Cessna 421C Monterey 7/13

He crashed it into the back side of the house (the side facing away from the departure path) in a descending right turn. From memory of that airport, a right turn is the last thing you'd want to do departing from that runway because it turns you into the hills, vs the flat land to the left. https://flightaware.com/live/flight/N678SW
 
luvflyin said:
Cleared for takeoff around 8:00. Shipped to departures around 9:20. Tower realizes somethings going wrong around around 10:00
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Couldn't tell by her readback if she understood the "report if not on top by 5K', remain at 5K' and advise" instruction, but she may have just had trouble getting her words out. However, reported tops at 2,000' so it may have had no factor in the incident since she never made it above 2K' to clear the tops anyway. Wonder if it was a medical issue with the confusion.
 
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I believe she started turning left after departure but then the controller tells her to turn right immediately as if there is a traffic conflict. The track logs on FlightAware show these turns.
 
SoonerAviator said:
Couldn't tell by her readback if she understood the "report if not on top by 5K', remain at 5K' and advise" instruction, but she may have just had trouble getting her words out. However, reported tops at 2,000' so it may have had no factor in the incident since she never made it above 2K' to clear the tops anyway. Wonder if it was a medical issue with the confusion.
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I never heard that type of clearance before, so it would have thrown me off too.
 
MooneyDriver78 said:
I never heard that type of clearance before, so it would have thrown me off too.
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It sounds like the clearance you get when you file or ask for IFR to VFR-on-top. We often use that in the Bay Area to get out of an airport that is IFR under the coastal stratus. Since she was a veteran Bay Area instructor I would guess it wasn’t unfamiliar to her. And maybe she was distracted by something else?
 
That’s not the track log. Click the link above that picture. Doesn’t have plots too far left, but it goes from 114 to 102, then back to the right. Regardless, the controller tells her when she checks in, “turn right immediately, right hand turn, heading 030” and then says something else which is hard to discern but includes a reference to “altitude immediately” and “three thousand seven hundred”. Then ten seconds later another controller on same frequency advises of a low altitude alert with instructions to climb to 5000.
 
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TrueCourse said:
That’s not the track log. Click the link above that picture. Doesn’t have plots too far left, but it goes from 114 to 102, then back to the right. Regardless, when I listened to the feed I am almost positive the controller says something about turning left then, “turn right immediately”.
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tower does say left a couple times. It's when she checks in with departures that she gets the turn right. The flight aware track indicates no left turn after departure was made. The timing of her takeoff clearance, the frequency change to departures and the timing of the turn right instruction from the departure controller seem to me indicate that the departure controller gave the right turn to 'salvage' the situation. By that time a turn back to the left didn't seem like a good idea. Time will tell when more detailed info comes directly from ATC tapes and radar data.
 
She sounded kind of stressed, like she was about to cry. I don’t know her so I’m probably completely wrong. Hopefully the investigation will reveal what happened.
 
Brad Smith said:
She sounded kind of stressed, like she was about to cry. I don’t know her so I’m probably completely wrong. Hopefully the investigation will reveal what happened.
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There are folk in another forum who knew her well. Said she did not sound like herself at all. She was 74, an ATP rated CFI with a careers worth of experience. Medical issues are being considered.
 
MooneyDriver78 said:
I never heard that type of clearance before, so it would have thrown me off too.
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cruiserandmax said:
It sounds like the clearance you get when you file or ask for IFR to VFR-on-top. We often use that in the Bay Area to get out of an airport that is IFR under the coastal stratus. Since she was a veteran Bay Area instructor I would guess it wasn’t unfamiliar to her. And maybe she was distracted by something else?
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I assumed it had something to do with the "VFR on Top" part of the clearance as well, but I don't have the Instrument ticket/depth of knowledge so I didn't want to speculate.
 
With the readback exhange, it doesn't sound like much of a medical/cognitive issue to me for a 74 year old. I've heard worse from 25 year olds. Don't know if I would put too much weight on that before takeoff, for the present. The descent before the impact is concerning, from maybe 1800 AGL. It has all the indications of a spiral dive in IFR, tightening circle, increasing airspeed and decreasing altitude in a linear fashion.
 
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luvflyin said:
There are folk in another forum who knew her well. Said she did not sound like herself at all. She was 74, an ATP rated CFI with a careers worth of experience. Medical issues are being considered.
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skyking3286 said:
With the readback exhange, it doesn't sound like much of a medical/cognitive issue to me for a 74 year old.
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For an ATP rated CFI with a careers worth of experience, I would have expected a more crisp exchange. She also failed to read back the runway assignment when cleared for takeoff.
 
TrueCourse said:
I believe she started turning left after departure but then the controller tells her to turn right immediately as if there is a traffic conflict. The track logs on FlightAware show these turns.
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No, she never turned left. Tower was trying to reach her to start the turn to the left after he handed her over to Departure.

The Departure controller screwed up by giving her the wrong direction - he told her to turn right immediately to a heading of 030 which was obviously to the left. I'm not sure you can tell definitely with the ATC recording and FlightAware info whether she started turning right before or after Norcal gave her the conflicting instruction. While the controller may have misspoken, I'm not sure that had anything to do with the right spiral.
 
luvflyin said:
Cleared for takeoff around 8:00. Shipped to departures around 9:20. Tower realizes somethings going wrong around around 10:00
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One thing I didn't notice until I downloaded both clips to Audacity and played them simultaneously:
At 10:00 tower reminds her to turn left and asks if she's still on frequency. At 10:09 she tells approach she's still on frequency. So it seems like there was some radio mismanagement as well.

Looks like the timing is:
8:06 tower cleared her for takeoff
8:10 she acknowledges
10:00 tower reminds her to turn left and asks if she's still on frequency
10:09 she tells approach she's still on frequency
10:15 approach tells her to turn right immediately to 030
10:23 approach says MVA is 3700
10:37 low altitude alert, climb immediately maintain 5000
10:51 tower asks how does she hear followed a split second later by approach asking if she's got an emergency


Flightradar24 says she was turning onto the departure runway around 38 minutes past the hour...
upload_2021-7-14_16-46-57.png

So she would have been somewhere around here when tower reminds her to turn left.
upload_2021-7-14_16-47-38.png
 
It's situations like this where I really appreciate the type of moving-map display that turns red when there's terrain at or near my altitude.
 
OK, now I can see that she didn’t start a left turn as instructed in the departure procedure. I interpreted the temporary change in track to the left as an initial change in heading, but it could have simply been the airplane briefly drifting.

If the timing (and positions on the map) of the previous post is all correct than the controllers “turn right immediately, right hand turn, heading 030” was intentional, not a mistake. She was already turning right anyway.
 
TrueCourse said:
OK, now I can see that she didn’t start a left turn as instructed in the departure procedure. I interpreted the temporary change in track to the left as an initial change in heading, but it could have simply been the airplane briefly drifting.

If the timing (and positions on the map) of the previous post is all correct than the controllers “turn right immediately, right hand turn, heading 030” was intentional, not a mistake. She was already turning left anyway.
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I think what you meant to say at the end was “...already turning ‘right’ anyway.”
 
Palmpilot said:
It's situations like this where I really appreciate the type of moving-map display that turns red when there's terrain at or near my altitude.
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In this case I don’t think it would have helped, a slow right turn and decent like that appears she became incapacitated.
 
MFE said:
Turns out there were also a passenger and a dog on board https://www.ksbw.com/article/monter...eleased-family-ntsb-press-conference/37027054
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It's terrible when a plane goes down and the pilot is lost, but even worse when passengers are involved. In this instance, the pilot had offered to fly the passenger to Sacramento. She lived in Rancho Cordova, and had been visiting her mom.

By happenstance the passenger met her death, a cruel occurrence that was unexpected. One wonders about the randomness of the universe and free will. As Sophocles said in the Greek tragedy Antigone, fate decrees and we must obey.
 
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Juan Brown offers a good analysis

 
skyking3286 said:
I've heard worse from 25 year olds
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..but this wasn't just rusty radio dialogue from a wet-ticket pilot. It sounded like she was struggling to comprehend the whole 'stay at 5,000 if not VFR by 5,000' thing.. for someone with her level of experience that shouldn't have caused that kind of hesitance. One thing for a <200 hr fresh IR ticket to goof a readback, something else for someone experienced

asicer said:
For an ATP rated CFI with a careers worth of experience, I would have expected a more crisp exchange. She also failed to read back the runway assignment when cleared for takeoff.
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Yeah, I agree

As a purely objective question, would a 74 year old woman be able to manage the control forces in an engine out on a heavier twin piston? My twin experience is only 50 hrs in Duchess and Aztec, but you do need a relatively "firm" amount of pressure until you are trimmed and feathered. My dad will be 75 in two months and honestly I can't imagine he'd had the physical strength, or cognitive ability, to fly.. much less manage an emergency
 
Tantalum said:
Juan Brown offers a good analysis

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Kind of disappointed he didn't put together the tower and approach recordings like I did in post #19.

I do wonder if she got the procedure confused. MRY5.MRY says right turn after 1100MSL departing 28L/R and climbing left turn departing 10L/R. If you look at the track, she maintains roughly runway heading until 1100MSL. Makes me wonder if she got the two departure instructions reversed.
 
Could be, but it still doesn't account for the tightening spiral dive from 1800' at the end. Sad to hear she had a passenger and a Dachsie on board too. NTSB will have its work ahead of it.
 
skyking3286 said:
Could be, but it still doesn't account for the tightening spiral dive from 1800' at the end. Sad to hear she had a passenger and a Dachsie on board too. NTSB will have its work ahead of it.
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Perhaps a sudden realization that they were headed towards terrain and a desperate attempt in IMC to maneuver out?
 
That radio exchange was not what I would have expected from an experienced CFI. You may have heard worse from a 25 year old, but I've never heard anything like that from a 25 year old CFI. According to her son, she had owned the airplane for ten years, so it was not a lack of familiarity.

There was some mention made of aircraft debris found distant from the main wreckage, leading to the possibility of in-flight breakup. If it's not that, I think it leaves cognitive impairment, perhaps a TIA, or cognitive decline. We see evidence of that in the public sphere on a daily basis.
 
LesGawlik said:
That radio exchange was not what I would have expected from an experienced CFI...
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Or a Class Charlie controller.... If the pilot cannot do a read-back of a simple taxi and runway assignment, that pilot should not be cleared for take-off.
 
That's putting a lot on the controller. I made calls like that during my training. Most of the time I had an instructor next to me. Does a controller have authority to deny a takeoff clearance because the pilot needed prompting to get the readback correct?

I have heard exchanges like that on VASAviation between KJFK and airliners. Should the controllers deny landing clearances? What should the passengers do?
 
At MYF they are very strict about requiring all runway crossing and hold short instructions with full call sign and runway number

I had a hard time understanding the controller but I was also a bit surprised that he wasn't requiring her to read back the full instruction

There's a spectrum there somewhere, controllers have saved pilots lives before.. Kalita comes to mind, I am sure there are others
 
NordicDave said:
Or a Class Charlie controller.... If the pilot cannot do a read-back of a simple taxi and runway assignment, that pilot should not be cleared for take-off.
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Tantalum said:
At MYF they are very strict about requiring all runway crossing and hold short instructions with full call sign and runway number

I had a hard time understanding the controller but I was also a bit surprised that he wasn't requiring her to read back the full instruction

There's a spectrum there somewhere, controllers have saved pilots lives before.. Kalita comes to mind, I am sure there are others
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If a pilot cannot clearly and confidently readback "Bug smasher N3456R, Taxi via Echo, Bravo, hold short rwy 1-0-R"; they shouldn't be given the clearance to taxi or take-off.

I'm NOT saying don't help the pilot or coach him/her, but if they can't perform a simple readback, might be something going on and best not to fly.
 
Tantalum said:
At MYF they are very strict about requiring all runway crossing and hold short instructions with full call sign and runway number

I had a hard time understanding the controller but I was also a bit surprised that he wasn't requiring her to read back the full instruction

There's a spectrum there somewhere, controllers have saved pilots lives before.. Kalita comes to mind, I am sure there are others
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What’s the Kalita story?

EDIT: found it I think, the hypoxia thing?
 
luvflyin said:
What’s the Kalita story?
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Yup! Controller realized that something was not quite right. I think there were a few others if you dig around, controllers get recognized for these things. But there's a huge grey area there. Is the pilot just sloppy? It would set a fairly big (and in my opinion, not good) precedent if controllers started declining take off requests, etc., just based on a hunch. BUT.. asking her to read back the full call sign and clearance, or gently asking if she needed a few more minutes, etc., might not be a bad idea. Who knows. I'm sure controllers hear sloppy comms all day but in the full accident chain her radio skills would appear to be a clue (or a red herring..)
 
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