Plane crashes into homes in San Diego, Ca

[Flying Keys]

I find it interesting that so many here are looking for the "reason", ie, bad AH, AP, pilot incapacitation or another item. Why do we always look for the excuse, and not just recognize the common root cause of 80% of the accidents are simply pilot error. Listening to the audio, it would seem the pilot was in over his head, and those conditions were not bad at all.

The human/automation interface has been a contributing factor in plenty of accidents, many of which can be boiled down to “pilot error.” Bettering our understanding of that interface, its limitations, and our limitations might prevent future “pilot error” accidents through development of better systems, procedures, training, even simple awareness.

Just saying “you suck” isn’t enough.

 

[asicer]

I find it interesting that so many here are looking for the "reason", ie, bad AH, AP, pilot incapacitation or another item. Why do we always look for the excuse, and not just recognize the common root cause of 80% of the accidents are simply pilot error. Listening to the audio, it would seem the pilot was in over his head, and those conditions were not bad at all.

I don't think anyone is saying that he wasn't in over his head. The question most are asking is what could have thrown him off his game, especially considering that the plane has flown 20 days out of the past 12 weeks and it looks like most if not all of them were at IFR altitudes.

 

[TrueCourse]

I find it interesting that so many here are looking for the "reason", ie, bad AH, AP, pilot incapacitation or another item. Why do we always look for the excuse, and not just recognize the common root cause of 80% of the accidents are simply pilot error. Listening to the audio, it would seem the pilot was in over his head, and those conditions were not bad at all.

It’s not always that simple. Besides, if you simply say “pilot error” and leave it at that, nothing good comes of it. Determining some particulars is particularly helpful to those curious to know and there is always someone that might benefit from figuring out what contributed to the accident.

 

[schmookeeg]

I find it interesting that so many here are looking for the "reason", ie, bad AH, AP, pilot incapacitation or another item. Why do we always look for the excuse, and not just recognize the common root cause of 80% of the accidents are simply pilot error. Listening to the audio, it would seem the pilot was in over his head, and those conditions were not bad at all.

Because as an instructor, I am curious WHERE the shortfall was that allowed this guy to run so amok. I assume other instructors in the past found him competent to fly a 340 without lawn darting, and I presume he may have done some dual instrument work in his past as well. I'm trying to learn from THEIR failures, through the proxy of this dead cardiologist who pooched it SO so badly. My intensity on this particular crash is borne from my total fear of letting one of my learner pilots loose with this sort of accident potential.

It's not just regs written in blood. Sometimes it's lesson plans too.

 

[Flying Keys]

N7022G made 24 flights into MYF in the past 12 months (all since January); all but three ended in a long (>5nm) straight-in approach to 28R. Two resulted in a extended right-base pattern entry to 28R, never a circle-to land or visual pattern to any other runway until yesterday.

Most pairings were KYUM-KMYF, with a few KPOC-KMYF, and one KPRC-KMYF.

 

[farmrjohn]

He was used to flying straight in to 28R and the need to circle to 23 seems to have confused him. That would explain starting to circle early and deviating right of the localizer prior to reaching MDA, not remembering the intent of the circling minimums are to get you in protected airspace to execute the circle visually while remaining in the protected airspace. He never cancelled IFR and with the weather at the time probably did not have Montgomery in sight to start a visual circle. Improper instrument approach procedure execution is likely a major causal factor, along with possible autopilot/instrument mis-management and spatial disorientation. Sad.

 

[Flying Keys]

He was used to flying straight in to 28R and the need to circle to 23 seems to have confused him. That would explain starting to circle early and deviating right of the localizer prior to reaching MDA, not remembering the intent of the circling minimums are to get you in protected airspace to execute the circle visually while remaining in the protected airspace. He never cancelled IFR and with the weather at the time probably did not have Montgomery in sight to start a visual circle. Improper instrument approach procedure execution is likely a major causal factor, along with possible autopilot/instrument mis-management and spatial disorientation. Sad.

This is exactly the scenario that played out in my head. That, and searching for the chart, maybe even trying to see if it could be programmed into the GPS as such.

 

[Flying Keys]

Another possible contributing factor after the break-out from the approach: there were two aircraft in relatively close proximity that could have added traffic alerts to his workload (depending on if his a/c was instrumented as such). One was a southbound C-130J “Raider47” that passed him about a mile to his right and 2,000’ above during the initial break-out vector. The other was a helicopter inbound KSEE, crossing 1/2 mile in front of him during the terminal dive. Both were called out to him by ATC as well.

KSEE tower called out the pre-accident twin Cessna to the helicopter (even though he wasn’t talking to the accident a/c), though I believe it had just crashed by the time the helicopter responded.

 

[skyking3286]

I guess the one thing that is most apparent is that the pilot for the last three seconds was a passenger in his own plane. No attempt to level wings, pull power, recover from a dive. There is a powerful psychological push for nearly all of us if we were presented with that sight picture in the cockpit- to pull up, if nothing else. It looks like a ballistic path rather than a pilot in command. That much we can agree on. Everything else is pure guesswork. And tragic for the those on the ground as well as the PIC.

 

[kyleb]

I guess the one thing that is most apparent is that the pilot for the last three seconds was a passenger in his own plane. No attempt to level wings, pull power, recover from a dive. That is a powerful psychological push - to pull up for nearly all of us if we were presented with that sight picture. It looks like a ballistic path rather than a pilot in command. That much we can agree on. Everything else is pure guesswork.

That made me think his head was down working the A/P or looking at a chart.

 

[Robert Gee]

In some way I hope it was a medical event.

 

[camorton]

He was used to flying straight in to 28R and the need to circle to 23 seems to have confused him. That would explain starting to circle early and deviating right of the localizer prior to reaching MDA, not remembering the intent of the circling minimums are to get you in protected airspace to execute the circle visually while remaining in the protected airspace. He never cancelled IFR and with the weather at the time probably did not have Montgomery in sight to start a visual circle. Improper instrument approach procedure execution is likely a major causal factor, along with possible autopilot/instrument mis-management and spatial disorientation. Sad.

He was having problems way before the circling minimums. From the ATC recordings it sounds like he wasn't even established on the localizer. A plane like this would probably have a pretty good autopilot. Maybe he was too dependent on it? A C340 would usually require annual sim training for insurance purposes. Hard to understand how a current pilot could botch this so badly.

C.

 

[Kenny Phillips]

In some way I hope it was a medical event.

Well, yes ... and no. They may just up the ante on our medicals, which, to be fair, are cursory, and rely more upon one's history than the exam itself.

 

[Bill]

In some way I hope it was a medical event.

Wow, that's hard to hear.

Sounds like as soon as he was cleared ILS 28R circle to land 23 he fell apart. I don't think he was expecting a circle to land.

 

[azpilot]

I find it interesting that so many here are looking for the "reason", ie, bad AH, AP, pilot incapacitation or another item. Why do we always look for the excuse, and not just recognize the common root cause of 80% of the accidents are simply pilot error. Listening to the audio, it would seem the pilot was in over his head, and those conditions were not bad at all.

I work in Aerospace engineering. What I do is not directly aviation related, but it's close enough for this discussion. Root Cause analysis is EXTREMELY important in everything we do. Blaming "operator error" in my world is the equivalent of claiming "pilot error" in the aviation world. To be blunt, claiming pilot/operator error is the lazy way to do root cause analysis.

Sure the operator/pilot made a mistake. In my world that means a part fails a test and it cost us money. In aviation, it means someone probably died. But there is a specific reason that pilot/operator made that mistake. Why did that happen. Was it poorly written instructions? Was (s)he tired? Not properly trained? Too much workload? Poor planning? It's vital that we as a community understand multiple levels of "why" the error was made by the pilot to prevent future pilots from making the same mistake.

 

[Tantalum]

Sounds like as soon as he was cleared ILS 28R circle to land 23 he fell apart. I don't think he was expecting a circle to land.

Which.. in itself shouldn't be daunting, and if it was, shows that the pilot was already near max saturation. You still fly the approach to the MAP. The clouds were high enough he'd surely have broken out well before he had to do any maneuvering. Or.. guess what, you can also deny the clearance. "Unable circle to land" .. he probably still could have gotten 28R.. I doubt the pattern was that busy. My understanding is there are commercial ops who's SOPs prohibit circle to land.

 

[Flying Keys]

“SoCal, is 22G clear for runway 23?”

This is the most telling communication. Not even established on the localizer for 28R for which he’s been cleared, drifting north as if he’s already setting up for the circle. This was mentioned above in this thread, but combined with that communication… damn.

 

[flybill]

Instrument rating and instrument proficiency are two totally different things. Maybe he was too reliant on the autopilot? Maybe he got the leans… who knows.

One thing is for certain…don’t be afraid to tell ATC you are behind the airplane and need help especially when close to the ground. Tell them you are behind the airplane, need immediate vectors. If you get told to fly the missed and your too far behind or confused to do so…tell them you are behind the airplane and need some help. You need a vector while you climb the plane. Don’t let your ego or fear of reprimand get in the way of keeping your ass alive. We practice engine outs, fires, partial panels, etc. but for some reason very few are taught how to ask for help.

 

[TrueCourse]

Where is there evidence he had even broken out of the clouds as he was drifting through the localizer? It’s been suggested that he could have been maneuvering for the circle (left base) for 23.

 

[RyanB]

You still fly the approach to the MAP. The clouds were high enough he'd surely have broken out well before he had to do any maneuvering. Or.. guess what, you can also deny the clearance. "Unable circle to land" .. he probably still could have gotten 28R..

I was thinking this exact thing. I can’t seem to figure out why a circle to land would’ve thrown him off so bad. Can’t execute the circling procedure as published? Fly the ILS for 28R and call it a day. I’m definitely thinking there was something else going on here.

 

[Echo419]

Copied over from r/flying:

I don't see anyone mentioning the fact that the controller had him intercept the glideslope from above, requiring a pretty rapid descent to try and catch it. He was still maintaining 3,800, as instructed, about 3 miles from the FAF, when the intercept altitude at the FAF is 2,500. The controller doesn't give him a full approach clearance, just a "join final". This seems to confuse the pilot, who asks specifically if he is cleared for the approach. Only after the pilot asks for clarification does the controller clear him and tells him to maintain 2,800 until established. At which point the pilot pushes it over and makes a -2000 fpm rate to try and catch the glideslope. This occurs simultaneous to intercepting the localizer. During this intercept and rapid descent he drifts off the localizers which prompts the missed approach, and subsequent climb/turn from the controller to vector him back around. Then in the attempted climb he gets disoriented, climbs and descends erratically, then crashes.

I really think the slam dunk approach onto the glideslope from well above may have contributed to his physical disorientation when transitioning into a missed approach climb. That's a lot of vertical acceleration changes, and his preoccupation with catching the glideslope may have contributed to his lack of focus on the localizer.

 

[Flying Keys]

You still fly the approach to the MAP.

Well, unless secondary minimums are in effect. /s

he probably still could have gotten 28R.

Strong southerly winds were not favorable for landing 28R w/a slightly quartering tailwind and ~10-13 knot crosswind component. Doable? Yes. Advisable? Not sure as I don’t have experience in that type. 23 would seem the best option for the majority of presumed traffic.

Relevant METARS:

KMYF 111853Z 18010KT 10SM BKN017 OVC028 19/14 A2980 RMK AO2 SLP086 T01940139

KMYF 111953Z 18013KT 9SM SCT023 OVC029 19/13 A2977 RMK AO2 SLP078 T01940128

 

[Flying Keys]

Copied over from r/flying:

He was definitely well above GS. Perhaps autopilot failed to couple into APR?

Regardless, the flight path, the question to approach paints a picture that he was maneuvering for 23.

Then rapid-fire instructions from ATC due to a MSAW alert got him hanging from the wicks. Am I on a missed approach? Am I still maneuvering for 23? Do I just follow ATC? (Answer is sort of 1, no to 2, yes on 3). But at this point, so far behind.

 

[MalibuJim]

But to st

I work in Aerospace engineering. What I do is not directly aviation related, but it's close enough for this discussion. Root Cause analysis is EXTREMELY important in everything we do. Blaming "operator error" in my world is the equivalent of claiming "pilot error" in the aviation world. To be blunt, claiming pilot/operator error is the lazy way to do root cause analysis.

Sure the operator/pilot made a mistake. In my world that means a part fails a test and it cost us money. In aviation, it means someone probably died. But there is a specific reason that pilot/operator made that mistake. Why did that happen. Was it poorly written instructions? Was (s)he tired? Not properly trained? Too much workload? Poor planning? It's vital that we as a community understand multiple levels of "why" the error was made by the pilot to prevent future pilots from making the same mistake.

But to start speculating this was a medical (as in multiple other threads) is not supported in the statistical history. Or to suggest his AP failed, bottom line, while there may be ancillary issues at play, even if it was his AP, he still FAILED to fly the plane, and it's not the AP's fault he was unable to retain control in a rather benign situation.

 

[Mtns2Skies]

But to start speculating this was a medical (as in multiple other threads) is not supported in the statistical history. Or to suggest his AP failed, bottom line, while there may be ancillary issues at play, even if it was his AP, he still FAILED to fly the plane, and it's not the AP's fault he was unable to retain control in a rather benign situation.

I think his point isn't that "Pilot Error" can't be the case, but rather "Pilot Error" doesn't go to a deep enough explanation of why the pilot errored.

 

[Tantalum]

Well, unless secondary minimums are in effect. /s



Strong southerly winds were not favorable for landing 28R w/a slightly quartering tailwind and ~10-13 knot crosswind component. Doable? Yes. Advisable? Not sure as I don’t have experience in that type. 23 would seem the best option for the majority of presumed traffic.

Relevant METARS:

KMYF 111853Z 18010KT 10SM BKN017 OVC028 19/14 A2980 RMK AO2 SLP086 T01940139

KMYF 111953Z 18013KT 9SM SCT023 OVC029 19/13 A2977 RMK AO2 SLP078 T01940128

Sure, the point is he did not have to box himself into an approach he was unfamiliar with. Those ceilings were above pattern altitude and plenty high to break out, cancel, and make believe he's VFR. This demonstrates an unfamiliar with the circle to land procedure.. and if he was unprepared alludes to a failure to grab the ATIS and properly brief when he was still way out

Copied over from r/flying

That's fairly common around here to get dropped in high.. there's a lot of terrain east of MYF, SAN, CRQ, RMN, and it's busy airspace. If you're going to SMO they keep you very high. The solutions to that are all within a competent pilot's tool bag
(A) slow down early
(B) fly a stabilized approach.. a 2K nose dive is not stable. There is no requirement that you have to hit the steps downs be exactly on the glideslope. You see a lot of people do these monster dives that I can't figure out. From the quote you posted even if he was doing 130 knots over the ground that still gives him 1.5 minutes to lose 1,300 ft.. that hardly requires a dive. Plus, there is no requirement you pass the FAF at its altitude floor. You still have almost 6.5 miles from PENNY to the MAP, there is still about 3 minutes to plan that descent, set a good VS rate. Stabilize out. At any rate he would have broken out plenty early.

 

[dreyna14]

One wonders how much actual you get between Yuma and San Diego even if he flew it weekly.

The west coast is known for consistent marine layer during the summer months. Sometimes it lasts for days. I had nearly seven hours of actual by the time I took my IR checkride because of it. It's usually a thin layer, and smooth, but offers many opportunities to get actual time. Sometimes it is solid from 1-4k ft and you can run multiple approaches while being vectored around in solid IMC.

 

[aftCG]

Wow, that's hard to hear.

Sounds like as soon as he was cleared ILS 28R circle to land 23 he fell apart. I don't think he was expecting a circle to land.

And George can't fly a circle to land

 

[47PILOT]

My guess, and it’s just a first reaction guess, is that he obviously got behind the plane for whatever reason and simply lost it.
I do hope we find out what happened but I highly doubt there’s enough left to tell us much

 

[PaulS]

For that first low altitude alert, he probably wasn't low at all, he was in a 2kfpm dive with every intention to level off on the GS, but that dive triggered the alarm as if he was going to blow through it, the controller just relays the alert.

The bottom line is don't put up with an approach you are not comfortable with, tell the controller it's not going to work and ask to be vectored around again. The other thing is if you a falling behind and going fast, slow the airplane down.

I still think something more than just disorientation was going on here, but maybe not.

 

[azpilot]

But to start speculating this was a medical (as in multiple other threads) is not supported in the statistical history. Or to suggest his AP failed, bottom line, while there may be ancillary issues at play, even if it was his AP, he still FAILED to fly the plane, and it's not the AP's fault he was unable to retain control in a rather benign situation.

Completely agree with this. There is certainly a lot of speculation going on. I've seen lots of discussion about possible medical issues and I don't see the evidence to support it. And ultimately it is the PIC's responsibility to fly the airplane.

But let's tug on the, "he still FAILED to fly the plane" thread a bit. Regardless of whatever else happened, whether it was his AP, or situational awareness, or spatial disorientation, or getting behind the airplane, anticipating one instrument approach and receiving one that he had was not familiar with, or just being confused; whatever else the distraction or problem was, something contributed to his inability to fly the airplane at that particular moment in time. It's critical that we in aviation discuss in detail how all of the potential causes could have contributed to his inability to fly the plane at that moment in time and understand how we can prevent those particular pitfalls from affecting us individually in the future.

So yes, he impacted the ground because he lost control of the airplane. But WHY did he lose control. It's critical that we understand what those distractions can be and how they can impact us. Unfortunately, in this instance we'll very likely never understand exactly what was going on inside the cockpit. So we will be left to speculate about what may have been happening that cause this particular pilot to lose control in what certainly seems to be fairly benign conditions.

 

[flyingron]

And George can't fly a circle to land

Well, you don't start circling until you're in visual so it's not clear why it makes a difference, but HDG mode works fine on my autopilot.

Of course, if you don't know how to use all the features...

 

[Tarheelpilot]

Medical issue?

 

[hindsight2020]

Put me down for simpleton IMC loss of control. Occam's razor.

 

[Ed Haywood]

I find it interesting that so many here are looking for the "reason", ie, bad AH, AP, pilot incapacitation or another item. Why do we always look for the excuse, and not just recognize the common root cause of 80% of the accidents are simply pilot error.

Human nature. Reminds me of a discussion on a FB group about a recent Decathlon crash in Georgia. Pilot did a low pass to show off for a pal, below treetop level, and tried to roll the aircraft. Of course he ate the trees on the far end. Decathlon is a pig when it comes to roll rate, and requires substantial nose up in inverted flight to avoid loss of altitude. Patty frigging Wagstaff could not roll that aircraft in that situation. And yet the discussion on the FB group was about carbon monoxide poisoning or a heart attack. Infuriating to me because according to my search of the NTSB database he is at least the 10th Decathlon pilot to eliminate himself from the gene pool in this exact manner.

 

[MalibuJim]

Completely agree with this. There is certainly a lot of speculation going on. I've seen lots of discussion about possible medical issues and I don't see the evidence to support it. And ultimately it is the PIC's responsibility to fly the airplane.

But let's tug on the, "he still FAILED to fly the plane" thread a bit. Regardless of whatever else happened, whether it was his AP, or situational awareness, or spatial disorientation, or getting behind the airplane, anticipating one instrument approach and receiving one that he had was not familiar with, or just being confused; whatever else the distraction or problem was, something contributed to his inability to fly the airplane at that particular moment in time. It's critical that we in aviation discuss in detail how all of the potential causes could have contributed to his inability to fly the plane at that moment in time and understand how we can prevent those particular pitfalls from affecting us individually in the future.

So yes, he impacted the ground because he lost control of the airplane. But WHY did he lose control. It's critical that we understand what those distractions can be and how they can impact us. Unfortunately, in this instance we'll very likely never understand exactly what was going on inside the cockpit. So we will be left to speculate about what may have been happening that cause this particular pilot to lose control in what certainly seems to be fairly benign conditions.

Doubtful we will ever know what really happened, and the debris will offer little to no insight as there probably wasn't much left to analyze. We all know how the final report is going to read, and it will likely fall squarely on the pilot.

 

[FormerHangie]

I wonder if he had something giving him incorrect pitch information. The controller kept telling him to climb, he acknowledged those instructions, but did not climb. If whatever he was looking at for pitch was misleading him, that could have been why he was still descending when he needed to be climbing.

Considering the speed of impact and the amount of fire, I don't think the examination of the wreckage and his remains is going to tell us anything.

 

[Fearless Tower]

Where is there evidence he had even broken out of the clouds as he was drifting through the localizer? It’s been suggested that he could have been maneuvering for the circle (left base) for 23.

We don't know for sure. Bases were around 2400 and he got down to around 2400 right about the time ATC cancelled his approach clearance. Only the deceased knows what was visible at that moment.

 

[Fearless Tower]

I wonder if he had something giving him incorrect pitch information. The controller kept telling him to climb, he acknowledged those instructions, but did not climb. If whatever he was looking at for pitch was misleading him, that could have been why he was still descending when he needed to be climbing.

He did climb initially....but so abruptly that he got down to 100 kts and then pitched back down again. It would seem he wasn't climbing because for some unknown reason he was having difficulty controlling the airplane.

 

[dreyna14]

That's fairly common around here to get dropped in high.. there's a lot of terrain east of MYF, SAN, CRQ, RMN, and it's busy airspace. If you're going to SMO they keep you very high. The solutions to that are all within a competent pilot's tool bag

I can attest to this. At KOXR and KCMA, if you get vectored south by Mugu they will dump you at the FAF at 4,000 because of terrain. You then have to dump a ****load of altitude to get one the glideslope. Had to do this twice in IMC. It isn't fun but doable if you are aware and prepared.