OH - Coast Guard search for 6 people in plane missing over Lake Erie, Cleveland, 27 Dec 2018

[dotr]

.

NTSB releases report on Lake Erie plane crash that killed 6​

.

From link.
htmlReport
"The National Transportation Safety Board determines the probable cause(s) of this accident to be:


Controlled flight into terrain due to pilot spatial disorientation. Contributing to the accident was pilot fatigue, mode confusion related to the status of the autopilot, and negative learning transfer due to flight guidance panel and attitude indicator differences from the pilot's previous flight experience."

 

[deugirtni]

From link.
htmlReport
"The National Transportation Safety Board determines the probable cause(s) of this accident to be:


Controlled flight into terrain due to pilot spatial disorientation. Contributing to the accident was pilot fatigue, mode confusion related to the status of the autopilot, and negative learning transfer due to flight guidance panel and attitude indicator differences from the pilot's previous flight experience."

(I'm assuming it was meant to read 'altitude' indicator differences?)
Very sad story.

 

[dotr]

(I'm assuming it was meant to read 'altitude' indicator differences?)
Very sad story.

They really did mean attitude not altitude! imo
Attitude indicator - Wikipedia
"The attitude indicator (AI), formerly known as the gyro horizon or artificial horizon, is a flight instrument that informs the pilot of the aircraft orientation relative to Earth's horizon, and gives an immediate indication of the smallest orientation change. The miniature aircraft and horizon bar mimic the relationship of the aircraft relative to the actual horizon. [1][2] It is a primary instrument for flight in instrument meteorological conditions. [3][4]"

 

[PrairieWind]

I hadn't heard anything about this for a while and sort of forgot about it. I didn't read the NTSB report, but from the article, I gather that the pilot/father, due to fatigue and/or inexperience, became spacially disoriented and just flew the plane into the lake. Is that right?

 

[dotr]

I hadn't heard anything about this for a while and sort of forgot about it. I didn't read the NTSB report, but from the article, I gather that the pilot/father, due to fatigue and/or inexperience, became spacially disoriented and just flew the plane into the lake. Is that right?

If i understood the report correctly, the pilot initially tried to engage the autopilot function but it did not do so. He may not have noticed that the autopilot was not employed, because the pilot was possibly fatigued and became disoriented.
Hope i got that right, imo, speculation.rbbm
htmlReport
"It is likely that the pilot attempted to engage the autopilot after takeoff as he had been trained. However, based on the flight profile, the autopilot was not engaged. This implied that the pilot failed to confirm autopilot engagement via an indication on the primary flight display (PFD). The PFD annunciation was the only indication of autopilot engagement. Inadequate flight instrument scanning during this time of elevated workload resulted in the pilot allowing the airplane to climb through the assigned altitude, to develop an overly steep bank angle, to continue through the assigned heading, and to ultimately enter a rapid descent without effective corrective action. A belief that the autopilot was engaged may have contributed to his lack of attention.

It is also possible that differences between the avionics panel layout on the accident airplane and the airplane he previously flew resulted in mode confusion and contributed to his failure to engage the autopilot. The lack of proximal feedback on the flight guidance panel might have contributed to his failure to notice that the autopilot was not engaged.

The pilot likely experienced some level of spatial disorientation due to the dark night lighting conditions, the lack of visual references over the lake, and the encounter with instrument meteorological conditions. It is possible that once the pilot became disoriented, the negative learning transfer due to the differences between the attitude indicator display on the accident airplane and the airplane previously flown by the pilot may have hindered his ability to properly apply corrective control inputs.

Available information indicated that the pilot had been awake for nearly 17 hours at the time of the accident. As a result, the pilot was likely fatigued which hindered his ability to manage the high workload environment, maintain an effective instrument scan, provide prompt and accurate control inputs, and to respond to multiple bank angle and descent rate warnings.

 

[PrairieWind]

If i understood the report correctly, the pilot initially tried to engage the autopilot function but it did not do so. He may not have noticed that the autopilot was not employed, because the pilot was possibly fatigued and became disoriented.
Hope i got that right, imo, speculation.rbbm
htmlReport
"It is likely that the pilot attempted to engage the autopilot after takeoff as he had been trained. However, based on the flight profile, the autopilot was not engaged. This implied that the pilot failed to confirm autopilot engagement via an indication on the primary flight display (PFD). The PFD annunciation was the only indication of autopilot engagement. Inadequate flight instrument scanning during this time of elevated workload resulted in the pilot allowing the airplane to climb through the assigned altitude, to develop an overly steep bank angle, to continue through the assigned heading, and to ultimately enter a rapid descent without effective corrective action. A belief that the autopilot was engaged may have contributed to his lack of attention.

It is also possible that differences between the avionics panel layout on the accident airplane and the airplane he previously flew resulted in mode confusion and contributed to his failure to engage the autopilot. The lack of proximal feedback on the flight guidance panel might have contributed to his failure to notice that the autopilot was not engaged.

The pilot likely experienced some level of spatial disorientation due to the dark night lighting conditions, the lack of visual references over the lake, and the encounter with instrument meteorological conditions. It is possible that once the pilot became disoriented, the negative learning transfer due to the differences between the attitude indicator display on the accident airplane and the airplane previously flown by the pilot may have hindered his ability to properly apply corrective control inputs.

Available information indicated that the pilot had been awake for nearly 17 hours at the time of the accident. As a result, the pilot was likely fatigued which hindered his ability to manage the high workload environment, maintain an effective instrument scan, provide prompt and accurate control inputs, and to respond to multiple bank angle and descent rate warnings.

Thanks. I am assuming that " negative learning transfer" is engineer speak for "didn't realize?" LOL.

So essentially since this plane's instrument panel and cockpit were laid out differently from his previous plane, and he didn't have a whole of time in this new plane, he didn't realize that he had not actually engaged the auto-pilot when he thought he had. As a result the plane climbed too high and began to bank. Then dove. Because of the dark sky, no reference out over the lake, spacial awareness is lost and again, because of the different instrument display, the pilot is unable to determine what is wrong and/or how to correct it. Splash.

 

[Indy Anna]

Thanks. I am assuming that " negative learning transfer" is engineer speak for "didn't realize?" LOL.

So essentially since this plane's instrument panel and cockpit were laid out differently from his previous plane, and he didn't have a whole of time in this new plane, he didn't realize that he had not actually engaged the auto-pilot when he thought he had. As a result the plane climbed too high and began to bank. Then dove. Because of the dark sky, no reference out over the lake, spacial awareness is lost and again, because of the different instrument display, the pilot is unable to determine what is wrong and/or how to correct it. Splash.

RBBM
I guess you could put it that way. IOW, he didn't transfer the knowledge he learned to successfully fly his previous aircraft to the new airplane which crashed because of of the differences?

You explained it well. Probably, fatigue also contributed to his inability to correctly read the instrumentation, and maybe he was in so much of a hurry to sit back and relax (due to fatigue) to pay attention to the instrument panel. JMO

Very, very sad.

 

[deugirtni]

They really did mean attitude not altitude! imo
Attitude indicator - Wikipedia
"The attitude indicator (AI), formerly known as the gyro horizon or artificial horizon, is a flight instrument that informs the pilot of the aircraft orientation relative to Earth's horizon, and gives an immediate indication of the smallest orientation change. The miniature aircraft and horizon bar mimic the relationship of the aircraft relative to the actual horizon. [1][2] It is a primary instrument for flight in instrument meteorological conditions. [3][4]"

Oops, should've looked it up. Who would've known!? (Other than those versed in aviation lingo!) That's what I get for **advertiser censored*uming*, thanks for the correction!

 

[Betty P]

RBBM
I guess you could put it that way. IOW, he didn't transfer the knowledge he learned to successfully fly his previous aircraft to the new airplane which crashed because of of the differences?

You explained it well. Probably, fatigue also contributed to his inability to correctly read the instrumentation, and maybe he was in so much of a hurry to sit back and relax (due to fatigue) to pay attention to the instrument panel. JMO

Very, very sad.

IIRC (and the report doesn't give much information) there was no indication the pilot did anything at all after takeoff. The report is fairly brief, it doesn't mention whether there were any sounds in the cockpit after take off, prior to the crash. Could the pilot have lost consciousness?

There was also this

An autopsy and toxicology testing were not performed due to the limited remains recovered.

This crash was so severe, they recovered very little in the way of human remains. The pilot may have been intoxicated. He and his family had just left a Cleveland Cavaliers basketball game, he may have had a few drinks. So sad.

 

[MsMarple]

As an aside, in the investigation docket there are two letters from other pilots writing about similar experiences with the airport, in particular difficulties with the sudden absence of lights when turning away from Cleveland and how it could cause spatial disorientation.

Ever since I heard about the accident last month, I have been thinking about a situation I had at that same airport during a night takeoff in clear VFR weather conditions. I was flying my C182 and after takeoff on a westbound runway, I was expecting a left turn after takeoff towards KHLG. I was assigned a right turn out over the lake. When I made that turn, it was instantaneous IFR conditions. There was a black hole!! No horizon at all. No stars, no lights anywhere. If I had not transitioned to the gauges until completing my turn towards the SE, I would have had severe spatial disorientation. When completing the turn, the lights appeared along the shoreline and everything was OK again.

I encountered a similar situation at the same location 20 to 30 years ago. I can consult my logbooks for more detailed information, but remember that the location, time of day, clearance etc. were comparable.
... I believe that turning away from the lights of Cleveland into the absolute darkness over Lake Erie may result in pilot disorientation at too low an altitude to recover.

Accident ID CEN17FA072 Mode Aviation occurred on December 29, 2016 in Cleveland, OH United States Last Modified on June 21, 2018 11:06 Public Released on June 21, 2018 11:06 Total 35 document items
You can also view the plot of the plane as it took off, climbed higher than the stipulated altitude then banked right and lost altitude. This should link to it. Follow the direction to click the button to either view it or download it.
Document 1 Plot of ADS-B Position Data Filing Date June 21, 2018 1 page(s) of Image (PDF or TIFF) 1 Photos
About a minute after takeoff warnings started going off. First was the "altitude" warning as the plane climbed beyond 2,000 feet. 15 seconds later the "bank angle" alert sounded (banking too steeply) followed 12 seconds later by the "sink rate" alert (descending too fast). 4 1/2 seconds later the first of 7 "pull up" warnings began along with the "overspeed" alarm. 10 seconds later the last warning is heard - the plane is less than 200 feet above the water at this point - then nothing. All of this happened in under a minute!

Right after the bank angle alert the tower stopped getting radio responses from Mr. Fleming but his responses could be heard on the voice recorder, indicating that he forgot to push the talk button. IMO this is when things went to hell. I think he was momentarily disoriented, which might not have been too serious - if he had engaged the autopilot.

The average pilot response time to alerts is 5.5-10 seconds but IMO Mr. Fleming lost time trying to understand what was happening because he believed the plane was on autopilot. He may have then mistakenly believed the first alerts were nuisance (false) alerts but when additional alerts and alarms started sounding it was probably already too late. MOO.