Accident Case Study: High Aspirations
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- เผยแพร่เมื่อ 23 ส.ค. 2023
- On a hot summer afternoon, July 25, 2020, the pilot of N7677C-a normally aspirated Piper PA 32 Cherokee Lance - gets ready to depart South Valley Regional Airport, a small nontowered airport just southwest of Salt Lake City, Utah. The pilot has planned a cross-country flight to Page, Arizona, and then a sightseeing flight over the Grand Canyon - a treat to cap his family’s Utah vacation.
Join the AOPA Air Safety Institute as we examine the circumstances that led to the tragic outcome of the flight just minutes after takeoff. We look at factors that would affect the flight, including high-density altitude conditions.
ASI’s Accident Case Studies seek to share critical lessons to make us all safer pilots.
Apply credit to your ASI transcript for watching this video: bit.ly/ACSHighAspirationCert
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This is a tough one, as I think many pilots could see themselves in this position. It's easy to brush off the accident reports where the pilot does something grossly illegal or dumb and say we would never do that. In this case, the plane wasn't overweight and wasn't out of CG. The book said the takeoff could be done. Took the runway that aligned with the most recent wind report. Considered effect of density altitude on mixture setting (though perhaps too late). No single decision/mistake on its own was enough to cause this accident. It was the classic aligning of holes in the swiss cheese, where multiple small errors combine to make a huge one. Very sad and a good lesson for us all. Thanks ASI!!!
I couldn't agree more. This is really not a good example of pilot error. Obviously a conscientious pilot, followed all of the regulations, and was not outside of the envelope in any way. I'm sure that if he took off Against the Wind he would not have had a problem. And we all know the wind can shift whenever the wind wants to shift. He could have checked wind direction 5 seconds before takeoff and the wind still could have shifted. This is what has always made me nervous about flying. Even doing everything right is not a guarantee of safety.
Still would argue that it is a failure of regulatory bodies to allow planes to be certified with poh that seem to have almost nothing to do with reality… a 50% margin of safety on certified poh numbers? The margin of safety should be published in the poh at least no one would ever have an accident because their normal flying aircraft didn’t meet those numbers…
Absolutely agree. The numbers said it could be done. I cannot comfortably say that I wouldn’t have attempted the flight myself if I had been in the situation.
Planes have one job - maybe the Piper aircraft company would prefer it if you used their performance product with half a tank and seats empty
@@jfmrod It would be hard for manufacturer to estimate how much someone's engine or airfoil would degradation based on their use case, let along what's your habit on the yoke which also would affect the performance.
In airline there are now performance monitoring program for each individual airframe, I wonder if it could be done with GA as many people already have some sort of computer device around.
Always leaves a pit in my stomach when a pilots family and/or other families are on board.
Me too. I'm just happy _someone_ survived this one, most of these stories they all die.
@murrethmedia I agree. My heart aches for the little girl in the back especially. Lost her mother, and the fact that she remembers how the pilot struggled with a lever tells me this is burned into her mind. Tragic.
Too hot for t/ off!...
I love this channel, but there is a lot of speculation as to the cause of the crash here. I do agree that this was definately not ideal conditions, but the book numbers say 500 ft/minute. Even if you only get 50% of the book numbers that's still 250 ft/min, which is a climb. I have my money on the motor having an issue of some kind and not making full power. I feel like it should have made it. If the book numbers are not reasonably accurate, then Lance pilots can rip that page out of the owners manual and chunk it.
I know density altitude is real and I know it was a risky takeoff. I am not condoning his takeoff decision under the circumstances but it just doesn't feel right to draw conclusions and throw this pilot under the bus. The engine might have simply not been making full power. He might not have fully realized until airborne and too late to abort takeoff.
not to mention the person killed in their house...
Humbling, educational and so watchable. Haven't missed one of these in over 10 yesrs. Thank you.
Sometimes feels like they only put one out every 10 years...
Couldn't agree more. I'm not even a pilot but I like to watch these
He's been doing these for that long??? Where have I been??? 😄
Our goal is to put one out every quarter. We're a small shop and they're time consuming to do. Donations help 🙂
@@wardentex1810 they're so well done though. It takes time to produce them I'm sure.
It’s really sad to see how an ostensibly good, careful pilot can get themself and their passengers wrapped up over missing the small things.
I would have to say it’s the plane manufacturer and certification agency that seem to have “missed the small things”. I can guarantee that no accident investigation agency would put the fault on the pilot if this was a Boeing or airbus passenger jet that missed the published figures by about 30%…
May be did all the small things right but missed a big thing: leaning for max power at this density altitude.
@@jfmrod The book numbers are for a brand new airplane off the factory floor and being flown perfectly by a professional test pilot. This airplane was built in 1975, so far from being brand new. Throughout my training I have been told to take the book numbers with a grain of salt when it comes to flying some of these older model aircraft.
@@Chr15T I agree, if that would be enough to tip the balance then the video should emphasise that more, not that the POH numbers don't match with reality. The issue with the latter situation is that there is not much to be done except not believe certified POH and benchmarking your plane/engine before trying to fly it at the limit of the performance envelope.
@@bodenwhitmore7699 I've heard the same, but this case shows that you need a lot more than a grain of salt... what I realize is that you can't take much for granted in flying, specially when changing the flight setting and parameters like weight. Essentially take every flight with a new configuration/setting as a test flight and you will be able to maximize safety.... do real world performance benchmarks
Don't forget that aircraft performance is normally tested with a new engine, plugs, magnetos, fuel system, etc. I have been surprised more than once with an airplane that simply didn't perform to specifications. Never push the limits unless you know exactly what you are flying.
A 500 FPM is a very big variation. Not to mention being under the max gross.
A properly maintained airplane should perform close to the POH. Even if 30 years old.
No, engine performance degrades with hours flown. Propeller wear can be a factor as well. When I overhauled my Cessna engine, I got five knots more cruise speed. @@Chr15T
I think the new engine part is the lesson here, but I would argue that POH numbers should rather be conservative and have a 20% margin built in, especially on these cases with hot high altitude close to max weight. No reason there isn’t an extra large margin of safety written in the POH, I doubt this situation would be tolerated if it was a Boeing or airbus passenger jet that didn’t takeoff as advertised in the POH!
If it's possible to use mixture to increase power beyond what is good for engine longevity, the manufacturers could be doing that during those test flights.
This happened to me early in my flying. I was flying an Archer, full fuel, with two large passengers, both in the back seat at KEYW on a hot summer day. The plane took all the runway, and lifted very slowly. I got lucky, I flew the pattern at 300' AGL and landed immediately, no incidents occurred. A mistake I never made since.
Were you over max takeoff weight?
@@hellogoodbye4728 ...and aft CG, and in a Piper.
Many Archers have a 180hp engine. Perhaps this was a 160?? I flew an Archer II 180 back in the day and loved it's excess performance. Max gross in the summer and it would climb at 1200fpm to 4000-5000' in the Florida summer, where I'd finally be able to stop sweating. Nice feature!
Thanks for sharing.
I recall a run-up for a C172 pre-buy on a scorching-hot afternoon with an instructor at Falcon, Mess AZ. He was taking his sweet-ol' time adjusting the mixture for best power but after about 2 minutes i said (not gonna lie, in a condescending tone), 'what are you doing?' He politely told me he usually takes about 5 minutes determining best power. During climbout he told me the lose about one airplane per year there on TO. Never forget that
Wonder how many of those lost were from dudes just not understanding what they're doing when they're moving the red knob... 5 mins to lean the mix wtf hahaha
To be fair, I know tons of instructors who move to az to instruct and have no idea how to lean an airplane let alone lean for taxi or takeoff. Like these people literally don’t know how to do it
Most ridiculous thing I've ever heard.
Sedona is the same
Everyone leans for power at takeoff, it’s not in the POH afaik so why do instructors recommend it?
If you think you need that extra power then stay in the ground
Thank you for these respectful and educational case studies. This one is a good reminder that even diligent pilots aren't immune from accidents. Let's all continue to learn from others' mistakes.
Oh man this being called "high aspirations" is chefskiss.
I'm surprised nobody else has named a video about hypoxia named this.. (about human hypoxia, not engine hypoxia)
Best aviation series on TH-cam, hands down.
This is very good, but there are several other very good "aviation series" on youtube
th-cam.com/video/R5CFhVvMTkk/w-d-xo.htmlsi=HkQvc_wCqLLXFuAS
th-cam.com/video/tPshcA2E4i0/w-d-xo.htmlsi=sm-P7hIhhmSkxYy1
Up
A great analysis and video, a few lessons I take away from this are,
(1) Treat every flight as if you have never flown the same route before. No two flights are ever the same.
(2) Never do it so close to performance limit. That 50% padding advice actually surprised me. I never thought I needed that much, but now that I've thought about it, I think since in a airplane things can happen so fast, that 50% sounds just about right for the decisions you make on the ground and the time you need in the air.
(3) Always double check ASOS/AWOS just before takeoff, in case winds shift or other conditions change, which may lead to lots of recalculations.
(4) Take friends or family for sightseeing in much more favorable weather conditions than this case...much. That said, overriding your own confidence, and your desire to let everyone have fun, is very hard -- takes a lot of mental practice and still not enough.
If you are incapable of underpacking (myself included), you either have to have an aircraft tolerant of what you bring consistently at any and all weathers and airports (the more expensive option) like a Caravan, or be accepting of the no-go option. These six seat aircraft are usually very handy, but with the small naturally aspirated piston, they seem to show up often in these debriefings. Same horsepower as my Explorer, which does not need to fly.
"That 50% padding advice actually surprised me."
I was told that since day 1 of flight training, and I will always follow it. My instructor (in his 70's with 50 years of flying) always emphasized this: book numbers are with a brand-new, perfectly-performing aircraft and a test pilot.
@@jaysmith1408key lessons in this case is when in doubt don’t do it I think he had doubts about this trip which is sad and his eagerness got the best of him
Most stories we hear on this channel are of some pilot who doesn't do their due diligence and pays for it with their life. I feel like this pilot was a good one who just made a couple of mistakes that doomed him.
Personally I would say that the mistake was cutting the margins too fine.. it was a mindset problem not a case of getting the numbers wrong.. the lesson here is give yourself more room for things not working out.
@@jamesgraham6122as an engineer I disagree. I would be awake at night if I thought I published numbers without sufficient margins. Everything I publish should be useable to the full extent of the envelope even in the worst case scenario.
I do nuclear power, not aircraft, but in publishing these numbers I’d run calculations for 20% payload weight error, 5 degrees temperature error, 300 feet altitude error, engine 10% over TBO, and one worst-case unknown engine degradation.
So something like 37 degreee Celsius, 4800 ft MSL, 30hp engine degradation due to mechanical wear and one unknown cause, and an extra 300lb of payload.
Then I’d pad my answer by 50% or slash by 33% accordingly and publish that number.
If I’m publishing numbers that customers need to pad on their own to create a safety margin I’m failing, and I’m killing people.
It seems they got quite a lot of helpful information from the friend's daughter.
That is one brave little girl, to relate such things about a plane crash that killed her mother.
Yes, how she even noticed that!!
@@nancykaufmann3993 She was probably interested in aviation, so she was paying attention.
Possible future aviator, there. So sorry that she lost her mom in this crash, though.
Shout out the narrator for doing a great job despite having to fill the biggest shoes in the business
What happened to the old narrator? This guy did well, but the old narrator was missed by me :(
@@TheMrSmurfette Travis retired from our video work. He was an iconic voice for us for many years. We're grateful for his work with us and wish him well! Welcome, David, our new narrator!
Yes I noticed right away that it wasn’t that same iconic voice.
I was waiting for the first word of narration to be "It's...." and when it wasn't I knew the narrator was different. Travis had a distinctive style that really worked, and David has a different distinctive style that is apparent already. Great job on this video, with due respect to its tragic subject.
@@richardmcspadden9189 He did a great job.
I wonder if flying with around half fuel to Page, AZ in the morning and refueling there to half fuel would have made all the difference. I got this awful feeling in the beginning when the details started coming in (full passenger compartment, luggage, full fuel tanks, high altitude, hot afternoon.) It's sobering to learn from these reports, and my thoughts are always with the victims, survivors, and families. I'm sorry for your losses.
These are expensive lessons, paid with the most precious price, the best way to honor these losses is to pay close attention and ensure they are not repeated.
That's a good compromise.
I fully believe that his flight would have been successful with 1/2 to 3/4 tanks and taking off into the wind. He was within limits (albeit in an older plane) and those two seemingly minor things would have probably changed the game. We'll never know, but density altitude scares me more than any other aviation challenge. It's invisible and unforgiving when it strikes.
@@smartysmarty1714yeh i would have to agree, this pilot was astute and got mighty unlucky, he was 200 pounds under gross and Maybe even just noticing the wind change and taxiing back to apprpriate runway might have done the trick or even just leaning out a little better for full max power perhaps, but regardless this pilot didnt deserve that fate after being so on top of all his numbers
From the photos of the wreckage, it is a miracle that anyone survived.
As an instructor who has always taught more from the principals in "Stick and Rudder" than from some of the poor energy management airmen certification standards, my heart goes out to this pilot, his family, and those affected on the ground. ACS teaches "acceleration in ground effect to Vx or Vy as appropriate." While I appreciate the addition of "in ground effect," neither Vx nor Vy was appropriate here. Vx had become Vy and Vy is just too slow for maneuvering flight. Having flown low powered training size airplanes in the mountains for years, I have learned that nearly all mountain flying is maneuvering flight. Even down drainage in the desert, he was constantly in the realm of maneuvering flight. Everywhere, but especially in the mountains, I have taught the basic level in low ground effect takeoff as default. More than a few times in many engine failures at low altitude, this extra free ground effect energy has made maneuvering to a suitable landing site possible. Why do we teach pitching to Vy with half a mile of runway ahead? Why do we teach giving up the free extra ground effect energy that will provide zoom reserve airspeed, even cruise airspeed, before the end of the runway. Why do we teach giving up the free extra ground effect energy that will make life and death difference sometime in our flying career? This well trained and competent pilot, based on his training, was lacking the training that would have saved him and his family. That was not his fault. As a part of the training community, that was our fault.
Thanks for the insight. I'm not familiar with the term "maneuvering flight" in the sense of a regime, can you clarify how you define that?
Being a CFI in the east we rarely have to deal with DA issues but your insight is invaluable. Two things stand out on this one. Wind check before takeoff. He could have just asked the tower, then changed runways and worked out a Bravo clearance to get established in a climb. Second, the 50% padding on performance seems vey prudent as these older aircraft, and who knows about the engine compressions, would have contributed to even less power available than book values. Seems to me this should have been an early morning departure as he would have had that going for him with a much lower density altitude. Almost seems like a turbo is a must have for high density altitude flying in the west. Thanks again for your great insight!
I must have messed up my reply last night so here goes again. I define maneuvering flight as flight at an altitude too low to recover from inadvertent rather than planned practice stall. It is somewhat understandable that flight instruction is from a high altitude orientation since most pilots spend the majority of their time up high enough to recover from inadvertent stall. It is pretty obvious, also, why after reducing incidents and accidents for years, general aviation has not reduced fatalities at all. We act like maneuvering flight does no or should not exist. As a crop duster and pipeline pilot, I lived there many years. On pipeline, that was 25 hours a week at 200' with waiver. We will not decrease LOC fatalities until we invest in low altitude orientation and instruction. We can't expect our students not to stall at low altitude around the airport if we continue to teach them to maintain altitude at all cost and to pull on the yoke on every turn. What does the airplane want to do in a turn? Is it wrong?@@will-9000
Just found your book and its on my list to read once I finish The Killing Zone.
Interesting, thank you. So is it fair to say that in maneuvering flight, upon loss of power etc the priority should be to maintain safe airspeed and fly the plane to the ground rather than attempting to climb at all costs (which results in stall-spin)? @@jimmydulin928
My thoughts go out to the entire Air Safety Institute team and the loss of their leader, Richard McSpadden. These videos are incredibly well done and well produced. Thank you all for the hard work over the years and please continue to honor Richard's memory by continuing this series until ALL accidents are eliminated!
I’m so appreciative you keep making new Accident Investigation videos like this
What happened to establishing an airspeed @ approximate distance on takeoff roll and if you don't hit that number before rotation speed simply reject the takeoff. 6 people onboard probably added pressure to fly as well. Terrible someone was killed in their home.
I’m not sure establishing speed at a certain distance would have worked in every case and also maybe not in this one. You could be hitting rotation speed more or less where you expect only to find out the plane is unable to climb because performance is below what is advertised in the POH, the problem is you only find that out close to the end of the runway…
@@jfmrod Everything may happen, but this is very unlikely. The way the indicated airspeed is measured makes it directly related to the lift, unless the aerodynamics of the airplane is severely damaged. The problem of high density altitude is that the engine does not develop the full power, so that the sufficient indicated airspeed is either not reached, the required for it length of the runway is not available. I agree with @jonasbaine3538 that observation of the airspeed during takeoff roll and timely rejection of takeoff would have saved the day.
@@ikono2 when the plane is on the takeoff roll you have close to zero angle of attack, and therefore reduced drag, once you rotate to increase lift, you increase drag, its quite likely that you can accelerate to rotation speed and not be able to lift off and climb once you rotate and lets not forget ground effect which reduces needed AOA for lift and therefore lift induced drag too.
@@kleinersternlifotografie4875 The rotation speed is well above the stalling speed, so if you are able to accelerate to the speed of rotation, you will be able to climb. However, if you rotate at the stalling speed, it will be exactly as you describe. For example, I fly sometimes PA28 Archer, its stalling speed with some flaps and at MTOW is 53 KTS IAS, however, according to POH I am expected to rotate at 65 KTS IAS. Certainly, the airplane would be able to lift off even below 53 KTS due to ground effect, but may eventually not be able to climb. However, if it is able to accelerate to 65 KTS while rolling, it will climb despite of some eventual loss of airspeed due to induced drag.
A sobering reminder about hot and heavy. Thank you for making this.
…. Don’t forget High…. Hot, Heavy and High 😳
As a fellow Lance owner, this video hits home. Great job and so many good lessons here for us to takeaway.
Very humbling and an eye opener. So many variables. Thank you so much AOPA for putting these videos together. We all can learn from each other's experiences.
Thanks for watching, Val & Eric
Even more scary that he was so highly regarded for his cautious, thoughtful approach.
Yes, quite scary. My impression was that he was cautious and thoughtful about the wrong things. Carefully weighing baggage while not understanding that flying at near gross weight was a bad idea. Full fuel load, followed by a careful preflight didn't compensate for a hot afternoon.
Another very well done video with some very important takeaways. It seems the pilot was very conscientious, but still failed. It's a reminder that I need to cross every i and dot every t when I fly. Thanks ASI.
Agreed Dan, and your video on Gryder was very informative.
@@89.I too don't see what errors he committed. Was if fuel mixture? Flaps? Or did he rotate prematurely?
@@89.The book shows a theoretical condition at time of manufacture flown with perfect technique. This aircraft, (and most in the GA fleet,) was not recently manufactured nor flying in that theoretical situation and no pilot should expect themselves to be capable of perfection. The pilot may not have been "wrong," but clearly he wasn't right either. Unfortunately it's a judgement call not MSFS 2020. The lesson is, stay well inside the envelope. If you're close to the numbers, you probably need to reschedule the flight.
@@89. Gotta remember that the numbers in the book were achieved by professional test pilots. This pilot had 800 hours, which is good, but not in the same league. Clearly not enough experience to have known the difference between "I expect this cruddy climb performance because of DA so let's continue" vs "This ain't happening, so reject take off."
@@gottesma Agreed and I don't think we can say he was negligent or anything of the sort. He just miss judged his personal go/no-go. It's terrible and the accident report rightly assigns liability or fault, but no further. This sort of call could catch a lot of experienced pilots out. Those book numbers are calculated based on solid math, but there are a whole lot of variables that can't be mathematically predicted even from the best test pilot data. Unfortunate and I feel sad for the survivors and the victims families. That's why we study accident reports and adjust our personal envelopes accordingly.
My dad owned a Cessna 177RG when I was a teenager. From his experience the airplane would not climb out of ground effect below 90 knots. No matter what was in front of him he had to keep the nose down until the plane reached 90 knots.
There were a couple of hairy moments climbing out of Truckee, Ca and once out of Death Valley in hot weather. But just keeping calm and not yanking back on the controls things always worked out.
Nice thing about taking off from Stove Pipe Wells in Death Valley taking off to the East it open desert and down hill a long way.
They should really rename the phrase “high density altitude” to either “high altitude density” or “low density altitude”. The first way makes no sense at all.
I was shocked to hear that any of the persons onboard survived such a destructive crash!! 😮 That's pretty remarkable. My thoughts are very much with them, and with those who also lost a loved one on the ground. Thanks as always to the ASI for their respectful, non-catastrophising, educational coverage of such incidents - very much hope it can help save other families from experiencing such loss in future...
I'd have to agree. I've been in aviation for 30+ years and have watched a ton of videos, and unless I'm forgetting something, this is the first time I've seen the instant "plume of smoke" combined with survivors. The two never go together. I'd imagine that people on the ground acted extremely fast to remove the passengers before the fire broke out, but still remarkable that anyone made it out of this one alive.
Pilot and mechanic-helper here.. one detail no one mentions is engine conditions. Clearly they were close to GW, high dens altitude and downwind. With respect to the engine, if it has tired jugs, old carb needing several adjustments and a carb heat door that doesn't fully close that can make a MASSIVE difference in performance. I assisted with work on a Cherokee 140 (O-320) that had 900 hours on the NEWEST jug, 3700 SMOH (yes you read that correctly) and a mixture cable that wasn't right and the best static RPM could do (KBTR, so sea level) was 2100.. The pilot that flew the bird in complained of "long take off roll." Advise the mechanic gives...do a static RPM check every once in a while.
Yep. Magnetos, too. A set of tired mags near or past inspection/overhaul time can easily lose a couple degrees of timing. That's significant.
I agree with you 100%. I've flown 0-320s and 0-360s that didn't come close to the rated HP. I don't pretend to know the history on the engine, but everyone just assumes that it performed like new. Even with the high DA and fuel mixture issues, that Lance could barely accelerate and climb out of ground effect. My experience tells me there was something wrong with the engine as well.
I can’t believe 3 people survived this!? Iam so happy there were survivors. Normally in these types of situations, nobody lives. RIP to those who perished. 😞
They have a new narrator, the old guy was great
I began my flight training at 00V/KFLY, 6,000 MSL, in summer. DA was absolutely *drilled* into my skull even before the first flight. It just blows my mind that this happens every year to far more experienced pilots.
@@jonathanparle8429 I'd say that's just semantics, as it was another in a list of factors working against the pilot that led to a tragic outcome. Very unfortunate and saddening.
@@jonathanparle8429Yeah, this was a case of all the Swiss cheese holes lining up. Terrible no matter what. :-/
I disagree. The tailwind was a big factor in my opinion based upon my experience in my turbo-Lance. Probably because of the wing, but a tailwind on a climbout after takeoff and just out of ground effect makes for a very sluggish climb at high altitude. In the high desert/mountains where the wind can flip pretty quickly, it has happened to me three or four times and my solution is a level to slow climb to turn into where the wind is now coming from and climb performance improves tremendously (to normal). In an N/A airplane, your climb rate be 150 -200 fpm on climbout, and we must learn to accept that, climb in a pattern around the airport to altitude and then be on our way. @jimmydulin928's comment above about the need for good skills at slow flight in these circumstances. He is correct. The other is training on overcoming the tendency to keep pulling back on the yoke to try to climb. Push forward to save your life. @@jonathanparle8429
I learned at KAPA and experienced a very slow climb on a hot day during training. Seem to remember the IKEA across the highway getting very large indeed… This story seems especially tragic-do your best to get it right, still die. Cause imho goes back to planning-when seeing *all* the numbers going high, weight, temp, afternoon takeoff, DA… and with family and kids onboard… be conservative and call it a day. Disappointed kids will get over it.
Curious, what’s DA in this context?
When I'm not sure about performance, I always make note of expected takeoff roll. It things don't seem to be going to plan, I reject the takeoff. I've only had to do it once in 20+ years, but it's a good way to make sure technique, performance, and conditions are not in aligned to kill me and others.
How anyone on that airplane survived is a miracle.
Not mentioned here but hinted at and SO important...with a non turbo engine you have to lean at high elevation airports for BEST PWR! If you do not lean the engine for t/o you will actually perform a partial power t/o.
Run engine to full throttle on rwy and lean to best power, depending on the plane thats max rpm or max EGT and than enrich with about 50-100degrees. Please look at leaning graphs showing best power and best economy and how to obtain that.
The pilot clearly started leaning while airborne( sudden increase in EGT's) which indicates he was probably not at max power during t/o.
Also any use of flaps not recommended on this plane as with plenty of runway the goal is to get airborne with least amount of drag, 1st notch of flaps only lowers the pitch attitude a bit but also increases drag.
Thank you Air Safety Institute for these videos. Please produce more of them. Very humbling and informative. I think many of us would have made the exact same decisions this pilot did. Prayers for the families affected by this tragedy.
I feel that people leaning out the mixture is highly underrated. I've seen instructors go full rich on an NA airplane at higher density altitudes, I'm guessing from habit.
Agreed. We did so on 100°F days in Cincinnati, at under 500 MSL (Sunken Lunken, surrounded by hills). Seeing a density altitude several thousand feet higher was remarkable. Even so, underpowered planes (C150, etc.) would require a turn upriver to ensure terrain clearance.
Definitely lean for best power above 3K density altitude. I know a lot of pilots from cooler climates who go full rich on all takeoffs and landings out of habit or due to the checklist. Same can be said about carb heat on landing. Can't do that often in AZ, unless it's January.
Leaning the airplane at any significant DA is most definitely a step to take. Also, putting the gear up on positive rate on a NA single at high DA is also a good idea. If you lose the engine over the runway, just let the insurance company pay for the gear up - much better than failing to climb.
@@N1120A I'm not multiengine yet, but thanks for the gear up tip. If you don't mind a question. How about flaps? Would they help on takeoff where you lose an engine, or would the drag erase any benefit? Basically, how do flaps effect minimum controllable airspeed.
@@SGTSnakeUSMC I've not flown a Lance, but a regular Cherokee procedure is that high DA always is a no flap takeoff
The most frustrating part of this is the NTSB, once again, placing all of the blame on the pilot. He followed the book to the letter, did everything right, and the plane didn't perform to spec, and they even acknowledged this. Sure, AOPA tells you to pad the numbers by 50%, but there's a lot of things wrong with that. The AOPA isn't the FAA. Padding the numbers by 50% would make some planes just flat out unflyable in any condition. Where'd the 50% number come from anyway, a good guess? What's the point of numbers if we're just guessing to begin with?
I think the biggest problem is in the POH. We're taught to treat it as the word of god, yet time and time again the numbers come out flat wrong, and someone dies because of it. I think there needs to be some accountability there.
Those POH/AFM numbers these days are fairly good ; they are supposed to be what the average pilot can achieve ,if, and it’s a big ‘if’ , the pilot does everything as the book suggests .
We don’t know if he leaned the fuel properly before takeoff. If he did then there would be no reason to fiddle with it just after climb out as he seemed to.
His climb rate was dependent on NO FLAP and a Vy appropriate to that DA which is lower than a sea level one . [ Vx increases somewhat with DA ].
Another nuisance for him would be a decrease in IAS in about the first 100’ AGL as he was climbing in a tailwind [ which he may not have realized ]
This is solely on the pilot.
@@TJATJA1982 explain.
@@aramusbelmont4992 It's super close to both COG and weight limits on a very hot day. He's flying his family and kids - wouldn't you want a bit more leeway? Did he need to be flying that leg with full tanks? Messing with the mixture lever in those critical moments - shouldn't he have leaned before take-off? Seemingly taking off way under the suggested speed? Stalling the plane into the ground?
Near max weight, high altitude, hot and taking off downwind - cutting the margins very fine indeed.
My respects and sympathies to the families of the pilot and the passenger, but this was not the fault of the POH.
I think the biggest thing is that he did not abort when the airplane was not flying. We all know what a normal take-off feels like, even heavy. If you're hearing the stall horn on rotation, it's your *last* warning to save your aircraft. He had 2,000 feet to pull the power back - but more importantly - he had 800 hours to build personal minimums for takeoff, including having a point where he will abort if the aircraft is not in a stable climb. The Airplane Flying Handbook recommends to pilots of GA aircraft that personal minimums be "Abort if not airborne by one half the runway length", or something else easy an quick to determine on a takeoff roll.
This pilot was a better pilot than me; He did everything right up until that last moment where his experience and skill should have led to pulling the throttle and stopping on the remaining runway. That's the only critique I can give to an otherwise great pilot who was screwed by tired aircraft.
That AOPA 50% rule is very important. Every engine decreases in performance as time passes as time goes by. Very good maintenance is critical in my opinion as is padding your safety margins.
Acting like your life depends on every decision is not paranoid, you just get used to thinking this way. My father was an Air Force fighter pilot and motorcycle rider, and he taught me many things to help me stay alive. He would say to his fellow pilots and me "they are out there trying to kill you, it's your job to not let it", "they" referred to all the relevant dangers.
I always look forward to these Accident Report productions. So well made, so useful. Thank you for this service to all pilots all over the world.
Some of the best content on TH-cam.
This channel convinced me that aviation is a domain for pros only. And even that is no guarantee. The hours needed to remain "current" are laughably inadequate.
(4:14) The lead-up to this accident flight revealed all the ingredients in a recipe for disaster: 90°F air temperature; high air field altitude; the presence of density altitude; max fuel onboard; max passengers onboard; wife's gut feeling of danger ignored by the pilot; weight & balance aft of allowable CG (not specified but I'm betting). Overloaded, underpowered, with adverse weather conditions including density altitude, the accident aircraft could only flounder for a bit in the air before crashing. I'm grateful that the missus and rear passengers survived.
SO IMPORTANT that we learn from situations like this, so we don't repeat the same mistakes. All these types of pilot errors are preventable. God bless the ASI for putting these videos out there for us to learn from.
Thanks AOPA for making these high quality, life saving videos. They teach us pilots a lot. Please never stop doing these.
AWOS costs $20k - $110k and wind sock costs $125.00
Insidious. It is humbling to watch this. My condolences to the family. I have included the 70/50 rule in my pre-takeoff check list, although this might not have worked as the aircraft became airborne before but did not climb. I always check density altitude during pre flight and will double check now along with AWOS info. If anything has changed, reassess before taking off or abort if needed. Don't let pressure or circumstances push you.
I remember the first time I got a real world lesson in density altitude which was a pucker moment and I was so mad at myself for not running the numbers better. We took off from another airport and wanted to do a full stop taxi back at an intermediate airport. It was warm and I think density altitude was close to 6000. In reviewing my flight video, I was actually higher than I thought after takeoff but the fact that I didn't know for sure really bothered me. Density altitude is no joke. These videos truly help in reminding that every flight is different and to definitely do your homework. Thank you AOPA.
I had a similar moment one hot summer day ~20 years ago, when I took 2 friends in a C172 to Hummel Field (W75) from Hanover (OFP) in Virginia, to have dinner at that nice German/Italian restaurant across the street from the runway. (It's not there anymore 🙁) Takeoff from OFP was no problem with 5000+ ft. runway. Hummel, however, was only 2000 ft. + change, but I thought by the time we finished dinner it would be cool enough, so I never did the calculation for the takeoff distance for the obstacle clearance and for the weight of 3 people. And in those days, before they cleared more of them, the trees were closer to the north end of the runway. I did the short-field takeoff from Hummel. The ground roll felt a little sluggish. I could've and should've stopped, but didn't. After the rotation, the climb-out was sluggish too, very slow in gaining altitude. Although I probably had plenty clearance, I was genuinely scared during the whole climb-out that I might hit the tree top, and I never concentrated more on having my wings level and my proper airspeed. I must've looked a little pale, only that no one could tell in the dark. I never took anyone there like this again in that kind of weather, even if the calculation showed enough clearance. I only wish I hadn't needed a self-lesson that way.
Good video, many thanks for producing it. They are really well done!
Some constructive feedback - you knew that was coming 😊 - I think it would have been helpful to other pilots to go one step beyond the rather light "probable cause" that the NTSB produced. For example, "don't fly when heavy, hot, and high" is good advice, but this aircraft could have flown fine if it had been leaned properly before takeoff. By the time the pilot realized this and started leaning, it was too late and I'm sure he was under massive stress, sadly.
A lot of focus on the wind direction, but that really only impacts takeoff and landing roll distance - once the aircraft is in the moving air, it does not care about wind direction or speed. Clearly if there is increasing windspeed as you climb, that will have a negative impact.
Thank you very much for producing these videos - they are saving lives. Please keep up the great work!
Agreed. You should still trust the POH even if heavy, high and hot. If your numbers + 50% indicate that you have sufficient performance to fly then I don't see why you shouldn't.
My aircraft cares about wind direction. It seems to climb faster in a headwind…just like a kite.
isn't it proper procedure when operating out of a high altitude airport to set the mixture for the highest rpm in the run-up?
Wind speed generally increases with altitude: windVelocAt(agl) = obsWindVelocity * (agl / obsWindHeight)^(alpha) where
The value of alpha depends on the roughness and obstructions present in the terrain. Over open water or smooth, flat terrain, alpha values tend to be lower, often in the range of 0.1 to 0.15. Over more complex terrains with obstacles like trees, buildings, or hilly landscapes, alpha values are higher, ranging from 0.2 to 0.4 or even more.
The point being:
A 6kt wind at an AWOS 33ft can turn into a 10kt wind at 120ft AGL (the highest altitude of N7677C according to GPS data).
Taking off in a tail wind and losing 4kts airspeed during the initial climb is much different than gaining 4kts of airspeed for free when taking off up wind, especially for a heavy plane with reduced engine performance.
As logic turtle says below , angle of climb will be affected even if rate of climb isn’t , no matter headwind or tailwind; also up through 100’AGL there will be a loss of IAS in a tailwind due to ground friction . Normally this would be barely noticeable under conditions not near the edge of the envelope , but in this case it could have been critical for the pilot .
Every single one of your videos are incredible. RIP to those that perished, and may the rest of us learn from the mistakes that took place
The performance charts are based on a brand new plane. Over time, surely performance degrades. This is something I think about a lot when doing flight plans.
Prayers straight from the heart for the survivors and what they must have gone through and are still going through. Prayers, too, for the safety and sound judgment of all pilots trying to learn from this tragedy.
Thank you for sharing. Weight and balance is no joke, even when you're within spec, this is a humbling reminder to always leave margin room for safety in your calculations.
I have been through the same situation at that airport with a different outcome. Taught me that one has to carefully plan and anticipate a hot and high take off....
I think not a lot of us realize how badly temperatures affect performance until you experience it firsthand. When I was doing my CPL checkride it was 34C outside and we got one of the weaker Warrior IIIs that the flight school had. We were well within CG and weight. Wind was calm (few kts headwind) and it was also a paved runway. Everything was fine right until I started to get out of ground effect. After that we could barely pass the VOR station in the climb out path. Had I tried to accelerate to normal operating speeds before clearing it we would be in an accident report too.
After this I had my ME checkride in a Seminole and with 34C outside the single engine performance was literally like a C152, during the single engine go-around I had 0 climb performance with full thrust until flaps and gears were fully up. After that we got around 50-75 fpm, all this with only 2 people on board, had the airplane been full with passengers we probably had negative climb.
These are amazingly well produced and always very informative and educational. Thoughts and prayers to all lost in each of these episodes. We must all always strive to be continuing education and learning up until the day we stop flying
Great roduction value ,writing, and VO in this video. Well done!
RIP those that didn't make it.
Tragic, just awful set of circumstances. The learning opportunities represented in the case reviews have undoubtedly made aviation safer. Beautiful put together, and a masterful analysis of events.
I LOVE THIS SERIES!! I wish more episodes came out more often
I am a new pilot and fly a 65 Mooney C and maybe because of my age or newness I fly 10% under my W/B numbers. I figure the plane is new to me and I am new to flying why push it. I fly out of a non towered airport and always look at both windsocks on the field on my way to run up. I very much appreciate these videos because I have much to learn.
You sound like a well trained professional pilot...!!!
Unfathomably heart breaking...
Thank you for this lesson. It's really the little things that each one seems insignificant, but when stacked together can seal your fate.
Condolences to all the victims' surviving family.
These case studies are so well done....thank you.
I hope you continue posting these Accident Case Studies as they are so helpful.
Really hope we start seeing more of this content. ACS is the best aviation videos on youtube.
It's super easy to get lulled into complacency when we are student pilots or new private pilots because we know we can fill the fuel tanks and hop into the C-172 by ourselves and generally be OK on weight & balance and max gross weight.
The situation drastically changes when we go to higher terrain and warmer temperatures. Plus the POH numbers are based on new aircraft with highly experienced test pilots at the controls.
So wild to jump into this video and it be my home airport where I take lessons and fly at least 3-4 times a week. Thank you for this video that we can all learn from!
I’m just in tears watching this, especially seeing video from the crash scene. Such a tragedy.
First thank you to Air Safety Institute for publishing this unfortunate case from Utah in 2020. My prayers to the families and communities involved. Wishing all aviators years of real world experience.
Sad to see. That tail wind was a killer. A reminder to always check that sock!
Great to have another video. Please post more AOPA.
A classic case of "the book says we can" but it turned into a series of small mistakes and oversights that stacked against the pilot and passengers.
A big factor has to be feeling unused to an anemic climb. In a Grumman, high DA, you just HAVE to be accepting of 100/50/0 fpm sometimes, and accept that a climb is a climb. If you're used to unloaded, low weight performance, a poor climb can induce panic, fiddling with the mixture, and reduced attention on flying the airplane. Flying the airspeed, not the climb rate, can be life/death.
Brilliantly produced as always, with many useful lessons to learn. Tragic when lives are lost.
Totally preventable.
It's hard to comprehend how the 12-year-old walked away from the crash and fire with no significant injuries. It reminds me of Sailor Gutzler.
I think it is very important that these videos are made. Not only are the specifics of the incident itself important to those already in aviation and those who are on their way to a PPL, but there is also a general lesson about diligence and meticulousness on safety factors. It's so easy to become used to things working out, that one may not realize how thin the swiss cheese has become and how more likely the holes are to line up.
Thank you for this educational video friend. Condolences to the families and friends. Quick recovery for the injured 🤕. May they rip Amen 🙏.
Typically when watching these types of GA air accident videos, it's the pilot who becomes complacent or over confident in his or her abilities - yet in this case, apart from taking off with a tail wind combined with high density altitude, the pilot seemed meticulous and very competent which just goes to show that any one of us can experience the same when specific scenarios are stacked up against us.
So sad. It sounds like the pilot and his wife were careful to make sure balance and weight were within the maximum limits for the current density altitude, as well as performing a preflight inspection.
He did all of that correct....its just him departing with that close to max weight..high density altitude....and the tailwind.😣
@@hardy2k11And the flaps .
Near max weight, high altitude, hot and taking off downwind stacked all the cards against a successful flight. An early morning departure with less-than-full fuel, into the wind, would still leave engine performance (is it tired? Is it leaned correctly?) in question. Too many unknowns here for a safe (or least unsafe) departure.
Just found this channel today, and I just wanted to say that I really enjoyed the content! Keep up the good work.
Sad and humbling.
I was a reporter in Salt Lake City when this happened. I’ll always remember being at the scene that day, such a tragedy. Thank you for this video, very well done.
Very well done video.....quality and informative, guaranteed this will save many lives.....thank you for producing
Sometimes we study accidents that, while still useful to review and learn from, are harder to relate to because they involve extreme negligence or lack of ability. This one is tough because he was clearly a good pilot who took extensive preparations, but still encountered this extremely catastrophic outcome. Sobering AF
Thank you for this lesson and reminder - certainly a mistake we could all make if not for constant vigilance and skepticism of the book numbers. This pilot may well have saved my life.
Excellent video. As usual. Thanks
How could 1 pilot cause all that misery. RIP to all.
Very sad, but worth considering. Thank you for this excellent presentation
Sincere condolences all around. The new narrator did a commendable job; but I must admit that I prefer the previous one.
I fly a 1976 Piper Lance and it never makes book numbers. I always takeoff with flaps 25 it barely climbs at max gross with only 10% of flaps.
Lots of red flags here: high temps, close to max gross weight, high altitude, tail wind, adj the mixture after T/O. We have more control over our decisions than we think we do.
I would argue none of those things were the main factor for a pilot who appeared to be quite meticulous in the planning. The bigger problem imo is the real plane specs not matching what is on the poh. What is on the poh should have been mandated to be guaranteed under a normal performing aircraft and not what maybe someone can achieve once with a perfect pilot. Only then would this accident have been avoided, and this is mainly a regulation problem.
The Pilot of Lance N7677C was careful and conscientious in his preflight preparations in a high DA flight that he intended to perform with his wife and kids and with a family friend and her daughter onboard; but as meticulous as he was- it still was not enough to prevent a tragic outcome. Possibly too close to gross weight; given the 90 F. degree weather, tailwind take-off due to shifting wind direction, and the real-world condition of the engine power and compressions as opposed to POH data, piloting techniques, all ganged up on him. As others have said too- the AOPA's 50% additional margins being added in might have given him a very different outcome. So sad for all involved.
This one is tough. It really seemed like he did everything right, and should have been fine. Terribly sad and a good lesson how insidious high altitude flying can be.
Back in 1966, I got myself in a situation that I had to divert to an airport with an ILS that was only about 20 miles from my home base. After landing, I had to make the decision whether to finish my trip. I thought about it. There was no defined reason not to make the 15 minute flight (night with some scattered fog) but I got this creepy feeling. That airplane did get home, probably the next day, but it wasn't me flying it. I borrowed a car and went home.
I feel a little better when I see situations where the pilot was a cowboy because it's easy to say, "I would never be that reckless." But when a pilot's actions are described as the sort of careful, conscientious behavior that I think I would aspire to, it hits a little closer to home.
Thanks for these case studies.
Jeez, this is not your typical high DA accident. The pilot did almost everything right. The exceptions being missing the change in wind direction and not aborting the takeoff. Even on the takeoff he likely had 70% takeoff speed at 50% of the runway, the typical rule of thumb for high DA. Even the negative effect of the tailwind was likely a non-issue as the plane flew for some distance after takeoff. I'm usually one to blame a "stupid pilot" but in this case it seems like the plane just wanted to kill him.
Recently heard the following: "What does your plane say to you after you close the hangar door?" Answer, "Next time I'm going to kill the SOB." That's what this feels like.
A really sad accident.
Never trust a Piper Lance!
More of these, please!!!!
This was one where he got too comfortable. Pushing the limit barely is all it takes. Snowball affect. It can quickly roll into something massive once it gets going.