Early Analysis: N7022G - Cessna 340 Crash October 11, 2021 Santee San Diego, CA
Vložit
- čas přidán 13. 10. 2021
- On October 11, 2021, a Cessna 340 crashed into a neighborhood in Santee, California, killing the pilot, one person on the ground and seriously injuring two others. Weather conditions at the time of the accident were broken ceilings, varying from 1,700 to 2,400 agl, and 10 miles visibility with forecast turbulence. The pilot was experienced in the airplane and had flown this route several times. He was receiving vectors to intercept the ILS approach to Runway 28R and then circle to land Runway 23 at Montgomery Field (KMYF). In Early Analysis: N7022G, the AOPA Air Safety Institute makes a preliminary assessment of the accident, addressing notable portions of the tragic flight and highlighting areas the NTSB will likely investigate to determine a probable cause.
Read the AOPA Air Safety Institute’s Spatial Disorientation Safety Spotlight to learn more about factors that might have contributed to this accident. www.airsafetyinstitute.org/spotlight/spatialdisorientation
FINAL REPORT RELEASED: The National Transportation Safety Board has released its final report (WPR22FA004) regarding the investigation into the Cessna 340 (N7022G) accident.
data.ntsb.gov/carol-repgen/ap...
UPDATE: The National Transportation Safety Board has released its preliminary report (WPR22FA004) regarding the investigation into the Cessna 340 (N7022G) accident.
data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104080/pdf
From that report I could appear that the pilot got distracted and lost 1000 ft altitude. In a span of about 80 seconds, he goes from 3500 ft to 2500 ft, that's a lot of time to think about he losing control of the airplane. Maybe, the ATC warning about low altitude alert immediately after, got the pilot triggered to pull on the yoke and get the airplane in stall?
Glad to see this "Early Analysis" video from ASI, I hope this gets done occasionally. One point I would add to this video, from an ATC perspective. I strongly encourage any pilot who is becoming disoriented to let us controllers know to please slow down and/or simplify our clearances.
Excellent point.
As someone considering becoming a private pilot this is very useful to hear.
Let's hope it doesn't become like 'Probable Cause' by that hack which I shall not even name.
what would be a good phraseology to request that? how would I tell ATC discreetly that I'm falling behind the airplane and instructions.
@@asho1735 I think you gotta through your pride out the window and say “I am struggling to hold and undersea my attitude”. ATC will know what you mean
I met this man a handful of times as he’s been a customer of mine as he traveled for pleasure with his family in this airplane for a couple of years now. Sadly we all quickly become pretty judgmental, armchair pilots. When it’s someone you can put a face to, and someone you’ve seen with their airplane, with their family, I suddenly become a million times more compassionate. I hope we all gain some perspective for the fragility of each flight we take. This man will be missed. I hope the investigation, and the conversations surrounding this accident, cause us to take seriously our training, our commitment to proper maintenance, and our dedication to holding ourselves to a standard of razor sharp proficiency. Regardless of what your mission is, what ratings you hold, or even what aircraft you fly, excellent execution of each phase of flight is the standard. If you’re not measuring your performance against the standard of excellence, you’re doing yourself, your passengers, and in some cases those on the ground a grave disservice. End of rant. Rest In Peace 22G.
Correct, sorry to know you lost a person you knew. I did some C340 time flying charter here in Australia years ago and I've spent ages thinking about it until a LAME mate I work with now just said - "You and I cannot guess what his thought process was or what kit that plane had on it (we were talking autopilot set ups getting complex for old twins). Spot on. We're the lucky ones to be sitting and having a beer saying "nah I wouldn't have done that" considering we've never been there.
Hard to be compassionate when his actions killed an innocent person....
@@rafborrero he didn't intend to. Imagine driving your car and a tyre blows or something falls off a truck and you hit it then take out a pedestrian. It's tragic and worthy of sympathy for all involved.
Thank you, Sir, I knew the Doctor for many years. In fact, he was my Cardiologist. A passionate and good Doctor and Pilot. His Hangar was directly behind mine and I saw him fly regularly. We both used the same well-versed IA for our maintenance and depended on that "mechanic" for very good care. We do miss him here in Yuma, as he touched many pilots lives.
@@rafborrero This happens everyday on America's highways. There were 46,000 auto fatalities in 2022. Tens of thousands of those were caused by a driver error. Unless someone is driving completely recklessly, I've never heard someone say that a driver "killed someone" else in the car with a driver error. Can you imagine a news headline like that? People would puke to read something like "Mother turns wrong way into oncoming traffic and murders her entire family." No, It's seen for what it is: an accident. A driver was rushed and forgot to look right, a driver got distracted and ran off the road. Maybe a tire blew out and they didn't see it in time in front of them. It's way different in a plane. Planes are far more complex to operate and a split second error can cost someone their life. Unless the person is completely reckless, maybe there should be more compassion for pilots.
Thanks for doing this ASI. The shock from this tragic accident is fresh on our minds and in conversations around the airport. The early analysis is almost like a debrief that really helps us make sense of it and recommit ourselves to safety.
this is my new favorite channel. I'm not even a pilot; Just an enthusiast. The analyses are so concise and well-communicated. Well done!
Let's not forget the loss of the UPS driver. Great points about turbulence and going from bright VFR to darker IFR being disorienting. Work load was high with multi ATC altitudes and headings. Last he never grasped the circle to land and that overloaded him further. Pushing power up to climb can make you feel like you are falling back or in steep climb resulting in lowering the nose despite the flight instruments. It sure looks like spatial disorientation. BOTH engines were turning, high power and in sync with prop tips near supersonic from the sound. He was going fast when he hit.
@@downc212 You are not even a pilot are you? You are trolling right? I am +12,000 hour ATP, CFI and 38 yrs ago flying checks in light twins, night in sold IMC and known ice. Yes work load is high in light twins. Yes he BLEW the approach. Again I suspect you are not a pilot except for PC simulator games or a low time VFR only pilots.
Let's assume you are an instrument twin rated pilot with 100's of hours of actual instrument time in light twins. IF Yinitial
Add to the fact he did not understand the circle to land. That just overloaded him even more. As a CFI (Inst and Multi) back in early 90's I know the training I got and gave. I can see a pilot getting a multi engine instrument rating and never really flying a circle, especially in real world conditions. It is extremally demanding in real conditions to circle to land. Granted the conditions at the airport were not particularly low, however to out and break off an approach an maneuver low to the ground and make tight turns to final is not easy VFR under a ceiling in a mountainous area. So shhhhh.
@@gmcjetpilot now I just want to know what that guy said
@@JasperStJean me too but either way it seems like this rich guy should not have been piloting an airplane over a populated area. I don’t know why this is even allowed. Rank amateurs playing with deadly toys.
This and that rated yada yada… still an amateur and obviously incompetent and basically guilty of manslaughter.
@@steviesevieria1868 Rank amateur? Video (3:30) said pilot was highly experienced, over 1,000 hours on this airplane which he owned, commercial IFR license. Doesn't sound amateurish to me. Besides the obvious pilot error assessment, it is possible he was incapacitated by a medical situation. Regardless, it is a sad outcome.
@@Ax89 OK, let’s say maybe he had a medical condition. Then he shouldn’t have been flying an airplane over peoples heads. These rich boys get away with anything just because they’re rich. Amateur pilots should be banned.
This looks to be a case of " Somatogravic Illusion" It can be a very confusing signal to the brain. At 2:45 the Pilot is asked to make sure he is climbing and not descending and he replies 22 Golf is climbing, This I believe is the most critical clue of what and why he continued descending. Similar to the Grave Yard Spiral his body sensation had a stronger influence on what was perceived by his flight instruments. This happens during a Go Around of Missed Approach procedure. The aircraft accelerated from 106 kts to 200 kts in a short time during the right turn and the acceleration gave him the sensation of a climb and this caused the Pilot to disregard what his flight instruments were telling him and began to push the nose down to stop the sensation. That's a Normal Reaction. We need to put more emphasis on Missed Approaches and Go Arounds in Training. Transitioning from nose low attitudes slow speeds, Low Power Settings to a Reverse of all this is and can be very Challenging.
Very interesting observation and educated theory, James. Thanks!
If he didn't rest after working and before flying then fatigue can be a big problem. Lots of doctors with high performance airplanes have fallen into that trap. After a long work day they jump in their plane and head out for a 2-3 hour flight. Toward the end of that flight the fatigue rushes in and problems occur. It is something that bears consideration. His voice sounds like a fatigued person trying to handle a busy situation that becomes very stressful because of the fatigue.
Stroke
Art you are correct. However this (Yuma to San Diego)'flight takes an average of 45 minutes & it happened at 12:15 pm. I'm sure the investigators will see what his morning schedule was like or if he'd been up for an extended period of time.
@@jwwj30 not all MDs work 9-1700. Given his expertise he could have flow to work at 0 dark thirty, busted 6+ hours in surgery or even had a late case take 12-16 hours, I have known doctors that do that, then jumped into plane to fly home.
The Dr. lived in SD and commuted to Yuma for work so he was coming home from work.
@@cerealkiller5983 which is why I brought up fatigue.
Thank you for everything that you do for Aviators - and fans of Aviation on CZcams!
This was an outstanding summary of the facts to date. I was very happy to see the AOPA ASI step up so quickly on this high visibility accident. I’ve been an AOPA member for nearly 30 years and have contributed many times to the ASI. Material like this reaffirms the value you guys bring to the GA community.
Thanks for your support that helps make our safety work possible!
@@thatguy6207 I don’t know…..that’s kind of a stretch in my mind. Maybe he had a medical issue, maybe there was something wrong with the A/C that distracted him to the point where he became task saturated….maybe his altitude deviations were a conscious decision on his part to stay under the broken layer but not tell approach….maybe the airplane was too much for him and this was the time it caught up with him, maybe the in and out of IMC disoriented him to the point where he lost control, maybe a bird strike. Lots and lots of maybes.
@@TheAirplaneDriver Clearly air traffic control sent him back above the broken layer at 2700 that he was trying to stay below. Once he got back into the clouds above 3000, he became disoriented, and lost control. He had clear visual of the terrain and would have been safe otherwise as it's very apparent from the track and the terrain map
@@mnr646 I don’t disagree. That certainly is one of the possible scenarios (and yes, I agree the most likely) but I believe we should give him the benefit of the doubt and hope that we get a good NTSB analysis. The only reason I am balking is that he had a lot of time in that airplane and one would have thought he could have done better than that. But, we’ll see.
Thorough & fair assessment. It's hard to put together a well-researched video like this on such short notice - well done, and keeps us all safe. Looks like those AOPA donations are going to great use! More of this please
@@thatguy6207 it's well documented that the Vegas controller did not in fact have a stroke. And "don't fly alone if you had the vaccine"!?!??? Man, you seriously need to re-evaluate your information sources.
Bullshit. There's no documentation that McCarran was not a stroke. Zero. Try using a different water cooler.
And you say "well documented" - pffffft especially for that. Pfffffffffffffffffffffft.
The comments section strikes again
@@troo_story tell that to the Delta pilot who died in flight from complications of the drug.
@@ProfessionalPilot NO authoritative sources have reported the alleged incident. In particular there are no ATC records of any Delta aircraft declaring either PAN or Mayday during the claimed time period - note that ATC information is available publicly and in real time. The person who put the allegations in the public domain is someone who has repeatedly made false claims abour the various Covid vaccines.
How does this cannel not have millions of followers? It has the best accident assessments of any channel I've ever seen. It doesn't put on corny sad music at the end or completely reanimate the flight, but it's professional and probably more helpful to real pilots. Someone share this with everyone they know.
Because most people are ghetto as sht and dont care about these things. People like you are kind of the minority anymore unfortunately. Civility is on the way out.
tháy Wátchinğ Péwtié Peis
youtube restricts real numbers so they pay channels less
A buddy of mine was in the pattern 15mins prior and it was windy but no real turbulence. Thanks for the update. Very sad indeed.
sounds like CO or stroke
Thanks for sharing this analysis. I'm a new pilot and I watch a lot of your videos to learn from others. Always be vigilant, never complacent.
Wow! Your video is very comprehensive and you explaining it as you go along makes it very enjoyable for me to watch and learn from. Thank you sir
Very well done sir. Your voice and calm delivery really help a non-pilot understand in a basic way, what happened.
Good report. I've flown this area frequently and it can be challenging in/out of low cloud cover and changing/rising terrain. Add turbulence and visibility challenged and it can be difficult when faced with last minute changes. It is an airplane that requires substantial preparation in the approach environment. Looks like he didn't quite understand the approach situ and got behind. Very sad. Hope the families of all concerned find peace.
You explained complex matters very clearly so that I as a non-expert could understand your explanation. Thank you.
I would like to see more of these Early Analyses. More AOPA accident presentations are needed...
I'm late but thank you for all the behind the scenes work to put this together for us. My condolences to family and friends of the deceased and injured and to our first responders as doing that job has got to be traumatic in some way.
Thanks Aopa Air Safety Institute, Please do a Full Case Study on this one!!! Love those. Whenever I feel a situation is creeping up on me or I even remotely think of doing something stupid, I hear the narrator's voice in my head.
@@thatguy6207 did I say this was the full story? We all know this is just preliminar, the full story will be told then. I encourage AOPA for these Accident Case Studies - and you’re already juming to conclusions and blaming the Vax? Please. If you fly you know the plane doesn’t care where you’re from, what you look like, if you get Vaxxed or not. All it knows is that there is a tragedy here AND WE ALL SHOULD EAIT FOR ACTUAL RESULTS, not push agendas.
I live near Teterboro Airport in NJ and this "circle to land' procedure killed a crew of a small jet coming in from Philadelphia. This happened in VFR but conditions were VERY windy and I think, the pilot flying was confused with this 'circle to land' procedure. He completed the the 'circle' part but cranking that left turn to final, with the winds on steroids, his left was too sharp for his speed and he crashed to the before and right of the runway in a parking lot. No one on the ground was hurt/killed.There is video on that crash as well. You did a nice job explaining.
I remember that.
There was a lot wrong with that flight. I believe it was a Lear 35. May they Rest in Peace. We need to learn not to make the same mistakes.
Not a pilot or ATC, but my recollection of the Terterboro crash is that much more was wrong there than just the circle approach, you may want to read up more on that tragedy before you post...
@@nevadaracer00V Thanks Krystal…I’ll break down the NTSB report for ya. At what part would you like me to add your ‘recolection’?
@@harrisongould9460 There's a video on it from this channel (video id: BML2lfqaK-4). The title is Accident Case Study: Just a Short Flight.
I know absolutely nothing about aviation except that plane go up and down but I'm addicted to these breakdown videos
Well done analysis with great visuals to improve understanding of what the plan was and what actually occurred.
My dad was a CFI in the 70's and 80's and he really kept up with his training. Even though he was a CFI he often flew with other CFI's.
This doctor had lots of time in this plane, but I would be interested in how much training time he had.
Dad mentioned to me that he had a great many very skilled and successful doctors and lawyers who were especially bad at picking up bad habits. If you don't keep up with your training you may develop bad habits that can get you into problems, especially when conditions are less than perfect.
Good doctors and lawyers tend to be a bit arrogant, for good reason. It takes a lot of intelligence and skill to be a good doctor or lawyer, but that doesn't mean you make a good pilot.
How can you tell if you're a good pilot? If you think you can do better taking a flying with a CFI once in a while, you're okay.
If you think you know everything and can handle anything, worry.
How can you tell if you're a good pilot?...Being a subscriber to this channel and learning from other pilot's mistakes, as well as watching the webinars.
@@02markcal A good pilot knows he can never learn enough. They can always do better. A poor pilot thinks he already knows enough and nothing he can learn can make him better.
I am medical doctor and a private pilot. A good doctor and a good pilot always learn . We can not avoid mistakes but we can learn from these....
@@georgiostagaris6416 I’m not a doctor but am familiar with the phrase “practicing medicine”. Pilots and doctors alike should never stop learning.
Probably picked up "BAD HABITS" "SHORT CUTS" doing his SURGERY TOO! QUIT MAKING EXCUSES FOR POOR FLYING SKILLS of someone WHO NEVER SHOULD have been given a Pilot's License!!! Maybe too many are being "BOUGHT" by wealthy, lets say, DOCTORS!!! One way they "get away" with it is BECAUSE they have people like YOU WHO COVER UP the TRUE CAUSES which was INCOMPETENCE!!!!
Very well and detailed analysis. I’m very glad to see the ASI back at analyzing accidents.
The main reason for watching these sad loss of lives is to hopefully learn from them.
My deepest condolences to all of the families involved.
Don't know how these videos popped up for me, but glad they did. Extremely well done. Not a pilot, and never wanted to be one. Stunned to realize how many things need to be considered when piloting. After watching a bunch of these. Not only do I not want to be a pilot, I don't want to be a passenger either. Bless you guys.
Thanks for releasing this so quickly. A lot of people have heard the ATC on this and it was leaving people confused as to why or how.
Circling approach - May 2017 N452DA Teterboro - July 2021 N695TR Truckee - October 2021 N7022G Santee. Perhaps the NTSB should look at circling approach in Part 91 flights. Perhaps the NTSB should read the 2011 FSF paper which stated
"... controlled flight into terrain
(CFIT) studies have shown that runway aligned approaches (LNAV only) are some 25
times safer than circling approaches and that once some form of vertical guidance is
added to these, then the safety margin is increased again by some 8 times.
It is of concern that, in commercial aircraft accidents associated with circling
approach during the last two years, there were in total at least 304 fatalities..."
I have watched many of the other reports on this accident, Richard your report was miles ahead of the others. Thank you for offering a detailed and level view of this horrific tragedy.
Thank you sir, sincere respects to his loved ones.
👍 Thanks for sharing this analysis with us. 🙏🏼
Really excellent content, great video. These are always tragic but this one had a double tragedy when someone on the ground just going about their daily existence had their life taken,. As soon as I heard the strain in his voice I was thinking "Divert divert just go somewhere else with better weather or easier approach" but it was not to be.
I am glad this was put out there early on. so much speculation that with this pilots experience I think it is clear in his voice he was saturated. So far I think at this point a good lessons will be learned here as my take away from this would be to let ATC know "I'm having some problems here" And tell them what is best for you and not worry about what's best for them.
@@thatguy6207 pure speculation has no place here.
@@Chris-bg8mk Yes it does Chris. That is the whole purpose of these comment sections. ALL WE HAVE ARE OUR SUPPOSITIONS. READ MINE ABOVE. By the way I spent four years in the Air Force as a crew chief and know a thing or two about flying.
Walter I agree with your comments. Unfortunately it is human nature to not ask for help until one is deep into trouble where time is of the essence. A very general nebulous communication to ATC like "I'm having some trouble" requires ATC to engage in a prolonged back and forth in an attempt to collect more and more information so ATC can better understand the issue and how ATC can help. "I'm disoriented and need your help to get me to the runway" cuts through all the egotistical B.S.so ATC can immediately give simple, short, precise instruction with vectors, while monitoring altitude, speed and direction of the plane. If a was a pilot that told ATC "I'm disoriented....." while in IMC or close to those conditions, I know I would appreciate a a few strong reminders to trust my instruments while also getting those concise, simple instructions in a cool and calm voice.
@@benth162 ....WHERE is it? THEY (SCREWtube) ‘canceled’ you or what?! SERIOUSLY, I wanted to read your comment; Oh, and I agree. Sometimes ALL we have are “guesses, assumptions...OR speculation(s)”. Unless FACTS are KNOWN, “educated” guesses have to suffice @ times...
@@m118lr This what I found at another site that I wrote on this subject: "Juan Brown also describes what was going on and I left him a multi paragraph comment. Personally I believe that a man with that many hours of flying in that particular plane and how many times he flew that rout, I am of the mind that he was having either a stroke or a minor heart attack. The only other idea I would entertain is that his instruments were feeding him the wrong information. I live only a mile and half from Montgomery field and used to work just two hundred yards from Gillespie field in the Santee and El Cajon valley. When he turned right he kept turning right instead of what you described he needed to do to come to the runway the tower was trying to get him to land on. The tower could not see the plane but did see it on their instrumentation. When the pilot keep turning right he would eventually end up at the town of Santee which is where he crashed. When he descended down out of the clouds he could have seen where he was which was a valley, and the possibility his plane was already in a configuration he could not pull up out of when he needed to get over the mountain so he could get back to Montgomery Field. A veteran pilot as he was supposed to be, would not have become that confused unless his plane malfunctioned or he had a compromising physical issue. I think it was a stroke because of how he was answering the tower and not being able to tell where he was in his mental confusion."
Great to see a new video! Terrible accident though. I agree with your analysis. Pilot being overwhelmed combined with spacial disorientation likely played a large role. Excellent video, can’t wait for more!
czcams.com/video/NFAnWlxwgc8/video.html
Fantastic video, enjoyed watching it and hope to see more like this to learn from
Something doesn't sound right. Sounds almost like 2 different people responding to ATC.
Completely normal. The 2nd voice was a controller supervisor. Hear it all the time when controllers are training or an “issue” occurs on the frequency
I don't understand why you can show the crash video and have commercials while Blancolirio channel can't show the crash video because he will get banned from making money!?!??!? Can someone knowledgeable explain,please
Just a theory, but I would think ASI does not monetize this channel, thus the difference.
Thank you, nicely done update.
Excellent analysis. A good job in getting this out so quickly. Thanks
Thanks for this video. Very informative. Love safety institute.
Once he blew the ILS approach and broke off he transitioned to hand flying the airplane IMC in fairly turbulent conditions .. ATC (correctly) vectored him around and to immediately climb away from rising terrain ... leading to a high workload right hand IMC climbing turn .. which can very easily lead to a tight right hand spiral descending turn ... RIP :(
Have to trust the guages
Graveyard spiral
His read-back on the final two transmissions would back that
czcams.com/video/NFAnWlxwgc8/video.html
Should’ve put the auto pilot back on
I'm about as far from an aviation expert as one can get, and am grateful for the plain-speaking on this channel. (I've flown as a passenger on small jets dozens of times - always with pro pilots.)
The ability to determine causes of these accidents has improved exponentially even in the last twenty years. I believe videos like this could prevent so many tragedies...if the right folks heed them.
RIP to those lost and Godspeed to those in the air.
Thank you Richard
This is a story of a pilot who disengaged the autopilot and then got disoriented. You should always be alert and watching your attitude indicator but why turn off the autopilot? Switch to heading mode and dial in the headings. Take the time ATC is giving you to brief your plate again, verify systems are armed properly and then shoot the approach. Sometimes people get so flustered with technology that they forget they can simply “hand fly” using the heading function. Unless his autopilot failed there isn’t a reason to disengage it in IMC until minimums in a single pilot environment. It’s there to decrease your workload.
Feel like this highlights some pilots being so lazy with their readbacks that you can't tell if they're being lazy/cocky or having an actual medical problem.
He sounded tired to me. His radio skills for a pilot with his experience did not seem to match.
Close to the end, he was barley legible. My 1st thought is he is having a medical emergency.
@@willburrito9710 could have been having a TIA, getting close to actual stroke.
@@thatguy6207 Interesting comments, and have to say I hadn't consider the possibility. I have to sleep on it, but fully understand where you are coming from and what you are suggesting.
Someone needs to roll back the ATC tapes from earlier in the flight and his previous flights and compare his interactions. Should be pretty simple to see if he was off his game on this flight.
Thanks for the enlightenment and the important information.
I'm not a Pilot (apart from Simming)..but this Channel is in my top five...utterly fascinating
I agree that a transition from auto-pilot to hand flying seems to be a contributing factor. The tracks during his vectors are arrow straight, as soon as he passes the localizer his track becomes erratic. I would guess the auto-pilot was not on approach mode and failed to capture the localizer. He may have become flustered and turned off the auto-pilot in an attempt to salvage the approach, but if he wasn’t well briefed and prepared he may not have known exactly how to proceed. This may have caused him to turn right and descend in an attempt to see the runway and join the final for 23.
I had the same thought with respect to going to a visual circle to land approach to 23 - the deviation makes sense then if he doesn't know where he is and doesn't think he'll get ILS and instead is going to try to hit airfield visually.
I had two thoughts, this was one of them. The other thought, he was having a medical issue like a stroke or CO poisoning.
@tie oneon Because there is a minimum vectoring altitude in the area. If the pilot does NOT report field in site on or above that MVA. the ATC can’t give a visual approach where the pilot can maneuver anyway he wants to land. Therefore atc has to issue a clearance to a runway that has an approach that makes sure he has terrain separation both vertical and horizontal until the pilot can have visual of the airport.
@Noah H I’m familiar with disorientation, the auto pilot theory to me absolutely makes sense. The fact that he had new avionics in the plane that he likely wasn’t familiar with the nuances like autopilot not working when the approach activates, unless you selected it. Plane flying perfect, then when it’s on the ils you can tell from the tracking it was being hand flown like he’s way behind the plane. Do I think disorientation played a factor, once he was behind the plane? Yes. Do I think he was struggling trying to fly ifr by hand with avionics unfamiliar while likely focused on trying to get autopilot to reengage… yes. The reason I suggested there may be a medical component, like stroke, is the changes in altitude effect the pressures inside our body, which can free clots to cause CVA, MI and PE’s. clotting disorders are currently a widespread issue of all age groups because there is a virus out there that causes long term clot risks. His radio responses, and flight tracking were looking good, then after the decent, the anxiety of not getting the approach he anticipated, cause his BP to rise further increasing the risk of CVA. His flight track became erratic, his altitude control became erratic, his voice became slurred, inappropriate response, etc you could tell he wasn’t comprehending what he was being told and couldn’t comprehend what he was seeing. Sure these responses can happen under stress, disorientated, etc… but it was a pretty simple approach, you follow the needle in. The complicity of a circling approach doesn’t get complicated until you are performing it when runway is in sight and the conditions he had were Vfr well above the DA for the circling part. Ie it wasn’t like he was approaching a circling approach at minimums with 1 mile visibility at the ground.
With those two theories, I personally think the unfamiliarity of the avionics auto pilot issue makes the most sense, combined with not being fully prepared for the approach. Course I’m a new ifr pilot, not a 20,000 hour ATP, I’m still very much learning. The auto pilot issue I personally experienced during my training, it was intentionally set up by my instructor to have me experience that issue. Believe me, your mind wants to get that autopilot working, especially when your expecting it to do the work while you multi task trying to catch up from being behind the airplane.
@Noah H I’ve experienced disorientation, I still don’t think the was the main culprit here. I tend to believe in the autopilot disengaging when the approach activated because it was selected ahead of time. Getting him behind the aircraft, while he’s trying to figure out a different approach then what he expected, I’m guessing he was frantically trying to reactivate the auto pilot, while trying to hand fly, while trying to understand the unexpected plate he didn’t expect to use. At some point you just have to go missed, fly the gauges and get atc to get you to a safe area to work it out.
How many hours did he have in real instrument conditions with this plane as a solo pilot?
Weather was not that bad.
@@outwiththem Agreed, come to Newfoundland and find real weather.
I love these ASI videos. Informative and designed to keep us alive and safe.
Thank you 🙏
Thank you for a very professional and methodical analysis of the available information.
My initial reaction is that he was became disorientated over the circle procedure. Looks like he wanedt to go straight to base for runway 23 and became confused when ATC gave him a right 90.
Always impressed with the quality of the information and the production of the video. Well done.
Excellent video and even more explanation 👍
Great analysis, thank you.
I was kinda hoping this analysis would have included the KYMF ATIS so we would know what the ceilings, cloud bases - tops etc were. As soon as the good Doctor was told to circle to land rwy 23 his tone, voice, cadence changed drastically .
You can go in and listen to the entire Approach conversation with this pilot at LiveATC. The controller can be heard giving the latest ATIS information: "1700 scattered, 2700 overcast". I'm still trying to find out the tops but haven't seen it on any source.
Blancolirio channel. Ceiling was like 1700’ so should have been non factor even for circling.
@@thatguy6207 Interesting take.
@@keithhoss4990 if you look at his flight on FlightRadar24, he was mostly above 2700 feet, the altitude at which the same approach controller reported was overcast. Also, this video discusses that flying in and out of IMC can often be more of a distraction than just being in solid IMC.
All that information, including his confusion at reading back the controllers confirmation of instructions and nervous cadence suggest spatial disorientation resulting in loss of control.
Yes, you could tell in his voice that he didn't seem to mentally fully comprehend that ATC request, which is odd because it sounds like he had flown the ILS Rwy28 circle to Ryw23 before?
Thanks for your explanations. I'm only an aviation enthusiast yet understand and learn from you. Thank you sir many blessings your way 🙂
I know nothing about flying but love these videos
It's great to see ASI doing these sort of analysis close to the accident.
As a controller myself and also a pilot I heard several issues on the way this flight was handled. 1. The pilot of 22G sounded confused and was flying erratically and probably task saturated. 2. The controller sounded harsh and threatening when he should have been just the opposite. That tone from the controller was fueling the pilots disorientation in my view. As a paid professional you should be able to pick up when a pilot is in distress and bring down your attitude.. good early analysis Richard.. sorry for this families loss and to those on the ground..
I disagree, I thought the controller did everything he could to stop the incident. It’s easy to say in hindsight that he should’ve done this or that. Even still, it doesn’t really explain why the plane came down at all, and in that video it was in a dive.. very strange incident to say the least
Thanks. Great video.
Scary stuff ... I'm no longer a pilot but from listening to ATC, he just seemed overwhelmed and/or confused and/or simply fatigued. He also seemed to be a handful of steps behind the plane. Things were happening too quickly for him to comprehend kinda like he did no preflight briefing and hopped into the plane in Yuma like he was driving a car and then had no clue what a circling approach was... Thank You for your clear and concise analysis. Keith Chicago IL
Though I guess it is possible the onset of some illness (perhaps the flu/Covid) caught him off guard which was the cause of his confused/distracted state of mind and all he wanted to do was get home...
I flew later that day out of KSEE when the winds were much stronger. The turbulence was surprisingly light for the amount of wind we had, and the clouds did produce more turbulence but I wouldn't consider it a factor to this flight. The guy just didn't know how to operate his autopilot, was confused about a circle to land procedure (maybe he didn't do those often), and he clearly wasn't very instrument proficient when autopilot was off - maybe an over-reliance on the autopilot. My theory is he disengaged autopilot to try to comply with the climb instructions and was not proficient to be flying IMC by hand.
Extremely well stated!! THANK YOU for having the guts to call it like it is!!! Too many people hemming and hawing trying to be “politically correct”. I feel really sorry for the innocent people on the ground that were injured and killed as a result of this. And it gives GA a very bad rap, and is a disservice to those who respect and know their limitations!! In other words, don’t treat these things like your “personal Ferrari” (rollseyes).
Do you think during this banking turn towards the north he was mistaking the sensation for climbing and just never looked at his altimeter?
Said the guy that can't taxi on center-line and rotates half a second after "speed's alive". lol
@@XPoChangLinX what are you talking about?
@@daszieher I’m talking about the OP’s flying videos. Judging other pilots when his own flying leaves much to be desired.
RIP to the pilot & the UPS driver. Stay safe out there friends.
Thanks for putting this early analysis out. The crash was 4 blocks from my childhood home so very interested in hearing more about this as the investigation completes.
Great to hear this update . Very timely
Had he simply gotten himself established on the final approach course and began his descent, he would have broken out below 1700' and been able to proceed VFR to circle/land on 23. I've viewed the other knowledgeable videos on this mishap and it seems to me the pilot did not understand what "circle to land" meant. I got the feeling he had never done an actual IFR approach that ended in a circle to land. Perhaps that is something more pilots should practice (with a qualified pilot or instructor in the right seat) in actual IMC as the narrator noted.
You nailed it... ...and saved me a lot of typing.
He still should have been able to see the ground though once he got low enough, even though he was coming down fast, right? I don't get why he wouldn't have recovered from that, unless he was passed out or had some medical issue.
@@jeffploetner I have watched the final descent video many times. I've spent the past five minutes trying to mentally analyse the abnormal airflow over the control surfaces to determine what control inputs would regain control of the aircraft. Five minutes. He had eight to fifteen seconds to figure out the correct control applications and apply them, from when came out of the clouds until impact.
@@KennethAGrimm I must not understand then, is it not a stable controllable plane? Don’t you “just” straighten out your bank (left aileron) then pull up?
@@jeffploetner Yes if he was merely in a steep bank. But that was way beyond a steep bank. If it had been a steep bank, the plane would still have been following its nose, only in a curved instead of straight line. As it breaks out of the clouds, we see the nose yawed nearly 45 degrees from the direction of motion. In such a configuration, the control surface do not function properly. It appears that when the ATC supervisor cut in with the "Pull up!" order, the pilot jerked the yoke back and stalled the aircraft, and then an unsuccessful spin-recovery left the aircraft flying sideways and nearly inverted.
I know he has flown into and out of this airport numerous times, but do you happen to know if he’s ever had to navigate a circling approach there before?
This is the first question that comes to mind. Sounds like he got behind and panicked.
Looking at all the previous flight tracks, no.
You guys are awesome.
The plane doesn't seem to be in IMC during the final descent before impact...and it's very strange that there was no attempt by the pilot to correct the trajectory, like if he was incapacitated or because of some technical failure
I have to wonder if there wasn't some medical issue that lead to this. The pilot was highly experienced and he had a capable autopilot. There must be something else going on. It looks like he never even tried to recover once he cleared the clouds. One would have thought he would at least level the wings and try to pull out of the dive. Just to early to tell.
Excellent briefing
Juan Brown also describes what was going on and I left him a multi paragraph comment. Personally I believe that a man with that many hours of flying in that particular plane and how many times he flew that rout, I am of the mind that he was having either a stroke or a minor heart attack. The only other idea I would entertain is that his instruments were feeding him the wrong information. I live only a mile and half from Montgomery field and used to work just two hundred yards from Gillespie field in the Santee and El Cajon valley. When he turned right he kept turning right instead of what you described he needed to do to come to the runway the tower was trying to get him to land on. The tower could not see the plane but did see it on their instrumentation. When the pilot keep turning right he would eventually end up at the town of Santee which is where he crashed. When he descended down out of the clouds he could have seen where he was which was a valley, and the possibility his plane was already in a configuration he could not pull up out of when he needed to get over the mountain so he could get back to Montgomery Field. A veteran pilot as he was supposed to be, would not have become that confused unless his plane malfunctioned or he had a compromising physical issue. I think it was a stroke because of how he was answering the tower and not being able to tell where he was in his mental confusion.
You can almost hear the confusion and then the panic set in as the work load increased, as he couldn't quite get all of the instructions back to the atc. I hate the circling approach, especially for a single pilot. God bless you sir. So sad for the family and the panic of the atc desperately trying to get the pilot to realize he's heading down out of control.
Pilot makes no effort to level the plane in the video.
What would be good to know if if this was his first time doing ils 28 circle to land 23. This would most probably have to be hand flown about 3-4 miles out.. but he never got that far. But looks like he wanted to turn right much sooner that he should.. Maybe then hand fly and then he got back into solid imc. He also sounds stressed and rushed even way out.
This happens. Have you ever seen somebody “shut down?” You are right he was in bad shape way out. Maybe he was sleep deprived. He was losing some sort of battle and he probably knew it.
czcams.com/video/NFAnWlxwgc8/video.html
This is an outstanding video. Thank you for the excellent content.
I live in SD and I remember this crash...iinteresting and well done video
It's also possible the doctor had just worked a busy 12-hour hospital shift after the flight to work which would likely leave anyone fatigued.
kudos on following up quickly with the expert analysis!
All instrument approaches at this airport (6 runways total) start with either ILS or RNAV for 28R. Only 28R is straight in, while the other 5 directions are circling. More than likely the pilot knew this, and briefed similar approaches in the past. The pilot verified tower frequency (there are two) with the ATC while he was still at 10,000 feet, ie well in advance. This tells he was getting all ducks lined up ahead of time and that he is a very meticulous person (also take his profession into account). There was something else that threw him off, not the lack of preparedness.
It's San Diego. Is it not likely he's only gotten straight-in or visual approaches every time there?
@@michaelglasier7282 You mean actually landing only on 28R? I don’t know this airfield, but it seems pretty unlikely: I just read that this was a regular commute for him, and that he’d actually made the roundtrip *25* times, just since July! So while I guess it’s possible, it seems to me pretty statistically unlikely that he flew this route with that kind of frequency over the last three (I think it was?) years, but never did a circling instrument approaching any of the other five runways. I’m inclined to agree with a sho; something unusual seemed to be going on here.
@@HalfShelli I've heard that was a regular commuting route as well, but according to Flightaware he'd only flown that route 5 other times in that period. All of them ended with a straight-in to 28R.
Sorry if this has been answered already but do we know if he still had a vacuum system?
Curtis Andre I hope that we all understand the possibility of becoming involved in a moment of confusion and the need to identify that at once without allowing ego to interfere. The more I learn the more I realize how little I know.
Something was bothering this pilot. The ATC instructions were all very clear and with his experience should have been pretty easy to follow. But his responses sounded like he was almost too busy to even bother to make them clear, and at times were almost unintelligible. He was abrupt, unclear and obviously not in control of his altitude. I agree that they may find that the plane had an avionics issues, which would have made him frustrated - especially if he could not diagnose the problem. Once he realized that he missed the localizer, the controller really had difficulty helping him control the flight. Sad...
He sounds "off" to me. Don't know why that might have been. And he's talking too fast.
czcams.com/video/NFAnWlxwgc8/video.html
@@dirkvanderlaan31 - I have been a subscriber to Probable Cause channel for quite a while, and like that he sometimes disagrees with the NTSB and other crash analyzers at times. In fact, this case does look like a possible pilot incapacitation. And most of the comments on Dan's video did notice the deteriorating quality of the pilot's responses to ATC - especially when he had problems controlling his altitude. You can tell that the controllers were quite concerned by his replies and his flight behavior.
I'm not 100% convinced that the pilot experienced spatial disorientation as the weather at the time the clouds are broken and he (the pilot) probably also had good visibility on the ground. Something else must be a factor in this crash as it appears he's struggling even as he approaches the localizer intercept. And even then, as he's waived off, ignores ATC instructions, maintains altitude instead of climbing. We know he can still see the ground - it's not foggy, or nigh time.
And yet he still slowly circles right, and ends up going into the ground at a fairly linear angle. It's as if he's no longer in control of himself or his aircraft - maybe unconscious?
Something else is up... but this is just my opinion. I'm no air crash investigator. Just an observer.
Yeah a commercial licence holder with an instrument rating struggling to follow simple instructions such as climb and maintain 5000, he kept descending even after being instructed multiple times to climb. For someone as proficient as him it's hard to explain, would make me question his examiners otherwise if he can't do such simple IFR flying.
I've seen this kind of thing multiple times in the simulator (mostly). It happens when someone becomes disorientated. They become flustered and their flying ability completely disappears.
I live in Santee about 2 miles from the crash site. It was a pretty uncommonly blustery day that day with clouds and we have a varied terrain. It's been 25 years since I last piloted a plane but I remember thinking that I wouldn't like to be flying in that that day. Requesciat in pace.
That pilot was unconscious,the linear angle clearly shows that as there was absolutely zero attempt to try to pull out or correct - nothing.
@@francinecorry633 not necessarily. To me his disorientation let him in that attitude (a spiral dive). As he came out of the clouds, there was no possibility for recovery anymore. He most likely was just pulling back on the controls, which has no hope of recovering a spiral dive.
Given the sometimes stilted response to ATC in the latter stages of this flight I am wondering if this pilot was suffering some type of debilitating medical episode causing serious misjudgment in his ability to fly and control the aircraft. Seems to be overly flustered for what should have been a reasonably straight forward procedure.
Any updates by now? I think what needs be taken off the table is instrument malfunction (attitude indicator in particular), before pinning it on disorientation. Really hard to see how an experienced pilot would repeatedly assume he's climbing when he's not, especially after getting reminded about his altitude a couple times?
I'm almost 100% positive he did not understand what a circle to land procedure was. You can see him turning north which is where you would expect him to go if he was trying to line up for a 23 approach. He was probably flipping through his charts looking for an ILS 23 approach that doesn't exist. He got back into the clouds, autopilot was off and he was distracted looking for charts that don't exist.
What's weird about that video is that that he's clearly popped out of the marine layer, significantly banked over and is on a screaming trajectory towards the ground. I don't see any indication that he tries to arrest his flight attitude or obvious decent. That's weird to me. Makes me wonder if he had a physiological problem that compounded his flight problem. Anyone IFR rated that flies out of San Diego has good experience popping in and out of the marine layer. I used to fly out of Montgomery and it's common practice for those qualified in the area.
That's true. It appears as if the pilot was incapacitated doesn't it?
On the time of the accident, KSEE have a broken layer at 2700, tops at 3800 ish, and winds were coming from the south at 10-15 kts
So where's this IMC?
Medical....
So sad 😢Prayers for the families
This pilot sounded like he may have had a medical issue? It sounded like he slurred, like a stroke? This should have been an entirely survivable situation, right up until the final moments of the mishap. ASI, thanks for these videos.
Ahh, the 'circling approach' bites again
2 points I don't understand
1: Once he intercepted the localizer for runway 28, why didn't he just continue the approach? That seems like the easiest path.
2: Fuel management on 300 series Cessna can be tricky. But this is only a 45 minute flight. Couldn't it have been flown on the main tanks?
Was in the air that day and in the area and I can attest to heavy winds up there
It was not spatial disorientation. This dude had a stroke or heart attack the weather wasn't bad enough for him to get into any kind of hard IMC. You don't ignore multiple calls to level wings & pull up because of spatial disorientation. This guy had way way more going on than IMC.
I’m gonna put my money on disorientation but , we’ll see how the investigation goes
Video of it dropping out of cloud, weather doesn't look that bad.
His voice is very strained, he sounds like someone who is having trouble staying conscience.
How do you avoid bad weather conditions such as this when flying? Say you are planning your routes routinely and there are already other routes that say Southwest, Delta, etc. run that they know have better weather/traffic patterns how do you know what is the best route for avoiding bad weather such as this? Is there a way to choose an aircraft that can fly above/avoid bad weather such as this?
Listening to the audio I doubt the accident pilot ever understood the clearance ILS to runway 28R CIRCLE to land runway 23. It doesn't sound like he and ATC are at all on the same page. I've only flown into that airport once and it was decades ago. Is this ILS to one runway then circle to land to another runway something commonly used at this airport (like Tetorboro NJ-similar and commonly used) or was something unusual going on? Sounds like the pilot was expecting to fly the ILS to 28R then he mentions runway 33, is there a stand alone approach to 33? As far as your analysis of winds aloft, turbulence, notes on Sectional charts-I don't know it sounds like a "normal day of flying" to me rather than some demanding weather scenario.