Hendricks Crash- NTSB Prelim

Saw on AvWeb that the preliminary file on the Hendricks King Air crash that
spawned much discussion here has been posted:

http://ntsb.gov/ntsb/brief.asp?ev_id...04X01760&key=1

For reference, here is the approach plate:

http://204.108.4.16/d-tpp/0411/05648L30.PDF

My take-away:

1. The FAF (BALES) was supposed to be crossed at 2600; they crossed it at
3900
2. They leveled at 2600 "in the vicinity of" the MAP; MDA there was 1340
3. 1 miles past the MAP, they descended again, at least to 1800, after which
altitude readout was lost. At this point they were 3 miles past the airport.
4. Three minutes later they reported missed and were told to climb and
maintain 4400.
5. Terrain was impacted at 2400', with the wings level.

If I read this correctly, it sounds like they (1) confused the FAF and the
MAP and (2) waited way too long to go missed. I am also interested in
hearing more about the missed instructions they received. As I read this,
they continued on the 305 inbound course all the way through. If they were
flying at 100-120kts (typical config for a king air 200?) they would have
been anywhere from 5-9nm from the airport when they reported missed. I
cannot find a terrain map so I don't know what else might be out there, but
it seems that if they had been turned right (as the published missed
specifies) they would have had plenty of obstacle clearance, but again, I
might be missing something.

The plane was equipped with a VFR GPS and no GPWS, according to the report.
Not exactly a gold-plater, it sounds like. Still, a VFR GPS will show you
when you've passed the airport.

-cwk.

C Kingsbury wrote:



If I read this correctly, it sounds like they (1) confused the FAF and the
MAP and (2) waited way too long to go missed.

Either that or they were making the DME measurements from some other point
than I-UVM, or they used some bogus waypoint for these distances in the GPS.
However, I can't figure out any obvious answer. All the likely fixes that
they might have selected by mistake would put them too far east rather than
too far west.

I agree that they had confused the MAP with the FAF.

One scenario I am thinking is that he had dialed in the MAP
into the GPS and was planning on using it for DME. Then, when
told that he was going to be holding for half-an-hour figured
that he would dial the FAF into the GPS to use for holding and
use the DME from the FAF to determine the MAP.

When he was unexpectedly cleared for the approach while turning
inbound, he forgot that he hadn't swapped the GPS over to the FAF
yet. That would also provide an explanation why he didn't see
the airport pass on the GPS -- he thought that he was getting
distance from the FAF.

C Kingsbury wrote:

Saw on AvWeb that the preliminary file on the Hendricks King Air crash that
spawned much discussion here has been posted:

http://ntsb.gov/ntsb/brief.asp?ev_id...04X01760&key=1

For reference, here is the approach plate:

http://204.108.4.16/d-tpp/0411/05648L30.PDF

My take-away:

1. The FAF (BALES) was supposed to be crossed at 2600; they crossed it at
3900
2. They leveled at 2600 "in the vicinity of" the MAP; MDA there was 1340
3. 1 miles past the MAP, they descended again, at least to 1800, after which
altitude readout was lost. At this point they were 3 miles past the airport.
4. Three minutes later they reported missed and were told to climb and
maintain 4400.
5. Terrain was impacted at 2400', with the wings level.

If I read this correctly, it sounds like they (1) confused the FAF and the
MAP and (2) waited way too long to go missed. I am also interested in
hearing more about the missed instructions they received. As I read this,
they continued on the 305 inbound course all the way through. If they were
flying at 100-120kts (typical config for a king air 200?) they would have
been anywhere from 5-9nm from the airport when they reported missed. I
cannot find a terrain map so I don't know what else might be out there, but
it seems that if they had been turned right (as the published missed
specifies) they would have had plenty of obstacle clearance, but again, I
might be missing something.

The plane was equipped with a VFR GPS and no GPWS, according to the report.
Not exactly a gold-plater, it sounds like. Still, a VFR GPS will show you
when you've passed the airport.

-cwk.

C Kingsbury wrote:

Saw on AvWeb that the preliminary file on the Hendricks King Air crash that
spawned much discussion here has been posted:

http://ntsb.gov/ntsb/brief.asp?ev_id...04X01760&key=1

For reference, here is the approach plate:

http://204.108.4.16/d-tpp/0411/05648L30.PDF

My take-away:

1. The FAF (BALES) was supposed to be crossed at 2600; they crossed it at
3900
2. They leveled at 2600 "in the vicinity of" the MAP; MDA there was 1340
3. 1 miles past the MAP, they descended again, at least to 1800, after which
altitude readout was lost. At this point they were 3 miles past the airport.
4. Three minutes later they reported missed and were told to climb and
maintain 4400.
5. Terrain was impacted at 2400', with the wings level.

If I read this correctly, it sounds like they (1) confused the FAF and the
MAP and (2) waited way too long to go missed. I am also interested in
hearing more about the missed instructions they received. As I read this,
they continued on the 305 inbound course all the way through. If they were
flying at 100-120kts (typical config for a king air 200?) they would have
been anywhere from 5-9nm from the airport when they reported missed. I
cannot find a terrain map so I don't know what else might be out there, but
it seems that if they had been turned right (as the published missed
specifies) they would have had plenty of obstacle clearance, but again, I
might be missing something.

The plane was equipped with a VFR GPS and no GPWS, according to the report.
Not exactly a gold-plater, it sounds like. Still, a VFR GPS will show you
when you've passed the airport.

-cwk.

Nicholas Kliewer wrote:

I agree that they had confused the MAP with the FAF.

One scenario I am thinking is that he had dialed in the MAP
into the GPS and was planning on using it for DME. Then, when
told that he was going to be holding for half-an-hour figured
that he would dial the FAF into the GPS to use for holding and
use the DME from the FAF to determine the MAP.

When he was unexpectedly cleared for the approach while turning
inbound, he forgot that he hadn't swapped the GPS over to the FAF
yet. That would also provide an explanation why he didn't see
the airport pass on the GPS -- he thought that he was getting
distance from the FAF.

Sorry about the top posting.

Another thing to consider... If he confused the FAF with the MAP, he
would have thought that he was 2 miles from the FAF when RADAR saw
him 3 miles past the airport. If his approach speed is ~120kts, he
called the miss three minutes later at about the right time.

Nicholas Kliewer wrote:
: I agree that they had confused the MAP with the FAF.

: One scenario I am thinking is that he had dialed in the MAP
: into the GPS and was planning on using it for DME. Then, when
: told that he was going to be holding for half-an-hour figured
: that he would dial the FAF into the GPS to use for holding and
: use the DME from the FAF to determine the MAP.

: When he was unexpectedly cleared for the approach while turning
: inbound, he forgot that he hadn't swapped the GPS over to the FAF
: yet. That would also provide an explanation why he didn't see
: the airport pass on the GPS -- he thought that he was getting
: distance from the FAF.

Interesting scenario and is consistent with the data. I haven't found any
word that there was an actual DME onboard. If your idea is correct, it would provide
fuel for the knee-jerk "Pilot error" explanation that appears to be applied in as many
cases as possible.

-Cory

************************************************** ***********************
* Cory Papenfuss *
* Electrical Engineering candidate Ph.D. graduate student *
* Virginia Polytechnic Institute and State University *
************************************************** ***********************

This is one of the few plausible explanations I've heard. One thing
seems certain .. he thought he was referencing the FAF when in
reality he was referencing the MAP. Although you'd have thought
they'd have wondered why they never got the OM indicator. Also
since it says "ADF Required" I would hope they had one .. and
then wonder why they wouldn't notice why the needle was pointing
at the tail as they approached what they THOUGHT was the FAF.
GPS's are a great tool, but they can sure confuse the situation if
your switchology gets out of whack.

"Nicholas Kliewer" wrote in message
...
I agree that they had confused the MAP with the FAF.

One scenario I am thinking is that he had dialed in the MAP
into the GPS and was planning on using it for DME. Then, when
told that he was going to be holding for half-an-hour figured
that he would dial the FAF into the GPS to use for holding and
use the DME from the FAF to determine the MAP.

When he was unexpectedly cleared for the approach while turning
inbound, he forgot that he hadn't swapped the GPS over to the FAF
yet. That would also provide an explanation why he didn't see
the airport pass on the GPS -- he thought that he was getting
distance from the FAF.

Well, it's the old saw about being able to avoid any one link in a chain of
errors. Maybe the ADF was INOP? That would be a surprise. I know if my ADF
says one thing and my GPS another I'd probably trust the GPS. And on a bad
day we've all gotten fixes and altitudes confused, even for just a second.
We can do plenty of training, etc., to try and minimize the risk of any
individual error but we're all human and sometimes you have a bad day. And
sometimes, perhaps both members of a 2-pilot crew with thousands of hours in
type simultaneously pick the same day to make their month's quota of
screw-ups, and it's low IMC in the mountains. There but for the Grace of
God...

-cwk.

"OtisWinslow" wrote in message
...
This is one of the few plausible explanations I've heard. One thing
seems certain .. he thought he was referencing the FAF when in
reality he was referencing the MAP. Although you'd have thought
they'd have wondered why they never got the OM indicator. Also
since it says "ADF Required" I would hope they had one .. and
then wonder why they wouldn't notice why the needle was pointing
at the tail as they approached what they THOUGHT was the FAF.
GPS's are a great tool, but they can sure confuse the situation if
your switchology gets out of whack.

wrote:
Nicholas Kliewer wrote:
: I agree that they had confused the MAP with the FAF.

: One scenario I am thinking is that he had dialed in the MAP
: into the GPS and was planning on using it for DME. Then, when
: told that he was going to be holding for half-an-hour figured
: that he would dial the FAF into the GPS to use for holding and
: use the DME from the FAF to determine the MAP.

: When he was unexpectedly cleared for the approach while turning
: inbound, he forgot that he hadn't swapped the GPS over to the FAF
: yet. That would also provide an explanation why he didn't see
: the airport pass on the GPS -- he thought that he was getting
: distance from the FAF.

Interesting scenario and is consistent with the data. I haven't found any
word that there was an actual DME onboard. If your idea is correct, it would provide
fuel for the knee-jerk "Pilot error" explanation that appears to be applied in as many
cases as possible.

-Cory

"knee jerk" pilot error explanation? IF he was using a non-IFR certified
GPS to determine his DME, then it would definitely be pilot error, since
DME was not even needed for this approach, and if he used non IFR
certified equipment to provide something not needed and that contributed
to the mishap, then it was an error on the pilots part. I get the
impression, based on the wording in the report, that the aircraft had
operational DME, otherwise they would have pointed the lack of DME out
when they talked about the pilot requesting DME legs in the holding
pattern and referred to DME minimums. Perhaps he mistook station passage
of the LOM with station passage of the DME transmitter, knowing that
passing the LOM was start of final, but mentally expecting he would have
0 DME readout to confirm he passed the FAF. He started descent one mile
passed the MAP (MAP is 1 DME), so that would equate with a 0 readout on
the ILS/DME. It appears he started final descent as he overflew the DME
transmitter (wrong station passage).

It appears that he was initially navigating satisfactorily from the LOM
(he passed over it from the South to enter the hold) so he should have
known when he overflew it inbound and had passed the FAF inbound, and
yet he didn't descend at that point? The timelines indicate he was
probably 9 miles beyond the MAP when he initiated missed approach (He
was 3 miles past the airport at 1230:16 and called missed approach at
1233:21).

It may be something as simple as lack of situation awareness and not
studying the procedure before flying it, or it could be an aircraft
malfunction (one of the blades on the right propeller was bent aft
rather than forward; I thought that if it's spinning on ground contact
it bends forward), or something else. Guess we'll have to wait for the
final report to see what the conclusions are and if they can pinpoint
the cause.

I noticed the controller offered 10 mile legs; this exceeds the maximum
leg length for the size of pattern that would be expected at that
location based on holding speed and altitude. (This had no effect on the
mishap, and if the controller was using his MVA to provide obstruction
clearance, then it wouldn't matter)

No matter what the cause, it was a sad day for Hendricks motorsports.

JPH

MAPS like IUVM 1 are generally NOT in the GPS database, especially a VFR one.
The localizer itself is usually in the IFR databases, not sure about VFR databases.

Nicholas Kliewer wrote in message ...
I agree that they had confused the MAP with the FAF.

One scenario I am thinking is that he had dialed in the MAP
into the GPS and was planning on using it for DME. Then, when
told that he was going to be holding for half-an-hour figured
that he would dial the FAF into the GPS to use for holding and
use the DME from the FAF to determine the MAP.

When he was unexpectedly cleared for the approach while turning
inbound, he forgot that he hadn't swapped the GPS over to the FAF
yet. That would also provide an explanation why he didn't see
the airport pass on the GPS -- he thought that he was getting
distance from the FAF.

C Kingsbury wrote:

Saw on AvWeb that the preliminary file on the Hendricks King Air crash that
spawned much discussion here has been posted:

http://ntsb.gov/ntsb/brief.asp?ev_id...04X01760&key=1

For reference, here is the approach plate:

http://204.108.4.16/d-tpp/0411/05648L30.PDF

My take-away:

1. The FAF (BALES) was supposed to be crossed at 2600; they crossed it at
3900
2. They leveled at 2600 "in the vicinity of" the MAP; MDA there was 1340
3. 1 miles past the MAP, they descended again, at least to 1800, after which
altitude readout was lost. At this point they were 3 miles past the airport.
4. Three minutes later they reported missed and were told to climb and
maintain 4400.
5. Terrain was impacted at 2400', with the wings level.

If I read this correctly, it sounds like they (1) confused the FAF and the
MAP and (2) waited way too long to go missed. I am also interested in
hearing more about the missed instructions they received. As I read this,
they continued on the 305 inbound course all the way through. If they were
flying at 100-120kts (typical config for a king air 200?) they would have
been anywhere from 5-9nm from the airport when they reported missed. I
cannot find a terrain map so I don't know what else might be out there, but
it seems that if they had been turned right (as the published missed
specifies) they would have had plenty of obstacle clearance, but again, I
might be missing something.

The plane was equipped with a VFR GPS and no GPWS, according to the report.
Not exactly a gold-plater, it sounds like. Still, a VFR GPS will show you
when you've passed the airport.

-cwk.

Doug wrote:
MAPS like IUVM 1 are generally NOT in the GPS database, especially a VFR one.
The localizer itself is usually in the IFR databases, not sure about VFR databases.

Besides, if they had used the MAP or even the Airport Reference Point, they would
have descended earlier and missed earlier. To believe that scenario they would
have had to select a west of the airport.