C525 goes missing over Lake Erie with 6 aboard

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pelmet
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by pelmet »

av8ts wrote:English damn it pdw, english
The English translation is...it is never the pilots fault for doing stupid stuff, always the wind somehow not being completely calm.

In reality for this case, we know extremely little and there may not be much more hard evidence to come out of it.
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by Taxivasion »

PDW is a troll... ignore him
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by Rookie50 »

cncpc wrote:
armchair wrote:The accident files are overflowing with similar cases, but few systems are left in place to share lessons learned and for pilots to learn from others mistakes. So many businessmen, doctors, dentists and other such with more money than brains have met that same fate: thou can afford it therefore thou shall not dare flying commercially like other peasants.... I don't feel so bad for the egotistical pilots involved but more so for those relatives and friends they killed in vain.
Very valid point underlined.

I saw Ahramin respond to someone taking a Chief Pilot position and asking for advice. His good advice was to go through accident reports related to the new CP's position. And, in commercial aviatiion, people are paid to do that and it can be time consuming, but I do think having that practice sets out very good ops managers and CP's from merely Transport Canada approved.
Respectfully, total crap. Stupidity in killing oneself and passengers isn't confined to buiness guys with money, and is well represented in commercial ops of all types. The North is littered with airplanes, eg. Gee, the well regulated FTU's, should be the safest operation out there, think nothing of sending a flight instructor and 2 kids into convective night IMC. Don't label business guys across the board.

FWIW I fly low end stuff, the guys I've met flying higher stuff -- never met one that safety wasn't an obsession, they went to flightsafety, Ect. This blanket cowboy image is totally wrong.
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by armchair »

Fair enough that we shouldn't paint everyone with the same brush and common sense prevails that most pilots - private and commercial - are indeed very safe. To frame the particular issue is to narrow it to the pressure to make it home in marginal conditions. Most accidents of this type involve some type or variety of get-home-itis. Got to be back home for this or for that.... The other is currency.. Not easy to zip on your pilot suit and be expected to be in character immediately with friends around. In fact the majority of the mistakes I made in my piloting career involved private or non-revenue flights with guests or friends, where my attention was divided between my guests and the job of being PIC.

I terms of our Cessna pilot here, he certainly was no cowboy, no issue here. But consider the new upgraded version of the Citation, with 5 eager family members, added to the workload of single pilot IMC... It adds up and dont forget questionable currency. The black hole catches many pros, including the two ORNGE pilots who lost a S76 in a blackhole departure in Northern Ontario, killing 4. John Kennedy Jr did fall victim to visual illusion too. Twice in my 30+ years career I had my partner intervene to take controls when I had the leans on a night take-off. Not easy on your pride but the dude next to me was on the ball doing his job and saw I was struggling and took control. I did the same to others a few times as well. That is why 2 heads are always better than 1 in IMC. Peace out
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by Rookie50 »

armchair wrote:Fair enough that we shouldn't paint everyone with the same brush and common sense prevails that most pilots - private and commercial - are indeed very safe. To frame the particular issue is to narrow it to the pressure to make it home in marginal conditions. Most accidents of this type involve some type or variety of get-home-itis. Got to be back home for this or for that.... The other is currency.. Not easy to zip on your pilot suit and be expected to be in character immediately with friends around. In fact the majority of the mistakes I made in my piloting career involved private or non-revenue flights with guests or friends, where my attention was divided between my guests and the job of being PIC.

I terms of our Cessna pilot here, he certainly was no cowboy, no issue here. But consider the new upgraded version of the Citation, with 5 eager family members, added to the workload of single pilot IMC... It adds up and dont forget questionable currency. The black hole catches many pros, including the two ORNGE pilots who lost a S76 in a blackhole departure in Northern Ontario, killing 4. John Kennedy Jr did fall victim to visual illusion too. Twice in my 30+ years career I had my partner intervene to take controls when I had the leans on a night take-off. Not easy on your pride but the dude next to me was on the ball doing his job and saw I was struggling and took control. I did the same to others a few times as well. That is why 2 heads are always better than 1 in IMC. Peace out
Good comments. Specific aircraft or conditions, might be a different conversation. Look at say a PC 12, highly automated systems. Lower workload.

SP with Pax can be distracting. I make no bones about being a low time amateur. With my family (or anyone) I've long had a silence rule below 1000 AGL, and especially a night departure. Really take my time on those, and I've felt weird stuff too on a night or IMC departure.

I don't mix night and IMC, not experienced or current enough. I study accidents and don't like the huge spike in night ops. Getting ever more wary of night, even VMC. A different class of airplane, if I ever luck into a SE turbine, would be more comfortable in that aspect.

You're right for the non pro SP there is a lot less support. I have always had mentors I sought out and talked about how stupid or not my flying decisons were, so much gray in that regard.

I think pro or non pro, it's simply being willing to say no, wait, or divert. Done all of these. I do think training family to shut up or help monitor is important, too, or at least not be a distraction. Can kiss and make up on the ground. :)
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by pdw »

pelmet wrote:
av8ts wrote:English damn it pdw, english
The English translation is...it is never the pilots fault for doing stupid stuff, always the wind somehow not being completely calm.
We ALL know it's the pilot's responsibility, to take care of the aircraft so it does not crash. Please highlight any posts where I have given you an impression to the contrary. Perhaps there IS a grey area on occasion where it's easy to confuse that if i've pointed out shears as they show up as 'potential cause' in wx-hist. Fault and cause are kept separate when investigating.

It's clear that when potential causes are found (the holes in the swiss cheese if you will), that one or more of these findings are often proven to be fault. The legal system is pretty good at working out who's to blame, but I understand that the investigators have to stick to exposing cause.
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by cncpc »

pdw wrote:"Therman Munsun" final approach was in doing crosswind circuits rwy19 /182T in winds from 280 at the time of the accident .. and closest wx-hist both CLE and YNG north of Akron show the 25C/26C (a spike in temp/pressure) and both show approx 15kts-NW 4pm Aug2 1979 (keeping in mind it's usually muchless-strong at the surface) . A different practise-experience would happen than was expected (seeing the previous practise-approaches on that same runway were 80-90deg/lighter crosswind) when this gust from 310 (130-140deg taiquartering) was transitioned.

In observation: This latest tragedy in the same area can also fall under some shear-accident suspicion in addition to the spacial disorientation idea, .. the climbing turn North into that strong left crosswind perhaps is a much stronger encounter (esp with any tailquartering effect thru the last few degrees of turn) than the "PK WND 260 35kts" recorded at BKL/surface lee of the city "ca 2300"(ASN) on Thursday night.
The powerful lake effect wind brought snow streamers all the way to Niagara on the Lake at the time (where i live) northeast off that lake, which is rare unless the lakewinds are whipping-up very strong across warmer water.
Um..that's not what I meant by Therman Munson Syndrome.
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by pdw »

Pilots who's dough of business success have gotten them into the cockpit of a high performance AC with all the bells and whistles and one day find out at the wrong time they are still not practised enough when wx or vis is too tough for the experience level (or even some influence in the way of identifying the no-go situation).

Is that about right ?
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by armchair »

pdw wrote:Pilots who's dough of business success have gotten them into the cockpit of a high performance AC with all the bells and whistles and one day find out at the wrong time they are still not practised enough when wx or vis is too tough for the experience level (or even some influence in the way of identifying the no-go situation).

Is that about right ?
Sums it up to me!

Now how do we get that message to the majority of pilots who never read AVCANADA forums, TSB reports or whatever printed mags that are left? As cncpc said some keen operators and CPs/SMS managers may collate and prepare such reports as part of their SMS but not so likely for private ops. COPA magazine runs a few summaries but even COPA has a very limited reach. As old-fashioned and traditional as it was, the mailed-in versions of the Aviation Safety Letter and the Aviation Safety Maintainer to all licensed pilots and AMEs were the only tangible products left reaching that entire target audience at their home, and in their face and usually ended up in many bathrooms as practical safety reading.
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by cncpc »

pdw wrote:Pilots who's dough of business success have gotten them into the cockpit of a high performance AC with all the bells and whistles and one day find out at the wrong time they are still not practised enough when wx or vis is too tough for the experience level (or even some influence in the way of identifying the no-go situation).

Is that about right ?

That's close enough.
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by Old fella »

looks like a lot of info here for a C525c single pilot operations and an owner non-professional pilot- by that I mean a pro who does fly full time as a career
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by Rookie50 »

Might be simplistic, but I wonder what setting trims carefully have to do with these accidents, and no immediate turns after takeoff. Even in the spam can, especially at night I've made sure elevator trim would guarantee a positive climb after takeoff without my assistance.

I've recalled night VFR (hazy) black hole takeoffs where literally I've had zero sensation of movement, climbing or otherwise, except via instruments. Surreal, almost Transition to this almost instant, where a day, IMC takeoff even into a 3- 500 foot ceiling, there's a much more gradual effect.

The closest, and most similar day instance, was a IMC departure from YSB, easy ceiling but pure white haze IMC. Zero movement sensation. Most during the day seem more ragged, helps the body adapt. Perhaps.

Maybe it's the transition, plus possibly slightly out of ideal climb trim, that gets people. Just a thought from a lower timer.
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by pdw »

The right/climbing departure turn (mentioned previous page by Taxivasion) would have been rough ... with 30-40kt gusts.










Edit / regarding the references (below):
Tricky components in some of those accidents (whether unexpected or overlooked) weren't pointed out by the investigations at all. Just pointing out presence of shear is not blaming the accident on it, .. it's ONE contributing factor. Why hide the information ?
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by pelmet »

pdw wrote:
pelmet wrote:
av8ts wrote:English damn it pdw, english
The English translation is...it is never the pilots fault for doing stupid stuff, always the wind somehow not being completely calm.
We ALL know it's the pilot's responsibility, to take care of the aircraft so it does not crash. Please highlight any posts where I have given you an impression to the contrary.
viewtopic.php?t=109761
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by ChrisEvans »

Coast Guard was able to locate and recover the CVR (located from pinging)
and has been flown to Washington DC.

Tail section, part of fuselage - and some passenger remains have
been recovered.

Recovery is on hold due to current condition.
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by pelmet »

One of the chief pilots I flew with once said, we have all made mistakes...there are the ones we admit to and the ones we don't talk about. A long time ago, when I had not much flying time, I flew a very nice approach into an airport with close-in terrain in marginal weather at night. Speed and heading control was nice. We had to circle and vis was deteriorating in snow. Altitude was low for a circling procedure. I knew that if we missed the approach that it was critical to initiate a 30 degree bank turn in the proper direction to avoid hitting hills not only ahead of us but even in the direction of the turn if the bank angle was too shallow....and turning the other way was not an option due to even worse terrain. The weather deteiorated and we had to go around while we were on the downwind leg. I added power and started the turn, increasing the bank to 30 degrees for our 180 degree turn out of there. The gear was selected up and flaps started being retracted. It was all raw data flying with none of the conveniences of any kind of modern technology. But I flew it beautifully, not at 29 degrees and not at 31 degrees but exactly 30 degrees. The outside view was pitch black with not even a hint of light.

There was only one problem, unknown to me I was descending instead of climbing. Why.....I was being effected by a somotogravic effect. It was only when I was told about the descent that I realized it and we climbed out of there. Why did it happen? I was so obsessed about maintaining 30 degrees of bank that I stopped scanning anything else other than the portion of the attitude indicator relevant to the bank angle. In fact, I had been pushing forward on the control column and significantly so, but I only really realized that upon analysis after the event.

How do you prevent this from happening? Scan, Scan, Scan. Scan those instruments. Just because you have been flying great doesn't mean you will be a few minutes from now. And if you are in a go-around or departure with turn situation, it can really help to say to yourself "scan, scan, scan" maybe even in advance of an expected situation because you don't realize that you are not doing it. Once you get a lot of instrument experience, perhaps it will come more naturally but there have been several jet crashes on go-arounds with experienced pilots who didn't scan, scan, scan at critical times. Of course, now there are flight directors, etc but they can be giving bad info due to automation mismanagement and you have to ignore them.

You hear about these types of accidents but never any of the finer details of how exactly it came to be, why they were not scanning. And I had definitely read about these types of accidents when it happened.

Why do I talk about this now. Because of the picture of the families at this link involved in this accident. If talking about it helps save the life of some other pretty girl and all the family somewhere because someone here read about it, then it is worth discussing a big mistake. Its fine to discuss the mistakes of others most of the time but we should all be willing to admit our own mistakes.

http://www.kathrynsreport.com/2018/06/c ... 614sb.html

The accident report is out and it looks like the pilot didn't scan, scan, scan while he was in the turn over very dark Lake Erie. His reason for not scanning may have been different than mine but the result was the same... a descent.

https://app.ntsb.gov/pdfgenerator/Repor ... l&IType=FA
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by pelmet »

Single-Pilot Overload: A Black-Hole Departure Into Lake Erie


A Cessna 525C (Citation CJ4, N614SB) crashed into Lake Erie moments after takeoff from Runway 24R at Cleveland’s Burke Lakefront Airport (KBKL) on Dec. 29, 2016, at 2257 EST. Darkness, windy and snowy conditions, marginal VMC existed at the airport at the time.

The pilot, his wife, two sons, a neighbor and the neighbor’s daughter were on board returning to Ohio State University Airport (KOSU) in Columbus where the airplane was based. The group had initially departed KOSU about 1730 and arrived at KBKL about 1800. The visit to Cleveland would be quick. Their mission was to attend a basketball game and head home. All six were killed and the airplane destroyed when it crashed, broke up and sank into the lake. The entire flight lasted less than 90 sec.

The two-week search and recovery efforts for the airplane and its occupants captured national media attention. The weather during the effort was miserable, the lake wind-blown and icy and the water murky. Nevertheless, local, state and federal public safety agencies ultimately recovered the victims and some of the airplane.

The pilot’s family and his guests were well-known in Columbus. He was CEO of a beverage distribution company and an enthusiastic private pilot. He had accumulated 1,205 hr. total time, 427 of them in multiengine turbine airplanes. He had logged 121 hr. of nighttime flying and 145 hr. of actual instrument time.

The pilot earned a Cessna 525 (CJ4) single-pilot type rating on Dec. 8, 2016, after completing an FAA check ride in the accident airplane. The rating was added to his private pilot certificate that already included ratings for single-engine and multiengine airplanes, instrument and helicopter. Two weeks later, he completed a CJ4 simulator-based recurrent training course at FlightSafety International.

At the time of the accident, he had a total of 56.5 hr. in the CJ4. Of that time, 8.7 hr. were as pilot-in-command, which included the practical test. His most recent logged flight was on Dec. 17 from Orlando International Airport (KMCO) in Florida to KOSU. His night experience in the CJ4 totaled 16.8 hr.; actual instrument in make and model totaled 2.5 hr., and simulated instrument totaled 16.1 hr.

The pilot had owned a Cessna 510 Mustang for about two years before purchasing the CJ4. He had logged 372.9 hr. total time in that aircraft. He was in good health with no significant medical issues.

On Dec. 29, the day of the accident, the pilot arose about 0600 and was in the office by 0800. He visited a construction site and returned to the office after lunch. He left for the day around 1600. By the time he started the engines for the return flight to KOSU, he had been up and about for 17 hr.

The pilot had received weather briefings before leaving Columbus and they were reasonably accurate — IMC but not especially difficult for the CJ4’s avionics and systems although perhaps challenging for a tired pilot in a new airplane.

The observations from KBKL and Cleveland Hopkins International (KCLE) indicated that marginal visual conditions prevailed at the time of the accident. Precipitation was reported in the 1-min. observations at KBKL until 2251, with none reported at the surface until 2342. While the surface temperature remained above freezing after the airplane landed at the lakefront facility and about the accident time, the dew point temperature remained below freezing the entire time with precipitation occurring on and off in the snow shower activity.

At 2253, the observed conditions at KBKL were: wind, 260 deg. at 25 kt., with gusts to 31 kt.; 8 mi. visibility in light snow; scattered clouds at 1,200 ft., broken clouds at 2,200 ft., overcast clouds at 3,200 ft.; temperature, 1C, dew point, -2C; and altimeter, 29.74.

At 2300, the conditions at the airport were: wind, 260 deg. at 22 kt., with gusts to 31 kt.; 9 mi. visibility; scattered clouds at 1,500 ft. AGL, broken ceiling at 2,300 ft. AGL, overcast skies at 3,900 ft. AGL; temperature, 1C, dew point, -2C; and altimeter, 29.74.

There were no SIGMET advisories valid for Burke Lakefront at the accident time; however, AIRMET advisories Zulu, Tango and Sierra, issued at 2145, were valid and forecast IFR conditions due to precipitation and mist, moderate icing conditions below 10,000 ft. MSL, and moderate turbulence below 10,000 ft. MSL. The possibility of a trace to light icing was present at low altitudes at the time of the accident.

How It Happened

NTSB investigators reviewed ATC communications, the CVR transcript, ADS-B data and FADEC unit data to create the following timeline:

At 2247, the pilot contacted the KBKL tower controller and requested an IFR clearance.

At 2250, he requested a taxi clearance, and 5 min. later informed the tower controller he was holding short of Runway 24R and ready for takeoff. The controller subsequently cleared him for takeoff and instructed him to turn right to a heading of 330 deg. and maintain 2,000 ft. MSL after departure. The pilot acknowledged the clearance.

At 2256:33, the engine power increased, and 15 sec. later the airplane became airborne.

At 2257:09, an automated voice annunciated “altitude.” A second “altitude” annunciation followed 14 sec. later. (Safety Board investigators noted that in normal operations, the altitude preselect mode will provide an annunciation passing ±1,000 feet from the preselected altitude. Once tracking the selected altitude, the system will provide an alert if the airplane deviates more than 200 ft.)

At 2257:25, a sound similar to a decrease in engine power was recorded. Two seconds later, the EGPWS annunciated an excessive bank angle warning. (The EGPWS will provide a warning if the bank angle exceeds 50 deg. when the airplane is operating 210 ft. above ground level or higher.)

At 2257:29, about 2 sec. after the bank angle warning, the tower controller instructed the pilot to contact departure control. The CVR recorded “to departure six one four sierra bravo;” however, the tower controller did not receive that communication. (The CVR will record any audible sound that is picked up by the cockpit area microphone or a connected microphone such as on a pilot’s headset. However, any sound picked up by a pilot’s headset will not be transmitted unless the push-to-talk switch is simultaneously depressed. The presence of the pilot’s response on the CVR recording in conjunction with the absence on the ATC recording is consistent with the pilot not having the push-to-talk switch depressed.)

At 2257:37, the controller again attempted to contact the pilot. However, 2 sec. after the controller’s transmission, the EGPWS provided a “sink rate” warning to the pilot. The pilot again responded, “six one four sierra bravo,” but this was not received by the tower controller. (The EGPWS will provide a sink rate warning when the aircraft is within 2,450 ft. of the terrain. At 2,450 ft., the triggering descent rate is 5,007 fpm. This varies linearly to a descent rate of 964 fpm at 10 ft.)

Beginning at 2257:43, the EGPWS provided “pull up” warnings at 1.6-sec. intervals until the end of the CVR recording. During that time, a sound similar to the overspeed warning began, which continued until the end of the recording at 2257:58.

The tower controller made several additional attempts to contact the aircraft, then initiated search and rescue procedures.

ADS-B position data helped investigators re-create the flight profile:

The airplane had crossed the departure end of the runway and began a climbing right turn. (The bank angle steadily increased until 2257:31, when it reached about 62 deg. (right wing down). Over the next 14 sec., the bank angle decreased to about 40 deg. right wing down. The bank angle decreased further to about 25 deg. right wing down shortly before impact.)

About 2257:28, the airplane became established on a magnetic course of 310 deg. During that time, the airplane reached an altitude of approximately 2,925 ft. MSL. About 5 sec. later, the airplane entered a descending right turn that continued until the final data point that was recorded at 2257:52 and was located 1.83 mi. northwest of the airport. The altitude was 775 ft. MSL, about 205 ft. above the lake.

A Safety Board performance study indicated that after takeoff the airplane’s pitch attitude was about 5 deg. nose up for approximately 8 sec. The Citation accelerated to about 215 kt. The pitch attitude increased to about 16 deg. nose up and the rate of climb reached over 6,000 fpm during the initial climb.

Beginning about 2257:25 and continuing over the next 12 sec., the pitch attitude began to steadily decrease until reaching about 15 deg. nose down. The airplane accelerated to about 300 kt. and the rate of descent reached about 6,000 fpm once it became established in the descent. The maximum operating limit speed (Vmo) below 8,000 ft. is 260 KIAS.

The ADS-B data included information related to the altitude preselect and heading bug settings. The altitude preselect setting was consistent with the 2,000-ft. altitude assigned to the accident flight. The heading bug was set to 240 deg. until 2257:11. Over the following 12 sec., the heading bug was reset to 329 deg., where it remained for the duration of the flight. The CVR recording ended at 2257:58.

No visual cues were available to the pilot during this departure. KBKL is located along the south shoreline of Lake Erie within the metropolitan area of the city. The airport elevation is about 584 ft., which is approximately 14 ft. above the level of the lake. Visual cues are available from the city lights south of the airport. However, there is a lack of visual cues north of the airport due to the lake’s expanse.

Two local pilots discussed with investigators the lack of visual cues at the airport at night. One described the conditions as a “black hole” during a dark night, VFR departure. The second noted that turning toward Lake Erie and away from the lights of the city may result in “absolute darkness” for a pilot.

The Investigation

Two weeks of bad weather made recovery difficult. The airplane was fragmented. The nose section was not recovered other than the baggage compartment doors and the nose landing gear assembly, which had separated from the airframe. The cockpit window assembly — pilot and copilot windshields and side windows — was structurally intact. Each window was shattered but remained in place, except for portions of the copilot windshield outer pane, which was missing. The copilot’s windshield exhibited a red impact mark near the center of the windshield. (The mark was examined by ornithologists from the Smithsonian Institution — National Museum of Natural History; no evidence of bird feathers or DNA.)

No portions of the cockpit controls or instrumentation were recovered other than the center pedestal assembly that was separated and damaged. The right throttle lever, flap handle, engine run-stop switches, and friction adjustment handle were missing.

Sections of the left- and right-side fuselage structure were recovered but badly deformed. Smaller sections of the airframe structure including wing carry-through spar sections and structural splice assemblies also were recovered.

The aft, right-side cabin seat frame and the pilot and copilot seat frames were not recovered. Several seat cushions, including the pilot and copilot seat-back cushions were located.

The left and right wings had separated near the wing roots and showed extensive fragmentation and deformation.

The left engine was never found; however, the deformed left exhaust assembly was located. The right engine and its inlet and exhaust assemblies were recovered, but its forward bypass duct and fan case assemblies had separated and were lost. The fan blades remained attached to the hub. Each blade exhibited gouges, scraping and deformation (curling) at the blade tips consistent with rotation at impact.

The right fuel delivery unit was separated and recovered. The unit exhibited damage consistent with impact.

No anomalies consistent with a pre-impact failure or malfunction of the airframe structure, flight controls or engines were observed.

Airplane Control

Interviews with his instructor determined that the pilot was trained to consistently use the autopilot after takeoff after reaching at least 300 ft. AGL. The instructor also told investigators the pilot had inadvertently pressed the autopilot transfer button instead of the autopilot engagement button on two occasions during training without recognizing the error.

Another possible factor — the CJ4’s attitude presentation was different from the Mustang’s. The attitude indicator presented by the PFD on the Cessna 525 was an egocentric (“inside out”) type display. An “inside out” perspective involves a fixed aircraft symbol and moving horizon similar to what a pilot sees when looking outside of the aircraft. On the other hand, the Cessna 510 utilizes an exocentric (“outside in”) display. An “outside in” perspective involves a fixed horizon and a moving aircraft symbol.

Studies have demonstrated, said the Safety Board, that pilot performance with sole experience using either of these types of displays is similar; however, performance degrades when experienced pilots switched between the two types of displays. This, of course, can contribute to spatial disorientation.

The flight guidance panel (FGP), located on the glareshield, allows the pilot to select manual or autopilot guidance for airplane control. The autopilot button is located on the upper row of button controls near the right side of the panel. Autopilot engagement is indicated in the flight control system display area along the upper portion of the primary flight display (PFD). There is no indication of the autopilot status on or near the autopilot button on the flight guidance panel.

Investigators said a comparison of the Citation 525 systems and those of the Citation 510 revealed that the autopilot engagement button on the latter is located in a slightly different location on the AFCS panel. Autopilot engagement is indicated along the upper portion of the PFD in both airplanes. In addition, an indicator light adjacent to the autopilot button on the AFCS panel is illuminated when the autopilot is engaged.

Spatial disorientation is always possible in black-hole departures (and many other situations.) The FAA Civil Aeromedical Institute’s publication, Introduction to Aviation Physiology, defines spatial disorientation as a loss of proper bearings or development of a state of mental confusion as to position, location or movement relative to the position of the earth.

Factors contributing to spatial disorientation, says the FAA, include changes in acceleration, flight in IMC, frequent transfer between VMC and IMC, and unperceived changes in aircraft attitude.

The Safety Board’s investigators also pointed to the FAA’s Airplane Flying Handbook (FAA-H-8083-3A), which describes some hazards associated with flying when the ground or horizon is obscured. The handbook states, in part: “The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation.”

The Accident Chain

This CJ4 black-hole departure lasted less than a minute and a half. The pilot had less than 10 hr. command time in an airplane whose instrumentation and controls were slightly different from a similar airplane in which he had several hundred hours. During training, those slight differences had led the pilot to mis-select autopilot modes. He was also seeking guidance from a PFD that displayed dynamic attitude differently from that with which he was familiar. There were no visual cues from the black night outside the cockpit once the right turn began. Even routine departure communications went awry, perhaps because he failed to finger the push-to-talk button correctly.

A quick exploration of the NTSB accident database shows that black-hole departure accidents are not uncommon. Black holes have trapped all manner of pilots from solo pilots in single-engine trainers to airline crews in commercial operations.

Black-hole departures are essentially zero-zero takeoffs once the airplane rotates. They require planning, concentration and alertness. The abrupt loss of visual cues followed by low-altitude pitch changes and turning maneuvers is disorienting.

Despite all the hype popular media gives “multitasking,” humans can only attend to one thing at a time. (While we can move our attention quickly among a number of things, the results are not always positive.) Successful black-hole departures depend on the flight crew performing the basics one step at a time — rotate, establish climb, configure the aircraft, engage the FD/AP and keep your attention inside. Until all that is squared away, don’t even think about turning maneuvers. If something in the sequence isn’t working as planned, level the wings, climb and (when you can) let ATC know what you are doing.

At one time or another we’ve all been taught that the proper sequence of cockpit duties is to aviate, navigate and communicate. This sequence is nowhere more important than during the execution of a black-hole departure, and especially as a single pilot.
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RatherBeFlying
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by RatherBeFlying »

One has to wonder if the pilot did night flights while taking conversion instruction.

I confess wondering why the second COM was not working the first time I flew a certain airplane at night. Examination on the ramp showed it was a Narco with a concentric flat on-off switch that was not lit.

The sim instructors would do well to include black hole departures in the syllabus; maybe sneak it in with some added ATC workload and see how well the student manages priorities.

A clearance of runway heading to 5000 would have added margins.

He busted his clearance to 2000 by getting to 2925 and may have been trying to get back down. But he was missing the buttons, including the PTT. Was he hand flying or thinking the autopilot was engaged?
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Eric Janson
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by Eric Janson »

A low altitude level off after take-off can be a very tricky maneuver in a high performance jet.

It requires a large pitch and power change and it's very easy to accelerate through flap speeds. Add in single Pilot IFR and it can all go wrong very fast.
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complexintentions
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Re: C525 goes missing over Lake Erie with 6 aboard

Post by complexintentions »

Is a CJ4 really a "high-performance" jet?

Not being facetious, but I thought it was a descendant of the Citation I/II?
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