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Incidents & Oops: Educational Analysis, Discussion and Experience

Farmboy

MEMBER
Middlebury, VT
While I don't have high expectations that this may take off, the other day SJ & I were discussing Flip Flop hats, Incident rates and Pilots, in no particular order. This of course was intermixed with attempts of communication on different levels, such as one pilot stating ETA was 6:10, and the other pilot saying that's weird, I only show 5:30 in a slower super cub. (Later discovered one was quoting time of day, while the other was quoting estimated flight time)

The endless text conversation continued as normal, weaving it's way through the maze of good topics; crushed ego's, old-timers, Arkansas wind, staying current, imparting wisdom and campfire provoking comments.

That was then, and of course this is now. Time has passed but the thoughts remain the same. SJ thought I could be an enabler, and while I've lead a few pilots astray, in reality I'm just a kid compared to those of you on here that have been there and done that, quite literally.

I've not learned well from books, but I do learn from listening and watching. I listen to most pilots. I really focus and listen to a select number. And others I not only pay attention to, but I follow like a kid meeting his hero, watching the skills, attempting to emulate, sifting the stories to capture the gold nuggets that they impart on for anyone to hear, but only a few may realize. These are some of the "campfire" moments, but it's also in the air over the comm, as some 91 year old kid tucks his wingtip into your rear-seaters ear and you hear his voice over the comm quietly say "don't put me in the trees".

It's these moments that I cherish, where even if it knowledge I know, it's a reinforcement of focus on what we are doing, pay attention and know what's expected. If it's something I wasn't thinking of or didn't know, its another gold brick to stick in the memory banks of Fly Well and Don't Suck.

Coming back to the topic at hand, I had somewhat dismissed the idea of pushing forward with this. But one of the facebook groups I follow, previously named "Aviation Accidents and (something)", now renamed oddly "the junior GA reporter", does a nice job of simply posting the facts of aviation incidents from initial report all the way to final NTSB reports. There's always some armchair discussion in the comments but that's easy to ignore.


This information is relevant only because I read a number of reports just out today that really should not have happened, or the pilots mindset was one that we really don't have enough information on. And it prompted me to sit down at the keyboard. So here we are.
 
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Scenario 1.

All, or many of us, have likely pushed on beyond our comfort level at some point or another in our flying careers. We also know that repetitive success reinforces the concept that doing it will continue to be successful. And, the comfort level threshold rises like a stairway to heaven with each successful outcome. Right up until you reach heaven.

If you look at the photos in the docket, 1-1/2 hrs later the fog was gone and the runway as clear and beautiful.

Copied from the FB page.
On November 3, 2022, about 1009 eastern daylight time, a Beech A36 airplane, N84R, was destroyed when it impacted terrain at the Tucker-Guthrie Memorial Airport (I35) Harlan, Kentucky. The private pilot was fatally injured. The airplane was operated by the pilot as a personal flight conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

The pilot was a physician, and the purpose of flight was to attend to his patients for scheduled appointments at a medical office near the destination airport. He had frequently flown into the airport, which was located in mountainous terrain. Review of flight track data found that the flight followed a route that was consistent with what the pilot had entered into a flight planning application shortly before flight. Upon arrival in the destination airport area, the pilot announced over the airport’s common traffic advisory frequency that he would circle to land. There were no further communications recorded from the pilot.

Flight track data revealed that the airplane completed a total of three approaches to the runway. The weather conditions reported at the time of the approaches were low instrument flight rule (IFR) conditions. Based upon hourly weather observations at the airport, surveillance video, and a pilot-rated witness located at the airport, visibility was likely restricted to 200-300 ft due to fog and low clouds. Based upon a witness statement and flight track data, it is likely that on each approach the pilot descended to a lower altitude in search of the runway environment. On the third and final approach, the airplane impacted a ravine and steep rock wall about 50 ft below the runway elevation and 375 ft short of the runway threshold (the runway sat atop of rising terrain, with a valley below). Based on this information, it is likely that the pilot descended below the runway elevation on final approach, which resulted in the pilot’s controlled flight into terrain while searching for the runway environment.

The pilot did not file a flight plan, nor communicate with air traffic control during the flight after departing under visual flight rules (VFR). The airport had one published GPS circling instrument approach procedure. The airplane’s flight path and altitude were not consistent with this approach, and the weather conditions were far below published visibility and cloud ceiling minimums for the approach. Additionally, a few weeks before the accident, the airport had issued a Notice to Air Mission, which advised that the runway end identifier lights, and all airport lights, were out of service. Due to the extremely low visibility and clouds, it is unlikely that the runway lights would have aided the pilot’s search for the runway environment.

Review of the pilot’s past flights into the accident airport found that he routinely conducted teardrop circling maneuvers to land in poor weather. Within the 90 days before the accident, a total of four flights were identified in which the pilot was able to land by circling over the airport under IFR or low IFR weather conditions. The approaches were likely conducted under VFR and into instrument meteorological conditions (IMC), given that the altitudes and flight track flown were not consistent with the published instrument approach procedure.

There was one additional flight located in the pilot’s logbook, about four years before the accident, where remarks noted that he attempted an approach to the accident airport to check the low IFR conditions. The remarks noted that the low IFR conditions were confirmed during an approach, and he subsequently diverted to a nearby airport that he also frequently flew to. This nearby airport’s weather reporting station, around the time of the accident, reported similar low IFR conditions to the accident airport.

There was no record that the pilot received a weather briefing before the flight, and it is not known what information he reviewed. Had he checked the weather, he would have seen that the destination airport was reporting low IFR conditions, as well as the other nearby airport that he had diverted two on the flight four years prior. While the pilot had logged several hours of actual instrument flight experience in the preceding 90 days before the accident, he did not possess instrument currency for the accident flight (nor had he filed an IFR flight plan).

The investigation found that the pilot routinely flew VFR to the accident airport and conducted circling maneuvers to land into IMC. The pilot’s repeated VFR flight into IMC, his decision to fly an approach that was not consistent with the instrument approach procedure published for the airport, and lack of instrument currency demonstrated an anti-authority hazardous attitude, in which he repeatedly disregarded regulations and demonstrated poor judgement. It is possible that the pilot’s decision to conduct the flight was in-part influenced by his scheduled appointments with his patients, which would have increased the external pressures to complete the approach to landing.

 
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Scenario 2.

The low pass is a favorite of mine, I admit. And I enjoy the literal interpretation of the phrase. But it can bite. What are your qualifications/experience/instruction for ground level flight. An aerobatic performer must perform a certain number of events under the watchful eye, inside the altitude box allowed, before achieving the greatest achievement of no altitude restriction. There is a risk-reward measurement in life. We can't stop living, and sometimes bad things just happen. What we can do is mitigate the chances. Low level barrel rolls may not fall into that category.

Copied from the FB page.
On August 21, 2022, at 1403 mountain daylight time, an experimental amateur-built Vans RV-8, N184DJ, was substantially damaged when it was involved in an accident near Scio, Oregon. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

Relatives of the pilot said the pilot would often conduct low-altitude flights and perform aerobatic maneuvers over their home. They stated that on the day of the accident, the pilot overflew their home and made a total of three passes. During the third pass, the relatives estimated the airplane was about 100 ft above the ground flying from north to south when it entered a barrel roll and descended out of sight behind trees, where it impacted the ground. The family members stated that they thought the pilot started the maneuver lower than normal and that the maneuver was not flown smoothly. They described hearing the engine running steady and did not hear anything abnormal before the accident. Flight data from an onboard flight instrument and a separate witness video corroborated the relatives’ statements. Examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation.

The accident is consistent with the pilot electing to conduct an ostentatious flight display at low altitude and his subsequent failure to perform a rolling aerobatic maneuver correctly, which resulted in a loss of control and impact with terrain.

 
Scenario 3.

Mark Murphy gives a talk about picking an airplane that while new to him, "how different it could be?". Everything about his story is reasonable, right up to the point of he and his brother in a spin that nothing was working to recover from, until miraculously it did. They later read the POH, weighed the airplane, and found that an inadvertent spin in the configuration they were in (two up, aft CG) was placarded in bold letters as UNRECOVERABLE. The base point is, learn your airplane before you fly it.

The incident below is not one like Mark's. The pilot didn't have 4000 hrs in all types of aircraft, with tickets of all sorts. And in some ways it's hard to guess at the state of mind of the pilot in understanding his decisions. But one must remember that it all makes sense to you when you climb in the cockpit. And you are likely the only person you asked, pilot or not.
Should you ever ask another person for their opinion of what you're going to do? Make a phone call to a friend, talk about your plan for the day and listen when they respond maybe. Or if you're the friend, perhaps you think about why your friend is calling, and consider the value of your response to them?

The gentleman below was 73. Little is known. He was a student pilot with unverified hours other than what he put down on a medical application 4 years prior to the accident. Had he even flown in those four years? Was he alone in life? Was this a bucket list item?
(I am slightly familiar with an older pilot that wanted a tailwheel airplane to take his grandson flying. Having the where-with-all, he had one built. In the meantime he got some tailwheel instruction, working towards a biannual. He wanted it bad, but at his age and coordination even with two different instructors he couldn't get signed off to fly tailwheel solo. It was heartbreaking, but from a safety aspect, for the best)

Learn what your skills are. Fly often to maintain them, make them better, and stay sharp. But really really know your airplane.

Copied from the FB Page.
On November 15, 2022, at 1530 eastern daylight time, an experimental amateur-built DA-2 airplane, N4307Q, was substantially damaged when it was involved in an accident near Oak Hill, Florida. The student pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The student pilot purchased the experimental amateur-built, tailwheel-equipped airplane on the morning of the accident. Witnesses reported seeing the accident airplane taxi up and down the runway several times, followed by a takeoff attempt at full engine power. During the takeoff roll, the airplane never became airborne and instead veered left, departed the runway, and impacted a tree. Examination of the airplane revealed no evidence of preimpact mechanical anomalies that would have prevented normal operation.

The seller of the airplane stated that he owned the airplane about 2 years and had accrued only 3 hours of flight time in it. He stated that the airplane’s flight controls were “very sensitive.” The seller reported that he asked the accident pilot if he had any flight hours in a tailwheel airplane, and the pilot reported that he had “a few.” The student pilot reported 70 total hours of flight experience on his most recent medical certificate application over 4 years before the accident. His pilot logbook was not located, and no determination could be made about any recent flight experience, tailwheel experience, or experience in the accident airplane make and model.

The circumstances of the accident are consistent with the pilot’s loss of control during takeoff.

- Probable Cause: The student pilot’s failure to maintain directional control during the takeoff roll, which resulted in a runway excursion and collision with a tree.
 
Beechtalk.com has a mostly informative section, “crash talk”. It’s mostly about Beech accidents and mostly civilized. The stated goal is to learn from others misfortune. A recent thread was started by a man whose 540 cratered in his Saratoga and how he managed an off airport “landing” that wrecked the plane but resulted in a minor injury for his passenger and none for him.
 
Scenario 3.

Mark Murphy gives a talk about picking an airplane that while new to him, "how different it could be?". Everything about his story is reasonable, right up to the point of he and his brother in a spin that nothing was working to recover from, until miraculously it did. They later read the POH, weighed the airplane, and found that an inadvertent spin in the configuration they were in (two up, aft CG) was placarded in bold letters as UNRECOVERABLE. The base point is, learn your airplane before you fly it.

The incident below is not one like Mark's. The pilot didn't have 4000 hrs in all types of aircraft, with tickets of all sorts. And in some ways it's hard to guess at the state of mind of the pilot in understanding his decisions. But one must remember that it all makes sense to you when you climb in the cockpit. And you are likely the only person you asked, pilot or not.
Should you ever ask another person for their opinion of what you're going to do? Make a phone call to a friend, talk about your plan for the day and listen when they respond maybe. Or if you're the friend, perhaps you think about why your friend is calling, and consider the value of your response to them?

The gentleman below was 73. Little is known. He was a student pilot with unverified hours other than what he put down on a medical application 4 years prior to the accident. Had he even flown in those four years? Was he alone in life? Was this a bucket list item?
(I am slightly familiar with an older pilot that wanted a tailwheel airplane to take his grandson flying. Having the where-with-all, he had one built. In the meantime he got some tailwheel instruction, working towards a biannual. He wanted it bad, but at his age and coordination even with two different instructors he couldn't get signed off to fly tailwheel solo. It was heartbreaking, but from a safety aspect, for the best)

Learn what your skills are. Fly often to maintain them, make them better, and stay sharp. But really really know your airplane.

Copied from the FB Page.
On November 15, 2022, at 1530 eastern daylight time, an experimental amateur-built DA-2 airplane, N4307Q, was substantially damaged when it was involved in an accident near Oak Hill, Florida. The student pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The student pilot purchased the experimental amateur-built, tailwheel-equipped airplane on the morning of the accident. Witnesses reported seeing the accident airplane taxi up and down the runway several times, followed by a takeoff attempt at full engine power. During the takeoff roll, the airplane never became airborne and instead veered left, departed the runway, and impacted a tree. Examination of the airplane revealed no evidence of preimpact mechanical anomalies that would have prevented normal operation.

The seller of the airplane stated that he owned the airplane about 2 years and had accrued only 3 hours of flight time in it. He stated that the airplane’s flight controls were “very sensitive.” The seller reported that he asked the accident pilot if he had any flight hours in a tailwheel airplane, and the pilot reported that he had “a few.” The student pilot reported 70 total hours of flight experience on his most recent medical certificate application over 4 years before the accident. His pilot logbook was not located, and no determination could be made about any recent flight experience, tailwheel experience, or experience in the accident airplane make and model.

The circumstances of the accident are consistent with the pilot’s loss of control during takeoff.

- Probable Cause: The student pilot’s failure to maintain directional control during the takeoff roll, which resulted in a runway excursion and collision with a tree.

One of the things that many Super Cub pilots assume is that their Super Cub is legal and safe to perform "intentional spins". While administering a flight review, this discussion can get complicated. For one thing, while the Super Cub is in fact approved for intentional spins, it's important to read the "conditions" attached to that authorization. For the PA-18 150, for example, intentional spins are approved only in the Utility category, and prohibited in the Normal category. Maximum gross weight for the airplane in the Utility category is 1500 pounds, and the aft CG limit is quite a ways forward, compared to the Normal Category. And, BTW, this placard is required to be in view in the cockpit:

The following placards must be displayed:
(a) On the instrument panel in full view of the pilot:
(1) "Operate in Normal or Utility Category in compliance with approved Flight Manual.
Airplane marked for Normal Category. Acrobatics (including spins) prohibited in
Normal Category."

So, the problem is: very few Super Cubs I've met can fly with two "normal" humans aboard, and enough fuel for even a short flight, and still be under 1500 pounds. Not to mention the CG issue.

Add to that a set of Bushwheels, for example, or any of a number of other modifications that are common in these airplanes, and there is a serious question whether the airplane can now be operated in the Utility category in any case, because of the mod.

Yet, I hear pilots occasionally mention that they received dual instruction in their Super Cub in spins.

Those are called "Test Pilots".

MTV
 
Another point about spins is that they are considered an aerobatic manuever by the FAA.

Pilots training for a flight instructor certificate must have logged spin training and recovery as one of the requirements for that rating. [They do not have to demonstrate spin recovery on the practical examination, by the way]. If the airplane they train in is approved for spins, the instructor and trainee may do the C.F.I. spin training requirement without wearing emergency parachutes.

The F.A.R.s require all others performing spins, even in an airplane certified to do them, to wear a T.S.O.ed emergency parachute that has been inspected, packed, and sealed within the last 180 days.

Can you safely practice spins in an airplane certified to do them without wearing a parachute? I think so, but if you are going to break regulations you at least ought to be aware you are doing so.
 
Parachutes are required only when “carrying any person (other than a crewmember)”. In other words, you can do spins while solo.

I enjoy spins, but quit doing them when I put on VGs and big tires.
 
Experience teaches some that having it work out ok once, it should again. For them the only real learning occurs when it doesn't the first time.

Gary
 
I enjoy spins, but quit doing them when I put on VGs and big tires.
WHY? Do you know or suspect something the rest of us are unaware of? Do you think for some reason that spins with those items are unsafe? If so, there should be some discussion, as there are a lot of Cubs so equipped.
 
Parachutes are required only when “carrying any person (other than a crewmember)”. In other words, you can do spins while solo.

I enjoy spins, but quit doing them when I put on VGs and big tires.
I enjoy spins too and think all pilots should have spin recognition and recovery training.

The Feds I know have a different interpretation of F.A.R. 91.307 (c) than you do. I agree with you that that's how the paragraph reads, but they interpret it as "each occupant of the aircraft is wearing an approved parachute". Remember, it's the FAA; it doesn't have to make sense.
 
I enjoy spins too and think all pilots should have spin recognition and recovery training.

The Feds I know have a different interpretation of F.A.R. 91.307 (c) than you do. I agree with you that that's how the paragraph reads, but they interpret it as "each occupant of the aircraft is wearing an approved parachute". Remember, it's the FAA; it doesn't have to make sense.

(d) Paragraph (c) of this section does not apply to—

(1) Flight tests for pilot certification or rating; or

(2) Spins and other flight maneuvers required by the regulations for any certificate or rating when given by—

(i) A certificated flight instructor; or

(ii) An airline transport pilot instructing in accordance with § 61.67 of this chapter.
 
I read the regulation as well, but I can't control how individual FAA personel interpret it. Reason, practcal experience, reading comprehension, and competency don't appear to have been used in that interpretation.
 
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WHY? Do you know or suspect something the rest of us are unaware of? Do you think for some reason that spins with those items are unsafe? If so, there should be some discussion, as there are a lot of Cubs so equipped.
Pete,
As I’m sure you know, SOME modifications remove the aircraft from the utility category, or prohibit spins. You’d have to look at the Flight Manual amendments for that information.

But, mods were almost certainly not spin tested to recover from a developed spin. When the FAA, without any flight testing, decided that big tires were “dangerous”, our outfit and the State Aircraft Division hired a certified test pilot to conduct flight tests on two Super Cubs, wearing a variety of tires.
He found no unusual flight characteristics with any of the tires, except slightly slower cruise speed.
But, the best of my knowledge, he only conducted the normal category flight test maneuvers…..I‘m not sure he demonstrated developed spins, as would be required for utility or aerobatic category certification.

Has Airframes, or whatever they’re called this week, demonstrated fully developed spins in a Cub on Bushwheels? I don’t know.

MTV
 
Sidetrack thought on flight testing developed spins in a cub.

Anyone know of a test pilot that safety departed (parachuted) from a cub cockpit while in a spin?
 
I have a lot of time traveling to work each morning.
For those of you instrument rated, I have a question.
Regarding the “doctor in the bonanza” from above, even though it doesn’t look like the case, say you inadvertently found yourself over the airport and below VFR minimums. As his flight track suggested continued VFR flight he would have had some reference to surrounding terrain.

But, he held an IFR ticket, and he had recorded 3 approaches in the last 90 days, and had an IPC.
So what would cause you to not dial in and fly the published approach?

I’m not looking for “being stupid”, I’m trying to get a better understanding of what mindset might cause you to shoot that approach VFR with no apparent respect to the IFR approach.
 
Pete,
As I’m sure you know, SOME modifications remove the aircraft from the utility category, or prohibit spins. You’d have to look at the Flight Manual amendments for that information.

But, mods were almost certainly not spin tested to recover from a developed spin. When the FAA, without any flight testing, decided that big tires were “dangerous”, our outfit and the State Aircraft Division hired a certified test pilot to conduct flight tests on two Super Cubs, wearing a variety of tires.
He found no unusual flight characteristics with any of the tires, except slightly slower cruise speed.
But, the best of my knowledge, he only conducted the normal category flight test maneuvers…..I‘m not sure he demonstrated developed spins, as would be required for utility or aerobatic category certification.

Has Airframes, or whatever they’re called this week, demonstrated fully developed spins in a Cub on Bushwheels? I don’t know.

MTV
Mike, Aerobatic category requires 6 turn spins (fully developed). The others, only one turn prior to less than one turn recovery. If these large tires are STCd, then spins were demonstrated for the approval. If only a field approval, then it is likely there were no flight tests accomplished. I'm curious why sjohnson decided to stop doing spins which he claimed he enjoyed doing. Did he actually find something dangerous which we should know about?
 
I'm curious why sjohnson decided to stop doing spins which he claimed he enjoyed doing. Did he actually find something dangerous which we should know about?
I quit doing spins in the Cub because I do not know the effect of the combination of VGs and big tires and I don’t want to be a test pilot. While both mods are STC’ed, they were certified independently of each other as far as I know.
 
As an anecdote, long before I bought my Cub and before the big tire era, it was used to give spin training to prospective CFI’s. On one such flight, the passenger (the CFI) had to unbuckle and lean forward to exit the spin. Knowing this CFI, they were probably aggravating the spin for fun. We were all younger then.

Also, while testing my theory about moose stalls, I found that the cub will snap roll ( horizontal spin) like a top, at well above stall speed, say 60 mph. In a hard level turn, this does not require any additional elevator input, only inside rudder and outside aileron. In this maneuver, it’s best to let the plane continue until it’s nearly upright to recover. Attempting an earlier, even immediate, recovery results in inverted flight. this testing was done without VGs.

The point is, an unrecoverable spin is well, unrecoverable, and it’s not hard to find unexpected behavior. It’s fun to stay well within the known spin recovery envelope, but I don’t want to test the margins.
 
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Regarding the doctor in the Bonanza, I believe the airport has one GPS approach. On the day in question the wx was below minimums for that approach. He had flown that approach before but he had also done what he did on his last flight a few times before. Scud running over the top looking for a hole to get down. That’s what I get out of reading the NTSB report and also comments from folks who knew him on “Beechtalk”
 
Mike, Aerobatic category requires 6 turn spins (fully developed). The others, only one turn prior to less than one turn recovery. If these large tires are STCd, then spins were demonstrated for the approval. If only a field approval, then it is likely there were no flight tests accomplished. I'm curious why sjohnson decided to stop doing spins which he claimed he enjoyed doing. Did he actually find something dangerous which we should know about?
Pete, I’m aware of that test requirement, but an airplane approved for intentional spins must be tested to developed spin, aerobatic category or utility, right? And Normal category “spin testing” only requires one turn and normal recovery in one additional. So, if you apply an STCd mod that was only tested to one turn, doesn’t that automatically eliminate spin approval?

If not, it sure seems like it should, and in fact, the person that puts that aircraft in a DEVELOPED spin may be in for a surprise.

MTV
 
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Pete, I’m aware of that test requirement, but an airplane approved for intentional spins must be tested to developed spin, aerobatic category or utility, right? And Normal category “spin testing” only requires one turn and normal recovery in one additional. So, if you apply an STCd mod that was only tested to one turn, doesn’t that automatically eliminate spin approval?

If not, it sure seems like it should, and in fact, the person that puts that aircraft in a DEVELOPED spin may be in for a surprise.

MTV
All STC or TC single engine approvals require one turn spin testing. AND THEN are placarded against intentional spins. To be approved for spins they must pass the six turn requirement.

sjohnson is right to question the combination of VGs and big tires as they are separate approvals, not a combined approval. It's interesting that only the IA signing the 337 must determine the flight characteristics of the combination. How is an IA supposed to know? Yet he is given the authority to make the decision.

I can't recall ever doing a developed spin. Unless it was during my younger years when I didn't know the difference and never counted the turns. I did do a 6 or 7 turn unintentionally flat spin once. That was interesting.
 
I quit doing spins in the Cub because I do not know the effect of the combination of VGs and big tires and I don’t want to be a test pilot. While both mods are STC’ed, they were certified independently of each other as far as I know.
Same.
 
Sidetrack thought on flight testing developed spins in a cub.

Anyone know of a test pilot that safety departed (parachuted) from a cub cockpit while in a spin?
No, but I have jumped from Cubs and flown while several others jumped from the PA-11 in level flight. The rear seat is easier to exit from.

If properly motivated (i.e. the airplane is unrecoverable) I think it would be possible to exit from the front seat of a Cub.
I have a lot of time traveling to work each morning.
For those of you instrument rated, I have a question.
Regarding the “doctor in the bonanza” from above, even though it doesn’t look like the case, say you inadvertently found yourself over the airport and below VFR minimums. As his flight track suggested continued VFR flight he would have had some reference to surrounding terrain.

But, he held an IFR ticket, and he had recorded 3 approaches in the last 90 days, and had an IPC.
So what would cause you to not dial in and fly the published approach?

I’m not looking for “being stupid”, I’m trying to get a better understanding of what mindset might cause you to shoot that approach VFR with no apparent respect to the IFR approach.
Some mountain airports have approach ceiling minimums well above VFR minimums due to obstacles in the approach path or affecting the missed approach climb. Assuming good visibility underneath the clouds, that ia a time when you might elect to stay under the cloud ceiling to safely arrive under VFR conditions.

in this incident, the pilot had to know that both the ceiling and visibility were very low. It was unlikely to be able to see the runway environment even after arriving over the airport at a low altitude while flying VFR in IFR conditions. Even if you were planning to try this, you would at least want to arrive aligned with a runway in case you did get a glimpse of the ground.

I very rarely try a second approach if I miss the first one. Exceptions might be blowing snow or fog that is in the process of breaking up. A third attempt after the second missed approach is statistically a dangerous operation.
 
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All STC or TC single engine approvals require one turn spin testing. AND THEN are placarded against intentional spins. To be approved for spins they must pass the six turn requirement.

sjohnson is right to question the combination of VGs and big tires as they are separate approvals, not a combined approval. It's interesting that only the IA signing the 337 must determine the flight characteristics of the combination. How is an IA supposed to know? Yet he is given the authority to make the decision.

I can't recall ever doing a developed spin. Unless it was during my younger years when I didn't know the difference and never counted the turns. I did do a 6 or 7 turn unintentionally flat spin once. That was interesting.
My point is that unless those mods were fully spin tested (and a one turn spin is, by definition, an ”incipient spin”, as opposed to a developed spin), the airplane should no longer be legal to spin. No combination of mods necessary. And, I’d bet that VERY few modifications that are approved on these airplanes were ever truly spin tested.

Ive done five or six turn spins in a PA-11….a bone stock example. We used two Cessna 172s at the school for spin training. They were both late models, with 180 hp engines. One was a very nice spinner, though you had to hold in full deflection of in spin controls or it'd exit the spin itself. The other was the opposite: Had to aggravate it to get it to enter the spin, then itd go three or maybe four turns and BANG, it’d pop out of the spin and enter a tight spiral.

The “happy spinner” we did five or six turns in, the other airplane we never got more than three or four. “Identical“ airplanes, obviously rigged different.

Alsodid spin training in a 7 GCB Champ. Beautiful spinner, though it took a while to climb high enough…..

MTV
 
Regarding the “doctor in the bonanza” from above, even though it doesn’t look like the case, say you inadvertently found yourself over the airport and below VFR minimums. As his flight track suggested continued VFR flight he would have had some reference to surrounding terrain.

But, he held an IFR ticket, and he had recorded 3 approaches in the last 90 days, and had an IPC.
So what would cause you to not dial in and fly the published approach?

I’m not looking for “being stupid”, I’m trying to get a better understanding of what mindset might cause you to shoot that approach VFR with no apparent respect to the IFR approach.
To answer your specific question, yes, I would rather fly an illegal IFR procedure than nose around VFR to see what I might find - if those were my only two options. I guess I'd just have to hope that I didn't kill anyone who happened to be flying the approach legally. This guy was 51nm from Tri-Cities, which had six instrument approaches available to him, two of which are ILS. He had options.

In any case, flying the approach into I35 wouldn't have helped this pilot. The minimum altitude on the approach is almost 1,400' AGL and the weather at the time was reporting 200' overcast with 4 SM vis. The final approach course is offset from the runway centerline 10° and the runway end identifier and runway lights were inop. The only way this pilot was getting in is with a white cane and a shit ton of dumb luck. A simple weather briefing or dialing up AWOS during the flight would have told him so.
 
We are all more careful, through and questioning then these guys, right?

*****

On April 18, 2022, about 1329 central daylight time, a Piper PA-28-140B, N8891N, was substantially damaged when it was involved in an accident near Panama City, Florida. The pilot and passenger were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight.

Before the accident flight, the airplane had been started and taxied, but not flown in several years, and had been stored outdoors during that time. The pilot was aware of the condition and history of the airplane and conducted a cockpit orientation and cursory review of the onboard paperwork with the airplane’s owner. The pilot subsequently checked the fuel and oil to assure that they were at the proper levels and that no water or debris was indicated by samples from the drain ports. The pilot and the mechanic (who had performed the only recorded maintenance and inspection on the airplane in the previous 5 years) planned to take a short flight in the general vicinity of the airfield and then land. The weight and balance were within limits, and there was about 25 gallons of fuel on board. Ground operations were unremarkable. All the electrical gauges were within limits and the battery indicated that it was charged. The engine ran smooth, and all indications were within limits.

The pilot stated that before takeoff, he decided to perform the pre-takeoff checks twice - each followed by a high-speed taxi down the runway to rotation speed. “The aircraft performed flawlessly” and he then then did a final runup and magneto check, lined up, advanced to full throttle, and began the takeoff roll.

The airplane accelerated and became airborne as expected, but as they approached the departure end of the runway the engine rpm suddenly decreased to about 2,400 rpm and airspeed began to decrease. He ensured the mixture was full rich and the throttle was full in. He believed that the engine was running fine, but at reduced rpm. The engine rpm then decreased to 2,100 rpm. He then checked that the throttle was full in, the mixture was rich, the primer was in, and the fuel pump was on, as he lowered the nose to maintain airspeed. However, engine rpm began to decrease as if he was slowly pulling the throttle to idle. The engine was not running rough, just slowly decreasing uncommanded to idle (and at this point the propeller was likely windmilling). As they approached a highway, they were in a descent below best glide speed. He realized he would not be able to turn and try to land on the highway without stalling. They were descending at such a rate that they could not make it to a nearby road or some small clearings just south of it, so he aimed between pine trees and tried to align the airplane’s flight path with the planted pattern of the trees and prepared for a forced landing. Just above the treetops, he slowed to stall speed and attempted to use rudder to keep the wings level as the wings impacted the trees to slow them down before the airplane came to rest.

During the impact sequence, the airplane was substantially damaged. Postaccident examination revealed that the engine displayed numerous areas of corrosion, missing paint, and a wasp nest was adhered to the accessory case. Water was discovered in the gascolator and boost pump, which upon further examination was determined to not be an approved boost pump. Corrosion was present in the engine-driven fuel pump, and the carburetor fuel inlet screen displayed several areas where corrosion and debris were adhering to the screen. Further examination also revealed water in the carburetor float bowl. Based on this information it is likely the engine sustained a complete loss of engine power due to fuel contamination.

The airplane Owner’s Handbook stated under “PREFLIGHT” that the airplane should be given a thorough visual inspection before each flight, including visually checking the fuel supply, securing the fuel caps, draining the fuel tank sumps, checking that the fuel system vents were open, checking for obvious fuel and oil leaks, and checking that the required papers were in order and in the airplane. Under “GROUND CHECK” (which occurs after the engine is started), it also required that the pilot check the magnetos, vacuum indicator, oil temperature, oil pressure, and carburetor heat, as well as turning the electric fuel pump off momentarily to determine that the engine-driven fuel pump was functional. Just before takeoff, it required that the pilot check that the fuel was on the proper tank, the electric fuel pump was “ON,” the engine gauges were checked, the carburetor heat was “OFF,” the mixture was “RICH,” the quadrant friction knob was set, the wing flaps were set, the trim was set, the controls were free, the door was latched, and the belts/harnesses were fastened. The pilot purportedly accomplished all these checks twice—each followed by a high-speed taxi down the runway to rotation speed—and then performed a final runup and magneto check before takeoff. However, examination of the tachometer hour meter indicated that the time from engine start to the loss of power was only about 2 tenths of an hour (approximately 12 minutes at cruise rpm).

Examination of airplane maintenance records revealed that the mechanic inspected and serviced the airplane about 4 days before the accident. The entry in the airplane maintenance records made no mention of an annual inspection. Further examination revealed that an annual inspection had occurred about 6 years prior. During that inspection, 19 discrepancies were discovered and the “airframe was determined to be UNAIRWORTHY.” About 14 months later, a document was produced by a mechanic that listed the 19 discrepancies found during the annual inspection, and that they had been remediated. However, the document did not state that an annual inspection had been completed. No other maintenance entries were found in the airplane maintenance records after the document was produced from about 5 years until the entry that occurred 4 days before the accident, and a review of the engine maintenance records revealed that the most recent engine overhaul was completed more than 50 years before the accident.

Review of the manufacturer’s published guidance for 100 hour/annual inspections indicated that approximately 174 checklist items were required to be checked/inspected during a 100 hour/annual inspection. About 18 of the checklist items had to do with inspection of the fuel system, including checking the wing tanks and fuel lines, the gascolator, boost pump, enginedriven fuel pump, carburetor inlet screen, and carburetor. Additional review of the “GENERAL” section also revealed that one checklist item stated, “Appropriate entries made in the Aircraft and Engine Logbooks” and another stated, “Airworthiness & Registration Certificates in the aircraft and properly displayed.”

The pilot had accrued about 3,870 total hours of flying experience, 3,182 hours of which was as pilot in command. However, most of the pilot’s total flight hours were in several turbojet powered airplanes, and, at the time of the accident, he had no flight hours in the accident airplane make and model. Although he was transitioning to an unfamiliar airplane, he did not seek specific training in the new airplane’s systems and operating characteristics to include normal, abnormal, and emergency procedures.

Thus, the evidence indicates that the mechanic should have been familiar with the scope and details to be included in annual and 100-hour inspections, and should have been familiar with the general items to be checked during inspections, but due to the airplane’s maintenance history and his inadequate inspection the contamination in the fuel system was not detected.

Also, the pilot, who was the last barrier in preventing the accident and was aware of his lack of experience in the airplane, did not seek specific training, was either unaware of or ignored the risks inherent in flying an airplane that had not flown in many years, and either rushed or performed an incomplete preflight inspection and runup, which resulted in him failing to detect the contaminated fuel.

- Probable Cause: A total loss of engine power due to fuel contamination. Contributing to the accident was the inadequate maintenance and inspection of the airplane and engine by maintenance personnel, and the pilot’s inadequate preflight inspection and runup.

- Report:

- Docket:
 
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