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0:00 a pilot was flying home from vacation when something went terribly wrong he made a desperate radio call and what the controller said next was the reason why the family of the victim sued the FAA and that's really the most tragic part of this entire story that's why we're going to talk about what happened during the flight the deadly mistakes that were made and who was responsible for this tragedy I'm Hoover and welcome to your pilot debrief Our Story begins on September 7th 2015 when three people barded a small aircraft in Sarasota Florida to fly to Greensboro North Carolina in order to refuel before they plann to continue the Journey Back Home to Pennsylvania Unfortunately they never made it to Greensboro Michael was 55 years old and he was an attorney and
0:47 also a well-known philanthropist in his community and he was the pilot flying the plane also on board was his wife chrisy who is 53 years old and Christy's father Clarence who is 82 years old according to the investigation Michael had a Private Pilot certificate with an instrument rating but because his log book was never recovered the NTSB had to rely on the testimony of his flight instructor and other Pilots that flew with him to get a better understanding of his experience during the investigation they discovered that Michael owned a Piper Cherokee which is a four- seat single engine aircraft with fixed landing gear according to his flight instructor Michael had over 800 hours of Total flight time in the aircraft including a lot of experience flying in instrument weather conditions and those that knew Michael said he was
1:32 a safe and conservative pilot but the most important thing you need to know about the Piper Cherokee that he owned is that it wasn't equipped with Advanced avionics or an autopilot and that meant Michael had a lot of experience hand flying the aircraft using basic instruments without relying too much on newer technology eventually Michael wanted to upgrade to a newer aircraft and in August 2015 he purchased a beachcraft A36 Bonanza which would be the airplane that he would crash 1 month later now if you're not familiar with the Bonanza it's a six- seat single engine aircraft with retractable landing gear Advanced avionics an autopilot and an engine that produced about 100 more horsepower than the Piper Cherokee this was a big upgrade for Michael so after he purchased the aircraft he called his flight instructor and got a full
2:18 checkout to obtain his complex airplane endorsement this included 6 hours of flight time and an hour and a half of ground instruction his instructor also spent time demonstrating how to use the Gman 530 that was installed in the aircraft for instrument approaches even though a part of his training included flying practice instrument approaches these were all done in VFR conditions and Michael never flew with a hood on this is a tool that Pilots can use to limit their visibility tojust the instrument panel so they can simulate flying and instrument conditions that meant he didn't have any experience flying in IFR conditions in the new aircraft so he needed to be very careful when it came to his plan Michael's last flight with his instructor was on September 2nd and just
3:04 two days later he decided to take his wife and his father-in-law and fly from his hometown in Pennsylvania down to Florida for a few days to visit family because he wanted to stay safe he invited a friend who was also a pilot that owned a bonanza to fly down there with him now that friend would act as a safety pilot for the flight which in my opinion is probably one of the best things you can do when you're still trying to get comfortable flying a new aircraft during the flight down to Florida Michael's friend helped him practice loading instrument approaches into the Garmin 530 and they even had a chance to fly a practice instrument approach now keep in mind that Michael only had about 6 hours of experience in the aircraft prior to this trip so the more practice he got with the avionics the better Michael's friends said the flight was mostly VFR and uneventful and
3:50 Michael was getting a lot more comfortable with the Garmin by the time they arrived in Florida the only problem was the friend wasn't planning to make the trip back to Pennsylvania with him so Michael was on his own and that's when his plans started to fall apart according to a witness Michael planned to fly home on September 7th because his father-in-law needed to make it to a doctor's appointment the following day and my guess is this probably created a little bit of pressure for Michael to make it back home on the day of the crash that's why I always recommend if you're flying yourself somewhere you better have a flexible schedule because you don't want to put yourself in a situation where you feel pressured to make a flight happen now in terms of the trip the first flight was going to be from St Petersburg to Sarasota and it's not clear why they were making that stop but we know that when Michael showed up
4:35 at the St Petersburg airport he called to get a weather briefing and he filed an IFR Flight Plan saying the flight would take 15 minutes the weather briefer warned him about a convective sigment for embedded thunderstorms to the west of his route of flight but because Michael was in a hurry to get airborne presumably to beat the storm he interrupted the briefer and ended the call after about 3 and 1/2 minutes now thankfully they made it to Sarasota without incident and after they landed Michael filed a new IFR flight plan to Greensboro North Carolina and he called to get another weather briefing this time he was warned that there was an air met for IFR conditions for pretty much his entire route to North Carolina but instead of talking more about that Michael was focused on the storm that was approaching Sarasota and when he was
5:20 told it was about 12 miles away he tried to end the briefing so he could get airborne before the storm that's when the briefer tried to warn him saying that he could get in trouble for not providing Michael with the full briefing so Michael reluctantly told him to continue but then shortly thereafter he interrupted him again saying okay I'm perfect thank you for all the help and he hung up the phone and hopped in his airplane and took off a few minutes later before we talk about what happened during the flight I want to say that one of my goals has always been to help people stay safe and that includes protecting your personal data that's being sold online that's why I want to thank delet me for sponsoring today's video because they helped protect your personal data and your right to stay private the problem is there are data broker companies that collect huge
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6:51 me.com debrief and use the promo code debrief at checkout or just scan the QR code that's on your screen that's join delet me.com / debrief and use the code debrief to get 20% off the first 3 hours of the flight were relatively uneventful but the IFR conditions that Michael was warned about that extended through the Carolinas would soon become a factor in this tragedy the Greensboro airport was reporting 10 Mi visibility with overcast skies at 1100 ft with the cloud tops around 4,000 ft according to the investigation when Michael checked in with the approach controller he was told to expect to land on Runway 5 right Michael asked if he would be flying a visual approach and he also asked again which Runway he would be landing on the
7:36 controller told him to expect the ILS approach due to the weather and also reminded him a second time that he would be landing on Runway 5 right at this point Michael was still above the clouds and this was about 10 minutes before he would descend into the weather this would have been a great opportunity for him to turn the autopilot on if it wasn't already and that way he could go heads down to review the approach and also make sure that the gar was programmed correctly keep in mind that this was 3 hours into the flight so he had plenty of time to get the weather updates earlier and he should have already been prepared for the approach instead there must have been some confusion in the aircraft because 2 minutes later Michael asked the controller again which Runway they would be landing on and he was told for the third time that he would be landing on Runway 5 right 10 minutes later Michael
8:22 was cleared to descend to 3,000 ft and as he passed through 3600 feet he told the controller he was about to go IMC meaning he would be in the clouds now my guess is he didn't think twice about doing so because he probably had a lot of experience flying in instrument conditions and the truth is that everything seemed to be going fine at first the NTSB didn't mention whether he used the autopilot for the approach but according to the adsb data it seemed like he was hand flying for the rest of the flight he leveled off at 3,000 ft and turned to The Heading the controller directed that's when the controller advised him that he was 9 miles from Pagan and instructed him to turn right heading 020 to maintain 3,000 ft until he was established on the localizer and cleared him for the ILS Runway 5 R approach just to give you some
9:09 perspective this is the ILS approach to Runway 5 right and Pagan is about 7 miles from the end of the runway this is a fairly simple approach and Michael just needed to stay at 3,000 ft until he intercepted the localizer signal which gives him the lateral guidance to the runway and then he would begin a right turn to follow that course until he intercepted the Glide slope which provid provides the vertical guidance but the thing I want to point out is that all of the altitude restrictions on this approach are at or above altitudes the reason that's important is because if Michael wanted to make this a lot easier on himself he could have asked the controller to level off at 3600 feet or whatever would have kept him out of the clouds until he was established on the localizer that way he could intercept the Glide slope while he was above the clouds and minimize his time flying in
9:54 the weather unfortunately he didn't do that and the situation is about to get a whole lot worse instead of turning to the assigned heading of 020 Michael rolled out heading 030 now I know that might not seem like a big deal but it meant it was going to take him longer to intercept the localizer signal because it was a shallower intercept angle that's why 2 minutes later he still wasn't seeing the localizer signal and he must have gotten worried because he asked the controller how do you like this route of flight that's when the controller told him to turn left to a heading of 360 and Report established on the the localizer Michael immediately responded saying turning left or right for 360 and the controller told him left toe heading 360 however Michael didn't start turning left and
10:40 instead he continued Straight Ahead a minute later the controller asked him if he was established on the localizer and Michael responded by saying established if I could have vectors to final please now that didn't make any sense because if you're established then you don't need vectors and he had already been given vectors to final the controller started to tell him you are established because he was looking at the radar and that's what it looked like but he can't make that call so he asked Michael again if he was established on the localizer and this time Michael said I believe I am unfortunately the truth is that he wasn't established and the controller told him that he just flew through the localizer signal and then he canceled his approach clearance and told him to turn to a heading of 320 so that way he could sequence him back in with the other aircraft they were trying to land
11:26 and that's when things really started to fall apart 2 minutes later the controller told him turn left heading 230 for vectors for the ILS Runway 5 right Michael read back the instructions but then he turned to a heading of about 280 which was about 50° off course the controller asked him to verify that he was on a 230 heading and Michael started to respond saying negative but he never finished the radio call and about one minute later the controller asked him again what heading he was on and Michael responded saying current heading 166 we needed decent we are almost disoriented and now we know there's a real problem but what the controller did next was the reason why the family sued the FAA after the crash before I explain how they crash
12:13 let me just say that first of all there's no such thing is almost disoriented if you think you're disoriented you are and there's nothing wrong with declaring an emergency next don't wait until the situation gets out of control before you ask for help Michael was struggling with the approach for at least 5 minutes and he never said anything about it Michael was at 2700 ft when he said he was getting disoriented and just 7 seconds later instead of telling him to climb to 4,000 ft to get above the weather the controller asked Can you accept a no gyro turn to final and Michael said yes if you're not familiar in a no gyro approach instead of giving you a specific heading to fly the controller is going to tell you which direction to turn and when to stop turning and it's based on the pilot
12:59 flying a standard rate of turn of 3° per second this isn't the kind of approach that pilots fly on a regular basis in fact the last time I did one of these for practice was probably about 20 years ago when I was flying the Strike Eagle now typically this is something that's only used in an emergency situation like when your heading indicator is no longer reliable but in this case Michael never reported any malfunctions and the controller never tried to verify if there's anything wrong with his aircraft the investigation would later discover that the controller wasn't familiar with standard rate turns in regards to no gyro procedures and couldn't recall the last time he got training on emergencies or how to determine an emergency situation the controller described the situation as a priority but not an emergency the controller would go on to say that he was aware that Michael was
13:45 disoriented and he was trying to get him on a solid Vector so he could level the wings and then climb back up above the clouds but that's not exactly what happened 30 seconds after Michael said he was disoriented the controller told him to start a left turn and then 16 seconds later he told Michael to maintain 2500 ft then another 15 seconds later he told him to start a right turn reversing his Direction although Michael started the right turn over the course of the next 60 seconds he switched direction again and made a 360° leftand turn without the controller saying anything to him that's when the controller finally told Michael to climb and maintain 4,000 ft to see if he could get him back above the clouds Michael responded only with his call sign and the controller told him again to climb and maintain 4,000 because at that point
14:33 Michael was losing altitude and down at 2100 ft a few seconds later heavy breathing was heard on the frequency as Michael asked if there was a nearby Airfield the controller told him Greensboro was only 7even miles away screams were heard on the radio as the aircraft entered a steep spiral and everyone on board died when they impacted the ground this was an absolutely terrible tragedy and the family of the victim sued the FAA claiming that they failed to adequately train and prepare the controllers to respond to the situation which led to incorrect controller actions that likely made Michael's disorientation worse and ultimately resulted in his death however I'd argue that the truth is Michael just made a very sad and tragic mistake by putting himself in a situation that he wasn't
15:19 capable of handling his prior experience flying in the weather and the Piper Cherokee likely resulted in him being overconfident in his ability to fly the approach even this was a new airplane with avionics that he wasn't familiar with in fact before he made the trip to Florida his flight instructor specifically warned him not to fly in the weather until he gained more experience in the new aircraft the NTSB said there were deficiencies in the faa's training of controllers which led to incorrect controller actions that likely aggravated Michael's spatial disorientation but it was Michael's loss of aircraft control that caused the crash eventually the Court ruled against the family saying that Michael never should have been flying in those conditions to begin with and even if the controller had told Michael to climb above the clouds instead of offering him
16:05 the no gyro Vector there was no guarantee that he would have been able to comply because he was already struggling to maintain heading and altitude I'd like to know what you think about all of this so be sure to leave a comment below and I also want to thank delet me for sponsoring today's video be sure to go to join delet me.com dbrief and use the promo code debrief or scan the QR code on your screen to get 20% off and if you get a chance check out this other video and I'll see you on the next debrief
