355 Envoy 3936 Wrong Runway Landing at O’Hare with Rob Mark & HondaJet Crash in Arizona
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Have you ever misidentified the airport you were planning to land at or misidentified the runway you were supposed to land on? Today we have three stories of experienced pilots making those kinds of mistakes, including one in which an airline crew recently landed on the wrong runway at Chicago O'Hare. And to help walk us through those stories, award-winning journalist Rob Mark will be joining us today.

And during the second half of the show, we'll talk more about my somewhat controversial episode 353 called System Failure, Decision Making, and Choosing the Best Airport to Land. And in that segment, I have an apology to you, the listener, as I felt the tone of that show was not what you've come to expect from me, and I'll explain how that came about.

Hello again and welcome to Aviation News Talk where we talk in general aviation. My name is Max Trescott. I've been flying for 50 years. I'm the author of several books and the 2008 National Flight Instructor of the Year. My mission is to help you become the safest possible pilot. Last week in episode 354, we talked with Eric Peterson about the very first sale of G100UL fuel in the nation. So if you didn't hear that episode, you may want to check it out at aviationnewstalk.com slash 354.

And if you're new to the show, welcome. So happy that you found us here. And now if you would, in whatever app you're using to listen to us, touch either the subscribe key or if you're using the Spotify or Apple podcast app, the follow key so that next week's episode is downloaded for free. And let me remind you that this is a listener supported show and we've got all kinds of ways you can show your love and support for the show. Just go out to our support page at aviationnewstalk.com slash support where you'll find links to support the show via PayPal, Venmo, Zelle and Patreon.

And when you make a donation, I'll read your name on the show. Before we jump into our conversation with Rob Mark, let me mention that I'm back on the road again. At the moment, I'm recording from my hotel room in Tennessee as I'm about to bring back a brand new Cirrus SR22TG7 with a client.

The G7 is the model introduced earlier this year with new avionics that are nearly identical to the Garmin G3000 Perspective Touch Plus avionics used in the Cirrus SF50 Vision Jet. I'm looking forward to my first long trip in this new aircraft model. I also want to mention that I have a large backlog of material that I hope to get out to you soon on some recent accidents.

For example, I recorded this show with Rob Mark over a week ago, but pushed it out so that we could bring you the breaking news of the first sale of G100UL Avgas in the nation. And speaking of new fuels, I'd like to thank the listener who shared this piece of information with me. You may have read in September that Swift Fuels received an STC for their 100R Avgas.

though it's limited to late model Cessna 172s with Lycoming IO360 L2A engines. And the listener pointed out to me that San Carlos Flight Center, located just south of San Francisco, is now running all 12 of its Cessna 172s, which are all late model R and S models, on Swift Fuel's new 100R unleaded gasoline. So congratulations to them and to Swift Fuel's.

And I was saddened to hear about the crash of a Honda jet on Tuesday at Falcon Field in Mesa, Arizona. This was a takeoff accident that killed five people. The jet reached a peak speed of 133 knots before it aborted the takeoff roughly 3,400 feet down the runway. The airplane was unable to stop, overran the end of the runways, and went through the airport perimeter fence before crashing into a vehicle. A post-crash fire ensued.

Four people on board the plane, including the pilot and a 12-year-old boy, died at the scene. A fifth person on the plane survived and was hospitalized with burns. Also, the driver of the vehicle that was hit died. The plane was doing 89 knots as it reached the end of the runway, and it traveled another 700 feet to its final resting spot on the road. It's certainly too early to know what happened, but I can think of several different causes of past jet takeoff accidents, any of which might have been involved in this crash, and most of them are pilot error-related.

One potential cause is failure to remove the gust lock or control locks.

When I was in Scottsdale two weeks ago, Mike Goulian gave a presentation on normalization of deviance, something he talked with us about here on this show back in episode 153. During the presentation, he talked about a Gulfstream that departed his home airport of Bedford, Massachusetts with the control locks in place. That plane went off the end of the runway, killing all on board. He said that during the investigation, it was found that the crew had flown the plane together over 100 times,

and that on only about 2% of the flights did they do a controls free and correct check, which is of course on the checklist. But they apparently fell into a pattern of skipping that step, and they paid with their lives because of it. Now I've never flown a Honda jet, but I did look online at the gust locks. There's one in the cockpit that's composed of a red strap that wraps around the control column and then hooks into the instrument panel.

That looks like it would be very hard for a pilot to miss. However, there's a second external one which appears to slide under the rudder to lock it in place. It doesn't look like there's anything that would lock the elevator, except for the gust lock inside on the control column. There have been some jet crashes that occurred when the flaps were not set properly for takeoff.

The HondaJet POH mentions setting flaps to the takeoff position twice, once in the before taxi checklist and again in the before takeoff checklist. However, it appears that the HondaJet is approved to take off with flaps up, as in the takeoff checklist it says nose up, pitch attitude at rotation, 13 degrees for flaps up, 12 degrees for flaps at takeoff slash approach. So theoretically, even if the flaps weren't set properly, apparently this jet can still take off.

We've also seen jet crashes occur when the parking brake was still set during the takeoff roll. We talked on this show about one such crash of a Cessna Citation that occurred within just the last few years.

But that seems unlikely to be the cause of this crash, as the aircraft reached 133 knots, which is well above rotation speed, so it didn't seem to have any trouble accelerating on the runway. Now, VR, or rotation speed, varies depending upon the weight, the field elevation, temperature, and runway slope and condition. And I went into the HondaJet POH to try to estimate VR for the accident aircraft.

Falcon Fields at 1,394 feet when the temperature at the time of the accident was 21 degrees C. At max gross takeoff weight of 10,600 pounds, VR was about 115 knots indicated. V1 was 110 knots and V2 was 120 knots.

The winds at the time of the accident were calm, so true airspeed and ground speed should be about equal. An indicated airspeed would be about 3% less than true airspeed. So clearly the accident aircraft was above rotation speed, but for some reason the pilot either didn't or couldn't rotate the aircraft.

V1, which I've calculated as 110 knots, is the maximum speed at which a pilot can safely stop a plane on the runway during takeoff if an emergency occurs. It's also the minimum speed at which a pilot can continue a takeoff after an engine failure or other issue. It's also known as decision speed. Essentially, once you're past the speed, you need to commit to flying the plane and not abort the takeoff unless there's some reason the aircraft won't fly.

In this case, the aircraft was well above the 110 knot V1 speed, and yet for some reason the plane either didn't or was unable to rotate. Now the reason you don't want to rotate after you reach V1 is that generally at that speed, it's more dangerous to abort than it is to continue with a takeoff. As we can see in this and other high speed abort accidents, running off the end of the runway at high speed is often fatal for the crew and passengers.

By the way, the V2 speed, which we calculated as 120 knots, is the minimum speed at which a multi-engine aircraft can safely climb if one of its engines fails during takeoff. It's also known as the takeoff safety speed. So this aircraft clearly should have been able to climb, even on one engine, at the speeds that it reached on the runway. Now, an extreme case is engine fire. Even with a fire in one engine above V1, it's generally considered safer to take off than to abort.

That's because in most twin-engine jets, the engines are located and attached in such a manner that they could burn off and depart the aircraft. Though ideally, a pilot would like to have made it around the pattern in time before that happened. Even in the Vision Jet, which is a single-engine jet, the titanium encasement around the engine is supposed to keep the fire from burning through that encasement for 15 minutes, which should be time to get back around the pattern and land.

Apparently, the HondaJet was flown by a single pilot, and another possible cause could be the pilot having some type of medical event. I talked with Rob Mark today, and he added that perhaps something broke during the takeoff roll. So as pilots, we have control over many of the things we just discussed. Things such as gust locks, flap settings, and brake settings should all be caught during a proper preflight. So please be deliberate in your preflights and try not to miss any steps.

And pilot decision-making, such as committing to taking off when you reach V1, is something that twin-engine pilots should cement in their thinking. A good pre-departure briefing will include everything you'll do as you reach various airspeeds on the runway, including committing to fly once you reach V1.

Now, let me tell you a little about Rob Mark. He's an award-winning journalist who writes for a number of aviation publications, and he's the author of the Jetwine blog. Now, here's our conversation with Rob Mark. Rob, welcome to the show. So great to have you back here. Hey, it's nice to be back, Max. You brought up an interesting issue that happened at Chicago O'Hare. Why don't you go ahead and outline the history of Envoy Flight 3936 and what happened when they landed at O'Hare?

This happened in late September, and what really interested me the most was that it's one of those Swiss cheese moments, and for those people that may not remember that, that's where just enough things have to go wrong in order to cause an incident or an accident. And this could have been way worse than it was, and it was really just luck that it didn't turn out badly for anybody. But on September 25th,

About 15:26 Central Time, Envoy Airlines Flight 3936 and Embraer 170 was cleared for the instrument landing system approach to land on Runway 10 Center at Chicago O'Hare. Unfortunately, the crew landed on Runway 10 Left instead. Now, nobody was hurt, which is a good thing,

And of course, the NTSB released a preliminary report last week, which I thought was really, really interesting. And if you look at the history of the flight, you'll begin to piece together some of the reasons that this airplane slipped through the holes of the Swiss cheese. The flight crew reported that before departure, based on the current weather at O'Hare, they assumed they were going to be landing after an ILS on runway 27R, which is landing to the west at O'Hare.

Before the airplane began its descent into the terminal area, they obtained an ATIS which indicated they would now expect runway 9 left, which meant they were landing the other way. Subsequently, ATC changed their arrival to an SB-5 arrival, which was programmed into the flight management computer, and the crew briefed it. Based on that brief, they assumed they would most likely be assigned runway 10 right.

After checking in with the approach controller, they were assigned runway 10 center. Now, I don't know how many runway changes have gone on in your mind there so far, about four, I think. Now, the good news is that the weather was good VFR at the time, and it was daylight.

After checking in with the approach controller, and again, the crew was assigned runway 10 center, the captain briefed the approach with the first officer who was the flying pilot. And they planned that, it looked like a visual to runway 10 center, but they couldn't get the ILS to work for that runway. And most professional crews, even on a visual, like to have that ILS tuned in because it's a backup to make sure you're headed to the right runway.

Now, of course, they couldn't get it to load, and the captain actually tried to manually make the system accept the frequency. Unfortunately, it didn't work. Now, one thing that's interesting, he never mentioned this to the approach controller, that they couldn't make the ILS come up. Anyway, the captain contacted the tower at O'Hare, stating they were on a visual approach to runway 10 center, and the aircraft was cleared to land on 10 center.

However, the aircraft was actually aligned and landed on runway 10 left. Now, if you want to be on top of this, you could go into the system and look at approach plates or the airport diagram for O'Hare. And 10 left and 10 center, oh, I believe they're 1,300 feet apart. So they're pretty close to each other. Be that as it may, it was a really solid VFR day.

Now, the NTSB did a review of the ATC communications, and it revealed that after checking in with approach control, Envoy was told to expect 10 center.

And about six minutes later, Envoy 3936 was instructed to fly a heading of 060 and intercept the 10 center localizer, which of course didn't work in this airplane, but they didn't inform the controller. Now they read back, instead of a 60 heading, they read back a right turn to a 090 heading to intercept, which would have taken them away from the airport and

About 30 seconds later, Envoy 3936 was instructed to maintain 170 knots to Ray and contact the tower. And the instructions were read back by the crew. Now, what's interesting is that Ray is the final approach fix for runway 10 center on the ILS, which is the ILS that this crew could not make work in their flight management computer. So,

They accepted the instruction, but how they were going to identify this fix when the localizer didn't work is beyond me. Anyway, they checked in with O'Hare Tower and told them they were on a visual for 10 Center, and they were cleared to land, except they landed on the left runway.

And the NTSB took one passage out of the 7110.65, which is the air traffic control Bible. It's kind of like the AIM is for the pilots.

And it revealed that the controller noticed the runway alignment error and coordinated with the 10 left controller, which is a different frequency, and allowed Envoy 3936 to continue and land on the incorrect runway because there were no traffic conflicts.

But at no time did the approach controller ever notify Envoy 3936 that they were lined up for the wrong runway. Nor did the crew mention to ATC that they could not tune in the localizer. So this is a comedy of errors here. And it just amazed me that this didn't turn out worse than it did, which was just

simply landing on the runway, turning off and taxiing to the gate. Again, part of that was the weather was good. Part of it was that there was no other traffic lined up for the left runway. But again, why nobody said anything is beyond me. In fact, clarify this for me, Max. Is it a reg or is it in the AIM that it says if you have trouble with a

navigation device you're supposed to speak up to the controller. Yeah, I think that's in the FARs and essentially says that if you're flying IFR, anytime you have an equipment failure, I don't think it's specifically navigation. I think it's any equipment failure, but we'll look that up and add some information about it.

And let me just jump in and say that I looked it up. The reg that Rob was referring to is 91.197, and it says in part, "...the pilot in command of each aircraft operated in control airspace under IFR shall report as soon as practical to ATC any malfunctions of navigational approach or communication equipment occurring in flight."

Yeah, what's fascinating to me is that in some sense, the normal, if you'd say, guardrails didn't exist. And by that, I mean, ATC sort of acts as a guardrail to make sure that the pilots are doing what they should be doing. And yet they let them continue to do what they weren't supposed to be doing. And so the big question in my mind is, why did ATC let them continue to do what was clearly an error and not do what they were supposed to be doing?

It would have been a lot less controversial for everyone if they just corrected them and say, hey, you know, you're lined up at the wrong runway. You need to turn to the right to join 10 Center. Well, it is an interesting question about why didn't each of them do something very simple like speak up?

The controllers didn't tell the pilots they were lined up for the wrong runway and the pilots never told the controllers that they could not make the localizer come in on their airplane. And there is a rule in the air traffic handbook that says when you become aware that an aircraft is aligned with the wrong surface, inform the pilot and issue control instructions and or appropriate clearances.

And wrong surface landings is a big deal these days with the FAA. So, again, what happened here? Nobody knows. Now, I talked to a controller at O'Hare and I asked him about this. And he mentioned that this shouldn't happen anymore.

I thought, OK. And it seems like within days of the time of this incident, which was September the 23rd of this year, the FAA installed a software update to the computers at O'Hare Tower and at the approach control facility.

that would prevent this so that if an aircraft were lined up for the wrong runway, the system would beep at them. And they would do that because if you've ever seen the ADS-B targets on a radar scope, they follow the impression of the aircraft and tell you what altitude they're at, what speed they're doing, and what this new software patch is going to do. In this case, it would have said 1-0-C. So the controller would know, oh, that airplane's headed to 10 center.

And if they were lined up on the wrong runway, the computer would say, hey, this airplane's not supposed to go to the left runway. They're supposed to be on the center. And it will beep at them. So again, that's something that came in just a little bit late for this particular crew. Because again, the tower people said nothing as well. So two sets of controllers that noticed an airplane landing on the wrong runway and said nothing to the pilots.

and the pilots knowing that something was wrong. But again, they said nothing as well. How many people do we have here who should have been talking that weren't saying anything to anybody? Yeah. So that software patch, I guess, would tell them what they already knew in this particular case. So

The only difference would be if the controller spoke up, which they didn't. It is kind of funny how they seem to think that they were going to solve this problem on the back end and did not even inform the pilots of, oh, we've fixed this for you. We're going to let you land on the wrong runway, which seems like an odd solution.

In the history that you're reading there, it said that they were cleared for the ILS 10 center, but then they checked in with the tower saying that they were on the visual for 10 center. So that's an interesting discrepancy. It kind of makes me wonder if they were just trying to cover for the fact that they didn't have the localizer tuned in unless at some point they were initially cleared for the ILS and then later asked for the visual and were given the visual, which certainly could have happened.

Well, that's an interesting point because the approach control normally turns the aircraft on and sends them over to the tower outside the final approach fix. In this case, Ray is about roughly five miles from the end of the runway. So it's not like they were squeezed for time. And again, you think about this and they're lined up and neither one of them said, okay, if we're lined up for the center runway,

Where the heck is the left runway? Now, I don't know how often this crew had been in and out of O'Hare, but O'Hare is a base for Envoy. So you've got to assume that they'd been in there a couple of times. But again, O'Hare has six runways running east and west and two running northeast-southwest.

But the distance between the left runway and, say, the other parallel east-west runway, say, runway 9 right is...

Oh, it's got to be 5,000 feet, I would think. So they can't have easily mistaken the left for something else. So why didn't they catch that? Again, the crew is probably going to get some kind of remedial training from the airline, but my guess is that the controllers will be getting some remedial training as well. Yeah, I would agree. I think there's a little bit of retraining required all the way around there.

You know, I certainly remember one time going in one of my first times into San Jose International, which at that time had three parallel runways and looking at it on final. To me, it appeared that there were five runways and I was totally confused. And it wasn't that I was looking at the taxiways. It was that the black marks from all the tires disappeared.

landing appeared to split each of the runways in half. And so that's why I had difficulty identifying the runway. I think one tip that we can pass along for everyone is anytime you're going into an unfamiliar airport, use a tool like ForeFlight's 3D view to take a look and see what

what does this airport look like from the direction that I'm coming in? I did that for this particular approach to see what it looked like coming into O'Hare. And there's a lot of concrete down there and a lot of parallel taxiways as well. And even though the parallel taxiways are a little bit more narrow, yeah, it's pretty easy, I think, to get confused going into O'Hare. Now, you and I have both flown into O'Hare before.

Go ahead and describe just how busy things can be and how much spare time there might be for this crew to have mentioned all these things to the controllers.

Well, again, at this time of the day, I don't know how busy the controllers were, but for the controller on 10 Center to yell over to the guy that's working the traffic on the left runway and say, hey, do you have room if this guy lands on the left? I mean, they couldn't have been too busy, but it worked out. I mean, normally they're fast.

three or four miles in line behind each other. Typically, they'll use one set of parallels just for departures and another set of parallels just for landings. And then the only thing they've got to do is the ground control gets a little busy getting people to and from the runway. But you wouldn't have two airplanes landing and taking off on the same runway at O'Hare. So thank goodness for that. But

Again, on a busy night, I have been to the west of O'Hare looking toward downtown Chicago. And when they're landing to the west, you'll see two or three or four different lines of aircraft landing with their landing lights on 15, 25 miles out, all three or four miles behind. And it just looks amazing.

Like it's an invasion of aliens because there are so many lights all headed for O'Hare. But I thought the first time when I was flying 135 charter, we used to go in there a fair amount to pick up people. And I thought the landing part was pretty easy to,

because, you know, the controllers made it easy. We knew what we were going to do, but taxiing around was unbelievable. They spit that out so quickly that before we'd even land, we'd say, okay, we know we're going to go to the northeast side. We're probably going to get

This taxiway, that taxiway. So we'd have some idea in the back of our head of where we're going to go. But, of course, you could never go directly because they had to stop you at times to let another airplane go by and then let you go through and maybe stop you at the next intersection. But, no, by the way, turn right at this intersection instead. Hold short of, you know, go, blah, blah, blah, blah.

And after a while you got used to it, but boy, I can tell you those first six, eight times I went into O'Hare at night or when it was raining, I was just, I was burned out by the time I got to the FBO. Yeah, no doubt. Taxing can take what, 20 minutes sometimes there if they're busy. So I got to say, I'm fairly sympathetic to the airline crew, just having been into O'Hare and knowing just how busy crazy it can be. And then if you,

layer on top of that some type of system failure or maybe user error. I mean, we don't know why the ILS wouldn't load properly for them. But the other thing I think is that when things get really busy, I think we as pilots tend to say less and offer up

fewer things that we might offer up when things are not so busy. So for example, if there's just a lot of traffic on the radio, I think pilots kind of realize, oh, if I now put in some lower level piece of information such as, well, I can't get the ILS tuned in, they may just figure, eh, you know, it's so busy, I'm not going to mention that. Not to say that that's the right thing. Clearly, they should have done that. But I think that when frequencies get really busy, I

think as pilots, we edit ourselves a little bit and we just don't say as much. And we'll just kind of let something slide thinking, hey, frequency is too busy to jump in and mention this one thing. Oh, and we're not a visual anyway. I mean, there's the airport right there. I can see the runway. I mean, why bug them about the fact that the localizer doesn't work? And on top of it,

Yikes, maybe it's something we did wrong that I haven't caught right now. And I don't want to be embarrassed by somebody saying, hey, yeah, Envoy, why don't you put in the right frequency? You know, the localizer works for me.

So I think there's some of that as well, but all of these are just little holes in the Swiss cheese that at any other time, something would have blocked this from happening. Luckily, nobody was hurt. Yes, I agree. You take any one of these things, typically it would have been caught in some other way, but in this particular case, the slices of the cheese just all lined up so that the air made it

completely through a set of holes. Now, I think another thing that can get involved in these wrong runway kinds of things is fixation. Pilots will often see something and once they've kind of locked in on it, they no longer see all the other stuff around. They're just kind of focused intently on that one thing. And I think that is part of why

We see airplanes sometimes landing at the wrong airport. You know, the first airport they spot, oh, that must be the one. And then they just don't see that there are other ones around. And I think the same thing with runways. If you kind of spot a particular runway and you think that's it, then it's pretty hard to notice all of the conflicting information that might suggest to you that maybe it really isn't the right runway because you're sure that it is and you're locked in on it.

I just came back from spending three days in Scottsdale, Arizona, where I attended Converge, which is the annual seminar program that Cirrus puts on for vision jet pilots. And we had about 80 vision jets that flew in, which is pretty impressive when you face there were about 500 to 600 of them. So a significant percentage of the fleet flew in, more than 100 vision jet pilots, and

And Cirrus's chief pilot gave a presentation. And I was intrigued to learn that Cirrus actually has 400 pilots on staff, which is pretty amazing. So as a chief pilot, you've got to be responsible for all the policies and the procedures and making sure that pilots understand them and are getting trained properly and following them and so on. And as he was flying to Scottsdale for this particular event, he stopped in Albuquerque along the way to refuel.

And he mentioned that it was nighttime and he saw an airliner that was headed for a particular runway. And somehow it didn't quite seem like that was right to him. And he spotted the runway he was supposed to land on and lined up for it. And the controller said, hey, you're lined up for the wrong runway. And he shared this to everybody at the conference.

And I think it's important for everybody to realize, yes, all of us make mistakes and we want to admit them and try to understand them and make sure that we don't repeat at least that particular mistake in the future.

Something that came to mind as you were mentioning that was what I thought would have been the most embarrassing wrong airport landing that I'd ever heard of. I remember a cargo 747 was inbound to Wichita some years ago and was trying to aim for, I believe it was 19 left.

And the pilots saw what they... Oh, there it is. There's the airport. And they just aimed for it. And it was just like you said, they weren't going to let anything else get in the way. They didn't tune in an ILS to back them up. And what they did is they landed at a GA airport, Jabara Airport, which is up northeast of Wichita. And I think it had a...

just under 5,000 foot runway. But they got it down and they got it stopped. And there's a video somewhere on the internet. They had to completely empty the airplane and defuel it to a certain extent and then turn it, I mean, at some point to get it back out of that short runway because it's

Even though a 747 has good short field performance, it was only 4,000 and some feet long. But my guess is that that crew got some serious retraining. Yes, indeed. And I'm sure that they were a fairly high time crew, which just says it doesn't matter how many hours you have. Any of us in a particular given day or situation can make these mistakes. So we just have to continue to focus on training.

the job it's so easy to kind of think oh this is going well and relax a little bit and then since get ever so slightly complacent and then zoop something will slip right by you so anyway good discussion there i wanted to say something too if i could about your episode 353 where the uh

a person thought you may not have handled the instrument failure the correct way. And I listened to that and I listened to it twice actually, because I thought it was so interesting.

And, I mean, I'm sorry I'm on your side. That was not a, oh, my God, the sky is falling kind of situation to me. And if I remember correctly, it was the engine instruments that failed but nothing else, correct? Yes, that's right. We had a failure of essentially all of the engine sensors and a few other sensors as well. So that was episode 353. The title was System Failure Decision Making and Choosing the Best Airport to Land. And I got to say, I had some –

second thoughts after I released that. And I got a couple of emails fairly soon after it came out and they were kind of split, which was kind of odd in itself. Some of them said, wow, you really told that guy good deal. That's what you should have done. And other people said, well, you know, you sounded a little snarky or you sounded a little, um,

I can't remember the words, but... Snarky covers quite a bit. Yeah, it does. And I agree with those comments. I think that, as I think back, I know that I was...

kind of preoccupied. I was angry about, you know, something for the past few days that was totally unrelated to aviation, the podcast or my health or any of those kinds of things. And I think that kind of came out a little bit in terms of, of my response. Uh, and so when I read that email initially, I just thought, wow, this sounds kind of accusatory and it sounds, uh,

You know, it didn't seem like just a question. It seemed like it was, you know, saying, hey, you really did this wrong, Max. And my wife read it and she said, I think you read a little bit too much into this, Max. I don't think he was, you know, being as harsh as maybe you thought. Anyway, I sent an apology to the listener, which she accepted. And I just kind of said, you know what?

Kind of a bad day. And if I were to redo it, I probably wouldn't have said it just that way. And in fact, within a day or two afterwards, I went back and I made about 10 edits to it to kind of clip out the stuff that was unnecessary that made it a little less friendly than I try to be normally on the podcast.

So I guess as I look back on that, I would say that while I still stand by the answers that I gave, and a lot of people were very supportive about the answers I gave, I think my tone was wrong. I made a mistake there. I should have been kinder and gentler, which is what I try to be. But, you know, what can I say? I've been doing this 350 episodes seven years.

I had a bad day. I apologize to him and I apologize to the listeners because I don't want them to have to hear that kind of harsh tone from me when they come here to listen to the podcast. But we also don't want to lose sight of the fact that your advice was very good in that episode. And that when, in this case, the engine instruments failed, it's the pilot's responsibility to say,

Okay, this failed. How does this affect my flight?

Moving forward, I forgot how far away from the destination you said you were. I think an hour or something. Yeah, it was about an hour and a half to go. Okay. So again, the engine instruments failed. And I know your listener was mentioning that you'd have no idea what was going on with the engine on the Cirrus without those instruments. That's very true to some extent. But the airplane was flying just fine.

It didn't know that the engine instruments had failed, nor, my guess is, did it care. It just knew that all of the cylinders were popping correctly, the power was set correctly, mixture was set correctly, and the airplane was moving along great. There's no need to touch anything. You might not like it that some of the engine instruments have failed, but I think the correct way to handle something like that is to look at the situation and say, okay,

Okay, the engine instruments quit. Now, I've got to be on the lookout here. Something is up. I don't quite know what it is yet, but is something else going to fail coming up? Now, if something else had randomly failed that was involved in the avionics, I just said, no.

you know, I don't like where this is going. And I think I'm just going to peel off here and land at some airport just to be safe. Because again, I don't know what, we might be seeing a cumulative effect of something that we absolutely cannot identify.

that later on somebody might say, well, you saw this happen. You saw that happen. Why didn't you take some action? But again, at the first sign of instrument failure, that's not a big deal. But again, you only learn that with experience.

But also this person, if I remember correctly, was flying a DA40NG. Now, electrical issues in the Diamond are way different than they are in the Cirrus. And that's the advantage of saying, if I'd been in the Diamond, I would be much more concerned about

because of the alternator failure and you did the right thing, you pushed the essentials bus. But if you hadn't done that, that could have led to something much more severe. But that's on that particular airplane, and it doesn't work like that all the time. I used to fly one of the original Citations, the Citation II, and we had stuff break once in a while, and you'd go,

Okay, well, we don't have that. All right, well, you know, we're VFR. I mean, the jet, the turbines are turning fine. We've got plenty of fuel, and there's nothing to be concerned about. But again, that's one of those decisions that you make based on your experience, and it is often different in each and every airplane.

And, you know, when I was thinking about this, when I was trying to get set up for what I was going to mention today, I went back and looked at a story I wrote in 2010. But for those that may not have been aware of it, in June of 2009, an Air France A330 crashed into the Atlantic, the South Atlantic, on a trip from Rio de Janeiro to Paris. And it killed everybody aboard.

The awful part about it was that it brought up some of what we were just talking about in terms of the Cirrus. The airplane was flying fine. It was just, it was absolutely fine. But what they were into, because it was night, they were passing through the area known as the intertropical convergence zone, which is near the equator.

And the one issue with the very light winds at the equator is that when you encounter convective activity around the equator, it's different than the kind of thunderstorms that we see up here in the northern hemisphere.

The storms can grow to heights of more than 60,000 feet, which means those are some pretty severe thunderstorms. And the weather there is something you don't want to fly into. So this crew knew that and they were going to try and go around these thunderstorms. And it just so happened, here's that Swiss cheese again, that the relief pilots,

was in the left seat because the captain had gone off on a break because it's a very long flight and he was in the rest area and they had a relatively new guy in the right seat that was actually the pilot flying. And, um,

As they approached this area of thunderstorms, of course, they didn't fly through it, but they got close enough that they ran into some severe icing issues and the pitot tubes froze up. I mean, they're not supposed to because they're heated, but they did. And as it turned out later, it was an equipment failure and those talus pitot tubes were all removed from airplanes because there was a defect in them. But be that as it may.

Again, the airplane was flying just fine. Flight level 350, straight and level, and then ba-ding. With no pitot, the autopilot and the autothrust system disconnected.

And at the same time, the airspeed indicators went wacky because of this, this PEDO system static failure. There was an imbalance in the system and airspeed indicators suddenly started to indicate a

much higher speed indicated than what the crew was actually experiencing. Nobody had touched the throttles, nobody pitched the airplane down, but the airspeed was showing and they just made a mistake. They just misinterpreted what was going on. They saw the airspeed going up thinking, oh my gosh,

Why would the airspeed be going up? We must be diving. And the pilot in the right seat began to pull. Now, of course, the Airbus does not have a control wheel. It's like the Cirrus. It has a side stick. And so the pilot misinterpreted what they were seeing on the both pilots did actually misinterpreted the airspeed indication, which said the airplane was speeding up, which it really wasn't.

And they're on manual control. They see the airplane starting to look as though it is increasing in speed. However, they miss the cue that, gee, the noise level in the cockpit isn't any louder than it was in cruise flight, which would have been one tip off.

So in reaction to believing the airplane was speeding up, the pilot started to increase back pressure on the stick to try to pull the nose up, except the nose didn't need to go up because the airplane was just fine. And unfortunately, he kept pulling back until the airplane stalled. They got a stall warning. They got the stall, stall, stall. And still, even with that,

The pilot said, no, no, this airplane is diving and I'm going to hold the stick back. And he held the stick back all the way to the water. And the airplane basically fell almost flat into the waters of the South Atlantic. And again, it was a situation where the airplane was just fine. If they had just taken a breath and said, okay, I've got to hand fly this, but why would the airspeed be going up?

And there's no change. We haven't touched the power. We haven't changed the pitch. Something else is going on here. I don't know what it is yet, but it's just fine right now. Just leave it alone. And let's see if we can figure this out.

And as it turned out, just before they hit the water, the airspeeds started to come back because they had a digital flight data recorder on it. And they said the airspeed indicator started to indicate normally at that point. But the airplane was falling at a rate of 10,000 feet per minute down. So even if they had caught it at, say,

Going through flight level 180 on the way down, they're not certain if the crew could have saved the airplane because the only thing you could do was to push the stick forward, reduce the angle of attack to get the wing flying again. And again, we wonder how this team was trained.

Did they have an awful lot of just plain old attitude instrument flying in their logbook where I remember my instructor used to pull all kinds of shenanigans on me to see if I could maintain control of the airplane at times when I

instruments were telling me one thing and my brain was saying something was wrong and could I figure it out before I got myself into trouble. I remember we used to do stalls under the hood just because

You know, if you can do stalls in VFR weather, the fact that you can't see out the window should have nothing to do with it. You still react the same way. You reduce the angle of attack, full power, reduce the angle of attack, and you get the airplane flying again. So it was just so sad to see that this crew missed these cues again.

And they took a whole bunch of people with them. This was 15 years ago. We haven't had a situation like that happen since. Thank goodness. Again, you just got to make sure that when something fails, that you don't just react and start moving things and flipping switches and turning and making all kinds of gyrations. Give the airplane a chance to tell you what is going on first and

before you make any changes. So that was one that came back to me. Yep. And your last point fits in with what I was just going to comment on, which is, I think in the Air Force, they say when you have an emergency, the first thing you do is wind the clock, which means essentially do nothing, take a breath. Don't just immediately, as you said, start doing all kinds of things without at least a plan of how you're going to deal with that. Now, a big difference with Air France was that it was at night, and so it's kind of hard to see

But we were lucky enough that we were in clear VFR conditions. And so for us, it was very obvious that this was just failures of sensors and that everything else was operating completely correctly. Interestingly, when I was at the Scottsdale event with the Vision Jet Pilots,

I talked with someone there who said that this particular show, episode 353, had come up in discussion at Cirrus in some type of meeting. And the key thing that I think came out of their conversation was, yeah, now if you've got something like a fuel injector that's giving you a problem,

Hey, that's a heck of a lot more serious. Go land immediately. That's not the kind of thing where you're going to go, oh yeah, this will get better or this will go away. No, for engine related kinds of things, I would be on the ground instantly because, you know, what I've learned is if you lose the oil pressure, man, that prop is going to stop at about

two or three minutes. You just don't have a lot of time. Or if you have a sudden loss of manifold pressure or of RPM, that's not good. This was clearly not the case. This was just sensors. To me, the analogy, and of course, no analogy is perfect, but

But to me, the analogy is that if I'm driving a car and the speedometer suddenly goes out, well, I can still tell how fast the car is going just because I can see what the flow of traffic is and we all have a sense of what our relative speed is and so on. And that's very much the situation that we were in. It wasn't the airspeed indicator we lost, but it was kind of the equivalent of something that told us about the performance of our engine. That was gone, but nothing else had changed.

Now, the one thing that I don't think I emphasized enough in episode 353 is

I know I mentioned it a little bit, but that is there is nothing wrong with being more conservative than we were in the decision-making that we made on this particular trip. Now, I would say that we're in the lucky position that I have a lot of system knowledge about the Garmin G1000 and the perspective. And so for me, it was pretty easy to identify, oh, okay, this is a failure of a particular unit. Not everybody is going to be in that position. And so it's

The system knowledge is king. You really want to try and master your airplane and learn as much about it as you can. None of us is going to know everything about all of the systems in our airplane. And if you have any doubt, well, yeah, for sure, get it on the ground. On the other hand, if it's crystal clear that this is an isolated failure, not one that's going to cascade into other failures, it's going to be a big deal.

and that it's not something that affects the outcome of the flight, well, then no need to panic. As you mentioned, the Air France people did. They kind of panicked and rushed to a solution which was not needed.

Yeah, and that's true. I've only had one engine failure in my entire career, and it was just luck that we got the airplane down in one piece. I was in the right seat of a P210, a pressurized 210 flying down to southern Georgia with a pilot friend who was really, he was checked out in the airplane, but he wanted another pilot with just because he didn't have that much experience in the airplane.

And so if people haven't seen single-engine Cessnas, all the engine instruments are kind of lined up on the right side of the panel where almost nobody sees what's going on. And I always thought that was kind of weird, but I just happened to be sitting in the right seat, and I noticed the oil pressure just take a little boop, and it dropped down and then went right back up. And I went, whoa, whoa, did I—

Did I mistake that? Maybe that's not really what I saw. And then I saw it do it again. I said, Jerry, turn this airplane around. He said, well, why? I said, just turn it around. And we cranked it back. And then as we were heading back, I think we were down in the Paducah, Kentucky area when this happened. And we were...

I don't know, we were VFR, but I think maybe we were, you know, like 11.5 or something like that. So we were high up. But as we started to turn it around, the airplane just kind of slowed down. And I went, oh, my God, the engine is, the whole thing is shutting down. And luckily we had passed an airport about,

maybe six or seven miles, uh, earlier. And I said, we, we know that I don't remember what the name of the airport was then, but, uh, we headed for that. And once we had the, uh, airport made, we dropped, of course, the power at this point is back at idle because we realized Angel wasn't running anymore. There was no point trying to push it. But, uh, as we got close, I said, okay, we've got the landing. We'll make it. I said, let's put the gear down. And, uh,

Cause you know, at that point, even though I was riding along as just kind of a comfort person, the instructor part takes over. And I said, look, I've got more time in this airplane than he does. And I'm not going to wait to see if he makes a mistake because there's no chance to clean it up. Uh,

But he put the gear down and of course the gear on the P210 is like Cessna's Cardinal. It would fold back into the back of the fuselage and then swing forward as the wheels come down. And as we put the wheels down, I looked out to the right and the gear, they were dripping with oil. I mean, they were just covered in oil.

And so we touched down, landed, got the thing stopped and we stopped on the runway and somebody from the local FBO set a truck out. But as we got out of the airplane, I looked in the whole bottom of the airplane was covered in oil. It was just dripping everywhere. And what it turned out to be is that a turbocharger line had busted at altitude because the airplane had just come out of maintenance.

And, you know, it was a shop that we knew well. It was where it had been worked on forever. You know, did the guy not tighten the nuts properly? Was it the hose itself? We don't know. All we knew is that, man, we got the airplane down in one piece and that was just fine with me. But,

Boy, was there a lot of oil on the runway in the bottom of the airplane. Yeah. And I remember when glass cockpit aircraft first started coming out in general aviation, which I would trace back to 2003 for the Cirrus and 2004 for the G1000 and Cessnas and Diamonds and things like that.

I heard so many comments from people that said, oh, this all-electric airplane, man, I would never want to be flying that because if I had a failure, man, it's going to be much worse than that airplane. And my comment to people at the time and since then has been, yes, but there is so much more redundancy in these newer aircraft aircraft.

that I pray that if I have a failure, I'm in one of these newer aircraft because we have so much additional redundancy. And the other flip side to that is that I have seen far fewer failures in the last 20 years flying mostly glass cockpit aircraft than we used to see in older aircraft. So I think it's a better world that we're moving toward with more capabilities in the aircraft, a lot more redundancy, both in the electrical systems, as well as with the

other equipment. But still, the bottom line is system knowledge is king. You got to learn as much as you can about your systems. And then when something fails, make what you think is the best decision. There's not going to be one right decision for all pilots and all airplanes, even in the same situation. So if in doubt, be conservative, get it on the ground as quickly as possible. That's right. And

The airplane doesn't know that some of these electronic toys have failed. I mean, as we used to call them when glass cockpits first came to be, because I was one of those guys that said, oh my God, this is so complicated. I heard stories of guys at the airlines that could not transition from the steam, the round gauges to glass cockpits, and they retired early.

But again, there's so much more information that they give you that often gives you a chance to say, okay, what is really going on here? Do we have an emergency or do we have a system failure that is annoying but not critical? And that's what we get paid for. Even pilots that have their own airplanes that don't get paid, that's what we get paid for is to make those kinds of decisions.

And a lot of it comes with experience. You have so much experience in the Cirrus that I would never question anything that you told me about how you dealt with something. Now, put me in that diamond star that the other person was flying? I don't know. I don't know.

And hopefully when they checked me out, they just said, if you have an alternator failure, you've got to make sure you hit this essential bus. Because if I didn't know, I would have probably put the airplane on the ground too. But I'd have to later be saying, I don't think I had a really thorough checkout in this airplane. Or I really should have studied the systems in this aircraft in much more detail than I did. Because if

I had, I would have known that this indicates that and that this was not something to panic over, but something, and I shouldn't say panic. We never panic in an airplane. As you said earlier, you mentioned wind the clock. Another instructor, when I was getting checked out in a Baron said, take a breath, count to five, one, two. And I go, well, yeah, we got it. No, no. Count to five.

And I, you know, but it works because you need to get past that initial rush of adrenaline that says, oh my God, something's happening and I'm really afraid. And it's not all like that because if you treat it that way all the time, when there really is a problem, you're going to be so overwhelmed, you won't know what to do. So, yeah.

Count to five. See, people can't even wind a clock anymore, can they? Because it's all electronic. Yeah, it's true. We're winding the metaphorical clock. So I think today what this has really shown is we operate in an incredibly dynamic environment. That's right. We talked about the pilots at O'Hare, certainly a dynamic environment there. We've talked about system failures, and that's also very dynamic. The key thing is for us as pilots just to keep our head in the game and to continue to make the best possible decisions today.

We can when all these things come up. Rob, thanks so much for joining us here today. Hey, listen, thank you so much for having me, Max.

I hope people will stop by at jetwine.com and see some of the stories that I'm writing about. And then when they're done, they can sneak back over here to Aviation News Talk and listen to your podcast. And they'll spend an afternoon and they'll be really, really much smarter than they probably were before they checked in with us. Okay. Thanks so much, Rob. Take care. Bye.

And my thanks to Rob Mark for joining us here today. You can find more of his work at jetwine.com.

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