PC-12/45 NTSB UPDATE In Flight Breakup! 26 Feb2023
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- čas přidán 8. 09. 2024
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To be clear- the loss of control was followed by the inflight breakup. NOT the other way around.
How reliable was the 27000 fpm descent rate? This is incredible.
Flying fighters we encountered SD quite often...I have been briefed about 2 Canadian F18 cases that pilots had to eject due to SD and one Swedish fighter case...We sometimes had this phenomena while formation flying in IMC...an example is the Russian formation crash in the mountains...
Other situation was doing BVR fighter manouvres /aerobatics VMC night... those could put you in SD due to canopy reflections...that is why fighter aircraft (eastern or western types) have always have auto-level, auto-pull-up recovery and robot-pilot-approach-land functions dating back to 1980s....usually it is a big red push button on the stick...
Of course the other frequent reason was the G-lock or grey-out due to over Gs...to develop these systems...
@@jgrazzi If the plane loses the tail (such as after a hard pull-up overloading the elevator) it's likely to turn the nose more or less straight down. And that will result in a very high speed so it may rip off a wing.
So it's likely the flight data is correct and this plane really did fall at a mad pace.
Is a breakup to be expected in a spatial disorientation scenario, or is that rare? Could the PC-12 be built with too thin of safety margins, or is too variable on other factors? Do planes in this category have pilot aids to prevent a overspeed or over G? We're those overridden or could the weather have just taken a stable flight suddenly past limits? Breakups seem like the worst because of the instant you know it's too late to recover comes so soon. Very sad outcome for the 5 folks and their friends and family. Thank you for your insight and education. Only through deep understanding, broadly distributed can lessons be applied to help prevent these tragedies occuring again.
Sooo something mechanical a failure possibly occured causing loss of control or difficulty maintaining positive control of the aircraft....
Then the overspeed..
... Then the breakup....
GOT IT...
Or did you want to retire with the FAA ?
Or Boing boing gone to the max ?
Their motto : blame the dead men or itz bad for business... just sayin.......
Spatial disorientation is truly insidious. I was over northern Minnesota in an old but very well equipped Champ one night during severe clear conditions. The density and color of the stars perfectly matched those of the farm lights, causing the gyros in my head to tumble. My head was in a climbing left turn while the gauges claimed I was still straight and level. I flew about 45 minutes in what felt like knife edge flight (yes it's impossible) until Minneapolis came over the horizon which instantly cleared everything up in my head. That was the most exhausting flying I've ever done. Trust your gauges instead of your head, boys and girls.
Wow, I’ve read a lot about false horizons illusion, and I always thought it could be rather prudent to actually get the horizon and the sky mixed up. However this is my first time reading a firsthand account of what it’s like. Thanks for sharing this, it gives a young pilots like myself some insight into spatial disorientation.
That’s really interesting and I’m not being sarcastic
my instructor was saying
a.no such thing night-vfr
b.for imc you need 2 guys or gals, and
c.if no horizon reference, your eyes become the ...attitude indicator and "fight your feelings" by scanning your instruments, this is the remedy that kills the spatial disorientation enemy !
I fly day vfr only out of the mpls area where I hangar my plane. As a vfr pilot I’m allowed to fly at night where the horizon can just disappear once I leave the metro area ( think JFK Jr ) but can’t fly thru clouds in the daytime. For myself ( just me ) I don’t fly at night and don’t need to be anywhere that badly.
Trust your gauges... No kidding! 🙄
This is why having two pilots in the cockpit is so very important. I was shooting an approach in the jet I fly and our autopilot was inoperative, Not a big deal with two qualified pilots. I got disoriented in IMC and luckily the guy I was flying with had my back and made the correct callouts to help me re-establish my scan. It can happen to any of us.
Eventually FMS's should have AI driven systems that could be one step ahead and warn the pilot of an impending situation, using firm detailed voice commands to implement corrective action. The system could also monitor medical vitals and take control if the pilot locks up.
I 100% agree. It amazes me that to US is still allowing single pilot commercial operations.
@@submechanophobia768 All computers and AI are made by humans; designed, manufactured, and programmed, which renders them susceptible to failure. As well, the pilots would have to wear telemetry for their vitals to be fed in - no fun at all.
@@submechanophobia768 we are a VERY, VERY long way from Ai systems being anywhere near capable of doing that.
@@Isaacmantx I suspect you are not an AI expert and are flying by the seat of your pants here. 🤔
I was an airline pilot for nearly 37 years. Obviously, all in 2 or 3 pilot cockpits. After I retired, I took a job at a single pilot IFR air ambulance company flying several models of King Airs. We had well maintained, but rather primitively equipped airplanes, instrument wise. During my airline career I always alternated between flying coupled approaches with hand flown ones in order to maintain "stick and rudder" skills. The problem I found with the air ambulance operation was that we flew so little every month that maintaining proficiency was a problem. It wasn't unusual to get less than 20 hours a month, and that mostly in VFR conditions. The rest of the time we were just on standby. There was also the pressure from the med team to complete the mission, even if prudence indicated it was safer not to do so. At the very least, it is my opinion that ALL air ambulance operators should be required to have 2 pilots in the cockpit.
I can imagine the pressure is intense and from all sides if you have an ill passenger needing to get somewhere or needing to leave to pick someone up. How many were lost?
I came from a 13-year career in air medical transport. Safety always comes first... Right up to the point it interferes with profit.
@@cousineddie7898 so what you're saying is that safety never comes first. Surprise, surprise.
@@cousineddie7898 The death toll from single pilot IFR crashes will continue to rise if the FAA doesn't step in to stop it. Sadly, this is not high on "Mayor Pete's" agenda. The families of those killed short get together and file big class action lawsuits agains these big air ambulance outfits. That would remove the profit motive.
@@brentbeacham9691 I thought, five. I remember seeing pilot, a ride along, two medical professionals, and the Patient.
R.I.P. to those who lost their lives. Thanks Juan and please everyone fly safe.
I one started to get vertigo flying night VFR out of North Las Vegas towards San Diego. Over the desert, it’s hard to tell the stars from the few lights on the ground.
Really made me sit up in my seat, light touch in the controls, trust the instruments, and only moved my eyes and not my head.
Ended fine, but it was a total wake call.
Thanks for critiquing these accidents as it saves lives. 👍
I forget what planet it was, but my dad and I were flying from Texas to Oklahoma, and it was black with no ground reference, and he said we needed to descend or that other plane was going to smash us like a bug. Then we laughed that it was a planet, and I was amazed because it looked like it was moving. But I got queasy from the descent and had to watch the gauges and let him look out the window.
@@Parkhill57 Yeah, I've heard lots of stories of pilots confusing a planet for another aircraft's landing lights. Even from the ground, they can look quite similar. The worst thing about it is that what a planet looks most like is... another aircraft headed straight towards you with no apparent motion to the left or right.
Great story. Probably Venus. It's the brightest planet and really could look like a plane coming towards you.
@@pilotboy2612 Venus is most likely; it’s very bright, and only appears relatively low in the sky.
You're commitment to in depth understanding of these aviation crashes is valuable to all of us. You present the an informed summary of available facts of the situation and make tentative but informed comments relevant to the matter. What is so excellent about your commentary is that it remains open to other input and that it is founded on your own extensive experience as an aviator.
For me this is a classic example of the citizen-journalist in action.
And if his initial interpretation of the available information is eventually shown to be inaccurate, Juan is the first to point it out and explain why the new interpretation is is better.
I was once driving late at night during a heavy Wyoming snowstorm on a very smooth, dark stretch of lonely highway. My car's speed was exactly matching the wind speed making the snow to appear that I was stopped and that the snow was falling straight down! It was very spatially disorienting and required from me a serious mental exercise to convince myself that I was still moving forward at 45mph. Truly an eerie experience!
I had the same experience in ground fog. The lines on the road, and my doing 25 MPH to power through the night, was actually disorienting. I was lucky a big truck with his headlights above the fog passed me, and I pulled-in behind him and flew formation.
Imagine if we had journalism like this in the non-aviation world.
Follow the money.
All journalism should be Party approved for correct speech and Allowed Thinking
Juan is a subject matter expert here, I get your point but surely we can't realistically expect every journalist to personally be an expert on every topic they might cover?
@@sfulibarri not an "expert" maybe, but at least have a working knowledge of the subject matter.
@@sfulibarri
But the Main Stream Media pretends to be SMEs
This makes me sick, I have about 100 hours in the left seat of N273SM, it was a wonderful aircraft. I knew the paramedic pretty well too.
This guy is the best out there at explaining things.
He is, isn't he? A natural born teacher!
Always clear and concise
amen.....dme in la
He needs to do 45 min vids with at least a half hour of banjo picking ...keep aviation out it completely.
Of course, a professional Airman trained by the best, the U.S.A.F. passing his expertise on.
I’m glad your channel is here to explain how these investigations are done. I also really appreciate your focus on safety
Agreed, thank you and hello from the UK 🏴
Thanks! My heart goes out to everyone who experiences a loss from an aviation mishap. As a depot-level avionics contractor for the Coast Guard in North Carolina, everything I learn from your coverage of mishaps helps me be more diligent in my job and gives me a better understanding of structural failures and what happens when inspections might not have been done effectively. I hope all maintainers take this to heart and never settle for it's good enough for government work attitude. Thanks again for the great content.
I'm an aviator and have over 630 hours of time flying the Pilatus PC-12. I have the highest of respect for this fine aircraft. It will be interesting o see what led up to these series of events that led to it catastrophic failure.
Same here, 2400 hrs. A very well built and impressive aircraft.
Spatial Disorientation is a very real, potentially violent occurrence. In flight school I was placed in a chair with a stick. I was told to turn my head 90 degrees to the left and tilt my head straight down with eyes closed. The instructor then spun the chair around in a circle for about 30-45 seconds. He then stopped the chair, instructed me to sit up and center the stick. Because my brain thought I was rolling inverted as I sat up, I literally almost threw myself out of the chair in an attempt to become “upright.” This happened within 2 seconds of stopping the chair. This was similar to the dead man’s spin illusion where two or more semicircular canals are affected and give a false perception of level. The only two ways to avoid this phenomenon are to believe and trust the instruments and stay on them, or hand off the controls to a competent instrument qualified copilot. Single pilot IFR in IMC is a significant risk that should be avoided in general aviation.
That's a really striking example, and your instructor sounds like someone who could really teach in a fantastic way. I'm not a pilot myself but I once flew a proper simulator "into the soup" and the sensation was almost physically sickening. In fact, when I left the simulator I felt fragile for some time afterwards, and at the time I did this I was riding fast motorcycles on track days at high speeds so I was used to a certain amount of "being thrown around/throwing myself around".
The Minneapolis FSDO office had a chair that did the same thing, called it the vomit comet/chair. They took it to Oshkosh and let people ride it there too, sad to say i rode it twice, it sure teaches you about the leans and spatial disorientation. Thanks Juan
I have been in a similar experience, and it was both not fun and incredibly eye opening. And a bit pukey
I've always been an aviation fan, so I've flown plenty of passenger miles, have been a private pilot, and a skydiver. During those times, I never had spatial disorientation. Interestingly, mine happened on the ground... I was with a friend in Minneapolis when I was about 25 years old, and as part of our "urban hike", we went out onto one of the bridges that cross the river, and were under the roadway section, lying on one of arches below, looking down about 75 feet into the river. We were lying on top of one of the bridge's arches, perpendicular to the direction of the flow, which was "head to toe". After a few minutes of that, I experienced the illusion that I was somehow tipping over toward the river, and it caused a fair amount of panic, with me pushing myself back from the edge, gripping what I could, to avoid "sliding in". Very strange... It's only happened to me that one time, but although I was healthy and sober, it was a frightening illusion.
I live in Greece and I have been to the Corinth Canal a number of times. The canal is in a deep gorge, if you stand in the middle of the bridge and look down, it does the same thing. It seems to be pulling you over the edge. It doesn't happen to everyone, but it is a very weird feeling.
I actually felt your fear while reading your post. Wow . As a pilot I have experienced spatial disorientation and it is real scary
That was not spatial disorientation. What you experienced is a type of vection, more specifically linear vection.
@@mmayes9466 Well that happened to me, and I didn't have a label for it. Now I do. Also reading a 1993 paper called "Factors affecting the onset and magnitude of linear vection". Thanks for the info!👍👍😁
@@mmayes9466 I stand corrected. :)
been there done that in primary flight training with spatial disorientation while "under the hood" in a 150 on a clear sunny day... thought all was fine and I was slightly climbing and my instructor said, pull your hood .... we were in a spiraling dive and I never "felt it" one tiny bit. But I guarantee you, I remember it clearly to this day decades later..
I experienced SD diving in a lake during a checkout night dive. Reaching the bottom at 60' immediately ushered up silt and such that my flashlight was of no help. Fortunately I had been trained to follow bubbles, which appeared to be going DOWN. Close call and one I'll never forget.
I have experienced it luckily with an instructor. The feeling the aircraft is doing something that it is not is so strong it makes you think all the instruments are wrong. You know in your mind you are rite and they are wrong. Crazy powerful and I can see where it can lead to a crash quite easily.
Damn. You almost think there needs to be something physically hooked up to the pilot to give him physical feedback.
What does it feel like to be wrong? It feels just like being right. (Until you fine out you were indeed wrong.)
@@TheFrenchPug there is something physically hooked up to the pilot giving him feedback.. it’s called their inner ear, the problem is that feedback it’s giving is totally untrustworthy.
I was under the hood on a practice ILS when instructor said look up, we were in a 45° bank, shocking to say the least.
l have had it .I look down in my lap for a minute and close my eyes and then get back on the instruments and ignore everything else The instruments are always right
Over the 10 years that I flew the PC-12, I had three encounters with severe turbulence that disconnected the auto pilot and left the plane temporarily out of control. Luckily, these occurred during the daytime. I had good visual references. Without an immediate power reduction it would have been easy to over-stress the airframe.
I guess the reason for not having a Vb (turbulence penetration speed) for GA aircraft is "no filght in turbulent conditions supported" !
The pilot of this arcraft was Scott Walton, the brother of Washington Capitals radio announcer John Walton. A GoFundMe has been eastablished to support Mr. Walton's widow and three young daughters.
Quite frankly if the pilot was going to do this line of emergency work in these conditions (which I applaud) he should have purchased appropriate insurance for his family ahead of time so his family was protected in case of an accident................
@@jaycahow4667 Well, let's not take his lack of foresight out on his widow and little girls.
@@elizabeth5985 The kids I understand, the wife is as guilty as the pilot..........
Presumably, if I go there I'll see a whopping big donation from the company involved in yet another such incident? They could then no doubt deduct that from any settlement arrived at later on. But earlier receipt might still be most useful.
I'm sure the company has a life insurance policy
During the first (right) turn from the SID, the speed quickly decayed from 200kts to 113kts, but still held altitude. So, the Auto Pilot or Pilot was trying to hold altitude against a strong downdraft. Shortly after, the speed zoomed right back to 200kts. Still 19,000. Generally, a big downdraft will be followed by an updraft. It seems that at this time, he was hand flying. He may have been using Vertical Speed mode during the climb, causing the AutoPilot to fight the downdraft. Icing and Moderate Turbulence likely led to the Spacial Disorientation; Graveyard Spiral; break-up. I think that all these companies should be required to have two pilots. It is a Charter Part 135 flight after all.
- Gold Seal CFI. Citation & Learjet pilot.
Juan, I experienced a short spacial disorientation episode when training solo at night in a Piper Apache when looking out I couldn't differentiate the stars in the sky from lights on the ground. I recovered a very scary situation by getting back on instruments. I remember that night some 55 years later. So I know where you are coming from and my condolences to all involved in this accident.
Good info and update.
Years ago around the mid 90s a buddy and I witnessed a Fouga crash at KLGB. I remember calling the tower and telling them I witnessed the crash. The guy blew me off saying something to the effect that they got it handled. Next time I’ll contact the ntsb directly.
Even if you hear or view the aircraft and it appears perfectly normal, THAT IS INFORMATION in an accident investigation like this. Don't be hesitant to call and let them know.
Thanks for keeping us up to date on this accident. You really have your ear to the ground when reporting on these cases. Many news rooms don’t even mention them.
Your always accurate with the details which makes it easy for everyone to understand.
Thank you my friend.
Stay safe.
You do great work Juan! Stay Safe. Heartbreaking story. There is a lot of abuse and pressure that is growing in the medical industry of practitioners and staff. I feel this could be a factor in this tragedy.
What are your thoughts on it?
First my condolences to the families impacted by this accident.
Spatial disorientation is very hard to overcome in my experience here in Alaska. Your brain and body telling you one thing but the instruments old school 6 pack are our saving grace! Keeping your head in the cockpit with a constant scan of the attitude indicator, altimeter, directional gyro and airspeed indicator. Always coming back to the the AI keeping wings level or in a coordinated climb or turn. We practice unusual attitudes but is not the same. It is better then nothing. Keeping your scan sharp is how I keep the blue over brown but it is work. Now with glass it is similar but different. These newer planes have some impressive avionics and autopilots which reduce your workload.
To me having and using autopilot is our best choice to staying coordinated in nighttime or hard IMC. Using the GFC 600/700 has a level button just for times like this. It takes over and gives us pilots a chance to regroup.
Juan and other experienced pilots, what can a pilot do if they find themselves in this situation? Do you agree that the autopilot is are best option if available?
I am just an humble Alaskan pilot that works hard keeping myself and my passengers safe. I do not have near the time of pilots in these accidents. I am constantly learning and getting better but I hate seeing accidents with no real solution. We owe it to these pilots and passengers to get better, we cannot settle for less.
Thank you Juan for your dedication to the aviation community. I know you want the same thing as myself. Everyone stay safe out there. 👨🏻✈️
That’s all fine and dandy but this particular on these model PC-12s the autopilot will disconnect during moderate turbulence. It’s been fixed on the PC-12NG.
I excellent report. I flew the PC-12 for many hours and I think in the turbulence that existed at that time it kicked the auto pilot off and that started it going on the way down
I don't understand it. Are not the pilots trained for when the auto pilot kicks off? Even in IFR. Just pay attention to your instruments right. How many planes flew through the heavy turbulence that day? Seems like everyone else made it through fine, auto pilot or not.
@@superbiketech Any single PIC authorized operation is a handful of work. Once autopilot checks out, you own the plane, which was unexpected. If you're not proficient in IMC then you're going down in flames.
@@dryan8377 Starting to sound like one of those unsafe hiring practices they've been introducing lately? But I hope not. Been a lot of close calls and accidents recently.
Huge red flag with so many accidents in a row, same with the Air Tanker crashes in Australia. Sure it's all high risk stuff but there needs to be a line drawn to establish acceptable risk. When you start adding up all the lives lost it's not a small number.
These companies won’t hire people who have a lot of experience and savvy, enough to stay out of trouble. They always hire a demographic of people who are hungry for experience, will keep pushing, and won’t say “no” to whatever harebrained stuff the companies ask of them. Nobody can or will do anything about this in our system. So this is going to keep happening again and again forever. Nobody who can change things cares and nobody who cares can change things, so there you go.
Flying is risky. That's what makes it fun.
@@chester8420 not fun when your plane breaks apart en route to your cancer treatment
Single pilot night in low IFR is a big risk factor multiplier.
Any aircraft can be pulled apart in the air and this accident is no reflection on the aircraft at this stage, I would say.
Excellent report. Thanks
I definitely know what your talking about as I’ve experienced it many years ago flying in the Air Force. I was a GIB in an F-101B flying in a three ship formation with two F-106’s doing radar interceptions out over the range. It was a beautiful Sunny morning when we took off and after about 35 mins into the mission we were contacted by the base controllers that a severe thunderstorm had developed somewhere and was rapidly approaching the base. All aircraft were ordered to expedite an RTB. We formed up on the left wing of the lead with the other 106 on the right. As we were about 15 miles out the controller updated us that the storm was about 10 mins from the base and that there were several other aircraft in the area in route to the base. We started going in and out of smaller clouds as we got closer and lead told us to tighten it up to prevent going Popeye. The closer we got we were rapidly given directional changes from the controller to avoid traffic. Turbulence started to increase as well as the broken clouds scattered everywhere. That’s when we entered a larger cloud and everything went white with the wing tip of the lead barely visible and continuing to make course corrections as given to us. That’s when it hit me thank God I wasn’t flying. Not sure exactly how long we were in the soup and about maybe 1200’. I was looking out the left side of the canopy and feeling that we were in a right bank when we broke out in a left bank and I was staring at the ground. What a total mind blowing experience being in total White out thinking you were in a right bank and BOOM you break out and looking at the ground in a left bank. I’ll never ever forget that experience. In no way did it compare to the chair spin disorientation training we had for vertigo. I never wanted to experience that again and was always aware of it especially in bad weather. I tried not to make rapid head turns and pay more attention to the instruments to refresh my mind as to the attitude I was flying in during reduced visibility. It can come on fast or creep up on you as in my situation but always completely overcomes your senses.
I love how you continued to aviate, navigate and communicate after you lost the sheets of paper! You continued talking about the imprtant details (aviate), kept track of the information flow of the video (navigate), and then finally when you had the video more under control you picked up the sheets of paper (communicate).
Hey Juan, I work for a Pilatus Service Center here. The PC12 is equipped from the factory with a voice recorder, but it is an LRU that every so often fails. The testing for this unit can be vague with some 135 AAIPs. On a side note, in my experience, Guardian does a better job than some others in maintaining their ambulance fleet.
Having worked for a couple 135 ops, guardian being one of them, I think Guardian is the better of the two. All legacy fleet but well maintained.
LRU definition? Thanks!
@@bigjeff1291 Line Replaceable Unit
@@FlyWithAlexMora Thank you Alex!
What is LRU. Definition didn’t print. Thanks
Drove on a narrow mountain road with no guard rail and a hefty drop off one side in dense fog at night. Could not see the road in front of me. Literally could not tell if I was going uphill or downhill, so probably have a slight idea.
You were in the clouds
I have de-iced plenty of planes that came fresh out of a hanger. The plane is so warm, water vapor in the air condenses on it, then it cools before departure and frosts up. Its usually a quick hit with Type 1 and your good, but its needed.
The aircraft flew just fine up to almost 19,000 feet. If there was ice on the wings at the time of departure, one might conclude ice was not initially a problem with this flight. Something happened that caused the aircraft to turn South off its flight plan and then go into a series of climbs and dives.
@@jimw1615 How about ice that may have begun accumulating as they climbed? Say, at 15000 or 16000?
@@gprang Yes, that is the "million-dollar question", and one we may never know for sure.
@@jimw1615 I was not being specific to this incident, but a general comment about hangered A/C can need the orange cool aid!
You are right, given the altitude they achieved on the ground icing is not likely a problem.
This happened in my little town, I live right across the freeway from this accident. I did not see or hear anything, RIP!
Thanks for the update Juan! You always make it easy for us none aviation people to understand.
I have fond memories of the vertigon trainer at Vance AFB. Every three years we needed a chamber refresher and the vertigon was popular as everyone liked to compare their printouts. In my old age I have monthly bouts of vertigo, and it is worse than that trainer. Can't close one eye or even both to make it go away..
Agree 1000% with your view of spacial disorientation being incapacitation! Thanks for the updated info, Juan!
In the early 90’s, a medical aircraft crashed in our area of Western Colorado.
From what I remember, a little girl had swallowed a quarter.
They departed Rifle Colorado, enroute to Denver. Night time, about this time of year. They hit a mountain ridge about 10 miles out, south of New Castle Colorado.
Miraculously, everyone survived. They had to spend the night, while search & rescue looked for them.
That was quick JB. Thanks for the follow-up.
Take care and fly safe. 🖖🏼🤟🏼
Good stuff Juan. We all appreciate your dedication to this (and other) tragedies. Hopefully we can make air travel safer based on what we learn.
Anybody considered the extremely strong mountain wave activity in the Reno area, especially around the 15-20K fot level. The downdrafts and turbulence in that area can be extreme. I kknow, I've flown into Reno many times with the B727 and DC8.
Well stated Sir
And in some severe icing and that's a bad situation to be in.
Yes. All are very well aware
Its usually always a bumpy ride out of Reno even on clear days.
That snow.... Never seen snow and likely never will. Looks amazing out there
I live in rural South Australia sooooo not much snow around here. Can cook an egg on my car though 😬
You're only missing experiencing it for the first time. Then, after that, you don't want to have to deal with it.
Thank you for the update. I look forward to the NTSB complete report.
Perhaps look to the Royal Flying Doctor Service in Australia for best practice in operating single pilot PC12 and King Air aeromedical medical retrievals all weather day and night in remote locations. I think they have or had the largest PC12 fleet in the world. Not unusual for them to be landing on unlit station properties at night with just car headlights at each end of the airstrip etc. RFDS have an enviable 94 year safety record and operate in some of the most difficult situations you can imagine. If you pay as well as the airlines and employ the most experienced pilots (that stay for their whole careers) it can be done.
I appreciate this Juan for finding out this information on the PC-12
Juan - You were right about inflight break-up!! Event that forced need for overspeed etc may still come out in investigation, but we're still faced w/loss of 5 brave hearty soles doin' their best for others in crappy weather no less.....may their soles Rest in Peace.....
Mike and Mark Patey have just upgraded their Pilatus with a new engine. Mark has some interesting comments about pilot work load on the older versions compared to their update.
My nephew was hired by Guardian last fall, qualified on their simulator in Palatos SLC, and was having a medical when they found stage 4 cancer and he passed away. He was 60 and had 45 years of experience as a pilot, in the Army, and as an FAA inspector, and had just moved to Reno.
Thank you for the update. Excellent reporting.
Captain 👨✈️ Browne, thank you for update on this very sad event.
Keep warm, much respect from your neighbor here in Merced.
Captain sums it up just right!
My home airport is in the smoky mountains, 24A, and have experienced severe mountain wave turbulence twice in the last year in benign VFR day conditions. The scariest experiences I’ve ever had. Really tossed me around…thought my aircraft was damaged and I was a goner. I can’t imagine what it would be like in night severe IMC.
Great update Juan. Watching your previous vid on this crash reminded me that you did mention this breakup as a possibility. Cheers from CYYB.
Appreciate the update. Great reporting as usual, Juan. 👍
Thanks for this great updates and conclusions, always a good source for thought. Greetings from Switzerland
I was wondering if that last bit of the flight that was visible on FlightAware was inverted and might be a break up in action.
Seeing stuff like this over and over again just breaks my heart.
I appreciate your efforts to continue posting videos regarding aviation accidents and the safety lessons ( implications ) of each event. Thank You !
I've been working on my instrument rating (getting close) and it seems odd that a pilot that can fly a PC12 wouldn't be proficient at flying on the gauges. I guess PC12's are glass panels though. Turbulence could knock the autopilot off and probably did.
The only spatial disorientation that I've experienced was in a "thing" called the Vertigon. I was at airshow in the early 80's and AOPA or some organization had it there. I got in that thing and they closed the "canopy". They started giving me startup instructions, then takeoff clearance, then headings and altitudes. It's been a long time since I did it and I don't recall everything but when they said that I needed to switch tanks and to reach under the seat for the valve, I was done. I didn't just reach, I bent over to look for it. I lost control and couldn't recover. They had to help me out of that thing when they opened the canopy lol. My logbook has a "Wow! I Flew the Vertigon" sticker in the back of it. I'll never forget that feeling.
So yeah... if it was spatial disorientation I can see how it would get out of hand very quickly. It just feels like something would have initiated the pilot to get off of the gauges... That first or second hole in the Swiss cheese is what I'm wondering about...
I would love to read or see more about that device (Vertigon), but can find nothing online. Do you have any more clues or keywords I can try?
If you don't think this can not happen to ANY of us, you are in the wrong business...
@@blancolirio I know it can happen to anyone but something triggers it. That's what I'd like to know. What put the pilot into that situation. I'm just a private pilot working on my instrument rating, with a little actual. No corporate or big jet time. In the case of the Vertigon they were turning it while I was inside and couldn't see out. I moved my head 180 degrees-ish down and that started the fluid in the inner ear turning (or something like that). It's the most disorienting thing I've ever experienced. Spin training was nothing like that experience. In the real world I don't think I would survive if it happened to me.
Sounds similar to something they had at the Calgary Stampede late 70's. When they asked you to switch tanks, and being unfamiliar with its location, one had to put your head down to find it. When you looked up, nothing made any sense, and you are done. It may have had a rotating component that started so very slow, that you couldn't detect it. Opened the hatch and the whole world was spinning. They gave preference to pilots to try it out. A good wake up call. Fun too.
Michael : The autopilot packed up (turned itself OFF) due to turbulence and the pilot was taken by surprise and slow to get on the instruments? Turbulence could also have put the aircraft into an unusual attitude accelerating the problems.
Disorientation is so easy. I rode an FAA Vertigon back in the 70's. When the voice in my headset told me to pick up my dropped pencil, I cracked my head on the headrest thinking the the thing had rolled over. Never forgotten lesson.
Blessings to all that knew and loved the victims in this tragedy.
I remember back in the 90's a flying service I worked for in Alaska had to install TCAS in most of their aircraft, it was a very expensive upgrade
When I first joined the Air Force and out of tech school as an F-16 crew chief, we lost a test pilot and Lockheed photographer at Edwards due to spatial disorientation. It can happen to anyone regardless of how experienced and well trained you are.
I have had spatial disorientation while driving at night in heavy fog. The kind of thing where you find yourself inexplicably accelerating while you think you are going uphill. It is a wildly difficult thing to recover from when you are moving. But fairly easy once you stop the car. I can't imagine how difficult it would be in a three dimensional environment where you can't stop.
It speaks to one’s ability to trust the instruments. If they’re working.
I have had similar issue driving in heavy big flake snow storm in the mountains east of ABQ back in the mid 90's. I actually had to watch the GPS to know when we finally were headed down the mountain again to get out of that stuff. The memorizing flakes coming at the windshield from the glare of the headlights really can play with your mind. Had to keep stop watching in front of the car and look out the side window for bits at a time. There was almost no way to know if you were going up or down.
Had similar happen when driving at night in a blizzard, Speedometer said I was moving at 35 MPH but visually it seemed I was standing still. Finally realized that the stakes that are set about 100 meters/yards apart on the side of the road were going by used this to get to a "safe place" to pull off the Interstate. I could see well in front of the vehicle it was just that it felt like I was standing still.
A group of friends and I had been away for a weekends camping on our motorbikes and a new riser had joined us on her little 125. We'd had a nice ride up country on the Friday keeping to small bike speeds (even though we were all on larger machines), had a great weekend and were returning home on the Sunday.
A heavy sea fog had rolled in and visibility was severely curtailed. We put "our duckling" in the middle of our pack and steadily made our way back down the country. Visibility was getting worse. I was tail-end-charlie as I had the fastest bike and the most riding experience.
The pack pulled over into a lay-by to gather ourselves and check on our new rider. She was OK but obviously nervous. They decided to put me up the front as I had the most experience at leading a pack of riders and knew the roads more (pre SatNav days). We pulled away and settled in to a steady 30-35mph along this A Road dual carriageway.
Some miles later I saw a headlight approaching in my offside mirror in lane 2, thinking that it may be Tail-end-charlie warning me of a problem I flashed my brake lights on the front lever and began to slow down when all of a sudden our little duckling comes screaming out of the fog in a cacophony of two stroke rasp and blue haze and belts it past me leaving a hole behind in the fog.
I knew she was in trouble and cogged it down a couple of gears and went after her. Luckily, a GSXR1100 can get a wriggle on quite quickly when you ask it to. I undertook her, pulled in front and flashed my brake light. She got the message and I moved her over into the shoulder. A short while after, everyone caught up and pulled in around us.
We worked out that she had drifted out of lane, lost sight of the bike ahead and then lost speed awareness. She'd then decided to accelerate "a bit" to catch up with us and passed everyone in lane 2 which is when I saw her go past me like I was looking for parking 😆.
I did give her the option of temporarily "breaking" her bike so she could get recovered and then I'd fix it again when she was home but she soldiered on and got it home.
When I was a kid, we lived in Moose Jaw (home of the Snowbirds). They had a fatal crash of one of the solo pilots when the horizontal tail came off in the middle of low altitude maneuver. The pilot ejected as the aircraft impacted the ground nose low. I remember seeing a picture of the crash, showing him going out through the canopy.
The investigation resulted in a strengthening of the T-bracket mount, and regular inspections. That crash really stuck with me, as my neighbour had taken me over to the hangar not long before that accident. Just wanted to share this useless reflection...
I recently had a run in with spatial D. I was flying a GPS approach, single pilot, in a plane with no autopilot. All was good until I made the turn onto the final approach course. As I rolled out of the turn to what felt like level flight I watched the DG keep turning, so I scanned back to the attitude indicator that showed I was still in a bank. I corrected to a bank about 20 degrees the opposite direction to catch the approach course. When I did this my inner ear was screaming that I was over banking. It was a struggle unlike anything I have experienced before, to stay in that attitude to catch the needle and the correct inbound course. Once the needle centered and I rolled back into what the attitude indicator said was level flight, my inner ear was still telling me I was in a 20 degree bank. I flew the next 5 or 6 miles in what felt to me a 20 degree bank, but I was tracking the course and the instruments said I was level. I wish I could explain the overwhelming feeling that came over me to forget what the instruments are saying and do what feels right. It was an exhausting battle between my brain and inner ear. Thankfully the training that I have had prevailed, and I just kept saying to myself "trust your instruments your inner ear is lying to you". I broke out and the whole world flipped 20 degrees in a split second. After this experience I completely understand how someone could let spatial d overwhelm them and lose control of the aircraft.
The NTSB has been keeping their eye on air ambulance services for several years, if Guardian has four accidents in the last few years, I’m sure that’s why a senior member came out for this investigation, to underline the importance.
Your my favorite keep up with the good work🙌🏾
I am very curious to know what happened here. I experienced spatial disorientation in a Cessna 310 departing Cleveland Burke Lakefront. We were going south, but because of the buildings we had to make it 270° turn to the north over the lake. I thought I was climbing until my friend in the left seat tapped the VSI. I was starting to descend. I fixed my mistake and we continued on to Philadelphia. It was pitch black over the lake and I thought I was doing what I should’ve been doing.. Never again.
Excellent updates. Your dedication in reviewing the past NTSB reports to frame the data is much appreciated by the rest of us in the aviation community. While accident reports are often a bit on the sad side of things, I always get excited when I see the blue dot beside your Blancolirio logo in my subscription feed because I know I'm about to get the most up-to-date content with professionally framed insight.
It seems issues like this involving the 2 most popular turboprops are on the rise. A 1250 SHP PT6 behind a big 5 blade prop, and Vne of 280kts. It seems that would be easy to exceed going downhill. I wonder if Mrs. Garmin does a call out for that? I thought I remembered the Pilatus having a "straight and level" button on the panel too. For situations just like this, hitting the button would return you to straight and level flight. The ultimate choice for this one though was a Holiday Inn. --gary
There was a ton of severe turbulence in that region Friday evening. FL200-340 if I remember correctly. Air-carrier sized aircraft were reporting it. It seems to have been driven by an upper trough running down the west coast. Would hate to be in those conditions in a small turboprop single.
I wonder if the wingtip departing and taking out the horizontal stab is a possibility. I missed if you said which side it was, if both parts came from the same side. I guess you'd have to look for an impact mark on the stabilizer to know.
I think it was the right wing tip... Radar dome might have tipped it over the edge
Amazing winter JB. Up here in Crescentcity at about 20' elevation there is still inches of snow on the ground in the shadows. We literally had a bizzard on Thursday. For about four hrs. It had been snowing since wed morn but it came and went. Thursday we had 6-7 inches of accumulation in about 4 hrs. The highest snow fall recordings since the 30's.
Thank you for the fast update!
Thanks for the clarification Juan!
At the end of the Flight Aware track the spiral turns into a back-and-forth squiggly line. That's the breakup path.
RENO ACCIDENT UPDATE
JUAN,
Great stuff here with this update, as per usual from Blancolirio World Headquarters analysis par excellence....!
I am surprised that this Medivac flight had no VCR or FDR and wonder if this is something related to the airplanes flown by this company alone, or is it something applicable to all EMS flights....?
I would imagine this will get NTSB attention after this accident, with pressure being brought to bear on the FAA for the implementation of the appropriate rule changes and requirements.
On this issue alone the FAA does appear to be found wanting.....
The earlier point made about why a flight to a Salt Lake City Hospital rather than making use of the hospital in Reno, is a valid one.....although the need for specialist medical treatment and availability might be a consideration here.
I would suggest it is highly likely that the insurance companies involved..... both the insurers of the airplane and the medical insurers, (especially the latter), will be very involved in 'discussions' as this investigation progresses.
The two issues of the lack of VCR / FDR.....and choice of hospital.....would seem to me to be the 'heads of pins' that insurers might wriggle on in any number of ways.
When one adds into the mix the medical insurance cover applicable to the patient in this instance.....AND.....the insurance cover of the Doctors' (specialist or otherwise), and the Hospitals, we could be looking at a wide mix of responsibility, negligence, culpability and less than fastidious attention to detail amongst any number of insurance companies.
Methinks that down the road a piece threatened court action and possible litigation between 'Our Learned Friends' representing the insurance companies, might come to pass.
James Hennighan
Yorkshire, England
man, that blows
RIP people 😥
Juan, thank you for educating us about aviation incidents and safety.
You ever notice how quiet it is outside when its snowing!?
One day when I was finishing my cross countries to get my GA license I was on final into SkyPark in Sonoma. I was just about to make the turn when I entered a cloud. I did not have any experience in instruments, but I knew enough (i thought....) if I ever needed it. It felt like I was in the cloud for about a minute, even though in actuality i'd guess only a couple of seconds. That's all it took to convince me that I'd have to get instrument training if I was going to continue in aviation.
I'm here to tell the tale...so I did successfully move out of the cloud and land. I'll never forget the feeling of pure panic.
יוי
We have a small airport in our town (no TSA) and a little airline that flies the Pilatus 3 times a day to the bigger airport in the state. It’s also single pilot and they are all just barely learning to shave. One morning they hadn’t called to board yet and I asked the counter lady if there was an issue and she said she thought the pilot was in the restroom. I found him snoozing in a chair and had to wake him up so we could go. We can also have thick freezing fog conditions. I’m starting to wonder if the convenience is worth the risk.
I contacted the NTSB yesterday Juan. I have already had a response from them. Thanks for the heads up
You're doing a great job of bringing us the FACTS without making a lot of assumptions. Appreciate that "stabilized" approach. :D
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The weather at the time on hwy 50 was 0/0 and severe icing conditions on the road surface. I am surprised that anything east of Reno could stay in the air at all. I suspect they picked up a ton of ice when going through that front. Reno at the time had much better weather but as you went east it was horrendous. It's a sad scene to visit. Luckily no one on the ground was injured, it was very close to houses.
Icing conditions can change with altitude. I haven't seen any icing reports yet and in the ATC communications I've heard so far, the pilot didn't report icing. I'm not saying he didn't pick up ice just that it doesn't appear to have been enough to alarm him.
I used to fly the PCXII 45's brand new we first got them, at RFDS Western Australia circa 2003 as a fleet replacement of the B200 kingair. Having also flown the newer PCXII 47 Ng's - I much prefer the large Honeywell PFD / ND on the 47. Single pilot Aeromedical was still the most demanding commercial flying I have done. Air France 447 as an example shows as humans we are all susceptible to startle and disorientation, regardless of crew compliment.
I take my hat off to the work you guys carry out. Seen you guys in action on some questionable strips and have had the pleasure of meeting a retired RFDS Kingair Pilot through work several years ago. All seem pretty happy with the PC-12.
But Air France was an example of when relying on instruments proved futile as well. Frozen Pitot tubes sealed their fates, those poor people!
Juan, do you remember a few months ago I, quite by chance, had lunch with Bruce Landsberg in Greenville with a bunch of local Av geeks, and I discussed your blog with him...he acknowledged that he had heard of you. db.
Thank you for making all of this understandable.
Spatial disorientation and single pilot, hard ifr is a wild, and incredibly delicate situation.
Snowfall in Reno was heavy on Friday. I spent the afternoon shoveling 4-5 inches of snow from our long driveway. I quit at about 6:30 pm and by then my 'work' was covered by an inch + of new snow. We had another 4-6 inches to shovel once again on Saturday morning. Our house is on the SW side of Reno at about 4500 ft elev. The voice communication between the Reno control tower and the pilot missing his turns on the taxiway indicates that the snowfall must have been just as bad down there at the airport. Saturday weather was comparatively mild and probably good flying conditions. Why did they get the urge for going in foul weather at 9 pm Friday?
Medevac operations have a lot of mission pressure. Not saying it's an excuse but certainly can participate in decision making processes.
Get ready for a lot more the next 3 days
Thank you for your excellent presentation. Unbelievable that any aircraft wouldn’t have a flight recorder in this age of technology.
I agree with you on everything especiallyon having a CVR. This accident will definitely put Pilatus and Care Flight on the spotlight now with the NTSB.
Thank you for the update.
There's a bunch of two crew air carrier accidents where both crew were disoriented, along with several single pilot disorientation accidents in night "VFR".
In a turboprop sim, the left seat pilot got the airplane upside down at 16,000' and kept it that way while I was shouting at him from the right seat that he was inverted all the way down to the ground.
The Artificial Horizon will keep you and your passengers alive - provided you use it.
Interesting.. I've done about 1500 hrs night VFR Ag without experiencing this and no IFR so I'm not qualified regarding this scenario but...I am trying to understand how someone can not look at their artificial horizon for an extended period of time... Genuine question...
I used to be an instructor using simulators and one of the failures was to fail the vacuum pump9s) in IMC. Depending on the equipment, the autopilot could follow the ADI and give the pilot a false sense of being in control until he / she notices the heading wandering too. Being able to catch this early with a good scan and revert to hand flying on backup instruments or partial panel is usually the only way out of this mess.
Thanks for the update Juan, very sad incident.
Remember a PC-12 break up several years back that involved a very low time pilot owner who lost control and broke up. They found one or two of his children about 5 miles from the actual crash and the rest of his family in the crash! HORRIBLE accident!
That was a horrible accident. May these poor souls RIP
Yes, seems very similar to this one.
thanks for the update juan. i hope ntsb can sort these issues and prevent further crashes of these planes.