Mooney down in Norfolk

[midlifeflyer]

It's incidents like these make me wonder if we should have two or even more alt minima depending on various factors - Single pilot vs multi crew. Recency. Aircraft equipment etc etc. A 777 with 25000 combined hours on the flight deck would probably get away with this but not a single pilot flying a rented aircraft that has no weather protection and no back up instruments...

There *are* multiple minimums based on various factors. They are called "personal minimums."

[ryoder]

If he were I an aircraft with a BRS would he have pulled it?

[PTK]

This flight was the perfect storm it seems. A series of events in a chain where evidently no attempt was made to break it.

On the contrary, it was allowed to grow and lead to the worst case scenario with eerie predictability.

http://mooneysafety.com/tapestry

[midlifeflyer]

If he were I an aircraft with a BRS would he have pulled it?

 

There's no way to know that. I flew a rental Cirrus for a while and joined the Cirrus type club for a year. One of the hot topics at the time was concerns with the lack of use of the BRS system. If you're interested, this is a link to the video COPA Safety Program presentation called "CAPS...Consider."

 

The problem in this accident is that it at least appears (we're just speculating based on limited information) to be the typical chain of poor choices rather than a single catastrophic event. Late night departure, deteriorating conditions, not taking earlier opportunities to divert...  coupled with what may be a lack of proficiency in flying an approach to minimums - again speculating, but the "windshield wiper" localizer needed could just be a pilot over-correcting as he got closer to minimums rather than a problem with the localizer; and if it was the localizer, GPS was an option- the GPS LPV minimums for are the same as the ILS at KORF. Add the stress of the situation and it's questionable whether pilot would have had the presence of mind at that point to even consider pulling the chute.

[ArtVandelay]

If he were I an aircraft with a BRS would he have pulled it?

Look like he was ok till on short final, at below pattern altitude the chute doesn't have time to deploy.

[flyboy0681]

My worst fear is being in a situation substantially worse than forecast. If the guy left with the forecasts as bad as what it turned out to be, then we can agree it was a bad decision in the first place. But if the forecasts indicated otherwise, then it may be harder to say if you wouldn't have made the same go decision as well.

 

I'm relatively new at instrument flying and would be interested to know how accurate a terminal forecast is, say, six hours out.

[Marauder]

I'm relatively new at instrument flying and would be interested to know how accurate a terminal forecast is, say, six hours out.

Forecasts are just educated estimates of what the model predicts. They are a good starting point to make an initial assessment of the predicted weather. In the good old days, when I was going some distance, I would get updated weather enroute from FlightWatch or a FSS to see if the forecast is holding up.

The tools are getting better (like skew-Ts) and with onboard weather capability (like XM and ADS-B ), surprises should be less. But to quote a famous philosopher; "Weather is like a box of chocolate, you never know what you are gonna get".

[kmyfm20s]

He most likely had the legal fuel reserve but in this case legal reserves wouldn't be enough. With out having all the fuel in one tank and with moderate turbulence most likely causing it to slosh around it would cause a porting issue.

[Cris]

"This flight was the perfect storm it seems. A series of events in a chain where evidently no attempt was made to break it.

On the contrary, it was allowed to grow and lead to the worst case scenario with eerie predictability."

This as Pete points out is a classic example of an accident chain. It might be interesting to lay out all the parts of the chain which contributed to this unfortunate event. In the military we are taught that a break anywhere along the chain alters the outcome. It relates to judgement but also to checklists and to personal commitment. As an example one might make a commitment that any two of the followining is a no go decision. Night flight, inoperative autopilot/equipment, flight after a business day or flight with a passenger who has not flown in a small A/C previously. Those might be considered personal minimums and each pilot will develope their own. The point being they may not be violated under any circumstances. The same is true with a list for the accident chain. Weather is one but there are many others to be considered. In my own case I ask my crew or passengers prior to takeoff if there is any reason we should not go. Once I had my son, a Navy pilot, tell me while at the end of the runway he was not comfortable with the weather. It was raining and we were enroute to a Mooney maintenance clinic. At the same time one of the plugs was giving a bit of a problem on run up. That did it and we returned to the ramp. I lost some money but we are still flying. I really wanted to go to that clinic but I do not regret the decision. It could have been quite differant had we departed. Flying is not inherently dangerous but it is terribly unforgiving.

[flyboy0681]

Forecasts are just educated estimates of what the model predicts. They are a good starting point to make an initial assessment of the predicted weather. In the good old days, when I was going some distance, I would get updated weather enroute from FlightWatch or a FSS to see if the forecast is holding up.

The tools are getting better (like skew-Ts) and with onboard weather capability (like XM and ADS-B ), surprises should be less. But to quote a famous philosopher; "Weather is like a box of chocolate, you never know what you are gonna get".

 

And as a great American once said, Stupid is as stupid does.

[aviatoreb]

"This flight was the perfect storm it seems. A series of events in a chain where evidently no attempt was made to break it.

On the contrary, it was allowed to grow and lead to the worst case scenario with eerie predictability."

This as Pete points out is a classic example of an accident chain. It might be interesting to lay out all the parts of the chain which contributed to this unfortunate event. In the military we are taught that a break anywhere along the chain alters the outcome. It relates to judgement but also to checklists and to personal commitment. As an example one might make a commitment that any two of the followining is a no go decision. Night flight, inoperative autopilot/equipment, flight after a business day or flight with a passenger who has not flown in a small A/C previously. Those might be considered personal minimums and each pilot will develope their own. The point being they may not be violated under any circumstances. The same is true with a list for the accident chain. Weather is one but there are many others to be considered. In my own case I ask my crew or passengers prior to takeoff if there is any reason we should not go. Once I had my son, a Navy pilot, tell me while at the end of the runway he was not comfortable with the weather. It was raining and we were enroute to a Mooney maintenance clinic. At the same time one of the plugs was giving a bit of a problem on run up. That did it and we returned to the ramp. I lost some money but we are still flying. I really wanted to go to that clinic but I do not regret the decision. It could have been quite differant had we departed. Flying is not inherently dangerous but it is terribly unforgiving.

 

This is an example of this forum Mooneyspace, and type forums in general, at their best.  This is becoming a really good thread.  It started out with horror, and a reaction back a bit toward anger and blaming the pilot - and I will be first to say that I was throwing stones too. For which I apologize.

But that passed, and now we are just discussing what-if's regarding this flight as a discussion point to self-affirm and positively develop ourselves into better aeronautical decision makers.

[201er]

I'm relatively new at instrument flying and would be interested to know how accurate a terminal forecast is, say, six hours out.

Pretty accurate but not perfect. If we compare the TAF to the METAR presented in this discussion:

 

FM040800 22014KT 4SM -DZ BR OVC004

KORF 040851Z AUTO 22015KT 3SM BR OVC003 08/06 A2992 RMK AO2 SLP133 60017 T00780061 56022 TSNO

The TAF for 0800 and the Metar for 0851 coincide pretty closely. They forecast winds to be 220@14kts and they were actually 220@15kts. Visibility was forecast to be 4SM and it was actually 3SM. The light drizzle did not start yet but the mist was as forecast. They forecast 400 overcast and they got 300 overcast. Overall pretty close. However, half an hour later (closer to the time of the accident) things got a tad worse. But that tad worse would be a deal breaker:

 

KORF 040920Z AUTO 22020G27KT 2 1/2SM BR OVC002 08/07 A2992 RMK AO2 PK WND 22027/0920 T00830072 TSNO

 

Winds not only picked up but got gusty. Visibility went down a little. But more importantly ceilings came down to absolute minimums. So not only would the pilot be going through the grinder in turbulence but also having to do that to minimums and then it is questionable if he would actually pop out or not upon reaching them. The forecast was barely off but when it's that close, it can make or break the entire situation (especially with fuel running low).

 

I have a question. Why did he divert to Norfolk? Surely he could have gotten the weather by XM, ADS-B, or flight service. Norfolk was barely above minimums. Why go there?

[Steve65E-NC]

An often quoted memonic that I find helpful in making this type decision: "Remember that they will bury you on a pretty day with the sun shining."

[Steve65E-NC]

Still, I wonder why the ATC tapes that we have heard have nothing being said by either party after the offer for Radar guidance. I hope, and suspect, that they are incomplete.

[22 others]

Here ya go:

 

Part I  The "transcript" covers this

LiveATC feed: http://archive-server.liveatc.net/korf/KORF-Mar-04-2015-0830Z.mp3

 

Part II:

http://archive-server.liveatc.net/korf/KORF-Mar-04-2015-0900Z.mp3

[Amelia]

Why divert to Norfolk? Norfolk was close to Suffolk, the uncontrolled field where the pilot missed an RNAV-GPS  approach with substantially higher minimums. The field was below minimums for the approach. He was already talking to Norfolk Approach. It seems he didn't have a WAAS GPS, (not approach capable, in other words) and Norfolk has a tower, and an ILS to 200 feet, with the (gusty) wind right down the runway. Due to the low-level turbulence and some reported equipment difficulties, he was having trouble tracking the approach course both places. He also had reported low fuel. I think the decision to land at ORF was a logical decision-- at THAT very late point.

 

Better decision, in perfect hindsight, given the widespread IFR and LIFR conditions all along his route, and poor forecasts, would have been to call it quits for the night far earlier, at a well-equipped and well-lighted airport,  refuel, and land at Suffolk sometime after noon the next day well-rested, in sunshine, once the rain and heavy fog moved out. Better late than never!

[PMcClure]

Like most of you, I have done the radar surveillance  guidance approaches in training. It was a fun exercise.  I cannot imagine doing this in the middle of the night, having missed 3 times already, heavy turbulence, low fuel and knowing it is my last chance to live. Chilling. 

[flyboy0681]

Like most of you, I have done the radar surveillance  guidance approaches in training. It was a fun exercise.  I cannot imagine doing this in the middle of the night, having missed 3 times already, heavy turbulence, low fuel and knowing it is my last chance to live. Chilling. 

 

 

Chilling is the only word that comes to mind.

[AndyFromCB]

Why divert to Norfolk? Norfolk was close to Suffolk, the uncontrolled field where the pilot missed an RNAV-GPS  approach with substantially higher minimums. The field was below minimums for the approach. He was already talking to Norfolk Approach. It seems he didn't have a WAAS GPS, (not approach capable, in other words) and Norfolk has a tower, and an ILS to 200 feet, with the (gusty) wind right down the runway. Due to the low-level turbulence and some reported equipment difficulties, he was having trouble tracking the approach course both places. He also had reported low fuel. I think the decision to land at ORF was a logical decision-- at THAT very late point.

 

Better decision, in perfect hindsight, given the widespread IFR and LIFR conditions all along his route, and poor forecasts, would have been to call it quits for the night far earlier, at a well-equipped and well-lighted airport,  refuel, and land at Suffolk sometime after noon the next day well-rested, in sunshine, once the rain and heavy fog moved out. Better late than never!

 

Yeap, hotels are much cheaper than funerals. The Mrs now looks at a map before all trips to pick alternates. We have explored some fun "destinations" that way. Had a blast at the Dells on the way to Oshkosh because I did not feel like plowing thru some low buildups for 30 minutes or trying to top them to then descend thru them was going to be fun. Flying is supposed to be fun. Want to be somewhere on time? Take a turbine and an extra pilot.

[Steve65E-NC]

Ref: ATC Audio part II

Curiouser and curiouser. Perhaps the pilot was trying to use a mis-set gyro to get runway alignment after he saw approach lights. I feel sorry for the ATC guy: he stayed in there.

[midlifeflyer]

 It seems he didn't have a WAAS GPS, (not approach capable, in other words) 

 

I'm not sure we know whether he had a WAAS GPS or not or if he simply preferred the localizer.

 

But just as a point of information, the selection from your post I bolded is incorrect. A WAAS GPS is not required for approach capability. WAAS allows for the use of LPV minimums on the approach and limits the pilot to LNAV minimums.

 

If the pilot in this case did not have WAAS, yes it is relevant in this case since the weather was well below the LNAV minimums. Just clarifying the technicality.

[Amelia]

I heard, but cannot confirm, that his panel-mount GPS was an older model that was certified for en route IFR. No word on what other equipment, portable or otherwise, he might have had on board, but attempting the approach at SFQ with the equipment he was said to have, and the weather he had, arguably wasted time and fuel he might have been used to save his life, perhaps one of several unfortunate decision-links in the fatal chain. I may learn more from people with better knowledge than I can claim, in which case, I will take it all back.

[midlifeflyer]

I heard, but cannot confirm, that his panel-mount GPS was an older model that was certified for en route IFR. No word on what other equipment, portable or otherwise, he might have had on board, but attempting the approach at SFQ with the equipment he was said to have, and the weather he had, arguably wasted time and fuel he might have been used to save his life, perhaps one of several unfortunate decision-links in the fatal chain. I may learn more from people with better knowledge than I can claim, in which case, I will take it all back.

 

If he did not have a GPS that was approach certified, you are quite correct. And that would certainly account for his declining  a GPS approach.  No need to take anything back since we're all speculating anyway. I was just pointing out approach certification is not a WAAS vs not WAAS issue. 

 

I think we can all agree there were probably links in this tragic chain that could have been broken at various points.

 

Curious - does anyone know any good sites to be able to get a picture of what the weather was that night in a larger geographic area. It would be interesting to know what options there were assuming after the first missed, the pilot decided that heading toward substantially higher minimums would be the best choice. How far would he have had to travel?

[Amelia]

That would be interesting. I know I looked out the window toward the Albemarle Sound marveling at 0/0 pea soup, then at the flight planner's weather map, before turning in the previous night just before midnight, and saw the whole midatlantic seemed to be speckled with red and pink dots, with very few, if any, blue dots. That's not a scientific study, but I think would have been way beyond my chicken level! The difference between 350' reported and 200' mins just isn't enough for me to slip through, especially with that kind of turbulence.

[Bob_Belville]

Mooney Flyer posted this link to FB:

 

http://wavy.com/2015/03/04/plane-owner-talks-about-norfolk-crash-pilot/