As we go through life, there’s a presumption that people who are more experienced and have had more training are better qualified to make the right decisions and do the right things. Except, that’s not always true. People who are more experienced and have had more training often can be just as mistaken in their decision-making and require as much help as novices. It took years for that notion to work its way onto the airline flight deck so that first officers who knew the captain was doing something wrong could freely speak up. In fact, sometimes a host of experience and training can give a person a sense of bravado and invulnerability. In that case, accidents are just waiting to happen, and one of them did on March 4, 2017.
The accident location was Duette, Florida. The airplane involved was a 1977 Beech B60 Duke. The six-seat, twin-engine airplane was being used on an instructional flight. It cruised at about 178 knots and had a maximum takeoff weight of 6,775 pounds and a service ceiling of 30,000 feet. Power came from two Lycoming TIO-541-E1C4 engines, each rated at 380 horsepower. It had come out of annual inspection just two days before the accident and had just over 3,271 hours when it got the signoff.
There were two people on board, and both were killed in the accident. One was a private pilot who had recently bought the airplane, and the other was a flight instructor. The private pilot, age 58, was rated for single-engine and multi-engine land airplanes. He didn’t have an instrument rating. He held a second-class FAA medical certificate that had been issued on April 4, 2016. On an application for airplane insurance just over a month before the accident, he reported having 1,120 total flight hours with 800 in multi-engine aircraft, including 200 in Beech B60 airplanes.
The insurance company required the pilot to have biennial ground and flight training. Because the B60 was a fairly new purchase, the pilot arranged training through a company that maintained a directory of flight instructors who specialized in various airplanes. The instructors acted as independent contractors for the company. They weren’t trained or evaluated by the company and were required to maintain their currency and qualifications on their own. The company didn’t provide flight training manuals for the instructors but did specify that the instructors had to follow FAA Practical Test Standards or a specific aircraft flight manual, whichever was more restrictive.
The NTSB reported that the instructor, age 90, held a commercial certificate and was rated for multi-engine land and single-engine land and sea airplanes. He had an instrument rating and also was rated for gliders. His instructor ratings were good for single-engine, multi-engine and instruments. He last received an FAA second-class medical certificate on October 6, 2014. A company profile sheet for him showed a total time of 20,900 hours with 9,355 in multi-engine aircraft and 18,900 hours of dual instruction given. It showed that he had 165 hours in Beech Duke airplanes. It also showed that he was an airframe and powerplant mechanic. The profile sheet gave some of his aviation background, which included owning a flight training school in the 1970s and subsequently working for a major flight training school in Florida for about 10 years. During that time, he was the chief pilot, an instructor and FAA designated examiner. Following that, he went to work for a general aviation airplane manufacturer in Florida, where he was a flight instructor for one of its models and co-developed the training program for the product line. After that, he worked for other flight schools, including being the chief pilot for an airline’s training program at one of the schools. In 2011, he became a contract instructor for the company through which he was working with the owner of the Duke.
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At about 12:40 p.m., the airplane took off from Sarasota-Bradenton International Airport (KSRQ) in visual meteorological conditions. This was the second day the pilot was receiving instruction. There was no flight plan filed for the local flight, but it was given flight following services. About 10 minutes after departure, the pilot canceled flight following, and for the next 30 minutes FAA radar showed airwork being performed over a rural area northeast of the airport. Numerous 360-degree left and right turns, along with figure-eights, were shown on radar. Just before the airplane was lost from radar, it had been maneuvering between 1,000 and 1,200 feet MSL in the vicinity of the accident site. The airplane entered an uncontrolled descent and impacted trees and the ground, and burst into flames.
Investigators interviewed a witness who saw the airplane in straight and level flight, going “kind of slow,” with the nose gradually pitching up. Using a model airplane, he showed the airplane falling off on one wing and entering a spiraling descent. He said the engines sounded smooth and continuous, but the engine sound increased throughout the descent. Two other members of the witness’ family gave nearly identical statements to investigators.
Another witness, who was in a group riding motorcycles, saw the airplane make a slow roll. He said that at first he thought the airplane was a crop duster. Others in the group watched the airplane depart straight and level flight and enter a near-vertical spiraling descent. They couldn’t hear the sounds of the airplane’s engines over the sounds from their motorcycles. Some went to the crash site but couldn’t get close enough to help because the flames were too intense.
Investigators accounted for all major components of the airplane at the crash scene. The fire had consumed a lot, including the cockpit instruments and switches. The engines had significant impact and fire damage.
Investigators found that after the first day of flying with the instructor, the pilot had spoken with some of his friends about the experience. One of them, who started flying with the pilot in 1999, reported that the pilot had owned two other Duke aircraft beginning in 2007. He said he talked with the pilot the night of the first day of instruction, and the pilot said the instructor had told him to do some things with which he didn’t agree. The friend quoted the pilot as saying the instructor had told him not to push the mixture and propeller pitch controls full forward on approach to land. The friend quoted the pilot as saying the instructor said the reason was that it made more noise and wasted gas.
The next morning, the pilot again contacted the friend and reported they were doing stalls with the power off or very low at a 20-degree left bank. The friend quoted the pilot as saying that while his normal procedure for stall recovery was to push the nose down, level the wings and apply power, the instructor told the pilot to apply full power, then lower the nose and then level the wings. The friend reported that the pilot said when he did so, the airplane entered a spin and made 1.5 turns before recovery. The pilot was reported to have said they were at 3,000 feet when the airplane entered the spin, but the instructor denied that it was a spin because the airplane hadn’t made three turns.
The friend also reported that the pilot told him the instructor had him do an instrument approach to a runway, which had the airplane landing in a tailwind. The pilot said the winds were gusty, which added to the difficulty. The friend asked if the instructor mentioned doing a circle to land on a runway favoring a headwind. The friend said the pilot said no, but the instructor did ask why he landed downwind, and the pilot replied, “Because that is what you said to do.”
Another friend of the pilot told investigators that after the first day of instruction, the pilot was going to fly over to meet the friend and his wife for dinner at Apopka, Florida, and then spend the night. The friend said the pilot phoned and described a flight he said, “scared me down to the core of my spine.” The friend wrote to investigators, “I asked him what had happened. He stated that they where (sic) flying at 3,000 feet in slow flight preparing to do a power on stall. When the plane started to stall, the instructor reached over and pulled the power on the starboard motor causing the plane to go inverted. (The pilot) said it took him a thousand feet to get the plane gathered up and regain his composure. (The pilot) said it took so much out of him that he had already gotten a hotel room, was going to get something to eat and then get to bed as he was worn out.”
The NTSB’s report quoted from the FAA’s Airplane Flying Handbook, which explained that the standard stall recovery procedure is to reduce the angle of attack, roll the wings level and add power as needed. It also warns that single-engine stalls or stalls with significantly more power on one engine than the other should not be attempted due to the likelihood of a departure from controlled flight and possible spin entry. It notes that no multi-engine airplane is approved for spins, and their spin recovery characteristics generally are very poor.
The NTSB also quoted from the FAA’s Flight Instructor Airplane Practical Test Standards regarding multi-engine airplanes, which stated, in part, “stalls must not be performed with one engine at reduced power or inoperative and the other engine developing effective power.”
In determining a probable cause of this accident, the NTSB gave no weight to the tendency many have to defer to more experienced individuals, or elders, or even those who hold more FAA certificates and ratings than we do and, therefore, are presumed by the government to know more and be better qualified. The Safety Board said the accident was due to the pilot’s decision to perform flight-training maneuvers at low airspeed at an altitude that was insufficient for stall recovery. Contributing to the accident was the flight instructor’s inappropriate use of non-standard stall recovery techniques.
In its report on this accident, the NTSB makes suggestions for preventing similar accidents, something it doesn’t always do. The Safety Board says that accidents result when the pilot doesn’t accurately perceive situations that involve high levels of risk. It says that, “applying behavior modification techniques, recognizing and coping with stress, and effectively using all resources, pilots can substantially improve the safety of each flight. Remember that effective risk management takes practice. It is a decision-making process by which pilots can systematically identify hazards, assess the degree of risk and determine the best course of action. Pilots should plan ahead with flight diversion or cancellation alternatives, and they should not be afraid to change their plans.”
What the NTSB leaves out is that effective risk management often involves going with your gut reaction and not being dazzled by a résumé or seniority. There’s a whole concept that took years to be accepted in the airline industry, crew resource management, designed to help overcome the seniority inhibition. A strong argument can be made that the pilot of this accident airplane, if he was genuinely as upset after the first day of flying with the instructor as his friends reported he was, could have and should have listened to what he was telling them about his experiences and just pulled the plug on the whole thing.
Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, visit www.ntsbreporter.us or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.