TSB Report C177 loss of control ILS 07 YOW Dec 14/11

[pdw]

In this case, the pilot's errors of judgment and skill were so damning that
they could not be left out.. Everything else was.

Ok, so it was a bad decision all around . How high up on the glidelope at the first 1/2 scale deflection ... 5-6 miles out ? 1/4 mile high ?

To the south, YGK is already showing the 30kts starting at the surface ... CYOW only has one surface-gust showing 16-17 knots just before their approach, otherwise had 6-7 knots sustained East/ENE til then (but that's 5 miles ahead right at the airport).

The report states 100kts airspeed on approach (an estimate ?) which is what the Flight-aware records for CF-EFQ are showing in Groundspeed. How is this measurement recorded ? With any icing catch involved ... what is the minimum airspeed speed suggested for an approach ? How easy is it really to dip down to an iced minimum speed if not ruling out the unexpectedly gust-prone crosswind conditions ?

On the southerly heading in the procedure turn the GS is 80kts, but turning Northeast during interception of the glideslope is 110kts GS. If the component got to be tailquartering ... it must have been a southerly one at the higher altitudes of the approach track for rwy 7 ( ~ 60 degrees true).

[Doc]

We're leaving out the fact that a flight test is far from real life. It's simply a photograph of a moment in time, under stressful circumstances. I've seen pilots who can shoot approaches with the best of them pooch the same approach in a test situation. Seriously. This guy had what? 500 or so hours? Total time, and fingers are being point at his being a basically crappy pilot? I've been known to do less than, shall we say, text book approaches on check flights. So have some of you!
The big problem here was not the pilot's lack of skill, but rather his decision to be where he was in the first place.
I'd have proceeded to an airport with more suitable weather, for my airplane, and experience level.
A blatant case of "get home itis". Perhaps he had an early appendectomy.

[Colonel Sanders]

Back in the 1990's I used to do a lot more IFR training
than I do now. Busy, busy, busy, these days.

Not sure I'm allowed to mention this - a moderator may
get enraged - but I found that people got behind the
airplane on the ILS typically below 500 AGL, when the
needles started to get sensitive.

To deal with that, I would have people hand-fly to CAT II
limits, 100 AGL. You can even get a endorsement to do
that legally in the USA in a Category A aircraft (see the
FARs), hand-flown. No auto-pilot.

Once they had mastered that, I would have them land
under the hood. Again, at the risk of enraging people
with all sorts of delicate feelings, it was a tremendously
educational exercise, and a great emergency training
procedure.

Another exercise I liked - again, at the risk of upsetting
people - was on a smooth night, fly the ILS with the
knobs all the way in, and the gear up. 200 mph below
500 AGL, the needles are incredibly sensitive. If you
can do that, 100 mph is a piece of cake.

Like landing with a strong crosswind - YOU are the
limitation. Do something about it.

From what the TSB says, I would have never have
recommended this guy for his IFR flight test, with his
performance. Whomever did has got some serious
reflection ahead of them.

A lot of people think I am hard on their feelings. True
enough. But my students don't crash airplanes, and
they don't kill themselves and their passengers.

Here on AvCan, we learn that hurt feelings are more
important than hurt people. I find that bizarre, but I
guess that's an age thing.

[ReserveTank]

Is there a way for the public to know who recommended him for an IFR flight test and the name of the examiner who passed him? In my opinion, they share some liability for the crash. They KNEW he was incapable of performing an ILS under normal conditions but he was recommended and passed anyway. It's akin to medical malpractice.

[pdw]

63% is closer to "3/4 scale" ... 62% is nearer to "1/2 scale"

Too much discretion left there in the estimating ... IMO ... in splitting hairs between 1/2 and 3/4.

Should "3/4 scale" be a high estimate, and then reconsidered, it's easy to re-determine it more fairly later on .. as really only the "1/2 scale" deflection.

An examiner is never privy to a whole list of investigated history the way it is itemized in this report.

[Doc]

Is there a way for the public to know who recommended him for an IFR flight test and the name of the examiner who passed him? In my opinion, they share some liability for the crash. They KNEW he was incapable of performing an ILS under normal conditions but he was recommended and passed anyway. It's akin to medical malpractice.

Don't even THINK of going there. Would LOVE to see this post deleted! Can you say CAN OF WORMS?

[ReserveTank]

ReserveTank wrote:
Is there a way for the public to know who recommended him for an IFR flight test and the name of the examiner who passed him? In my opinion, they share some liability for the crash. They KNEW he was incapable of performing an ILS under normal conditions but he was recommended and passed anyway. It's akin to medical malpractice.


Don't even THINK of going there. Would LOVE to see this post deleted! Can you say CAN OF WORMS?

Maybe a can of worms to some...The report indicates that he couldn't really fly an ILS in training (and he unfortunately proved it in actual flying). He should not have passed his IFR flight test if he could not fly an ILS, period. I must be clear that the pilot's decision-making ultimately killed him and his passenger. That still does not absolve the instructor(s) for recommending him and the examiner for passing him knowing the deficiencies. It's a case of poor instruction (just keep flying the guy till you have no choice but to recommend him) and the examiner's need to be known as someone who passes you on flight tests (financial motivation). This lack of care for training and testing sometimes shows up as a fatal accident, with culpable parties protected. And for what?

[pdw]

This lack of care for training and testing sometimes shows up as a fatal accident, with culpable parties protected. And for what?

It that sense you're referring to it a bit like the safety check on a car; having that safety check certificate doesn't mean at all you can go and find fault with the mechanic and sue for wrongful certification if something doesn't jive ... such as if something breaks or shows up as going faulty once you have the plates but before the safety-check's period expires. The safety is good for 36 days, but that doesn't mean anything more than permission to get the plates. Was determined to be safe upon inspection.

We the owners are responsible for anything that needs servicing at all times after that; we are in charge of our vehicles safety, ... just like the pilot is in charge, once certified.

The original problem here is they flew into icing where determined they should not have been, which otherwise would have been just another IFR practice opportunity for these owners. Tailquartering gusts can be very unnerving by themselves (no icing) ... and when weather is colder (stronger gust effects) the flight examiners will not even test you when there's icing conditions because they know it's illegal when iced up, ... nevermind without a de-icing system.

We can read about similar countless high-wing Cessnas that fell off an ILS after passing through icing conditions (Caravan Pilots forum), where the stakes are not comparable to warm / ice-free weather.

[Doc]

If a FTE passed him on a flight test, the instructor is totally off the hook. Not that there should be a "hook" in the first place. If you fly within the prescribed parameters on THAT particular day..you PASS.

[Doc]

pdw......WHERE is it stated "they flew into icing..."? FYI, just because the freezing level was the surface, does NOT mean they encountered any in flight ice.

[pdw]

It's a real issue of contention here, the TSB report isn't able to prove there was ice catch. You're right. The air at the surface at YOW is underpinning from (retreating toward) NE. Low pressure system to the WEST (trough extending in from Southwest)

Trouble is that CYRP (Carp) ... near where the procedure turn was, doesn't have any weather details to offer .. and neither does CYSH to the southwest. That's where icing conditions would have had to be evident for there to be some concrete proof ..

With the forecast icing conditions you wouldn't see it building on the tail, ... the cardinal doesn't have struts which are an indicator (the thinner struts are visible to the pilot and if building ice .. will be doing similarly on the HS leading edge).

[Colonel Sanders]

From what the TSB says, I would have never have
recommended this guy for his IFR flight test, with his
performance. Whomever did has got some serious
reflection ahead of them.

Don't even THINK of going there. Would LOVE to see this post deleted! Can you say CAN OF WORMS?

You guys are missing the point. Regardless of what paper
is pushed, at the end of the day, the instructor that
recommended this guy for his IFR flight test has to live
for the rest of his life with the responsibility for at least
being partly responsible for his death, and the death of
his passenger.

Maybe that wouldn't bother you young guys who have
a very slippery sense of personal responsibility, but that
would bother the h3ll out of me.

I am afraid that I simply do not understand the new-age
(and oh-so prevalent) reasoning that it's ok for someone
to die. Just don't hurt their feelings, or you are REALLY
going to be in trouble. I am trying hard to understand that
reasoning.

Speaking of hurt feelings ... I received a fascinating email
from someone who had previous dealings with the Cardinal
pilot, and hurt his feelings because he would NOT recommend
him for his IFR. He can't post here, of course, because of
a lifetime ban. Surprising.

[Maynard]

We're leaving out the fact that a flight test is far from real life. It's simply a photograph of a moment in time, under stressful circumstances. I've seen pilots who can shoot approaches with the best of them pooch the same approach in a test situation. Seriously. This guy had what? 500 or so hours? Total time, and fingers are being point at his being a basically crappy pilot?

I think I have to be a thorn in your side and disagree with your post Doc. One bad flight test sure, sh&t happens, to everyone. But one after the other? And not even getting airborne because of weak knowledge? If you see 4 Photographs of a beaver, how many do you need to see to believe its a beaver?(plane, animal, genitalia, your choice ) The evidence is obvious; maybe not that he's a crappy pilot, but that he was barely, (if), capable of flying IFR.

[Shiny Side Up]

You guys are missing the point. Regardless of what paper
is pushed, at the end of the day, the instructor that
recommended this guy for his IFR flight test has to live
for the rest of his life with the responsibility for at least
being partly responsible for his death, and the death of
his passenger.

Partly, but at the end of the day, remember who bears the ultimate responsibility for maintaining one's own safety, the guy who takes on the mantle of PIC.

Maybe that wouldn't bother you young guys who have
a very slippery sense of personal responsibility, but that
would bother the h3ll out of me.

Its not fair to paint the young with this brush. You and I know that there are bad people out there who aren't phased by such stuff. Lots of them train people to fly.

I am afraid that I simply do not understand the new-age
(and oh-so prevalent) reasoning that it's ok for someone
to die. Just don't hurt their feelings, or you are REALLY
going to be in trouble. I am trying hard to understand that
reasoning.

It has nothing to do with hurt feelings, or at least people not being afraid to hurt someone's feelings. Ultimately, we (collectively) can't keep people out of the air. After all, for every one of these guys with an IFR ticket who shouldn't have one, there's one of these guys too.

viewtopic.php?f=118&t=86185

Who's the instructor to blame there? Who's the pilot examiner to blame? I hate to say it, but I've run into way more of these types of pilots than I would wish were out there. And its not "ok" for them to die, but it also seems to be almost inevitable that a lot of these guys are going to have their lives serve as warning to others and regrettably those warnings will often go unheeded by those who need to heed them the most.

If our cardinal pilot was turned down by your acquaintance, one wonders how many other instructors did the same before he gravitated to someone with some what lesser qualms about flying with them and recommending them. They're out there those bad apples and sooner or later those seeking the lowest common denominator are going to find it. Lots of times I find it has something to do with a perceived right to fly rather than a privilege earned. That's just my opinion and feeling on that issue. I've had lots of similar experiences. I recall one fellow who's feelings were hurt since I didn't want to do his night rating for free. He's went on to a stellar piloting career of bending at least one airplane, and making a great attempt when I saw him last of trying to wreck another. Guess what, he found some schmuck to do it for free (incidentally he was also the person who figured it was cool to practice with foggles on by himself - I really wish I was making shit like this up). Another fellow I know, whom I sent packing as a student due to his extremely poor attitude towards everyone in general - staff as well as other students - went through seven other instructors before obtaining his PPL and then promptly wrecked a taildragger he bought on his first flight with it. He was too awesome for needing an instructor it turned out.

At the end of it, while the instructor and pilot examiner are less than stellar, the blame for this guy's passing lies squarely on his own shoulders. Lets not lose sight of that.

The depressing part is that there seems to be no end of human stupidity when it comes to this problem, aviation will continue to draw the blood of those who don't appreciate the risks and what the stakes in the game really are. We play "pilot" for keeps. Its supremely depressing when people have to pay this price the hard way, but I ain't wasting my energy and tears on those who ain't going to take the time to take care of themselves. I can spend my energy trying to make those who want to put in the effort and care enough about this miracle that is flying to stay in the game.

[Colonel Sanders]

Its not fair to paint the young with this brush

Yes, but they are particularly vulnerable. I get PM's
and email all the time from youngsters, new to the
business, who are trying to be talked into doing bad
things in an airplane, and are looking for advice on
what to do.

Guess what I tell them?

Hell, at my last flight instructor refresher course this
subject came up. The youngsters there - some of them
half my age - told me that they simply couldn't say
no, when asked to do stupid and dangerous things,
unlike cranky old me, whom is unafraid to say "no"
and hurt a few feelings, which seems to be a capitol
offense in Canada these days.

The flight instructor that recommended the Cardinal
pilot didn't say "no". He didn't hurt any feelings. Was
it the right decision?

aviation will continue to draw the blood of those who don't appreciate the risks

I couldn't have said that better myself. However, if
you point that out to a low-time pilot, by saying,
"Hey, that's gonna hurt", the reply often be, "F__k off,
you stupid old man", and a discussion of genitalia will
ensue. I don't understand the constant discussion
about genitalia.

Like watching a small child with his hand out, walking
towards a spinning radial arm saw, I have my doubts
about how this is going to work out.

[pdw]

What's really coming out in the last few posts is "taking the time to look after yourself as a pilot", but also that there are (reading between the lines) hidden money issues that can produce the risk of losing currency for some pilots, .. and the kitty over at any FTU isn't going to be too tolerant of Volks who need extra lessons but are having trouble coughing up the full amount ahead of time.

We're trying to compare a one fifth owner who has managed to arrange an aircraft purchase from the standpoint of more-limited resources with someone who's not putting in any effort to be current. I sure hope that 'just because we don't like someone, that they aren't going to get help from us'.

It sounds like it must have been a fair time/money committment on the part of this Cardinal pilot to keep the IFR license.

[Shiny Side Up]

Yes, but they are particularly vulnerable. I get PM's
and email all the time from youngsters, new to the
business, who are trying to be talked into doing bad
things in an airplane, and are looking for advice on
what to do.

The ones you have to worry about are the ones who don't ask for advice. But then again we all have to grow up someday, we're all big kids now, paying the big kids game. In my experience there's guys who are going to do stupid shit and there are guys who are going to figure it out. The ones doing stupid shit you can't tell them otherwise. I've had to fire a few of these in my time. Eventually they're going to be old bad instructors or dead ones. Same could be said of pilots in general. It seems that some want to run at the bullet.

Now a related more complicated problem is whether you just tell a student who seems to lack a sense of self preservation "@#$! off" or do you spend effort to bring them around? Knowing that if you send them packing that they'll find themselves someone who's going to be willing to endanger them. That's what the really tough choice for an instructor is. the older I get the less convinced I am that you can help a lot of these people, their fates seem somewhat inevitable.

Hell, at my last flight instructor refresher course this
subject came up. The youngsters there - some of them
half my age - told me that they simply couldn't say
no, when asked to do stupid and dangerous things,
unlike cranky old me, whom is unafraid to say "no"
and hurt a few feelings, which seems to be a capitol
offense in Canada these days.

They merely don't understand what's at stake. Some may never understand, but its easy to forget the pressures of being new. There might be something to be said that bad instructors are ones who never mature so somewhere in their minds they're always trying to prove themselves.

The flight instructor that recommended the Cardinal
pilot didn't say "no". He didn't hurt any feelings. Was
it the right decision?

Given what one knows about what would seem to be the instructor/examiner combo they probably don't give a shit. Something to think about: for all these young potentially learn the had way instructors out there, there's someone teaching them, and it isn't a group of young guys who are overseeing the cranking out of said new instructors. There's a group of old guys who's goal is to make bucks of the endless stream of these young up and comers. So I don't think the problem is endemic strictly to the new end of our pool of instructors. I suspect when you become an old-bad instructor, its hard to imagine one somehow is unaware of the risks, but rather just don't give a @#$! about the young ones you send out to meet them.

I couldn't have said that better myself. However, if
you point that out to a low-time pilot, by saying,
"Hey, that's gonna hurt", the reply often be, "F__k off,
you stupid old man"

I get old guys do lots of the same thing. In the end, some people just never change, as above. I don't think there's going to be a day when we won't be reading about these sorts of accidents. They will continue to take old, young and everything in between when their luck runs out.

[Rookie50]

I'll repeat that regardless of competency displayed on a flight test or elsewhere, conditions as they were that night, 100-200 foot ceilings, at night, in potential icing conditions, SE piston, are way too dangerous -- even if no icing -- for a non - commercial pilot. Too low for me, and (I think I am ) reasonably competent IFR.

[Colonel Sanders]

With all due respect, in the absence of icing, I don't
see a problem with hand-flying the ILS7 to CAT I
minimums (200 AGL) at night as long as you have
lots of gas to get to a good alternate (crucial).

The problem is, if CYOW has a dewpoint problem,
probably so does CYGK and maybe CYUL.

So in the absence of icing, my main problem is lack
of a good alternate.

I think an ILS to 200 AGL at night is great training.
You don't always break out above 500 AGL, before
the needles get really sensitive.

Oh yeah, you need decent cockpit lighting. Most
singles have horrible cockpit lighting.

EDIT -- I remember, years ago, flying the 421 into
someplace in Virginia, or West Virginia? Morgantown
rings a bell. Anyways, we were on top in VMC, but
everywhere around was reporting not only very low
ceilings, but also very low visibilities, which is a horse
of a different colour.

Rolling in on the localizer, I thought it was neat that
the wx radar was painting rows of hills on either side,
that we were descending in between.

It was nice and still, which made it easy. Carefully,
gently, needles in the donuts, at sure enough at 200
AGL, the threshold of the runway appeared in the murk
as advertised. Throttles back, we landed.

Guy before us missed. Guy after us missed. One
has to wonder if they really kept the needles in the
donuts all the way down to minimums, or bailed early.

Teaching IFR, it was a common error to see students
with large deflections in the LOC and GS. Not good.
More practice required.

At the risk of being attacked as usual, I might opine
that hand-flying IFR skills are a lot like formation skills.

Takes a lot of practice to get really good at it, and
after you do get good, they are annoyingly perishable
without constant practice. Not terribly egalitarian.
Sorry about that.

[Rookie50]

Training; with a experienced safety pilot, to simulated 200 or even 100, at night; is one thing. Am all for it. I'm all for training in difficult conditions. Thats why; I don't get FTU's who refuse to train in actual IFR, in gusty conditions with a 40 knot wind at 3000'. Great ILS training.

Planning flights; as a (low time) weekend warrior PPL, to a 200 foot ceiling, one mile vis, single pilot, single engine, at night, like these guys did, is quite another thing; and pushes the boundaries of risk way way too far IMO.

[Doc]

Training; with a experienced safety pilot, to simulated 200 or even 100, at night; is one thing. Am all for it. I'm all for training in difficult conditions. Thats why; I don't get FTU's who refuse to train in actual IFR, in gusty conditions with a 40 knot wind at 3000'. Great ILS training.

Planning flights; as a (low time) weekend warrior PPL, to a 200 foot ceiling, one mile vis, single pilot, single engine, at night, like these guys did, is quite another thing; and pushes the boundaries of risk way way too far IMO.

Agreed
I'm not a weekend warrior PPL, and I would NOT "plan" to be, where they were, flying what they were flying.

[Colonel Sanders]

gusty conditions with a 40 knot wind ... Great ILS training

I probably don't have your experience and qualifications,
but it has been my observation (around my neck of the
woods) that when the ceilings and vis are really low, it
is generally pretty calm, which allows you to set up a
really nice, steady approach.

I know on the east coast this is NOT the case - you
can have very low ceilings and vis, with very strong
winds at the same time. But that doesn't really matter
to me, because Atlantic Region TC phoned me up a few
years back and told me that if I ever flew there, they
would figure out something to charge me with. So,
I won't ever fly in Atlantic Region. Can't fight city hall.

[pelmet]

But that doesn't really matter
to me, because Atlantic Region TC phoned me up a few
years back and told me that if I ever flew there, they
would figure out something to charge me with. So,
I won't ever fly in Atlantic Region.

That doesn't sound very professional. Why would they do something like that?

[Colonel Sanders]

Why would they do something like that?

Phone TC Enforcement up in Atlantic Region
and ask them. All I know is that when the
goverment threatens me, I say, "Yes sir!"

[pdw]

pdw......WHERE is it stated "they flew into icing..."? FYI, just because the freezing level was the surface, does NOT mean they encountered any in flight ice.

Flight-aware shows the airspeed fluctuations before controlloss at 7:12pm (2 hours after dark). WX history shows a strong 'component' variation during their approach. Temperature records at CYOW are given as both ZERO and 1degC (two separate weather readings on the hour for 1900/7pm). IMO the temp was slightly below 1/2 degree C and then went above 1/2 degree at the time.

What's the minimum lapse rate taken to 2200AGL where navigating the turnaround NORTHWEST of CYOW in cloud for the alternate approach 10nm and DOWNWIND of those surface temps in MIST that were recorded twelve minutes earlier ?

IMO with at least SOME ice catch the following applies:
IMO they might have been a bit too high / fast on glideslope because of the headwind/gusting in higher groundspeed-than-IAS at first. Thus there was a sudden need to cut some power to comply to the slope, while also the gust can reduce speeds heavily at the same time (and a cardinal is known for slowing fairly rapidly anyway when cutting power). This is immediately followed by a sudden reducing headwind / or even the slightly tail-quartering gust, but it's fairly strong here. How exact is the radar record for those seconds of this accident flightpath ?

Above the approach / south of CYOW, the winds are starting southerly; below the approach and northeast of the airport the very COLD underpinning air (known as "retreating air") forces against higher elevation NE of CYOW, but in the process remains flowing (increasingly less) from NE (more EAST) while continuing to favour runway 7 near the surface.