NTSB Final Report -Truckee Challenger Crash Circle to Land
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They knew things were a bit sketchy when they said “we don’t want to make the news”. Unfortunately, they made the news.
Yep, dad gum it, they thought they had it till they didn’t.
If the PIC would let the SIC have the plane would that have helped ?
Seems like it was the SIC who was mentally committed to getting on the runway despite a very unstable approach. He also likely activated the spoilers, which combined with the bank angle ultimately caused the plane to turn into a PSFO (Plane-Shaped Falling Object) @@unfaix
@zombieman9509 ah thanks for clarification, I was confused as to who was in charge.
Indeed, exactly!
Worked for the CHP in Truckee for 20 years... you have no idea how many plane crashes we went to at that airport.
If I am correctly interpreting the 4113 in your signature I can say this with confidence: A young boy is a theory and an old man is a fact. Well done.
California Highway Patrol? CHP? Disgusting tyrant 🤢🤮🤮🤮
@@RemingtonArmy-Wow‼️🫡
Overshooting?
What is the significance of the 4113?
This senseless accident is so very reminiscent of the fatal Lear 35 fatal circling accident at Aspen in 1991. It killed my twin brother. His final words to the other captain were “No! No! Your stall….(impact). The other captain had a known reputation as reported by first officers of flying very unstabilized mountain approaches. My twin, as director of ops chose to fly with the errant captain to provide remedial training and hoped to thwart his termination for incompetence. He found out first hand the truth expressed by the super scared first officers. As a staff instructor at SimuFlite, and a party to the investigation, I was allowed to make formal CRM presentations spotlighting my brothers accident and his last ditch effort to wrestle the controls from the PF captain and abandon the highly unstabilized circling approach. History does repeat itself but at least we do get better with tombstone engineering! Great work as always Juan.
I am so sorry for the loss of your twin brother. Thank you for sharing.
Get over it.
@@rudybishop9089 shut up Mason.
I’m sorry for your loss, even all these years later. In a way loss gets better with time, but in another way it gets harder. I hope you’re having a great life, just sorry you’re not having it with your twin brother still here on earth.
@@rudybishop9089well aren’t you a nasty little piece of work!!!!! 🙄🙄🙄🙄🙄🙄🙄🙄
Didn’t realize they had initially planned and had been cleared for the straight-in to 11. The most powerful word the pilots didn’t use was simply, “Unable,” when ATC gave them the new approach. They forgot that, as pilots in command, we decide where the aircraft is going, and ATC’s job is to make that happen safely and in coordination with other traffic. They might have had to spend a few minutes holding, but that would have been nothing compared to this tragic outcome.
My precise thought also. On approaches like this and in an aircraft like this, you don't want to change horses (approaches) in the middle of the stream.
@@DrJohn493 and in visibility conditions they had.
Did a straight in on 29 the day before in a 310. That was quite a decent coming over the top. Barely VFR because of the smoke. Looks like the role of PIC was not firmly established.
I was in Truckee at the time of this event. Being from SoCal I am familiar with wildfire smoke, and this day was an extreme in smoke and low visibility.
Well it shows the impact of not following procedure. Truly boggles the mind how two experienced pilots can get themselves in such a mess.
Well, they were certainly experienced - but not as a crew together! Juan described the 'inverted command gradient' very well.
Thanks Juan for another excellent accident analysis!
Pilots are, quite rightly, taught to operate aircraft in a rigorous and disciplined manner. One of the consequences of this approach is that they may not know how things look and feel when they are in trouble and therefore they may not be quick to recognise and react to danger. I know *exactly* how it feels to take the fast left hand bend on the local main road too fast because I have done it several times, but I have no experience of anything equivalent in an aircraft, or even in a simulator. I can't help wondering whether professional pilot training should include the opportunity to do it badly wrong in a simulator.
It's not mind boggling when you look at the bigger picture: it's during covid, very likely these pilots were suffering the economic impacts thereof. They just got hired by a new startup company with pressure to get this new plane chartered and in their fleet, and the primary investors are in the back. In their minds they're perhaps thinking "If I go around the man and his wife are going to wonder if I'm competent to fly for them"
@@mcpr5971 It still boggles my mind regardless.
That's really not everything. I mean, there was a stall warning. How can two pilots ignore a stall warning and initiate a TOGA plus go around, plus cleaning up the airplane, in such a situation? I don't get it.
Has there been a history of those pilots flying regularly right to the edge of a stall - so they get the stall warning all the time or what's the cause for that?
Excellent report Juan. For the life of me I do NOT understand why these two guys got themselves into this mess. Too high, too fast, 100 miles behind that airplane, all they had to do was abandon that approach, go around, get organized, get out in front of that thing and stabilize the approach. If they had, they and their passengers would be alive today. Tragic.
My thoughts exactly.
Exactly. Pride got the best of them. If I would've been sic on that flight I would've looked at the pic and said, "I don't like this at all, we are rushed and behind this airplane, let's just go around, we all want to live to see tomorrow".
It’s such a sad loss. The cockpit seemed so chaotic.
John Dunn was my dads next door neighbor. He was a super nice guy that would give you the shirt off his back and was a wonderful dad and husband. A huge loss.
Who was John Dunn? I’m guessing the SIC?
@@OMG_No_Way John Dunn Dallas, TX from what I found in his obituary - Rainer Capital, a commercial real estate investment firm, is this a SIC ? I'm a former Architect lived in Sacramento, CA 33 years ago, with an interest in this crash. 1st officer & another passenger from Minnesota
I've known a lot of dunns. Every one has been a pretty solid person
Dunn was a passenger. NOT one of the pilots!
This wasn’t a medical flight , you might be thinking of the Lear jet crash .
Thank you very much for this video. I am just a humble low hour PPL guy, but I ended up in a high, overshot situation on my 3rd solo, but thankfully my instructor's and your words echoed in my mind, so I went around. Thanks to my instructor (and you), I was relaxed on downwind, because I knew I made a mistake, but it was corrected, so I had whole new chance to make a perfect landing.
Good for you and also your instructor!! If things don’t look right on landing go around, regroup, and try it again. Safety first, always!
Nice
Good on you. I have a little bit of float plane flying experience and there's a passage in the book, "Flying A Floatplane" by Marin Faure that says that there is no shame in going around as many times as you need to make sure you are going to have a safe landing. He goes on to say that the safest place for your airplane is in the air, aside from perhaps a hanger, so take your time in doing a safe landing.
This is good news. Juan out here, saving lives. Safe landings my friend!
Every approach is a go around with an option to land.
Circling to land in low vis especially at night is down right dangerous. I flew freight in a Seneca II. I had to land at night at airport that often required circling to land. The approach was to runway often not favorable to winds. At night and low visibility you lost airport in the turn for a moment and there was no ground references....
Pasquale! This is a very similar accident to the Lear 35 in Teterboro. Besides operational lessons learned, there is a lesson for charter management and customers. Management needs to know what they are doing, in this case, like the approach, it was rushed and shoddy. The lesson for customers (I know it was customer investors onboard) is to thoroughly evaluate a charter company’s reputation. The airlines are sucking up every possible eligible pilot. I would not set foot on a charter aircraft in these times.
"We don't want to make the news". Hauntingly prophetic.
These poor dudes were a hot mess according to that transcript
Slick folks trying to focus on money. Got out over their skis
Juan, great breakdown as usual. I fly SP on an Ultra, I have to do a circle to land often at home airport but, it’s usually the reciprocal RWY. It is very challenging indeed. Sometimes you just have to go wings level, exit the area and regain your thoughts. Sad event for sure..
They literally said "we don't want to be news". This should've been a clear red flag they had broken down (poor resource management) and they should go around and reorganize themselves. There was such unprofessionalism between themselves and the task at hand... They are fortunate no one else was hurt, a school bus was missed by seconds... GetThereitis...
There were four passengers on the flight who lost their lives.
Go around----seemingly the two hardest words for crews in trouble to conceptualize.
I loved that you quoted Tom Pasquale’s! Heard it many times at AA recurrent training. Never fell asleep, during his class.
One of my favorite sayings is “successful outcomes can reinforce bad habits.” When I see actions like those in this crash I wonder how many times these pilots took risks, cut corners, just winged it and survived. Those habits sometimes catch up with you.
“Normalisation of deviance.”
@@nickboylen6873 Indeed, exactly.
And that can certainly be applied well beyond the aviation world. From driving a vehicle to even making poor short term business decisions that one can get away with...until one day it comes to bite you in the ass.
Complacency
@@Nfarce Yes, indeed.
One thing that I can't get out of my head, and the NTSB can't really weight on that aspect, is the mindset of the pilot. A new hire on his first flight with the company, having a major investor of said company as a passenger, without having a proper visa to go fly commercially.
Is it possible that being stressed out of you mind because you don't want to fuck up your new job put you in a "land at all cost" mindset?
The SIC trying to cool down the PIC seem to indicate a high level of stress.
Thanks for your very detailed analysis Juan. Have to tell you that I find this incident very troubling and it was difficult for me to listen when you read the CVR transcript. I'm not sure that I would really classify this as an "accident" as there was so much wrong with the operation, pilot hiring, and aircraft operation. As you said, there were MANY holes is this cheese! Reminds me a bit of the Learjet crash years ago at KTEB. I'm amazed at how so called professional pilots can not see these errors adding up, and not make the decision to go around and regroup. I know we're all human, and humans make mistakes, but this was totally uncalled for.
You're right about circling approaches. Very demanding, and I think too many chances to make mistakes. In the Sim we tend to practice our circles at relatively large airports such as KMEM, KJFK, or KICT, where there is plenty of room and flat terrain. With so many new GPS approaches to so many runways I think the need to circle anymore is greatly diminished. At my company night circling approaches were not allowed, but we were able to do them during the day. We flew into KTEB a lot, and for much of that time it was quite normal to shoot the ILS Rwy 06, circle to land Rwy 01 or 19. That changed somewhat when they got an ILS to Rwy 19.
Have been following the Mig-23 accident on your channel as well as a few others, and there seem to be a lot of "armchair pilots" commenting about it. I guess everyone is entitled to their opinion, but some of the commits are ridiculous and very uninformed!
Thank you again for your level headed, expert analysis Juan-it's always appreciated and extremely valuable! Always enjoy your videos from Australia. I spent many months there doing aerial photography in a Learjet 36 in 2015-2018, and love the country and its people. Take care...
My impression was while listening to Juan reading the CVR transcript: Only Holes, no Cheese.
Excellent walk through of the NTSB docket....you are without peer in this space. Again, thank you for your analysis and explanation.
I fly a CRJ, similar to the challenger. Flaps 45, with spoilers and gear is too much drag to overcome. The airline I fly for we are not allowed to use spoilers at flap 45 setting for this reason.
These two pilots were probably far more efficient individually. In this case, imho, they inadvertently got their antlers locked together. Flying the plane diminished as they worked communicating with each other. It seems that the SIC saw this coming well before it actually happened. His remark about not wanting to be in the news breaks your heart. The loss of those pilots and passengers seems so unlikely given the vast experience sitting in the cockpit.
Not a pilot. But something stuck with me that Juan said couple years ago. Aviate. Navigate. Communicate. Sounds like this broke down in the cockpit.
Wise old journeyman electrician old me early on. When things go bad back off, reexamine, get back to a simplified plan and reattempt.
This is great advice in so many different realms of life. Sometimes just backing off, taking a minute to clear your head and rethinking your plan makes such a world of difference.
Flight spoilers deployed on final, the final slice of cheese.
The amygdala can cause bad decision making.
If you feel rushed, recognise and breathe. Don’t push on. Hold, slow down or go around.
An extra ten minutes is not as long as eternity.
They tried to salvage a badly executed and poorly understood approach. Big mistake. I don't understand why they didn't just go "missed approach" and buy themselves a little breathing time to get much better situated.
Especially since one of them verbalizes that they "don't want to make the news". They knew it was sketchy, yet continued on anyway. Not enough patience and too much poor decision making.
Yeah, the Captain seemed to have get-there-itis and wasn't going to call missed approach (though, clearly should've) and the FO seemed to realize they were in trouble but didn't feel comfortable/confident in calling it? It's strange to me. There but for the grace of God go I... and I hope I never get stuck in that tunnel vision.
As a side note here, CRM should be pushed in other fields, particularly Nursing/Medical. I'm yet another non pilot who lurks on this channel, but so easy to understand your explanations. Bravo Mr blanco.
What is CRM ? people can't talk any more with full sentences no wonder there is confusion
@@funcisco1504 Crew resource management. Basically divvying up responsibility. Who is doing what and when. Also, while I share your frustration with acronyms, CRM is a very common one in aviation and your snark was unwarranted.
I have a few friends working in the operating room who have described to me their attempts to implement CRM, briefings, and checklists. It sounds like they’re making an effort to implement CRM/TEM at least at their hospital.
Gotta love that Mr. BLANCO, which means
"White", when his real name is Browne!!!
O.k., just a little irony!
But it was a great report .
@@richwightman3044 Sometimes just a sharpie mark on the right or left side makes all the difference to prevent cutting off the wrong leg.
I watch most videos, especially if I hear of a crash. So informative. It takes a special repetitive mindset to fly, is what I've learned, Not a pilot, but admire and respect all pilots. Stay safe.
if we keep watching this channel we will never become pilots LOL
I am a retired IT guy, operations. I spent 40 years troubleshooting problems and operating equipment. And that ground-based hectic environment I learned to do things in the right order and try to avoid getting cute. You try to be cute and do too much at once you end up with egg on your face.
My instructor told me "flying is boring, there is a right way, and that's the only way, so you do it the same every time, you don't just make it up as you go along"
@@JohnRodriguesPhotographer I was a recording engineer and later also developed and managed large software applications and both were very much like flying, although safer, except for careers. When you get bored or tired and hotdog it, or succumb to an impatient client even when you've lost situational awareness, hoping for the lucky outcome, disaster recovery is inevitable, to whatever degree possible (same for those who won't test). But in the air, lives are lost, tragically. But up there or down here, you can *always* go around. My admiration for those who not only pilot, but also develop software for aviation and spaceflight, and take responsibility for lives, which I could never do. At the end of a hard day, I could always get a grip by saying, "At least it's not life or death. No one died." I can't imagine otherwise.
@@gasdiveI think this mindset can cause more accidents. It makes you think "I'd never do that, that would never happen to me," but we are all human and there are gray areas and times with external pressures, which is why even the best pilots can get into trouble. Flying requires humility and good decision-making as much as skill and experience.
As a PIC on the Bombardier CRJ 200 , and 700, an international IP on the CRJ 200 in 5 different countries, an IP in sims on the 200, 700, and 900, and last an IP on the Challenger 604, I had one rule as regards the flight spoilers. If you deploy the spoilers you may not take your hand off the handle until you have stowed them back in- period, dot. Unsats were more than a few for this but I trust they learned the lesson. Needless to say this was a huge contributing factor and a needless loss of control.
PPL and even above.. A LOT of your content should be added to the curriculum... ala. Mandatory watching / reading... I've learned a LOT of things outside of general training by way of you.
Neither one of them ever even consider "should we just go around?" 😞
Well done explanation as usual. Flight crew was new to working together, PIC had limited experience in the make/model, first time in this plane & facing bad viz. Circumstances where pre-planning the landing was especially critical & unfortunately lacking.
CVR at 0:59 seconds before impact (FO): “We don’t want to be on the news.” Horrible breakdown of CRM/SA
14:32 - I was fortunate to listen in on several senior pilots discussing this tragic incident, They mostly attributed the short turns to the pilots rushing. I don't think they had the transcripts at the time. But hearing your explanation about why these pilots may jave been compelled to make such tight turns makes a lot of sense. Man, it seems like they had so many things going against them. RIP
The tight loop caused the problem. They should have been far further out, giving themselves time to descend to their minimums at the correct speed, before entering a long glideslope.
In this situation, minor horizontal moves to align with the centerline of the runway are easy, but trying to do everything at the same time is dangerous and likely to fail.
What I don't understand about this, is the fact they didn't abort and try again. I know it's easy from an armchair, but it's clear the approach "got away from them". Such a shame lives were lost here.
It's wonderful how you explain these things, I've learned SO much! Thank you Juan!
As a GA pilot with complex airplanes I can attest to “oh I can fix this” rather than going around. Sometimes it’s an overconfidence of skills or the situation at hand.
This is why you brief your departure and arrival (and should do so even in a small & simple GA aircraft, and even when flying solo). By verbalizing your plan in an emergency, you mentally plant the seed for the option, and give yourself a chance at being able to select the option during the fleeting moment when it becomes available/necessary.
After earning their licenses, most Pilots (and I say this as a pilot) are not generally in the habit of practicing go-arounds or missed approaches - unless its for a BFR or a check-flight. So we're not generally thinking through these options and aren't mentally "spring-loaded" to put them into action.
@@kaimoenck3154yep! you can fix a lot of bad approaches when you have 5 times the required runway. But take that mentality into a bigger plane and you got a problem.
EGO.
Another factor many people don't consider, especially those who aren't pilots (and even some who are single engine GA pilots), is how fast everything is happening in a plane like this that's moving at almost 200mph. You don't have the luxury of covering this distance at 70mph like you would in a car.
An awkward dynamic between the pilots for sure that we typically don’t see at the airlines. Good analysis, Juan. RIP.
They had plenty of time to get this right. Poor coordination between the two pilots. Such a shame. Thank You Juan for this excellent but sad report. Best Regards
I personally think this type of approach should be banned. Hightened performance anxiety from crews operating small charter airlines under high pressure
Sounds like this partnership was a shitshow from the beginning
sounds like they were both fighting each other on the controls the final minute of the flight..
Completely salvageable with a go-around.
Tragic!
It sounds like a company that was run by children, for a childish purpose. Not to run a good company, but to just build it up and make it appear valuable so it could be sold on
You just described our government
I was on highway 80 and witnessed this crash. The plane flew right over the highway over me and just went down into the trees seconds later. Sad day!
Sorry you had to witness that - especially while driving.
I can tell you who was in control of the aircraft at the end of the flight. Sir Issac Newton.
Gravity…it’s the law!
With Darwin as his FO
Well, at the end, we know it wasn't Bernoulli.
I'm working on my PPL right now and have watched several of your videos and they are always so informative and thorough. It amazes me how many pilots with thousands of hours make simple mistakes such as failing to prepare and study their arrival airport to make sure the facilities are adequate for their arrival. This whole accident could have been avoided if either pilot took the time preflight to check their scheduled arrival airport and noticed the obvious fact that one of the runways was too short for their aircraft. This is one of the first steps I've been taught when planning a cross country flight. Study your arriving airport, and plan one or two backup airports in case of unacceptable conditions at your primary airport. Constant reminder that in aviation, no matter how experienced you are, it's often the little things like this that are easy to overlook and can have catastrophic consequences. It's like you always say... never put yourself at a disadvantage in the cockpit.
You did a great job on this Juan, thank you. Accidents like this are terrible, but your work goes a long way in helping all of us learn from other’s mistakes and making us safer pilots.
There's a YT channel called Approach and Departure Videos. I always like to watch/listen to the briefing the Captain and FO go through and how thorough their process is. Sadly this situation was the opposite it seems.
Superb Channel he's an utter Professional and Everything a great Captain Embodies.
I hate that airport
Never wanted to go in there
My goodness, that CVR transcript was absolutely horrible to hear. That whole event was a nightmare of disfunctional flying, poor communication, lack of procedures and absolutely abysmal cockpit resource management.
If we operated like that in the airlines, there would be major crashes around the world every day.
It sounds like the crash started with engine start. The crew was never on the same page and completely out of phase with each other.
The captain Alberto, was my neighbor and very good friend , i flew with him many times on challengers 600 , 601, 604 and 605. He was very experienced flying challengers with over 17 years of experience on the aircraft. He left behind a 3 year old baby girl. Alberto was a super nice guy.
Absolutely best channel on TH-cam. Thank you Juan your videos are always respectful and factual. Tremendous value in your reports.
Former US Navy Aircrew coordination instructor.
@blancoliri0-- yes sir?
@@charliemike5813 That's not an official account of this channel, it's a spam bot. Just click on the Report toggle (the three vertical dots on the right of the comment).
I don't understand why they didn't know the original runway was to short. Seems to me they should have known before even taking off.
Yes, that is strange. Shows a lack of good preflight planning. Could have also looked at the chart while enroute.
That's not correct. Watch the video again. They were all planned up for a straight in approach to a landing on the long runway, 11. Then ATC told them to use Rwy 20 instead. That runway was too short, so the PM (right seat) said they would need to circle to land on 11 from the 20 approach. The PF (left seat) did seem not to know that Rwy 20 was too short. Probably bec he was new to Truckee and newish to the aircraft type. But they should have briefed this beforehand. Another imperfection that day.
For a couple pilots with a lot of hours, they sounded horribly overwhelmed, how come they hadn’t looked at their charts way I had of time for runway length, and on top of that the chaotic way that they dealt with each other just sad as heck to listen to this
The charts had been hacked by communist rebels just hours before their flight. As to the seeming lack of synergy and grasp of the severity of the position they put themselves in, it's been surmised by pentagon offcials that either one, or both, of the pilots may have been covert lizard people.
Alot of work in this video, thanks again and a very interesting turn of events leading into this crash. I lived very close to the crash site and rode snowmobiles in the mountains there very tricky terrain to navigate,
Seems the copilot sensed the pilot’s apprehension and tried to calm him but in the end it all went to hell.
The CVR is more sad than anything else....
The critical element in this case was the auto throttle automation, IMO. The surprise came when the auto throttle was turned off and the confusion of it being turned back in or remaining off. You would think that with two experienced pilots, before the crash, one or both would revert to basic stick and rudder skills and execute the fundamental actions of, power up, pitch up, clean up, and speak up. Even if they were still going to try and save the botched approach and not go around, you would think that one or both would have done the obvious and fly the damn airplane no matter what decision about the approach was made. To me, this was a case of one pilot deciding to shed all automation and fly the plane like a skilled pilot with basic hands on controls of stick and rudder, pitch and power and another pilot who wanted to fly with some combination of automation along with basic flying controls. Poor power management due to confusion of the levels of automation. Here we have two pilots with two almost completely different plans competing for control of the aircraft. Of course,, the flying pilot's plan is going to fail if the non flying pilot is not doing what is being commanded and is doing things not being commanded at various times. The plan should be what the flying pilot wants until the PIC either takes over completely or a new plan is improvised and agreed upon. Basic CRM always includes "a positive exchange of controls" and that may include total control. Confusion in the cockpit is a killer. Plan your flight and fly your plan and recognize when your plan has to be scrapped. The PIC failed to take significant enough control to prevent this crash unfortunately.
"At the first , second, third sign of confusion "GO AROUND " should have been commanded by either pilot.
As usual, excellent report. Incomprehensible. I can see your pain and disgust. Sorta reminds me of Colgan style errors. I've flown in and out of Truckee at least a dozen times. It's a legit bowl surrounded by high terrain. A lovely airport but challenging. There are few exit options for the poorly planned mission. Planning in and out of there has to be very precise and certain. Very sad to see this level of airmanship. So unfortunate, RIP.
My first circle-to-land at minimums taught me two things: I don't like circle-to-land approaches, and I don't like minimums.
Yes. And yes.
I work hard to never stack the deck against myself, not even a little bit, let alone in a do-or-die type scenario. Very sad.
Amen
another video to put me on the edge of my seat!
My instrument instructor once told me if you only remember one FAR for the oral, memorize 91.175 (1) says... the aircraft is "continuously" in a position from which a decent to landing can be made at a normal rate of descent using normal maneuvers. When I was in the middle of hacking up my first circle to land, he asked me if there was any FAR's that could help, and after thinking for a 3 Mississippi, I scrubbed the approach and asked to be resequenced. My point is there doesn't seem to be any part "continuously normal" and as Juan said the inverse cockpit hierarchy delayed the decision making one second too late. So sad. Thanks Juan for putting the time in to very comprehensive explanations that help all of us.
I knew and worked with the first officer of this flight for many years, he was an incredible guy and will be missed by many.
RIP
I’m always curious what type of hours these pilots with thousands and thousands of hours have. Hours flying day, VFR or IFR on simple profiles where they are not challenged or challenging themselves to get better… Empty calorie hours if you will. Do you think there is something to be said for quality hours vs just having a lot of empty hours. At the first sign of trouble these aviators are making really strange decisions due to a lack of experience.
Thoughts?
I also wonder about that, because it the experience they had sure didn't show well here. It is also clear they didn't know this aircraft well
I agree. Perhaps they were never challenged with IROP situations.
Sometimes these high-hour pilots remind me of the phrase, “Forty years of experience, or one year of experience 40 times?”
@@PeopleAlreadyDidThis agree
Lots of lofty career plans interfering with physics and logistics.
Been very quiet on the FAA/OEM/ATO side of the house since this report was released…Time will tell though, because this was a classic human error chain that resulted in the accident, and not just the crew…
Very nicely done. So easy to see from here, now. So many stupid decisions, made worse by the cockpit dynamics and desire to "make it work". I have seen this a lot in my career. Fortunately, most of that was in a 121 cockpit where we were armed with SIGNIFICANT guard rails in terms of GOOD SOP's and techniques to recognize, minimize, and mitigate mistakes. Now that I am flying 135, it's like starting all over as I am often paired with very low-time and inexperienced FO's who do not have the luxury of all the training I received in the 121 world. None of us are born to fly. We have to keep working at it. Complacency is a killer. Get home itis is a killer. This video will help someone, somewhere, someday.
They were technically cat C and legal in that sense at full flaps (45). A couple of things on that.
-OEM procedure for circling in this Type is flaps 30, a ref+17, Flaps 45 leaving MDA. In must cases that places approach speed just in Cat D.
-I am not aware of an OEM procedure that allows circling at flaps 45, however some certified operators have an approved procedure for circling at flaps 45 Vref+10. It is in fact, the better way to fly the maneuver all be it not technically legal in most operations.
Still the approach speed in the flaps 45 configuration will place you squarely into CAT C.
There are two things I think the FAA could do to help with issues in Circling.
One is to relax the requirements for training circling approaches in 142 training organizations. Currently there are very strict rules that dictate what airports can be used to train and check a circling maneuver in a simulator. Due to this if you get a type rating from FSI your circle was done at MEM or JFK with very few exceptions. Not Sure about CAE but I am sure it is similar.
Better than that would be a more diligent push to expand RNP AR capabilities. Airports like this need RNP AR approaches and there needs to be reasonable access to the training for operations that are too small to have a custom approved training program that includes it.
Currently the AR portion of the RNP A is a unicorn for most operations. It really should just be included as an FSB item for aircraft that are capable which would mean that every type rated pilot is capable.
Juan's remark about visibility in smokey conditions is absolutely on point..especially here on the westcoast of the US. The ASOS/AWOS measure water droplets in the air & not the smoke particles..so the systems can report a P6SM visibility but in actuality: it maybe lower than 3 SM in smoke. One must be very vigilant in accepting visual approach clearances at night in smokey conditions & terrain..let alone a circle to land one. However, that was just one of many aspects of this accident. Clearly, the flight crew member roles were not-defined on this flight or at the enterprise.
Sounds like a Text book illustration of cascading incompetence that may prove ultimately useful for educating pilots. Thousands of hours merely often serve to inculcate (terminal) complacency.
Very sad ending Juan,dunno mate it great you reporting these incidences but it must be draining on you ,safe flying,take care from ballarat in Oz,🙏🙏👋👋👍🇦🇺
Right out of the gate, where were the heads of the pilots when they began an instrument approach on runway 2-0 which was too short for them to land on?
Well explained Juan.
I’m very familiar with the characteristics and indications of stall on the Challenger.
This tragedy was textbook ‘Swiss cheese’.
You are quite correct in the command gradient of the Captain and FO.
After retiring from my job in aircraft manufacturing, I joined a major airline as a retirement gig.
I was that high time FO flying with very young Captains.
After our day one pairing brief, I would pull the young Captains aside to remind them that they’re the In Command and the decision makers. Admittedly, some felt a little intimidated at first, but settled right in afterwards.
@@baaa4698I don't know if you are in the industry and if so your experience level, so excuse me if this is something you already know and you were asking for other reasons, but I was that low time captain occasionally flying with more experienced first officers early in my career. I did fly with some that would do exactly this, where they make it clear that I was the pilot in command. I always appreciated it because when there is an unbalanced crew like this, it can be intimidating being the less experienced captain. There is always a bit of time to fly together to feel out the dynamics between the two crew members.
Is the more experienced first officer going to push his experience level aggressively and try to act as pseudo captain from the right seat?
How do I command this crew dynamic as a less experienced captain so as to be in charge, but not feel like a phony?
So, senior first officers that had significantly more experience than me that would set the ground rules right away on the first day like this person did really helped me in those times. They would make it clear that even though they were more experienced than me, I was pilot in command. Then I would reply to them that I value their experience and am open to learning if they had suggestions. This put me at ease, that they respected my position as captain, and we could work together as an effective team. Another reason this was helpful, because unfortunately it didn't always work that smoothly in these types of situations, hence the appreciation for this type of preflight communication. There definitely were pilots in that scenario where the first officer with the greater experience didn't respect the captain's position. In these situations there tended to be two people, both working like they are in charge and a "too many cooks in the kitchen" situation would occur. Both pilots worked independently in their side of the flight deck, with very little communication, and the crew resource management would start to break down.
@@baaa4698superiority complex
@@baaa4698 what @flyinfella said.
Exactly, a ship can’t have two captains. Well, it can… at the bottom of the ocean.
I think the biggest mistake they made was not looking at the airport diagram, and therefore the runway lengths, before they ever left the ground. They would have never started the approach to the short runway. Problem solved.
Exactly what I was thinking. That flight planning was deficient.
Maybe I’m the one confused but 1) it sounded like 11 was their initial destination runway until Oakland tower confused them and told them 20 was clear. 2) the PIC said that 20 was too short to land on indicating he had examined the diagram and runway lengths prior to departure. 3) they came to an agreement of sorts to go for 11 the longer runway 4) the issues were numerous but they were too high and two fast and flying VFR in IFR conditions. Unfamiliar with each other, that plane, that airport. And possibly even language barriers, etc.
Are pilots just physically incapable of acknowledging that a situation has gotten away from them, and that a complete reset is necessary? After watching so many of these videos, I don't know that I'd even accept a ride on a corporate jet if it was offered to me. RIP the 4 souls in the back who likely had no idea of the s#$tshow going on up front.
“Truckee” is such a funny name in my opinion. Just sayin.’
I have no sympathy for someone starting companies with no intention to maintain them.
I have a huge amount of sympathy for the non-pilot victims.
Thanks for the matter of fact reporting.
I'm just a private pilot single engine rating, so I appreciate your expertise in this assessment.
Be safe. There are old pilots and the bold pilots. There are very few old and bold pilots.
Juan excellent analysis as always Sir - but - one minor point that frequently gets overlooked in analyzing a circling approach... Prevailing visibility is reported in statute miles, which if using DME (which uses nautical miles) would lessen the arc of visibility on the approach to a 2.6nm ring, which is less than the 3 mile arc depicted on your overhead diagram at 15:00. But again, just a minor correction and no one else does such an amzing job keep up the good work!
At some point I was hoping to hear a clear and concise “my controls” also looks like somebody didn’t keep their hand on that speed brake lever plus it couldn’t have been armed and should have by this point…
Possibly more mission focused than safety focused. A lot of that may have come from company management that doesn’t like to be told NO. Sometimes pilots forget that the “mission” is to get the plane and pax on the ground SAFELY, not just get there. You have to be able to say NO. Go around, climb out, get some altitude and take some time to talk about it. There was no real Pilot in Command of this aircraft. I’ve been to Truckee many times. It’s interesting even on good wx days.
This is the classic path to disaster called: "Links in the Chain to Disaster". Had they stopped at any "link" they were "forging" before the last link, thecrash would not have occurred. CRM nees to recognize, even verbalize: "That's link 1" such as when the Captain said: "Rnway's to short. CANNOT accept an approach to it!". Crew responds: "Link 1" It could be called "Link 2" because nobody in marginal conditions should be doing a "Circle" when a straight in is available!
i feel like neither of them bothered to read any of the charts for that airport before or during the flight otherwise they would of known that runway was too short already and they were just flying by the seat of their pants. the circle approach they took being so wrong or not knowing where the holding pattern point was seems like more evidence toward that and thus probably never knew there was a straight approach available to that runway.
Flying by the seat of one's pants in 2021. Apparently didn't look at the flight before flying it. The planned approach and divert should have been briefed before takeoff when it would have been noticed that circling was not authorized and that one runway was too short. So many accidents could have not happened with a little of what the military calls "mission planning".
"you have plenty of time..." Um, no you don't.
The quantity and variety of information that I have learned from you is incredible. Your explanation of what went wrong here was an incredibly informative, sad but perfectly presented synopsis. I truly appreciate your work.
Thank you. .
Beautiful analysis and cogent presentation. Thank you.
Thanks Juan. I learn so much every time I watch your content.
As soon as I saw the SIC’s hours I thought of the cockpit authority gradient that could have played a role in the challenges leading up to the accident.
Right seat was most likely evaluating the left seat, as he was a new hire with less overall experience, new to the aircraft type, and a foreign national to boot. It happens all the time. As Juan said, when things get sideways, whoever has a better handle on it needs to take over with clarity and purpose. It's just not completely clear in this case that either one of these pilots was going to do the right thing here---level the wings, apply high power, clean up the plane, and execute a missed approach. Poor CRM got them into a very bad place---low and slow, very dirty with gear, flaps, and spoilers all out, and trying to horse the plane back to a runway they had well overshot---but even the right seater was still talking about trying to salvage the approach up to the very end, not talking about getting the hell out of there and regrouping, as they should have.
@@DerekJohnson-us7vy Indeed, exactly!
Glad I didn't try to pursue a professional flying career... & instead ended up landing a good job at Boeing and being able to continue my involvement and enjoyment of aviation (& some awesome CAD/CAM technology in a manufacturing organization). Hats off to the professional pilots that work in this challenging environment. thanks for sharing, gracias
just actually stunning,,, they got themselves boxed in, sad for the trusting folks along for the ride.. thanks juan
Swiss cheese? That whole sequence was so full of holes, there was no room for cheese! Sooo many times they could have simply gone around and set up again with positive results.😢
I was struck by the Nervous wordy Chatter between the two. Unusual. Was wondering what was up with that.
Probably the poor visibility, vertical terrain, and unfamiliar airport. They failed to flight plan; the were on approach and realized the runway was too short.
Interesting report, similar but to as bad as the pilots of the Teterboro, circle to land Learjet crash, but a case where the pilots seemed rushed, and behind the aircraft
I also thought about the Learjet crash at El Cajon, CA Gillespie Field circle to land crash at night.
@@jimb3093Yes, very similar.
I think the Teerboro crash had even less professionalism but it was close
The Teterboro guys were MILES behind that airplane before it ever left the ground at its departure airport…
And, those two were little more than warm bodies occupying a seat, that whole operation was a sad mess…
@@dwaynemcallister7231 Yes,
terrible CRM and professionalism, especially by the left seater. I won’t even call him pilot in command, because he was not in command of anything. Feel bad for the right seater-he asked several times for the left seater to take over, but he refused!😢 Just sad…
I appreciate how you read the transcript. It helps everyone understand what happened.
Juan,
Thanks for deciphering this report. My daughter is a corporate pilot that has flown mid and wide body jets. I share your videos with her all the time. As you can appreciate that all pilots can learn by others mistakes. I believe you are helping everyone when sharing your point of view. Thanks for the work you do!!!
Go arounds are free. I just don’t get it.
I noticed on the Flight Simulator that I crashed more often when trying to land with an unstable approach. Sometimes you can save it, sometimes you can’t. My conclusion-always setup and fly a stable approach. Especially in jets.
Outstanding report Juan. Lot's of material to move through. A tragic ending to a very confused situation.