This senseless accident is so very reminiscent of the fatal Lear 35 fatal circling accident at Aspen in 1991. It killed my twin brother. His final words to the other captain were “No! No! Your stall….(impact). The other captain had a known reputation as reported by first officers of flying very unstabilized mountain approaches. My twin, as director of ops chose to fly with the errant captain to provide remedial training and hoped to thwart his termination for incompetence. He found out first hand the truth expressed by the super scared first officers. As a staff instructor at SimuFlite, and a party to the investigation, I was allowed to make formal CRM presentations spotlighting my brothers accident and his last ditch effort to wrestle the controls from the PF captain and abandon the highly unstabilized circling approach. History does repeat itself but at least we do get better with tombstone engineering! Great work as always Juan.
I’m sorry for your loss, even all these years later. In a way loss gets better with time, but in another way it gets harder. I hope you’re having a great life, just sorry you’re not having it with your twin brother still here on earth.
Seems like it was the SIC who was mentally committed to getting on the runway despite a very unstable approach. He also likely activated the spoilers, which combined with the bank angle ultimately caused the plane to turn into a PSFO (Plane-Shaped Falling Object) @@unfaix
John Dunn was my dads next door neighbor. He was a super nice guy that would give you the shirt off his back and was a wonderful dad and husband. A huge loss.
@@OMG_No_Way John Dunn Dallas, TX from what I found in his obituary - Rainer Capital, a commercial real estate investment firm, is this a SIC ? I'm a former Architect lived in Sacramento, CA 33 years ago, with an interest in this crash. 1st officer & another passenger from Minnesota
Didn’t realize they had initially planned and had been cleared for the straight-in to 11. The most powerful word the pilots didn’t use was simply, “Unable,” when ATC gave them the new approach. They forgot that, as pilots in command, we decide where the aircraft is going, and ATC’s job is to make that happen safely and in coordination with other traffic. They might have had to spend a few minutes holding, but that would have been nothing compared to this tragic outcome.
My precise thought also. On approaches like this and in an aircraft like this, you don't want to change horses (approaches) in the middle of the stream.
Did a straight in on 29 the day before in a 310. That was quite a decent coming over the top. Barely VFR because of the smoke. Looks like the role of PIC was not firmly established.
Excellent report Juan. For the life of me I do NOT understand why these two guys got themselves into this mess. Too high, too fast, 100 miles behind that airplane, all they had to do was abandon that approach, go around, get organized, get out in front of that thing and stabilize the approach. If they had, they and their passengers would be alive today. Tragic.
Exactly. Pride got the best of them. If I would've been sic on that flight I would've looked at the pic and said, "I don't like this at all, we are rushed and behind this airplane, let's just go around, we all want to live to see tomorrow".
I was in Truckee at the time of this event. Being from SoCal I am familiar with wildfire smoke, and this day was an extreme in smoke and low visibility.
Thank you very much for this video. I am just a humble low hour PPL guy, but I ended up in a high, overshot situation on my 3rd solo, but thankfully my instructor's and your words echoed in my mind, so I went around. Thanks to my instructor (and you), I was relaxed on downwind, because I knew I made a mistake, but it was corrected, so I had whole new chance to make a perfect landing.
Good on you. I have a little bit of float plane flying experience and there's a passage in the book, "Flying A Floatplane" by Marin Faure that says that there is no shame in going around as many times as you need to make sure you are going to have a safe landing. He goes on to say that the safest place for your airplane is in the air, aside from perhaps a hanger, so take your time in doing a safe landing.
Well, they were certainly experienced - but not as a crew together! Juan described the 'inverted command gradient' very well. Thanks Juan for another excellent accident analysis!
Pilots are, quite rightly, taught to operate aircraft in a rigorous and disciplined manner. One of the consequences of this approach is that they may not know how things look and feel when they are in trouble and therefore they may not be quick to recognise and react to danger. I know *exactly* how it feels to take the fast left hand bend on the local main road too fast because I have done it several times, but I have no experience of anything equivalent in an aircraft, or even in a simulator. I can't help wondering whether professional pilot training should include the opportunity to do it badly wrong in a simulator.
It's not mind boggling when you look at the bigger picture: it's during covid, very likely these pilots were suffering the economic impacts thereof. They just got hired by a new startup company with pressure to get this new plane chartered and in their fleet, and the primary investors are in the back. In their minds they're perhaps thinking "If I go around the man and his wife are going to wonder if I'm competent to fly for them"
That's really not everything. I mean, there was a stall warning. How can two pilots ignore a stall warning and initiate a TOGA plus go around, plus cleaning up the airplane, in such a situation? I don't get it. Has there been a history of those pilots flying regularly right to the edge of a stall - so they get the stall warning all the time or what's the cause for that?
One of my favorite sayings is “successful outcomes can reinforce bad habits.” When I see actions like those in this crash I wonder how many times these pilots took risks, cut corners, just winged it and survived. Those habits sometimes catch up with you.
And that can certainly be applied well beyond the aviation world. From driving a vehicle to even making poor short term business decisions that one can get away with...until one day it comes to bite you in the ass.
Circling to land in low vis especially at night is down right dangerous. I flew freight in a Seneca II. I had to land at night at airport that often required circling to land. The approach was to runway often not favorable to winds. At night and low visibility you lost airport in the turn for a moment and there was no ground references....
The captain Alberto, was my neighbor and very good friend , i flew with him many times on challengers 600 , 601, 604 and 605. He was very experienced flying challengers with over 17 years of experience on the aircraft. He left behind a 3 year old baby girl. Alberto was a super nice guy.
As a side note here, CRM should be pushed in other fields, particularly Nursing/Medical. I'm yet another non pilot who lurks on this channel, but so easy to understand your explanations. Bravo Mr blanco.
@@funcisco1504 Crew resource management. Basically divvying up responsibility. Who is doing what and when. Also, while I share your frustration with acronyms, CRM is a very common one in aviation and your snark was unwarranted.
I have a few friends working in the operating room who have described to me their attempts to implement CRM, briefings, and checklists. It sounds like they’re making an effort to implement CRM/TEM at least at their hospital.
I'm working on my PPL right now and have watched several of your videos and they are always so informative and thorough. It amazes me how many pilots with thousands of hours make simple mistakes such as failing to prepare and study their arrival airport to make sure the facilities are adequate for their arrival. This whole accident could have been avoided if either pilot took the time preflight to check their scheduled arrival airport and noticed the obvious fact that one of the runways was too short for their aircraft. This is one of the first steps I've been taught when planning a cross country flight. Study your arriving airport, and plan one or two backup airports in case of unacceptable conditions at your primary airport. Constant reminder that in aviation, no matter how experienced you are, it's often the little things like this that are easy to overlook and can have catastrophic consequences. It's like you always say... never put yourself at a disadvantage in the cockpit.
As a PIC on the Bombardier CRJ 200 , and 700, an international IP on the CRJ 200 in 5 different countries, an IP in sims on the 200, 700, and 900, and last an IP on the Challenger 604, I had one rule as regards the flight spoilers. If you deploy the spoilers you may not take your hand off the handle until you have stowed them back in- period, dot. Unsats were more than a few for this but I trust they learned the lesson. Needless to say this was a huge contributing factor and a needless loss of control.
I watch most videos, especially if I hear of a crash. So informative. It takes a special repetitive mindset to fly, is what I've learned, Not a pilot, but admire and respect all pilots. Stay safe.
I am a retired IT guy, operations. I spent 40 years troubleshooting problems and operating equipment. And that ground-based hectic environment I learned to do things in the right order and try to avoid getting cute. You try to be cute and do too much at once you end up with egg on your face.
My instructor told me "flying is boring, there is a right way, and that's the only way, so you do it the same every time, you don't just make it up as you go along"
@@JohnRodriguesPhotographer I was a recording engineer and later also developed and managed large software applications and both were very much like flying, although safer, except for careers. When you get bored or tired and hotdog it, or succumb to an impatient client even when you've lost situational awareness, hoping for the lucky outcome, disaster recovery is inevitable, to whatever degree possible (same for those who won't test). But in the air, lives are lost, tragically. But up there or down here, you can *always* go around. My admiration for those who not only pilot, but also develop software for aviation and spaceflight, and take responsibility for lives, which I could never do. At the end of a hard day, I could always get a grip by saying, "At least it's not life or death. No one died." I can't imagine otherwise.
@@gasdiveI think this mindset can cause more accidents. It makes you think "I'd never do that, that would never happen to me," but we are all human and there are gray areas and times with external pressures, which is why even the best pilots can get into trouble. Flying requires humility and good decision-making as much as skill and experience.
My instrument instructor once told me if you only remember one FAR for the oral, memorize 91.175 (1) says... the aircraft is "continuously" in a position from which a decent to landing can be made at a normal rate of descent using normal maneuvers. When I was in the middle of hacking up my first circle to land, he asked me if there was any FAR's that could help, and after thinking for a 3 Mississippi, I scrubbed the approach and asked to be resequenced. My point is there doesn't seem to be any part "continuously normal" and as Juan said the inverse cockpit hierarchy delayed the decision making one second too late. So sad. Thanks Juan for putting the time in to very comprehensive explanations that help all of us.
Absolutely best channel on UA-cam. Thank you Juan your videos are always respectful and factual. Tremendous value in your reports. Former US Navy Aircrew coordination instructor.
@@charliemike5813 That's not an official account of this channel, it's a spam bot. Just click on the Report toggle (the three vertical dots on the right of the comment).
Juan, Thanks for deciphering this report. My daughter is a corporate pilot that has flown mid and wide body jets. I share your videos with her all the time. As you can appreciate that all pilots can learn by others mistakes. I believe you are helping everyone when sharing your point of view. Thanks for the work you do!!!
Thank you for your work on this. Ken Dunn was a passenger and a close family friend. This is a gut wrenching listen for me. So many mistakes. Tragic for all.
You did a great job on this Juan, thank you. Accidents like this are terrible, but your work goes a long way in helping all of us learn from other’s mistakes and making us safer pilots.
Juan, great breakdown as usual. I fly SP on an Ultra, I have to do a circle to land often at home airport but, it’s usually the reciprocal RWY. It is very challenging indeed. Sometimes you just have to go wings level, exit the area and regain your thoughts. Sad event for sure..
Not a pilot. But something stuck with me that Juan said couple years ago. Aviate. Navigate. Communicate. Sounds like this broke down in the cockpit. Wise old journeyman electrician old me early on. When things go bad back off, reexamine, get back to a simplified plan and reattempt.
This is great advice in so many different realms of life. Sometimes just backing off, taking a minute to clear your head and rethinking your plan makes such a world of difference.
Thanks for your very detailed analysis Juan. Have to tell you that I find this incident very troubling and it was difficult for me to listen when you read the CVR transcript. I'm not sure that I would really classify this as an "accident" as there was so much wrong with the operation, pilot hiring, and aircraft operation. As you said, there were MANY holes is this cheese! Reminds me a bit of the Learjet crash years ago at KTEB. I'm amazed at how so called professional pilots can not see these errors adding up, and not make the decision to go around and regroup. I know we're all human, and humans make mistakes, but this was totally uncalled for. You're right about circling approaches. Very demanding, and I think too many chances to make mistakes. In the Sim we tend to practice our circles at relatively large airports such as KMEM, KJFK, or KICT, where there is plenty of room and flat terrain. With so many new GPS approaches to so many runways I think the need to circle anymore is greatly diminished. At my company night circling approaches were not allowed, but we were able to do them during the day. We flew into KTEB a lot, and for much of that time it was quite normal to shoot the ILS Rwy 06, circle to land Rwy 01 or 19. That changed somewhat when they got an ILS to Rwy 19. Have been following the Mig-23 accident on your channel as well as a few others, and there seem to be a lot of "armchair pilots" commenting about it. I guess everyone is entitled to their opinion, but some of the commits are ridiculous and very uninformed! Thank you again for your level headed, expert analysis Juan-it's always appreciated and extremely valuable! Always enjoy your videos from Australia. I spent many months there doing aerial photography in a Learjet 36 in 2015-2018, and love the country and its people. Take care...
14:32 - I was fortunate to listen in on several senior pilots discussing this tragic incident, They mostly attributed the short turns to the pilots rushing. I don't think they had the transcripts at the time. But hearing your explanation about why these pilots may jave been compelled to make such tight turns makes a lot of sense. Man, it seems like they had so many things going against them. RIP
The tight loop caused the problem. They should have been far further out, giving themselves time to descend to their minimums at the correct speed, before entering a long glideslope. In this situation, minor horizontal moves to align with the centerline of the runway are easy, but trying to do everything at the same time is dangerous and likely to fail.
Pasquale! This is a very similar accident to the Lear 35 in Teterboro. Besides operational lessons learned, there is a lesson for charter management and customers. Management needs to know what they are doing, in this case, like the approach, it was rushed and shoddy. The lesson for customers (I know it was customer investors onboard) is to thoroughly evaluate a charter company’s reputation. The airlines are sucking up every possible eligible pilot. I would not set foot on a charter aircraft in these times.
Well done explanation as usual. Flight crew was new to working together, PIC had limited experience in the make/model, first time in this plane & facing bad viz. Circumstances where pre-planning the landing was especially critical & unfortunately lacking.
Ahh, the reading of the cockpit transcript sent shivers down my spine. The holes in the cheese on this one all seem like relativity small holes, but once they all line up...two pretty experienced pilots stall their craft into the ground. Such a bummer and a tragedy. Great report Juan. I really appreciate your videos. I'll probably never be blasting around in a Challenger, but I feel like we can all learn a lot from these accidents.
Juan's remark about visibility in smokey conditions is absolutely on point..especially here on the westcoast of the US. The ASOS/AWOS measure water droplets in the air & not the smoke particles..so the systems can report a P6SM visibility but in actuality: it maybe lower than 3 SM in smoke. One must be very vigilant in accepting visual approach clearances at night in smokey conditions & terrain..let alone a circle to land one. However, that was just one of many aspects of this accident. Clearly, the flight crew member roles were not-defined on this flight or at the enterprise.
These two pilots were probably far more efficient individually. In this case, imho, they inadvertently got their antlers locked together. Flying the plane diminished as they worked communicating with each other. It seems that the SIC saw this coming well before it actually happened. His remark about not wanting to be in the news breaks your heart. The loss of those pilots and passengers seems so unlikely given the vast experience sitting in the cockpit.
Love your content. As a former military helo crewman and current flight student I find great value in mishap break downs. Thank you for the great lessons learned and reaffirmed.
The quantity and variety of information that I have learned from you is incredible. Your explanation of what went wrong here was an incredibly informative, sad but perfectly presented synopsis. I truly appreciate your work. Thank you. .
Very good, Juan! A circling approach is by far the most demanding, and by definition, the most potentially dangerous. That is the reason we in the major airline world do not do them!
Every time I see a circle-to-land approach plate I think of this incident and the one at TEB. But ultimately here the approach was only one hole in the Swiss cheese. A very sobering transcript and a well done report. Thank you Juan.
They had plenty of time to get this right. Poor coordination between the two pilots. Such a shame. Thank You Juan for this excellent but sad report. Best Regards
I personally think this type of approach should be banned. Hightened performance anxiety from crews operating small charter airlines under high pressure
Glad I didn't try to pursue a professional flying career... & instead ended up landing a good job at Boeing and being able to continue my involvement and enjoyment of aviation (& some awesome CAD/CAM technology in a manufacturing organization). Hats off to the professional pilots that work in this challenging environment. thanks for sharing, gracias
There's a YT channel called Approach and Departure Videos. I always like to watch/listen to the briefing the Captain and FO go through and how thorough their process is. Sadly this situation was the opposite it seems.
Well explained Juan. I’m very familiar with the characteristics and indications of stall on the Challenger. This tragedy was textbook ‘Swiss cheese’. You are quite correct in the command gradient of the Captain and FO. After retiring from my job in aircraft manufacturing, I joined a major airline as a retirement gig. I was that high time FO flying with very young Captains. After our day one pairing brief, I would pull the young Captains aside to remind them that they’re the In Command and the decision makers. Admittedly, some felt a little intimidated at first, but settled right in afterwards.
@@baaa4698I don't know if you are in the industry and if so your experience level, so excuse me if this is something you already know and you were asking for other reasons, but I was that low time captain occasionally flying with more experienced first officers early in my career. I did fly with some that would do exactly this, where they make it clear that I was the pilot in command. I always appreciated it because when there is an unbalanced crew like this, it can be intimidating being the less experienced captain. There is always a bit of time to fly together to feel out the dynamics between the two crew members. Is the more experienced first officer going to push his experience level aggressively and try to act as pseudo captain from the right seat? How do I command this crew dynamic as a less experienced captain so as to be in charge, but not feel like a phony? So, senior first officers that had significantly more experience than me that would set the ground rules right away on the first day like this person did really helped me in those times. They would make it clear that even though they were more experienced than me, I was pilot in command. Then I would reply to them that I value their experience and am open to learning if they had suggestions. This put me at ease, that they respected my position as captain, and we could work together as an effective team. Another reason this was helpful, because unfortunately it didn't always work that smoothly in these types of situations, hence the appreciation for this type of preflight communication. There definitely were pilots in that scenario where the first officer with the greater experience didn't respect the captain's position. In these situations there tended to be two people, both working like they are in charge and a "too many cooks in the kitchen" situation would occur. Both pilots worked independently in their side of the flight deck, with very little communication, and the crew resource management would start to break down.
What I don't understand about this, is the fact they didn't abort and try again. I know it's easy from an armchair, but it's clear the approach "got away from them". Such a shame lives were lost here. It's wonderful how you explain these things, I've learned SO much! Thank you Juan!
As a GA pilot with complex airplanes I can attest to “oh I can fix this” rather than going around. Sometimes it’s an overconfidence of skills or the situation at hand.
This is why you brief your departure and arrival (and should do so even in a small & simple GA aircraft, and even when flying solo). By verbalizing your plan in an emergency, you mentally plant the seed for the option, and give yourself a chance at being able to select the option during the fleeting moment when it becomes available/necessary. After earning their licenses, most Pilots (and I say this as a pilot) are not generally in the habit of practicing go-arounds or missed approaches - unless its for a BFR or a check-flight. So we're not generally thinking through these options and aren't mentally "spring-loaded" to put them into action.
@@kaimoenck3154yep! you can fix a lot of bad approaches when you have 5 times the required runway. But take that mentality into a bigger plane and you got a problem.
Another factor many people don't consider, especially those who aren't pilots (and even some who are single engine GA pilots), is how fast everything is happening in a plane like this that's moving at almost 200mph. You don't have the luxury of covering this distance at 70mph like you would in a car.
Alot of work in this video, thanks again and a very interesting turn of events leading into this crash. I lived very close to the crash site and rode snowmobiles in the mountains there very tricky terrain to navigate,
I fly a CRJ, similar to the challenger. Flaps 45, with spoilers and gear is too much drag to overcome. The airline I fly for we are not allowed to use spoilers at flap 45 setting for this reason.
As usual, excellent report. Incomprehensible. I can see your pain and disgust. Sorta reminds me of Colgan style errors. I've flown in and out of Truckee at least a dozen times. It's a legit bowl surrounded by high terrain. A lovely airport but challenging. There are few exit options for the poorly planned mission. Planning in and out of there has to be very precise and certain. Very sad to see this level of airmanship. So unfortunate, RIP.
PPL and even above.. A LOT of your content should be added to the curriculum... ala. Mandatory watching / reading... I've learned a LOT of things outside of general training by way of you.
The good folks at YT have FINALLY allowed an advertisement in this episode in the ad tracker! THANK YOU for your programming efforts. And nice new watch, a sponsor possibly?
Gosh I miss old Tom....So much great advice. During my check airman stint I always used his analogy of the farmer letting the air out of the stuffed up cow for overconfident crews. Just stick the pocket knife in far enough to let the air out, not far enough to cause damage...
Thanks so much Juan for the insights regarding these scenarios. The human factors aspects in this one are significant (and cringe worthy). Now retired for seven years, I spent my entire career in Part 91 corporate jet operations starting in 1980 and almost all of the SOPs that evolved throughout my career paralleled the Part 121 training programs. Over the years, the major training organizations (FlightSafety , SimuFlite) began to include human factors, CRM, etc. but I never understood why the FAA required circling approaches (to minimums at night) in the curriculum. I’m glad to hear the 121 carriers have abandoned the practice.
And Juan, thanks again for your time and effort. Over the years I think you have implanted a lot of food for thought into many young professional pilots and have had a impact on the prevention of possible accidents. Keep up the good work. 🙏
As usual, an amazingly clear picture painted by Juan! I'm a firm believer in the adage, "Slow is fast and fast is slow". If these guys had taken a holding pattern, figured out their situation and briefed a proper landing, there could have been a different outcome. Plus, they needed to comunicate their limitations to the controllers and pick the best landing situation for their aircraft.
Juan excellent analysis as always Sir - but - one minor point that frequently gets overlooked in analyzing a circling approach... Prevailing visibility is reported in statute miles, which if using DME (which uses nautical miles) would lessen the arc of visibility on the approach to a 2.6nm ring, which is less than the 3 mile arc depicted on your overhead diagram at 15:00. But again, just a minor correction and no one else does such an amzing job keep up the good work!
Juan great job! As usual You got a WN/AA near miss outta PHX today as well as the “Vegas Air Races” in 2024. You’re gonna be busy! Thanks for all you do! Keep up the great work!
I recognize these must be difficult stories to cover, but for those of us eager to learn more about flying, they are etching invaluable lessons in our minds.
They were technically cat C and legal in that sense at full flaps (45). A couple of things on that. -OEM procedure for circling in this Type is flaps 30, a ref+17, Flaps 45 leaving MDA. In must cases that places approach speed just in Cat D. -I am not aware of an OEM procedure that allows circling at flaps 45, however some certified operators have an approved procedure for circling at flaps 45 Vref+10. It is in fact, the better way to fly the maneuver all be it not technically legal in most operations. Still the approach speed in the flaps 45 configuration will place you squarely into CAT C. There are two things I think the FAA could do to help with issues in Circling. One is to relax the requirements for training circling approaches in 142 training organizations. Currently there are very strict rules that dictate what airports can be used to train and check a circling maneuver in a simulator. Due to this if you get a type rating from FSI your circle was done at MEM or JFK with very few exceptions. Not Sure about CAE but I am sure it is similar. Better than that would be a more diligent push to expand RNP AR capabilities. Airports like this need RNP AR approaches and there needs to be reasonable access to the training for operations that are too small to have a custom approved training program that includes it. Currently the AR portion of the RNP A is a unicorn for most operations. It really should just be included as an FSB item for aircraft that are capable which would mean that every type rated pilot is capable.
As soon as I saw the SIC’s hours I thought of the cockpit authority gradient that could have played a role in the challenges leading up to the accident.
Right seat was most likely evaluating the left seat, as he was a new hire with less overall experience, new to the aircraft type, and a foreign national to boot. It happens all the time. As Juan said, when things get sideways, whoever has a better handle on it needs to take over with clarity and purpose. It's just not completely clear in this case that either one of these pilots was going to do the right thing here---level the wings, apply high power, clean up the plane, and execute a missed approach. Poor CRM got them into a very bad place---low and slow, very dirty with gear, flaps, and spoilers all out, and trying to horse the plane back to a runway they had well overshot---but even the right seater was still talking about trying to salvage the approach up to the very end, not talking about getting the hell out of there and regrouping, as they should have.
So sad! Thank you Juan for the excellent coverage and lessons. Perhaps a good indicator to reset things and stop the Swiss cheese model is when someone says "we don't want to make the news".
Very sad ending Juan,dunno mate it great you reporting these incidences but it must be draining on you ,safe flying,take care from ballarat in Oz,🙏🙏👋👋👍🇦🇺
Hi Juan, there was a near miss (or hit depending on your perspective) at Phoenix International, we are all waiting on your video about it, your videos are always very insightful and informative. Thank you.
I noticed on the Flight Simulator that I crashed more often when trying to land with an unstable approach. Sometimes you can save it, sometimes you can’t. My conclusion-always setup and fly a stable approach. Especially in jets.
Excellent analysis, again. Really appreciate the depth of your review, Juan. You highlight another important aspect of the safe flight 'chain'.....the organizational structure of the operation, There's so many reasons airline companies have generally displayed such excellent safety records, but something that is often overlooked is the organizational structure. In this accident, it appears that 'structure' was not mature and therefore weak and contributed to the accident.
They literally said "we don't want to be news". This should've been a clear red flag they had broken down (poor resource management) and they should go around and reorganize themselves. There was such unprofessionalism between themselves and the task at hand... They are fortunate no one else was hurt, a school bus was missed by seconds... GetThereitis...
At some point I was hoping to hear a clear and concise “my controls” also looks like somebody didn’t keep their hand on that speed brake lever plus it couldn’t have been armed and should have by this point…
@blancoliri0-- okay how do we do this? Much respect for you. I'm just a ex ag pilot with 4000 hrs fixed and 1000 helo. Always wanted to go to air tankers but now just to old. Plus 3 crashes and a few wire strikes I didn't count. But I lived to tell stories. I was also the chief pilot of several ag ops and had to drug test myself. Funny how that works. I can relate to the power of someone who you think is more experienced. However my experience was working for operators who weren't pilots. They were constantly pressuring me to fly in bad weather or busted up aircraft. Actually quite a ag service in Georgia and the owner attempted to hire my friend down the street. He asked why I wouldn't fly, the aircraft had a busted exhaust manifold. He told him he wouldn't fly it either. Got rehired that day and the aircraft got fixed. Just got to know your limits.
One thing that I can't get out of my head, and the NTSB can't really weight on that aspect, is the mindset of the pilot. A new hire on his first flight with the company, having a major investor of said company as a passenger, without having a proper visa to go fly commercially. Is it possible that being stressed out of you mind because you don't want to fuck up your new job put you in a "land at all cost" mindset? The SIC trying to cool down the PIC seem to indicate a high level of stress.
If ever you were going to apply the James Reason / Swiss cheese model to an example here’s another belter . Unstable , no correct cockpit authority (or backward) gradient , challenging conditions coupled with a challenging airport and allowing themselves to get overloaded with changes very close to arrival . Very sad and very hard as a professional pilot to watch through as it’s frustratingly avoidable. Once again great job Juan , thorough and fair with some lessons that are prudent from PPL to very advanced . This simply should not happen with near a combined 20000hrs in crew experience but it did , and sadly will again .
Thank you Juan for this follow up video, my family and I were in the parking lot next to the golf course when this happened. I heard the plane coming in and wanted to see it land and thought the runway was close to us. Next thing I know all I hear is the screaming whistle from the engines and saw it crash through the trees. It was an insane day for sure.
I read the written transcript of the Cockpit Voice Recorder and some of the NTSB interviews with company officers that are included in this NTSB Docket Information prior to continuing my listening of Juan's presentation. That made it easier to follow the excellent piece that is just another of his many UA-cam programs pertaining to aviation accidents.
Flight spoilers deployed on final, the final slice of cheese. The amygdala can cause bad decision making. If you feel rushed, recognise and breathe. Don’t push on. Hold, slow down or go around. An extra ten minutes is not as long as eternity.
Very nicely done. So easy to see from here, now. So many stupid decisions, made worse by the cockpit dynamics and desire to "make it work". I have seen this a lot in my career. Fortunately, most of that was in a 121 cockpit where we were armed with SIGNIFICANT guard rails in terms of GOOD SOP's and techniques to recognize, minimize, and mitigate mistakes. Now that I am flying 135, it's like starting all over as I am often paired with very low-time and inexperienced FO's who do not have the luxury of all the training I received in the 121 world. None of us are born to fly. We have to keep working at it. Complacency is a killer. Get home itis is a killer. This video will help someone, somewhere, someday.
This senseless accident is so very reminiscent of the fatal Lear 35 fatal circling accident at Aspen in 1991. It killed my twin brother. His final words to the other captain were “No! No! Your stall….(impact). The other captain had a known reputation as reported by first officers of flying very unstabilized mountain approaches. My twin, as director of ops chose to fly with the errant captain to provide remedial training and hoped to thwart his termination for incompetence. He found out first hand the truth expressed by the super scared first officers. As a staff instructor at SimuFlite, and a party to the investigation, I was allowed to make formal CRM presentations spotlighting my brothers accident and his last ditch effort to wrestle the controls from the PF captain and abandon the highly unstabilized circling approach. History does repeat itself but at least we do get better with tombstone engineering! Great work as always Juan.
I am so sorry for the loss of your twin brother. Thank you for sharing.
Get over it.
@@rudybishop9089 shut up Mason.
I’m sorry for your loss, even all these years later. In a way loss gets better with time, but in another way it gets harder. I hope you’re having a great life, just sorry you’re not having it with your twin brother still here on earth.
@@rudybishop9089well aren’t you a nasty little piece of work!!!!! 🙄🙄🙄🙄🙄🙄🙄🙄
They knew things were a bit sketchy when they said “we don’t want to make the news”. Unfortunately, they made the news.
Yep, dad gum it, they thought they had it till they didn’t.
If the PIC would let the SIC have the plane would that have helped ?
Seems like it was the SIC who was mentally committed to getting on the runway despite a very unstable approach. He also likely activated the spoilers, which combined with the bank angle ultimately caused the plane to turn into a PSFO (Plane-Shaped Falling Object) @@unfaix
@zombieman9509 ah thanks for clarification, I was confused as to who was in charge.
Indeed, exactly!
John Dunn was my dads next door neighbor. He was a super nice guy that would give you the shirt off his back and was a wonderful dad and husband. A huge loss.
Who was John Dunn? I’m guessing the SIC?
@@OMG_No_Way John Dunn Dallas, TX from what I found in his obituary - Rainer Capital, a commercial real estate investment firm, is this a SIC ? I'm a former Architect lived in Sacramento, CA 33 years ago, with an interest in this crash. 1st officer & another passenger from Minnesota
I've known a lot of dunns. Every one has been a pretty solid person
Dunn was a passenger. NOT one of the pilots!
This wasn’t a medical flight , you might be thinking of the Lear jet crash .
Worked for the CHP in Truckee for 20 years... you have no idea how many plane crashes we went to at that airport.
If I am correctly interpreting the 4113 in your signature I can say this with confidence: A young boy is a theory and an old man is a fact. Well done.
California Highway Patrol? CHP? Disgusting tyrant 🤢🤮🤮🤮
@@RemingtonArmy-Wow‼️🫡
Overshooting?
What is the significance of the 4113?
Didn’t realize they had initially planned and had been cleared for the straight-in to 11. The most powerful word the pilots didn’t use was simply, “Unable,” when ATC gave them the new approach. They forgot that, as pilots in command, we decide where the aircraft is going, and ATC’s job is to make that happen safely and in coordination with other traffic. They might have had to spend a few minutes holding, but that would have been nothing compared to this tragic outcome.
My precise thought also. On approaches like this and in an aircraft like this, you don't want to change horses (approaches) in the middle of the stream.
@@DrJohn493 and in visibility conditions they had.
Did a straight in on 29 the day before in a 310. That was quite a decent coming over the top. Barely VFR because of the smoke. Looks like the role of PIC was not firmly established.
"We don't want to make the news". Hauntingly prophetic.
Excellent report Juan. For the life of me I do NOT understand why these two guys got themselves into this mess. Too high, too fast, 100 miles behind that airplane, all they had to do was abandon that approach, go around, get organized, get out in front of that thing and stabilize the approach. If they had, they and their passengers would be alive today. Tragic.
My thoughts exactly.
Exactly. Pride got the best of them. If I would've been sic on that flight I would've looked at the pic and said, "I don't like this at all, we are rushed and behind this airplane, let's just go around, we all want to live to see tomorrow".
I was in Truckee at the time of this event. Being from SoCal I am familiar with wildfire smoke, and this day was an extreme in smoke and low visibility.
Thank you very much for this video. I am just a humble low hour PPL guy, but I ended up in a high, overshot situation on my 3rd solo, but thankfully my instructor's and your words echoed in my mind, so I went around. Thanks to my instructor (and you), I was relaxed on downwind, because I knew I made a mistake, but it was corrected, so I had whole new chance to make a perfect landing.
Good for you and also your instructor!! If things don’t look right on landing go around, regroup, and try it again. Safety first, always!
Nice
Good on you. I have a little bit of float plane flying experience and there's a passage in the book, "Flying A Floatplane" by Marin Faure that says that there is no shame in going around as many times as you need to make sure you are going to have a safe landing. He goes on to say that the safest place for your airplane is in the air, aside from perhaps a hanger, so take your time in doing a safe landing.
This is good news. Juan out here, saving lives. Safe landings my friend!
Every approach is a go around with an option to land.
Well it shows the impact of not following procedure. Truly boggles the mind how two experienced pilots can get themselves in such a mess.
Well, they were certainly experienced - but not as a crew together! Juan described the 'inverted command gradient' very well.
Thanks Juan for another excellent accident analysis!
Pilots are, quite rightly, taught to operate aircraft in a rigorous and disciplined manner. One of the consequences of this approach is that they may not know how things look and feel when they are in trouble and therefore they may not be quick to recognise and react to danger. I know *exactly* how it feels to take the fast left hand bend on the local main road too fast because I have done it several times, but I have no experience of anything equivalent in an aircraft, or even in a simulator. I can't help wondering whether professional pilot training should include the opportunity to do it badly wrong in a simulator.
It's not mind boggling when you look at the bigger picture: it's during covid, very likely these pilots were suffering the economic impacts thereof. They just got hired by a new startup company with pressure to get this new plane chartered and in their fleet, and the primary investors are in the back. In their minds they're perhaps thinking "If I go around the man and his wife are going to wonder if I'm competent to fly for them"
@@HyenaEmpyema It still boggles my mind regardless.
That's really not everything. I mean, there was a stall warning. How can two pilots ignore a stall warning and initiate a TOGA plus go around, plus cleaning up the airplane, in such a situation? I don't get it.
Has there been a history of those pilots flying regularly right to the edge of a stall - so they get the stall warning all the time or what's the cause for that?
One of my favorite sayings is “successful outcomes can reinforce bad habits.” When I see actions like those in this crash I wonder how many times these pilots took risks, cut corners, just winged it and survived. Those habits sometimes catch up with you.
“Normalisation of deviance.”
@@nickboylen6873 Indeed, exactly.
And that can certainly be applied well beyond the aviation world. From driving a vehicle to even making poor short term business decisions that one can get away with...until one day it comes to bite you in the ass.
Complacency
@@Nfarce Yes, indeed.
It’s such a sad loss. The cockpit seemed so chaotic.
I loved that you quoted Tom Pasquale’s! Heard it many times at AA recurrent training. Never fell asleep, during his class.
Circling to land in low vis especially at night is down right dangerous. I flew freight in a Seneca II. I had to land at night at airport that often required circling to land. The approach was to runway often not favorable to winds. At night and low visibility you lost airport in the turn for a moment and there was no ground references....
The captain Alberto, was my neighbor and very good friend , i flew with him many times on challengers 600 , 601, 604 and 605. He was very experienced flying challengers with over 17 years of experience on the aircraft. He left behind a 3 year old baby girl. Alberto was a super nice guy.
As a side note here, CRM should be pushed in other fields, particularly Nursing/Medical. I'm yet another non pilot who lurks on this channel, but so easy to understand your explanations. Bravo Mr blanco.
What is CRM ? people can't talk any more with full sentences no wonder there is confusion
@@funcisco1504 Crew resource management. Basically divvying up responsibility. Who is doing what and when. Also, while I share your frustration with acronyms, CRM is a very common one in aviation and your snark was unwarranted.
I have a few friends working in the operating room who have described to me their attempts to implement CRM, briefings, and checklists. It sounds like they’re making an effort to implement CRM/TEM at least at their hospital.
Gotta love that Mr. BLANCO, which means
"White", when his real name is Browne!!!
O.k., just a little irony!
But it was a great report .
@@richwightman3044 Sometimes just a sharpie mark on the right or left side makes all the difference to prevent cutting off the wrong leg.
I'm working on my PPL right now and have watched several of your videos and they are always so informative and thorough. It amazes me how many pilots with thousands of hours make simple mistakes such as failing to prepare and study their arrival airport to make sure the facilities are adequate for their arrival. This whole accident could have been avoided if either pilot took the time preflight to check their scheduled arrival airport and noticed the obvious fact that one of the runways was too short for their aircraft. This is one of the first steps I've been taught when planning a cross country flight. Study your arriving airport, and plan one or two backup airports in case of unacceptable conditions at your primary airport. Constant reminder that in aviation, no matter how experienced you are, it's often the little things like this that are easy to overlook and can have catastrophic consequences. It's like you always say... never put yourself at a disadvantage in the cockpit.
As a PIC on the Bombardier CRJ 200 , and 700, an international IP on the CRJ 200 in 5 different countries, an IP in sims on the 200, 700, and 900, and last an IP on the Challenger 604, I had one rule as regards the flight spoilers. If you deploy the spoilers you may not take your hand off the handle until you have stowed them back in- period, dot. Unsats were more than a few for this but I trust they learned the lesson. Needless to say this was a huge contributing factor and a needless loss of control.
I watch most videos, especially if I hear of a crash. So informative. It takes a special repetitive mindset to fly, is what I've learned, Not a pilot, but admire and respect all pilots. Stay safe.
if we keep watching this channel we will never become pilots LOL
I am a retired IT guy, operations. I spent 40 years troubleshooting problems and operating equipment. And that ground-based hectic environment I learned to do things in the right order and try to avoid getting cute. You try to be cute and do too much at once you end up with egg on your face.
My instructor told me "flying is boring, there is a right way, and that's the only way, so you do it the same every time, you don't just make it up as you go along"
@@JohnRodriguesPhotographer I was a recording engineer and later also developed and managed large software applications and both were very much like flying, although safer, except for careers. When you get bored or tired and hotdog it, or succumb to an impatient client even when you've lost situational awareness, hoping for the lucky outcome, disaster recovery is inevitable, to whatever degree possible (same for those who won't test). But in the air, lives are lost, tragically. But up there or down here, you can *always* go around. My admiration for those who not only pilot, but also develop software for aviation and spaceflight, and take responsibility for lives, which I could never do. At the end of a hard day, I could always get a grip by saying, "At least it's not life or death. No one died." I can't imagine otherwise.
@@gasdiveI think this mindset can cause more accidents. It makes you think "I'd never do that, that would never happen to me," but we are all human and there are gray areas and times with external pressures, which is why even the best pilots can get into trouble. Flying requires humility and good decision-making as much as skill and experience.
My instrument instructor once told me if you only remember one FAR for the oral, memorize 91.175 (1) says... the aircraft is "continuously" in a position from which a decent to landing can be made at a normal rate of descent using normal maneuvers. When I was in the middle of hacking up my first circle to land, he asked me if there was any FAR's that could help, and after thinking for a 3 Mississippi, I scrubbed the approach and asked to be resequenced. My point is there doesn't seem to be any part "continuously normal" and as Juan said the inverse cockpit hierarchy delayed the decision making one second too late. So sad. Thanks Juan for putting the time in to very comprehensive explanations that help all of us.
Absolutely best channel on UA-cam. Thank you Juan your videos are always respectful and factual. Tremendous value in your reports.
Former US Navy Aircrew coordination instructor.
@blancoliri0-- yes sir?
@@charliemike5813 That's not an official account of this channel, it's a spam bot. Just click on the Report toggle (the three vertical dots on the right of the comment).
Juan,
Thanks for deciphering this report. My daughter is a corporate pilot that has flown mid and wide body jets. I share your videos with her all the time. As you can appreciate that all pilots can learn by others mistakes. I believe you are helping everyone when sharing your point of view. Thanks for the work you do!!!
An awkward dynamic between the pilots for sure that we typically don’t see at the airlines. Good analysis, Juan. RIP.
I'm just a private pilot single engine rating, so I appreciate your expertise in this assessment.
Be safe. There are old pilots and the bold pilots. There are very few old and bold pilots.
I appreciate how you read the transcript. It helps everyone understand what happened.
Go around----seemingly the two hardest words for crews in trouble to conceptualize.
Excellent walk through of the NTSB docket....you are without peer in this space. Again, thank you for your analysis and explanation.
I knew and worked with the first officer of this flight for many years, he was an incredible guy and will be missed by many.
RIP
Thank you for your work on this. Ken Dunn was a passenger and a close family friend. This is a gut wrenching listen for me. So many mistakes. Tragic for all.
You did a great job on this Juan, thank you. Accidents like this are terrible, but your work goes a long way in helping all of us learn from other’s mistakes and making us safer pilots.
Juan, great breakdown as usual. I fly SP on an Ultra, I have to do a circle to land often at home airport but, it’s usually the reciprocal RWY. It is very challenging indeed. Sometimes you just have to go wings level, exit the area and regain your thoughts. Sad event for sure..
Not a pilot. But something stuck with me that Juan said couple years ago. Aviate. Navigate. Communicate. Sounds like this broke down in the cockpit.
Wise old journeyman electrician old me early on. When things go bad back off, reexamine, get back to a simplified plan and reattempt.
This is great advice in so many different realms of life. Sometimes just backing off, taking a minute to clear your head and rethinking your plan makes such a world of difference.
Thanks for your very detailed analysis Juan. Have to tell you that I find this incident very troubling and it was difficult for me to listen when you read the CVR transcript. I'm not sure that I would really classify this as an "accident" as there was so much wrong with the operation, pilot hiring, and aircraft operation. As you said, there were MANY holes is this cheese! Reminds me a bit of the Learjet crash years ago at KTEB. I'm amazed at how so called professional pilots can not see these errors adding up, and not make the decision to go around and regroup. I know we're all human, and humans make mistakes, but this was totally uncalled for.
You're right about circling approaches. Very demanding, and I think too many chances to make mistakes. In the Sim we tend to practice our circles at relatively large airports such as KMEM, KJFK, or KICT, where there is plenty of room and flat terrain. With so many new GPS approaches to so many runways I think the need to circle anymore is greatly diminished. At my company night circling approaches were not allowed, but we were able to do them during the day. We flew into KTEB a lot, and for much of that time it was quite normal to shoot the ILS Rwy 06, circle to land Rwy 01 or 19. That changed somewhat when they got an ILS to Rwy 19.
Have been following the Mig-23 accident on your channel as well as a few others, and there seem to be a lot of "armchair pilots" commenting about it. I guess everyone is entitled to their opinion, but some of the commits are ridiculous and very uninformed!
Thank you again for your level headed, expert analysis Juan-it's always appreciated and extremely valuable! Always enjoy your videos from Australia. I spent many months there doing aerial photography in a Learjet 36 in 2015-2018, and love the country and its people. Take care...
My impression was while listening to Juan reading the CVR transcript: Only Holes, no Cheese.
14:32 - I was fortunate to listen in on several senior pilots discussing this tragic incident, They mostly attributed the short turns to the pilots rushing. I don't think they had the transcripts at the time. But hearing your explanation about why these pilots may jave been compelled to make such tight turns makes a lot of sense. Man, it seems like they had so many things going against them. RIP
The tight loop caused the problem. They should have been far further out, giving themselves time to descend to their minimums at the correct speed, before entering a long glideslope.
In this situation, minor horizontal moves to align with the centerline of the runway are easy, but trying to do everything at the same time is dangerous and likely to fail.
You need to be working at the NTSB. Your attention to detail is second to none.
Neither one of them ever even consider "should we just go around?" 😞
Pasquale! This is a very similar accident to the Lear 35 in Teterboro. Besides operational lessons learned, there is a lesson for charter management and customers. Management needs to know what they are doing, in this case, like the approach, it was rushed and shoddy. The lesson for customers (I know it was customer investors onboard) is to thoroughly evaluate a charter company’s reputation. The airlines are sucking up every possible eligible pilot. I would not set foot on a charter aircraft in these times.
Well done explanation as usual. Flight crew was new to working together, PIC had limited experience in the make/model, first time in this plane & facing bad viz. Circumstances where pre-planning the landing was especially critical & unfortunately lacking.
Ahh, the reading of the cockpit transcript sent shivers down my spine. The holes in the cheese on this one all seem like relativity small holes, but once they all line up...two pretty experienced pilots stall their craft into the ground. Such a bummer and a tragedy.
Great report Juan. I really appreciate your videos. I'll probably never be blasting around in a Challenger, but I feel like we can all learn a lot from these accidents.
Juan's remark about visibility in smokey conditions is absolutely on point..especially here on the westcoast of the US. The ASOS/AWOS measure water droplets in the air & not the smoke particles..so the systems can report a P6SM visibility but in actuality: it maybe lower than 3 SM in smoke. One must be very vigilant in accepting visual approach clearances at night in smokey conditions & terrain..let alone a circle to land one. However, that was just one of many aspects of this accident. Clearly, the flight crew member roles were not-defined on this flight or at the enterprise.
These two pilots were probably far more efficient individually. In this case, imho, they inadvertently got their antlers locked together. Flying the plane diminished as they worked communicating with each other. It seems that the SIC saw this coming well before it actually happened. His remark about not wanting to be in the news breaks your heart. The loss of those pilots and passengers seems so unlikely given the vast experience sitting in the cockpit.
Love your content. As a former military helo crewman and current flight student I find great value in mishap break downs. Thank you for the great lessons learned and reaffirmed.
The quantity and variety of information that I have learned from you is incredible. Your explanation of what went wrong here was an incredibly informative, sad but perfectly presented synopsis. I truly appreciate your work.
Thank you. .
Very good, Juan! A circling approach is by far the most demanding, and by definition, the most potentially dangerous. That is the reason we in the major airline world do not do them!
Every time I see a circle-to-land approach plate I think of this incident and the one at TEB. But ultimately here the approach was only one hole in the Swiss cheese. A very sobering transcript and a well done report. Thank you Juan.
They had plenty of time to get this right. Poor coordination between the two pilots. Such a shame. Thank You Juan for this excellent but sad report. Best Regards
I personally think this type of approach should be banned. Hightened performance anxiety from crews operating small charter airlines under high pressure
Gut wrenching analysis but replete with wisdom. Thanks again, Juan. You are providing a great service to the aviation community.
Glad I didn't try to pursue a professional flying career... & instead ended up landing a good job at Boeing and being able to continue my involvement and enjoyment of aviation (& some awesome CAD/CAM technology in a manufacturing organization). Hats off to the professional pilots that work in this challenging environment. thanks for sharing, gracias
There's a YT channel called Approach and Departure Videos. I always like to watch/listen to the briefing the Captain and FO go through and how thorough their process is. Sadly this situation was the opposite it seems.
Superb Channel he's an utter Professional and Everything a great Captain Embodies.
Well explained Juan.
I’m very familiar with the characteristics and indications of stall on the Challenger.
This tragedy was textbook ‘Swiss cheese’.
You are quite correct in the command gradient of the Captain and FO.
After retiring from my job in aircraft manufacturing, I joined a major airline as a retirement gig.
I was that high time FO flying with very young Captains.
After our day one pairing brief, I would pull the young Captains aside to remind them that they’re the In Command and the decision makers. Admittedly, some felt a little intimidated at first, but settled right in afterwards.
@@baaa4698I don't know if you are in the industry and if so your experience level, so excuse me if this is something you already know and you were asking for other reasons, but I was that low time captain occasionally flying with more experienced first officers early in my career. I did fly with some that would do exactly this, where they make it clear that I was the pilot in command. I always appreciated it because when there is an unbalanced crew like this, it can be intimidating being the less experienced captain. There is always a bit of time to fly together to feel out the dynamics between the two crew members.
Is the more experienced first officer going to push his experience level aggressively and try to act as pseudo captain from the right seat?
How do I command this crew dynamic as a less experienced captain so as to be in charge, but not feel like a phony?
So, senior first officers that had significantly more experience than me that would set the ground rules right away on the first day like this person did really helped me in those times. They would make it clear that even though they were more experienced than me, I was pilot in command. Then I would reply to them that I value their experience and am open to learning if they had suggestions. This put me at ease, that they respected my position as captain, and we could work together as an effective team. Another reason this was helpful, because unfortunately it didn't always work that smoothly in these types of situations, hence the appreciation for this type of preflight communication. There definitely were pilots in that scenario where the first officer with the greater experience didn't respect the captain's position. In these situations there tended to be two people, both working like they are in charge and a "too many cooks in the kitchen" situation would occur. Both pilots worked independently in their side of the flight deck, with very little communication, and the crew resource management would start to break down.
@@baaa4698superiority complex
@@baaa4698 what @flyinfella said.
Exactly, a ship can’t have two captains. Well, it can… at the bottom of the ocean.
What I don't understand about this, is the fact they didn't abort and try again. I know it's easy from an armchair, but it's clear the approach "got away from them". Such a shame lives were lost here.
It's wonderful how you explain these things, I've learned SO much! Thank you Juan!
As a GA pilot with complex airplanes I can attest to “oh I can fix this” rather than going around. Sometimes it’s an overconfidence of skills or the situation at hand.
This is why you brief your departure and arrival (and should do so even in a small & simple GA aircraft, and even when flying solo). By verbalizing your plan in an emergency, you mentally plant the seed for the option, and give yourself a chance at being able to select the option during the fleeting moment when it becomes available/necessary.
After earning their licenses, most Pilots (and I say this as a pilot) are not generally in the habit of practicing go-arounds or missed approaches - unless its for a BFR or a check-flight. So we're not generally thinking through these options and aren't mentally "spring-loaded" to put them into action.
@@kaimoenck3154yep! you can fix a lot of bad approaches when you have 5 times the required runway. But take that mentality into a bigger plane and you got a problem.
EGO.
Another factor many people don't consider, especially those who aren't pilots (and even some who are single engine GA pilots), is how fast everything is happening in a plane like this that's moving at almost 200mph. You don't have the luxury of covering this distance at 70mph like you would in a car.
Alot of work in this video, thanks again and a very interesting turn of events leading into this crash. I lived very close to the crash site and rode snowmobiles in the mountains there very tricky terrain to navigate,
I fly a CRJ, similar to the challenger. Flaps 45, with spoilers and gear is too much drag to overcome. The airline I fly for we are not allowed to use spoilers at flap 45 setting for this reason.
Thanks Juan. I learn so much every time I watch your content.
As usual, excellent report. Incomprehensible. I can see your pain and disgust. Sorta reminds me of Colgan style errors. I've flown in and out of Truckee at least a dozen times. It's a legit bowl surrounded by high terrain. A lovely airport but challenging. There are few exit options for the poorly planned mission. Planning in and out of there has to be very precise and certain. Very sad to see this level of airmanship. So unfortunate, RIP.
Outstanding report Juan. Lot's of material to move through. A tragic ending to a very confused situation.
another video to put me on the edge of my seat!
PPL and even above.. A LOT of your content should be added to the curriculum... ala. Mandatory watching / reading... I've learned a LOT of things outside of general training by way of you.
The good folks at YT have FINALLY allowed an advertisement in this episode in the ad tracker! THANK YOU for your programming efforts. And nice new watch, a sponsor possibly?
Tom Pasquale, I always looked forward to his class at recurrent. A prince of a man.
Gosh I miss old Tom....So much great advice. During my check airman stint I always used his analogy of the farmer letting the air out of the stuffed up cow for overconfident crews. Just stick the pocket knife in far enough to let the air out, not far enough to cause damage...
Thanks so much Juan for the insights regarding these scenarios. The human factors aspects in this one are significant (and cringe worthy).
Now retired for seven years, I spent my entire career in Part 91 corporate jet operations starting in 1980 and almost all of the SOPs that evolved throughout my career paralleled the Part 121 training programs. Over the years, the major training organizations (FlightSafety , SimuFlite) began to include human factors, CRM, etc. but I never understood why the FAA required circling approaches (to minimums at night) in the curriculum. I’m glad to hear the 121 carriers have abandoned the practice.
And Juan, thanks again for your time and effort. Over the years I think you have implanted a lot of food for thought into many young professional pilots and have had a impact on the prevention of possible accidents. Keep up the good work. 🙏
As usual, an amazingly clear picture painted by Juan!
I'm a firm believer in the adage, "Slow is fast and fast is slow".
If these guys had taken a holding pattern, figured out their situation and briefed a proper landing, there could have been a different outcome. Plus, they needed to comunicate their limitations to the controllers and pick the best landing situation for their aircraft.
just actually stunning,,, they got themselves boxed in, sad for the trusting folks along for the ride.. thanks juan
Juan excellent analysis as always Sir - but - one minor point that frequently gets overlooked in analyzing a circling approach... Prevailing visibility is reported in statute miles, which if using DME (which uses nautical miles) would lessen the arc of visibility on the approach to a 2.6nm ring, which is less than the 3 mile arc depicted on your overhead diagram at 15:00. But again, just a minor correction and no one else does such an amzing job keep up the good work!
Juan great job! As usual You got a WN/AA near miss outta PHX today as well as the “Vegas Air Races” in 2024. You’re gonna be busy! Thanks for all you do! Keep up the great work!
I recognize these must be difficult stories to cover, but for those of us eager to learn more about flying, they are etching invaluable lessons in our minds.
CVR at 0:59 seconds before impact (FO): “We don’t want to be on the news.” Horrible breakdown of CRM/SA
Thanks for the matter of fact reporting.
Beautiful analysis and cogent presentation. Thank you.
They were technically cat C and legal in that sense at full flaps (45). A couple of things on that.
-OEM procedure for circling in this Type is flaps 30, a ref+17, Flaps 45 leaving MDA. In must cases that places approach speed just in Cat D.
-I am not aware of an OEM procedure that allows circling at flaps 45, however some certified operators have an approved procedure for circling at flaps 45 Vref+10. It is in fact, the better way to fly the maneuver all be it not technically legal in most operations.
Still the approach speed in the flaps 45 configuration will place you squarely into CAT C.
There are two things I think the FAA could do to help with issues in Circling.
One is to relax the requirements for training circling approaches in 142 training organizations. Currently there are very strict rules that dictate what airports can be used to train and check a circling maneuver in a simulator. Due to this if you get a type rating from FSI your circle was done at MEM or JFK with very few exceptions. Not Sure about CAE but I am sure it is similar.
Better than that would be a more diligent push to expand RNP AR capabilities. Airports like this need RNP AR approaches and there needs to be reasonable access to the training for operations that are too small to have a custom approved training program that includes it.
Currently the AR portion of the RNP A is a unicorn for most operations. It really should just be included as an FSB item for aircraft that are capable which would mean that every type rated pilot is capable.
As soon as I saw the SIC’s hours I thought of the cockpit authority gradient that could have played a role in the challenges leading up to the accident.
Right seat was most likely evaluating the left seat, as he was a new hire with less overall experience, new to the aircraft type, and a foreign national to boot. It happens all the time. As Juan said, when things get sideways, whoever has a better handle on it needs to take over with clarity and purpose. It's just not completely clear in this case that either one of these pilots was going to do the right thing here---level the wings, apply high power, clean up the plane, and execute a missed approach. Poor CRM got them into a very bad place---low and slow, very dirty with gear, flaps, and spoilers all out, and trying to horse the plane back to a runway they had well overshot---but even the right seater was still talking about trying to salvage the approach up to the very end, not talking about getting the hell out of there and regrouping, as they should have.
@@DerekJohnson-us7vy Indeed, exactly!
I was on highway 80 and witnessed this crash. The plane flew right over the highway over me and just went down into the trees seconds later. Sad day!
Sorry you had to witness that - especially while driving.
So sad! Thank you Juan for the excellent coverage and lessons.
Perhaps a good indicator to reset things and stop the Swiss cheese model is when someone says "we don't want to make the news".
Very sad ending Juan,dunno mate it great you reporting these incidences but it must be draining on you ,safe flying,take care from ballarat in Oz,🙏🙏👋👋👍🇦🇺
I can tell you who was in control of the aircraft at the end of the flight. Sir Issac Newton.
Gravity…it’s the law!
With Darwin as his FO
Well, at the end, we know it wasn't Bernoulli.
Hi Juan, there was a near miss (or hit depending on your perspective) at Phoenix International, we are all waiting on your video about it, your videos are always very insightful and informative. Thank you.
I noticed on the Flight Simulator that I crashed more often when trying to land with an unstable approach. Sometimes you can save it, sometimes you can’t. My conclusion-always setup and fly a stable approach. Especially in jets.
Thanks for this excellent explanation of the situation.
Excellent analysis, again. Really appreciate the depth of your review, Juan. You highlight another important aspect of the safe flight 'chain'.....the organizational structure of the operation, There's so many reasons airline companies have generally displayed such excellent safety records, but something that is often overlooked is the organizational structure. In this accident, it appears that 'structure' was not mature and therefore weak and contributed to the accident.
They literally said "we don't want to be news". This should've been a clear red flag they had broken down (poor resource management) and they should go around and reorganize themselves. There was such unprofessionalism between themselves and the task at hand... They are fortunate no one else was hurt, a school bus was missed by seconds... GetThereitis...
There were four passengers on the flight who lost their lives.
At some point I was hoping to hear a clear and concise “my controls” also looks like somebody didn’t keep their hand on that speed brake lever plus it couldn’t have been armed and should have by this point…
Seems the copilot sensed the pilot’s apprehension and tried to calm him but in the end it all went to hell.
A+ Content Appreciate the instruction -lessons learned / take the time to understand the plate before the seat of the pants kicks in
Fantastic analysis of this. You are on top of your game Juan. Keep em coming.
@blancoliri0-- okay how do we do this? Much respect for you. I'm just a ex ag pilot with 4000 hrs fixed and 1000 helo. Always wanted to go to air tankers but now just to old. Plus 3 crashes and a few wire strikes I didn't count. But I lived to tell stories. I was also the chief pilot of several ag ops and had to drug test myself. Funny how that works. I can relate to the power of someone who you think is more experienced. However my experience was working for operators who weren't pilots. They were constantly pressuring me to fly in bad weather or busted up aircraft. Actually quite a ag service in Georgia and the owner attempted to hire my friend down the street. He asked why I wouldn't fly, the aircraft had a busted exhaust manifold. He told him he wouldn't fly it either. Got rehired that day and the aircraft got fixed. Just got to know your limits.
Very sad. Thank you for coming back to close the loop with the NTSB final report after your initial report out on this.
One thing that I can't get out of my head, and the NTSB can't really weight on that aspect, is the mindset of the pilot. A new hire on his first flight with the company, having a major investor of said company as a passenger, without having a proper visa to go fly commercially.
Is it possible that being stressed out of you mind because you don't want to fuck up your new job put you in a "land at all cost" mindset?
The SIC trying to cool down the PIC seem to indicate a high level of stress.
If ever you were going to apply the James Reason / Swiss cheese model to an example here’s another belter . Unstable , no correct cockpit authority (or backward) gradient , challenging conditions coupled with a challenging airport and allowing themselves to get overloaded with changes very close to arrival . Very sad and very hard as a professional pilot to watch through as it’s frustratingly avoidable. Once again great job Juan , thorough and fair with some lessons that are prudent from PPL to very advanced . This simply should not happen with near a combined 20000hrs in crew experience but it did , and sadly will again .
Great breakdown as always sir. Appreciate your insight on these incidents.
Thank you Juan for this follow up video, my family and I were in the parking lot next to the golf course when this happened. I heard the plane coming in and wanted to see it land and thought the runway was close to us. Next thing I know all I hear is the screaming whistle from the engines and saw it crash through the trees. It was an insane day for sure.
Wow!
This content is excellent. I admire your ability to break down these situations. Tip of the hat.
These poor dudes were a hot mess according to that transcript
Ahh the joys of Part 135 operations, reminds me of a similar slimy jet charter organization I once flew for out of Scottsdale.
I read the written transcript of the Cockpit Voice Recorder and some of the NTSB interviews with company officers that are included in this NTSB Docket Information prior to continuing my listening of Juan's presentation. That made it easier to follow the excellent piece that is just another of his many UA-cam programs pertaining to aviation accidents.
In 14.000 hours I did this once, and it was carefully planned (I was the F/O and it was at Ronaldsway). It's a blighter to do.
Flight spoilers deployed on final, the final slice of cheese.
The amygdala can cause bad decision making.
If you feel rushed, recognise and breathe. Don’t push on. Hold, slow down or go around.
An extra ten minutes is not as long as eternity.
Very nicely done. So easy to see from here, now. So many stupid decisions, made worse by the cockpit dynamics and desire to "make it work". I have seen this a lot in my career. Fortunately, most of that was in a 121 cockpit where we were armed with SIGNIFICANT guard rails in terms of GOOD SOP's and techniques to recognize, minimize, and mitigate mistakes. Now that I am flying 135, it's like starting all over as I am often paired with very low-time and inexperienced FO's who do not have the luxury of all the training I received in the 121 world. None of us are born to fly. We have to keep working at it. Complacency is a killer. Get home itis is a killer. This video will help someone, somewhere, someday.
The Part 135 I worked for did NOT allow circling approaches at ANY airport during hours of darkness or low vis.
sounds like they were both fighting each other on the controls the final minute of the flight..