Mobile, AL: CAP, 2 Fatal, N784CP, ERA16FA100

A

Axtel4

Pre-takeoff checklist
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Axtel4
The FBO owner was concerned about the accident pilots flying at night given the potential for fog and offered them a courtesy car and assistance with obtaining accommodations for the night. The crew acknowledged his concern about the weather but wanted to return to BFM in time for their CAP meeting and before the fog set in.


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Tampico Trauma said:
The FBO owner was concerned about the accident pilots flying at night given the potential for fog and offered them a courtesy car and assistance with obtaining accommodations for the night. The crew acknowledged his concern about the weather but wanted to return to BFM in time for their CAP meeting and before the fog set in.


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FYI their destination BFM (Brookley) sits adjacent to Mobile Bay and can easily get fogged in, and I think that may be why the FBO guy was concerned, although MOB itself was beginning to or had fog forming too.
 
No, while experienced, not qualified. He missed one key qualification. Aeronautical Decision Making.



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may be a case of get there itis. May they Rest in Peace
 
Zeldman said:
Was the plane IFR capable.??
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CAP planes usually are, although not all of them have the latest avionics. The Kathryn's Report linked above lists it as a Cessna 182T, which is a G1000 model, so it was definitely IFR capable.
 
Palmpilot said:
CAP planes usually are, although not all of them have the latest avionics. The Kathryn's Report linked above lists it as a Cessna 182T, which is a G1000 model, so it was definitely IFR capable.
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The NTSB report talks about the G1000 as well. It said it had the KAP140 so I'm guessing no WAAS. And definitely no GA button or FD.
 
Palmpilot said:
CAP planes usually are, although not all of them have the latest avionics. The Kathryn's Report linked above lists it as a Cessna 182T, which is a G1000 model, so it was definitely IFR capable.
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Thanks, I was not sure.
 
Palmpilot said:
CAP planes usually are, although not all of them have the latest avionics. The Kathryn's Report linked above lists it as a Cessna 182T, which is a G1000 model, so it was definitely IFR capable.
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BTW, although quite rare some 182T can have steam gauges.
 
asicer said:
BTW, although quite rare some 182T can have steam gauges.
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Interesting - I didn't know that. However, it's a late enough model that I can't imagine that there are any that are not equipped for IFR.
 
As a lapsed CAP pilot(changed states, not yet gotten a chance to get my checkride up here yet) I was curious what prompted the reg changes with significantly more requirements for Instrument flight. I guess this was part of it.
 
chartbundle said:
As a lapsed CAP pilot(changed states, not yet gotten a chance to get my checkride up here yet) I was curious what prompted the reg changes with significantly more requirements for Instrument flight. I guess this was part of it.
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Could be. The increased requirements for takeoff could help, although I'm not so sure about some of the requirements about what to do if you find the weather below CAP's minimums when you get to the destination. Some of them seem like they could actually reduce safety.

"9.10.5.3.5. When established on any segment of the approach, should weather decrease below the minimums authorized by the flight release, the pilot in command is expected to abort the landing and continue on to the planned alternate airport or establish a holding pattern and wait until conditions again meet the above requirements. If conditions at available alternates and the primary airport do not improve or otherwise meet these requirements, pilots may exercise discretion and approach to published minimums."
​
Most flight releases will only authorize minimums to either 800 and 2, or 500 and 1, depending on the qualifications of the flight release officer. Authorizing minimums below 500 and 1 requires wing approval.
 
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Palmpilot said:
Could be. The increased requirements for takeoff could help, although I'm not so sure about some of the requirements about what to do if you find the weather below CAP's minimums when you get to the destination. Some of them seem like they could actually reduce safety.
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Yea, I'm fine with dispatch minimums, but artificially restricting the ability to make an approach I've never been a fan of. And is sounds even worse since if the AWOS says I have the 800 and 2, and I get there and realize I'm still in the clouds at 800 AGL I have to go missed even on an ILS.

Luckily it's almost never IFR up here in Oregon.
 
I forget, does the pre-WAAS G1000 have a terrain database?
 
chartbundle said:
Yea, I'm fine with dispatch minimums, but artificially restricting the ability to make an approach I've never been a fan of. And is sounds even worse since if the AWOS says I have the 800 and 2, and I get there and realize I'm still in the clouds at 800 AGL I have to go missed even on an ILS.

Luckily it's almost never IFR up here in Oregon.
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Yeah, if you were on an ILS and a new ATIS came out with a ceiling 100 feet lower than CAP's minimum, which is 300 to 600 feet above the usual FAA minimum, do they really think that aborting the approach would improve safety? Missed approaches have risks of their own, as this accident demonstrates, because the missed approach is where the crew died.

Another issue is the apparent assumption that conditions will get better if you wait around in a holding pattern. It's just as likely that the weather will deteriorate instead of getting better. Decision-making in that situation really needs to be more sophisticated than what it's possible to put in a regulation.

And then there's the bit about going to your planned alternate, which ignores the possibility that a safer alternate may turn out to be available once actual, not forecast, weather conditions are known.

At least they put in the bit about going down to FAA minimums if there's no other choice (duh!), but it seems like the first part of the paragraph could impose a potentially fatal delay in making that decision.

Once the aircraft is up in the goo, personally, whether it's CAP or FAA regulations, my goal is to live long enough to attend the hearing!
 
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Palmpilot said:
And then there's the bit about going to your planned alternate, which ignores the possibility that a safer alternate may turn out to be available once actual, not forecast, weather conditions are known.
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Here in the Willamette valley in Oregon and similarly in the California central valley where we often get widespread conditions, often your alternate may be in or over the mountains, or to an airport with a much less preferable approach. Having to fly from Eugene at 600 and 1 1/2 where the pilot has shot the ILS 50 times, over the mountains and into Bend where they may have been once just because it's 1000 and 3 there really doesn't seem like an improvement in safety. Similarly having to go from a nice full ILS to some airport with a VOR-A and 800 and 2 minimums just because that airport is currently reporting 900 and 3 doesn't seem smart either.

Oh well, I still need to find a 182 and a checkpilot before I have to worry about pesky stuff like that.
 
Zeldman said:
Was the plane IFR capable.??
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Most are. I found one annoying thing was CAP cheaped out in the G1000 airplanes. Here’s a panel that’ll do very useful stuff, and they’d only pay for the bare basic nav updates to keep them legal.

Terrain? Nope. Any of the advanced features the aircraft will do? Nope.

Seemed not to meet their “safety” stated goal to me not to keep the damn avionics databases, all of them, and all safety features, updated.

Been a while. Maybe they got over that stupidity.

I suggested they get the firmware update that Garmin made available back then to allow flight logging into the SD card and then review for pilots doing super stupid things. Like operating engines past limits. Because one was suspected of doing so regularly. (How you regularly fly the thing to make the engine cluster turn red in a multi person cockpit and nobody notices and/or says anything also ticks me off, but anyway... just log it and threaten anyone tampering with SD card with being tossed permanently...)

No budget for non-mandatory firmware updates.
 
Nav data is kept up to date. I don't know about the other databases.
 
The pilot checked in with the control tower and was cleared to land on runway 15. At 1944, the pilot declared a missed approach and the control tower responded by restating the climb to 2,000 feet and verified that he was issued the runway heading; the pilot responded "affirmative." Shortly thereafter, the tower controller noticed that the airplane was not climbing and reissued the instruction to climb to 2,000 feet; the pilot responded "roger." This was the last transmission made by the pilot. At 1945, the tower controller informed approach control that the airplane had been lost from radar.
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I don't understand this part of it - Roger, I'm going around, but I keep descending? The go around call was at about 300', the impact with trees was at 90'.

If an 11,000 hour ATP can screw this up then anyone can. Or is 11,000 hours part of the problem?
 
chartbundle said:
Yea, I'm fine with dispatch minimums, but artificially restricting the ability to make an approach I've never been a fan of. And is sounds even worse since if the AWOS says I have the 800 and 2, and I get there and realize I'm still in the clouds at 800 AGL I have to go missed even on an ILS.

Luckily it's almost never IFR up here in Oregon.
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I'm guessing you're not in the Western part of the state... ?
 
denverpilot said:
Most are. I found one annoying thing was CAP cheaped out in the G1000 airplanes. Here’s a panel that’ll do very useful stuff, and they’d only pay for the bare basic nav updates to keep them legal.

Terrain? Nope. Any of the advanced features the aircraft will do? Nope.

Seemed not to meet their “safety” stated goal to me not to keep the damn avionics databases, all of them, and all safety features, updated.

Been a while. Maybe they got over that stupidity.

I suggested they get the firmware update that Garmin made available back then to allow flight logging into the SD card and then review for pilots doing super stupid things. Like operating engines past limits. Because one was suspected of doing so regularly. (How you regularly fly the thing to make the engine cluster turn red in a multi person cockpit and nobody notices and/or says anything also ticks me off, but anyway... just log it and threaten anyone tampering with SD card with being tossed permanently...)

No budget for non-mandatory firmware updates.
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Our guys always babied our 182T, to the point of being really annoying. Our G1000/GFC700 plane had the SAREX package which was REALLY nice. The G1000/KAP140 wasn't nearly as capable but should have handled an IFR flight with no issue.
 
Probable cause released:

The pilot's loss of airplane control during a missed approach in instrument meteorological conditions due to spatial disorientation. Contributing to the accident was the pilot's inadequate preflight and inflight weather planning which resulted the pilot's selection of an unsuitable alternate airport, and the Civil Air Patrol's inadequate flight release procedures and inadequate oversight of the flight.
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https://app.ntsb.gov/pdfgenerator/R...tID=20160202X33553&AKey=1&RType=HTML&IType=FA
 
bflynn said:
I don't understand this part of it - Roger, I'm going around, but I keep descending? The go around call was at about 300', the impact with trees was at 90'.

If an 11,000 hour ATP can screw this up then anyone can. Or is 11,000 hours part of the problem?
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Maybe a 1,000 hours, 11 times? Or maybe they just had a bad day - we all be human; mostly our mistakes don't kill us. Mostly.
 
"The pilot's failure to climb the airplane during the missed approach procedure is consistent with the effects of spatial disorientation in the form of a somatogravic illusion"

I see this quite often during IPCs especially from rusty pilots. Heck I see people do this even with VFR go-arounds...the pilot adds power and the airspeed increases instead of the altitude.
 
dmspilot said:
"The pilot's failure to climb the airplane during the missed approach procedure is consistent with the effects of spatial disorientation in the form of a somatogravic illusion"

I see this quite often during IPCs especially from rusty pilots. Heck I see people do this even with VFR go-arounds...the pilot adds power and the airspeed increases instead of the altitude.
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We evil instructors also know how to INDUCE it in folks who’ve never experienced it. Like you said, most Instrument students will “find it all on their own” but when I run into pilots who say they haven’t ever experienced it, I offer to go up with them sometime and show them.

There’s about three techniques and almost always one of them will induce either “the leans” or the fore/aft illusion in most people.

Personally I did it to myself quite well without him needing to induce it and @jesse thought it was funny I couldn’t sit upright in my seat at night under the hood after some maneuvers and an approach or two. Best experience ever for it happening for real in IMC someday.

If someone hasn’t had it happen (VFR or IFR pilot) they should mention it the next time they’re out with a CFI. Flight Review, flight to breakfast, whatever. The good CFI should know some tricks on how to mess with anyone’s vestibular system.

Experiencing it in a controlled environment with someone there to keep you upright and flying is a good thing to have in your back pocket later when it happens and you’re fighting it.
 
dmspilot said:
"The pilot's failure to climb the airplane during the missed approach procedure is consistent with the effects of spatial disorientation in the form of a somatogravic illusion"

I see this quite often during IPCs especially from rusty pilots. Heck I see people do this even with VFR go-arounds...the pilot adds power and the airspeed increases instead of the altitude.
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Good tid-bit, good to know.
 
dmspilot said:
"The pilot's failure to climb the airplane during the missed approach procedure is consistent with the effects of spatial disorientation in the form of a somatogravic illusion"

I see this quite often during IPCs especially from rusty pilots. Heck I see people do this even with VFR go-arounds...the pilot adds power and the airspeed increases instead of the altitude.
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Had it happen with a student one night on the missed off Hilton Head. I even thought to myself, this is perfect conditions for spatial D. Sure enough, the 090 and 2,000 took us into the black abyss. Not long into it the student levels off and I say “you’re leveling off...keep the climb going.” Just a few seconds later he levels again, then starts a quick descending right turn. He immediately identifies it and says “I’m disoriented! You have the controls...f***!”
 
labbadabba said:
Dang they dinged CAP procedures as a contributing factor. That's bound to cause some palpitations.
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It is absurd for the NTSB to fault the CAP procedures when no such oversight or procedures are required for a part 91 flight.
 
labbadabba said:
Dang they dinged CAP procedures as a contributing factor. That's bound to cause some palpitations.
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It's already come through. There's new guidance on what level of flight release approval you need to have based on conditions. From memory the crew flew into the trouble, so I'm not sure it would have prevented this accident. But it is a way to call attention to riskier flights and ask someone less directly involved to evaluation the risk/gain comparison.
 
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