Wednesday, July 14, 2021

Cessna 421C Golden Eagle III, N678SW: Fatal accident occurred July 13, 2021 near Monterey Regional Airport (KMRY), California


National Transportation Safety Board investigator Eric Gutierrez updates the media on July 14 about a plane crash in the Monterra residential development off of Highway 68 the day prior.
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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.

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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; San Jose, California
Textron; Wichita, Kansas
Location: Monterey, CA
Accident Number: WPR21FA270
Date & Time: July 13, 2021, 10:42 Local
Registration: N678SW
Aircraft: Cessna 421C
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General aviation - Personal

On July 13, 2021 about 1042 Pacific daylight time, a Cessna 421C, N678SW, was destroyed when it was involved in an accident near Monterey, California. The pilot and passenger were fatally injured.

The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Review of recorded communication from the Monterey air traffic control tower revealed that the pilot canceled their initial instrument flight rules (IFR) clearance and requested a Visual Flight Rules (VFR) on top clearance. The controller subsequently issued a VFR-ON-TOP clearance via the Monterey Five departure procedure, which included instructions to turn left after takeoff to join the Salinas very high frequency omni directional range (VOR) 264° radial. The controller issued a clearance for takeoff and shortly after, instructed the pilot to contact the Oakland Air Route Traffic Control Center (ARTCC).

Review of recorded communication from the Oakland ARTCC revealed that the pilot established radio communication with the Oakland ARTCC controller as the airplane ascended through 1,700 ft msl. The controller noticed the airplane was turning in the wrong direction and issued an immediate right turn to a heading of 030° which was acknowledged by the pilot. The controller then immediately issued two low altitude alerts with no response from the pilot. No further radio communication with the pilot was received.

Recorded Automatic Dependent Surveillance-Broadcast (ADS-B) data provided by the Federal Aviation Administration (FAA) showed that the airplane departed from runway 10R at 1738:44 and ascended to 1,075 ft msl before a right turn was initiated. The data showed that at 1740:14, the airplane continued to ascend in a right turn and reached an altitude of 2,000 ft msl before a descent began. The data showed that the airplane continued descending right turn until ADS-B contact was lost at 1740:38, at an altitude of 775 ft, about 520 ft southwest of the accident site as seen in figure 1. 


A witness located near the accident site reported that he observed the accident airplane descend below the cloud layer in a nose low attitude with the landing gear retracted. The witness stated that the airplane made a right descending turn and impacted the top of a pine tree before it traveled below the tree line, followed by the sound of an explosion.

The preliminary weather for the MRY airport reported that at 1054 PDT, winds from 280° at 7 knots, visibility of 9 statute miles, ceiling overcast at 800 feet agl, temperature of 15°C and dew point temperature of 11°C, altimeter setting of 29.99 inches of mercury, remarks included: station with a precipitation discriminator.

Examination of the accident site revealed that the airplane impacted trees about 1 mile south of the departure end of runway 10R. The first identifiable point of contact (FIPC) was a 50 to 75 ft tall tree that had damaged limbs near the top of the tree. The debris path was oriented on a heading of about 067° and was about 995 ft in length from the FIPC, as seen in figure 2. The main wreckage was located about 405 ft from the FIPC. Various portions of aluminum wing skin, right wing, flap, aileron, engine, propeller blades, and propeller hub were observed throughout the debris path. Additionally, several trees were damaged throughout the debris path. The fuselage came to rest upright against a residential structure on a heading of about 045° magnetic at an elevation of 447 ft msl. The wreckage was recovered to a secure location for further examination. 


Aircraft and Owner/Operator Information

Aircraft Make: Cessna 
Registration: N678SW
Model/Series: 421C
Aircraft Category: Airplane
Amateur Built: No
Operator: On file 
Operating Certificate(s) Held: None
Operator Designator Code:

Meteorological Information and Flight Plan

Conditions at Accident Site: IMC 
Condition of Light: Day
Observation Facility, Elevation: KMRY,165 ft msl 
Observation Time: 10:54 Local
Distance from Accident Site: 1 Nautical Miles
Temperature/Dew Point: 15°C /11°C
Lowest Cloud Condition: 
Wind Speed/Gusts, Direction: 7 knots / , 280°
Lowest Ceiling: Overcast / 800 ft AGL
Visibility: 9 miles
Altimeter Setting: 29.99 inches Hg 
Type of Flight Plan Filed: IFR
Departure Point: Monterey, CA 
Destination: Sacramento, CA (KMHR)

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: On-ground
Ground Injuries: 
Aircraft Explosion: On-ground
Total Injuries: 2 Fatal
Latitude, Longitude: 36.575343,-121.82523 (est)

Those who may have information that might be relevant to the National Transportation Safety Board (NTSB) investigation may contact them by email witness@ntsb.gov, and any friends and family who want to contact investigators about the accident should email assistance@ntsb.gov. You can also call the NTSB Response Operations Center at 844-373-9922 or 202-314-6290.

Mary Ellen Carlin of Pacific Grove.


Alice Diane Emig was a passenger on the plane along with her Dachshund, Toby.

117 comments:

  1. Home not occupied at time of crash.

    https://www.montereycountyweekly.com/blogs/news_blog/small-plane-crashes-into-a-home-outside-monterey-regional-airport-off-of-highway-68/article_f43b61fe-e407-11eb-b9b9-03c242bf4f6b.html

    https://flightaware.com/live/flight/N678SW

    ReplyDelete
  2. Female, experienced owner and CFI, presumably the PIC at takeoff. Had a female passenger, were headed to Mather Airport near Sacramento. Crashed SE of the airport in a richy house section, just south of Hiway 218, toward Laguna Seca Raceway. Sad.

    ReplyDelete
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    1. Not discounting your account, but according to LiveATC, the destination was SNS/VFR on top. Do you mind sharing the source of your information / KMHR as destination with a passenger?

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    2. I searched the local news both print and video, and that information was given. The usual news media drama and of course the very perishable fast-changing dynamics of the mishap, but Mather was given as the destination. If that was in error, and you have better info, then that's good to see the necessary correctives of the story. Based merely on the initial reports, she had a problem / problems after takeoff (runway 28???), and was attempting to come back and land. I lived in Monterey for two years and I'm familiar with the airport and the impact area - that's a very nice elevated area with very nice homes and million-dollar views, just south of the Salinas Highway that runs past Laguna Seca.

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    3. The confusion comes from the pilot filing for nearby Salinas on a trip arranged to deliver the passenger back to her home in Rancho Cordova, right next door to Mather.

      The purpose of the pre-planned stop at Salinas is unexplained, but if additional people were being picked up to ride along for a day trip outing to the Sacramento area, they were lucky to not live closer to Monterey Regional.

      News link below explains that after visiting her mom for three weeks, the passenger needed to get back to her hometown of Rancho Cordova near Sacramento:

      https://www.montereyherald.com/2021/07/14/mch-l-crash-0715/

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    4. When you file IFR to VFR on top at Monterey, you are generally cleared to the Salinas VOR. They know you'll be out of the marine layer and canceling long before you get there.
      Robin

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  3. I have a lot of time in a performance modified 414 and these cabin class pressurized Cessna piston twins are awesome aircraft so long as they are managed correctly (both in maintenance and by book flying). They don't go down without a reason. RIP to both and hopefully the cause whatever it is will be found rather quickly. These pressurized 400-series twin Cessnas are getting fewer and far between in the skies as the years go by.

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  4. Tragic. Another Cessna 400 series fatal crash on takeoff. The list just keeps getting longer.

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  5. AWOS archive shows overcast at 800 feet:

    KMRY 131735Z AUTO 27008KT 10SM OVC008 15/12 A2997
    KMRY 131740Z AUTO 27005KT 10SM OVC008 15/11 A2997
    KMRY 131745Z AUTO 29005KT 10SM OVC008 15/11 A2997

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  6. News story with ATC audio and NTSB breifing:

    https://www.ksbw.com/article/climb-immediately-audio-released-from-air-traffic-control-before-plane-crash/37016764

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  7. There were reports that parts of the plane were found about a mile from the crash site.

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  8. I love the C model 400 series but they are getting old and tired. I have roughly 2500 wonderful hours in them, my old company just scrapped and sold off all of theirs due to age. Too difficult to maintain, too unreliable. You can only do so much with a very complex 40 year old airplane.

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    1. I concur. I flew a modified 414, a later 1982 model, for about five years and ~1400 hours as corporate pilot in the 1990s. That company was later bought out in the early 2000s and the plane came with the sale. The buying company wanted nothing to do with it after looking at the maintenance logs and traded it in on a pre-owned CitationJet. The pressurized 400-series Cessna twin pistons very good aircraft for the time. They could fly high and fast and into moderate icing. However they are a handful and you need to be up on them at all times. An engine out, especially during climb after takeoff, requires immediate recognition of which engine has failed and a prop feather accordingly. Just a few seconds delay in diagnosing an engine out situation can literally spiral out of control real quick. Plenty of crash reports of that happening.

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  9. Listening to ATC audio she seems to be impaired prior to takeoff.
    https://www.youtube.com/watch?v=JbkFeypsi9g

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    Replies
    1. cognitive, substance, ? 'impairment' ....

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    2. A 10 July LiveAtc 2000Z to 2030Z recording has the pilot's pre-takeoff tower conversation of that day for comparison. Listen for "Golden Eagle six seven eight sierra whiskey" to come on after approximately the 24 minute mark.

      The correct file ends in KMRY-Jul-10-2021-2000Z.mp3, reachable without violating their terms of service that forbid direct file linking, at:
      https://www.liveatc.net/archive.php

      Here is the 10 July departure track, for reference:
      https://globe.adsbexchange.com/?icao=a8fb15&lat=36.599&lon=-121.859&zoom=13.6&showTrace=2021-07-10&leg=1&trackLabels

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    3. The person on the radio sounds distracted and anything but confident. I repeatedly thought she said 6780W instead of 678SW.

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  10. Local Pilot based out of KMRY. Spoke with some eye witnesses on the field and personally witnessed the smoke plume and pulled over for emergency trucks en route to accident.

    - Very experienced PIC. ATP CFI CFII MEI. I had a reference page from a local flying club that listed all of her qualifications, but they took the page down 24 hours after the crash.
    - 73 - 74 years old. Based on her HS Graduation date posted on Facebook
    - Her route was KWVI to SNS (Not KSNS) but the Salinas VORTAC for VFR on Top. SNS is the first waypoint in the MRY5 Departure when taking off on 10R. You can verify all of this via the LiveATC archives.
    - Weather was Overcast 800, visibility was at least 5 miles verified by my own eyes. Wind felt calm, but 5Kts seems reasonable.
    - Airport chit-chat is that she was flying a friend home to the Mather area.
    - Flight track shows a climbing Right turn to about 1900, then a continued descending right turn to impact with the house at speeds >150Kts. From lift-off to impact is <1 min per Flight-aware data.
    - Location of the crash (verified by my own eyes) is SE of the airport, and SW of Laguna Seca. But it is basically on the ridge-line just south of final for 28L. Local pilots (Which she was) know to stay NORTHish of Final as there is not much forgiveness to the south if you are low. To the North is Fort Ord, a big open space area with better emergency options.

    Very sad time for MRY Aviation.

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  11. Gearbox failure on the 421 can also be difficult to recognize especially during takeoff. The engine is running but zero thrust. All the pilot has is indications of high manifold pressure and a zero thrust light. Hard to digest in a high workload environment. Just speculation at this point.

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    1. You've seen a zero thrust light on a 421C? doesn't exist.

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    2. I have, I used to fly a 1976. Lights were located on the throttles accompanied by a horn after illumination. I’m not sure if this was standard equipment or an option. I also know this because they would occasionally go off in cruise in IMC in temps below freezing.

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    3. I have seen the device you mention advertised, in the late 80s. I bought my first twin in MRY and got my ME rating there in '89. Such a beautiful area.
      Here is the patent for the Low thrust detection system for aircraft engines.
      Patent: US4538777A
      RIP to the deceased.

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  12. Photo and map links below locate the engine that came to rest beyond the house. It's location relative to the house provides a rough indication of aircraft heading at moment of impact with the house.

    Photo of engine near blacktop driveway under sheriff's cruiser:
    https://pbs.twimg.com/media/E6MvgKuVgAISxEZ?format=jpg&name=large

    Engine close up:
    https://pbs.twimg.com/media/E6MvgKtVgAI8dJs?format=jpg&name=large

    Map-pinned engine location at end of blacktop driveway:
    http://maps.google.com/maps?t=k&q=loc:36.570721+-121.833584

    Twitter source post for engine photos:
    https://twitter.com/AlaniLetang/status/1415026967364071427

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  13. GTSIO only likes on AvGas.

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  14. Has anyone considered that she was disoriented or lost her AI? ATC told her to turn right immediately fly heading 030. Which should not have had any impact as it's a 20 degree turn off of runway heading. She began to do that but just kept turning. If you look on flight aware and listen to the ATC simultaneously, you can see that she was in a hard right turn. At the same time, she was increasing speed and losing altitude rapidly. An experienced pilot knows that in an aircraft emergency like power loss, you need to keep the plane close to emergency descent speed for maximum glide duration. She was well above that on impact. I've flown in that soup in Monterey and when you get in it you don't know which way is up, down or sideways. You must rely on your instruments and if she had an AI failure or she was disoriented this can account for the steep turn with increase in speed and loss of altitude. NTSB will be able to tell if the engines were both making power by the way the props are bent so we'll wait and see. Just giving a different perspective other that engine failure.

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    1. To offer a friendly correction: Runway 10 heading is 100 degrees, not 10 degrees. Turning from runway 10's heading to a new heading of 030 requires a left turn of 70 degrees if you are on track straight out.

      It is likely that ATC's "turn right immediately fly heading 030" was issued in response to seeing the right turn that was already underway based on observed position in that moment. Be careful trying to time correlate ADS-B position to voice transmissions.

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    2. The reason the controller "might" have said "turn right immediately fly heading 030°" is because the last recorded data point shows the aircraft heading 350°, which would be a continued right turn of about 40° to 030°
      Here's the last data point info: Notice the decent rate of -8640 ft/min
      Speed:187 kt
      Altitude:▼ 1,075 ft
      Vert. Rate:-8640 ft/min
      Track:350.4°
      Pos.:36.567°, -121.837°

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    3. "An experienced pilot knows that in an aircraft emergency like power loss, you need to keep the plane close to emergency descent speed for maximum glide duration."

      Emergency descent profile will definitely not provide one with maximum glide duration. It is the speed and descent angle which will get you to the ground as quickly as possible, for example if there was a loss of cabin pressure or maybe an uncontrolled inflight fire. Emergency descents often entail putting out as much drag as one can and descending as expeditiously as possible. For an engine failure in a multi-engine aircraft, the lowest speed one would want would be single-engine safety speed, sometimes called blue-line. It looks like this aircraft exceeded that speed by a very large margin in its final descent. The pilot definitely had the experience so I'm very curious about what may have happened.

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    4. Experience does not necessarily mean competence.

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  15. Here's her credentials:

    MARY ELLEN CARLIN
    905 EGAN AVE
    PACIFIC GROVE CA 93950-2405
    County: MONTEREY
    Country: USA
    Medical Information:
    Medical Class: Third Medical Date: 1/2019
    MUST WEAR CORRECTIVE LENSES FOR DISTANT VISION AND HAVE GLASSES FOR NEAR VISION.
    BasicMed Course Date: None BasicMed CMEC Date: None
    Certificates
    AIRLINE TRANSPORT PILOT
    FLIGHT INSTRUCTOR
    GROUND INSTRUCTOR
    Certificates Description
    Certificate: AIRLINE TRANSPORT PILOT
    Date of Issue: 7/11/2017
    Ratings:
    AIRLINE TRANSPORT PILOT
    AIRPLANE MULTIENGINE LAND
    COMMERCIAL PRIVILEGES
    AIRPLANE SINGLE ENGINE LAND
    AIRPLANE SINGLE ENGINE SEA
    Type Ratings:
    A/CE-500
    Limits:
    ENGLISH PROFICIENT.
    CE-500 SECOND IN COMMAND REQUIRED

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    1. Did she not have an Instrument Rating?

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    2. The Airline Transport Pilot certificate has an Instrument Rating as a prerequisite. When a pilot earns their ATP, its designation replaces the IR on the certificate.

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    3. Expired Medical? Last info I saw showed the extension ended on 03/31/2021.

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  16. Myers continued. "One day someone is here and perfectly well, and then all of a sudden, they're gone."
    I can so relate - I've lost 12 friends in numerous separate plan crashes. They were healthy human beings until they took that last flight. May God give her peace in her grief.

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  17. Salinas was her clearance limit, which is normal for an IFR to VFR on-top clearances when the pilot intends to continue VFR for the rest of the flight. Listening to her errors in reading back the simple and straightforward clearance is concerning. Her speech sounded stressed and almost trembling. She made multiple errors and omissions while using improper phraseology in her taxi instructions and taxi readbacks all the way to takeoff. Perhaps we all can learn from such a tragedy, to somehow constantly evaluate ourselves for our mental fitness in factors such as stress.

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    1. My thoughts exactly...given her training and experience, unless there was a event like death of spouse right before the trip...I don't see an explanation for "high stress"...this is a mission she had flown many times, for which she was totally qualified. I'm thinking perhaps "mini-stroke" at the time of departure?

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    2. I'm thinking there's a reason her medical certificate is expired.

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  18. If the wind was from the west at 5-8 kts, why did the pilot depart east?

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    Replies
    1. Excellent question. Archive AWOS shows West wind readings for the entire day. Here is the link for the full day's data dump:

      https://mesonet.agron.iastate.edu/cgi-bin/request/asos.py?station=MRY&data=all&year1=2021&month1=7&day1=13&year2=2021&month2=7&day2=14&tz=Etc%2FUTC&format=onlycomma&latlon=no&elev=no&missing=M&trace=T&direct=no&report_type=1&report_type=2

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    2. When KMTY operates with an overcast they use the ILS to 10R even with a tailwind. Thus the departures are on RWY 10 as well. There is too high of terrain east of the field to certify an ILS. It's all non-precision approaches into the field westbound with much higher minimums, minimums well above the existing overcast at the time.

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  19. If this information is correct -- and realizing there's a good chance it isn't -- her medical privileges expired five months ago.

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  20. FAA medical database may get another round of embarrassment if this pilot's 24 month expiration of the January 2019 Third Class was superseded by a fresh medical cert that was not updated in the registry.

    The near and far corrective lens requirement of the 2019 medical makes it necessary to wear progressive or multifocal eyeglasses. Head tilting to read panel instruments through the lower portion of the lenses adds to the risk of illusion in IMC.

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    Replies
    1. Quite possible. My 3rd class medical was 18 months ago and is still not in the registry, but FAA in OKC told me it is in their records, so I'm OK.

      Delete
  21. She was told by ATC to make an immediate right turn.
    https://archive.liveatc.net/kmry/KMRY-App-Dep-Jul-13-2021-1730Z.mp3
    Final transmission starts at 14:14. ATC instructs pilot to make immediate right hand turn to 030.

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    Replies
    1. Even it that's true, the pilot shouldn't go into a right hand spiral dive.

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    2. A 14:14 time hack in the 1730Z LiveAtc recording = 17:44:14Z.
      The last ADS-B data point was at 17:40:35Z, just before impact.

      That playback interpretation puts the "turn right" command at least three minutes after impact.

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    3. https://archive.liveatc.net/kmry/KMRY-App-Dep-Jul-13-2021-1730Z.mp3
      Just listen to the recording and you will hear it. Something weird about the time hack thing. Not always consistent. Not sure why. Just listen and you will hear the pilot say the tail number, she's on frequency, and ATC says to make immediate right turn to 030, which she acknowledges. Since her bearing was 010, that would be a climbing 20 right turn. And, Yes, we all know that does not mean go into a spiral. Seems like an equipment failure to me, if I were to guess...

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    4. Playing flight sim in footy jammies wasn't enough to educate somebody that runway 10 is 100 degree heading, not 10 degrees.

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    5. Also incorrect terminology.
      The difference between heading and bearing in navigational terms:

      Heading is the direction the aircraft is pointing

      Bearing is the angle in degrees (clockwise) between North and the direction to the destination or nav-aid

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  22. Mumbling, bumbling readback of ATC taxi and takeoff clearances. Not the correct mental state to be flying a 421 solo into low IMC. Passenger deserved better.

    ReplyDelete
    Replies
    1. if ATC could or would simply have directed, "seven eight Sierra Whiskey return to your terminal, and shut down, your communictions are breaking up!" or something to that effect.

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  23. That house she hit is a posh place ...
    https://www.realtor.com/realestateandhomes-detail/7548-Monterra-Ranch-Rd_Monterey_CA_93940_M27065-56392

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    Replies
    1. And that was jut their 3 million+ "vacation/getaway house....geez!

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  24. Someone earlier mentioned Aircraft may have been mis-fueled.
    This statistically happens 2 or 3 times a year in GA airplanes.

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    Replies
    1. Wasn't my comment, but the "GTSIO only likes on AvGas." comment implied that possibility.

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  25. I wonder about her recency of experience. Flying skills are perishable, especially as one gets older. I can personally attest to that at 64.

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  26. Not exactly low IFR. The ATIS was calling it at 500 bkn, 900 ovr. Oftentimes in the summer at KMRY, and probably this time, the cloud-cover barely extends beyond the east end of the runway. That’s why smaller A/C are cleared to depart to the east with a slight tailwind, sometimes never even entering real IMC, but still requiring an IFR clearance. One comment i have is . . . why do controllers need to talk so fast when they are on a low workload? And this case is an example of that. Pilots need to scold them sometimes and tell them it’s not appreciated.

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  27. Debris carryover suggests that the pilot almost recovered from the dive.

    The impact at the house flung one engine 500 feet beyond the structure, landing by a short asphalt spur East of the residence. The pitch angle at contact with the house must have been mostly horizontal, or the engine and other debris that was found East of the house could not have ended up where it did.

    The witness to the crash described a period of horizontal flight.

    From the Monterey County Weekly story linked in the first comment:
    "Tony Trujillo, a caretaker for the Monterra association, witnessed the crash." "I saw the plane fly very low and heard some of the trees crackling," he says, "then the plane hit the house. Went right into the living room."

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  28. I may have missed it, but I will surmise that an ATC callout of "If possible, level your wings and maintain level flight!" would have been helpful. I realize that ATC personnel don't pretend to fly the airplane - they issue vectors or guidance, and the pilot is expected to do that pilot stuff and make it happen. I wonder if an interface of ATC training with pilots could go through such scenarios and result in recommendations of such callouts? Just thinking out loud . . . .

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    1. At the point that it would be obvious to ATC that the aircraft was out of control (quick descent and erratic heading) the pilot would already know they were in big trouble, or it would be past the ability to save it anyhow. Chatter from ATC would really not be anything but a distraction at a time the pilot doesn't need any distractions. They may feel the need to try to answer thus adding yet another task.

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    2. Leveling the wings and maintaining level flight would have taken them straight into the mountains south of the airport. They needed to continue the turn to avoid the rising terrain they had inadvertently turned into after departure. That's why ATC gave them the turn instruction.

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    3. Yeah, I get that, but my point is that something like "78 Sierra Whiskey, in rapid descent, level your wings NOW, maintainin level flight (or CLIMB) NOW!!" in an emphatic voice might be something that could be discussed. Just pondering . . . . this from a guy who used to set my RADALT at 1000 feet after an IFR T/O, and one afternoon, as I was flying out to the ship to get some traps on the Lexington, the alert went off as I had gotten distracted, in IMC, and had failed to level off at 1200 feet. I realize this may be apples and oranges, and the state of the pilot's attention and workload (she may not have been recency IFR proficient) may make all this moot, just pondering if an emphatic ATC callout might be something to consider as a pilot - controller training session????

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  29. Haven't seen anyone comment on this yet.

    Clearance was the MRY5 DP, which from runways 10L/R is "Climbing LEFT turn heading 329°." Which makes sense as terrain is lower north and west than it is to the east and south.

    Maybe I missed a clearance in the spotty LiveATC feeds, but what was ATC’s urgency for her to turn RIGHT immediately, regardless of the heading she was on? Seems that took her directly into rising terrain.

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    Replies
    1. ATC's "turn right" transmit was after they saw the turn and spiral dive underway. Read back thru the earlier comments to understand how mismatched the time correlation is when listening to LiveAtc.

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    2. 10-4, makes sense, thank you.

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  30. This particular departure was to the east, but looking at the departure history for this aircraft, every other departure it made this year from Monterey was to the west, which would require a right turn after takeoff. I would surmise that the primacy of always turning right after departure took hold and while in the clouds with zero outside references, the pilot followed the departure procedure she followed every other time while leaving Monterey. The controller's mumbled instruction to turn left when switching her to approach did nothing to provide any clarity. I listened to him 10 times and even when I knew he was saying turn left, I could not make it out. I'd imagine that in the middle of her right turn, she started getting terrain warnings and that combined with departure's instruction to turn right immediately led to overbanking and spatial disorientation.

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    Replies
    1. To add to your hypothesis, consider that those West departures mean that the pilot logged no IMC departures from KMRY at all this year prior to the accident day.

      Repeating Steve's explanation of the downwind IMC operation:

      "When KMRY operates with an overcast they use the ILS to 10R even with a tailwind. Thus the departures are on RWY 10 as well."

      This means that the RW28 departures she made were all VFR. It is possible that her unexplained voice stress comm patterns resulted from trepidation about having to fly in IMC to keep her commitment to the passenger when her recent adjustment in personal ADM has been to decline flying in IMC.

      Simplest explanation is disorientation of non-IMC current pilot.

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    2. I think that was the cause of the stress in her voice. She felt like she had to get her friend home and didn't want to back out of her commitment.

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    3. Her passenger would've appreciated candor A LOT more than a desire to meet a commitment.

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  31. Wondering if Toby was caged/restrained up the back or if he was sitting in Moms lap up front. Ms Carlin was evidently distracted during the read backs.

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  32. We as humans make the decision whether or not we will fly but that poor puppy did not, that shit pisses me off.

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    1. Dark humor aside, this was a very sad, probably very preventable mishap, as most of them are. Unless there was a fueling error or aircraft systems malfunction we don't yet know, best to let this play out in the investigation and not do pot shots at the pilot or aircraft ground handling error. When the actual cause is possibly found, then chalk that to another lessons learned / relearned. Unfortunately, those dang humans keep messing up. Sadly. We lost an F-14 on the cat shot many years ago with the launch bar improperly engaged with the catapult shuttle. It was night time, but there were at least five or six sets of eyes that should have seen that. Everyone missed it. The cat fired, and after about 1/4 stroke or so, the shuttle spit the launch bar, and now the jet was too fast to stop and too slow to fly, despite full burner. Thank God for Martin Baker.

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  33. It would take the NTSB ten minutes to ascertain, through FBO fueling reports, IF this accident airplane had been misfuelled. Releasing that info would serve to alert pilots to a very real danger while this fiery crash IS STILL RELEVANT. See accidents involving N51RX, and N421PK.

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    1. Pilots being present for fueling is the best prevention, but recent misfuels involve techs not observing port markings AND not having the foggiest idea of what type of powerplant is in front of them.

      The fuel techs that fail apparently don't have any interest in learning to recognize the obvious visual difference between recip and turbine engines. It's just a job and they are likely to be obsessed with their phone, earbuds in, playing tunes and no interest or curiosity whatsoever about aircraft.

      If only they could glance away from their phone long enough to see the difference:

      - Cooling fins and cylinder barrels visible in the cooling openings and no big side piped exhaust = piston.
      - No cooling fins or cylinder barrels visible and big side piped exhaust = turbine.

      The N326CW Aerostar mis-fueling included tipping the wide Hoover Nozzle to dispense the fuel, defeating even that preventative measure.

      Any fuel tech that can't instantly tell the difference between a recip and turbine aircraft can't "sanity check" his work and has no business fueling aircraft.

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    2. Based on this apparently being such a high speed impact, it is not likely this was a loss of power event. Of course only the engine tear downs will confirm that. But based on how far one of the engines was thrown my bet is on engines operating to impact. And what's up with all the crash photos being removed? That is public information.

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    3. Would cooling fins or cylinder barrels be visible on an aircraft diesel engine? This also would be classified a reciprocating engine. I have heard of a mishap involving the refueling of a diesel powered plane with gasoline. Something else to muddy the waters.

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    4. Fair point about diesel powered aircraft. Reinforces the point that good training with attention to task at hand and verifying fuel port placards is required.

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  34. I have about 1k in the 421s and another 1k in 400 series. Live about 2 miles from the crash and very familiar with MRY. Who the hell knows what happened. I have read most 421 NTSB reports when I took the reigns of it. What always shocked me was it was not some low time pilot but one with good experience.

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    1. Ah yes the mantra of the NTSB: "Who the hell knows what happened". If you had truly read "most 421 NTSB reports" you would have some insights into this accident.

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  35. To get a understanding of how practiced and current the pilot was for IMC departures from KMRY, it is informative to look for all N678SW flights from January 1, 2020 thru the 2021-07-13 accident day.

    Departures in IMC are easy to determine, working from Steve's explanation that KMRY departures on a Westward heading indicate that KMRY is not operating under IMC.

    Searched through each day in both years, with the understanding that some flights might not be recorded in the Adsbexchange database:

    KMRY Westward departure flights:
    2020-01-19 Local, 2020-02-16 UC Davis, 2020-03-05 Local, 2020-04-24 Local, 2020-05-11 Local, 2020-05-23 Local, 2020-06-10 San Jose, 2020-06-14 UC Davis, 2020-07-03 San Jose, 2020-10-16 Local, 2020-11-01 Local, 2020-12-11 Local, 2020-12-14 Local, 2020-12-29 Local, 2021-01-09 Local, 2021-01-29 Local, 2021-04-03 Local, 2021-04-10 Local, 2021-04-11 Local, 2021-05-23 Local, 2021-06-10 Local, 2021-06-24 Local, 2021-07-10 Local.

    KMRY Eastward departure flights:
    2020-07-17 Local, 2020-11-20 Local.

    Weather per AWOS archive for the 2020-7-17 17:40Z departure:
    KMRY 171710Z AUTO 25002KT 10SM OVC009 16/13 A3002
    Weather per AWOS archive for the 2020-11-20 19:22Z departure:
    KMRY 201854Z 04008KT 10SM CLR 16/03 A3021

    The only verifiable KMRY IMC departure for N678SW in the Adsbexchange database since January 2020 was July 17, 2020, a full year before the accident.

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  36. This is absolutely tragic
    Toby was so cute

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  37. The leg strength required for rudder after one quits in a 421 is astonishing.

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    1. They are equipped with rudder trim.

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    2. It’s relative. It might be difficult for a slightly built man or your average female, but 421s are no worse than a lot of other piston twins. IIRC the Beech Duke has the highest rudder force near VMC, on the order of 150 pounds, but this of course can be trimmed out.

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  38. Suffered a stroke.There was no recovery possible.

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    1. As of this writing, the medical examiner/coroner DID NOT release any medical information or forensic statement. The "stroke" commentary is inaccurate information. Please disregard the comment from SkyKing.

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    2. @Anon- While it's too early to definitively assign causes, pilot incapacitation should be considered. It sounds like the remains will be putrefied and/or burned beyond usefulness for testing, but SK's idea should be given consideration.

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    3. Sky King could have posed his thought as "If suffered stroke..."

      Seems unlikely that a incapacitated pilot would recover control and accomplish nearly level flight at impact with the house as groundskeeper witness account and debris carryover appear to indicate.

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  39. I flew with her as my instructor a few times out of Palo Alto many years ago, and she always made sure I had a plan for engine failure (among other plans). She was in high demand as an instructor.

    She's had that Golden Eagle for at least 20 years, and flew a lot. I'd be very surprised if she was disoriented, but not so surprised if one of those geared engines had a problem.

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    1. I am of the same opinion. I flew with her many years ago and have nothing but the accolades.
      I wouldn't be surprised if the gearbox on the right engine failed (they are geared engines) thus making her to turn right.

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    2. Nothing wrong with geared engines. They work fine as long as they are maintained well and not abused, like any mill.

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    3. Yes, geared engines are fine if maintained, and she had plenty of money to maintain her plane. But if the gearbox fails, it can be harder than usual to identify the failure and feather the correct engine. If this is what happened, I'd expect a definitive answer from the NTSB. The whole thing was sure over fast.

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  40. Preliminary report's sequence of communications seems to suggest that she erred and just turned the wrong direction after takeoff. Someone had commented up thread that the familiar right turn she had made in all those RW28 departures might have happened by mistake.

    https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103470/pdf

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  41. The NTSB Preliminary is out on the crash. If things remain the same, we will know more in two years. I did listen to the audio a couple times. The heavy-accented controller tells her she needs to come left, which she apparently started to do. Another controller then comes on in let's say an urgent voice telling her to turn right. Which is exactly what she did, into the trees and dirt.

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  42. Preliminary Report:
    https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103470/pdf
    I was acquainted with the pilot. From all reports of her that I have heard, she was a competent multi-engine instructor, and very familiar with the airplane she was flying and with the Monterey Five departure procedure. I personally do not believe that she accidentally goofed and turned descending right instead of climbing left. Something else must have been going on. I still cannot figure out why, at any point of the flight, even when she was turning right and spiraling down, ATC would instruct the pilot to make a right turn to 030 (ZERO THREE ZERO). That makes no sense. I could see maybe right turn to 0 (ZERO), or 010 (ZERO ONE ZERO), or maybe even 020 (ZERO TWO ZERO). I personally think that was a goof by the ATC controller, but I also think that by the time he said it, she was already crashed or out of control and seconds from crashing. So, I don't think the instruction by ATC had any effect on the flight one way or another. But, of course, I'm must speculating.

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    1. Doesn't make sense now to think the instruction by ATC had no effect on the flight. The preliminary report reveals that the pilot acknowledged the turn command before the descent began.

      The NTSB is able to time-correlate comm, ADS-B and radar information. Observe what was stated in the report, bolded for significance:

      "Review of recorded communication from the Oakland ARTCC revealed that the pilot established radio communication with the Oakland ARTCC controller as the airplane ascended through 1,700 ft msl. The controller noticed the airplane was turning in the wrong direction and issued an immediate right turn to a heading of 030° which was acknowledged by the pilot."

      And this:
      "... the airplane departed from runway 10R at 1738:44 and ascended to 1,075 ft msl before a right turn was initiated. The data showed that at 1740:14, the airplane continued to ascend in a right turn and reached an altitude of 2,000 ft msl before a descent began."

      Some clear conclusions from the bolded text:
      1. Pilot was turning right and still ascending, not descending when Oakland ARTCC intervened with the immediate turn command.
      2. The pilot acknowledged the Oakland ARTCC's right turn command and added 300 feet during the interval when that comm was in play, reaching 2000' MSL. The descent was after she acknowledged the Oakland ARTCC.

      Ironically, if nothing had been said to the pilot it is likely that there would only have been an improper departure track flown and nearby traffic avoidance required instead of this crash. Oakland ARTCC was also managing area traffic separation when that 030 heading instruction was given.

      The preliminary report shows that when the call came in to turn, the pilot's altitude was above Jacks Peak's MSL elevation, the Golden Eagle was still climbing, and the flight was soon to be on top of the overcast.

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  43. This comment may be buried in the noise, but...
    A caution to people who listen to audio from LiveATC.net and conclude pilots are not giving full read-backs, not giving aircraft call-signs, etc. The LiveATC audio recordings are often from radio scanners that are scanning multiple frequencies, and *very* often portions of pilot and controller transmissions are missed, usually with the beginning chopped off. So a read-back like, "678 sierra whisky cleared for take-off" gets recorded on someone's LiveATC feed as, "...eared for take-off" making the pilot sound unprofessional or impaired, when they may not be either.

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    1. You bring out a important point not covered in LiveAtc FAQ's. There is absolute certainty of chopped or missed captures for serial scanning in LiveAtc feeders of airports listed with combined channels.

      Obtaining the LiveAtc feed to make the transcript in comments on the Marchetti N28U accident was done by picking the "KLWS Ground/Tower" selection in the pulldown menu. The heard audio included both Ground and Tower transmissions. The pilot's transmission is front-end chopped just as you describe at his final cleared for takeoff response.

      Fortunately, FAA recordings at towers are dedicated per-frequency recordings instead of stop on scan. Those recordings also include time correlation.

      Good post - thank you.

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  44. I know this is late in the investigation and resolve. If i may put in an observation. First of all I'd like extend my condolences to the families of both occupants. Secondly I'd like to fully acknowledge the pilots credentials for a safe IFR flight into IMC flight regardless of the med certificate status. If i may clarify what i mean by med cert status, 1)
    as long as she is not flying for hire (ATP, Comm or flight training)her second class will drop to 3rd class status(on the assumption couldn't renew due to the pandemic just an assumption) 2) sometimes a pilot can and probably do make a flight when even the second class has expired, refer to assumption above however regardless of technicality pilot can still perform IFR flight with a 3rd class medical which this was. Therefor based on my reading she wasn't out of bounds physically or competently, technically maybe, but that is such a minor infraction all things considered. what i see that transpired is this, PIC requested cancellation of an IFR CLRNC to a VFR on TOP.(ther fore no regional ATC was aware of the flight other then KMRY, the controller said approved via MRY5 DP Procedure. the MRY5 dp Prcedure is a climbing left/Right turn to a course of 329 deg.hdg to intercept the 264 radial of the SNS VOR. that's all fine. Here in lies problem, no fault to anyone or anything, number (1)according to the APP plate the departure for BOTH 28 L/R AND 10 L/R is to pick up 329 deg.( the only difference is whether it's a right turn or left turn to 329 deg)as mention in a previous post her departures had been "routinely for a year" departures on 28 L/R to intercept the SNS 264 radial outbnd. meaning "routtinely" a right turn. (a complacency all pilots have suffered from time to time)after wheels up gear up pwer settings initiated a right turn as per "routine". problem (2) -Confusion- the controller's comms should have been abort the right turn she had established (as the ADS-B indicates from all her approx year long time T/O on 28)and come left to 329 Deg hdg per dprt proc. It is my assumption that most controllers would be "possibly familiar" with immediate area Proc. If not one other possibility would be on initial contact from the pilot could have been "oakland ctr N678SW, (establish comms because no IFR clearence) Oak ctr responds then pilot could have said dptr KMRY on MRY5 dpart climbing through (altitude) at that point an abbraviated departure could been instructed (or at least seems to be able) so based on reading here the controller exacerbated the issue that started initially with the pilots complacency. unless the preamble up top is a typo where the controller said turn right to HDG 030, and it should have been TYPED the controller said turn left to HDG 030. however i do believe the mistake became evident a little to late based on eyewitnesses that the aircraft was almost level at impact. i know this more then likely could be ripped apart but that is what i read here. it seems a (1) complacency on the part of the pilot and (2) not enough comms between pilot, KMRY twr and Oak ARTCC.

    Anon-7

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    1. Oakland ARTCC gave a heading instruction to a off-track, ascending, right-turning aircraft upon establishing comm, based on what the controller had on the display for all aircraft in the area at that moment.

      Ridiculous to suggest that commenters, who were not at that controller's display seeing the real time situation, could issue a "better" instruction.

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  45. Question I want answered is why a 74-year old pilot with no current medical certificate was flying an airplane in the first place.

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    1. Database may not be up to date, same as the Joe Lara medical. FAA got dragged hard on that one. The database is famously inaccurate.

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    2. The confusion lasted about three days over Joe Lara's medical certificate.

      The NTSB prelim report of N66BK makes clear that Joe Lara held a current medical certificate. It didn't take the NTSB a long time to get to the bottom of a very simple question.

      Here, the NTSB prelim report on N678SW doesn't have any mention of medical certificate. If there's a medical certificate the NTSB would know about it.

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    3. Rage-baiting on medical certs is risky using the database. NTSB included info on Lara certs in the preliminary only because of the huge controversy the erroneous database had caused and media stories about it.

      It actually took three weeks of pressure from Lara's people before the database correction was made. Wouldn't have gotten corrected at all if they hadn't given the media a copy of the AME exam paperwork and exposed the error and misrepresentations.

      KR captured details in this 14 June med comment:
      http://www.kathrynsreport.com/2021/06/cessna-501-citation-isp-n66bk-fatal.html?showComment=1623713578450#c1183620232538679318

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    4. I see your point. Agree with you that the Lara pressure was unique and may have expedited the answer. That same pressure is not present here. I agree with that.

      I remain interested in whether or not this pilot was fit to fly. If she was fit to fly then that's one thing. If she was not fit to fly then that's a big problem.

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    5. Yes, it will be a letdown if the medical was not renewed and she wasn't at least operating on a special issuance that met requirements while resolving a renewal hiccup, which can sometimes be the case.

      Given her reputation for excellence, being patient to learn the answer is the honorable perspective.

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  46. Max Trescott, host of the excellent Aviation Newstalk podcast https://aviationnewstalk.com/ , talked about this accident on episode 197. Max knew the CFI and talked about the likely cause (she turned right when the departure procedure called for left turn).

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  47. the need to enforce a sterile cockpit in general avaition. good read @ https://www.aopa.org/news-and-media/all-news/2000/june/pilot/the-sterile-cockpit. "To paraphrase Ecclesiastes, there is a time to speak and a time to be silent. Keep the cockpit sterile and your thoughts pure."

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  48. This event occurred with MRY and NCT not ZOA. IFR/VFR is an IFR clearance even on top maintaining vfr altitude until cancellation. 99.5 % of ifr/vfr on top are cancelled before clearance limit of SNS vortac. With regards to comments she sounded impaired, anyone who heard her on radio knows she sounded like that normally and for years.

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  49. Dog loose in the cabin has caused more than one fatal crash.

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  50. Dog loose in the cabin has caused more than one fatal crash.

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  51. "Spoken Instruction Understanding in Air Traffic Control:
    Challenge, Technique, and Application" for your read @ file:///Users/apple/Downloads/aerospace-08-00065-v2.pdf
    Received: 25 January 2021
    Accepted: 1 March 2021
    Published: 5 March 2021

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  52. I am very sad to hear of this accident. My condolences to the families of both people. This aircraft is significant to me because I was one of the team who performed the avionics fit to it after initial delivery from factory to the Royal New Zealand Airforce. It was registered as NZ7940 while operated by NO 42 Squadron until it was sold on 03 April 1991.

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