TNFlygirl crash analysis

[Squawk7700]

Stumbled across this tonight and thought it was an interesting watch.

Clearly she was struggling with the autopilot and it’s likely that’s what brought her to an untimely end. Seems she was completely missing the basics of power and pitch and was potentially more interested in making YouTube videos with 400 hours total time, than going back to basics.

The significant part is around the 18 minute mark, onwards, however the whole video is interesting,
especially how she was getting little value from her IFR instructor.



https://youtu.be/ViO1j1iYn18?si=Cwtopt4jP3k_eBz-

[Ex FSO GRIFFO]

What with the distraction of the auto pilot, the function of which she did not understand, the continual referencing of the additional i-pad, or whatever it was, fiddling with the GPS......
and the instructor sitting right there, but not instructing.....

And she forgetting the basics of how to fly the aircraft....all with some 400 hours.
The mind boggles.

And then later with her father on board....disaster.
But, it really is all very sad - especially with the standard of her 'training'.....

[JanetFlight]

Besides the fact there are some mistakes and things that could have been improved, IMHO i do not agree some comments on this YT link advocating 400 hours are quite few.
Back in the middle 90's, half of my CPL class here on EU vast lands started doing TGL's circuits on the L-1011 on the right hand seat right after finishing it with some 170 hours TT.
All of us succeeded till this very day, except me due disease needed to remain on the ground since 2012 unfortunately.
May she rest in Peace <3

[NoelEvans]

Poor basic training is so often the problem. ...

In some training organisations there is far, far too much 'rush' to get onto more 'attractive' aspects of training that plodding away at getting the basics right at early stages gets missed. And then later that lack of understanding and ability comes back to bite, like ...
... like this crash?

[menekse]

More worrying is the fact that a lot of youtube and instagram pilots are flying airliners. Avherald is full of pilot induced incidents, accidents are coming

[ZFT]

More worrying is the fact that a lot of youtube and instagram pilots are flying airliners. Avherald is full of pilot induced incidents, accidents are coming
For an industry that has never been as safe, that's a strange statement.

[menekse]

And the sad reality is that the type of people now running famous universities in America that have been in the news lately, will leap to hire someone like her over me for the same reasons that they hired Harvards plagiarizing and bigoted president, all the while accusing people like me of being what they in fact actually are.

How sick society has become.
A walk in European airports and you will see first hand the kind people they hire for this occupation. Wonder if they can reach the overhead panel or if it is safe to wear an oxygen mask with these beards. Adverts from EU airlines are portraying exactly that
Currently I work in ME, moving back to EU in a few months, can't believe that I will actually miss some stuff here

[punkalouver]

On a separate subject,

Here is an interesting quote from the Youtube video comments:

"I was part of the team that developed and certified the Century 2000 Autopilot system and I could not have explained its functions any better myself. Excellent job as usual Juan. Over my many years working for the manufacture of this autopilot, I had many opportunities to train pilots on its use. I won't say I've seen it all but certainly too much.

I have also been involved in accident investigations involving other autopilots models from the same manufacturer. In those cases, the root cause was autopilot miss management as well. I think you are right on track to suspect some sort of mis-trimmed situation that precipitated this accident. And, in my opinion, its not the actual mis-trimmed control forces that can't be overcome as much as the extreme distraction and confusion such a situation causes. I believe pilots misdiagnose the problem as "I can't disengage the autopilot" when in reality the autopilot is disengaged. The remaining high control forces from an out of trim aircraft causing them to put all their efforts into finding a way to disengage the autopilot, which is of course fruitless at best and fatal at worst.

During STC certification flights, trim runaway analysis requires placing the plane in power dives with as much as 60 lbs of back pressure on the controls to maintain redline. Yes, I said back pressure. Surviving those test took lots of planning, preparation and mental fortitude. So its not hard to understand how a moderately to severely miss trimmed situation could go wrong in a hurry for a low time pilot, or most pilots in IMC conditions. The irony of this accident is that this version of the Century 2000 didn't have electric trim, as you so accurately explained. So if miss trimming was a contributing factor, it had to have been mis-trimmed by the pilot, manually"

[ShyTorque]

Besides the fact there are some mistakes and things that could have been improved, IMHO i do not agree some comments on this YT link advocating 400 hours are quite few.
Back in the middle 90's, half of my CPL class here on EU vast lands started doing TGL's circuits on the L-1011 on the right hand seat right after finishing it with some 170 hours TT.
All of us succeeded till this very day, except me due disease needed to remain on the ground since 2012 unfortunately.
May she rest in Peace <3

Well done your safe career. But by definition you would have been flying two crew with (and learning from) a Captain with a lot more experience.

[Maoraigh1]

Were the stated hours total, in command, (logged solo but with another pilot in RHS), or solo?

[Bleve]

When I learnt to fly, there were two basics that were ‘beaten’ into us. Apart from P+P=P, there was ‘Trim or Die!’.

[Equivocal]

Back in the middle 90's, half of my CPL class here on EU vast lands started doing TGL's circuits on the L-1011 on the right hand seat right after finishing it with some 170 hours TT.I'm not a professional pilot but my understanding is that any pilot that may end up in a transport aircraft with 250 or less hours should have been trained for that eventuality, i.e., to be fully familiar with multi-crew operations and system management, and for that training to be continued onto the flightdeck. Whether this is a good idea is open to discussion but it has largely worked to date. It seems to me that this is a very different training regime to that the unfortunate pilot in this accident went through, and with good reason.

[RickNRoll]

Despite the excellent makeup making her look younger she was actually 45. Thats not old but it's not like most pilots who start young when you are more alert and learn more quickly.

I have watched several of her videos now and her situational awareness was never there. She couldn't multitask. She always depended on the passenger helping. Someone blamed this on these being woke times. I very much doubt she was a lefty. More a case of women getting independently wealthy like the rich doctors this plane was killing back in the '60s. She was focused on the gear and not the fundamentals.

[Trossie]

More worrying is the fact that a lot of youtube and instagram pilots are flying airliners. Avherald is full of pilot induced incidents, accidents are coming

For an industry that has never been as safe, that's a strange statement.
An important point to note:... an industry that has never been as safe ...menekse is talking about its future.

Sad. But true.
​​​​​​​

[Asturias56]

how do you see the fact that some people are wearing beards is going to lead to a rise in accidents Trossie?

[menekse]

how do you see the fact that some people are wearing beards is going to lead to a rise in accidents Trossie?
Oxygen masks are designed to seal with the skin. In case of toxic smoke in the cockpit beard hairs won't allow this sealing.
An example of that though it's not aviation are the Iranian soldiers during Iran Iraq war. Masks couldn't protect them from chemical weapons cause beards allowed toxic air enter the mask.
I am pretty sure that a report of a future accident will include it.
I think that I am not the only one who thought that, still no one is bothered to enforce regulations
And of course the oxygen leak cause of hairs in case of cabin pressure loss

[brokenagain]

Oxygen masks are designed to seal with the skin. In case of toxic smoke in the cockpit beard hairs won't allow this sealing.

That’s an old wives tail that’s been disproven.

SFU STUDY BUSTS MYTH ABOUT FACIAL HAIR ON PILOTS (https://www.sfu.ca/science/news/2018-news/sfu-study-busts-myth-about-facial-hair-on-pilots.html)

[what next]

That’s an old wives tail that’s been disproven.
Even Lufthansa, who are known nitpickers with regard to these things, have discarded their "no beards"-policy more than two decades ago.

And regarding the topic: One is not supposed to talk badly about deceased persons, but after watching a couple of her latest videos - partly in fast-forward-mode to be honest - I really wonder what she did in the cockpit during those (alleged) 400 hours of flying. If she had come to me for her instrument training I would have done everything that I can to persuade her to go boating or horse-riding instead of instrument flying. All her instructors who were not brave enough to tell her that share some responsabilty in the sad outcome.

[Genghis the Engineer]

The Royal Navy has had fighter pilots with beards, wearing oxygen masks in fighter cockpits, since WW2 to my certain knowledge. I've never heard of it causing a safety hazard.

Personally I think that some 2000+ years after the razor was invented, a smooth chin remains smart and preferable, and I have no desire to ever grow this sort of face fungus. But, that's a matter of personal aesthetic - I know of no sound safety reason a pilot needs to be cleanshaven.

Knowing all of the onboard systems, and having proper trimming discipline on the other hand - essential.

G

[DAHenriques]

Were I critiquing this accident giving a training session to instructors after watching this film my perspective in back engineering this woman's troubles would be geared more toward the macro than the micro involved with how this unfortunate incident ended.
When these things happen it's always a temptation to get right into the minutia seeking to find something in the details that we can then assign as either part of or directly to as the cause.
Quite frankly, in this film I see a great deal of concentration on the autopilot and its associated functions as a major issue involved with this accident. All this might be true but as instructors we should be looking deeper into what we are witnessing on our monitors.
After a lifetime spent analyzing aircraft safety and accident detail what I saw watching this film disturbed me as almost immediately I became aware that there was more to learn from this accident than the mistakes being made with the autopilot.
First of all, I am not now nor have I ever been a huge fan of allowing ANY third party activity in the cockpit while a dual session is active. This includes additional passengers in the plane and most certainly allowing the student to be filming the session with intent to publish the film on the internet.
With these factors in play there is no way to totally eliminate them as distractions. I won't delve deeply into the psychology involved here as it's quite complex and frankly beyond the intended scope of this post.
What I will say is that ANY activity not directly involved with the interface between instructor, student, and the aircraft contains huge potential to split the concentration of the student between several sources and this is NOT conducive to quality flight instruction.
In this film we see an instructor with a student who is having trouble understanding the functions of the autopilot. It is right here we see the need to examine the micos further.
Lesson plans need to be flexible and instructors need to be flexible. The instant while in flight the instructor notices that a student lacks working knowledge of a system that is a critical factor in the dual being given the instructor MUST depart from the lesson plan and solve that issue by a switch into remedial education to solve that missing factor in the equation.
If something of value can be taken from this unfortunate incident it has involve instructors taking a serious look at the instructor's role in this and what could have been done differently in how this student was handled from the very beginning.
Dudley Henriques

[visibility3miles]

What bothers me is the video says that there was clear weather. I’m just a private pilot, but I’m used to going along at a steady altitude (unless there are severe updrafts and downdrafts) and only adjust the trim manually by small amounts when I expect to have to change altitude.

Then again, I’ve never focused on social media when I fly. That may have taken higher priority in this case than, “Aviate, navigate, communicate.”

Punkalouver said that the mis-trim must have been done manually, but I can’t imagine why you would intentionally would “mistrim” the plane to such a degree that you’d send it into a fatal nosedive.

Perhaps they were confused by the autopilot, and were adjusting the trim the wrong way to try to compensate for the increased variation in altitude and, consequently, airspeed.

I admit, I’ve never had to adjust the trim in an emergency, and never changed it by more than slight increments. I’ve never flown with an autopilot.

I did know a private pilot that had the cable to the trim tab break, causing them to go into a steep dive, but they managed to muscle the plane into a safe landing at the nearest airport after declaring an emergency.

[RatherBeFlying]

A personable attractive lady with money – what male would not be bending backwards to help her get what she wants?

[visibility3miles]

Shouldn’t there be some sort of online training available for how to use autopilots so you can refine your skills and make your mistakes on the ground?

[EXDAC]

I own and operate an aircraft with dual axis autopilot but no automatic pitch trim. Like the Century 2000 in the accident aircraft my system provides trim prompts to the pilot. In many, perhaps most, cases the proper response to a trim prompt is NOT to change trim but to adjust power!

[AerocatS2A]

Besides the fact there are some mistakes and things that could have been improved, IMHO i do not agree some comments on this YT link advocating 400 hours are quite few.
Back in the middle 90's, half of my CPL class here on EU vast lands started doing TGL's circuits on the L-1011 on the right hand seat right after finishing it with some 170 hours TT.
All of us succeeded till this very day, except me due disease needed to remain on the ground since 2012 unfortunately.
May she rest in Peace <3
Agreed. 400 hours is plenty, provided they are quality hours. If you have a good grasp of basic flying principles then learning an autopilot is really just about understanding how the machine will try to do what you would be doing if hand flying and what its limitations are. If you have a solid foundation then you will be mentally flying the plane while manipulating the autopilot. On the other hand if you don’t have the basics down then turning the autopilot on becomes akin to handing control over to someone else and letting yourself become a passenger who doesn’t understand what’s going on and doesn’t know when or how to intervene.

[DAHenriques]

Agreed. 400 hours is plenty, provided they are quality hours. If you have a good grasp of basic flying principles then learning an autopilot is really just about understanding how the machine will try to do what you would be doing if hand flying and what its limitations are. If you have a solid foundation then you will be mentally flying the plane while manipulating the autopilot. On the other hand if you don’t have the basics down then turning the autopilot on becomes akin to handing control over to someone else and letting yourself become a passenger who doesn’t understand what’s going on and doesn’t know when or how to intervene.

This is an excellent analogy.
Dudley Henriques

[EXDAC]

Anyone here actually fly with the Century 2000? My read of the Pilot's Operating Manual makes me believe that the pitch reference is continuously changed as long as the UP or DN button is pressed. That idea was dismissed in the linked accident video.

The manual discussion of the UP DN buttons, and pitch modes in general, is very sparse but does include:

"*PITCH MODIFIER SWITCHES - The pitch modifier switches are momentary push-button type, located on the right side of the Mode Programmer, used to modify the airplane’s attitude and to shift the AP from the ALT mode to the ATT mode."

I read that as - brief push changes from ALT to ATT mode with current pitch attitude being held. If the UP or DN button is held then the ATT reference continuously changes in the direction corresponding to the held button.

Was Juan Browne right that holding UP/DN does nothing because the buttons are "momentary action" or do they continuusly change the ATT mode pitch reference?

[Teddy Robinson]

This is an excellent analogy.
Dudley Henriques

I go with that.
Another accident that should really never have happened.
Social media seems to be a very two edged sword, on the one hand raising awareness, and teaching how to avoid accidents in the first place, on the other we have people perhaps with other motivations.

[MechEngr]

Momentary switches typically remain closed as long as the user pushes them. This is distinguished from latching switches that stay in place, such as push-on/push-off or lever switches.

What effect a momentary switch has when held closed depends on the way it is used - if it directly controls current to a motor or light the motor or light will continue to operate. If it is something like on a keyboard or mouse, then it is up to software to determine what is going to happen. At the least the controller that attached to the switch will typically make repeated readings to see if the switch is still closed and the software running on the controller can tell by timers how long it has been closed to decide if it should auto-repeat or just register as a single push and wait. This reading rate can be a hundred thousand times a second, which would make typing a real challenge if there was no built-in delay.

A similar situation is seen in cruise/speed controls on cars. One short push (and getting read a few thousand times) typically gives a + or - of 1 mph. Hold it for more than that and the controller starts adjusting the speed until the user releases the button. I would expect the trim to be operated in this mode.

[Trossie]

how do you see the fact that some people are wearing beards is going to lead to a rise in accidents Trossie?What a totally nonsense question! Where have I said anything about 'beards'??

While I am about it, let me correct your grammar for you:
How do you see the fact that some people are wearing beards is going to lead to a rise in accidents, Trossie?
Back to the topic, as has already been stated on here, those wanting 'instant fixes' and to 'show everyone' during their training without really working towards an understanding of what they are trying to learn, are those who are "going to lead to a rise in accidents".

[Prob30Tempo TSRA]

Anybody who spends more time wandering about the camera angle , than the aircraft state or airmanship is a risk to me .

Sadly with the interweb intermingled with access to fantastic narcissistic outlets like YouTube the younger generation take their eye off the ball .

Its not just wannabes either - how many videos do we need of people ( not normally the instruments or runway view ) manipulating or fighting in a lot of cases their A737 bus towards the ground

[DaveJ75]

Anybody who spends more time wandering about the camera angle , than the aircraft state or airmanship is a risk to me .

Totally agree - extremely frustrating to see. Far too much time pi$$ing about with A/P and tablets. Fly the damn aircraft!

[DogTailRed2]

Does anyone use Microsoft Flight Simulator to familiarise themselves with a particular aircraft and avionics?
Some of the more expensive aircraft in the sim are very accurate.

[Luray]

A walk in European airports and you will see first hand the kind people they hire for this occupation. Wonder if they can reach the overhead panel or if it is safe to wear an oxygen mask with these beards. Adverts from EU airlines are portraying exactly that
Currently I work in ME, moving back to EU in a few months, can't believe that I will actually miss some stuff here
Menekse,

When I joined ab in 2019 they still had no facial hair policy but it was changed 1 month later making it legal. In a week a lot of young pilots looked like they are homeless. I don't know why people grow pubic hair on their faces. It makes em look dirty and unprofessional. Once I saw a lady captain from **** EU airline and she was covered in tattoos, hands , neck and even something on the forehead.
I always iron my uniform and shave before going on duty. There is no better feeling than a splash of bay rum or aquavelva on a freshly shaved skin.

Apologies for the off topic. Feel very sad for the pilot and her father. Try not to forget that flying machines will kill you unless you die of natural causes.

[Luray]

Does anyone use Microsoft Flight Simulator to familiarise themselves with a particular aircraft and avionics?
Some of the more expensive aircraft in the sim are very accurate.

Msfs can help with initial IFR training if you know what you are doing. It can also be beneficial for some panel familiarization on light AC. But if you talk about expensive complex aircraft it won't be much of a help. Its all about 2d vs 3d depth illusion. I used to play a lot of 737 cl on msfs and when i finally got to seat on real 737cl sim I was lost. Overhead panel looked like a forest of toggles. And I already had thousand hours on complex aircraft that had more buttons than 737)

[Genghis the Engineer]

As my professional life has me flying a lot of types, I do sometimes use MSFS to familiarise myself with cockpits, switchology, etc. It is also probably the least worst of all the main commercial sims for performance and handling qualities but to be honest I don't usually trouble myself with that aspect. But yes, for learning your way around the controls, it can be quite useful especially if, like me, you might be flying a dozen types a year.

That said, the types where I don't have the benefits of a grown-up to check me out, usually there's no readily available sim model either. For those I usually spend hours to days on the ground teaching myself into it.

G

[menekse]

Menekse,

When I joined ab in 2019 they still had no facial hair policy but it was changed 1 month later making it legal. In a week a lot of young pilots looked like they are homeless. I don't know why people grow pubic hair on their faces. It makes em look dirty and unprofessional. Once I saw a lady captain from **** EU airline and she was covered in tattoos, hands , neck and even something on the forehead.
I always iron my uniform and shave before going on duty. There is no better feeling than a splash of bay rum or aquavelva on a freshly shaved skin.

Apologies for the off topic. Feel very sad for the pilot and her father. Try not to forget that flying machines will kill you unless you die of natural causes.
Uniform and not freshly shaved skin don't come along together unless you are a submarine crew where you save the water supplies.
I fly a gulfstream and never saw any pilot with beard in this area of aviation, where the passengers - clients want the best and pay for it. I carry 2-3 shirts with me and sometimes I wash them in the hotel room sink when I spend much time away from base.
Some posters referred to a 2016 university study in Canada to prove the safety of beard and oxygen mask application. Why to bother, maybe it's safe to fly with flip flops, a university study maybe it proves it safe, why to wear shoes during a 10 hours cruise?

[bingofuel]

I carry 2-3 shirts with me and sometimes I wash them in the hotel room sink when I spend much time away from base.


Surely on Gulfstream daily rates you could pay the hotel laundry fee?

[Discorde]

Anyone here actually fly with the Century 2000? My read of the Pilot's Operating Manual makes me believe that the pitch reference is continuously changed as long as the UP or DN button is pressed. That idea was dismissed in the linked accident video.

The manual discussion of the UP DN buttons, and pitch modes in general, is very sparse but does include:

"*PITCH MODIFIER SWITCHES - The pitch modifier switches are momentary push-button type, located on the right side of the Mode Programmer, used to modify the airplane’s attitude and to shift the AP from the ALT mode to the ATT mode."

I read that as - brief push changes from ALT to ATT mode with current pitch attitude being held. If the UP or DN button is held then the ATT reference continuously changes in the direction corresponding to the held button.

Was Juan Browne right that holding UP/DN does nothing because the buttons are "momentary action" or do they continuusly change the ATT mode pitch reference?

The Century 2000 pitch adjuster perhaps operates in a similar manner as that on the Vickers Vanguard (a British 4-turboprop 1960s airliner). The control was a rocker switch spring-loaded to OFF (vertical position). A gentle push-and-hold movement lowered pitch attitude at a slow continuous rate. Releasing the switch locked the current attitude. A stronger push lowered pitch at a greater rate. Opposite movement for pitch up. If the autopilot ALT HOLD was selected it auto trimmed pitch attitude and the rocker 'gentle' mode was inop. A stronger push or pull disengaged ALT HOLD and changed pitch as described above.

[menekse]

I carry 2-3 shirts with me and sometimes I wash them in the hotel room sink when I spend much time away from base.


Surely on Gulfstream daily rates you could pay the hotel laundry fee?
I find it easier than organizing with the hotel and I know exactly what time will be ready, that's important when you receive a phone call to be ready for a pick up in an hour

[RickNRoll]

She's still getting new subscribers.

[netstruggler]

She's still getting new subscribers.

I'm not surprised at that.

I am surprised that the family haven't taken the site down.

[Ivor_Bigunn]

Quote:

"Was Juan Browne right that holding UP/DN does nothing because the buttons are "momentary action" or do they continuusly change the ATT mode pitch reference?"

Near the start of the video Juan B explains that in this particular aircraft the autopilot is NOT connected to the Trim Wheell at all. There is no electric trim, only manual.

On the control yoke there are no trim buttons, only an Autopilot disconnect switch.

So the Autopilot only lights a light when it wants a Trim change, but the Pilot must implement the change manually with the Trim Wheel. Sadly, the pilot does not seem to have grasped this.

IB

[EXDAC]

Quote:

"Was Juan Browne right that holding UP/DN does nothing because the buttons are "momentary action" or do they continuusly change the ATT mode pitch reference?"

Near the start of the video Juan B explains that in this particular aircraft the autopilot is NOT connected to the Trim Wheell at all. There is no electric trim, only manual.

On the control yoke there are no trim buttons, only an Autopilot disconnect switch.

So the Autopilot only lights a light when it wants a Trim change, but the Pilot must implement the change manually with the Trim Wheel. Sadly, the pilot does not seem to have grasped this.

IB

Your answer does not comment on the function of the UP/DN switches. Why did you quote my question?

Do you have anything to add to the explanation provided in Pilot's Operating Manual - https://wfc-hpn.org/wp-content/uploads/2021/04/Century_2000AutoPilotPOH.pdf

[421dog]

I fly a baron currently, which is equipped with a century 41 (nearly the same, but with electric pitch)
the video was incorrect with regard to how one moves between “ALT” and “ATT”.
One must actually push the appropriate button to change modes. If the “UP” or “Down” button is pushed while in the “ALT” mode, the plane will make a furtive effort to go in the desired direction, but will remain in the “ALT” mode.
Furthermore, while the up and down buttons are technically momentary, the rate of climb or descent is not discretely selectable. One simply pushes the switch, and counts. Supposedly, after 2 or 3 seconds (during which not much happens) the rate of climb or descent is roughly around 100ft/min for each additional minute. (But it’s not really, it actually just sort of does whatever it wants to do, and requires constant adjustment as altitude/airspeed changes. One cannot use the autopilot without employing either the “ATT” or “ALT” mode.
In my particular iteration, I can put the Autopilot in “HDG” Mode, and engage the GNSS add-on function which will provide GPS tracking and roll steer, but no VNAV. Trying to fly a glide slope on an RPV with the “UP/Down” buttons is essentially impossible due to the inaccuracy and lag inherent in the system.
Cessna, Bendix, Stec and Garmin had a much better idea….

[rugmuncher]

I'm not surprised at that.

I am surprised that the family haven't taken the site down.

Ad revenue and keeping the site as a memory so people can learn from her experiences may be deciding factors.

[EXDAC]

I fly a baron currently, which is equipped with a century 41 (nearly the same, but with electric pitch)
the video was incorrect with regard to how one moves between “ALT” and “ATT”.


"*PITCH MODIFIER SWITCHES - The pitch modifier switches are momentary push-button type, located on the right side of the Mode Programmer, used to modify the airplane’s attitude and to shift the AP from the ALT mode to the ATT mode."

Either the Century 41 behaves differently from the Century 2000 or one of the descriptions is wrong. At least you have confirmed that continuous press of UP/DN changes the pitch reference for the Century 41 so thanks for that.

I would expected that disconnecting for the transition to climb or descent and then re-engaging in ATT mode when in trim would give far better results that trying to establish a climb or descent by changing ATT reference.

As for rate of response - The Century 2000 manual says:

"*PITCH AXIS:
Command Attitude - 0.7° per second attitude change.
Gust Recovery - Maximum rate consistent with passenger comfort.
Maximum System Capability - 2.4° per second ."

I assume that this means holding UP or DN will change the ATT reference at 0.7 degrees/second. What this does to vertical speed will depend on power and pitch trim. Unlike the Garmin system I fly the Century 2000 has no closed loop VS mode.

[DAHenriques]

I'm curious.
Has anyone suggested that unless the AP disconnect switch was inoperative and there was a question as to how ANYTHING worked on the AP, that there was always the option to go manual, deal with the problem and/or remain manually flying the airplane?
Also, has anyone wondered why the instructor didn't change the lesson plan (on the fly) to deal with the remedial education required concerning the student and the AP?
I admit I haven't been deeply engrossed in this incident and this specific thread but these factors seem extremely pertinent to me.
Have I missed something?
Dudley Henriques

[EXDAC]

Either the Century 41 behaves differently from the Century 2000 or one of the descriptions is wrong.

I found a Century 41 manual here - https://www.mooney.com/wp-content/uploads/2020/12/Edo-Aire-Mitchell-Century-41-Autopilot.pdf

The pitch modifier function of the Century 41 appears to be significantly different from the Century 2000.

[EXDAC]

I'm curious.
Has anyone suggested that unless the AP disconnect switch was inoperative and there was a question as to how ANYTHING worked on the AP, that there was always the option to go manual, deal with the problem and/or remain manually flying the airplane?

Speaking as a pilot and CFII - Yes, that was the obvious action that should have been taken. It's hard for me to imagine how a pilot would allow a flight control system to kill them in day VMC.

Speaking as a retired avionics systems engineer with some experience of automatic flight controls development and certification - I simply wanted to know how this autopilot system was intended to work and whether the comments made by Juan Browne were valid.

[DAHenriques]

Speaking as a pilot and CFII - Yes, that was the obvious action that should have been taken. It's hard for me to imagine how a pilot would allow a flight control system to kill them in day VMC.

Speaking as a retired avionics systems engineer with some experience of automatic flight controls development and certification - I simply wanted to know how this autopilot system was intended to work and whether the comments made by Juan Browne were valid.

No need to stress the experience angle. I'm not faulting your post or your comment. LOL.
My questions were more general in nature. Simply curious.
Dudley Henriques

[Ivor_Bigunn]

From Exdac:

"Your answer does not comment on the function of the UP/DN switches. Why did you quote my question?"

Ok, sorry, I misunderstood/misread your comment.

I simply wanted to clarify that the plane in question did not have electric autotrim, and therefore the Up/DN buttons only try to change the plane's attitude, they do not necessarily cause climb/descent. Perhaps the buttons should be labelled "Nose Up" and "Nose Down" for greater clarity? Although I would think that any competent PPL pilot would understand this anyway.

Additionally, there are 2 annunciator lights on the Autopilot panel that read "Trim Up" and "Trim down", but these are not indicators of what the control surfaces are doing, instead they are instructions to the pilot to implement the trimming manually. They light up when the autopilot calculates that a trim adjustment is necessary, and go off when the pilot has responded, and successfuly altered the pitch attitude.

As Juan says, tragically the pilot does not seem to have grasped any of this.

Anyway, sorry again for my misunderstanding, I hope we are "cool" !

IB

[BFSGrad]

During these altitude fluctuations, the controller twice provided instructions to the pilot to contact the Memphis Air Route Traffic Control Center; however, neither of the instructions were acknowledged by the pilot. During the final moments of the flight, a faint communication from the pilot stating the airplane’s registration and “Debonaire” followed by an emergency declaration and an unintelligible word. About 60 seconds later, a faint and largely unintelligible transmission from the passenger was transmitted.

Aviation Investigation Preliminary Report - N5891J (https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193491/pdf)

[RickNRoll]

So the chips containing the video have been recovered.

[RetiredF4]

This ancient autopilot system and its limitations is easy to understand, if you know what it physically does: It manipulates the yoke with motorized inputs to it like the pilots arm would do, which in turn affects the primary flight control surfaces. It basically is a substitute for the pilots hand on the yoke. It has no control over power and trim, does not control speed, altitude, or vertical speed. It only controls the attitude of the aircraft as long as it is able to do so.

Imagine you are flying without trimming, you turn, climb, accelerate and decelerate, climb and descent without trimming, without adjusting power. Imagine the forces on the yoke and the influence to the aircraft performance in relation to speed and power. That describes the limited capability of that ancient autopilot only in part, because while a pilot should take note of all the outcome, this autopilot will only recognize the force it needs to control the pitch and request a change by the trim lights "up" and "down".

Looking at the videos it is imho obvious that this pilot lacked the necessary system knowledge and at the final stage general airmanship.

[Ivor_Bigunn]

RetiredF4:

Perfect Post.

That is what I have been trying to say in 2 posts, but not nearly as clearly as your one!

It is incredible to me that anyone would fly a plane for many, many flights, but not have any basic understanding of pitch/power, apparently. Surely it easy to grasp that climbing in a plane is like going up a hill in a car, and therefore more power is required, so you press the accelerator?

And I got the impression from her videos that she thought that when the "Trim Up/DN" lights were illuminated, the autopilot was trimming the plane for her, which of course it could not, because the plane lacked electric trim.

IB

[EXDAC]

This ancient autopilot system and its limitations is easy to understand, if you know what it physically does: It manipulates the yoke with motorized inputs to it like the pilots arm would do, which in turn affects the primary flight control surfaces. It basically is a substitute for the pilots hand on the yoke. It has no control over power and trim, does not control speed, altitude, or vertical speed. It only controls the attitude of the aircraft as long as it is able to do so.

The Century 2000 Autopilot system does have an Altitude Hold mode (ALT).

[RetiredF4]

The Century 2000 Autopilot system does have an Altitude Hold mode (ALT).

You probably misread the last sentence of the citation, where I wrote attitude, and you read altitude.

[what next]

The Century 2000 Autopilot system does have an Altitude Hold mode (ALT).

And a proper approach mode including glideslope. It is not the dumb kind of "wing leveler" device found in some light aircraft. And the UP and DOWN buttons acting on the attitude and not on the vertical speed is not unique to this autopilot either. The only unusual feature are the trim lights that prompt the pilot to trim manually. In similar autopilots the trim lights illuminate when the autopilot acts on the trim. As was written above, the accident pilot seems not to have been aware of that. Flying on autopilot for some time, possibly with power and altitude changes, may leave the aircraft in an out-of-trim condition outside the force that the autopilot servos can handle. When the autopilot subsequently disengages, a rapid change in pitch will follow as a consequence. Everyone who has flown old(ish) light aircraft for some time will sooner or later encounter this situation. Lightplane autopilot control forces are in the order of 15 to 25 force pounds, like lifting a bucket of water. Apart from the startle effect and possible disorientation in instrument meteorological conditions they are easily controllable manually. Especially in this flight with two pilots on board.
Let's hope the data cards of the video cameras are not damaged by the fire as they will certainly reveal what exactly led to this accident.

[EXDAC]

You probably misread the last sentence of the citation, where I wrote attitude, and you read altitude.

Quote - "does not control speed, altitude, or vertical speed. It only controls the attitude"

You said it does not control altitude. It does.

[EXDAC]

Let's hope the data cards of the video cameras are not damaged by the fire as they will certainly reveal what exactly led to this accident.

That is my hope too. I suspect there is more to this accident than autopilot mismanagement.

[netstruggler]

Quote - "does not control speed, altitude, or vertical speed. It only controls the attitude"

You said it does not control altitude. It does.

Isn't the truth that it monitors the altitude and controls the attitude accordingly?

[BEACH KING]

This ancient autopilot system and its limitations is easy to understand, if you know what it physically does: It manipulates the yoke with motorized inputs to it like the pilots arm would do, which in turn affects the primary flight control surfaces. It basically is a substitute for the pilots hand on the yoke. It has no control over power and trim, does not control speed, altitude, or vertical speed. It only controls the attitude of the aircraft as long as it is able to do so.


Looking at the videos it is imho obvious that this pilot lacked the necessary system knowledge and at the final stage general airmanship.
Agree with most of what you have stated, and I feel tremendous sadness for the family and friends of this Father and Daughter who loved aviation. I hope the resulting investigation will deliver some lessons that we can reflect and learn from.

Your criticism of the autopilot system is probably and understandably from a modern Jet perspective. However ancient autopilots of the era are not that far removed from modern autopilot function in non-fadec piston engine aircraft, in that they do not control power. This particular autopilot did control altitude, attitude and glideslope, but not trim (which may well have been the cause of the accident), but many autopilots of the era did.. as they incorporated electric trim. This Century 2000 unit was designed for aircraft with no electric trim fitted.
Leaving aside for a moment that the autopilot was probably 35 years old and modern advances in digital electronics, reliability, weight savings have changed the game to some extent.. the function is not that much different if you understand how the thing works.
A reasonably similar fatal accident occurred with a PC12 in February last year with the latest of tech.

[EXDAC]

Isn't the truth that it monitors the altitude and controls the attitude accordingly?

In ALT mode the AP attempts to maintain the difference between the altitude and the altitude target at zero. It is controlling the aircraft altitude. How it does that, and the concept of inner and outer control loops, is probably out of scope here.

[OPENDOOR]

Isn't the truth that it monitors the altitude and controls the attitude accordingly?
Yes. It is an altitude hold only option. It has its own barometric pressure sensor and can only alter the attitude via the elevator. No electric trim and no auto-throttle. There is a trim up/trim down indicator on the autopilot display that the pilot is supposed to monitor and make appropriate adjustments with the trim wheel. It is not clear if the pilot understood this.

[EXDAC]

There is a trim up/trim down indicator on the autopilot display that the pilot is supposed to monitor and make appropriate adjustments with the trim wheel. It is not clear if the pilot understood this.

There seem to be several people posting here who do not understand the proper response to illumination of the trim annunciators. Only after setting appropriate power for the desired climb or descent vertical speed should a trim annunciator be taken as an indication to change pitch trim.

Forget about the autopilot for a moment. How do you transition from hand flown altitude hold to hand flown VS target climb or descent?

[BFSGrad]

Especially in this flight with two pilots on board.
Other than an off-hand comment the accident pilot made in one of her videos, I am not aware of any evidence to support her father holding any pilot ratings.

[OPENDOOR]

There seem to be several people posting here who do not understand the proper response to illumination of the trim annunciators. Only after setting appropriate power for the desired climb or descent vertical speed should a trim annunciator be taken as an indication to change pitch trim.

Forget about the autopilot for a moment. How do you transition from hand flown altitude hold to hand flown VS target climb or descent?

With ALT selected the "annunciator" (two labeled lights) will tell you to trim if necessary. Same with HDG or NAV, it doesn't know it just senses control loads.

[EXDAC]

With ALT selected the "annunciator" (two labeled lights) will tell you to trim if necessary. Same with HDG or NAV, it doesn't know it just senses control loads.

You are flying AP coupled ALT hold mode and the aircraft is in trim at the desired airspeed. You fly through a sinking airmass. The AP drives the pitch servo to increase nose up elevator and illuminates the TRIM UP annunciator. What do you do?

I would add power.

[what next]

You are flying AP coupled ALT hold mode and the aircraft is in trim at the desired airspeed. You fly through a sinking airmass. The AP drives the pitch servo to increase nose up elevator and illuminates the TRIM UP annunciator. What do you do?

I would add power.

I think the correct answer is: do both. Follow the indication of the trim indicator to make life easier for the autopilot and add power if you observe the airspeed decreasing.

[OPENDOOR]

You are flying AP coupled ALT hold mode and the aircraft is in trim at the desired airspeed. You fly through a sinking airmass. The AP drives the pitch servo to increase nose up elevator and illuminates the TRIM UP annunciator. What do you do?

I would add power.
It has been thirty years since I flew a Rockwell Commander 112a with a Century autopilot. It had electric elevator and rudder trim. In ATL only small MP adjustments were required.

[RetiredF4]

Your criticism of the autopilot system is probably and understandably from a modern Jet perspective.

I'm mot criticizing the autopilot, it can't do more than it was designed to do. My criticism is pointed at those, who use this system without the proper system knowledge. While I feel sad about the death of the female pilot and her father, it still is most probable that the pilot failed badly. There also remains the question wether she received ample instructions about the limitations of the installed autopilot system with manual trim only, training and evaluation could be the elephant in the room.

I have no modern jet experience, as my nickname states I flew Phantom F4 aircraft, over 3.000 hours, 1/3 of them instructing and evaluating. The most civilian modern jet Cockpit I ever occupied as a pilot was a Caravelle simulator for ATPL training and following successful check ride.

The autopilot of the Phantom was similar in the limitations as the century series one and could kill you if operated without the necessary oversight and control. Especially the "Altitude hold" had its traps.

That brings me back to responses like
"it controls altitude", it could cause out of trim conditions....."


Afaik from the manual and the informations provided this aircraft had no electric trim and no auto throttle, all the inputs from the autopilot acted directly onto the yoke. If the pilot does not trim manually, then the trim stays at its position where the pilot had put it prior engaging the autopilot. Same with the power. An out of trim situation is caused when the aircraft parameters ( TAS, pressure altitude, CG to name a few) are changed and the trim is not adjusted manually and / or the deviating parameter is not corrected to the original value.

There might be a misconception about using the term "control" and it might be on my side, as I'm no native english speaking person. Only an autopilot controlling auto trim and auto throttle could control altitude alone over time. Such a system needs a lot if inputs and feed back loops the used autopilot in the discussed accident aircraft didn't have. Sure an average pilot can use this autopilot to control the altitude without auto trim and auto thrust, the autopilot alone can't and here the knowledge of the pilot looks amiss.

Going back to my original post, this autopilot only acts on the yoke, operating power and trim are out of its reach as it would be to a pilot whose hands were tied to the yoke. Would the pilot have known this, she would have controlled speed and altitude, the traces show no sign of such action, to the contrary. The oscillation deviation of speed and altitude increases in each cycle, until hitting the ground.

There is a time to be sorry, but we only learn from the truth. Not saying though that it will be my truth. Enough said, there will be those who understand, and those who will have to make their own way of learning.

Fly safe, merry Christmas and a peaceful year 2024.

[421dog]

And a proper approach mode including glideslope. It is not the dumb kind of "wing leveler" device found in some light aircraft. And the UP and DOWN buttons acting on the attitude and not on the vertical speed is not unique to this autopilot either. The only unusual feature are the trim lights that prompt the pilot to trim manually. In similar autopilots the trim lights illuminate when the autopilot acts on the trim. As was written above, the accident pilot seems not to have been aware of that. Flying on autopilot for some time, possibly with power and altitude changes, may leave the aircraft in an out-of-trim condition outside the force that the autopilot servos can handle. When the autopilot subsequently disengages, a rapid change in pitch will follow as a consequence. Everyone who has flown old(ish) light aircraft for some time will sooner or later encounter this situation. Lightplane autopilot control forces are in the order of 15 to 25 force pounds, like lifting a bucket of water. Apart from the startle effect and possible disorientation in instrument meteorological conditions they are easily controllable manually. Especially in this flight with two pilots on board.
Let's hope the data cards of the video cameras are not damaged by the fire as they will certainly reveal what exactly led to this accident.

it doesn’t do gps glide slopes though (afaik) and certainly not on my bird

[kap'n krunch]

Other than an off-hand comment the accident pilot made in one of her videos, I am not aware of any evidence to support her father holding any pilot ratings.

He was not a rated pilot. My understanding is that he liked to accompany his daughter and she felt more comfortable with him aboard. From the few videos I watched after the crash, she seemed to rely upon him quite a bit to assist with looking outside while she was heads-down and for general support with the aircraft. There were a few radio calls she missed that dad had to prompt her to respond. Also, she had more than a few “why is it doing this” questions that dad helped figure out.

[rog747]

Such a sad tale, poor lady trying to make her flying dream come true (perhaps too prematurely it seems), and whilst doing so her Dad also loses his life as well.

All very tragic, and quite telling that One's Training and your very own aptitude to Fly is paramount.

Poor folks.

[Uplinker]

Seems to me that this autopilot needs to activate the Master Caution if it calls for re-trimming but re-trimming has not been adjusted for, say, 5 seconds.

A little trim up or trim down light on the autopilot itself seems a bit too subtle to me. Is there a trim demand light in front of the pilot as well ?

Of course, any competent pilot would be used to automatically re-trimming after a power or speed change. How did this pilot's lack of trimming and mode confusion come to pass, and why did her instructor sign her off ?

FLY, Navigate, communicate, (capitalisation deliberate).

RIP

[what next]

it doesn’t do gps glide slopes though (afaik) and certainly not on my bird

I took the information about glide slope capability from the operarting manual that someone posted way up in this thread. Of course there are different installations of this autopilot, like with and without pitch trim capability, so not all will be fitted with this option.

[what next]

Seems to me that this autopilot needs to activate the Master Caution if it calls for re-trimming but re-trimming has not been adjusted for, say, 5 seconds.

Did this aircraft have a master caution indicator at all? I have flown (and still do) quite a lot on piston singles an twins, but never saw such an indicator. However, the manual of this autopilot (the link can be found in posting #44 of this thread!) states that if no action is taken for some time, an aural warning will be generated. So there is a warning system coming with the out-of-trim condition. But of course, in order to know what causes the warning sound, someone must have told the pilot about it or otherwise the pilot must have bothered to read the manual.

This is the relevant quote from the manual:

"The Century 2000 may be ordered as a Trim
Prompting autopilot. This means automatic
control (autotrim) of the elevator trim is not
available on these system. When the autopilot
displays a flashing TRIM UP or TRIM DOWN on
the annunciator, the pilot should manually move
the trim control of his aircraft in the direction
indicated on the autopilot. When the autopilot
determines that the trim condition is satisfied,
the trim lamp on the annunciator will extinguish
and the pilot should stop his trim
action. There are 2 degrees of trim prompting. For a small trim error the
trim prompt will flash approximately once each second. A large trim error
will cause the prompt to flash approximately 3 times per second. A large
error not corrected for a period of approximately 2 minutes will sound an
alert for 5 seconds. The alert will repeat every 2 minutes until the large
error is corrected."

[Uplinker]

Ah, fair enough. I have no specific knowledge of these types or this autopilot, but somehow the out-of-trim condition was missed, hence my questions.

I wonder if the aural alert can always be heard in a noisy cockpit and through headphones, and whether there is a trim light near the pilot's eye line.

Or maybe the pilot got confused and was moving the trim the wrong way - there are some clipped-on notes obscuring the trim wheel,

[what next]

I wonder if the aural alert can always be heard in a noisy cockpit and through headphones, ...

I would say yes absolutely, these aural warnings are designed for noisy cockpits and pilots wearing headsets.

...and whether there is a trim light near the pilot's eye line.

It is in the avionics stack in the middle of the panel and clearly visible for the pilot. Watch this video here (for at long it is still available on YouTube) where she tries out the autopilot after it came back from being repaired: https://www.youtube.com/watch?v=q2wIUOIgINk
She has absolutely no idea what she is doing and at one point her non-pilot (as we now know) father must tell her that the autopilot is actually engaged in altitude-hold-mode. The trim light is flashing all the time but she couldn't care less. And in the end she commits the cardinal sin of disconnecting the autopilot from it's control panel instead of using the disconnect button on the yoke whilst gripping that steadily. But again, someone had to tell her about those things or she should have read the manual, neither of which obviously happened.

Or maybe the pilot got confused and was moving the trim the wrong way - there are some clipped-on notes obscuring the trim wheel,

Everything is possible.

[IFMU]

Many years ago, when I was a student pilot, I went to Oshkosh with a 300 hour pilot who owned a Cherokee 6. We both lived in the same town in Connecticut. He was not a very accomplished aviator, which was actually a good learning experience for me. He had a single axis autopilot and knew how to couple it to the Loran. He held altitude within about +/-500 feet much of the time. Had any of that kit crapped out, and had I not been there, I think he would have gotten lost. But I did notice an interesting thing about the autopilot. About every 10 minutes, it would make a correction to the left, then go back to S&L. I found this very curious, especially as a young electronic flight controls engineer at Sikorsky Aircraft. After a glorious week at my first Oshkosh we were headed home and I asked him if I could hand fly the aircraft for a little while, and he said yes. The aircraft had yaw trim as well as pitch trim, and they were all out of whack. I trimmed everything and after about 10 minutes he got nervous and put it back on autopilot. For the next 600 miles it never did the correction to the left again. We also held altitude a lot better after that. I'm sure the trim never moved again until he sold the airplane.

What others have said about manual trim and autopilots makes a lot of sense. I'm glad my companion only had single axis autopilot capability as I am sure he could have been in this scenario as well. The only substitute for airmanship is luck, and that is a hard thing to count on.

[RickNRoll]

I would say yes absolutely, these aural warnings are designed for noisy cockpits and pilots wearing headsets.



It is in the avionics stack in the middle of the panel and clearly visible for the pilot. Watch this video here (for at long it is still available on YouTube) where she tries out the autopilot after it came back from being repaired: https://www.youtube.com/watch?v=q2wIUOIgINk
She has absolutely no idea what she is doing and at one point her non-pilot (as we now know) father must tell her that the autopilot is actually engaged in altitude-hold-mode. The trim light is flashing all the time but she couldn't care less. And in the end she commits the cardinal sin of disconnecting the autopilot from it's control panel instead of using the disconnect button on the yoke whilst gripping that steadily. But again, someone had to tell her about those things or she should have read the manual, neither of which obviously happened.



Everything is possible.
That guy is one of her former instructors, he always wears that baseball cap. It's not here father. He was about as useful as the other instructors. All the other videos with her previous instructor, the young guy with the mo have been taken down. Probably because there were people saying he should be charged with negligence in the comments.

[CISTRS]

Video 2:27ish...
"Positive rate of climb"
"Gear down"
???

[Flyingmac]

I used to fly a PA32 fitted with this autopilot. There was no autotrim function on the AP. There was an out of trim indicator top left of the panel, and an electric trim switch on the yoke. Adjust trim and light goes out. Only problem I ever had was staying awake with the AP engaged.

[SQUAWKIDENT]

I've been following this on the excellent blancolirio channel.

It was very difficult to watch the video he included in his first report. I was shouting "THROTTLE!!" at the screen.

From the latest blancolirio video the initial report says that they found some intact memory cards from the camera gear. That will be a difficult watch for the NTSB if the video files are recoverable.

Poor girl. Distinct lack of basic understanding and training.

[Uplinker]

In the two videos I have seen; (posted in this thread); this pilot's instructors have been terrible.

One was hyperactive - taking over, with hands all over the instrumentation; making unrequested adjustments and confusing and distracting the pilot. The other "instructor" was almost asleep, and virtually no help at all. Neither were remotely helpful and it sadly does not surprise me that this pilot did not have the basic, fundamental mindset, personal organisation or situational awareness that a GA pilot needs for single pilot operations.

Both were very poor instructors, and this pilot had not got the basics drummed into them. Nor had the operation of the autopilot been explained, (or even studied).

But the guy with the beard obviously did not know how the autopilot worked either - when the pilot was trying to climb, without adding power, he just sat there doing and saying nothing while the speed rolled back towards the stall speed, (at which point the pilot correctly disconnected the AP; although she incorrectly thought the autopilot wasn't working, and she clearly had not trimmed the elevator).

Why didn't the instructor say: "You're climbing the aircraft, what else do you need to do now ?" {add power}. And then; "Does this autopilot trim for you?" {no, you always need to manually trim}. Two simple questions which would have instantly given full understanding to this pilot, with which they would probably not have gotten themselves into whatever situation caused the later crash.

And I think that too much tech was being used, too early. The pilot seems reasonably able to hand-fly, and adjust engine fuel mixture etc, but has far too many distractions with all the extra tech; the autopilot, the iPad map, the Go-Pros etc. The pilot clearly spent a lot of time editing the videos and adding clips from other films to make certain points. Had that time been spent studying the theory and operation of the autopilot, and of basic GA navigation, I think we would have seen a different outcome here.

At the very least, I hope those two instructors read this thread and buck their ideas up, and that new pilots in similar situations to this poor lady will learn from this too.

RIP

[Ivor_Bigunn]

Sadly, "The guy with the beard" was not an instructor, or a qualified pilot at all, he was her father who also died in the crash.

Very, very sad.

But some instructor passed her as qualified for a PPL. He needs serious punishment.


IB

[Uplinker]

Sadly, "The guy with the beard" was not an instructor, or a qualified pilot at all, he was her father who also died in the crash.
That guy is one of her former instructors, he always wears that baseball cap. It's not here father. He was about as useful as the other instructors...........

She says to that guy with the beard "Am I your first today?", (i.e. student). She would not have said that to her own Dad.

And a little later the same guy with the beard talks about buzzing a local motor racing circuit in his own plane and showing them what speed really is. So he is a pilot.
(RTFA !).

[wiggy]

It wasn’t clear to me initially but from what I can work out there were two bearded blokes and only one is an instructor.

The gent sat in the RHS during the apparent near stall was the non-pilot father.

The one in the RHS who discussed the motor racing circuit may well have been an instructor given the context of the discussion.

[ehwatezedoing]

And I think that too much tech was being used, too early.
Perfect summary of this mess.

[EXDAC]

But some instructor passed her as qualified for a PPL.

An instructor gave her ab initio training
An instructor signed her off for the PPL check ride
A DPE or FAA examiner issued her PPL certificate
An instructor should have signed her off for high performance aircraft

There were lots of opportunities to recognize and correct any issues with her ability to act as pilot in command.

I was thinking about this accident before I went to bed last night and thought I would have nightmares about it. The scenario I imagined was that AP mismanagement got the airplane trimmed nose down. The pilot was able to hold altitude but asked the non pilot passenger for nose up trim. Now which way do you move the trim wheel for nose up trim? You move it DOWN. My nightmare scenario has the pilot calling more and more urgently for nose up trim and the passenger responding by moving the trim wheel more and more UP.

[OPENDOOR]

From the preliminary NTSB report. ERA24FA058

The wreckage, including two intact digital video recording devices, were retained for further examination.


That's going to make grim viewing for someone but at least there will be little doubt as to the cause.

[RickNRoll]

An instructor gave her ab initio training
An instructor signed her off for the PPL check ride
A DPE or FAA examiner issued her PPL certificate
An instructor should have signed her off for high performance aircraft

There were lots of opportunities to recognize and correct any issues with her ability to act as pilot in command.

I was thinking about this accident before I went to bed last night and thought I would have nightmares about it. The scenario I imagined was that AP mismanagement got the airplane trimmed nose down. The pilot was able to hold altitude but asked the non pilot passenger for nose up trim. Now which way do you move the trim wheel for nose up trim? You move it DOWN. My nightmare scenario has the pilot calling more and more urgently for nose up trim and the passenger responding by moving the trim wheel more and more UP.
She was wondering in one video why the plane wasn't moving properly while taxiing. Her father had put the handbrake on.

[ehwatezedoing]

She was wondering in one video why the plane wasn't moving properly while taxiing. Her father had put the handbrake on.
You never know in those You Tube videos if they are faking it or not. Although probably not in this case regarding the end result...

[Uplinker]

........The scenario I imagined was that AP mismanagement got the airplane trimmed nose down. The pilot was able to hold altitude but asked the non pilot passenger for nose up trim. Now which way do you move the trim wheel for nose up trim? You move it DOWN.

Depends how the trim wheel is mounted, but yes, could be.

OR; when flying with her father, maybe she went back to investigating the autopilot 'not climbing', but this time instead of disconnecting the AP when approaching stall speed, she either got distracted, or she let it continue below stall speed waiting to see if it would make corrections. Obviously, it couldn't, not having a power lever motor or a pitch trim motor, so eventually, the aircraft went into a full stall. And/or a spin.

Given her lack of SA - she allows the aircraft to move forwards while eyes inside, when she is supposed to be holding it on the toe brakes waiting to line up - a sudden unexpected stall or a spin would most likely have completely thrown her. Did she know how to get out of a stall ? Did she remember and apply the instantaneous correct flight control actions for a stall or a spin ? Given the terrible instructors she suffered; I sadly really doubt it.


She was wondering in one video why the plane wasn't moving properly while taxiing. Her father had put the handbrake on.

She seems to have suffered a lot from people in the RHS doing un-commanded stuff. "You have control - I have control" . Only one person flying at a time. Very simple but fundamental rule to follow. "If I want you to do something, I will tell you".


I really hope that instructors everywhere will use this set of videos as material for training and review; of how not to do it, and take lessons from them.

[EXDAC]

Depends how the trim wheel is mounted, but yes, could be.

The pictures I have seen of the Debonair and Bonanza show the trim wheel is near the left seat plot's right knee with the aft and lower sectors of the wheel exposed for manipulation by the pilot.

If that's true then the wheel could be moved by pulling/pushing the bottom of the wheel or by raising and lowering the aft facing part of the wheel. Can someone with experience in this aircraft type confirm that's the way the trim wheel is used when electric trim is not fitted?

Is the sense of this trim wheel the same as in most other aircraft i.e. rotating the wheel top forward, rear up, bottom back, front down will all produce nose down trim?

[MetAl]

There’s a whole crop of new folks who spend more time setting up their cameras than on the preflight & planning.

But hey, ya can make more money from YouTube than FO pay.

[AvionicsWiz]

Mine was simpler.

Fly The Plane.

I'm speaking as a 35-B33 Debonair pilot with 1100 hours in the plane. She was not keeping up with SIMPLE requirements at 400 hours, which is very troubling.

In one video, ATC had them (TNFlyGirl and the instructor) go around on a missed approach. The instructor seemed to think they were fine, and he asked (when ATC asked if they needed help) what was wrong.

They were 900 feet below the waypoint altitude.

You can hit the ground 900 feet below a waypoint. That's why it's the minimum altitude at that point, so I see why ATC cancelled their clearance and sent them around.

Yet both TNFlyGirl and the instructor were oblivious. You fly an approach like this, you get asked to call the tower when you land, if you even land.

Unfortunately, this is another pilot who is more interested in making videos (LOOK AT ME) than flying the plane.

A Debonair is a Bonanza with a straight tail. It was supposed to be the cheaper plane, to pull market share back to Beech from the Cessna 210 and Piper Comanche aircraft, which were slightly less expensive than the Bonanza. The Debonair is just as slippery and "go fast" as the Bonanza, it picks up speed readily. You have to be thinking ahead of the plane at all times - and sadly, she was 3 steps behind the plane at all times.

As to the "doctor killer" comment, that was attributed to people who were flying Cessnas moving into the Bonanza line. In a Cessna 172 or 182, you were puttering along at 2500 feet. You see the airport, you could descend.

In a Bonanza, you're up higher, and these same pilots who were used to flying a less slick plane would point the nose down, and exceed VNe. There was also the problem with the straight 35, the 35A and the 35B models, where they did not have the later tail reinforcements, which led to problems as speed picked up causing elevon fluttering and failure.

However, this has NOTHING to do with TNFlyGirl's crash. This was someone who was never keeping up with the plane. Find the videos - watch. Her instructor is handling comms, manipulating instruments and the GPS, and telling her what to do. That's just crazy!

[NoelEvans]

And I think that too much tech was being used, too early.

Perfect summary of this mess.
"Tech" doesn't fly aeroplanes. If the basics are not learnt and understood properly then just don't fly. All those basics in understanding that have gone missing in this incident can be taught on a J3 'Cub', where the only electrics are the magnetos. Keeping 'tech' out of it and learning the basics properly should be the way that people learn to fly.

There’s a whole crop of new folks who spend more time setting up their cameras than on the preflight & planning.

Because they don't actually enjoy the flying themselves, they just want to show everybody "what they are doing". Sadly a very 'shallow' bunch of people.

I once taught someone on his first airline flight and as we popped above cloud, he turned to me saying "Excuse me a moment", turned to the side window overlooking the view of the clouds below, held his clenched hands to the window and exclaimed "Yes!", turned to me again with a big smile and said "Sorry, I needed to do that!", then continued with his job. He really enjoyed flying and was pleased to have got where he was and that moment meant so much to him. No cameras, no "showing everyone else", but that moment will still be etched in his mind. (As is my memory of it!)

Can we 'bin' all the shallow 'glitzy' "tech" and have some more real pilots? Pilots can only fly an aeroplane through an autopilot if they understand how to fly the aeroplane in the first place. And the best pilots are those who, when they have any uncertainty about what the autopilot is doing, will disconnect the autopilot and fly the aeroplane themselves. Because they can.

(The idea of 'driverless cars' on the road, with a similar lack of understanding of driving, horrifies me!!)

[DAHenriques]

There are enough aspects to this incident to choke a horse.
One can go through the mistakes made and indeed the entire scenario from the beginning and find the entire thing filled from top to bottom with factors that should never have happened.
The ultimate answer to this is that literally EVERYTHING was wrong from beginning to end.
The incident is literally filled with "what not to do".
Were I to be lecturing on this I would not only be discussing the incidentals but as well the system that allows incidents such as this one to develop and take place.
There is much to be learned here and it's easy to get bogged down in specific details. The danger there is in possibly losing the "big picture".
Dudley Henriques

[AvionicsWiz]

With respect, no autopilot acts on the yoke.

There are servos in the aircraft, which act on the control surface cables or turnbuckles as needed. The yoke follows these servos as they are connected to the same device.

It's semantics, but saying the AP acts on the yoke itself is factually incorrect.

I've had two autopilots in my Debonair, the first being a Brittain Acu-Trak II wing leveler, which would track Nav 2, and the second being a S-Tec 55X, which is fully coupled with electric trim. It took me a week of reading the manual, trying the simulator, and then flying with an instructor to learn how to drive the S-Tec. Now that I'm proficient, it's easy to use.

I can tell from her button pushing - she didn't know what she was doing with the Century 2000. I say that as the former Avionics Editor for both Private Pilot Magazine and Custom Planes Magazine - I'm familiar with the Century 2000.

The "big picture" here is she was behind the plane.
Yes, that's pretty much it. You have an indicator above it to show you where you are, trim wise.

Other than slow flight, I seldom if ever see my flight trim outside of +/- 3.

The "details" are she was not keeping up with flying.

My wife says she can't even understand ATC, but I respond (most of the time correctly) quickly. I manage the single pilot IFR workload by WORKING AHEAD.

She was never up with the plane. The flight tracks and altitude tracks on the accident day clearly show this. It was a trim fight, and she was losing.

[DAHenriques]

The "big picture" here is she was behind the plane.
Yes, that's pretty much it. You have an indicator above it to show you where you are, trim wise.

Other than slow flight, I seldom if ever see my flight trim outside of +/- 3.

The "details" are she was not keeping up with flying.

My wife says she can't even understand ATC, but I respond (most of the time correctly) quickly. I manage the single pilot IFR workload by WORKING AHEAD.

She was never up with the plane. The flight tracks and altitude tracks on the accident day clearly show this. It was a trim fight, and she was losing.

Indeed she was behind the plane........and she didn't understand this..................and she didn't understand that..........and she was in over her head..........and there is a question about over concentration on her extra-curricular camera fixation causing a split in attention........and there is the ALT/ATT question........and more for sure........and the ultimate question as to why each of them individually apparently didn't go manual , take the AP out of the attitude equation.......and simply fly the airplane.
You can go on and on. The trim?????????? Anytime there is a control issue involving trim you disconnect the AP and fly the airplane.
The "big picture" questions all of this as a sequence of events that had an unfortunate end.
The main point here is that it wasn't any ONE FACTOR that caused this incident. It was, as it usually is with these things....a series of events, each one, and all of them contributing to the end result.
In other words.........the "big picture".
Dudley Henriques

[AvionicsWiz]

I have a different perspective.

Take away 1 thing and this accident doesn't happen.

That one thing is the proficiency of the pilot. If the pilot was proficient and capable, this event doesn't happen. The plane would have flown on to it's destination. No crash, no NTSB, no deaths, no destruction of the plane.

The rest of the observations are just bullet-holes around this bullseye.

I say this as someone who has performed Root Causes on numerous events, both human performance related and equipment related. This is unfortunately all on TNFlyGirl, and her inability to Fly The Plane.

As I pilot who wrote for:
Plane & Pilot
Flight Training
Custom Planes
Private Pilot
Avionics News
The American Bonanza Society
Sport Aviation
and a few others, I've had the chance to fly right seat in some interesting planes.
And in a few cases, I was behind in the right seat. The planes were new to me, were very complex, and they moved very fast. I declined the opportunity to land one that was established on final into Las Vegas - I had already mentally totaled in my mind the cost of the engines and props if I binged the nose gear and caused a collapse due to my lack of knowledge and proficiency, and said "No thank you."

Or as the plaque used to say at my previous airport: "Flying is incredibly fun and rewarding. It also has no tolerance at all for any mistakes made."

Then there is the equally appropriate aphorism: "There are old pilots and bold pilots, but there are few old, bold pilots."

She was TOO bold. Insensitive to the risk. Lacking proficiency in the aircraft with the avionics.

It should be a cautionary tale to any YouTuber who wants everyone to look at them. But it likely won't be.

[Bleve]

… I would not only be discussing the incidentals but as well the system that allows incidents such as this one to develop and take place.
To me this is the big picture: Why did the training and checking system give her a licence in the first place?

[AvionicsWiz]

It would appear your assumption would have to be that she had her check ride in this plane.

I can tell you the three examiners I have dealt with would not have passed any person without the ability to have adequate CRM. Nor would any of the Flight Instructors I have had the pleasure (or displeasure in one case) of working with.

I would posit that her original Private Pilot checkride was done in a more economical and docile aircraft, along the lines of a Cessna 152, 172, or perhaps a Diamond DA20 or DA40, or even a Piper Tomahawk, Warrior, or Cherokee.

Such aircraft are not complex, and have around a 30% (in my opinion, not based on any specific analysis) less cockpit workload. Everything is essentially manual. Speed increases and trim are simple and easy.

Unless we get a look at her logbook, or she recorded and published her check ride (and if she did, I'm not aware of it), we will never know.

The Complex signoff is an instructor signoff. How did she get it? Likely by meeting the requirements of the rule. Control the plane, use the cowl flaps (not on a C33 generally), and coordinate flaps and landing gear. If she was using the same instructor that she was in the video, (you know, the one who was manipulating the radios, and was unaware of the altitude bust on approach) then it wouldn't surprise me that such a Complex Rating was signed off.

I know for my transition, my insurance company required 10 hours of flight time with an instructor. Again, same instructor could essentially provide the same instruction we saw, which I think we could both agree was ineffective.

Do you happen to know what TNFlyGirl did her original Private Pilot checkout in?

[kap'n krunch]

Obviously there were multiple factors involved in this situation. Distractions with the cameras, autopilot, ATC, dad pressing buttons, etc. In my opinion, based upon years of studying pilot behavior and accidents, while all those factors were causal to the crash, the ultimate reason that a serviceable plane crashed on a sunny day was that when the a/p ultimately was disconnected the trim was so severely out of whack that she was physically startled and perhaps unable to overcome the yoke force necessary to arrest the descent as the speed increased. It may have been noted elsewhere, but it’s possible after disconnecting the a/p, while Jen was trying to fly the plane, dad was inadvertently making the situation worse by reaching across and under the panel adjusting the trim in the wrong direction.

[netstruggler]

Do you happen to know what TNFlyGirl did her original Private Pilot checkout in?

One of the [now removed] YouTube videos was titled "Auto Pilot For My Instrument Check Ride - What Did I Choose?", and it gave the reasons behind her intention to not use the autopilot or Garmin during the check-ride in her aircraft.

She could have changed her mind of course.

[EXDAC]

It may have been noted elsewhere, but it’s possible after disconnecting the a/p, while Jen was trying to fly the plane, dad was inadvertently making the situation worse by reaching across and under the panel adjusting the trim in the wrong direction.

See post 91.

[AvionicsWiz]

That would be the Instrument Checkout.

Unless the rules have changed, you aren't using an autopilot on that. They want to see you hand fly, since the autopilot is not a redundant system, and can fail.

I'm curious what she flew originally for her Private Pilot checkout.

All of her past aviation videos are removed. All I can see is her real estate videos.

Distractions are distractions. So what? The key were was that she wasn't keeping up with and in control of the plane. Look at the video posted earlier in this thread with the crash analysis. She was getting way too much help to keep up. Her dad wasn't a pilot - who was helping her keep up during that flight? Nobody.

If Dad reached across to help and went the wrong way with the trim, it would be:
1. Very obvious as backpressure on the yoke would increase
2. Subject to immediate feedback.

The Beech Debonair trim wheel has printing on the pilot side where you can see "UP" and "DOWN." My friend Dan has a 1965 C Model, and I've flown with him. It's basically the same as a B model with nicer 3rd windows and a better air skeg on tail.

[Uplinker]

Many are assuming this was a trimming problem, but I think she probably stalled it, got into a spin and couldn't recover in time. RIP

In one video she is cruising at 4,500', which is too low for a newish student to practise spin recovery, especially if she was not expecting to spin.
.

[AvionicsWiz]

One must wonder if you are a pilot, or read the preliminary NTSB Report.

Or if a pilot, if you have ever spun in a plane. I have.

From the NTSB Preliminary Report:
About 1019, the airplane entered the first of a series of climbs and descents with corresponding fluctuations in its observed groundspeed. (Note: This indicates a trim issue, not a stall / spin since the groundspeed correlates to the climb and descent) During these oscillations, which varied in magnitude, the airplane’s altitude varied between about 6,400 ft and about 5,300 ft. About 1057, the airplane entered a descent that arrested about 4,300 ft at a groundspeed of 143 kts, after which it climbed to 6,050 ft and slowed to 85 kts. (More of the same - not in control, fighting the plane.) The airplane then began to descend rapidly before ADS-B contact was lost in the vicinity of the accident site. During the last several seconds of the flight, the airplane was on a ground track of 262° descending at a groundspeed that reached a maximum of 228 kts, and the estimated maximum descent rate was about 11,900 ft per minute. (This is not a spin profile. In a spin, you drop in a near vertical configuration, as neither wing has lift.)

In my spins (Cessna 152, Super Decathlon, 35-B33 Debonair (unintentional), the following happened:

Slow flight was the initiation condition. in the 152, I couldn't maintain rudder control, the plane rolled and started spinning. My direction was VERTICAL, not on any angle. I reduced power, used opposite rudder to stop the spin, used the ailerons and elevator to level and break the stall, and restored power.

In the Super Decathlon I was training under the late Gene Littlefield for aerobatics. These were deliberate spins, so we'd go up high, and do the same thing I did in the 152, and the same thing to recover. The Super Decathlon is rated for spins, and I had Gene flying in the back seat to help me if I got into trouble, which I didn't.

In my Debonair, I was doing Commercial maneuvers working on my commercial rating with an instructor in the right seat. Again, at minimum controllable airspeed, she had me pull to a stall. My pull was slow, one wing stalled first, and the Debonair rolled inverted and started spinning.

I identified the spin verbally and executed spin recovery. Obviously successful or I wouldn't be writing this.

All three spins had the same elements - very fast (around 4000 fpm) vertical descents, no angle.

This plane left a 5 foot deep crater, with a "fan-spray of debris." That isn't a spin crash - those "pancake" and have very confined debris fields. They generally don't make that big of a crater.

Sorry, this was not a stall-spin. No way.

[Prob30Tempo TSRA]

Has a sudden medical issue been considered ?

[Uplinker]

My sincere apologies; AvionicsWiz. I missed that there was an NTSB report.

But, really, I take great exception to your jumping to that sort of language.

I see that you are new here; you will find that we prefer a more "gentlemanly" polite approach towards each other; You could have simply gently corrected me.

For what it's worth; yes, I am a real pilot, with nearly 12,000 hours total time; in GA but mostly passenger jet airliners. And, yes, I have spun planes, both deliberately during training, and once, accidentally in a twin turbo-prop, (while under instruction).

I will read the report, now I know there is one.

[EXDAC]

The Beech Debonair trim wheel has printing on the pilot side where you can see "UP" and "DOWN."

Can you please post a picture or at least say whether the relationship between wheel rotation and trim sense is conventional (aft sector up = trim nose down).

Am I correct in thinking these direction markings could not be seen from the passenger seat?

[IFMU]

NTSB preliminary:
https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193491/pdf

[EXDAC]

If Dad reached across to help and went the wrong way with the trim, it would be:
1. Very obvious as backpressure on the yoke would increase


If the pilot was already pulling back with all the effort they could manage then an increase in nose down trim will not change the backpressure. It is already limited by pilot strength.

What happens is that the nose goes further down increasing airspeed and descent rate (as described in the NTSB report).

[First_Principal]

My sincere apologies.... You could have simply gently corrected me....

Logged in to simply 'like' your response, but was thwarted as there's no facility on this forum. So a 'well said' comment will suffice I trust, no wish to derail the main conversation otherwise.

FP.

[NoelEvans]

"Well said" as well!!

(I've also spun an aeroplane or few... Harvard, C150/C152. PA28, PA38, R2160, DH82a... and taught people to spin, ;) )

Let's stick to being gentlemen!! :)

[B2N2]

NTSB preliminary:
https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193491/pdf

What a sad read.
Knowing that an hour with the manual and an hour with even a half decent instructor would have likely prevented this fatal event.

[AvionicsWiz]

A sudden medical issue wouldn't explain the unstable altitude control during the flight.

In a trimmed condition, an airplane will settle at an airspeed and altitude. It may climb (if trimmed up) until engine power is reduced by the thinner air before it levels out, or descend into the ground if trimmed for a descent.

However, no trim level will result in the plane going up and down and up and down like this. This to me looks like a Trim Runaway event (which is why current autopilot installations put "kill switches" right in the pilot's field of vision.) Mine are directly below the HSI. Flip the trim switch off, trim is dead. Flip the autopilot switch off, the autopilot is dead.

For a trim runaway to happen, autotrim has to be installed and has to malfunction. It has been established that this aircraft was not equipped with autotrim. So that isn't a potential failure path.

You pull back the throttle to flight idle.
Extend the landing gear (knowing you are beyond legal extension speeds of 144 kts probably, and will lose or damage your gear doors.)
If you are going down fast, both of those actions will:
1. Slow you
2. Cause the plane to level slightly due to the drag.

They cannot be seen by the passenger. They are on the pilot side of the center column, which includes the nose gear position indicator.

I don't have any pictures which show this. The next time I'm in the area, I'll snap a shot. I'm grounded due to COVID-related heart issues at this time, so I haven't been flying.

[EatMyShorts!]

Is the metallic wheel just above the right rudder pedal of the left seat pilot the trim wheel?

https://cimg5.ibsrv.net/gimg/pprune.org-vbulletin/2000x1504/1703845831_ebc17378e22a1954eb2514f43007520de39eb191.jpeg

[AvionicsWiz]

That is the one.

It isn't metal, it's a thick plastic so it doesn't chill your hand in the winter. It's also lighter than metal, and weight is important in airplanes.

The printing is on the left side of the wheel where the pilot can see it. The actual "Trim Indicator" which shows your degree of trim nose up or down, is above and to the left of the actual wheel. You can see it (and see direct feedback to your inputs) as you move the wheel.

[EXDAC]

Is the metallic wheel just above the right rudder pedal of the left seat pilot the trim wheel?

Yes, that is the trim wheel.

[OPENDOOR]

https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/147x366/remove_before_flight_91db24c4512f3c97c68baf6b76214a1851fb08d 7.jpg
Not going far with that instruction.

[AvionicsWiz]

I suspect like you, I'm waiting for the final NTSB report on this.

It will come soon, but it appears this is just waiting for the NTSB to say what happened.

[mjh FE]

A sudden medical issue wouldn't explain the unstable altitude control during the flight.

In a trimmed condition, an airplane will settle at an airspeed and altitude. It may climb (if trimmed up) until engine power is reduced by the thinner air before it levels out, or descend into the ground if trimmed for a descent.

However, no trim level will result in the plane going up and down and up and down like this. This to me looks like a Trim Runaway event (which is why current autopilot installations put "kill switches" right in the pilot's field of vision.) Mine are directly below the HSI. Flip the trim switch off, trim is dead. Flip the autopilot switch off, the autopilot is dead.

For a trim runaway to happen, autotrim has to be installed and has to malfunction. It has been established that this aircraft was not equipped with autotrim. So that isn't a potential failure path.

You pull back the throttle to flight idle.
Extend the landing gear (knowing you are beyond legal extension speeds of 144 kts probably, and will lose or damage your gear doors.)
If you are going down fast, both of those actions will:
1. Slow you
2. Cause the plane to level slightly due to the drag.

They cannot be seen by the passenger. They are on the pilot side of the center column, which includes the nose gear position indicator.

I don't have any pictures which show this. The next time I'm in the area, I'll snap a shot. I'm grounded due to COVID-related heart issues at this time, so I haven't been flying.

Care to elaborate the described behavior of trimmed/untrimmed general aviation aircraft?
-M-