Deadly Descent: Beechcraft Breaks Up in Terrifying Incident
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- เผยแพร่เมื่อ 2 ก.ค. 2024
- #mayday #aircrash #N440H
Tuesday 3 May 2016
Fatalities: 3 / Occupants: 3
The instrument-rated pilot was conducting a personal cross-county flight and was operating on an instrument flight rules flight plan. While he was flying in visual conditions between cloud layers at 7,000 ft and heading toward the destination airport, he reported to air traffic control that the airplane had experienced a vacuum pump failure and that he had lost the associated gyroscopic instruments and part of the instrument panel. The pilot continued toward the destination airport because it had the best weather conditions compared to alternate nearby airports; however, after accepting radar vectors for the GPS approach to the airport, he reported that the airplane had entered instrument meteorological conditions (IMC) and that he had lost a "little bit" of control. He then reported that more of the instruments had failed and that he was trying to get back to 7,000 ft. Shortly after, the controller provided the pilot with the weather conditions at a closer airport and asked him if he would like to try to land there; however, no further communications were received from the pilot. Review of radar data revealed that the airplane made several course and altitude deviations as it proceeded northeast until the end of the data.
The airplane was found separated in multiple pieces along a 0.4-mile-long debris path. Based on the radar data and debris path, it is likely that the pilot experienced spatial disorientation while maneuvering the airplane in IMC without a full instrument panel, that he subsequently lost airplane control, and that the airplane broke up in flight due to overstress during the ensuing uncontrolled descent.
Review of a vacuum pump manufacturer's service letter (SL) revealed that the mandatory replacement time for the make and model vacuum pump was 500 aircraft hours or 6 years from the data of manufacture, whichever came first. Compliance with the SL was not mandatory for 14 Code of Federal Regulations Part 91 operations. The vacuum pump was manufactured in May 1999, which was 17 years before the accident. Additionally, the airplane was not equipped with a backup/standby vacuum pump.
Metallurgical examination of the vacuum pump revealed that the rotor had separated radially in numerous locations. Three vanes remained intact, and three vanes separated into numerous pieces. Rotational scoring/rubbing marks were observed on the rotor and pump housing.
Additionally, debris was noted in the inlet screen, but the engine had impacted a dirt field. It is likely the rotor's contact with the pump housing caused the failure of the pump rotor and vanes; however, it could not be ruled out that debris ingestion contributed to their failure.
The pilot had severe coronary artery disease, and toxicological testing revealed low levels of diphenhydramine, a sedating antihistamine allergy treatment and sleep aid, and zolpidem, a prescription sleep aid. However, there was no evidence that the pilot's heart disease or sedating medications impaired his performance or incapacitated him.
Probable Cause: The pilot's loss of airplane control while operating in instrument meteorological conditions with only a partial instrument panel due to a failure of the airplane's vacuum pump.
Contributing to the accident were the pilot's spatial disorientation and the operation of the vacuum pump beyond the 6-year time limit recommended by the vacuum pump manufacturer.
• Deadly Descent: Beechc...
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Based on the radar data and debris path, it is likely that the pilot experienced spatial disorientation while maneuvering the airplane in IMC without a full instrument panel, that he subsequently lost airplane control, and that the airplane broke up in flight due to overstress during the ensuing uncontrolled descent.
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Why oh why do people do this??
"I have an emergency, but I'd like to press on for hundreds of more miles, rather than landing at the nearest available to sort things out"
A vacuum issue and partial panel is not going to get better, it can easily get worse (and it did), the weather can change (and it did), and the longer you're in the air the less options you have.
Land while you have VMC and at least a partial panel.
@@pyme495 agree with you
A couple of reasons not to panic and force the issue into a more immediate solution. The situation was stable in VMC affording time to come up with the best plan. Once the problem was defined, which didn't take too long, the approach to solution was figuring out the best way to maneuver to land while remaining VMC or minimizing IMC exposure to transition to VMC as high above ground level as possible with immediate access to an airport to land. There was time to get an experienced instructor pilot on the radio to work with the pilot and help talk him down. Also by not landing immediately afforded fuel burn that would mitigate post landing or crash fire. All in all, poorly handled by the aviation community.
He was in VMC, but above the clouds. He knew he was going to have to descend through those clouds regardless, and was looking for the option with the highest ceiling and best chances.
This was a VFR on top situation: operating in VMC but he already had solid IMC below him when the failure occurred. His destination had the best weather and the best chance of getting down through the cloud deck alive.
He was vfr on top. Did you listen to the same video?
Go offshore, descend into the clear, land the pane in VFR
@@johnkeith2450 that's the right way
@@Flight_Followernot always possible
He still could have used his compass. You are correct
Yes...THIS!
A 180 degree turn to remain VFR on top till VFR conditions could be found might have been better than continuing toward the destination. Very difficult “nightmare “ situation! R.I.P.
Gethomeitis may have been a factor here.
@@luismartinez-my1nk Need for better Aeronautical Decision Making for sure!
The Bonanza is such a nice aircraft, but I wouldn't fly IFR without at least a backup artificial horizon. Better yet, rip out the 1950's technology vacuum system and pop a couple of G5s in there with battery backup. That pilot knew all too well what kind of trouble he was in when the vacuum system quit. Nightmare situation. RIP.
GI275s for the win!
Sad since G5s are an integrated pop-in installation that any Bonanza owner would this is pocket change.
I have a backup electric pump in my Piper. It worked just fine, when my vacuum pump went.
IMO Flying IFR this century with vacuum instruments is insane.
@@AirBlairNZabsolutely
Yeah that controller had no idea what partial panel was, so that "emergency" meant nothing to him. The pilot must take initiative, there's no other way to do it.
A Bonanza is a very clean airplane, and picks up speed very fast. This scenario isn't unusual for a Bonanza with a pilot that isn't proficient at IFR. I was almost killed a long time ago with the same scenario in a Bonanza with an IFR rated pilot that hadn't flown any actual IFR in almost a year. Lesson learned. Sad.
2.5 hours of fuel. Was the weather overcast in every direction for 2 hours of flight time?
Dry vacuum pumps fail. Oil vacuum pumps better but they were messy. A couple of things to help staying alive are proficiency and redundancy. RIP. Hopefully this accident prevents another.
Better to go electric with battery backup. Pretty sure a $3k Garmin G5 ticks all of those boxes.
No Gyro means land at the nearest suitable airport and not all the way to your original destination..
@@edwardrichardson5567 exactly it was not necessary to go to destination
Possibly! But the report did say the weather was better at the destination so the details of that situation matter. The destination may have been the nearest with VMC, in which case the decision would have been justified. One would have to delve into the details to see if this was the case.
@@flyer617 moreover, we don’t the situation in the cockpit too
His destination had the best weather vs alternates. They changed controllers during his flight so he had to explain his situation to a controller who didnt understand. He was above the clouds but the new controller ignored his request to not be in and out of the clouds.
Were you there?
turn around to airport you came from.
He's IMC
@@747heavyboeing3 didnt atc ask him if he wanted to head back? he decided to go forward?
I felt bad when he said he hoped for clearer skies. He told the controller he didn't want to go back IMC but they didn't know what vaccum system failure meant, so they didn't pick up on the danger he was in when he reported going back into IMC. Once he went back into the clouds they were dead. He ripped that Bonanza into pieces. I didn't expect to see what I did in the docket photos back when I first watched this accident on ASI. He was out of imc but the new controller put him back in it thinking vaccum system loss wasnt a big deal.
a vacuum pump is mounted on the engine to provide suction to twirl the vaned gyro rotors inside the flight instruments. practicing for partial panel failure is tedious and not necessarily a guarantee to a successful outcome in this kind of emergency. those who choose to fly in instrument conditions in single engine aircraft should invest in back-up electric gyro instruments or other redundancy options.
Seems like there was a coastal wx system but what about to the west and south?
exactly, but need to be careful, What was the weather to the west? Can Only speculate. Certainly would be pinging controllers for help on that. Ipad with foreflight is a great investment
If the pilot couldn’t handle emergencies like this in IFR conditions he shouldn’t be flying in them. Complacency and lack of proficiency has no place in aviation, unless you want to die. Knowing your limitations and using good judgment is a must for longevity of life.
In training instruments would be covered to simulate failure. I found it was best for me to cover them when they actually failed to keep my mind from distractions and confusion.
Don't know if his heading indicator was functioning or not, but an increase in heading numbers indicates a right turn, decreasing a left. Dropping 10 flaps and the gear will slow the plane during descents, giving more time to react. I've flown under the hood using turn and bank indicator and heading only and it worked out okay. Trim for best glide and a gentle 500fpm descent and don't look out the windscreen!
Poor guy must've been terrified. Did he not check weather at his destination and route? All it takes is a quick call to the ASOS.
"Partial or vacuum system lost, thank you" the ATC probably didn't know what it meant, say you have no horizon or whatever the problem is, and clarify what it means in reality like "unable IMC". In this case the second horizon probably died just before the crash (just assuming they had a backup when flying IMC)..
I used to have a wonderful F33A Bonanza. The previous owner had the foresight to install an electrically operated backup vacuum pump, along with an electric attitude indicator. Thankfully I never needed either in flight, but they sure were a comfort factor.
Still a shame! RIP!
Declared an emergency and keeps flying to his designation? Dumb. Land at closest VFR airport immediately! Everything going wrong from his first call. Get down fast.
Steam gauges are great, but always have electronic gauges too. Horizon, VSI, speed altitude, everything is available electronic... requesting a radar approach was smart... don't know why they didn't give it to them
if you are VFR with an inop vacuum pump you'd be insane to go IMC......just fly out of the area of weather until you can see the ground.......several videos on YT of people continuing into IMC and crashing.....needlessly dying.
he was on an IFR flight plan and already above the weather, there was no way to decend without going IMC and he knew it.
@@hyperiondan you're an idiot......
@@hyperiondan I disagree. Sounds like he was VMC and entered IMC in cruise which is a choice. There doesn't appear to be any effort to look for airports outside of the weather region. Use that fuel and fly west!
This has resignation written all over it.
In 2004 a friend of mine in a Bonanza who was IFR rated flew into a storm at night, lost control, spun, crashed, exploded, and killed all 3 aboard. Just minutes earlier he had talked to a controller who made no mention of a storm immediately ahead on his filed flight plan. He told that controller his altitude. A fourth person declined the week-end hunting trip on Friday morning citing safety concerns. Lucky guy. A lawsuit was filed against the FAA. Despite the law being on their side I believe the FAA settled. A lot of money was up for grabs because they all had big time high paying jobs. And all his brothers were lawyers. They were not going to get out lawyered to death.
I also thought the controller was showing that he too was getting stressed as his tempo and volume went up when the pilot was starting to deviate. Controllers need to stay calm and reassuring. The pilot was so wrong to press on!
I think I would have looked farther away for better weather.
Why is losing a vac pump an emergency? I flew old raggedy ass Beech 18s all my life.Sched & charter for Uncle Fred's Federal Express & E mery Air. It was never IF something wasn't going to quit but when. Fire, electrical smoke, DG out? Attitude out? Use other side. Thoss don't work, use airspeed, compass, turn & bank. No radios? Follow comms out procedures. VOR out, use ADF.
For a long time now there have been handheld GPS available that display flight and navigation instruments. Great backup insurance and a way to confirm status of the panel.
That won’t help when you’ve lost your attitude indicator
This was very sad. Too many pilots forget to practice partial panel once they get their IFR ticket. After I got my instrument rating I would often fly in IMC for as long as 3 hours and would routinely cover up instruments and do an entire flight parial panel. Then one day my AI failed shortly after take off just as I entered IMC and had to do a parial panel NDB approach back into FRG. What would feel like a high pressure emergency to most felt almost routine to me because I had become very proficient on partial panel.
Loss of vacuum instruments should not have to end in a fatality. There is plenty of redundancy in the panel and maintaining partial panel proficiency should be be a part of any pilots regular routine. The fact the the only legal requirement for IFR proficiency rests on approaches and holds is not enough. Every IFR pilot should get use to hand flying partial panel on a regular basis.
Which instruments did you cover?
@@arip9234 both vacuum instruments, AI and DG. It really helped develop use of airspeed and altimeter as pitch instruments and TC as bank. Also helped develop use of compass for heading.
@@DanielTorres-tm2wwOK. But if your vacuum system is down, your TC is also gone…and you’re blind in IMC. what then?
No, TC is electric.
@@DanielTorres-tm2wwIt was vacuum in my written exam but good 👍🏻
VFR on top? A very bad idea and should not be allowed. My condolences to the family.
He was on an IFR flight plan, when he said VFR he meant VMC
Ask for a VFR or high ceiling airport with radar coverage past the cloud ceiling and instruct you want the radar guy at the selected airport to be following and talking to you to announce if counter banking is needed to stay straight. Let down using the simple altimeter. Watch the windscreen compass for precept to balance staying level.
RIP
RIP
I have a mild suggestion though it'll be over thought and I can hear every excuse coming out because of it, but when someone like this has this happen to them why do we never fly up a wingman to help bring him down? I know why? People will say why put two planes in danger, but boy it would be nice if we had pilots with steel ones that could rescue somebody's son/daughter etc.... from certain death if they felt like they were stuck on top.
But my biggest suggestion is for all of you single engine flyers is to spend the money for a ballistic mount parachute!!! How can you put a cost on your life????
And I'm seeing way to much of the sub aviators eating dirt and its depressing 😢😢
Wishing for good weather is better done when we are on the ground..
Loosing just the adi should not be the end. Recognising it in time is.😢 After you loose the vac pump you have only 30 minutes on the standby adi. After that you are dead.
Instument panel problem of any kind would cause me to land at the nearest opportunity. Period. He lost more than just the vacuum pump. Geez.
Listen to the audio again. He was looking for an airport with the best conditions. Having to do an approach to minimums on partial panel without being proficient would have had a lower probability of success. He had 2.5 hours of fuel so he had the option to look for the best landing option. Although I don't think HFD was his best choice, but then again I don't know what the weather behind him looked like.
I can't believe the controller was mystified as to what "partial panel" means.
Why can't you beleive that?
Imc requires utmost discpline
Why keep going turn back immediately
because weather was better at the destination than where he departed from
Are you declaring an emergency, YES, But are you really declaring an emergency, YES!!!, Copy but are you...? WTF ATC?
Trajic , very sad.
R.I.P
when did this happen
2016 asn.flightsafety.org/wikibase/186933
Thanks, but not being a pilot, what exactly is a vacuum problem?
Hey Shawon
The vacuum system consists of an engine driven vacuum pump, a vacuum gauge and it powers the attitude indicator and the directional gyro.
The attitude indicator (formerly called the artificial horizon) is a gyroscopic instrument that will show the wings being level or a right or left turn. It will also show nose-up or down. Generally, it's the most important instrument on the panel.
The directional gyro (DG) is basically a compass that is not affected by errors resulting from turns.
Losing these while flying in the clouds is a pretty serious emergency.
Please read description from @Flight_Follower. A non-working attitude indicator in the clouds leaves the pilot with the inabiilty to know what is level while flying; the plane could point up or down and without the indicator you wouldn't know. Yes, there are other queues but sensory overload kicks in and therefore, loss of control.
A vacuum pump is needed to operate the equipment that IFR pilots need. With out it pilots are limited on information they need to fly IFR. To bad this pilot dint have a back up for his vacuum pump.
@@Flight_Follower Would the spirit level app on a phone show attitude?
GIYF
well dont fly in bad weather!!!!!!!
Don't ever get on one if you are not ready and willing to die.
Was he VMC when he declared the emergency and then proceeded to go up the East Coast and put himself in the clouds?
He was vfr on top
@@SeligTiles, then I’m staying there until I find some clear skies to get her down.
@@mebeingU2 oh I see… you fly something with unlimited fuel. MSFS?
@@SeligTiles He was IFR in VMC, between cloud layers
@@SeligTiles He was not VFR on top. He was IFR in visual conditions.
Was this a "V" Tail ?
I've never trusted those, and refuse to fly them.
No V tail ever crashed itself.
@@skjoe1115 ......ha....don't be so sure! 😁
@@danb6838 Give an example.
@@skjoe1115 ....Ironically, there was just another V-tail mid air break-up in Franklin, TN back in May. Check out the reports on N47WT....
@@danb6838 Was the airplane pilot less?
Man why do people do this.
Fly?
@@AlbertHess-xy7kyGet there itis
@@mikemicksun6469 We fly to get there.
PPLs pay attention.
This is yet another “mission oriented” (going from one place to another in a fast and capable aircraft in bad weather on a time crunch) flight that ended in fatal disaster.
There is a huge (fatal) uncanny valley between day VFR $100 hamburger flights in a Cessna 172… and the safe security of a turbine, pressurized, known icing, two crew aircraft preferably FAR 25 and Part 135 or better.
If you aren’t willing to cancel the trip and take airlines, turn around and go home, leave the aircraft at destination or a diversionary airport, you have no business flying. I fly a FAR 25 two crew aircraft under rules that are equivalent to Part 121 and I cancel A LOT of trips due to weather or mechanical issues.
Also.. for you American pilots. Declare the emergency and say Mayday Mayday Mayday. I swear, you guys are more afraid of lawyers than death.
We all have a brilliant backup in our pocket. At minimal cost. Our smartphones have gyros built in that are far more accurate and far more reliable than the 'official' equipment. Even for those who can afford an airplane, a complete avionics upgrade cists a fortune, and means a long downtime. For me, this is murder by FAA, just like Kobe and many other accidents. FAA regulations are unbelievably retarded : they force ancient, unsafe, expensive equipment instead of focusing on new tech and safety. You can download an artificial horizon FOR FREE ! I hope someone sues the FAA and liberates GA from them pencilpushers.
That is an alarming amount of anger you have there .
Kobe was a CFIT event .
A glass cockpit can be put into almost any aircraft with FAA cert.
ATC can’t fly the aircraft for you , they’re advisory status.
Fly safe 👍
@duncandmcgrath6290 yes with synthetic vision even CFIT can be eradicated, i am very angry as good people and entire families are being lost, time and time again. 700hrs mtbf is unacceptable, FAA is just doing the opposite of what they should be doing.
The ATC controller is behaving more like an attorney or is simply not very familiar with flying.
Controllers control, they do not fly. Pilots are not very familiar with controlling, they have never done it.
@@AlbertHess-xy7ky That's a short sighted response and useless non sequitur. Be that as it may, all the better to shift him to other ATC backup frequency(s), get an experienced pilot on the radio to help talk him through handling the situation better. The pilot needed more help from ATC than simply clearly path; he needed coaching likely beyond ATC's skill set, full grasp of the situation, and mandate.
@@theshadow5800 You expect controllers to know how to fly airplanes? The pilot was in over his skill level, the controller was not. Control facilities do not have pilots on staff. Like aircraft do not have controllers on board. Controllers control aircraft, they do not fly them. Poor pilots need instructors, not controllers. He got in over his head, he screwed the pooch. Have you ever been in a control facility controlling in IMC?
Pilots fly, controllers control, no non sequiturs need apply. They have very different jobs to do.
@@AlbertHess-xy7ky Please reread my posts on this. I do not expect controllers to know very much at all. That's why I suggested that a reasonable approach to siding this pilot was to go discrete ATC frequency which is isolated from regular traffic and get an experienced IFR instructor on the radio to work as a team... ATC (weather, routing, airports), instructor pilot, and airplane pilot.
@@theshadow5800 You want to the controller to switch to a "discreet" frequency? A "private" controller? Just one plane to control? Where is the controller going to get an experienced IFR instructor? Should every control point have one, 7/24? How much will that cost?
The pilot killed the 2 passangers for his ego
Do life have no value?
Very Tragic🥲
Controller hasn't got the faintest idea how potentially dangerous this situation was, "partial or vacuum system lost"??
This is why I always take a simple level with me to see which way is up if I have a failure.
A bubble level only tells you if your turns are coordinated. You can be in a 90-degree bank with the bubble showing you're 'level'. Beside's it's 100% guaranteed that this aircraft had a ball-indicator, unaffected by the vacuum system loss.
@@mgd3333 I’m talking about my bullseye level.
Why didn’t he just set it down after declaring emergency
Because he was between cloud layers, he needed to descend through the clouds to get it down, weather was better at the destination than where he was.
get-there-itis. if there was any MVA to VFR within fuel range should have diverted
Do life have no value?
RIP
It do gots value.