Catalina Crash

Mike, you're winning the eloquence derby. Very insightful, and I can't disagree. To me, this is the heart of it:

In reply to:

---

The nature of pilots is to push the envelope. We must do so, or we'd never graduate beyond the gentle-breeze-straight-down-the-runway-landings we were authorized to do when we started flying

---

The only way to improve, as you know and say, is to keep trying new things. This is the meaning of the old saw about flying being a contest between how fast you gain experience versus how fast you use up luck. The line between "situations that are increasingly challenging and so develop your skills," and "situations that are dangerous and which you might not survive" is often clear only in retrospect. For instance, in my own case: I understand much more about thunderstorms, having been vectored almost into the middle of one (over upstate New York) three-plus years ago. But the cost of that understanding could have turned out to be fatally high.

I have talked about this many times with William Langewiesche -- who literally grew up in airplanes, with his father, Wolfgang, and who now is my colleague at the Atlantic. His attitude boils down to: keep learning, keep trying, keep being obsessed by details and competence. But also remember that it is a dangerous activity and in the end a lot of it comes down to fate and luck.

Mike:
Well stated but I do not think it has to be that "complicated". This is not a situation of whether you are "good enough" to do certain things. It is a matter of practicality and common sense. No matter how "good you are" or how recent your training, you are not going to be able to land in below minimum weather. Why? because you still have to see the runway to land. TERPsters have spent a good deal of time designing that approach you are flying. If they say you can only get to 400 feet and the weather is 100 feet, you can be Chuck Yeager himself and you are not going to be able to land.
Experience teaches you to be cautious and hopefully teaches you to be rigid and stick to the guidelines of the approach.. Following the procedure PROPERLY and do not bust minimums and every approach will be safe. It is silly to shoot an approach when you know the ceiling is below minimums because, once you get to DH/MDA that is as low as you can go; period. The only exception is if you do not believe the reported weather for some reason or you expect the weather to be better by the time you are at DH/MDA. The fog scenarios we discussed a few days ago MAY fall into that category but usually it is best not to start the approach.
No matter how bad the weather is, if you do not bust minimums and know how to fly the airplane, you will not hit anything.
The REAL QUESTION: Why did this very experienced pilot go below minimums? Basic IFR training teaches us to fly to DH/MDA, look up, if you cannot see the runway, go around and go somewhere else in this case. My guess: His vast experience probably influenced him to be too cocky and to think he could go below minimums when someone with less experience could not.
BIG MISTAKE!

In reply to:

---

The REAL QUESTION: Why did this very experienced pilot go below minimums? Basic IFR training teaches us to fly to DH/MDA, look up, if you cannot see the runway, go around and go somewhere else in this case. My guess: His vast experience probably influenced him to be too cocky and to think he could go below minimums when someone with less experience could not. BIG MISTAKE!

---

Brian,

However, he did NOT go below minimums, at least, not as I understand the preliminary report. He remained level at the DH but failed to climb during the Missed Approach.

Hence the slightly different conversation.

- Mike.

Mike:
That is merely a matter of semantics. Proper procedure says if you cannot see the runway WHEN YOU REACH DH/MDA, unless you are not at the missed approach point, you perform a MISSED approach. All this requires is following the PROPER procedure. It is not rocket science and it does not take unusual skill to follow the "cook book" of the approach. Other folks in calm well thought out scenarios have already done the "homework" for you. Just follow the recipe and you will not crash as this pilot did. You just have to believe there are no exceptions to this rule; PERIOD.

Mike,
The flight was an instructional one. It is quite possible that the experienced CFI/ATP was looking out while the student (a commercial pilot whose experience was not given) was flying. Perhaps the CFI didn't realize they had passed the MAP.
One really dangerous thing about two pilots who are not used to crew coordination, CRM and division of responsibilities is that each may assume the other is doing something and as a result nothing gets done.
Interestingly the minimum visibility for the approach is one mile and the visibility given to the plane was 1.5 miles so even with the ceiling it would have been legal to shoot the approach even if it were an air carrier operation (visibility is the controlling factor)

In reply to:

---

Mike:
That is mere3ly a matter of semantics. Proper procedure says if you cannot see the runway WHEN YOU REACH DH/MDA, unless you are not at the missed approach point, you perform a MISSED approach. All this requires is following the PROPER procedure. It is not rocket science and it does not take unusual skill to follow the "cock book" of the approach. Other folks in calm well thought out scenarios have already done the "homework" for you. Just follow the recipe and you will not crash as this pilot did. You just have to believe there are no exceptions to this rule; PERIOD.

---

Brian,

No disagreement there. My concern is that a mistake may have been made by a very experienced pilot. As Jerry mentioned, it's possible that a CRM issue was to blame. We'll probably never know.

If what happened was a deliberate disregard of procedure, it is of course a different discussion.

- Mike.

Wouldn't this type of accident have been avoided with modern (and now available/affordable) avidyne/G1000 type avionics?
As I understand it, the MFD would have clearly shown the ridge (in red), and the Terrain Awareness and Warning System (TAWS) would have been issuing ground collision messages (e.g. 'Pull up!pull up!').
Shouldn't we expect this type of procedural error to be unthinkable with an avidyne or G1000 installed, with the wonderful situation awareness they bring?

A pilot would have to both make a procedural mistake, and ignore the clear avionics terrain information/warnings.

My prayers and deepest sympathies go out to the families of these pilots. Seeing the other posts here, I feel that I am not the only one who got a sickening knot in the stomach from reading the NTSB report and studying the plate. (Thank you, Roger)

I did ask myself how I could keep from ever having this happen to me. I think others here might offer some better answers than mine, but here goes:

Just my opinion, but it seems that the pilot (and instructor) did clearly miss the MAP (otherwise they would have executed the missed procedure, why didn't he climb? He didn't think he had to, yet) and it would be just a few moments at 2100' from there to impact. I take at least two lessons away from this:

Lesson 1) Assuming the accident aircraft was navigating only with its VOR or VOR/DME (and didn't have a GPS of some type on board) my Cirrus aircraft would give me an immense advantage with respect to the apparent loss of precise positional awareness. I haven't looked on the 430, but I assume the approach and MAP is there and I would have known and would have climbed. I am therefore flying a safer aircraft in that regard. This is why I have an SR22. That does NOT mean I am over relying on the plane, it simply means I have a better tool to keep track of where I am and that is a HUGE advantage when in IMC.

Lesson 2+)Lesson 1 notwithstanding, always, always, always know exactly, precisely how to identify the MAP and know the missed procedure. Look at your sectional in advance and see what kind of bad s@#t you will hit if you don't execute the procedure properly. Know the area. Don't take the missed procedure for granted. It is there for a reason. Look at the sector altitudes. Study the plate. When in doubt, assuming you are on the approach, immediately climb and execute the missed approach procedure.

I can speak somewhat to this point as on a recent flight, in night IMC, rain and some mod. turb., I was given an off-airway vector to a hold for an ILS. I turned to the heading and then realized I did not know the terrain (I never planned to fly that routing, but that's what ATC wanted). After a few seconds I realized how easily it was to get killed flying IMC, and returned to the airway until I had the sectional out and the terrain digested. It turns out I was safe at my current altitude (the airway MEA), but the relief I felt while plowing through the rain and blackness knowing that a granite cloud was not going show up unexpectedly was indescribable. The same experience happened at the holding fix. I was able to clearly see the published hold on the MFD and stay on the protected side, even with a 40kt xwind at my holding altitude that kept pushing me to the wrong side of the race track. It was the first time I have ever felt comfortable holding and that was because I knew exactly where I was. And again, this in driving rain, turbulence, and at night.

What have others learned here?

I have learned two things:
1) There are NUMEROUS examples of IFR accidents where the crash was caused by lack of postional awareness. This one has reinforced the notion that on ANY instrument approach, it is absolutely mandatory that you know hwre you are on the approach at ALL times. Our Avidyne/Arnav helps immensely with that process but as I am flying an approach I want to be keenly aware of where I am right up until landing.
2) You must fly the instrument approach as published with no deviations. All altitude restrictions are to be met. If there is any doubt about where you are or what altitude you should be at, you should start a missed approach.
This is the one time that precise awareness of where you are and what is around you is critically important. There are a lot of busy tasks to perform during an IFR approach. You got to know hwre not to go!

In reply to:

---

Wouldn't this type of accident have been avoided with modern (and now available/affordable) avidyne/G1000 type avionics?

---

Warren,

Indeed, the installation of TAWS was among the recommendations of the FAA's TAA (Technically Advanced Aircraft) study, in which both Cirrus and COPA participated. It wouldn't help in many cases (loss of control, etc.), but it could possibly have been a life-saver in this accident.

- Mike.

Jim,

I'm totally in the boat with you regarding the circumstances in which I would initiate an approach - with one exception, that being instructional flight.

The instructor that I use for recurrent training I believe is excellent. She has said that she wants to take me out and do an approach where we know it's below minimums, and will have to do a missed. She's already had me do an almost zero-zero ILS (VMC, with foggles). When we discussed doing these things, I questioned why, considering that I don't plan to get myself into those circumstances in the first place. Her comment regarding an instructional flight where we knew we'd have to do the missed was "You never know...the conditions could change and do you want the first time you experience a missed in actual to be with me, or by yourself?" I asked about the near zero-zero, and said I'd never do it under any circumstances. Her response was "Never? What if you find yourself in a fuel crisis, engine trouble, iced-over windshield etc.? Do you want to at least have this as an option?" Yes, I might well use the 'chute under these circumstances. My point is that on an instructional flight, I wouldn't necessarily view what they tried to be a problem. Of course, not executing the approach properly is an entirely different matter.

What do you, or others, think?

Andy

In reply to:

---

As I understand it, the MFD would have clearly shown the ridge (in red), and the Terrain Awareness and Warning System (TAWS) would have been issuing ground collision messages (e.g. 'Pull up!pull up!'). Shouldn't we expect this type of procedural error to be unthinkable with an avidyne or G1000 installed, with the wonderful situation awareness they bring?

---

One issue that others have raised is that a really helpful TAWS may need to have an audio cue (i.e. "terrain, terrain") to be effective. In other words, if one is already disoriented enough to not know about nearby terrain, will just having it displayed passively on the MFD be enough?

I would guess that's how the G1000 terrain feature works, as the G430/530 terrain feature does not have audio prompting.

And I don't even think the Avidyne has any type of TAWS information at all, does it? The Arnav has a little terrain information but it certainly wouldn't jump out at you if you were already confused and oversaturated with tasks...

So, IMHO, yes, TAWS would help these types of accidents from occuring, but I'm not sure either the Avidyne or the G1000 has the type of TAWS needed...

I wonder how many pilots will blindly head the "pull up" command and proceed to stall their plane? Perhaps TAWS should state "Add Power! Climb!" Or perhaps, be more terrain aware and suggest a turn to a proper direction as a climb will not always be possible.

In reply to:

---

I wonder how many pilots will blindly head the "pull up" command and proceed to stall their plane? Perhaps TAWS should state "Add Power! Climb!" Or perhaps, be more terrain aware and suggest a turn to a proper direction as a climb will not always be possible.

---

Andy,

Do all TAWS systems say "Pull Up"? I seem to remember one on a simulator saying "Terrain! Terrain!", but I couldn't swear to it.

On the other hand, "Pull Up!" cuts a step out of the mental process - instead of describing a situation that the pilot has to react to, it simply tells the pilot what to do. It's pretty tough to stall an airplane that's in cruise configuration by pulling up (not impossible, but tough), so perhaps the FAA views that wording as optimal for most situations.

I don't know - just asking...

- Mike.

Mike,

The aircraft I've flown that say "Pull up, pull up!" were in aircraft with radar altimeters.