Early Analysis: N7022G - Cessna 340 Crash October 11, 2021 Santee San Diego, CA
HTML-код
- Опубликовано: 27 сен 2024
- On October 11, 2021, a Cessna 340 crashed into a neighborhood in Santee, California, killing the pilot, one person on the ground and seriously injuring two others. Weather conditions at the time of the accident were broken ceilings, varying from 1,700 to 2,400 agl, and 10 miles visibility with forecast turbulence. The pilot was experienced in the airplane and had flown this route several times. He was receiving vectors to intercept the ILS approach to Runway 28R and then circle to land Runway 23 at Montgomery Field (KMYF). In Early Analysis: N7022G, the AOPA Air Safety Institute makes a preliminary assessment of the accident, addressing notable portions of the tragic flight and highlighting areas the NTSB will likely investigate to determine a probable cause.
Read the AOPA Air Safety Institute’s Spatial Disorientation Safety Spotlight to learn more about factors that might have contributed to this accident. www.airsafetyinstitute.org/spotlight/spatialdisorientation
FINAL REPORT RELEASED: The National Transportation Safety Board has released its final report (WPR22FA004) regarding the investigation into the Cessna 340 (N7022G) accident.
data.ntsb.gov/...
UPDATE: The National Transportation Safety Board has released its preliminary report (WPR22FA004) regarding the investigation into the Cessna 340 (N7022G) accident.
data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104080/pdf
From that report I could appear that the pilot got distracted and lost 1000 ft altitude. In a span of about 80 seconds, he goes from 3500 ft to 2500 ft, that's a lot of time to think about he losing control of the airplane. Maybe, the ATC warning about low altitude alert immediately after, got the pilot triggered to pull on the yoke and get the airplane in stall?
This looks to be a case of " Somatogravic Illusion" It can be a very confusing signal to the brain. At 2:45 the Pilot is asked to make sure he is climbing and not descending and he replies 22 Golf is climbing, This I believe is the most critical clue of what and why he continued descending. Similar to the Grave Yard Spiral his body sensation had a stronger influence on what was perceived by his flight instruments. This happens during a Go Around of Missed Approach procedure. The aircraft accelerated from 106 kts to 200 kts in a short time during the right turn and the acceleration gave him the sensation of a climb and this caused the Pilot to disregard what his flight instruments were telling him and began to push the nose down to stop the sensation. That's a Normal Reaction. We need to put more emphasis on Missed Approaches and Go Arounds in Training. Transitioning from nose low attitudes slow speeds, Low Power Settings to a Reverse of all this is and can be very Challenging.
Very interesting observation and educated theory, James. Thanks!
this is my new favorite channel. I'm not even a pilot; Just an enthusiast. The analyses are so concise and well-communicated. Well done!
Glad to see this "Early Analysis" video from ASI, I hope this gets done occasionally. One point I would add to this video, from an ATC perspective. I strongly encourage any pilot who is becoming disoriented to let us controllers know to please slow down and/or simplify our clearances.
Excellent point.
As someone considering becoming a private pilot this is very useful to hear.
Let's hope it doesn't become like 'Probable Cause' by that hack which I shall not even name.
what would be a good phraseology to request that? how would I tell ATC discreetly that I'm falling behind the airplane and instructions.
@@asho1735 I think you gotta through your pride out the window and say “I am struggling to hold and undersea my attitude”. ATC will know what you mean
I know absolutely nothing about aviation except that plane go up and down but I'm addicted to these breakdown videos
This was an outstanding summary of the facts to date. I was very happy to see the AOPA ASI step up so quickly on this high visibility accident. I’ve been an AOPA member for nearly 30 years and have contributed many times to the ASI. Material like this reaffirms the value you guys bring to the GA community.
Thanks for your support that helps make our safety work possible!
@@thatguy6207 I don’t know…..that’s kind of a stretch in my mind. Maybe he had a medical issue, maybe there was something wrong with the A/C that distracted him to the point where he became task saturated….maybe his altitude deviations were a conscious decision on his part to stay under the broken layer but not tell approach….maybe the airplane was too much for him and this was the time it caught up with him, maybe the in and out of IMC disoriented him to the point where he lost control, maybe a bird strike. Lots and lots of maybes.
@@TheAirplaneDriver Clearly air traffic control sent him back above the broken layer at 2700 that he was trying to stay below. Once he got back into the clouds above 3000, he became disoriented, and lost control. He had clear visual of the terrain and would have been safe otherwise as it's very apparent from the track and the terrain map
@@mnr646 I don’t disagree. That certainly is one of the possible scenarios (and yes, I agree the most likely) but I believe we should give him the benefit of the doubt and hope that we get a good NTSB analysis. The only reason I am balking is that he had a lot of time in that airplane and one would have thought he could have done better than that. But, we’ll see.
I live near Teterboro Airport in NJ and this "circle to land' procedure killed a crew of a small jet coming in from Philadelphia. This happened in VFR but conditions were VERY windy and I think, the pilot flying was confused with this 'circle to land' procedure. He completed the the 'circle' part but cranking that left turn to final, with the winds on steroids, his left was too sharp for his speed and he crashed to the before and right of the runway in a parking lot. No one on the ground was hurt/killed.There is video on that crash as well. You did a nice job explaining.
I remember that.
There was a lot wrong with that flight. I believe it was a Lear 35. May they Rest in Peace. We need to learn not to make the same mistakes.
Not a pilot or ATC, but my recollection of the Terterboro crash is that much more was wrong there than just the circle approach, you may want to read up more on that tragedy before you post...
@@nevadaracer00V Thanks Krystal…I’ll break down the NTSB report for ya. At what part would you like me to add your ‘recolection’?
@@harrisongould9460 There's a video on it from this channel (video id: BML2lfqaK-4). The title is Accident Case Study: Just a Short Flight.
My dad was a CFI in the 70's and 80's and he really kept up with his training. Even though he was a CFI he often flew with other CFI's.
This doctor had lots of time in this plane, but I would be interested in how much training time he had.
Dad mentioned to me that he had a great many very skilled and successful doctors and lawyers who were especially bad at picking up bad habits. If you don't keep up with your training you may develop bad habits that can get you into problems, especially when conditions are less than perfect.
Good doctors and lawyers tend to be a bit arrogant, for good reason. It takes a lot of intelligence and skill to be a good doctor or lawyer, but that doesn't mean you make a good pilot.
How can you tell if you're a good pilot? If you think you can do better taking a flying with a CFI once in a while, you're okay.
If you think you know everything and can handle anything, worry.
How can you tell if you're a good pilot?...Being a subscriber to this channel and learning from other pilot's mistakes, as well as watching the webinars.
@@02markcal A good pilot knows he can never learn enough. They can always do better. A poor pilot thinks he already knows enough and nothing he can learn can make him better.
I am medical doctor and a private pilot. A good doctor and a good pilot always learn . We can not avoid mistakes but we can learn from these....
@@georgiostagaris6416 I’m not a doctor but am familiar with the phrase “practicing medicine”. Pilots and doctors alike should never stop learning.
Probably picked up "BAD HABITS" "SHORT CUTS" doing his SURGERY TOO! QUIT MAKING EXCUSES FOR POOR FLYING SKILLS of someone WHO NEVER SHOULD have been given a Pilot's License!!! Maybe too many are being "BOUGHT" by wealthy, lets say, DOCTORS!!! One way they "get away" with it is BECAUSE they have people like YOU WHO COVER UP the TRUE CAUSES which was INCOMPETENCE!!!!
Circling approach - May 2017 N452DA Teterboro - July 2021 N695TR Truckee - October 2021 N7022G Santee. Perhaps the NTSB should look at circling approach in Part 91 flights. Perhaps the NTSB should read the 2011 FSF paper which stated
"... controlled flight into terrain
(CFIT) studies have shown that runway aligned approaches (LNAV only) are some 25
times safer than circling approaches and that once some form of vertical guidance is
added to these, then the safety margin is increased again by some 8 times.
It is of concern that, in commercial aircraft accidents associated with circling
approach during the last two years, there were in total at least 304 fatalities..."
Good report. I've flown this area frequently and it can be challenging in/out of low cloud cover and changing/rising terrain. Add turbulence and visibility challenged and it can be difficult when faced with last minute changes. It is an airplane that requires substantial preparation in the approach environment. Looks like he didn't quite understand the approach situ and got behind. Very sad. Hope the families of all concerned find peace.
I am glad this was put out there early on. so much speculation that with this pilots experience I think it is clear in his voice he was saturated. So far I think at this point a good lessons will be learned here as my take away from this would be to let ATC know "I'm having some problems here" And tell them what is best for you and not worry about what's best for them.
@@thatguy6207 pure speculation has no place here.
@@Chris-bg8mk Yes it does Chris. That is the whole purpose of these comment sections. ALL WE HAVE ARE OUR SUPPOSITIONS. READ MINE ABOVE. By the way I spent four years in the Air Force as a crew chief and know a thing or two about flying.
Walter I agree with your comments. Unfortunately it is human nature to not ask for help until one is deep into trouble where time is of the essence. A very general nebulous communication to ATC like "I'm having some trouble" requires ATC to engage in a prolonged back and forth in an attempt to collect more and more information so ATC can better understand the issue and how ATC can help. "I'm disoriented and need your help to get me to the runway" cuts through all the egotistical B.S.so ATC can immediately give simple, short, precise instruction with vectors, while monitoring altitude, speed and direction of the plane. If a was a pilot that told ATC "I'm disoriented....." while in IMC or close to those conditions, I know I would appreciate a a few strong reminders to trust my instruments while also getting those concise, simple instructions in a cool and calm voice.
@@benth162 ....WHERE is it? THEY (SCREWtube) ‘canceled’ you or what?! SERIOUSLY, I wanted to read your comment; Oh, and I agree. Sometimes ALL we have are “guesses, assumptions...OR speculation(s)”. Unless FACTS are KNOWN, “educated” guesses have to suffice @ times...
@@m118lr This what I found at another site that I wrote on this subject: "Juan Brown also describes what was going on and I left him a multi paragraph comment. Personally I believe that a man with that many hours of flying in that particular plane and how many times he flew that rout, I am of the mind that he was having either a stroke or a minor heart attack. The only other idea I would entertain is that his instruments were feeding him the wrong information. I live only a mile and half from Montgomery field and used to work just two hundred yards from Gillespie field in the Santee and El Cajon valley. When he turned right he kept turning right instead of what you described he needed to do to come to the runway the tower was trying to get him to land on. The tower could not see the plane but did see it on their instrumentation. When the pilot keep turning right he would eventually end up at the town of Santee which is where he crashed. When he descended down out of the clouds he could have seen where he was which was a valley, and the possibility his plane was already in a configuration he could not pull up out of when he needed to get over the mountain so he could get back to Montgomery Field. A veteran pilot as he was supposed to be, would not have become that confused unless his plane malfunctioned or he had a compromising physical issue. I think it was a stroke because of how he was answering the tower and not being able to tell where he was in his mental confusion."
Feel like this highlights some pilots being so lazy with their readbacks that you can't tell if they're being lazy/cocky or having an actual medical problem.
He sounded tired to me. His radio skills for a pilot with his experience did not seem to match.
Close to the end, he was barley legible. My 1st thought is he is having a medical emergency.
@@willburrito9710 could have been having a TIA, getting close to actual stroke.
@@thatguy6207 Interesting comments, and have to say I hadn't consider the possibility. I have to sleep on it, but fully understand where you are coming from and what you are suggesting.
Someone needs to roll back the ATC tapes from earlier in the flight and his previous flights and compare his interactions. Should be pretty simple to see if he was off his game on this flight.
Thanks for sharing this analysis. I'm a new pilot and I watch a lot of your videos to learn from others. Always be vigilant, never complacent.
You explained complex matters very clearly so that I as a non-expert could understand your explanation. Thank you.
This is a story of a pilot who disengaged the autopilot and then got disoriented. You should always be alert and watching your attitude indicator but why turn off the autopilot? Switch to heading mode and dial in the headings. Take the time ATC is giving you to brief your plate again, verify systems are armed properly and then shoot the approach. Sometimes people get so flustered with technology that they forget they can simply “hand fly” using the heading function. Unless his autopilot failed there isn’t a reason to disengage it in IMC until minimums in a single pilot environment. It’s there to decrease your workload.
I don't understand why you can show the crash video and have commercials while Blancolirio channel can't show the crash video because he will get banned from making money!?!??!? Can someone knowledgeable explain,please
Just a theory, but I would think ASI does not monetize this channel, thus the difference.
Juan Brown also describes what was going on and I left him a multi paragraph comment. Personally I believe that a man with that many hours of flying in that particular plane and how many times he flew that rout, I am of the mind that he was having either a stroke or a minor heart attack. The only other idea I would entertain is that his instruments were feeding him the wrong information. I live only a mile and half from Montgomery field and used to work just two hundred yards from Gillespie field in the Santee and El Cajon valley. When he turned right he kept turning right instead of what you described he needed to do to come to the runway the tower was trying to get him to land on. The tower could not see the plane but did see it on their instrumentation. When the pilot keep turning right he would eventually end up at the town of Santee which is where he crashed. When he descended down out of the clouds he could have seen where he was which was a valley, and the possibility his plane was already in a configuration he could not pull up out of when he needed to get over the mountain so he could get back to Montgomery Field. A veteran pilot as he was supposed to be, would not have become that confused unless his plane malfunctioned or he had a compromising physical issue. I think it was a stroke because of how he was answering the tower and not being able to tell where he was in his mental confusion.
Very well and detailed analysis. I’m very glad to see the ASI back at analyzing accidents.
The main reason for watching these sad loss of lives is to hopefully learn from them.
My deepest condolences to all of the families involved.
I know nothing about flying but love these videos
I agree that a transition from auto-pilot to hand flying seems to be a contributing factor. The tracks during his vectors are arrow straight, as soon as he passes the localizer his track becomes erratic. I would guess the auto-pilot was not on approach mode and failed to capture the localizer. He may have become flustered and turned off the auto-pilot in an attempt to salvage the approach, but if he wasn’t well briefed and prepared he may not have known exactly how to proceed. This may have caused him to turn right and descend in an attempt to see the runway and join the final for 23.
I had the same thought with respect to going to a visual circle to land approach to 23 - the deviation makes sense then if he doesn't know where he is and doesn't think he'll get ILS and instead is going to try to hit airfield visually.
I had two thoughts, this was one of them. The other thought, he was having a medical issue like a stroke or CO poisoning.
@tie oneon Because there is a minimum vectoring altitude in the area. If the pilot does NOT report field in site on or above that MVA. the ATC can’t give a visual approach where the pilot can maneuver anyway he wants to land. Therefore atc has to issue a clearance to a runway that has an approach that makes sure he has terrain separation both vertical and horizontal until the pilot can have visual of the airport.
@Noah H I’m familiar with disorientation, the auto pilot theory to me absolutely makes sense. The fact that he had new avionics in the plane that he likely wasn’t familiar with the nuances like autopilot not working when the approach activates, unless you selected it. Plane flying perfect, then when it’s on the ils you can tell from the tracking it was being hand flown like he’s way behind the plane. Do I think disorientation played a factor, once he was behind the plane? Yes. Do I think he was struggling trying to fly ifr by hand with avionics unfamiliar while likely focused on trying to get autopilot to reengage… yes. The reason I suggested there may be a medical component, like stroke, is the changes in altitude effect the pressures inside our body, which can free clots to cause CVA, MI and PE’s. clotting disorders are currently a widespread issue of all age groups because there is a virus out there that causes long term clot risks. His radio responses, and flight tracking were looking good, then after the decent, the anxiety of not getting the approach he anticipated, cause his BP to rise further increasing the risk of CVA. His flight track became erratic, his altitude control became erratic, his voice became slurred, inappropriate response, etc you could tell he wasn’t comprehending what he was being told and couldn’t comprehend what he was seeing. Sure these responses can happen under stress, disorientated, etc… but it was a pretty simple approach, you follow the needle in. The complicity of a circling approach doesn’t get complicated until you are performing it when runway is in sight and the conditions he had were Vfr well above the DA for the circling part. Ie it wasn’t like he was approaching a circling approach at minimums with 1 mile visibility at the ground.
With those two theories, I personally think the unfamiliarity of the avionics auto pilot issue makes the most sense, combined with not being fully prepared for the approach. Course I’m a new ifr pilot, not a 20,000 hour ATP, I’m still very much learning. The auto pilot issue I personally experienced during my training, it was intentionally set up by my instructor to have me experience that issue. Believe me, your mind wants to get that autopilot working, especially when your expecting it to do the work while you multi task trying to catch up from being behind the airplane.
@Noah H I’ve experienced disorientation, I still don’t think the was the main culprit here. I tend to believe in the autopilot disengaging when the approach activated because it was selected ahead of time. Getting him behind the aircraft, while he’s trying to figure out a different approach then what he expected, I’m guessing he was frantically trying to reactivate the auto pilot, while trying to hand fly, while trying to understand the unexpected plate he didn’t expect to use. At some point you just have to go missed, fly the gauges and get atc to get you to a safe area to work it out.
I'm about as far from an aviation expert as one can get, and am grateful for the plain-speaking on this channel. (I've flown as a passenger on small jets dozens of times - always with pro pilots.)
The ability to determine causes of these accidents has improved exponentially even in the last twenty years. I believe videos like this could prevent so many tragedies...if the right folks heed them.
RIP to those lost and Godspeed to those in the air.
How many hours did he have in real instrument conditions with this plane as a solo pilot?
Weather was not that bad.
@@outwiththem Agreed, come to Newfoundland and find real weather.
Wow! Your video is very comprehensive and you explaining it as you go along makes it very enjoyable for me to watch and learn from. Thank you sir
Pilot makes no effort to level the plane in the video.
Well done analysis with great visuals to improve understanding of what the plan was and what actually occurred.
Thanks Aopa Air Safety Institute, Please do a Full Case Study on this one!!! Love those. Whenever I feel a situation is creeping up on me or I even remotely think of doing something stupid, I hear the narrator's voice in my head.
@@thatguy6207 did I say this was the full story? We all know this is just preliminar, the full story will be told then. I encourage AOPA for these Accident Case Studies - and you’re already juming to conclusions and blaming the Vax? Please. If you fly you know the plane doesn’t care where you’re from, what you look like, if you get Vaxxed or not. All it knows is that there is a tragedy here AND WE ALL SHOULD EAIT FOR ACTUAL RESULTS, not push agendas.
I would like to see more of these Early Analyses. More AOPA accident presentations are needed...
My initial reaction is that he was became disorientated over the circle procedure. Looks like he wanedt to go straight to base for runway 23 and became confused when ATC gave him a right 90.
Scary stuff ... I'm no longer a pilot but from listening to ATC, he just seemed overwhelmed and/or confused and/or simply fatigued. He also seemed to be a handful of steps behind the plane. Things were happening too quickly for him to comprehend kinda like he did no preflight briefing and hopped into the plane in Yuma like he was driving a car and then had no clue what a circling approach was... Thank You for your clear and concise analysis. Keith Chicago IL
Though I guess it is possible the onset of some illness (perhaps the flu/Covid) caught him off guard which was the cause of his confused/distracted state of mind and all he wanted to do was get home...
Really excellent content, great video. These are always tragic but this one had a double tragedy when someone on the ground just going about their daily existence had their life taken,. As soon as I heard the strain in his voice I was thinking "Divert divert just go somewhere else with better weather or easier approach" but it was not to be.
Not proficient in IFR without autopilot, fumbling with the garmin and/or AP, way behind the airplane, and then vertigo. Stay proficient, stay alive.
The plane doesn't seem to be in IMC during the final descent before impact...and it's very strange that there was no attempt by the pilot to correct the trajectory, like if he was incapacitated or because of some technical failure
Had he simply gotten himself established on the final approach course and began his descent, he would have broken out below 1700' and been able to proceed VFR to circle/land on 23. I've viewed the other knowledgeable videos on this mishap and it seems to me the pilot did not understand what "circle to land" meant. I got the feeling he had never done an actual IFR approach that ended in a circle to land. Perhaps that is something more pilots should practice (with a qualified pilot or instructor in the right seat) in actual IMC as the narrator noted.
You nailed it... ...and saved me a lot of typing.
He still should have been able to see the ground though once he got low enough, even though he was coming down fast, right? I don't get why he wouldn't have recovered from that, unless he was passed out or had some medical issue.
@@jeffploetner I have watched the final descent video many times. I've spent the past five minutes trying to mentally analyse the abnormal airflow over the control surfaces to determine what control inputs would regain control of the aircraft. Five minutes. He had eight to fifteen seconds to figure out the correct control applications and apply them, from when came out of the clouds until impact.
@@KennethAGrimm I must not understand then, is it not a stable controllable plane? Don’t you “just” straighten out your bank (left aileron) then pull up?
@@jeffploetner Yes if he was merely in a steep bank. But that was way beyond a steep bank. If it had been a steep bank, the plane would still have been following its nose, only in a curved instead of straight line. As it breaks out of the clouds, we see the nose yawed nearly 45 degrees from the direction of motion. In such a configuration, the control surface do not function properly. It appears that when the ATC supervisor cut in with the "Pull up!" order, the pilot jerked the yoke back and stalled the aircraft, and then an unsuccessful spin-recovery left the aircraft flying sideways and nearly inverted.
Some are saying the pilot had a medical issue.
I'm not 100% convinced that the pilot experienced spatial disorientation as the weather at the time the clouds are broken and he (the pilot) probably also had good visibility on the ground. Something else must be a factor in this crash as it appears he's struggling even as he approaches the localizer intercept. And even then, as he's waived off, ignores ATC instructions, maintains altitude instead of climbing. We know he can still see the ground - it's not foggy, or nigh time.
And yet he still slowly circles right, and ends up going into the ground at a fairly linear angle. It's as if he's no longer in control of himself or his aircraft - maybe unconscious?
Something else is up... but this is just my opinion. I'm no air crash investigator. Just an observer.
Yeah a commercial licence holder with an instrument rating struggling to follow simple instructions such as climb and maintain 5000, he kept descending even after being instructed multiple times to climb. For someone as proficient as him it's hard to explain, would make me question his examiners otherwise if he can't do such simple IFR flying.
I've seen this kind of thing multiple times in the simulator (mostly). It happens when someone becomes disorientated. They become flustered and their flying ability completely disappears.
I live in Santee about 2 miles from the crash site. It was a pretty uncommonly blustery day that day with clouds and we have a varied terrain. It's been 25 years since I last piloted a plane but I remember thinking that I wouldn't like to be flying in that that day. Requesciat in pace.
That pilot was unconscious,the linear angle clearly shows that as there was absolutely zero attempt to try to pull out or correct - nothing.
@@francinecorry633 not necessarily. To me his disorientation let him in that attitude (a spiral dive). As he came out of the clouds, there was no possibility for recovery anymore. He most likely was just pulling back on the controls, which has no hope of recovering a spiral dive.
Listening to the audio I doubt the accident pilot ever understood the clearance ILS to runway 28R CIRCLE to land runway 23. It doesn't sound like he and ATC are at all on the same page. I've only flown into that airport once and it was decades ago. Is this ILS to one runway then circle to land to another runway something commonly used at this airport (like Tetorboro NJ-similar and commonly used) or was something unusual going on? Sounds like the pilot was expecting to fly the ILS to 28R then he mentions runway 33, is there a stand alone approach to 33? As far as your analysis of winds aloft, turbulence, notes on Sectional charts-I don't know it sounds like a "normal day of flying" to me rather than some demanding weather scenario.
I flew later that day out of KSEE when the winds were much stronger. The turbulence was surprisingly light for the amount of wind we had, and the clouds did produce more turbulence but I wouldn't consider it a factor to this flight. The guy just didn't know how to operate his autopilot, was confused about a circle to land procedure (maybe he didn't do those often), and he clearly wasn't very instrument proficient when autopilot was off - maybe an over-reliance on the autopilot. My theory is he disengaged autopilot to try to comply with the climb instructions and was not proficient to be flying IMC by hand.
Extremely well stated!! THANK YOU for having the guts to call it like it is!!! Too many people hemming and hawing trying to be “politically correct”. I feel really sorry for the innocent people on the ground that were injured and killed as a result of this. And it gives GA a very bad rap, and is a disservice to those who respect and know their limitations!! In other words, don’t treat these things like your “personal Ferrari” (rollseyes).
Do you think during this banking turn towards the north he was mistaking the sensation for climbing and just never looked at his altimeter?
Said the guy that can't taxi on center-line and rotates half a second after "speed's alive". lol
@@XPoChangLinX what are you talking about?
@@daszieher I’m talking about the OP’s flying videos. Judging other pilots when his own flying leaves much to be desired.
I was kinda hoping this analysis would have included the KYMF ATIS so we would know what the ceilings, cloud bases - tops etc were. As soon as the good Doctor was told to circle to land rwy 23 his tone, voice, cadence changed drastically .
You can go in and listen to the entire Approach conversation with this pilot at LiveATC. The controller can be heard giving the latest ATIS information: "1700 scattered, 2700 overcast". I'm still trying to find out the tops but haven't seen it on any source.
Blancolirio channel. Ceiling was like 1700’ so should have been non factor even for circling.
@@thatguy6207 Interesting take.
@@keithhoss4990 if you look at his flight on FlightRadar24, he was mostly above 2700 feet, the altitude at which the same approach controller reported was overcast. Also, this video discusses that flying in and out of IMC can often be more of a distraction than just being in solid IMC.
All that information, including his confusion at reading back the controllers confirmation of instructions and nervous cadence suggest spatial disorientation resulting in loss of control.
Yes, you could tell in his voice that he didn't seem to mentally fully comprehend that ATC request, which is odd because it sounds like he had flown the ILS Rwy28 circle to Ryw23 before?
The pilot sounded blurred and confused at the very end of the flight. The weather showed ample visibility up to 2700' and fuel load issues would have shown up a lot earlier than just at the very end of the flight. No one is listening to how the pilot's speech becomes blurred and confused as the flight progresses. I say this was a medical condition-induced accident.
This happened on October 2021, where a Cessna 340 was approaching San Diego. The pilot had over 1100 hrs. of flying time on this plane. they think it spacial disorientation. He was a MD going from Yuma to San Diego
I'm almost 100% positive he did not understand what a circle to land procedure was. You can see him turning north which is where you would expect him to go if he was trying to line up for a 23 approach. He was probably flipping through his charts looking for an ILS 23 approach that doesn't exist. He got back into the clouds, autopilot was off and he was distracted looking for charts that don't exist.
Given the sometimes stilted response to ATC in the latter stages of this flight I am wondering if this pilot was suffering some type of debilitating medical episode causing serious misjudgment in his ability to fly and control the aircraft. Seems to be overly flustered for what should have been a reasonably straight forward procedure.
I have to wonder if there wasn't some medical issue that lead to this. The pilot was highly experienced and he had a capable autopilot. There must be something else going on. It looks like he never even tried to recover once he cleared the clouds. One would have thought he would at least level the wings and try to pull out of the dive. Just to early to tell.
Just a simple question. Blancolirio channel was heavily cautioned about showing the crash vid by RUclips. And basically told no. We're you??? You showed the the vid.
RUclips pays ad revenue to content creators that opt in. If you do, in order to keep ad money, you have to meet their standards. It's much stricter than normal youtube standards. Blancolirio does participate in the ad sharing program. Chances are Air Safety Institute doesn't use the channel for ad dollars. What he was saying was that his videos are being demonetized but they aren't being deleted.
Worthwhile review of many factors. I was very strongly struck by the communications from the pilot-a poster-child for get-there-itis: nervous, hurried, agitated, not professional or calm. Something was wrong in that plane. Did he have to get to the bathroom? And, of course, all the other stuff about possibly being unfamiliar with circling to land, spatial disorientation and all...
Thanks for this video. Very informative. Love safety institute.
This is so informative! Great job, fantastic reporting!🌻🌼🐝 Keep it up 🙌
Nice debriefing....RIP Spad.
It's also possible the doctor had just worked a busy 12-hour hospital shift after the flight to work which would likely leave anyone fatigued.
Co' mon AOPA guy. WEATHER WAS GOOD VFR. Only some clouds at 1,700 agl. No big deal for him. Had done same many times over..
I have 1400 hours in one particular CE340A, flying out of KSEE and KMYF. My bird would not fly hands off. It would roll off on the left wing, knife edge and start heading down, until corrected (just like in the video). I did have a 20 gallon aux tank in the left nacelle, not all 340's have this. Given the way the aircraft went in I strongly believe the pilot was incapacitated.
It’s obvious to me as well and it’s also obvious to me that this video was intentionally made to throw people off course, aka propaganda
Did he ask for a circle to land or was that pushed by ATC?
I'm not so sure he was actually thinking he was climbing. It sounds to me more like he was trying to comply but for some reason couldn't and didn't want to make a fuzz about it. After that first "climb immediately" at least my eyes would have been glued to the instruments and I can't imagine he could have been missing this for more than a minute. No idea why he couldn't climb but overall that seems more likely to me.
More than likely RWY23 was the runway favoring the wind. It was quite windy and gusty in San Diego the day of the accident. Typically the wind in San Diego is out of the west so RWY28 is normally the runway of choice. The clearance was very straight forward - cleared for the approach RWY28 circle to land RWY23. For some unknown reason everything went to hell just before approach. We will probably never know what really happened.
Thank you for a very professional and methodical analysis of the available information.
Pilot was not well
Of course I'm speculating but it appears this pilot was attempting to circle to runway 23 while still in IMC conditions. If you listen to the communications, he appears to be confused as to what exactly is expected shortly after he accepts the approach clearance. He begins turning right almost immediately, away from the 28 localizer. I believe in order to try and line up with runway 23. The controller then asks him if he is correcting back to the 28 localizer. After which he responds by attempting to confirm that he is supposed to be maneuvering in order to line up with runway 23. It appears he is completely confused after that point. Possibility because the controller is telling him to correct back to the left, when he knows he has to turn right in order to line up with 23. It could very well be this pilot did not fully understand the ins and outs of exactly how to execute an approach when it requires a circle to land maneuver when operating in IMC conditions. In this case, his actions would have been correct, except that he is supposed be visual with the airport PRIOR to circling. Just my 2 cents.
I agree, this was exactly what I thought was happening too!
Excellent analysis. A good job in getting this out so quickly. Thanks
What's weird about that video is that that he's clearly popped out of the marine layer, significantly banked over and is on a screaming trajectory towards the ground. I don't see any indication that he tries to arrest his flight attitude or obvious decent. That's weird to me. Makes me wonder if he had a physiological problem that compounded his flight problem. Anyone IFR rated that flies out of San Diego has good experience popping in and out of the marine layer. I used to fly out of Montgomery and it's common practice for those qualified in the area.
That's true. It appears as if the pilot was incapacitated doesn't it?
Curtis Andre I hope that we all understand the possibility of becoming involved in a moment of confusion and the need to identify that at once without allowing ego to interfere. The more I learn the more I realize how little I know.
Just discovered the pilot was aged 64. As a retired pilot - now after 65. I would not relish an older twin, single pilot in IMC conditions.
Thank you sir, sincere respects to his loved ones.
I think the circle to land really threw him off he deviated right like if he was going straight to rwy 23.
My thoughts, too. It would explain why he never got on the localizer-looks like he was headed straight for 23, and he seemed to fixate being cleared for 23. Still doesn’t explain the accident, though.
I was instantly reminded of the Leerjet 35A crash in 2017 - "ILS 6 circle to land runway 1"
dont think he was use to flying a circling approach in actual IMC. Looks like he was trying to get below the cloud deck to report visual on the airport hoping he would get cleared visual for 23
Great to see a new video! Terrible accident though. I agree with your analysis. Pilot being overwhelmed combined with spacial disorientation likely played a large role. Excellent video, can’t wait for more!
ruclips.net/video/NFAnWlxwgc8/видео.html
Great analysis, thank you.
On the time of the accident, KSEE have a broken layer at 2700, tops at 3800 ish, and winds were coming from the south at 10-15 kts
So where's this IMC?
Medical....
I suspect a medical issue caused or contributed to the accident.
Looks like he got the circle- to- land clearance possibly as he was near intercepting the localizer, and he missed part of the clearance (see partial read- back). Added to this, he was already in a slight right turn when ATC started advising him to climb. If he doesn't realize he's in a turn, he'll just pull back, which will make him feel like he's climbing, but really he's tightening his turn and descending. 🤷🏾♀️
I'm surprised no-one has factored in pilot incapacitation...?
This is a classic case of a overwhelmed pilot, a Cessna 340 twin can be extremely taxing flying single pilott if you let the aircraft get ahead of you, even worse in broken ceiling with turbulance which can be disorienting trying to make an approach at 200 knots, at that speed things happen extremely fast and can stack up quick especially if you're not proficient which is strange as he seemed to be and had 1000 hrs in this aircraft. It was very obvious he was way behind the airplane, task saturation and when ATC told him to climb immediately he was in and out of cloud only about 6 miles out, i think he panicked, probably still configured in approach settings, yanked back on the yoke and got surprised by the plane pitching up more than expectrd causing somatic graphic illusion and possibly spatial disorientation believing he's climbing when he's in reality in a spiraling right turn better known as the death spiral. He was clearly disoriented for some reason at 70 degrees nose down full power and at over 250 knots when he hit the ground.......RIP
Yeah I think that spaz of a controller panicked the guy into yanking on the yolk....
@@thatguy6207 Please take this misinformed conjecture elsewhere. This is not the place.
@@ChadDidNothingWrong that spaz of a controller was as calm as he could get considering he was watching a guy fly to his death, and there was nothing he could do about it. Quit babying pilots and maybe they won’t crash a plane every day, like they do today. You should become a controller and show us how it’s done.
@@ChadDidNothingWrong No, that controller was doing a good job trying to save him.
@@ChadDidNothingWrong What? The controller was fine. The idiot behind the yoke was the problem. Airplanes have yokes, eggs have yolks.
How do you avoid bad weather conditions such as this when flying? Say you are planning your routes routinely and there are already other routes that say Southwest, Delta, etc. run that they know have better weather/traffic patterns how do you know what is the best route for avoiding bad weather such as this? Is there a way to choose an aircraft that can fly above/avoid bad weather such as this?
What would be good to know if if this was his first time doing ils 28 circle to land 23. This would most probably have to be hand flown about 3-4 miles out.. but he never got that far. But looks like he wanted to turn right much sooner that he should.. Maybe then hand fly and then he got back into solid imc. He also sounds stressed and rushed even way out.
This happens. Have you ever seen somebody “shut down?” You are right he was in bad shape way out. Maybe he was sleep deprived. He was losing some sort of battle and he probably knew it.
ruclips.net/video/NFAnWlxwgc8/видео.html
Curious if he had flown that same circle to land approach before? Based on his radio transmissions, it really seemed like he didn't completely grasp how to fly that approach but was too embarrassed to say so. I believe he broke off the localizer for 28R because he was trying to line up for runway 23. In his mind, he was circling to land on 23...just starting the circle much sooner the the approach procedure called for.
kudos on following up quickly with the expert analysis!
All instrument approaches at this airport (6 runways total) start with either ILS or RNAV for 28R. Only 28R is straight in, while the other 5 directions are circling. More than likely the pilot knew this, and briefed similar approaches in the past. The pilot verified tower frequency (there are two) with the ATC while he was still at 10,000 feet, ie well in advance. This tells he was getting all ducks lined up ahead of time and that he is a very meticulous person (also take his profession into account). There was something else that threw him off, not the lack of preparedness.
It's San Diego. Is it not likely he's only gotten straight-in or visual approaches every time there?
@@michaelglasier7282 You mean actually landing only on 28R? I don’t know this airfield, but it seems pretty unlikely: I just read that this was a regular commute for him, and that he’d actually made the roundtrip *25* times, just since July! So while I guess it’s possible, it seems to me pretty statistically unlikely that he flew this route with that kind of frequency over the last three (I think it was?) years, but never did a circling instrument approaching any of the other five runways. I’m inclined to agree with a sho; something unusual seemed to be going on here.
@@HalfShelli I've heard that was a regular commuting route as well, but according to Flightaware he'd only flown that route 5 other times in that period. All of them ended with a straight-in to 28R.
Thanks for putting this early analysis out. The crash was 4 blocks from my childhood home so very interested in hearing more about this as the investigation completes.
Thanks for the enlightenment and the important information.
Excellent briefing
Sounds to me like this pilot was confused by ILS 28R circle to 23 and thought he was being cleared for 23 direct. He never intercepts the LOC and gets flustered by the clearance. I would imagine he was used to having the autopilot fly his approaches and this circle to land was not something he could program into his GPS. Confusion, divided attention and then SD. I wonder how many times he flew a circle to land approach.
Controller contributed to the workload of the pilot, not taking into account the obvious uncertainty the pilot is expressing and an overload of instructions. One of the first you do as a controller when a pilot is struggling is you simplify and clarify to ensure the pilot understands and safety can be maintained.
Flying in airplanes is dangerous enough but this is why I don't fly in small planes.
His voice is very strained, he sounds like someone who is having trouble staying conscience.
Why was not allowed to land on the ils runway? Was it closed? Why not a left vector?
It seems surreal seeing Richard doing these videos knowing that he’s no longer alive after perishing in a small plane crash last year.
Would it had served to be on auto pilot and feed the changes in course and altitude into auto pilot and let the plane do the work?
Too bad for the victim on the ground. At least he didn't kill his entire family or drive that thing into a school. His task was straight forward and simple, and still couldn't do it.
Right from the beginning, you can tell that this man is not mentally prepared for this approach. Someone like me would have been happy to get him up to speed on instrument procedures, but you can't make pilots show up and ask for instruction. So, if you are a doc who wants to fly when you can, find a kid who has the ratings and some actual instrument time to act as a support system so you have another brain to interact with. If you have to say, "you have the airplane" it's better than a policeman knocking on your front door to tell your family the bad news. If you are smart enough to become a doc, then good Lord, be smart enough to know your limitations.
Narcissist much?
@@baaa4698 Experienced pilot. It may look like narcissism to you when someone knows what they are talking about. Many folks don't like it when someone can demonstrate knowledge that helps others.
@@baaa4698 Then you should know better. BTW, I started flying in 1960 as long as we are measuring d***s.
@@baaa4698 An adult using "yer?" Really? I think you are a BS artist.
@@baaa4698 Your message is unintelligible. We are talking about a man who died, and you are talking about typing a letter? You have not added anything to this safety discussion, so I am going to stick with you being a BS artist. If I am wrong, and I sure can be wrong, you can share some experience that helps others learn from this accident. Maybe Dan is right, and this doc had a medical problem that could be traced to recent immunizations, but that idea would take an entire board of experts to pour over, and even then, if that is the case, it could be suppressed for political reasons. You have a good night.
I think the language barrier is a big problem here. Terrible readbacks, lack of understanding. The controller did all he could to help him.
He had 1000-1500 AGL clear to recover and there was no attempt made on cloud breakout to do anything - It remained near knife edge climb power into the ground. He was incapacitated at that point and my money would be on an in-flight stroke or other medical issue leading to the ever increasing disorientation.
Go ahead and assume the plane you're flying is climbing. Then with a 10,000 fpm descent, break out of the clouds and allow a quick second or two to figure out why the sky above you looks a lot like trees and houses. Then how much time does that leave to recover?
@@michaelglasier7282 rate of descent was @2800-3000 last ping - Even if we said 5000 that's at least 8-10 seconds before impact if you go pessimistic on the clouds (which were broken at 3 levels in the first place - It wasn't even IMC at KMYF or KSEE).
Now count to 10. It's a long time. He was at 80-90 degrees bank (not upside down) - Any pilot would reaction roll - But he did a steady state climb power knife-edge dive into the ground.
He also stopped answering calls 30 seconds before that. That time with adrenaline and "something" would happen. Some type of reaction noted. At least throttle back or some roll attempt.
He was a very current and well trained pilot - Over 1000 hours in his 340. His comms and actions remind me of being on the phone with my dad when he had a stroke - Moments fully aware and them mass confusion.
@@AlpineWarren I respectfully disagree, though I do appreciate your answer. I do think his descent rate was higher just based on the frequency of ADSB hits and what the last one showed. I also think the clouds could have been a bit lower, I think they showed 3000 broken at one airport and 2300 at the other. Again, I would expect with everything else he had going on and an assumption that he thought he was in a climb, it really could have taken quite a long time after breaking out below to look out the window and then realize what his attitude was. And even then, with that bank angle, if he only had the instinct to pull back from the dive, obviously it wouldn't have helped. It's likely to have been spatial disorientation or a medical issue, and unfortunately we will probably never know.
Thank you Richard
An IFR rating means very little. You have to have real time experience in real IFR weather. The best thing I ever did as a pilot was to hire an instrument instructor to fly with me on a scheduled run I had for the old Emery Air Freight in Beech 18s. That actual experience, over three days, gave me the real confidence I needed to be successful, remain alive & not kill any innocent people. Get off your autopilot. HAND FLY YOUR AIRPLANE.
Bingo. I received my IFR rating in Oklahoma during the winter. Guess what? It's frequently overcast in OK in the winter. And because of this much of my training was in actual IFR conditions. You don't need to wear a hood when it's 400' overcast and 1 mile! I probably had 15-20 hours of actual IFR the day I took my checkride. I was flying out of Riverside, doing my work at Okmulgee and Tulsa Int. The day after my ride I walked into the FBO (Tulsa Pilots Club - now long gone) and rented a 172. Flew it to McAlester, then to Ada, and up to Wiley Post in OKC, shooting approaches to each. 90 percent of that flight was actual IFR. Best experience for a low-time IFR guy is to get in the plane and fly it! Hone your skills. Hand-fly the plane. Build confidence. "Competence builds confidence" is what my designated examiner and aerobatic instructor used to say. RIP Calvin G Bass. USAF Ret.
@@lbowsk exactly. Experience comes from doing it. I somewhere read that it takes a factor of ten each rung up the improvement ladder, i.e.:
1 h to know what you're talking about
10 h to actually perform the tasks
100 h to perform the task without supervision
1,000 h to be very proficient
10,000 h to mastery
All figures are to be taken as rough approximates, other factors apply.
These are my thoughts exactly. He had a lot of time in the airplane, but how much was the airplane on autopilot? if so, was it when he was in actual? There have been accidents where pilots rely on the autopilot and atrophy their stick and rudder skills, and then when the autopilot fails, they cant handle the illusions. Let's not outrule instrumentation error coupled with a poor scan, in turbulent weather. Very easy to get disoriented even as a proficient and competent fully alert pilot.
@@13megaprime I agree with all except your last sentence to a degree. If a pilot is confident & proficient he shouldn't ever become confused. However, there have been times when I was single pilot (99% of the time) doing night charters for Federal Express into busy metropolitan airports & become temporarily confused (disoriented) with the overall situation in IFR weather. So I guess, thinking back, I agree with your last sentence too....to be entirely honest. :)
@@billcallahan9303 much respect to you freight dawgs. might join the ranks one of these days... fly safe ;)
Thank you, nicely done update.
Excellent video and even more explanation 👍
Thanks. Great video.
You can see the guy is in way over his head in VMC, probably spatially disoriented and openly flustered, which for a doctor who has been through sleep deprivation training is saying a lot. A 340 is a hot rod airplane and can get away from you quickly, especially when all the factors go against you. We don't know, but this guy probably already had a long day on top of it. With an 80 degree bank, you also have to wonder if he didn't get inverted, which would explain reporting climbing when he was losing altitude. Great video, it will be interesting to see what they find out about this tragic affair.
From his voice on ATC it sounds like he could be partially incapacitated. Potential for histotoxic hypoxia or some other medical issue. I would be surprised if the investigation doesn’t look into a smoke/fumes incident.
I recently was privy to the flight data from a recent fumes incident (landed safely). The pilots were struggling to speak properly, comprehend commands and had terrible airspeed and altitude control. It sounded eerily similar to this.
Possible but very unlikely in this airplane. The 340A uses turbochargers from the inlet side for pressurization and they also can heat the air to some degree. There is no ability to mix with exhaust gases in this setup. It does have a gas heater, that if he was using it, could have potentially led to carbon monoxide poisoning although again unlikely. I'm wondering if he had some other medical issue occur. I also own a 340A and am very familiar with the systems on the plane.
To me, it sounds a lot more like he's just progressively falling behind the plane and the situation, potentially complicated by stress from the circumstances. Of course, look at it, but I expect it to be far more likely that there is no evidence of a medical or a hypoxia/fumes issue in this case.
This pilot was medically incapacitated for some reason, not hypoxia! The weather wasn’t that bad, in and out of cloud, so I doubt it’s spatial disorientation! Both engines were running just fine.
HIS READBACKS IS TOTALLY UNPROFESSIONAL AND DRIVES CONTROLLER INTO WARP SCANNING AND HEAVY WORKLOAD. I FEEL BAD FOR THE CONTROLLER WHO SAVED HIS LIFE TWICE BEFORE THE CRASH. PUSHBUTTON PILOT LETTING HIS GARMIN BECOME PIC.
Please turn off the ALL CAPS!
I’m calling “medical” on this one.
Finally, a new one!
The pilot sounds confused and couldn't track the loc correctly. I don't think vectoring him towards the high terrain was the best decision from ATC. I wonder if a turn left avoiding the hills was an option for the ATC. If so he should have probably considered that as the safest option and even offer a landing in RWY 28. It is hard to get alarmed if the pilot doesn't communicate but his speech tone and way of flying are possible enough to trigger the controller´s senses.
Maybe turning left towards the southwest would help. But that’s towards high density population and San Diego international airport. I live in SD was very sad to hear about this tragedy. My friend fly in and out of Montgomery often.
These type of circle to land approaches have been abolished by the airlines for a reason. I think they should be prohibited in general. It doesn't have to be this way.
I’m an airline pilot and we do circle to land approaches like this occasionally. They are not banned at all. KLGA and KMDW are two busy airports that come to mind that frequently do ILS, circle to land approaches. That said, they can be cumbersome and can take you off guard if you’re not fully prepared for them. Additionally, flying in and out of a ragged bottom cloud deck is particularly distracting as mentioned in the analysis.
@@chrisantoniscountryman-pur9954 I think some airlines do not permit them but I might be wrong.
I’ve worked for four airlines in my career and all four permitted them.
@@chrisantoniscountryman-pur9954 Okay then. I must be mistaken about that. I thought Juan Browne said his airline did not permit but now I'm not sure if I heard him correctly.
I live about 200 yards off the approach path to our local airport which is large enough to handle twin turboprops. On my front step I can watch them come in from miles out. Occasionally while I am outside I will see an airplane conducting a circle to land approach, and I always watch it until it goes out of sight. Especially when there is any kind of low cloud layer (solid/broken). Fortunately, no accidents at this airport since I moved here seven years ago.