NTSB Final Report Addison King Air Crash

[@saratogapilot6100]

I am now 70 and finding that always using checklists -- which I rarely did when flying single pilot as a young person -- is actually a comfort and a confidence-builder. When my 77-year old pilot wife is with me, we try to emulate airline-style CRM that we learned by watching KZbin cockpit videos. It might look a little silly, but these tools are a great help in keeping we older people in the air as long as possible.

[@svyt]

I'm going to encourage you here and say that I don't find it silly *at all*. If I see someone doing that (or if I get to participate myself from the right seat), I think "man, this pilot has it buttoned down" and I feel like it adds a level of professionalism and safety.

[@FRANKSNAKE71]

Good for you! I just turned 70 and fly Robinson helicopters. I use checklists for preflight and startup regardless of having memorized them years ago. Checklists save lives.

[@rinzler9775]

Some people might think it sounds corny - but if Mr "I dont need no checklist or co pilot input" for this accident had have done one, then 10 people would still be alive.

[@tedmoss]

@@rinzler9775 Yes it takes more than one mistake (usually) to cause an accident.

[@matoatlantis]

Well, you are 70 and 77 year old pilots so you must be doing something right.

[@demagescod9657]

This case was near to me... both geographically and personally. I flew many many hours with the PIC.. In fact, I began my career with him. I have many stories, good and bad flying with him. He taught me a lot by showing me what not to do. The sad truth is that I and many others that flew with him believed strongly that we would some day read about him. My hope was that he would be alone when it happened. My worst fear came to be when I received the call and learned the plane was full. Horrible. I often stress over whether or not I could have done anything to prevent this. As a person, Howard was a good man. As a pilot he was scary. His bulk of experience made him complacent and overconfident. His stubbornness kept him in the cockpit despite his bad ankle and old age. There are a lot of lessons that all pilots can learn about this crash. The sad part is, we should all ALREADY know these lessons. Be humble and don't let your experience let you believe you are beyond mistakes or above SOP. And Keep your stick and rudder skills sharp. We have moved into an age where stick and rudder skills are declining and they are paramount to a baseline of safety. You simply have to maintain those skills. Another less obvious lesson that I think a lot of pilots are forgetting is to look outside when you can. I have no doubt Howard had his head buried in the cockpit despite it being VMC. If he had looked outside and flown the damned aircraft they would all still be alive.

[@cremebrulee4759]

Thanks for this personal insight. It a answers questions that many of us had.

[@Goosemancan]

wow, thanks for the comment. sorry to hear about that, but i think you are confirming a lot of peoples suspicions tbh. all the best.

[@Beau-r4r]

Kinda wish u would’ve spoke up about him maybe those poor folks would be alive today I’d love to listen to the stories of that pilot must be crazy that what u thought would happen happened the poor kid in the right seat got shafted too in this crash

[@ElChupahuahua]

So, you decided not to speak up? You decided not to warn people or go to the FAA and/or press?

[@aaronlopez3585]

A long time ago something my flight instructor taught me was not to overestimate my skills because if carelessness doesn't kill you foolishness will. I've never forgotten that advice. Thanks Juan

[@phillm156]

A very good advice in every aspect of life.

[@VictoryAviation]

That’s a helluva quote

[@VictoryAviation]

@@DrewNorthup well... yah. That’s why it’s good advice.

[@guidospaini7339]

@@VictoryAviation Somewhere in the Internet I've found this, which was attributed to Capt 'Lamps' Lamplugh: "Aviation in itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect".

[@robertalonzo5725]

Life lesson right there

[@Alixper]

Thank you I had an Instrutor he told me I don’t use check lists it takes to long. Got a new flight instructor the next day.

[@hiflier7197]

Absolute excellent judgment on your part!

[@robb3652]

Should be reported to FAA.

[@totallyrandom1126]

Wow, what an idiot………you, on the other hand, prove to be VERY smart…

[@jonathanneal4397]

He/She should not be instructing if he is teaching basic fundamentals wrong...excellent choice in selecting another instructor.

[@77thTrombone]

Kudos to you, Ali. Frankly, I'm not proud to say it, but I would not have had that wisdom in my young adulthood.

[@Mash4096]

I remember during my PPL flight training, that i found it difficult to control the yoke one-handed during landing. When i expressed this to my flight intructor, he explained it to me straight and simple; "Without your hand on the throttle, you don't have full control of the airplane." This has always stayed in my head ever since.

[@kennethpadgettflightparame3548]

Arrogance, pride, ignoring checklists/procedures will (sooner or later,) kill you. Especially in aviation. It’s just a matter of time. Thanks Juan for another great accident breakdown analysis.

[@tedmoss]

I was a fireman at Goldsboro, NC when a B-52 co-pilot was so busy looking at his checklist that he was not watching his wingtip and hit a fire truck and destroyed it. (Or so it was told).

[@mikekuczynski1552]

People forget it’s a dangerous sport , it only takes one time and you can be dead .

[@teleclasster]

I'm not a pilot but have always wondered why planes crash, and this site has taught me so, so much.

[@LeeKobe1]

Unfortunately, most crashes are caused by pilot error/ego.

[@gretchenlittle6817]

Likewise! And showing the friction control on the Luscombe really helped me understand how the King's left engine lost power.

[@edwinhsingmaster9135]

It's no different than crossing the center line while operatinga vehicle. The term is "Normalization of Deviance", and it may get you and some innocent people dead! I.e. The Challenger Spacecraft. Leaking seals for 6 years.

[@steveperreira5850]

If you become a pilot, and you are a sufficiently lousy pilot like a large fraction of them are, and you want to kill yourself and a whole bunch of other people, get yourself a twin engine, it will help you a lot in your endeavor.

[@guidospaini7339]

@@steveperreira5850 It's a little blunt way to present it, nevertheless I would like to add: "...and the good engine will fly you to the accident site".

[@jdhaase1417]

Juan, this reminds me of what could’ve happened several years ago when I was in copilot seat of a twin Cessna 414 departing Meigs Field in Chicago. I was just a private pilot at the time and only a passenger this day. The owner of the aircraft added an extra passenger at the last minute. The pilot did not reconfigure weight and balance. The plane taxied so slow that the pilot got out to make sure tires were inflated and after he did he proceeded. I’ll never forget the roll out on the runway as I watched the airspeed and the fence at the end of the runway. That airspeed was slow to climb and the fence got closer and closer and the pilot lifted off at the last second. As we climbed out over Lake Michigan I could hear the stall horn faintly screaming as we climbed and made our turn to the south. We were probably overweight and/or near aft limits at least for a short field takeoff. To this day I wonder why I’m still alive. That was a close call. The pilot should’ve taken the time to recalculate weight and balance that day. Not worth taking chances.

[@bokhans]

😬😩

[@ChrisCoombes]

Your description sounds terrifying

[@DARANGULAFILM]

I was a passenger on a small commuter service where the pilot was multitasking everything. There was no apparent booking desk and all passengers were standing around confused. The pilot eventually turned up hunting for his passengers. Time was getting away. He had to fly his circular route in time to link with a larger aircraft later. So we hustle out to the Piper Navajo, he loads luggage and we clamber aboard. With skill he is able to start his engines still staying hot from the 42 degree weather. He has to chase the port engine with the starter but eventually it runs. Then in the meantime somebody else has parked an aircraft and blocked him in. He can't taxi past and then turn sharp enough to get on the taxiway without running something over. The other operator does not get the hint so the pilot shuts down and gets out to negotiate and the other aircraft is moved. He comes aboard and restarts two now very sulky heatsoaked engines. As we begin to taxi, one of the passengers observes the hatch on the portside nacelle floating up and down. The pilot throttles the engines back, has a think, looks to the tower, keeps the engines running as for sure at least one will not start, then climbs past passengers and luggage in the rear, goes out the rear step door, which is out of the tower's view, secures the hatch, climbs aboard again and teases his way back to his seat. Our taxi and take-off was uneventful. If he did so at all, the pilot pulled back little power in cruise. Those poor engines. I was becoming nervous watching the pilot stress out as it all escalated towards hell for him but we got there okay.

[@tomsmith3045]

I don't like commuter flights at all.

[@paulazemeckis7835]

@@DARANGULAFILM i would have insisted to exit the plane.

[@Weasel1970]

It’s always tragic to discuss these topics, but I enjoy the way you spell things out in detail and enjoy your channel. Thank you for taking the time to make them.

[@demef758]

Many people view failure analysis as gruesome, but it has to be done. It's how we learn about system weaknesses and then correct them. The scary part about this crash is that there appears to be no way to correct it....

[@jerrymarbury9365]

​@@demef758 they need more of it and make pilots review and listen to the CVR so they can hear the terror of people about to be incinerated.trying to insulate people from reality adds to their denial

[@swashington942]

Why is it tragic to discuss these topics? Work for KZbin?

[@tilmanfrers7206]

Thanks for not beating around the bush about the cause of this accident. You're not afraid to potentially offend some people with your critique (I know a few pilots who would fit the character you're describing), and that's good.

[@nikovbn839]

If you know people like this, show them this video. Maybe they won't kill anyone and live longer themselves.

[@cremebrulee4759]

​@@nikovbn839maybe, but people like that aren't usually open to suggestions or criticism. They will never see themselves as someone this could happen to.

[@linuspoindexter106]

12:00 The pilot gets the Blanco Lirio Glare Of Disgust!

[@majobis]

Yes I saw that and how much it upset him on what this pilot did as well as others who fly aircraft this way.

[@steveperreira5850]

He sure does and he deserves it. What really disappoints me is that just about everyone that had experience flying with this guy knew that he was incompetent, yet they and the system did nothing to remove him from being a commercial pilot. The pilot himself is primarily to blame, but there is a measure of guilt that should be felt by the whole industry that allows incompetent pilots to fly when They are well known to be incompetent.

[@StortWeldingCoLLC]

YES HE DID!!!!!!!!!!!!!!

[@keepitreal6487]

@@steveperreira5850 Interesting. So how many pilots reading this thread know of someone like this...wonder if this is a turning point....can things really change??

[@TachyonDriver]

He got one earlier in the video too at about 6:05 when Juan mentioned the amount of sideslip. Not only did he give the G.o.D he let out the Sigh of Resignation ;)

[@UnlikelyHero]

My Dad had over 30,000 hours when he retired and still used the checklist for every flight. I'm working on my PPL right now and will be doing the same. Safety First is my motto.

[@FlyingWildAZ]

You better go straight to part 121 or you are gonna be shocked by the ugly truth you will find in this business.

[@dehoedisc7247]

My dad would use a checklist with knee board and paper maps in the family 1959 Chrysler when we went on the highways. He also had an Air Force job as aircraft commander of a B-47.

[@tedmoss]

@@dehoedisc7247 B-47 pilots do it with six.

[@johncox4273]

⁠@@FlyingWildAZI flew corporate for 45 years, both airplanes & helicopters, and while there are some shady Part 91 operators, there are also many excellent ones that take safety very seriously. They train regularly, have excellent maintenance, and never push their pilots. Just wanted to point that fact out to people reading this comment.

[@kennysherrill6542]

Juan this is gut wrenching in so many ways, as an aircraft mechanic I've serviced this model aircraft so I'm familiar with the controls. It's is sad for the loss of life, my Instructors hammered into me procedures are what you follow because people who wrote them died doing so. Like this pilot has now written a new chapter for us to learn by and innocent people paid the price. Thank you Sir for your hard work bringing this to us, you have the best channel I believe, your very well equipped and knowledgeable on these subjects. SEMPER FI 👍👍👍👍👍🇺🇸❤

[@telquad1953]

My thanks to you for producing videos you know will be demonetized. I worked on aviation ground equipment (radar, comms, and ATC displays) for 45 years and still care very much. Safety is a way of life.

[@jendarjendar9233]

Juan, i have been watching your Chanel for over a year now. i'm 52 PPL working on my AGI for ground so i can teach ground only. i have learned so much from your chanel and with the grace of god i can try and prevent some of the stuff covered on your Chanel happening to me. god bless you . so happy your back in the right seat after going through your medical. your truly an inspiration to me..thank you

[@percyfaith11]

10 years flying in the Navy and not being a youngster when I got into the right seat in the airlines gave me the maturity to notify the "old man" in the left seat if something unsafe was going on, no matter what he said about it. That's the 2nd in command pilot's greatest responsibility.

[@sop2510]

Sounds like the pilot was spinning those cosmic tumblers every time he flew. On this takeoff they finally aligned and took nine innocent lives.

[@zollo9623]

There is an incredible up close video of this accident on WFAA (KZbin). They requested an “open records” request which released the videos they (NTSB) have. Great educational videos! Thank You for your time, patience & thorough explanations of what occurs during these unfortunate accidents!

[@Jerrylumdegaard]

My God, how many holes did this pilot line up in the Swiss cheeses slices? Incredible number of errors on this one. Awesome cockpit breakdown in the mighty Luscombe as well!!!

[@steveperreira5850]

One, no checklist Two, no CRM Three, no preflight Four, overweight by 600 lb Five, nearly out of balance Six, hand off throttle Seven, lift off to slow Eight, wrong Rudder Nine, nose high TEN People killed! What was left of the pilot should have been tarred and feathered.

[@jsmith1746]

When I was flying the Beech 1900, which is basically the largest member of the King Air family, the procedure was for the pilot monitoring to guard the throttles until 400 AGL. The flying pilot would remove his/her hands from the throttles at V1, but the pilot monitoring's guarding of the throttles was the safety against the possibility of the throttles accidentally sliding back. Also, at least for the 1900, the auto feather system is a required item. If it did not arm by 80 knots, which was indicated by two green lights labeled 'AFX' next to the torque gauges, then it was an abort. At low altitudes and high power settings, pilots could not react fast enough to an engine failure to manually feather the prop before losing control. We actually demonstrated this in the sim many times, and it was pretty scary to see how fast you could lose control. This is a very sad and senseless loss of life. A professionally run flight deck could have saved the lives of all on board.

[@robinmyman]

Absolutely the worst case of pilot incompetence I’ve heard of.

[@pokerbosscycler]

yeah smh 🤦‍♂️

[@jeanineavila9506]

Pride kills.

[@bjs2022]

The old, overly self-confident guy in the Lake Amphibian at Oshkosh comes close. Several people told him not to fly but he ignored them and killed himself and a backseat passenger. The “copilot” survived.

[@jerroldbates7015]

How sad.😢

[@csouthland]

It's easy to judge in leisure what others had to do in hast. The whole flight lasted 17 seconds.

[@easttexan2933]

Good info Juan. I think we all initially thought this was an engine failure and in a way, it was with the same results. Such a tragic loss of life.

[@ColinWatters]

I was only ever a glider pilot but twice when I rode in powered aircraft the pilot asked me to keep a look out and speak out if I wasn't happy with anything. I was pleased to see him do "what if" checks before we went anywhere. Pretty much the same planning that I was taught to do before being winch launched. It takes seconds. Saves lives.

[@Ro32da72]

'We're here to learn, not to criticise.' This is what keeps me coming back to this fine channel. It's astounding that YT demonitise your content, given it's inherent value to the aviation industry. Your accurate and compassionate analysis of these incidents will, if it hasn't already, prevent an accident. It's so important that we discuss these events in a mature and non-judgemental way, and you do that so well. Thanks Juan, keep banging the drum dude.

[@bouncebynum]

Good grief...it's even worse than Dan suspected. This is infuriating.

[@kenhurley4441]

Hey Juan,,,, I just turned 71 (5-19) and yep I can't do the things I use to be able to do. However hopefully I haven't created any bad habits in my flying. These videos keep my "tuned" up on flying. One of these days (next year) I'll fly out to Grass Valley and see you. Thanks for another great video!

[@Ozinater]

Great video. I`m a flight instructor and it bugs me to no end when students take their hand off the throttle and put it on the yoke, dashboard or in their lap during takeoff/climb or approach/landing. The other day departing the circuit, one of my students let go of the throttle and rested his hand on the dash while we were climbing, so I took the liberty of pulling the power back myself (which he reacted to and added it back in). He was a little perplexed initially but I told him that not guarding the throttle during those phases of flight is a potential invitation for me to monkey with the power setting... Or if I`m not there, for the throttle to slide out by itself. We had another guy recently who was convinced for a few (probably terrifying) moments that he had an engine failure right after takeoff, but in reality the throttle was just sliding out because he took his hand off of it.

[@johnstudd4245]

Maybe I missed it, but was the sole reason for loss of power in the left engine the uncommanded movement of the power lever? This guy mentions a drop of prop rpm from about1720 to 1688 as being "significant". A drop of 30 rpm or so in one prop is significant? Was it the prop rpm lever or the power lever that moved? This guys report on the information is not very clear or complete as to understand what really happened, other than the pilot procedure was terrible.

[@billdonohue2389]

You can hear the anger in your voice because of such a senseless loss of life. All the pilot had to do was follow the rules and instructions and this very possibly could have been avoided. So sad.

[@sm3xym3xican76]

My frustration arose when he mentioned that there was no use of checklists on the CVR, as well as the pilot having a history of not using them. Pilots live and die by their checklists, and you should never get complacent with them

[@donanders2110]

The fact that this man, flew a perfectly good airplane into a hangar, killing innocent people, is mind boggling!

[@keepitreal6487]

the outcome was never gonna be good for anyone in that situ...but better to hit anything horizontal than inverted at full chat.

[@gocanada9749]

I hope the families went after the pilot's assets

[@orthopraxis235]

@@gocanada9749 Causing a war over a dead man's assets does not address nor fix the root causes in this scenario.

[@orthopraxis235]

Is it "mind boggling"? This can happen to any human, at any time, so it shouldn't be considered mind boggling. Any pilot has the potential to perform this badly, that should serve as a reminder to train, simulate,analyze and improve one's performance as part of a flying career. Thinking that is it mind boggling, as you if cannot understand how it could happen, puts you in the position of potential hubris and oversight regarding your own abilities. Any or all of a past pilot's mistakes any other pilot can make, on any given day. Sure, it's sad, exasperating and frustrating to see this chain of events, but surely not mind boggling. Pilot's need to be vigilant for their potential for carelessness so that they train to avoid it. That's the main lesson here. Beating on the memory of a man who has been already down serves no useful purpose. To say it's mind boggling, shows that you don't recognize each of us has the potential to perform terribly, and we need to be ever vigilant to guard against that via our awareness and training.

[@donanders2110]

@@orthopraxis235 I am sorry, typing a dissertation, does not make this any less mind boggling!! There was nothing wrong with this plane. The fact that this man, flying as long as he had, would cut corners an not use check lists, boggles my mind! This was not human error (which we are all capable of) this was flat out negligence, he made a choice to be this careless!!

[@stevedittrich4411]

This was a very informative program. As a private pilot, the use of a checklist was drummed into my head. As they say, there are OLD pilots, and there are BOLD pilots. But there are very few OLD, BOLD pilots. One thing about flying. You rarely get a chance to repeat your mistakes.

[@jimmcafee4153]

My dear neighbors/friends of 20+ years were on this plane. Just makes you sick to think this accident was 100% avoidable!!

[@ianutube22]

I'm sorry to hear that. Like with all things involving humans, not all pilots are equal. I agree that this was completely avoidable.

[@FreedomfromFeminism]

I think we all agree that your excellent channel does a great service to GA by identifying common accident causes AND as importantly, by stressing to all pilots such crucial information as using checklists, proper CRM, GWT an CG calculations, risks of IMC and icing, etc., etc., etc. The fact that KZbin punishes you through demonetization is ridiculous and perversely hinders our ability to further learn from our collective mistakes. Shame on YOU, KZbin Keep it up Juan. You are doing invaluable work.

[@cjc1103]

Juan really knows his subject, and spends a lot of time researching and producing videos to help other pilots. As a pilot myself I have been in situations where the captain makes questionable decisions, as the copilot you have to know when to speak up, and when it's not going to matter much, so save your ammo. I would have called him out on the weight and balance, and not following the checklists, made him do a takeoff brief, and I certainly wouldn't have flown with him more than once.

[@flyingmonkeystunts9730]

Thanks for how you conducted this video. I was friends with 3 of the people on this aircraft. The information is important but the sensitivity is appreciated.

[@jameshoopes6467]

The huge sigh told me everything I needed to know.

[@dustyflair]

where? when? put the time line ref, capt obvious.

[@vincenthighwind7622]

@@dustyflair 6:04 Wasn't hard to catch if you pay attention

[@dustyflair]

@@vincenthighwind7622 I didnt have 20 minutes to listen for 1 second...Jeez....this is too easy

[@jackievarughese3945]

My instructor always told me to use my checklist, even if it's easy ones like climb checklist on a 172, if i don't do it he called me out. I'm really thankful for having someone that taught me right.

[@gfel9468]

After skipping checklists, panic flying without gathering his SA after things hit the fan, this pilot quite literally steered the plane into the ground. Man this one is tough to watch.

[@232K7]

SA ? situational awareness? Genuinely curious; cheers

[@Parattchi]

@@232K7 spatial awareness, knowing where he is in the air and which way he's going.

[@svyt]

@@Parattchi A respectful correction: in aviation terms, "SA" is used to represent "Situational Awareness". Spatial awareness is certainly one specific *part* of that, but the idea of Situational Awareness is much more broad, and encompasses the entire picture of the flight. Not just "aviate, navigate, and communicate" (which are certainly "the big 3" tasks on the priority list) but also everything else that factors into the conduct of your flight. SA includes all kinds of stuff - the systems, capabilities, and any faults of this particular aircraft; the skills and capabilities of a co-pilot; the weather here, and the weather ahead; the list goes on. As GFel94 pointed out, an awareness of which engine is at fault in a reduced-thrust scenario in a twin is *absolutely critical* to the decision-making process of what to do next. Checklists add a layer of safety against forgetting something important (i.e. friction locks) and briefings allow you to pre-think some of the most common/consequential emergency scenarios (e.g. power loss) so that if they occur, you have already "practiced" the scenario in your head, which can give you a head start in reacting in real time. Skipping checklists and briefings removes those layers, and decreases your safety margins. You can do that for years, play the odds, and have nothing bad happen ... until something bad happens, and suddenly you are caught unprepared.

[@dfb1111]

Another great episode, thanks for the no punches explanation. This is an example of true critical thinking to learn from an event and focus on the measures needed to prevent tragedy in the future. Those of us willing to listen thank you for taking the time to produce and present this video.

[@tomcorwine3091]

I do that same index finger thing with the throttle, but I never even really thought about it until you mentioned it.

[@steveperreira5850]

I think everybody does it that way with that kind of throttle? Don’t you think? That’s the only way I ever did it. You use your index finger as a reference and to allow smooth sliding of the throttle as Juan Says.

[@tomcorwine3091]

@@steveperreira5850 I guess. I just never thought about it until Juan said something. Then I was like, “Yeah, I do that too.”

[@mikehunt2190]

I can tell you in my experiences that a lot of old men have a major problem with taking advice or suggestions from someone much younger than them. The pilot not wanting his co pilot touching anything or having any input on the controls is an example of that.

[@davidbeattie1366]

Young men never ignore good advice… NOT.

[@chamonix4658]

@@davidbeattie1366 thats not what he's saying at all, where did he say that? stop projecting

[@davidbeattie1366]

@@chamonix4658 please re-read. He says older men have a hard time taking advice from younger people. There are young people who have the same problem. If anything, an older pilot has learned the value of accepting advice. That usually has contributed to him being an older pilot.

[@johncox4273]

@@davidbeattie1366thanks David! As a “senior” pilot that often works with young pilots, I find that they usually value my experience and are very open to taking advice. I’ve had my share of young copilots over the years, and have always enjoyed working with them. I always kept the lines of communication open, and always included them in the aircrafts operation. In most operations gone are the days where the left seater told the guy in the right seat to sit there, don’t touch anything, and shut up!

[@nhwilkinosn]

It really bothers me how many of these accidents (this and the 9 oh 9 come to mind) where these... "Seasoned" pilots REFUSING to let a certified pilot assist in emergencies... Leading to tragedy. Great reminders of the kind of pilot i NEVER want to be.

[@ccpperrett7522]

@@coriscotupi exactly!

[@Andyaero]

"Seasoned" doesn't mean smart. As a fresh out of school private pilot I flew several times with much more experienced commercial pilot and every time before engine start he used to brief me on the basics of his airplane and asked me to speak up if I see or feel something wrong. Nobody in a sane state of mind would intentionally refuse extra set of hands and eyes in the cockpit when these hands and eyes already sitting on the right seat.

[@nhwilkinosn]

@@Andyaero yep. There's a reason i put the seasoned in essentially air quotes. I'm glad that the age of "the captain is God" is dying, but sad that that's also somewhat literally true. Every time i watch one of these videos, it urges me to be more diligent and exacting in my checklist usage and crew resource management. I try to tell everyone i fly with the same thing. You see something you don't like or don't think is normal, for the love of all that's holy, speak up, and speak up right away

[@ShuRugal]

The 121 industry may have learned from the Tenerife disaster, but it's clear that the lesson was mainly one that MANAGEMENT learned, and enforced, but individual pilots of that era did not.

[@homecats1]

If I’m getting in an airplane in the right seat and could play any part in potentially saving the flight, you bet your sweet ass I’m gonna make myself heard by the pilot or I’m getting off the airplane.

[@johnrosenberg9407]

There are thousands of King Airs flying and thousands of King Air pilots. They should know that the friction knobs are critical enough that, in our operation at least, they are the first item on the before takeoff checklist. The main reason for power lever migration isn't because of typical vibration but instead because of a purposeful design. There is a heavy duty spring under the cowling that is designed to push the power levers toward idle. This is a safety feature so that in the rare event a power cable breaks the engine won't overspeed and damage itself by going to full gas generator (N1) RPM. Instead, it will harmlessly wind up to idle RPM. In the King Air, it is essential that the friction knobs are tightened before takeoff and during the takeoff all the up to a safe altitude, the pilot flying should keep his/her hand on the power levers. If momentarily removing the hand to raise the gear, then immediately place the hand back on the power levers. Power lever migration may seem obvious when an engine loses thrust but not always so. Ther are cases in the past where an engine was suspected of having failed without noticing that it was simply that the power lever migrated back toward idle. So, after sensing a thrust loss with the attendant yaw, fly the airplane first, and then grab a handful of power levers and push them up. If that solves the problem then the thrust loss was recoverable. If the engine does not regain its torque, then it truly may have failed and is not recoverable. If the autofeather system is armed and there is a loss of torque, the propeller should start the feathering sequence. However, if the loss is due to power lever migration, autofeathering will nor occur because the system will be disarmed. Both power levers must be pushed up to activate arming switches under the power quadrant cover that are the equivalent of where 90% N1 will occur.

[@harrickvharrick3957]

Thanks for that great info. However that sounds like it could (should) be designed a lot better and more intelligent, even if in just a mechanical way, than a mere spring under a knob pushing 'the wrong way', a built-in certainty to prevent too many rpm's in case that...

[@ЗлаяСобачка-ч6э]

@Harrick V Harrick yep, FADEC and autothrottle, must be installed on the plane, which costs about 8 millions bucks.

[@stripeybeast]

What a wild crash. I had a desk against the window of the 10th floor of a building overlooking addison airport. Obviously didn’t see the crash itself, but the fireball and smoke were very very eerie. Was tough to keep working - took a walk over near the hangar and it was understandably a media frenzy.

[@firemedic5100]

I had a pilot who was also an A&P for many years, and had several hundred hours in the 300, told me this on the day this crash happened. To him, based on what he had already seen on the news, he felt it almost had to be pilot error. He said he has lost thrust on an engine due to a mechanical issue, and while it can be disastrous if not handled properly, it is not that complicated if procedures are followed. No checklist, no CRM is begging for a bad outcome. Such a shame.

[@sagittarius_]

Thanks for a super video as always, Juan! This kind of accidents always reminds me of the terrible 747 Canary Islands crash caused by a "shut up and do as I say"-captain...

[@user-px1wj2uv3r]

I haven't seen the Swiss Cheese diagram since the Navy. It's a great way of explaining, not just safety, but high standards in general. Look the other way long enough, and the holes will always line up. 👌

[@allanschuster3520]

Age may not have been a factor but attitude certainly was. Thanks for the review.

[@jospi2]

Reaction time gets slower with age.

[@steveperreira5850]

I would prefer younger pilots fresh from training, and more alert, but age was not the problem here as you say, he was a cowboy not an aviator.

[@LIamaLlama554]

71 year old has no businesses flying innocent passengers anywhere.

[@SheepWaveMeByeBye]

My 73 year old father in law falls asleep while driving. He didn't do that when he was 40.

[@avfan967]

@@LIamaLlama554 that is a completely ridiculous statement. Shows bias and prejudice and that’s not what we take out of any accident, we take out performance, training, and proficiency. All of those were obviously lacking for whatever reason and there are countless numbers of accidents all composed of those same issues at a variety of ages. It’s about attitude not about age. The author of this video is equally bias and even mentioning that and knows better. Not sure what his intention was, but it’s off the point and many other commenters are pointing it out to him

[@johnparkman8150]

As always...great analysis Juan...I learn something from you every video...im 56 years old and just got my ppl last August...but appreciate everything you do so thanks!!!

[@HamBown]

Thanks as always for the great coverage Juan. It sounds like this guy was an accident waiting to happen for a long time; too bad it had to happen with a bunch of other people on-board.

[@lapoint7603]

A friend of mine quit flying commercially at 70 yrs of age. He said that there was a huge increase when he turned 70 and that it was prohibitive for his company to continue to insure him. He amassed over 35,000 hrs, most of it in Navajos and Mooneys.

[@leeadams5941]

Thanks for this...one of the things I like about your reports is you call a spade a spade and not a shovel. Had the unfortunate experience to fly with some folks like the pilot in my military career. Problem is they usually end up killing more than themselves when their incompetence finally catches up with them. As usual the video and the conclusion is excellent.

[@Markle2k]

The B-52 pilot who killed his crew while practicing for an airshow at least apologized before impact.

[@gomphrena-beautifulflower-8043]

Even us non-pilots have learned from Juan and other serious Aviation channels: CRM and checklists must NEVER be deviated from.

[@232K7]

Especially checklists!!! If checklists are adhered to then accidents become virtually impossible

[@77thTrombone]

Actually, checklists _can_ be deviated from when the ratio of "problem magnitude" to "available energy+time" is sufficiently excessive. Know your memory items. Checklists are preferred, but don't checklist yourself into the ridgeline.

[@leokimvideo]

Very VERY similar incident as happened at Sydney Airport in 1980 with a Super King Air 200 that killed 13 people. Pilot had engine failure just after takeoff and attempted to land but crashed into the sea wall at the end of the Botany Bay runway. In fact the similarities are scary similar in both crashes. Maybe Juan it's worth looking back on the fatal Sydney King Air crash. I remember it well as a 12 year old.The cause of the engine failure has not been determined, but the most likely explanation is that the aircraft was operated in a reduced power configuration which, under the prevailing conditions, rendered its single-engine performance critical in respect to aircraft handling. From memory the pilot turned on the failed engine side.

[@Clough42]

I loved the slower, somber version of your theme music for the montage, ending with the souls on board. Well done.

[@marklaw1434]

Classic normalization of deviance. Thanks for your clear and concise analysis Juan.

[@Badge1122]

When I started flying my instructor told me to read Stick and Rudder. I did very carefully and fully understood how a plane flys. I never hear about that book today.

[@FlyingWildAZ]

Stick and Rudder is still the bible, and any pilot worth his salt has read it.

[@joelgeudtner8187]

I just bought it yesterday, can't wait to read it. I'm 64 and just now learning to fly!

[@j.gregory5669]

One of your best, very clear and concise. Keep up the great work!

[@255-southcarolina8]

Not a pilot but learning a lot from you thank you for the content and information

[@stewartsmith1947]

Thanks Juan . You and Dan will save a lot a lot of pilots and people . Thanks for the great informative videos .

[@alexwilliams865]

Juan, I'm with you on about 90% of your dissection of this event. I am a King Air 350 captain at a 135 operator. We train hands off the throttle at V1, just the same as any other multi engine turbine crew does to prevent inadvertent throttle changes after V1 and to reinforce commitment to treat any post v1 failure as an in-flight failure. Throttle migration is however a well known King Air foible. This accident is full of crew issues, but I'd argue that a hand on the throttle was not necessarily one of them.

[@rumbecker5085]

the issue here is that it was a single pilot and 2 crew operation. PNF should have set takeoff power and set the friction locks and set climb power again at 400 feet. I have 8000 hours on king airs all 2 crew, power levers on these aircraft have a tendency to creep back, I always could count on the PNF to set the friction locks properly

[@FlyingNDriving]

You step on the correct freaking rudder pedal, it's not fucking rocket science to use your feet to keep the nose pointed down the center of the runway

[@iowaphotos9107]

Thanks Juan. Teamwork makes the dream work. Hopefully there are lessons leaned and lives saved in future flights by this review.

[@Ozgrade3]

Escellent video Juan. This video should be included in Human Factors class. I'm a 5000 hr CFI. You take your hand of the throttle during take-off, it's an instant fail, or I pull the throttle back to idle (assuming we have enough runway). Instructors - do that 3 times and your student won't do it again. A tip for ME instructors....... that was given to me during my own training. When the student has the throttles, place your fingertips at the base of the throttle leavers so you can feel where the throttles and prop levers are without looking at them. That saved my bacon several times.

[@jt200drivr]

Been waiting for this final report. Glad it is finally out

[@univibe23]

In the AF we had a saying: Airplanes don't crash by compartment. If someone sees something wrong speak up and take action.

[@irvcranistan]

Hi Juan, Greetings from Japan. I watched this video (and others) and like your style, your fact-based analysis and real time review of the subjects. I thought you did a great job (props including toy ship) on the "Ever Given" container ship stuck in the Suez Canal. All the best, Steve FAA A&P, Private Pilot, former Boeing FSR & "MRJ Fleet Chief." Nagoya, Japan

[@smoothoscillator1]

I learned a lot watching this video. Your analysis of this accident was great. Made me think of John Madden analyzing a play during a football game.

[@chuckcampbell3927]

Great job Juan. So very sad. Lost a friend back in 77 in almost the same way. You can never train enough. 🛫🛬📖

[@guidospaini7339]

Again Juan, thanks for the time and effort to compile and present us this information in a simple and useful manner. This allow us to understand what really happened in this tragic event. And also help prevent the repetition of these accidents.

[@stanbrow]

Thanks for the solid analysis, and explanation.

[@pilotpotts62]

A tough subject that needs to be addressed as well is encouraging pilots like the right seater in this situation to NOT stand for behavior like this. It’s hard because a lot of people at a young stage in their career can get into situations where the flight time is number one priority. Remember it’s not worth your life to put up with an unsafe pilot. It will be hard to speak up and possibly walk out, but there will be more opportunities.

[@irvhh143]

Not if the senior pilot has you blacklisted. Too many trainees and too few right seat opportunities.

[@ai-d3982]

@@irvhh143 you could also refuse to fly with a potential deadly colleague

[@michaelpcooksey5096]

@@irvhh143 How about reporting the senior pilot if you survive the flight? or... maybe feign sickness and just exit the plane?

[@FlyingWildAZ]

I'm glad you acknowledged the almost impossible position these poor kids in the right seat are in. The right answer briefs wonderfully in the classroom, but real life just ain't like that. Only by the grace of God do many make it through this phase in their early career.

[@quest2outdoors]

I grew up flying with my father he taught me everything to do taking off and landing in case there was a problem what a shame this man thought he needed to do it all himself

[@2101case]

Centuries before human flight, wise men recognized that pride goeth before a fall. Some things never change.

[@TheTonylewis365]

Again ! 1st class report, well done Sir.

[@robsaudio]

Juan; Really enjoy your channel, intelligence & seasoned airmanship. Don't think I've missed very many of your AND Dan's Probable Cause informative & educational awareness of man & his flying machine. All the best, Sir. R. Smith

[@oldguydoesstuff120]

This is a very sad report to hear. It sounds to me like there really isn't much to learn here. The lessons this crash teach us have all been taught before.

[@lynnkramer1211]

There is something to learn for someone in the right seat. Can you not see that?

[@oldguydoesstuff120]

@@lynnkramer1211 I can. But like I said, that lesson has been taught before. More than once.

[@NicolaW72]

@@oldguydoesstuff120 Indeed. It sounds like a crash fifty years in the past.

[@bernardc2553]

100's of times & Paid in blood!

[@oldguydoesstuff120]

@@lynnkramer1211 On reading your comment again, I see that I didn't express myself as clearly as I could have. I should say that it appears to me there is nothing NEW to learn from this crash. That is what makes it so sad. This crash appears to have been preventable by learning from previous crashes and avoiding the mistakes that have been made before.

[@collinreesejones5525]

Another excellent video! I have tons of time in my Mooneys...would take off without oil before I would take off without doing my CHECKLIST! I always do a takeoff briefing even when I am usually alone!!! Good habits!!!!! Thanks Juan😁

[@Bluenoser613]

Wouldn't it be such a treat to have an instructor like Juan

[@baomao7243]

I am currently ASEL but have been seriously contemplating pursuing AMEL. I have spent a lot of time pondering the “perishable” nature of skills, esp. emergency procedures and the reduced “time to act” margin on takeoff/landing for multiengine (and inadvertent IMC) Your videos do a great job of showing that safety has no shortcuts and that consistent procedures and recurrent training are ESSENTIAL. Thank you for analyzing these incidents, Juan. These videos are sobering.

[@satguy]

In the end it boiled down to the pilot being a stubborn old man. And no prior checkride showed this.

[@stevegiboney4493]

1000 hours in type would tend to make the pilot think “ I got this”

[@satguy]

@@stevegiboney4493 Or complacent, which brings me back to my checkride question.

[@buckmurdock2500]

You mean his checkride 30 yrs prior?

[@satguy]

@@buckmurdock2500 I'm assuming of course he had a multi-engine with a complex aircraft endorsement, with an instrument rating. That means a check ride every 24 months, unless somethings changed.

[@buckmurdock2500]

@@satguy Oh, you are referring to a flight review, see 14 CFR § 61.56. That is not a checkride, it is not pass/fail. The pilot completed a flight review 11 months prior to the accident which was satisfactory.

[@thomasjunkins6491]

So thankful there are people out there like you Juan investigating these accidents and going over the data. Have a great Wednesday afternoon.

[@rdoody2067]

I’m 71 and can remember my primary training in my 20s. We didn’t use checklists in our C-150s. My question later on in the more complex aircraft was why didn’t we? Never the less I use checklists no matter how simple the aircraft. It is a good habit to have. I have my multi as well. This is incredibly tragic and avoidable event.

[@flyingphobiahelp]

Great job as always, Juan. Thanks for explaining to your subscribers how much work is put into the NTSB investigation and hence why reports take over 12 months to publication. BTW New Zealand airline pilots are exempted from the age 65 rule BUT are restricted to flying domestically.

[@davemcgowan2731]

Excellent presentation. The facts are scary.

[@RaymondCore]

This happened just before I retired and moved away. I lived less than a mile from Addison Airport and flew in and out on my friend's Bonanza. Thanks for closing the book for me. Nice airport; large enough for 737s. I would say 'complacency' killed those folks.

[@Sugah_J]

I work for the airlines and fly complicated jets. I haven’t done it as long as you have Juan, but the fact remains that I can hop in my simple 172, go without using a checklist and probably be just fine. However, I use it every damn time because I know two things: when things hit the fan you revert to your training and most importantly: I’m not perfect. Checklists don’t forget things. This is an absolutely tragic accident. CRM saves lives.

[@danieltopham5911]

This was a tragic accident and so unnecessary. Thanks to your and sites like yours these types are coming to the forefront much faster and better described than in the past.. This was so unnecessary it is hard to describe.

[@Ghostopheles]

I saw the aftermath a day or two after it had happened, know the guy who owns the hangar next to that one. Harrowing scene, nice to finally know what went down.

[@marktownsend7361]

Hands down the best Aviation breakdown videos on the internet !!!! Sir exceptional work once again.

[@simonsmith3060]

I can't tell you how many Human Performance errors we reviewed in my brief Nuke career that involved the dreaded Pilot-Copilot combination. Where the older, senior grade, more experienced operator was an asshole. Tenerife being the most egregious example in the flying business, Dyatlov at Chernobyl being the worst nuclear example. Happens more than it should. One method we found that worked was to train the junior partner to try to get the senior into "Teaching Mode". If the junior operator can get the senior into helping him understand without challenging his seniority, without sounding like an idiot, many of the crusty and emotionally conservative seniors would turn into an instructor. But there were always those guys who wouldn't.

[@TexasKid747]

Hi Juan B. I hated to see this event unfold at the field where I took the few flight lessons I did take way back in the 1980's, but I am always glad, educated and impressed with your input. At almost 60 now, I hope to return to flight one day, now that the kiddo's are adults and KADS would be my field of choice. Thank you for all of your content. Cheers from Texas.

[@publicmail2]

Dead Foot Dead Engine! Get the nose down, raise gear, and verify dead foot dead engine, put necessary rudder INTO working engine, secure dead engine and fly the plane.

[@Captndarty]

Is that what you do?

[@thompsonjerry3412]

We hope we all do that, push and fly.

[@pittss2c601]

Aerobatic pilots do that regularly without conscious thought.

[@OfficialUSKRprogram]

But my checklist says to shut down the engine first! What am I gonna do?!?

[@charlescrisefi8784]

You don’t have time for deadfoot bs 100 ft of the ground . The rudder is and all that drag is what got him into trouble!

[@WolfPilot]

Great video Juan! Thanks for getting this produced. That pilot had no business flying that king air. I have heard from somebody that he had a bum right foot or leg as well, that may have contributed to the faulty rudder input.

[@villagecarpenter2266]

Why wasn't this pilot reported? Obviously someone knew he wasn't doing the right thing. I would have said something to someone!

[@lynnkramer1211]

You wouldn't just sit there on your hands and hope for the best? Trying to not ruffle the captain's feathers and maybe have to find another job or get black listed as insubordinate? Complacency can kill.

[@buckmurdock2500]

Where does one report these airmen? And what evidence does one use?

[@pylt93]

@Philip Noah we have a saying in my country: captains get themselves killed, first officers let the captain to kill them (sounds better in Spanish)

[@joebrandon385]

Report to WHO, those that flew CP were there for experience or non required cp pay

[@ivansemanco6976]

This is tough topic. I the past our club lost two friends, young military pilot and experienced old guy. Young guy was superior pilot but sometimes he pushes limits too far and he dont have a B plan, in my opinion. So they died at unsuccessful recovery from intensional spin in the new plane during certification tests, they dont have sufficient altitude to leave plane in case of problems. So after accident more stories about him comes out but also that no one was able to push him to CAA, because this guy was lovely person, believe me, if you are in troubles and you need help, this guy is first who helps you. He spend all his spare time at arfield doing everything neccessary for club and us, club members. Flying was his life. So no instructors, inspectors and examiners was able to stop him, they arguing with him, advice him... Yes, we are all guilty that we doesnt stop him...

[@descamm9313]

Sobering thoughts, just hope that pilot's and budding pilots take notice of this terrible accident..

[@lonnywilcox445]

This report makes your past couple of videos on single wing stalls all the more appropriate. It looks like a textbook case of what not to do when loss of power on a multi-engine aircraft occurs. It also became very clear in this instance where the term "augering in" comes from. If you only have 1 wing flying there is no other way to go in but a nose first spin. Tragic for the passengers to have died because a pilot was too comfortable in his position and too tight fisted with sharing knowledge with the less experienced crew assigned to work with him.

[@RobSAtlanta]

I appreciate your excellent safety commentary. I like “Missionary bush pilot” channels use of a customized mechanical switch checklist and verbal rehearsal of engine out on takeoff procedures, every flight.

[@JasperFromMS]

It's not right that they run ads on your videos that they demonitize. That should be a breach of contract.

[@hanro7430]

KZbin released new terms and conditions a week or so ago that says it can

[@hanro7430]

@Daniel Hostetler i know

[@Yora21]

Contract? What contract? It's google, you're nobody. They do whatever the hell they want to do.

[@DrHarryT]

@@Yora21 And that is precisely why I run an ad blocker.

[@cheddar2648]

More properly it is tortious interference . And the coffers of KZbin and Alphabet should be stripped bare for these crimes. Seeing as they are now aligned with and in lock step with the Dept. of Justice Anti Trust Division and the Federal Government at large, the odds of accountability are about that as the odds of survivable for the passengers aboard the King Air in question.

[@VeronicaKingsley]

Thanks Juan. Great informative video as usual. Another reason for having your index finger up against the lock ring and throttle knob in your palm. You know exactly how much throttle you are into. Think about stepping on the brakes of your car. Do you know exactly how close you foot is to the bottom floor limit? Yes, when it's too late. Demonetized video but okay for KZbin to place ads onto your video to Monetize their pockets. Way to go KZbin.

[@chandlerhull5988]

I hope to start flying one day. One of my goals is that recounts of my flights never sounds like an NTSB report.

[@Alixper]

Sad but thank you for your excellent analyst of accident. Helps me as a young pilot.