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UK PA 28 Alps Fatal Inquest

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UK PA 28 Alps Fatal Inquest

Old 6th Dec 2023, 02:08
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UK PA 28 Alps Fatal Inquest

Assistant Coroner David Manknell found that the family were tragically killed due to the lack of training and experience of the pilot.

Jonathan Goldstein, 50, was piloting the plane when it crashed into the northwest flank of the Hubschhorn mountain in Switzerland, the inquest was told.

Tragically, the aircraft was also carrying his wife Hannah, 36, and their daughter Saskia as it flew 2,200 feet below the recommended height through the Alps.

The Inner London South Coroner's Court heard the family took off in a single-engine Piper PA-28 Cherokee Arrow, making stops in Troyes, France, and Lausanne, Switzerland, ahead of flying to Italy.

Mr Goldstein, the pilot, had flown for a total of 365 hours by August 4, 2019, the inquest heard.

He took off from Lausanne at 9.43am and was flying at an altitude of 4,100 feet, travelling at 120 knots.I do find that a lack of training and experience in mountain flying contributed to the accident.At 10:23am, he turned right, towards the Simplon Pass, and two minutes later witnesses saw the plane hit the north face of the Hubschhorn mountain.

The aircraft impacted with the terrain at an almost flat altitude and the plane burst into flames.

Mr Goldstein was flying 2,200 feet below the recommended height through the Alps, but an investigation was unable to determine why.

It was a clear, sunny day, visibility was 70km or more, with a wind of eight knots, the inquest was told.

Assistant Coroner Mr Manknell said: 'He had limited experience in mountain flying and never received any adequate training.
'Overall, I find that the accident in which the pilot lost control at low altitude caused the stall.'

He added that the 'lack of anticipation caused the stall, which caused the crash.'

Mr Manknell said: 'It seems to me that I cannot find that it was grossly negligent and consequently criminal.

'There is no evidence that there is such deviation to what would be expected.

'Having considered it very carefully, it is not open to me to come to a conclusion of unlawful killing.

'I have also considered a short-form conclusion ... which is air accident.

Following the loss of three lives, Mr Manknell said he would write a recommendation to the Civil Aviation Authority that those with PPL (A) pilot licences should take necessary training to fly over mountains.
He added: 'It is my opinion that I do have a concern that future deaths could occur and that actions should be taken to prevent future deaths.'The training that Jonathan had was not appropriate for mountain flying.

'It seems to me that is certainly possible to be replicable. I therefore do make a recommendation, which I make to the CAA and I ask them to consider it.

'The recommendation will make clear that the PPL is less than is required in at least one other country.'


https://www.dailymail.co.uk/news/art...shed-Alps.html

Last edited by Mike Flynn; 6th Dec 2023 at 02:24.
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Old 6th Dec 2023, 09:52
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'Mr Goldstein was flying 2,200 feet below the recommended height through the Alps, but an investigation was unable to determine why.'

I know why: he took the GAFOR reference altitude for the Simplon Pass of 6,800ft as the recommended crossing altitude. 1500ft has to be added to this altitude to give the minimum crossing altitude of 8300ft and this is clearly shown on the Swiss VFR chart...

Source: the pilot's postings on the Euroga forum as 'jgmusic'.

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Old 6th Dec 2023, 13:30
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Is there an official accident report on this tragic event?
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Old 6th Dec 2023, 14:16
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Yes. Here is the Swiss report which is quite detailed.

https://skynews.ch/wp-content/upload...-BVDH_SB_e.pdf

Last edited by Mike Flynn; 6th Dec 2023 at 15:07.
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Old 6th Dec 2023, 16:16
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Thanks Mike. After 24 years layoff from flying I was so lucky to fly an Arrow similar to my own, like riding a bicycle and immensely enjoyed. However, I was mystified by its new electronics such as Garmin, as I am today by my wife's iphone.

Reading this sad report I hear again my dear friend and instructor Desmond, Catalina instructor from WW2 and later Cranwell QFI. "Never mind the erratic ADF Mike, just FLY the damn thing. Never trust a black box, remember that a black box can't see out and has no fear anyway". For box read tablet.
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Old 6th Dec 2023, 16:43
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40 years of flying in France and mountain flying from Chambéry, which taught me alot, plus many alps crossings - most except one- which I really enjoyed.
But 7'000 FT QNH and wishing to cross the Simplon Pass ?, Well there is a "barrier" in front of you of peaks well above 10'000 Ft which you can avoid overflying right above the pass but you would sill need to be at 9'000 FT minimum to have some margin. It has to be a clear day with no wind,
If we consider a rough power loss of 3% per 1000 Ft which is 30% at 10'000 Ft at standard density altitude, it needs further correction in the summer hot days, plus aircraft performance charts are based on leaning, and at that altitude without leaning you would loose another 10%.

Not unusual to be up there with your heavy loaded aircraft - travelling with family and fuel -, fuel enriched engine struggling for air with an indicated airspeed around 90-95 kts in a single full throttle.....
9'500 feet is a bare minimum whether trying to cross the Simplon, or Big or Small St Bernard west of it, better monitor your trajectory right, for this you need some experience, and be able to correct any trajectory on the vertical plane well ahead as there is no margin for immediate extra altitude gain to avoid obstacles.
The technique taught is to cross any ridge at a 45 degree angle right or left giving an escape route to back up either way in case of trouble
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Old 6th Dec 2023, 18:41
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Wise words Markkal - thank you.
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Old 6th Dec 2023, 21:55
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Originally Posted by Marginal Standard
'Mr Goldstein was flying 2,200 feet below the recommended height through the Alps, but an investigation was unable to determine why.'

I know why: he took the GAFOR reference altitude for the Simplon Pass of 6,800ft as the recommended crossing altitude. 1500ft has to be added to this altitude to give the minimum crossing altitude of 8300ft and this is clearly shown on the Swiss VFR chart...

Source: the pilot's postings on the Euroga forum as 'jgmusic'.

I don't think that can be correct.

I attach 3 extracts from the Final Report (which is excellent, I think):



So the pilot had crossed the Simplon before, and therefore knew the required min height.


So the pilot did not plan a flight at 6,800 ft AMSL.

And this is what his entry to the Simplon Pass must have looked like, with 3 miles to run to the impact site:


Yikes, that looks dangerous !! (His flight path is indicated by the large arrow). The weather was clear without clouds.

A very sad incident.

IB
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Old 7th Dec 2023, 01:34
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This is the aircraft moments before the fatal stall.





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Old 7th Dec 2023, 08:37
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Ivor - I suggest you go to the Euroga forum and search for all posts by 'jgmusic' on the subject of 'Flying>GAFOR routes', you will see that he had no understanding of the concept of Reference Altitude.

I believe that having his wife and infant child in the back seat was a serious distraction, you could hear it in his radio calls to Sion, they were published on the Swiss Aviatik-Stammtisch / Vorfaelle / Unfaelle website.

He flew at 6000ft because of the baby and thought he only had to climb a further 1000ft or so to cross the Simplon.

The inquest has recommended to the CAA that UK PPL training includes mountain flying. All that is required is that all read 'DAS Alpenmanual' by Ueli Bodmer...
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Old 7th Dec 2023, 15:47
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Markkal who knows the mountains has said it all, although I don't think rich mixture was a factor as my own Arrow like other Lycomings I remember became lumpy around 4000ft and by FL100 the red knob was near the forward stop for smooth running.

I too am puzzled by p12 of the report, "Both routes in SkyDemon were planned by the pilot at an altitude of 15 900 ft." Again wonky memory, but I think the ceiling of the Arrow was 16,000 ft and it would need a very long time to reach it. What a sad story.
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Old 7th Dec 2023, 16:17
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Originally Posted by Marginal Standard
I

The inquest has recommended to the CAA that UK PPL training includes mountain flying. .
That would not help much as first you do not have high mountains in the UK to train on but more importantly you cannot learn the Alps in a couple of training hours during a cursus. What would help is dedicated " mountain" endorsement obtained locally..
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