5 related adults dead in Cessna 340 crash

kayoh190 said:
What kind of pro pilot? If you’re talking about an airline guy that hasn’t seen a W&B in 30 years, I can understand. Some 91 dude flying a 414, a flight instructor, etc...not so much. ;)
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135 & corporate. The kind that have to demonstrate their weight and balance prowess annually.
 
I think the real point was that the plane’s MX was questionable, the guy’s currency was in question (especially for a takeoff with less than 1000 RVR), and he didn’t inspire the confidence of several others.

A Part 91 0/0 takeoff is legal. When my wife was flying the S-92 up in Newfoundland they were autborized down to 600 RVR for takeoffs and landings. However that was a 2-pilot crew in a $25M machine flying 600+ hours a year and receiving regular training. Big difference between that (or a very current and proficient instrument pilot) vs someone who’s got a bad case of get-there-itis. I’ve taken off in similar conditions before single pilot, but in those days I was flying 500ish hours a year with lots of actual IMC.

That said, I will be curious to read the probable cause report. We’re assuming that this is pilot error entirely, but the elevator trim tab is questionable. When this crash first happened, there was question whether the trim tab may have let loose, as there’s an AD on replacing those bolts.
 
Ted DuPuis said:
That said, I will be curious to read the probable cause report. We’re assuming that this is pilot error entirely, but the elevator trim tab is questionable. When this crash first happened, there was question whether the trim tab may have let loose, as there’s an AD on replacing those bolts.
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The trim tab issue is answered in the docket. The actuator was yanked past it's normal limits. Unless he flew it around like that prior to the crash, it was a result of the accident, not the cause. This wreck would not keep me from getting into a 340.

I can give you the probable cause:

Loss of control immediately after takeoff for undetermined reasons.
Contributing factors were low instrument meterological conditions and lack of instrument currency of the mishap pilot.
The aircraft was found to be loaded 94lbs above MTOW the pilot static check had expired. Whether either contributed to the outcome could not be determined.
 
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Half Fast said:
Unless one of those conditions is being a year and a half past due for IFR cert of the xpndr and pitot system, he should not have been flying this plane in ANY sort of IFR. IFR cert skipped, engine maintenance skipped and fraudulent entries in maintenance log,.... Who knows whether he was "current and proficient" as an instrument pilot, but he does not seem like a prudent fellow so I doubt it.
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He might have been thinking something like...."I am a lawyer and I can do anything I want". Which is what type attitude.?? No, I would not fly that plane except in day VFR and then only to the shop that is going to make necessary inspections and repairs to get it current. And no, knowing what I know now about the pilot I would never get in a plane he is about to fly. All part of risk assessment.

In some planes I have previously flown I probably would not have had any problem taking off in those conditions, except probably not with passengers. Back when I flew for a living approaches to minimums were just part of the daily routine, as minimum weather for takeoff. Again, risk assessment.
 
benyflyguy said:
“what would the PoA members be writing about my smoking hole if I did this and it turned badly”
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Hahahaha! I've thought the exact same thing as well.. especially since I've met a couple of you it would be particularly embarrassing
 
I guess I’m probably the only one here who looked at the videos and thought the visibility was better than I expected. Certainly not ideal, but not the death sentence everyone is making it out to be.

As far as the autopilot and the trim, no one here knows where it was set when he started the takeoff roll.

The maintenance? Was the expired pitot static inspection an oversight or blatant disregard? Yes it should have been done, but I don’t know what the circumstances were so I won’t judge, but most of you have made up your mind. The oil change entries? I’d like to know if the owner even knew they weren’t being done or was that a mechanic bilking his customer. The annuals were just “13 month annuals” like many folks do.

Maybe the guy was the accident waiting to happen that he is being accused of, maybe not. I’m just not willing to condemn him over anything I’ve seen so far.
 
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benyflyguy said:
Are they off the link above??
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Look up the accident number. Then go on the ntsb website to the 'docket management system'. One of the documents is called 'videos something'. When you open that file, there is a tab/selector called 'related files' which brings you to two mp4s with the videos.

One of the videos was shot from the helicopter EMS hangar and the plane can be heard but not seen. The distance from the vantage point of the helicopter pilot who shot it to the runway centerline is 936ft. As the plane was not visible, visual range was <900ft. The medevac helo pilot estimated an RVR of 400-600ft.

The first responding fire engine had difficulty navigating on the airport due to the poor visibility.
 
hindsight2020 said:
Your assertion was vague, so forgive me for presuming. Do you mean the "indignity" behind light piston equipment you paid too much for, failing to meet your expectations of a legitimate all-weather transportation conveyance?
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No, I mean people dying
 
Dave Theisen said:
I guess I’m probably the only one here who looked at the videos and thought the visibility was better than I expected. Certainly not ideal, but not the death sentence everyone is making it out to be.
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When visibility is that low you have to figure there are deer on the runway, or birds, or cows, or a lost grandmother driving around looking for the Seven Eleven Store. Out away from the buildings, the temperature is probably lower and the fog greater. If you can't see the other end of the runway at an uncontrolled field, I think a back-taxi to visually clear for obstructions/more dense fog would be prudent. Voluntarily adopting standard takeoff minimums as a part 91 flight would be prudent too.

Dave Theisen said:
As far as the autopilot and the trim, no one here knows where it was set when he started the takeoff roll.
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The autopilot commanded nose down trim if turned on on the ground, say for testing. Left unset...

Dave Theisen said:
The maintenance? Was the expired pitot static inspection an oversight or blatant disregard? Yes it should have been done, but I don’t know what the circumstances were so I won’t judge, but most of you have made up your mind.
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Apparently it failed last time, so the mechanic repaired the leak, but didn't coordinate with the avionics shop for another test. The owner didn't followup either.


Dave Theisen said:
The oil change entries? I’d like to know if the owner even knew they weren’t being done or was that a mechanic bilking his customer.
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The mechanic said he talked to his son and realized the oil and filter weren't actually changed after all, so the log entry was in error. I think over the past two years there may only have been about 50 hours logged time on the engines, so maybe somebody decided to let the oil go for another year and didn't log that decision.

Dave Theisen said:
I’m just not willing to condemn him over anything I’ve seen so far.
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You would hope a lawyer would focus on actual risks, not taking them on behalf of risk-ignorant passengers, instead of just the letter of the law.
 
Looking at the W&B chart on the NTSB report, he was overweight and leaning aft, but not ridiculously so.
 
arkvet said:
Forgive me as I’m sure it’s posted somewhere but where are these videos?
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Look up the accident number. Then go on the ntsb website to the 'docket management system'. Search for the docket in the database. One of the documents is called 'videos something'. When you open that file, there is a tab/selector called 'related files'which brings you to two mp4s with the videos.
 
sonopoa said:
Can you name some learning points.

The NTSB Factual report: https://app.ntsb.gov/pdfgenerator/R...tID=20171224X03602&AKey=1&RType=HTML&IType=FA
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Sure, how about this line from that report:
"According to two fixed base operator (FBO) employees at BOW, the pilot requested that the airplane be towed from the hangar to the ramp. The pilot stated that he wanted a tow so that he did not have to taxi next to the other hangars because of reduced visibility and dense fog."

So learning point #1 is that if the fog is too thick to travel at 10mph it is WAYY to thick for travel at 80mph
 
Datadriver said:
Sure, how about this line from that report:
"According to two fixed base operator (FBO) employees at BOW, the pilot requested that the airplane be towed from the hangar to the ramp. The pilot stated that he wanted a tow so that he did not have to taxi next to the other hangars because of reduced visibility and dense fog."

So learning point #1 is that if the fog is too thick to travel at 10mph it is WAYY to thick for travel at 80mph
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I don't believe that this is indicative of fog too thick to take off in...it's very likely just minimal clearance down the hangar rows that fog makes more difficult. Notice that he DID taxi to the runway, apparently with no difficulty.
 
tawood said:
The fact that two different people decided to video/film his take off, to me, is more than a coincidence...
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Probably the most telling fact of this entire thread. From now on I am going to add “check for videographers” in my preflight / taxi checklist. If I see one person videoing I probably should do a quick recheck of everything and reconsider the ADM. 2+ and she’s going back to the hangar!
 
Datadriver said:
Sure, how about this line from that report:
"According to two fixed base operator (FBO) employees at BOW, the pilot requested that the airplane be towed from the hangar to the ramp. The pilot stated that he wanted a tow so that he did not have to taxi next to the other hangars because of reduced visibility and dense fog."

So learning point #1 is that if the fog is too thick to travel at 10mph it is WAYY to thick for travel at 80mph
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As you can see here on the internet, there is no shortage of pilots who have done so and will do so again and its bascically no big deal. They survived it, so anyone can do it, even if they fly 20hrs/year. Also, the airlines will do low-visibility takeoffs, and I mean who needs a dual-crew, independent AHRS, radio altimeter and a Cat III runway, if you just keep the DG nicely lined up, its so easy anyone can do it with a little bit of practice. Monkey-see, monkey-do, you crash two or three times, you'll get it right eventually.

And that breakfast in Key West, its to die for !
 
I’m flying C414 and 414As about 250 hours a year. I think the 340 is close. Aft cg makes a big difference in where the trim needs to be set for take off. If the trim in accident plane was way off AND it was over max gross AND it was loaded aft of the certified cg limit, it would have been a real handful. Dealing with that in LIFR conditions would be a challenge.

Regardless of the above, any pilot whose plane has 2 $60,000 engines sitting on the wings and has zero oil changes in three years is a nut job.
 
Dave Theisen said:
The maintenance? Was the expired pitot static inspection an oversight or blatant disregard? Yes it should have been done, but I don’t know what the circumstances were so I won’t judge, but most of you have made up your mind. The oil change entries? I’d like to know if the owner even knew they weren’t being done or was that a mechanic bilking his customer. The annuals were just “13 month annuals” like many folks do.
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My concern isn't the 13 months; it's the pencil-whipped "no-oil oil changes." These were part of annuals (2 of them) and were only discovered because of hours written on one of the oil filters. Who knows what else wasn't done, yet signed off anyway, on these two annuals?
 
Half Fast said:
My concern isn't the 13 months; it's the pencil-whipped "no-oil oil changes." These were part of annuals (2 of them) and were only discovered because of hours written on one of the oil filters. Who knows what else wasn't done, yet signed off anyway, on these two annuals?
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My point was, everyone is blaming that on the pilot and using that to characterize his overall attitude. Did he even know the work wasn’t being done?
 
Hmmm.......

Way back in post 133, @Radar Contact wrote:

My speculation on this accident (obviously I may be way off):

If you look at the position of the elevator trim tab, it is full up. If it was in the position during the take-off, it would have been likely to cause the aircraft to slam back down shortly after lift off. The elevator trim tab is currently under a recent AD due to issues that cause full deflection/loss of control. It is an easy/cheap fix...if fixed properly. Mine has been done and I visually inspect it prior to every flight. Back in September a 402 crashed back down on the runway with this exact same issue.
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That speculation would be in line with the tire chirps heard on the video.

Thoughts?
 
Dave Theisen said:
My point was, everyone is blaming that on the pilot and using that to characterize his overall attitude. Did he even know the work wasn’t being done?
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Unknown whether he knew, of course, but he probably should have known; the final responsibility is his. But don't forget about the IFR cert for the xpndr and the pitot/static system. The pilot certainly should have known that was way overdue, and he chose to make an IFR flight anyway.

A single occurence of a false logbook record might have been an oversight but two is a deliberate act. Is there likely to be any action against the mechanic?
 
Half Fast said:
A single occurence of a false logbook record might have been an oversight but two is a deliberate act. Is there likely to be any action against the mechanic?
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Mechanic blames the shop helper. So its all a-ok.
 
... and here I am obsessively doing a vot check in the log book before an IFR flight. SMH

I was really hoping with this accident that we would find out that the guy was not a total clown and some unrelated element caused the plane to crash. Oh well
 
Tantalum said:
...
I was really hoping with this accident that we would find out that the guy was not a total clown and some unrelated element caused the plane to crash. Oh well
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I hate to say it, but I think when these things happen most of us hope that it was some sort of poor judgement, or better yet foolishness or even stupidity, on the part of the pilot so that we can convince ourselves that the same thing can never happen to us.

The same type of thing occurs in all risk activities I'm familiar with. Human nature, I suppose.
 
weilke said:
As you can see here on the internet, there is no shortage of pilots who have done so and will do so again and its bascically no big deal. They survived it, so anyone can do it, even if they fly 20hrs/year. Also, the airlines will do low-visibility takeoffs, and I mean who needs a dual-crew, independent AHRS, radio altimeter and a Cat III runway, if you just keep the DG nicely lined up, its so easy anyone can do it with a little bit of practice. Monkey-see, monkey-do, you crash two or three times, you'll get it right eventually....
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It's so easy, a cave man can do it! ;)
 
Half Fast said:
I hate to say it, but I think when these things happen most of us hope that it was some sort of poor judgement, or better yet foolishness or even stupidity, on the part of the pilot so that we can convince ourselves that the same thing can never happen to us.

The same type of thing occurs in all risk activities I'm familiar with. Human nature, I suppose.
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The best response to seeing stuff like that is to resolve to do our best to avoid making those mistakes ourselves, not to try to fool ourselves into thinking we're infallible.
 
I accept the risk of a crash because of my love of flying. I am not naive enough to believe it couldn’t happen to me. However, in the unlikely event that I do wind up in an NTSB report, there are a few phrases that will NOT be present. The phrases you will not find include, “fuel exhaustion”, “a BAC of .xx”, “drug screen positive for...”, “exceeded gross weight”, “out of CG”, or “departed VFR in IMC conditions”.
 
Half Fast said:
Hmmm.......

Way back in post 133, @Radar Contact wrote:



That speculation would be in line with the tire chirps heard on the video.

Thoughts?
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I shared the report and vids with a friend who had a 340, and flew the hell out of it until
He upgraded to an MU2. He found the report haunting, he had the same autopilot. He said a lot of ppl will take off IMC and pop autopilot on before gear is up and that if trim was way out the plane would be near impossible to control.
He flies out of FL a lot as well and has seen that fog. Told me sad thing is that it usually burns off in less than an hour. Not sure if 340 you need to do it, but he was telling me for MU2 they have protocols for ‘runaway trim’
 
benyflyguy said:
I shared the report and vids with a friend who had a 340, and flew the hell out of it until
He upgraded to an MU2. He found the report haunting, he had the same autopilot. He said a lot of ppl will take off IMC and pop autopilot on before gear is up and that if trim was way out the plane would be near impossible to control.
He flies out of FL a lot as well and has seen that fog. Told me sad thing is that it usually burns off in less than an hour. Not sure if 340 you need to do it, but he was telling me for MU2 they have protocols for ‘runaway trim’
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I live near KBOW. At that time last year we had fog for several days that was thicker and higher than typical, and lasted until nearly noon. I cancelled a couple of my own flights that week.
 
Hey guys... looks like the final report was published: https://app.ntsb.gov/pdfgenerator/R...ID=20171224X03602&AKey=1&RType=Final&IType=FA

There was some heated(?), no, "passionate" debate about the merits of taking off in that thick fog, so in light of that these findings are interesting:

Couple interesting elements of note:
-the plane was over max gross
-the plane was outside of its CG
-airspeed was not attained and or maintained, this was the noted cause

It notes the pilot was spatially disoriented


**It seems plausible and likely that he became spatially disoriented, however the only thing we know for a fact is that the aircraft was overloaded and outside of its CG envelope.. that *can* be deadly even on a totally beautiful clear VMC day

Either way, something to learn from, and shows the decisions that were deadly leading up to this... maybe had the aircraft been a few hundred pounds lighter he'd have climbed better, been able to maintain better control (or not crash) and been on top of the fog shortly there after
 
I wonder how they calculated the weight of the aircraft at the time of the accident, and the cg, after most of it had burned away.
 
Salty said:
I wonder how they calculated the weight of the aircraft at the time of the accident, and the cg, after most of it had burned away.
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I thought the same thing.. but figured they'd use what the FBO said they had for fuel, plus the known empty weight, plus who they knew was on the plane (based on their medical records)? Basically a pilot took off in dense fog in an overloaded plane outside of its CG.. triple facepalm. You can only pull he rubber band so far until it snaps
 
I truly doubt being 100 lbs over weight had a major effect on the outcome. The CG according to their graph was pretty well centered, just outside the upper limits due to the weight so it likely didn't have an effect on pitching moments. I imagine given the conditions as soon as he rotated all he saw was total whiteout. How many instrument rated pilots have practiced rotating, lift off, and transition under the hood or with no outside visuals? Granted if he was lighter, there certainly would have been a larger safety margin where the plane could have overcome a less than perfect rotation.
 
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