NTSB recommendation re: Mooney accident in WY last fall

[Everskyward]

I didn't want to add to this already lengthy and sometimes OT thread so I started a new one.

Minnesota Father and 3 sons missing in Wyoming

http://www.ntsb.gov/Recs/Letters/2011/A-11-032-034.pdf

On October 25, 2010, about 1352 mountain daylight time, a Mooney M20J airplane, N201HF, collided with mountainous terrain near Lander, Wyoming. The pilot and three passengers were fatally injured, and the airplane sustained substantial damage. The airplane was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Instrument meteorological conditions likely prevailed at the time of the accident, which operated on an instrument flight rules (IFR) flight plan to Pierre Regional Airport (PIR), Pierre, South Dakota. The flight originated from Jackson Hole Airport (JAC), Jackson Hole, Wyoming, at 1305.

After review of the air traffic control (ATC) services provided to the pilot by Jackson Hole Air Traffic Control Tower and Salt Lake City Air Route Traffic Control Center (Salt Lake Center), the National Transportation Safety Board (NTSB ) is concerned that the published IFR departure procedures available to aircraft departing JAC may be inadequate. In addition, the NTSB believes that the en route automation modernization (ERAM) ATC software in use at Salt Lake Center needs improvement to ensure that IFR aircraft are afforded necessary en route minimum safe altitude warning (E-MSAW) protection.

 

[gismo]

I didn't want to add to this already lengthy and sometimes OT thread so I started a new one.

Minnesota Father and 3 sons missing in Wyoming

http://www.ntsb.gov/Recs/Letters/2011/A-11-032-034.pdf

Looks to me like the pilot fell into a trap painted by ATC and enhanced by the pilot's relative inexperience with mountain IFR flying. For once I almost completely agree with the NTSB's recommendations.

 

[SkyHog]

Holy cow! The NTSB actually found a probable cause other than "Pilot Error?" I'm honestly surprised the probable cause wasn't:

"The pilot's failure to maintain separation from the ground during instrument conditions in an area with known mountainous terrain"

 

[Everskyward]

Holy cow! The NTSB actually found a probable cause other than "Pilot Error?"

They haven't found a probable cause yet. These are errors in the system that they think may have been contributing.

 

[bbchien]

I've recently departed from JAC in the Seneca, and that was to the north, in IMC. The route cobbled together by the pilot and ACT does indeed require 16,000 and should have been declined by the M20J driver, as there is no such route- it's based on Max terrain clearance.

It amazes me that the pilot accepted something that he knew by his transmissions he could not accomplish, esp with a touch of ice.

Very tragic. We are, collectively, not very smart. "Can you maintain 16,000" is a yes/no question.

 

[Jaybird180]

According to the chart posted in the NTSB report, the obstacle height for that grid-square is 14,200. He would have needed 16,200 to safely clear. Although I agree that the ERAM software needs to be updated to include the alerts for COAST MODE, the PIC should have discovered this during his preflight planning.

I don't understand why the're talking about MIA of 15,800. Can someone explain that to me when it's below the 2,000 foot gap needed to cross the obstacle height?

 

[pericynthion]

The actual highest point in that area is Gannett Peak at 13804ft. The MEF of 14200ft on the sectional includes a certain amount of buffer to deal with possible uncharted towers etc. Presumably the MIA polygon (unavailable to pilots) was designed based on the actual obstruction height, and I guess it's considered alright to round down by 4 ft.

 

[gismo]

According to the chart posted in the NTSB report, the obstacle height for that grid-square is 14,200. He would have needed 16,200 to safely clear. Although I agree that the ERAM software needs to be updated to include the alerts for COAST MODE, the PIC should have discovered this during his preflight planning.

The problem was compounded by the fact the pilot did his preflight planning based on a northerly departure and a 14,000 MEA maximum.

 

[AdamZ]

"Can you maintain 16,000" is a yes/no question.

You know Bruce that is an excellent comment. It really is. I recall instances where ATC asked me a question and I responded with something like I'm trying or I'll try. We really need to think of the situation and decide on whether how we respond to ATC makes a difference in our safety.

 

[Jaybird180]

You know Bruce that is an excellent comment. It really is. I recall instances where ATC asked me a question and I responded with something like I'm trying or I'll try. We really need to think of the situation and decide on whether how we respond to ATC makes a difference in our safety.

I can imagine that there are times when the pilot would not know if the question from ATC was a MIA recommendation (safety) or sequencing recommendation (inconvenience).

 

[Everskyward]

I recall instances where ATC asked me a question and I responded with something like I'm trying or I'll try. We really need to think of the situation and decide on whether how we respond to ATC makes a difference in our safety.

But I think the final mistake was this.

At 1349:39, the controller advised the pilot that he was in an area where the MIA was 15,800 feet and asked the pilot if he was “… able to maintain your own terrain and obstruction clearance?” The pilot responded that he was at 14,500 feet. The controller then asked if the pilot could maintain his own terrain and obstruction clearance for the next 10 minutes. The pilot responded, “…affirmative, I can do that,” and the controller acknowledged.

We as pilots have many times said we don't want the controller flying our airplane so what is the controller supposed to do when he/she receives a response like that?

 

[Jaybird180]

point made

 

[gkainz]

"Can you maintain 16,000" is a yes/no question.

I wonder how many interpret it as a challenge, not a yes/no question?

 

[Trapper John]

I wonder how many interpret it as a challenge, not a yes/no question?

Will the controller say, "Is that your final answer?"

 

[Ted]

Holy cow! The NTSB actually found a probable cause other than "Pilot Error?" I'm honestly surprised the probable cause wasn't:

"The pilot's failure to maintain separation from the ground during instrument conditions in an area with known mountainous terrain"

Well, that was the cause. The guy should've known where he was flying. He was flying a plane that was completely inadequate for the conditions and terrain, got iced up, and crashed. This really was his fault.

However, if there is something with the system that could be improved, I'm glad to see that change happening as a result of this.

 

[flyingcheesehead]

Well, that was the cause. The guy should've known where he was flying. He was flying a plane that was completely inadequate for the conditions and terrain, got iced up, and crashed. This really was his fault.

However, if there is something with the system that could be improved, I'm glad to see that change happening as a result of this.

Agreed 100%.

After looking at this again, he was cleared on a route that he had no business being on even at 16,000. ATC fail. However, his filed altitude was 9,000 - WTF??? Pilot fail. (OROCA's in the area are 16,100 and the lowest MEA off the JAC VOR is 13,500.) Clearly, the pilot didn't have a clue what he was doing.

Looking at this again, here's the failures I see:

ATC:
* Clearing the pilot on a route (KICNE->RIW) at an altitude below the OROCA.

FAA:
* No MSAW for airplanes in coast mode.
* No warning for airplanes predicted to enter MIA polygon below MIA
* ODP's not allowed to have transition routes.

Pilot:
* Filing an altitude WAY below the minimum IFR altitude
* Filing for a departure in the wrong direction
* Accepting an unsafe clearance
* Accepting responsibility for terrain and obstruction clearance that he couldn't provide

So, I fully expect the final NTSB report to blame this one on the pilot, and rightfully so. He did not follow proper IFR procedures. However, there are obviously some things the FAA could do that could also have helped ATC warn the pilot that he was being dumb earlier in the process.

 

[N801BH]

I've recently departed from JAC in the Seneca, and that was to the north, in IMC. The route cobbled together by the pilot and ACT does indeed require 16,000 and should have been declined by the M20J driver, as there is no such route- it's based on Max terrain clearance.

It amazes me that the pilot accepted something that he knew by his transmissions he could not accomplish, esp with a touch of ice.

Very tragic. We are, collectively, not very smart. "Can you maintain 16,000" is a yes/no question.

The good doctor was here recently and witnessed the " terrian" we deal with every day. Reading the report is a recipe for multiple lawsuits from every direction.... I agree tho,, the PIC has the final responsibility for conducting a safe flight and clearly he was lacking in that dept.........
Another thing that amazes me is the comment on 'damage' . as substantial... yeah right..... The whole episode is so sad.

Ben.

 

[Jaybird180]

Well, that was the cause. The guy should've known where he was flying. He was flying a plane that was completely inadequate for the conditions and terrain, got iced up, and crashed. This really was his fault.

However, if there is something with the system that could be improved, I'm glad to see that change happening as a result of this.

Shoulda had a K model

The good doctor was here recently and witnessed the " terrian" we deal with every day. Reading the report is a recipe for multiple lawsuits from every direction.... I agree tho,, the PIC has the final responsibility for conducting a safe flight and clearly he was lacking in that dept.........
Another thing that amazes me is the comment on 'damage' . as substantial... yeah right..... The whole episode is so sad.

Ben.

I think that's policy speak

 

[chucky]

ATC:
* Clearing the pilot on a route (KICNE->RIW) at an altitude below the OROCA.

I think it's the MIA that the centers need to abide by, not the OROCA, and that was 15,800 in that area according to the NTSB report, so 16,000 was fine. But he got 14,000 from the ground controller, apparently, which was clearly bad, whichever minimum altitude we're talking about. If I get an altitude assignment from ATC, I trust it's a safe altitude, even if it's below the OROCA. The NTSB report isn't clear about when controllers figured out that the Mooney was cleared at an unsafe altitude, or if any controller actually violated the regs, but clearly something went wrong, or at least didn't went as right as it could have on the ATC side.

 

[Trapper John]

Shoulda had a K model

Even Mr. Magoo has 20/20 hindsight.

 

[sba55]

I think it's the MIA that the centers need to abide by

I suppose so, but they look at the MVA. From what I understand, that's what ATC really cares about. Sadly, MVA charts aren't really published.

If I get an altitude assignment from ATC, I trust it's a safe altitude

I wouldn't trust it. There's been quite a few accidents where pilots got vectored into mountains. Always verify.

 

[Jaybird180]

I wouldn't trust it. There's been quite a few accidents where pilots got vectored into mountains. Always verify.

...endorsement for Synthetic Vision?

 

[weilke]

I suppose so, but they look at the MVA. From what I understand, that's what ATC really cares about. Sadly, MVA charts aren't really published.

That is something I dont really understand. The mountains, navaids and radar locations dont exactly move around. Issuing them in a (electronic) map format once a year shouldn't be that hard.

 

[Trapper John]

I wouldn't trust it. There's been quite a few accidents where pilots got vectored into mountains. Always verify.

I would be very interested in seeing a legitimate reference where a controller directed a flight into terrain.

 

[weilke]

I would be very interested in seeing a legitimate reference where a controller directed a flight into terrain.

http://www.ntsb.gov/Recs/Letters/2011/A-11-032-034.pdf

 

[Trapper John]

http://www.ntsb.gov/Recs/Letters/2011/A-11-032-034.pdf

But that doesn't support the claim that, "I wouldn't trust it. There's been quite a few accidents where pilots got vectored into mountains".

 

[chucky]

I wouldn't trust it. There's been quite a few accidents where pilots got vectored into mountains. Always verify.

Well, around here it's pretty common to get vectors below the OROCA (4200 right over my head, if I remember right), and I don't concern myself with it too much, even if I'm in the soup. Of course, I know the area well enough to know I'm not going to hit anything, so maybe it's not a good comparison. But it's not easy to verify every altitude you get. On an airway or approach, sure, but with direct clearances it's much more difficult, short of querying the controller every time "confirm this altitude is above your MVA/MIA", which I can see getting on the controllers nerves pretty quickly.

Which probably just goes to show that the NTSB's suggestion of published transition routes on ODPs is a really good one. In this instance, of course, the fact that the pilot filed 9000 for any route in that area makes one wonder if a published transition would have alerted him, but maybe he deliberately lowballed it to get the lowest altitude ATC would give him.

Really, what this drives home for me is how critical it is to thoroughly understand how to transition from the runway to the airways, and not only the way you plan to do it but all the ways you might reasonably have to do it, due to weather changes or ATC reroutes. I'm realizing I'm too lazy with that here in the flat northeast. Since I'm moving out to California in the fall, that needs to change pronto.

 

[N801BH]

Well, , the fact that the pilot filed 9000 for any route in that area makes one wonder if a published transition would have alerted him, but maybe he deliberately lowballed it to get the lowest altitude ATC would give him.

.

You cannot even get out of the valley here at 9000... I believe the controller pretty much told him that on the initial readback. The tower here does an outstanding job given the deck of cards they play with. IMHO.

 

[flyingcheesehead]

Well, around here it's pretty common to get vectors below the OROCA (4200 right over my head, if I remember right), and I don't concern myself with it too much, even if I'm in the soup. Of course, I know the area well enough to know I'm not going to hit anything, so maybe it's not a good comparison. But it's not easy to verify every altitude you get. On an airway or approach, sure, but with direct clearances it's much more difficult, short of querying the controller every time "confirm this altitude is above your MVA/MIA", which I can see getting on the controllers nerves pretty quickly.

I don't accept clearances that I can't verify are at a safe altitude... That said, I can only remember one time where I was cleared to an "unsafe" altitude, and it was probably the MVA for the area but it was 100 feet below the FAF altitude for the approach. Generally, enroute clearances are above the minimum altitudes published on the enroute charts - Or maybe it's because I file that way.

If I'm not flying a direct route for any reason, part of my preflight planning is to figure out at what points on my route I can accept a direct clearance at what altitude so that I know immediately when a controller says "cleared direct Podunk" whether I can safely accept it.

As far as clearances below MEA, OROCA, etc. that generally happens in a terminal environment where I can use the MSA's on the approach plate to verify the altitudes.

I think that the controllers do a great job for the most part - Sometimes I wonder if they can read my mind. I once filed an airway route from Albany, NY to Bangor, ME that had MEA's below 3,000 just in case I ran into ice in the climb. But, I filed for an altitude that would put me above the tops. Controller gave me "Upon reaching 7,000, cleared direct Bangor." Perfect!

Which probably just goes to show that the NTSB's suggestion of published transition routes on ODPs is a really good one.

That's not what they're saying, though - They're saying to replace those particular charted ODP's with SIDs because ODP's aren't allowed to have transition routes for some reason, which really confuses me. Why not?

Really, what this drives home for me is how critical it is to thoroughly understand how to transition from the runway to the airways, and not only the way you plan to do it but all the ways you might reasonably have to do it, due to weather changes or ATC reroutes.

 

[chucky]

If I'm not flying a direct route for any reason, part of my preflight planning is to figure out at what points on my route I can accept a direct clearance at what altitude so that I know immediately when a controller says "cleared direct Podunk" whether I can safely accept it.

I like that idea. I'm going to steal it from you.:wink2:

 

[flyingcheesehead]

I like that idea. I'm going to steal it from you.:wink2:

Please do!

 

[bbchien]

"Can you maintain 16,000?" must clearly be a yes/no answer. The Granite doesn't say, "hmmm. I'll be 14,800 today!" So you bring your best IFR game.


On the second shot, if you could see far enough to the right, Gannett peak would appear about the same height as Grand Teton. It's in the middle of a long formidable ridge N/S between 12,400 and 13,200 at the south end, with 13,800 in the middle. A brief of the sectional was a part of the IFR prep as my SE service ceiling for my departure conditions was 15,000 feet.

Everything that you can see is at 11,000 or above, when we broke out. That all being noted, I think the airspace is designed for twin turbine aircraft and we are simply, poorer cousins.

Ben has his powerhouse E-type for a reason, I'd wager.....

 

[dtuuri]

"The controller revised the pilot’s filed altitude and flight plan and amended the route to follow the southbound departure to the KICNE intersection and then fly direct to Riverton, Wyoming, to rejoin the original routing. No published transition route from KICNE to Riverton was available..."​

The TETON THREE DEPARTURE (OBSTACLE) is a graphic ODP that looks just like a SID at first blush. It zigs westbound at the 27 DME off runway 19 and continues for 50 more miles in the wrong direction (pilot wanted to go east).

According to AIM 5-2-8 e. 2. (my em):

"2. After an aircraft is established on an SID and subsequently vectored or cleared off of the SID or SID transition, pilots must consider the SID canceled, unless the controller adds “expect to resume SID.” Aircraft may not be vectored off of an ODP until at or above the MVA/MIA, at which time the ODP is canceled."
​

I didn't see any indication the flight was 'vectored' (EDIT: non-radar@KJAC), yet ATC cleared it off of an ODP which had the apearance of a SID to the pilot.

The letter from the NTSB states that:

"At the time of the accident, the published departure procedures had restrictions that required the pilot to amend the original route to account for the southbound departure."​

Actually, that's not true. This was a Part 91 operation and pilots are allowed to think for themselves. The visual climb over airport for both north and southbound departures specify crossing the the VOR at 10,800 MSL. The northbound GEYSER FOUR DEPARTURE (OBSTACLE) then provides course guidance while the pilot climbs to 14,000 MSL, an altitude within reach of the Mooney, according to the PIC, but well above the filed altitude of 9,000'.

The pilot had a Hobson's choice: Wait out the weather for higher ceilings or fly the ODP for 27 miles straight out and then turn the opposite direction for 50 miles to reach the en route structure. Of course, in today's environment of GPS, radar following and moving maps--who's actually going to do THAT? Especially when ATC obliges with an on course clearance. Oh the hazards of the saw, "File what you want, fly what you get."

dtuuri

 

[weilke]

Of course, in today's environment of GPS, radar following and moving maps--who's actually going to do THAT?

Someone attached to his life.

The pilot in this accident was looking into getting a P-Baron to better suit his travel needs. He didn't get to where he was in life by being stupid or reckless, it is a shame that a combination of his decision making and a failure in the ATC 'safety net' conspired to effect this outcome.

 

[dtuuri]

Someone attached to his life.

The pilot in this accident was looking into getting a P-Baron to better suit his travel needs. He didn't get to where he was in life by being stupid or reckless, it is a shame that a combination of his decision making and a failure in the ATC 'safety net' conspired to effect this outcome.

Yes, and I didn't mean to imply anything else. The vintage of the aircraft has me wondering if a moving map was even installed. What I meant was, choosing to fly 100 nm out of the way (out to the en route fix west and back) would be almost unthinkable for today's aviator accustomed to all the safety nets. In a bygone day, without radar and only marginal VOR reception available, making a different decision would have (probably) been a whole lot easier. If this pilot made an error it would have been not seeing/realizing the implications of (OBSTACLE) after the 'graphic' ODP name. It looked just like any SID which ATC can certainly cancel in mid-stream. At KJAC, that amounts to a tourist trap. It's a mistake I might have made too.

dtuuri

 

[Everskyward]

He didn't get to where he was in life by being stupid or reckless, it is a shame that a combination of his decision making and a failure in the ATC 'safety net' conspired to effect this outcome.

I wouldn't go so far as to say he was stupid or reckless but I would say he was very naive. Just because someone is successful in one endeavor doesn't necessarily make them good at something else. I noticed that in the previous thread that people who have flown small airplanes in the mountains were saying when others, mostly from the flatlands, were trying to blame his lack of understanding of instrument procedures or the confusion with ATC. I think that there were some problems with the procedures and ATC but I can't understand why he took off in those conditions on that route in that airplane at all. I would think that the minimum airplane you would have wanted on that day would be turbocharged and certified for icing. I think that it's a good idea for people who want to fly IFR in their small airplanes in the mountains to try it on a VMC day the first time to see what it is they are actually facing then try to imagine what it might be like in turbulence and icing.

 

[Clark1961]

I think that it's a good idea for people who want to fly IFR in their small airplanes in the mountains to try it on a VMC day the first time to see what it is they are actually facing then try to imagine what it might be like in turbulence and icing.

As one who flies a non-de-iced turbo single in the mountains reading the post of a pilot with thousands of hours including lots of mountain flight, all I can say is amen. I'm IFR rated and don't even consider an IMC flight into or out of the hills.

 

[Michael Picc]

The problem was compounded by the fact the pilot did his preflight planning based on a northerly departure and a 14,000 MEA maximum.

Agreed-

Newbie question 4 ya:
Unlike a VFR route, how can I really do a thorough Preflight of a certain route when flying under IRF ATC May ask me to fly headings 230 degrees for 20 minutes then change heading around traffic. Flying for 20-25 minute sections of a flight at speeds over 130-150 might temporarily have me close to another state. I can’t preflight a distance that changes before I take off with any fine details etc.

Of course if ATC is keeping me on my assigned route I can follow on my GPS but once ATC redirects me- all bets are off right?