NTSB Preliminary Report on Saratoga Crash at Pine Mountain Lake in Groveland, California
The NTSB released its preliminary report on the Pine Mountain Lake crash. As usual, the preliminary report contains no conclusions concerning the cause of the crash. For that, we'll have to wait up to 4 years. The preliminary report does, however, hint that the NTSB's investigation will focus on whether the pilot pressed on into weather beyond what the regulations allowed.
The full text of the report is here. Some excerpts:
Instrument night meteorological conditions prevailed at the accident site, and no flight plan had been filed.
Instrument weather conditions are those that require a pilot to fly by reference to his instruments rather than by looking out the window. To fly in instrument conditions, a pilot must be instrument-rated, his plane must be properly equipped, and he must have a clearance from air traffic control. He is not necessarily required to file a flight plan. For example, instead of filing a flight plan, the pilot may have departed San Carlos in good weather and then obtained a "pop-up" clearance from air traffic control before entering instrument conditions at Pine Mountain Lake. Nothing unusual or unsafe about that.
A pilot, who stated that he flies to the airport most weekends, reported attempting to
land a Cessna 510 while on an instrument flight plan, about 1 hour prior to the accident. He reported that throughout the instrument approach he was unable to identify the runway environment. He performed a missed approach, and diverted to Modesto where he landed uneventfully. He stated that he has flown into the airport utilizing the instrument approach regularly over the last few years, and this was the first time he had to divert to an alternate airport.
As discussed in this post, crash, a pilot on an instrument approach to runway 27 must "go missed" if he descends in the clouds to the minimum allowable altitude -- in this case 770 feet above the ground -- and still can't see the runway. Instead of going missed as required, some pilots will descend "just a little further" believing that, in just a few more seconds, they will break out of the clouds and the runway will appear before them. Descending below the minimum altitude set forth in the instrument approach procedure is a violation of FAA regulations and a leading cause of instrument approach-related accidents. The NTSB seems to suggest that the pilot of the accident aircraft, N4175A, must have ventured below minimums to get beneath the clouds because the Cessna jet had to go missed. However, the fact that the Cessna was forced to execute a missed approach at the airport one hour before the accident means little. Weather can change in an hour.
The remaining two propeller blades were attached at the hub. All of the blades exhibited leading edge gouges, and varying degrees of tip twist.
Gouges and blade twist is an indication that, the time of impact, the engine was developing power. Engine trouble can likely be ruled out.
A third witness, located 1/2 mile northeast of the approach end of runway 27, heard a low flying airplane, which he presumed was flying directly over his house, with engines running "full bore."
What was the pilot doing 1/2 mile northeast from the runway? (See image below.) As discussed in this post, the pilot should have been lined up for a straight-in approach. And during the approach procedure, the pilot should have been throttled back for descent. A pilot typically applies full throttle only when going missed.
Related Post: Piper Saratoga Crash at Pine Mountain Lake
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land a Cessna 510 while on an instrument flight plan, about 1 hour prior to the accident. He reported that throughout the instrument approach he was unable to identify the runway environment. He performed a missed approach, and diverted to Modesto where he landed uneventfully. He stated that he has flown into the airport utilizing the instrument approach regularly over the last few years, and this was the first time he had to divert to an alternate airport.
cy. The families of his passengers, however, probably cannot.
engines. The NTSB will exclude members of the victims’ families and their technical representatives from the investigation, feeling that they have nothing to offer. (Sad but true.)
airspeed just above the minimum flying speed, the asymetric thrust generated by the operating engine can flip the aircraft onto its back and out of control. A "Vmc roll", as it is called, is almost always fatal. When an engine quits during the critical takeoff phase of flight, a pilot -- even one who does everything right -- may not be able to land the twin-engine aircraft safely. Fog and a short runway (such as Palo Alto's) make matters only worse.
the parachute is to safely return the aircraft to earth if it is damaged in a mid-air collision. Unfortunately, the parachute didn't help in this case. Video of the Cirrus wreckage, on fire, descending beneath its canopy is
ave an operating transponder. Most gliders don’t have transponders. We don’t know whether the Pawnee’s transponder was on.
oming suggests
three crew members on board. According to an article in the
The actuators move the helicopter's rotor blades, allowing the pilot to control the flight of the aircraft. The AS350B's hydraulics -- similar to a power steering system in a car -- help move the helicopter's actuators.
This past April, the
happened in the Oakdale crash. The design has caused at least 10 deaths so far.
sure no one tampers with it. The Board investigator inspects, documents, and photographs the wreck.
But in an excellent
place in it. On Friday, the NTSB came out with a block-buster
airspace near major airports unless they have first obtained a clearance from air traffic controllers. If a pilot obtains the necessary clearance, controllers will dictate the pilot's path and use radar to monitor the pilot's every move.
When, as here, there is no post-crash fire, fuel exhaustion is a prime suspect. No fire often means that there was no avgas (aviation gasoline) on board to burn. But it's unlikely this accident was caused by fuel exhaustion. Though it didn't ignite, there was plenty of
he crash. The NTSB will ask Teledyne Continental Motors to participate in the investigation, and to help it determine the cause of the accident. As part of the investigation, the NTSB, along with representatives of Teledyne, will disassemble the engine and test its various parts. (Pictured right is an IO-550 engine being disassembled after a crash in 2001.) Of course, since Teledyne itself might be responsible for the crash, it's participation in the investigation presents a conflict of interest. It is like the police asking the suspect for help in solving the crime. To make matters worse, the NTSB will not allow the victims' families or the families' lawyers to participate in the investigation at all. The conflict of interest is discussed further
protections of MICRA, because the ambulance company was properly considered a “health care provider.” The ruling extended the umbrella of MICRA's protection from doctors to ambulance drivers, at least when those drivers are licensed as EMT’s..jpg)
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The service bulletin warns that failure to perform the inspection can result in engine failure. Because the risk is so great, the manufacturer labeled this particular service bulletin "mandatory."
Miles O'Brien, a former CNN correspondent,
generates a voice urging him to “Pull Up! Pull Up!” The plane’s wings secrete fluid that helps prevent them from icing up in poor weather. The cockpit has airbags, and its seats protect the passengers in a crash by absorbing 26 times the force of gravity. The Cirrus is the only aircraft of its kind that comes with a rocket propelled parachute that can shoot out of the back of the plane in an emergency. Partly as a result of all its safety features, the Cirrus has become the most popular general aviation aircraft, with sales surpassing long-time industry leaders Cessna, Beechcraft, and Piper.