112TW Go-Around Final Report Update
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- čas přidán 7. 10. 2023
- 112TW Go-Around Final Report Update
Bonanza Go-Around Gone Horribly Wrong
• AccidentReview Bonanza...
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FlyWire is about exploring flight and the freedom this incredible experience brings us on a personal level. Flying has always captured the imagination and excitement of living life to its fullest. Hi, I'm Scott Perdue. In a former life I flew the F-4 and F-15E, more recently I retired from a major airline. I've written for several aviation magazines over the years, was a consultant for RAND, the USAF, Navy, NASA as well as few others, wrote a military thriller- 'Pale Moon Rising' (still on Kindle). But mostly I like flying, or teaching flying. Some of the most fun I had was with Tom Gresham on a TV show called 'Wings to Adventure". We flew lots of different airplanes all over the country. Now with FlyWire I want to showcase the fun in flying, share the joy and freedom of flight and explore the world with you. Make sure you subscribe if you want to go along for the ride!
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As always, an excellent and thorough analysis, Mr. Pudue! I am a mere 1000 hour PPL, and I fly a PA28-236 out of CA35 which is just south of Anguin. I flew a few minutes north and landed at Anguin once. It is such a beautiful spot to fly into and to visit. On a ridge overlooking the world-famous Napa valley, for goodness sake. This is probably a secondary factor to the ones you highlighted, but when I landed there for my first and only time, I was struck by the extremely undulating terrain around the airport. The runway is on a plateau or a mesa surrounded by valleys, hills, and mountains. (Sort of like Sedona, but less dramatic.) Atypical topography like this messes with the mind's expected sight picture. Landing on a mesa felt to me a bit like I imagine it would be to make a carrier landing. And I had heard about downdrafts landing on mesas like this, so I came in a bit high and fast. I didn't have a PIO, but it wasn't my best landing, by a long shot. Thankfully I was flying alone and in the left seat. No other distractions. Sitting in the right seat, not having just made long flight from SoCal to NorCal, which has also been pointed out. Add those factors all together and I can so easily see how this could happen to many pilots. RIP to these three and peace to their families. Thank you, Scott, for finding a way to save lives with grace, not sensationalism.
*sitting in the left seat
Thanks for sharing your observations Derek!
Every pattern/approach should be thought of as setting up for a go-around. If everything looks good, switch from go-around to landing.
I like that!
I was always taught that the default is a go-around. I still have a hair-trigger and will perform a go-around for even the weakest of reasons. PAPIs out of service? Crosswind? Gusty? You'll probably see me treat it as a low approach/ go around to feel things out.
This pilot was one of my group of about 5 others who flew together just about every weekend and hung out at KSNA together during the week. We were all best friends. It's still a shock.
Sorry for your loss.
😔
This is a table top airport. The approach can create illusions, with the surrounding terrain dropping away steeply, narrow upslope runway, and buildings facing you at the end as you touch down. I've landed here a number of times and it's never comfortable. Especially if you don't have an accurate altimeter setting. This is one runway you need to be on your game.
My DPE. "Take me to Angwin".
I learned to fly there. None of the local airport/runway issues you mention would have been a problem if he flew a normal approach speed and crossed the threshold on speed and altitude.
I fly in there several times a year and it does require one to be on his/her game.
Great analysis Scott. Good catch on the pilot adjusting the prop rpm instead of the throttle and the rotation from the tree. I’m looking forward to flying w you in a few weeks in my bonanza.
Former MEI and current 767 Check airman here. At work in the 767, I must stay proficient in both seats - and I do. I also fly my Baron quite a bit, and will not sit in the right seat flying with other pilots because of the huge threat of me not being proficient in the right seat. I will get there, with another Baron qual'd MEI, but I must have enough humility to know what I'm good at now, and what I am not.
Thanks for the comment!
This probably involved one of those terrifying moments where you go back and forth on what course of action you want to take, think you commited to one, then change your mind, then again... each time digging yourself deeper.
As someone who recently got a cfi, changing from left to right seat, even in a 172 was something that took some getting used to, especially approach and landing
Thank you for the update Scott, I still go back from time to time to review this accident since it happened and I remember reaching out to you on your website asking if you would cover this accident way back when it happened. Excellently presented as usual.
Thank you, I appreciate that!
This was, in my opinion, a "physiological emergency", either code yellow or code brown. We don't ever discuss this "human factor". I have personally had many discussions with the witness. They made an early radio call reporting way close, way too high, way too fast. The approach remained that way. The witness was simply astonished at the approach speed and height on final. Having talked it out with her at length it seems reasonable that after a long flight a 74-year-old man simply didn't want to embarrass himself in a packed plane with his daughter by his side if he didn't get to a restroom. As related by the witness account, this aircraft was unstable 6 miles out, unstable on downwind/base/final. Not a little unstable. Just "balls out I'm landing this plane on the first attempt period" unstable. The "get there itis" caused by the need to use a restroom is severe. I'm absolutely convinced that was the human factor that led to all the subsequent errors and crash.
Could be Peter. But I can only rely on facts that are known.
@@FlyWirescottperdue could be a thousand, or at least half a dozen reasons the pilot might have wanted to land ASAP...
worried about weather worsening/uncertain of go-around procedures in the terrain/unsure about his fuel status or getting low on fuel.... all these could be reasons for hurrying to land.
we can surmise one thing... the guy was clearly desperate to land... why is only conjuncture!
Why could it not be a matter of “I always landed after my approach the past 30 years, today is no different “?
Advice is so very well stated, thanks, going to refer this video to my ground students
Terrific analysis. Tremendous, really. What a great service. And "telling it like it is" when it's useful.
if not stabilized, if bouncing, go around. As it's said "you like to fly, anyway," so look at it as an opportunity to do a little more flying!
Whew - phone back in the saddle for now. Sorry about this sad accident. Good analysis. Agree with you. It doesn't sound like the best of judgement may have been exercised here. I got the impression of dominoes falling, where mistake #1 leads to the next one, etc. Gotta know when to hold em, and know when to fold em - and go around.
Thanks for sharing. Take care.
Thanks Nancy. Definitely chain of errors here.
Enjoyed this video from start to finish. Very informative. Awesome visual backdrop/set for this one. Thanks.
Todd
I figured you'd like it!
You figured right...
Well said and thanks again.
Keep it going Scott Great Stuff.
All TO's are an engine about to quit
All landings are a go around about to happen.
Well done Scott. I understood everything with one listen.
As a CFI, practicing go arounds is one of the most dangerous things I do with students. Actual go arounds are even more exciting. I spend a fair amount of time going over how to e perform go arounds on all flight reviews and instrument proficiency checks. Well worth getting some instruction if you haven’t practiced this maneuver in a while. Once you get a PIO going it can be hard to recover.
That is true. I teach no drama Go-Arounds. I don’t like drama.
High value Scott, thank you very much.
It seems to me that if you want to hold a bonanza with a single yolk, the more experience pilot would sit in the left seat. This is a sad story.🙏
Scott - i think that ForeFlight photo which appears to show a very crooked, undulating runway… is just a bad satellite image. The actual runway is perfectly straight, a little sloping to the north (per the AF/D), but other photographic images confirm that it’s nothing like what shows up on ForeFlight (which would be nuts).
Can confirm it's straight. I land here weekly.
Thanks Keith. I was wondering if crooked runways were actually a thing.
My club flew T182RG;s and T210's. I did short final go arounds all the time, for fun.
Angwin-Parrett Field has Cessna Citations and a variety of piston twins in and out of the airport, some based there. But the pilots of those planes certainly know to fly in with stabilized approaches. When landing on RWY 16, there is an ample overrun (extension) at the end of the runway and before the ramp/hanger area, too. This was another example of sloppy (behind the airplane) airmanship all around by the Right Seat Pilot (RSP).
Yep once the airplane starts outrunning a pilot especially at low or near grade altitude the conclusion isn't going to be positive...often deadly!
For what it's worth. I witnessed this accident & provided a statement to the NTSB. The loss of controll looked more like it was caused by stall spin than the tree contact. However I was a quarter mile or so away and couldn't see perfectly. Maybe they hit the tree while entering the spin?
I don't think so. If it was a stall/spin it would not have traveled another 500'. I can see that from your perspective it would have looked like that.
There is a condition you can get in, nose high, high power... low and slow and nowhere to go.
Push and lose altitude to gain airspeed or pretty much anything else stalls it.
I think they got in that condition.
Indeed... the backside of the Power Curve.
It's really wild when you first feel that at the controls. "Hang on, I have 2400 RPM, and I've stopped."
I got to meet the wife and mother of the pilot and daughter. She was selling off some of his aviation items. She was a very strong woman and I felt honored to meet her. She invited me in their beautiful home and we spoke briefly about the accident (I didn't want to get in a details or pry) And you can see they loved Aviation. They had a map on the wall showing their cross country flight from California to the Caribbean and various other aviation items scattered around the house.
I'm a low hour pilot in comparison and I guess the point is the reminder for me is it can happen at any time and always be vigilant. A sad situation and the item I bought off her lives in my hangar and will be a reminder to always keep my guard up.
RIP aviators.
Good thing to meet her.
The only go-around I ever did was on my check ride for my private pilots license at Meacham Field in Ft Worth. 1976. I was too high and fast on approach and instinctively initiated a go-around. My check ride pilot complimented me on doing it after we landed. Said "you're a good little pilot". I had just turned 17.
In a 1946 65-hp Champ, go-round is always in my head every landing.
I don't have many hours but I find it totally weird/odd when setting in the right seat! I mentally and visually just not matured to feel comfortable trying to fly even when at a safe altitude levels. So sorry for such a tragic yet preventable accident 😟
Great advice, thanks.
I enjoy the content and there is great information in this video, however I would really like it if you would get please a serious microphone or turn up the volume
Single yoke plus this non-ideal setup in old style Bonanza panels - besides the non CFI action. That’s why I specifically looked for post 1984 A36s only!
My condolences to family and friends! RIP!
Good briefing Gunny. My already private or commercial students who were willing to change to the basic level in low ground effect to cruise airspeed on long runways for both takeoff and go around and then cruise climb had few iterations of the outcome being in doubt. I had few retractable airplane students and didn't push ground effect as much because they liked to get out of ground effect pretty quick for the gear. Still cruise climb. What are your thoughts on extensive use of ground effect for both takeoff and go around? Also I flew low powered, tired airplanes. Occasionally I needed the extra free ground effect energy. I also taught, especially at high weight and/or DA, if pulling on the yoke doesn't get the climb you want, try pushing. I understand that uphill at the end could have messed with this technique some, or maybe not.
How many times do we have to go through these go around failures!! Especially Bonanza airplanes... If you're going to go around, hard right rudder and nose downward pressure is a must! Also, a stabilized approach is necessary, or.... GO AROUND!
Excellent lessons
Thanks 👍
What an awful scenario. I completely agree with the material proficiency impact alone of flying right seat versus left, notwithstanding the throw over issues. So many preventable issues here. Sad ending of life. RIP aviators.
If the prop was not set to max rpm it would have led to being fast on approach at every given rpm. The prop is not providing the same aerodynamic braking. On the go around you won't get full horsepower and you won't get it as quickly. Prop full is in GUMPS for a reason.
Just a thought: Sometimes a tired pilot may try to save a landing rather than go around. This was a long flight and part of it was through LA, which can be stressful and tiring.
All the more important to be on your guard.
Good report Scott. On the numbers and three green.
🌏🇭🇲
Phone challenges - will have to watch later. Thanks for sharing.
Conclusion, never force a landing!
That crooked, bumpy and lumpy runway looks like the Highway 29 corridor did after the Napa quake a few yrs ago...Highway ?29 and the Downtown region are continuing to be appropriately fixed in some manner of a triage system. Perhaps they should add that so-called runway to the list of asphalt casualties!
(Please note: This comment does not relate exclusively to the featured incident.)
Sadly, whether it's driving a car or flying a plane it seems to be part of human nature to give a dire situation one more try, to think, "I can still do this! I can save it! I can fix this!"
Sometimes you get away with it.
In most cases you're gambling with things that aren't yours to lose. Having 'the right stuff' may be desirable if you're a wartime fighter pilot or a racing driver risking your own neck, but I can't see that it has any place in the real world.
A great deal of a professional airline pilot's training seems to focus on reprogramming our risky, instinctive 'I think I can save this' attitude.
I wonder: is it more of a strong, independent alpha-male thing, like not reading instruction manuals, or not asking strangers for directions when you're lost because it's an admission that you're not fully in control of the situation? I've never heard a man admit to being anything other than a very good driver, for instance. But they can't ALL be very good. Look at the statistics.
Whatever. Rigorous training is supposed to replace square-jawed determination with the automatic response of relying on established routine, formal check-lists, and making the right split-second decisions (TOGA or not TOGA?) when a mix of common sense, pride and panic are telling you to 'give it one last try' before quitting.
Wrestling your damaged plane down onto the deck of a storm-tossed aircraft-carrier when under fire and out of fuel is one reason for avoiding a go-around.
I can't think of another good one.
I haven’t flown a Bonanza so can’t comment on what works for that, but when I was learning to fly back in the 70s (sadly, that’s not a typo) in a C150 my very high-time instructor taught me to handle a bounce this way when the approach speed was a little high and the sink rate also too high. As soon as reaction time permitted when the airplane bounced, let the control wheel move briskly forward to the neutral position or slightly forward of it. This isn’t really a push on the yoke as much as just quickly relaxing back pressure applied during the flare. Hold this for about a second and then gradually pull back on the yoke again without adding power, unless your bounce was due to dropping in from a too high stall. Most PIOs are induced by not reacting swiftly and aggressively to that first bounce which then gets you out of phase with the airplane. If you maintain back pressure until the airplane is at the apex of the bounce and then release the back pressure as the nose begins to trip again, you are now out of phase with the airplane and a PIO is nearly guaranteed.
While learning to land, I got to practice this technique a good number of times and the Cessna spring steel gear would really throw you back into the air if you hit very hard. I have used this technique in all other airplanes I have flown (all Cessna 100 series or PA28s) and it has worked in everything I have flown. I have yet to get into a PIO as this technique, properly executed, pretty much makes that impossible.
Try this on your next bounce and see how well it works (preferably with a CFI if you aren’t a fairly experienced pilot). Maybe it doesn’t work with other airplanes, but with a light Cessna or Piper, it works well.
I have a question for you. At a critical altitude, when trying to clear an obstacle at the end of the runway and the gear is still down. Should you retract the gear which robs engine power, or leave the gear down and let all the power go to producing thrust and therefore lift?
Good question. I can only answer… it depends. On your judgement.
Thank you for answering! @@FlyWirescottperdue
If I was taking off at a runway that was so short or high that I needed the gear up to clear the trees, I'd offload PAX, fuel, wait for a cooler day, or take some other action - I wouldn't risk it.
Electric gear systems will require minimal power from the engine - only up to the max power of the alternator. Assuming a 24v 150amp alternator, that gives about 3600 watts, or less than 5 HP. This is the most extreme case for an aircraft like this - no idea what kind of alternator was in this particular model. From what I understand, the LG circuit breaker is 20 amps on 24v systems, based on my reading of the internet, which gives only about 1/2 HP. I've seen 35ams on 12v systems.
Someone smarter than me can do the calculations of the additional drag of having the gear out at that speed, and see if it's more than the HP needed to get the gear up.
I'm confused. The NTSB report said both pilots held PPLs for single engine land. So was there really "flight instruction" being given? This was a father and daughter in a plane their family owned. I'm sure both of them had many take offs and landings in this airplane. Right seat take offs and landings are a skill all pilots should learn.
The throw over yoke was a cost effective solution to a lack of space but everything else about them is a compromise. I always hated them.
Whats a throw over yoke?
@@doctriestosew4333 It's a single yoke generally in the centre of the instrument panel that can be slid left or right ('thrown over") so that the aircraft can be flown from left seat or right seat. The idea is to help maximise the limited space available in a very small cramped cockpit (two interconnected yokes would take up more room and conceal instruments). Generally, they are easier to fly from the left seat position because of the instrument placement (though there are doubtlessly exceptions). Not suitable for training because it takes time to throw them over and for other reasons ...
@@benpatana7664 thank you. Excellent explanation...makes a lot of sense now
The idea of any landing is if it is possible (to land safely) and things are good, normal, and with an acceptable stabilized approach...
I think in the UK I can let someone fly above 500 feet. So on an approach shoukd be mine below 500 feet.
Does'nt everything go to the firewall???
I wonder what the dynamic was like between father/daughter, outside of the cockpit, and what the pre-flight went like.
I love my Dad, but I am sure if I was being instructed, I would use somebody else. Dad and I fought when under pressure.
I know both personally. Excellent father daughter relationship...no power struggle..she was a newly minted pilot.
@@user-rf4fg1th1q That's exactly what I would expect. He has taken over at some point in the flight, but then she is recommending something, right when she sees things starting to unravel. I mean he is watching, but stepping in didn't fix it.
It feels like he didn't have 100% confidence in her, taking contol during a critical phase of flight, but then she starts to doubt his call, late in the move.
I am certain these were good people.
All I am saying is sometimes we treat family different than we do strangers.
I've landed at that airport before. That runway has some major undulations and it isn't easy to stay in the center of the runway.
The notification was visual and silent. Let's check it out.... Land long, live short. As I remember hit the power and start trimming nose down because well you don't want it to put you in a pitch up stall state that quick.
Bonanza's are definitely a pitch trim airplane!
These assessments are when you're at your best. Thanks, Scott.
Maybe prevent murder/suicides like this, in future. Or not. Yuky. Either way, you're trying.
"Don't act like a CFI if you are not." Down the slippery slope we go! Can I take a friend for a ride and let them have the controls at 3000 feet? Can I let them sit in the left seat? Can I let them fly it down to final approach?
In the USAF WSO's can't fly below 2000' AGL. How's that for a guide?
👍✅
"Don't cowboy it" Cowboys always get a bad rap!
Airspeed on final, airspeed on final, airspeed on final
ALWAYS plan on a bolter….every landing….you just never know….rip.
I was taught that there's no such thing as a failed landing; it's a successful go-around.
Many of these too fast approaches and go arounds accidents are because the owners are "Anti Forward Slip". Why? Because slips are for those small plane pilots, im a Bonanza Pilot! , or Im a Cirrus Pilot, i dont need slips!, NAA!. So they find themselves needing them and landing too long. Then have to do a go around, which is like a touch and go. But.. NAA! i dont practice touch and goes, because that is for little airplanes too, NAA! And ... They pay the price.
Sorry to say it, but so many are arrogant anti "Small airplane maneuvers", NAA!, We dont need to practice those small airplane maneuvers, We are big airplane owners, NAA!..
😎
This is just sick. I could transition from left seat to right seat no problem. So should any c f I with a few hours under their belt.
Single engine planes of that weight and aspect ratio should be banned and illegal.... As well as most other...😂
CFI,,CFI,, who teaches one to become a CFI???AFI,BFI??C comes after AorB,,
A CFI that has done at least 200 hours of instruction.
“Big bucks” 😆
Dad decided to take daughter and her husband on a trip to Napa in his plane, he tried to give her lessons and information along the way as they both shared flying...he is using this instructor garbage as some kind of excuse..it was family, this happens all the time, and that was the real cause of the crash, it probably wasnt the first time they flew together like this either..only this time it went wrong..poor husband in the back innocent...I saw the wreckage in the vineyard