N9156Z Minnesota crash final report

[Schllc]

1 hour ago, DCarlton said:

A few years ago, I remember an instructor telling me to "use your pedals to keep the nose pointed towards the runway" during a VFR approach.  Now I'm wondering what I was doing before he said that.  It does seem like there's some cross controlling involved if you do that.  This part of flying seems so instinctive I actually can't tell you exactly what I do.... do.  In IFR, I'm certain I'm not using just pedals especially if I can't see the runway.  

I use the pedals on very short final, only to align the plane to the runway before touchdown, otherwise i am crabbing. Isn’t otherwise technically a slip?

 

[Shadrach]

On 3/24/2023 at 12:52 PM, DCarlton said:

A few years ago, I remember an instructor telling me to "use your pedals to keep the nose pointed towards the runway" during a VFR approach.  Now I'm wondering what I was doing before he said that.  It does seem like there's some cross controlling involved if you do that.  This part of flying seems so instinctive I actually can't tell you exactly what I do.... do.  In IFR, I'm certain I'm not using just pedals especially if I can't see the runway.  

If you have a wing leveler it sort of complicates the issue because the it will seek to hold the wings level during rudder inputs. Without it, the inside wing would drop naturally due to asymmetric lift caused by the yaw.  If the pilot or wing leveler holding wings level while inducing yaw with the rudder, they are necessarily inducing an asymmetrical AOA as the inside wing will require additional up aileron and the outside wing additional down aileron to maintain level flight.  Is it teetering on knifes edge? No...not unless done at an unusually low speed. but it's not good airmanship in my opinion.  However, in IMC an overloaded/fixated pilot steering solely with their feet could get into trouble with little margin for recovery. 

[dzeleski]

1 hour ago, Hank said:

Yeah, me too. Small corrections on final approach, hold rudder until centered then relax. Call it 2º, anything more turn the yoke like always. But not on the whole approach! Just short final, especially with an ILS where the cone gets really narrow.

Use the yoke to turn, climb and descend. Add some rudder to stay coordinated in turns. Use pitch trim to eliminate yoke forces on long-ish climbs and descents, but not if you're 100' high on approach . . . .

At some point, "rules" go away and common sense must apply. In aviation, many times there is zero tolerance for using zero tolerance rules, and they usually end badly.

Yeah exactly im talking inside the FAF.

1 hour ago, Ragsf15e said:

I was taught bank angle equal to degrees of correction required.  Obviously you don’t actually think “2 degrees off heading, so i need 2 degree bank…” but that’s the guideline.  Very small bank, just pressure on the yoke for very small correction.  The airplane should stay coordinated though.

 If you’re 10 degrees off heading, you don’t need a 30 degree bank turn, 10 degree bank would work just fine.

16 minutes ago, Parker_Woodruff said:

Quick, tiny, coordinated bank left or right should do it.  Keep in mind we have an aileron/rudder interconnect.

Interesting. Guess ill need to try a few things the next time I go up for some practice.

 

1 hour ago, 1980Mooney said:

Per the accident pilot’s friend/advisor, the accident pilot would typically fly half standard-rate turns using just the rudder pedals.  That would be uncoordinated flight.

Yeah that is insanity.

[Shadrach]

1 hour ago, DCarlton said:

A few years ago, I remember an instructor telling me to "use your pedals to keep the nose pointed towards the runway" during a VFR approach.  Now I'm wondering what I was doing before he said that.  It does seem like there's some cross controlling involved if you do that.  This part of flying seems so instinctive I actually can't tell you exactly what I do.... do.  In IFR, I'm certain I'm not using just pedals especially if I can't see the runway.  

During a VMC cross wind approach, I will sometimes opt to slip into the wind using rudder to hold runway alignment.  However, that is not the same thing as skidding the airplane in level flight.  Stalling in a slip results in the high wing stalling first. A skidding stall is how a snap roll is initiated.

[Shadrach]

1 hour ago, 1980Mooney said:

Per the accident pilot’s friend/advisor, the accident pilot would typically fly half standard-rate turns using just the rudder pedals.  That would be uncoordinated flight.

Exceed critical AOA under said conditions and snap roll city...

[Shadrach]

3 minutes ago, 1980Mooney said:

ADS-B Exchange - track aircraft live (adsbexchange.com)

I count fifty-six (56) 180 degree turns in 1 hour 17 minutes on this practice flight.  He must have really been unsure of his ability to turn the plane. 

If you look at the turns, he would generally enter the turn at about 130- 140 kn, then climb about 200-300 ft as his speed would deteriorate to about 60 kn. in the middle of the turn. Then he would descend back to his entry altitude gaining speed back to about 120- 130 kn. on the exit of the turn.

Yikes...Climbing skid in IMC, near MGW with speeds deteriorating to near Vso but likely with a clean airframe.   

[Mooney in Oz]

1 hour ago, Andy95W said:

I think it’s interesting that nobody has asked why he wasn’t using his autopilot.

That is a very good question that I too was going to ask. This is despite there is no mention as to whether there was evidence the autopilot was or was not serviceable.

Companies I have worked for all had a strict SOPs policy of no hand flying when conducting instrument approaches in IMC conditions, therefore requiring autopilot coupled approaches.

I see in this case, the cloud base was 1,100 feet AGL and overcast.

[Fly Boomer]

I just went back and skimmed through this whole topic, and I didn't pick up any reason to assume that the senior doctor was flying during the accident flight.  I think it was Katherine's Report that said there was no radio traffic.  Maybe he was disabled, and the right-seater tried to take over?

[GeeBee]

Broken thumb tells you who was flying.

 

[amillet]

4 hours ago, 1980Mooney said:

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I count fifty-six (56) 180 degree turns in 1 hour 17 minutes on this practice flight.  He must have really been unsure of his ability to turn the plane. 

If you look at the turns, he would generally enter the turn at about 130- 140 kn, then climb about 200-300 ft as his speed would deteriorate to about 60 kn. in the middle of the turn. Then he would descend back to his entry altitude gaining speed back to about 120- 130 kn. on the exit of the turn.

Practicing lazy 8’s 

[hais]

1 hour ago, Fly Boomer said:

I just went back and skimmed through this whole topic, and I didn't pick up any reason to assume that the senior doctor was flying during the accident flight.  I think it was Katherine's Report that said there was no radio traffic.  Maybe he was disabled, and the right-seater tried to take over?

I thought the flying pattern implied it was the pilot based on similarities to previous flights .

Assuming it was, I wonder why they would put themselves in a situation they know they can't handle. Maybe they were impaired? Maybe they did not anticipate the difficulty? 

[jetdriven]

9 hours ago, DonMuncy said:

I have never used just rudder to correct direction of flight. No wonder I am not a good pilot.

Ya me neither. 

[jetdriven]

6 hours ago, Mooney in Oz said:

That is a very good question that I too was going to ask. This is despite there is no mention as to whether there was evidence the autopilot was or was not serviceable.

Companies I have worked for all had a strict SOPs policy of no hand flying when conducting instrument approaches in IMC conditions, therefore requiring autopilot coupled approaches.

I see in this case, the cloud base was 1,100 feet AGL and overcast.

Problem with that is skills degrade. 

[jlunseth]

9 hours ago, Andy95W said:

I think it’s interesting that nobody has asked why he wasn’t using his autopilot.  This is the same thing that killed JFK Jr. more than 20 years ago, and we keep relearning the same lesson.

Yes, an instrument rated pilot should be able to fly the entire flight by hand.  He/she should also have the good judgement to use the autopilot during challenging actual conditions.

That was my first thought also. That flight was not particularly challenging though, from a weather standpoint. It was a relatively thin stratus layer, we get that around here often, would not have been turbulent. I have to say, if I were a pilot not up to speed on my instrument skills I would use the AP. It is possible that, since he normally flew RNAVs and was given an ILS in this case, that he did not feel confident in setting the system up to fly an ILS with the AP. Who knows?

[BloodRedSkies]

It’s a common thing more plane than skill and proficiency. Being a Twin Cities resident I was shocked when it happened. Understanding your own limitations and being honest with yourself is the only was to prevent things like this. He had a lot of links in that chain of events too. I remember that day it was not a challenging IFR day by any means. It will be interesting to see as the cost of everything including GA goes up if that pushes more people towards not being proficient. 

[T. Peterson]

12 hours ago, dzeleski said:

Soooo.... Are we saying on a stable approach we shouldnt use the rudder to fix a small deviation? Say 2-3 degrees? Cause thats exactly how I was taught. Something larger and the yoke gets involved. The pressure on the pedal is pretty low though and the ball doesnt really go too far away from being centered.

Normal turns I obviously dont just use the rudder though... thats kinda insane.

I was taught the same for very small corrections to prevent an over correction. That technique was not what killed this fellow. He was simply over his head and over-controlling from sheer panic.

[Fly Boomer]

10 hours ago, 1980Mooney said:

If you go to NTSB Carol and look at the Final and the Docket:

FINAL

A friend of the accident pilot, who had accumulated about 3,000 hours of flight experience, stated that he flew frequently with the accident pilot..... The friend was “confident” that the accident pilot would have attempted to have the autopilot engaged during the accident instrument approach because the airplane was operating in instrument conditions at the time. The friend was also “certain” that the pilot would not have allowed the passenger who was a student pilot to fly the airplane while in instrument conditions

I believe that the "friend" listened to the recording to confirm it was the 72 year old physician/surgeon that owned the plane.  I don't think there is any question that it was the owner flying the plane.  

ATC Transcript

The investigator reviewed the FAA replay for the Flying Cloud Airport (FCM) air traffic control
tower (ATCT). The following information was revealed: 

17:38:39: The pilot initiated communications with FCM ATCT. The pilot’s transmission was disjointed: “Mooney 56 Zulu ……. ah ….….with you”
17:38:47: ATCT cleared Mooney N9156Z to land on Runway 10R. The pilot did not respond.
17:39:03: ATCT repeated a landing clearance. The pilot did not respond. During this time period, the airplane tracked left of the approach course, accelerated about 50 knots groundspeed, and descended about 300 ft.
17:39:17: ATCT repeated a transmission to Mooney N9156Z. The pilot stated: “go ahead”. 
17:39:22: ATCT repeated a landing clearance and the pilot stated: “ah 56 Zulu”. During this time period, the airplane turned right (back toward the approach course) and descended an additional 300 ft.
17:39:30: ATCT transmitted a low altitude awareness alert. The pilot stated: “roger, 56 Zulu”. 

No further transmissions were received from the pilot.
17:39:40: The airplane turned left abruptly and began to rapidly descend

When I read that transcript, it sounds like some level of impairment to me, but maybe that communication interchange was typical for him.

[hais]

In summary:

* Improper techniques were used to control the airplane

* These techniques are hazardous, but did not cause the accident

* Accident caused by disorientation due to limited proficiency in IMC

* Medication could be a factor 

* In terms of hours, the pilot was experienced 

So what lessons can we draw?

1. Proper training

2. Use of flight risk assessment. 

 

 

 

 

 

 

[Hank]

2 hours ago, hais said:

In summary:

* Improper techniques were used to control the airplane

* These techniques are hazardous, but did not cause the accident

* Accident caused by disorientation due to limited proficiency in IMC

* Medication could be a factor 

* In terms of hours, the pilot was experienced 

So what lessons can we draw?

1. Proper training

2. Use of flight risk assessment. 

3. Don't fly in IMC when you aren't current and proficient. 

[Shadrach]

3 hours ago, Fly Boomer said:

When I read that transcript, it sounds like some level of impairment to me, but maybe that communication interchange was typical for him.

He was not on his A game by any means and the substances in his system could have contributed to that. The being said, the transcript is absolutely consistent with mental overload (which is indeed an impairment). It looks to me like he recognized something was wrong during or just before the initial call and devoted all mental resources to regaining situational awareness and control. No surplus of mental bandwidth to devote to effective communication.

[cliffy]

Learning from the mistakes of others is good BUT it is  sharp and precise when "the others" are close friends.

I've lost several close friends in 60 years of flying. 

     A 19 year old friend ( I was 19 also) in a "high and hot" accident in a C-150

     A renowned Doctor in a Bonanza in heavy icing

     A newly minted IFR pilot in foul Wx at night 

     A Corsair F4U pilot doing low altitude aerobatics he wasn't well trained for

     2 very experienced Jerstar pilots flying into a hill trying to get in, at night, in hilly country

     An Airline Capt who's airplane caught on fire and went into a swamp

There are more. All but the last could have been averted by the pilot.

A couple of observations-

As Dirty Harry said, "A man's got to know his limitations"

and My Mantra-

You're not a safe pilot until you have been tempered. You're not tempered until you do something in an airplane that scares the living hell out of you and YOU know YOU did it to yourself. Flying takes on an entirely different aspect after that. 

If you feel invulnerable- you'll never get tempered. 

This activity we call "flying" can kill us The sooner we realize that the better. 

I haven't seen much progress along that line in 60 years of seeing the same stupid mistakes being made year after year after year. 

The fact remains that not everyone is cut out to be a pilot. On every airline I have worked for there was always 1% or 2% of the pilots that should have been doing something else in life for a vocation. With the pilot shortage now we will see an increase in the 1 or 2% over the next decade. 

 

[Fly Boomer]

3 minutes ago, cliffy said:

The fact remains that not everyone is cut out to be a pilot. On every airline I have worked for there was always 1% or 2% of the pilots that should have been doing something else in life for a vocation

I suspect this holds true when you replace "pilot" with any other vocation, and replace "airline" with any other business.  The difference is that most of those substitutions don't lead directly to death.

[GeeBee]

40 minutes ago, Fly Boomer said:

I suspect this holds true when you replace "pilot" with any other vocation, and replace "airline" with any other business.  The difference is that most of those substitutions don't lead directly to death.

An airline I was at had a guy who could not check out as Captain. He failed 4 times (you normally only get 3 but a LCA blew the check ride so they had to give him another bite at the apple.) They eventually fired him. About two years later I pick up the LA Times and see his picture.....top grossing realtor in LA County. He finally found his calling.

[jlunseth]

36 minutes ago, cliffy said:

Learning from the mistakes of others is good BUT it is  sharp and precise when "the others" are close friends.

I've lost several close friends in 60 years of flying. 

     A 19 year old friend ( I was 19 also) in a "high and hot" accident in a C-150

     A renowned Doctor in a Bonanza in heavy icing

     A newly minted IFR pilot in foul Wx at night 

     A Corsair F4U pilot doing low altitude aerobatics he wasn't well trained for

     2 very experienced Jerstar pilots flying into a hill trying to get in, at night, in hilly country

     An Airline Capt who's airplane caught on fire and went into a swamp

There are more. All but the last could have been averted by the pilot.

A couple of observations-

As Dirty Harry said, "A man's got to know his limitations"

and My Mantra-

You're not a safe pilot until you have been tempered. You're not tempered until you do something in an airplane that scares the living hell out of you and YOU know YOU did it to yourself. Flying takes on an entirely different aspect after that. 

If you feel invulnerable- you'll never get tempered. 

This activity we call "flying" can kill us The sooner we realize that the better. 

I haven't seen much progress along that line in 60 years of seeing the same stupid mistakes being made year after year after year. 

The fact remains that not everyone is cut out to be a pilot. On every airline I have worked for there was always 1% or 2% of the pilots that should have been doing something else in life for a vocation. With the pilot shortage now we will see an increase in the 1 or 2% over the next decade. 

 

Yup, me too.

[DXB]

It's worth noting diphenhydramine (Benadryl) can be detected in blood up to 48 hours after a dose and so might not have been a factor in the accident or even been used illegally per FAA guidelines.  Regardless, as an antihistamine, there are so many other cheap, effective options over the counter (OTC) with much better side effect profiles that still using Benadryl for this purpose makes zero sense.

As we head into allergy season, it's nice for hay fever cripples like me to review the current FAA guidelines on OTC allergy meds:

https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/media/AllergyAntihistamineImmunotherapyMedication.pdf

My suggested FAA- approved seasonal allergy OTC regimen based on personal experience and professional knowledge is as follows:

(1) first start a steroid nasal spray (FAA approved) - very effective, use it every day consistently for benefit because it has little effect with single use. It has a very safe side effect profile, even with long term daily use

(2) if that's not enough, add daily desloratadine or loratadine (Clarinex/Claritin). FAA approved, H1 receptor selective drug with minimal sedating anticholinergic side effects of diphenydramine.

(3) if that's not enough, use daily fexofenadine (Allegra) instead of (2). It's an FAA approved, more potent H1 receptor selective drug that causes minimal sedation.  Allegra-D (fexofenadine with added pseudoephedrine) is also a great option for extra decongestion and is FAA approved. You can also legally add pseudoephedrine with any of these meds to great benefit- I'd suggest the 12 hr extended release form.  

(4) if that's STILL not enough, add on daily montelukast (Singulair), which is not OTC and requires a prescription and works by a completely different mechanism. Though it's FAA approved, I'd still be careful with it - it causes brain fog in me so I can't use it - I think I'm in the minority though.

(5) If you still have prominent eye symptoms after all that, use one of the listed approved eye drop antihistamines, which are excellent.  Some are OTC like Pataday (what I use).  Just remember not to put it on top of contacts; put the drops in a few minutes before inserting contacts.  

(6) If you still have prominent nasal symptoms after all that, use OTC azelastine (Astelin/Astepro) nasal spray 1-2x/day- another topical antihistamine. It is also FAA approved and could also be used up front instead of (2)/(3) but I prefer to use a low side effect oral drug first since you can treat all the affected mucous membranes with one pill.  I also find it uncomfortably drying for my nose and so only use it occasionally when things get really bad.  

It's also worth noting that the most potent OTC H1-selective antihistamine is actually cetirizine (Zyrtec) - an excellent choice instead of (2)/(3) for the folks like me who need all the help they can get.  It causes no sedation in me but does so in some folks and unfortunately it is not FAA approved for this reason - you legally can use it intermittently but not while flying.