Plane crash Gillespie Field, San Diego

dtuuri said:
They were below circling minimums (by a lot) and I was trying to say that similar altitudes to what they were flying might have been legit at another airport. In other words, we can't just blow it off as not complying with the approach chart — there are real lessons here even for pilots who go by the book, i.e., bank angle and proper configuration for speed. But I'm not saying that caused the accident, just a reminder that it "could" have, so don't let it happen to us.
Click to expand...
has anybody looked at the metar reported altimeter setting on that night though? we just see the ADS-B reported altitude which is only pressure altitude, not the true altitude

wunderground says at San Diego it was 29.95 (couldn't find KSEE specifically) so you braniacs tell me what their real altitude was
 
Nate9191 said:
has anybody looked at the metar reported altimeter setting on that night though? we just see the ADS-B reported altitude which is only pressure altitude, not the true altitude

wunderground says at San Diego it was 29.95 (couldn't find KSEE specifically) so you braniacs tell me what their real altitude was
Click to expand...
Actually, I did check SNA's setting (the departure airport on the short flight) using the METAR history site linked to earlier in this thread. If I interpreted the times and dates correctly it was slightly lower than SEE, so even if they forgot to reset it wouldn't account for 500 feet of altitude variance. Feel free to double check.
 
dtuuri said:
Actually, I did check SNA's setting (the departure airport on the short flight) using the METAR history site linked to earlier in this thread. If I interpreted the times and dates correctly it was slightly lower than SEE, so even if they forgot to reset it wouldn't account for 500 feet of altitude variance. Feel free to double check.
Click to expand...
i'm not at all saying the ADS-B reported 800ft was like 1500ft actual MSL or something, just trying to get a better picture of how high they really were
 
I think the PC will be lack of CRM. After all the other aspects, the weather, the short runway, the deviation east of the runway, the low pattern, the close pattern, and the terrain in the windshield, the captain flying a left pattern should have been looking left, and the FO should have been watching the gauges. I think both were looking for the runway, and the plane was not flown.
 
Lindberg said:
Would this operation have required a FDR & CVR?
Click to expand...
Possibly a CVR (required for a turbine airplane with more than 5 passenger seats), but not an FDR (I think that’s more than 10 seats).
 
Last edited:
LesGawlik said:
I think the PC will be lack of CRM. After all the other aspects, the weather, the short runway, the deviation east of the runway, the low pattern, the close pattern, and the terrain in the windshield, the captain flying a left pattern should have been looking left, and the FO should have been watching the gauges. I think both were looking for the runway, and the plane was not flown.
Click to expand...

I agree, except for a different interpretation of crew responsibilities.

In my world, proper CRM dictates the PF should have been flying the aircraft and managing airspeed and altitude. The PNF should have been calling out flight path information, e.g. "extend the turn to final, you’re right, you’re left, you’re low, you’re high, runway in sight” until they were aligned with the runway and on short final. I have been told by those that know these things that the SIC was the PF. This would be expected, because the PIC, as PNF, would have the better ability to spot Runway 27R from his left seat.

While the crew had performed the runway change maneuver many times, in this instance, the reported scattered cloud layer (not mentioned by ATIS or ATC, but by witnesses) was so low, and as a result the aircraft was also, I believe it presented a sight picture they were unaccustomed to because of the low slant range. The crew was trying to locate the runway threshold among a sea of lights. Minutes after the crash, the scattered layer was estimated to be about 600' above the surface. It is fair to say the scattered cloud layer could have caused the crew to lose sight of the RWY 27R threshold.

I believe this caused both pilots to focus on acquiring that visual contact rather than one of them flying the aircraft, which was in a critical state owing to its low altitude, configuration with flaps and landing gear down, and a steep bank in a short radius turn. The aircraft was in a high drag profile with flaps and gear down, along with a turn whose radius was decreasing and bank angle increasing as the crew attempted to locate the runway. This combination required strict adherence to a safe airspeed, which, in a matter of seconds, was allowed to decay until the aircraft stalled and spun onto Pepper Avenue.
 
LesGawlik said:
I think the PC will be lack of CRM. After all the other aspects, the weather, the short runway, the deviation east of the runway, the low pattern, the close pattern, and the terrain in the windshield, the captain flying a left pattern should have been looking left, and the FO should have been watching the gauges. I think both were looking for the runway, and the plane was not flown.
Click to expand...

That’s not how PC works.

Lack of CRM will likely be a contributing factor, but PC will read something like ‘Probable cause is the failure of the accident pilot to maintain control of the aircraft while accomplishing a low altitude maneuvering to land in marginal VFR conditions’
 
3393RP said:
I agree, except for a different interpretation of crew responsibilities.

In my world, proper CRM dictates the PF should have been flying the aircraft and managing airspeed and altitude. The PNF should have been calling out flight path information, e.g. "extend the turn to final, you’re right, you’re left, you’re low, you’re high, runway in sight” until they were aligned with the runway and on short final. I have been told by those that know these things that the SIC was the PF. This would be expected, because the PIC, as PNF, would have the better ability to spot Runway 27R from his left seat.
Click to expand...

Back when I did several circling approaches, we did it differently. The pilot flying would be on the same side as the runway during the circle. The pilot flying would be looking outside the majority of the time and glancing at the instruments. The pilot not flying would mainly be looking at the altitude, airspeed and calling them out. Same two pilots almost all the time and most of the time we were very familiar with the airports.

It worked well for us.
 
Well, even the FAA is getting into the speculation game with a webinar about this accident on 1/28/2022. See link here for details.
 
Turbo-Arrow-Driver said:
Well, even the FAA is getting into the speculation game with a webinar about this accident on 1/28/2022. See link here for details.
Click to expand...
Yeah, well, they ought to stow the tone of this inquest, IMO:

"There is much to learn from the facts, not in dispute...

'We continue to make the same foolish aeronautical decisions repeatedly because we choose to make the conscious decision to not learn from the mistakes of others and our own past experiences.'-- Scott Allen FPM, HNL FSDO WP13"
​
"Foolish decisions"? Nothing wrong with the choice of approach or desire to circle, IMO. Did they really "decide" to bust minimums or simply misread the altimeter by 1,000 feet? It has happened. They could have accidentally been in the process of descending to 400' MSL thinking they were headed to 1400' circling minimums. When things didn't look quite right optically, they could've started to ease back up higher, as shown in the ADS-B plot. The low point was about 700' MSL (312' AGL), so does anybody really think 312' AGL was the crew's target altitude for a circling approach? The last plot after starting to climb was 950' MSL (562' AGL), 250' above the low point and increasing, so the "mistake" could well be one of instrument interpretation not decision-making. It's always good to remind pilots not to bust minimums, but they ought to take more care when it comes to casting aspersions, imo.
 
Last edited:
dtuuri said:
Yeah, well, they ought to stow the tone of this inquest, IMO:

"There is much to learn from the facts, not in dispute...

'We continue to make the same foolish aeronautical decisions repeatedly because we choose to make the conscious decision to not learn from the mistakes of others and our own past experiences.'-- Scott Allen FPM, HNL FSDO WP13"
​
"Foolish decisions"? Nothing wrong with the choice of approach or desire to circle, IMO. Did they really "decide" to bust minimums or simply misread the altimeter by 1,000 feet? It has happened. They could have accidentally been in the process of descending to 400' MSL thinking they were headed to 1400' circling minimums. When things didn't look quite right optically, they could've started to ease back up higher, as shown in the ADS-B plot. The low point was about 700' MSL (312' AGL), so does anybody really think 312' AGL was the crew's target altitude for a circling approach? The last plot after starting to climb was 950' MSL (562' AGL), 250' above the low point and increasing, so the "mistake" could well be one of instrument interpretation not decision-making. It's always good to remind pilots not to bust minimums, but they ought to take more care when it comes to casting aspersions, imo.
Click to expand...
I agree in principle but to end up where they were by accident without recognition of how sketchy the situation truly was would require a level of incompetence that would cause me to question the training and checking program of that 135 company.
 
dtuuri said:
Yeah, well, they ought to stow the tone of this inquest, IMO.”

“Nothing wrong with the choice of approach or desire to circle, IMO. Did they really "decide" to bust minimums or simply misread the altimeter by 1,000 feet? It has happened. They could have accidentally been in the process of descending to 400' MSL thinking they were headed to 1400' circling minimums. When things didn't look quite right optically, they could've started to ease back up higher, as shown in the ADS-B plot. The low point was about 700' MSL (312' AGL), so does anybody really think 312' AGL was the crew's target altitude for a circling approach? The last plot after starting to climb was 950' MSL (562' AGL), 250' above the low point and increasing, so the "mistake" could well be one of instrument interpretation not decision-making.
Click to expand...

Agreed the planned FAA event does have a certain attitude and tone that is a bit of a turn off. If memory serves me correct, that speaker, an accident lawyer, has a certain approach to making his points.

I’ll disagree and say there WAS something wrong with the desire to circle after the approach, given the weather conditions and workaround needed to get it done. And, it’s very optimistic to think they may have made an altimeter mistake.
 
Last edited:
TrueCourse said:
I’ll disagree and say there WAS something wrong with the desire to circle after the approach, given the weather conditions and workaround needed to get it done.
Click to expand...
Did you see the weather posted back on the first page? It was VFR:


The final approach course was aligned with the arrival course, too, and the runway circled to was surely the only legal one to land on with a wet runway.

TrueCourse said:
And, it’s very optimistic to think they may have made an altimeter mistake.
Click to expand...
In my history I have a recorded event where I misread the altimeter by 1000'. I was going the other way, up not down, when it happened in a DC-10 simulator at United Airlines back in 1979. I was in the pre-hire evaluation phase and was executing a missed approach at a sea-level airport. Accustomed to home fields situated around 1000' MSL elevation, I began the required left turn at 700' rather than the stipulated 1700' in the missed approach instructions. I guess I can confess now, all these years later, without consequence to the sim evaluator who broke silence and brought my mistake to my attention against company policy. It isn't that hard of a mistake to make. Btw, he began writing furiously on his clipboard after that moment and in fact I got hired despite my mistake. Big picture-wise, I must have done well enough on the rest of the flight to be forgiven. Ultimately, I resigned after a multi-year furlough that began a few months later.
 
This was not CFIT. I doubt there was an altimeter error involved.
 
dtuuri said:
Did you see the weather posted back on the first page? It was VFR:

The final approach course was aligned with the arrival course, too, and the runway circled to was surely the only legal one to land on with a wet runway.
Click to expand...

The approach itself, nearly aligned with RWY17 was not a problem.

dtuuri said:
Did you see the weather posted back on the first page? It was VFR:
Click to expand...

Yes: 3SM RM BKN020 OVC026 before and 3SM RM BKN011 OVC026 after.

Yes, it's VFR - marginal VFR actually - but I don't believe that makes it ideal or even good enough. It's night time, it's marginal weather, it's a circling maneuver that's not authorized at night even when leveling at the minimums (1440 MSL). I don't need much more to say, "well this isn't a good idea, let's avoid this".

I've done numerous circle to lands at the end of an IFR flight, some at night, all in jet aircraft. It was never what I would consider a simple or easy maneuver when you are booking along at 120+ knots, complying with circling minimums. Although I could be wrong, I don't recall trying one with the visibility at the bare bones minimum published. Except in the sim, of course. As long as you comply with the way it's supposed to be done, you can either maneuver to land or go missed.

Here is something to consider. The accident airplane appeared to cross the IF and FAF at the appropriate altitudes. Next intersection is TOMTY with a crossing height of 1580 MSL and they appeared to cross at that altitude. It's 3.7nm from the runway. If you are planning in advance to do the circling maneuver you'll be leveling off at 1440 MSL which happens quickly after TOMTY as you descend. In this case, the call of "airport in sight" didn't occur until just under 2nm to the runway when approximately 1000 MSL (600 AGL). I believe the crew most likely had the intention to circle before starting the approach (and probably before they left SNA), so this next comment is based on that. Why continue the descent on the approach with a circle in mind knowing you'll be very low when you pick up the runway? Knowing in advance the visibility and the circling minimums and how the approach is designed, this is why I don't believe it's a good idea. It's a can of worms.

If a jet is flying the very same flight path at night in CAVU, it would probably level off at 1900 MSL (1500 AGL), or at the very least 1400 MSL (1000 AGL), to perform the circle. I just don't see it as OK to get much lower in 3SM visibility to attempt this.
 
TrueCourse said:
The approach itself, nearly aligned with RWY17 was not a problem.



Yes: 3SM RM BKN020 OVC026 before and 3SM RM BKN011 OVC026 after.

Yes, it's VFR - marginal VFR actually - but I don't believe that makes it ideal or even good enough. It's night time, it's marginal weather, it's a circling maneuver that's not authorized at night even when leveling at the minimums (1440 MSL). I don't need much more to say, "well this isn't a good idea, let's avoid this".

I've done numerous circle to lands at the end of an IFR flight, some at night, all in jet aircraft. It was never what I would consider a simple or easy maneuver when you are booking along at 120+ knots, complying with circling minimums. Although I could be wrong, I don't recall trying one with the visibility at the bare bones minimum published. Except in the sim, of course. As long as you comply with the way it's supposed to be done, you can either maneuver to land or go missed.

Here is something to consider. The accident airplane appeared to cross the IF and FAF at the appropriate altitudes. Next intersection is TOMTY with a crossing height of 1580 MSL and they appeared to cross at that altitude. It's 3.7nm from the runway. If you are planning in advance to do the circling maneuver you'll be leveling off at 1440 MSL which happens quickly after TOMTY as you descend. In this case, the call of "airport in sight" didn't occur until just under 2nm to the runway when approximately 1000 MSL (600 AGL). I believe the crew most likely had the intention to circle before starting the approach (and probably before they left SNA), so this next comment is based on that. Why continue the descent on the approach with a circle in mind knowing you'll be very low when you pick up the runway? Knowing in advance the visibility and the circling minimums and how the approach is designed, this is why I don't believe it's a good idea. It's a can of worms.

If a jet is flying the very same flight path at night in CAVU, it would probably level off at 1900 MSL (1500 AGL), or at the very least 1400 MSL (1000 AGL), to perform the circle. I just don't see it as OK to get much lower in 3SM visibility to attempt this.
Click to expand...
True marginal VFR is uncomfortable in broad daylight. If it was truly CAVU, I'd be VFR straight in, probably wouldn't need to file at all for that puddle jump.
 
True, which is why I wrote “if….flying the very same flight path…”
 
TrueCourse said:
Why continue the descent on the approach with a circle in mind knowing you'll be very low when you pick up the runway?
Click to expand...
Precisely my point — they could have missed the level-off altitude due to some distraction and thought they were 1000' higher than actual. As you reported, the ceiling was 2000' and HAA was 1100', so very do-able and legal at night under VFR rules, especially with intimate local knowledge. Why they were down so low is the question because what we know about the weather doesn't explain it.
 
Last edited:
dtuuri said:
Precisely my point — they could have missed the level-off altitude due to some distraction and thought they were 1000' higher than actual. As you reported, the ceiling was 2000' and HAA was 1100', so very do-able and legal at night under VFR rules, especially with intimate local knowledge. Why they were down so low is the question because what we know about the weather doesn't explain it.
Click to expand...
How many times have you seen scraggly dirty bottoms that are effectively reducing visibility several hundred feet lower than reported? You know that all 1100 foot ceilings are not created equal. Some allow good visibility at 1099’ some are much lower. With your experience I’m confident you know exactly what I’m talking about. I’m telling you they didn’t have the visibility to do the circle. Kept it tight and low so they could see the runway and stalled. Have you watched the videos of the crash that are circulating?
 
Tarheelpilot said:
Kept it tight and low so they could see the runway and stalled. Have you watched the videos of the crash that are circulating?
Click to expand...
Stalling sure seems likely and something good to discuss as a warning for others, but the crash site as reported where I read about it was at Pepper Drive and N. Morrison Mollison. Also, the plane reportedly hit wires. If that's true, a couple things: 1) The flight path would have gone right over a big hill flying at 950' MSL, the base of the hill being 200m according to a topo map online which is about 650' MSL. 2) The location of the accident in the above notice for a pilot meeting is east of that hill. So, if the FAA's map is correct then a stall seems more likely, if the reporter's location is correct they could have hit something on the hill, which might be one reason for the "NA" at night. I couldn't tell much from the videos I watched.

The accident does raise the incongruity of allowing VFR operations to circle at night and IFR "contact" approaches to circle and IFR "visual" approaches to circle, but not let IFR RNAV approaches to circle. Another thing, let's say you're correct and the weather was as you imagined it and the crew nefariously canceled IFR in order to dip under a low cloud base and descended enough to be 500' below and therefore "legally VFR". I can't imagine an experienced pilot being more concerned with VFR cloud clearance than altitude above the ground, can you?
 
Last edited:
dtuuri said:
Precisely my point — they could have missed the level-off altitude due to some distraction and thought they were 1000' higher than actual.
Click to expand...

Since they crossed the IF, IAF, and TOMTY at the published altitudes (and were presumably reading their altimeter correctly), I think it's highly unlikely with only a few hundred feet until minimums and four hundred more until their level off altitude that they suddenly started reading them incorrectly.

What I can imagine happening is if the crew hadn't faced this scenario before and instead of leveling off at circling minimums and waiting until the runway was in sight, they continued following the VP down until they picked up the runway, then leveled off, and suddenly realized the position they have put themselves in being at such a low altitude. The descent was relatively constant until the final level off. Or, having picked up the runway when they did (calling it at about MDA) they had to continue their descent below MDA in order to maintain visual with the airport (see prior post about ragged bases). Either of these, are a bad place to be in.

dtuuri said:
Stalling sure seems likely and something good to discuss as a warning for others, but the crash site as reported where I read about it was at Pepper Drive and N. Morrison. Also, the plane reportedly hit wires. If that's true, a couple things: 1) The flight path would have gone right over a big hill flying at 950' MSL, the base of the hill being 200m according to a topo map online which is about 650' MSL. 2) The location of the accident in the above notice for a pilot meeting is east of that hill. So, if the FAA's map is correct then a stall seems more likely, if the reporter's location is correct they could have hit something on the hill, which might be one reason for the "NA" at night. I couldn't tell much from the videos I watched.

...Another thing, let's say you're correct and the weather was as you imagined it and the crew nefariously canceled IFR in order to dip under a low cloud base and descended enough to be 500' below and therefore "legally VFR". I can't imagine an experienced pilot being more concerned with VFR cloud clearance than altitude above the ground, can you?
Click to expand...

The crash site ended in front of 1201 and 1209 Pepper Drive. Based on the last few ADS-B altitude readings, they were outside of and above the first hill and didn't hit the second hill. The wire strike is simply what happened before it impacted the ground. It was a stall, simply exceeding angle of attack or accelerated.

Oh, and I don't believe anyone attempting this maneuver at night will be concerned about being 500' below bases to stay VFR legal.
 
dtuuri said:
Stalling sure seems likely and something good to discuss as a warning for others, but the crash site as reported where I read about it was at Pepper Drive and N. Morrison Mollison. Also, the plane reportedly hit wires. If that's true, a couple things: 1) The flight path would have gone right over a big hill flying at 950' MSL, the base of the hill being 200m according to a topo map online which is about 650' MSL. 2) The location of the accident in the above notice for a pilot meeting is east of that hill. So, if the FAA's map is correct then a stall seems more likely, if the reporter's location is correct they could have hit something on the hill, which might be one reason for the "NA" at night. I couldn't tell much from the videos I watched.

The accident does raise the incongruity of allowing VFR operations to circle at night and IFR "contact" approaches to circle and IFR "visual" approaches to circle, but not let IFR RNAV approaches to circle. Another thing, let's say you're correct and the weather was as you imagined it and the crew nefariously canceled IFR in order to dip under a low cloud base and descended enough to be 500' below and therefore "legally VFR". I can't imagine an experienced pilot being more concerned with VFR cloud clearance than altitude above the ground, can you?
Click to expand...
Well. Regardless of the details. A good airplane was flown into the ground by a good crew that just ducked up. Hopefully we can learn from this and it won’t be the same lesson we learned last time. I’m seriously doubtful of the originality of this duck up.
 
TrueCourse said:
The crash site ended in front of 1201 and 1209 Pepper Drive. Based on the last few ADS-B altitude readings, they were outside of and above the first hill and didn't hit the second hill. The wire strike is simply what happened before it impacted the ground. It was a stall, simply exceeding angle of attack or accelerated.
Click to expand...
If you're sure of the site then they didn't go over the hill, but the last hit before the crash was 950' and they crashed near the base of that hill which is at 650'. So they were only 300' above the base and they even had to climb to get up that high. In other words, I wouldn't rule out hitting something (such as the power lines on the sectional in that area). I wouldn't rule out stalling either, though.
 
dtuuri said:
If you're sure of the site then they didn't go over the hill, but the last hit before the crash was 950' and they crashed near the base of that hill which is at 650'. So they were only 300' above the base and they even had to climb to get up that high. In other words, I wouldn't rule out hitting something (such as the power lines on the sectional in that area). I wouldn't rule out stalling either, though.
Click to expand...
After reviewing both of our posts I have decided that you are giving the benefit of doubt and I am giving the benefit of being human. Regardless of the specifics I hope we can learn from this but frankly we have had plenty of opportunities prior to this one…
 
You must log in or register to reply here.
Back
Top