If you look at SkyVector they had a tower that was 200 ft below them off to the left.
Yes. When I heard the pilots say they would “go around,” I suspected they really thought they were at the airport, perhaps even (briefly) after the ATC warned them about their altitude.* There’s no need to “go around” when you’re nowhere near an airport — it doesn’t even make semantic sense!
It’s really looking like they confused the road I mentioned above (Ranchwood Avenue) with the runway. They must have not used (not prepared and/or disregarded) any and all nav aids, AND failed to notice the absence of runway approach lights, PAPIs, etc.
It seems disaster really was narrowly averted (by an alert ATC) — for those on the ground and in the plane.
*I just now checked Reddit, and someone noted that the plane was close to stall speed (I think according to FlightAware), implying they were fully committed to landing (flaps out, etc.)
ETA: WildaBeast, yup.
Apparently they were cleared for a visual approach, and I’ve seen speculation elsewhere on the internet that they may have mistaken something else, like a highway, for the runway, and were descending towards that rather than the actual runway. But I stress that is pure speculation.
ETA: I see you ninja’ed me with the same speculation about confusing a road for the runway.
The commercial pilots can chime in but I can fly off a $500 Ipad and see everything in extreme detail. It’s not legal to fly an approach but it draws extended lines off the runways and marks the distance in rings. There must be a commercial version that gives pilots that kind of situational awareness.
Trying to catch up here; gonna be a few posts.
Thanks for coming back to this one.
As to citing NTSB links, what I do is search up the report entry in NTSB’s database, then capture the link to the docket page or the report page. And post that here. As you say, quoting snippets is hard and requires just what you did. But having gone to the trouble to locate the report, it’s easy enough to include the direct link to it so others don’t need to repeat the sometimes vexing search through NTSBs semi-crappy website.
Here’s the report; this link will download the PDF to your machine:
https://data.ntsb.gov/carol-epgen/api/Aviation/ReportMain/GenerateNewestReport/106014/pdf.
That’s sure the right answer. One can find oneself in a place where you’re too high / far down the runway to land on it, but not high enough to get to a safe spot due to terrain, etc., and just then the engine loses a bunch of power, or maybe all of it. But that was not this.
This was an instructor not really ready to deal with a partial power situation that probably started at brake release. He (?) just let the situation deteriorate until it was unrecoverable despite all the warning signs he was noticing but not acting on. The expectation of routine ops can be remarkably blinding to folks of the wrong mindset.
The icing the NTSB was speaking of was almost certainly carb icing, not airframe icing. Which carb icing may well have started forming the moment they started the engine. High vacuum (i.e. idle) is the main time carb icing occurs. Maybe easy to remember to turn on carb heat during an idle descent, but also easy to forget during idle taxi ops. Early Fall is also the time people forget about cold weather ops since it’s just starting to be cold. In the biz we have refresher training on winter ops in August to move those concerns back to top of mind before they’re needed and hot weather refresher in about April for the same reason.
Other potential non-icing causes are, as @Magiver pointed out, mag troubles. Or fouled sparkplugs from excessively rich operations, or even a mixture control that was mis-set for takeoff or the linkage had become loose so the cockpit knob/lever was in the right place, but the bellcrank or whatever on the actual carb was not.
My dad owned a small flight school. I started in 150s and similar rag taildraggers. I’d been flying for a decade before I touched my first jet in USAF. I get your POV completely.
What was poignant for me was the coming full circle. I can recall lusting after the size and speed and newer gizmos in a 172 just as you did. This one was petty raggedy all around, but did have a small GPS navigator on the panel along with the rest of the ancient avionics. Which GPS gizmo would have been Star Trek stuff when I started. But at the same time was tiny and hard to use versus the stuff in a modern jet.
Is there much training for flight instructors on how to actually be an effective teacher? My dad told me some of the things he did as an instructor, and I’m not sure if they were good teaching techniques. I remember my first instructor teaching me how to do a walk-around, including checking for water in the fuel. At some point, it dawned on me that I didn’t know what water in the fuel would actually look like. I found a puddle and added some water to the drain cup so I’d know what I was looking for. (Don’t worry, I didn’t add it back to the tank.)
There were probably other things that we talked about, but never actually practiced. There were so many things to pay attention to during takeoff that I don’t know if I was really looking for the plane to be low on power. I took off once on a single magneto by accident. I think it might have helped if my instructor had me do an aborted takeoff at some point. Not everyone has the same learning style I do.
I thought carb heat wasn’t supposed to be used on the ground. It bypasses the air filter so presents a chance of sucking objects into the engine. I think “carb heat – OFF” was on the post-landing checklist for a 172.
I have never been a CFI. But my overall attitude is that yeah, there’s not much emphasis given on learning how to teach, nor is there any thorough evaluation of the pile of old wives tales so often taught. Your example of the fuel sample is very apt.
IMO private flight instruction is a cottage industry and it really ought not be. At least not for anyone hoping to move to a professional pilot position. Bad ideas and bad habits implanted early are notoriously hard to dislodge later. Some Part 141 schools are quality. Others are like the scam tech schools preying on folks wanting to be a welder or a car mechanic.
As to carb heat, different airplanes have different procedures. Your comment about not using it on the ground is stirring long-dormant and now vague memories I sure didn’t think of when I posted. You may well be right.
But if indeed one is taxing around in conditions where carb icing can occur on the ground and procedures call for not using it on the ground ever, then how is that circle to be squared? I know I don’t know.
For a fixed pitch prop, actual power output == actual RPM. If the engine is making the rated takeoff RPM, it’s making the rated takeoff power; it can’t be otherwise. If nobody looked at the RPM gauge during takeoff, or nobody knew what a normal reading would be on takeoff, so the reading they looked at and observed was meaningless to them, then nobody should have been in that airplane.
For a constant-speed prop it’s the combination of RPM and manifold pressure. If they’re both right then the power output must be right. If they’re not, it’s not.
Terribly unforgiving of any carelessness, incapacity, or neglect. Some things are eternal. Just like gravity.
CFI candidates get a training module called the “Fundamentals of Instruction”. It’s a fairly thin booklet about how to teach (I was actually exempt from it because I was a certified teacher when I got my flight instructor certificate, but was still responsible for the information).
IMHO, the FOI is very out of date in terms of research, and comprises a… heh… crash course in how to be a teacher. Add to that a few factors:
-
Most CFI candidates don’t actually want to be instructors. They do it to build time and experience on their way to being an airline pilot or something similar.
-
Teaching is a largely subjective skill even when practiced by serious educators, so the results with CFI candidates are pretty haphazard.
-
It takes time and experience to be a good teacher, even for the most well intentioned. But most CFIs don’t do it very long as a full-time endeavor.
-
Once the checkride is passed, there isn’t much to enforce good teaching technique. That being said, I do think the FAA is correct in that they largely don’t micro-manage the way CFIs do things, which is a mistake public schools often make.
I used to bill myself as one of the few pilots who loved being a CFI, which was true. If I could make the same living as I did as an airline / charter pilot I would have stayed a full-time instructor. And it was a full-time job for years. I built a reputation for being able to help and retain problem clients (medical issues, problems with other instructors, learning plateaus etc).
It didn’t happen often, but on the occasions I saw truly bad instructors harming clients it really made me angry. It does a disservice to everyone.
Figured this might be a good place to ask an aviation related question.
My son is starting at Iowa State this fall pursuing an aerospace engineering degree. His interest lying mainly on the aeronautical side.
They are now offering as a minor Cyber Physical Systems. Any opinions on if this is a good minor to pursue along with aerospace? Will it offer him any advantages looking for an internship/job later on? Does it depend on his interest in that area or is all of aviation headed that way anyways?
As someone working in the aerospace industry, cyber is definitely a plus. Security at the hardware level is a hot issue.
I have a granddaughter starting at Embry Riddle this Fall, also in aeronautical (astronautical ?) engineering.
Best wishes!!
Indeed, current aircraft are so heavily networked internally that protection needs to be baked in from the specification and design stage onward.
I did not mean to ignore the SWA mistaken low approach near OKC. I’ve just been snowed under and even now there’s not much reliable info out there.
Short version is there’s plenty of avionics built into the airplane to provide a nice safe route to the correct runway. If the pilots use it. There are plenty of procedural steps to prevent reduce the likelihood of biting off on the wrong runway. If the pilots do them. There are plenty of good habits pilots can have to deal with correctly indentifying the point of intended landing out the window. If the pilots have been trained on them and use them often enough that they become reliable habit, not occasionally remembered cherries on the procedural sundae. etc.
At 9 miles from the end of the runway they should have been at about 9*300 = 2700 feet above the ground. The “terrain” there is very flat at ~1300MSL. So about 4000 on the altimeter is the right altitude for where they were versus the correct runway. You don’t get to be at 500AGL ~= 1800MSL through an altimeter setting mistake. You get there, at least in VMC, by descending there while flying visually towards what you think is the runway.
This has all the earmarks of them doing it the old fashioned way, where we used to look out the window and spot the airport and land on it. Lots less fiddling; just drive. But we’re all not nearly as good at that as we used to be. And for many of the younger folks they may never have even developed that skill. Oops.
It was a bit after midnight and they were finishing a ~4 hour flight from Las Vegas. We don’t know when or where their workday started. Good bet it wasn’t in Las Vegas; more likely it was somewhere upstream one or two cities previously. Who knows how tired and therefore unreliable they had become?
At that time of night ATC is also kinda tired and lax and maybe understaffed so maybe at 30 miles and 8 minutes out they say “Hey Southwest, you want a visual approach?” They look out the window, see the whole of Oklahoma City laid out before them, glowing cheerily in the clear summer night, know generally where the airport is and what it looks like since they’ve been there umpteen times, know they have their onboard electronic helpers, and say “Sure”. ATC says: “OK, you’re on your own. Have fun.” Then basically ignores them until one of ATCs computers clues the controller into thinking about them again.
Which decisions on both SWA’s & ATC’s parts at a stroke takes about 8 layers of procedural protections and removes them in the misguided pursuit of 30 seconds of time savings.
That sort of thing used to be common during the daytime at low traffic fields. Now it only occurs late at night. And it does feel good to be reminded of the old days of more freedom and flexibility when flying was less about computer programming and more about aviating.
Wrong runway and wrong airport close calls or actual landings occur as a small but steady drumbeat industry-wide. Most are embarrassing, some are dangerous or actually lead to crashes.
Back when I was a union goon in the early 1990s I participated in a sorta similar case while defending a crew from company discipline. In this case ATC had turned them loose at 2am 40 miles from the airport. They had visually picked out an actual airport to approach once released. But not the correct airport. They had noticed the ILS wasn’t working, but they chalked that up to the late night and it being switched off since the tower was closed. And there was no other good electronic assistance to find the field. Which was not uncommon in the 80s and even into the early 2000s.
They realized it was Podunk Muni as they were over the runway and nothing looked right about the surrounding town or airfield. They went around and proceeded sheepishly to the correct destination and landed uneventfully. Except for a night watchman at the wrong airport who they awoke and who called the police, nobody would ever have been the wiser in that pre-computer era. But … had they gone a few seconds longer and touched down on the municipal runway they’d have run off the end at a pretty good clip; the runway was far too short to get stopped on and the window to perform a successful touch and go in a jet is only a couple seconds long. Which ain’t gonna happen in time if you’re not already primed for it. Disaster averted at the last moment.
My guys back then goofed for sure, but they had a lot of help from the supporting cast of ATC and facilities and time of day and weather. SWA last week made the same mistake but with rather less “help” from everyone else except ATC who may well be the initial causal factor. These kinds of screwups ought to be a 100% thing of the past, not the 99.999% thing of the past they are.
CAVEAT: all this is based on the negligible details we have available. There may be a bunch more to the story.
Given the increase in drones and other unmanned/unpiloted systems, yeah, I’d say a cybersecurity background is a very good thing. We’re going to have some “interesting” events in the coming decades (hacked aircraft, etc.). We will undoubtedly build in as little security as possible until something proves that it was insufficient. At which point there will be great demand for people with that background.
could anybody donate a couple of sentences on carb-icing? Sounds weird (yet interesting) to a non pilot … esp. at 18°C ambient … why is this an obvious thing on planes but not on cars (at least at those temps) …
TIA
This is off top of my head from many years ago. Someone with more current (or greater) lightplane experience can probably provide better context.
Several overlapping things:
-
In traditional air-cooled aircraft engines, the carb is on the bottom of the engine and is separate from the engine itself, feeding the fuel air mixture to the cylinders through pipes. Unlike a car where it’s bolted to the top of the intake manifold that’s bolted to the cylinder block or head. As a result the carb in a car tends to be heated by conduction through all the metal, while that of a lightplane tends to be cold. Or at least have much less conductive heat supplied.*
-
Any carb and throttle plate represents a pressure loss device, which causes cooling of the incoming air and water vapor on the back side of the throttle plate versus the ambient air temperature. This happens in cars and airplanes alike. What is different is airplanes can spend multiple minutes at idle during a descent. Cars don’t do much of that. The longer the engine is idling the more net cooling is applied to the metal parts, eventually cooling them below freezing. Then water starts sticking to the parts in the form of ice.
-
The fuel being flowed into the airstream itself is being atomized / evaporated which releases a lot of cold into the air stream, further cooling the air. Same for cars, but airplane engines are generally run much richer than even 1960s carbureted cars were. Their carbs are also primitive 1940s designs with that stasis enforced by FAA regulation and the tiny size of the market not financially supporting innovation.
-
Airplanes spend time at altitude where the air is colder. On a warm summer day on the ground it can still be near freezing up at lightplane altitudes. The higher altitude portions of descents are where the ambient temp is low enough that the air temp downstream of the closed throttle is at/below freezing. Which slowly inexorably accumulating constriction of airflow may not matter at idle and won’t be apparent until you add power to level off. If that first happens at traffic pattern altitude, and the carb is 2/3rd clogged with ice, you may not have enough power to maintain level flight, nor the altitude remaining to resolve teh problem before you descend to ground level. Oops. The point there being that prevention is worth a lot of cure. Lots of carb het is used every day that may ell not have been physically necessary but was still procedurally required on a “just in case” basis.
For sure this is irrelevant to the accident we’ve been talking about, but 18C is not all that warm compared to the cooling effects discussed above. -
Airplanes spend a lot more time in clouds, regions by definition of 100% humidity that’s full of condensing water. Cars spend rather little time driving in pea soup fog.
This also isn’t relevant to the accident, but is to general operations.
* The B-36 was an interesting case of this.
On the PW 4360 radial engines, and indeed most radial engines of that pre- to post- WW-II era, the carbs are mounted on the back of the engine, opposite of where the crankshaft emerges to turn the prop. That protects the carbs from the cold incoming windblast and leaves them in the wake of heated air behind the engine. Very little carb icing.
On the B-36 the installed the engines in a pusher configuration. Which meant carbs forward and prop aft. That had two consequences the engineers either under-anticipated or could never quite cure:
-
The carbs were much colder, being the first part of the engine to be hit by the ambient air blast at altitude for hours on end. They were prone to severe carb icing and keeping them from icing up was a perenial problem.
-
The lack of prop-assisted windblast on the ground led to engines that overheated quickly and easily. Also hard to cure.
Bottom line: The standard prop-forward arrangement has multiple synergistic benefits that all turned into synergistic drawbacks when the engines were turned around.
The NTSB is not happy with Boeing:
Worth reading the whole thing.
Notwithstanding these requirements, we learned that on June 25, 2024, Ms. Elizabeth Lund, Senior Vice President, Quality, Boeing Commercial Airplanes, gave a long-planned media briefing without the knowledge or consent of the NTSB at which she released non-public investigative information and made unsubstantiated speculations about possible causes of the Jan. 5 door-plug blowout, which is directly at issue in the ongoing investigation. We have verified that part of the released information was either inaccurate or unknown to the NTSB while other parts were not previously disclosed to the public. Such a release or withholding of critical information from our investigators are blatant violations of NTSB’s regulations and the party agreement. This disregard of the federal regulations and rules governing NTSB investigations cannot be tolerated.
This is the second warning we have issued to Boeing in just this year regarding its flagrant violation of the NTSB rules. It is crucial that the investigation speaks with one voice — that of the NTSB — to prevent the release of inaccurate, misleading, unconfirmed, and out-of-context investigative information to the media, public, and lawmakers, which is exactly what occurred during Boeing’s media briefing. In the briefing, Boeing also portrayed the NTSB investigation as a search to locate the individual responsible for the door plug work. This is false and misleads the public regarding the purpose and scope of the NTSB’s purposes.
As our party agreement permits, we considered removing Boeing as a party to the investigation in response to the continued failure to comply with our regulations and the party agreement. However, we decided that Boeing will remain a party, but no longer have access to the investigative information the NTSB produces as it develops the factual record of the accident.
Imagine being so incompetent that you can’t even be trusted with information relating to an investigation of your own product.
thx, for the quality post!
really interesting to learn how some change in (what seems minor parameters) call for a - often - completely different solution…
One would impulsively say, just slap a proven car engine in there (a plane) and call it a day … until 3D gravity pushes oil away from the pickup in the sump and you are in for a white knuckle flight
Carb icing is something that would slowly lower power output and different planes are more susceptible than others. It’s corrected by pulling hot air from a shroud around the exhaust.
It doesn’t take much in a simple airplane for things to go south. I had a plane that lost power AFTER I did a runup which included a carb heat test. I was lined up for departure, advanced to full power on both mags and it didn’t reach full power. My first reaction was to pull carb heat again and then swap back and forth between mags and leaning the mixture. It just got worse with everything I tried which freaked me out because I was 30 seconds away from being airborne and eating up runway. I had a bad habit of ignoring the run-up time restriction on the carb which I think was 2 seconds. I probably gas soaked the plugs before the left mag impulse coupler snapped (timing issue) adding to the problem.
It’s very possible that I soaked the plugs on the runup and then again when starting the takeoff roll. I’m usually very careful to check but it’s also possible that the primer pump was not locked after priming and that allowed gas to siphon into the engine.
To this day that still freaks me out. The plane is supposed to run at almost full power on a single mag.