3 March 2014
By Dick Rochfort, ATP, CFII - Master Instructor
NTSB Identification: WPR14FA127
14 CFR Part 91: General Aviation
Accident occurred Monday, March 03, 2014 in Truckee, CA
Aircraft: PIPER PA 46 350P, registration: N9281F
Injuries: 1 Fatal,1 Serious.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
On March 3, 2014, at 1032 Pacific Standard Time, a Piper PA 46 350P, N9281F, collided with terrain approximately 5 miles east of the Truckee-Tahoe Airport, Truckee, California. The commercial pilot was seriously injured, and the single passenger was fatally injured. The airplane was registered to, and operated by, the commercial pilot under the provisions of 14 Code of Federal Regulations, Part 91. The airplane's left wing was separated from the fuselage resulting in substantial damage to the airframe. Marginal visual flight rules (MVFR) conditions prevailed for the flight, which operated on an instrument flight rules (IFR) flight plan. The flight originated at John Wayne-Orange County Airport, Santa Ana, California, about 0800.
The pilot was in communications with Oakland Center while on the GPS-A approach into Truckee-Tahoe Airport. Upon completion of the instrument approach the pilot executed a missed approach and proceeded to fly in an easterly direction not consistent with the published missed approach procedures. Oakland Center lost radar contact and radio communications with the airplane and pilot. The airplane wreckage was located about an hour later in the mountain range east of the airport at an elevation of 8,000 feet mean sea level (msl).
The Truckee-Tahoe Airport Automated Weather Observation System (AWOS-3) reported at 0950 that the wind was from 180 degrees at 7 knots; visibility was 9 statute miles, and an overcast cloud layer was at 3,000 feet above ground level (agl). At 1050, the reported weather conditions were wind from 300 degrees at 5 knots; 6 miles visibility in light rain, and an overcast cloud layer at 2,200 feet agl.
The published minimum descent altitude (MDA) for the Truckee-Tahoe GPS-A approach is 8,200 feet mean sea level (2,300 feet agl).
This accident will likely be officially labeled “pilot error” - Controlled Flight into Terrain (CFIT). It is not possible to know at this point, exactly what happened on the morning of March 3, 2014 and I do not wish to criticize the pilot no matter how egregious his errors (if any) may have been. I want to focus on common causal factors for this type of accident and give you, the reader, a few "take-away" ideas that you might readily implement to make yourself a better, safer, more confident pilot.
There are two aspects to every procedure no matter how simple or complicated it may seem. First, the pilot must constantly be aware of the aircrafts position at all times. This task should be simpler in the glass panel cockpit but there is evidence which suggests otherwise. Second, the pilot must know the one best way to make the aircraft go where it is supposed to go with or without the autopilot. It could be said that this second aspect is the bandwidth hog, but the truth is, both can chew up significant bandwidth creating a ripe environment for errors of omission.
Bandwidth management is the ability to not allow distractions to interfere with timely critical task completion. This is not a problem to be solved, it is a condition to be managed. I encourage each pilot to seek the one best way to accomplish these tasks by operating the same way each and every time using a well-vetted set of checklists, flows, memory items and SOP (standard operating experience).
Staying on the thick black line of the procedure is arguably the most important critical task. One common error which can cause confusion which can lead to this type of accident is a failure of the GPS to automatically sequence during the approach. This subtle but entirely predictable event can lead to a major loss of SA (situational awareness) and/or a serious distraction.
Note also the importance of having cumulative distance (CUM as opposed to DIS) displayed on the flight plan page so there is no confusion about total distance from a particular fix.
The best way to consistently get it right is to use a “Flow”. By definition a flow is a series of actions which must be considered by the pilot; not a checklist of tasks to be completed. The flow must be well vetted so as to be appropriate in every approach scenario. I recommend a six step flow followed by three questions:
1 – Activate (the approach correctly on Garmin) There are essentially three ways to accomplish this, depending on the circumstances.
2 - Flip – the correct VOR/LOC frequency into the active frequency box on both VHF Nav radios (obviously not necessary on and RNAV or GPS approach except for crossing radials and backup information)
3 - Flop – verify that the CDI (course deviation indicator) is set to the proper source (VLOC or GPS as needed)
4 - Set – the course on the HSI or verify it is set if you have an EHSI (electronic horizontal situation indicator)
5 – ID - identify the approach using the briefing strip on the approach plate and the blue banner on the Garmin navigator
6 – Arm the approach on the autopilot
Then immediately ask yourself three questions:
Which way? - Which way should I be going and is the autopilot making the aircraft go where I want it to go
How low? - What altitude should I be at and is the autopilot correctly configured to make that happen
What’s next? How long until the next step-down, turn or decision point.
Resist the temptation to simply recite what you expect to happen. The answer to the three questions lies on the panel in the approach setup. Look at the relevant information on the panel to confirm everything is set correctly. Study this procedure in training until you have a setup that will instantly answer these questions in every scenario with little or no button pushing. The expected outcome can only consistently occur if you insist on the procedural discipline to operate the same way each and every time. You can view a two minute YouTube demonstration video on this topic on my YouTube Channel at: https://www.youtube.com/watch?feature=player_detailpage&v=S-Mgqcl_9VQ
This video is also hosted on my website at www.rwrpilottraining.com in the Pilot Reference Library under IFR Operations.
Knowing the location of a proper VDP (visual descent point) will definitely help you find the runway or know in a timely fashion when a circle or a missed approach is likely. I compute the VDP using a ratio of 300 ft. per NM; that is, for every 300 feet I am above the threshold I know I will need 1 mile to effect a normal 3 degree descent (Pythagoras knew that and he wasn’t even a pilot!). As an example; many non-precision approaches bring us to 600 ft. AGL. An MDH of 600 ft. tells me that if I don’t see the runway from 2 miles away, I may be in for a circle or a missed approach. This very concept renders a straight-in 1 mile visibility minimum useless is most cases.
The Truckee-Tahoe GPS-A approach requires a rate of over 1000 feet per NM to get to the MDA (Minimum descent altitude) by the VDP. This rate of descent is not recommended; and that there is no published straight-in minimums is a huge hint. You should be looking for the runway at the VDP, not the MDA or the MAP. Looking for the runway in front of you when you get to MDA is probably a bad idea in this case because it’s most likely underneath the aircraft.
Since pilots are all human, we can only do one thing at a time. Excellent pilots do exactly the right thing at the right time and in the correct sequence utilizing the least amount of bandwidth. Experience makes this easier, but this is only true when you have had excellent experience. Excellent experience is derived from excellent training. This compelling concept is most important to the pilots who fly the least; so if you are flying less than 200 hours a year, get busy.
Consider training twice per year and ask your instructor to help you construct a set of checklists, flows and memory items which will guide you through each phase of flight, including the approach. Use these items ... same way each and every time. Have and use well-vetted Standard Operating Procedures. It is within the SOP that you will find a fast and accurate way to improve upon your aeronautical decision making (ADM).
“Do the same thing the same way, to a high professional standard every time. Set your standard, stick with it, don’t violate it and let no outside pressure change it. Discipline is going to keep you alive.” (Fred Kaiser, FAASTeam Program Manager).
Good pilots are not thrill seeking risk takers. Good pilots are well trained risk managers who endeavor to possess ATP level skills and knowledge. Always strive to improve your risk management capabilities by insisting on excellent training. Excellent training does not cost any more or take any longer and excellent training can help prevent accidents. Change is difficult, but when you commit to this process you will become a safer, more confident pilot. You owe it to yourself, your family, and the entire General Aviation community.
If you are flying any PA46 you should consider yourself lucky. In my opinion, for the money, it is the most capable GA aircraft available today. It is an excellent value and it is getting better every year.
If you would like more information on this or other strategies for improving the safety of your flying, or if you have comments or questions, you may contact me directly at firstname.lastname@example.org
Additional information on this and other important topics is available at the PA46 Pilot Reference Library at: http://www.rwrpilottraining.com
This article is available for reprint upon request.
Fly Safely – Train Often