Monday, October 11, 2021

Cessna C340, N7022G: Fatal accident occurred October 11, 2021 in Santee, San Diego County, California

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 Diego, California 
Textron Aviation; Wichita, Kansas

Samarth Aviation LLC 


Location: Santee, California 
Accident Number: WPR22FA004
Date and Time: October 11, 2021, 12:14 Local
Registration: N7022G
Aircraft: Cessna 340A 
Injuries: 2 Fatal, 2 Serious
Flight Conducted Under: Part 91: General aviation - Personal

On October 11, 2021, at 1214 Pacific daylight time, a Cessna 340A, N7022G, was destroyed when it was involved in an accident near Santee, California.

The pilot and one person on the ground were fatally injured, and 2 people on the ground sustained serious injuries. 

The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The flight departed from Yuma International Airport (NYL), Yuma, AZ at 1121 mountain daylight time and was destined for Montgomery-Gibbs Executive Airport (MYF), San Diego, California.

Review of Federal Aviation Administration Southern California Terminal Radar Approach Control (TRACON) facilities and recorded Automatic Dependent Surveillance-Broadcast (ADS-B) data revealed that at 1203:58, the controller broadcasted a weather update for MYF and reported the visibility was 10 miles, ceiling 1,700 ft broken, overcast skies at 2,800 ft, and runway 23 was in use.

At 1209:20, the controller issued instructions to the pilot to turn right to a 259° heading to join final, to which the pilot acknowledged while at an altitude of 3,900 ft mean sea level (msl). 

About 28 seconds later, the pilot queried the controller and asked if he was cleared for the ILS Runway 28R approach, with no response from the controller.

At 1210:04, the controller told the pilot that he was 4 miles from PENNY intersection and instructed him to descend to 2,800 ft until established on the localizer, and cleared him for the ILS 28R approach, circle to land runway 23.

The pilot partially read back the clearance, followed by the controller restating the approach clearance.

The pilot acknowledged the clearance a second time. 

At this time, the ADS-B data showed the airplane on a westerly heading, at an altitude of 3,900 ft msl.

Immediately following a traffic alert at 1211:19, the controller queried the pilot and stated that it looked like the airplane was drifting right of course and asked him if he was correcting. 

The pilot responded and stated “correcting, 22G.” 

About 9 seconds later, the pilot said [unintelligible], VFR 23, to which the controller told the pilot he was not tracking the localizer and canceled the approach clearance. 

The controller followed by issuing instructions to climb and maintain 3,000 ft, followed by the issuance of a low altitude alert, and stated that the minimum vectoring altitude in the area was 2,800 ft. 

The pilot acknowledged the controller’s instructions. 

At that time, ADS-B data showed the airplane on a northwesterly heading, at an altitude of 2,400 ft msl. 

At 1212:12, the controller instructed the pilot to climb and maintain 3,800, to which the pilot responded “3,800, 22G.” ADS-B data showed that the airplane was at 3,550 ft msl. 

About 9 seconds later, the controller issued the pilot instructions to turn right to 090° for vectors to final, to which the pilot responded “090 22G.” 

At 1212:54, the controller instructed the pilot to turn right to 090° and climb immediately and maintain 4,000 ft. 

The pilot replied shortly after and acknowledged the controller’s instructions.

About 3 seconds after the pilot’s response, the controller told the pilot that it looked like he was descending and that he needed to make sure he was climbing, followed by an acknowledgment from the pilot.

At 1213:35, the controller queried the pilot about his altitude, which the pilot responded 2,500 ft.

The controller subsequently issued a low altitude alert and advised the pilot to expedite the climb to 5,000 ft. 

No further communication was received from the pilot despite multiple queries from the controller. 

ADS-B data showed that the airplane continued a right descending turn until the last recorded target, located about 1,333 ft northwest of the accident site at an altitude of 1,250 ft msl.

Figure 1 provides an overview of the ADS-B flight track, select ATC communications, and the location of the destination and surrounding area airports. 


Examination of the accident site revealed that the airplane impacted a residential street on a heading of about 113° magnetic heading. 

The debris path, which consisted of various airplane, vehicle, and residential structure debris was about 475 ft long and 400 ft wide, oriented on a heading of about 132°. 

Numerous residential structures exhibited impact related damage and or fire damage. 

All major structural components of the airplane were located throughout the debris path.

The wreckage was recovered to a secure location for further examination. 

Aircraft and Owner/Operator Information

Aircraft Make: Cessna 
Registration: N7022G
Model/Series: 340A
Aircraft Category: Airplane
Amateur Built:
Operator: On file
Operating Certificate(s) Held: None
Operator Designator Code:

Meteorological Information and Flight Plan

Conditions at Accident Site: VMC 
Condition of Light: Day
Observation Facility, Elevation: KSEE,387 ft msl
Observation Time: 11:55 Local
Distance from Accident Site: 2 Nautical Miles
Temperature/Dew Point: 19°C /13°C
Lowest Cloud Condition: 
Wind Speed/Gusts, Direction: 12 knots / 17 knots, 200°
Lowest Ceiling: Broken / 2700 ft AGL
Visibility: 10 miles
Altimeter Setting: 29.8 inches Hg 
Type of Flight Plan Filed: IFR
Departure Point: Yuma, AZ (YUM) 
Destination: San Diego, CA (MYF)

Wreckage and Impact Information

Crew Injuries: 1 Fatal 
Aircraft Damage: Destroyed
Passenger Injuries: 
Aircraft Fire: On-ground
Ground Injuries: 1 Fatal, 2 Serious
Aircraft Explosion: Unknown
Total Injuries: 2 Fatal, 2 Serious 
Latitude, Longitude: 32.85702,-116.96358

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. 

SANTEE, California — The siblings of a UPS driver who was killed when a plane crashed into a Santee neighborhood last year have filed a wrongful death lawsuit.

Steve Krueger, 61, had worked for UPS for about 30 years and was planning his retirement at the time of the crash on October 11, 2021.

Two people died, the pilot, Dr. Sugata Das, and Krueger.

Jeff Krueger is one of the plaintiffs in the lawsuit filed in San Diego County Superior Court.  He sat down with CBS 8 to talk about his brother.

“He was just a great guy as a brother. He didn't have kids. So, my kids were kind of like his kids.  He was the cool uncle.  He was the one who taught them how to water ski because he had his jet boat.  And he goes snow skiing with us and all that,” said Jeff Krueger.

Shortly after the crash, the National Transportation Safety Board posted a preliminary report. But the report said nothing about why the plane crashed or who was at fault.

“We need more information.  I mean, we're really still in the dark.  We haven't got anything back from the FAA. And, initially, they said it was going to be at least two years for them to complete the investigation and give us anything,” said Krueger.

Steve Krueger’s three surviving siblings are hoping they will get more information about the pilot and the company he was flying for, Samarth Aviation LLC in Arizona. Yuma Regional Medical Center is also named as a defendant in the lawsuit.

Attorney Robert Kashfian represents the family. He said the discovery phase of the lawsuit should yield more information.

“I want to ask questions directly.  I want to be able to take a deposition. I want to be able to look at certain records that I don't have access to at this point,” said Kashfian.

The lawsuit alleges Dr. Das was flying the plane as part of his job at Yuma Regional Medical Center and the defendants were “negligent and careless” in the operation of the flight, which resulted in the crash.

CBS 8 reached out to Yuma Regional Medical Center. A spokesperson said Dr. Das worked at the medical center, but he was not employed there. 

Attorneys representing the medical center still have to respond to the lawsuit in court.

“It’s going to be up to the jury to decide what kind of damage the family members have suffered as a result of this incident,” said Kashfian.

Jeff Krueger still keeps in touch with the homeowners whose houses burned down at the scene of the crash.  Those neighbors are still rebuilding, one year later.

“This isn't just about Steve. There are other people that it impacted,” said Krueger.


Dr. Sugata Das
~

Steve Krueger
~


On October 11, a small plane descended from the sky above Santee, California, a suburb outside San Diego, and crashed into two residential homes, leading to two deaths. 

In the days that followed, some social media users seized on the news, claiming without evidence that the accident had been caused by a COVID-19 vaccine. 

"Epidemic of plane crashes linked to vaccine-related strokes in pilots," reads text across an October 17 video posted to Rumble.

The video was flagged as part of Facebook’s efforts to combat false news and misinformation on its News Feed.

The video’s claims are entirely baseless. The cause of the Santee crash has not yet been established, said a representative for the National Transportation Safety Board, the government agency investigating the accident.

The video hinges its claim on the fact that Dr. Sugata Das, the pilot of the crashed plane, was a cardiologist, who would have been "required to get the vaccine." However, it does not provide any proof of its assertions that a stroke resulting from a vaccine caused the accident. 

In addition, the video’s claim that the COVID-19 vaccines have caused an "epidemic" of plane crashes is not based in fact, a spokesperson from the Federal Aviation Administration told PolitiFact. 

"The Federal Aviation Administration has seen no evidence of aircraft accidents or pilot incapacitations caused by pilots suffering medical complications associated with COVID-19 vaccines," FAA spokesperson Crystal Essiaw wrote in an email. 

The rate of fatalities resulting from aviation accidents has actually been at a low point during the period COVID-19 vaccines have been available to the public. 

According to FAA’s statistics, 0.96 aviation fatalities occurred every 100,000 flight hours in 2019, before the coronavirus began to spread in the U.S. In 2020, that rate decreased to 0.91. And in 2021, after the COVID-19 vaccines became available, it reached 0.74, its lowest point in at least the last six years. 

According to the FAA’s guidelines, pilots are not allowed to fly for 48 hours after they have received a dose of the COVID-19 vaccine, the period within which most side effects subside

Our ruling 

A video posted to Rumble claimed that there is an "epidemic of plane crashes linked to vaccine-related strokes in pilots."

As evidence, the video cites a plane crash that killed two people in Santee, California. The National Transportation Safety Board told PolitiFact that the cause of the crash has not been established and that there is nothing to support the video’s claims. 

The Federal Aviation Administration told PolitiFact that it has seen no evidence of aircraft accidents or pilot incapacitations caused by pilots suffering from medical complications involving COVID-19 vaccines. 

The rate of aviation fatalities has reached a relative low point during the period COVID-19 vaccines have been available to the public. 
 
See the sources for this fact-check: 

A Rumble video, October 17, 2021 

Interview, Crystal Essiaw, spokesperson for the Federal Aviation Administration, October 19, 2021

Interview, Keith Holloway, spokesperson for the National Transportation Safety Board, October 19, 2021


Federal Aviation Administration, FAQs on Use of COVID-19 Vaccines by Pilots and Air Traffic Controllers, accessed October 19, 2021




SANTEE, California — A report from the San Diego County Medical Examiner’s Office Thursday fills in some of the details missing since a small plane crashed into a Santee neighborhood Monday, leaving two people dead and leveling two homes.

The report offered the latest official recounting of that day’s event, as the chaos of the crash left details about how the plane went down and what it hit first initially hazy.

UPS driver Steve Krueger, 61, had been pulling up to a stop sign on Greencastle Street — a few blocks from Santana High School — when the aircraft hit his work truck first, the medical examiner says. “The aircraft continued and then collided with two homes in the neighborhood and caught fire,” the report details.

Calls to 911 drew a massive emergency response, and when the flames were extinguished from the driver’s vehicle, Krueger’s death “was confirmed without medical intervention,” the medical examiner wrote.

The medical examiner also formally identified the Arizona cardiologist who had been piloting the plane, Dr. Sugata Das, and confirmed his age, 64, which was not initially provided by his practice when they confirmed his death ahead of officials.

The medical examiner could not shed light on what caused Das to crash in the first place, stating only that he “lost control of the aircraft and landed in a residential neighborhood.” Determining why the plane went down is up to the National Transportation Safety Board, which packed up plane wreckage and left Santee Wednesday to spend another two weeks working on their investigation in Arizona.


Dr. Sugata Das
~














Delivery company UPS identified in a letter to employees the longtime worker who died Monday after an airplane clipped his truck while on the job, killing him just as he was on the verge of retirement.

Steve Krueger, who was a UPS employee for more than 30 years, is one of the two people killed in Monday’s tragic crash. He was doing his rounds in Santee and was in his delivery truck when a Cessna C340 nosedived from the sky and crashed into a residential neighborhood.

“Our employees and Steve’s family need to know that he will always be remembered by his UPS family,” the delivery company said in its letter on Monday.

Krueger, an Ocean Beach resident, was fond of snow and the outdoors and had just purchased a home near Mammoth Lakes, a local told NBC 7. The late delivery driver was just months away from retirement and planned to spend much of his time in his new home.

Jim Leutkemeyer said Krueger owned property in Ocean Beach and took great care of his tenants. He said the UPS employee’s dedication to them went as far as vacuuming the rooftops to ensure they lived in clean conditions.

Leutkemeyer, a neighbor and friend of Krueger's, added that he enjoyed the UPS worker's playful sense of humor, which he said will be missed dearly.

“I was always joking with him because he’d say, ‘Can you help me, you know? I’m getting ready to start this project.’ and I’d say, ‘Oh, my back just flared up.’ So we always joked back and forth about our age,” Leutkemeyer said. “I’m going to miss that. I just can’t believe this happened to Steve.”

On Tuesday, UPS issued another statement regarding Krueger's devastating death.

“We are heartbroken by the loss of our driver Steve Krueger, and extend our deepest condolences to his family and friends," the company's statement read. "Those who knew Steve said he took pride in his work, and his positive attitude and joyful laugh made the hardest days a little lighter."

"Steve was held in high regard and will be greatly missed."

The company coordinated a moment of silence in honor of Krueger at 12:14 p.m. Tuesday – 24 hours after the fatal impact. A flag outside the UPS customer service center in Kearny Mesa was held at half-staff in remembrance of the employee.


Dr. Sugata Das
~



Steve Krueger
~


A doctor piloting a Cessna C340 that crashed Monday in Santee near Santana High School has been identified as one of at least two people killed in the incident, officials said.

The plane was headed to San Diego from Yuma, Arizona. It was supposed to land at Montgomery-Gibbs Executive Airport in Kearny Mesa, according to the flight plan, but never made it. It is unclear if the pilot was attempting to make an emergency landing at Gillespie Field in Santee, which is just a few miles from where the plane crashed at around 12:15 p.m.

According to witnesses, the plane, which had tail number N7022G, went down along Greencastle Street where it intersects with Jeremy Street. The wing of the plane clipped a UPS truck that was nearing a stop sign, killing the driver. The fuselage then slid toward two homes and exploded, witnesses said.

The chief medical officer of the Yuma Regional Medical Center confirmed Monday evening that the pilot of the plane was a colleague.

“We are deeply sad to hear news of a plane owned by local cardiologist Dr. Sugata Das which crashed near Santee,” said Dr. Bharat Magu. Chief Medical Officer at YRMC. “As an outstanding cardiologist and dedicated family man, Dr. Das leaves a lasting legacy. We extend our prayers and support to his family, colleagues and friends during this difficult time."

A family friend told NBC 7 that Das worked at the YRMC but lived in San Diego, flying back and forth frequently.

In audio of Das' exchanges with Air Traffic Control about a half-mile from the runway, a controller can be heard telling Das his plane is too low.

“Low altitude alert, climb immediately, climb the airplane,” the controller told Das.

The controller repeatedly urges the plane to climb to 5,000 feet, and when it remains at 1,500 feet warns: “You appear to be descending again, sir.”

Shortly before 2 p.m. at a news conference near the crash scene, Santee Fire Department Deputy Fire Chief Justin Matsushita confirmed that at least two people died in the crash or the ensuing fire.

"It's a pretty brutal scene for our guys and we're trying to comb through it," Matsushita said, adding that he was unsure if there were additional fatalities. He did say that the debris field from the crash extended nearly a block to the southeast.

An investigator from the National Transportation Safety Board (NTSA) was expected to be at the scene Tuesday morning, the agency said.

In addition to the pair of destroyed homes, at least five more were damaged.

Matsushita said two people were taken to local hospitals for treatment. Neighbors told NBC 7 they are a husband and wife who were saved from the charred home on the corner struck by the body of the plane. The woman was rescued through a window, her hair singed and face burned. Her husband was rescued from the back yard, pulled through the fence to safety by neighbors.  




SANTEE, California — Colleagues confirmed that the Cessna C340 that crashed into homes in Santee on Monday was owned by Dr. Sugata Das – a cardiologist who worked at the Yuma Regional Medical Center in Yuma, Arizona.  

The center's chief medical officer issued a statement, saying in part, "As an outstanding cardiologist and dedicated family man. Dr. Das leaves a lasting legacy. We extend prayers and support to his family, colleagues and friends during this difficult time". 

Home security camera video shows the Cessna C340 as it plunges from the sky and hurtles to the ground below. A moment later, a fiery explosion could be seen from miles away. 

At least two people have died following the crash and two homes were destroyed. 

Minutes earlier, air traffic control noticed something wasn't right.

"It looks like you are drifting off course. Are you correcting?” an air traffic controller could be heard asking.  

The audio between the pilot of the Cessna C340 heading from Yuma to Montgomery Field in San Diego and the air traffic controller reveals moments of intense alarm - and possible confusion. 

The controller on the ground is heard warning the pilot that he is flying dangerously low and requesting that he increase his altitude.  

"Climb immediately,” the controller says. “Maintain 4,000. OK. It looks like you are descending, sir. I need to make sure you are climbing, not descending.”  

And then just a half-minute later the controller’s commands become more frantic. 

"Low altitude alert. Climb immediately. Climb the airplane. Maintain 5,000. Expedite the climb. Climb the airplane please.”  


236 comments:

  1. Santee Deputy Fire Chief report at 1:52 PM 10/11: "Multiple confirmed fatalities, number unknown", including the plane and no word yet on the UPS driver. Debris field almost the entire block. Two homes destroyed, while at least 2 additional damaged. More than one news report pointed to a possible landing attempt on the neighborhood street.

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    1. Two homes involved in fire. Elderly couple minor injuries, taken to UC San Diego Medical Center. Possibly aided by a good Samaritan, as the airplane (attempting to land?) hit a car, a boat and a "UPS' truck, according to the son of the folks who lost their home talking to news reporter at scene. No info on the "UPS" driver or the aircraft occupant(s). Gillespie Field is nearby.

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    2. UPS driver reported dead now.

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  2. Looks like N7022G on flightaware.

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  3. After listening to ATC audio posted to YouTube, this was spatial disorientation. Got way behind the plane which you can clearly hear in his voice.

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    1. yes. he was cleared to intercept LOC 28R in KMYF but turned in the opposite direction into terrain. sad

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    2. yes .. physician from Yuma, AZ ... sounded like very high workload trying to capture then ILS .. RIP to all :(

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    3. Seeing the back patio video of the actual dive and crash, the weather was enough to the pilot to see the distant mountains and surrounding terrain to pull up. The dive was consistent in a straight line to the crash impact with no manuveuring which indicates possible pilot incapacitation.

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    4. He was probably used to flying in VFR weather in Yuma. With 300 days of clear weather then you go to the beach cites in CA have that marine layer to deal with.

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    5. He had a lot of hours, commercial rating as well obviously private. It's probably not "used to flying vfr in Yuma". Got behind the plane and the situation. Aviate Navigate communicate with the first one having overcome by spatial disorientation.

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  4. Photos show the burned UPS truck but it did not look like it was hit and the driver seat was empty. The driver may have been on foot making a delivery to one of the homes and was sadly in the wrong place at the wrong time. The odds of that happening are just unfathomable. With all those homes there and everyone having home security cameras these days, this event almost certainly must have been captured on video from multiple angles.

    So sad for the UPS driver just out trying to earn a living and then gets taken out like that. Sad for all lives lost and RIP for the families and friends.

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  5. https://archive.liveatc.net/ksan/KSAN-SOCAL-App-Dep-East-Oct-11-2021-1900Z.mp3

    At 9:30 it gets hairy.

    https://flightaware.com/live/flight/N7022G/history/20211011/1700Z/KNYL/KMYF

    Lost the needle as if he were distracted. ALWAYS have the second nav radio and vor/ cdi set up for the approach, if you punch the wrong buttons you click off the AP and hand fly, assuming you are current.


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  6. You can hear his entire approach on LiveATC - N7022G

    https://archive.liveatc.net/ksan/KSAN-SOCAL-App-Dep-East-Oct-11-2021-1900Z.mp3

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  7. https://globe.adsbexchange.com/?icao=a95ea1&lat=32.858&lon=-116.969&zoom=16.5&showTrace=2021-10-11&trackLabels

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  8. The pilot was on an IFR flight to Montgomery-Gibbs in San Diego, with a clearance to land ILS RWY 28R circle to land RWY 23. The ATC controller was sending him around with an intent to bring him in with vectors, after he drifted way off the localizer. At the time of the event, ceilings were 2,700-3,000 broken.

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    1. What I don't get, though, is that the videos taken after the crash show a few puffy clouds but a mostly clear and sunny sky. Maybe I'm just not seeing the right perspective from the video footage I've found, but it doesn't seem like he suddenly descended out of the soup too late to save it.

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    2. If you listen to the ATIS, broken layer was at 1700' and overcast was at 2800' AGL.

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    3. Marine layer I grew up in that area gray sky everyday until after lunch time about 2pm burns off. Keeps the place nice and cool, but we had lot of plane crashes peeps flying from desert states maybe were IFR rated but hadn't done it in years.

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    4. The KSEE METAR which was nearest the crash site was reporting 2700 broken.

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  9. The aircraft was on an instrument approach into Montgomery-Gibbs Executive, cleared for the ILS RWY 28R circle to land RWY 23. After he drifted well off the ILS, ATC sent him around with vectors, planning to bring him back in with vectors. He started having problems with his altitude, and was urgently advised several times to climb. A helicopter in the pattern at Gillespie Field (along with a few other light GA aircraft doing pattern work) had him in sight, and witnessed the crash. The ceilings at the time were reported between 2,700-3,000 broken.

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  10. The aircraft was on an instrument approach into Montgomery-Gibbs Executive, ILS RWY 28R circle to land RWY 23. The aircraft was sent around and was going to be brought back with vectors, after ATC observed that he’d drifted well off the ILS. He started having difficulties with his altitude, and was urgently advised several times to climb. A helicopter in the Gillespie Field pattern (along with several other light GA aircraft doing pattern work) was behind him and reported traffic in sight, and witnessed the crash. Ceilings at the time were between 2,700-3,000 broken.

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    1. About 5 minutes after the crash, an aircraft called up Gillespie tower and requested a class D transition (top of D is 2400 MSL). He was granted a transition above 2400, but immediately requested lower because that would “put him in and out of clouds.” That gives you a possible idea of the cloud bases. If they were ragged or scattered at 2400 MSL, that’s only ~2000 AGL over Santee (even less clearance above the surrounding hills). But the pilot of the accident aircraft was well above the reported bases for most of the accident sequence, anyway.

      Spatial disorientation is a high probability. Watch for power/energy management to come into play as an exacerbating factor - look at groundspeeds during the final 90 seconds. Earlier segments were very precise, as if on autopilot. After the re-vector began, it was very erratic.

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    2. Spatial disorientation or task saturation does not explain this to me. He was warned so many times to pull up. Something else was going on with this guy. Wild guess here maybe some sort of impairment, CO, fumes, or drugs/alcohol. Either that or some sort of medical impairment. I remember when my dad had his stroke he seem totally normal but just had no idea what he was doing and couldn't comprehend when we asked him to come here or something like that I don't remember what it exactly was, but we realized he was not acting normal and eventually called 911. He spent the last 10 years of his life needing 100% care like his mentality went to the level of a 12 year old sometimes younger sometimes older. Until he passed earlier this year. My gut says something happened to this dude medically or similar. Prayers to his family & UPS man. Dr.s should require extra training since their crash rate is so high (partially kidding).

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    3. Dr Das was highly disciplined.

      He was extremely fit.

      He did not consume alcohol.

      The only drugs he knew off were probably the medicines which he may have prescribed to his patients for treatment of their ailments. And he had many patients whose lives he had touched.

      He was passionate about his work and aircraft.

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    4. With that being said he probably had a stroke or an MI.

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    5. I think the situation got ahead of him, sadly. Not sure but he did sound very stressed in the transmissions. He was somehow not believing his instruments. They will be analyzed I'm sure if possible to see what they were showing from the physical wreckage. I don't recall if he published a photo of the cockpit obviously this age aircraft might well have good steam gauge array. Glass won't be so easy to verify.

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  11. That security video is harrowing. The plane is in a fairly steep dive and looks to be rolled about 45 degrees to port. I'll be interested to see what the NTSB has to say, don't want to be an armchair speculator here and look like a know-it-all jackass.

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    1. I don’t know about you, but I’m speculating because I’m trying to hone my skills and studying to be an NTSB investigator. So maybe you shouldn’t armchair speculate our comments.

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  12. Wow... he came out the clouds at a high rate of speed. RIP to both

    https://youtu.be/J2NWtIyiSHo

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  13. My First Officer and I heard this man on two separate frequencies as we arrived into San Diego Lindbergh. He had problems hearing and understanding clearances and for reasons he didn’t share on air, seemed to have difficulty controlling the flight path of his aircraft. The approach controller did an excellent job trying to get him to recover, including removing all instructions except to climb straight ahead to a safe altitude but after a certain point he was apparently overwhelmed and ceased to respond. We landed to find this heartbreaking news. We raised a beer to his memory this evening.

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    1. Did it sound to you like he might have been impaired like CO or a stroke? I cant see someone being so task saturated that they ignore so many warnings to pull up. I mean I know it happens but this guys history shows he flies regularly. I know that doesn't make you a good pilot but it just seems odd given the conditions that day. Cheers to the Dr & blessing to his family!

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    2. Agreed sounds like a partial incapacitation.

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    3. Is it likely to get CO poisoning work in a twin?

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  14. SUGATA DAS

    ...
    County: YUMA
    Country: USA
    Medical Information:
    Medical Class: First Medical Date: 8/2020
    MUST HAVE AVAILABLE GLASSES FOR NEAR VISION.
    BasicMed Course Date: 6/19/2017 BasicMed CMEC Date: 6/19/2017
    Certificates
    COMMERCIAL PILOT
    Certificates Description
    Certificate: COMMERCIAL PILOT
    Date of Issue: 10/24/2014

    Ratings:
    COMMERCIAL PILOT
    AIRPLANE MULTIENGINE LAND
    INSTRUMENT AIRPLANE
    PRIVATE PRIVILEGES
    AIRPLANE SINGLE ENGINE LAND


    Limits:
    ENGLISH PROFICIENT.

    Basic med?

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    1. Basic med is allowed for aircraft with 6 or fewer seats below 6k lbs.

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    2. He was on basic med wonder why he could not pass a medical maybe he was on a SI before? 340 is under 6k lbs

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    3. I am leaning towards a stroke, something about the way he replied reminded me of when my dad had one and seemed normal but lost somehow before we took him to the ER. Perhaps the Dr. had a stroke, CO poisoning, or other medical issue. (im just a dude on the internet & dont know anything lol)

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    4. Yes the "Basic Med" was in 2017, but people are missing the ACTUAL First Class Medical Issued in August, 2020.

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    5. Keep in mind people who don't fly for a living sometimes do Basic Med because it's just easier to do. It's an hour min drive to my closest AME.

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    6. The odds of having a medical issues right when you are meant to intercept a loc and don’t seem slim especially with his medical background. Poor guy. It sure is a sad accident for someone who really liked flying and tried very hard to be a good pilot ie upgrades to plane, interest, and maintenance of hanger mentioned etc.

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  15. Rough to listen to. He had ways to avoid this.

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  16. I consider myself fortunate to have Jamie Dockins as my flight instructor for my instrument training . Jamie is a thorough professional and would consider her ENTHUSIASM as one of her numerous qualities that have made my flight training truly enjoyable.

    Clearly, Jamie came through as my first choice amongst many top quality flight instructors and I am certain to expand her role as a mentor, as I continue my training to be an accomplished and SAFE pilot.

    My personal experience with Jamie has spurred the flying bug in my teenage son, who aspires to solo at 16 and get his private license at 17.
    -Sugata Das M.D.

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  17. Mad Doctor Das, or Doc, as he is affectionately known here, is a full-time cardiac surgeon and part-time aviation nut. He has completed his Commercial Multi-Engine rating and wants to go all the way to Airline Transport Pilot! He lives in Yuma & commutes 400 miles just to fly here with CFI Greg Boylan. When he is not saving lives, he is flying high up in the sky!

    ReplyDelete
    Replies
    1. "wants to go all the way to Airline Transport Pilot!" I guess that explains why he got his first class medical in 2020, although it appears he never renewed it.

      Delete
  18. Rest in peace Doc (and UPS driver) 🙏🙏

    ReplyDelete
  19. Single pilot IFR is HARD. wx was IFR. He was in "the soup"
    Single pilot IFR in a twin In actual IMC is mind bending. Sounds like spatial disorientation.

    ReplyDelete
    Replies
    1. Looking at the video from the accident scene, it was scattered - didn't look like "the soup". My money is on something medical.

      Delete
    2. Newbie question. if both engines and systems are working fine, why would it matter if it was a twin?

      Delete
    3. Because in general, twins are faster and heavier and require thinking ahead vs. a single engine airplane.

      Delete
    4. The light Cessna twins are slippery, and slowing them down in advance is part of setting up to land. If you just pull off the power and nose them over, they don't slow down, they pick up speed. Then you've got a lot more to deal with than just flying the approach.

      Delete
  20. The circle to land clearance may factor in here. There seemed to be confusion and tension around that in the readback. Perhaps he was trying to pull up the circle-to-land minimums right as he was intercepting the localizer and got behind?

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  21. Condolences to Dr Das' family and UPS employee's family who died in this tragedy. I read the ATC transcript and came up with 4 possible problems: 1. This aircraft was 42 years old so why would a cardiologist making good money fly something so obsolete? Old aircraft crash at twice the rate of modern aircraft. Aircraft choice is a puzzle. 2. Making a circling approach in good weather can be a challenge but in IMC it can be a little overwhelming, especially flying single pilot. When was the Doctor's last circling approach in IMC or a simulator? 3. If the Cessna 340A had lost an engine during this approach phase, the ability for it to climb more than 100-200 fpm was not possible. Flaps and gear would need to be up, rudder trim would have to be set, failed engine propeller would need to be feathered, good engine power set at max. In other words, there's a whole bunch of stuff to do in order to achieve a meager climb of 200 fpm. Was the Doctor able to do all this and still capture the localizer for RWY 28 and prepare for a right turn to intercept the final approach course for RWY 23? 4. The Cessna 340A was pressurized but if there were any cracks in the mufflers, carbon monoxide could have entered the cabin and compromised the Doctor's ability to navigate, communicate, and fly the aircraft as required. The aircraft was 42 years old. When were the mufflers changed, inspected, etc? All accidents involving loss of life are tragic and this one is no exception. RIP

    ReplyDelete
    Replies
    1. What's your source on "old aircraft crash at twice the rate of"

      The fact is the GA fleet is old, especially in airplanes of this class. They have not been made in decades so there are no "new" options.

      This airplane could be a reliable an safe airplane if flown by a professional pilot.

      Delete
    2. Yes "unknown", its only as old as the last annual.

      Delete
    3. Circling approach is a VMC maneuver. You do not circle IMC. If you do not have the runway in site to circle, you go around. If he was VMC, he did not have to intercept the LOC.
      Plenty of 50-60 year old airplanes flying perfectly safe. Where do you get your information.
      I've been flying multi engine airplanes for 30 years. You make a single engine go around seem impossible. It is not that difficult. You do need to practice it though.

      Delete
    4. You will not find a muffler on a C340A. The exhaust AD mentioned is to prevent fires, not CO poisoning. The 340 fit Dr. Das' mission profile quite well, and therefore it was not obsolete. I would argue it was one of the best possible choices of aircraft. The single engine rate of climb is 300FPM or better, and most twins flown light will pick up another 100 or more. SE service ceiling is 15,800 feet. It is one of the best aircraft for mountain flying in my opinion.

      Delete
    5. This was obviously Spatial Disorientation look at the angle as he broke out below the clouds he was almost straight down. It was not CO he was speaking clearly. He probably wasn't proficient in IMC simulators will not create SD. The Marine layer is tricky because you fly above it in VMC then have to descend down though it controllers giving all kinds of turns which the sudden change after hours of VMC to IMC can create SD only takes a few bad turns get into a death spiral. Maybe if he had a new cirrus he could have used CAPS. I have a friend with a 340 most of the time he flies alone don't know why anyone who want large twin only fly alone. I would rather have a new cirrus if I could afford it.

      Delete
  22. Cessna 340 and 340A subject of an AD regarding their exhaust systems frequently cracking which requires repetitive inspections. Was the aircraft current on this inspection?

    https://www.aopa.org/advocacy/advocacy-briefs/regulatory-brief-faa-issues-long-awaited-twin-cessna-exhaust-ad-(3)

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  23. Looks like a fair bit of non pilot comments here that I can clarify. First, if it was 2400 Scattered or even Partly Cloudy, then it was likely quite milky from a visibility perspective. Milky conditions, depending on the sunset or sun position, can be challenging conditions if you are relying on visual landing cues and they can be deceptively challenging, as opposed to just popping out of a layer, for example. This particular area is hilly and can be daunting if you are not precise in your instrument approach procedures and process. The approach to the runway features lots terrain peaks and valleys and requires precision if not familiarity. Finally, the C340 is a super nice and capable aircraft. It is, however, a handful single pilot IMC (Instrument), so it takes a high level of proficiency in IFR to be comfortable and safe. The C340 is labor intensive management of airspeed, altitude and fuel and if you don't have high proficiency in IFR, it can easily eat you up. I had a 414 for 8 years and that airplane - much like the 340 - is simply a high workload airplane even in standard conditions. But they are wonderful airplanes with great performance capability. Sadly, this one looks like the airplane just got away from him.

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    Replies
    1. The reported visibility at both KSEE and KMYF was 10SM at the time of the accident, which is as clear as can be reported. "milky conditions"? Really? I don't believe the term is in the AIM, any of the FAA texts, nor used by any CFI I've ever heard. In any case, I don't think visibility was a factor here because ATC told the guy about 7 different ways to climb immediately over the course of several minutes, yet the ADS-B and videos all show him doing a nose dive straight into houses.

      Delete
  24. Wow everyone, seems to have an expert opinion here, some rather crude - ("look like a know-it-all jackass"...or..."another day, another doctor") "really I hope these words are not coming from the pilot community..!

    I noticed very few comments from those that knew this man!

    I had met Dr. Das, I have witnessed this plane, it was always hangered ("his hanger was his Sanctuary") the plane was spotless, nothing left to chance!

    The "twin" wasn't his only plane, Dr. Das, is well versed in a very fast aerobatic plane, so I doubt that he had an issue with spatial disorientation..!

    And btw his Son did get his license, of which Dr. Das, was extremely proud, and the likelihood of his son reading this forum is probably pretty high, so act like men and show some respect for a fellow Pilot, and his Son...

    So Mr. ("another day, another doctor")– It is my bet that you wouldn't be talking about Dr. Das this way, if you where laying in an ER; your left arm burning with pain, feeling like an elephant just sat on your chest, your eyes full of fear?

    To Dr. Das Son:
    It was an amazing experience flying from Phoenix to Yuma in my "ex-Tom Cat" pilot friend's super fast aerobatic plane. Getting to show that plane to your father, along with the mechanic that built the plane.
    Giving your Father hope that the mechanic could duplicate the same for your Father.
    It was a bit surreal witnessing your Father's hanger Sanctuary. And super cool seeing his other plane, which was also very fast, and especially fun experiencing "Your Father's overall coolness..!"

    Signed,
    TW

    ReplyDelete
    Replies
    1. @Luv Flying Fast
      That's nice that you knew him genius, any chance you knew the people he killed on the ground?

      Delete
    2. flying a very fast aerobatic airplane does not make one immune to spatial disorientation.

      Delete
    3. SD can happen to anyone I'm sure he was a good person he was human like anyone else. Humans make mistakes aviation doesn't forgive humans for making a mistake. I live in Phoenix, and I grew up in Southern CA near the beach area the marine layer crashes planes. Look what happened to Kobe Bryant SD crashed that pilot he had years of experience flying in the area.

      Delete
    4. Regardless of whom he was in life. Spatial disorientation can occur in anyone - military pilots have had to eject due to it. Listening to the ATC tapes and reviewing the profile it all seems routine until the busy ATC gives him an instument landing clearance - late at his prompting with a "circle to land" on another runway. He then overshoots the approach path and deviates from that path failing to intercept the localiser and is then instucted to go around after which he fails to gain altitude. Raido calls are short clipped and not completely answered. I suspect (the investigation will review this) that he was task saturated, likely unable to configure the aircraft rapidly enough to intercept the localiser, suddenly off autopilot hand flying in IMC (which may not have been anticipated) and atempting to fly a circle to land approach in IMC in a heavy work load twin engine aircraft. He may not have done this for a while, he then appears to believe himself to be climbing whilst actually descending in a right hand bank at high power which is characteristic of spatial disorientation. Sadly once he exited the clouds at high speed it was too late to recover. RIP. My thoughts on what could be learnt from this - difficult. Prepare for your approach early, consider the options and be prepared for ATC to throw you a curveball - consider whether you'd accept a "cricle to land" if they offer it, personally I hate "circle to land" it was invovled in another crash recently, I feel it increases task loading (particularly single pilot twin engine in IMC). don't wait too long before prompting ATC for clearance and make sure you do it early enough to give yourself time, if it's too late don't accept it go around. CRM be aware of when you're becoming task saturated and go around early. If the concern that you are spatially disorientated even enters your head - engage the autopilot and let it do the climbing (no matter how wierd it feels). Trust your instuments - or at least your backup ADI (if you have one). It's true there's nothing wrong with old aircraft and they're as safe if maintained as modern ones - BUT there have been big improvements in avionics and navigation over the years and upgrading those can make a difference to taskloading. RIP.

      Delete
    5. You do know circle to land is a Vmc procedure, right? You don’t maneuver until you have the airport in sight.

      Delete
    6. “”AnonymousThursday, October 14, 2021 at 4:22:00 AM EDT
      Regardless of whom he was in life. Spatial disorientation can occur in anyone - military pilots have had to eject due to it.””
      Truly one of the best posts on here, good advice for any pilot. I’ve experienced SD, more than once. Once your brain conflicts with the facts presented by your instruments, you no longer are flying the aircraft.

      Delete
  25. SOCAL approach gave weather at Montgomery as 170/10, 10M vis, 1700 broken, 2800 overcast. Wondering if this was a thin fog layer at 2800, and as the pilot intercepted the localizer he descended into the fog layer and got disoriented. I doubt he was on autopilot at this point, as he drifted off the localizer. I'm wondering if he was totally confused on how he was going to circle to land VFR on 23. He seemed to totally lose situational awareness soon after he intercepted the localizer (and dropped into the overcast layer). So sad....

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    Replies
    1. This was his home airport. That's why this is so confusing to me. He seemed to struggle with repeating the approach clearance for the ILS 28R circle 23. And then when he strayed off final course he asked about rwy 23 even though his focus needed to remain on final approach course until he reached circling mininimus for rwy 23.

      Delete
    2. Yes, good point. Thought the same unless they don’t usually do the circle. I’m not familiar with that airport.

      Delete
    3. I knew Doc. He was also my cardiologist!! His hangar is behind ours. He was a dedicated doctor and pilot. I listened very carefully to the recording 3 times. He answers were not typical of his normal speech , so I suspect a medical problem. Also, I see you commenting many times--how about using a real moniker?

      Delete
  26. Wow everyone, seems to have an expert opinion here, some rather crude - ("look like a know-it-all jackass"...or..."another day, another doctor") "really I hope these words are not coming from the pilot community..!

    I noticed very few comments from those that knew this man!

    I had met Dr. Das, I have witnessed this plane, it was always hangered ("his hanger was his Sanctuary") the plane was spotless, nothing left to chance!

    The "twin" wasn't his only plane, Dr. Das, is well versed in a very fast aerobatic plane, so I doubt that he had an issue with spatial disorientation..!

    And btw his Son did get his license, of which Dr. Das, was extremely proud, and the likelihood of his son reading this forum is probably pretty high, so act like men and show some respect for a fellow Pilot, and his Son...

    So Mr. ("another day, another doctor")– It is my bet that you wouldn't be talking about Dr. Das this way, if you where laying in an ER; your left arm burning with pain, feeling like an elephant just sat on your chest, your eyes full of fear?

    To Dr. Das Son:
    It was an amazing experience flying from Phoenix to Yuma in my "ex-Tom Cat" pilot friend's super fast aerobatic plane. Getting to show that plane to your father, along with the mechanic that built the plane.
    Giving your Father hope that the mechanic could duplicate the same for your Father.
    It was a bit surreal witnessing your Father's hanger Sanctuary. And super cool seeing his other plane, which was also very fast, and especially fun experiencing "Your Father's overall coolness..!"

    Signed,
    TW


    Sorry God,
    I didn't know the countless lives that he also saved either!

    It is comforting to know oh genius one that you are the counter of counters, please continue your soul sucking darkness where it is wanted..!

    ReplyDelete
  27. Luv flying fast
    Flying aerobatics doesn't make one immune to spatial disorientation as your looking outside the cockpit. Except maybe the military, and they don't do it at low level. Sad for his family and friends though.

    ReplyDelete
  28. The balcony cam makes the descent angle look really steep. Another camera in the neighborhood shows the plane at a less steep angle but still at very high speed.

    https://www.msn.com/en-us/news/us/new-video-shows-plane-nosedive-explode-in-santee-neighborhood/ar-AAPqDLT?ocid=msedgdhp&pc=U531

    ReplyDelete
  29. Here is a different video with sound. It sounds as if both engines are running and, at a very high power setting. The decent angle is very steep and the plane appears to be in a greater than a 45 degree bank angle.

    Here are the 3 planes that he owned

    https://registry.faa.gov/AircraftInquiry/Search/NameResult (enter samarth in the name field)

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    Replies
    1. That's typical of SD spiral dive they break out below the clouds engines screaming full power. Last year we had that other Cessna Twin crashed that guy yanked back on the yoke when he saw the ground. They had sound hear the engines screaming and then loud snap as the wings folded up.

      Delete
  30. It could have been an undiagnosed partial/total power loss in one engine. If that happened, he would have been distracted trying to figure out what was going on while getting vectored for the approach in very busy airspace (would explain the heading confusion). When finally told to climb, if he hadn’t identified the problem at that point, he would have pushed both throttles up and pitched up, expecting normal performance and if one engine was bad, a Vmc roll over would be possible.

    However, the lack of a radio distress call could point more to a physiological issue.

    ReplyDelete
  31. Correct - doing aerobatics is almost the opposite of instrument flying - trusting 'seat of pants' and estimating with visual confirmation. What matters is experience and expertise with instrument flying and instrument accuracy / maintenance.

    Unfortunately I agree with most others, if I had to guess heads-down then heads up in clouds, spatial disorientation, perhaps clicked off the autopilot in a state of bad trim. Unfortunately could be a multitude of factors.

    He did not sound like a pilot that was infrequently flying or low hours, but in sunny Arizona it is hard to get true IMC so may have been out of practice. RIP

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  32. This is my uncle folks - while I appreciate you trying to understand what the issue is, can we atleast pretend to feel bad that he died instead of doing a clinical analysis of why? What's worse is that this tragedy cost more than one life and imagining my uncle's last few moments before crashing is absolutely harrowing. He had an incredible zest for life and was 110% dedicated to his two sons who will now have to figure out life without him. We are all incredibly devasted. I hope the authorities can figure out the truth and help all other pilots be safe.

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    Replies
    1. As pilots and retired pilots we look at accidents as learning experiences for the rest of us. So random speculation is going to happen. What most of us don't expect is blatant disrespect of the deceased. As a retired pilot I used to tell people "No one wants to arrive alive more than ME". I am certain no one wanted to arrive alive more than Dr. Das. It is not only unfortunate that Dr. Das died but a UPS driver as well. That is why we call them accidents. Anyone that has flown more than a handful of hours has done something stupid. Most of us have had a close call that could have turned out poorly if not for a little luck.

      I welcome the unsubstantiated theories and responses. What we don't need are jerks making comments like Another day Another Dr.

      Delete
    2. I'm sorry for your loss, however, I'm even MORE sorry to those on the ground who were injured, lost their lives, lost their homes, and lost family members (pets).

      Kathryn's Report is an educational/informational AVIATION ACCIDENT website for aviation professionals, enthusiasts, the legal community, and the general public.

      Rather than admonish those commenting, perhaps consider that aviation websites such as this (there are many, though none so well curated) may not be for you in so early a time of the grieving process.

      Delete
    3. I very sorry for your loss. Your uncle was a brilliant doctor who saved countless lives during his career. As for the post-incident analysis, please realize that this is something that pilots always do in an effort to save future lives. By learning from what happened to our fellow pilot here, we literally ensure that his loss was not in vain.

      Delete
  33. To nephew - don't get down or think that most of the pilots here are talking down or disrespecting the pilot. Only a very very few misguided individuals are being disrespectful.

    At this time one of the remaining greatest services your uncle can still do is prevent other pilots from making the same mishap. So pilots will often do a really cold and clinical analysis of what happened. Doctors do the same during M&M conferences.

    We DO feel bad, but that's not going to bring him back, and we don't want to lose any other doctors, pilots, or passengers. So analysis is critically important. Sometimes we take it too far and just rest assured I think all of us, deep in the back of our minds, know it could be us next, so we want to do EVERYTHING to make sure it isn't.

    RIP. Truly sorry about your uncle. He probably did not suffer at all. RIP to the UPS driver and innocents on the ground. We do need to understand the tragedy.

    ReplyDelete
  34. To Nephew. Family, and Loved Ones:
    Please take comfort in knowing that few, if any of these “opinionated bloggers” knew or had ever met (‘Your wonderfully kind intelligent Uncle, Father, Husband..!)

    ‘I had the privilege of meeting him only once, for an hour, and in that hour his phone rang off the hook, with emergency call after call; each call seemed to need his medical advice…there is no doubt that “this man was a Savor of Life!”–– Which means he valued lives that he did not know, including those that lost their lives on this sad day…he was not a reckless man.

    There is no doubt in my mind that Dr. Das, practiced his piloting exactly as he practiced “His Life Saving Cardiatric practice”––with precision and focus.

    It was apparent to me that flying was the one place that he could reset himself, so that he could keep saving lives.

    Something obviously happened that was unusual, or out of his control…(“ignore them all,” take comfort in knowing that it is easy to hide behind a computer screen spewing “anonymous opinions!”)

    And yes “his zest for life was intoxicating,” I had hopes of becoming a good friend of this wonderful man!!!

    tw

    ReplyDelete
    Replies
    1. "Dr. Das, practiced his piloting...with precision and focus."

      Except when he didn't and killed innocent people.


      "Something obviously happened that was unusual, or out of his control…"

      You're "obviously" make excuses for him by making false assumptions.

      Delete
  35. The ATC tape was so sad. Maybe wrong freq for ILS since he missed the localizer or wrong course. Not sure what system he had for nav. Poor guy. Sounds as if he was very into flying. So sad. Tough to go between several airplanes as a hobbyist I’m sure.

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    Replies
    1. Setting the wrong frequency should not happen if the approach is properly briefed well ahead of time. A good best practice to avoid incorrect programming is to set up both navigators for the approach.

      Delete
    2. Good point. Not sure which nav he had. Did he have dual controls. Was he in ground source nav. Not sure how far out he was but if he kept descending which is so sad and scary on the ATC tape maybe he thought he was following an ILS but was not. Good point about the briefing seems it will soon be an ntsb emphasis area with all of the poor briefing related crashes lately. Sounds as if he went between a lot of different aircraft so maybe hadn’t flown this one in a while and made an IFR nav mistake. To continue to descend? What was that about?

      Delete
    3. He had a commercial pilot rating. He wasn't a "hobbyist".

      Delete
    4. Yes he should have been able to fly a loc and ils to commercial standards. Sad for those who passed away that did not happen.

      Delete
  36. Twenty-five years ago I learned to fly from a doctor. I was in an EAA Chapter with several physician pilots and they were as meticulous as one could get. They also knew when it was time to hang up their wings.

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  37. I have a "what-if" scenario for this thread. Dr. Das admitted he was right of course and was correcting to track the localizer. ATC acknowledged and permitted him to continue but then later cancelled the approach clearance right after he asked about runway 23 when he was supposed to be tracking ILS 28R inbound. Perhaps mentioning runway 23 was a slip of tongue???

    What if Dr Das had said he was correcting course back to ILS 28R and ATC had allowed him to proceed? The final approach fix is at 2800' MSL and the broken layer is at 1700' AGL (2100' MSL) which is 800' above circling minimum. Also the approach plate shows that FAF to rwy 28R is clear of any obstructions (gray shading).

    My haunch is that the canceling of his approach clearance started to unravel everything for Dr. Das. He in effect had to go missed (when is last time he did this in actual IMC?) while getting urgent instructions to act quickly. He became task saturated and spatially disoriented all at once. The radar shows he climbed and descended twice before complete loss of control.

    How far off ILS final course does one have to stray for ATC to intervene and cancel your clearance??? Or is it subjective? The pilot should abort an approach if CDI reaches full deflection. Would it be possible to tell after the fact based on the track of the plane if this condition occurred?

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    Replies
    1. ATC did everything right, we have essentially all the info ATC had. Cancelled approach when he was clearly not tracking localizer and giving progressively more simple instructions (level wings and climb). Can't get much simpler than that.

      I appreciate what ifs but yours would require atc letting a clearly unstable approach continue and appears to be trying to shift responsibility from the PIC. This was the good doctors issue not ATC.

      Delete
    2. Your spot on likely he was used to flying in Arizona weather 300 sunny days a year. I'm sure he was a good person but the guy on the ground had nothing to do with him only a few days away from his retirement. Needs to be higher standards for IFR rating I have heard easy to cheat with fogged glasses, or a hood even if don't mean to. SD kills many each year nothing seems to change with the testing. FAA needs to raise the bar make sure someone is proficient.

      Delete
    3. I take back my "what-if" scenario after mapping and comparing his track to the final approach course for ILS 28R (in Foreflight). He was not only right of course. The ATC communication suggested he had strayed of course but he was never established on course in the first place. His lateral deviation as he approached final approach fix was over 2000' when he should have been less than 1822' (or 0.3nm) as he crossed the FAF. He should have seen a full scale deflection indication on his HSI/CDI and at that point should have asked to abort the approach. Unless he was still somehow trying to set up for runway 23 which might explain why he asked the question. ATC made the right call to cancel the approach. This was just one of other links in the accident chain that led to a tragic outcome. IFR currency does not equal IFR proficiency.

      Delete
  38. Just wondering: I flew into KMYF a few times in a Mooney, and once went through extreme turbulence very low and essentially on the approach to the field. If you look at the sectional charts, about 60 nm NE of the field is Julian VOR, and right next to it is a label "Caution: Extreme turbulence and severe up and downdrafts during high wind conditions". I don't know if/how when that applies, but it caught me by surprise that day. I remember that the autopilot disconnected, and I ended up seriously off course from the ILS intercept, and almost went around. Weather that day was good and severe-clear VMC. Had I been in "the soup" in an unfamiliar airplane, that could have ended badly.

    Just wondering if something like that could have happened. The pilot was in the vicinity....

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    Replies
    1. Interesting. So if autopilot disconnects during extreme turbulence and severe up and down drafts (and they do), was the doctor busy trying to get it reconnected and distracted from flying the airplane?

      Delete
  39. Offered the following as a possibility, not as a criticism:

    Misinterpretation of instructions can be as simple as substituting familiar actions when the one that was not understood has receded in memory from not being utilized.

    It's almost as if he misinterpreted the circling approach instruction as meaning he should get into the left pattern for RW23 and just broke away from intercepting ILS 28R to go make it happen.

    If discontinuing pursuit of 28R was intentional, the responses that followed are consistent with just reacting to each new controller command that came after that.

    Review of training history and content may determine that the pilot was not up to speed on performing what is defined for a circular approach. The out of character airmanship disconnect highlighted by the confusion over 28R vs. 23 and not picking up the ILS 28R to get in close and down to MDA for circling makes sense if he did not associate a functional understanding of what the controller's circling approach instruction intended.

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    Replies
    1. I also wonder about proficiency of circling to land....but wouldn't a simple, "request to land 28R or unable to circle 23" have worked to eliminate the confusion?

      Delete
    2. I wonder why he didn't use the auto pilot to intercept and track final course. An ad for this plane on a broker's page showed it had a Collins AP. Or perhaps as someone suggested earlier the navigation wasn't correctly configured right before ATC clearance to intercept final approach fix so he had to hand fly. Yes this is speculation but as pilots we are trained to use all available resource for a safe outcome and that includes asking ATC for delay vectors if needed. Using the AP should help buy one more time and preempt SD.

      Delete
    3. The broker ad from 10 years ago is not reflective of the equipment on board. He had a modern digital autopilot installed. I agree it was likely not configured properly to intercept the localizer. But not clear what happened after that.

      Delete
  40. As a former approach controller at several busy airports, my advice to pilots that get 'behind' the aircraft and recognize it, do the following. Tell the controller you need a vector and an altitude. Forget the approach clearance or procedure. Pilots often get overwhelmed trying to fly the plane, fix the problem, comply with ATC. While on the vector, stabilize the aircraft, diagnose what's wrong, get yourself oriented. Then tell ATC what you need. If a pilot tells ATC they've got a problem and need some time straightening it out, we'll be happy to help and almost certainly nothing negative will result from it.

    ReplyDelete
    Replies
    1. Controller Pete, that is the best advice I've heard on this thread. Many pilots think that there are no options with ATC. I've flown hardcore IFR single pilot in the Pacific NW for most of my career. All of the controllers I've worked with will essentially bend over backwards to make sure the flight lands safely. I've gotten "penalty vectors" because things didn't work out. But it's better than a ball of flames landing. ATC is your best friend, not your enemy. Like any profession, there are a few less than desirable controllers. Exception, not the rule.

      Delete
    2. Absolutely second this! Reading thru all these comments for first time and being a pilot since 1986 (owning as many as 34 in a fleet and currently with 3 and flying out of both MYF, SEE and Yuma), Pete makes the only truly respectful, decent, to the point, and obviously correct comment. I don't know whether the Doc (who I didn't know) had a stroke, heart attack, something else (possibly spatial disorientation -- but that would be my last guess), or even if he would've had time to make a request as Pete suggests (if the Doc had a medical event) -- but Pete's comment is spot on and we should all learn from it. Immediately (if you have time) tell breifly and concisely and as quickly as you can tell ATC "Sir/Mam I need a vector and an altitude now. I have an issue." And of course if it's an emergency declare immediately (which gives you priority over all others). You don't even have to state the nature of the emergency -- just declare and get on a safe vector and safe altitude. But again if you're having a stroke or heart attack -- you may not even get time for that.

      Delete
  41. The METARs closest to the time of the crash were KSEE BKN 2700; KMYF BKN 1700, OVC 2800. I suspect Dr. D was solid IMC until he began to intercept the ILS for 28R. LIkely he was in and out of the clouds at that point, causing him to transition between visual and instruments--a great recipe for spatial disorientation. Once he transitioned to visual, he may have been resistant to following ATC instructions as a climb would take him back into IMC.

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  42. So sorry for all involved. My biggest nightmare in flying is hurting an innocent bystander. I hope we are able to figure out what happened and prevent this from happening again.

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  43. So sorry. My biggest fear in flying is hurting an innocent bystander. I hope that causation is established so we can learn from this tragedy.

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  44. Never read such emotional replies on KR before. After review of all info, audio, track, video, he hit the ground with two engines at or near full power, high speed and sharply banked. Sobering. In the last moments of the flight he struggled to intercept and track the LOC. ATC canceled Inst approach clearance, gave several climb to (3000, 3800, 4000) last being 4000' and with vectors. Last to Hdg 090. ATC asked if he was climbing. Pilot said climbing. ATC was getting low altitude alerts and asked what altitude he was at. It sounded like he said 2500'. ATC said "climb immediately". That was the end of his transmissions.

    Getting canceled approach, multi attitudes, multi headings very rapidly, plus managing the a light piston twin, could overloaded any pilot. MISSED APPROACH in the initial or final phase of an approach, by ATC or pilot decision, can be more difficult than if at minimums over the runway. Canceled or aborted approaches are rarely if ever taught or practiced (I am a CFI/ATP), but they happen in real life. There is no plan for or expected early miss or aborted approach, thus a bit of shock factor and feeling of being behind. In glass planes it is set up for miss at MAP. Spatial disorientation or not, he lost control. From the sound and video of impact I heard twin engines running in sync, high RPM possibly prop tips at or near supersonic, in steep nose down bank at very high speed (very high speed).

    Adding full power level flight in IMC gives the feeling of falling back or climbing. If not reading, interpreting and controlling by flight instruments, could result in pilot lowering the nose. Add a bank and spiral positive G's this can cause disorientation. All speculation if he had spatial disorientation. Bar mechanical failure we can say he lost control for many possible reasons, and this is tragic.
    RIP Steve Krueger and Dr. Sugata Das....

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    Replies
    1. I've seen pilots get somatogravic illusion while instructing them, and it's terrifying. One pilot was going full power while starting a missed approach--so, very low altitude--and the next thing I know he's pushing the stick all the way forward. Happened so fast the attitude indicator was almost completely brown by the time I said "my controls." I remember when I was first learning how to fly, reading about illusions like that and thinking that was silly. But it's very, very real, and very deadly.

      Delete
  45. And how many other pilots are there who, like those featured here on KR, are flying happily about, blithely unaware of the precise set of circumstances that will bring them to grief?

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    1. A lot of pilots here including myself come to KR to read accident stories and reports to reinforce anything can go wrong in any sequence of events to cause a bad outcome. We will never stop learning from every accident. I can't speak for others, but for myself, I think a hell of a lot more about dying in a crash if something goes wrong than I do on the ground driving my automobile. Driving on the ground day in and day out in the city and on the interstates where mile for mile I have an insanely higher chance of getting killed in a crash whether my fault or someone else's.

      Delete
    2. But that's not what the poster you replied to asked. I am sure they all think about dying.
      It was how many are "blithely unaware of the precise set of circumstances..." Precise. Set of circumstances.
      As in have situational awareness and constantly expand their knowledge to fill any gaps to be more precise.
      Being precise may also help with understanding risks and chances correctly, e.g. while driving.
      Blithely unaware...

      Delete
    3. ^^I understood his comment clearly. Understanding an accident means understanding the root causes. And I say causes in plural because in any aircraft fatality report you want to look at in history, there is more than one cause and instead a sequence of events that leads to the final event. Every pilot should recognize the danger of when he or she starts getting behind the aircraft and behind in ATC instructions (the two are almost always directly related). There are countless reports here with fatal crashes and ATC communications of confusion in the cockpit.

      So the point to his question is, I would hope very few out there just blissfully go up and don't think about the various things that can go wrong. The key to being a good pilot is making sure you are prepared in all aspect of flight by the book from pre-flight to shut down. The problem is we have too many GA pilots who take short cuts in the entire flight operation due to complacency. Whether that was this case or not is up to the NTSB's final report.

      Delete
  46. This sounds like classic vertigo in IMC, he was nervous and didnt read back correctly.

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  47. I've met pilots who are "nervous" of IMC. If you are nervous to go into IMC you should be nowhere near IMC and are not an instrument pilot. Go back and practice, practice, or get some real IMC with an instructor when able.

    I second the guy that said my greatest fear is hurting somebody else. Doesn't matter how many lives you save beforehand, taking an innocent is pretty rough. If ever happens hope it is mechanical problem and nothing pilot could do. There but by the grace...

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  48. I've read the whole thread. This cought my eye ...

    Medical Class: First Medical Date: 8/2020
    MUST HAVE AVAILABLE GLASSES FOR NEAR VISION.

    He'd been flying at 10,000 feet for a while probly with sunglasses. At some point, just maybe, he tried to transition to his readers and he dropped them.

    if he dropped his glasses that may not by itself constitute an emergency. But certainly would be a stressor adding to the notion of task saturation and overload. Not only would close vision be impaired but there could have been a degree of embarassment and reluctance to confess.

    Someone mentioned turbulence. Yeah -- I took primary training at KSEE in the '80s in the fall. As a student on final, once had to use full control deflection just to maintain an even keel. Instructor said, "Wow that was a big one ..." Very likely another stressor.

    We have lotsof facts and lotsof speculation. Likely we'll never know, but think this to be a healthy excercise -- might be a chapter in a textbook someday.

    Jim

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  49. I’m not sure why he was pushing to be cleared for the ILS. It makes me think he was very confused. Someone mentioned this as his home airport so you would think he would be way more comfortable than he sounded and not need to be told the min vector alt. He seemed fixated on descending.

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    1. (MYF) is Not his "home airport" He was based at Yuma AZ (NYL) with 3 airplanes in the hanger.

      Delete
  50. According to ADS-B data, He might of been having a problem with the autopilot.
    Autopilot and altitude hold on, then alt hold off, then autopilot on, autopilot off altitude capture changed, alt hold on etc... Finally at 14:12.52 autopilot and altitude hold off, altitude capture set at 3800'. Heading capture was set from 296 degrees at 14:12.27 to 090 degrees at 14:12.34 and, remained at that selection until the accident. Autopilot was never re-engaged after 14:13.02.

    JW

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    1. His autopilot was doing what he asked of it.

      In his reaction to the unfamiliar circle approach instruction, he discontinued the loaded ILS 28R approach and set altitude hold at 2800 to satisfy the ATC's altitude instruction while turning right to get aligned for a left pattern landing to MYF RW23 as his "circle approach" response. He set the 296 degree heading capture after he got established on the path that would get him there.

      If he had not been interrupted, he would have landed visual to 23. Notice that he fed the autopilot the requested altitude changes and the 90 degree turn as the ATC's panicked requests came in. He was not having a medical episode, he was just using the autopilot to fly the plane as he always did.

      The autopilot mode under "STUFF" and selected altitude / selected heading in "FMS SEL" shown by Adsbexchange are very revealing for aircraft that transmit that extra data in the ADS-B extended squitter block.

      It will take two years, but the NTSB will examine that transmitted extended squitter Nav data correlated to precise timing in the ATC recording and correctly deduce that the pilot was making a left pattern to 23 approach as his response to the "circle approach" instruction.

      Delete
    2. If he was "just using the autopilot to fly the plane as he always did", Then it should not have been "off" unless He sensed some issue or malfunction with its performance. Heading and altitude can be changed in the FMS while the autopilot is active. Also, He might of had the approach to 28R punched in but, according to ADS-B, it was never activated. That shows up under "stuff" only when "activated".
      JW

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    3. This is one of several high performance aircraft accidents I've seen where the pilot was trying to get their automation to work rather than flying the airplane. FTFA.

      Delete
    4. This! That transition from the mental state where the pilot is monitoring the airplane to one where the pilot shuts off the AP and suddenly has to hand fly — that's where the trouble starts. Typically, the AP isn't doing what the pilot wants (usually because he/she pressed the wrong button or didn't have the heading selector set), the pilot overreacts, shuts off the AP, but isn't ready or able to hand fly. Or, worse, too scared to hand fly in IMC, the pilot continues messing with the AP until it's too late.

      My technique is to get the AP set up, but to always hand fly for at least the first few minutes when entering IMC, and to only click on the AP after confirming that my scan is good, the plane is trimmed and that I've got the airplane completely under control.

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  51. >If he had not been interrupted, he would have landed visual to 23.

    Stop that. That's just unwarranted speculation and almost certainly not true. If entering pattern for 23 would safely start turn well past hwy 15, he was still many miles out, likely in the clouds. If he hadn't been interrupted he might have drifted into the mountains east of the airport. I'm familiar with the area, the controller did the right thing breaking him off not following the loc for a vector back.

    If he was VMC he could have said he had a visual of the airport and requested VFR approach.

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    1. The pilot wasn't drifting into terrain. He turned and established a NW heading that would take him over Lake Murray and track west of 1300' MSL Fortuna Mountain. Ten seconds before the controller cancelled the approach, the pilot asked "is two two golf clear to land runway two three?".

      Continuing that NW track would have put him in position to turn left 3.5 nautical miles after Lake Murray and then leave a 2.5 mile straight-in final to complete into RW23. He wasn't "many miles out" when he asked for the clear to land 23.

      The controller did what he had to do, but keep in mind that the pilot was asking permission to carry out the RW23 landing he intended to make from the track he was on before his comm exploded. At that time he was just short of Lake Murray and not yet in position to request VFR.

      It is not unwarranted to suggest that the pilot was actually aware of where he was relative to MYF and intentionally navigating to the NW track he had begun for reaching runway 23 when he asked for clearance to land 23.

      Also, it has become known from the Twin Cessna owners group that the pilot was looking at dual Garmin glass, not the old panel from the outdated advert that is being shown on youtube.

      Delete
    2. I don't understand these posts above. If the pilot was doing as you said, had Fortuna in sight and the airport, he would simply say "field in sight, request visual 23" and gotten the visual. He would not have accepted controller vector and crashed.

      This was an experienced pilot, I'm sure he knows the words "cancel IFR".

      I disagree with the speculation which is probably not what happened, and trying to turn the onus on the controller who, with all information available, did everything right.

      Delete
    3. The post stated that he was just short of Lake Murray and not yet in position to request VFR when his comm exploded.

      There was no suggestion that he had the runway in sight at that distance and ready to cancel IFR, only that he was on a northwest track to carry out his interpretation of the CTL instructions.

      The post stated that the controller did what he had to do. That is not trying to turn the onus on the controller.

      Much has been made of the obvious loss of control, task saturation and disorientation that occurred after the pilot asked "is two two golf clear to land runway two three?". The posts above examined the period prior to that time and presented the following observation:

      "It is not unwarranted to suggest that the pilot was actually aware of where he was relative to MYF and intentionally navigating to the NW track he had begun for reaching runway 23 when he asked for clearance to land 23."

      Delete
  52. Condolences to the family. I have never seen so many idiotic and disrespectful comments.
    I probably have several thousand hours in Twin Cessnas. They are very easy to fly airplanes and are not high work load except in emergency situations. I hate the Twin Cessnas primarily because of the poor exhaust system design. Many of the commenters are ignoring the fact that the Doctors supervisor said that he had made the same flight hundreds of times. The Doctor is listed as the builder of a Vans RV9A built in 2015 and a RV10 built in 2021.
    I have flown with Doctors who were way better than some of the airline pilots I have flown with and a few who were not very good.

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  53. Carbon monoxide is much more likely to occur from the gas operated cabin heater located in the nose,than the exhaust from the outboard reciprocating engines. (No bleed air)
    Although it appears to be task saturated and spacial disorientation.

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  54. >I have flown with Doctors who were way better than some of the airline pilots I
    >have flown with and a few who were not very good.

    That's my experience too. Pretty accurate assessment written by a doctor: https://airfactsjournal.com/2015/12/doctors-bad-pilots/

    I've also seen some of the very best and worst pilots as MDs.

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  55. (No bleed air) The 340 is pressurized. What in the world do you think pressurizes the cabin??? Another display of total ignorance.

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    1. This comment is absolutely correct! So many idiotic comments here pre-supposing CO2 can't enter the cabin from pressurized twins. Either they don't know pressurized twin systems (i.e., where the bleed air comes from) or they're blatantly ignoring this possibility that CO2 does and often enters pressurized cabins. Also (in case someone gets ready to suggest it) don't think that because he was at a lower altitude that the pressurization system would not have been pushing bleed air into the cabin. Yes indeed it's still pushing air into the cabin. And depending on where you set your pressurization dial to in your pre-landing or approach checklist -- bleed air will continue to pressurize the cabin until as little as 500' AGL (or even the ground if you happen to set the dial to that level). So CO2 poisoning should not be knocked off the suspect list, and neither should stroke, heart attack or other unknown debilitating , catastrophic medical event. Geez why everyone here is so fixated on spatial disorientation in this thread is beyond me -- and immediately eliminating CO2 poisoning, stoke, heart attack, etc. etc. etc. You all would make lousy investigators of any kind of forensic investigation (aviation or otherwise). Yo yos - all of ya's.

      Delete
  56. >(No bleed air) The 340 is pressurized. What in the world do you think pressurizes the cabin??? Another display of total ignorance.

    Accident aircraft is a piston, not a jet, so the poster is right. The piston 340 uses a separate mechanically-driven pressurizer not bleed air. He is not the ignorant one.

    Those in glass houses...

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    1. Mechanically driven pressurizer? No. Maybe in antiques, called a cabin supercharger. The 340 is pressurized by air robbed from the turbochargers. Exhaust gas driven. Bleed air is an appropriate term.
      CO poisoning maybe unlikely. The heat doesn't come from the exhaust. Doesn't in most piston twins. There is an STC to add that to Navajos, maybe others, but twins generally use combustion heaters. Which do fail and can poison you, but depends on if he was using the heater. He was cruising @ 10000, maybe he was. The pressurization alone provides some heat. The AD is because the weird twin cessnas have the turbo mounted to the airframe, while the engine wiggles away on its rubber mounts. The exhaust between the two is prone to cracking.
      Instrument rated, smart guy, passionate about Aviation, flies aerobatics, blah blah...doesn't mean squat. Ya gotta be current, and not everyone is good at it, ratings or not. The weather doesn't sound all that bad, but he sounded like he knew he was getting a little behind it all.
      Some air force test pilot offed himself in Ohio in a c421 about a year ago. In IMC, spiraled into a flat field. Scott Crossfield, x-15 test pilot, did it in a c210, flew into a thunderstorm. Overconfidence about one's instrument skills and the weather is a real killer. I've been spatially disoriented in IMC. It was a good lesson.
      The Dr. problem is that they can afford planes like this, and, maybe being smart, aren't humble enough to respect it, or admit that they aren't that sharp in IMC. If they aren't, that is.

      Delete
    2. I checked and you are right, it is driven by the turbo compressors. For some reason I thought 340 had an old mechanical like supercharger connection to a separate compressor in event one engine failed, but looks like either engine can support cabin pressure driven by turbo compressor. I'd still take issue at calling this "bleed air" which typically is from jet turbine, I don't know of any other engineer that would really call that a bleed air system but I guess technically why not.

      And I agree with everything else you said, more money than skill is a bad combo whoever you are doctor or not.

      Delete
  57. Okay, my read on this having done many of these approaches in IMC, is that the pilot was confused about what to do when given the ILS 28R approach, circle to land 23, and because he was not handling the radio appropriately in my view, answering in very hurried ways, not making it clear to the controller what he was saying, the controller just moving on in several cases, and then at around 11:35 in the clip:

    https://archive.liveatc.net/ksan/KSAN-SOCAL-App-Dep-East-Oct-11-2021-1900Z.mp3

    the pilot actually appears to say "VFR runway 23", so that his drifting right was perhaps his attempt to start circling to land runway 23, and perhaps his indicating VFR runway 23 meant he was visual for 23 so thought he had this in sight. But if you look at flight aware, he is far away from the field, not even at the FAF (PENYY) when the controller calls him out for "drifting" right, he then says correcting, but then comes on a little later with the "VFR runway 23", so in my view he is thoroughly confused about what he is supposed to do in a circle to land situation and was winging it, did not have a continuous visual on the field, and became spatially disoriented and the rest is history.

    I don't think a medical event. I think it was a pilot who did not understand what he was supposed to do and did not ask for clarifications, did not communicate as he should have if he had the field in sight (so if he had the field in sight he should have so indicated and then asked to go visual for runway 23).

    The MDA for circle to land on ILS 28R approach is 920ft MSL, so that had he just stayed on the final approach course like he should have and descended on that course until hitting the MDA or until the runways and his circling approach were in full view, and then just following the circle to land procedures where this guy clearly was not doing it as he was far to far out of the circle to land zone to be breaking off from final to circle to 23 (as in several miles too far out!) On this approach with the clouds at 2000ft or whatever, with a 920ft MDA, that is a super straightforward final approach and getting well below clouds and WITHIN THE CIRCLE TO LAND ZONE, and then everything is in sight and easy.

    Perhaps he broke off and went to hand fly and then went back into the clouds as he was descending to get below the clouds to pick up runway 23, but he was too far outside the circle-to-land zone and so the controller was all over him to climb as he was far below the minimum vector altitude for the approach.

    This was a fairly simple, straight forward approach to do with those conditions and seems the pilot may not have fully understood what he was supposed to do, not familiar with circle to land procedures, and didn't appropriately clarify and was not clear on the radio, and perhaps caused the very unfortunate outcome. Of course he could have had a medical event or something bad went on with the plane, but my interpretation of his trajectory and radio comms fits the above.

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  58. >I probably have several thousand hours in twin Cessnas......

    Sounds suspiciously like a bit of fiction going on in this comment!

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  59. >I probably have several thousand hours in twin Cessnas. "Probably"
    This seems suspiciously like this commentor is doing a bit of pretending!!

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  60. This seemed to be the best description of accident so far:

    https://m.youtube.com/watch?v=A9DMo2DE9ow

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  61. 310,340,402,414,421,425(PT6) for 36 years. Five years full time in 31,340, 414 and conquest. Part 135 Instructor and check airman on 414 and 421. NOT a pretender. Twin Cessna time is mixed with a wide variety of other aircraft. I have no need or desire to separate the Twin Cessna time. 3800 hours of freight dog time in just four years in other aircraft. Soloed in 1957.

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  62. From the SimCom Cessna 340 manual: Turbocharger compressor-----and to the cabin for pressurization. The source for pressurization is commonly referred to as "bleed air" from the compressor side of the turbocharger.

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    1. Thanks I looked it up and commented again above. Despite being an engineer I had never heard it referred to that before outside context of a jet compressor segment. I'm in a different field of engineering tho. I also just misunderstood an engine diagram I saw and thought it had a belt / linkage to drive the compressor.

      Delete
  63. AOPA just put out an "early analysis" video on the accident: https://www.aopa.org/Training-and-Safety/Online-Learning/Early-Analysis/N7022G
    It's the most complete account I've seen so far. I learned from it that this C340 had been upgraded with new Garmin avionics, including a GFC600. I did a similar upgrade for my F33A a year ago. I spent time on the Garmin simulator while waiting for the install, and thought I knew it pretty well. Wrong! The number of "what the %#%! is it doing now?" moments was surprisingly large. If they had occurred in IMC, they would have been serious. It took me quite a bit of time to be competent enough with the new equipment to safely fly IFR. I wonder if that was a factor here.

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  64. One engine ended up at the third house from the end over the back fence line. Video shows what's left of the engine at 1:01 to 1:04:
    https://youtu.be/WWjzrhAx0wg

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  65. NTSB = The BEST aviation accident analysis in the entire world. Their air safety investigators are 100% dedicated to aviation. Thank you all for everything you do!

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  66. After viewing:

    https://www.youtube.com/watch?v=3FHdC1_Jxc0

    It is clear to me it was SD followed by basic panic and task overload leading to a stall and LOC in imc. No need to look for some incapacitation. If he got himself a first class last year it also means his health was top notch.

    It is the same situation as the highly experienced pilot of Kobe Bryant's heli also got in trouble in IMC and made basic, avoidable mistakes leading to a nose down crash at high speed in terrain. It doesn't matter the experience on paper and whatever was pencil whipped by attending seminars and the like... what matters here is the likelihood of little experience in hard IMC and a busy airspace.

    Likewise here no autopilot was engaged and the pilot was probably confused by a circling approach which he may not have ever done. His conversations gradually showed task overloading and him saying he was climbing while he was actually descending is textbook SD and shows he most likely haven't flown by hand in IMC recently.

    The 300 series has a complex fuel management and those twins are best left to professional 135 operations. Like one of my instructors said the only reason to have a twin is for vanity and to look cool on the ramp but everything else is complex and unnecessary for a single pilot occasionally flying his family on long commutes. Any Piper or Cessna or Cirrus single would have done the job perfectly well.

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  67. 22G announces "...VFR runway 23..." at 11:35 of the audio. He should have said "runway 23 in sight, cancel IFR" which would have made unnecessary subsequent ATC instruction for canceled approach and re-vector. Non standard comms from 22G led to ATC not understanding his intent.

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    1. His actual wordage is more easily deciphered when the mp3 file is played at lower speed. He asks:
      "Socal, is two two golf clear for runway two three?"

      Delete
    2. That makes no sense. Is he saying he has 23 in sight? Or is he asking “clear for the ils circle to land 23”? and he means to correct back to the ils? Why wasn’t he able to navigate the loc and ils?

      Delete
    3. I agree, makes no sense. I listened it to a few times, and the more I do the more I think that he didn't know what the 'circle to land' procedure was.

      Delete
    4. His apparent trouble understanding circle to land did not include unfamiliarity with loading, acquiring and coupling the ILS 28R approach.

      He had done so on 2020-11-20, 2020-11-26, 2021-01-26, 2021-02-03, 2021-03-05, 2021-04-15(no landing), 2021-05-25(no landing) and 2021-09-01(no landing).

      The no landing flights were apparently just glideslope practice with a return to Yuma after kicking off the nav inside the fence at MYF. You can see that the "autopilot,vnav,approach,lnav" nav modes are displayed together as he goes down the glideslope in the Adsbexchange sidebar for all of those dates.

      And there were more dates, with variations of modes in effect
      Modes "vnav,approach,lnav" dates: 2020-12-04, 2021-04-09, 2021-05-08,
      Modes "autopilot,approach" dates: 2021-06-18

      Delete
    5. He might not have understood the circle portion of the approach and that was why he queried ATC about “clear for 23” except he queried ATC over being cleared for the ils which did make it seem as if he understood the procedure. Still don’t know what he meant by asking if he was clear for 23. He read back instructions for ILS intercept. Maybe he altered his nav programming in expectation of circle and knocked off the approach mode but it still doesn’t explain why he didn’t correct back to the ils when he had been the one to query ATC over being cleared for the full ils approach.

      Delete
    6. I wouldn't put too much stock in the autopilot modes reported by adsbexchange. I've looked at what it's reported for my own aircraft and at best it is delayed by half a minute or more and a worst it is completely off showing modes that definitely were not active. Even more mysterious is that my ads-b out transmitter is a standalone tailbeacon that replaces the tail light and is not connected to the autopilot in any way, so how it is determining the autopilot modes is either some sort of black magic or a complete guess.

      Delete
    7. Boy you guys are over-thinking this. I listened to it too. He's merely (rightly or wrongly) asking for a clarification of basically ". . I'm cleared on the ILS did you also just clear me for 23 after I'm done." We can probably debate till the cows come home as to whether that's what he was truly saying (and yes he could've stated it better and yes that's not 100% the proper procedure) but that's all he's doing -- looking for a quick clarification. He knows the airport, he knows the pattern is probably full -- he just asking "am also cleared into the 23 pattern." I suspect he's waiting to hear back from the controller something like "Yes 22G, after you cancel your IFR tower will give you your final visual clearance into the pattern or circle to land for 23." Yes I concede that's not all proper or precise protocol but you hear that kind of exchange all the time. But it was not biggy -- he's just getting a clarification. I don't suspect he gets all that plussed over it as everyone is suggesting.

      Delete
  68. Some have suggested that his communication with ATC seemed off and rushed. So out of curiosity I looked up his last flight from Yuma to same Montgomery-Gibbs airport. The last time he flew this leg almost 4 weeks earlier, there were similar communication challenges and his manner of speaking was essentially the same as on the accident flight date. He was on a IFR flight plan but notified ATC approach that he wanted the visual approach to KMRY 28R instead of the ILS 28R. I assume the field was VMC. My conclusion based on his previous flight on same leg is that his communication with ATC on the accident date was not out of the ordinary. We are expected to repeat ATC instructions verbatim to avoid confusion. Unfortunately however his communication became a contributing factor in the eventual tragedy. Also if he had not skipped shooting the approach back in September it may have helped the day he really needed it.

    N7022G IFR flight from KYML to KMYF: Departed 21 Sept 2021 at 18:19Z
    About 18:40Z…
    Das: Socal N7022G is uh niner thousand. Information Xray.
    Delay due to other ongoing communication…
    ATC: N22G you are trying to check in?
    Das: Ah yeah 22G has the information Xray. We will like to request the visual 28R.
    ATC: 7022G, you can expect that.
    3 mins later…
    ATC: N22G fly heading 270, vectors for your descent. Descend and maintain 6000.
    Das: Seven zero 6000 zero golf
    2 mins later…
    Das: Socal 22G uh descend to 7000?
    Das stepped on other communication…
    Das: Socal 22G confirming 7000
    ATC: 22G you can descend and maintain 6000 now
    Das: (unintelligible) 22G
    2 mins later…
    ATC: N22G Cleared direct to NESTY. You can join the localizer there.
    Das: Uh direct NESTY and I will like to do the visual 22G
    ATC: 22G (looking) you can still do the visual. Uh you know what, you can go direct PENYY. Report the field when you get it.
    Das: Direct PENYY 22G
    1 min later…
    Das: (unintelligible)…direct NESTY
    ATC: Who said they were direct to NESTY, who was that?
    Das: 22G
    ATC: 22G Cleared direct to NESTY. Descend and maintain uh 4200 now.
    Das: 42 hundred 22G
    1 min later…
    ATC: N22G descend and maintain 3800. The field 2 o'clock. 10 miles.
    Das: The field is in sight. 3800. 22G
    ATC: N22G cleared visual approach runway 28R. Contact tower 119.2
    Das: Uh…cleared for the visual. Contacting tower. 22G

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    1. Pilot's October 6 communications with Yuma approach and tower are similar. He did understand the controller and perform a hold at CAZZI required to sequence a Citation ahead of him.

      LiveAtc's scanning of three frequencies clips off and misses some of it, but worth a listen, particularly the interactions with tower and N---6AV while 22G is trying to locate runway 17 in the haze noted from a previous day's fire.

      Sign-in thru holding at CAZZI:
      https://archive.liveatc.net/knyl/KNYL1-App-Dep-Oct-06-2021-1400Z.mp3

      Hold release thru switch to tower:
      https://archive.liveatc.net/knyl/KNYL1-App-Dep-Oct-06-2021-1430Z.mp3

      Announcing 7,6,4 miles, looking for RW17:
      https://archive.liveatc.net/knyl/KNYL1-Del-Gnd-Twr-Oct-06-2021-1430Z.mp3

      Yuma October 6 Track:
      https://globe.adsbexchange.com/?icao=a95ea1&lat=32.874&lon=-114.738&zoom=10.2&showTrace=2021-10-06&leg=1&trackLabels&timestamp=1633530549

      Delete
    2. In the pilot's comm coming into Chandler Municipal on 29 September, he says descending left traffic for two two left, immediately in excited voice corrects the runway to two two right, followed by the tower advising right downwind to two two right.

      It is hard to understand the lack of certainty on pattern directions going into Chandler if you have owned the accident airplane 11 years and operated out of nearby Yuma all of that time. Are we supposed to speculate that he had carbon monoxide or medical issue impairment during that arrival?

      Comms:
      https://archive.liveatc.net/kchd/KCHD-Twr1-Sep-29-2021-2300Z.mp3
      Track:
      https://globe.adsbexchange.com/?icao=a95ea1&lat=33.239&lon=-111.902&zoom=11.5&showTrace=2021-09-29&leg=1&trackLabels&timestamp=1632837652

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    3. When I fly IFR I always write what I hear before repeating ATC's instructions. Based on the communications I've heard so far, it doesn't sound like he utilized this basic cockpit resource management (CRM) tool. Instead he relied on his memory and he often times didn't get it right. It's no wonder the idea of incapacitation seems appealing but in my view not the most likely explanation.

      Single pilot IFR in a multiengine is challenging enough. Not using all available resources sets one up to fall behind the plane which will lead to mistakes from which one may not recover.

      Delete
    4. After listening to that October 6, 2021 exchange at his home airport, where the good Doctor Das couldn't even find the runway, needlessly delays a King Air inbound who tries to help him, then says he is going to make a tailwind straight in because he "has the runway in sight", oblivious to any sort of sequencing of traffic or working with the other planes, makes me realize, unfortunately, that this guy was a world-class poor pilot.

      No offense to kin, but that is not how a good pilot flies, operates, or communicates, and supports the evidence he just didn't even know what a circle to land approach is.

      Likely disorientation giving crash.

      Many pilots once getting their private ticket, know they need more instruction so continue on to the higher ratings with more hours. He needed to concentrate on radio basics, pattern sequencing, communication skills, hand-flying a localizer, techniques to locate an airport if low visibility, and a whole host of other soft skills.

      Take a listen to those recordings posted by the anonymous above. It is not pretty. He steps on others, answers wrong call signs, can't find the airport, interferes with traffic flow, and all around bumbles around in the sky.

      Delete
    5. Listening to the comms on several recent flights will dispense with any belief of incapacitation as a possible cause of the pilot's failure to complete the ILS 28R pickup on the accident day.

      For example, the pilot had a tendency to miss radio changes at handoffs after controllers advised him to contact the next function and gave the frequency for it. The controller would have to tell him he was still on their frequency and read him the new one again. You wouldn't expect that to happen often to an experienced pilot, particularly at home field Yuma.

      Those handoff re-instructions are heard at the tower handoff to ground as he exits the runway at Henderson October 4 (LiveAtc link below) and approach handoff to tower going into Yuma October 6.

      Prior to the Yuma handoff, the pilot mistakenly responds to a controller communication made to another aircraft and the controller has to advise 22G that the transmission was for another aircraft.

      The confusion heard going into Chandler Municipal on 29 September is very telling. Anyone who hasn't listened to that comm exchange and pondered why he was not up to speed on how the traffic flow works there is missing the plot.

      Henderson arrival recording:
      https://archive.liveatc.net/khnd/KHND-Oct-04-2021-2330Z.mp3

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  69. Looking at the above, the commentaries of him "being super experienced" and "enthusiastic" are off... In fact student pilots that are learning are always very enthusiastic but not necessarily proficient. In my opinion he was an amateur. Maybe he got his commercial but we don't know how many times he had failures on the way for his written or private or instrument.
    He certainly wasn't proficient in his communications with ATC and I can probably say he wasn't in hard IMC either, given the rarity of actual IMC between San Diego and Yuma most of the year. Add a very sophisticated twin that is unforgiving to the mix and whatever his ambitions were to pilot something as advanced as this aircraft and it becomes clear he simply got way over his head and lost control. KISS.

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  70. Some of the "ratings collectors" I know that are amateur (have commercial, sometimes ATP) are bad pilots who need a CFI in the right seat most of the time and are ironically bad aviators. It varies, however.

    Despite being super enthusiastic this guy just might have not been that good to become overwhelmed like that. We need to always really ruthlessly self-assess ourselves as GA pilots are not constantly tested like the airlines.

    Tragedy regardless.

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  71. Some facts: 340 registration issued 6/16/2010
    Commercial Cert issued 10/24/2014
    Privat pilot single engine indicated Comm Flight test was in Multi Engine, probably the 340.
    First Class medical issued 8/2020. Reverted to third class end of August 2021
    Date of issue of multi engine not available.

    ReplyDelete
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    1. Multi engine cert shows up in Citydata's listing of Yuma pilots recorded in the March 2016 dated snapshot:
      Commercial - Airplane Multiengine Land
      Commercial - Instrument Airplane Pilot
      Private - Airplane Single Engine Land

      The bottom of the page in Citydata pilot listings always includes a last updated date, useful for looking back in time. The March 1, 2016 dated snapshot of Yuma pilots reveals that the Commercial Multiengine rating was on his ticket at least 5.5 years before the accident.

      http://www.city-data.com/pilots/yuma-city-arizona.html

      Delete
  72. Your opinion of "bad pilots" would likely change dramatically if you got to see some of the 135 operators flying piston twins and even turboprops.
    My last job there were two pilots that I worked with that were not qualified for a private certificate. Twin Turboprops both were single pilot certified. Company check airman. Don't know if the FAA would have been any better. At the top end of the spectrum Gulfstream at Aspen, landing illegally after dark, hit a mountain and killed all on board. All the Capt needed to do was say to the passengers "would you like to reschedule or land at an alternate airport?"

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    1. So very true. Just look at two incredibly experienced Lear pilots that took off from Brown Field at night a few years ago (just south of this airport) in VFR conditions and turned east bound (but decided to stay low) and remain in VFR conditions and flew straight into the side of a San Diego mountain for the absolutely worst reasons known to man. What makes any of these experienced 135 pilots any better operators than anyone else (and this was "times 2" -- so the idiocy is even doubly exacerbating and confounding)

      Delete
  73. There is no logical explanation for the 340 accident except pilot incapacitation.
    The gas heater in the nose of the 340 is a possible source of carbon monoxide.

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    Replies
    1. Boom! I think you nailed it -- this wild-ss stretch that everyone is making to an immediate damnation due to spatial disorientation is confounding. Why is it so hard to fathom the everyday, (how many a minute across our country) incidences of strokes, heart attacks, air poisoning (regardless of source) occurrences? I'm not saying it wasn't spatial disorientation -- but I didn't hear enough in the tapes to convince me we should knock out any of a number of other possibilities.

      Delete
  74. AD 2017-06-03 for Stewart Warner heaters. Because the AD is partially based on heater time it is believed that some airplanes have never been required to comply with AD because heater has not acquired the hours for the first inspection.

    ReplyDelete
    Replies
    1. You mis-remembered the AD. No aircraft initial heater inspection was delayed longer than it's next annual and calendar recurrence applies. See bolded times/intervals:

      The AD period of inspection:
      "Within the next 10 hours TIS of the combustion heater after May 5, 2017 (the effective date of this AD) or the next scheduled 100-hour inspection, annual inspection, or phase inspection that occurs 30 days after May 5, 2017 (the effective date of this AD), whichever occurs first, and repetitively thereafter at intervals not to exceed 250 hours of combustion heater operation or two years, whichever occurs first, do the following inspections and PDT listed in paragraphs (g)(1) through (4) of this AD."

      There is a replacement heater available since 2018 as an approved AMOC that eliminates the recurring inspections. A TSO certified CO alarm/pulse oximeter such as a Guardian AERO 455 may have been installed. The Doc's maintainer will be able to inform the investigators about the heater status and whether he installed a CO alarm.

      The AD:
      https://rgl.faa.gov/Regulatory_and_Guidance_Library/rgad.nsf/0/2430fe9b3cbc805e862580f4005017e7/$FILE/2017-06-03.pdf

      Delete
  75. My vote is for incapacitation. Perhaps health related but possibly a problem with the heater. I departed KNYL not long before the good doctor, It wasn’t particularly cold out but a cold front was blowing through and he may have used the heater traveling westbound. He apparently commuted regularly in the plane, I sincerely doubt that any unimpaired pilot would have any problem keeping the shiny side up on a VFR day. And 1700 and 10, particularly with a broken ceiling, is VFR. I suspect that the doctor was a good pilot, flying an aircraft that he was comfortable with, and KMYF is not a difficult airport.

    ReplyDelete
  76. While ATC did a great job, as usual, sequencing the aircraft at KMYF that day, Dr Das could have requested a straight in for RWY 28 and rejected the circle to RWY 23 instruction from the controller. While pilots must comply with ATC clearances and instructions (FAR 91.123), the pilot (PIC) is still the final authority as to the operation of their aircraft (FAR 91.3). In my experience, as long as you are not going to run into another aircraft or fly into terrain, the controller is usually happy to accommodate your request and let you do what you need and/or want to do during any given phase of flight. I believe Dr Das could have made this request to simplify the approach and it would have been approved. If the request had not been approved, the appropriate action at that point would have been to tell the controller he was on a missed approach and request instructions for a heading and altitude. This would have given the Doctor more time to get the aircraft and approach sorted as necessary.

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    1. Good post. The straight in 28R decision would of course include consideration of the wind. The archive wind readings from 19:00Z when he started descending from 10,000 MSL through the crash at 19:15Z are:

      KMYF 111900Z AUTO 19011KT
      KMYF 111905Z AUTO 19013KT
      KMYF 111910Z AUTO 18011KT
      KMYF 111915Z AUTO 19011KT

      The 28R straight in would experience the steady 11 knot crosswind from 190 but not gusts. Have to get MYF tower concurrence and prevent collision risk crossing 23.

      Archive METAR Source:
      https://mesonet.agron.iastate.edu/cgi-bin/request/asos.py?station=MYF&data=all&year1=2021&month1=10&day1=11&year2=2021&month2=10&day2=12&tz=Etc%2FUTC&format=onlycomma&latlon=no&elev=no&missing=M&trace=T&direct=no&report_type=1&report_type=2

      Delete
  77. Although he had shot the ILS 28R approach at this field several times before as noted in comment above, it's becoming more apparent from what we now know that he had never done the circling approach to runway 23.

    If you look at the ADSB for the flight, just before he was cleared for the approach he had reduced his speed to about 135kts and was maintaining 3,900ft. When he is given the clearance for the approach his descent rate gets as high as 2250 ft/min and his speed gets up to 192kts. That would seem to me to be an unstable approach but not a deal breaker yet. He knows he is coming in fast so he wants to start the base turn for runway 23 early so that he doesn't overshoot 23. As a result his attention is divided between shooting the ILS 28R approach which he had done several times before and landing on runway 23 which all indications are he had never done at this field, at least not as part of a circling maneuver. This explains his clarification of whether he was cleared for 23.

    Catergory B (I assume this light twin falls here) maximum circling speed is 135kts. As he approached FAF his speed should have been reduced. Instead he reached up to 192kts trying to get down to 2400ft MSL to intercept the glide slope on the one hand while anticipating an early left base for runway 23 on the other hand.

    He was told well in advance to expect runway 23 but if he didn't feel comfortable with the maneuver, he never spoke up. As PIC we have been given a one word sentence, "Unable!" This allows us to negotiate a different plan with ATC. Unfortunately too often we hesitate to use it until it's too late.

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  78. I’m glad you brought up the approach categories. I don’t like the aopa presentation because it leaves that out instead focusing on ground track only. I don’t think a student like the good doctor had proven himself to be would just forget the approach categories. I don’t think he had an issue with the circle. I think he had an issue navigating the loc and ils and either failed to recognize that or failed to report it. Maybe SD or CO issue had already set in. Will be interesting to hear the final report.

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  79. The max demonstrated crosswind for Cessna 340 is 23 knots so landing RWY 28R would have presented no problem with winds from 190 @11 knots. The arrival on RWY28R would have been a non-event and two people would still be alive.

    ReplyDelete
  80. Some issues that don't compute: the crash site is defined by a street intersection in Santee. That location is north and slightly east of KSEE. That is a long ways from the KMYF localizer. For reference KSEE is eight plus miles from KMYF. A least two aircraft were reported to have seen the airplane in the dive and clear of clouds. KSEE weather was 2700 broken and ten.
    Regarding runway 23, circling to 23 is not allowed at night.
    I don't believe I have ever landed on 23. Many of my flights to MYF were at night, tower closed, always straight in to 28. Several years ago I saw information stating that there is a very significant bump on 23 at the intersection of 28. I don't know if that has changed.
    Regarding surface wind at MYF I consider that insignificant.

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    1. The plane appears to be under positive control at least till the point where he was directed to turn to heading of 090. If he was in and out of clouds and then found himself in an unusual attitude right as he broke out, he could easily have frozen especially if he thought he was climbing. At this point he is already behind the plane and task saturated. It would only take a few seconds accelerating towards the ground with climb power to impact the ground. It has been documented that there is often a delayed reaction to an emergency in the cockpit, often taking several seconds for the flight crew to digest what is going and and react accordingly, time Dr Das didn't have. If this counts as incapacitation then I could accept that.

      Delete
  81. Regarding mention of canceling IFR, I consider that very bad judgement in Class Bravo airspace. In this case there was no need to cancel, after landing with tower in operation it is handled by the control tower. Tower closed or non tower airport is a different scenario.

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    Replies
    1. Suppose you have the field and runway in sight from 5 miles out - is it not permissible to call runway in sight in lieu of flying the full circle to land procedure ?

      Delete
  82. After looking at some of the previous radio transmissions and the pilots flight history and ratings I think the aopa was very premature to speculate that dr dad was attempting an inappropriate ground track for the circle. I doubt a man this studied would try to circle that far out. I think he made a mistake with his nav programming for ils (as he did not intercept). I think his transmission of “clear for 23” was just a varification that he was still cleared for the ils circle to land as he had been queried over his lack of loc intercept. I think he might have gotten the spacial disorientation after the stress and confusion over messing up the ils. I don’t think there is a way to know what he thought or would have done in a circle procedure as he never got that far. I’m not sure why the aopa focused on that unless they wondered about the “clear for circle” transmission which, like I typed, I think was just a review that he was clear for that approach after being corrected back to localizer.

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  83. sorry dr das and verification rather

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  84. My guess - the views of the final seconds to impact show an airplane clearly not being controlled by a human. He's incapable of maneuvering due to biological incapacitation, controls are locked, or it was intentional. The wx wasn't that bad, the airplane was in VMC conditions in enough time to roll wings level and pull up. Speculation is rampant, as always, in the fluid dynamics of such a mishap. Facebook should stay out of it.

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    1. Mike S-
      Finally someone who gets it. Had this been weather at circling minimums or ILS straight in minimums I could consider the possibility of disorientation.
      However the weather was good VFR. The only logical explanation is incapacitation.
      One additional point, there are posters here who clearly do not understand how the ILS 28, circle to 23 should be flown.

      Delete
    2. Unfortunately, speculating incapacitation on the day of the accident doesn't account for the pilot's confusion about traffic flow at Chandler September 29, the noted airmanship issues in the Yuma arrival October 6 and similar shortcomings in other recent flights.

      The accident pilot's failure to pick up the ILS 28R presents itself in the recorded comms in the same manner as those other examples of airmanship issues revealed by the LiveAtc recordings highlighted in comments upthread.

      There are posters here who clearly have not listened to the recorded comms of the pilot's other flights.

      Delete
    3. No friend - you don't get it! Not at all. There is a huge leap (massive) to go from communications mix-ups and therefore immediately crossing other suspects off the list like CO2 poisoning, stroke heart-attack, massive angina, and countless other catastrophic medical conditions or even control surface failures -- or even runaway a/p trims and trim servos (so many to list here). For more than 2,000' (maybe even 2,500') that plane is in a hard over nose dive that was not near a slow speed (that would've made loss of lateral and vertical axis control unrecoverable -- and yes I've flown the 300 series and 400 series twins as an owner for many hours "live" and in sims). A person with their wits about them still shows elements of "recovery" even at less than 1,000' (WATCH the now famous video of the 421/414 twin, i forget which, that went nose dive into a shopping center parking lot (with 7 people aboard) near John Wayne Airport in Orange County just a couple years ago. He goes nose dive (due to near stall or stall conditions) at just about 1,000' Even with that little altitude and not much airspeed to work with over his control surfaces you can still see in the video that with about 300' feet to go he's pulling out of it (as he's watching the parking lot in front of him) SO MUCH SO that the plane hits the parking lot almost flat on its belly (look at the wreckage. The entire fuselage in nearly completely and entirely intact he hit so flat). FRIEND THAT'S WITH JUST 300' to go. That's impressive! You want to tell me this doctor has nearly 1/2 mile of airspace between him and the ground (that YES he's looking at -- no dispute -- from at least 2,400' of ceiling, if not more) and going diagonally he's probably got more like 3/4 of a mile to 1 mile from base to diagonal trajectory to the ground and he doesn't show the slightest???, not even remote, signs of attempting to recover??? This is so far from spatial disorientation is unbelievable (i'm not saying it couldn't be a possibility of an contributing factor). But something much, much more was at play to not allow him ANY attempt of recovery here -- and again I implore you to watch the Orange County crash where a pilot was in an absolute straight down nose dive in a 400 series (heavier and tougher to start a recovery than the lighter 340) and you see him pulling out with just 300' to go -- impressively I might add, to the point that he "pancakes" it in. You guys are ignoring the obvious.

      Delete
  85. >One additional point, there are posters here who clearly do not understand
    >how the ILS 28, circle to 23 should be flown.

    And unfortunately a deceased pilot who doesn't understand it either.

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  86. News follow-up story reveals that the burn injuries to the couple who were home when the plane hit are more serious than the accident day rescue video had portrayed.

    https://fox5sandiego.com/news/local-news/couple-injured-in-santee-plane-crash-recovering-in-hospital/

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  87. Reading entire thread first time (and since folks declare their backgrounds, mine is former owner FBO, owned 34 plane fleet and 4 helicopters, all ratings (through commercial) since 1986 and currently own 182, Cessna 421 (very similar to the 340 but heavier) and Citation jet. There are a number of very possible reasons that IMHO are being ignored in favor of an immediate jump judgement to the easiest, and least insightful, one of "spatial disorientation" (SD). Knocking off all the other obvious suspects (which I'll point out) in favor of SD is foolhardy and irresponsible.
    1) Powerful Tornado-like Vortices
    a.As 22G is establishing or correcting on the LOC, and in one of the very final ATC transmissions, SoCal calls out to him a cautionary advisory of a massive military C-130 (behemoth!) just to his right and to the north at his 22G's "2-o'clock position" and barely 3-miles out and cautions "wake turbulence" and that 22G is now cleared to 2,800' and note that C-130 is descending to just above him to a restricted altitude of 4,000' (possibly separating them to no less and 1,200' vertically apart). The two wing C-130 vortices each (read: powerful horizontal tornadoes) according to NTSB (read NTSB Special Investigation Report 1994 on wing vortices) for 3+ minutes after an aircraft passes (and the vortices become bigger and more powerful the larger the aircraft). In the 1994 NTSB Special Investigation Report it cites from '83-93' a count of 51 accidents/incidences (that is "known" -- note the number could be much higher) and that in those 27 deaths, 8 serious injured, and 40 aircraft substantially damaged/destroyed. Those of us experienced pilots who have been caught in them know that there is very little you can do but only hold on for dear life (particularly if you're in a lighter aircraft). I was in a 737 once where we were flipped 90 degrees entirely on our side before recovery.
    b. When 22G clearance on the ILS is voided and he's told to turn northbound towards 1,600' Cowles Mountain (minimum vectoring altitude is 1,000' above that at 2,600) . . is 22G therefore going to be turning into and underneath the C-130 that was called out at his 2 O'clock position? It seems a real possibility. He's told to climb first to 4,000' and then to 5,000' (presuming he's clear of the C-130) but are indeed those severely/catastrophic vortices still lingering in his area for 3+ minutes (and the NTSB report would have you understand and be aware of?). Net-net you can't see them -- so if they hit you like an metal iron fist then you're going to be flipped onto your side and thrown down like ( . . . well exactly like you see 22G descending out of the clouds). Also interesting note (that no one brings up) -- in the very last transmission (if you listen carefully) there is a bleed-over aural warning from the ATC control board as ATC is speaking to him about 5,000 feet. I can't make it out entirely but the computer aural warning clearly says 22G. It sound like it says with "Tango Emergency 22G". Or "Traffic Emergency 22G". Perhaps someone here from ATC can listen closer and tell us what it is. I suspect it might be "Tango Emergency" meaning perhaps 22G was getting below the vectoring altitude. But if it was "Traffic Emergency" then it could bring the C-130 (or other traffic) into play in this accident.

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  88. 2) Control Surface Failure
    Could a major control surface failure have occurred? Rudder/aileron/flaps? Take just the flaps for instance. Had he been configured for landing (well guess what -- he was) and his flaps were fully down and after being given a vector (090) and altitude to climb to and after he sucked up his gear and "cleaned his up his plane" (i.e., at some point in "cleaning up" and as he initiated his climb he would've been retracting his flaps. If one flap retraction failed (i.e., asymmetrical flap condition) then the flaps are bigger and more powerful than the two ailerons and an asymmetrical flap deployment does -- well you guessed it -- try to flip your plane over minimally to a sideways nosedive and if you don't figure out what's happening super quick -- all you're going to do is try and fight it while you head to the ground in a position ( . . . well in a position like he's seen coming out of the clouds in -- i.e., on his side and headed for the ground) and unless he quickly surmises what has happened, which isn't always intuitive, you'll have little chance of recovery -- particularly at speed 22G was going.
    3) Runaway Trims
    There is little debate here, and I think we all can concede, he was using his a/p on off throughout the flight from time of departure at Yuma through arrival. Did he disengage his a/p and start using his yoke trim switch (up or down) and/or even keep a/p engaged and use heading bug and alt pre-select or any other a number of combinations and did one of the trim servo motors lock up (i.e., runaway trim situation?). Again unless you've continued to train for this situation (and even if you do train for it) it's a very difficult situation to overcome and again particularly at the speed he was going at (if you're quick and reach over and pull the trim or a/p circuit breaker and have it marked easily to do so you've got a better than fighting chance. I keep a heavy "red" string on all mine - i can pull the string and the breaker at once -- and no the string is not STC'd. Oh well). But net-net if you try and just fight the runaway trim -- you may be doomed into uncontrolled flight.
    4) Medical Incident
    Why everyone wants to dismiss the possibility (merely because he was current on his medical?). Crazy. Those of us pilots have all listened to the now-famous ATC-net tapes of the King Air pilot near Fort Meyers Fla who utters a climb out acknowledgement and you don't so much as hear a sigh. And the very next transmission is a passenger that has run up to the SIC seat and report "My pilot is dead" (yes current medical etc.) and the passenger with almost 100 hours under his belt is vectored to land the King Air at Ft. Meyers. Then there is the Cessna 182RG that took off out of this very field MYF we're discussing just 3 or 4 years ago and flew up to Santa Monica where he clearly became incapacitated and left his auto-pilot on and just flew straight line into one of the Los Angeles Forest mountains. Or the 414 Cessna with the 82 year old woman in Wisconsin that reports her husband just keeled over and she has to fly the plane (and she does --- not pretty but she walks away from it on the runway). And there are countless, countless other stories. CO2 poisoining, stroke, heart-attack, other -- any number of medical conditions could've caused a slow roll to the side (as he passed out) and nosed directly in with no sign of attempting recovery.

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  89. 5) One Engine Failure
    One prominent aviation accident attorney (that flies out of MYF and Philly) has published out a paper on this incident pointing to a possible engine-out situation that he believes the pilot may have had difficulty managing. I'm not sure how he draws that conclusion and I consider this a lower probability suspect but a suspect that nonetheless can't be discarded. Tests on both engines will no doubt be done by NTSB and there are tell-tail signs they'll be looking for. So they'll know soon enough if that's a good suspect.
    6) Spatial Disorientation (SD)
    IMHO - this seems the least likely suspect yet most here seem hyper-fixated on it. The momentary SD can no doubt account for an aircraft's upset condition as seen exiting the clouds. And using some past "communications mix-ups" to justify that conclusion is a huge leap to go all the way to total loss of skills/ability/knowledge to maintain basic straight-level flight? And cross everything else off? For more than 2,000' (maybe even 2,500' or even 3,000') that plane is in a hard over nose dive that was not near a slow speed (that would've made loss of lateral and vertical axis control unrecoverable -- and yes I've flown the 300 series and 400 series twins as an owner for many hours "live" and in sims).

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    1. "One prominent aviation accident attorney (that flies out of MYF and Philly) has published out a paper on this incident pointing to a possible engine-out situation that he believes the pilot may have had difficulty managing. I'm not sure how he draws that conclusion"

      Because he can peg responsibility on a corporation and sue them, that's how he draws that conclusion!

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  90. 5) (cont.) A person with their wits about them still shows elements of "recovery" even at less than 1,000' (WATCH the now famous video of the 414 twin that went nose dive into a shopping center parking lot (with 7 people aboard) near John Wayne Airport in Orange County just a couple years ago. He goes nose dive 180 degress due-straight-down (and due to near stall or stall conditions) at just about 1,000' Even with that very little altitude and not much airspeed to work with over his control surfaces you can still see in the video that with about 300' feet to go he's pulling out of it (in a much, much heavier Cessna twin at full Gross Weight which is much heavier than the 340 and as he's watching the parking lot in front of him) SO MUCH SO that the plane hits the parking lot almost flat on its belly (look at the wreckage!). The entire fuselage is in nearly complete and entirely perfect condition he hit so flipping flat -- and that from a nose dive!! They all died in that 414 from blunt belly impact -- but surprisingly not nose down or cratered-in condition). And that's with just about 300' to go when you see him recovering. Folks that's impressive! And you want to tell me this doctor has nearly 1/2 mile of airspace between him and the ground (that YES he's looking at -- no dispute -- from at least 2,400' of ceiling, if not more) and note: going diagonally he's probably got more like 3/4 of a mile to 1 mile from base to diagonal trajectory to the ground -- AND he doesn't show the slightest???, not even remote???, signs of attempting to recover??? And you want to tell me he's conscious (or "not" fighting one of the other failures above??) This is so far from spatial disorientation is unbelievable (i'm not saying it couldn't be a possibility of an contributing factor). But something much, much more was at play to not allow him ANY attempt of recovery here -- and again I implore you to watch the Orange County crash where a pilot was in an absolute straight down nose dive in a 400 series (heavier and tougher to start a recovery than the lighter 340) and you see him pulling out with just 300' to go -- impressively I might add, to the point that he "pancakes" it in. There is a long way to go here in this accident and I'm confident or at least hopeful that NSTB will not be jumping to some possibly very obvious and erroneous conclusions as AOPA has irresponsibly done (last I'll ever support them) and many others here. Good luck with the investigation.

    X. Why the fixation on spatial disorientation is confounding. Why is it so hard to fathom the everyday, (how many a minute across our country) incidences of strokes, heart attacks, air poisoning (regardless of source) occurrences? I'm not saying it wasn't spatial disorientation -- but I didn't hear enough in the tapes to convince me we should knock out any of a number of other possibilities.

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