You didn't read aloud the most important line in the NTSB completely - the last annual inspection on the airframe and both engines was completed THE DAY BEFORE THE ACCIDENT. Should an annual have detected the throttle lever problems?
While not speculating on this accident, any flights immediately following heavy maintenance* should be treated with caution. * - A GA annual inspection may OR MAY NOT involve heavy maintenance depending on the discrepancies found and fixed.
Absolutely yes, a good mechanic would have their hands on every part of that engine, it's like I use to tell new A&P's 20 years ago, a good mechanic see's as much with their hands, as they do with their eyes
My grandfather was an aircraft mechanic during ww2. We were working on my car together once when i was a teenager. I dropped a spark plug on the concrete😮. He picked it up and threw it in the trash without even looking at it.
@@johnhopkins4920 the point is that the spark plugs are porcelain. Even if it doesn't look broken from an impact with the ground, it is likely to have suffered internal damage and will not perform properly. It's easier and cheaper to replace a dropped (and potentially damaged) spark plug before installing it than to have problems out in the field. In the realm of aviation, installing a damaged spark plug could kill you. In this case, it killed the instructor.
@@johnhopkins4920 It's standard proceedure regarding aircraft plugs that if you drop one there's a potential to crack the porcelain insulator. Many times those cracks aren't visible to the naked eye, so any dropped plugs are immediately tossed in the trash. Same dynamic at work on automotive plugs, but a failed plug in a car won't kill you.
It was in a Seminole at Fort Pierce that my instructor shut off a fuel selector so that an engine failed seconds after I went missed approach - I closed both throttles, lowered the gear and told the tower "MAY DAY, Seminole (which ever one it was), is engine out and landing Runway Niner." (Fort Pierce didn't have parallel runways in 1990, and 9-27 were the numbers then). Full flaps and a bit of a slip got her slowed down enough to get down and stopped....I don't even remember if the tower cleared us to land (we had been cleared for the option, but then called "going missed"). That response was not what my instructor anticipated...but he decided that it was a better choice than the extreme precision needed for a single engine climb out. I grew up in Colorado, where any twin without turbos tends to have a single engine ceiling below the terrain, at least in the summertime, so my response was to act the same as if the engine quit in a single. Before each takeoff we briefed that if an engine failed while there was runway ahead, we would close the throttles and land. I figured I'd rather go off the east end slowly (right in front of the fire station) than hit the trees at 88 KIAS (or, as it turns out, hit the concrete upside-down). We started the engine, taxied back and went back to Vero Beach, and I learned firsthand that there is not necessarily any paperwork involved in declaring an emergency. My instructor explained to the tower that he had shut it off, that it hadn't failed, but that I didn't know that in the moment. It was about my second flight in the Seminole, and I hadn't figured out yet that more than half the hours I would spend in Seminoles would be with one either simulated or actually shut down. Most of my hours before that were in a Mooney M-20E - I found the Seminole a remarkable way to spend twice as much fuel with the same size cabin, going slower, or the same amount of fuel (with one shut down), going a LOT slower while making one leg tired.
@@kevina8172 In case of an engine failure in those light twins, the remaining engine is perfectly capable of flying the airplane all the way to the crash site.
When it comes to light twins I prefer the ones with turbocharged piston engines. Ideally turboprops are the way as they have no issue at all flying and climbing on one engine. “One leg tired” hahaha. Yeahhhh I remember multi training. I wonder why they didn’t switch sides with the dead engine.
I'll throw this out and feel free to slam me, but.... When things go to s..t in a light twin while low and slow and you are behind the mental power curve; pull both power levers idle, lower the nose, level wings and pick a spot to touch down without worrying about the gear or flaps.
One of the first things I learned 50 years ago as a student pilot was exactly that. I was taught (with very few exceptions) NEVER turn back to the runway and do what you said.
I was never aware of how dicey these low powered light twins were until I started watching this channel. No room for anything but a perfect response from the pilot when you lose an engine at pattern altitude. As noted by someone else on a previous light twin crash report on this channel: A twin engine plane won't get you there twice as fast but it can get you in trouble twice as fast.
It’s unimaginable that these older marginal aircraft are still allowed to fly! Be done with this nonsense! Retire and recycle as much and be done with it
Condolences to the family of the flight instructor, and hopes that the student will make a full recovery. I think the NTSB would have the best team ever with Juan Browne and Greg Feith contributing their complete attention to the smallest details.
@@zlm001 What is it about Greg that you don't like? He was the leader of the go team for the NTSB for a long time. And, if you have been in the business world at all you would know that professionals don't have to like each other to get the job done.
Every time I flew an airplane just out of annual, I considered the first five to ten hours as test flights. I did not practice engine out procedures for a few hours.
It's a big block of Swiss cheese. The spark plug descriptions were baffling, it's not usually a weak point for mechanics. The throttle lever with the serrations would have still been working during start and take-off so it would have also looked fine during inspection. I have my own opinions on the state of flight training in North America as another factor. I will be following this one, it should be an eye opener.
@@ianrobertson3419 Maybe…maybe not on the throttle connection serations. A slightly loose bolt may have gotten through the run-up fine but loosened during the flight. When the time came for the go-around, a more “immediate” throttle movement could have caused the slippage resulting in incomplete full throttle achievement. The spark plug issue is very strange indeed. I built and maintained N36LV for 6 years. Every post-annual flight was treated like my initial experimental fly-off time: nobody but me and 4 pages of checklists in the plane for 2 hrs, followed by pulling the cowlings and checking everything one last time.
@@bwalker4194 Yes, the spark plug issue seems quite odd. One would think that the gap would have been checked before install, but I wonder if the plugs were dropped at some point.
Back when I was doing my multi training in a Seneca (PA34-200) we started single engine with reducing one to idle, after some experience with that my instructor introduced actually shutting down so I would understand both the difference, and especially the effect of not getting the dead engine feathered. Of course, all this was happening at a nice safe altitude, until the day the engine wouldn't restart so I was going to get the experience of a real single engine landing. My instructor read the single engine go-around checklist to me twice, making sure I knew what I had to do. He also said, if we have to go around we were going to climb out straight until we got to pattern altitude. It was a warm day, but near sea level, so he also said if it wasn't climbing well he would take over the controls and put it down straight ahead. We would only turn with altitude and reasonable single-engine climb. The landing was anticlimactic - no fuss, no muss.
You gotta keep flying that plane straight ahead into the crash site. When something like this happens, the plane now belongs to the insurance company. Don't try to salvage this kind of thing by doing turns any more than about 30º. So sad.
When low, airspeed is more important than altitude. And that means keeping turns 1 g, regardless of bank angle, by releasing back pressure on the yoke in all turns.
If the pilot did something to cause the crash then their actions should be critiqued (criticized). I don't know why you think not being critical of a pilot is a good thing.
@@0101-s7vBecause being critical resolve nothing and makes no one safer. We can learn from others' mistakes without throwing mud at them, especially if they're dead.
@@BlueSkyUp_EU I think your confusing "being critical" with chastising. That's different. My view is that it's better to learn from OTHER bulls mistakes than it is to learn from your own. But we can't learn if we refuse to talk about pilot error openly and honestly.… if there even was any in this case.
@@MrOlgrumpy We can't say at this point that there was no pilot error. Even if the engine failed due to a maintenance issue, there may have been a way to make a survivable landing.
I have to say the Seminole is a wonderful training aircraft. Incredibly easy to fly, wonderfully predictable and in the training environment the airplane really speaks to you. Sad story, I'm sure the crew tried to do everything right but when something suddenly surprises you in a critical stage, it can be challenging for sure. RIP.
I hate flying the Seminole. Hated it. My instructor drummed into us from day one in the aircraft that the second engine was purely there to take you to the scene of the crash, and that if ANYTHING went wrong on take off or landing with either engine, pull the power on both, and park the airplane straight ahead wherever you can. (Thankfully, our training field had options to do this in both directions) Trying to turn back will ALWAYS kill you. 😢
@@CS_247I loved the Seminole but I get your point. The thing is most trainer twins are underpowered to some degree so its nothing against the Seminole specifically. I would argue its better to have weak engines (and weak turn tendancy) than engines that can easily keep you flying but will spin the aircraft in a heartbeat, at least for training, and the general consensus seems to be the same.
I did my multi engine training at Embry-Riddle Prescott in the Seminol. It is a underpowered multi trainer especially in a high density altitude environment like Prescott Arizona!! I always planned to land straight ahead wheels up in an emergency. This aircraft is easy provided you have good skills. This instructor made the wrong choice attempting a return to the runway. ERAU 80 CFIA&I ret.
Keep your airspeed up at all costs, don't stall and spin. Drill this into your mind, accept you may end up damaging the plane. Your odds of survival will ALWAYS be greater flying the airplane to the ground rather than an inverted nose dive.
I got my multi engine rating in the PA-44 at ERAU Prescott (5045' field elevation). We used to say that on a single engine it gave us a chance to choose were we would crash.
I tookoff in a fully loaded Cherokee 6 (260) Rwy 22 at Moorabbin in the late 60s ......short runway and straight over houses. The first flight after the 100 hrly.......they hadn't torqued-up the plugs and I thought that was IT. It was the day i started going grey.
I was a multi engine instructor in an old Apache It was underpowered and had very poor performance in the hot humid air in Miami I don’t know how I survived that time in my youth
This accident is of special interest for me, as the student pilot is a friend of my sister in law and her husband (a retired airline captain). He is a mentor for the student pilot. We are thankful the young man survived and wish him a speedy recovery. My condolences go to the family of the instructor. An engine failure on short final is very demanding, especially in a light twin like this. It is also worth to note that VMCA in this aircraft is very close to the stall speed. Aircraft weight and density altitude determine what will happen first. It will be easy to say, as an afterthought, that they should have landed straight ahead. But considering the plan was to turn right during the simulated go-around (they were on a VFR flight), and the startle effect they experienced, it is understandable that they started on the turn as a part of the planned procedure. This put them in a very difficult position for landing. Hopefully, this accident will lead to a better understanding of the risk factors involved in flight training in light twins, and that the instructors from now on make a mental plan of how to act if this scenario should happen to them.
I'm starting to wonder if engine failure training in a twin would be better performed in a very basic simulator. Or at least a large number of failures simulated before doing it for real. Fully agree that the briefing to get the plan in short term memory is very helpful.
My multiengine training was in the 150 h.p. Apache, with 5 hrs in type in 1967. Did not find it difficult to fly on one engine but you were assured of a gradual decent to terra firma. The twins in those days did not have to maintain altitude much less go around on one engine. Check ride September in Oklahoma so had conditions not favorable for one engine operation. At reaching altitude for exam setup cruise and awaited desired maneuver from DFE. When scanning for traffic I noticed oil streaming over top cowling on left engine. Fixated my attention momentarily and DPE asked what I was doing and as I looked over in front of him I pointed to the oil pressure gauge which was decreasingly rapidly. To view the left engine he had to lean forward and when he did he immediately said to go to engine out procedure. The left engine had the hydraulic pump for landing gear so while he is declaring an emergency to tower I am applying 39-40+ pump's to lower the gear. In good position to fly midfield so tower could confirm gear down, enter downwind leg to an uneventful landing,yes the emergency vehicles were there as well as most of the staff, students lined up in front of hangar. Because I discovered the problem and performed the most critical test properly on the critical engine out he passed me while we taxied to the ramp. Ruptured oil cooler hose was the culprit, enough oil for analysis showing no abnormal metal in screen so the engine was good to place in service which made Spartan very happy. Total time in class was 5.6 hr. Most of my time thereafter was in Aztec under Part 135 but as DPE and testing twins after annual/engine change I flew several including the Beech Duke.
@@garymiller5624 Yes! On a hot summer's day, the single engine rate of climb was a -50' per min. Depending on your altitude, you'll be landing shortly 🙂
It has been about 25 years since my multi training in a Seminole. I do remember one thing though. All single engine approaches were complete full stop landings. Only practiced single engine go around at safe altitude. There is to much pressure to get these kids trained and out the door. Pressure from all directions.
Exactly. Treat every simulated single landing as a real landing. That way if there are any issues with the engine, just land as usual and no problems. Never turn into the dead engine to try to land on another runway. Land straight ahead. Especially at this airport which has grass and bushes ahead, no buildings or structures to worry about except a fence.
The report said the engine failure was simulated by setting the throttle to idle position. I've given instruction in several multi-engine aircraft (recip and turbine) and an engine failure was simulated by setting the throttle to a zero thrust condition that simulated a feathered propeller . Setting the throttle to idle position causes too much drag, especially in light multi-engine aircraft. I trained for my multi-engine rating in a Piper Apache and the drag of an engine at idle resulted in negative performance. In this case an engine at idle, an unfeathered propeller and an extended landing gear is just too many performance degradation factors.
Most young instructors don’t understand basic physics, math or engine operation. I had an instructor who did not know what an engine compression cycle was. Argued with me why it is safe to fly a 172 with an over pressure front strut. He was 21yrs old
Agreed. I did my multi engine conversion some years ago in a Seminole and the one engine inop procedure was for the instructor to set the throttle on the "failed" engine to zero thrust - I think it was about 12" MAP from memory. Even then countering the yaw gave my leg a real workout while going through the simulated shutdown procedures. Can't imagine you'd have enough rudder authority to maintain control if it was set to idle.
@@Tumleren Zero thrust means you use a little power to simulate a feathered propeller (no drag and no thrust). Idle power will cause the propeller to windmill and absorb energy, causing drag, and is like an unfeathered prop on a dead engine.
IIRC from my days doing ME instruction in the Seminole, we simulated a feathered prop's zero thrust with about ~15 inches of manifold pressure, as an engine running at idle would have the prop blades at flat pitch, increasing drag. Unsure if it was part of the accident chain, but certainly didn't help the situation. IMO the Seminole was a great Part 23 twin trainer, as it clearly demonstrated that having two engines does not guarantee the ability to fly out of an engine failure.
Thanx Juan for the update! As a pilot and or flight instructor , you always have to plan for the worst and hope for the best ! I used to harp on this topic with my students and copilots and some of them would say ,I was a doom and gloom guy ! Flying is a beautiful experience but we’re really Not supposed to be there !Always keep in mind it can easily kill you .And when you think about it all the time while flying it takes a lot of the fun out of it ! Hopefully the loved ones here can cope with their loss ! (True Safety Is No Accident)
My personal rule is if the bank angle exceeds 45 degrees (one engine out) close both throttles, land straight ahead. With Vmca roll it’s out of control parameters and you have to get it back.
regardless of maintenance issues, don't you keep nose down and wings level to get speed up before doing a bunch of turns with a dirty (gear / flaps etc) plane if on one engine or low on power/speed.
Great video Juan. We continue to see light twin accidents. We appreciate all you do and use your videos in our light twin training. This is the most dangerous phase of pilot training for sure. We agree with you 100% on know the limitations and stick to them. Do not try to be a hero and save the plane. Pull the throttles and glide to the ground without the turning tendencies and rely on your engine (one or two) out landing training to fly the plane to the safest point ahead to walk away.
I fly out of KFPR regularly. This flight school has lost a few airplanes to carb ice. My guess is they don’t think about it correctly since they’re in sunny Florida. The problem is the crazy high humidity here. Just my $0.02.
I did my twin endorsement in the Seminole. I would get engine out after take off and it maintained single engine best rate of climb speed no problem. However I never did single engine landing. I'm bit puzzled by the spark plugs gaps. You would think the engines would run rough during pre-takeoff run up.
Mixture was between full rich and idle cutoff. Sounds like they were still leaning from being at 5000 and never went full rich when coming back into the pattern, which would result in reduced power when going full throttle at the lower altitude.
NTSB didn't say explicitly, but it does sound feasible that there was some pilot error involved there. Pretty sad they died during a training exercise.
If the pilot pushed both levers full rich as stated in the interview, that’s a problem with the mixture linkage at the carburetor, where there also seems to be a bad throttle cable linkage.
@@hotprop92 I might be missing something, but I don't see in the report anything about the position the mixture levers (in the cockpit, that is) were found in. The pilot recalls pushing everything full forward, and one carburetor was found full rich and the other halfway. I agree that it points to a linkage problem, especially given the problem found with the throttle, but they don't explicitly rule out faulty recollection by the surviving pilot.
@@jdmillar86 yes your right, but if you've flown a modern twin you know the mixture levers are paired side by side as are prop and throttles. I suppose it's possible to hit one lever but not the other or only halfway in this case, but nonetheless, highly unlikely.
Might be a good idea to add a calculation of single-engine rate of climb to the preflight briefing. Based on weight, CG, and density altitude it would allow the instructor and student to decide if a single-engine go-around is possible under current conditions while still safely on the ground; if not, cancel the flight or go do some other maneuvers.
a maintenance related accident occurs in GA once for every 4.3 million flight hrs. That's ~15% of all accidents. How does your heart feel about the 85% caused by other reasons? Are any of those clearly avoidable?
There are multiple factors to any aviation accident, the final report will direct some recommendations to the industry and improve safety at all levels.
Sounds like the throttle was working fine though damaged, however when they reefed on it to initiate the go-around/come out of the simulated 1 engine it finally stripped out
That the student survived is beyond belief !!!. I did my ratings in the BE55 which had sufficient power to make me comfortable but I always felt that the more 'affordable' twins were a bit too marginal.for my liking.
My educated guess is that the mechanic took apart the carb and didn't put it back together properly. Probably also just threw in whatever plugs were there and went to the next plane. I'm not accusing anyone, but you can't honestly explain a zero gap plug without someone just not looking.
I have almost 500 hrs in the Seminole as both a student and CFIMEI . What is not mentioned here is, if they were on an elongated simulated single engine flight, if they " cleared " the simulated dead engine before attempting the approach. This is done at the base leg, or about 1500' AGL , to make sure your simulated dead engine is still responsive. You don't wait until MDA to find out. It's always best to find out if your " simulated single engine approach " is indeed simulated.........or the real thing, before you get to MDA.
Sounds like the company that did the recent engine overhaul and also the mechanic that missed the wear on the throttle linkage in the April annual may all be in trouble.
Juan, I sense your frustration over our current instruction crew. My first instructor was a grumpy Major flying KC-135’s. After 42 years of flying I retired without accidents or violations. Our instructors are like some of my F.O.’s. They don’t know what they don’t know. I wouldn’t let them fly as Captain until they could pass the test. The test was I had to be able to sleep at night if I dispatched them as Captain. Condolences to the family of the lost instructor.
I said it before ...and I'll say it again. I am lucky to have survived training in ...and instructing in, a seminole. Looking back , I never knew how close to death I was ....yikes
Great video, Juan! I love learning about aviation from you and Dan Gryder. Even though I am not a pilot, I enjoy learning about all the practices, principles and rules involved, including DO NOT TURN INTO THE BAD ENGINE!! Whether it's this light twin or a B-17 commemorative flight, the "rule" applies equally and mercilessly.
Seems Lately, many pilot Training accidents involve very Young FI's that Couldn't have much personal flying Experience....Things seemed Safer when older, more seat time, Experienced flight instructors was the norm.....
As an MEI, I'm very fortunate to have had my DPE provide instruction, once I'd completed all requirements of the check-ride. His drilling in of rudder blocking, and even hands over the throttles during simulated engine failures, and course, never turning into a dead engine, ... have saved me from the understandable and possible acts of an inexperienced student a few times. Heartbreaking - RIP Classic turn into the dead engine yielding tragedy.
The MEI should have cleaned up the aircraft, and flown straight ahead. ..then altitude permitting, only make turns into the good engine. Rest In Peace.
Agree, since the plug would not produce any spark. This "should have" revealed itself during the magneto check prior to takeoff... assuming that they did so.
Very unlikely, unless the wrong spark plug was used. More likely something broke, like a piston ring. Possibly FOD, when mechanic dropped a bolt down the intake.
During my training on C421s and PA31s the instructor would pull the mixture just on reaching minimum descent altitude. At least it demonstrated a realistic asymmetric thrust condition since the engine would more or less feather.
I haven’t flown a Seminole in a long time but I remember in training if all else fails. Your last resort is to pull both the throttles and fly it in level to the crash site.
Even as a non pilot I know not to turn into the dead engine and it is amazing how many experienced pilots make that mistake. Such a shame that someone loses their life for something that basic. Thanks so much for the update Juan.
Yeh. Your first statement explains the rest. Turning into the dead engine is a myth. Turning into the dead engine is done regularly during training. Both in the simulator and actual flight training. Done it many times. It’s normal.
@@guitarhillbilly1482 Shot a few approaches in a PA-44 one engine out. This requires a 180 degree heading reversal into the dead engine. (If the instructor chooses so). Typically that occurs at about 1100’ agl. It’s not a big deal.
Was watching a horrible story that happened just a couple of days ago, a medivac single engine aircraft carrying 1 pilot, a nurse, the patient & family members, 14min into the flight it came down there were no survivors. The video was about when to say no, flying conditions are to bad. Conditions were bad the pilot had trouble finding the correct turn to the runway because of snow, ATC also said there is moderate turbulence. Very sad set of circumstances.
Juan - just love you channel & reports - although, some sad - However, we always learn from them. That said - looking at the picture - how the student pilot survived is amazing... Best
A genuine query, what type of experience is required to become an instructor pilot? I just can’t see how experienced someone can be in a highly skilled profession at 22. Don’t get me wrong, they can be competent, but having all the ticks in the right boxes doesn’t translate to “experienced”.
Your comments regarding the CFI points to why the FAA will be stressing slow flight manurers when examination flight are conducted for all pilot exams and BFR s
Whenever I fly, whether as a passenger or pilot in a General Aviation format aircraft, I always check the maintenance records of the aircraft. If maintenance was recently done, I feel safe to fly alone, but I never fly with passengers, and always stick to simple patterns before an extended flight.
I was fortunate in my Navy career to have King Airs for the twin training. If I won the lottery I would purchase one this afternoon. Rest in peace those that were lost. Greg Moore, New Zealand.
King Airs are great airplanes but I would be very reluctant to turn into a dead/ low power engine even in a King Air . Especially low altitude low airspeed.
@@ivansemanco6976 Don't know if the Piper has enough Rudder and Vertical Stabilizer to overcome a full power engine turning into the dead / reduced power engine .
Thanks, it would be interesting to know how many casualties arise from training for single engine go around, vs the number that occur due to actual failures.
Some CFIs in the comments say that the method used here to simulate an engine failure is not a good one, as it increases drag. On real life scenarios you would feather the dead engine, so you will not have that drag. So I think it will be also interesting to learn what method has been used for those training flights that went wrong.
In the last four to five years I’ve seen nothing but crap come out of FL. Not saying it’s all bad, but every plane I’ve inspected that’s come from FL has been a total s-show.
That's a good question. It sounds like that lever was loose all along but picked that moment to get so loose that it no longer moved the throttle. We need an A&P to say whether that connection is supposed to be inspected in a way that would have revealed the looseness. A solid day's work for Murphy either way.
@@stacymcmahon453didn't juan read that the report said the teeth on the link were rounded over? It sounds like maybe that connection had been poor for a long time and had been getting ground down?
Having time in a Geronimo, if you have ANY ISSUES either practice or not and at an airport that is at 5000 feet you really have to be on your game to do anything other than stick it on the ground straight ahead….it becomes VERY SPORTY to deal with. At seal level you might have some options but i would guess very few.
The NTSB report page at 8mins said the last annual inspection was the day before the accident flight. Worth checking if work was done on the throttle linkage during preparation for the inspection. And why the inspection didn't find the loose linkage connection and maybe add that to future inspections.
Sounds like a combination of holes in the swiss cheese all lined up perfectly. I would not be comfortable not knowing who had done the maintenance of any engine my life depended on in a general aviation plane.
Good analysis as usual Juan. Interesting conflict in either perception or reality of the rated private pilot multi-student, stating there was no engine power from either side on the 'GO' and the instructor pilot, she reported to tower OEI.
Howdy sir, would you be able to do a video on The N1125A crash in Virginia? It happened around the time all the United flights had issues. You may be planning on a video when the final report comes out, but I would love to have your perspective on this accident. Thanks and I really appreciate the work you do! 🙌🏻
I’m still amazed at this video and then reading the comments that there’s almost nobody commenting or even asking or telling whether or not any of the propellers were found in the feathered position! It sure appears I’m the only one catching this! They wouldn’t stand a chance at making it if they were trying to fly with one windmilling.
Incorrect mixture combined with incorrect or zero spark plug gap even on one or two cylinders says there’s not going to be correct combustion when needed. The fuel mixture can’t readily be ignited, therefore no power when requested. - Maybe the valves springs were worn or clips or the piston(s) kissed the plug(s). - Maybe the mechanic or whoever changed the plugs never gapped them or banged them near the holes before insertion. - It could’ve been as it usually is, a Swiss Cheese combination of things.
Simulated zero thrust is a specific RPM (looks like it's 2180 in the Seminole). Idle would produce more drag than a feathered non spinning prop. We did the same thing when I got my multi many years ago in a Duchess. I live very close to an airport with a very high amount of training aircraft, with several Seminoles that fly traffic patterns almost all day long, and it's a bit concerning. They're noisy too. And the engines sputter every now and then.
We just watched this video. Did we hear correctly, Annual Inspection 29 March, crash 30 March? Was this the first flight after an annual? Does it sound plausible that throttle/propeller/mixture controls had been disconnected and not properly reconnected, therefore the engine did not respond to throttle controls?
Simulated single-engine is not throttle idle. That gives you drag from that idling prop. I don’t remember the setting for “zero thrust” on the Seminole.
Questions for the aircraft mechanics: What do you think the condition of the sparkplugs in the right engine means? As a former auto mechanic, the gap issues seem inconsistent with only 200hrs of operation. Opinions? Aren't the plugs pulled to check compression during an annual?
The only way you have 0 gap is someone didn't look at some point. HOW it got that way.. that's also worrying as that usually indicates damage between the manufacturer and installation - somewhere along the chain.
It seems like when things go wrong, it's always worse in a twin that it is and a single engine. I see so many reports on twin engine crashes that it makes me think that a single engine aircraft is much preferable and safer.
They actually are. The downside is that flight training to be a commercial pilot in the U.S. has this as a prerequisite, and most single engine planes are very slow and lack enough range. Not all, but many, and so there is also a drive to get a twin as then you can fly to the Bahamas or similar, where it's a headache in a small single. Yes, there are long-range fast singles, but 2-4 million for one is... yeah... not beginner budget friendly. But I'd still rather run a good single that I save up for versus the complexity of multiple engines - unless I had to for some reason.
The emergency was not necessarily to immediately land but rather to get control , stabilize , try to determine the situation, and if indicated feather , and then gentle maneuver for landing via checklists. If at all possible get straight and level not immediately initiate a turn. Declaring emergency allows you to do whatever is necessary. Engine out may mean engine stops but also applies to engine or prop malfunction which may lead to confusing behavior but require throttling back the bad engine. Full power on good engine straight ahead, clean up, blue-line, get control, stay calm, gentle gradual turns only to good side. Avoid sudden inputs or sudden maneuvering and keep it as simple as possible. This accident might have been avoided with more care calmness and finesse.
Hmmm… from the perspective of someone who tinkers with non-aviation mechanics, seems to me spark plug gap tends to increase with wear, and if I were to see one smashed or with no gap I’d be wondering if it shredded/spun a rod bearing allowing the piston to hit the plug (and head)?
The plug that had a closed-up gap was in the cylinder on which impact damage prevented the investigators establishing whether there was compression and valve train integrity.
I am completing multi in a seminole. Basically anything "long and complicated" in case of engine loss is above 500ft AGL. Everything else is stay on the runway, stay on the runway, brake and go for the trees, if left the runway and below Vmc, straight ahead clean the place and find place to land. If single engine works, do all the necessary things (identify, verify, feather) and see if you have enough power to climb or maintain. No need for abrupt maneuvers in this case. Even with my weight and the instructor's weight, only once the plane could not climb with one engine, in the summer with high density altitude (could still maintain altitude at full power, and safely above Vmc)
I was lucky to have a master train me Multi.. There was no simulation. We drilled engine off full feather and did a couple of dozen single engine landings and even a single engine approach/landing under the hood. RIP
So a dead throttle is the gremlin. The details are so important. When you're required to overhaul an aircraft engine by law, does the rest of the aircraft need to be inspected also? 🇨🇦
You’re not required to overhaul the engines at all. If the engines cylinders make proper compression, no metal in the oil, etc., you’re good to go. However, it’s industry standard to overhaul those engines at 2200 hours
@@mpgofast obviously you missed the “industry standard” part of my comment. You just like to argue though, don’t you? Also, please read 14 CFR parts 43 and 91 and let me know where it says overhaul at 2000 hours or to use manufacturers recommendations. Also, if you watched the whole video, you would have heard that the overhauls weren’t due yet and that the throttle arm was found loose on the carburetor throttle shaft.
@@MrBe787 There are Lycoming SB that recommend hours, I went above 2000 hrs because we had a history of the engine to determine airworthiness and when to stop flying
l always hated being the first pilot to fly a plane immediately after an annual or 100 hr inspection. Lots of horror stories, including engine failure over the runway once. RIP to the instructor, and may the student find comfort. That had to be traumatic!
You didn't read aloud the most important line in the NTSB completely - the last annual inspection on the airframe and both engines was completed THE DAY BEFORE THE ACCIDENT. Should an annual have detected the throttle lever problems?
While not speculating on this accident, any flights immediately following heavy maintenance* should be treated with caution.
* - A GA annual inspection may OR MAY NOT involve heavy maintenance depending on the discrepancies found and fixed.
Yes a inspection is required to see those errors in the carb linkage but could be easily overlooked if it was working on the inspections prerunup
Absolutely yes, a good mechanic would have their hands on every part of that engine, it's like I use to tell new A&P's 20 years ago, a good mechanic see's as much with their hands, as they do with their eyes
OH MY I sense a loss of a 145 cert coming.
07:57 he reads the date of the last annual, I guess you didn't hear it.
My grandfather was an aircraft mechanic during ww2. We were working on my car together once when i was a teenager. I dropped a spark plug on the concrete😮. He picked it up and threw it in the trash without even looking at it.
I had an instructor in A&P school who always said, "Unlike Maxwell House Coffee, these things [spark plugs] are only good til the FIRST drop!"
Are you testifying your grandpa was a jerk? If not, what’s your point?
@@johnhopkins4920 the point is that the spark plugs are porcelain. Even if it doesn't look broken from an impact with the ground, it is likely to have suffered internal damage and will not perform properly. It's easier and cheaper to replace a dropped (and potentially damaged) spark plug before installing it than to have problems out in the field. In the realm of aviation, installing a damaged spark plug could kill you. In this case, it killed the instructor.
@johnhopkins4920 He was a kind man, and an excellent mechanic. Sorry for the /whoosh over your head.
@@johnhopkins4920
It's standard proceedure regarding aircraft plugs that if you drop one there's a potential to crack the porcelain insulator. Many times those cracks aren't visible to the naked eye, so any dropped plugs are immediately tossed in the trash. Same dynamic at work on automotive plugs, but a failed plug in a car won't kill you.
It was in a Seminole at Fort Pierce that my instructor shut off a fuel selector so that an engine failed seconds after I went missed approach - I closed both throttles, lowered the gear and told the tower "MAY DAY, Seminole (which ever one it was), is engine out and landing Runway Niner." (Fort Pierce didn't have parallel runways in 1990, and 9-27 were the numbers then). Full flaps and a bit of a slip got her slowed down enough to get down and stopped....I don't even remember if the tower cleared us to land (we had been cleared for the option, but then called "going missed"). That response was not what my instructor anticipated...but he decided that it was a better choice than the extreme precision needed for a single engine climb out. I grew up in Colorado, where any twin without turbos tends to have a single engine ceiling below the terrain, at least in the summertime, so my response was to act the same as if the engine quit in a single. Before each takeoff we briefed that if an engine failed while there was runway ahead, we would close the throttles and land. I figured I'd rather go off the east end slowly (right in front of the fire station) than hit the trees at 88 KIAS (or, as it turns out, hit the concrete upside-down). We started the engine, taxied back and went back to Vero Beach, and I learned firsthand that there is not necessarily any paperwork involved in declaring an emergency. My instructor explained to the tower that he had shut it off, that it hadn't failed, but that I didn't know that in the moment. It was about my second flight in the Seminole, and I hadn't figured out yet that more than half the hours I would spend in Seminoles would be with one either simulated or actually shut down. Most of my hours before that were in a Mooney M-20E - I found the Seminole a remarkable way to spend twice as much fuel with the same size cabin, going slower, or the same amount of fuel (with one shut down), going a LOT slower while making one leg tired.
Very nice wright up sir. I am a 50 yr Bonanza owner, really dont understand the need for low power twins they kill a lot of people,
@@kevina8172 In case of an engine failure in those light twins, the remaining engine is perfectly capable of flying the airplane all the way to the crash site.
@@coriscotupi It seems that may actually be a rather limited range.
When it comes to light twins I prefer the ones with turbocharged piston engines.
Ideally turboprops are the way as they have no issue at all flying and climbing on one engine.
“One leg tired” hahaha. Yeahhhh I remember multi training. I wonder why they didn’t switch sides with the dead engine.
@@kevina8172 a lot of people obtain multi-engine ratings in these airplanes uneventfully . . . Do you really think more powerful twins would be safer?
I'll throw this out and feel free to slam me, but.... When things go to s..t in a light twin while low and slow and you are behind the mental power curve; pull both power levers idle, lower the nose, level wings and pick a spot to touch down without worrying about the gear or flaps.
Better chance of survival following your suggestion.
Yep. Speed/Altitude/Ideas. You need 2 outa 3.
Was thinking the same thing
One of the first things I learned 50 years ago as a student pilot was exactly that. I was taught (with very few exceptions) NEVER turn back to the runway and do what you said.
Yep...airport magnetism has claimed quite a few souls.
I was never aware of how dicey these low powered light twins were until I started watching this channel. No room for anything but a perfect response from the pilot when you lose an engine at pattern altitude. As noted by someone else on a previous light twin crash report on this channel: A twin engine plane won't get you there twice as fast but it can get you in trouble twice as fast.
I think I learned that on the piper Apache? The instructors said if you lose one engine the remaining engine will take you to the crash site
It’s unimaginable that these older marginal aircraft are still allowed to fly! Be done with this nonsense! Retire and recycle as much and be done with it
It's sad. I'm surprised anyone manged to survive that wreck.
Damn, I didn’t catch it the first time that the student survived!
Wow. She wasn’t just simulating a single engine scenario, she was in it the whole time.
Condolences to the family of the flight instructor, and hopes that the student will make a full recovery. I think the NTSB would have the best team ever with Juan Browne and Greg Feith contributing their complete attention to the smallest details.
Personally, I can't are stand Greg, but I'd like to see Juan do some videos with the other guys on that podcast.
@@zlm001 What is it about Greg that you don't like? He was the leader of the go team for the NTSB for a long time. And, if you have been in the business world at all you would know that professionals don't have to like each other to get the job done.
My maintenance hinky-meter is spiking at this tragic loss. "The last airframe and engine annual was completed the day before the accident"!
Every time I flew an airplane just out of annual, I considered the first five to ten hours as test flights. I did not practice engine out procedures for a few hours.
Yeah botched (or worse...) maintenance appears to be a legitimate question here.
It's a big block of Swiss cheese. The spark plug descriptions were baffling, it's not usually a weak point for mechanics. The throttle lever with the serrations would have still been working during start and take-off so it would have also looked fine during inspection.
I have my own opinions on the state of flight training in North America as another factor.
I will be following this one, it should be an eye opener.
@@ianrobertson3419 Maybe…maybe not on the throttle connection serations. A slightly loose bolt may have gotten through the run-up fine but loosened during the flight. When the time came for the go-around, a more “immediate” throttle movement could have caused the slippage resulting in incomplete full throttle achievement.
The spark plug issue is very strange indeed.
I built and maintained N36LV for 6 years. Every post-annual flight was treated like my initial experimental fly-off time: nobody but me and 4 pages of checklists in the plane for 2 hrs, followed by pulling the cowlings and checking everything one last time.
@@bwalker4194 Yes, the spark plug issue seems quite odd. One would think that the gap would have been checked before install, but I wonder if the plugs were dropped at some point.
Back when I was doing my multi training in a Seneca (PA34-200) we started single engine with reducing one to idle, after some experience with that my instructor introduced actually shutting down so I would understand both the difference, and especially the effect of not getting the dead engine feathered. Of course, all this was happening at a nice safe altitude, until the day the engine wouldn't restart so I was going to get the experience of a real single engine landing.
My instructor read the single engine go-around checklist to me twice, making sure I knew what I had to do. He also said, if we have to go around we were going to climb out straight until we got to pattern altitude. It was a warm day, but near sea level, so he also said if it wasn't climbing well he would take over the controls and put it down straight ahead. We would only turn with altitude and reasonable single-engine climb. The landing was anticlimactic - no fuss, no muss.
You gotta keep flying that plane straight ahead into the crash site. When something like this happens, the plane now belongs to the insurance company. Don't try to salvage this kind of thing by doing turns any more than about 30º. So sad.
And I wasn’t even her airplane.
That close to the ground I'd say less than 10 degrees either side, probably even far less since the gear was down.
@@oldowl4290 I should have said heading changes of less than 30. I didn’t mean bank angle for sure
@@oldowl4290 And another multi engine claims a young future airline pilot. Colgan Air claims another victim via the US Congress
When low, airspeed is more important than altitude. And that means keeping turns 1 g, regardless of bank angle, by releasing back pressure on the yoke in all turns.
Juan you do a great job of giving the facts without being critical of pilots but use what happen as a lesson to other pilots.
If the pilot did something to cause the crash then their actions should be critiqued (criticized). I don't know why you think not being critical of a pilot is a good thing.
@@0101-s7vBecause being critical resolve nothing and makes no one safer. We can learn from others' mistakes without throwing mud at them, especially if they're dead.
@@BlueSkyUp_EU I think your confusing "being critical" with chastising. That's different. My view is that it's better to learn from OTHER bulls mistakes than it is to learn from your own. But we can't learn if we refuse to talk about pilot error openly and honestly.… if there even was any in this case.
This appears to be a maintenance issue,beyond the control of the pilot while airbourne.not a pilot failing !
@@MrOlgrumpy We can't say at this point that there was no pilot error. Even if the engine failed due to a maintenance issue, there may have been a way to make a survivable landing.
I have to say the Seminole is a wonderful training aircraft. Incredibly easy to fly, wonderfully predictable and in the training environment the airplane really speaks to you. Sad story, I'm sure the crew tried to do everything right but when something suddenly surprises you in a critical stage, it can be challenging for sure. RIP.
The truth is we all would probably do the same. It's just horrible luck. There's no time to think in this situation.
I hate flying the Seminole. Hated it. My instructor drummed into us from day one in the aircraft that the second engine was purely there to take you to the scene of the crash, and that if ANYTHING went wrong on take off or landing with either engine, pull the power on both, and park the airplane straight ahead wherever you can. (Thankfully, our training field had options to do this in both directions) Trying to turn back will ALWAYS kill you. 😢
@@CS_247I loved the Seminole but I get your point. The thing is most trainer twins are underpowered to some degree so its nothing against the Seminole specifically. I would argue its better to have weak engines (and weak turn tendancy) than engines that can easily keep you flying but will spin the aircraft in a heartbeat, at least for training, and the general consensus seems to be the same.
I did my multi engine training at Embry-Riddle Prescott in the Seminol. It is a underpowered multi trainer especially in a high density altitude environment like Prescott Arizona!!
I always planned to land straight ahead wheels up in an emergency.
This aircraft is easy provided you have good skills. This instructor made the wrong choice attempting a return to the runway.
ERAU 80 CFIA&I ret.
Keep your airspeed up at all costs, don't stall and spin. Drill this into your mind, accept you may end up damaging the plane. Your odds of survival will ALWAYS be greater flying the airplane to the ground rather than an inverted nose dive.
I got my multi engine rating in the PA-44 at ERAU Prescott (5045' field elevation). We used to say that on a single engine it gave us a chance to choose were we would crash.
I await further investigation to see what they find in the maintenance records and procedures. You described some troubling findings.
I tookoff in a fully loaded Cherokee 6 (260) Rwy 22 at Moorabbin in the late 60s ......short runway and straight over houses. The first flight after the 100 hrly.......they hadn't torqued-up the plugs and I thought that was IT. It was the day i started going grey.
I hope it wasnt Superior Aviation that had worked on the Cherokee 6.
@@johndavies8608 well I certainly wouldn't call it superior 😕
I was a multi engine instructor in an old Apache It was underpowered and had very poor performance in the hot humid air in Miami I don’t know how I survived that time in my youth
This accident is of special interest for me, as the student pilot is a friend of my sister in law and her husband (a retired airline captain). He is a mentor for the student pilot. We are thankful the young man survived and wish him a speedy recovery. My condolences go to the family of the instructor.
An engine failure on short final is very demanding, especially in a light twin like this. It is also worth to note that VMCA in this aircraft is very close to the stall speed. Aircraft weight and density altitude determine what will happen first.
It will be easy to say, as an afterthought, that they should have landed straight ahead. But considering the plan was to turn right during the simulated go-around (they were on a VFR flight), and the startle effect they experienced, it is understandable that they started on the turn as a part of the planned procedure. This put them in a very difficult position for landing.
Hopefully, this accident will lead to a better understanding of the risk factors involved in flight training in light twins, and that the instructors from now on make a mental plan of how to act if this scenario should happen to them.
I'm starting to wonder if engine failure training in a twin would be better performed in a very basic simulator. Or at least a large number of failures simulated before doing it for real. Fully agree that the briefing to get the plan in short term memory is very helpful.
would a left turn have aligned them better?
My multi training was in a '56 PA-23-150 Apache. A forgivable old cow on landing but a handful to fly on one engine.
My multiengine training was in the 150 h.p. Apache, with 5 hrs in type in 1967. Did not find it difficult to fly on one engine but you were assured of a gradual decent to terra firma. The twins in those days did not have to maintain altitude much less go around on one engine. Check ride September in Oklahoma so had conditions not favorable for one engine operation. At reaching altitude for exam setup cruise and awaited desired maneuver from DFE. When scanning for traffic I noticed oil streaming over top cowling on left engine. Fixated my attention momentarily and DPE asked what I was doing and as I looked over in front of him I pointed to the oil pressure gauge which was decreasingly rapidly. To view the left engine he had to lean forward and when he did he immediately said to go to engine out procedure. The left engine had the hydraulic pump for landing gear so while he is declaring an emergency to tower I am applying 39-40+ pump's to lower the gear. In good position to fly midfield so tower could confirm gear down, enter downwind leg to an uneventful landing,yes the emergency vehicles were there as well as most of the staff, students lined up in front of hangar. Because I discovered the problem and performed the most critical test properly on the critical engine out he passed me while we taxied to the ramp. Ruptured oil cooler hose was the culprit, enough oil for analysis showing no abnormal metal in screen so the engine was good to place in service which made Spartan very happy. Total time in class was 5.6 hr. Most of my time thereafter was in Aztec under Part 135 but as DPE and testing twins after annual/engine change I flew several including the Beech Duke.
@@garymiller5624 Yes! On a hot summer's day, the single engine rate of climb was a -50' per min. Depending on your altitude, you'll be landing shortly 🙂
It has been about 25 years since my multi training in a Seminole. I do remember one thing though. All single engine approaches were complete full stop landings. Only practiced single engine go around at safe altitude. There is to much pressure to get these kids trained and out the door. Pressure from all directions.
Same case with me.
Exactly. Treat every simulated single landing as a real landing. That way if there are any issues with the engine, just land as usual and no problems. Never turn into the dead engine to try to land on another runway. Land straight ahead. Especially at this airport which has grass and bushes ahead, no buildings or structures to worry about except a fence.
Thanks blanco. You should do a video on light twin operation and the pitfalls. You certainly have a way of explaining things so I understand.
Thanks for doing these, Juan!
The report said the engine failure was simulated by setting the throttle to idle position. I've given instruction in several multi-engine aircraft (recip and turbine) and an engine failure was simulated by setting the throttle to a zero thrust condition that simulated a feathered propeller . Setting the throttle to idle position causes too much drag, especially in light multi-engine aircraft. I trained for my multi-engine rating in a Piper Apache and the drag of an engine at idle resulted in negative performance. In this case an engine at idle, an unfeathered propeller and an extended landing gear is just too many performance degradation factors.
Most young instructors don’t understand basic physics, math or engine operation. I had an instructor who did not know what an engine compression cycle was. Argued with me why it is safe to fly a 172 with an over pressure front strut. He was 21yrs old
Great insights from both of you, thanks! Do you have any idea as to why the student would say that they've lost thrust on both engines?
Agreed. I did my multi engine conversion some years ago in a Seminole and the one engine inop procedure was for the instructor to set the throttle on the "failed" engine to zero thrust - I think it was about 12" MAP from memory. Even then countering the yaw gave my leg a real workout while going through the simulated shutdown procedures. Can't imagine you'd have enough rudder authority to maintain control if it was set to idle.
What's the difference between idle and a zero thrust condition? - not a pilot
@@Tumleren Zero thrust means you use a little power to simulate a feathered propeller (no drag and no thrust). Idle power will cause the propeller to windmill and absorb energy, causing drag, and is like an unfeathered prop on a dead engine.
Thank you very much for the Update! My Condolences to the Families and Friends of the Flight Instructor. Another really sad Story.
IIRC from my days doing ME instruction in the Seminole, we simulated a feathered prop's zero thrust with about ~15 inches of manifold pressure, as an engine running at idle would have the prop blades at flat pitch, increasing drag. Unsure if it was part of the accident chain, but certainly didn't help the situation. IMO the Seminole was a great Part 23 twin trainer, as it clearly demonstrated that having two engines does not guarantee the ability to fly out of an engine failure.
Thanx Juan for the update! As a pilot and or flight instructor , you always have to plan for the worst and hope for the best ! I used to harp on this topic with my students and copilots and some of them would say ,I was a doom and gloom guy ! Flying is a beautiful experience but we’re really Not supposed to be there !Always keep in mind it can easily kill you .And when you think about it all the time while flying it takes a lot of the fun out of it ! Hopefully the loved ones here can cope with their loss ! (True Safety Is No Accident)
My personal rule is if the bank angle exceeds 45 degrees (one engine out) close both throttles, land straight ahead.
With Vmca roll it’s out of control parameters and you have to get it back.
regardless of maintenance issues, don't you keep nose down and wings level to get speed up before doing a bunch of turns with a dirty (gear / flaps etc) plane if on one engine or low on power/speed.
Yes, and doubly so with a plane that has literal *feet* of climb per minute on one engine due to the miserable power to weight ratio.
Great video Juan. We continue to see light twin accidents. We appreciate all you do and use your videos in our light twin training. This is the most dangerous phase of pilot training for sure. We agree with you 100% on know the limitations and stick to them. Do not try to be a hero and save the plane. Pull the throttles and glide to the ground without the turning tendencies and rely on your engine (one or two) out landing training to fly the plane to the safest point ahead to walk away.
I fly out of KFPR regularly. This flight school has lost a few airplanes to carb ice. My guess is they don’t think about it correctly since they’re in sunny Florida. The problem is the crazy high humidity here. Just my $0.02.
In the UK the only times I've had carb ice have been in summer. Around 25 deg and humid seemed to be the worst combo.
I did my twin endorsement in the Seminole. I would get engine out after take off and it maintained single engine best rate of climb speed no problem. However I never did single engine landing. I'm bit puzzled by the spark plugs gaps. You would think the engines would run rough during pre-takeoff run up.
Mixture was between full rich and idle cutoff. Sounds like they were still leaning from being at 5000 and never went full rich when coming back into the pattern, which would result in reduced power when going full throttle at the lower altitude.
NTSB didn't say explicitly, but it does sound feasible that there was some pilot error involved there. Pretty sad they died during a training exercise.
If the pilot pushed both levers full rich as stated in the interview, that’s a problem with the mixture linkage at the carburetor, where there also seems to be a bad throttle cable linkage.
The report points out that though the mixture lever was at full rich the mixture lever on the carb was nominally halfway.
@@hotprop92 I might be missing something, but I don't see in the report anything about the position the mixture levers (in the cockpit, that is) were found in. The pilot recalls pushing everything full forward, and one carburetor was found full rich and the other halfway. I agree that it points to a linkage problem, especially given the problem found with the throttle, but they don't explicitly rule out faulty recollection by the surviving pilot.
@@jdmillar86 yes your right, but if you've flown a modern twin you know the mixture levers are paired side by side as are prop and throttles. I suppose it's possible to hit one lever but not the other or only halfway in this case, but nonetheless, highly unlikely.
Might be a good idea to add a calculation of single-engine rate of climb to the preflight briefing. Based on weight, CG, and density altitude it would allow the instructor and student to decide if a single-engine go-around is possible under current conditions while still safely on the ground; if not, cancel the flight or go do some other maneuvers.
It breaks my heart when I hear about poor maintenance that probably caused a clearly avoidable accident.
Poor maintenance more than likely contributed to the accident, but it was caused by pilot error.
a maintenance related accident occurs in GA once for every 4.3 million flight hrs. That's ~15% of all accidents. How does your heart feel about the 85% caused by other reasons? Are any of those clearly avoidable?
There are multiple factors to any aviation accident, the final report will direct some recommendations to the industry and improve safety at all levels.
🦘🇦🇺Thank you Juan for the concise clarity of the issue. It really helps avionic understanding ✈️ 🙏
Got my multi plus the check ride in a Seminole. I remember my instructor being very cautious on stalls and single engine-out practice.
I’m just starting multi training in a BE76-180 so… I’ll definitely keep this in mind
Sounds like the throttle was working fine though damaged, however when they reefed on it to initiate the go-around/come out of the simulated 1 engine it finally stripped out
That the student survived is beyond belief !!!. I did my ratings in the BE55 which had sufficient power to make me comfortable but I always felt that the more 'affordable' twins were a bit too marginal.for my liking.
Can’t agree more
Annual performed on 3/29, accident occurred 3/30. Hmmm 🤔.
My educated guess is that the mechanic took apart the carb and didn't put it back together properly. Probably also just threw in whatever plugs were there and went to the next plane. I'm not accusing anyone, but you can't honestly explain a zero gap plug without someone just not looking.
How could plugs be so F’ed up? IDK how much plugs cost but they have to cheaper than a funeral
I have almost 500 hrs in the Seminole as both a student and CFIMEI . What is not mentioned here is, if they were on an elongated simulated single engine flight, if they " cleared " the simulated dead engine before attempting the approach. This is done at the base leg, or about 1500' AGL , to make sure your simulated dead engine is still responsive. You don't wait until MDA to find out. It's always best to find out if your " simulated single engine approach " is indeed simulated.........or the real thing, before you get to MDA.
Sounds like the company that did the recent engine overhaul and also the mechanic that missed the wear on the throttle linkage in the April annual may all be in trouble.
A plug with zero gap means that someone didn't look and installed it anyways.
Juan, I sense your frustration over our current instruction crew. My first instructor was a grumpy Major flying KC-135’s. After 42 years of flying I retired without accidents or violations. Our instructors are like some of my F.O.’s. They don’t know what they don’t know. I wouldn’t let them fly as Captain until they could pass the test. The test was I had to be able to sleep at night if I dispatched them as Captain. Condolences to the family of the lost instructor.
I like your idea
Look up the requirements for CFI and MEI and you will probably see why the frustration.
I said it before ...and I'll say it again. I am lucky to have survived training in ...and instructing in, a seminole. Looking back , I never knew how close to death I was ....yikes
Thank you for taking the video suggestion Juan, always great to hear your perspective!
Great video, Juan! I love learning about aviation from you and Dan Gryder. Even though I am not a pilot, I enjoy learning about all the practices, principles and rules involved, including DO NOT TURN INTO THE BAD ENGINE!! Whether it's this light twin or a B-17 commemorative flight, the "rule" applies equally and mercilessly.
Seems Lately, many pilot Training accidents involve very Young FI's that Couldn't have much personal flying Experience....Things seemed Safer when older, more seat time, Experienced flight instructors was the norm.....
The classic impossible turn followed by the almost inevitable stall spin.
Not to mention turning into a dead engine--you never, never do that!
@@ABQSentinel never say never...
@@tstanley01never
L
@@ABQSentinel VMC is like zombies. You raise the dead.
As an MEI,
I'm very fortunate to have had my DPE provide instruction, once I'd completed all requirements of the check-ride.
His drilling in of rudder blocking, and even hands over the throttles during simulated engine failures,
and course, never turning into a dead engine,
... have saved me from the understandable and possible acts of an inexperienced student a few times.
Heartbreaking - RIP
Classic turn into the dead engine yielding tragedy.
The MEI should have cleaned up the aircraft, and flown straight ahead.
..then altitude permitting, only make turns into the good engine.
Rest In Peace.
Another top number report mate ,sad about the loss of the instructor pilot .take care safe flights,👋👋🙏🙏👍🇦🇺
A spark plug with no gap points towards dynamic re-gapping, i.e. the piston has hit the plug.
That’s what I was thinking too
Agree, since the plug would not produce any spark. This "should have" revealed itself during the magneto check prior to takeoff... assuming that they did so.
Very unlikely, unless the wrong spark plug was used. More likely something broke, like a piston ring. Possibly FOD, when mechanic dropped a bolt down the intake.
For a car yes... Not aircraft sparkies.
@@Parkhill57ahhh “dropping a bolt down the intake” for an aircraft engine isn’t a thing. The intakes are on the bottom of piston AC engines.
Thankyou for another great post and very well presented as we have all come to expect from yourself.
Thankyou.
During my training on C421s and PA31s the instructor would pull the mixture just on reaching minimum descent altitude. At least it demonstrated a realistic asymmetric thrust condition since the engine would more or less feather.
Thanks again for the insight. So many twin training fatal accidents in the last few months.
This is so informative! Great job, fantastic reporting!🌻🌼🐝 Keep it up 🙌
I haven’t flown a Seminole in a long time but I remember in training if all else fails. Your last resort is to pull both the throttles and fly it in level to the crash site.
Thanks sir. Another example of a tragic/preventable accident we can ALL learn from.
Even as a non pilot I know not to turn into the dead engine and it is amazing how many experienced pilots make that mistake. Such a shame that someone loses their life for something that basic. Thanks so much for the update Juan.
I'm not a non-pilot but I know a blanket statement "not to turn into the dead engine" is meaningless.
Yeh. Your first statement explains the rest. Turning into the dead engine is a myth. Turning into the dead engine is done regularly during training. Both in the simulator and actual flight training. Done it many times. It’s normal.
It's amazing how many single engine out situations the pilot attempts to turn back to the runway and stall/spins the aircraft into the ground.
@@raoulcruz4404 bet it's not practiced below 500 ft AGL at Minimum Airspeed in a real aircraft.
@@guitarhillbilly1482 Shot a few approaches in a PA-44 one engine out. This requires a 180 degree heading reversal into the dead engine. (If the instructor chooses so). Typically that occurs at about 1100’ agl. It’s not a big deal.
The MEI sounds like a hero the way she took control of the aircraft.
Was watching a horrible story that happened just a couple of days ago, a medivac single engine aircraft carrying 1 pilot, a nurse, the patient & family members, 14min into the flight it came down there were no survivors. The video was about when to say no, flying conditions are to bad. Conditions were bad the pilot had trouble finding the correct turn to the runway because of snow, ATC also said there is moderate turbulence. Very sad set of circumstances.
Knowing when to fold 'em when the odds say no-go is sound wisdom. There are too many Pilatus and Cirrus crashes nowadays. Poor judgement.
Juan - just love you channel & reports - although, some sad - However, we always learn from them. That said - looking at the picture - how the student pilot survived is amazing...
Best
A genuine query, what type of experience is required to become an instructor pilot? I just can’t see how experienced someone can be in a highly skilled profession at 22. Don’t get me wrong, they can be competent, but having all the ticks in the right boxes doesn’t translate to “experienced”.
Your comments regarding the CFI points to why the FAA will be stressing slow flight manurers when examination flight are conducted for all pilot exams and BFR s
Whenever I fly, whether as a passenger or pilot in a General Aviation format aircraft, I always check the maintenance records of the aircraft. If maintenance was recently done, I feel safe to fly alone, but I never fly with passengers, and always stick to simple patterns before an extended flight.
I was fortunate in my Navy career to have King Airs for the twin training. If I won the lottery I would purchase one this afternoon.
Rest in peace those that were lost. Greg Moore, New Zealand.
King Airs are great airplanes but I would be very reluctant to turn into a dead/ low power engine even in a King Air . Especially low altitude low airspeed.
@@guitarhillbilly1482In this case it was not intentional in my opinion, full power engine does his job turn the plane to wrong direction…
@@ivansemanco6976 Don't know if the Piper has enough Rudder and Vertical Stabilizer to overcome a full power engine turning into the dead / reduced power engine .
@@guitarhillbilly1482 Above Vmca yes but as low power twin we see how it behaves…
@@guitarhillbilly1482 Yes totally agree. Had a prop governor fail one time, that certainly caught my attention.
Thanks, it would be interesting to know how many casualties arise from training for single engine go around, vs the number that occur due to actual failures.
I can't think of the last time I heard of a genuine engine out crash compared to light twin simulated engine out deaths. It's crazy.
Some CFIs in the comments say that the method used here to simulate an engine failure is not a good one, as it increases drag. On real life scenarios you would feather the dead engine, so you will not have that drag. So I think it will be also interesting to learn what method has been used for those training flights that went wrong.
Many general aviation mechanics in Florida don't even make $20 per hour. How can you get a qualified and educated A&P to work for that?
In the last four to five years I’ve seen nothing but crap come out of FL. Not saying it’s all bad, but every plane I’ve inspected that’s come from FL has been a total s-show.
Would an annual not include checking the throttle linkages? 🤔
Thanks for what you do, Juan.
That's a good question. It sounds like that lever was loose all along but picked that moment to get so loose that it no longer moved the throttle. We need an A&P to say whether that connection is supposed to be inspected in a way that would have revealed the looseness. A solid day's work for Murphy either way.
Yes, it’s part of the annual inspection. I am a shop manager of a large flight school that works on PA44-180s.
An annual is only good for the time inspected. It passed then signed off but the next day = It doesn't last a year.
@@stacymcmahon453didn't juan read that the report said the teeth on the link were rounded over? It sounds like maybe that connection had been poor for a long time and had been getting ground down?
Having time in a Geronimo, if you have ANY ISSUES either practice or not and at an airport that is at 5000 feet you really have to be on your game to do anything other than stick it on the ground straight ahead….it becomes VERY SPORTY to deal with. At seal level you might have some options but i would guess very few.
The NTSB report page at 8mins said the last annual inspection was the day before the accident flight. Worth checking if work was done on the throttle linkage during preparation for the inspection. And why the inspection didn't find the loose linkage connection and maybe add that to future inspections.
Thank you Juan.
Sounds like a combination of holes in the swiss cheese all lined up perfectly. I would not be comfortable not knowing who had done the maintenance of any engine my life depended on in a general aviation plane.
Flying light twins is no joke.
Good analysis as usual Juan. Interesting conflict in either perception or reality of the rated private pilot multi-student, stating there was no engine power from either side on the 'GO' and the instructor pilot, she reported to tower OEI.
A old "rule of thumb" is a tire/wheel assembly extended has as much drag as the entire wing on same side..
Howdy sir, would you be able to do a video on The N1125A crash in Virginia? It happened around the time all the United flights had issues. You may be planning on a video when the final report comes out, but I would love to have your perspective on this accident. Thanks and I really appreciate the work you do! 🙌🏻
I’m still amazed at this video and then reading the comments that there’s almost nobody commenting or even asking or telling whether or not any of the propellers were found in the feathered position! It sure appears I’m the only one catching this! They wouldn’t stand a chance at making it if they were trying to fly with one windmilling.
👍🙂 Thank you Juan.
Incorrect mixture combined with incorrect or zero spark plug gap even on one or two cylinders says there’s not going to be correct combustion when needed. The fuel mixture can’t readily be ignited, therefore no power when requested.
- Maybe the valves springs were worn or clips or the piston(s) kissed the plug(s).
- Maybe the mechanic or whoever changed the plugs never gapped them or banged them near the holes before insertion.
- It could’ve been as it usually is, a Swiss Cheese combination of things.
Simulated zero thrust is a specific RPM (looks like it's 2180 in the Seminole). Idle would produce more drag than a feathered non spinning prop. We did the same thing when I got my multi many years ago in a Duchess.
I live very close to an airport with a very high amount of training aircraft, with several Seminoles that fly traffic patterns almost all day long, and it's a bit concerning. They're noisy too. And the engines sputter every now and then.
It's especially bad when it happens in the training environment. RIP
Hope the student uses his new second chance wisely.
Great report. Great man. Thank you Juan.
Thanks Roderick!
There is a Seminole circling above my city always at night and I have heard it up there in some pretty rough weather.
We just watched this video. Did we hear correctly, Annual Inspection 29 March, crash 30 March? Was this the first flight after an annual? Does it sound plausible that throttle/propeller/mixture controls had been disconnected and not properly reconnected, therefore the engine did not respond to throttle controls?
Brief the missed completely , call out configuration changes, right seater confirms.
Simulated single-engine is not throttle idle. That gives you drag from that idling prop. I don’t remember the setting for “zero thrust” on the Seminole.
Great job as usual. Thank you.
Questions for the aircraft mechanics: What do you think the condition of the sparkplugs in the right engine means?
As a former auto mechanic, the gap issues seem inconsistent with only 200hrs of operation. Opinions?
Aren't the plugs pulled to check compression during an annual?
The only way you have 0 gap is someone didn't look at some point. HOW it got that way.. that's also worrying as that usually indicates damage between the manufacturer and installation - somewhere along the chain.
Thanks for all the light twin details, warnings and recommendations. When I get to multi training I’ll know how to quiz my instructor
It seems like when things go wrong, it's always worse in a twin that it is and a single engine. I see so many reports on twin engine crashes that it makes me think that a single engine aircraft is much preferable and safer.
They actually are. The downside is that flight training to be a commercial pilot in the U.S. has this as a prerequisite, and most single engine planes are very slow and lack enough range. Not all, but many, and so there is also a drive to get a twin as then you can fly to the Bahamas or similar, where it's a headache in a small single. Yes, there are long-range fast singles, but 2-4 million for one is... yeah... not beginner budget friendly. But I'd still rather run a good single that I save up for versus the complexity of multiple engines - unless I had to for some reason.
The emergency was not necessarily to immediately land but rather to get control , stabilize , try to determine the situation, and if indicated feather , and then gentle maneuver for landing via checklists. If at all possible get straight and level not immediately initiate a turn. Declaring emergency allows you to do whatever is necessary. Engine out may mean engine stops but also applies to engine or prop malfunction which may lead to confusing behavior but require throttling back the bad engine. Full power on good engine straight ahead, clean up, blue-line, get control, stay calm, gentle gradual turns only to good side. Avoid sudden inputs or sudden maneuvering and keep it as simple as possible. This accident might have been avoided with more care calmness and finesse.
Hmmm… from the perspective of someone who tinkers with non-aviation mechanics, seems to me spark plug gap tends to increase with wear, and if I were to see one smashed or with no gap I’d be wondering if it shredded/spun a rod bearing allowing the piston to hit the plug (and head)?
The plug that had a closed-up gap was in the cylinder on which impact damage prevented the investigators establishing whether there was compression and valve train integrity.
I am completing multi in a seminole. Basically anything "long and complicated" in case of engine loss is above 500ft AGL. Everything else is stay on the runway, stay on the runway, brake and go for the trees, if left the runway and below Vmc, straight ahead clean the place and find place to land.
If single engine works, do all the necessary things (identify, verify, feather) and see if you have enough power to climb or maintain. No need for abrupt maneuvers in this case.
Even with my weight and the instructor's weight, only once the plane could not climb with one engine, in the summer with high density altitude (could still maintain altitude at full power, and safely above Vmc)
I was lucky to have a master train me Multi.. There was no simulation. We drilled engine off full feather and did a couple of dozen single engine landings and even a single engine approach/landing under the hood. RIP
I never use Champion plugs in ANYTHING as a result of 55 years of engine experience.
I wrenched on Harleys for decades and owned a shop for 10 years, and you're right, Champion plugs are terrible. Very easily fouled. I always use NGK.
I'll second that emotion.
Champion aircraft plugs are excellent if they are well cared for. I won't put them in my cars, though. NGK is usually my go-to brand.
So a dead throttle is the gremlin. The details are so important. When you're required to overhaul an aircraft engine by law, does the rest of the aircraft need to be inspected also? 🇨🇦
annually
You’re not required to overhaul the engines at all. If the engines cylinders make proper compression, no metal in the oil, etc., you’re good to go. However, it’s industry standard to overhaul those engines at 2200 hours
@@MrBe787 I would like to be on the jury, when lycoming says 2000 hrs and you know more than Lycoming
@@mpgofast obviously you missed the “industry standard” part of my comment. You just like to argue though, don’t you? Also, please read 14 CFR parts 43 and 91 and let me know where it says overhaul at 2000 hours or to use manufacturers recommendations. Also, if you watched the whole video, you would have heard that the overhauls weren’t due yet and that the throttle arm was found loose on the carburetor throttle shaft.
@@MrBe787 There are Lycoming SB that recommend hours, I went above 2000 hrs because we had a history of the engine to determine airworthiness and when to stop flying
l always hated being the first pilot to fly a plane immediately after an annual or 100 hr inspection. Lots of horror stories, including engine failure over the runway once. RIP to the instructor, and may the student find comfort. That had to be traumatic!
thanks
Amazing anyone made it out of that.