As a long-time maintenance shop owner, I had a HARD FAST RULE of not helping someone start an aircraft with a dead battery. I would charge a battery free of charge but never hand prop or plug in a cart to an aircraft with a dead battery. This accident is exactly why. PEOPLE WHO ARE IN A HURRY ARE IN A HURRY TO DIE! 60 years of accident-free fixing and fly airplanes and helicopters.
@@RandomName841 oh I know that I’m being anonymous, but trust me I am not at all trying to spend that hell I work for. In my opinion, it should be called “little Boeing “ Shop ran by accountant, only looking for the dollar. Anything to save a dime.
At 8 pm there are no lights on that end of the island. There are cliffs on both ends of the plateau runway and in a nature conservatory. You need to arrange transportation off the site during operational hours. But flying in the dark, below runway height (cliff) you wont see anything without the moon. Flown in many times, and thankfully out an equal number.
One night I slept on a concrete FBO floor with a phone book as a pillow in a somewhat similar situation. Was one of the best safety decisions I ever made.
@@kewkabe I've worked up a kit that weighs well under 10lbs, including a little alcohol burner and pot. I just need a better solution for off-field tie downs. The A&P who does my annual recommended The Claw.
My son slept in the back, I tried to sleep in the front of a Cardinal in below freezing conditions rather than cross the sierras at night. Miserable long night. Could have been worse.
Even if the battery was fully charged it would take about half of the battery in starting both engines. Without lighting at the airport, I’ll bet they taxied using the landing lights because the taxi light isn’t that good on the 55 Baron. This would have taken the battery even further down before they started the takeoff. By this time both of the alternators would be really hot and ready to give up. I’ll bet the landing lights were still on when the landing gear was tried to be retracted. Heavy Baron with the landing gear down and no electrical system would make it really hard to climb. Let the nose down just a little bit and here comes the ground. I flew a 55 Baron for two years four days a week; I would not have tried that takeoff. My boss tried to fire me because I would not take him to an unlit airport at night. I'm still here to tell you about that.
did that boss happen to have a death-wish?!? I mean I know people do not think things through, but even to a non-pilot that should appear very obviously dangerous...
Would gear down alone make that much difference? At 20C, 2000 pressure altitude, the POH shows 1450fpm climb gear up. Doesn't seem possible that gear down would make all of that climb performance disappear.
@warren5699 At what weight and CG will you get the full 1,450 fpm climb? Man, five people is a lot, and who knows what else they were carrying in addition to a battery charger.
Back in the day one of my early flight instructors was a real old-timer (he had shaken Orville Wright's hand). He told me something I remember well - went like this: "If you fly enough, the day will come when the only safe decision will be to simply choose not to go. Be ready for this: it will try to sneak up on you and get under your guard."
My comment is, after 50 years of flying professionally and privately that there will be many days not to go, PERIOD. Not to go is a very normal part of being a pilot.
Juan, long time Baron owner/operator and 121 driver. I'll add that if they followed an external start procedure with an external battery plugged into the nato plug, the alternators would be switched off. I bet the alts fields were not turned on after start, and the battery didn't have enough juice to raise the gear. Then when the gear wasn't heard, the distractions became overwhelming. My heart goes out to all involved.
" B bus under volt " If the alternator was not operating, are there any warning lights or is there just a volt meter? With a high electrical load and no alternator, the fuel injected engines would start to have a problem. In the automotive world, there is a compensation for high / low voltage as injector open time can vary with voltage but there are limits. The other issue is, if the gear started to raise, does it have to complete a cycle before aborting and remaining down? If the gear is stuck in an operation cycle, this would continue to drain the battery. Low voltage would also affect lighting and other systems making it apparent they are losing power.
I've been to Catalina a lot. If you need a place for 5 ppl to stay, there's room. It's a very welcoming and hospitable place. The airport manager could have made all the arrangements if they asked.
I was passenger on our company's small plane, from Denver to St. Louis for business, when we developed engine problems over Kansas: not enough power to get above weather. Declared real emergency, landing okay at Manhattan, KS. Pilots said mechanics would work on it and will page you when it's good. - Late in the day I get paged to come back, so I call, "Great, it's all fixed?" "Well, no, couldn't fix it; so we're just flying back home." "Flying? What's the weather en-route?" "Well, thunderstorms...." !!! "Good luck; I'm taking the Greyhound Bus!" (They made it safely, and my bus ride was hellish, but I'd do it again. Bad odds eventually bite you.)
As in this crash, one less person on the plane probably would have swung the odds to success. So avoiding the flight may have saved the others from a bads scare or tragedy as well as yourself.
Catalina airport should set up a pilot break room with some cots. If you get stranded at the airport after hours, there are basically zero options for accomodations by the airport and it can be next to impossible to arrange transportation down to Avalon. Even the credit card safety device won't help you. Pretty much the only option to stay near the airport is tent camping, but you probably need a permit (and of course need to have a tent). There is also typically poor to no cell phone service by the airport, so even researching and arranging a back up plan can be very challenging.
It's called "Group Think Mentality" 5 pilots wanting desperately to get home late at night convinced each other no matter the number of issues "auh we can make it no problem". Unfortunately "problems" all the holes lined up and no one made it off the island. My heart goes out to the surviving families. Thanks for the analysis Juan.
We’ll never know which ones if any voiced disagreement or felt pressured by seniority into not having an opinion. But in the end you still have a choice to fly.
Even worse, if one of them had said I'm not going, the difference in weight might have been enough that they would have all made it and that one would be osterized for being unreasonably cautious.
@@doug112244I think you mean "ostracized". Oster is a brand of kitchen appliances, famous for their blenders. "Osterize" evokes an unpleasant mental image.
Juan, Thank you for your service. My father was a USAAF B-29 navigator in the Pacific 1944-45. He died in 2016 age 94 and the Air Force send an Honor Guard for his funeral. Paul (in MA)
Hi Paul - my dad was a B-29 navigator in the Korean War. 51 missions. Died in 2021 at 93, Air Force Honor Guard at his funeral was amazing. Truly the "Greatest Generation." - Dave in Houston
A similar incident I was involved with as the en route controller at ZAB in 1982. A Baron, N36969, had departed ELP via V94 V19 TCS PRC onto LAS. I was on sector 19 and upon departure the ELP TRACON controller advised me that it took two takeoff attempts on a 12020ft runway. The aircraft was handed off and comm switched to me. Along the way I had constantly vector the aircraft to intercept the airway as they continually flew through it. Initial altitude was 10000ft but the minimum vectoring altitude was 12000ft TCS PRC. There was reported icing conditions and several NOTAMs issued concerning icing. Approaching TCS I climbed the aircraft to 12000ft and handed the aircraft off to sector 17. I informed the 17 controller the difficulty with this aircraft. I gave 17 control and noted they climbed them to 14000ft. A few minutes later 17 called me asking if I had heard from N36969. The aircraft had encountered icing, lost control, and crashed at the 9,300 FT level of a 9,600 ft peak in the San Mateo mountains resulting in six fatalities. The aircraft was loaded an estimated 392lbs over gross weight at departure.
I recently cancelled a flight I really wanted to take to visit some friends. I got in the plane and the PFD was dead. Now, I have a good mix of old and new instruments and two mechanics told me that technically the plane fully met both VFR and IFR lists of necessary instruments. Yet, the conditions were IFR along the route and my return flight would have been at night. The autopilot was also consequently unusable. There was just no way I was going to fly with those handicaps, especially in IFR and night conditions. So I am here to tell you about it. A couple weeks later I picked a nice VFR day to bring it to the shop.
Credit card can work most of the times but I have "slept" at a few FBO's in a chair waiting for better conditions. Some times in the rental car. The drive or pressure to go can be very strong. It is tough to step back and try again later. Disengage and think past the current circumstances. You ultimately want to get home safe.
I can relate. I've spent some nights on the couch in a FBO myself, but I always slept pretty soundly while listening to the rain and thunder overhead that I had contemplated navigating through hours earlier.
Sleeping on the couch in the FBO isn't bad at all. My hangar is an hour's drive from home. If I want to make a dawn departure, I just drive over the night before, preflight, fuel, and crash on the couch with a laptop and some cat videos. There's a coffee pot and a microwave for a gas station burrito before I leave. The airport manager is completely cool with it.
I used to travel a lot in a C-172 and on long trips I would usually store the rear seat in the trunk of my car (room for bicycles, etc). If you take the front seats out and put them under the plane and add an air mattress to the floor, 2 not-too-large people can get a reasonable night's sleep. Done that several times in a pinch.
pilot mechanic here, another mechanical issue given battery need charging, both alternator drawing max engine load to produce amperage to battery, so less engine power available in critical take off phase
A 70 amp alternator at 28 volts is producing 1960 watts, or about 3 HP. I doubt that's a noticable effect on climb rate. The pilot simply didn't maintain best climb speed in this case.
I’ve been flying for over 40 years now and the best advice I ever got was from my very first flight instructor. He said, do not ever get into any airplane that makes you nervous even if you aren’t flying it.
Our next door neighbor offered to take me and my daughter (around eight years old at the time) up with her and her husband (amateur pilot, computer consultant by occupation) in the plane they owned. I have no interest in flying in anything but scheduled commercial aviation, and politely declined. A few months after the conversation, the neighbor, during a training flight so she could get her own pilot's license, turned a Cessna belonging to the flight school, into a ball of scrap metal, the wings all crumpled (I saw pictures), rolling the aircraft as she came in to land, apparently due to turbulence from a helicopter. It was a near miracle that her and her instructor both walked away, though she did have a fractured eye socket that required reconstructive surgery.
@@pulaski1 It becomes challenging when you have friends who you don't trust as PIC. I have a couple of good friends that I will not fly with because they make bad decisions. Making that decision has gotten easier as I've gotten older because I trust my judgement more. Flying is dangerous and even if you do everything right it can still kill you. It's worth the risks to me but everyone does their own calculus on it.
@@AndySpicer Because back in the day, with a string of unpredictable trainees in trainers maintained in large part by A&P trainees, there were a whole host of things that could and did go wrong, caused by either group. 😊 By the time I had been flying for a few years, I would certainly have been nervous at times trying to operate as a CFI there.
So they send a broken airplane to save people from another broken airplane. Then they fly a very heavy, broken airplane into a black abyss against the wishes of the airport manager. It sounds like the good lord tried to tell them a few different ways it wasn't a good idea to take off that evening.
The rescue pilot said he HAD to go. Turns out, the world wouldn't have ended had he spent the night on Catalina. It seems, self-importance was his undoing.
@@RockandRollWoman There were no innocent lives lost. That would have been someone on the ground. The airport manager clearly said they were breaking the rules and flying at their own risk. Any one of them could have said stop or decided to exit the plane and let the others take their chances.
I'm training for my private, I'm really glad you post these videos so we can learn what not to do. The most shocking part of this accident is the fact that multiple pilots all agreed to do something so foolish.
When you're a pilot sometimes you think you know what you're doing and feel like you can handle any emergency. But the dead failed to realize, it takes only one mistake. An electrical problem on an aircraft? How foolish you must be to continue.
The people being "rescued" probably felt pressure to leave, despite all the red flags, and they took a chance. Their situation caused a pilot to have to come to their rescue, so they probably felt obligated to go with him, since he was in a rush and needed to get back for some self-important reason. Anyway, hindsight is easy. Risky things like this have been done thousands of times without catastrophic events taking place.
Now ask yourself this: If those five pilots who had much, much more experience than you have made such a bad decision, how can you be sure that you won't do the same sometime in the future? After all, all five of them had certainly read far more accident reports than you have, yet they still took off. If you continue flying, one day, or night, you're going to find yourself in a similar situation. Be sure to recall this accident when that day or night arrives. .Good luck with your training.
I've spent the night sleeping in the PA28-181 of the flight school I worked at. Late at night, uncontrolled field, no money for a hotel anyway. I'm alive to talk about it. Did it again in the PA44-180. Always took safety seriously and pushed down the urge for get-there-itis. Plug those holes in the swiss cheese.
Make sure you're taking care of yourself Juan. I feel like you've been covering a lot of fatalities this year. Don't feel pressured. As always though, I love your videos as someone who's just an aviation fan
If this plane had electronic mags (ie Surefly) then operating the gear with a dead battery would cause loss of the mag (ask me how i know). Its worth checking what kind of mag setup this plane had.
Electronic Magneto seems to be a contradiction in terms. A Magneto is purely mechanical and needs no battery to produce a spark. However, on startup a Magneto may have poor spark, and an auxiliary electronic assistant will enhance startup performance. However, once the engine is running the electronic enhancement is not needed. Therefore, if battery power were to completely disappear in flight the Magneto would still provide sufficient spark to keep the engine running. If Surefly is a electronic replacement that cannot keep the engine running without battery poser, then I would think myself a fool to choose it. Surefly would not be termed a Electronic Magneto, it would be an Electronic Ignition. Names describe function, and if names are misused sometimes we die.
@@ewathoughts8476It all depends on how the electrical system is setup: If you have a 24v battery and a 28v system, then there's a voltage regulator/inverter in there somewhere. The alternators are probably 24v, but if one is inop, and the other one can't keep the battery up by itself, then chances are the regulator/inverter is also cooked - which is why the battery/alternators are failing to begin with. Even if the alternators are putting out 14v each, or 24v each, if you lose one, you won't have enough juice to run everything. At least, not for long. Then again, the fact they had to charge the battery just to start engines tells you they had a bigger problem than they thought. Hell, could also be something as simple as corroded or loose connections.
I feel this , can't help but feel like this was entirely preventable. :( Personally , I would have rather slept in the hanger than get into the plane after watching engine not start , at night. A D M . RIP and condolences to those that lost family members.
I doubt either of the so-called "student pilots" were given much say. And of the other three, two were employees of the pilot flying. It's pretty clear who was calling the plays here.
Thanks for the video Juan. I don't fly, but I do teach classes for young people getting their Pleasure Craft Operators Card (small boat license), and I've actually started working "Use your superior judgement to avoid having to use your superior skills" and the credit card rule into my lessons about safe trip planning and on-water risk management for those young boaters. It's a very clear and easy to understand shorthand for such an important concept that is applicable in both GA flying and recreational boating, fields where as non-professional operators we are taking our lives and those of our trusting passengers in our own two hands, without any corporate structure to keep us on track and watch our risk-stacking for us. You are doing good work. Keep it up as always.
Boating Safety and Hunters Safety were required in my family. Thank you for teaching the kids out there. I believe a course should be required for anyone that boats or hunts. A Boating License should mandatory for anyone going out on the water.
People need to carry CASH as a backup not credit cards. Cash is king and can pay for everything everywhere anytime, especially in emergencies. Reliance on a credit card will leave you stranded with empty fuel tanks and nowhere to stay if your CC gets lost, tagged for fraud, systems down, etc. There's cash on me and hidden in all my vehicles for a reason.
Starting to fly early 80's, we usually had a number of AOPA magazines in the clubhouse and I have learnt so much from the (usually) last page article: "Never Again" . Just by reading and listening to other pilots stories, one can really learn (if you are willing) such a lot and avoid so many mistakes. Never underestimate the value of these lessons, such as this channel for example. Thank you!!
In the eighties and nineties I wa a Part 135 operator as both a pilot and Check Airman. Flew in and out of Santa Catalina with PA60’s and PA 31T. This accident is a good example of the “Error Chain” and pilot lack of systems knowledge. True, as an A&P it is easy for me to be critical but my gut feeling is the operator had no idea of electrical power distributions and limitations. The fact that the Baron needed the weak battery charged before enroute to Catalina probably indicates there was insufficient amperage reserves to power a full electric landing gear system. Keep in mind, Pilot probable has every light illuminated for take off and was basically operating on what power the system produced with engines running. Surely, there also would have been insufficient amperage for an air relight. I was blessed to have two great FAA inspectors as POI, PAI and PMI’s who taught me well. And, I retired from UAL after thirty plus years and flew maintenance post HMV verification flights where systems knowledge is essential. As a 135 Check Airman and also an A&P, I would always ask the candidate before and during a Check Ride “ What if” scenario questions Andy”How would you manage that irregularity and/ or systems failure. Comprehensive Systems knowledge makes for good Decision on making along with SOP and FAR adherence respect. Juan, please consider a follow on analysis when the NTSB report is finalized. Thank you for your efforts that contribute to air safety and pilot proficiency. Sometimes it is better to abort the sortie than go at all costs, in this case five lives. As Clint Eastwood said in “Dirty Harry” ….” A man’s got to know his limitations”.
Thank you for your analysis. Understanding a weak battery before Catalina, but in flight, isn't the (Starting) battery just another load on the system and your alternators generate power and would be used to power the landing gear?
@ Close, but think of the battery as an accumulator of, in this case, voltage with sufficient amperage to power things _ including high demand landing gear hydraulic pump. Please see goutvols103 response. A battery can have 12 or in this case 24 volts but if ther is not enough amperage, it won’t power high demand devices. Jim Caufman’s explanation is excellent. I once had a 727 new flight engineer who mismanaged the essential power off operating engines when we were shutting down engines successively on a maintenance test flight. Poof - darkness as demand overloaded the power output of the remaining 2 operating engines. He was yelling and I turned over my shoulder and told him to chill as the blue sky was still up and we were flying in clear air. I simply said for him to turn on essential power so we had comm 1. Now rebuild the systems and we will be fine.
@ enroute, the battery rebuilds its charge from the start but that takes time and is compromised by the drain on charging system. Think of the battery like an accumulator - it absorbs voltage surges and augments low voltages due to spikes. This is one reason why many charter operators use an external power source to start. When I operated a Bell 206-L1 for flights from Long Island to NYC would always start the jet engine with a double truck battery mounted on the landing dolly. This way, I always had a full charge if I had to shut down at 34th street or the now extinct 60th street heliports
I know for a fact as it happened to me ,that an electrical retractable landing gear system will cause total blackout when the Gear up switch is activated with not enough electrical power to do so. 50' up, positive rate of climb, gear up switch activated and all of the panel lights go black. I flipped the gear level back down and the lights and radio powered on. I manually ratcheted the gear to get green down and locked indication and flew the 7 miles back to my home airport gear down and landed safely. Had I not known to remove the amp strain on the system, it would have been bad. I did have a flashlight on a lanyard around my neck. My single engine aircraft could climb with the gear down although less than 500 fpm.
It's sounding very likely that this is what happened. Gear up... sudden dark cockpit. It may have been almost pitch black in there, we'll probably never know.
Another great instructional video. I recall that many years ago my helicopter crew and I spent the night at a small airport terminal rather than continue into a bad weather situation. We were returning to base after a long deployment and the get home itis was might powerful. Fortunately we made a difficult but correct choice. Thanks.
You pointed out something a lot of people, including pilots, don't understand about vehicle electrical systems. The charging system in a vehicle - auto, aircraft, whatever - is designed and intended to keep a charged battery charged, NOT charge up a dead battery! That's why they're called a charging system. The electrical systems essentially run off the battery, not the charging system. Dead batteries MUST be charged off-circuit with a bench-type charger, then tested under a load to determine if it's suitable for service since a depleted charge lowers the battery's internal resistance, which can overload the charging system and cause a failure. Good job Juan!
Sir, you may be right. Most people have experienced a flat battery on their auto, and had it jump started. Then the alternator charges up the battery over 10-15 minutes of driving. ie it's nominally a 12V system but the alternator puts out power at 14V, and lots of it. The battery gets recharged and if it drops dead overnight you get a new battery. So, maybe the electrical system is not _designed_ to recharge a dead battery, but it usually can. I'm not disputing what you say. I don't know one way or the other, but I feel that you shouldn't castigate people whose experience tells them that a charging system _can_ charge a battery.
@@fightingforfaith3541 yup, I’d rather you not jump your aircraft, but if you do, least wait 30 mins on ground to charge back up. It at the least puts undue stress on the charging system.
Landed at Catalina many times. It’s very remote. That road to Avalon is a 45 minute roller coaster ride on the scheduled shuttle bus. Full of potholes the whole way. I thought the windows were going to fall off, the bumps and rattling was so loud. Likely your stuck there at night, nobody’s coming up that dangerous crap road to get you. Get out early, and give yourself lots of buffer for clouds and nightfall.
Flew Barons for many years. All time favourite light twin. Having said that, if you didn't play by rules and know your systems it was unforgiving. Great review! Thanks!
I love flying into Catalina but it's not something you do without plenty of advanced thought. Flying in around dusk or thereabouts def requires contingency planning. Took a plane full of kids there this Summer but didn't love the conditions so decided to simply do a low fly by and back down over town, instead of landing. Sad story, but I suspect you are right, lots of can-do ppl working an earnest but clearly flawed solution. RIP aviators. Bless all of you.
My dad is the what’s in your wallet actor. Also 787 pilot for united. I am a commercial rated pilot, we fly to Catalina a lot. We watch your channel together when he is home. Good comment at the end! Rest in peace to the pilots
Five (5) pilots did not get to make a consensus decision to go/no-go. It likely came down to the older owner of the Baron, a CFI, and former flight school owner. His decision was likely supported. One might ask if his personality was autocratic.
From a mountaineering and scuba diving background, it’s always best to avoid getting into a bad situation in the first place rather than thinking you can just bail yourself out of trouble. My mountaineering instructor once said “overnight bivouac” is French for you’ve f**ked up. Have an emergency shelter but don’t plan on using it. Scuba diving had a “spiral of decline” model where a mishap always gets worse and worse. Stop the mishap from proceeding at the first layer of Swiss cheese.
100% and I might be biased, but I'd only fly in a private plane if the pilot/owner had a mechanical background like me, and/or was a scuba diver. You can't train someone to understand mechanical things, they have to be "built" a certain way to be able to enjoy and get it. And with diving, the grim reaper is very near and you can feel it, and it's drilled into you on your first day of open water.
Oh dear. The Baron is a classic masterpiece. I painted a lot of them here in Wichita at Beech in the 80's. This is sad, god bless the souls lost in this tragedy.
Hi Juan you are a total (aviation) stud - thanks for putting all this out. I’m in your Patron group, 2000 TT multi-instrument rated, now “retired” but sure would have enjoyed flying and learning from you.
I am not a pilot, but I have been in small airplanes. You have given me a lot to think about the next time I go up. I definitely don't want to be on YOUR channel because of the flight I'm on! Thanks for all you do!!
The term you are referring to about all the pilots talking themselves into something is called “group think”. I don’t fly but I operate a large metropolitans power grid. When you are in a high stress situation some one has to step up and take charge and make a decision. Weighing in all the factors and possible outcomes and make the decision for the group. Lots of accidents have occurred because too many parties get involved and the lines start to blur and you might totally be against what the group wants to do but you won’t speak up because the group has already made the decision. The definition for group think is as follows: Groupthink is a psychological phenomenon that occurs when a group prioritizes consensus over critical thinking when making decisions. It can lead to irrational or dysfunctional decisions because group members may not consider alternatives or the potential consequences.
I carry a light goose down comforter. Usually the best airport as a alternate is the one you just passed. I fly a lot at night and if I have to divert to another airport there may not be any cell coverage. So I know that I can make it until the next morning without freezing to death or I won't push on into worsening weather.
Thanks Juan for this report. I always (for lack of a better word) ‘enjoy’ watching your videos, because they are factual but you never fail to show some emotion (anger/frustration/surprise). This particular case is massively depressing…and unfortunately left 5 people dead. Just imagine how often others do the same thing, with the same attitude, and succeed…in other words don’t end up in the stats. Keep up your good work, do you ever layover in Amsterdam? A321neo capt based at Schiphol.👍🏼
Reminds me of something Petter said over on Mentour Pilot. When taking multiple crew members assessments into consideration for any decision, it’s important to start with the lease experienced person, and end with the most experienced person. This prevents a senior captain, for example, from driving the decision making. The junior officers will fall in line with a bad decision instead of standing up to their captain.
And what to say about the flight school? So they rented a poorly maintained plane to the instructor and his two students. And then, sent another poorly maintained plane to rescue their clients, owned by someone that didn't care about safety?
This brings up an interesting question: In a situation like this (non-towered airport), when the takeoff is not approved and in violation of airport guidelines, but they takeoff anyway, what is the consequence? Does the airport have any authority to enforce some kind of punishment?
I flew out to Catalina with a (former) buddy who has serious contempt for authority issues. At that time (late 1980s) you would call the airport and the manager would say something along the lines of "landing approved". It was not at ATC "cleared to land", but it's a private field and while they cannot prevent you from landing - for instance by parking a vehicle on the runway - there's nothing wrong with a little courtesy and respect. My buddy wanted to know what the point was of calling since there's no tower and no requirement per se to get permission to land. I have not spoken with him in some time, but I get the same sense reading about this incident. Some people do not have a temperament that is compatible with flying.
I can only speak to experience in Canada, but from having worked at a municipally-owned airport with a contracted operator, the operator has absolutely zero authority to say or do anything to prevent a pilot from taking off or landing.
I'm glad you mentioned at the end that it is difficult at Catalina to get accomodations. It really is and I can see how someone would want to leave after hours because the mainland and the nice bed at home are both so close vs trying to get a ride down to Avalon or worst case sleep outside the restaurant building. But as you've explained well, he stacked the odds against him. Had it been just a night after hours departure in an airplane without issues, lower T/O weight it would have been no issue.
Too many people in aviation, simply have a very deficient knowledge about the systems on the airplane they are flying... Thus, when a mechanical, hydraulic, pneumatic or electrical problem surges, they are completely incapable of properly diagnosing it, much less capable of going around it, and the problem ends up killing them.
Pure speculation on my part: I'm not a pilot but am an EE. "If" the battery/charging system was marginal, when he attempted raising the gear, the imposed load may have caused system voltage to momentarily spike downward, possibly causing some dash equipment to blank out or reset. As Juan mentioned, if the artificial horizon display was electric and momentarily stopped working, that could have doomed them. Short of recovering the battery and attempting to replicate the failure, we'll likely never know.
A friend of mine did almost the exact same thing. Left the master on in a Centurion and had a dead battery at night. He got a jump and let it run for 10 minutes then took off. He was at Mariposa Airport. It's a mountain airport in a hole with higher terrain 360 degrees and very dark. As soon as he raised the gear handle everything went black. He called me on the cell to go to our home airport and turn the lights on and see if I was available to do the task because his comms were out. Without comms he wouldn't be able to turn on the airport lights. In the time I was on the phone with him he decided to go back to Mariposa with the timer ticking on the airport lights and he also didn't know the status of the gear. I was scared to death, and I wasn't in the airplane. I stayed with him on the phone until he landed safely. It felt like I was in the plane next to him. It scared him enough to where he won't operate there at night anymore. I also learned what not to do in that situation.
The function of an alternator is to keep a fully charged battery, fully charged. As soon as a battery gives you trouble, replace it before it eats your alternator
If the universe is telling you it’s no go, it’s no go. The magneto trouble on the first plane, plus battery issues on the Baron, plus pushing departure past a the airports limits should be enough for your intuition to be ringing loud alarm bells..even if your brain says you can do this, sometimes you just have to accept that the universe is telling you something different, and to respect that, because the universe knows best. What a sad and unnecessary loss of life.
Juan, it is just painful to hear about all these "pilots" who kill themselves and others by being over confident. Thank you for your detailed a serious reporting on these situations.
Happy Vet's day from a landlocked sailor. USN, 68-74, ETR-2, NAS Miramar, 70-74. Maintained GCA RADAR and TACAN. Part time job at the auto hobby shop. Had a blast generally speaking.
My two cents as an A&P IA, MEL, FET/J. The on board battery charger was probably a trickle charger that the owner used to insure a low use battery was up when they wanted to fly. The only problem with these is that they often boil the water out of the battery with constant use. Electrolyte level MUST be checked prior to flight. If the electrolyte level was below the top of the plates, the battery will not take a full charge. The plates may even be damaged at this point. The Continental engines are absolute misery to hot start if you don't have a feel for what the engine is asking for. (More fuel, flooded start, boost pump, more cooling time...) 40+ years working on GA aircraft I've discovered that over priming and using a flooded start technique works for me,most of the time... An extended cool time is the best though. Obviously the pilot did not have a good technique on the first start. So after the successful second start, 1) Did the alternators BOTH come on line? If one didn't come on the other was carrying a near maximum load, trying to charge the battery and power radios and lights, and the electric boost pumps. 2) Did he load shed for a weak battery take off? The primary draw would have been an undercharged battery, so reduce the load to min lighting and essential radios only. 3) Were the alternators synched properly? If one alternator was carrying the load on take off, as soon as the gear was selected up it may have induced an overload and OPENED the circuit protection, which then, if the other alternator picked up the load, it may have tripped off also. So now the worst case is a gear stuck in transit causing more drag, cockpit lighting dimming, radios failing, and a pilot trying to figure out how to reset the charging system while in a black hole. Something to think about: If there were pilots in the back seat, the emergency gear extension crank is available to them. It's not fun, but you can crank the gear up in an emergency, as this most obviously was. Was there enough time? I can't speculate. 4) Full power. Yes the engines may be trashed but they probably would last long enough for an emergency return. In the last 40 years, I have seen a definite downgrade in pilot skills. I taught systems at a university flight school (until COVID wrecked the training program), I was absolutely amazed at the lack of system and performance knowledge by the CFI's that were taking the class. The planes in the GA fleet are getting weary. If you fly, you better know how things work, because you may just have the rest of your life to come up with a solution.
Agree 100% also if this issue has been ongoing battery cable connections and starter all come into contributing to high amperage slow crank conditions making things worse.
The Baron was notorious for frying alternators and difficult in hot starts...as I remember the hot starts was mixture rich and hit the high pressure pump for 3 seconds, then mixture out, full throttle, once the engine starts quickly retard the throttle and immediately increase the mixture. A very impressive airplane.
Makes me wonder if the sudden load on the electrical system/weak battery when he tried to retract gear was just too much and it caused a full electrical "blackout" immediately after takeoff.
It makes you appreciate good decision making all the more. Last winter I was working at an airport during a freezing rain event. The ops director asked me to go check the friction index on the runway because a crew wanted to depart in a Global Express a few hours after dark. I ran the check and told ops "There's no friction out there at all! Tell those guys if they think they're leaving tonight they're idiots." That plane was still sitting on the ramp when I came in to work the next morning, I was glad to see.
Man you run a good channel , firm but respectful they couldn’t have known the gear wasn’t going to come up but they were already having problems and they shouldn’t have taken the chance
Great job as usual. Here's what probably happened. The engines were producing normal thrust, but when they hit the landing gear lever that battery gave up the ghost and they had total electrical failure. This would have been very startling and, while they were moving over a black abyss, the pilot lost track of his altitude and sink rate. And they hit the cumulo-dirt.
Exactly. Having and using the battery charger at that hour was an alarming decision. Out of the five of them, no one knew the mechanics involved? Very sad for the friends and families left behind.
Thats why I find this wreck particularly sad. I'm sure they defaulted to trusting the much more experienced pilot who owned the plane. I know I sure would have as a student pilot.
Thanks Juan and all your fellow pilot veterans. Your contributions to our country and its distinguished aviation history will live on forever. While I’m sure that the residents and homeowners of Catalina are generous and hospitable Americans, were they not on this particular night, sleeping in the dirt on typical SoCal evening in October is rarely fatal. Flying into terrain almost always is. Survival can be uncomfortable but it always makes a good story afterwards.
If I were NTSB, I would be looking at the positions of the circuit breakers, and then I'd be examining the alternators. But I'm not NTSB. Happy Veterans Day, Juan, and fellow brothers and sisters out there.
I've never departed from an unit runway at night, but I have departed into black hole conditions. In these cases, the instant you rotate you will have no visual references. You must immediately focus on your instruments to maintain airspeed and heading until reaching a safe altitude. Any distraction could prove fatal.
So sad for the families and friends. Excellent job of reporting Jaun, as always. I can see him running the battery down on an attempted hot start. I've seen it done. Overestimating his climb performance with the gear down and flying it into the ground in the soup seems like the likely scenario.
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As a long-time maintenance shop owner, I had a HARD FAST RULE of not helping someone start an aircraft with a dead battery. I would charge a battery free of charge but never hand prop or plug in a cart to an aircraft with a dead battery. This accident is exactly why. PEOPLE WHO ARE IN A HURRY ARE IN A HURRY TO DIE! 60 years of accident-free fixing and fly airplanes and helicopters.
@@TheReadBaron91That's pretty much just stealing at that point lmao
A aircraft mechanic after my own heart.
@@TheReadBaron91its not making money its being greedy in doing it that motivates fatal decisions.
@@RandomName841 oh I know that I’m being anonymous, but trust me I am not at all trying to spend that hell I work for. In my opinion, it should be called “little Boeing “
Shop ran by accountant, only looking for the dollar. Anything to save a dime.
At 8 pm there are no lights on that end of the island. There are cliffs on both ends of the plateau runway and in a nature conservatory. You need to arrange transportation off the site during operational hours. But flying in the dark, below runway height (cliff) you wont see anything without the moon. Flown in many times, and thankfully out an equal number.
One night I slept on a concrete FBO floor with a phone book as a pillow in a somewhat similar situation. Was one of the best safety decisions I ever made.
Bravo
You can get a backpacking tent, sleeping pad, sleeping bag and backpack to carry it, all under 20 lbs.
@@kewkabe I've worked up a kit that weighs well under 10lbs, including a little alcohol burner and pot. I just need a better solution for off-field tie downs. The A&P who does my annual recommended The Claw.
My son slept in the back, I tried to sleep in the front of a Cardinal in below freezing conditions rather than cross the sierras at night. Miserable long night. Could have been worse.
Yup. Better to have a rough night resting then try to push it.
Even if the battery was fully charged it would take about half of the battery in starting both engines. Without lighting at the airport, I’ll bet they taxied using the landing lights because the taxi light isn’t that good on the 55 Baron. This would have taken the battery even further down before they started the takeoff. By this time both of the alternators would be really hot and ready to give up. I’ll bet the landing lights were still on when the landing gear was tried to be retracted. Heavy Baron with the landing gear down and no electrical system would make it really hard to climb. Let the nose down just a little bit and here comes the ground. I flew a 55 Baron for two years four days a week; I would not have tried that takeoff. My boss tried to fire me because I would not take him to an unlit airport at night. I'm still here to tell you about that.
Solid decision making. Glad you’re still around to share the story
as an example.
Your boss should thank you for saving both lives!
did that boss happen to have a death-wish?!?
I mean I know people do not think things through, but even to a non-pilot that should appear very obviously dangerous...
Would gear down alone make that much difference? At 20C, 2000 pressure altitude, the POH shows 1450fpm climb gear up. Doesn't seem possible that gear down would make all of that climb performance disappear.
@warren5699 At what weight and CG will you get the full 1,450 fpm climb? Man, five people is a lot, and who knows what else they were carrying in addition to a battery charger.
Back in the day one of my early flight instructors was a real old-timer (he had shaken Orville Wright's hand). He told me something I remember well - went like this: "If you fly enough, the day will come when the only safe decision will be to simply choose not to go. Be ready for this: it will try to sneak up on you and get under your guard."
My comment is, after 50 years of flying professionally and privately that there will be many days not to go, PERIOD. Not to go is a very normal part of being a pilot.
Juan, long time Baron owner/operator and 121 driver. I'll add that if they followed an external start procedure with an external battery plugged into the nato plug, the alternators would be switched off. I bet the alts fields were not turned on after start, and the battery didn't have enough juice to raise the gear. Then when the gear wasn't heard, the distractions became overwhelming. My heart goes out to all involved.
Excellent Point!!
They were in to moch of a rush get the engines started even if it takes a half an hour your already in the dark fcb
" B bus under volt "
If the alternator was not operating, are there any warning lights or is there just a volt meter?
With a high electrical load and no alternator, the fuel injected engines would start to have a problem. In the automotive world, there is a compensation for high / low voltage as injector open time can vary with voltage but there are limits.
The other issue is, if the gear started to raise, does it have to complete a cycle before aborting and remaining down? If the gear is stuck in an operation cycle, this would continue to drain the battery.
Low voltage would also affect lighting and other systems making it apparent they are losing power.
@@bobroberts2371aircraft engines have mechanical fuel injection systems. No electrical required.
@@stevemagnuson7051 If the high pressure fuel pump mechanical too? How does this mechanical FI system operate? RE How does it measure incoming air?
I've been to Catalina a lot. If you need a place for 5 ppl to stay, there's room. It's a very welcoming and hospitable place. The airport manager could have made all the arrangements if they asked.
I was just about to say, if they had contact with him and about the emergency and decided to over night, it'd be a flick of wrist.
where?
not to mention there is ferry with like 30 trips daily to Long Beach last departure at 7:45 pm.
@@KuostA There are more that 25 Hotels and a large number of BNBs
My guess is that the Airport manager Did say that but hubris said No.
Happy Veteran’s Day Juan. Thank you for your service.
I was passenger on our company's small plane, from Denver to St. Louis for business, when we developed engine problems over Kansas: not enough power to get above weather. Declared real emergency, landing okay at Manhattan, KS. Pilots said mechanics would work on it and will page you when it's good. - Late in the day I get paged to come back, so I call, "Great, it's all fixed?" "Well, no, couldn't fix it; so we're just flying back home." "Flying? What's the weather en-route?" "Well, thunderstorms...." !!! "Good luck; I'm taking the Greyhound Bus!"
(They made it safely, and my bus ride was hellish, but I'd do it again. Bad odds eventually bite you.)
As in this crash, one less person on the plane probably would have swung the odds to success. So avoiding the flight may have saved the others from a bads scare or tragedy as well as yourself.
That pilot's decision flow chart has a box for "fuck it - go ahead"
And it looks like the F-it box was near the top of the chart!
Catalina airport should set up a pilot break room with some cots. If you get stranded at the airport after hours, there are basically zero options for accomodations by the airport and it can be next to impossible to arrange transportation down to Avalon. Even the credit card safety device won't help you. Pretty much the only option to stay near the airport is tent camping, but you probably need a permit (and of course need to have a tent). There is also typically poor to no cell phone service by the airport, so even researching and arranging a back up plan can be very challenging.
great idea for alot of fix base operator places..
cant you just sleep in the plane?
@SpidaMez extremely uncomfortable
@@SpidaMez5 people ?
@@SpidaMezthat's a lot of people on a small plane.
It's called "Group Think Mentality" 5 pilots wanting desperately to get home late at night convinced each other no matter the number of issues "auh we can make it no problem". Unfortunately "problems" all the holes lined up and no one made it off the island.
My heart goes out to the surviving families.
Thanks for the analysis Juan.
We’ll never know which ones if any voiced disagreement or felt pressured by seniority into not having an opinion. But in the end you still have a choice to fly.
@@hunterwyeth - We might find out one day. Perhaps one or more of them texted a loved one, with fear, before departing.
Even worse, if one of them had said I'm not going, the difference in weight might have been enough that they would have all made it and that one would be osterized for being unreasonably cautious.
And the airport manager. He's feeling it also.
@@doug112244I think you mean "ostracized".
Oster is a brand of kitchen appliances, famous for their blenders. "Osterize" evokes an unpleasant mental image.
I wonder how often these "unauthorized" dark takeoffs happen.
Juan,
Thank you for your service.
My father was a USAAF B-29 navigator in the Pacific 1944-45. He died in 2016 age 94 and the Air Force send an Honor Guard for his funeral.
Paul (in MA)
Rest in peace to your Dad. They truly were part of an extraordinary generation in our nation's history.
Hi Paul - my dad was a B-29 navigator in the Korean War. 51 missions. Died in 2021 at 93, Air Force Honor Guard at his funeral was amazing. Truly the "Greatest Generation." - Dave in Houston
@@mortalclown3812 Amen to that! The sacrifices they were forced to endure.....
A similar incident I was involved with as the en route controller at ZAB in 1982.
A Baron, N36969, had departed ELP via V94 V19 TCS PRC onto LAS. I was on sector 19 and upon departure the ELP TRACON controller advised me that it took two takeoff attempts on a 12020ft runway. The aircraft was handed off and comm switched to me. Along the way I had constantly vector the aircraft to intercept the airway as they continually flew through it. Initial altitude was 10000ft but the minimum vectoring altitude was 12000ft TCS PRC. There was reported icing conditions and several NOTAMs issued concerning icing. Approaching TCS I climbed the aircraft to 12000ft and handed the aircraft off to sector 17. I informed the 17 controller the difficulty with this aircraft. I gave 17 control and noted they climbed them to 14000ft. A few minutes later 17 called me asking if I had heard from N36969.
The aircraft had encountered icing, lost control, and crashed at the 9,300 FT level of a 9,600 ft peak in the San Mateo mountains resulting in six fatalities. The aircraft was loaded an estimated 392lbs over gross weight at departure.
I recently cancelled a flight I really wanted to take to visit some friends. I got in the plane and the PFD was dead. Now, I have a good mix of old and new instruments and two mechanics told me that technically the plane fully met both VFR and IFR lists of necessary instruments. Yet, the conditions were IFR along the route and my return flight would have been at night. The autopilot was also consequently unusable. There was just no way I was going to fly with those handicaps, especially in IFR and night conditions. So I am here to tell you about it. A couple weeks later I picked a nice VFR day to bring it to the shop.
Credit card can work most of the times but I have "slept" at a few FBO's in a chair waiting for better conditions. Some times in the rental car. The drive or pressure to go can be very strong. It is tough to step back and try again later.
Disengage and think past the current circumstances. You ultimately want to get home safe.
I can relate. I've spent some nights on the couch in a FBO myself, but I always slept pretty soundly while listening to the rain and thunder overhead that I had contemplated navigating through hours earlier.
Sleeping on the couch in the FBO isn't bad at all. My hangar is an hour's drive from home. If I want to make a dawn departure, I just drive over the night before, preflight, fuel, and crash on the couch with a laptop and some cat videos. There's a coffee pot and a microwave for a gas station burrito before I leave. The airport manager is completely cool with it.
I used to travel a lot in a C-172 and on long trips I would usually store the rear seat in the trunk of my car (room for bicycles, etc). If you take the front seats out and put them under the plane and add an air mattress to the floor, 2 not-too-large people can get a reasonable night's sleep. Done that several times in a pinch.
@@nostooge
@@Frank-hm3ue Yes?
pilot mechanic here, another mechanical issue given battery need charging, both alternator drawing max engine load to produce amperage to battery, so less engine power available in critical take off phase
A 70 amp alternator at 28 volts is producing 1960 watts, or about 3 HP.
I doubt that's a noticable effect on climb rate. The pilot simply didn't maintain best climb speed in this case.
Exactly, like a magnetic brake. Less torque and less power when it is needed the MOST.
I’ve been flying for over 40 years now and the best advice I ever got was from my very first flight instructor. He said, do not ever get into any airplane that makes you nervous even if you aren’t flying it.
Our next door neighbor offered to take me and my daughter (around eight years old at the time) up with her and her husband (amateur pilot, computer consultant by occupation) in the plane they owned. I have no interest in flying in anything but scheduled commercial aviation, and politely declined.
A few months after the conversation, the neighbor, during a training flight so she could get her own pilot's license, turned a Cessna belonging to the flight school, into a ball of scrap metal, the wings all crumpled (I saw pictures), rolling the aircraft as she came in to land, apparently due to turbulence from a helicopter. It was a near miracle that her and her instructor both walked away, though she did have a fractured eye socket that required reconstructive surgery.
Retired ATC and corporate flyer. I'm glad my instructors back in the day didn't hold to that. 😁
@@ReflectedMiles Why?
@@pulaski1 It becomes challenging when you have friends who you don't trust as PIC. I have a couple of good friends that I will not fly with because they make bad decisions. Making that decision has gotten easier as I've gotten older because I trust my judgement more. Flying is dangerous and even if you do everything right it can still kill you. It's worth the risks to me but everyone does their own calculus on it.
@@AndySpicer Because back in the day, with a string of unpredictable trainees in trainers maintained in large part by A&P trainees, there were a whole host of things that could and did go wrong, caused by either group. 😊 By the time I had been flying for a few years, I would certainly have been nervous at times trying to operate as a CFI there.
So they send a broken airplane to save people from another broken airplane. Then they fly a very heavy, broken airplane into a black abyss against the wishes of the airport manager.
It sounds like the good lord tried to tell them a few different ways it wasn't a good idea to take off that evening.
Sad that innocent lives were lost.
The rescue pilot said he HAD to go. Turns out, the world wouldn't have ended had he spent the night on Catalina. It seems, self-importance was his undoing.
@@RockandRollWoman There were no innocent lives lost. That would have been someone on the ground. The airport manager clearly said they were breaking the rules and flying at their own risk. Any one of them could have said stop or decided to exit the plane and let the others take their chances.
You can bet that the families of those lost will sue the airport, the airport manager for not doing enough to stop them from taking off.
@@OMGWTFLOLSMH sounds a bit like that KLM pilot on the canary island back in 77
Happy Veterans Day Juan. Thank you for your service and your awesome videos. Keep up the great work!
I'm training for my private, I'm really glad you post these videos so we can learn what not to do. The most shocking part of this accident is the fact that multiple pilots all agreed to do something so foolish.
for another example of "group think" - watch Mentour Pilot's recent analysis of AF736
When you're a pilot sometimes you think you know what you're doing and feel like you can handle any emergency. But the dead failed to realize, it takes only one mistake. An electrical problem on an aircraft? How foolish you must be to continue.
The people being "rescued" probably felt pressure to leave, despite all the red flags, and they took a chance. Their situation caused a pilot to have to come to their rescue, so they probably felt obligated to go with him, since he was in a rush and needed to get back for some self-important reason. Anyway, hindsight is easy. Risky things like this have been done thousands of times without catastrophic events taking place.
Now ask yourself this: If those five pilots who had much, much more experience than you have made such a bad decision, how can you be sure that you won't do the same sometime in the future? After all, all five of them had certainly read far more accident reports than you have, yet they still took off.
If you continue flying, one day, or night, you're going to find yourself in a similar situation. Be sure to recall this accident when that day or night arrives. .Good luck with your training.
@@jiyushugi1085 Remember, two of them were student pilots.
The more information on this story.. the worse it gets.
I've spent the night sleeping in the PA28-181 of the flight school I worked at. Late at night, uncontrolled field, no money for a hotel anyway. I'm alive to talk about it. Did it again in the PA44-180. Always took safety seriously and pushed down the urge for get-there-itis. Plug those holes in the swiss cheese.
Make sure you're taking care of yourself Juan. I feel like you've been covering a lot of fatalities this year. Don't feel pressured.
As always though, I love your videos as someone who's just an aviation fan
If this plane had electronic mags (ie Surefly) then operating the gear with a dead battery would cause loss of the mag (ask me how i know). Its worth checking what kind of mag setup this plane had.
How you know?
Sounds like a design flaw. TBH.
@@connormclernon26
Look up "rhetorical question" 😄
Electronic Magneto seems to be a contradiction in terms. A Magneto is purely mechanical and needs no battery to produce a spark. However, on startup a Magneto may have poor spark, and an auxiliary electronic assistant will enhance startup performance. However, once the engine is running the electronic enhancement is not needed. Therefore, if battery power were to completely disappear in flight the Magneto would still provide sufficient spark to keep the engine running. If Surefly is a electronic replacement that cannot keep the engine running without battery poser, then I would think myself a fool to choose it. Surefly would not be termed a Electronic Magneto, it would be an Electronic Ignition. Names describe function, and if names are misused sometimes we die.
@@ewathoughts8476It all depends on how the electrical system is setup:
If you have a 24v battery and a 28v system, then there's a voltage regulator/inverter in there somewhere. The alternators are probably 24v, but if one is inop, and the other one can't keep the battery up by itself, then chances are the regulator/inverter is also cooked - which is why the battery/alternators are failing to begin with. Even if the alternators are putting out 14v each, or 24v each, if you lose one, you won't have enough juice to run everything. At least, not for long.
Then again, the fact they had to charge the battery just to start engines tells you they had a bigger problem than they thought.
Hell, could also be something as simple as corroded or loose connections.
Who wants to bet that at least one of these pilots was afraid to be the first one to say STOP.
None of them are afraid anymore.
The Abilene paradox.
I feel this , can't help but feel like this was entirely preventable. :(
Personally , I would have rather slept in the hanger than get into the plane after watching engine not start , at night. A D M . RIP and condolences to those that lost family members.
@@goutvols103i was just gonna say this. 😢
I doubt either of the so-called "student pilots" were given much say. And of the other three, two were employees of the pilot flying. It's pretty clear who was calling the plays here.
Thanks for the video Juan. I don't fly, but I do teach classes for young people getting their Pleasure Craft Operators Card (small boat license), and I've actually started working "Use your superior judgement to avoid having to use your superior skills" and the credit card rule into my lessons about safe trip planning and on-water risk management for those young boaters. It's a very clear and easy to understand shorthand for such an important concept that is applicable in both GA flying and recreational boating, fields where as non-professional operators we are taking our lives and those of our trusting passengers in our own two hands, without any corporate structure to keep us on track and watch our risk-stacking for us. You are doing good work. Keep it up as always.
Boating Safety and Hunters Safety were required in my family. Thank you for teaching the kids out there. I believe a course should be required for anyone that boats or hunts. A Boating License should mandatory for anyone going out on the water.
People need to carry CASH as a backup not credit cards. Cash is king and can pay for everything everywhere anytime, especially in emergencies. Reliance on a credit card will leave you stranded with empty fuel tanks and nowhere to stay if your CC gets lost, tagged for fraud, systems down, etc. There's cash on me and hidden in all my vehicles for a reason.
@@mattgayda2840 I agree. Always carry cash.
Starting to fly early 80's, we usually had a number of AOPA magazines in the clubhouse and I have learnt so much from the (usually) last page article: "Never Again" . Just by reading and listening to other pilots stories, one can really learn (if you are willing) such a lot and avoid so many mistakes. Never underestimate the value of these lessons, such as this channel for example. Thank you!!
AOPA has a good podcast - same name and content as that last page article!
@Jennifer-uy1qg thanks for the info!
In the eighties and nineties I wa a Part 135 operator as both a pilot and Check Airman. Flew in and out of Santa Catalina with PA60’s and PA 31T. This accident is a good example of the “Error Chain” and pilot lack of systems knowledge. True, as an A&P it is easy for me to be critical but my gut feeling is the operator had no idea of electrical power distributions and limitations.
The fact that the Baron needed the weak battery charged before enroute to Catalina probably indicates there was insufficient amperage reserves to power a full electric landing gear system. Keep in mind, Pilot probable has every light illuminated for take off and was basically operating on what power the system produced with engines running. Surely, there also would
have been insufficient amperage for an air relight.
I was blessed to have two great FAA inspectors as POI, PAI and PMI’s who taught me well. And, I retired from UAL after thirty plus years and flew maintenance post HMV verification flights where systems knowledge is essential. As a 135 Check Airman and also an A&P, I would always ask the candidate before and during a Check Ride “ What if” scenario questions Andy”How would you manage that irregularity and/ or systems failure. Comprehensive Systems knowledge makes for good Decision on making along with SOP and FAR adherence respect.
Juan, please consider a follow on analysis when the NTSB report is finalized. Thank you for your efforts that contribute to air safety and pilot proficiency. Sometimes it is better to abort the sortie than go at all costs, in this case five lives. As Clint Eastwood said in “Dirty Harry” ….” A man’s got to know his limitations”.
Thank you for your analysis. Understanding a weak battery before Catalina, but in flight, isn't the (Starting) battery just another load on the system and your alternators generate power and would be used to power the landing gear?
@
Close, but think of the battery as an accumulator of, in this case, voltage with sufficient amperage to power things _ including high demand landing gear hydraulic pump. Please see goutvols103 response. A battery can have 12 or in this case 24 volts but if ther is not enough amperage, it won’t power high demand devices. Jim Caufman’s explanation is excellent.
I once had a 727 new flight engineer who mismanaged the essential power off operating engines when we were shutting down engines successively on a maintenance test flight. Poof - darkness as demand overloaded the power output of the remaining 2 operating engines. He was yelling and I turned over my shoulder and told him to chill as the blue sky was still up and we were flying in clear air. I simply said for him to turn on essential power so we had comm 1. Now rebuild the systems and we will be fine.
@ enroute, the battery rebuilds its charge from the start but that takes time and is compromised by the drain on charging system. Think of the battery like an accumulator - it absorbs voltage surges and augments low voltages due to spikes.
This is one reason why many charter operators use an external power source to start. When I operated a Bell 206-L1 for flights from Long Island to NYC would always start the jet engine with a double truck battery mounted on the landing dolly. This way, I always had a full charge if I had to shut down at 34th street or the now extinct 60th street heliports
@@kenrhodes948 100% and in my languages a car or plane battery is called an "accumulator" because it's in a constant state of depletion or charging.
I know for a fact as it happened to me ,that an electrical retractable landing gear system will cause total blackout when the Gear up switch is activated with not enough electrical power to do so. 50' up, positive rate of climb, gear up switch activated and all of the panel lights go black. I flipped the gear level back down and the lights and radio powered on. I manually ratcheted the gear to get green down and locked indication and flew the 7 miles back to my home airport gear down and landed safely. Had I not known to remove the amp strain on the system, it would have been bad. I did have a flashlight on a lanyard around my neck. My single engine aircraft could climb with the gear down although less than 500 fpm.
It's sounding very likely that this is what happened. Gear up... sudden dark cockpit. It may have been almost pitch black in there, we'll probably never know.
Another great instructional video. I recall that many years ago my helicopter crew and I spent the night at a small airport terminal rather than continue into a bad weather situation. We were returning to base after a long deployment and the get home itis was might powerful. Fortunately we made a difficult but correct choice. Thanks.
Thank you for your service Juan. These accident review accounts apply to other activities too such as driving, boating or a high risk operation.
You pointed out something a lot of people, including pilots, don't understand about vehicle electrical systems. The charging system in a vehicle - auto, aircraft, whatever - is designed and intended to keep a charged battery charged, NOT charge up a dead battery! That's why they're called a charging system. The electrical systems essentially run off the battery, not the charging system. Dead batteries MUST be charged off-circuit with a bench-type charger, then tested under a load to determine if it's suitable for service since a depleted charge lowers the battery's internal resistance, which can overload the charging system and cause a failure. Good job Juan!
Sir, you may be right. Most people have experienced a flat battery on their auto, and had it jump started. Then the alternator charges up the battery over 10-15 minutes of driving. ie it's nominally a 12V system but the alternator puts out power at 14V, and lots of it. The battery gets recharged and if it drops dead overnight you get a new battery. So, maybe the electrical system is not _designed_ to recharge a dead battery, but it usually can.
I'm not disputing what you say. I don't know one way or the other, but I feel that you shouldn't castigate people whose experience tells them that a charging system _can_ charge a battery.
@@fightingforfaith3541 yup, I’d rather you not jump your aircraft, but if you do, least wait 30 mins on ground to charge back up. It at the least puts undue stress on the charging system.
@@TheReadBaron91 That's it!
Landed at Catalina many times. It’s very remote. That road to Avalon is a 45 minute roller coaster ride on the scheduled shuttle bus. Full of potholes the whole way. I thought the windows were going to fall off, the bumps and rattling was so loud. Likely your stuck there at night, nobody’s coming up that dangerous crap road to get you. Get out early, and give yourself lots of buffer for clouds and nightfall.
Flew Barons for many years. All time favourite light twin. Having said that, if you didn't play by rules and know your systems it was unforgiving. Great review! Thanks!
Happy Veteran's Day, Juan! Thank you for your service!
Thank you Mr. Brown. I have particular love for the Baron. I took my ATP checkride in a Baron 55 in 1978.
I love flying into Catalina but it's not something you do without plenty of advanced thought. Flying in around dusk or thereabouts def requires contingency planning. Took a plane full of kids there this Summer but didn't love the conditions so decided to simply do a low fly by and back down over town, instead of landing. Sad story, but I suspect you are right, lots of can-do ppl working an earnest but clearly flawed solution. RIP aviators. Bless all of you.
Juan, thank you for your military service!!
My dad is the what’s in your wallet actor. Also 787 pilot for united. I am a commercial rated pilot, we fly to Catalina a lot. We watch your channel together when he is home. Good comment at the end! Rest in peace to the pilots
Sounded like 5 pilots had a bad case of infectious Go Fever
terminal getthereitis indeed
Five (5) pilots did not get to make a consensus decision to go/no-go. It likely came down to the older owner of the Baron, a CFI, and former flight school owner. His decision was likely supported. One might ask if his personality was autocratic.
From a mountaineering and scuba diving background, it’s always best to avoid getting into a bad situation in the first place rather than thinking you can just bail yourself out of trouble. My mountaineering instructor once said “overnight bivouac” is French for you’ve f**ked up. Have an emergency shelter but don’t plan on using it. Scuba diving had a “spiral of decline” model where a mishap always gets worse and worse.
Stop the mishap from proceeding at the first layer of Swiss cheese.
100% and I might be biased, but I'd only fly in a private plane if the pilot/owner had a mechanical background like me, and/or was a scuba diver. You can't train someone to understand mechanical things, they have to be "built" a certain way to be able to enjoy and get it. And with diving, the grim reaper is very near and you can feel it, and it's drilled into you on your first day of open water.
In my scuba diving days we called it the "incident pit" much easier to stay clear of than get into....
I don't comment about much, but thank you for your military service and service to the thousands of GA pilots, Juan!!!!
Excellent report Sir. As a veteran I appreciate your TH-cam channel. Have a most wonderful day
Thank you Juan for your service
Oh dear. The Baron is a classic masterpiece. I painted a lot of them here in Wichita at Beech in the 80's. This is sad, god bless the souls lost in this tragedy.
Doo-Dah Ks
Hi Juan you are a total (aviation) stud - thanks for putting all this out. I’m in your Patron group, 2000 TT multi-instrument rated, now “retired” but sure would have enjoyed flying and learning from you.
Thanks for the update Juan.
I am not a pilot, but I have been in small airplanes. You have given me a lot to think about the next time I go up. I definitely don't want to be on YOUR channel because of the flight I'm on! Thanks for all you do!!
Thank you Juan for your service. Thank you for bringing these updates to us.
The term you are referring to about all the pilots talking themselves into something is called “group think”. I don’t fly but I operate a large metropolitans power grid. When you are in a high stress situation some one has to step up and take charge and make a decision. Weighing in all the factors and possible outcomes and make the decision for the group. Lots of accidents have occurred because too many parties get involved and the lines start to blur and you might totally be against what the group wants to do but you won’t speak up because the group has already made the decision. The definition for group think is as follows: Groupthink is a psychological phenomenon that occurs when a group prioritizes consensus over critical thinking when making decisions. It can lead to irrational or dysfunctional decisions because group members may not consider alternatives or the potential consequences.
Thanks for keeping the lights on.
@@JHe-f9t there’s a lot of us working behind the scenes to keep things going!
Good video. Thank you for your service sir and for your expertise with your channel.
I carry a light goose down comforter. Usually the best airport as a alternate is the one you just passed. I fly a lot at night and if I have to divert to another airport there may not be any cell coverage. So I know that I can make it until the next morning without freezing to death or I won't push on into worsening weather.
Thanks Juan for this report. I always (for lack of a better word) ‘enjoy’ watching your videos, because they are factual but you never fail to show some emotion (anger/frustration/surprise). This particular case is massively depressing…and unfortunately left 5 people dead. Just imagine how often others do the same thing, with the same attitude, and succeed…in other words don’t end up in the stats.
Keep up your good work, do you ever layover in Amsterdam?
A321neo capt based at Schiphol.👍🏼
Shoulda slept in a Cold Arsed Aircraft on the Ramp…
Reminds me of something Petter said over on Mentour Pilot. When taking multiple crew members assessments into consideration for any decision, it’s important to start with the lease experienced person, and end with the most experienced person. This prevents a senior captain, for example, from driving the decision making. The junior officers will fall in line with a bad decision instead of standing up to their captain.
Yet another example of poor aeronautical decision making. Tragic, especially with multiple fatalities.
Multiple pilots nonetheless. Shocking
Never have thought about the issue comes from a weak battery. THNAK YOU for bringing it up. One more valuable lesson learned.
And what to say about the flight school? So they rented a poorly maintained plane to the instructor and his two students. And then, sent another poorly maintained plane to rescue their clients, owned by someone that didn't care about safety?
This brings up an interesting question: In a situation like this (non-towered airport), when the takeoff is not approved and in violation of airport guidelines, but they takeoff anyway, what is the consequence? Does the airport have any authority to enforce some kind of punishment?
They could go to the FSDO and report them for 91.13
Notify the Local FSDO
I flew out to Catalina with a (former) buddy who has serious contempt for authority issues. At that time (late 1980s) you would call the airport and the manager would say something along the lines of "landing approved". It was not at ATC "cleared to land", but it's a private field and while they cannot prevent you from landing - for instance by parking a vehicle on the runway - there's nothing wrong with a little courtesy and respect. My buddy wanted to know what the point was of calling since there's no tower and no requirement per se to get permission to land.
I have not spoken with him in some time, but I get the same sense reading about this incident. Some people do not have a temperament that is compatible with flying.
I can only speak to experience in Canada, but from having worked at a municipally-owned airport with a contracted operator, the operator has absolutely zero authority to say or do anything to prevent a pilot from taking off or landing.
I'm glad you mentioned at the end that it is difficult at Catalina to get accomodations. It really is and I can see how someone would want to leave after hours because the mainland and the nice bed at home are both so close vs trying to get a ride down to Avalon or worst case sleep outside the restaurant building. But as you've explained well, he stacked the odds against him. Had it been just a night after hours departure in an airplane without issues, lower T/O weight it would have been no issue.
Thanks Juan. It's extremely hard to believe that five pilots were not concerned about the electrical system problem.... horrific.
Too many people in aviation, simply have a very deficient knowledge about the systems on the airplane they are flying... Thus, when a mechanical, hydraulic, pneumatic or electrical problem surges, they are completely incapable of properly diagnosing it, much less capable of going around it, and the problem ends up killing them.
And the same five aviators deciding to break the rules on departure times at the airport and ignore the advice of the airport manager. Crazy.
Pure speculation on my part: I'm not a pilot but am an EE. "If" the battery/charging system was marginal, when he attempted raising the gear, the imposed load may have caused system voltage to momentarily spike downward, possibly causing some dash equipment to blank out or reset. As Juan mentioned, if the artificial horizon display was electric and momentarily stopped working, that could have doomed them. Short of recovering the battery and attempting to replicate the failure, we'll likely never know.
Happy Veterans Day Mr Browne. Thank you for your service. 🇺🇸
A friend of mine did almost the exact same thing. Left the master on in a Centurion and had a dead battery at night. He got a jump and let it run for 10 minutes then took off. He was at Mariposa Airport. It's a mountain airport in a hole with higher terrain 360 degrees and very dark. As soon as he raised the gear handle everything went black. He called me on the cell to go to our home airport and turn the lights on and see if I was available to do the task because his comms were out. Without comms he wouldn't be able to turn on the airport lights. In the time I was on the phone with him he decided to go back to Mariposa with the timer ticking on the airport lights and he also didn't know the status of the gear. I was scared to death, and I wasn't in the airplane. I stayed with him on the phone until he landed safely. It felt like I was in the plane next to him. It scared him enough to where he won't operate there at night anymore. I also learned what not to do in that situation.
That sounds scarily similar to this crash, borderline electrics are bad enough in a ground vehicle.
Been there (at Mariposa), done that. Go around at night. Terrifying!
@@winfriedwilcke1705LOL at least at night you don’t see what you’re flying over!
Thank you for your service Juan and all other vets!
The function of an alternator is to keep a fully charged battery, fully charged. As soon as a battery gives you trouble, replace it before it eats your alternator
Thank you for your service Juan...Happy Veterans Day.
This Baron crash was unfortunate...so many pilot passengers and a chain of bad decisions...RIP
Thank you for your service, Juan.
If the universe is telling you it’s no go, it’s no go. The magneto trouble on the first plane, plus battery issues on the Baron, plus pushing departure past a the airports limits should be enough for your intuition to be ringing loud alarm bells..even if your brain says you can do this, sometimes you just have to accept that the universe is telling you something different, and to respect that, because the universe knows best. What a sad and unnecessary loss of life.
Thank you sir..for your service!.. military...and G.A. !
Juan, it is just painful to hear about all these "pilots" who kill themselves and others by being over confident. Thank you for your detailed a serious reporting on these situations.
Thank you too Juan, for then, and for the work you do now on your channel.👍🤙
Happy Vet's day from a landlocked sailor. USN, 68-74, ETR-2, NAS Miramar, 70-74. Maintained GCA RADAR and TACAN. Part time job at the auto hobby shop. Had a blast generally speaking.
My two cents as an A&P IA, MEL, FET/J. The on board battery charger was probably a trickle charger that the owner used to insure a low use battery was up when they wanted to fly. The only problem with these is that they often boil the water out of the battery with constant use. Electrolyte level MUST be checked prior to flight. If the electrolyte level was below the top of the plates, the battery will not take a full charge. The plates may even be damaged at this point.
The Continental engines are absolute misery to hot start if you don't have a feel for what the engine is asking for. (More fuel, flooded start, boost pump, more cooling time...) 40+ years working on GA aircraft I've discovered that over priming and using a flooded start technique works for me,most of the time... An extended cool time is the best though. Obviously the pilot did not have a good technique on the first start.
So after the successful second start, 1) Did the alternators BOTH come on line? If one didn't come on the other was carrying a near maximum load, trying to charge the battery and power radios and lights, and the electric boost pumps. 2) Did he load shed for a weak battery take off? The primary draw would have been an undercharged battery, so reduce the load to min lighting and essential radios only. 3) Were the alternators synched properly? If one alternator was carrying the load on take off, as soon as the gear was selected up it may have induced an overload and OPENED the circuit protection, which then, if the other alternator picked up the load, it may have tripped off also. So now the worst case is a gear stuck in transit causing more drag, cockpit lighting dimming, radios failing, and a pilot trying to figure out how to reset the charging system while in a black hole. Something to think about: If there were pilots in the back seat, the emergency gear extension crank is available to them. It's not fun, but you can crank the gear up in an emergency, as this most obviously was. Was there enough time? I can't speculate. 4) Full power. Yes the engines may be trashed but they probably would last long enough for an emergency return.
In the last 40 years, I have seen a definite downgrade in pilot skills. I taught systems at a university flight school (until COVID wrecked the training program), I was absolutely amazed at the lack of system and performance knowledge by the CFI's that were taking the class. The planes in the GA fleet are getting weary. If you fly, you better know how things work, because you may just have the rest of your life to come up with a solution.
Agree 100% also if this issue has been ongoing battery cable connections and starter all come into contributing to high amperage slow crank conditions making things worse.
Juan, I also want to salute you for your service past, present and future. Thank you sir
The Baron was notorious for frying alternators and difficult in hot starts...as I remember the hot starts was mixture rich and hit the high pressure pump for 3 seconds, then mixture out, full throttle, once the engine starts quickly retard the throttle and immediately increase the mixture. A very impressive airplane.
They could have kept the left engine running, to give a fighting chance to start the right after boarding...
Makes me wonder if the sudden load on the electrical system/weak battery when he tried to retract gear was just too much and it caused a full electrical "blackout" immediately after takeoff.
Sad that so many poor decisions were made with so many experienced pilots involved.
It makes you appreciate good decision making all the more. Last winter I was working at an airport during a freezing rain event. The ops director asked me to go check the friction index on the runway because a crew wanted to depart in a Global Express a few hours after dark. I ran the check and told ops "There's no friction out there at all! Tell those guys if they think they're leaving tonight they're idiots."
That plane was still sitting on the ramp when I came in to work the next morning, I was glad to see.
Man you run a good channel , firm but respectful they couldn’t have known the gear wasn’t going to come up but they were already having problems and they shouldn’t have taken the chance
Thank you for your service!
Thank you so much for your work Juan. You help me immensely. This one hit home for me!
Great job as usual.
Here's what probably happened.
The engines were producing normal thrust, but when they hit the landing gear lever that battery gave up the ghost and they had total electrical failure. This would have been very startling and, while they were moving over a black abyss, the pilot lost track of his altitude and sink rate.
And they hit the cumulo-dirt.
Juan and veterans everywhere, thank you!
"Thank you for the timely Detailed report Juan. It is a scope on the event and the pilot's action to comfirm a result." 👍
Thanks for updating us on this accident. All too common type of GA accident. Not surprised insurance is going up for GA.
It seems strange (to me as a non-pilot) that five pilots agreed to take this much risk.
Exactly. Having and using the battery charger at that hour was an alarming decision. Out of the five of them, no one knew the mechanics involved? Very sad for the friends and families left behind.
Thats why I find this wreck particularly sad. I'm sure they defaulted to trusting the much more experienced pilot who owned the plane. I know I sure would have as a student pilot.
with that much knowledge, what could go wrong?
@@spencerjohnson7103 and if a student got off, they'd have been light enough to make it and would have given him crap forever,
Three pilots. Two dubiously titled "student pilots" who, in all likelihood, were just fare-paying passengers.
Thanks Juan and all your fellow pilot veterans. Your contributions to our country and its distinguished aviation history will live on forever.
While I’m sure that the residents and homeowners of Catalina are generous and hospitable Americans, were they not on this particular night, sleeping in the dirt on typical SoCal evening in October is rarely fatal. Flying into terrain almost always is.
Survival can be uncomfortable but it always makes a good story afterwards.
Juan, thank you for your service!
Juan - the term you were looking for at 11:20 is the Abilene Paradox, a collective fallacy.
If I were NTSB, I would be looking at the positions of the circuit breakers, and then I'd be examining the alternators. But I'm not NTSB. Happy Veterans Day, Juan, and fellow brothers and sisters out there.
Thank YOU for your service, Sir.
Thank you for your service, Juan! 🇺🇸
I've never departed from an unit runway at night, but I have departed into black hole conditions.
In these cases, the instant you rotate you will have no visual references. You must immediately focus on your instruments to maintain airspeed and heading until reaching a safe altitude.
Any distraction could prove fatal.
Yes, Thanks Juan and thank-you to all Veterans !!!!
Hey Juan, much obliged to you for your service!
Thank you for your service Juan
Thank you for your service Juan.
Before receiving a PPL everyone should be required to view 100 of your streams. Keep up the great reporting JB
And sleep on the FBO couch for a night! Lol
Agreed. This, and Pilot Debrief.
So sad for the families and friends. Excellent job of reporting Jaun, as always. I can see him running the battery down on an attempted hot start. I've seen it done. Overestimating his climb performance with the gear down and flying it into the ground in the soup seems like the likely scenario.