crash – Aviation News Talk

357 N881KE R44 Houston Tower Collision: What All Pilots Can Learn + GA News

Max talks first about the tragic crash of a Robinson R44 helicopter (N881KE) in Houston on October 20, 2024, which claimed the lives of four people. This accident, while specific to helicopters, offers lessons applicable to all pilots.

Overview of the Incident
Weather conditions were favorable, with 10 miles visibility and minimal cloud cover. The crash occurred nine minutes into the flight, during a communication with air traffic control (ATC), suggesting potential distractions or loss of positional awareness.

Change as a Risk Factor
A major theme discussed is the impact of change on flight safety. Changes, whether in operations, procedures, or environment, introduce risks that can disrupt established defenses against accidents. In this case, two key changes are relevant:

NOTAM for the Tower Lights: A NOTAM indicated the tower lights were out of service, but evidence suggests at least one light was operational. This procedural issuance of NOTAMs during ownership changes might have created confusion, but it likely didn’t directly contribute to the crash.
New Flight Route: A week prior, the operator began running tours from Ellington Airport, requiring pilots to navigate new routes. The accident flight originated from this new location, raising questions about pilot familiarity with the area’s obstacles.

Helicopter-Specific Challenges
Helicopters, such as the R44 involved, face unique risks:

Obstacle Avoidance: Helicopters often fly at lower altitudes, increasing their exposure to tall structures like radio towers. Pilots must rely on visual spotting, especially at night, as older helicopters often lack modern moving maps and glass cockpits. The accident R44, a 2002 model, may have been similarly under-equipped.
Distractions: Passenger chatter is common during tours and can divert a pilot’s attention. Unlike some advanced audio systems in airplanes, basic helicopter intercoms make isolating the pilot’s focus more difficult. The accident occurred while the pilot was communicating with ATC and tracking another helicopter, adding to the potential distractions.
Night Vision Limitations: At night, cockpit lighting and reflections off the bubble canopy can impair visibility. Accidental flash photography from passengers can also degrade a pilot’s night vision.

Training and Safety Management
The episode raises questions about the operator’s training protocols for the new Ellington location and whether safety management systems (SMS) were in place to identify potential hazards. SMS, while not required for Part 91 operations, are mandated for Part 135 operations and could mitigate risks in air tours.

Broader Lessons and Recommendations

Monitor Changes Carefully: Changes in routes, airports, or aircraft should trigger heightened awareness. Pilots should anticipate and address second-order effects stemming from changes.
Manage Distractions: Pilots must recognize and compartmentalize distractions. A technique mentioned involves labeling a distraction and deciding to address it only when safe to do so.
Enhance Night Operations: Dim cockpit lights to improve night vision and adapt to darkness. Brief passengers on avoiding flash photography.
Know Your Obstacles: Familiarity with local terrain and obstacles is crucial, particularly for night operations or flights in new areas. Pilots should prioritize obstacle clearance when in doubt.
Industry Improvements Needed: The air tour sector has historically higher accident rates, particularly for Part 91 operators compared to Part 135. Enhanced surveillance, pilot training, and safety regulations could reduce these disparities.

Conclusion
This tragic accident underscores the importance of preparation, situational awareness, and the mitigation of distractions. While helicopters like the R44 are uniquely versatile, their operational environment demands a heightened focus on safety, particularly during tours and night flights. Pilots are encouraged to internalize these lessons to ensure safer flights for themselves and their passengers.

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News Stories

Mentioned on the Show
Video of the Week: Robinson R22 loses control and hits parked plane
Checkrider Platform for DPE Scheduling
The U.S. Commercial Air Tour Industry: A Review of Aviation Safety Concerns
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355 Envoy 3936 Wrong Runway Landing at O’Hare with Rob Mark & HondaJet Crash in Arizona

Max talks first about the fatal crash of N57HP, a HondaJet, which crashed earlier this week during takeoff from Falcon Field in Mesa, AZ. The aircraft reached 133 knots on the runway, well above the rotation speed of 115 knots, before rejecting its takeoff. It was still doing 89 knots, when it crossed the departure end of the runway. It continued for another 700 feet, hitting a vehicle on a road. Four people in the jet and the driver of the vehicle died. One person on the jet survived with severe burns. Max talked about recent causes of jet takeoff accidents, including failure to remove gust locks, failure to properly set flaps, leaving the parking brake on, and making an improper decision to not continue the takeoff after V1, which Max calculated as 110 knots for this flight.

Max also talked with Rob Mark about a near-miss incident at Chicago O’Hare involving Envoy Flight 3936, an Embraer 170. The incident took place on September 25th, when the aircraft was cleared to land on Runway 10 Center but mistakenly landed on Runway 10 Left instead. This misalignment was the result of multiple small errors—a classic “Swiss cheese” moment where various lapses align to create a potentially dangerous situation.

Rob explains that the flight crew initially planned for a different runway based on the weather at O’Hare, leading to multiple runway reassignments as they approached the airport. They eventually prepared for Runway 10 Center, but encountered a problem tuning in the ILS for that runway. Despite attempts to manually input the frequency, they couldn’t get it to work. However, they didn’t inform air traffic control (ATC) of this issue, possibly due to the busy airspace environment and their assumption that a visual approach would suffice.

ATC, on their part, also didn’t catch the misalignment. Although they noticed the crew was veering off course, they didn’t alert them or reroute the flight. This mutual silence allowed the flight to land on the incorrect runway, with neither party stepping in to prevent the error. Rob points out that Runways 10 Center and 10 Left are only 1,300 feet apart, making it relatively easy to confuse the two, especially in a complex airport like O’Hare with multiple parallel runways.

Interestingly, shortly after this incident, the FAA implemented a software update for O’Hare’s radar system. This new software is designed to alert controllers if an aircraft aligns with the wrong runway, aiming to prevent future mistakes like this. Both Max and Rob agree that such system improvements are valuable, but they stress that clear communication between pilots and controllers remains crucial to safety. They discuss how pilots, when overloaded with information or busy airspace, may withhold minor issues from ATC, inadvertently increasing risk.

Ultimately, Max and Rob highlight that this incident underscores the need for vigilance and transparency in aviation. Although no one was harmed, the event serves as a reminder of how easily minor missteps can compound, creating hazardous situations.

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Mentioned on the Show
Envoy 3936 wrong runway incident at Chicago O’Hare
HondaJet N57HP fatal runway overrun at Mesa, AZ
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350 N831AZ SR22 Crash at Provo, UT and Stall/Spin Prevention

In this Aviation News Talk podcast episode, Max Trescott examines the crash of N831AZ, a Cirrus SR22, at Provo, Utah, focusing on the technical and situational factors that led to the accident. The aircraft took off from St. George, Utah, and flew for about 90 minutes before entering Provo’s busy traffic pattern for runway 13. The aircraft followed a slower light sport aircraft, leading to spacing and speed challenges in the pattern, which were critical to the crash.

First Approach: Airspeed Management Issues
The podcast outlines the first approach to runway 13, where the Cirrus displayed inconsistent airspeed control throughout. Despite instructions to fly specific speeds (100 knots on downwind, 90 on base, and 80 on final as per the Cirrus Flight Operations Manual), the pilot fluctuated greatly. Initially, the aircraft was 20 knots faster than required on final approach, only to slow to 4 knots below the target by the runway threshold. This constantly decreasing speed was problematic, contributing to an unstable approach and high workload for the pilot.

When discussing why maintaining a stable airspeed is essential, the host highlights several risks. For example, a continually decreasing speed can lead to control issues, making it harder to manage the aircraft’s energy state and potentially causing a stall. In the Cirrus case, the aircraft was instructed to go around due to its proximity to the slower aircraft ahead. However, this action did not remedy the underlying airspeed management issues.

Second Approach: Stalling and Spinning
The Cirrus’s second traffic pattern had some improvements but ultimately led to the crash. Airspeed control remained inconsistent, and the aircraft decelerated too rapidly during the base turn. Within seconds, the speed dropped from 86 knots to 70 knots—well below the target speed. This led to a stall and subsequent spin, with eyewitnesses reporting the plane made two full turns before crashing into Utah Lake.

The crash was severe, with the airframe sustaining heavy damage. A parachute was visible on the water’s surface, though it was unclear whether the pilot deployed it or if it was deployed by the impact.

The Importance of Airspeed Stability
Throughout the episode, the host emphasized the importance of airspeed stabilization, citing it as a major factor in both this crash and a similar accident involving a DA42 at AirVenture. Stable airspeed allows the pilot to maintain better control over the aircraft, reduces workload, and minimizes the risk of stalling. In contrast, pilots who allow their airspeed to fluctuate are at greater risk of being distracted, losing focus, or encountering control issues.

The host also discussed how adding flaps can cause a rapid deceleration, especially in a Cirrus. To counteract this, pilots should simultaneously push forward on the control stick and adjust the trim when adding flaps. Failure to do so can cause the nose to rise, leading to a dangerously slow airspeed.

Spacing Issues and Situation Awareness
Another point discussed was how the Cirrus pilot’s failure to manage spacing with the slower Sport Cruiser contributed to the accident. At one point, the Cirrus was only 0.3 nm behind the slower aircraft, prompting the controller to issue a go-around. However, the pilot did not adequately slow down, further complicating the situation.

The podcast underscored the responsibility of pilots in faster aircraft to maintain adequate separation, particularly at busy airports. In this case, the Cirrus pilot might have been inexperienced in managing such scenarios, especially coming from a non-towered airport like St. George, where traffic patterns are often less congested. The lack of a robust avionics system in this older Cirrus, which could have provided critical traffic information, may have further hindered the pilot’s ability to manage separation and situational awareness.

Lessons in Training and Aircraft Type
The podcast also touched on broader trends in Cirrus accidents, particularly those involving older models like the SR22 involved in this crash. The host pointed out that older Cirrus aircraft, especially those with round gauges and lacking modern avionics, have significantly higher accident rates than newer models equipped with the Perspective or Perspective+ systems. He speculates that this is partly due to the fact that pilots flying older aircraft may not invest as much in high-quality training.

The accident Cirrus was an older model (#3 in the SR22 series), and it’s suggested that the pilot may not have received sufficient training in managing airspeed and spacing in busy environments. This is particularly relevant when considering that the pilot had obtained his medical certificate in 2021, suggesting that he might have only been flying for a few years.

Final Thoughts and Safety Recommendations
The episode concludes with key takeaways from the crash. The most important lesson is that maintaining proper airspeed is critical for safety in the traffic pattern. The podcast host advises pilots to pay attention to their airspeed during each leg of the pattern, use trim effectively when adding flaps, and practice stabilizing their airspeed to avoid the risks of stalling.

Furthermore, the host stresses the importance of training, particularly in aircraft like the Cirrus SR22, which requires careful management of its high performance. He also advocates for better situational awareness and maintaining a sterile cockpit during critical phases of flight to minimize distractions.

The crash serves as a tragic reminder of the need for pilots to stay vigilant, well-trained, and fully engaged in every aspect of flight operations, particularly in complex traffic patterns.

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Operation Airdrop Hurricane Helene Relief
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341 N1089W Bonanza Takeoff Crash at KISP, Long Island MacArthur Airport

In this special episode of Aviation News Talk, Max discusses a recent fatal crash involving N1089W, a Beechcraft A36 Bonanza, at MacArthur Airport in Long Island. The aircraft lost power shortly after takeoff, leading the pilot to attempt a 180-degree turn back to the runway, a maneuver often referred to as the “impossible turn.” The plane crashed short of Runway 6, resulting in the deaths of both the pilot and passenger.

The aircraft, with both the pilot and a passenger on board, took off at around 6:15 p.m. local time. Shortly after takeoff, the engine began to sputter and pop, as reported by an airport employee who witnessed the event. The plane reached an altitude of approximately 150 feet before the pilot attempted to turn back to the runway. The aircraft crashed just short of Runway 6, with the wreckage indicating a left wing low and nose-low impact. The left wing and main landing gear were significantly damaged, and the engine was found separated from the aircraft.

Max analyzes the situation, noting the difficulty of executing what is often called the “impossible turn”—a 180-degree turn back to the runway after an engine failure on takeoff. He explains that this maneuver is challenging, especially for faster aircraft like the Bonanza, due to their larger turn radius. The episode includes a discussion of the physics involved, noting that a faster aircraft’s turn radius increases with the square of its speed. This makes it significantly harder for such aircraft to return to the runway compared to slower aircraft.

The podcast emphasizes that the “impossible turn” often involves more than just a simple 180-degree turn. Due to the offset from the runway, pilots typically need to execute additional turns, making the total turn angle around 306 degrees. Max cites an aviation organization video that demonstrates the challenges of this turn with different aircraft types, including a Bonanza, which failed to complete the turn in the demonstration.

Max also explores alternative options that might have been available to the pilot. He suggests that had the pilot used the full length of Runway 24 instead of making an intersection departure from Taxiway Bravo, the aircraft might have had a better chance of reaching a different landing surface, such as Taxiway Whiskey or Runway 6. He speculates that the pilot might have chosen the intersection departure for convenience, as the FBOs are closer to this point than the start of Runway 24. This decision, while saving a few minutes, may have limited the pilot’s options in the emergency.

He also notes that pilots’ instincts often drive them to turn back to the runway, which feels like a safe haven. However, this instinctual reaction can be dangerous, as the necessary maneuvers to return to the runway are complex and fraught with risk. Max advises that pilots should instead prepare for potential emergencies by identifying suitable landing spots straight ahead, which can be reached without attempting the risky turn back.

Max shares a list of ten key points from episode 68 on the “impossible turn,” highlighting the dangers and complexities of the maneuver. He advises against practicing the “impossible turn” at low altitudes and stresses the importance of thorough training and preparation for emergencies.

The episode concludes with Max encouraging pilots to always use the full length of the runway if possible, to increase their options in case of an emergency. Max’s overarching message is one of preparedness, caution, and the importance of continuous training for pilots.

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Mentioned on the Show
Aviation-Safety.net: N1089W Bonanza crash information
Epi sode #68 10 Things to Know about the impossible turn after a Takeoff Engine Failure Emergency

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337 Yeti Airlines flight 691 crash – Human Factors for General Aviation Pilots

Max discusses the critical role of human factors in aviation safety, prompted by the tragic crash of Yeti Airlines flight 691 in Nepal in 2023. He emphasizes that pilot error is a significant contributor to aviation accidents, accounting for about 80% of them, underscoring the importance of understanding and mitigating human factors to enhance flight safety. He highlights the significance of human factors, which can affect any general aviation aircraft.

The episode centers on the crash of Yeti Airlines flight 691, an ATR 72, which crashed during a visual approach to Runway 12 at Pokhara International Airport. The flight crew had already completed two legs between Kathmandu and Pokhara earlier in the day. The accident occurred in VMC, with the flight crew initially cleared to land on Runway 30, but later requesting a change to Runway 12 without providing a reason.

During the approach, the Pilot Flying (PF) disengaged the autopilot and called for flaps to be set to 30 degrees. However, the Flight Data Recorder (FDR) did not record any flap movement. Instead, both propellers entered a feathered condition, resulting in a loss of thrust. The cockpit voice recorder (CVR) captured the crew performing the before-landing checklist without noticing the incorrect flap position. Despite increasing the power lever angle, both engines remained at flight idle, contributing to the loss of thrust.

As the aircraft descended, the crew struggled to manage the situation. The PF handed control to the Pilot Monitoring (PM), who also noticed the lack of engine power. The aircraft entered a left bank, and the stick shaker activated, warning of an impending stall. Despite attempts to regain control, the aircraft crashed, killing all 68 passengers and four crew members.

The investigation into the crash revealed several human factors contributing to the accident. The use of noise-canceling headsets by the PF may have reduced his ability to detect auditory cues indicating engine issues. Additionally, the high workload and distractions from operating into a new airport contributed to ineffective Crew Resource Management (CRM) and checklist adherence. The new Pokhara airport’s challenging approach, with a tight circuit and no published instrument procedures, further increased the crew’s workload.

Trescott delves into the SHELL model used to analyze human factors in the accident. The SHELL model examines the interaction between Software, Hardware, Environment, and Liveware (people). The analysis highlighted that the crew’s high workload and distractions, coupled with the challenging visual approach, led to critical errors. The proximity of the propeller condition levers and flap handle on the ATR 72’s center pedestal also contributed to the inadvertent feathering of both propellers.

In discussing workload, Max emphasizes its impact on pilot performance. High workload can lead to increased errors, task degradation, and poor performance. He explains that workload is influenced by task difficulty, the number of tasks in parallel or series, and the time available to complete tasks. Pilots can mitigate high workload by starting descent and approach planning earlier, slowing down the aircraft, and increasing flight path length. These strategies provide more time to complete tasks methodically, reducing the risk of errors.

Trescott also highlights the effects of high workload, such as attentional narrowing and task shedding. Under high workload, pilots may focus excessively on one task, neglecting others, leading to errors and decreased situational awareness. He shares an anecdote about a glider pilot who, under high workload and anxiety, fixated on the landing area and neglected airspeed monitoring, resulting in a stall and crash. This story parallels the Yeti Airlines crash, where high workload and distractions led to the crew’s inability to manage the aircraft properly.

The episode continues by discussing how high workloads can affect decision-making processes. High workload can lead to rapid decisions made without considering all factors, options, or complexities. When pilots are under high workload, they might simplify decision criteria to reduce their workload quickly. This can increase the chance of errors as tasks might be performed hastily and without thorough consideration. High workloads can also lead to autonomous routines or checks being underprioritized, which may cause critical steps to be overlooked.

Task engagement and concentration on a single task are benefits of high workload, but they also pose risks. The captain on the Yeti flight, despite his experience, may have allowed some tasks to become too routine, not giving them the attention they required. Processes that require executive control—such as concentrating, calculating, or performing unfamiliar tasks—can add significantly to workload. When these tasks are combined with existing ones, especially under time constraints, the risk of excessive workload increases.

Trescott explains that task difficulty is often the most challenging workload driver to reduce. However, pilots can manage time limitations by allowing more time for tasks, which helps to avoid workload buildup. Effective CRM practices, such as delegating tasks to colleagues, can also help manage workload. Emergency situations are particularly challenging, but creating time and managing tasks between crew members can help.

Recognizing high workload is critical, but individuals might not always realize it in the moment. Changes in time perception and task absorption can make high workloads less obvious. Therefore, relying on individuals to recognize and manage their workload is unreliable unless they have specific training. Recognizing changes in situations before workload increases and noticing high workload in others are more effective triggers for managing workload.

High workloads can lead to decreased situational awareness, reduced attention span, slower reaction times, increased errors, auditory exclusion, tunnel vision, physical stress responses, impaired decision-making, communication breakdown, and task shedding. Understanding these responses is crucial for developing strategies to mitigate risks associated with high workload.

The episode concludes with a reflection on the experience of the pilots on Yeti Airlines flight 691. The crew was experienced, but the new airport’s challenges and distractions contributed to errors. The check captain’s familiarity with the controls and potential overconfidence might have led to complacency. Trescott warns that overconfidence and complacency are key factors that can erode safety benefits from experience.

Trescott emphasizes the importance of strategies to catch and correct mistakes, highlighting that all pilots are human and fallible, and proactive measures are essential for safety.

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Mentioned on the Show
Yeti Airlines flight 691 Final Report
Flight-crew human factors handbook
Episode #283 Wings to Rotors: How to add a helicopter rating

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328 Buying a Plane and Crashing on Way Home – N8924Y Piper Twin Comanche

Few tragedies are more poignant than the loss of a pilot on what should have been a routine flight. Many pilots dream of buying their own airplane. But for some pilots, this dream turns into a nightmare all too soon. They never make it home. Instead, they crash along the way, their hopes and aspirations shattered in an instant. This scenario, sadly, is not uncommon. A quick search of the NTSB database reveals numerous accidents involving recently purchased aircraft, many of which occurred shortly after the new owners took possession.

One such tragedy involved the crash of N8924Y, a Piper Twin Comanche, and serves as a sobering reminder of the risks inherent in aviation. The pilot, Rob Prestininzi, had recently acquired the aircraft and was flying it home when disaster struck. The circumstances surrounding the crash share eerie similarities with other accidents of its kind: a long day of flying, fatigue, the pressure to reach a destination, limited experience in the aircraft make and model, and challenging nighttime conditions.

In the case of N8924Y, the pilot’s journey began at Savannah Hardin County Airport in Tennessee, where he picked up the aircraft after a friend had flown him there earlier in the day. Despite encountering various issues, including a landing gear problem and deteriorating weather, the pilot pressed on with the flight. As darkness fell, he found himself struggling to troubleshoot the landing gear issue while simultaneously hand-flying the aircraft and communicating via cell phone.

Tragically, the aircraft ultimately stalled and crashed, claiming the life of the pilot. The NTSB investigation revealed a series of factors that contributed to the accident, including the pilot’s failure to monitor airspeed, the presence of a burned-out landing gear indicator bulb, and the challenges of troubleshooting the issue in low-light conditions.

One of the most haunting aspects of the accident is the realization that it could have been prevented. Had the pilot been more experienced in the aircraft or taken steps to address the landing gear problem earlier in the flight, the outcome might have been different. Additionally, the pressure to complete the journey and the reluctance to deviate from the original plan likely clouded the pilot’s judgment and contributed to his decision to press on despite the challenges he faced.

As aviators, we must recognize the importance of maintaining situational awareness and making sound decisions, especially when faced with adversity. It’s essential to prioritize safety above all else and be willing to reassess our plans in the face of changing circumstances.

The tragic loss of Rob Prestininzi serves as a somber reminder of the need for constant vigilance and adherence to best practices. It highlights the dangers of get-home-it-is, which under the right circumstances can affect any of us. His memory lives on as a cautionary tale for pilots everywhere, urging us to learn from his mistakes and strive to be better, safer aviators.

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Mentioned on the Show
Flightaware.com ADS-B data for N8924Y flight data

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327 N84R Beech A36 Crash in KY – Pilot Breaks multiple FAA Rules + GA News

Max discusses a tragic accident that involved a 55-year-old physician who crashed his Beech A36 aircraft, N84R, at Tucker Guthrie Memorial Airport in Harlan, Kentucky, on November 3, 2022. The pilot departed from Knoxville at around 9:32 a.m. with the purpose of attending scheduled appointments at a medical office near the destination airport.

Despite low instrument flight conditions at the time of arrival, the pilot did not file a flight plan, communicate with ATC, or receive a weather briefing before departure. Upon arrival in the airport area, he announced over the CTAF his intention to circle for landing. However, subsequent flight track data revealed that the airplane completed a total of three approaches to the runway, none of which were consistent with the published instrument approach procedure, and all were conducted in low instrument flight conditions.

Witness accounts and flight track data suggested that the pilot routinely landed at the airport under similar weather conditions in the past, displaying a pattern of circling approaches not consistent with published procedures. Additionally, the investigation revealed that the pilot was not instrument current and had a history of conducting circling maneuvers in instrument meteorological conditions (IMC) without clearance.

The NTSB’s final report identified the pilot’s hazardous anti-authority attitude as a contributing factor to the accident, along with his decision to fly into IMC without proper clearance or adherence to established procedures. Furthermore, toxicology testing revealed the presence of methamphetamine and phentermine in the pilot’s system, both of which are substances prohibited by the FAA for pilots due to their potential to impair judgment and performance.

The NTSB emphasized the importance of recognizing and countering hazardous attitudes, such as anti-authority, through adherence to regulations and good decision-making practices. It also highlighted the necessity of effective risk management and honest self-assessment, particularly regarding medical fitness and proficiency in flying. Psychological factors such as risk-taking tendencies, normalization of deviance, and overconfidence were also discussed as potential influences on the pilot’s decision-making process.

Ultimately, the probable cause of the accident was determined to be the pilot’s decision to continue visual flight into IMC during an approach to land, resulting in controlled flight into terrain. The NTSB’s findings underscored the critical importance of adherence to regulations, proper training, and vigilant risk management to ensure aviation safety and prevent avoidable accidents.

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325 N51FM SR22 Crash at Paso Robles – When to fly the Hold at an IF/IAF

Max talks about the accident of N51FM, a Cirrus SR22T at Paso Robles, CA, and emphasizes the importance of understanding approach procedures, particularly when starting an approach from an IF/IAF fix with a racetrack. The accident involved a pilot who failed to follow correct procedures, leading to a crash, though fortunately, all occupants survived. Max breaks down the mistakes made by the pilot and discusses the implications for instrument pilots.

The flight began in Scottsdale, AZ, with the aircraft flying towards Paso Robles after a stop at Big Bear, CA. The host highlights deviations from standard procedures during the approach to Big Bear and the subsequent flight to Paso Robles. The pilot’s missteps include flying the traffic pattern in the wrong direction and excessive speeds that deviated from Cirrus standard operating procedures.

The crucial part of the flight occurs when the aircraft receives clearance for an RNAV (GPS) approach to Paso Robles, specifically to the combined IF/IAF waypoint HOVLI. The host emphasizes the importance of understanding approach segments and when to fly holds at IF/IAFs. In this case, the pilot was required to fly a holding pattern at HOVLI due to the direction of approach. However, the pilot failed to adhere to this requirement, leading to subsequent errors.

After receiving clearance for the approach, the pilot failed to fly the hold at HOVLI, resulting in being significantly above the required altitudes for subsequent fixes. The aircraft’s approach becomes unstable, with including reaching the Vne speed of 208 knots on the approach, and a descent rate that reached 2300 feet per minute. Fortunately, the pilot decided to circle back to runway 19, but instead lined up for runway 13, and then crashing between the two runways.

Max analyzes the human factors that may have influenced the pilot’s decision-making, including pressure to complete the flight, risk perception, and overconfidence. The importance of recognizing and mitigating these human factors is emphasized, highlighting the need for robust training and a safety-oriented mindset.

The accident serves as a cautionary tale, highlighting the consequences of deviating from standard procedures and the importance of maintaining situational awareness and decision-making abilities, especially in challenging situations. The host encourages pilots to prioritize safety, utilize resources effectively, and be willing to execute a go-around when necessary.

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Mentioned on the Show
ADSBExchange.com ADS-B data for N51FM flight to Paso Robles
RNAV (GPS) 19 approach to KPRB, Paso Robles, CA

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322 N960LP TBM 960 Truckee crash; Robinson helicopter factory tour + GA News

Max talks about the details of the crash of a TBM 960, N960LP, at Truckee, California last weekend. He also talks in detail about his factory tour last week of Robinson Helicopter.

The pilot, by all accounts well trained and experienced in the aircraft. The flight originated from the Centennial Airport, south of Denver, and lasted about 3 hours and 15 minutes. Weather at the time the pilot flew the approach was ½ mile visibility and snow with clouds scattered at 300 feet and overcast at 700 feet. However the approach minimums were 1 mile visibility and the MDA is 582 feet AGL. So the clouds were approximately 120 feet above minimums, and the visibility was ½ mile….less than the minimums.

Max talks about how the pilot flew the instrument approach more or less successfully, though he descended more than 200 feet below the minimums, and he started his turn for the missed approach 1.3 miles beyond the missed approach point. While he flew the approach with the autopilot, he flew the missed approach by hand, and lost control.

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Mentioned on the Show
Robinson Helicopter Company Factory Tour video
#227 My Near-Fatal Icing Incident
#233 What You Need to Know about Advisory Glide Slopes
Truckee Airport Procedures and Noise Abatement

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319 Hot Springs Jet Crash, United FL 2477 Houston Overrun, Fuel Related Accidents + GA News

In this episode, Max discusses the crash of N1125A, a 1991 ASTRA/GULFSTREAM 1125 SP business jet at Ingalls Field Airport in Hot Springs, Virgina. It was the third fatal business jet crash in the U.S. in just five weeks. Five people on board were killed. The aircraft had been purchased just 3 ½ months early. ADS-B data shows it had a normal approach on the ILS down to about 1000 feet AGL, where the data stopped. Strong winds prevailed, and it’s likely that there were strong downdrafts on short final, which may have brought the jet down.

Several airline pilots send feedback about the United flight 2477 taxiway overrun at Houston. They also talked about the FOQA programs which would have provided automatic reporting, if this approach to landing met the airline’s criteria for an automatic go around. Max also reads listener emails related to the ten fuel-related accidents discussed last week.

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News Stories

Mentioned on the Show
Astra Jet N1125A accident ADS-B Data
Fear of Landing Blog
NTBS Final report: N90559 Stall/Spin/Spiral Accident
Airline Speedrunning Tweet
AC 120-82 Flight Operational Quality Assurance
Rob Mark’s JetWhine blog
Rob Mark’s video: Flying the A380
Coleal 2009 Legal Interpretation

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Check out our recommended ADS-B receivers, and order one for yourself. Yes, we’ll make a couple of dollars if you do.

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Check out Max’s Online Courses: G1000 VFR, G1000 IFR, and Flying WAAS & GPS Approaches. Find them all at: https://www.pilotlearning.com/

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“Go Around” song used by permission of Ken Dravis; you can buy his music at kendravis.com

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