feet above the ground."

 

[avbug]

Ken,

This may be the point at which you want to stop asking questions and let the matter rest. I say that in your interest, as you appear to want to find something that is not there. You may not like what you hear.

From the preliminary report, there appears to be nothing more here than loss of control by the pilot. The pilot missed the ILS course, flew through it and back, and was finally told to execute a missed approach by the controller.
The pilot failed to follow the controllers instructions. He missed his assigned heading. He then flew back to the final approach course where he created a traffic conflict, and was given emergency turn instructions to get him out of the problem he just created. He failed to maintain the assigned altitude, and ultimately crashed.

I understand that you're going to want to see an error that was beyond the control of your uncle, and something that shows he did everything right but fought impossible odds. That certainly doesn't appear to be the case. Short story; he screwed up, killing himself and his passengers.

You indicated that you thought perhaps he had lost his instruments and radio. The odds of that happening all at once are astronomical. It's also extremely unlikely, as the controller provided information to him prior to vectors to the final approach course, to which he responded; his radio was working. Had he experienced instrument failures at that point, he would certainly have made an indication of that loss to the controller. He continued off course with some very large deviations from the course centerline, and failed to execute a missed approach.

Ultimately, ATC ordered him to execute the missed approach, and assigned a heading to turn to. His radio was still working, he was still acknowledging the calls, and still accepted the clearance without any acknowledgement of a problem. Clearly his flying was a big problem at this point; it was very erratic and inaccurate. There is no indication of an instrument problem, or a radio problem. That said, there could certainly have been such a problem, but the pilot gave no evidence of being aware of the problem...a failing on the part of the pilot either way.

Failure to maintain altitude, regardless of any navigational capability, is another matter. The pilot may or may not have been disoriented by the "hard turn" to avoid traffic, but his flying was erratic enough to begin with that one cannot necessarily try to blame his final failure on the controller. He missed every altitude, heading, and assignment he'd been given on the approach phase of the flight.

Your second scenario is also highly improbable, nigh impossible. it involves a passenger flying the proceedure. That the pilot continued to respond to ATC and accept clearances, headings, and assignments, suggests that this is certainly not the case. Why would a passenger with "some flying experience" know enough to talk to ATC, but be foolish enough to not say something about an incapacitated pilot? Didn't happen.

When the pilot went missed approach, he wsa given a heading to fly. he failed to make that heading, and instead continued his turn. His turn, going where he was not supposed to be, put him in conflict with another airplane that was flying the approach he had just been pulled from. To avoid a collision, ATC told him to turn left. He was told to turn left until he was headed west. Instead he flew northeast, and the hard left turn was ATC trying to keep him out of a collision because he was going in the opposite direction of his assigned heading.

During each of these events, he was communicating; he is radio was working. He never reported any failure of any kind, but instead continued to respond to and accept clearances, communicate altitudes, and press the approach...something no pilot would do with failed equipment, certainly without identifying the nature of the problem. No request for priority was made, no request for assistance, no identification of any incapacitation in any way. Even noting that the pilot was off course by a very large degree, he continued to press the approach when he should already have executed a missed approach.

Why your uncle continued to do these things is unknown. Speculation at this point as to the whys is inappopriate; those things may never be known. Apparent by the information presented here is only a case of pilot error, pure and simple. Several errors are in evidence, most glaringly that of continuing the approach when it was going so badly...something that occured long before the missed heading and the hard turn to avoid a traffic conflict that the pilot created on his own.

There may be extenuating unknown circumstances. A janitrol heater, known for frequent failures in light twins, that filled the cabin with carbon monoxide. Or any infinite number of other possibilities. but that's all guesswork involving unknown quantities. Tox screening will identify an excess of carbon monoxide in each victim at a uniform rate...that will give a sure indication. But anything less, especially lacking any evidence or even material suggestion to that fact, should be counted purely as wild speculation. What is provided in the incomplete, preliminary report, is detailing of a pilot who made a series of basic navigational and aircraft control errors, and finally impacted a structure while maneuvering at an altititude where he shouldn't have been, in a location he shouldn't have been, on a heading he was never assigned, following maneuvering to avoid a traffic conflict he created.

It's important to understand that nobody is immune from spatial disorientation. No matter how much instrument experience one has, one is never immune. Those who have been flying highly sophisticated aircraft are probably even more susceptible, and don't realize it, as they're so used to flying using automatic aircraft control systems; corporations and airlines all but insist on it most of the time. For one coming from that kind of equipment to something as basic as a navajo, the possibility of running into trouble may be surprisingly unexpected, and real.

Contrary to what many believe, the risk every time we fly is the same. Either we will make it, or we will not. A 50% chance. Statistical gurus with all their gobbledegook will try to muddy the water, but the truth is that no matter how much experience one has, no matter what kind of training one has, no matter how many times one has flown or done something in the past, the same possibilities exist on every flight. Either you will survive, or you will not.

We do all we can to ensure that the flight ends well. We plan. We calculate. We use checklists, follow proceedures. But underneath it all, we are human beings. We experience the same inflight illousions, the same lying sensations that our inner ears whisper to us. We are tempted to continue when we should not, we are too proud to tell the unseen voice on the radio that we have a problem or are not performing up to standards. We sometimes fly when we have a cold, when we should not, or using medication when we should not. We accept small mechanical problems, telling ourselves that it's minor, that we know best. We push below minimums just that little bit. We do things that are human and hope that our calculations, checklists, planning, and proceedures will keep us from ourselves. It works, most of the time. Not always.

Am I going to tell you on thanksgiving that your uncle screwed up and killed himself and five people? Yes. I am. Does this change the nature of who your uncle was, or mean that he was a bad pilot or human being? No. What it means is that there before the grace go we all; we are all susceptible to the same thing;we spend our careers and flying lives making every effort to ensure that it doesn't happen. I'm sorry it did.

Most of us look on each accident, each fatality, each loss, as a building block to our own understanding. Somewhere, someone is grieving for each of those blocks; what is a learning experience to most of us is a real, tragic loss to someone. To you. And to those you love. And I'm sorry that it's so. The best that can be said, and it's no comfort to you or to your family, is that publishing your uncle's loss may save another's life by providing a testament and a lesson to the critical nature of instrument flying. In his final time among us, your uncle may leave a legacy that means others will not suffer the same fate; of that fact you may take some consolation.

Good luck in your continuing quest to explore the details of this event as they emerge. They may or may not be what you hope to hear, and some of it you may never know. Knowing it won't change what has happened, and knowing it won't make it easier or go away, and it won't bring back your uncle or his passengers. I hope it does help you bring some closure to the event, and to move on.

 

[kenimpzoom]

Avbug thanks for being completly honest, I really do appreciate it. Your reply is exactly what I was looking for. If my uncle screwed up, then so be it. I can handle it, people make mistakes. But I will examine every possibility.

I really dont think anyone here will be able to tell me. But I would like to narrow down what could have happened.

So his whole approach was really bad and thus you would say it went bad from there? I am not familar with how far out of the flight path a pilot normally wanders, but 1 mile does sound like alot.

My first scenario, he would have lost instruments when ATC told him to go around. Perhaps they were going a little crazy on approach, and that explains his blown approach. Then they went out completly on his abort.

I think you misunderstood my second scenario, I had him become incapacitated on the abort, not on the initial approach. I would really like to hear the ATC recordings so I could learn more from the inflections in his voice.

Thanks again everyone.

Ken

 

[RonO]

Previous Navajo crash

For what it's worth, let me call your attention to a crash of a Navajo near Ithaca, NY several years ago--don't recall exactly when. The Navajo with two aboard crashed during an approach after the flaps deployed asymmetically--that is to say, one wing flap lowered to the position the pilot commanded and the other did not, resulting in asymmetic lift and a roll that the pilots were unable to counteract with ailerons. The incorrect flap extension was the result of a mechanical problem related to the flap mechanism on one side. If I recall correctly, an AD was issued.

You can look up the record of the accident on the NTSB website.

 

[kenimpzoom]

Thanks for the info, Ken​

​

​

​

NTSB Identification: DCA82AA009
Scheduled 14 CFR Part 135: Air Taxi & Commuter
Accident occurred Tuesday, January 05, 1982 in ITHACA, NY
Probable Cause Approval Date: 1/5/1983
Aircraft: PIPER PA-31, registration: N546BA
Injuries: 2 Fatal.

THE ACFT WAS ON A SCHEDULED COMMUTER FLT FROM UTICA, NY TO WASHINGTON, DC WITH A STOP AT ITHACA, NY. THE EN ROUTE PORTION OF THE FLT FROM UTICA TO ITHACA WAS NORMAL. AT 0735 EST, THE ACFT WAS AT 6000 FT MSL WHEN APCH CONTROL INFORMED THE AIRCREW TO EXPECT AN ILS APCH TO RWY 32 AT ITHACA. AT 0739, AN EMERG WAS DECLARED CONCERNING A SPLIT FLAP COND WITH 1 FLAP DWN. DRG THE NEXT 5 MIN, THE CREW RETAINED CONTROL OF THE ACFT WHILE DSCNDG FROM APRX 2500 TO 1900 FT. AT 0744:40, THE CREW RPRTD ON THE LOCALIZER COURSE AT 9 MI FROM THE ARPT, THEN RPRTD MAINTAINING CONTROL WITH FULL RGT AILERON. SHORTLY AFTER RPRTG THE GND IN SIGHT, THE PLANE CRASHED & BURNED IN A WOODED AREA, 6.7 MI FROM THE ARPT. IT DESCENDED THRU THE TREES IN AN 80 TO 90 DEG L BANK, APRX 24 DEG NOSE DWN. FND R FLAP 34 DEG DWN & L FLAP UP. THE INBOARDFEMALE SPLINE COMPONENT OF THE L FLAP FLEX CABLE WAS WORN & THE MALE FITTING WOULD ROTATE WITHIN. CAR 3.339 REQD A MECHANICAL FLAP INTERCONNECT WHEN ACFT CAN NOT BE CONTROLLED W SPLIT FLAPS. MOD LOW ALT TURBC & LOW LVL WND SHEAR ENCTRD
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

FLT CONTROL SYST,WING FLAP CONTROL..WORN
FLT CONTROL SYST,WING FLAP CONTROL..INADEQUATE
ACFT/EQUIP,INADEQUATE HANDLING/PERF CAPABILITIES..MANUFACTURER
FLIGHT CONTROL,FLAP..ASYMMETRICAL
AIRCRAFT HANDLING..NOT POSSIBLE..PILOT IN COMMAND






Contributing Factors WEATHER CONDITION..TURBULENCE
WEATHER CONDITION..WINDSHEAR

 

[kenimpzoom]

Well they posted the final report but they didnt really come out and say what happened. I can read between the lines and figure out it was CFIT due to spacial disorientation.

Is there any reason they didnt state that, or will that be added later?

Final report:
http://www.ntsb.gov/ntsb/brief.asp?ev_id=20041124X01866&key=1

Thanks, Ken

 

[flx757]

Ken,

This is the FACTUAL report, not the FINAL. As of today, the final report has not been issued by the Board, and therefore there is no probable cause listed.

Once the final report is issued, they will "come out and say what happened", or at least issue a "probable cause".

The investigation is not complete until this final report is issued, and 6 months time is not typical for the NTSB to issue a final report on a fatal accident. I would expect at least 12 months if not longer.

 

[kenimpzoom]

Thanks for clearing that up, I assumed factual meant final.

But from this report sounds like the plane was in good working order, correct?

Ken