ATC Audio of TNFlyGirl Fatal Accident Released

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DeltaCharlie172

DeltaCharlie172

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I think this is such an important case study.

NTSB Final Report
Full NTSB Docket :blueplane:

IMO the variety of substances found in her system was just part of a larger cascade of problems that led to this fatal and tragic accident. Even if the NTSB did not find that those substances contributed directly to the accident, there is a wealth of lessons to learn.

We can have a discussion about this sensitive topic without personal attacks or other things that violate PoA rules. Keep it clean.

Updated Pilot Debrief
 
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This tragedy stands out, for so many reasons. It draws our interest, when so many other accidents provide more applicable learning opportunities for so many of us.

I feel badly for her family and friends. Amazing that her father flew with her so often.
Feel badly for the controllers when I hear audio such as this.
The video that Hoover dissected on pilot debrief shows so much, imo. When she was hand flying, and not distracted, her actual aviation skills may have been sufficient to fly without endangering (although I May stand corrected, I recall competent circuits, approach and landings, t&gs, etc) in her vids.


Disconnect the ap, throttle back, hand fly the airplane.

Re the pilot debrief vid-
I was amazed that on a cavu day, flying over terrain she should have known instinctively both from the ground and in the air, where she’d lived for decades-flying 40nm between Rockwood airport and Knoxville downtown- she was “turned around” and didn’t know which direction to fly.
That’s really hard for me to understand or fathom. Rockwood, I-40- heck the river and the sun location- all should have made it almost instinctual as to which rough direction she should fly.

From the final report, the flight school GM said she did poorly on her instrument phase check before the fatal accident. She was clearly still trying to learn- but failing.
How should her instrument cfis have dealt with her training deficiencies? Revisit ppc training, rather than instrument training?

A 10,000 rpm rate of descent? Must have been terrifying.
 
FWIW, the audio came straight out of the NTSB accident docket.

It is somewhat reassuring that a VFR on flight following does get followed up on when they disappear. According to the ATC audio summary, an alert notice was issued 2 minutes after they weren’t able to reach oher on frequency or on guard.
 
SFDukie said:
Feel badly for the controllers when I hear audio such as this.
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Yes, me too. When hopelessness, panic and resignation is conveyed over to another person who can’t help, just moments before they die, is something that I’m sure will stay with them forever…
 
SFDukie said:
A 10,000 rpm rate of descent? Must have been terrifying.
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Absolutely! I found it odd that the father can faintly be heard in background saying "help us." Makes you wonder if there was more going on before the accident. I can only speculate but first thought was pilot incapacitation.
 
I don't think this was any unusual chain of events. I don't think it was unexpected to some. I can simultaneously feel bad for the pilot, while placing the blame squarely on the pilot. They knew the airplane was too much for them, pretty sure that was documented. They had to know that certain medications are disqualifying for flight, and they should have known that the conditions that they were treating were also likely disqualifying.

If a pilot doesn't know how trim works, or how to hand fly straight and level, there's going to be a problem.

From what I've read about this, the only other thing I question is how someone signed her off on complex, and on high performance. When I did that, part of it was unusual attitude recovery, and part of that was unusual attitude recovery when the CFI played around with the trim. I'd be willing to bet a sandwich that she never did that. Being either nose high and near stall, or pointed down and near Vne will wake up a good pilot who isn't on medication. If someone doesn't really have the skill/experience, and finds themselves in that situation and impaired, it's probably not going to end up well.

I feel bad for the father, too, but at the same time I wonder if he was encouraging her in the right direction on all of this. Maybe something a little less potentially deadly would have been a better outlet. Like yoga or something. And I don't mean that to be a joke at all.

Oh yeah, and IBTL.
 
The audio doesn't sound like two people succumbing to CO poisoning. I know some people raised as a possibility when the accident first occurred. Of course, I don't know how people with CO poisoning sound when they talk, but I'm guessing it wouldn't sound coherent.
 
dmspilot said:
He didn't dissect anything, I did and he plagiarized my work. He doesn't have the original video and if he did wouldn't be able to dissect it since he thinks a Garmin 430 is an autopilot.
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I think the point there was that she was unable to figure out how to turn the 430 on after turning it off.

IMO anyone listening would realize he made a simple human mistake (called the 430 an autopilot) as he also spoke about the autopilot and nothing about it being off. I understood what he meant and sounds like you did also. Even laughed when he called the 430 an autopilot. Had she disengaged the autopilot would outcome be different?

What was your work that was plagiarized? Would be interested in seeing it.
 
dmspilot said:
The audio doesn't sound like two people succumbing to CO poisoning. I know some people raised as a possibility when the accident first occurred. Of course, I don't know how people with CO poisoning sound when they talk, but I'm guessing it wouldn't sound coherent.
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That’s my understanding too. Confusion, slowed, less coherent speech are what comes to my mind.
That’s not what we heard on the ATC recording.
 
Albany Tom said:
From what I've read about this, the only other thing I question is how someone signed her off on complex, and on high performance. When I did that, part of it was unusual attitude recovery, and part of that was unusual attitude recovery when the CFI played around with the trim. I'd be willing to bet a sandwich that she never did that. Being either nose high and near stall, or pointed down and near Vne will wake up a good pilot who isn't on medication. If someone doesn't really have the skill/experience, and finds themselves in that situation and impaired, it's probably not going to end up well.
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:yeahthat:
 
It seems to me the immediate “issue” is startle response. It’s a powerful thing that can override about anything.

That brings us to what could likely make you MORE susceptible to that phenomenon, and that could easily be even barely under the influence of, well, about anything that detects from normal performance or cognition. Even being heavily distracted by personal problems (not the case here, mentioned to illustrate the point).

Once you’re in startle response mode, and don’t have the skills to recognize that (not overtly trained) and recover from it, the rest is uninteresting, it’s inevitable.

Swiss cheese. She could easily just barely pass all the rest of what’s required, but be in a heightened state of vulnerability to startle response and the rest is history.

This sort of thing seems more common… why? Honestly, I think it’s a case of personalities more susceptible to this, in years past, simply not wanting to try this endeavor (maybe because just perceived as too dangerous?). Now we constantly tout how safe it is, and folks who might not otherwise wanna, now wanna.

Gonna go one step further… did her meds make her more susceptible, or not enough of them? There’s a scary trend developing where some docs think you should be drug monitored to ensure COMPLIANCE WITH PRESCRIPTIONS. Geesh, we’re not good at making sure you don’t have them in your system (certifying honest folks has been the historical successful marker), much less do you have them at the right amount…

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dmspilot said:

Working on a follow up.
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I do not see any plagiarism (both use Fair Use doctrine). Hoover used ADS-B data in CloudAhoy (or similar), while other video used ForeFlight without ADS-B data (drawn flight path). Each with their own commentary. Either way both are great videos of the dumpster fire flight.

Can't wait for an updated video from both gents.
 
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:) I have a shelf for 'weird' chemical things. Loctite small screw, thread sealant, and the kind that never ever comes off. Epoxy putty, dielectric grease, anti-seize, break free, silicone spray, etc.

10mm sockets? No idea where they are... And if I ever move, I'm sure the next person will find the dozens of #2 Phillips screwdrivers I've apparently misplaced.
 
dmspilot said:

Working on a follow up.
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I previously hadn't paid any attention to this pilot's antics and fatal crash, so watching this video is my first exposure to them. My comments below about her skills are so obvious that it seems silly to post them.

It's almost beyond belief any person could first obtain a pilot certificate and then the required endorsements to fly a Debonair yet display this level of incompetence. One of the primary tasks one learns to perform when progressing into cross country operations is that prior to takeoff, the compass heading for a direct flight to the destination is identified. All she had to do once airborne was make a slight turn to the right and fly a straight path.

The final outcome was predictable, and I'm curious as to what, if any, investigative efforts were made regarding her instructors and DPE.
 
Nice catch by @dmspilot. She never adjusted prop or mixture during that flight.

I wonder if perhaps her iPad and 430 we're not sync'd up. One on north up and the other on track up?

So many red flags and her missing an ATC hand off wasn't the nail in the coffin. Just unfortunate timing. I still think it's more likely than not that the autopilot did work correctly. But she didn't know how to work it and trimmed the wrong way overworking the autopilot.
 
She was incompetent. Zero situational awareness except making videos for an income stream.

The CFI's signed off on her? Really? Must have been nice operating the radios for her during the check rides, probably doing the TO's and landings too. No true CFI in their right minds would have allowed this. The instructors were probably young males that were giddy to sit next to her. Did they do the preflights and gas it up for her too?
 
FlightmechH3 said:
She was incompetent. Zero situational awareness except making videos for an income stream.

The CFI's signed off on her? Really? Must have been nice operating the radios for her during the check rides, probably doing the TO's and landings too. No true CFI in their right minds would have allowed this. The instructors were probably young males that were giddy to sit next to her. Did they do the preflights and gas it up for her too?
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Those are a lot of assumptions with no evidence.
 
Doc Holliday said:
Do we know that? Could it be that on her PPL checkride she performed to the standard?
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Agreed...poorly worded. My point was, even if her cfis gave her a pass for being cute, at some point she had to get past a dpe, who (hopefully) would make her perform to the standard.

Eta: I guess what I was saying is it's hard to imagine her being so incompetent and still passing her ppl ride. I regret posting on this thread because I'm not adding anything useful. She obviously slipped through the cracks in the system, whether that was cute girl syndrome, emotional issues/ pharmaceuticals, or just getting herself in over her head.
 
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There's a difference between being able to pass a one time check ride and proficiency. I know of several pilots right now that have pilot certificates and if they had to take a check ride today they wouldn't be able to pass it.

A check ride is a snap shot of a place in time, nothing more. Proficiency has to be maintained and improved upon. Too often those two are confused.

"You're only as good as your last flight."
 
I am willing to give her DPE the benefit of the doubt, and say that she could have practiced enough to pass the checkride standards on the checkride day. I am less willing to give the same to her instructors, but I also doubt her defiencies in skill are entirely the fault of her instructors wearing hot-girl goggles. A pilot who barely passes standards still passes, but is a mediocre pilot at best - and if they don't continually strive to hone their skills after the checkride, they will quickly become a poor pilot at best and an unsafe or dangerous pilot otherwise.

In another thread on the subject, another poster said something along the lines of "She may have passed her checkride by being a passable Cherokee pilot, but not a good airplane pilot".
 
Lets play with the meds factor a bit as a possible lessons learned. Disclaimer: all I know is what the report shows in terms of chemistry in the body tissue. I do not know whether there were prescriptions for those meds, or whether they were disclosed to an AME.

One factor that seems like a current infinite loop is the ability to not disclose medications from a physician / psychologist to the AME or BasicMed physician. Sadly, there is a growing list of of tragic ending examples where pilots hold back on disclosing medications in order to keep flying. This creates a difficult position for the aviation community as we regularly get lots of attention when a plane falls out of the sky, for any reason. Yet people are able to drive their cars on the same meds and it is rare if anybody past the local neighbors find out when tragedy happens.

Overall, for this analysis, I am in the camp of not doing a realistic IMSAFE before flight as the leading contender. Whether IMSAFE was taught and firmly reinforced during flight training is an open question.
 
Jim K said:
Agreed...poorly worded. My point was, even if her cfis gave her a pass for being cute, at some point she had to get past a dpe, who (hopefully) would make her perform to the standard.

Eta: I guess what I was saying is it's hard to imagine her being so incompetent and still passing her ppl ride. I regret posting on this thread because I'm not adding anything useful. She obviously slipped through the cracks in the system, whether that was cute girl syndrome, emotional issues/ pharmaceuticals, or just getting herself in over her head.
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The root cause of the accident could be a few different things. Not understanding automation, poor stick and rudder, pharmaceuticals, distracted, etc. Throw a dart and pick a reason. We're beating a dead horse at this point and collectively saying "wow".

We could blame the examiner. But on whatever particular day she was deemed to meet the standard. We could blame the CFI for signing her off, but... See above. To think at least two separate qualified individuals got suffered pretty girl syndrome as some have alluded, I'm not buying. She met a standard but perhaps that's an indictment on the standard itself?

Hypothetically, if she failed her checkride or if her instructor refused to give the hp/complex endorsements. Would the end result be the same? Would this accident still have happened? I'll argue yes. She's already shown regulations don't matter by way of toxicology. Did she lie about her prescriptions? Was she getting these drugs a more back alley way? She still knew she couldn't fly with those drugs. Whos to say lacking a certificate or endorsement would have mattered. People have flown without before.

She was a drugged up bad airman. Perhaps without the former the latter would be better. I hate the resignation of ones own fate. But she did this to herself more than the system did it to her. She acknowledged she was bad. Her father acknowledged she was bad. Perhaps her father didn't know about the drug use. And while this accident was sad. He's a little complicit as well. I don't blame the system. She very well could have flaunted it regardless since she already did.

Perhaps a 44709 was in order. But that would have been up to someone with signatures in her logbook. And that would be a steep threshold for me to report. But I think this is a good case study for cfi's giving flight reviews or endorsements to maybe not be so cavalier with their signature.
 
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SkyGazer said:
I am in the camp of not doing a realistic IMSAFE before flight as the leading contender. Whether IMSAFE was taught and firmly reinforced during flight training is an open question.
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Offfset by not getthereitis, but maybe what I’ll call videoitis. My adoring fans need another video, and the revenue sure is nice too. I better go fly.
 
It’s just a minor point, but it may not be fair to describe her father as complicit.
He’s a passenger. Her radio calls on the day of her fatal accident do not sound overtly, obviously, impaired to me. Obviously that doesn’t excuse failure to report use of benzodiazepines by the pilot.
 
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