231EC 231 Fatal Baker, OR on Aug 10, 2018

[kortopates]

Interesting accident report of a 231 that went down Aug 11, 2018 at Baker, OR.  Although its only a factual report without a final determination of cause they list "Instrument Failure" as the defining event. Although they did find a broken vacuum pump that had been installed in 1994, 24 years ago with 1400 hrs, and not replaced recently after the pilot had a hard landing/prop strike  with sudden stoppage. But the pilot was not flying instruments, was not instrument rated and accident occurred in beautiful VMC conditions. I thin when you read the report you'll conclude the failed vacuum pump didn't have any thing to do with the accident unless the pilot was distracted by it when he would have been better served looking out the window.  

It really reads more like what we often accuse our Cirrus brethren of for getting into more airplane than we can handle. 2 fatalities due to a stall-spin executing a go around after a failed landing attempt; apparently too high and too fast from witness accounts. 

No shortage of signs that this accident was inevitable - but I still don't see how anyone could have really stopped this from happening. We probably all know a pilot that has some similar traits and  feel helpless to do anything about it. 

http://www.kathrynsreport.com/2020/08/flight-instrument-malfunction-failure.html

 

 

Edited August 16, 2020 by kortopates

[NJMac]

Wonder if the instructor has changed any habits after seeing the results of signing off someone who they knew wasn't ready? How sad the copilot wanted to learn since she didn't trust the right seater. I wouldn't fly with someone I didn't trust. Those photos make me queezy.

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[kortopates]

On 8/16/2020 at 2:14 PM, NJMac said:

Wonder if the instructor has changed any habits after seeing the results of signing off someone who they knew wasn't ready? How sad the copilot wanted to learn since she didn't trust the right seater. I wouldn't fly with someone I didn't trust. Those photos make me queezy.

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Yes indeed. In a sense, the instructor, (and not sure it was the same instructor), lost his ability to prevent the pilot from soloing the Mooney prematurely once the pilot had received his Complex and High Performance endorsements in the C210. With those endorsements in hand, all the accident pilot needed technically to solo was the insurance company's mandated number of dual hours.

My guess though is that it was the same instructor, and the report gave the story that after 5 hrs dual for the C210 the pilot really wanted his sign off which the instructor wasn't ready to give so they did a mock x-ctry flight where the pilot had numerous challenges - reading that and how he get signed off really does make you wonder how the pilot could have fixed those issues in just another 2.5 hrs since he signed him off at 7.5 hrs. My guess is they did another 2.5 hrs in the local pattern where he better in a familiar pattern without having to slow down and enter a pattern. 

But once he had insurance company mandated hours of dual in his logbook for the Mooney, he could fly his Mooney solo regardless what his instructor advised him. The one thing going for the pilot and the instructor was that the pilot was continuing to get instruction to improve his skills and I imagine that included some supervision from his instructor perhaps during his flight planning to new destinations. Obviously it was no where near enough, and not only did the pilot die, he took his friend with him. 

[Vance Harral]

This is, in my opinion, the instructor's most difficult dilemma.  Is it a CFI's responsibility only to give the specific training required by the FAA/insurance company?  Or is it in fact the CFI's responsibility to train a pilot to the CFI's own personal standards of safety?  Some of both?

My most recent experience with this involved a pilot who wanted a flight review, and sign-off to fly a local flying club's 172s.  But after several flights and nearly 6 hours of dual instruction, I remained uncomfortable with his situational awareness around airports.  He was often (not always) unreasonably far behind the airplane, but would continue barreling into the pattern anyway.  The pilot was conscientious and reasonable, wanted to learn, not a macho type - all the good attitudes one looks for.  But since we didn't seem to be making any progress together, I suggested he fly with another instructor, and he did.  The other instructor signed him off immediately, and told me privately, "He met standards, and I've seen much worse!"  This left me with a queasy feeling, especially since the other instructor recently stated he was about to retire from flying (one wonders if he just didn't care all that much).

So, the sign-off in that pilot's logbook is not my signature, but he's "out there".  I think about this a lot.  One can always decline to sign off a student.  But the result of that is often that the student simply shops for an instructor with lower standards.

[kortopates]

8 minutes ago, Vance Harral said:

This is, in my opinion, the instructor's most difficult dilemma.  Is it a CFI's responsibility only to give the specific training required by the FAA/insurance company?  Or is it in fact the CFI's responsibility to train a pilot to the CFI's own personal standards of safety?  Some of both?

My most recent experience with this involved a pilot who wanted a flight review, and sign-off to fly a local flying club's 172s.  But after several flights and nearly 6 hours of dual instruction, I remained uncomfortable with his situational awareness around airports.  He was often (not always) unreasonably far behind the airplane, but would continue barreling into the pattern anyway.  The pilot was conscientious and reasonable, wanted to learn, not a macho type - all the good attitudes one looks for.  But since we didn't seem to be making any progress together, I suggested he fly with another instructor, and he did.  The other instructor signed him off immediately, and told me privately, "He met standards, and I've seen much worse!"  This left me with a queasy feeling, especially since the other instructor recently stated he was about to retire from flying (one wonders if he just didn't care all that much).

So, the sign-off in that pilot's logbook is not my signature, but he's "out there".  I think about this a lot.  One can always decline to sign off a student.  But the result of that is often that the student simply shops for an instructor with lower standards.

Good points Vance and this one of the big reasons why I only give Wings Flights Reviews. With a Wings Flight Review the client needs to demonstrate the requirements from the ACS to ACS standards which are much less subjective. So anything that isn't done to the standards of the ACS we'll do again until they are. Of course that doesn't guarantee the pilot is going to get all the instruction they may need and like you said above as well, the client can always seek out another instructor. 

But in the above accident case, it wasn't a flight review and there was no sign off required beyond the dual required by the insurance company. But sure we can and should discuss with any pilot that is still having difficulty after the required hours that we should continue to work and most pilots are quite agreeable. But for the most part the insurance company usually gets the number of required dual hours right. Yet of course we sure don't want to release anyone that doesn't feel comfortable in their new plane yet either and I've seen that as well. But  regardless of our recommendation, its up to the client to elect to continue instruction after the minimum so big part of it is our ability to convince them of the need - if they need convincing - thankfully few every do.

Like your discomfort with a student, I once had a client that I was transitioning to an E model. To make a long story short, I was contacted by the buyer for transition training and when we met he made it clear to me he only wanted the ONE hour of dual his insurance company mandated and then he would be leaving to fly his new E home a couple of hours away. Obviously one hour was very brief and my normal transition training begins with a few hours of ground going over every system and every piece of equipment in the plane - nope he wasn't interested. I could have declined but I didn't and gave him the best hour I could including some emergency procedures time. I was worried for quite awhile but thankfully the pilot is still flying the E years later.  

[Bob - S50]

I'm not a CFI (thank God) but I did instruct in the Air Force.  While we used to say that anyone could learn to fly, I'm of the opinion that some people should take the hint and give up.

I don't know where the line should be drawn, but the Air Force only allowed a specified number of hours or missions to learn the tasks being taught.  If you couldn't learn it within that time frame you washed out.

Maybe the civilian world should set up something similar but I don't know what that would be.  Can't solo within 30 (or 40 or 50) hours?  Can't get that PPL within 75 (or 100 or..)?  Some limit on how long we will let someone try to learn.  Maybe an extension in allowed hours for an extensive break in training.  If they can't learn within the time limit then they are done.  We aren't doing anybody, including the student, any favors by allowing them to continue when they really have no business being turned loose on the world.

Edited August 18, 2020 by Bob - S50
grammar

[Vance Harral]

17 hours ago, kortopates said:

Good points Vance and this one of the big reasons why I only give Wings Flights Reviews. With a Wings Flight Review the client needs to demonstrate the requirements from the ACS to ACS standards which are much less subjective. So anything that isn't done to the standards of the ACS we'll do again until they are.

A fine idea, and I'll point out there's no prohibition in requiring performance to ACS standards even in a "traditional" FR, not based on the Wings program.

Trouble is, many things the ACS addresses are expressed qualitatively rather than quantitatively, and therefore still require judgement and interpretation.  Because I'm in a story-telling mood, and using real-life examples from my own instructional experience, let's consider Private Pilot ACS Area of Operation III, Task B (Traffic Patterns).  I present to you five different pilots presenting for a Flight Review, who are asked to fly to a nearby uncontrolled field for some pattern entry/exit and takeoff/landing practice:

1. Pilot 1 listens to the AWOS 15 miles out, tunes the CTAF 12 miles out, and uses a combination of others' radio calls, the reported winds, and runway info from Foreflight to choose a runway of intended landing.  By 5 miles out she has set the DG bug to reference the runway of intended landing, tentatively has a visual on the runway itself (not just the airport), and has identified a 45-degree entry heading.  Enters 45 and prior to turning downwind, has a firm visual on the runway numbers.  Proceeds to fly a perfect pattern entry.  Slows to 1.3 Vs0 abeam the numbers, and proceeds to fly a perfect base/final/landing.  Obviously a great performance, but note that almost none of the particulars I mention here are called out as specific requirements in the ACS.
2. Pilot 2 listens to the AWOS 8 miles out after a minor struggle to remember the 25 KHz push/pull knob behavior on COM2, and hears winds are calm.  He tunes the CTAF 6 miles out, and the frequency is silent.  Cue a minute or so of discussion about which of the 4 runways at the uncontrolled field is appropriate for landing, while I say, "You tell me, you're the PIC".  Pilot chooses a runway, but seems uneasy about it.  At 3 miles out he calls entering the 45, but says a different runway than he initially picked.  10 seconds later he recognizes and corrects this mistake on the radio (we've all been there), and proceeds to fly a passable traffic pattern to a reasonable landing.  Enters the downwind a little fast, and gets a little slow on final, but not enough to raise the pucker factor.  Seems exhausted on landing and you can tell he was stressed all the way around the pattern.
3. Pilot 3 is "trying to learn Foreflight".  She's still trying to set up radio frequencies and choose a runway 7 miles out - not because she doesn't know how the radio works, but because she's struggling with the Foreflight UI.  Visually identifies the field at 5 miles out and heads for it, but still hasn't chosen a runway.  At 3 miles out about to turn 45 for "some" runway, she says "You know, I'm a little screwed up here.  I'm going to turn away from the airport and fly some 360s until I'm set up.  She proceeds to do so, and subsequently gets the radios tuned, enters the pattern, and flies a passable pattern and landing.
4. Pilot 4 is the nicest old guy you'll ever meet.  No iPad, still uses paper charts (perfectly legal).  Says the only flying he does is touch-and-gos at local airports in his 182 he's owned for 20 years.  Has an obviously-years-old "cheat sheet" with their runways and frequencies.  It matches current data, but when you ask him how often he updates the cheat sheet, he says he always calls for a briefing and expects the briefer to tell him if anything has changed.  Flies to a nearby airport.  Tunes the CTAF 10 miles out, but never bothers to listen to the AWOS.  When you inquire about this, he says "I've been flying in this area for 35 years, and the only thing that's going to make the winds at KXXX substantially different from KYYY where we just took off 10 minutes ago is a local gust event that the AWOS isn't going to tell me about anyway."  Makes a reasonable choice of landing runway.  Makes proper announcements on CTAF, but enters the pattern at 800' AGL and says, "I learned 800' AGL instead of 1000' and that works for me."  When you point out the chart supplement says TPA is 1000' AGL, he says "That's just a recommendation, not regulatory, and the student pilots that fly here can't hold their precious 1000' AGL altitude within 200' anyway - everyone should be keeping their head on a swivel."  His airplane is ADS-B out equipped because it's the law, but he doesn't care about ADS-B in and points out people still have mid-airs even with traffic avoidance systems.  Flies the 45, and downwind, at nearly full throttle at well over 120 KIAS.  Yanks the throttle back on base and throws out those huge Cessna flaps, and flies all the way to short final at about 1.5 Vs0, pointing out that "airspeed is life".
5. Pilot 5 is totally dependent on GPS to navigate to a nearby airport.  Still hasn't visually ID'd the runway at 5 miles out, in part because he's too busy with his head buried in his iPad.  Gets to 3 miles out before you ask, "You see the airport, right?"  Says he does, continues barreling toward the airport at cruise speed while incorrectly tuning the wrong AWOS frequency.  Seems puzzled he doesn't hear any weather info and asks you if the AWOS is out of service.  You finally have to instruct him to turn away from the airport while he gets things settled.  Pilot proceeds to do no less than four 360s trying to get settled.  Finally turns inbound and makes a radio call with the wrong runway number.  Is 500' above TPA on the 45, etc. 

OK, so Pilot 1 certainly meets ACS standards, and Pilot 5 certainly doesn't.  What about the other 3 folks?  Are you going to refuse an FR sign-off on the basis of their performance?  If so, what task in ACS Area of Operation III Task B are you going to say they didn't meet?

I tell these stories not to be snarky - I'm sure Paul knows the ACS doesn't quantitatively address everything.  But in real life as an instructor, I'm comfortable with some of Pilots 2-4, and uncomfortable with others.  Other instructors will be comfortable signing off pilots I might be uncomfortable with, and vice-versa.  Ultimately, there are still a lot of judgement calls being made, ACS or no ACS.

[EricJ]

13 minutes ago, Vance Harral said:

Ultimately, there are still a lot of judgement calls being made, ACS or no ACS.

All of aviation is like this.

 

[DanM20C]

2 hours ago, Vance Harral said:

Ultimately, there are still a lot of judgement calls being made, ACS or no ACS.

This is absolutely true.  But the wings program gives a level of liability protection to the CFI that a traditional FR doesn't.   With the wings program the CFI doesn't endorse the next two years of that pilot, the FAA does. 

I think I have flown with every pilot on your list.

Cheers,

Dan

[Hank]

7 hours ago, DanM20C said:

This is absolutely true.  But the wings program gives a level of liability protection to the CFI that a traditional FR doesn't.   With the wings program the CFI doesn't endorse the next two years of that pilot, the FAA does. 

I think I have flown with every pilot on your list.

Cheers,

Dan

Hey, leave me out of this! I haven't flown with either of you guys!

I also haven't found a CFI who uses Wings. Most say it's too complicated, and I certainly gave up figuring out how it's supposed to work  . . . . 40 page Help? YGBSM . . . .

[mike_elliott]

Personally, I wont "sign a guy off" unless I would allow my wife (current not first) to fly with them. That said, only a handful have failed to demonstrate this safety and mastery skill set within the normal insurance parameters. These pilots usually give themselves away in their opening statement on the call "Insurance company requires me to have 5 hrs dual are you available to meet this and do you have 20 hrs in a Mooney xxxx?" vs. "I just purchased a Mooney XXX and want to get some training in it to learn how to fly it"

I also use the wings program, it is really simple actually, Hank. 

[gsxrpilot]

As the pilot in the other seat, so to speak. I like to work with CFI's the same way I work with A&P/IA's. I don't ever want the first meeting to be for any sort of check ride, flight review, IPC, or annual inspection. Let's get to know each other first...