Did get-there-itis and lack of preflight planning lead to the crash of a Mooney M20J into a power line tower in Montgomery County, Maryland on November 27? The Flight Safety Detectives think so.

The aircraft had taken off from Westchester County, New York, and was bound for the Montgomery County Airpark in Gaithersburg. Around 5:40 PM, for reasons still under investigation, it crashed about a few miles away from the runway. The crash was close to home for Greg, who lives just four miles from the site.

John, Greg and Todd talk about the investigation ahead for the FAA and NTSB. They explore key questions:

  • Did the pilot do proper preflight planning?
  • Was the pilot monitoring the weather and taking appropriate action as it developed or was he trying to tuck under the weather?
  • Was the pilot following proper procedures for the approach?
  • What is this pilot’s history?

This event appears to be a perfect example of the need for preflight planning. The weather forecast called for rain and low visibility. The pilot should have planned alternatives if it was not safe to land at the Gaithersburg airport.

Related documents at the Flight Safety Detectives website:

  • Related accident from 1992 (PDF)

Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.

Episode 142

The NTSB has issued an urgent aviation safety recommendation for all operators of DHC-3 Otters to conduct an immediate one-time inspection of the horizontal stabilizer actuator lock ring. This is the result of the NTSB’s initial findings in the ongoing investigation of the Sept. 4, 2022, crash of a De Havilland Canada DHC-3 in Mutiny Bay, Washington.

Wreckage recovered from this accident reveals evidence related to the horizontal stabilizer actuator. The actuator has two parts that were screwed together and secured with a circular wire lock ring. It appears the lock ring was not seated properly. The two barrel sections unscrewed, leading to a loss of pitch trim control and the loss of the aircraft.

John and Todd explore the ways that components are kept from coming loose in airplanes, including the lock ring that is the subject of this safety recommendation. Get their insider view of the preliminary findings, possible causes of this crash, and probable next steps in the NTSB investigation.

They also talk about the implications for anyone involves in this crash that resulted in loss of life. No one wants to make a mistake, especially one that causes a crash.

Related documents at the Flight Safety Detectives website:

  • NTSB Preliminary Report
  • NTSB Investigative update
  • NTSB Safety Recommendation
  • Press release about the inspection recommendation
  • NTSB investigation page

Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.

November 16, 2022

Passenger Suicide in Flight

Episode 141

The NTSB database has just 74 events involving suicide and the focus of this discussion is the only one that involves a passenger rather than a pilot. The event took place in 2000, when a passenger on a Twin Otter plane intentionally opened the emergency exit door in flight.

As we enter the holiday season, this accident is a reminder of the additional pressures many people experience. The Flight Safety Detectives ask everyone in aviation to be especially diligent.

In this case, another passenger saw the person open the door and tried to keep her from exiting the aircraft. Recent years have shown that unusual things can and will happen on aircraft.

John and Todd discuss the importance of acting when you see something that isn’t right. They wonder how many aviation safety issues have been averted due to the quick actions of someone who noticed something and did something about it.

Related documents at the Flight Safety Detectives website:

- NTSB Final Report (PDF)

- NTSB Public Docket (PDF)

Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.

 

Episode 140

A look inside the world of experimental aircraft is prompted by John Denver’s fatal crash 25 years ago. Denver was flying an experimental aircraft he had recently purchased. The non-standard placement of the fuel selector valve was found to be at the heart of the issues that lead to the crash.

John, Greg and Todd talk about how experimental aircraft are built and maintained. They talk about how modifications are made, often with little oversight.

The particular Long-EZ plane that Denver purchased was built with the fuel selector site valve mounted on the bulkhead behind the pilot’s left shoulder. Using it literally required the use of a mirror and pliers.

The setup, combined with questionable preflight decisions, set John Denver up to fail. Witnesses describe the engine sputtering, a steep nosedive and a crash into the ocean off the California cost. The NTSB concluded that the root cause was issues related to the fuel selector valve.

The Flight safety Detectives offer words of caution to the experimental aircraft community to make sure that safety is top of mind at all times.

Related documents available at the Flight Safety Detectives website:

- NTSB report of fatal Long-EZ crash from 1997 (PDF)
- NTSB report of WACO crash from 1989 (PDF)

- Public Docket Fatal 1997 crash

Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.

Episode 139

A pilot in a Cessna 150 making a short trip in Australia got himself into trying circumstances that led to a crash into trees. This episode dissects the preplanning failures that doomed this 1994 flight.

The pilot took off at 3:50 a.m. on a schedule that would get him home for Christmas. Predicted bad weather caught up with him, and a partial failure of the instrument control panel added to the situation. The plane crashed into trees, and fortunately the pilot was able to walk away.

His choices stacked the deck against him including choosing to fly at night, deteriorating weather conditions, and self-induced pressure to be home for the holidays.

“Every flight has a set of circumstances. It is up to you as the pilot to determine if the circumstances are right before you take off,” Todd says.

Related documents available at the Flight Safety Detectives website:

  • ATSB accident report: C152_ATSB_Dec_1994.pdf
  • Magazine article on the crash: Asia_Pacific_Air_Safety_Marc_1995.pdf

Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.

 

Episode 138

Flight Safety Detectives examine the crash of a Sabreliner twin engine plane in Ironwood, Michigan.  The pilots flew into severe weather and did not follow standard procedures to avoid engine flameout.

The pilots were on a day trip transporting two business executives. They flew into a level 5 thunderstorm and lost both engines. The investigation showed they did not use the established checklist for this type of situation.

John discusses the continuous ignition system that was not apparently turned on. That system is designed to allow for quick restart of the engines.

Todd and John highlight key lessons and takeaways including the value of using standard procedures, avoiding weather, flying within aircraft limits, and actions the pilots could have taken.

Related documents available at the FSD website:

  • NTSB Final Report (PDF)
  • AC 00-24B about Thunderstorms (PDF)
  • August 2002 Accident Prevention article about this crash (PDF)

Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.

 

Episode 137

The investigation of an issue involving a RJ100 in Sweden is relevant to everyone who flies sophisticated aircraft. Specifically, this investigation revealed issues related to the high angle of attack stall sensor that is commonly used in the aviation industry.

The Swedish authority that investigated the issue deployed a multi-person team. They were able to identify the maintenance errors that led to a false stall warning in flight.

John notes that the stick shake stall warning is the same event that started both 737 Max crashes, as well as an Air France A340 crash. These are just part of a long history of airplane stalls resulting in loss of aircraft and lives. In this case, the plane landed safely.

The final accident report has detail that can help prevent these types of accidents. John and Todd highlight the key findings for pilots and maintenance personnel.

Related documents are available at the Flight Safety Detectives website.

Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.

 

Episode 136

Was the fatal crash of a Piper PA46-500TP airplane the result of a plane with unresolved maintenance issues or a pilot with insufficient skills? The Flight Safety Detectives find that the NTSB report of this accident has no educational value or safety benefit.

Calling the single engine turbo-prop plane “not your father’s 172,” Greg brings to light the complexities of the aircraft involved. “When things go bad, they go bad very quickly.”

Todd adds his research on social media that indicates the pilot was uncomfortable with the plane. He notes that the pilot needed an unusually high number of hours to earn his instrument rating.

John covers the maintenance records. He wonders if the “no action taken” conclusion of the last work order was because the pilot declined repairs or if the root cause was believed to be the pilot’s inability to fly the aircraft.

The Flight Safety Detectives look at the NTSB report and available information to offer safety insights. They point to poor pilot skills and aeronautical decision making as important factors.

Accident details:

  • NTSB Accident Number: DFW08FA057
  • Public Docket: https://data.ntsb.gov/Docket?ProjectID=67401
  • NTSB Final Report (PDF available at flightsafetydetectives.com)
  • NTSB Witness Statement (PDF available at flightsafetydetectives.com)

Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.

 

Episode 135

The investigation into a June 2022 Cessna 182G crash in Texas is ongoing. The Flight Safety Detectives share initial facts and offer safety insights.

“A mechanical malfunction is high on my list to look at. Anything out of place, even a simple cotter pin, could have led to problems,” says John.

The detectives share the indications that there was loss of flight controls in the final stages of the flight. They share facts they have uncovered. Listen as they apply their experience to ask questions that the investigation should explore.

Weather conditions, possible mechanical issues, pilot experience, and more factors are explored. Hear what should be done to get beyond a superficial probable cause conclusion in this fatal air crash.

Accident details:

  • NTSB Accident Number: CEN22FA232
  • Preliminary Kathryn’s Report (PDF available at https://flightsafetydetectives.com/wp-content/uploads/2022/10/kathrynsreport.pdf)

Don’t miss what’s to come from the Flight safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.

Episode 134

Poor decision-making by the pilot is showcased in the examination of a Piper PA-24 crash in Angel Fire, New Mexico. The Flight Safety Detectives find that the NTSB report of this air crash provides helpful information and findings that every pilot can learn from.

Greg, John and Todd review the facts, conditions and circumstances of the accident to amplify the role of the pilot’s decisions before and during the flight. A lack of preparation led to this crash and two fatalities.

The pilot was not prepared for the gusty winds present at takeoff. He was also not familiar with the high-density altitude conditions common during hot weather at this airport. Todd estimates the pilot had about 45 seconds between realizing something was wrong and hitting the ground.

For links related to this episode, visit flightsafetydetectives.com

Don’t miss what’s to come from the Flight safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.

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