Wednesday, January 14, 2015

Loss of Control in Flight: Cessna 152, N757ZM; fatal accident occurred January 13, 2015 in New Smyrna Beach, Florida

Mihoko Tabata
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Aviation Accident Final Report - National Transportation Safety Board

Investigator In Charge (IIC): Hicks, Ralph

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities: 
Laura Burns;  Federal Aviation Administration / Flight Standards District Office; Orlando, Florida 
Textron Aircraft; Wichita, Kansas
Lycoming; Williamsport, Pennsylvania 

Investigation Docket - National Transportation Safety Board:


Location: New Smyrna Beach, FL
Accident Number: ERA15FA099
Date & Time: 01/13/2015, 2058 EST
Registration: N757ZM
Aircraft: CESSNA 152
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis

The commercial pilot was in the process of purchasing a block of flight time with the intent of building time toward an additional rating. According to the operator, the pilot did not complete the mandatory checkout. However, she possessed the keys to the airplane since she had flown the previous day with an instructor, but he did not approve her for solo flight because he believed she required additional practice landing the airplane with an instructor onboard. On the day of the accident, she flew an undetermined number of local, solo flights without the knowledge of the operator. The accident flight was initiated at night, presumably with the intent of operating in the local airport traffic pattern. About 7 minutes into the flight, the pilot likely encountered instrument meteorological conditions (IMC) and requested assistance from air traffic control.

An air traffic controller attempted to provide the pilot with radar vectors to a nearby airport; however, the pilot was unable to visually acquire that airport. The controller then observed the airplane on radar at 600 ft and descending and directed the pilot to climb and turn. A short time later, radar and radio contact were lost; the airplane had crashed. The level of damage and fragmentation of the wreckage was consistent with ground impact at a high velocity. The flight was conducted on a dark, moonless night, under an overcast ceiling, and the final portion of the flight was over the ocean. These factors would have reduced the pilot’s ability to perceive the natural horizon and increased her risk of spatial disorientation.

Although the pilot held an instrument rating and had recently completed an instrument proficiency check, on the night of the accident, she did not demonstrate the skills necessary to control an airplane in IMC. She also did not display the ability to adequately communicate her situation to the controller, nor did she seem to understand or comply with the assistance offered to her. Review of autopsy results and postaccident toxicological testing showed no evidence of any physiologically induced incapacitation or other impairment.

During the sequence of events leading up to the accident, the pilot communicated with two air traffic controllers. The pilot described that she was operating in conditions that limited her ability to navigate and potentially affected her ability to control the airplane under visual flight rules (VFR). Although the actions of the controllers did not directly contribute to the pilot’s loss of control while attempting to fly under VFR in IMC, the controllers did not act in accordance with Federal Aviation Administration (FAA) guidance that dictates how to assist pilots experiencing this type of emergency. Specifically, the controllers did not ascertain if the pilot was qualified and capable of IFR flight nor did they attempt to locate and direct the pilot toward the nearest areas reporting visual meteorological conditions. Further, a controller assisting the accident controller had the opportunity to solicit a pilot report from another pilot in a nearby airplane to ascertain if that airplane was operating above the reported IMC but did not do so. During postaccident interviews, the air traffic controllers indicated that they had not received FAA-required evidence-based simulation training on emergencies and described the computer-based emergency training that they received as poor quality.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to maintain control of the airplane while operating under visual flight rules (VFR) in night, instrument meteorological conditions, likely due to spatial disorientation. Contributing to the outcome was the radar controller's failure to follow published guidance for providing assistance to VFR pilots having difficulty flying in instrument conditions.

Findings

Aircraft
Performance/control parameters - Not attained/maintained (Cause)

Personnel issues
Spatial disorientation - Pilot (Cause)
Aircraft control - Pilot (Cause)
Lack of action - ATC personnel (Factor)
Use of policy/procedure - ATC personnel (Factor)

Environmental issues
Below VFR minima - Effect on operation (Cause)
Dark - Effect on operation (Cause)

Organizational issues
Emergency proc training - ATC (Cause)

Factual Information

HISTORY OF FLIGHT

On January 13, 2015, about 2058 eastern standard time, a Cessna 152, N757ZM, collided with a public beach at New Smyrna Beach, Florida. The commercial pilot was fatally injured and the airplane was substantially damaged by impact forces. The airplane was registered to a private company and was operated by the pilot under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Night, instrument meteorological conditions (IMC) prevailed for the flight, and no flight plan was filed. The local flight originated from Massey Ranch Airpark (X50), Edgewater, Florida, about 2040.

Prior to the accident flight, the pilot, who was a Japanese citizen, contacted Flight Time Building LLC to purchase a block of flight time in a Cessna 152. According to the company's website, the company sold "blocks" of flight time to licensed pilots, with 50 hours being the minimum-sized block. The company normally dispatched an airplane to the pilot upon completion of a ground and flight "checkout." According to the owner of Flight Time Building, on the day prior to the accident, the pilot flew a local flight with an instructor, followed by a cross country flight with a safety pilot, who was an instructor-in-training. The owner reported that the pilot was not "signed off" for solo flight after the flights on January 12. The flight instructor stated that he needed to see "improved landings" before he could approve her for solo flight.

On the day of the accident, she flew an undetermined number of local, solo flights without the knowledge of Flight Time Building personnel. She possessed the keys to the accident airplane since she had flown it on the previous day with the safety pilot. She refueled the airplane at her own expense and initiated the accident flight, which was a local, night flight in the traffic pattern at X50.

At 2042:03, a radar target correlated to be the accident airplane was about 1 nautical mile (nm) south of X50. Radar data indicated the aircraft was in a left, 360-degree turn.

At 2047:22, the accident pilot pilot transmitted on the emergency frequency, 121.5 MHz, "hello," followed by two more transmissions of the her saying "hello." This coincided with radar data that depicted the accident aircraft emitting a transponder code of, or "squawking," 7700 (emergency) about 3.5 nm south of X50, or about 8.4 nm south of New Smyrna Beach airport (EVB).

At 2047:42, the pilot stated "uh I don't know where I am I want to land." At 2047:52, the Daytona Beach (DAB) Radar South controller transmitted, "The aircraft that doesn't know where they are at; are they at 1,700 feet squawking emergency and 1200?" At 2048:21, the pilot transmitted "I want to land."

The EVB local controller heard the pilot asking for assistance on 121.5 MHz. Because the aircraft was close to EVB, he was able to establish communications. Between 2048 and 2053, the EVB local controller provided assistance to the pilot. The pilot advised the EVB air traffic controller that she could see the ground but could not maintain visual flight conditions. When the EVB local controller turned the pilot toward EVB, the pilot reported that she could see the airport, but a short time later said she could no longer see it. The EVB local controller then attempted to transfer communications to DAB approach control on 125.35 MHz.

At 2053:52, the EVB local controller advised DAB ATC that the aircraft was proceeding towards DAB, and that EVB would have the lights set on high intensity if they needed the airport. The DAB Radar South controller replied, "thanks, we are going to try it." At 2054:35, the pilot of N757ZM transmitted "hello" on the emergency frequency 121.5, and at 2054:41 continued, "on 125.25 no ah contact." The pilot had been instructed by EVB to contact DAB on 125.35 MHz. The DAB Radar South controller responded on 121.5 by asking the pilot if she could hear DAB.

At 2054:49, the pilot again transmitted that she was unable to reach anybody on 125.25. The DAB air traffic controller replied "ok just stay on this frequency you are all right, maintain your present altitude." The EVB local controller informed the DAB air traffic controller that the pilot could not hear DAB on 125.35. DAB advised the EVB local controller that the pilot was on the wrong frequency, and that the DAB controller would assist the pilot on the emergency frequency.

At 2055:15, the pilot transmitted "hello." The DAB air traffic controller established communications with the pilot on 121.5 and asked the pilot if she could hear DAB; the pilot responded, "I can hear you."

At 2055:22, the DAB controller instructed the pilot to "remain calm and to maintain present altitude." The DAB controller told the pilot to continue the right turn northbound towards EVB, and that the airport would be off the right side. The DAB controller added that EVB would have all the runway lights turned on to high and instructed the pilot to advise when she saw the lights.

At 2055:40, the pilot transmitted on 121.5 that she was heading 100 degrees, and asked the DAB air traffic controller what heading she needed to fly. The DAB air traffic controller told the pilot that if she were able, to turn left heading 360 and that EVB would be at the pilot's 12 o'clock position and one and a half nautical miles. After an unintelligible transmission from the pilot, the DAB controller told the pilot she was not required to read back any further transmissions, and to make the turn. The DAB controller instructed the pilot to advise when she saw the lights at EVB. The pilot verified the heading and asked if she needed a left turn, heading 300. The DAB air traffic controller instructed the pilot to continue a left turn, heading 360 and reiterated the EVB position relative to the aircraft. The pilot acknowledged the turn.

At 2056:57, the DAB air traffic controller told the pilot to land any runway at EVB if she saw the runway lights. At 2057:06, the pilot stated she was at 600 feet and the DAB air traffic controller instructed the pilot to maintain her altitude until she saw the airport. The pilot replied that she was in the clouds. The DAB controller told the pilot, "okay don't worry, don't worry, don't worry, don't worry ma'am, just calm down, calm down; make a left turn." The DAB air traffic controller then instructed the pilot to make a left turn to climb because she had been in a descent. The DAB air traffic controller advised the pilot it was okay to be in the clouds but that she needed to climb.

At 2057:48, the DAB controller asked the pilot if she was climbing, and told her that she needed to maintain at least 1,000 feet. The pilot acknowledged the climb to 1,000 feet, followed by an unintelligible transmission. The DAB air traffic controller reiterated the climb to 1,000 feet and for the pilot to advise DAB when she was comfortable. There were no further transmissions from the pilot.

A short time later, radar and radio contact was lost and the airplane crashed onto New Smyrna Beach, in shallow water. Radar data indicated a descending, right turn prior to impact. The altitude of the last observed radar target was 500 feet above mean sea level. Emergency responders arrived at the accident site shortly thereafter in an attempt to provide assistance.

PERSONNEL INFORMATION

The pilot, age 38, held a commercial pilot certificate with ratings for airplane single engine land, airplane multi-engine land, and instrument airplane. She was issued a Federal Aviation Administration (FAA) third-class medical certificate on August 18, 2014, with a restriction to wear corrective lenses.

Pilot records recovered from the wreckage indicated that the pilot had logged about 416 total hours of flight experience as of January 7, 2015. She had logged about 1.3 hours of night time and about 6.1 hours of actual instrument time prior to the accident flight. Logbook entries showed that she completed a 14 CFR Part 61.55 flight review and a 14 CFR 61.57(d) instrument proficiency check (IPC), in a Cessna 152, at Torrance, California on November 19, 2014. The flight review and IPC were performed with different flight instructors. Her pilot logbook indicated she flew about 2.4 hours on June 30, 2014, in a Beech BE-58 and did not log another flight prior to her flight review and IPC of November 19, 2014.

FAA inspectors interviewed the flight instructors who performed the flight review and IPC. Both flight instructors reported that the accident pilot showed no weaknesses, handled the radios during the flight, was familiar with the local area, and was a "good pilot."

AIRCRAFT INFORMATION

The airplane was a Cessna model 152 that was manufactured in 1977. The high-wing, fixed tricycle landing gear airplane was powered by a Lycoming O-235-L2C engine, rated at 110 horsepower at 2,550 rpm and was equipped with a Sensenich 72CK56-0-54 metal, fixed-pitch propeller.

According to the maintenance logbooks provided by the owner, the most recent annual inspection of the airframe and engine was completed on October 27, 2014, at 502.1 hours tachometer time. The observed tachometer time at the time of the accident was 525.8 hours. The aircraft total time was not recorded in on the logbook entries, and the owner estimated that the total time of the airframe was about 12,000 hours.

METEOROLOGICAL INFORMATION

The National Weather Service (NWS) Surface Analysis Charts for 1900 and 2200 on January 13, 2015 depicted a cold front moving across central into southern Florida with cold air stratus clouds behind the front. Numerous station models behind the front depicted visibilities restricted in mist or fog, with temperature-dew point spreads of less than 5° F, and in the vicinity of the accident site less than 3° F.

The NWS Weather Depiction Chart for 2000 depicted an extensive area of IMC extending from the accident site and across most of all of central and northern Florida, Georgia, South Carolina, portions of southern and eastern North Carolina, and portions of Tennessee, Alabama, Mississippi, and Louisiana. A second area of IMC was also identified over southern Florida ahead of the front in the vicinity of West Palm Beach with marginal visual meteorological conditions extending through most of central and into southern Florida. The closest visual meteorological conditions with ceilings above 3,000 feet and visibility greater than 5 miles were over southwestern Florida, and extreme south Florida. The chart indicated that fog and low ceilings were not a localized event over the New Smyrna Beach area, but extended over most of the area.

The National Center for Atmospheric Research regional radar mosaic for 2100 depicted no significant weather echoes associated with rain showers or thunderstorms in the vicinity of the accident site during the period.

The NWS 12-hour Low-Level Significant Weather Prognostic Chart valid for 0100 and available for briefing prior to the accident depicted the cold front moving across southern Florida with an extensive area of IMC expected over most of all of Florida, Georgia, South Carolina, Alabama, and into sections of Mississippi, and Tennessee. The chart depicted no significant turbulence outside of convective activity was expected, and depicted the freezing level near 12,000 feet over the region.

No weather reporting capability was present at X50. A review of the observations surrounding the area indicated that at the time the accident airplane departed from X50, IMC were already being reported surrounding the area at EVB, DAB, and to the south at the NASA Shuttle Landing Facility (TTS), Titusville, Florida.

EVB was located approximately 5 nm north of the departure airport at an elevation of 10 feet, and less than 3 miles west of the accident site. The airport had an Automated Weather Observation System. The weather conditions reported at 2055, or about 3 minutes prior the accident, included wind from 350° at 8 knots, visibility 8 statute miles, ceiling overcast at 500 feet, temperature 17° Celsius (C), dew point 16° C, altimeter 30.14 inches of mercury (Hg).

The next closest weather reporting station was DAB, located approximately 14 nm northwest of the departure airport at an elevation of 34 feet. The airport had a control tower and a federally installed and maintained Automated Surface Observation System (ASOS). The weather conditions reported at 2053, or about 5 minutes prior the accident, included wind from 020° at 9 knots, visibility 10 statute miles, ceiling overcast at 700 feet, temperature 18° C, dew point 16° C, and altimeter 30.14 inches of Hg.

The DAB special weather report at 2131 included wind from 360° at 11 knots gusting to 17 knots, visibility 1 statute mile, ceiling overcast at 400 feet, temperature 16° C, dew point 15° C, and altimeter 30.15 inches of Hg.

The DAB special weather report at 2146 included wind from 360° at 8 knots, visibility ½ statute mile in fog, ceiling overcast at 300 feet, temperature 16° C, dew point 15° C, and altimeter 30.15 inches of mercury. Remarks: automated observation system, tower visibility 1-mile, temperature 15.6° C, dew point 15.0° C.

Orlando Sanford International Airport (SFB), Orlando, Florida, was located 20 nm southwest of the departure airport at an elevation of 55 feet, and was equipped with an ASOS. The weather conditions reported at SFB, at 2100, included wind from 360° at 9 knots, visibility 10 statute miles, ceiling broken at 1,000 feet, overcast at 3,900 feet, temperature 19° C, dew point 17° C, altimeter 30.14 inches of Hg.

On the day of the accident, sunset occurred about 1745 and evening civil twilight occurred about 1811. Moonrise occurred at 0029, and moonset occurred at 1212.

The DAB North Controller, who assisted the accident controller, solicited pilot reports (PIREPS) for the DAB local area earlier in her shift, but could not recall their specific content. During the accident sequence, she had been working a Cirrus SR22, whose pilot requested the RNAV runway 29 approach into EVB. The SR22 was at 3,000 feet holding at RISRE, about 10 NM east of EVB and near the accident aircraft, but she did not solicit a PIREP from the pilot or ask about cloud tops.

COMMUNICATIONS

Paragraphs 10-2-8 and 10-2-9 of FAA order 7110.65 address how air traffic controllers should provide radar assistance to aircraft operating under visual flight rules (VFR) in weather difficulty, including techniques that should be used to the extent possible when providing assistance. They state [in part]:

10-2-8. RADAR ASSISTANCE TO VFR AIRCRAFT IN WEATHER DIFFICULTY

a. If a VFR aircraft requests radar assistance when it encounters or is about to encounter IFR weather conditions, ask the pilot if he/she is qualified for and capable of conducting IFR flight.

b. If the pilot states he/she is qualified for and capable of IFR flight, request him/her to file an IFR flight plan and then issue clearance to destination airport, as appropriate.

c. If the pilot states he/she is not qualified for or not capable of conducting IFR flight, or if he/she refuses to file an IFR flight plan, take whichever of the following actions is appropriate:

1. Inform the pilot of airports where VFR conditions are reported, provide other available pertinent weather information, and ask if he/she will elect to conduct VFR flight to such an airport.

2. If the action in subparagraph 1 above is not feasible or the pilot declines to conduct VFR flight to another airport, provide radar assistance if the pilot:

(a) Declares an emergency.

(b) Refuses to declare an emergency and you have determined the exact nature of the radar services the pilot desires.

3. If the aircraft has already encountered IFR conditions, inform the pilot of the appropriate terrain/obstacle clearance minimum altitude. If the aircraft is below appropriate terrain/obstacle clearance minimum altitude and sufficiently accurate position information has been received or radar identification is established, furnish a heading or radial on which to climb to reach appropriate terrain/obstacle clearance minimum altitude.

10-2-9. RADAR ASSISTANCE TECHNIQUES

Use the following techniques to the extent possible when you provide radar assistance to a pilot not qualified to operate in IFR conditions:

a. Avoid radio frequency changes except when necessary to provide a clear communications channel.

b. Make turns while the aircraft is in VFR conditions so it will be in a position to fly a straight course while in IFR conditions.

c. Have pilot lower gear and slow aircraft to approach speed while in VFR conditions.

d. Avoid requiring a climb or descent while in a turn if in IFR conditions.

e. Avoid abrupt maneuvers.

f. Vector aircraft to VFR conditions.

g. The following must be accomplished on a Mode C equipped VFR aircraft which is in emergency but no longer requires the assignment of Code 7700:

1. TERMINAL. Assign a beacon code that will permit terminal minimum safe altitude warning (MSAW) alarm processing.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located in shallow water at approximate coordinates 29 02 22.68N, 080 53 52.69W. The wreckage was pulled onto the beach by local authorities after coordination with the NTSB investigator-in-charge to prevent further damage and loss of parts.

The left and right wings separated from the fuselage during the impact sequence. The outboard 4 feet of the left wing was separated from the remainder of the wing. The right wing exhibited diagonal and aft crush deformation, beginning 2 feet from the wing root to the aft spar at the wing tip. Aileron control cable continuity was established through multiple recovery cuts and fractures consistent with overstress. A majority of the left aileron was not located. The wing flap actuator was found in the retracted (flaps up) position.

The fuselage was separated into multiple sections, including a section consisting of the engine firewall and instrument panel, the landing gear and cabin floor, and an 8-foot section of aft fuselage. The right main landing gear was not recovered. The nose landing gear was separated and located with the main wreckage.

The empennage separated aft of station 173. The horizontal and vertical stabilizers remained attached. The outboard half of the right horizontal stabilizer leading edge was crushed in an up and aft direction. Rudder and elevator control cable continuity was established through multiple recovery cuts and fractures consistent with overstress.

Both wing fuel tanks were breached during the impact sequence and no residual fuel of found. The fuel selector handle was found in the "on" position and the unit operated normally in the "on" and "off" positions when forced air was introduced into the selector valve. Sand was found in the fuel strainer bowl and screen. The odor of fuel was observed in the strainer bowl.

The propeller separated from the crankshaft flange and was found partially buried in sand at the location of the main wreckage. The blades exhibited twisting deformation, leading edge gouges, and surface polishing.

The engine was separated from the firewall. The carburetor, carburetor air box, and alternator were missing and were not located. All engine components were subjected to salt water and sand immersion. The carburetor flange was fractured from impact and was still attached to the oil sump. The carburetor data plate was lodged into the induction tube at the oil sump.

The valve covers, magnetos, vacuum pump, and exhaust were removed by investigators. Mechanical internal continuity was established by rotating the rear accessory gears at the vacuum pump drive with a mechanical device. All valve action was confirmed through 720 degrees of crankshaft rotation and thumb suction and compression was observed at all cylinders. A digital video boresope examination of the interior of the cylinders and the piston surfaces revealed normal operating signatures. The magnetos were turned with a hand drill and by hand rotation; no spark could be produced. The spark plug electrodes were normal in appearance except for salt water, oil, and sand contamination.

The inspection of the engine did not reveal any abnormalities that would have prevented normal operation or production of rated horsepower.

MEDICAL AND PATHOLOGICAL INFORMATION

A postmortem examination of the pilot was performed at the offices of the District 7 Medical Examiner, Daytona Beach, Florida, on January 14, 2015. The autopsy report noted the cause of death as "Multiple Blunt Traumatic Injuries" and the manner of death was "Accident."

Forensic toxicology testing of the pilot was performed on specimens of the pilot by the FAA Bioaeronautical Sciences Research Laboratory (CAMI), Oklahoma City, Oklahoma. The CAMI toxicology report indicated negative for carbon monoxide, ethanol, and drugs. Testing for cyanide was not performed.

ADDITIONAL INFORMATION

FAA Guidance to Pilots

In April 2003, the FAA published Advisory Circular 61-134, General Aviation Controlled Flight into Terrain Awareness. The circular stated in part:

"Operating in marginal VFR /IMC conditions is more commonly known as scud running. According to National Transportation Safety Board (NTSB) and FAA data, one of the leading causes of GA accidents is continued VFR flight into IMC. As defined in 14 CFR part 91, ceiling, cloud, or visibility conditions less than that specified for VFR or Special VFR is IMC and IFR [instrument flight rules] applies. However, some pilots, including some with instrument ratings, continue to fly VFR in conditions less than that specified for VFR. The result is often a CFIT [controlled flight into terrain] accident when the pilot tries to continue flying or maneuvering beneath a lowering ceiling and hits an obstacle or terrain or impacts water. The accident may or may not be a result of a loss of control before the aircraft impacts the obstacle or surface. The importance of complete weather information, understanding the significance of the weather information, and being able to correlate the pilot's skills and training, aircraft capabilities, and operating environment with an accurate forecast cannot be emphasized enough."

According to FAA Advisory Circular AC 60-4A, "Pilot's Spatial Disorientation," tests conducted with qualified instrument pilots indicated that it can take as long as 35 seconds to establish full control by instruments after a loss of visual reference of the earth's surface. AC 60-4A further states that surface references and the natural horizon may become obscured even though visibility may be above VFR minimums and that an inability to perceive the natural horizon or surface references is common during flights over water, at night, in sparsely populated areas, and in low-visibility conditions.

According to the FAA Airplane Flying Handbook (FAA-H-8083-3), "Night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references. Therefore, flight instruments should be used to a greater degree.… Generally, at night it is difficult to see clouds and restrictions to visibility, particularly on dark nights or under overcast. The pilot flying under VFR must exercise caution to avoid flying into clouds or a layer of fog." The handbook described some hazards associated with flying in airplanes under VFR when visual references, such as the ground or horizon, are obscured. "The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation."

Air Traffic Controller Training

As part of the investigation into this accident, air traffic controllers were asked about their preparedness to provide assistance to a pilot in an emergency situation. FAA air traffic controllers were required to undergo proficiency training that "maintains and upgrades the knowledge and skills necessary to apply air traffic procedures in a safe and efficient manner." This training included recurrent training and refresher training. Chapter 1 paragraph 5, (a) and (b), of FAA JO 3120.4N, Air Traffic Technical Training, addressed the requirements of recurrent and refresher training and stated [in part]:

JO 3120.4N Air Traffic Technical Training

a. Recurrent Training. Recurrent training is collaboratively-developed national safety training delivered via electronic means, instructor-led presentations, or any combination thereof. Recurrent training is intended to increase air traffic controller proficiency, enhance awareness of human factors affecting aviation, and promote behaviors essential for the identification, mitigation, and/or management of risk. Topics are derived from data collected through internal and external safety reporting systems and stakeholder input. Recurrent training is conducted via an 8-hour block of training, two rounds delivered yearly. Each round is comprised of approximately 4 hours of training selected from the topics listed below, and 4 hours of training on relevant and timely safety topics, such as but not limited to: Human Factors, Safety Culture, Threat and Error Management, Crew Resource Management, Event Recovery, and learning that promotes the maturity of the Safety Management System. Recurrent training requirements are identified annually NLT October 1st to be delivered the following calendar year. Recurrent training on the following items need not be duplicated in local refresher training:

(1) Safety alerts and traffic advisories, to include Minimum Safe Altitude Warning (MSAW) procedures and the relationship between charted minimum altitudes and underlying topography.

(2) Weather and other conditions that affect flight (e.g., icing, thunderstorms, windshear, and VFR aircraft that encounter instrument flight rules (IFR) conditions).

(3) Bird activity information and dissemination.

(4) Wake turbulence information and application.

(5) Line up and wait (LUAW).

(6) Runway Safety.

(7) Recovery in ATC Operations.

(8) Fatigue awareness.

b. Refresher Training. Each facility must maintain, in writing, an annual (calendar year) refresher training plan. Annual refresher training contains two elements: nationally and/or facility-developed curriculum and simulation training. Facilities are encouraged to review their quality control data (e.g., Quality Control Monitoring, Service Reviews, and Compliance Verification and data available in the Partnership for Safety Portal) to identify additional topics for annual refresher training in order to meet each facility's changing needs. The following topics must be included unless designated by the TA as not applicable.

(1) Unusual situations, lost aircraft orientation, aviation security procedures (including interceptor procedures and communications), hijacking, and other topics identified by the TA. (Training on emergency situations should be based on real-life incidents and aircraft accidents, stressing a lessons-learned approach.)

(15) Facilities with simulation capabilities such as AT Coach, ETG, TTG, DYSIM, TSS,TTL, SIMFAST, O21 lab, etc., must complete locally identified, evidence-based simulation training on the topics identified in paragraph 5.b., Refresher Training, deemed appropriate by the TA, as follows:

(a) A minimum of one hour of evidence-based simulation training in calendar year 2014.

(b) A minimum of two hours of evidence-based simulation training in calendar year

Appendix (J) of the JO 3120.4N Air Traffic Technical Training identified the definitions and state [in part]:

Appendix J. Definitions

17. Evidence-based Training: Training based on an analysis of safety data.

All of the air traffic controllers indicated the recurrent training required by the FAA was lacking, and they couldn't remember any substance of the topics. All of the recurrent training they could remember was via computer-based instruction or by slide-based presentation. Both of the air traffic controllers on duty the night of the accident could not recall any refresher training utilizing the simulator as required, and the supervisor indicated most controllers viewed the training as an annoyance.

History of Flight

Approach
VFR encounter with IMC
Loss of control in flight (Defining event)

Uncontrolled descent
Collision with terr/obj (non-CFIT)

Pilot Information

Certificate: Commercial
Age: 38
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 08/18/2014
Occupational Pilot:
Last Flight Review or Equivalent: 11/19/2014
Flight Time: 416 hours (Total, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N757ZM
Model/Series: 152
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 15280134
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 10/27/2014, Annual
Certified Max Gross Wt.: 1676 lbs
Time Since Last Inspection: 23 Hours
Engines: 1 Reciprocating
Airframe Total Time: 12000 Hours at time of accident
Engine Manufacturer: LYCOMING
ELT: Installed
Engine Model/Series: O-235-L2C
Registered Owner: SMTM HOLDINGS INC
Rated Power: 118 hp
Operator:On file 
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Night/Dark
Observation Facility, Elevation: EVB, 10 ft msl
Distance from Accident Site: 3 Nautical Miles
Observation Time: 2055 EST
Direction from Accident Site: 290°
Lowest Cloud Condition:
Visibility:  8 Miles
Lowest Ceiling: Overcast / 500 ft agl
Visibility (RVR):
Wind Speed/Gusts: 8 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 350°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.14 inches Hg
Temperature/Dew Point: 17°C / 16°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Edgewater, FL (X50)
Type of Flight Plan Filed: None
Destination: Edgewater, FL (X50)
Type of Clearance: None
Departure Time: 2040 EST
Type of Airspace:

Airport Information

Airport: New Smyrna Beach Muni (EVB)
Runway Surface Type: N/A
Airport Elevation: 10 ft
Runway Surface Condition:
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: Unknown
Total Injuries: 1 Fatal
Latitude, Longitude: 29.039722, -80.895278 (est)

NTSB Identification: ERA15FA099
14 CFR Part 91: General Aviation
Accident occurred Tuesday, January 13, 2015 in New Smyrna Beach, FL
Aircraft: CESSNA 152, registration: N757ZM
Injuries: 1 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On January 13, 2015, about 2058 eastern standard time (EST), a Cessna 152, N757ZM, collided with a public beach at New Smyrna Beach, Florida. The commercial pilot was fatally injured and the airplane was substantially damaged by impact forces. The airplane was registered to a private company and was operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Night, instrument meteorological conditions prevailed for the flight, and no flight plan was filed. The local flight originated from Massey Ranch Airpark (X50), Edgewater, Florida, about 2030.

Prior to the accident flight, the pilot, who was a Japanese citizen, contacted Flight Time Building LLC to purchase a block of flight time in a Cessna 152. According to the company's website, the company sells "blocks" of flight time to licensed pilots, with 50 hours being the minimum-sized block. The company dispatches an airplane to the pilot upon completion of a ground and flight "checkout." According to the owner of Flight Time Building, on the day prior to the accident, the pilot flew a local flight with an instructor, followed by a cross country flight with a safety pilot, who was an instructor-in-training. The owner reported that the pilot was not "signed off" for solo flight after the flights on January 12. On the day of the accident, she flew an undetermined number of local, solo flights without the knowledge of Flight Time Building personnel. She possessed the keys to N757ZM since she had flown it on the previous day with the safety pilot. She refueled the airplane at her own expense and initiated the accident flight, which was a local, night flight in the traffic pattern at X50.

An initial review of available radar data indicated that the pilot climbed to about 1,000 feet above mean sea level (msl) and was flying in the visual traffic traffic pattern at X50. The airplane was later observed in a climb to 1,700 feet msl and then a descent to 1,200 feet msl. During this time, the pilot set the airplane's transponder to 7700 (emergency) for about a minute. She began transmitting on guard (emergency) frequency and informed air traffic control (ATC) that she could not maintain visual flight rules (VFR) and could not see X50. Controllers provided assistance and directed her toward New Smyrna Beach Airport (EVB). The pilot informed ATC that she was at 600 feet and ATC directed her to climb. A short time later, radar and radio contact was lost and the airplane crashed onto New Smyrna Beach, in shallow water. Emergency responders arrived shortly thereafter in an attempt to provide assistance.

Weather conditions at EVB included an overcast ceiling at 500 feet and 8 statute miles visibility.

A preliminary review of pilot records recovered from the wreckage indicated that the pilot had logged about 416 hours total time as of January 7, 2015. Logbook entries showed that she completed a 14 CFR Part 61.55 flight review and a 14 CFR 61.57(d) instrument proficiency check, in a Cessna 152, at Torrance, California on November 19, 2014.






 
Tabata’s Facebook page contains a post from January  11, 2015  that appears to show a navigational map of New Smyrna Beach.


NEW SMYRNA BEACH — The Japanese pilot killed when her plane plunged into the ocean was rated to fly “blind” in the poor visual conditions she experienced. 

The pilot was identified as 38-year old Mihoko Tabata, according to the Volusia County Sheriff’s Office. In Tabata’s LinkedIn profile she listed herself as a commercial pilot from the greater Los Angeles area.

Tabata took off Tuesday in a single-engine Cessna 152 from Massey Ranch Airpark in Edgewater, but sometime during her flight told air traffic controllers with the Daytona Beach control tower that she didn’t know where she was and wanted to land. Controllers tried to guide Tabata to New Smyrna Beach Municipal Airport and urged her to climb in altitude to 1,000 feet. Tabata told controllers she had descended to 600 feet seconds before she lost contact with the tower, according to a digital recording.

Emergency crews responded to the plane crash about 9 p.m. and the wreckage was spotted about 20 feet offshore by the first units to arrive on scene.

Based on the preliminary autopsy results, Tabata’s death has been determined to be the result of injuries suffered in the crash, sheriff’s spokesman Gary Davidson said in statement.

New Smyrna Beach Police Officers Richard Kirkland and Kyle Burkhead were the first responders on the scene just after 9 p.m. Tuesday. In their incident report released Wednesday, the officers stated that the pilot had suffered “major injury to the face.”

Tabata is from Japan, although she has been living in the United States off and on and most recently came to Volusia County on Saturday, Davidson said.

Her family lives in Japan and was located and notified of her death through the assistance of the Japanese consulate in Miami, he said.

Neil Ramphal, owner of the plane Tabata was flying, said she did not have permission to fly the aircraft by herself.

Ramphal said Tabata had 420 hours of flight time and was trying to reach 500 hours at his company Flight Time Building, which offers personal flight instruction and specializes in providing planes for pilots to build their flight times. Tabata had been at Flight Time Building since Jan. 10, Ramphal said. Tabata’s Facebook page contains a post from Jan. 11 that appears to show a navigational map of New Smyrna Beach.

In 2013, the Federal Aviation Administration raised its qualification standards for commercial pilots, requiring that they have at least 1,500 hours flight time. However, the 500 hours Tabata was trying to achieve possibly could have allowed her to compete for a job with a foreign airline, said Tim Brady, dean of the College of Aviation at Embry-Riddle Aeronautical University in Daytona Beach.

“Depending on the type of flight program, training program she was in, she would have gotten her instrument rating at somewhere around 250, 350 hours, somewhere in that neighborhood,” Brady said.

An AIRMET, an advisory to pilots for potentially hazardous weather conditions, had been issued twice for the area on Tuesday warning of visibility of less than three miles and cloud ceilings of below 1,000 feet, said Tony Cristaldi, meteorologist and aviation program manager with the National Weather Service office in Melbourne. The AIRMET advisories are issued out of the Aviation Weather Center in Kansas City, Missouri, Cristaldi said.

“You have to be rated as having the ability to fly on instruments, basically flying blind just looking at instruments in order to fly in those type of conditions,” Cristaldi said.

Ralph Hicks, senior air safety investigator for the National Transportation Safety Board, said Wednesday that Tabata was a certificated instrument pilot.

“She was qualified for single-engine airplane, multi-engine airplane and instrument airplanes, which meant she had an instrument rating and the information I’m getting early on is that she was current with her instrument rating,” Hicks said.

Wreckage from the plane has been moved to Ramphal’s hangar at Massey Ranch Airpark and the beach has been cleared, Davidson said. Hicks said Wednesday that a preliminary report on the crash would likely be completed within seven days.


http://www.news-journalonline.com


NEW SMYRNA BEACH -- Investigators in Volusia County have released the name of the pilot who died after her plane crashed Tuesday night in the water off New Smyrna Beach.

The pilot, identified as Mihoko Tabata, was originally from Japan, and had been living in the United States on and off. She most recently came to Volusia County on Saturday, Jan. 10, three days before the crash.

Volusia County deputies said Tabata's family in Japan has been notified of her death via the Japanese consulate in Miami.

Tabata was flying a Cessna 152 Tuesday night and told the flight control tower in Daytona Beach that she didn't know where she was.

Pilot: I don't know where I am. I want to land.

Tower: Maintain your altitude until you see the airport.

Pilot: I am in clouds.

Tower: Don't worry, ma'am, just calm down. Make a left turn; just make a left turn if you can. I need you to climb though. Climb, you're descending. It's OK if you're in the clouds, but I need you to climb.

Pilot: I'm climbing.

That was the pilot's final transmission before traffic control called 911.

The remains of the aircraft were removed from the beach Wednesday. The National Transportation Safety Board has begun working to figure out what caused the crash. A preliminary report is expected to be released within seven days.

Investigators said Tabata was certified to fly a single-engine or multi-engine aircraft.

A group of student pilots in the same area at the time of the crash said weather conditions were treacherous Tuesday night.     

http://www.mynews13.com

New Smyrna Beach, FL – A 38-year-old native of Japan is the female pilot who died in a plane crash just off-shore of New Smyrna Beach on Tuesday night. 

The Volusia County Sheriff’s Office says Mihoko Tabata – a woman who lived in the United States off-and-on – was behind the controls of a  Cessna 152 when it crashed into the ocean surf just north of the Flagler Avenue beach approach.

“Based on the preliminary results of the autopsy, the death has been determined to be the result of injuries sustained in the crash,” says VCSO spokesman Gary Davidson. “Her family resides in Japan and was located and notified of the death through the assistance of the Japanese consulate in Miami.”

Authorities say it all started around 9pm Tuesday when Tabata radioed for help soon after takeoff from Massey Ranch Airpark in Edgewater, saying she was turning back due to the weather conditions.

First units arrived on scene around 5 minutes after 911 got the call for help and found the mangled plane bobbing in the surf about 20 feet from shore, with Tabata’s body mixed in with the wreckage. Authorities believe she was the only person on board at the time.

In an interview the day after with WNDB’s Marc Bernier, Volusia County Sheriff Ben Johnson said it appears Tabata wasn’t authorized to be flying solo and had been warned not to fly in rough weather. Conditions were foggy and rainy at the time of the accident.

It’s unclear at this time if there are any mechanical issues which might have caused the plane to crash. The Federal Aviation Administration and the National Transportation Safety Board are investigating.

Pieces of the mangled plane were pulled from the ocean water and are now in the FAA and NTSB’s hands as part of their investigation.


NEW SMYRNA BEACH — The 38-year old woman killed after the plane she was piloting through dense fog crashed into the ocean told air traffic controllers she was lost just minutes before she stopped communicating with the tower.

“I don’t know where I am,” the unidentified pilot can be heard telling the Daytona Beach control tower in a digital recording. “I want to, uh, land.”


Air traffic controllers tried to guide the woman, who took off Tuesday from Massey Air Park in Edgewater, to make a left turn to reach New Smyrna Beach Municipal Airport and told her to climb to 1,000 feet. During the course of the roughly 10 minutes of contact with the tower, the pilot said she was at 900 feet and at another point that she had descended to 600 feet. The pilot then, sounding panicked, told controllers she was in the clouds.


“Don’t worry, ma’am, just calm down. Calm down,” one of the controllers told the pilot. “Make a left turn if you can, climb though, I need you to climb. You’re descending. It’s OK if you’re in the clouds, but I need you to climb.”


Controllers lost contact with the plane seconds later.


The pilot did not have permission to fly the plane by herself, the owner of the aircraft said Wednesday.


“She was a time builder and she had not been checked out to fly the airplane by herself yet and she took it upon herself to go fly,” said Neil Ramphal, owner of Flight Time Building, which owns the plane.


The pilot had 420 hours of flying time and had set a goal of getting to 500 hours, Ramphal said. “Apparently she got lost and she was flying in dense fog. She was talking to Daytona and New Smyrna to direct her back to the airport.”


New Smyrna Beach police officers Richard Kirkland and Kyle Burkhead were the first responders on the scene just after 9 p.m. Tuesday. In their incident report released Wednesday, the officers stated that the pilot had sustained “major injury to the face.”



Kirkland and Burkhead said that when they arrived at the beach they saw the plane floating in the water. Several bystanders told them the pilot was still inside the aircraft. The two officers waded into the cold ocean and pulled the woman from the wreckage and onto shore. Kirkland felt for her pulse, but there was none, the report shows. The policemen went back into the ocean after someone said there was another person in the water, their report shows. The officers and a bystander flipped the plane over, but no one else was inside.

Investigators were at the crash scene Wednesday trying to piece together what happened to the single-engine Cessna 152.

Ralph Hicks, senior air safety investigator with National Transportation Safety Board, said the pilot was rated a certificated instrument pilot on single-engine or multi-engine aircraft.

“We do have the pilot log book that was recovered in the wreckage,” Hicks said. “That will help us out quite a bit.”

Crime scene tape blocked the wreckage area on the beach, just a short distance from busy Flagler Avenue as beachgoers began their early morning walks. By mid afternoon the fuselage had been removed from the beach as the tide rolled in.

“Sad story,” said Jim Musante, one of the steady stream of people who passed by Esther Street Beachfront Park to get a glimpse of the wreckage before it was moved. Many, like Musante, snapped pictures with their phones. 

The identity of the female pilot, whose body was pulled from the sea late Tuesday night, will be released once her identity is confirmed through autopsy and her family has been notified, said Gary Davidson, spokesman for the Volusia County Sheriff’s Office. He didn’t know if that identification would be made Wednesday.


Instructors for Flight Time Building said the woman was a good pilot, Ramphal said. Flight Time Building is a company that offers personal flight instruction and specializes in providing planes for pilots to build their flight times. Ramphal could not explain why the pilot was flying solo, other than to say she had the keys and it was an uncontrolled airport.

The Sheriff’s Office doesn’t know what time the plane took off from Massey Air Park, Davidson said.

The Daytona Beach FAA tower reported getting a final radar hit from the aircraft about a quarter-mile offshore Tuesday night as the plane was turning back toward the beach, he said.

Emergency crews from multiple law enforcement agencies quickly responded. The wreckage was spotted about 20 feet offshore in waist-deep water. Beach officers attached tow ropes to the plane and pulled the major pieces of the wreckage to shore. Smaller pieces also were gathered and placed on the beach to await further investigation.

Instead of his usual morning beach walk, John Kiernon, who lives on the North Causeway, decided to check out the scene from Esther Street Beachfront Park, where media staged to report on the crash.

“My wife told me there was a crash down here at the Flagler entrance, so I got in the car and came here. I walk by all the time.”

Hicks said a preliminary report on the crash would likely be released within a week.


“We’ll probably be here two or three days, documenting the wreckage in great detail,” he said. 

















NEW SMYRNA BEACH -- The woman who died when her plane crashed off New Smyrna Beach Tuesday night told the Daytona Beach Control Tower that she didn't know where she was.

What was left of the Cessna 152 was removed from the beach Wednesday afternoon, hauled off to a hangar where investigators will comb through the wreckage and the pilot's log to try to answer key questions.

Among them, what was weather like when she was flying, and what caused the crash?

Student pilot Antonio Olear and his classmates were on the road after flight school at the same time the Cessna 152 crashed. They know what conditions were like Tuesday night.

"Overall dangerous. Half a mile visibility, strong winds coming from various directions, just foggy overall," said Olear.

NTSB investigator Ralph Hicks said the pilot was rated a certificated instrument pilot on single engine or multi engine aircraft.

"The information that I'm getting early on is that she was current with her instrument rating," said Hicks.

However, something went wrong after the pilot took off from the Massey Air Park. Olear and his friends listened to the final transmission between the pilot and the Daytona Beach control tower.

Pilot: Hello?

Tower: Hello.

Pilot: I don't know where I am. I want to land.

Tower: Maintain your altitude until you see the airport.

Pilot: "I am in clouds."

Tower: Don't worry ma'am, just calm down, make a left turn, just make a left turn if you can. I need you to climb though, climb, you're descending. It's ok if you're in the clouds but I need you to climb.

Pilot: I'm climbing.

That was the pilot's final transmission before traffic control called 911.

Dispatch: 911, what's your emergency?

Daytona Beach Tower: This is Daytona Beach Traycom, I've got a potential downed aircraft southeast of New Smyrna Beach.

Dispatch: Ok potential bound aircraft?

Daytona Beach Tower: Downed!

"She was just scared out of her mind, lost in a cloud of mist," said Olear after hearing the transmission. "You don't see anything, battling strong wind conditions coming from different ways, I mean she was just trying to find her way home and she couldn't."

Rescue workers recovered the pilot's lifeless body shortly after the crash.

Flight Timebuilder owns the aircraft. Owner Neil Ramphal said the pilot was not checked out to fly the airplane by herself, that she was supposed to fly with an instructor.

49 comments:

  1. With all of those ratings and hours I at least give her slight benefit of doubt that she immediately focused in on the AI after getting into IMC. Makes me wonder if the AI was functioning properly if she verbally told ATC that she was climbing. Maybe a vacuum issue? I've been unintentionally caught in the clouds and I immediately forgot about whats outside and focused on my instruments. What scares me is how almost 99% of her almost-500-hours was during the day. That is kind of strange. Regardless, I suggest that anyone who flys in IMC and/or at night (IFR or VFR) get a Dynon D2 or similar backup device and also have it mounted properly and turned on at all times. When seconds count, you don't have time to fumble with your backup AI device. You need it immediately. The $900 Dynon D2 would have saved the life of a local cargo pilot after his main AI went out immediately after a takeoff into IMC.

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  2. @anymore

    That's why we train did partial panel maneuvers. Any Instrument can fall so it's critical that we learn to continually cross-check them. You should be able to immediately switch to your DG and altimeter to establish level, climbing flight pet the ATC instructions. Yes, a newer AI is desirable but she was flying a high-time 152, which I doubt the owner invested heavily in. I'm still not sure that the aircraft was IFR certified not that the pilot was IFR current. (I know she did her IPC but under what conditions?) She was also not signed off for solo flight in that aircraft so she may not have been familiar with the use of those particular instruments. Flying in IMC is serious for the single pilot and it's a mistake to put yourself in that situation if you're not 100% current as familiar with the aircraft.

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  3. Update: Dynon now has the D3 Pocket Panel. They have even reduced the price. I have one and practice with it all the time. Anyone who flys IFR should have one.

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  4. It's a strange system where this pilot who, whatever ratings she had, was not capable to handle the conditions but the controllers get censured - the decision to fly the aircraft after being told not to lies solely with her.

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    1. It's not always that way. In the accident of N7GA, controllers vectored a VFR aircraft straight into a mountain at night and the controllers admitted in interviews they had no idea there was a mountain there, yet the pilot got 100% of the blame, and zero blame or even need to educate the controllers about the terrain was called out in the final report.

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    2. three valuable words. Pilot In Command ! ! ! the Buck Stops with the "PIC"

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  5. Apparently she panicked to such a degree that training and skills went right out the window. Sad.

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  6. She was a frustrated long-running student - take a good look at her logbook totals in training vs. PIC time. Not sure how she qualified for commercial certification in 2010, but she certainly was not a working commercial pilot.

    The November flights had to be a wink/nudge pencil whip exercise. The time builder CFI who said her landings needed more work did a better job assessing her inability than the puppy mills.

    RIP, very sad - who knows if maybe family pressure made her take extra risks to get it done in hopes of a job.

    Logbook:
    https://dms.ntsb.gov/public/58000-58499/58239/586047.pdf

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  7. You can watch this whole accident flight with actual ATC communications on youtube put out by ASI Air Safety Institute. She could barley speak English That is why she is dead. You have to have a good command of the English language to be a pilot, and blaming the tower personal that the NTSB did in their report is bullshit. They had no idea WTF she was saying!!!

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    1. I agree with you and ATC being a partial factor is maddening since it seems equally clear from the audio that she wasn’t able to understand or comply with ATC directives… whatever language challenges she had must have intensified in the stress of her predicament.

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    2. If you’re going to come to a foreign country and try and do something dangerous, and illegal (stealing an airplane) then you better know how to communicate in said Country. If not, then get your training in a country that speaks primarily Japanese. Sad but this is the truth!

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  8. Here is what it sounded like... hello? hello? hello? hello? I am masayyy masayyy masayyy I want fly I want fly I need lando lando I cry I cry masayyy masayy just a little of what ATC had to work with.

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  9. Yes she did … if she hadn’t been stupid. A few of the stupid ones slip through … very few.

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  10. A more appropriate statement would be that she ‘hoped to have a brilliant career in front of her as a captain on a major airline’. You have to survive first.

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  11. Less than 11 minutes. That is how long ATC had contact with her before she lost COMPLETE control. Hard for me to see ATC being dinged on this. Poor English and never really declared the situation … I inadvertently flew into clouds. Panicked instead of establishing priorities … Aviate/fly the plane … Navigate/gain some altitude so you don’t fly into the ground or ocean … Communicate the situation. If the controllers had been working to help her for 30 or 40 minutes without using their guidelines, I could understand the ding. They had less than 11 minutes.

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  12. Pity that ATC at Daytona Beach (certainly with the good intent trying to help her) was kind of overloading its transmissions to the aircraft (in the last part of the flight). Instead of just saying "Turn left heading 360"..... a lot of additional informations and words were used/given which had the effect (in my opinion) to overload the very stressed pilot. Such redirections and instructions should occur step by step - very slowly and VERY SHORT. First turn her North/360 degrees, then only start to talk into trying to spot the brightly lit airport at 12 o'clock. Once she is really observed flying on heading North. In such emergencies and stressful situations (when the pilot is at its total LIMITS) a controller needs to be very short and be using simple-short instructions. One sentence/instruction per time at its maximum. The intent of what ATC did was certainly good and very well intended, but the effect was to most probably overload even more the lost pilot. KISS = Keep It Short and Simple! Many native English speakers - especially in the US - seem to lack of "empathy" and understanding/comprehension to be aware and understand how it is challenging to speak and communicate in a language with is foreign - a non-native language. This is not a critism, just a subject to be discussed and to be understood, It would be an excellent subject to be discussed in refresher- and in recurrent training courses for ATC and ATCOs. This does in no way excuse that the pilot in question clearly lacked the required language proficiency allowing her to fly solo. But thanks for trying to help her - this is really appreciated!

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    1. I agree 100% … happens often. I use the phrase ‘standby’ … works.

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  13. I'm not sure how this popped up now, but here's my side of the story. I met her in San Diego about three months before the accident. We were introduced by a mutual friend who had a business training pilots to Aviation English proficiency. I had retired from ATC (SoCal TRACON) less than a year earlier and was asked to evaluate her English.

    Miho, along with the woman who had the Aviation English business, and another pilot from Japan had lunch with me. After about 45 minutes of conversation, I did what I was asked and evaluated. I told Miho I couldn't understand most of what she was saying, and that I felt she was having trouble understanding me. Her friend from Japan spoke excellent English and actually had to translate some of my conversation into Japanese for Miho.

    I told her ATC could only help as much as she could communicate in English, under pressure. My friend had NO involvement in the English proficiency cert Miho had, and brought her to me out of concern. I never saw or talked to Miho again, getting the call from my friend a few months later that Miho had been killed.

    The NTSB has a link to contact the IIC, which I did. I was never contacted, and I had and still have lots to say. I pulled the recording and have it to this day. I play it at some of the pilot forums I speak at.

    The big takeaways here, in my opinion, are Aviation English is its own separate language, whether you are native English speaking or not. No doubt it's much tougher if English is a new or subsequent language, and even harder under life threatening pressure for any of us. The NTSB in their "Factor" tree or whatever they call it should include "Aviation English Proficiency" if they don't already.

    For all of the things that were done wrong, including the rubber stamp "English Proficiency", what it really came down to was an inablity to communicate adequately with ATC. The whole training thing to me is a red herring, and a joke. Had the ATC training been completed, it doesn't help squat if the pilot can't understand english. I think that should be a Probable Cause.

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    1. I stumbled into this report. Then went and looked up more about it. https://www.youtube.com/watch?v=0OFL9KrJTf4 I flew out of the Travis AFB flying club in the early 80's. Frequently flew to the Napa, CA airport which was an initial training base for Japan Airlines. They did all their training from PPL on up, then over to Moses Lake, WA for the Big plane training. Hearing this lady's communication in English , Reminds me of hear the JAL trainees in the pattern at Napa. They were a step better than her English.

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    2. It’s almost like God was trying to warn her through you…but she didn’t listen.

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    3. Oh please… 🤦🏼‍♀️

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  14. Seems the fundamental contributing factor to the accident is a profound lack of good judgement, to put it politely - if the wx was as bad as stated, and she departed in imc conditions intending a vfr flight. Lack of English proficiency rates a bit lower as cause imho.

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  15. Aviation is dangerous, and particularly unforgiving to poor decision making. How a pilot with that many hours and alleged experience could think that saying "Hello" on the frequency was appropriate is unbelievable. The ATC encounter is laughable. While the outcome probably wasn't going to be changed much, their lack of professionalism certainly was a factor in this accident, as noted by the NTSB.

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    1. I think cultural difference is another factor in this accident. The "Hello" communication attempt is a good example of this (my opinion). Of course you may put it down to lack of proficiency (English language proficiency), but I am pretty sure she would have reacted very differently if the incident occured in Japan. This Hello call was kind of a cry for help/support, but in a situation where she felt shy/not ready to communicate openly and clearly, what was the situation and what were her needs (at this moment). Sure, you can hit at her for lack of ....... (and there a few items to mention here). Many comments make clear what went wrong and what she lacked of.... But each accident is also a moment of reflection and an excellent starting point to improve the "system" (to make sure that it gets improved, more resilient and "better". The air traffic controllers (I am also one - retired, so, I have great sympathy for them) could have done better and helped more adequatly (to the point), even if it is totally unsure whether the outcome would have been better (in the end). It's always a learning point that you must try to improve and to ADAPT to the other side in order to make a maximum impact (for the better) on the other part (which is in a critical and dangerous situation... In my opinion it falls way too short if we stop by concluding "all pilots must have perfect command of English/English Phraseology before taking off - PERIOD". We need to learn, make the system more resilient and put more chances on our side to "save the day" if something goes wrong (or not as expected/anticipated). MY OPINION...

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    2. The controllers had the right to expect that her Certificate from The Santa Monica Institute of Aviation English actually represented a measured proficiency.

      The system would be more resilient if deficient students were unable to slide by the various gatekeepers.

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  16. I'm an antique, broken pilot. I learned to fly in a 1943 Beechcraft Staggerwing D-17s and a Luscombe 8c and later finished Part 141 professional pilot training. I went on to American, but hung up my wings shortly thereafter, as I soon discovered I didn't want to spend the remainder of my life living out of a suitcase while fighting airport traffic every day after sleeping in a hotel room every night. My first flight? Aged 4. I love reading armchair theories. The lady made a mistake. She ran out of luck before she filled her bucket. Godspeed.

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  17. The difficulty in English Proficiency for piloting is a puzzle. Pilot's LinkedIn shows earning a "Certificate General English Aviation" from The Santa Monica Institute of Aviation English and the Institute's Facebook condolences are expressed in a tribute.

    https://facebook.com/permalink.php?id=211775215533995&story_fbid=880808075297369

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    1. So sad to see her smiling and very happy on these pictures and now she is gone. RIP Mihoko Tabata

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  18. The circumstance of not getting proficient at english reminds me of friendship with Japanese-born students while at a Florida university. They moved to Florida to attend school from having been in California because the cultural enclaves in the universities there had made it possible to mostly remain immersed among Japanese speakers.

    They broke the cycle intentionally, to make the most of full English immersion in Florida. My part in helping out while spending time with them included figuring out how to aid learning to pronounce Casselberry, the part of town where they had apartments. We had a good laugh after they read aloud my written out spelling change to "Casserbelly" which sounded like a native English speaker when they gave it their spoken rendition.

    It was the 1970's, long before a spelling workaround like that among friends would draw criticism. Good people, good times. If Mihoko Tabata had been able to break out culturally into full time English immersion while in California, this tragedy might not have happened.

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  19. With a little luck she could have been a captain for a major airline.

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  20. I’m chiming in late, just had to comment on this. Is it just me, or do other older pilots in here wonder how the hell this gal got any of her ratings? On my instrument check ride in the mid 70s, I spent almost four hours from start to finish. Two and a half in the air flying every possible scenario at the time. Grueling and loaded with stress inducing demands from my retired, ex colonel Air Force examiner. Then came the two year check rides, all the way to todays flying environment. I look at this accident and scratch my head wondering how she made it past her solo private evaluation. Is it the school that issued her IFR pass? Do they graduate pilots that barely have a grasp? Then to think she passed her commercial rating? What the hell is going on?
    On a recent IFR flight into the Los Angeles basin, I listened to yet another IFR pilot lost and struggling to land at Burbank, with heavy airline traffic being diverted. It was solid IFR for miles, the pilot was apparently local out of Compton. For 30 minutes I listened to ATC guiding the pilot in, the aircraft he was flying was a Cirrus SR22 with GPS capability. He sounded totally inept, but thankfully landed safely. Again, I scratched my head. He repeatably indicated his Commercial IFR rating when asked by ATC. What the hell is going on?

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  21. You're not alone. I scratch my head too on this one. Same thinking. I liked her verbiage. "Hello?", over the radio. WTF

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    1. Look at this from a culture (difference) perspective. She didn't have the life-long experience to use English as her mother tongue as US-pilots have. And so, this was most probably a very (futile) attempt trying to get help and to find out of her "hole". Hoping to find a rope that could help her to guide her to safety....Sure, she clearly lacked of the communication skills to convey this openly and clearly on the frequency (and she was too shy - as many Japonese). I feel very sad for her loss - but I cannot understand why some people here call her an IDIOT - this is not fair!

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  22. I'm confused. Why vector her to land at New Smyrna in the dark and overcast with only a 500 foot ceiling, when Orlando and Daytona have 2-mile ILS runways, only 10 to 20 miles away? Bad English, fear, or not, climb to 3000 feet, engage the wing leveler or autopilot, and relax. Then work up the humble courage to ask for a talk-down to a major airport. Poor planning, worse execution. This isn't going out for a drive a car in the rain. At a minimum, a list of VOR and NDB frequencies and alternate landing sites, and a mental map of the area, a real map of the area. This is also the age of GPS navigation. How does anyone get lost these days? I know, it all seems so simple after-the-fact.

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    1. Comment by a Cirrus "pilot"? Sorry but I'm still laughing about your "engage the wing leveler or autopilot and relax". You mean put a kitten up on the glareshield and watch which way it leans or where exactly was that button in this 50 year old "time builder" Cessna 152 flown by a non-English speaking pilot who essentially stole the airplane departing on a dark and stormy night with almost no prior night flight. And they fault ATC?

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  23. This report is too painful to read and learn from, but one must. Lack of an adequate command of standard English radio communications was not the major problem here. In the early 90s, before GPS, I flew many long hours up and down the US east coast from Connecticut to Virginia in crowded airspace and bad weather with an old timer, who I swear I never heard speak into the radio more than maybe two words with his tail number, hitting all his VOR turns, slipping through and around traffic and into all visual and instrument landing patterns without saying anything, and he was meticulous about filing flight plans, getting weather reports along the entire route before takeoff, even for a simple pop-up clearance or short maintenance hop.

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  24. This reminds me of why one should not speak on a cell phone while driving a car. You're not there. Your mind is off in conversation land while everyone sees you weaving down the highway. Focus on your primary instruments. Maintain straight and level flight, then climb slowly to a safer altitude and maintain straight and level fight. Only then, briefly explain your emergency and ask for appropriate direction. Keep in mind that every time you open your mouth or listen, you are not seeing your instruments. You may be looking at them, but your brain is not seeing them, while your mouth and ears are engaged.

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  25. According to the NTSB:
    "Both flight instructors reported that the accident pilot showed no weaknesses, handled the radios during the flight, was familiar with the local area, and was a "good pilot.""
    If you listen to the ATC audio for this flight, you would immediately conclude that this pilot was NOT a pilot that had 'no weaknesses', could NOT handle the radios, and was definitely NOT a 'good pilot'.
    Yet, also according to the logbook records, she:
    "held a commercial pilot certificate with ratings for airplane single engine land, airplane multi-engine land, and instrument airplane."
    It is inconceivable to me that this pilot, after exhibiting almost a complete lack of airmanship, communication skills, and situational awareness, could possibly have attained the hours and ratings she claimed to have acquired.
    My crazy theory is that the pilot who attained those hours and ratings, was NOT the person who crashed the airplane on the evening of January 13, 2015.

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    1. Yep, crazier things have happened. On paper, and with 400+ hours, this was not a low-time pilot. Every rookie mistake seems to have been made here. 10 hours with no instrument practice would make more sense. It boggles the mind.

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  26. Another possibility or was she under the influence ?

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  27. None of this surprises me. I trained Japanese students for two years wishing to transition in helicopters after getting all their fixed wing ratings. Most were simply horrible pilots. They just didn't grasp the mechanics or art of flying, and few really understood and spoke English fluently. They were mediocre at best when everything was going well, but would completely fall apart if anything unexpected happened.

    If they were given any instructions over the radio that differed from the dozens of English ATC phrases they had been told to expect, they simply would just look over at me like a deer in the headlights. They committed many replies and instructions to memory but really didn't understand most of what was being said.

    I once got a call from the tower that my student doing pattern work on a remote side of the airport was just sitting on the ramp in his helicopter, blades spinning, but not responding in any way to there repeated attempts to contact him. I rushed over and with ATC's permission, I approached the idling helo to see what was the problem. The Japanese student was sitting in the PIC seat sobbing uncontrollably. The problem? ATC had told him to use caution as two fighter jet's were making their approach to an adjacent runway. Completely threw him. He had no idea what they were saying, and no idea what he was supposed to do.

    I complained constantly to my boss (my FIRST flying job) that we were just turning out unqualified pilots with the only checkout being their credit score. I quit after two years of this torture and never taught foreign students again. It was actually criminal. Out of 40-50 Japanese students I flew with, I'd say less than half were really able to fully communicate in English, And less than half of those were decent pilots. I only recall one exceptional Japanese pilot during this time. I'm sure many will say that is racist. But it's the truth.

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    1. Yours is the only explanation that makes any sense here. More troubling is the total lack of flying skills, not the language barrier. Technically, you could be deaf and mute and still have excellent flying skills. But you do need eye sight, logic, reason, knowledge of simple math and geometry, be able to read navigation charts, landing patterns, approach cards, have a mental map of your flight plan, tune the nav aids, oh, yeah, there is GPS, have hand-eye coordination to operate the throttle, mixture, propeller pitch, flap and gear handles, did I mention the autopilot? How many hours here, again?

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  28. I believe you @ Wednesday, June 28, 2023 at 7:57:00 AM EDT. Listening to ATC tapes of some of the foreign pilots at JFK, not great sometimes.

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