Accident Case Study: Delayed Reaction

and it's a frequent Celtic Larry you have a heavy to extreme cell at your 1 to 2 o'clock reports the pilot of the plane may have been doing aerial acrobatics just fly no stretch of the imagination are we healed and we may never be you it's just after 10 a.m. on December 20th 2011 morning rush hour is over in the New York metropolitan area but there's still plenty of traffic on Interstate 287 near Morristown New Jersey when a strange sight appears in the gray overcast sky drivers who happen to look up are stunned to see an aircraft spiraling toward the ground and a near vertical dive trailing smoke within seconds the doomed aircraft plunges into the southbound lanes and wooded median of I 287 several motorists have no choice but to drive through the fireball miraculously none of them are injured their narrow escape is the one bright spot in an otherwise grim situation all five people aboard the aircraft two of them young children are dead a multi-million dollar airplane is destroyed a major highway is closed for hours and countless lives are disrupted as a result why did it happen to answer that question we have to turn back the clock to 9:00 a.m. as the pilot of November 7 three one Charlie alpha a Secada TBM 700 is preparing for a flight from Teterboro New Jersey to Atlanta's Peachtree DeKalb Airport he's joined by his wife two children a business associate and the family dog the 45 year old pilot holds a private certificate and instrument rating and has logged over 1400 hours and 10 years of flying his total experience in the TBM is unknown but evidence suggests it may be as much as 700 hours he takes annual recurrent training in the aircraft and has successfully completed a simulator course in the past month the flight plan for the trip file via do aughts at 7 o'clock that morning lists an N route cruise speed of 292 knots at flight level two six zero there's no indication that the pilot has received an official weather briefing from do Otts or flight service though it seems likely he's gotten weather information from other unofficial sources it's 9:30 a.m. when ATC issues and ifr clearance for departure to the southwest eight minutes later the aircraft is cleared for takeoff you at the time of the accident the most prominent weather feature in the area was a cold front that had moved south across the region earlier that morning behind it lay a band of moisture that in combination with freezing temperatures aloft created the potential for dangerous icing conditions the area forecast valid at the time of the accident called for overcast ceilings at 7,000 feet with tops through flight level 180 zero in addition an airman had been issued advising pilots of moderate icing from the freezing level which varied between 3,000 and 9,000 feet to flight level 180 zero over an area covering most of New Jersey Pennsylvania Ohio and Maryland more worrisome than that rather vague warning however were the numerous pilot reports of icing just after 8:00 a.m. an American Airlines md-83 over Morristown the site of the accident made an urgent report of severe rime icing between 14,000 and 16,500 feet the pilot later stated that conditions were the worst heat encountered in 38 years of flying likewise the captain of a Canada regional jet operating near seven three one Charlie alpha at the time of the accident later reported that the rate of accumulation overwhelmed his wing anti-ice system he estimated that the aircraft picked up two and a half inches of ice on the protected areas of the wing and four inches on some unprotected areas within just a few minutes that particular report was of course not available to the pilot of seven three one Charlie alpha however there was no shortage of other PI reps earlier that morning several of them from large jet aircraft reporting moderate icing according to the aim icing reaches the moderate level when quote the rate of accumulation is such that even short encounters become potentially hazardous in contrast to the dangers lurking above weather at the departure Airport was quite good with excellent visibility and a high overcast and despite all the pilot reports prior to the accident the weather forecasting system generated no additional warnings apart from a minor update to the existing airman we can't be sure how much the pilot really knew about the weather situation that morning all we can say is whatever concerns he may have had they certainly didn't keep him from the party you it's now 9:55 a.m. and seven three one Charlie alpha is South westbound climbing through 8,000 feet on its way to 10,000 when it's handed off to a new controller at new york tracon ' we have seven three one Charlie alpha 8% so soon as you want you have to expose me to run for 14001 for 14 for playoffs and which I have for average ports of moderate run 15 through 17 light runs so there wasn't a problem with the 14 I'll keep you out if it gets worse let me know when the Senate takes your hand off while climbing and making a July tally up I want to know what happens if we get in there F we could go straight through it that's a proper Oh unbeknownst to the pilot due to the numerous icing reports officials at New York Center have determined that propeller aircraft filed at 16,000 feet and below should either be rerouted or held at lower altitude until clear of the icing presumably because it's filed altitude is flight level two six zero seven three one Charlie alpha is not affected by this policy three minutes later while climbing through 12,800 feet it's cleared into the heart of the icing one shall become itaewon seven thousand milks no.1 34.6 shown a 34-6 on the left one seven seventeen thousand four Charlie off we're just interested Institute I star they honor to be Russia you the TBM 700 is a high-performance aircraft it's 700 horsepower turbine engine allows it to cruise at nearly 300 knots and up to 30,000 feet it's a capable weather flying machine but like any aircraft it has limitations aircraft of this caliber passed through ice all the time but they rarely linger in it for the simple reason that their surface ceilings and climb performance make it easy to avoid known icing systems offer breathing room and light and moderate icing but severe ice is an entirely different story the TBMs operating handbook clearly states that the first step upon encountering severe icing should be to request priority handling from ATC the reason being that unless a pilot makes a quick getaway the de-ice boots will be overwhelmed by the rate of accumulation as ice builds drag increases rapidly and airspeed falls off to maintain a climb in this situation the pilot has to keep increasing the angle of attack adding to the drag and eventually exposing unprotected parts of the wing to ice things can get very bad very quickly the autopilot poses other dangers there's no evidence that seven three one Charlie alpha was on autopilot during the accident sequence but it's worth noting that in order to maintain a certain rate of climb an autopilot will simply keep pulling back as the aircraft loads up with ice by the time it abruptly disconnects or the pilot finally realizes the danger it may already be too late you by 10:01 a.m. a little over three minutes after its pilot reported entering IMC the TBM is at sixteen thousand eight hundred feet and picking up ice are seven three one Charlie up I will have higher fee as soon as I can you will get some light icing near 17 s once I absolutely confirm that light I think oh yeah it's like - yeah it's pretty light but now we've been in here for a little while higher one able be good only nine seconds later however the situation aboard 731 Charlie alpha has clearly taken a turn for the worse assembly once a level will get a little battle here can we get higher typically yes 15 seconds later the controller has coordinated a climb our seven three one Charlie alpha climb and maintain flight level two zero zero two zero zero four one Charlie alpha thank you it's not entirely clear what the pilots reference to getting a little rattle or possibly rattled means a post accident statement from the controller indicates he believes the pilot is simply worried about the icing but it's also possible the pilot is referring to a noise in the aircraft conceivably sounds made by the engine ingesting ice accident investigators will later find the switch for the inertial separator a mechanical device that prevents ice from entering the engine in the off position whatever the case the pilot begins his climb just over a minute later as the aircraft reaches an altitude of seventeen thousand eight hundred feet it suddenly turns 70 degrees to the left and enters a descent 20 seconds later a truncated call is heard on the frequency and stuff we want to tell the office declaring in the 48 seconds before the final ATC radar returned the aircraft Falls 15,000 400 feet at some point aerodynamic loads overstressed the airframe and caused the right wing and parts of the tail to separate on the ground at New York Center the realization that something terrible has happened begins to set in seven three one Charlie after New York you see that code 1 0 3 1 I think he's having trouble with the icing very much charlie yeah right now I don't know I think he's defending are you doing out of them I think he do I want to be seven three one Charlie I'll see you there the crash of November 731 Charlie alpha is a sobering example of just how quickly things can go wrong in certain weather situations even for an experienced well-trained pilot flying a capable aircraft in hindsight the immediate temptation is to speculate that an official weather briefing would have left the pilot better prepared for the conditions he eventually faced and perhaps it would have but large icing air mats are a dime a dozen during winter in the Northeast and it's not hard to imagine the experienced pilot of a German aircraft glancing through a list of Pi reps reaching the conclusion that he probably pick up a little ice during the climb and moving on just as he had dozens of times before it's also possible that more proactive warnings from ATC or better integration of pilot reports into the forecasting system might have made a difference that said as pilots we fly the weather we find not what was forecast and it's incumbent upon us to take the initiative with atc even or perhaps especially in high-density airspace sometimes experience harms more than it helps rather than making us more vigilant it can lead to a sort of comfortable complacency not only about the dangers we face but about our own capabilities and those of our aircraft complacency is arguably Aviation's most common fights and one of the hard truths about flying is that it's sometimes punished with extraordinary severity the pilot of 731 Charlie alpha was in the clouds for a total of approximately five minutes roughly two minutes passed between his first indication to ATC that icing was a problem in the beginning of the final plunge it takes time for the human mind to spin up when suddenly confronted with a problem it takes time to recognize that things have changed and process the idea that an extraordinary response is called for all during that time part of the mind is fighting against the new reality arguing stay the course two minutes isn't much time but it's enough time enough time to make a decision declare an emergency and reverse the climb or just push the nose over and worry about ATC later or at least that's what we'd like to think the truth of the matter which is that two minutes really isn't much time for someone who's surprised conflicted and almost certainly frightened is decidedly less comforting

Channel: Air Safety Institute

Views: 811,740

Rating: 4.9086046 out of 5

Keywords: Case Study (Literature Subject), Accident (Disaster Type), Reaction, Aviation Safety (Literature Subject), Aircraft Owners And Pilots Association (Organization), Cold Weather (Film), Icing (Dish), ASI, AOPA, pilot, fly, aviation, general, ga, vfr, ifr, spiral, plane, accident, crash, small plane, new, jersey, airplane, aircraft, N731CA, family, flight, logbook, aviate, simulator, plan, wing, faa, analysis, ntsb, tower, atc, weather, wx, learn, study, case, student

Id: 0JkLR_xgayM

Length: 14min 12sec (852 seconds)

Published: Thu Nov 14 2013

Reddit Comments

[u/arctic_radar]

Wow, ice is terrifying.

[u/SasoDuck]

That was fucking chilling, listening to a guy's last radio transmission before he died...

[u/siera117]

What's chilling about this is how fast everything developed. I'm not sure I would have reacted any different from the pilot waiting for ATC clearance for higher altitude.

It goes to show to listen to your gut, take the initiative and not wait for a bad situation to get worst.

Apparently it's better to ask for forgiveness than for permission, something I'll be remembering during theses winter months.

[u/youknowdamnright]

I really enjoy these videos despite the fact that they are very sad. I find it really important for us to realize the dangers we face and to see how the chain of events leads to an accident. I hope that if I ever encounter a bad situation, I will be better prepared by watching these accident case studies.

[u/evopeppy]

Unfortunately severe weather is one aspect of aviation we pilots are not very familiar with. We spend most of our training learning how to avoid severe weather so when a pilot finds themselves in the thick of it, most likely they will be experiencing it for the first time. Since only test pilots intentionally fly into severe weather the next best thing we can do is prepare ourselves mentally with knowledge. I would highly recommend the book Severe Weather Flying by Dennis Newton. amazon link

[u/MC2700]

A friend I work with, use to fly for this guy as his charter pilot... he said he was the best boss you could ever have. My Friend saw this a couple years after he got a new job flying charter (where I met him now) and broke down while watching it. The voice of the pilot in the briefing, is actually his boss. He showed it to us, after telling the story and he had to leave the room. I didn't know the pilot, but still listening to this give me goosebumps. Pay attention to Ice everyone, fly safe.

[u/Mike734]

I'd never heard this story. It's such a shame that an experienced pilot flying a capable aircraft couldn't make it through this weather. While it's easy to say he should have this or that, he should have been OK to climb through that ice. Notams are far too likely to say the "sky is falling". If I paid heed to every sigmet/airmet, I'd never leave the ground. This guy was let down by the aircraft, the ATC system, the FAA and bad luck. It really sucks innocent people died in a very scary final few minutes. I count myself lucky I haven't been in a similar situation in 20,000 hours. Flying really is unforgiving.

[u/rkiloquebec]

Few things are as haunting as a pilots last radio call. I hope I never experience it.

[u/godlyjack]

I actually remember this one. We were driving up to NY that day to visit some family.