planeandpilotmag.com 61the sounds of the airplane’s engines over the sounds from
their motorcycles. Some went to the crash site but couldn’t
get close enough to help because the flames were too intense.
Investigators accounted for all major components of
the airplane at the crash scene. The fire had consumed a
lot, including the cockpit instruments and switches. The
engines had significant impact and fire damage.
Investigators found that after the first day of flying with
the instructor, the pilot had spoken with some of his friends
about the experience. One of them, who started flying with
the pilot in 1999, reported that the pilot had owned two
other Duke aircraft beginning in 2007. He said he talked
with the pilot the night of the first day of instruction, and
the pilot said the instructor had told him to do some things
with which he didn’t agree. The friend quoted the pilot as
saying the instructor had told him not to push the mixture
and propeller pitch controls full forward on approach to
land. The friend quoted the pilot as saying the instructor
said the reason was that it made more noise and wasted gas.
The next morning, the pilot again contacted the friend
and reported they were doing stalls with the power off or
very low at a 20-degree left bank. The friend quoted the
pilot as saying that while his normal procedure for stall
recovery was to push the nose down, level the wings and
apply power, the instructor told the pilot to apply full power,
then lower the nose and then level the wings. The friend
reported that the pilot said when he did so, the airplane
entered a spin and made 1.5 turns before recovery. The pilot
was reported to have said they were at 3,000 feet when the
airplane entered the spin, but the instructor denied that it
was a spin because the airplane hadn’t made three turns.
The friend also reported that the pilot told him the
instructor had him do an instrument approach to a runway,
which had the airplane landing in a tailwind. The pilot
said the winds were gusty, which added to the difficulty.
The friend asked if the instructor mentioned doing a circle
to land on a runway favoring a headwind. The friend said
the pilot said no, but the instructor did ask why he landed
downwind, and the pilot replied, “Because that is what
you said to do.”
Another friend of the pilot told investigators that after
the first day of instruction, the pilot was going to fly over to
meet the friend and his wife for dinner at Apopka, Florida,
and then spend the night. The friend said the pilot phoned
and described a flight he said, “scared me down to the core
of my spine.” The friend wrote to investigators, “I asked him
what had happened. He stated that they where (sic) flying
at 3,000 feet in slow flight preparing to do a power on stall.
When the plane started to stall, the instructor reached
over and pulled the power on the starboard motor caus-
ing the plane to go inverted. (The pilot) said it took him a
thousand feet to get the plane gathered up and regain his
composure. (The pilot) said it took so much out of him
that he had already gotten a hotel room, was going to get
something to eat and then get to bed as he was worn out.”
The NTSB’s report quoted from the FAA’s Airplane
Flying Handbook, which explained that the standard stall
recover y procedure is to reduce the angle of attack, roll the
wings level and add power as needed. It also warns that
single-engine stalls or stalls with significantly more power
on one engine than the other should not be attempted due
to the likelihood of a departure from controlled flight and
possible spin entr y. It notes that no multi-engine airplane is
approved for spins, and their spin recovery characteristics
generally are very poor.
The NTSB also quoted from the FAA’s Flight Instructor
Airplane Practical Test Standards regarding multi-engine
airplanes, which stated, in part, “stalls must not be per-
formed with one engine at reduced power or inoperative
and the other engine developing effective power.”
In determining a probable cause of this accident, the
NTSB gave no weight to the tendency many have to defer
to more experienced individuals, or elders, or even those
who hold more FAA certificates and ratings than we do and,
therefore, are presumed by the government to know more
and be better qualified. The Safety Board said the accident
was due to the pilot’s decision to perform flight-training
maneuvers at low airspeed at an altitude that was insuf-
ficient for stall recovery. Contributing to the accident was
the flight instructor’s inappropriate use of non-standard
stall recovery techniques.
In its report on this accident, the NTSB makes sugges-
tions for preventing similar accidents, something it doesn’t
always do. The Safety Board says that accidents result when
the pilot doesn’t accurately perceive situations that involve
high levels of risk. It says that, “applying behavior modi-
fication techniques, recognizing and coping with stress,
and effectively using all resources, pilots can substantially
improve the safety of each flight. Remember that effective
risk management takes practice. It is a decision-making
process by which pilots can systematically identify hazards,
assess the degree of risk and determine the best course of
action. Pilots should plan ahead with flight diversion or
cancellation alternatives, and they should not be afraid to
change their plans.”
What the NTSB leaves out is that effective risk manage-
ment often involves going with your gut reaction and not
being dazzled by a résumé or seniority. There’s a whole con-
cept that took years to be accepted in the airline industry,
crew resource management, designed to help overcome
the seniority inhibition. A strong argument can be made
that the pilot of this accident airplane, if he was genuinely
as upset after the first day of flying with the instructor as
his friends reported he was, could have and should have
listened to what he was telling them about his experiences
and just pulled the plug on the whole thing. PPPeter Katz is editor and publisher of NTSB Reporter, an independent monthly
update on aircraft accident investigations and other news concerning the
National Transportation Safety Board. To subscribe, visit http://www.ntsbreporter.us
or write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY
10602-0831.