The REAL Pilot Mistake That Got Brittney Killed!

this is Britney and this is her airplane on the roof of a building after she crashed when she was moments away from Landing this was a heartbreaking tragedy in the investigation that followed would uncover several shocking details about how this happened and that's why I'm going to share with you the full story and the real mistake that got Britney killed I'm Hoover and welcome to your pilot debrief Our Story begins on the morning of April 13th 2022 in Salt Lake City when Britney was getting ready to make a routine flight to the Burley municipal airport in Idaho she had flown into the Burley airport 12 times already that year but tragically this flight would be her last on the day of the accident she completed one instrument approach and then when she came back around for a second something went terribly wrong video footage captured her aircraft in a nose High attitude as it crashed into one of the exhaust stacks on the roof of a building killing her instantly the question is why and to answer that we need to start by looking at the pilot Britney was only 30 years old when she died she earned her Private Pilot certificate while she was still in high school and graduated as a valedictorian of her class in 2010 she would go on to obtain a degree in business finance from Utah State University in 2018 and started flying full-time the following year becoming a commercial pilot and certified flight instructor at a flight school in Arizona in early 2020 when Co happened she moved back home to Idaho and began working as a pilot for a cargo company called Jim air the aircraft she was flying for them when she crashed was a 2013 Cessna 208b Caravan this is a high-wing aircraft typically capable of carrying nine passengers but it's also used for cargo purposes which is how it was being used on the day of the crash according to the investigation the aircraft was heavily loaded but it was still within the weight and balance limits for the flight when it comes to Britney's experience in this aircraft she started flying the Caravan in November of 2021 and passed her proficiency instrument and line checks in February of 202 22 just 2 months prior to the crash Britney had almost 1,400 hours of Total flight time and she logged almost 200 hours in the Caravan now the NTSB never said how much total instrument time Britney had but according to her flight Logs with Jim air she had about 26 hours of flight time and instrument conditions in the Caravan however only about 2 hours of that was logged between the time she passed her check right in February and the accident almost 2 months later the reason this is important is because even even though she was a well-respected pilot and was always careful she didn't have a lot of experience flying the Caravan in bad weather conditions and this was just one of the factors that contributed to the crash unfortunately the Caravan that Britney was flying didn't have a cockpit voice recorder or a flight data recorder because they weren't required eventually the NTSB determined that there was nothing mechanically wrong with the aircraft but one of the big factors they needed to consider was the weather on the morning of the accident the weather we at the Burley airport was forecast to be VFR conditions with Cloud ceilings around 2600 ft and 6 M visibility the only problem was the flight up from Salt Lake City was estimated to take 1 hour and 7 minutes and during that time there was a weather system moving through the area when Britney began her first approach the weather had deteriorated to a 2300t ceiling and visibility of only 1 mile due to light snow with a temperature of -3° c one of the problems with the weather is that it meant Britney would be flying in icing conditions although the aircraft was equipped with a TKS ice protection system there were still certain restrictions that Britney needed to be aware of one of those limitations according to the aircraft manual was that she was required to maintain a minimum air speed of 95 knots in icing conditions when the flaps are up when flying and approach in icing conditions the flaps should be set to 10° and no more than 20 degrees with a minimum air speed of 85 knots we'll talk more about this later when we look at what happened during the approach for now the important thing you need to know is that the investigation determined that there was no evidence of icing on the aircraft and icing did not play a role in the crash that said Britney was still concerned about icing because she didn't want to get stuck in Burley the airport is uncontrolled and they don't have any ding equipment on the ground and that's why her company policy recommended flying a low pass over the runway whenever necessary to assess the Airfield conditions in fact she tried to land at Burley the day prior but due to ground icing she had to divert Twin Falls just a short distance away the truth is her company never pressured any of their pilots to land at Burley and diverting to Twin Falls was a very common practice especially whenever there was bad weather when Britney got about 20 mi from the field she checked in with the approach controller and was told to expect the Arnav approach to Runway two and that brings us to the first approach this is the Arnav GPS approach to Runway 20 and the weather met the minimum requirements that Britain needed to fly the approach however when you only have one mile visibility it's going to be difficult to see the runway and one of the other challenges is that this is a non-precision approach meaning there's no vertical guidance for the pilot to follow to descend down to the runway and that's because it has a 3.75 degree visual decent angle for the final segment of the approach which is steeper than the normal 3D path found on most Precision approaches the reason why this approach is steeper than normal is because of the exhaust vent stacks on the roof of the process proc in plant located across the river about 2600 ft from the end of the runway basically they're too high to allow Pilots to fly a normal 3° path to the runway and I'm going to show you the measurements later of just how close they are to the aircraft that fly overhead for right now unfortunately there isn't much on this approach plate to warn Pilots about these Stacks there's a little symbol on the side showing an obstacle at an elevation of 4,179 Ft MSL but it doesn't say these are sticking up 100 ft above the ground right in line with the runway the other thing that's different about this approach plate is this section down at the bottom if you can fly a normal 3° path to the runway then the chart will look something like this with a gray shaded area that's known as a stipple however if an obstacle interferes with that 3° path then the gray area is removed from the chart now I know it might seem a bit backwards because our brain tells us that we should highlight things that are different or that might be a problem but that's just the way the approach plates are made thankfully Britney have flown into Burley 12 time so far that year and that means she's likely seen the exhaust Stacks before and was aware of how close they are to the runway and knew that they're a dangerous obstacle on this approach according to the adsb data during the first approach Britney maintained a relatively constant 3.75 degree path from about 6,800 ft all the way down to the runway she flew that approach with the flaps up at an air speed of about 130 knots which was well above the minimum air speed for having the flaps up and she probably did that so she wouldn't have to worry about any icing accumulating on the flaps she got below the clouds right around 2300 ft above the ground but because of the snow limiting the visibility to one mile she most likely didn't see the runway until she was right at her minimum descent altitude of 4560 ft once you get below the MDA it's a visual approach and that means you're responsible for obstacle clearance and if you lose sight of the runway you're supposed to execute a missed approach the investigation couldn't determine if Britney was using the autopilot during either approach approach but the one thing we know for certain was that she stayed on that 3.75 de path on the approach and that red line represents the exhaust Stacks that she flew directly over now she continued her descent in the airport surveillance video showed her crossing the runway threshold 20 ft high as she assessed the Airfield conditions before increasing the power and climbing away to execute the missed approach procedure before we look at what happened during her second approach we need to talk about how dangerous the exhaust Stacks are the gym State Processing facility is located on the east side of the Snake River across from the Burley airport and as a side note Gem State Processing is not related to gy air the company that Britney was flying for now when it comes to the processing plant the investigation didn't say when it was built but we know that the airport was there first and the city owns the land where the processing facility is located and they lease it to them in March of 2016 over 6 years prior to this tragedy the Burley Airport manager told the FAA that Jim state was building new exhaust stacks on their property and he believed they wanted to make all the stacks 100 ft high and he wanted to know if they had permission to do that the FAA responded saying they didn't have any information about that and when the FAA contacted Jim State they were told the stacks were 60 ft high and four more Stacks were being built it was around that same time that Southern Idaho Pilots were trying to warn officials that the stacks presented a safety concern and the city administrator at the time claimed that Jim State never told the city or the county about making the stacks bigger according to a lawsuit filed by Britney's parents the city was allegedly aware of the plans regarding the exhaust Stacks but a city official told the FAA in 2015 they weren't a hazard and the reason he said this was because of the economic benefit the expansion would bring to the city that right there to me is probably one of the most shocking things I found in this investigation now the fa eventually got more involved and they published a study in May of 16 saying that the height of the stacks was 70 ft above ground level and they were presumed to be a hazard to air navigation around that same time Jim State modified their plan because they needed to increase the height of the stacks in order to comply with EPA guidelines the FAA said the first study they did was just a preliminary finding and they conducted a second study based on the revised plan with the taller Stacks that second study was published in February 2017 and it said the new Stacks were now 100 ft tall but they no longer presented a hazard to air navigation the FAA required the stacks to be painted with orange and white Aviation paint and lit with red obstruction lights additionally any failure or malfunction of one of those lights for more than 30 minutes needed to be reported immediately to the FAA this is an example of how the stack should have been painted and this is a photo taken right after the accident reflecting that over 5 years after the FAA study the stack still hadn't been painted in accordance with the requirement you can also see that one of the lights wasn't working but the investigation didn't provide any details on when or if that had been reported to the FAA as required the stack that Britney hit also wasn't painted orange and white and the FAA couldn't determine whether the light on top was functioning prior to the crash and honestly my opinion is that it doesn't matter if that light was working or not if you can't see it because of the steam clouds the stacks are producing on the day that Britney was flying you had low ceilings and low visib ility and the winds were straight down the runway meaning it was blowing the steam directly towards Britney on the approach path that she was flying if you look at this video taken from an eyewitness just moments after the crash you can see the steam blowing towards the stack that Britney hit basically obscuring parts of the stack at times we'll talk more about these exhaust Stacks later but you have to keep in mind that Britney flew that first approach on that 3.75 de path right over the top of these Stacks without any problems now that brings us to what happened on her second approach and then I'll explain the real mistake that got her killed by the time Britney began her second approach the weather at the field was rapidly improving just 8 minutes after her crash the ceiling was reported to be 3,000 ft and the visibility had also improved to 2 and 1 half miles these are much better conditions than her first approach however there's still a light snowfall and it's still icing conditions and that meant that Britney should have been flying the approach with the flaps at 10 or 20° unfortunately she kept the flaps up just like on that first approach this is going to be a big factor in what happened next she got established on the 3.75 degree path to the runway but this time she was at least 25 knots slower than the first approach and she eventually would slow down all the way to 85 knots and maintained 85 knots for the last 30 seconds of her flight another problem with flying this approach with the flaps up at 85 knots is the nose of the aircraft is higher than it would be if she had the flaps down based on her height and nominal eye position this simulation shows the location of the exhaust stacks and the gray shaded area represents the instrument panel this is what she would have seen at 40 seconds prior to impact at 30 seconds before impact the runway is still in view but the exhaust stack became hidden behind the instrument panel and it would remain hidden from her view until about 3 seconds prior to impact but by then it was too late to do anything however that doesn't explain how she got low enough to hit it when she was easily able to avoid it on the first approach this drawing provided by the ntsv gives us a very clear picture of how the approach works if you're at 4,800 ft at jid on this approach which is the lowest you're allowed to be at that point and if you maintain a 375° path all the way to the runway you'll be 40 ft in the air when you cross the displaced Runway threshold that's perfectly fine but that vertical path only gives you 98 ft of clearance above the exhaust stack that Britney crashed into that's not a lot of room for error but now here's the really interesting part and I want to thank Juan brown with the YouTube channel Blanca Lio for pointing this out but I also want to thank the folks at the NTSB because they put a tremendous amount of effort into analyzing what happened in this tragedy and they rarely get the thanks they deserve for what they do so thank you for all of this according to the investigation the last adsb data point is right here and I've labeled that point J and that's where Britney was at an altitude of 4,387 F MSL and she was still on the 3.75 de path her ground speed was 100 knots and that means she was decending at 450 to 512 ft per minute that's a nice stabilized approach the problem is when she gets to point J that's 1,4 ft laterally from the exhaust stack and based on the height that she hit the stack Britney's rate of descent had to increase to about 1,500 ft per minute in the last few seconds of her flight which was about three times the decent rate she had been flying up to that point the question is how did that happen and what was the real mistake that got her killed according to a witness in what was seen in the surveillance video after Britney came out of the clouds she immediately went through a steam Cloud before hitting the stack that killed her the NTSB considered the possibility that the steam from those clouds increased the density altitude of the air that Britney flew through and that degraded her aircraft performance however after sense of analysis they said this wasn't a factor in the crash because studies showed the density altitude of the steam Cloud matched the surrounding air once it got about 200 ft away keep in mind that if you're on that 3.75 degree path you're only going to be about 100t above those Stacks when you fly over them and in my opinion the problem caused by the steam is more than just a density altitude issue it's the disruption of the air in and around that steam that could cause turbulence or momentary loss of lift this wouldn't have been a problem on the first approach because Britney was doing about 120 knots well above the margin for stalling and the faster speed would have resulted in the nose being lower and she probably could more easily see the exhaust Stacks however according to the NTSB when she flew that second Approach at 85 knots that put her in the regime where the stall warning horn might have activated so I think it's possible the steam clouds could have affected her aircraft performance but I also think she could have heard the stall warning horn and simply pushed the nose forward to recover not realizing the exhaust stack was directly in front of her unfortunately we'll never know for certain what caused Britney to lose altitude so quickly during the last few seconds of her flight the NTSB said the probable cause was that she got too low on the approach and the exhaust Stacks were a hidden danger in my opinion as heartbreaking as this tragedy was the real pilot mistake that got Britney killed was simply being in the wrong place at the wrong time when all the holes in the Swiss cheese lined up and if those exhaust Stacks hadn't been there then Britney would would most likely still be alive today and my heart goes out to her family and friends as they continue to search for answers if you learn something from this debrief be sure to let me know in the comments below and check out one of these other videos on the screen and I'll see you on the next debrief

Channel: Pilot Debrief

Views: 968,046

Keywords: brittney infanger, N928JP, pilot mistake, cessna caravan crash, cessna caravan, burley idaho crash, plane crash, plane crash on roof, brittney infanger plane crash, gem state processing plant crash, idaho plane crash, aviation, pilot debrief, Hoover

Id: 0uSUp_G3gjo

Length: 16min 43sec (1003 seconds)

Published: Sun Jun 23 2024