Cessnaflyer
Wooooooooooooooooooooooooooooooo
Exactly.
Another question for you Mike. Is this typical to take this long for the final factual report?
Factual NTSB Report from Ben's Crash
- Thread starter jtrain609
- Start date
Another question for you Mike. Is this typical to take this long for the final factual report?
For NTSB ones, yes. It depends how complex the accident is or the evidence gathered is. United 585 took a very long time, for instance.
Roger Roger
Bottom of the list
Well that just sucks.
As to the positioning of the fuel selector, my understanding is that popping a tank in a 206/207/210 is a pretty dramatic event and even with prompt action it takes a while to regain engine power. ppragman would know. It's entirely possible that the tank was switched to the full one, but switched back when that failed to produce a timely result. I also notice that the report does not note the position of the boost pump switch, which might have been helpful in determining what actions were taken after the loss of power.
The other thing about factual reports (and even about the final report) is it's really hard to know WHY a professional like Ben neglected to verify the quantity of fuel in the tanks, or to set the fuel selector to the fuller tank before takeoff. Was he rushed? Had he done this flight in this airplane a million times, and just complacent? Tired? Distracted? Did the gauges or another person lie to him about fuel on board? Unfortunately we'll probably never know.
Of course all of this is assuming that the person who noted no evidence of fuel spillage in the area of the broken line from the left tank was correct. Or that the fuel selector wasn't installed or assembled wrong (I've seen that before. Scary stuff).
As to the positioning of the fuel selector, my understanding is that popping a tank in a 206/207/210 is a pretty dramatic event and even with prompt action it takes a while to regain engine power. ppragman would know. It's entirely possible that the tank was switched to the full one, but switched back when that failed to produce a timely result. I also notice that the report does not note the position of the boost pump switch, which might have been helpful in determining what actions were taken after the loss of power.
The other thing about factual reports (and even about the final report) is it's really hard to know WHY a professional like Ben neglected to verify the quantity of fuel in the tanks, or to set the fuel selector to the fuller tank before takeoff. Was he rushed? Had he done this flight in this airplane a million times, and just complacent? Tired? Distracted? Did the gauges or another person lie to him about fuel on board? Unfortunately we'll probably never know.
Of course all of this is assuming that the person who noted no evidence of fuel spillage in the area of the broken line from the left tank was correct. Or that the fuel selector wasn't installed or assembled wrong (I've seen that before. Scary stuff).
Pilotforhire587
Lycra Man
Glad to see the report finally out. RIP Ben! We miss you man.
Why does it have to be any of the above? Why is it so difficult for people to accept that maybe it was just a screwup? An error by Ben? With no overriding boogyman or distraction or other causal factor? Pilots of all experience levels screw up; that's life. I've lost well over 35 guys and gals I personally knew in both military as well as civilian aviation. Each time, I have to separate the "personal" part of knowing them and look at their accident coldly, by the facts that are in evidence. Every one of them was a great pilot in hindsight....."the best there was", but very few of the accidents were something other than pilot error: A dreaded word that no one wants to hear, but one that is unfortunately the major cause of accidents. Failure of the human portion. Understanding and learning why that failure occurred is key. But like I said before, we ARE NOT finding new ways to crash airplanes and kill pilots. Nearly every accident there is in aviation, has been done before by someone else.
And when my number eventually comes up and I eventually pack it in someplace, you're damn right I don't want anyone making excuses for me. I want the cold hard facts of what I did right, what I did wrong, what I could've done better, what I committed, what I omitted, and what I had no control over; to all be brought to light and analyzed in the same way that I would do for anyone else and in any other accident, or like is done in my accident synopsis reports. That's the only way.....the only proper way....that the accident will have any lasting meaning.
Roger Roger
Bottom of the list
Of course it could have been a screw up! By all appearances it WAS a screwup. But the question is, why did he screw up? Isn't that the point of reading about accidents? He knew to check the fuel in the tanks. Everybody knows to check the fuel in the tanks. Why didn't he do it this time? Was it something I mentioned above, or did he just plain forget? And if that's the case, how do you just plain forget? What do I gather from this crash to keep me from forgetting? Thats the part I really want to know.
I'm not making excuses, I'm trying to find the unknown factor that makes a well trained brain miss something as fundamental as making sure the engine has a good supply of go juice. And maybe you're right. Maybe there was no unknown factor, maybe it was just a total slip of the brain, maybe he was in no hurry and well prepared for the flight and well rested and meticulous about his checklist use on the accident flight and briefed and reviewed emergency procedures and when push came to shove he just glossed over the position of the fuel selector or locked up on the emergency procedures. But I think you and I know that's not usually the case. People don't skip important parts of preflight because they're not in hurry or because they're well rested or because they maintain a healthy skepticism of the condition of the mass of parts flying in loose formation.
Taking a look at the Toxicology section of the accident report, it states this:
"The results of toxicological tests on samples retained during the autopsy were negative for alcohol. Levels of Acetaminophen, Brompheniramine, Dextromethorphan, and Diphenhydroamine were detected in the pilot's blood and urine specimens."
The latter meds are types that cause drowsiness, slowed reactions, and generally come with the warning of "do not operate heavy machinery when using this product". They are often found in over the counter cold and flu medicines, and aren't FAA approved for use. This is the most common method of their being in someone's system, however it isn't known factually where these came from.
Whether or not this was a causal factor to any error of omission of checklist or flow steps is not known, nor is it stated in the report to what amounts or levels were indeed found in Ben's system post-mortem. But they're there.
One big accident where these same meds were a factor, was the 1981 nighttime landing accident of USMC EA-6B Prowler 159910 from VMAQ-2 aboard the USS Nimitz, killing 14 on the flightdeck and 3 aboard the Prowler.
"The results of toxicological tests on samples retained during the autopsy were negative for alcohol. Levels of Acetaminophen, Brompheniramine, Dextromethorphan, and Diphenhydroamine were detected in the pilot's blood and urine specimens."
The latter meds are types that cause drowsiness, slowed reactions, and generally come with the warning of "do not operate heavy machinery when using this product". They are often found in over the counter cold and flu medicines, and aren't FAA approved for use. This is the most common method of their being in someone's system, however it isn't known factually where these came from.
Whether or not this was a causal factor to any error of omission of checklist or flow steps is not known, nor is it stated in the report to what amounts or levels were indeed found in Ben's system post-mortem. But they're there.
One big accident where these same meds were a factor, was the 1981 nighttime landing accident of USMC EA-6B Prowler 159910 from VMAQ-2 aboard the USS Nimitz, killing 14 on the flightdeck and 3 aboard the Prowler.
My point is, sometimes there is no answer. There is no boogyman, there was no gotcha around the corner, there was no "a-ha!" moment. Sometimes screwups just happen. Sometimes errors just occur. Oftentimes they won't be known with the facts at hand, and they just need to be classified as "unknown". Because by trying to fill in the blanks ourselves as pilots, more often than not, we fill them in incorrectly or by what we think we know; and that does disservice to the facts at hand. Your sentence I bolded above backs up what Im saying....there HAS to be a reason!!! And the answer is, no there doesn't. At least not one that's known by the facts. Only Ben knows the reason, as he was alone in the cockpit. Without a CVR or a surviving pax or something else, there's little for anyone to go on when it comes to this road of finding why.
All, some, or none of the reasons you cite above could be causal for why errors were made. What Im trying to say is that we'll likely never know, without anything in my previous sentence existing.
It's the EXACT reason I hate having professional pilots as witnesses to aircraft accidents, because they can never just tell my what they saw, they tell me what they "think". I don't give a hoot what you think, I just need factual observations.
The big takeways and learning points are these:
1. If you have an aircraft where it's possible to visually check the fuel level or dip the tanks, take the time to do so, at least on the first flight of the day. In many light civil aircraft, this is entirely possible to do. On aircraft like a 747 or F-15, you just have to accept what the gauges are telling you.
2. Know, and be prepared to execute, the proper procedures for an engine failure during any phase of flight, particularly those phases where time is not on you side, as on takeoff and landing. Know them cold to where they're second nature. This isn't to say that Ben necessarily didn't; this is only to re-emphasize that knowing them is paramount, because the time you'll need to execute them is normally the worst possible time. In any event, Ben didn't run the plane out of fuel, he only ran a tank out fuel......otherwise, there was at least 10 gallons remaining, just on the other side. As Roger Roger notes, the position of the fuel boost pump isn't noted in the report, yet still swapping tanks should garner fairly quick results one way or another, to some degreeor another, boost pump or not.
3. The Toxicological findings are interesting, and (depending on the levels found) could've played a factor in fatigue, or coordination, or speed of reflexes. However whether or not this is a factor is still unknown with the information given in the report cited. Therefore, more detailed analysis would be needed to be able to measure what degree this finding would have affected Ben himself. With what we know right here, right now, it's merely a finding that stands alone with no specific causal basis.
1. If you have an aircraft where it's possible to visually check the fuel level or dip the tanks, take the time to do so, at least on the first flight of the day. In many light civil aircraft, this is entirely possible to do. On aircraft like a 747 or F-15, you just have to accept what the gauges are telling you.
2. Know, and be prepared to execute, the proper procedures for an engine failure during any phase of flight, particularly those phases where time is not on you side, as on takeoff and landing. Know them cold to where they're second nature. This isn't to say that Ben necessarily didn't; this is only to re-emphasize that knowing them is paramount, because the time you'll need to execute them is normally the worst possible time. In any event, Ben didn't run the plane out of fuel, he only ran a tank out fuel......otherwise, there was at least 10 gallons remaining, just on the other side. As Roger Roger notes, the position of the fuel boost pump isn't noted in the report, yet still swapping tanks should garner fairly quick results one way or another, to some degreeor another, boost pump or not.
3. The Toxicological findings are interesting, and (depending on the levels found) could've played a factor in fatigue, or coordination, or speed of reflexes. However whether or not this is a factor is still unknown with the information given in the report cited. Therefore, more detailed analysis would be needed to be able to measure what degree this finding would have affected Ben himself. With what we know right here, right now, it's merely a finding that stands alone with no specific causal basis.
scooter2525
Very well Member
Roger Roger
Bottom of the list
Isn't that what I said in my first post? That the factual and the final report probably won't tell us why he didn't check the fuel...or switch before takeoff?
You did, but I bolded your statement a few posts above where you then fall into the rationalization trap of:
"......But I think you and I know that's not usually the case. People don't skip important parts of preflight because they're not in hurry or because they're well rested or because they maintain a healthy skepticism of the condition of the mass of parts flying in loose formation........
And my contention is that the above statement isn't necessarily true in a broadbrush sense. People can and do commit errors of comission or omission without explanation. Without some supporting evidence either way, that part of the "why" equation simply becomes an unknown. It sucks, but anything more than that would be pure speculation lacking factual basis.
Of course, there is the toxicological side of the report I cited, which I wish we could get more detailed information on; because it could potentially have been a factor. It's factual evidence, it's just unknown as to what degree, with what the online report summary says.
fly22
Well-Known Member
I miss Ben and was pretty close to him by social and JC standards. We did lunch at least once a month, usually every other week and would fly fish together often.
That being said I want to really emphasize my love and respect towards Ben and his family. However there are a couple points to share, and I share them with the highest regard and respect but do so to honestly HELP other JC ers. I almost feel guilty sharing this but hope it saves someone else.
Ben made two common mistakes that he repeated several times I flew with him.
1) He would stoke the fuel stick and show more fuel than he actually had. Im not sure if he put his thumb over it too late forcing more fuel up the stick and then cap his thumb or what but he we seldom pulled similar results when preflighting birds.
2) He often forgot to switch fuel tanks
I was flying that very bird with him 2 weeks prior from PVU to Vegas KVGT. We flew on one tank ( tanks wanst full to start with) until ee were over Mesquite. I noticed it and didn't say anything to him but I continued to monitor it. The engine started to hicup 3nm north of Mesquite. He thought the engine was falling apart and I pointed out to him that we hadn't switched tanks. He felt we should cancel our IFR to KVGT and land Mesquite (67L) to verify the engine was ok. We landed everything checked out and on our way to Vegas we went. After the stress of it had passed I shared my concern that he commonly made this mistake and it would kill him someday. I get the chills when I think about me lecturing about this.
PLEASE understand I don't write this up to throw my dead friend under a bus but to educate someone on here.
Jtrain called me three times in a row the night of Ben's death. I got a voicemail informing of his passing. Weird time and weird situation. Just a whole lot of weirdness that doesn't make sense.
Despite all of this he was still a hell of an aviator and an even better angler.
That being said I want to really emphasize my love and respect towards Ben and his family. However there are a couple points to share, and I share them with the highest regard and respect but do so to honestly HELP other JC ers. I almost feel guilty sharing this but hope it saves someone else.
Ben made two common mistakes that he repeated several times I flew with him.
1) He would stoke the fuel stick and show more fuel than he actually had. Im not sure if he put his thumb over it too late forcing more fuel up the stick and then cap his thumb or what but he we seldom pulled similar results when preflighting birds.
2) He often forgot to switch fuel tanks
I was flying that very bird with him 2 weeks prior from PVU to Vegas KVGT. We flew on one tank ( tanks wanst full to start with) until ee were over Mesquite. I noticed it and didn't say anything to him but I continued to monitor it. The engine started to hicup 3nm north of Mesquite. He thought the engine was falling apart and I pointed out to him that we hadn't switched tanks. He felt we should cancel our IFR to KVGT and land Mesquite (67L) to verify the engine was ok. We landed everything checked out and on our way to Vegas we went. After the stress of it had passed I shared my concern that he commonly made this mistake and it would kill him someday. I get the chills when I think about me lecturing about this.
PLEASE understand I don't write this up to throw my dead friend under a bus but to educate someone on here.
Jtrain called me three times in a row the night of Ben's death. I got a voicemail informing of his passing. Weird time and weird situation. Just a whole lot of weirdness that doesn't make sense.
Despite all of this he was still a hell of an aviator and an even better angler.
USMCmech
Well-Known Member
The one lesson that I think we should all take a way is that on any given day any of us can make a simple small mistake that can have disastrous consequences. That doesn't mean that Ben wasn't a great pilot, or that he wasn't a safe professional in everything he did. It only means that he made a mistake. How many of us have done the exact same thing, but got away with it?
One common theme you will find is that accidents happen to two kinds of pilots. Inexperienced low timers get into situations over their head because they don't know any better, and pros with thousands of hours in their log book will get killed by some small error in procedure or judgment.
One common theme you will find is that accidents happen to two kinds of pilots. Inexperienced low timers get into situations over their head because they don't know any better, and pros with thousands of hours in their log book will get killed by some small error in procedure or judgment.
In the case here, this wouldn't have been a factor, since this wasn't performed on the accident flight. It's a trend worth noting, but a non-factor in this case.
This trend, if you had in fact witnessed it occur more than once in order to establish it as a trend, is more troubling. If running a tank dry while in cruise flight with no emergency didn't prompt a pilot to immediately switch tanks as one of the first steps when the engine coughed and hesitated; then it wouldn't be a habit he could rely on doing instantly when in an emergency situation and things were happening fast, time was of essence, stress was high, and your life was on the line.
It's not throwing Ben under the bus, its simply a statement of observation regarding his piloting skills and habits which could very well be trend indicators; especially since the latter one is so related to what we've been discussing and what I mentioned of how he either: didn't have time to switch tanks; all the way across the spectrum of him not knowing to switch tanks......or the procedure not being ingrained habit; and everything in-between.
All of these are things that other pilots need to look at, read, understand, and learn from.
Boris Badenov
Fortis Leader
I don't have anything to add to MikeD's thoughts, spot on. I will say that I've run a 210 dry and it took ~15 seconds (guessing, hard to tell when you're pooping your pampers) to identify the problem, switch tanks, hit the boost pump, and get the engine back. When you're that close to the ground, you may not have 15 seconds, and if you do, you might be way too busy worrying about the impending forced landing to concentrate on getting the engine back.
However, as Mike pointed out, that's speculative. All we know is what's in the report. On that subject, I'll just add that I've done dumber things and lived.
However, as Mike pointed out, that's speculative. All we know is what's in the report. On that subject, I'll just add that I've done dumber things and lived.
ghoster
Onward Thru the Fog
May have already been said but last year when I had the annual on a Cessna 172M, one of the items was a mandated (Cessna paid for) seat restraint. It looks like any seat belt tensioner on a car and works the same way. If the seat releases and quickly starts back, the device locks and stops it in its tracks (no pun intended).