Epic E1000 CFIT Steamboat 13 Feb 26

Remember seeing Rocky Mountain Airways Dash 7 make approaches into SBS.
They flew right down the Yampa river downtown Steamboat.

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Rocky Mountain Airways historically operated de Havilland Dash 7 aircraft into Steamboat Springs (Bob Adams Field) using a private, specialized Microwave Landing System (MLS) approach. This tailored, steep-gradient approach allowed the airline to fly into the mountain-surrounded airport before modern GPS approaches.
Side-note - that bottom pic is at an old, no longer extant STOL strip at Avon (Vail). We think SBS is bad, that one had an 8° glidepath, in the pre-RNAV days, no less.
 
granted I’m not doing mental math, but just looking at the chart it would appear that if you saw the runway at WDCHK, altering course to the right to intercept the extended centerline would give you a pretty clear descent path for a normal, stable descent. What am I missing?
This could lead into a discussion about when it’s okay to bracket off final course guidance.
 
Side-note - that bottom pic is at an old, no longer extant STOL strip at Avon (Vail). We think SBS is bad, that one had an 8° glidepath, in the pre-RNAV days, no less.

Side note to side note - I am sitting about 100 yards from the site of the old Avon STOLport as we speak. I can see the ramp area from my window.
 
RNAV-E takes them in between Emerald Mt and Werner. Why didn't they use that? Winds favored 14? (I'm not an IFR guy.)
I tend to avoid circling-only approaches, 'cuz I don't like circling... It's possible that they didn't study the approaches enough prior to takeoff to realize what sort of trouble they were setting themselves up for.

I had not heard of an E1000 so I looked it up. That is one hot ship. Like flying a WWII fighter.
Not really. It's far better equipped than a WWII fighter, and far easier to fly due to modern aerodynamics. It's fast, but hardly faster than a TBM 900-series.

You better be on your game bringing that plane into that airfield in those conditions at night.
You'd better be on your game bringing any plane into that airfield in those conditions at night!

Night, mountains, scattered/broken layer, hot little ship. I bet the panel had everything - except a terrain warning.
Oh, I'm quite sure it had terrain warnings... But they get disabled when you're on an instrument approach. I didn't know that before this accident tho, and I'm a geek, so I'd say it's not common knowledge (or wasn't).

Wonder if they accidentally took out a few altitude constraints in the box, maybe a vertical direct too not thinking about what came prior
Doubtful. It's just really easy to fly the +V part of the approach, even below MDA, which in this case takes you right where this Epic ended up.

Garmin should never have a glide slope, advisory or not, that flies into a mountain.
How do they know there's a mountain? It's not like they're doing anything like surveying things. They're just taking the FAA's approaches and adding a standard 3 degree path to them. It's up to the pilots not to abuse them, though I guess today we can't expect people not to be over-reliant on automation. :(

I wonder if the "Visual Segment - Obstacles" or lack of a VDP is able to be encoded in ARINC 424, because if it is, then they could easily do a software update for all their units to not generate a +V glidepath on those approaches. Otherwise, not generating a glidepath when there might be terrain in the way is a lot more difficult and Garmin would have to come up with their own standards that varied from TERPS, and that probably opens them up to even more liability.

Side-note - that bottom pic is at an old, no longer extant STOL strip at Avon (Vail). We think SBS is bad, that one had an 8° glidepath, in the pre-RNAV days, no less.
There's some really interesting stuff about the Avon STOLport here. 4000 foot runway at 7538 MSL; Rocky Mountain's Dash 7s would approach at 77 KIAS (!) and 1000-1400 fpm. I'm surprised they could even fly that slow! I doubt such a thing would even be approved by the FAA today.
 
granted I’m not doing mental math, but just looking at the chart it would appear that if you saw the runway at WDCHK, altering course to the right to intercept the extended centerline would give you a pretty clear descent path for a normal, stable descent. What am I missing?
From the plate it appears that you
are correct....but that would require departing the approved approach course. At night in mountains? Seems unlikely to become a popular technique.
 
How do they (Garmin) know there's a mountain?
Look at a map. Run a simulation.

Agree that Garmin probably assumed the FAA would never issue an approach that flew you into a mountain if you started descending at the FAF. The PIC assumed Garmin autopilot would never fly them into a mountain. FAA assumed a pilot wouldn't fly below the MDA until past the mountain, which at night looked like the horizon.

So yes, a lot of "they shouldn't haves" to go around.
 
TBF, the FAA probably assumed a pilot would not fly a procedure at night which was NA at night.
Copy that. Still, lots of assuming by several participants, including the PIC. I'm kind of curious how this will all sort out. I hope the FAA and Garmin do thing differently, maybe look at approaches differently. And maybe pilots will as well.
 
Agree that Garmin probably assumed the FAA would never issue an approach that flew you into a mountain if you started descending at the FAF.
Descending at the FAF isn’t a problem. Descending below MDA can be. And Garmin is, I’m sure, well aware that an approach without a published glide slope or glide path isn’t designed for a glide slope or glide path.

The PIC assumed Garmin autopilot would never fly them into a mountain.
Pilots tend to assume a lot simply because they don’t learn their avionics or instrument procedures.

FAA assumed a pilot wouldn't fly below the MDA until past the mountain, which at night looked like the horizon.
Interestingly, if there’s a mountain between you and the airport, you won’t see the airport, and therefore shouldn’t leave MDA anyway.
 
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There is no doubt this is risky approach. It is not available for a landing on 32 at night. There are obstacles on visual segment below the MDA. And there are no minimums available at approach speeds above 120 KTS GS.

Perhaps it is too dangerous to be available at all. But it’s perhaps telling that, even within a group of Monday morning quarterbacks sitting safely at home, there seem to be at least a few comments about this chart that are contrary to what the chart says.
 
There is no doubt this is risky approach. It is not available for a landing on 32 at night. There are obstacles on visual segment below the MDA. And there are no minimums available at approach speeds above 120 KTS GS.

Perhaps it is too dangerous to be available at all. But it’s perhaps telling that, even within a group of Monday morning quarterbacks sitting safely at home, there seem to be at least a few comments about this chart that are contrary to what the chart says.
It is only risky if you don't follow the chart and violate regulations and use +V below the MDA. All approaches are risky if you ignore the chart and violate regulations.
 
there seem to be at least a few comments about this chart that are contrary to what the chart says.
What might those be? It would be helpful in understanding this situation and the comments.

All approaches are risky if you ignore the chart and violate regulations.
I disagree with equivalizing all approaches as having the same risk level because of the fact that any approach has risk. Agree that deviating from any chart has consequences. The questions are how likely is a deviation given the tasks required in the approach environment, and what is the level of consequences.
 
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I disagree with equivalizing all approaches as having the same risk level because of the fact that any approach has risk. Agree that deviating from any chart has consequences. The questions are how likely is a deviation given the tasks required in the approach environment, and what is the level of consequences.
As a night circling approach, it’s high risk. As a day straight in, not so much. But if you believe that the magenta line protects you more than your eyes on the visual segment, you increase the risk of the day straight in substantially.
 
What might those be? It would be helpful in understanding this situation and the comments.
Actually, all three I mentioned in that post. Just on this page, we have yours.
Garmin probably assumed the FAA would never issue an approach that flew you into a mountain if you started descending at the FAF.
You don't fly into a mountain descending at the FAF. You descend into a mountain when you improperly descend from the MDA without any of the required runway visual references (IR 101), especially on a straight-ion approach that is not authorized.

The problem I see is that people are trying to blame the chart and the availability of CDFA stabilized approach guidance down to the MDA (not down to the runway). This one is definitely less tolerant of error, but you could probably find similar errors in most fatal accidents where someone deviates from the IAP. So is the answer to get rid of instrument approaches, or just the ones I don't like? Or maybe the FAA is all wrong about stabilized approaches and we should go back to dive and drive?
 
So is the answer to get rid of instrument approaches, or just the ones I don't like?

Of course, no one is talking about getting rid of approaches, and of course it isn't trivialized down to "Like or dislike", but rather "how risky is this".

Agree - flying below the MDA was an error that killed them. Relying on the auto pilot killed them. But could not the autopilot have leveled at the MDA instead of continuing the decent? Could the Terrain warning have been kept on? Autopilot flying an approach isn't supposed to take you off course, take you to a dangerous spot.

Pilots make mistakes. Can we modify or replace this approach so that there is a greater margin for safety? Can we have an extra help from the autopilot?

Just on this page, we have yours.
Cool - what might that be in your opinion?
 
But could not the autopilot have leveled at the MDA instead of continuing the decent?
Probably. If the pilot managed the autopilot properly, definitely.

But it comes back to knowing your equipment, and what modes to use for an MDA vs a DA is a common point of remedial teaching where I work.
 
It’s an insidious approach. You can have the runway in sight at the FAF, descend on a CDFA, then lose it behind terrain just as you arrive at WDCHK. If you stay at MDA for just a couple tenths of a mile past WDCHK, you will see the runway again. If you fly about a dot high on the approach (given vertical guidance) or just fly a normal visual from that point you can keep the runway in sight the whole way, but it’ll be steeper than the nominal glidepath and you’ll basically skim the ridgeline.

The angle to meet straight-in criteria is calculated from the FAF, which can strongly insinuate that it’s a relatively shallow approach, but the reality is that it’s effectively much steeper. I question whether the symbology on the chart goes far enough to describe the magnitude of the obstacles and the resultant, safe glidepath needed to overcome them.

Either way, 5.5 miles is a pretty long way to fly at MDA. The closer in you get, the steeper the final becomes. You almost have to get and maintain visual with the runway immediately after WDCHK for it to be anything other than circling or a very steep straight-in. In that, you have to either have local knowledge or have a degree of quick trigonometric ability to continue as a straight-in and successfully avoid the towers/ridgeline and maintain a stable glidepath while still following final course guidance, otherwise it reverts to circling pretty quickly (secondary minimums?). Or you bracket off just after leveling off and regaining visual after WDCHK, then fly over the valley. Might be a tough call in low visibility.

So why make it such a thin margin? Why rely so heavily upon all the “gotcha” traps described above that require superior knowledge and skill to overcome? The flight test people figured out that this would be risky.

Considering the loss of visual on a CDFA at WDCHK and having to continue at MDA beyond, designating this approach as a straight-in is a misnomer. There’s basically one use-case for this as a legit straight-in approach, and that’s as a “cloud break” procedure (terminology not really used in the US) where you break out into (daytime) VMC above MDA and before WDCHK, then bracket east to continue a safe, stabilized, and relatively shallow descent as insinuated by the nomenclature describing the approach.

So either notate that more strongly, or raise the MDA and/or move WDCHK and call it what it is.
 
Agree - flying below the MDA was an error that killed them. Relying on the auto pilot killed them. But could not the autopilot have leveled at the MDA instead of continuing the decent?
We agree it's risky, but the question becomes, who is responsible for managing that risk? Autopilots are GIGO. They are stupid. They just do what you tell them to.

Yes, if (I don't know if they did or didn't), the pilot entered the MDA in the PFD minimums box, it would have shouted "MINIMUMS! MINIMUMS!" and the pilot could have tapped the ALT button on the autopilot. Or are you recommending that this be away from the control of the pilot and "George AI" should have complete control? You are welcome to your opinion, but I prefer to makes continue/abort decisions myself,
 
require superior knowledge and skill to overcome?
We will have to disagree on the level of knowledge and skill required to know that the runway environment has to continuously be in sight in order to continue descent from the MDA to the runway. I though that part is trained ad nauseum, with instructors and Examiners even requiring memorization of a whole bunch of details that come down to nothing more than runway environment in sight." (Never mind knowing what "NA" means on an approach plate.)

If you are saying equipment knowledge, I still think understanding +V and how to stop a descent are pretty basic things. The fact that people don't understand those is a training failure and not the fault of the approach designers or equipment.
 
We will have to disagree on the level of knowledge and skill required to know that the runway environment has to continuously be in sight in order to continue descent from the MDA to the runway.
No, we don’t disagree on that. But it’s one tree for the rest of the forest of my post. Why even start to call this a “straight in” if it really isn’t? I’m talking about streamlining the big picture - it starts with acknowledging that the approach isn’t technically useable as advertised without a lot of caveats.

(Edit to add - I also want to remind everyone that the runway can be in sight far after the FAF, satisfying 91.175(c). You actually lose sight of the runway in the descent on a CDFA after the FAF - but instead of going missed at that point, the design prompts us to continue at MDA until we regain it, thus increasing the nominal angle.)
 
You actually lose sight of the runway in the descent on a CDFA after the FAF - but instead of going missed at that point, the design prompts us to continue at MDA until we regain it, thus increasing the nominal angle.)
Why do you lose sight of it if you’re flying a straight path towards it?
 
who is responsible for managing that risk
The PIC

Or are you recommending that this be away from the control of the pilot and "George AI" should have complete control?
No, PIC has to have final control, just as with any navigation the AP is doing. But I am saying an AP shouldn't take the plane below the MDA without at least alerting the pilot. If an approach has an MDA, should it not stop there until approved by pilot to continue decent? With a DA, the GTN 650xi has the "Fly missed" option. Why not add a MDA alert?

We're after the same goal here - how to help out the PIC and the AP not fly a glide slope into a mountain.
 
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No, we don’t disagree on that. But it’s one tree for the rest of the forest of my post. Why even start to call this a “straight in” if it really isn’t? I’m talking about streamlining the big picture - it starts with acknowledging that the approach isn’t technically useable as advertised.
Maybe, I guess that removing straight-in minimums might alert one to the fact that the approach should not even be attempted straight in (although nothing prevents the pilot from trying). But in terms of "designed for," I think we have to look at the approach outside the context of this accident where it appears it was not flown as designed.

I'm looking at an approach to an airport surrounded by mountainous terrain. That immediately tells me to pay close attention and not pretend it's Florida or sit back and let Geroge fly the airplane unmonitored. The approach is designed to be flown at 120 KTS or less The profile view announces the existence of obstacles on the visual segment (a standard notation) that is backed up by a marked obstacle, with it's elevation, on the plan view's depiction of the final approach segment. It has an MDA that keeps the airplane about 750' above the obstacle until the runway environment is in sight with at least 1.5 miles continuous visibility.
 
Why do you lose sight of it if you’re flying a straight path towards it?
You can see the far end of the runway almost the entire time on a CDFA, until around and beyond WDCHK. The mountain obscures only the approach end until then due to the offset azimuth and the parallax of the close-in mountain. Not easily discernible at that distance, especially to the uninitiated.
 
Maybe, I guess that removing straight-in minimums might alert one to the fact that the approach should not even be attempted straight in (although nothing prevents the pilot from trying). But in terms of "designed for," I think we have to look at the approach outside the context of this accident where it appears it was not flown as designed.

I'm looking at an approach to an airport surrounded by mountainous terrain. That immediately tells me to pay close attention and not pretend it's Florida or sit back and let Geroge fly the airplane unmonitored. The approach is designed to be flown at 120 KTS or less The profile view announces the existence of obstacles on the visual segment (a standard notation) that is backed up by a marked obstacle, with it's elevation, on the plan view's depiction of the final approach segment. It has an MDA that keeps the airplane about 750' above the obstacle until the runway environment is in sight with at least 1.5 miles continuous visibility.
Right, and at that point, it’s really not within what’s considered straight-in criteria. I posted the resultant angles far earlier in the thread.
 
You guys are a lot more knowledgeable than I am, but I don't understand some of the debate here. Seems pretty simple. The approach was not legal at night. The pilot tried flying it at night. It killed him. Am I missing something?
 
You can see the far end of the runway almost the entire time on a CDFA, until around and beyond WDCHK. The mountain obscures only the approach end until then due to the offset azimuth and the parallax of the close-in mountain. Not easily discernible at that distance, especially to the uninitiated.
So you don’t “lose sight of “ the runway, you simply see only a part of the runway, which indicates that there’s something between you and the other part.
 
It’s advertised as a straight in and not useable within a normal straight-in descent angle. I’ve mentioned this several times.
Apparently your definition of “straight -in” doesn’t match the FAA’s. And I don’t think you’ll get them to change theirs to match yours.
 
You guys are a lot more knowledgeable than I am, but I don't understand some of the debate here. Seems pretty simple. The approach was not legal at night. The pilot tried flying it at night. It killed him. Am I missing something?
The discussion has moved on to challenging the usability of the approach even in the daytime and, to some degree, how much pilots should be protected from making mistakes.

Actually, it was legal at night, although not to runway 32.
 
You guys are a lot more knowledgeable than I am, but I don't understand some of the debate here. Seems pretty simple. The approach was not legal at night. The pilot tried flying it at night. It killed him. Am I missing something?
No, that’s all correct. It was a violation to continue below MDA at that point. It was likely they intended to fly a CDFA straight-in. However we don’t know that for sure - the intent could have been to continue on the straight in, then break off and circle to 14. But either way, mistakes were made when sight of the runway was lost.

The debate is about the big picture. Because we’re all super pilots in here that would never fall into any of the other traps, I suppose it’s all rhetorical.

But the point remains, there’s really only one avenue to make this a straight in under 3.77° and it’s a fairly unusual avenue that most flatlanders won’t have ever considered by looking at the chart.
 
So you don’t “lose sight of “ the runway, you simply see only a part of the runway, which indicates that there’s something between you and the other part.

That’d be tough to discern at those distances until you’re much closer.
 
But the point remains, there’s really only one avenue to make this a straight in under 3.77° and it’s a fairly unusual avenue that most flatlanders won’t have ever considered by looking at the chart.
That’s a training issue, not an approach design issue. And it’s not a problem for flatlanders who regularly flew that avenue in the flatlands.
 
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