FLIGHT REENACTMENT - PowerPoint PPT Presentation

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  2. Setting the Stage In this session we will recreate a flight utilizing the ACTUAL flight transcripts as recorded on the day of the accident. Unfortunately this accident did not end well. As you follow along and listen to the progress of the flight, try to visualize yourself in this situation and how you might be able to recognize the pilot’s chain of judgment decisions. On Saturday, May 4, 1969 a 42-year-old executive left Teterboro, NJ on a long anticipated cross-country flying vacation to Los Angeles. He was accompanied by his wife, their four children (all under five), and his father-in-law. The pilot had been planning the flight in great detail for some time, going as far as to meet with his flight instructor for advice and assistance. The pilot had 300 total hours on a commercial license with single- engine land and instrument ratings. 50 of his hours where in the last 90 days.

  3. Beechcraft C 33 Debonair - Performance Data The Aircraft The aircraft – a Beech C33 Debonair N2737T- had been purchased new by him and had dual VHF transceivers, dual VOR/ILS with glide slope receiver, ADF, DME, and transponder. The aircraft was also fitted with long-range fuel tanks, autopilot, and an oxygen system; the only anti-ice equipment, however, was a heated pitot tube. Beechcraft C33 Debonair – Performance Data

  4. Beech C33 Debonair


  6. The Trip Because the flight was to be conducted during daylight hours only, several overnight stops were planned. The first was Lexington, Kentucky. The following day, the aircraft arrived at Wichita Kansas, where the group stayed overnight before attempting the next leg, which would take them over mountainous terrain. At 8:58 on the morning of May 6, N2737T left Wichita for Farmington, New Mexico. Prior to departure, the pilot received a full weather briefing by telephone from Wichita FSS. The weather forecast indicated that he could expect to encounter IFR conditions with possible icing in the clouds over the Rocky Mountains. The destination airport was expected to be VFR at time of arrival. The pilot then filed an IFR flight plan via V73 to Hutchinson, Kansas; V10 to Lamar, Colorado; and V210 to Farmington. The initial cruising altitude was 8,000 feet, with a request for 15,000 feet passing Lamar. After takeoff from Wichita N2737T maintained normal radio contacts with Kansas City Center. The flight proceeded without reported incident and at 10:40 was approaching the Lamar VOR at 8,000 feet, precisely on schedule. At this point ATC was passed to Denver Center.

  7. Trip Overview

  8. Reenactment Begins

  9. Legend The following is a transcript of the relevant radio contacts with the pilot 37T= Beechcraft N2737T DEN= Denver Center Radar FMN=Farmington FSS and Tower * Denotes contacts between ground stations on direct land line.

  10. TIME: 1040 DEN—Beechcraft 2732 (sic) Tango, Denver Center, 8,000, report Lamar. 37T—Beech 2737 Tango, I will. DEN—Beech 37 Tango, squawk 1100, ident. 37T—Three-Seven Tango, ident. DEN—Three-Seven Tango in radar contact now nine miles east of Lamar. 37T—Three-Seven Tango, roger, thank you.

  11. TIME: 1051 37T—Denver Center, Beechcraft 37 Tango. DEN—Three-Seven Tango, go ahead. 37T—Yeah, keep in mind I’m on my way to higher altitude, sir. DEN—Yes, sir, I haven’t forgotten you. You can expect higher in, ah, 15 miles. 37T—Three-Seven Tango, roger, thank you.

  12. TIME: 1055 37T—Denver Center, 37 Tango. When you get an opportunity, check Farmington weather, please. DEN—The 1600 Farmington weather is, ah, estimated ceiling 2,000 overcast, visibility 10, and light rain. Temperature 40, wind 210 degrees at seven knots. 37T—Three-Seven Tango. That was, ah, be, ah, kind enough to check out a good alternate for me, because I was given way above VFR, ah, upon my, ah, estimated time of arrival at Farmington, things seem to have changed. DEN—Ah, 37 Tango, you’ll have to go to LaJunta Radio for, ah, any weather or alternates. We don’t have that information.

  13. Thoughts?

  14. TIME: 1057 37T—Three-Seven Tango. I’ll check with you again upon arriving at Farmington. DEN—Three-Seven Tango, ah, roger, you can contact Farmington Radio when you’re a little ways out, ah, to get the same weather, more current weather. 37T—Three-Seven Tango. Thank you. DEN—Beechcraft 237 Tango, climb and maintain, ah, 15,000 over. 37T—Three-Seven Tango. We’ll ah, climb to and maintain 15,000. DEN—Three-Seven Tango, roger, report reaching 15,000. 37T--…I’ll report reaching 15.

  15. TIME: 1120 37T—Denver Center, 37 Tango. Reporting level at 15,000. DEN—Three-Seven Tango, roger. DEN—Beech 2737 Tango, contact Denver Center on 126.1. 37T—That’s 126.1, thank you, good day. Three-Seven Tango. DEN—Good day, sir.

  16. TIME: 1140 37T—Denver Center, 37 Tango, maintaining 15,000. DEN—Ah, Beechcraft 27 (sic) Tango, Denver Center, ident. DEN---Beechcraft 37 Tango, Alamosa altimeter 30.00. 37T—Three zero zero zero, 37 Tango, thank you. 37T—Denver Center, 37 Tango, could you get a good weather check on, ah, Farmington, New Mexico, weather, please? DEN—Beechcraft 37 Tango, ah, Farmington one-hour-old weather, measured ceiling 1,100 overcast, visibility six miles, light rain and fog.

  17. TIME: 1140 continued… 37T—Is there a nearby airport that, ah, would have any kind of VFR at this time? DEN—Ah, Beechcraft 37 Tango, say again? 37T—I say, is there a nearby airport that would be, ah, VFR at this time, because it’s quite apparent I’m not going to be able to make it at, ah, Farmington. By the time I get there, it’ll probably be way down. DEN—Beechcraft 37 Tango, stand by; I’ll check on it.

  18. Thoughts?

  19. TIME: 1153 FMN—Farmington Tower. DEN—Say, is ah, your ceiling and visibility still about, ah, 1,100 overcast, six miles? FMN—Just a second, let me check it here. 37T—Denver Center, 37 Tango. How about Alamosa Municipal? DEN—Ah, Beechcraft 37 Tango, I’m checking with Farmington Tower now, they advise it is breaking. They’re taking another reading on the, ah, ceiling and visibility. FMN—Ah, Farmington Radio.

  20. TIME: 1153 continued… DEN—Ah, Radio? FMN—Yeah. DEN—Ah, is the ceiling and visibility still, ah, 1,100 and six? FMN—No. We got, ah, 400 scattered now, measured 1,400 overcast, 15 miles visibility, very light rain. DEN—Very light rain, ah, it’s breaking up? FMN—Yes, it is, it’s breaking up, ah, fairly rapidly right now.

  21. TIME: 1153 continued… DEN—Ah, ah, would you say, ah, in an hour; what would you guess? FMN—Oh, I’d imagine it’ll probably, ah, it’ll be about 2,000, I imagine. DEN—About 2,000 overcast? FMN—Ah, yes, uh-huh. DEN—Okay, thank ya much.

  22. TIME: 1153 continued… DEN—Bonanza 37 Tango, ah, Farmington advises, ah, that right now they have 400 scattered, measured ceiling 1,400 overcast, visibility 15, and very light rain. He says it’s breaking rapidly and expect in one hour to have about 2,000 overcast. 37T—Three-Seven Tango, right, ah, fine. Then I’ll push right to Farmington. Thank you very much, 37 Tango. DEN—Roger, and, if you can’t make it to Farmington, ah, Cortez and Durango are both reporting about the same, ah, 6,000 ceiling with 30 miles visibility. 37T—Three-Seven Tango. Fine, I’ll try it that way then, thank you very much.

  23. TIME: 1206 37T—Denver Center, Denver Center, emergency. Denver Center, emergency. Three-Seven Tango, emergency. DEN—November 37 Tango, this is Denver Center, say again. 37T—Emergency—I’ve all of a sudden lost my airspeed, I don’t know why. DEN—Ah, November 37 Tango, roger, you still at 15? 37T—Ah, how low can I go? DEN—Are you at 15,000, sir? 37T—Denver Center, how low can I go at this area? DEN-Ah, one, ah, four thousand, 14,000.

  24. Thoughts?

  25. TIME: 1207 DEN—November 37 Tango, what is your present heading, sir? 37T—Can you vector me around to a lower area? DEN—November 37 Tango, ah, what is your present heading, sir? 37T—Can you vector me around to a lower area? DEN—November 37 Tango, ah, what is your present heading, sir? 37T—Can you vector me to a lower area, sir? I’m at 14,300.

  26. TIME: 1207 continued… DEN—Roger, turn south heading 180, turn south heading 180. 37T—Center, are you reading me, sir? I’m 14,000 going down. DEN—Ah, roger, are you heading to the south? Are you heading 180 now, sir? 37T—Denver Center, can you help me? DEN—November 37 Tango… 37T—Denver Center, can you help me? Emergency.

  27. TIME: 1207 continued… DEN—November 37 Tango, affirmative, ah, try to ease off on your, ah controls. Keep your throttle forward, keep your throttle forward. Maintain as much altitude as possible, please. 37T—I’ll try to maintain 14,000 if I can, sir. My airspeed is way down. DEN—Ah, your airspeed working now? 37T—Yes, sir (unintelligible). DEN—November 37 Tango, do you have an airspeed at all? 37T—Any airspeed what sir?

  28. TIME: 1207 continued… DEN—Ah, is your airspeed indicator operating? 37T—Yes, sir, it is. DEN—You say that is affirmative, affirmative? 37T--…firm, affirm, yes. I’m using my static air source, my second static air source. I’m 13.7 sir. DEN—Ah, roger 13.7 and you’re heading south, is that correct, sir? 37T—I’m heading 240. DEN—Is that 240? 37T—Ah, 300.

  29. TIME: 1207 continued… DEN—Two zero zero, is that correct? 37T—(Unintelligible)…’ee zero zero , yes, sir, I’m going to get back on course now, sir. DEN—Ah, roger, and what is your altitude, sir? 37T—Thirteen five hundred. DEN—Ah, keep your airspeed up as high as possible, keep your airspeed up as high as possible, please. November 37 Tango. Do you have your throttle advanced, ah, to maintain as much speed as possible? 37T—Yes, sir, I have.

  30. TIME: 1209 DEN—Ah, what is your altitude now, sir? 37T—Altitude 13,200 airspeed 50 miles an hour, going down to zero and back up again. DEN—You say you’re going to try to go back up again? 37T—I’m trying to hold it up. DEN—Ah, 36 tango, are you in VFR conditions now? 37T--…gative, I’m socked in completely. FMN—Farmington Radio.

  31. TIME: 1209 continued… DEN—Farmington Radio, we’ve got an emergency out here, just, ah, east of the field, ah (unintelligible), your DF on? He’s transmitting on, ah 126.1. FMN—One twenty-six, ah, one? DEN—Yeah, he’s losing altitude. He’s ah, he’s lost his airspeed, he’s going down. FMN—Oh, oh. 126.1, huh? DEN—Yeah. FMN—Don’t have that on this, ah… DEN—You don’t? FMN—No, ah, how far east is he? DEN—Ah, I can’t talk any more, there’s too much…

  32. TIME: 1210 37T--…transponder, sit? DEN—November 37 Tango, say again? 37T—Do you have me on transponder? Do you have me on radar? DEN—Ah, negative, sir, radar contact lost. What is your altitude now, sir? 37T—Thirteen thousand, sir. DEN—Thirteen thousand, and do you have your throttle forward, is that correct? 37T--…sir, I’m heading 290 at this time.

  33. TIME: 1210 continued… DEN—Roger, heading 290. What is your altitude now? 37T--…Thirteen thousand, sir. DEN—Roger, 13,000. Are you in the clear at this time? 37T--…gative, I’m encountering icing on my windshield.

  34. TIME: 1211 DEN—Ah, Farmington? FMN—Yeah. DEN—Do you have any reports of, ah, weather out east of the field? FMN—Ah, no, it looks pretty good east of the field out there. I can see, ph, 20, 25 miles, ah, northeast. There’s some fog, but, ah, but looks in general, looks real good. DEN—What’s the bases? FMN—Oh, the bases about 400 scattered and, ah, then we got some higher cirrus above it.

  35. TIME: 1211 continued… DEN—Uh-huh, about where does it break off? Ah, do you see any type of weather to the east of that? FMN—Ah, no, it looks, ah, real good, ah, all the way east and to the southeast of us here. A little weather to the northeast, ah, quite a ways up there, but as a rule it looks real good to the east. DEN—Okay. FMN—Ah, Center? DEN—Yes? FMN—How far east is he?

  36. TIME: 1211 continued… DEN—I don’t know, ah, he;s pretty panicky right now, and I can’t get to the ra… FMN—Ah, okay, real good. DEN—Ah, November 37 Tango, do you have any visibility out of your left side or your right side? 37T—No visibility on any place. DEN—November 37 Tango, can you open the window a little bit? Could you open the window a little bit?

  37. TIME: 1211 continued… 37T—I can, sir, why? No, I can see out the window, but I’m socked in, oh, I can see the visibility now, I can see (unintelligible—15 miles in here or 15 mountains here), sir. I had a littler visibility; I can see mountains. DEN—November 37 Tango, what is your airspeed? 37T—Airspeed keeps going up and down, 40 and down, I’m going down sir.

  38. TIME: 1212 DEN—Ah, what is your heading now? 37T—Heading is 280. DEN—Roger, holding heading 280. What is your altitude now, sir? 37T—Twelve thousand five hundred, going up. DEN—Roger, 12,500, and what does your airspeed indicator read? 37T—It indicates about 50, and I’m going up again, ah, starting to go up again, sir. DEN—Roger, you’re starting to go up again, and ah, can, do you have any visibility at all?

  39. TIME: 1212 continued… 37T—No visibility now, I lost it again… DEN—No visibility, roger. 37T—Can I get out of this below, sir? DEN—Ah, 37 Tango, are you in the clear, are you in the clear? 37T—Negative, sir, I see a little faint, but not much, very hazy. 37T—Is there any clearing around here at all, sir, that I can head for?

  40. TIME: 1212 continued… DEN—Are you still heading, ah, to the west? Are you still heading to the west at this time? 37T—Two six zero now, I do see some mountains, sir, but very hazy. DEN—Try to stay in the clear, if possible; ah, do you have any visibility at all? 37T—Keep going in and out of my visibility, sir. DEN—Roger, remain VFR conditions, if, ah, possible…main VFR if possible, over. 37T—I’ll try, sir.

  41. TIME: 1213 DEN—Roger, continue to the west if you can and remain VFR. Head to the west as long as you can. FMN—Farmington Radio. DEN—Yeah, what’s your visibility, ah, at the field. FMN—At the field, ah, we’ve got better than 15 miles. DEN—Is it that way about all quadrants? FMN—Yes, right. DEN—Okay, thank you. FMN—Uh-huh. DEN—November 37 Tango, what is your present heading? November 37 Tango, what is your present heading? November 37 Tango, what is your present altitude, over?

  42. TIME: 1215 37T—I can’t keep it too long (unintelligible). DEN—Ah, say again altitude, say your altitude, November 37 Tango. Maintain as much altitude as possible. If you are VFR, maintain VFR, November 37 Tango, Denver Center, over.

  43. Timeline

  44. NTSB Identification: DEN69A004814 CFR Part 91 General Aviation Event occurred Tuesday, May 06, 1969 in DEL NORTE, COAircraft: BEECH 35-33, registration: N2737T ----------------------------------------------------------------------------------------------------------------------------FILE    DATE          LOCATION          AIRCRAFT DATA       INJURIES       FLIGHT                        PILOT DATA                                                               F  S M/N     PURPOSE----------------------------------------------------------------------------------------------------------------------------3-2433   69/5/6    DEL NORTE,COLO      BEECH 35-33         CR-  1  0  0  NONCOMMERCIAL             COMMERCIAL, AGE 42, 300        TIME - 1118                    N2737T              PX-  6  0  0  PLEASURE/PERSONAL TRANSP  TOTAL HOURS, UNK/NR IN                                       DAMAGE-DESTROYED    OT-  0  0  0                            TYPE, INSTRUMENT RATED.        DEPARTURE POINT             INTENDED DESTINATION          WICHITA,KANS                FARMINGTON,N MEX        TYPE OF ACCIDENT                                         PHASE OF OPERATION           COLLIDED WITH: TREES                                     IN FLIGHT: EMERGENCY DESCENT        PROBABLE CAUSE(S)           PILOT IN COMMAND - INADEQUATE PREFLIGHT PREPARATION AND/OR PLANNING           PILOT IN COMMAND - ATTEMPTED OPERATION W/KNOWN DEFICIENCIES IN EQUIPMENT        FACTOR(S)           WEATHER - ICING CONDITIONS-INCLUDES SLEET,FREEZING RAIN,ETC.           MISCELLANEOUS ACTS,CONDITIONS - AIRFRAME ICE           INSTRUMENTS/EQUIPMENT AND ACCESSORIES - FLIGHT AND NAVIGATION INSTRUMENTS: AIRSPEED           MISCELLANEOUS ACTS,CONDITIONS - ERRATIC           TERRAIN - HIGH OBSTRUCTIONS        WEATHER BRIEFING - BRIEFED BY FLIGHT SERVICE PERSONNEL, BY RADIO        WEATHER FORECAST - FORECAST SUBSTANTIALLY CORRECT        MISSING AIRCRAFT - LATER RECOVERED        SKY CONDITION                                            CEILING AT ACCIDENT SITE          OVERCAST                                                  1000        VISIBILITY AT ACCIDENT SITE                              PRECIPITATION AT ACCIDENT SITE          4 MILES OR LESS                                           SNOW SHOWERS, THUNDERSTORM        OBSTRUCTIONS TO VISION AT ACCIDENT SITE                  TEMPERATURE-F          NONE                                                      47        WIND DIRECTION-DEGREES                                   WIND VELOCITY-KNOTS           80                                                       16        TYPE OF WEATHER CONDITIONS                               TYPE OF FLIGHT PLAN          VFR                                                      IFR         FIRE AFTER IMPACT REMARKS- RECOVERY DATE 8/22/69. FLEW INTO KNOWN ICING CONDITIONS WITH NO DE-ICING EQUIPMENT EXCEPT PITOT.

  45. Any More Thoughts? How might using personal Minimums and assessing risk Influenced the outcome?