This was back in 1996. A recently released National Transportation Safety Board (NTSB) report puts a modern twist on pilots showing off. It turns out we don’t need Mom, Dad, or a Tomcat jet fighter to bend our safety sense. We don’t even have to do anything that feels extreme.

It was May 17, 2021. The weather in Michigan was good. Summer felt close. A 23-year-old pilot departed the Clare Municipal Airport (48D) in a Cessna 182, flying low and slow for two hours. He had a passion for aviation, already logging more than 600 hours aloft. The week before he had obtained his commercial multiengine rating, taking another step closer to his goal of becoming an airline pilot. He landed at the Romeo State Airport (D98) in Ray Center, purchased fuel, and departed from there at noon. An hour later, cruising at 500 feet, suddenly, with no warning and no radio call, the Cessna crashed into a dirt field.

He was flying pipeline patrol. This is a big business. There are loads of commercial pilots in high-wing planes flying above oil and gas pipelines. They are looking for leaks (apparently you can see changes in the vegetation around the leak) and right-of-way encroachments (such as construction activity, trees, or repetitive riding of ATVs causing erosion). Sometimes they fly with an observer, sometimes solo. On this day, the accident pilot was alone in his employer’s 182.

The 1965 Cessna 182H with a 230 hp engine had been flying for the pipeline patrol company for years. NTSB postaccident examination of the wreckage “did not reveal any evidence of a mechanical malfunction or failure that would have prevented normal operation of the airplane.” Likewise, autopsy results showed no medical issues for the deceased pilot. And the accident wasn’t tied to a metrological event. Ten miles away, the official observation was 74 degrees, scattered clouds at 5,500 feet, visibility 10 miles, wind 210 degrees at 5 knots. But the reason for the crash was obvious. It was even marked on the sectional chart.

Close to the field with the main wreckage was a 1,049-foot-high radio tower. The left wing and left cabin door were found by the tower’s base. The NTSB determined the probable cause for the accident to be “the pilot’s failure to maintain adequate visual lookout to ensure clearance from the radio tower and its guy wires.” Radar data shows the Cessna maintaining about 450 to 500 feet above ground level tracking the pipeline northwest. He had been maintaining the normal position, to the right of the pipeline. That’s standard operating procedure for airplanes and helicopters following roads or pipelines. Then he turned a little left, coming out of position and crossing over the pipeline. He wasn’t where he should have been. This was the side with the radio tower.

He saw it too late. The Cessna suddenly pitched up, climbing at 1,500 fpm. But it still collided with a tower support guy wire. The left wing separated from the fuselage at the wing root, falling almost straight down. The rest of the plane impacted in a field, a third of a mile from the tower.

That’s the “how” of the plane crash. But why did the pilot come off track? Why didn’t he see the tower earlier?

After the accident, the NTSB found that “it is likely the pilot was distracted while he used his mobile device in the minutes before the accident and did not maintain an adequate visual lookout.” Managing distractions is an airmanship task, requiring taking charge of our attention. And, down low, attention must be outside the cockpit. The mobile device the NTSB referenced was a smartphone, and this pilot wasn’t just texting or snapping photos, he had an audience. He was posting videos on Snapchat.

• READ MORE: Handheld Avionics

For those who don’t know, Snapchat is a social media messaging, photo, and video sharing platform popular with younger generations. Its defining feature is immediacy. Content is only available for a short time before becoming inaccessible, and after 24 hours it’s automatically erased. Several people were watching the pilot live on Snapchat. They were following his progress on the app’s map. Shortly before the accident, a video reportedly depicted the terrain ahead of the airplane’s position, including wind turbines and cornfields.

By the time the NTSB investigator in charge found out about the Snapchats, the platform had already deleted the footage. The agency was able to obtain screenshots of the Snapchat map, showing the pilot’s position as a jaunty, red biplane, and interviewed two people who had been watching online.

The last post was likely sent 35 seconds before the accident. He was 1.5 miles southeast of the tower, heading right toward it. If you’re playing with your phone, you’re not flying the plane. The NTSB concluded that “contributing to the accident was the pilot’s unnecessary use of his mobile device during the flight, which diminished his attention/monitoring of the airplane’s flight path.” He was too busy showing off.

Airline pilots impose a “sterile cockpit” below 10,000 feet, where phones are put away, and they don’t even talk about anything other than the flight. My glider club bans GoPros in the cockpit for the first month of the season. Professional YouTube pilots have assistants and set up multiple cameras that need no attention in flight.

Hollywood pilots extensively plan film shots and use professional aerial videographers.

After that F-14 crash, an NTSB investigator told me: “The most dangerous thing for an airplane is a camera.” Maybe pilots trying to be social media influencers should ponder this question—who is their camera really influencing? 

The post After the Accident: It’s Not Worth Showing Off appeared first on Plane & Pilot Magazine.

His arrival wasn’t pretty. The Bonanza pilot didn’t follow the published traffic pattern, placing the aircraft close to rising terrain on downwind. He was too fast on final approach, and he went around on the first attempt. A police officer arrived to check on the airplane, as the pilot had reported to ATC that he was low on fuel. Still, he was safely on the ground.

That was when the second guy approached and chatted about the chances of getting home. He recalls how the Bonanza pilot and his wife were both wearing red, matching their V-tail S-35. The first pilot’s advice was to stay in Andrews overnight. Heeding the warning, unhappy with the weather, the second pilot drove away.

The Bonanza pilot didn’t stay the night. He purchased 60 gallons of fuel and got a weather briefing. He later departed, crashing before making it out of the valley. The National Transportation Safety Board (NTSB) final report details departure planning issues—and one cockpit switch in the wrong position.

READ MORE: After the Accident: A Deadly Ditching

The accident pilot had 2,100 hours logged in more than a decade of flying. Almost all that time had been in a four-seat, fixed-propellor, fixed-gear Piper PA-28 Cherokee. He held a single-engine private pilot certificate with an instrument rating. In June 2021, he had purchased the 1965 Beechcraft S35 Bonanza, which required complex and high-performance training. An instructor flew with him for about 15 hours, reporting the new owner wanted to do everything “by the book” and was a very competent pilot. By the time he landed in Andrews, he had about 50 hours in the S35.

Bonanzas are six-seat, single-engine, retractable-gear planes—solid cross-country machines. First produced in 1947, they’ve been in continuous production longer than any other aircraft in history. The NTSB found no preexisting mechanical issues with the plane. The pilot’s executive assistant told the NTSB: “He did not allow anyone else to borrow or use his airplane. He was very meticulous about his airplane.”

The IFR trip had started in Liberty, Texas, with the goal of reaching Lancaster, Pennsylvania. A stop was planned at the Macon County Airport (1A5) in Franklin, North Carolina, but deteriorating weather led to the diversion into KRHP, east of a stationary front.

Low-altitude temperatures were in the mid-60s, close to the dew point. Cloudy skies with light rain predominated. At 6:49 p.m., the pilot called Leidos Flight Service for a standard IFR briefing to immediately leave KRHP for Lancaster Airport (KLNS). The briefer led with, “All right. Looks like convective SIGMET area for thunderstorms that’s coming up on you from the south as we speak. Looks like the sooner you can get out of there the better.”

Radar was showing heavy rain moving in, and there were other convective SIGMETs. “But looks like you can stay between those two, especially if you can get out before this next group that’s down toward the border moves in on you.” The briefer continued: “The adverse weather is mountain tops obscured in the higher terrain pretty much for your entire route of flight. … This is not going to be a VFR day today because I’m showing VFR, IFR, marginal VFR, and even a couple of low IFR spots within [a] 25-mile radius of your entire route.”

The pilot told Leidos: “I’m looking outside now. We should be able to get out of here. We can leave in five or six minutes. … Probably looks like we can get out of here VFR. Let’s go ahead and file an IFR flight plan. I’ll pick it up in the air.” Asked for a routing, the pilot said he’d have to look at his iPad, but he had left it somewhere. He requested direct KLNS, 466 nm away.

READ MORE: After The Accident: Two Cessna 210 Thunderstorm Accidents

An hour later, at 7:45 p.m., he departed VFR from Runway 8 at Andrews. The airport AWOS was reporting calm winds, visibility 7 miles, moderate rain, scattered clouds at 1,400 feet, overcast at 3,200 feet. That’s legally VFR. But the steep hills around the airport would have been hidden—and night was falling.

The sun had set at 7:16 p.m. Civil twilight time officially ended at 7:41 p.m.. Terrain a few miles to the north of the field rose over 3,000 feet above the field elevation. After takeoff, he turned 45 degrees left to a heading approximately that for direct to KLNS. Groundspeed was 95 to 100 knots, climb rate around 700 fpm.

At 7:49 p.m., 5 miles from the airport, the Bonanza collided with tall pines close to the ridgeline, coming to a stop inverted at 3,650 msl. The pilot and his wife both died in the crash. The NTSB found the probable cause to be “the pilot’s decision to fly toward rapidly rising, obscured mountainous terrain after departing [VFR] at night.”

Andrews has a published IFR departure procedure: “Remain within 3 nm of Western Carolina [Regional] while climbing in visual conditions to cross airport westbound at or above 4,900. Then climb to 7,000 via heading 251[degrees] and HARRIS (HRS) VORTAC R-356 to HRS VORTAC before proceeding on course.” This track guarantees ground clearance but requires a ceiling above 3,400 feet and 2 miles visibility. It also wasn’t a legal option, as the procedure was “NA [Not Authorized] at night.”

Still, he might have cleared the hills but for one thing. The NTSB observed the landing gear appeared to be extended at impact. The gear lever was in the down position.

A fear for any retractable gear pilot is landing with the gear up. But  pilots must also remember flying with gear down limits airspeed, increases fuel burn, and hurts climb performance.

Testing with an X-Plane 12 simulator with the reported parameters shows gear position makes a huge difference for this scenario. Repeatedly, I departed Runway 8, at pattern altitude turned to 045 degrees, brought the power back to 25 inches manifold pressure, and maintained a climb speed of 90 to 100 knots. Bringing the gear up after takeoff, I always cleared the ridgeline, averaging 4,500 feet msl. With gear down,
I always crashed, often at 3,600 feet.

READ MORE: After the Accident: Hard Deck Lessons

Habit, checklist discipline, and listening to your airplane are the principal ways to ensure gear retraction after takeoff. That said, writing about gear position and performance is easy compared to remembering to move that lever in a new plane in bad weather. There’s a fundamental difference between giving advice and following it.

Giving advice is like seeing a bear in your neighbor’s pool and texting they need to get it out. Following advice requires shooing the bear. The accident pilot’s friendly recommendation was: “You don’t want to go today. It’s really cruddy up there.” As the other pilot later told the NTSB: “Unfortunately, he did not heed his own advice.” 

Editor’s Note: This story originally appeared in the November/December 2023 issue of Plane & Pilot magazine. 

The post After the Accident: VFR Departure appeared first on Plane & Pilot Magazine.

The accident occurred on a cloudy, cold February afternoon in 2021. The National Transportation Safety Board (NTSB) has released its final report, and it contains some clues to the pilot’s thinking. There are no surprising mechanical or meteorological findings. No unexpected revelations. Instead, it was as it initially appeared—a normally functioning airplane flown below the published approach minimums out of the clouds and into the ground.

Cessna 441s are workhorses—this one powered by two 715 hp turboprop engines—and they are popular with charter operators. This 1978 model Conquest II had two pilots in the cockpit. One was a professional 18,000-hour airline transport pilot (ATP), the other a 770-hour pilot with a commercial certificate who had recently retired. It’s unknown who was in what seat, or who was flying at the time of the accident. What we do know is the more experienced pilot had been thinking about the instrument approach at their home airport for hours.

At 9:24 a.m., the ATP-rated pilot called Leidos Flight Service for a weather briefing. The plan was to fly from Belvidere, Tennessee, to Bowman Field Airport (KLOU) in Louisville, Kentucky, on to Thomasville Regional Airport (KTVI) and then return. It was “severe clear” at the destination, but closer to home a cold front was passing overhead. Right away the briefer talked about possible icing, as conditions were conducive for ice to form on wings and propellers in a cloud layer aloft. The briefer said, “The only trials and tribulations you have this morning [are] going to be punching through that layer as quickly as possible, minimizing the time in the clouds.” Asked if he had anti-ice or deice equipment on the Cessna, the pilot replied, “Yep, uh-huh. But I don’t like to use it.” The briefer calculated the icing layer was about 3,000 feet thick, and the pilot wouldn’t be in it long if he climbed at a good rate. The forecast for hat afternoon was for improving weather.

When heading back to home base, the pilots found the weather had not cleared. When they started the approach, the ceiling was 800 feet overcast, visibility 9 sm, with the ground temperature right at freezing, light rime icing conditions in the clouds, and tops of the clouds at about 4,000 feet. But for a Cessna 441, that’s well above the minimums published on the RNAV GPS RWY 36 straight-in approach of 400 feet and 1¼ sm. The final approach track has several altitudes, crossing the fixes at YOKUS at 4,000 feet, and WETSO at 3,000 feet, and with the LNAV/VNAV minimum altitude of 1,367 feet. The runway elevation is 979 feet.

The Cessna correctly crossed YOKUS at 4,000 feet and started a descent. It did not stop as prescribed at 3,000 feet but continued gently descending. At 2,300 feet, the radar data ends, at 2,100 the ADS-B data ends. The airplane hit trees close to the WETSO intersection at an elevation of 1,880 feet. It rolled inverted, hit the ground, and caught fire.

There was no distress call, and no medical or other unusual factors. The NTSB concluded the probable cause to be “the pilot’s failure to follow the published instrument approach procedure by prematurely descending the airplane below the final approach fix altitude to fly under the low ceiling conditions, which resulted in controlled flight into terrain.” It added, “the pilot likely attempted to fly the airplane under the weather to visually acquire the runway.” This might not be as rare as we’d like to think. While staying at published altitudes is a basic safety rule for instrument flying, a 2020 Embry-Riddle Aeronautical University peer-reviewed research study found compliance approaching the runway to be remarkably poor.

In fact, 96.4 percent of the 114 pilots descended below their stated personal minimums on a simulated ILS approach by an average of 303 feet. And 81.5 percent descended below the published federal minimums (by an average of 43 feet). The researchers noted, “These values are highly concerning.” The authors concluded that “pilots are knowingly or unknowingly accepting additional risk during a very critical phase of flight… A simulated (i.e., cash bonus) manipulation designed to mimic external pressures had no effect on pilots’ lowest altitude flown.”

The accident pilot had a possible motivation to descend below instrument altitudes. It’s not discussed by the NTSB, but this incident mirrors a fatal airline accident from December 1, 1993, at what is now called Range Regional Airport (KHIB) in Hibbing, Minnesota. A 19-seat twin-turboprop was on the localizer back course approach to Runway 13. Like other similar aircraft, the Jetstream 3100 was susceptible to tailplane icing. So a technique had evolved among line pilots to minimize their exposure to icing conditions. The NTSB report said the pilot’s “probable intention was to descend at higher than normal rates of speed to minimize the time in icing conditions.”

The Jetstream crew started the approach a little high, above the clouds, and descended at 2,200 feet per minute once on the final course. This high rate of descent inside the final approach fix was against written company procedures, partly because, when leveling out, it leaves little time or space for correcting errors. The airplane quickly descended below the minimum altitude and crashed into woods 4 miles from the airport—at about the same relative runway position as the Cessna 441.

In both accidents, the pilots were trying to manage the threat of airframe icing in the clouds with anti-ice or deice equipment they didn’t completely trust. They were trying to fly safely. And while minimizing time spent in cold, wet clouds is a valid general strategy, rapid descents inside the final approach fix is a dangerous practice. In both cases, no actual airframe icing was observed by investigators.

In trying to avoid icing, the pilots ignored basic instrument flying rules. Good pilots work hard to minimize threats, but sometimes risk management can be like holding too tight to a balloon. Push hard enough in one place, and it blows out somewhere else.

Editor’s Note: This story originally appeared in the October 2023 issue of Plane & Pilot magazine. 

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Another pilot on the frequency replied: “14A, how far north of the shoreline are you?”

“Right in the middle. I’m out here by…there…there’s a boat going by… there’s a tanker getting drug. I am out in the middle, and I’m going down now. I’m going in the water.”

It was 4:40 p.m. on January 26, 2021. The pilot, in the middle of the 10-mile Strait of Juan de Fuca between Victoria, British Columbia, and Port Angeles, Washington, alone in his 1949 Cessna 170A, had left Ketchikan, Alaska, more than six and a half hours earlier, heading to Port Angeles. He almost made it.

The other pilot asked: “Are you east or west of the [U.S.] Coast Guard station at Port Angeles, if you can tell me?”

“I don’t know, [indiscernible] water…I’m right by this boat…There’s a boat…There’s a boat getting towed by a barge. I’m going in the water now.”

The other plane called the U.S. Coast Guard, telling it the Cessna was by a boat. The pilot’s last radio transmission was: “Ya, I’m behind the boat, behind the boat.”

The 38-year-old had a commercial FAA pilot certificate, with seaplane and instrument ratings. The National Transportation Safety Board (NTSB) report estimates he had about 650 hours of flight experience. At the time of the crash, the pilot did not have a FAA medical certificate.

The trip had started in Kodiak, Alaska, one day earlier. The planned destination was Lake Havasu City, Arizona. That’s a long flight, but a journey he’d made before. He stopped in Sitka, and then in Ketchikan, where he spent the night. Both wing tanks were filled, as was an aux fuel tank in the fuselage. The aircraft had no record of the third tank in the maintenance logs. NTSB analysis of fuel receipts indicates its capacity was about 15 gallons.

The post After the Accident: A Deadly Ditching appeared first on Plane & Pilot Magazine.

The pilot had been flying for decades, logging 3,500 hours. He’d owned the 1946 North American T-6G for a while, accumulating more than 300 hours in type. The T-6 Texan (known outside the U.S. as a Harvard) is a 600 hp, two-seat aerobatic World War II advanced trainer—a very nice airplane. Accompanied by his 13-year-old grandson in the back seat, he circled back over the airport and flew 7 miles to the south.

Now over some fields and woods, he started a sequence of low-level aerobatics. Data from ADS-B and an onboard GPS recorder show many course reversals, with altitudes varying but rarely higher than 1,000 feet agl. Eyewitnesses corroborated the variations in altitude and reported the air show smoke system was on. A Snapchat video shows the T-6 maneuvering overhead just above the treetop level.

According to the accident report, the airplane ripped into trees at a steep angle and then impacted the ground, leaving a tightly contained accident site. Both the pilot and his grandson were killed. The National Transportation Safety Board (NTSB) investigated the accident. Both airplane and pilot were properly certified with current airworthiness documentation. The NTSB found “postaccident examination of the airframe and engines revealed no mechanical malfunctions or anomalies that would have precluded normal operation.”

There was no distress call, no other airplane around, no medical complications, and no issues with the fuel or weather. The recently released final report simply states the probable cause to be “(the) pilot’s failure to maintain clearance from trees while maneuvering at low altitude.” This was not an isolated or unique accident.

A few weeks earlier, on June 18, 2021, another experienced pilot went down while maneuvering at low altitude.

The 4,000-hour flight instructor and his 20-hour post-solo student took off from the Fernandina Beach Municipal Airport in Florida (KFHB) at about 11 a.m. It was 84 degrees Fahrenheit, and the lowest clouds were at 9,000 feet with high visibility and light winds. They were in the flight school’s 1971 Cessna 150L. After flying about 7 miles to the north, they practiced air work, turns, and slow flight.

Air traffic control radar records show several turns and airspeed changes consistent with training exercises. The altitudes seemed low, ranging between 800 and 1,000 feet agl. To see if this was normal practice, the NTSB interviewed the student who flew the accident airplane with the accident instructor earlier that morning. He said they “performed clean stalls, dirty stalls, and a power-off glide at altitudes between 1,000 and 1,200 feet” above the St. Mary’s River. They then returned to KFHB for some uneventful touch-and-gos. The instructor’s next flight followed a similar profile. Except that this time during the air work there was a sudden change.

One eyewitness reported the airplane as circling and turning while descending. Another said the aircraft descended nose-down in a “corkscrew” path. By the descriptions, it appears the Cessna stalled and spun, quickly smashing into the river in a near-vertical, nose-down attitude. Witnesses said it sounded as if the engine was running the whole time. After it struck the water, it quickly sank. Both pilots were killed.

Again, both airplane and pilot were properly certificated with current airworthiness and airman documentation. NTSB’s examination of the wreckage “did not reveal evidence of a preexisting mechanical malfunction or failure that would have precluded normal operation.” The student pilot was described by an instructor as “Sharp…She took her lessons seriously and was always prepared.” There was no distress call, no other airplane, no medical complications, and no concerns with the fuel or weather. The only issue was performing the maneuvers at low altitudes.

The FAA’s Airplane Flying Handbook (FAA-H-8083-3C) addresses the altitude for performing maneuvers that involve significant changes in altitude or direction. It states there should be sufficient altitude available for recovery before executing the maneuver. This, of course, depends considerably on the airplane and the maneuver, and in jets can be thousands of feet. More prescriptively it recommends “that stalls be practiced at an altitude that allows recovery no lower than 1,500 feet agl for single-engine airplanes.” Additionally, the FAA private pilot-airplane airman certification standards lists a requirement that all slow flight and stall tasks “be completed no lower than 1,500 (feet agl) for single-engine aircraft.”

The flight school followed a similar policy. However, this instructor was starting maneuvers at and below 1,000 feet agl.

The NTSB’s recently released final report determines the probable cause of the accident to be the “flight instructor’s decision to conduct slow flight training at an altitude below the flight school’s minimum recovery altitude and his delayed remedial action when an aerodynamic stall occurred.”

These accidents both feature the same root cause. The pilots went down because they were doing maneuvers too close to the ground. Maybe people do this because it looks cool or feels exciting. Maybe it’s because climbing to higher altitudes takes a lot of time. But setting a reasonable minimum altitude to finish slow flight, stalls, loops, or rolls gives a basic safety margin and is essential risk management.

This airmanship concept made it into the movie Top Gun. In air combat maneuvering training—also known as dogfighting—fighter pilots simulate flying down to the ground by setting a “hard deck” of (for example) 10,000 feet as a required safety buffer. Maverick busts the hard deck and is chewed out about it in the debriefing, but he gets to fly again. In reality, his Top Gun course would have ended there.

Hard decks are a serious safety rule. Setting a minimum altitude gives us lifesaving time and space to correct errors. Except in special circumstances, when that close to the ground we should be doing only one of two things—climbing or landing. 

Editor’s note: This story originally appeared in the August 2023 issue of Plane & Pilot magazine.

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ATC acknowledged the request, asked the pilot to report turning final for Runway 32, and if they needed assistance. The reply—“No, sir. We should be fine. Give you a call turning final.” That was the last transmission. N13VT went down while turning onto final, killing both pilots.

Their journey began at 6:30 a.m. on February 16, 2021, leaving Appleton, Wisconsin (KATW). Their destination was Sebastian, Florida (KX26), for planned maintenance. The airplane had issues with its retractable landing gear and was being flown on a ferry permit, which required the aircraft operate with the gear extended at all times. Also, the permit required a copilot even though the four-seat light piston didn’t require one.

The Velocity V-Twin is a two-engine pusher canard. Built as a comfortable long-haul cruiser with an advertised range of 1,100 nm, the experimental category fiberglass kitplane is a stunner. Outside, it looks like sort of a smaller version of the Beechcraft Starship. With big gull-wing doors, inside it has sports car styling with side-sticks and flat-panel displays.

On the front of the fuselage sit canards, small controllable wings that handle pitch control. Used in many aircraft, from the Wright Flyer to the Eurofighter Typhoon, canards can offer excellent control authority. They were designed to stall before the main wing, so at high angles of attack the nose automatically bobs down, always keeping the main wing flying.

On the back of the airplane are the propellers. Pusher aircraft allow the wing to fly in clean, undisturbed air and offer pilots unobstructed views. We don’t see a lot of pusher aircraft because the propellers work in the more turbulent air behind the wing, and there are troubles with engine cooling. What is certainly an advantage with the V-Twin design is the closeness of the two engines to the aircraft centerline, reducing unwanted yaw in single-engine operations. The airplane was built in 2020, and other than the gear mechanism issue, had no known mechanical discrepancies.

The pilots landed at the KJVL—a tower-controlled field with three paved runways—for fuel. The pilots pulled into the Janesville Jet Center and asked to be fueled up with 100LL. The manager remembers nothing unusual—“chitchat mostly”—about their flight down to Florida. The National Transportation Safety Board (NTSB) found no issues with the 100LL.

The weather was good in Janesville. It was winter, and for sure it felt cold, just 7 degrees Fahrenheit. But that’s nothing these two pilots, both in their mid-20s, who grew up in Wisconsin, hadn’t experienced before. The unlimited visibility, complete lack of precipitation, 5,000 foot cloud ceiling, and a light 9-knot wind out of the north would have been welcome VFR conditions.
They taxied out and took off normally. So what was the engine problem? And why couldn’t they return to land on the remaining engine?

Post-accident examination of the airplane revealed a chafed wire on the left-engine oil pressure sender. The NTSB report states that based on “ATC communication, the engine teardown, recovered MFD data, and POH rate-of-climb data, it appears that the flight crew may have shut down the left engine seconds after their radio call as a precautionary measure.” The damaged wiring harness caused the cockpit display to show a red “X” where the left engine oil pressure value would normally be. The left throttle, propeller, and mixture controls were found in their aft (shutdown) positions.

So far, so good—a precautionary engine shutdown and immediate return to land. The airplane continued to climb but at a slower rate consistent with single-engine performance. They were now heading south on a modified left downwind for Runway 32. The flying pilot further pitched down to a level flight attitude. Their indicated airspeed increased to about 16 knots above the maximum for flight with the landing gear extended (VLE is 140 knots for this Velocity V-Twin).

One minute and 10 seconds later, part of the right main gear door came off the airframe and struck the right propeller. All three blades separated about 18 inches outboard from the propeller hub, creating a total loss of right engine power. Immediately, their altitude and airspeed started to decrease. The NTSB performance analysis dryly notes that from here: “with both engines inoperative, N13VT likely did not have the energy required to glide back to the airport.”

As the airplane drifted lower, recovered onboard avionics data showed a rising angle of attack, followed by increasingly frantic gyrations in pitch and roll. The tower controller saw the airplane descend beyond trees southeast of the airport, in a left bank that started to tighten. The controller saw the airplane’s nose “almost pointed down toward the ground.”

The last eyewitness, walking his dog southeast of the airport, described the flight path “as similar to something that would be seen from a crop duster popping up over a field” with an engine “chopping at the air and working hard.” A few seconds later, it disappeared behind trees and crashed. The airplane came to rest inverted in a 3-foot-deep tributary of the Rock River, about a mile south of KJVL. The aircraft was found upside-down, mostly underwater, with its main landing gear in the air. One had the gear door plate attached; the other didn’t. The cause of death was officially reported as drowning and hypothermia, with complicating blunt-force injuries to the head.

The NTSB found no evidence of preexisting mechanical malfunctions or anomalies that would have precluded normal operation of the engines. It was after takeoff that the problems began.

To the pilots, this must have seemed like a nightmare worse than any simulator session. Soon after feathering the left prop and shutting down the left engine for an oil pressure problem, the right engine suddenly—violently—quit. Too far and too low to glide back to the airport, they would lose control and crash three minutes later.

Maybe a single-engine mindset would have saved them. In a single-engine airplane (or, of course, a glider) we must always be mentally ready to set down within gliding distance. Keep control and fly the airplane to the best landing spot. But multiengine pilots are usually more like systems managers, trained to operate on the remaining good engine to get to a suitable airport.

I thought it odd that only a 16-knot overspeed would break off bits of the landing gear, but the NTSB explained that mystery in its examination of the previous flight’s data. From Appleton to Janesville, the pilots flew the Velocity V-Twin well above the VLE speed of 140 knots for operation with the gear extended. In cruise, they maintained between 170 and 180 knots. Starting the descent, they reached 190, a full 50 knots above the listed maximum speed. The NTSB noted this may have weakened the gear door attachment points. Then, when single engine, the higher-than-normal sideslip angles may have helped force the door off the landing gear legs.
Two lessons are obvious from this crash, despite its crazy one-in-a-million double-engine failure: Don’t exceed aircraft limitations, and be prepared to land off-airport.

There’s a third lesson. Do we have to shut down an engine when the gauges show a big red “X”? An engine fire always requires a full shutdown. But if a powerplant seems to be running OK, might we be better off in some conditions letting it produce thrust for as long as possible?

For light aircraft, there have long been debates about whether two engines are really safer than one, the efficiency of pusher props, and the effectiveness of canards. This just-released NTSB report reinforces the reality that while a canard might stop you from stalling, it won’t keep you from crashing—and two engines won’t prevent you from losing all power. 

Editor’s Note: This story originally appeared in the July 2023 issue of Plane & Pilot magazine. 

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ATC acknowledged the request, asked the pilot to report turning final for Runway 32, and asked if they needed any assistance. The reply—“No, sir. We should be fine. Give you a call turning final.”—was the last transmission. N13VT went down while turning onto final for Runway 32, killing both pilots.

Their journey began at 6:30 a.m. on February 16, 2021, leaving Appleton, Wisconsin (KATW). Their destination was Sebastian, Florida (KX26), for planned maintenance. The airplane had issues with its retractable landing gear, and was being flown on a FAA ferry permit. The permit required the aircraft operate with the landing gear extended at all times. In addition, the permit required a copilot for the flight even though the four-seat light piston normally didn’t require more than one pilot.

The Velocity V-Twin is a two-engine pusher canard. Built as a comfortable long-haul cruiser with an advertised range of 1,100 nautical miles, the experimental category fiberglass kitplane is a stunner. Outside, it looks like something from a James Bond movie—sort of a smaller version of the Beechcraft Starship. Entering through big gull-wing doors, inside it has European sports car styling with side-sticks and flat-panel displays.

To some the airplane looks backwards. On the front of the fuselage sit canards, small controllable wings that handle pitch control. Used in many remarkable aircraft, from the Wright Flyer to the Eurofighter Typhoon, canards can offer excellent control authority. In this case, they were designed to stall before the main wing, so at high angles of attack the nose automatically bobs down, always keeping the main wing flying. 

On the back of the airplane are the propellers. Pusher aircraft allow the wing to fly in clean, undisturbed air and offer pilots wonderful unobstructed views. We don’t see a lot of pusher aircraft because there remain issues with the propellers working in the more turbulent air behind the wing, as well as troubles with engine cooling. What is certainly an advantage with the V-Twin design is the closeness of the two engines to the aircraft centerline, reducing unwanted yaw in single-engine operations. The accident airplane was built in 2020, and other than the landing gear retraction mechanism issue, had no known mechanical discrepancies.

The pilots landed at the Southern Wisconsin Regional Airport (KJVL)—a tower-controlled field with three paved runways—for fuel. The pilots pulled into the Janesville Jet Center and asked to be fueled up with 100LL. The manager remembers nothing unusual—“chitchat mostly”—about their flight down to Florida. The National Transportation Safety Board (NTSB) found no issues with the 100LL pumped aboard. 

The weather was good in Janesville. It was winter, and for sure it felt cold, just 7 degrees Fahrenheit. But that’s nothing these two pilots, both in their mid-20s, who grew up in Wisconsin, hadn’t experienced before. The unlimited visibility, complete lack of precipitation, 5,000 foot cloud ceiling, and a light 9-knot wind out of the north would have been welcome VFR conditions. 

They taxied out and took off normally. So what was the engine problem? And why couldn’t they return to land on the remaining engine?

At about 1,000 feet above the field, one of the pilots radioed the tower about an issue and requested the return to land. Post-accident examination of the airplane revealed a chaffed wire on the left-engine oil pressure sender. The NTSB report states that based on “ATC communication, the engine teardown, recovered MFD data, and POH rate-of-climb data, it appears that the flight crew may have shut down the left engine seconds after their radio call as a precautionary measure.” The damaged wiring harness caused the cockpit display to show a red “X” where the left engine oil pressure value would normally be. The left throttle, propeller, and mixture controls were found in their aft (shutdown) positions.

So far, so good—a precautionary engine shutdown and immediate return to land. The plane continued to climb but at a slower rate constant with single-engine performance. They were now heading approximately south on a modified left downwind for Runway 32. The flying pilot further pitched down to a level flight attitude. Their indicated airspeed increased to about 16 knots above the maximum for flight with the landing gear extended (VLE is 140 knots for this Velocity V-Twin).

One minute and 10 seconds later, part of the right main gear door came off the airframe and struck the right propeller—an immediate traumatic event. All three blades separated about 18 inches outboard from the propeller hub, creating a total loss of right engine power. Immediately, their altitude and airspeed started to decrease—slowly, steadily, and irrevocably. The NTSB performance analysis dryly notes that from here: “with both engines inoperative, N13VT likely did not have the energy required to glide back to the airport.”

As the airplane drifted lower, recovered onboard avionics data showed a rising angle of attack, followed by increasingly frantic gyrations in pitch and roll. Through the tower window, the controller saw the airplane descend beyond trees southeast of the airport. It was in a left bank that started to tighten. As this happened, the controller observed the airplane’s nose “almost pointed down toward the ground.”

Walking his dog southeast of the airport, the last eyewitness to see N13VT aloft described the flight path “as similar to something that would be seen from a crop duster popping up over a field” with an engine “chopping at the air and working hard.” A few seconds later, it disappeared behind trees and crashed. The airplane came to rest inverted in a 3-foot-deep tributary of the Rock River, about a mile south of KJVL. There was substantial damage to both wings,  canards, and the fuselage. The aircraft was discovered upside down, mostly underwater, with its two main landing gear legs sticking up in the air. One had the gear door plate attached; the other didn’t. The pilots were found dead in the wreckage.

Their cause of death was officially reported as drowning and hypothermia, with complicating blunt-force injuries to the head. 

The NTSB found no evidence of preexisting mechanical malfunctions or anomalies that would have precluded normal operation of the engines. It was right after takeoff that the problems began.

To the pilots, this must have seemed like a nightmare worse than any simulator session. Soon after feathering the left prop and shutting down the left engine for an oil pressure problem, the right engine suddenly—violently—quit. Too far and too low to glide back to the airport, they would lose control and crash three minutes later.

Maybe a single-engine mindset would have saved them. In a single-engine airplane (or, of course, a glider) we must always be mentally ready to set down within gliding distance. Keep control and fly the airplane to the best landing spot on the best terrain presented. But multiengine pilots are usually more like systems managers, trained to operate on the remaining good engine to get to a suitable airport.

I thought it odd that only a 16-knot overspeed would break off bits of the landing gear, but the NTSB explained that mystery in its examination of the previous flight’s data. From Appleton to Janesville, the pilots flew the Velocity V-Twin well above the VLE speed of 140 knots for operation with the gear extended. In cruise, they maintained between 170 and 180 knots. Starting the descent, they reached 190, a full 50 knots above the listed maximum speed. The NTSB noted this may have weakened the gear door attachment points. And then, when single engine, the higher-than-normal sideslip angles may have helped force the door off the landing gear legs.

Two lessons are obvious from this crash, despite its crazy one-in-a-million double-engine failure: Don’t exceed aircraft limitations, and be prepared to land off-airport. 

Plus, there’s a third lesson.

Do we have to shut down an engine when the gauges show a big red “X”? An engine fire always requires a full shutdown. But if a powerplant seems to be running OK, might we be better off in some conditions letting it produce thrust for as long as possible? I fly a two-engine airliner across the North Atlantic every week, and when we’re two and a half hours away from the nearest suitable airport, it will take more than a missing oil pressure indication to shut down an engine.

For light aircraft, there have long been debates about whether two engines are really safer than one, the efficiency of pusher props, and the effectiveness of canards. This just-released NTSB report doesn’t resolve any of those disputes. But it does reinforce the reality that while a canard might stop you from stalling, it won’t keep you from crashing—and two engines won’t prevent you from losing all power.

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The pilot had 15,000 hours of flight time. He had served three years in the U.S. Air Force as a young man and still was passionate about flying. He enjoyed being a flight instructor, including time spent teaching in seaplanes and multi-engine aircraft. His degree was in engineering, and at the time of the accident, he was president/owner of a 35-employee company that manufactures equipment for the mining and construction industry.

He started the day at home, a little north of Milwaukee, Wisconsin. In the afternoon, he uneventfully flew his 1978 Cessna P210N Centurion the 45 miles from West Bend Municipal Airport (KETB) to the Burlington Municipal Airport (KBUU) in Burlington, Wisconsin. The P210N is a 310-horsepower pressurized retractable-gear six-seater, a big, capable Cessna. Burlington Municipal is a small, friendly airport, with one 4,300-foot-long asphalt runway and a shorter turf runway. He had an appointment with a familiar maintenance shop. The plan was to “go over some configuration issues between his iPad and panel-mounted avionics and for some in person tutoring on operation of the recently installed GPS and ADS-B transponder.” After a productive few hours, the pilot refueled his Centurion and took off, heading back home to West Bend.

He didn’t get far. ForeFlight tracking data from his iPad shows him leaving the pattern to the north, then doing a left 270-degree turn, joining the left downwind leg at a 45-degree angle, and landing. All maneuvering seemed smooth and standard. Witnesses said the landing was normal. Why had he returned?

The pilot explained to the mechanic that the horizontal situation indicator (HSI, an upgraded gyroscopic heading indicator) had stopped working soon after takeoff. Looking under the panel didn’t reveal any obvious problems, so the mechanic recommended “we run the aircraft and taxi around so I could observe the behavior of the compass system. [The pilot] agreed and we both climbed in the airplane and he started the engine which I noted started very easily and ran very smoothly.” While doing taxing turns, they noticed the ammeter was “over on discharge. We tried some troubleshooting of the alternator system and agreed the compass likely stopped functioning due to low voltage.”

Back at the shop, the mechanic planned to test the alternator for field voltage. Opening the engine cowling, he saw the root cause of the problems—the belt was missing from the alternator. It was found in “bad shape,” broken, laying on the other side of the engine compartment. The pilot had a spare belt in the airplane, and while the mechanic installed it, the pilot and the mechanic’s wife relaxed at the quiet country airport. The mechanic noticed nothing else amiss with the engine, tensioned the belt, safety-wired the bolts, closed up the cowling, and inventoried his tools. He bid farewell to the pilot: “[J]ust start it up and verify it charges, if it does you should be all set and just head home. I’ll mail the log entry with the bill.” The pilot was trying to make a 7 p.m. dinner reservation with his wife.

After a routine engine run-up, he took off at 6:08. The wind was calm, no clouds, good visibility, temperature 73° Fahrenheit. The initial climb appeared normal, but the mechanic noticed the landing gear didn’t come up.

The C210 immediately rejoined the traffic pattern, announcing on the radio he was flying a low crosswind leg to join the right downwind. One witness, a CFI (Certified Flight Instructor) listening on the ground, described the pilot’s voice on all the calls as sounding normal. There was no sound of trouble. The Cessna turned a square base leg, then lined up on the extended runway centerline.

On final approach, the pilot got low and slow, so slow, in fact, that he stalled the plane, crashing into trees, coming to rest a quarter-mile short of Runway 29. The pilot was conscious but trapped in the strong metal airframe (it was a pressurized version of the C210). First responders kept him alive, and firefighters extricated him from the wreckage. However, he died in the hospital the next day.

After the accident, the mechanic noticed a missed call on his cell phone. The pilot had tried to call him during the short flight. The NTSB later determined that the engine was running fine at the time of the accident. The flight controls were also determined to be in working order. 

The one discrepancy was the alternator belt. The NTSB found “postaccident examination of the airplane revealed the replaced alternator belt was displaced from the engine-driven pulley and the alternator and was found lying near the back and bottom of the engine. Although this condition would affect the airplane’s electrical system, the displaced belt would not affect the engine power performance.” The electrical system was running on battery power. The battery showed 23.76 volts, a little below the nominal voltage of 24, though it was at only 21% capacity.

The NTSB assigned probable cause: “[T]he pilot did not maintain a safe altitude during the visual approach and subsequently lost control, which resulted in an impact with trees and terrain.” But why would a respected instructor pilot lose control in perfect weather at a familiar airport? We’ll never know for sure. But an old airline accident may be instructive.

Shortly before midnight on Dec. 29, 1972, Eastern Air Lines flight 401, a widebody Lockheed L-1011 TriStar on approach to land at Miami International Airport (KMIA), didn’t have a green indication in the nose gear indicator. Was the nose gear down and locked? The pilots cycled the landing gear up and then down again. The nose gear light still wasn’t green. The experienced crew of three climbed the plane back up and entered a holding pattern at 2,000 feet above the Everglades to troubleshoot the problem. One of the autopilots was engaged.

Work on the problem they did. The flight engineer and a jump-seating Eastern L-1011 mechanic went down to the avionics bay underneath the cockpit to look out a porthole to get physical confirmation of gear position. The first officer tried to remove and reinstall the nose gear position light lens assembly. The captain, according to the NTSB, “divided his attention between attempts to help the first officer and orders to other crewmembers to try other approaches to the problem.”

 “On final approach, the pilot got low and slow, so slow, in fact, that he stalled the plane, crashing into trees, coming to rest a quarter-mile short of Runway 29. The pilot was conscious but trapped in the strong metal airframe (it was a pressurized version of the C210).”

After a while, the autopilot clicked off, and the nose came down a little. The big three-engine jetliner started descending toward the dark swampy river. No one noticed until it was too late, and the plane crashed into the Everglades. One hundred and one people died. The tragic irony was that the gear was, in fact, down, and the only problem with the plane was a burned-out indicator bulb. There were four people in the cockpit, but nobody was watching the flight path. This accident led to a fundamental axiom of modern crew resource management (CRM) — always have one person fully engaged in flying the plane.

Of course, most pilots don’t have large crews to manage. When flying alone, you have to manage your own attention and awareness. You have to prioritize flying the plane, always monitoring heading, airspeed and altitude. The C210 pilot did the right thing by returning to Burlington. Twice. He resisted any pressure to make the restaurant reservation with his wife. And it’s admirable he was trying to understand the alternator issue. But maybe he gave too much attention to the electrical problem.

We do know he was trying to make a phone call in the traffic pattern. The NTSB wrote of the Eastern 401 crash, “the flightcrew did not monitor the flight instruments during the final descent until seconds before impact” and “the captain failed to assure that a pilot was monitoring the progress of the aircraft at all times.” Almost 50 years after that crash, we all still need to manage distractions and sometimes focus on just flying the plane. 

Do you want to read more After the Accident columns? Check out “Fatal Cirrus SR-22 CFIT in Las Vegas” here.

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They were level at 6,500 feet on a Visual Flight Rules (VFR) flight plan in radar contact with air traffic control (ATC). After being vectored around Nellis Air Force Base, they were north of the city, expecting a practice instrument landing system (ILS) approach and landing at North Las Vegas.

Approach control: “N7GA, turn left heading two seven zero.”

N7GA: “Two seven zero, seven gulf alpha.”

Approach control: “N7GA, altitude your discretion.”

N7GA: “Seven gulf alpha.”

ATC was busy for a while with other traffic, including a Medivac aircraft and a flight of four F-35 fighter jets departing Nellis Air Force Base.

N7GA: “We’re getting a low-altitude alert for N7GA, we gotta turn left.”

Approach control: “N7GA, turn left heading two five zero.”

N7GA: “Two five zero, N7GA.”

The Cirrus was low over the mountain ranges immediately north of Las Vegas. It was a completely clear night over the desert, with no clouds and unlimited visibility, and it was dark, with no moonlight. The pilot was flying VFR, talking to ATC but choosing his own cruising altitude. Using a landline, the approach controller’s assistant arranged a handoff for the Cirrus with North Las Vegas Tower, then the controller called on the radio to give the pilot the tower frequency.

Approach control: “N7GA, Nellis.”

Approach control: “N7GA, Nellis approach, reply not received if you hear me [unintelligible]. N7GA, radar contact lost.”

Approach control: “N7GA, Nellis
approach.”

On a landline, Nellis Tower called the assisting controller. “Hey, did you guys get an ELT on one two one point five?” They were asking the radar controller if they had heard an emergency locator transmitter (ELT) broadcasting on the emergency frequency, 121.5 MHz. Approach control replied, “We did.” The tower had more bad news: “Okay, ’cause we’re looking at, like, I don’t know, a flare out towards Gass Peak-ish, and now it looks like a fire over there.” 

The Cirrus had crashed into the mountain. A Las Vegas Metropolitan Police Department helicopter quickly arrived on scene and determined the crash was “not survivable.” No rescue efforts were made. Crews would not reach the rugged location until the next morning. The wreckage was found about 400 feet below Gass Peak’s highest elevation. It was close to its last recorded radar return, still at an altitude of 6,500 feet, the same altitude it had been cruising at since entering the Las Vegas area. All three people onboard died in the impact.

After the accident, the National Transportation Safety Board (NTSB) examined the fire-damaged airframe and engine, finding “no evidence of any preexisting mechanical malfunction that would have precluded normal operation.” In the March 2022 final accident report, it determined the probable cause to be “the pilot’s failure to maintain clearance from terrain during cruise flight in dark night conditions.” While that’s literally true, did he know the mountain was ahead of him? What was the “altitude alert” that ATC relayed, and shouldn’t the controller have warned the pilot of impending danger?

These types of crashes are called Controlled Flight Into Terrain, or CFIT (pronounced “see-fit”). A perfectly good airplane, under pilot control, impacts the ground. The terrain you descend into, or the terrain that’s rising up to meet you, isn’t visible until it’s too late to change your flight path to escape impact. It’s a serious issue when flying in the clouds, but it also happens in clear skies, typically on a dark night.

For VFR pilots, most of the time, we look out the window and can simply use our eyes to stay above the terrain. But there are exceptions. Sometimes a visual illusion can fool us. And flying over unlit mountains on a dark night requires special vigilance. With no moon and no lights on the ground, what in the day are obvious, grand peaks can look like black lakes. The most specular rocks can be truly invisible from the cockpit. At the time of the accident, the sun was more than 12 degrees below the horizon, and the moon was more than 37 degrees below the horizon. So, did the pilot know Gass Peak was even there?

I’m sure the pilot was familiar with the terrain to the north of Las Vegas. The mountains are clearly apparent during the day from the northern suburbs. He had lived in Las Vegas for a long time, retiring in 2015. Even more noteworthy is that he had retired from a career as an FAA air traffic controller at the McCarran (now Harry Reid) International Airport (KLAS). He had 440 hours of flight time over more than 10 years of flying, with about 123 hours in his Cirrus SR-22. This wasn’t a case of a transient pilot unaware of the local geography.

Moreover, the terrain is clearly marked on sectional maps and found in electronic databases. The pilot’s penultimate transmission, 22 seconds before the last radar return—“we’re getting a low altitude alert!we gotta turn left”—shows he was using some type of electronic device in the cockpit. The plane didn’t have a radar altimeter, but the pilot did have a Pro Plus subscription for the ForeFlight app on an iPad. Its hazard advisor feature requires GPS information, and we don’t know what GPS source the pilot was using. Ultimately, the NTSB was unable to determine the source of the alert and noted, “It’s likely that the pilot did not have sufficient time to maneuver to avoid terrain.” More sophisticated sensors feeding ForeFlight may have given him more warning. It’s also unknown what kind of terrain awareness display the pilot had available to him in the panel-mount avionics, but it’s hard to imagine he didn’t have some visual reference of the rising terrain ahead. 

Controlled flight into terrain (CFIT) accidents look like an altitude problem. But that’s not really true. CFIT accidents are often a situational awareness or positional problem. We believe our altitude is good—because we’re not where we think we are, or we’re not aware of the terrain immediately surrounding us. This pilot knew his altitude (6,500 feet), and he knew the altitude of Gass Peak (6,900 feet), and he probably knew all the higher safe IFR altitudes from his time as an air traffic controller. It’s possible he didn’t know Gass Peak was ahead of him. He may have thought he was well south of the mountain range.

ATC had taken the flight well to the north, but just before the crash, it was heading due west at 6,500 feet, where they would have had a great view of the bright lights of Las Vegas to their left. And if the pilot thought he was over the flatlands between the edge of the suburbs and the start of the Gass Peak foothills, 6,500 feet would be a good altitude. Maybe he was preparing for the practice ILS. Maybe being in radar contact reduced his concerns about altitude and position. He might have assumed that the controller was looking out for him, but ATC has few obligations to monitor or alert pilots of VFR flights to potential terrain conflicts. 

The air traffic control instrument flying rules (IFR) minimum vectoring altitude (MVA) over Gass Peak is 8,000 feet. One of the advantages of VFR flying is going lower and more direct than prescribed IFR routes, and we rely on clearing terrain visually. But still, shouldn’t the controller have warned the pilot of the mountains ahead? The controller’s manual, FAA order JO 7110.65Y, Air Traffic Control, says:

“Issue a safety alert to an aircraft if you are aware the aircraft is in a position/altitude that, in your judgment, places it in unsafe proximity to terrain, obstructions or other aircraft. Once the pilot informs you action is being taken to resolve the situation, you may discontinue the issuance of further alerts. !The issuance of a safety alert is a first priority.”

In a written statement, The U.S. Air Force controller said, “Although the MVA in the area is 8,000 MSL, I did not believe that the aircraft was at an unsafe altitude because regulations dictate that MVAs in mountainous areas are 2,000 feet above the highest obstacle.” The NTSB did not interview the controllers or further examine the safety aspects of this statement or the radar services provided.

The NTSB did note that choosing safe altitudes is ultimately the responsibility of the pilot. The Aeronautical Information Manual (AIM) is clear that when receiving terminal radar services while VFR, “these services are not to be interpreted as relieving pilots of their responsibilities to!maintain appropriate terrain and obstruction clearance.”

Flying VFR over unlit mountains at night requires knowing the altitude of the terrain. But knowing the altitude of the peaks isn’t enough. You have to know exactly where you are in relation to those peaks. The lights of the Strip are an amazing sight from the air, but as pilots, we have to know what’s hiding in the darkness ahead. 

VFR At Night

Do you want to read more After the Accident columns? Check out “Black-Hole Illusion Leads to Fatal Piper PA-32 Crash” here.

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The National Transportation Safety Board (NTSB) recently released its full report on this Oct. 20, 2019, accident. It carefully details the issues the instrument flight rules (IFR)-rated private pilot had in the clouds. However, the unsafe flight path and resultant crash happened long after the pilot had the runway in sight. Strangely, the NTSB never mentions the treacherous visual illusion that might have killed the pilot and his wife.

The couple had grown up in the same Florida town, they got married at 20 and stayed married for over 50 years. He was a veterinarian who founded a St. Petersburg animal hospital and, in the words of a Tampa Bay newspaper, “was the kind of veterinarian who put his home number in the phone book.” After attending a reunion at Auburn University, the couple were flying from the Columbus Airport (KCSG), Georgia, to Raleigh to visit friends. He’d been a pilot for decades, logging almost 3,000 hours. Together, they’d bought their first airplane in the 1990s and had owned several others over the years.

N534Z was a Piper PA-32-301 Saratoga, a comfortable fixed-gear single-engine airplane. It’s a 300-horsepower version of the Cherokee Six, a six-seater that looks just like what it is—a larger brother to the popular PA-28 Cherokee. This one was built in 1989 and had club seating in the back and capable avionics up front. In addition to an autopilot and traffic advisory system, it had two big-screen GPS navigation units. 

While an experienced pilot, the doctor may not have recently used all those tools in actual instrument conditions. According to the pilot’s logbook, he did not meet the recent instrument flight experience and night takeoff and landing requirements of CFR part 61.57 to act as pilot-in-command of an aircraft carrying passengers. His most recent instrument experience was on Nov. 26, 2018, when he logged three instrument approaches. His most recent night experience was logged on Nov. 3, 2018, when he recorded half an hour. 

Both of these were more than a year before the accident flight. His Flight Review was still valid, taken in a C172 at the start of 2019. The flight instructor said the doctor was going to New Zealand for an Outback flying tour with a Kiwi guide/instructor and wanted to be comfortable again in a high-wing aircraft after years in low-wings.

At 6:25 p.m., N534Z checked in with Raleigh Durham air traffic control (ATC) at 7,000 feet with the ATIS. The sun had set, the broken ceiling was at 1,000 feet above the ground. There was no precipitation or reduced visibility beneath that cloud deck. Light winds, 62 degrees Fahrenheit, RDU landing north. 

ATC told N534Z to expect the RNAV Runway 32 approach. The pilot said he was set up for Runway 5 Right. ATC replied that it could work him in, but 32 would be helpful for jet traffic inbound that needed the longer Runway 5. The pilot agreed and was issued a clearance direct to an initial approach fix and was then cleared for the approach. 

Getting closer to the airport, he was switched to the tower frequency and cleared to land. Then things started to fall apart.

Pilot: “Raleigh Approach, 34Z, I need to climb, my GPS, uh, my, uh, my approach just shut off.”

ATC: “Okay, N534Z, maintain 3,000.”

Pilot: “Can you tell me what my heading is, 236?”

ATC: “Your current heading does appear to be 230, just maintain 3,000 for now.”

The tower informed the Saratoga that he’d be re-sequenced for the instrument approach and handed him off to approach control. The pilot of N534Z then told the controller he was having problems with his heading. The pilot requested 4,000 feet to try to get above the clouds. He said his autopilot shut off, and he seemed confused over his position. The controller was comforting, talking slower: “34Z, no problem, looks like you’re direct NOSIC at this time, is that correct?”

Pilot: “Ah!er, 34Z, and er!let me figure out what’s going on here.”

ATC: “34Z, roger, just fly heading of zero five zero, zero five zero for now, and we’ll let you get settled and set up, and then we’ll bring you back in. Okay?”

Pilot: “Roger.”

ATC: “34Z, I’m showing you about 400 feet high, just when able maintain 4,000.”

This gentle hand-holding continued for a while. There was pilot confusion over headings, position, the spelling of fixes on the RNAV 32, his altitude drifted up and down, there were turns left and right; then vectors were given to join a straight-in final approach. The Piper was again cleared for the RNAV 32 instrument approach.

Pilot: “34Z, I just broke out.”

ATC: “34Z, roger, you got the runway in sight?”

No answer.

ATC: “34Z, you are cleared visual approach Runway 32.”

No answer.

ATC: “534Z, you are cleared visual approach Runway 32.”

Pilot: “I’m looking for the runway, there’s a lot of lights here.”

ATC: “34Z—low altitude alert. Maintain 2,000 please. Two thousand.”

Pilot: “Two thousand, 34Z.”

ATC: “And 34Z, the airport’s 12 o’clock and niner miles, you have it in sight?”

Pilot: “I believe I do. I think I see the beacon.”

ATC: “34Z, roger. Okay, if you’ve got the runway, you are cleared visual approach Runway 32.”

Pilot: “How am I doing on altitude. I’m 1,400.”

ATC: “34Z, your altitude is fine. If you have the airport in sight, if you have 32 in sight, you can do a visual approach, you’re cleared a visual approach, Runway 32.”

Pilot: “The only thing I see is the beacon.”

ATC: “Okay, 34Z, we’re going to turn the lights up to see if you can see the runway.”

Pilot: “34Z, I think it’s coming in now.”

Pilot: “34Z, I have the runway in sight.”

It was the pilot’s last transmission. 

He seemed task saturated, possibly facing an autopilot failure and problems sequencing GPS intersections. In the clouds at night at an unfamiliar airport. Unsure of position, requiring ATC radar assistance to join the final course.

Whether there were real equipment problems or just unfamiliarity issues, we’ll never know. But breaking out of the clouds and seeing the airport should have left those problems behind and resulted in a routine visual landing.

Instead, the Saratoga flew a constant descent path into the trees. It was missing from radar, no longer in sight from the tower cab, and not answering multiple radio calls. At 7:22 p.m., the controller-in-charge called Crash Fire Rescue services on the dedicated crash phone. The airport was closed for about 20 minutes as the emergency vehicles headed out into the thick woods east of the field looking for the plane. They didn’t find it.

It wasn’t until 10 o’clock the next morning that search crews discovered the wreckage. It was 1.18 miles from the runway threshold. The lengthy delay gives some idea how heavily wooded the 5,500-acre William B. Umstead State Park is that borders the airport. The initial point of impact was the top of a 100-foot-tall pine tree, where a large section of the right wing remained lodged. The physical evidence was consistent with a descent into the trees at a shallow descent angle. The cause of both deaths was multiple blunt force injuries. 

After the accident, toxicological tests were negative for ethanol and common drugs of abuse. The aircraft suffered serious impact damages, but the NTSB could find no pre-existing issues with the airframe or the instruments. The engine was running at the moment of impact.

The instructor pilots who flew the RNAV 32 approach right before the accident airplane were concerned about the plane behind them based on the radio calls they were overhearing. They landed, pulled off on a parallel taxiway and watched the inbound Saratoga through the back window. In an NTSB interview, one of them said, “the pilot was having trouble!sounded confused!the airplane was super stable!he was stable and visual for about 15 seconds!He just descended into the tree line. There was no erratic movement.”

Similar to other NTSB statements of probable cause, which merely state the facts of what happened and not why, the Board determined the probable cause to be “the pilot’s failure to maintain a safe glide path during final approach to the runway, which resulted in a collision with trees and terrain. Contributing was the pilot’s lack of recent instrument flight experience.” 

One can’t help but be reminded of how fragile, how fleeting, instrument currency is. Despite years of experience, skills atrophy fast. But why, when out of the clouds, did this pilot fly way below a safe glide path?

Investigators have identified the black-hole illusion since at least 1947. It’s a type of spatial disorientation that occurs on final approach when we don’t have the normal visual cues of a reliable horizon and underlying terrain. It’s one of the reasons large-approach light systems were designed at the end of runways for low-visibility landings. One FAA guide states, “a particularly hazardous black-hole illusion involves approaching a runway under conditions with no lights before the runway and with city lights or rising terrain beyond the runway. Those conditions may produce the visual illusion of a high-altitude final approach.” 

We see ourselves as too high, so we unconsciously correct this by descending lower, making the sight picture look right. But we end up physically low. Sometimes very low. The black-hole illusion is well named. When this illusion is present, it seems like a powerful gravity of pure darkness pulls us down. The actual geometry and psychology are still not fully understood, but current university research in simulators finds that the effect is real. Experienced pilots perform worse than low-time pilots, maybe because they trust their visual picture more. We can guard against black-hole illusion by always staying at or above electronic glide paths, always staying at or above visual glide paths like PAPI or VASI, and calculating minimum altitudes to fly on final based on distance from the runway. 

In 1974, a Pan American World Airways Boeing 707 crashed just short of Runway 6 in Pago Pago, American Samoa. That accident investigation report was maybe the first to use the term “black hole.” In 1997, an Air Sunshine flight crashed on approach to St. Thomas in the Virgin Islands. That NTSB report concluded, “evidence suggests that the absence of visual cues caused by the combination of dark sky and darkness over the water produced a ’black hole’ effect in which the pilot lost visual sense of the airplane’s height above the water.” 

The Saratoga pilot was having problems instrument flying, so breaking out into the clear, he may have quickly transitioned to controlling his flight path almost exclusively by using visual signals. Unfortunately, the final approach to Runway 32 at RDU passes directly over a large, completely dark state park. At night, under a 1,000-foot cloud ceiling, there are no lights between the airplane and the runway threshold. There is no horizon and no visible terrain. There are no approach lights. The lights of the airport are all behind the runway. It’s a classic black hole scenario, and the NTSB’s omission of the black-hole illusion in the probable cause does not help scientists cataloging and researching the accident cause. And it doesn’t help pilots guard against the insidious illusion that waits for all of us on some clear dark night. 

Do you want to read more After the Accident columns? Check out “Misfueling Leads To Disaster in Kokomo, Indiana” here.

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