NTSB Modifies Report on Nevada CAP Crash

[sardak]

This was the crash that killed Colonels Dion DeCamp and Ed Lewis. The thread discussing the NTSB factual report was locked due to a lack of decorum. We'll see how far this gets.

The modified factual report adds a section on air traffic control. Not that it matters to the final outcome, but the NTSB concluded that air traffic control errors were additional contributing factors to the crash.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's failure to maintain an adequate terrain clearance/altitude during climb to cruise. Contributing to the accident were rising mountainous terrain, the dark nighttime lighting condition, the pilot's loss of situational awareness, and the Federal Aviation Administration controller's failure to issue a terrain-related safety alert.

From the report
Air traffic control radar data revealed that the airplane was continuously visible to the controller on his radar display from the departure airport until impact with mountainous terrain. The airplane's course remained constant as he approached and impacted the mountain during the dark nighttime flight. The air traffic controller did not issue a terrain-related safety alert, as required by a Federal Aviation Administration order, because he did not observe a conflict with terrain. [The radar also displayed an image of the symbol depicting Mt. Potosi as Cap Flight 2793 approached the obstacle just prior to the accident.]

FAA Order 7110.65 states, in part, that a controller's duty priority is to "give first priority to separating aircraft and issuing safety alerts..." The safety alert is to be issued to an aircraft once the controller observes and recognizes a situation wherein the aircraft is in unsafe proximity to terrain, obstacles, or other aircraft. The controller "...must remain vigilant for such situations."

Mike

[es_g0d]

Is anyone aware if the terrain feature in the G1000 avionics was being used?  I don't know if its even possible to ascertain the status of the system without a full flight data recorder.

These gentlemen taught me a lesson; and while unfortunate, I heavily respect their teachings.

[lordmonar]

Too much damage to be sure.....

[wingnut55]

I believe that we are seeing more of these reports, I had a tower trainee tell me to turn into oncoming traffic twice within 1 hour. If I had not had situational awareness it could have gotten bad. However, Vegas is a very busy area and this does add some more important information. I think we will see more about this tragic accident that has affected so much of the CAP community.

[caprr275]

From what I heard from a briefing this weekend it was a brand new 182 with G1000, which would have had the terrain alerts as the got close to the mountain. A theory is that they were both heads down with the auto pilot on and they were flipping though the pages of the G1000 or trying out the XM radio.  CFIT (Controlled Flight Into Terrain) is a major problem in aviation today.  While the 2 pilots had over 58,000 hours between them they were not using proper CRM skills (Crew Recourse Management) It is a huge blow to CAP and their families and my hart goes out to them.

[John Browning]

I have something to say. One day (November 7, 2007), after the Nevada Wing Commander sent out an E-mail asking everyone not to talk about the Steve Fossett Search they are dead. Why? Did someone smell a rat in the wood pile. Not a Theory just a Fact.

John M. Browning III

[tsrup]

I have something to say. One day (November 7, 2007), after the Nevada Wing Commander sent out an E-mail asking everyone not to talk about the Steve Fossett Search they are dead. Why? Did someone smell a rat in the wood pile. Not a Theory just a Fact.

John M. Browning III

Simple OPSEC and courtesy to the next of kin.  It's not a conspiracy, it's a courtesy.

[Jerry Jacobs]

Is anyone aware if the terrain feature in the G1000 avionics was being used?

I attended a class on the pitfalls of the G1000 avionics system that talked quite a bit about this accident.  One theory is that most pilots turn off this feature on the ground because it will fill the screen with red on takeoff roll and final approach and never turn it back on again

[mynetdude]

Is anyone aware if the terrain feature in the G1000 avionics was being used?

I attended a class on the pitfalls of the G1000 avionics system that talked quite a bit about this accident.  One theory is that most pilots turn off this feature on the ground because it will fill the screen with red on takeoff roll and final approach and never turn it back on again

Perhaps that should be an item to turn on/off that should be listed on the "after takeoff checklists" or "before landing checklist" ?

[Mustang]

I attended a class on the pitfalls of the G1000 avionics system that talked quite a bit about this accident.  One theory is that most pilots turn off this feature on the ground because it will fill the screen with red on takeoff roll and final approach and never turn it back on again

Lack of a "Master Zeroize"/"Reset all settings to defaults" is one of the G1000's biggest flaws IMHO.  I'm not up on the latest software version, maybe they've added this, I don't know.