Cooler heads observed that the majority of unintentional spins occurred in the traffic pattern, particularly on the base-to-final turn, where there was no room to recover even if the pilot knew how to. So knowing how to spin and recover served no purpose, besides its entertainment value—which, to be sure, was considerable.

Under the new dispensation, pilots were taught, in theory at least, not how to recover from a spin but how to avoid one. Nevertheless, stall spins, usually in the traffic pattern, still account for more than a tenth of all airplane accidents and around a fifth of all fatalities. Because they involve a vertical descent, stall spins are about twice as likely to be fatal as other kinds of airplane accidents.

• READ MORE: A Cautionary Tale About Pilot Freelancing

Why has the FAA’s emphasis on stall avoidance not done more to reduce the number of stall spin accidents? There are probably many reasons, but I think the lack of realism in the training environment deserves some blame. The training stall is a controlled maneuver, briefed in advance, approached gradually, calmly narrated, and recovered from without delay. The real-life, inadvertent stall is sudden, unexpected, and disorienting.

The pilot does not see it coming and so does nothing to prevent it. The training stall is so reassuring that pilots fail to develop a healthy fear of the real thing. After this preamble, you may guess that I am going to talk about a fatal stall spin.

The airplane was a Van’s RV-4, an amateur-built two-seat taildragger with a 150 hp Lycoming engine. It had first been licensed 13 years earlier and later sold by its builder to the 48-year-old pilot, a 1,300-hour ATP with single- and multiengine fixed-wing, helicopter, and instrument ratings. For the past six months, the pilot had been on furlough from regional carrier Envoy Air, where he had logged 954 hours in 70-seat Embraer ERJ-175 regional jets.

On the day of the accident, he added 24 gallons of fuel to the RV and flew from Telluride (KTEX) to Durango (KDRO), Colorado, a 25-minute trip, to pick up a friend. They then flew back to Telluride, where the temperature was 1 degree Fahrenheit, and a 10-knot breeze was blowing straight down Runway 27. The density altitude at the runway was about 9,600 feet.

Entering a wide left-downwind leg at about 100 knots, the pilot gradually decelerated and descended. By the time he began his base-to-final turn, he was about 200 feet above the runway and was going to slightly overshoot the extended centerline if he didn’t tighten his turn. His airspeed dropped to 50 knots, and the airplane stalled and spun. An airport surveillance camera caught the moment—a blur, then a swiftly corkscrewing descent. It was over in a few seconds. Both pilot and passenger died in the crash.

• READ MORE: Two Fatal Cases of the Simply Inexperienced

The National Transportation Safety Board’s finding of probable cause was forthright, though it put the cart before the horse: “The pilot’s failure to maintain adequate airspeed…which resulted in the airplane exceeding its critical angle of attack…” Actually, the opposite happened: The pilot allowed the angle of attack to get too large, and that resulted in a loss of airspeed. It was the angle of attack, not the airspeed, that caused the stall.

Still, it was an airspeed indicator the pilot had in front of him and not an angle-of-attack indicator, so to the extent that the pilot was consciously avoiding a stall, he would have had to use airspeed to do so. 

The published stalling speed of the RV-4 at gross weight is 47 knots. In a 30-degree bank, without loss of altitude, that goes up to 50.5. Individual airplanes may differ.

But in any case it’s misleading to make a direct, mathematical link between bank angle and stalling speed, although the NTSB frequently does just that. When you perform a wingover, your bank angle may be 90 degrees, but your stalling speed is certainly not infinite. In the pattern, you can relieve the excess G-force loading associated with banking by allowing the airplane’s downward velocity to increase—assuming that you have sufficient altitude.

On the other hand, with your attention focused on the simultaneous equations of height, position, glide angle, and speed that your mental computer is solving in the traffic pattern, you may not even be aware of a momentary excursion to 1.2 or 1.3 Gs.

• READ MORE: Three-Mile Limit: Novice Pilots Succumb to the Perils of Total Darkness

The RV-4, with a rectangular wing of comparatively low aspect ratio and no washout, stalls without warning in coordinated flight but is well-behaved and recovers readily. Uncoordinated, it can depart with startling abruptness. It resembles all other airplanes in being less stable when the center of gravity is farther aft, so maneuvering at a speed just a few knots above the stall may be more perilous when there is a passenger in the back seat. Like most small homebuilts, the RV-4 is sensitive to fingertip pressure on the stick and easily overcontrolled.

The NTSB’s report on this accident does not include any information about how many hours the pilot had flown the airplane or how many of those were with a passenger. The FAA registry puts the cancellation of the previous owner/builder’s registration just one month prior to the accident, suggesting the pilot may not have had the airplane for long.

The pilot never stabilized his approach. He descended more or less continuously after entering the downwind leg several hundred feet below pattern altitude—to be sure, the pattern at Telluride is 400 feet higher than normal—and never maintained a steady speed even momentarily. His speed decreased more rapidly as he entered the final turn, perhaps because he felt he was a little too low and instinctively raised the nose. Besides, the terrain rises steeply toward the approach end of Runway 27, possibly making him feel he was descending more rapidly than he really was.

A final factor that may have played a part in this accident is the altitude. The runway elevation at Telluride is at about 9,100 feet. Density altitude doesn’t matter for speed control in the pattern if you pay attention to the airspeed indicator, because all the relevant speeds are indicated airspeeds. But your true airspeed, which is 10 knots greater than indicated, can still create the illusion that you have more speed in reserve than you really do when you are making a low turn to final.

There’s a reason that students are taught to establish 1.3 V_s on the downwind leg, begin the descent abeam of the threshold, and maintain a good speed margin throughout the approach. It helps keep the stall-spin numbers down.

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 Summer 2024 Ultimate Issue print edition.

The post Ultimate Issue: Analyzing a Fatal Final Turn appeared first on FLYING Magazine.

It was about 1 o’clock in the morning. The air on the surface was warm and humid. If he checked the weather—there was no evidence that he did—he would have expected to find widespread but patchy cloudiness over the route of flight and at the destination. In some places clouds were broken or scattered with tops at 3,000. Elsewhere buildups climbed into the flight levels. Ceilings and visibilities under the clouds were good, at worst 700 feet and 5 miles. The temperature and the dew point were only 3 degrees apart, however, and there was a slightly increased risk of fog formation owing to, of all things, particulate pollution from dust blown in from the Sahara.

During the short flight, he climbed to 3,600 feet, probably to get above some cloud tops. It was pitch-dark as the crescent moon was far below the horizon. As he neared his destination he descended to 1,500 msl, 1,300 feet above the terrain, and reduced his groundspeed from 175 knots to 100 knots.

The airstrip at which he intended to land was 3,500 feet long, 40 feet wide, and had a light gray concrete surface oriented 4/22. Other than a hangar on an apron at midfield, there were no structures on the airport and no edge lights along the runway.

The only lights were red ones marking the runway ends. The surrounding area was largely dark. Sam Rayburn Reservoir sat close by to the north and east, a vast region of uninterrupted black. Parallel to the runway, about half a mile north, was State Highway 147, lighted only by the headlamps of infrequently passing cars.

• READ MORE: Two Fatal Cases of the Simply Inexperienced

For almost an hour, the pilot flew back and forth over the airstrip, tracing a tangled path of seemingly random right and left turns. His altitude varied between 350 and 1,100 feet agl and his groundspeed between 65 and 143 knots. His ground track, as recorded by ATC radar, suggested no systematic plan, but it was broadly centered on the northeast end of the runway.

The last return from the Saratoga, recorded 54 minutes after it arrived over the field, put it 9,700 feet from the northeast end of the runway on a close-in extended left downwind leg for Runway 22 at a height of 350 feet agl and a groundspeed of 94 knots. The Saratoga was below radar for the remainder of the flight.

Its burned wreckage was found at the southern edge of the clear-cut area surrounding the runway, several hundred feet short of the threshold. A trail of parts led back across the clear-cut to its north side, where the airplane had clipped a treetop at the edge of the woods. From the orientation of the wreckage path, it appeared that the Saratoga may have overshot the centerline on base and was correcting back toward the approach end lights when it struck the tree.

In the course of the accident investigation, it emerged that the airplane was out of annual, its last inspection having occurred in 2017, the registration had expired, and the pilot’s medical was out of date. The pilot had 400 hours (estimated) but did not have an instrument rating and, in fact, had only a student certificate. The autopsy turned up residues of amphetamine, methamphetamine, and THC (the psychoactive component of cannabis), but investigators did not rule out the possibility that the drugs could have had a therapeutic purpose.

• READ MORE: Three-Mile Limit: Novice Pilots Succumb to the Perils of Total Darkness

The National Transportation Safety Board’s report on the accident declines to speculate on whether the drugs impaired the pilot in any way. In fact, the NTSB report concedes that “the pilot’s aircraft handling was not deficient relative to his limited experience of flying in night instrument conditions and the prolonged period of approach attempts.” The finding of probable cause cited only the pilot’s “poor decision-making as he attempted to land at an unlit airstrip in night instrument conditions.”

The pilot bought the Saratoga in 2016 and then took flying lessons, but he stopped short of getting the private certificate. His instructor said he had never given him any instrument training. The pilot’s wife said that he “normally” flew to the airport at night and circled down until he could see the runway.

The airport was in Class G airspace. What the cloud conditions were we don’t know—the nearest automated reporting station was 24 nm away—and so we don’t know whether the Saratoga was ever in clouds and, if so, for how long. Maneuvering around at low level for nearly an hour in darkness and intermittent IMC would be taxing even for many instrument-rated pilots, and so it seems likely that if the pilot was in clouds at all, it was only for brief periods.

• READ MORE: Fatal Cirrus Accident Shows That Some Knowledge Doesn’t Translate

Two things strike me about this accident. First, how close it came to not happening: If the pilot hadn’t clipped the tree, he might have made the turn to the runway successfully and landed without incident, as he apparently had done in the past. Second, that he had ever managed the trick at all. I can only suppose that the contrast between the runway clear-cut and the surrounding forest was discernible when there was moonlight and that he was able to use GPS and the runway’s end lights to get himself to a position where his landing light would illuminate the runway.

Rugged individualism being, supposedly, an American virtue, I leave it to you to applaud or deplore the nonconformist aspects of this pilot’s actions. Perhaps a certain amount of freelancing is inevitable in an activity like flying. But I deprecate his persistence. One of the essential arrows in every pilot’s quiver should be knowing when to quit. He set himself a nearly impossible goal, and after flying half an hour to his destination, he spent an hour trying to figure out how to get onto the ground.

If it was that difficult, it wasn’t worth doing. There were other airports—with runway lights—nearby.

At the time of the crash, the pilot was awaiting the decision of a Houston court in a wrongful  termination lawsuit that he had filed against a former employer. Five months later, the court found in his favor to the tune of $143 million. Thanks to a terminal case of “get-homeitis,” however, he wasn’t there to enjoy it.

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 May 2024/Issue 948 of FLYING’s print edition.

The post A Cautionary Tale About Pilot Freelancing appeared first on FLYING Magazine.

The next day, the wreckage of the 140, its front end crushed, was found a few hundred feet northwest of the pilot’s private strip. Since the flaps were down, it had evidently been approaching to land when it stalled and spun. There was no way to know why the mishap occurred, but the National Transportation Safety Board (NTSB) report on the accident noted that conditions were such that carburetor icing was likely.

Stall spins are, and always have been, a common cause of fatalities in general aviation. They often occur during turns at the base-leg end of the pattern. What made this accident a little less usual than most was the history that led up to it.

According to the NTSB, the father, 39, was a student pilot. He had learned to fly from his grandfather, who had no pilot certificate at all. The father began logging time in 2007 and stopped in 2015. He got his last FAA medical in 2014 and his last fight review in 2015. He had a student endorsement for a Cessna 150 but none for the 140. The NTSB estimated his total time as 40 hours, of which 20 were as pilot in command and 20 were in the 140. These estimates were based, apparently, on the fact that the pilot used the 140 to survey local water towers from the air and report levels to their owners.

• READ MORE: Three-Mile Limit: Novice Pilots Succumb to the Perils of Total Darkness

The CFI from whom the pilot had received some flight instruction—and who described him as a “safe pilot”—reported that the pilot knew he was not allowed to carry passengers with a student certificate, but he was “anti-regulation with the government.” The NTSB attributed the accident to the “student pilot’s noncompliance and lack of experience” but noted it was impossible to know who was at the controls at the time of the fatal stall. The father could have been upholding the family tradition by teaching his son to fly.

Three weeks after that accident occurred, a Cessna 421 crashed in a wooded area near the DeLand, Florida, airport (KDED), killing its three occupants. A couple of witnesses saw the airplane flying at low altitude. One, who spotted the airplane on two occasions 10 minutes apart, described the engines on the second sighting as sounding as if they were idling. Another witness reported hearing popping or backfiring sounds. The latter witness also reported the airplane rolled to the left three times before he lost sight of it behind the treetops. It’s not clear whether by “roll” he meant a full roll or, more plausibly, a wing dropping and then coming up again.

The NTSB concluded “it is most likely the pilot lost control of the airplane while maneuvering” and added that the “pilot’s lack of any documented previous training in the accident airplane make and model contributed to his inability to maintain control of the airplane.”

• READ MORE: Fatal Cirrus Accident Shows That Some Knowledge Doesn’t Translate

The pilot of the ill-fated 421 was a 500-hour SMEL CFI. His logbook lacked a “complex airplane” endorsement, but that was probably an oversight. A complex airplane is one with flaps, retractable landing gear, and a variable-pitch propeller. It would be difficult to earn a multiengine rating in an airplane without those features—there aren’t a lot of Champion Lancers left.

As pilots who have flown more than one type of airplane know, the actions required to keep them right side up are alike for all. This 500-hour CFI with 40 hours of logged multiengine time had managed to start the 421’s two GTSO 520s, taxi, take off, and fly for at least 10 minutes. He seemed to have demonstrated an ability to control the airplane.

The 421 had a somewhat checkered recent history. Its last annual inspection had been performed five years earlier, and its Hobbs meter had advanced only four hours in the meantime. Its previous owner had put it up for sale on eBay, and a Texas man had bought it for $35,000, sight unseen, intending to spend a few thousand dollars having it restored to airworthy condition and then resell it. The 50-year-old airframe had, according to aircraft.com, 5,713 hours, and both engines were well short of TBO.

NTSB investigators found nothing to suggest the engines had failed, but the condition of the propeller blades indicated “low rotational energy at impact.” Fire destroyed all fuel tanks, and the NTSB report does not comment on the quantity or quality of fuel residues or the presence or absence of water or other sediment in the engines or what remained of the fuel system.

The Texas A&P whom the owner had engaged to travel to Florida and restore the airplane to airworthy condition had located a pilot to deliver it for $4,500. That pilot, 32, was in the right seat when the crash occurred. With a private certificate and 155 hours, he was even less qualified than the left-seat pilot to fly the 421. The owner declined the suggested pilot and instead gave the job to a certain instructor whose name he did not recall.

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

Most likely, this was the instructor who was flying the airplane when the accident happened. At the time of the accident the airplane had not yet been signed off by the A&P, and afterward everyone involved denied having any idea what the two pilots and their passenger were doing flying it. The NTSB speculated that the flight was probably of a “personal” nature—that is, a joy ride.

The NTSB blamed both of these accidents on inexperience. Although the South Dakota pilot owned his airplane and had flown, on and off, for a dozen years, his experience had been intermittent. The least one could say is that when the accident occurred, he was more experienced than he had ever been before. As for the other cause cited, noncompliance, it’s hard to see how it qualifies as a cause.

Plenty of experienced and compliant pilots stall and spin, and nobody says they did so because they were too experienced or compliant. In the case of the Florida crash, the NTSB cited the “pilot’s lack of training and experience in the accident airplane make and model.”

The analysis fails to even suggest the possibility of an external cause, such as, say, a partial power loss in the left engine. In fact, as an online bodycam video of the arrival of would-be rescuers at the accident site shows, the airplane came to rest right side up and was not severely fragmented.

Was it really out of control? Or was the pilot valiantly trying to cope with an emergency not of his own making?

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 April 2024/Issue 947 of FLYING’s print edition.

The post Two Fatal Cases of the Simply Inexperienced appeared first on FLYING Magazine.

Both pilots were in their early 30s and were Polish nationals. Both held FAA private pilot certificates based on their Polish certificates. They were relative novices, with 210 hours total time between them, only 130 as pilot in command (PIC). Neither was instrument rated, and only one was legally qualified for night VFR flying. (Their FAA certificates required them to comply with the limitations imposed by their Polish ones.)

After having dinner in town, they returned to Key West International Airport (KEYW) around 8 o’clock. It was dark, the sun having set an hour and a half earlier. The moon, new two days before, was now a smiling sliver on the western horizon. By the time they boarded the airplane, it too had set.

Presumably because he was the one who had done the rental checkout, the less experienced pilot of the two, with 30 hours of PIC time, took the left seat, and his companion took the right. It was the pilot in the right seat, however, who held the night qualification.

• READ MORE: Fatal Cirrus Accident Shows That Some Knowledge Doesn’t Translate

They began their takeoff roll at 8:33 p.m. When they were airborne, the tower instructed them to make a left turn northbound, remain clear of Navy Class D airspace, and contact Navy tower for transition. “Navy” meant Naval Air Station Boca Chica (KNQX), whose airspace abuts that of KEYW.

The tower frequency for KNQX is 118.75, but the pilot read back only 118.7, followed by a pause and then the last three digits of the Cessna’s call sign, “five eight niner.” The “five” was ambiguous, but it is possible that the pilot handling the radios missed the final “five” in the Navy tower frequency. In any case, that acknowledgement was the last communication heard from the Cessna.

In the early afternoon of the following day, some pleasure boaters noticed an object floating in the water. They thought it might be a manatee and approached it cautiously, only to find that it was a human body. The water was shallow, just 7 feet deep, and perfectly clear. Parts of an airplane could be seen resting on the bottom. The site was less than 3 miles from the Key West runway. 

Accident investigators found that an airport surveillance camera had recorded the airplane’s lights as it departed. Its flight path was erratic, descending, leveling off, descending again, leveling off, and then disappearing from view.

A witness, who had been fishing from a nearby bridge and read about the accident in the newspaper the following day, reported having seen what he thought at the time was a firework but now realized might have been a red light on the airplane descending rapidly toward the water.

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

The National Transportation Safety Board (NTSB) attributed the accident to “the non-night-qualified pilot’s improper decision to depart in dark night meteorological conditions, which resulted in his subsequent spatial disorientation…”

A direct line from Key West to Miami bears about 055 degrees, and about half the trip is over open water. On a dark night, the danger of disorientation is great. The brightly lighted line of the Keys recedes on the right, while the dark Everglades lie ahead. Miami is a pale glow beyond the northeastern horizon. The two pilots having just returned from the Bahamas, flying over open ocean in a single-engine airplane evidently held no terrors. (They had, nevertheless, taken the precaution of wearing life jackets.)

Most likely, however, they had no idea that the main danger of a night flight over open water was not that they might have to ditch after an engine failure, it was that they would lose the horizon and fly into the water before they even realized that something was wrong.

The fact that one of them was legally qualified for night flying meant only that he had logged a certain number of hours and takeoffs and landings at night with an instructor, not that he had any experience flying at night in this particular kind of environment. In any case, the pilot with the night qualification was sitting in the right seat, and to the extent that he might have made better use of the attitude indicator, he was not in a position to do so.

This is not an unusual kind of accident. I have written in this column about many similar ones, including two Barons and a Citation that flew under control into Lake Erie immediately after taking off from Cleveland Burke Lakefront Airport (KBKL); a Lancair 550 and a Cessna 210 that crashed immediately after taking off on moonless nights in desert terrain; and a Piper Cherokee, on another island of the Florida Keys, that went into the water a couple of miles from the runway from which it had just taken off.

Note the recurrence of the phrase “taking off.” The airplanes that took off over a pitch-dark lake or desert invariably climbed only a few hundred feet before they began to bank, then the bank grew progressively steeper, and the climb became a dive. The pilots were unaware that anything was wrong. Once the lights disappear, the rest lasts a matter of seconds, or at most 2 or 3 miles.

The two Polish pilots did fine at first, while they were over the lights of Key West. It was only when they left the lights behind that the insidious effects of darkness beset them. Neither pilot had instrument flying experience beyond the hood work required for the private certificate, which bears more resemblance to an arcade game than the real sensations, physical and emotional, of piloting an airplane in total darkness.

In pilots’ careers certain dangers are bound to arise for which it is very difficult for an instructor to prepare them. Many of those dangers are associated with loss of a visible horizon, whether because of fog, clouds, or darkness.

Warnings to believe the instruments, not bodily sensations, may be memorized, emphasized, and faithfully repeated, but they are never so persuasive as the sensations themselves. One must work hard to develop the discipline to level the tilting wings of the attitude indicator despite an overwhelming impression that the instrument has failed and the airplane is still in level flight.

Unfortunately, not every airport has an ocean or large lake handy with which to impress upon the student pilot the perils of total darkness—and Warsaw is far from the Baltic Sea.

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 March 2024/Issue 946 of FLYING’s print edition.

The post Three-Mile Limit: Novice Pilots Succumb to the Perils of Total Darkness appeared first on FLYING Magazine.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.