C-140 Two Fatal 4/18/21

[AV8R_87]

Resurrecting this old thread to add the final report, including an analysis of the gopro footage recovered. I also would like to discuss some of the findings, and see what the rest of you would've done in that situation.

Final report:
https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102952/pdf

Specialist's report, includes screen shots and narrative:
WPR21LA166 ONBOARD IMAGE RECORDER AND AUDIO TRANSCRIPT - SPECIALIST'S FACTUAL REPORT

The short version (read the report for details):

They land at the accident airport due to a tach failure. After an inspection of the engine compartment, finding no oil leaks or other signs of failure, they elect to continue, with an inop piece of required equipment.
The crash happened at 19:48, with sunset at ~18:55 and end of civil twilight at 18:30. It was a night departure, in a pretty dark part of the country. The report concludes it was spatial disorientation, with the added distraction of an inop tachometer.



Topic for conversation:

The PIC had a total of 10.1 hrs of night time, with no logged night time in the preceding 90 days. While he was not in violation of 61.57(b), had the flight continued uneventfully he would've crossed that line a few minutes later. Without the tach failure and diversion, they would've gotten to their destination before 61.57(b) would come into play, but still in dark conditions, with minimal moon illumination. That's a pretty bad ADM failure, especially when having a commercial certificate and an instrument rating. That flight should've never been planned so close to night time with that level of night experience.
I am grateful to all the experienced pilots who were willing to educate me to the perils of night flying early on, emphasizing the dangers of a black hole night with no moon and lack of cultural lighting. Took a lot more than 10 hours before a moonless night flight over sparsely populated areas was something I'd consider.


A slightly more difficult one to talk about is the decision to depart with the inop tach. Yes, if you look at the rule book it's a slam dunk violation. The closest bit of civilization was about a four miles walk, so overnighting in the plane at an airport in the middle of nowhere was definitely not their first choice. But, rule book aside, with my (limited) knowledge of how a tach is driven from the accessory case, I'd feel a bit uncomfortable about continuing. Yes, it could be the tach itself that failed, or the cable. But what if it's something inside the accessory case, and now there are some chunks floating around, waiting to lodge themselves into something a lot more critical?

So, this is a question for the more knowledgeable people here - what would you have done? Even if you are an A&P, assume that's not the case for the purpose of this conversation.

 

[Lndwarrior]

Taking off a night, from that field elevation with no ambient light, in a poorly equipped 140 would have been a serious challenge for most pilots. I'm guessing that in the back of his mind he wasn't 100% sure of his diagnosis on the tach (though according to the report he was right). I'd guess the tach issue added to his stress level during the challenging takeoff. Maybe if I was flying alone I might have "attempted" this takeoff, but not with my wife in the plane. When she's in the plane my risk tolerance goes way down. And I probably wouldn't have survived the takeoff either.

Spatial D can happen fast and can really screw with your mind. It's more than just shock. You brain is seeing something and your body is feeling something that your mind cannot resolve.

All of a sudden nothing makes sense. As a result you have no idea what the correct response is. Your brain can just freeze your ability to react and it takes very little time in this state of mind before it turns deadly. Add in night and low visibility and its all over before you know it.

Of particular note abut this report is that the NTSB actually published some recommendations at the end. The "particular person who everyone on this board hates" has been calling out the FAA and NTSB on this very fact. According to their charter they are required to publish recommendations after an accident investigation. The "person in question" did some research and while i forget the numbers, the actual recommendations published after GA accidents was near zero in the past number of years.

Since he named specific and important people in the FAA I think maybe his harsh and blunt criticism maybe contributed to them publishing recommendations at the end of this report. His point being that these organizations are supposed to be helping improve GA safety and a part of this is providing learning from an accident investigation, and not just providing hard facts two years after the fact.

 

[MauleSkinner]

Of particular note abut this report is that the NTSB actually published some recommendations at the end.

…one of which is to seek training to ensure that you understand and can use any equipment in your airplane. The PDF of the Airplane and Engine Examination isnt opening for some reason. Be interesting to see if they had any gyros, and if so, was it (I would presume only one) spun up.

 

[Bell206]

what would you have done? Even if you are an A&P,

Unless someone was shooting at me, I wouldn't have flown out even if the pilot with me wanted to leave. And that is speaking as an A&P. Have spent quite few nights in an aircraft or worse. Sometimes you just need to tell yourself no.

Of particular note abut this report is that the NTSB actually published some recommendations at the end.

Safety recommendations are issued when needed and there are various protocols that are followed depending on the circumstances. Unfortunately, in the private/recreational GA side of things, people kill themselves for the same reasons over and over, so hard to come up with anything new except reissue the old ones. In this case, this report simply re-printed an NTSB Safety Alert from 2015 that was probably determined to be prudent in a vain attempt to remind people about reduced visibility dangers. No different than in the past 5 years there have been over 7 helicopter accidents due to weather/visibility issues, to include a very high profile one, yet just last week another helicopter did the same thing for the same reason. I seriously doubt there will be any "new" safety recommendations for that one as there are a million of them already existing. Sometimes you just can't fix stupid.

The PDF of the Airplane and Engine Examination isnt opening for some reason. Be interesting to see if they had any gyros, and if so, was it (I would presume only one) spun up.

Try this link.

 

[MauleSkinner]

I would read that as the attitude gyro wasn’t spinning, but the turn coordinator should have been usable.

 

[Bell206]

I would read that as the attitude gyro wasn’t spinning, but the turn coordinator should have been usable.

Except in the final report narrative they mention the AI was apparently working on the cockpit video they had. To me, if the AI wasn't working that fact would have been noted and possibly listed as a contributing factor. My guess it was operating and the pilot wasn't using it.

 

[Ed Haywood]

I would not have automatically diverted for an inop tach. If airspeed has not changed and everything else looks and sounds good, you know you have an indication issue, not a power issue. Unless the remainder of my route was over extreme terrain, or I needed exact power settings for fuel burn, I probably would have pressed on to the destination and done the troubleshooting there.

By far the most dangerous phase of night flight is takeoff. In Florida we lose aircraft all the time to night takeoffs over water. Venice lost 2 aircraft in a 6 month period last year, 8 dead. Once you get to altitude, you can usually get some kind of glow on the horizon for attitude reference. All the more reason not to land.

As an aside, I have an analog tach and an engine monitor with electronic tach. Redundancy is good.

 

[Ed Haywood]

My guess it was operating and the pilot wasn't using it.

Yep. Transitioning from visual reference to AI is hard, especially if you don't realize you have lost your visual reference. That's exactly how night takeoff accidents happen.

 

[Ed Haywood]

Wonder if it had ever been replaced?

 

[aftCG]

LORAN? Why is that listed?

 

[Ed Haywood]

LORAN? Why is that listed?

And why were they hauling around a couple pounds of gear that Obama declared obsolete in 2009?

 

[manac]

in a poorly equipped 140 would have been a serious challenge for most pilots

Plane had a AI and DG as well as a T&B. Not poorly equipped if everything was working. Not mentioned in the report, the instrument lights working would help.

The report doesn’t mention the last pitot static check and whether or not it was vfr/ifr.

The report mentions the specific 2198 rpm the engine was turning when it went in. Thats probably near full power at that altitude. Pilot had the same audio input. I don’t think the lack of rpm indication caused this crash.

The hero5 has gps, it would have been interesting data if it had been on and extracted.

 

[Ed Haywood]

Here's a good recent article about the challenges of the black hole departure. The article discusses the two fatal accidents at Venice, FL last year, but is just as relevant in this case. Key point:

“The departure is more of a risk than the approach is, because on the approach the pilot is already on instruments,” said McSpadden in October 2023, explaining that during black hole approaches the pilot is carefully watching the airspeed indicator, heading indicator, attitude indicator, and altimeter to maintain situational awareness. “On departure, the pilot may not be expecting to be on instruments, then the darkness comes at them rather quickly—and they are not ready to transition.”

 

[Hengelo]

“Unless someone was shooting at me” is going in the little black book.

 

[MRC01]

I agree with McSpadden. Treat night VFR departures like an instrument departure. Don't expect to see a horizon, even if you do see one you can't trust it due to common illusions. So fly it according to airspeed, heading, attitude, altitude. Do your scan and keep the needles where they need to be.

The FAA "moonless night" letter of interpretation says legal VFR conditions at night can be instrument for practical purposes, and in some cases justify logging the flight as actual instrument time.

Also, a day or two before the flight (to reduce surprises during pre-flight), ensure all bulbs, breakers, fuses, etc. are there. And alter personal minimums regarding wind, clouds, visibility accordingly. During night flight briefing, know what moon to expect and when it rises & sets. Also watch those temp/dewpt spreads as the Earth cools after sunset - you don't want that perfectly clear field you just took off from to fog up when the temperature drops.

 

[NavAir]

I have a lot more night time than the accident pilot, and have flown that area a number of times. No way I would fly there at night...

 

[AV8R_87]

I agree with McSpadden. Treat night VFR departures like an instrument departure.

I was taught the same mindset by a couple highly experienced pilots early on when my night hours were in the single digits. Made me (and my passengers) a lot more comfortable with night departures.
One other lesson, taught by the same people: never assume the other guy in the cockpit knows what he's doing. Trust, but verify. He might be getting spatially disoriented at any moment. Scan and be prepared to intervene, verbally or physically on the controls, if needed. I include this part in my passenger briefing as well.

While I like the fact that US pilots are allowed to conduct night flights as a part of their initial private certification, I can understand why Europe makes you get a separate night rating.

No way I would fly there at night...

That says a lot. The problem is most of the time we don't know what we don't know.

 

[woxof]

I would read that as the attitude gyro wasn’t spinning, but the turn coordinator should have been usable.

I read it as the attitude indicator showing no issues(working properly) and no evidence that it was not working properly. From the report.....

"-Attitude Indicator: Glass broken, pitch degrees not visible, roll pointer not present, artificial sky greater than 20° above the artificial horizon, general aircraft orientation indicated 10° right bank. Housing separated from the gyro assembly, gyro spun freely, rotor housing free of debris, and no rotational scoring signatures present. Rotor and spindle were unremarkable."

Which makes the possibility of spatial disorientation more likely(although impossible to ever truly confirm).