Plane crashes into homes in San Diego, Ca

ok, let’s say he did. Then what happens? FAA review for being behind the plane or skipping 28 and going to 23 without following the circling procedure? Medical review for being disoriented? I’m just an IFR student

tia

Those can happen once he gets on the ground intact, and should not be an operational concern. If the pilot had confessed to ANY sort of problem, he'd have gotten an even higher level of service from ATC, which is hard to fathom, because now all eyes, focus, and priority are on saving a pilot in trouble, instead of wondering "WTF is this hayseed doing???". Removing the uncertainty is the first step to getting assistance.

I've never been on-freq when full ATC heroics were deployed, but I've heard a few youtubes/liveatcs/whatevers and they will absolutely do everything in their power for you, and their powers are profound. You just gotta say "help"

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Once the crisis is over, the pilot would expect a friendly chat with the local FAA, and likely a 709 ride after some retraining and review. I've seen dudes go through it, it's a nothingburger. Think of it as a mandatory FR/IPC that addresses and improves whatever was lacking that day. It's not punitive, it's constructive.
 
I get it, but I count seven, yes seven commands issued by that controller to help a pilot obviously in trouble. Had the pilot followed any one of them, this crash wouldn't have happened. Not only do you need to ask for help, but listen to it when you receive it. This poor man didn't hear a thing the controller was saying. Sad.
I'm leaning toward some type of incapacitation; he was an experienced pilot, this shouldn't have confused him that much, even if not that much experience for CTL.
 
From my transcript:


19:03:52 SOCAL----------- “Information Tango current at Montgomery: wind 170 at 10, visibility 10, ceiling is 1700 broken, overcast at 2800, altimeter 29.81, runway 23 in use.”

This is very close to the METAR issued at 1853Z (10 mins prior):

KMYF 111853Z 18010KT 10SM BKN017 OVC028 19/14 A2980 RMK AO2 SLP086 T01940139
To me he was just expecting what he always got: ILS28R. And when he got something else it clearly totally threw him. You can hear it on the tape. His radio calls were rapid fire the entire time, to say the least. Then when he got "circle to land 23," it was "uh....."

Notwithstanding the fact that ATC announced 23 was in use, the METAR (and presumably ATIS) had the winds at 100-110 degrees @10knots off the runway he was expecting. That should have been a clue to at least perk your ears up and be ready for something different, given the fact that there was another runway better aligned to the prevailing wind and a circling approach for that runway existed.

My guess is that if his II went over this exact scenario with the good doctor on the ground, he might not immediately clue into the possibility of a different runway and a circling approach. Once it was pointed out to him, it would surely make sense, and I would further guess that if you then did a training flight playing out this scenario he would do just fine.

To me, absent mechanical or medical (and there's no reason to suspect the former and I would bet 100% against it being the latter), this is a human factors accident. He kept doing and expecting the same thing until something changed, and when it did he was caught with his pants down. Situational awareness. Don't just get the weather, listen to and understand the weather. Maybe he didn't hear "runway 23 in use" from approach. Still, he should have at least had it in mind as a possibility.

My lesson from this: brief the unexpected. And don't get lulled into routine. This isn't "time to make the donuts" just because you've done it 25 times this year.
 
Just to give an idea of what happens when a pilot gets disoriented…there was a Cherokee years ago that had a vacuum pump failure. He lost his AI and DG. In the process of being unable to hold a heading or an altitude, the pilot also indicated that his airspeed indicator, altimeter, and whiskey compass had failed.

One of the guys I was flying with at the time happened to be on frequency in his King Air, gave him a little partial panel instrument dual over the radio (I think it started off with “take your hands and feet off the controls”), descended below the clouds so he’d know what altitude to have the cherokee descend to, and once the Cherokee got below the clouds, he led him to a nearby airport.

turns out the pitot/static instruments and whiskey compass worked just fine, but when disorientation hits, it’s amazing how our brain lies to us to justify what we see.
 
Been here a few times.

Let's say doc had the minimum 1MM/100k sublimit liability coverage.

All of the claimants will assemble their damages. There will be dozens of 'injured's. Every attorney will be claiming for the full amount (1MM)

The insurance company will attempt to settle within the policy limits. Nobody will take that deal, so no progress can be made -- insurance needs to settle everything or nothing.

The insurance company now has $1MM to spend defending the doc against all of the claims against him, which is a decent amount of lawyer-power. The ones with a body count or property damage will prevail and get something. All of those karens who sued for PTSD will hopefully get told to kick rocks (our karens did -- doc may not be so lucky since he likely has an estate of some size, the greed will be enhanced)

It will take a year or two to unwind it all.
I'm generally not for new laws, but as a dad, I think there should be a reasonable expectation that some of the man's estate be left to provide for the kids he left behind. If you happen to be one of the people suing his estate and reading this thread - remember the kids. If this man had a medical emergency, that's not their fault and if you "win" big it's still a loss for everyone. Money doesn't solve this.
 
To me he was just expecting what he always got: ILS28R. And when he got something else it clearly totally threw him. You can hear it on the tape. His radio calls were rapid fire the entire time, to say the least. Then when he got "circle to land 23," it was "uh....."

Notwithstanding the fact that ATC announced 23 was in use, the METAR (and presumably ATIS) had the winds at 100-110 degrees @10knots off the runway he was expecting. That should have been a clue to at least perk your ears up and be ready for something different, given the fact that there was another runway better aligned to the prevailing wind and a circling approach for that runway existed.

My guess is that if his II went over this exact scenario with the good doctor on the ground, he might not immediately clue into the possibility of a different runway and a circling approach. Once it was pointed out to him, it would surely make sense, and I would further guess that if you then did a training flight playing out this scenario he would do just fine.

To me, absent mechanical or medical (and there's no reason to suspect the former and I would bet 100% against it being the latter), this is a human factors accident. He kept doing and expecting the same thing until something changed, and when it did he was caught with his pants down. Situational awareness. Don't just get the weather, listen to and understand the weather. Maybe he didn't hear "runway 23 in use" from approach. Still, he should have at least had it in mind as a possibility.

My lesson from this: brief the unexpected. And don't get lulled into routine. This isn't "time to make the donuts" just because you've done it 25 times this year.

Agree entirely. One point of order - he was told 23 was in use at his first check-in with SOCAL, about 10 minutes prior to the start of the “accident” tape.
 
I'm leaning toward some type of incapacitation; he was an experienced pilot, this shouldn't have confused him that much, even if not that much experience for CTL.

The problem with this theory is that he communicated his desire to get cleared to land 23 just after being scolded for diverging from the localizer. This shows intent.
 
I'm generally not for new laws, but as a dad, I think there should be a reasonable expectation that some of the man's estate be left to provide for the kids he left behind. If you happen to be one of the people suing his estate and reading this thread - remember the kids. If this man had a medical emergency, that's not their fault and if you "win" big it's still a loss for everyone. Money doesn't solve this.
And the kids of the people he killed?
 
I'm generally not for new laws, but as a dad, I think there should be a reasonable expectation that some of the man's estate be left to provide for the kids he left behind. If you happen to be one of the people suing his estate and reading this thread - remember the kids. If this man had a medical emergency, that's not their fault and if you "win" big it's still a loss for everyone. Money doesn't solve this.

Would life insurance provide for his kids (assuming his policy didn't have an exclusion for piloting), or would that get gobbled up in the lawsuit as well?
 
I get it, but I count seven, yes seven commands issued by that controller to help a pilot obviously in trouble. Had the pilot followed any one of them, this crash wouldn't have happened. Not only do you need to ask for help, but listen to it when you receive it. This poor man didn't hear a thing the controller was saying. Sad.
Agree ATC did all they could. Think the point some others were making was to realize you need the help sooner and ask for it. You can get pretty laser focused on completing an approach and move from a little behind to way behind before you know it. A lightbulb went off for me that asking for a vector and a climb when you get a little behind is a good thing to do vs continuing to try and fix it. That's a mental shift that, as one poster mentioned, really isn't trained as part of an IFR.
 
A lightbulb went off for me that asking for a vector and a climb when you get a little behind is a good thing to do vs continuing to try and fix it. That's a mental shift that, as one poster mentioned, really isn't trained as part of an IFR.

I agree, asking for a safe vector and altitude while you get your "stuff" back together can be a life saver. Fly for a while, calm down, re-brief the approach, and then when you're ready, ask to get vectored back around. This is where ample fuel reserves can buy time to re-group. I personally like at least an hour of reserve, 45min to me, while legal, may not be enough.

Like you say, good things to know that you may not receive during your IR training.
 
Would life insurance provide for his kids (assuming his policy didn't have an exclusion for piloting), or would that get gobbled up in the lawsuit as well?
It depends, but in general, life-insurance proceeds wouldn't be part of the estate unless the estate is the beneficiary.
 
I’ve typed stuff on this thread then backed out a few time. While I didn’t know him, he was a member over at the Twin Cessna owners group where he was highlighted in a recent magazine.

He had dual Garmin glass, top autopilot, top Twin Cessna specialty shop maintenance, lots of training in plane/regular sims, attended the engine/systems seminars, etc. He took training/safety way farther than the average GA Pilot. He had over 1000 hours in this plane and owned 3 planes of which one was an RV he built.

Seemed like a great person, doctor, husband, father and proponent of GA.

Fully understand the sentiment about him just getting confused about the circling approach and that snowballing. I wasn’t there and struggle to think that was it. He has the same amazing autopilot as me with envelope protection, etc.

My hope is that maybe with all the fancy avionics onboard that records data, they will be able to shed some light. My personal fear is what happens if the AHRS fails. I need to learn more about what drives my 4 separate AHRS systems on my plane. Is there a single failure point?? Maybe a common source via an ADC? I have to keep vacuum pumps for de-ice boots and plan to always have a vacuum AI. Of course I’ve also had 2 dual vacuum pump failures in less than one year.

I also try to keep in mind what altitude VMC is so if everything goes sideways I can hopefully climb to VMC levelish if going below isn’t an option. I’ve had an autopilot failure just entering IMC on an approach in a descending turn to intercept and it’s crazy the amount of information your brain has to process in seconds for a safe outcome. Simple anecdotes about be ready for anything doesn’t do justice to that situation for a single GA Pilot in the soup. Sorry for the ramble…

Prayers to his family.
 
I’ve typed stuff on this thread then backed out a few time. While I didn’t know him, he was a member over at the Twin Cessna owners group where he was highlighted in a recent magazine.

He had dual Garmin glass, top autopilot, top Twin Cessna specialty shop maintenance, lots of training in plane/regular sims, attended the engine/systems seminars, etc. He took training/safety way farther than the average GA Pilot. He had over 1000 hours in this plane and owned 3 planes of which one was an RV he built.

Seemed like a great person, doctor, husband, father and proponent of GA.

Fully understand the sentiment about him just getting confused about the circling approach and that snowballing. I wasn’t there and struggle to think that was it. He has the same amazing autopilot as me with envelope protection, etc.

My hope is that maybe with all the fancy avionics onboard that records data, they will be able to shed some light. My personal fear is what happens if the AHRS fails. I need to learn more about what drives my 4 separate AHRS systems on my plane. Is there a single failure point?? Maybe a common source via an ADC? I have to keep vacuum pumps for de-ice boots and plan to always have a vacuum AI. Of course I’ve also had 2 dual vacuum pump failures in less than one year.

I also try to keep in mind what altitude VMC is so if everything goes sideways I can hopefully climb to VMC levelish if going below isn’t an option. I’ve had an autopilot failure just entering IMC on an approach in a descending turn to intercept and it’s crazy the amount of information your brain has to process in seconds for a safe outcome. Simple anecdotes about be ready for anything doesn’t do justice to that situation for a single GA Pilot in the soup. Sorry for the ramble…

Prayers to his family.
My gut still says this is a medical.
 
I’ve typed stuff on this thread then backed out a few time. While I didn’t know him, he was a member over at the Twin Cessna owners group where he was highlighted in a recent magazine.

He had dual Garmin glass, top autopilot, top Twin Cessna specialty shop maintenance, lots of training in plane/regular sims, attended the engine/systems seminars, etc. He took training/safety way farther than the average GA Pilot. He had over 1000 hours in this plane and owned 3 planes of which one was an RV he built.

Seemed like a great person, doctor, husband, father and proponent of GA.

Fully understand the sentiment about him just getting confused about the circling approach and that snowballing. I wasn’t there and struggle to think that was it. He has the same amazing autopilot as me with envelope protection, etc.

My hope is that maybe with all the fancy avionics onboard that records data, they will be able to shed some light. My personal fear is what happens if the AHRS fails. I need to learn more about what drives my 4 separate AHRS systems on my plane. Is there a single failure point?? Maybe a common source via an ADC? I have to keep vacuum pumps for de-ice boots and plan to always have a vacuum AI. Of course I’ve also had 2 dual vacuum pump failures in less than one year.

I also try to keep in mind what altitude VMC is so if everything goes sideways I can hopefully climb to VMC levelish if going below isn’t an option. I’ve had an autopilot failure just entering IMC on an approach in a descending turn to intercept and it’s crazy the amount of information your brain has to process in seconds for a safe outcome. Simple anecdotes about be ready for anything doesn’t do justice to that situation for a single GA Pilot in the soup. Sorry for the ramble…

Prayers to his family.

Thank you for the insight. There are definitely some things that don't add up, especially given this gentleman's commitment to the craft.

One thing I haven't heard anybody (except the controller) mention: that C130J "Raider47" overflew a piece of airspace the N7022G occupied exactly 3 minutes later, right about the time he was getting to the top of the climb prior to the terminal dive. Raider47 was at 5000 at the time, 177kts GS.

When N7022G arrived at that same point over the ground exactly three minutes later, he was at 3400. Wind was out of the south. 22G's eastbound climb peaked 100 feet higher, at 3500, seven seconds later. Just 2NM and about a minute later, 22G crashed.

Those words the controller mentioned: "Caution, wake turbulence"
 
ok, let’s say he did. Then what happens? FAA review for being behind the plane or skipping 28 and going to 23 without following the circling procedure? Medical review for being disoriented?

I strongly doubt anything at all would happen. I don't think it would even get reported.
 
As horrible as this crash was, it could have been worse, with a high school nearby.

6C16A10A-C340-4C97-A549-8C8B9EC9A94E.jpeg
 
Thank you for the insight. There are definitely some things that don't add up, especially given this gentleman's commitment to the craft.

One thing I haven't heard anybody (except the controller) mention: that C130J "Raider47" overflew a piece of airspace the N7022G occupied exactly 3 minutes later, right about the time he was getting to the top of the climb prior to the terminal dive. Raider47 was at 5000 at the time, 177kts GS.

When N7022G arrived at that same point over the ground exactly three minutes later, he was at 3400. Wind was out of the south. 22G's eastbound climb peaked 100 feet higher, at 3500, seven seconds later. Just 2NM and about a minute later, 22G crashed.

Those words the controller mentioned: "Caution, wake turbulence"

Can that wake turbulence really drop ~1500 feet?
 
So, I learned something new today. On some aircraft, ADS-B reports autopilot mode.

https://globe.adsbexchange.com/?ica...2.4&showTrace=2021-10-11&timestamp=1633979449

If you go to ADSBexchange, you can see he is in A/P right up to the point where SoCal is trying to get him to read back the altitude restriction with the Approach clearance (you can actually click on the track line and if you scroll down on the left side, it will show the AP mode at that time).

Around the time he should be turning to intercept the loc, he kicks A/P off. He's hand flying the intercept and then is still hand flying when he starts deviating right heading straight for 23. Around the time ATC cancels his approach clearance, he puts it in Alt hold....but no lateral guidance. Then in the course of the vectoring/climb to the right the A/P goes off and on in various modes. Like he is trying to re-engage it, but the airplane isn't doing what he thinks it should.

Wonder what the A/P was set for when he originally kicked it off?
 
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So, I learned something new today. On some aircraft, ADS-B reports autopilot mode.

https://globe.adsbexchange.com/?ica...2.4&showTrace=2021-10-11&timestamp=1633979449

If you go to ADSBexchange, you can see he is in A/P right up to the point where SoCal is trying to get him to read back the altitude restriction with the Approach clearance (you can actually click not he track line and if you scroll down on the left side, it will show the AP mode at that time).

Around the time he should be turning to intercept the loc, he kicks A/P off. He's hand flying the intercept and then is still hand flying when he starts deviating right heading straight for 23. Around the time ATC cancels his approach clearance, he puts it in Alt hold....but no lateral guidance. Then in the course of the vectoring/climb to the right the A/P goes off and on in various modes. Like he is trying to re-engage it, but the airplane isn't doing what he thinks it should.

Wonder what the A/P was set for when he originally kicked it off?

Great find.
 
So, I learned something new today. On some aircraft, ADS-B reports autopilot mode.

https://globe.adsbexchange.com/?ica...2.4&showTrace=2021-10-11&timestamp=1633979449

If you go to ADSBexchange, you can see he is in A/P right up to the point where SoCal is trying to get him to read back the altitude restriction with the Approach clearance (you can actually click not he track line and if you scroll down on the left side, it will show the AP mode at that time).

Around the time he should be turning to intercept the loc, he kicks A/P off. He's hand flying the intercept and then is still hand flying when he starts deviating right heading straight for 23. Around the time ATC cancels his approach clearance, he puts it in Alt hold....but no lateral guidance. Then in the course of the vectoring/climb to the right the A/P goes off and on in various modes. Like he is trying to re-engage it, but the airplane isn't doing what he thinks it should.

Wonder what the A/P was set for when he originally kicked it off?
Interesting, I thought it was a big No-No to engage any kind of vertical guidance without lateral guidance engaged first..
 
The problem with this theory is that he communicated his desire to get cleared to land 23 just after being scolded for diverging from the localizer. This shows intent.

Aren't their certain parts of his financials that will be protected? His 401K, his Social Security, maybe Life Insurance. Those things do not go through the estate.
 
Wow, good info on the exchange/ADS-B A/P feature. I’ll have to go to the site and look at that. Unless you know exactly the steps to take, it can take more resources (attention) trying to setup the A/P correctly as it does to simply hand fly. Heck, dump the FD and simply maneuver via raw data if you have to.
 
Interesting, I thought it was a big No-No to engage any kind of vertical guidance without lateral guidance engaged first..
Not on the STEC 3100 (that he had). When you first engage the AP it’s in pitch and roll mode to capture what you have. You can do vertical with the push of a button or lateral or both indiscriminate of each other.
 
With the reported surface wind and the overall flight path/altitude deviations, I doubt this was a WT event.

I agree that it doesn’t explain the initial deviations and chasing (especially with the new info about the A/P engagement), but could it have caused the final upset that was unrecoverable?
 
Haven’t read the whole thread but a lot of blame on the CTL approach. I disagree 100%, how can you blame an approach that he never did? I’d put more blame on his understanding of the English/pilot language based on his expectations of which approach to use. He didn’t actually do ANY approach, so I don’t see how one can blame the actual approach.
 
Haven’t read the whole thread but a lot of blame on the CTL approach. I disagree 100%, how can you blame an approach that he never did? I’d put more blame on his understanding of the English/pilot language based on his expectations of which approach to use. He didn’t actually do ANY approach, so I don’t see how one can blame the actual approach.
People aren't blaming the approach so much as speculating on the possibility that the pilot wasn't prepared for/understanding the approach to complete it.
 
People aren't blaming the approach so much as speculating on the possibility that the pilot wasn't prepared for/understanding the approach to complete it.

Yep. Pretty much what I said. Except people are getting pretty specific on how to do a CTL approach which really has no bearing.
 
I’ve typed stuff on this thread then backed out a few time. While I didn’t know him, he was a member over at the Twin Cessna owners group where he was highlighted in a recent magazine.

He had dual Garmin glass, top autopilot, top Twin Cessna specialty shop maintenance, lots of training in plane/regular sims, attended the engine/systems seminars, etc. He took training/safety way farther than the average GA Pilot. He had over 1000 hours in this plane and owned 3 planes of which one was an RV he built.

Seemed like a great person, doctor, husband, father and proponent of GA.

Fully understand the sentiment about him just getting confused about the circling approach and that snowballing. I wasn’t there and struggle to think that was it. He has the same amazing autopilot as me with envelope protection, etc.

My hope is that maybe with all the fancy avionics onboard that records data, they will be able to shed some light. My personal fear is what happens if the AHRS fails. I need to learn more about what drives my 4 separate AHRS systems on my plane. Is there a single failure point?? Maybe a common source via an ADC? I have to keep vacuum pumps for de-ice boots and plan to always have a vacuum AI. Of course I’ve also had 2 dual vacuum pump failures in less than one year.

I also try to keep in mind what altitude VMC is so if everything goes sideways I can hopefully climb to VMC levelish if going below isn’t an option. I’ve had an autopilot failure just entering IMC on an approach in a descending turn to intercept and it’s crazy the amount of information your brain has to process in seconds for a safe outcome. Simple anecdotes about be ready for anything doesn’t do justice to that situation for a single GA Pilot in the soup. Sorry for the ramble…

Prayers to his family.

Thanks for posting this. I hope the data survived. It's not what I expected to hear about him. I still think the CTL instruction confused him, but what happened after that is anybody's guess.

Honestly, your post just makes this accident hit harder for me personally. This shouldn't have happened to him, yet it did.

Juan Brown did a video on this accident, his thought is Spatial Disorientation. His theory is that as he accelerated to climb, his inner ear messed him up with probably somatogravic illusion, so he stopped the climb, then just got totally disoriented. Add that to the confusion he probably felt over the approach and things just got beyond his ability to deal with it. That level button would have probably saved his life if indeed it was working.
 
Yep. Pretty much what I said. Except people are getting pretty specific on how to do a CTL approach which really has no bearing.


The CTL instruction threw him for a loop IMO, and that's where I think the relevance is. He was confused about it, and in my opinion, left the localizer to get aligned with runway 23, while still in IMC. After he began departing the localizer, he asks if he is cleared to land on runway 23, which is what makes me think that's what started this chain of events. What eventually killed him was his inability to get things back together after the controller cancelled his clearance. It doesn't make sense, but I think had he continued on the ILS 28 until he broke out, he would still be with us. It's just a sad outcome.
 
That level button would have probably saved his life if indeed it was working.
That goes into my confusion of this. With his commitment to training/safety, I’m thinking he would have understood his autopilot inside and out. I have tested the level button in some crazy (not filmed) situations and it always does it’s job. At a minimum you would have seen it trying to right the ship from the doorbell footage and I think it would have done it…if he was cognitively there to push the button.
 
From a post above, I believe he was a surgeon? From a flying doctor friend, his view was that their training can actually get them into trouble. When they are doing a procedure, they're trained to keep pushing through obstacles, adapt/overcome. They aren't trained to abort/redo, because it doesn't work with what they're doing. So things that may be perceived as "ego" may rather be an effect of "mission training" from their career.

Someone else mentioned that some instructors don't teach when to abort, other than intentionally going missed. Primary training, VFR approach, you're not stabilized the current training is to just go around. That's consistent I think these days. Is "go missed" if you're behind the approach a standard IFR training item to practice?
 
That goes into my confusion of this. With his commitment to training/safety, I’m thinking he would have understood his autopilot inside and out. I have tested the level button in some crazy (not filmed) situations and it always does it’s job. At a minimum you would have seen it trying to right the ship from the doorbell footage and I think it would have done it…if he was cognitively there to push the button.

Unfortunately I think he was overloaded.

One thing I was taught in my instrument training is not to automatically disconnect the autopilot when things aren't going correctly, unless it is very obvious there is something wrong with the autopilot.

It's like having an extra set of hands there, and allows you to focus on the problem at hand rather than having to take over flying the airplane, you have more bandwidth to solve problems.
 
From a post above, I believe he was a surgeon? From a flying doctor friend, his view was that their training can actually get them into trouble. When they are doing a procedure, they're trained to keep pushing through obstacles, adapt/overcome. They aren't trained to abort/redo, because it doesn't work with what they're doing. So things that may be perceived as "ego" may rather be an effect of "mission training" from their career.

Someone else mentioned that some instructors don't teach when to abort, other than intentionally going missed. Primary training, VFR approach, you're not stabilized the current training is to just go around. That's consistent I think these days. Is "go missed" if you're behind the approach a standard IFR training item to practice?

I once went missed on an RNAV approach just after the FAF because the GPS didn’t cycle to APP mode. Reason: I had left it in OBS mode and it never cycled.

The DPE in the right seat liked that I went missed. Because I recognized what I did and confessed/went missed, he let me try again without an unsat. Passed my instrument check ride.

I’ve made plenty of other mistakes, but that one stuck with me because of the situation and I guess it’s somewhat relevant to this.
 
I looked over this new A/P data. I figured out the ADS-B track replay doesn't play at actual speed as 1X is too slow and 5X is too fast when trying to match up to the ATC tape.

A few other things I noticed. If the data is accurate, the plane doesn't seem to maintain or capture altitude while it indicates A/P on. Then the A/P kicks off and stays off the rest of the time. The ALT SEL does show being set to 3000 feet on the initial missed clearance, then the 3800 feet and the 090 heading, but it never shows it set to the 4000 or the 5000 feet. What is strange is how the pilot sounded like everything was normal when he is asked "say altitude". He responds "2500" when he should have been climbing to 4000.

I did noticed on an earlier flight the "ALTHOLD" note on ADSBexchange was displayed even as the plane was landing. So, not sure how consistently reliable that information is, unless that button is selected on the autopilot without the autopilot actually being on. During the final vectors to this approach the ALTHOLD appears by itself at some strange times.
 
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Not on the STEC 3100 (that he had). When you first engage the AP it’s in pitch and roll mode to capture what you have. You can do vertical with the push of a button or lateral or both indiscriminate of each other.

Can you push the ALT button without the autopilot actually engage and get some result or benefit?
 
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