Accident Case Study: Final Approach


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Brought to you by AOPA Insurance (insurance.aopa.org) Link to certificate, WINGS credit, and ASI transcript: />Description: On January 13, 2013, a Piper Arrow collided with trees during an emergency approach to Delaware’s Dover Air Force Base. Come along as we re-create the pilot's final flight, and seek to understand the circumstances that led him down a path to disaster.



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Aviation (Industry) Aviation Safety (Literature Subject) Aircraft Owners And Pilots Association (Membership Organization) AOPA acs accident case study plane ASI airplane crash GPS Final approach final analysis Insurance Wings credit piper arrow collision collided Delaware Dover Air Force disaster



Darrin Nunyah
24 years Air Force retired here. Just wanted to say that you non-Air Force pilots needn't ever fear declaring an emergency and landing there in these types of situations. I get the idea from non-military experienced pilots that they fear severe repercussions for landing at a military field. But if you declare an emergency, the controllers will try to clear the way and get you down safely, like any other controller. Don't have the perception that you'll be jacked up by guards and taken for questioning, and your plane will be impounded. They have a military mission but their primary mission is public safety in an actual event.
Shaun Daskam
The biggest lesson I've learned: You never want to be featured in any of these videos.
Tom Rodabaugh
Many years ago I suffered fuel starvation on a VFR cross country caused by a fuel system malfunction.  I was within visual range of Brown field at Marine Corps Air Station Quantico, VA.  I turned on the fuel pump which brought the engine back to life as I put Brown field on the nose.  I did not have time to call the tower until after I landed.  Even though this is the same airport that the Presidential helicopters were based at, my reception by the Marines was welcoming.  I filled out some paperwork, fixed the problem, filled up with gas, and was on my way to my destination the same day.  The Marines even followed up to ensure that I had landed safely at my intended destination.  God bless the Marines, and don't hesitate to use any runway that will offer a safe landing in an emergency.
Phil Mann
Don't know where to begin, but this has lessons all the way around. The guy that got me into flying was a part-time lawyer and full time 727 pilot with United. He had thousands of hours, a well-equipped twin engine aircraft of his own, and possessed about the most calm, level-headed disposition I've ever seen. Despite these qualifications, on more than one occasion when we were planning to fly to visit a client, he checked the reports, looked at the sky, and said, "I don't like this weather, let's drive." That, I think, is why he retired as a Captain without incident, never bent an airplane, and, in his late 70s, is still alive
Paul Wiles
He was being too polite, and didn't want to be a bother to anyone. He sounded like a really nice guy. I am only vfr, but I would have declared an emergency when the atc said negative in a pretty stern tone. Heck, it's just so sad. My sincerest Condolences to his family
Chris Barnes
As a current air traffic controller I cringe at the way the controllers acted in this situation. It doesn't appear that ANY of them were helpful any more than was required. Towards the end of this video, and prior to him giving much indication that he was facing an issue, you can clearly hear in his voice that he is becoming increasingly stressed. The exchange regarding landing at Dover brings up a good point. I firmly believe that he would have been less apprehensive in declaring an emergency if he didn't think the iron fist of the FAA would come down on him. The FAA has created an atmosphere of over reaction and heavy handedness that has made most pilots (and even ATC) feel that the less the FAA knows the better. In this case declaring an emergency is bad enough...landing at a military base is the cherry on top. HOWEVER in this case, knowing what I know from both the ATC and pilot world, I would have landed at Dover without question...my feeling is that they would have been easier to deal with then the FAA.
Berkeley Bill
I had a fuel emergency and was forced to land at an Air Force base in Florida. Everybody was very nice there and after about an hour delay and some paperwork I was back on my way. I had no problem with the FAA concerning it. You've got to squawk like a chicken when you're up there and something goes bad-wrong. Being passive is counterproductive.
skyviper1973
No matter how old I get or how many hours I accumulate, I will always be a student pilot. Really appreciate these videos.
TheAviator
Controllers can declare an emergency for pilots. This accident is so sad, the controller should have ask how much fuel do you have? Controllers should do more to help. And yes I understand that the pilot was hesitant to call it an emergency... But come one let's save lives...
Bobby Creager
Air Safety Institute- This videos are great and so worth the time and effort.  As a CFI I take these in with huge respect and learning never stops.
Ruben Villanueva
Wow!, I was a military Air Traffic Controller, at Dover AFB, circa 1972. I was at the Approach Controller position, when I received a call from Phillie Approach. They had a light aircraft that was unable to land at PNE, due to weather. Phillie approach had the aircraft contact me. Dover weather was VFR, with a little mist along the coast line. I identified the aircraft and started vectoring it to then, Delaware Airpark (possibly 33N, now). It was located 9 nm nnw of Dover. I vectored the aircraft East to west, directly to 33N, he did not see the airfield, so i vectored him back West to east to 33N, again no joy with the airfield. The pilot then began reporting low fuel and that his engine was sputtering. I cannot recall wether the pilot declared an emergency or I did. I vectored him directly to Dover AFB, had the tower turn up the runway lights to full intensity and switch the strobe lights. We notified Dover police about the aircraft in the event he might try to land on the north-south highway between Dover and 33 N. The pilot made it to overhead Dover AFB, and was cleared to land on any runway he saw fit. Gladly, he landed, rolled to a stop. Later tanks were checked, both empty. I was very happy for the pilot and pax, that experience made my day! I am sorry to hear about the outcome of the other pilot. Nothing would have happened to that military controller. It is just the fear of breaking the PPR, Prior permission required, rule at military bases.
Kelly Trimble
I made a comment, but it either got deleted or didn't take or something. I just wanted to comment that I thought this guy drew the wrong controller. When she said there was an airbase nearby, but was emphatic that he wasn't allowed in there without declaring an emergency, implying that nobody was going to understand him declaring an emergency, she was REMOVING options, not helping him. She should have said something along the lines of "Dover is an airbase and technically you need to declare an emergency to get in there, but short of fuel is an emergency." Could have kept him alive. Anyway, if this offends some controller union somewhere, go ahead and delete it again. Whatever.
Ralph Corsi
I am a retired corporate Helicopter/Airplane pilot with a dual ATP. I still use my own small aircraft for my business. If I had gotten that weather forecast, I would have immediately cancelled my plans to fly. This would be for two reasons. The weather was quite low and I would not count on the forecast for better weather, too risky. Added to that, you would be arriving at night. I would not have felt comfortable dealing with that kind of low IFR at night. The pilot had several opportunities to change the outcome but the best would have been to find another way to get to his destination.
robertwaldo
If it wasn't for airplanes the country would be overrun with doctors and lawyers.
14598175
It is SO easy to Monday morning quarterback an accident like this, but the truth is, when you're up there, you're trying to work the problem so intensely that I think your mind pushes the worst case scenario out of the picture to prevent panic. I watch this and think "duh" yet I did the EXACT same thing 21 years ago. I had 450 hours, was in the same plane (not the T-tail though), only it was a Naval air station that I avoided. However, I was VERY lucky. My prayers go out to him & his family. - CFII/CMEL
John L. Fahnestock
Watching this video (and others like it) should be a required part of every GA pilot's BFR. So much practical information to be learned (reminder of) here that you wouldn't get otherwise. Thanks for taking the time to produce and publish. Who knows how many lives this may save going forward.
ElmerFudd♥guns
RobertWaldo (below) has an excellent point. I'm not a pilot, but I am a physician, so I'm addressing my comments to my fellow docs. Physicians are accustomed to being decisive and in control. By the time a surgeon has reached this point in his career, he's undoubtedly faced dozens of situations that involve very similar decision making. The situations and the stakes are seemingly similar -- he(she) is often isolated, making life and death decisions with no guaranteed outcome. After analysing his situation, he resolutely and confidently moves forward, and emerges successfully at the other end. "Successfully" from the perspective that he's exhausted but alive 100% of the time, and successfully in that perhaps 90% of the patients are alive. The 10% who didn't make it? Well, you're highly skilled and highly regarded, and no one could have done better. In other words, 100% of his "pucker factor" situations culminate with what seems the best possible outcome. Because he is not the one who's life is on the line. In the plane, he is. It's a mistake to translate our prowess in medical emergency decision making into emergency decision making in the air.
Timothy Stockman
I had an interesting situation once with a non-precision approach at a small airport in weather that turned out to be lower than forecast. Approach was expecting me to land, but the ceiling was lower than forecast, and I never saw the runway. As I came down the approach, they lost radar and radio contact (expected). So I started the published missed when time ran out, but when I got to an altitude where I should have been able to get approach, I did not. Then I noticed that a few other commercial flights were calling and not getting a response. So I asked one of them if they knew an alternate frequency. Approach was right there on the alternate frequency, and they said they had to shut down an entire communications site because of a gas leak. Anyway, shooting the approach again was unlikely, IMHO, to produce a different result, so I asked for vectors to an ILS approach at an airport about 25 miles away. In not too long, I was safely on the ground, topping off the tanks, taking a break, and planning the rest of my flight. It was SO much easier to plan on the ground and to have full fuel again! A very long time ago, when I was working on the instrument rating, the instructor said to me "Do you want to try a PAR?" I said "OK", and he said "Why don't you give Grissom a call and see what they say." (This was in the late 1980's.) The guys at Grissom AFB were really great and when my instructor finally said "Look up", I was just getting into position to make a low pass down Grissom's runway. It was awesome seeing all the KC135s parked on the ramp. Every pilot should experience a similar positive interaction with military controllers.
William Hendrix
I hate the final comments. The fact is if you're flying an airplane, the controllers have one job. What's that job? To safely help pilots and their passengers get from point A to B. That's it. What does that mean? Their job is to provide you with all the help you need. To be sure, this pilot made his share of mistakes, but there is plenty of blame to go around. ATC and those at Dover share responsibility in this stupid and useless death.
Muup Muup
If you're about to run out of fuel, it's an emergency. Communicate this. He could have landed at the military base.
Aviation Nut
The problem is that doctors got lots of money and they always by a lot more plane then they can handle.
Yakav8r55m
How many warnings were ignored here? Fuel costs nothing compared to the value of a life. If you are consuming up your IFR reserve and you're not on the ground with 20 minutes of fuel in the tanks, it's an EMERGENCY!! Make conservative personal minimums and don't violate them for anything. It's so ironic that he overflew one of the largest runways on the east coast because he let intimidation interfer with the human instinct for survival.
Bob M.
Plain and simple, He’s the PIC and should have declared an emergency...call Dover and say “I have an emergency and I am landing”..so sad.
spoofer20
I feel sorry for the ATC, she was probably kicking herself after realizing she could've helped a man from dying if she had been more concerned. A very tough thing to have on your shoulders... You can even hear her voice break when shes talking and she stumbles over her words because shes so nervous when she realizes hes going down.
CountryBoy Motovlogs
As alot of accidents, pride shame cost that pilot his life. Its a no brainer as he was coming up on dover all though an usaf base why he didnt declare an emergency befuddles me. He was out of fuel theres no more emergency than that. They would have vectored him in if he had just declared. Rip Brother.
herobo123456
THAT WOMNAN IN ATC ZERO HELP
Vic Wiseman
Currently training to be a controller. I found this very informative.
Ben Kolbeck
Keep doing these - they are excellent.
sadigov
Don't know who is more stupid, the pilot or the controllers?. Holy crap, these people have no logic. Declares emergency only after completely running out of fuel.
henry dumor
really poor piloting indecisive and unskilled
Riley Raine
He must not of known there was an ILS approach option. Its sad that the ATC did not offer that option.
MrTeotwawki
This guy was way to passive.
C Riley
ATC really failed
ThePurpleUFO
This was horrible to listen to...the guy's last minutes. "Keep talking to me, please!"
Bret Fugate
I hope that female ATC knows that she killed this guy
Rob S
Another extremely sad loss for the GA community. I think the issue about not speaking up when you're struggling is a very serious one. It's kind of an issue in general; some individuals have a hard time fessing up that they need assistance, or that their plans have gone awry. It's crucial to say whatever you need to no matter how uncomfortable it might make one feel. The evaluation says the pilot overlooked the ILS approach at Salisbury; however, this was in the opposite direction. I'm only a student and have no instrument time at all, but considering a downwind approach in times of crisis sounds non-intuitive to me, I imagine my mind would be elsewhere, too. It's a shame the controllers couldn't do more, the last one in particular. Yet the pilot was not forthcoming enough about the reality of his situation, so they were none the wiser. These evaluations are extremely well produced and invaluable to all pilots - students and veterans alike. I've learned an incredible amount from them, well done ASI, please keep them up.
Steinwaygrande
If he has asked for ILS assistance he would have been talked down and would be alive today.
unapro3
I guess the difference here is was the ATC switched on enough, or bothered, to pick up on the guys desperation. One would think that a big hint he was crying for help was the fact he asked if Dover was an option. A switched on ATC could have said "Only in an emergency sir, do you wish to declare an emergency?" the answer she gave almost implied that his situation wasn't an emergency and therefore Dover was not an option
Luca Brazi
Wish he asked for the ILS. I think he would have got in.
The Jason Knight Fiasco Band
I hope God had mercy on his soul. He sounded like a very nice man.
NetAndyCz
Just out of curiosity what happens when you declare emergeency and land on military base and they prove it was no emergency sitution and you could safely reach another airport? Do you pay fine, lose pilot license, go to jail? I guess as long as they will not shoot you down the E word is the way to go when you are running out of fuel in bad weather.
Justin Case
That low on fuel, with ceilings down all over the area... YES, it's an emergency. Land at Dover: HIRL, 9,000'+ long RWY (01/19), 200' ILS ceilings. Heck, if I know I don't have any more divert fuel remaining, I'd much rather crash on an airfield than in the woods somewhere. Worst comes to worst, he could have ditched in Delaware Bay. Lots of options are better than going down in the woods.
ThePurpleUFO
This is a great video...as an AOPA member I'm glad they are making good use of funds. A terribly sad story though...sorry.
Bart Simpson
He had to be getting tired poor guy. Flying In the soup takes it out of you. DON'T EVER BE SCARED TO REQUEST AN ASR.
Spanky Harland
weather is always unforgiving- as well as low fuel- if you make your final decision after you are out of fuel, you are never going to make it to the airport. I'd put it on the ground as soon as possible.
A D
Never be embarrassed to ask or declare emergency, he could've got a GCA/PAR and talked down to the numbers being a military base.
james rudolph
Not a pilot but iffy weather at night I would choose not to fly. Is this the "get-there-itis" I hear about?
UaAviator
Truly a sad case, with a lot of lessons to be learned.
Lord Sandwich
The sound of his voice when the plane was going down almost had me in tears. :'(
Craig Smith
He should have said, "I'm a taxpayer and I own the airport so I'm a comin' in because it's an emergency!" ;-)
Joe Goodin
I was flying that day from KFPR to KHEF with a stop at KHXD in a Columbia 400. I had plenty of fuel and could have flown back to NC if I had to. METAR was at minimums at HEF (Calm, 200ft OC, vis 2mi, BR) and my alternate KIAD was only slightly better, but the TAF said it was scheduled to improve. As we approached HEF it was obvious that it wasn't improving as quickly as it was supposed to; however, KCHO was MVFR. As I started the ILS 16L approach to KHEF at CSN a plane went missed at HEF on the ILS. I had already advised Potomac Approach that if I didn't make it into HEF I was heading to CHO, which was getting even better. Luckily I had another instrument rated pilot with me. As I reached DA on the ILS he called out seeing the approach lights, I continued down another 100ft and he called seeing the RW threshold. It was dark, bare minimums, and we'd been flying all day. I was so glad to be on the ground. I learned about the Arrow going down the next day. The story was strangely familiar. I was fortunate to have another pilot with me, much more fuel, and a safety valve (CHO) where it was relatively assured I could get in..
King Daniel
i would be so sad to be guided by that approach control when I have an emergency. She sounded like she doesn't care and obviously didn't treat this as a life and death situation.
duckgoesmooo
Really sad to see this. In an emergency, please, just yell at atc until you get what you want. ATC is there to help, theyre good people, but they don't know necessarily what youre going through in the aircraft.
Martha Vaughan
casting aspersions about after the accident accomplishes nothing. what should be taught and made clear DURING training is that assistance from a military facility is an acceptable option. Instead of thrashing about in the overcast burning precious fuel, SEEK HELP from any agency available. Worry about paperwork if and when it becomes necessary.
Andrew Squitiro
Very well done video. Learned a lot.
Bill Bright
By all means, if you feel your in real trouble, admit it and all air ports including military bases will endeavor to help. Flying around till you run out of fuel is a recipe for a crash.
Bob Beals
Fantastic video. So sad, but a learning experience to be sure!
Steve Hammond
Mishaps like thus just piss me off. This pilot has 600 hours, no mention of how many in type, and has a fair amount of actual instrument time in the last 90 days. Was an ILS available at his destination? Yes, it was. Was their Wx above the minimum 200/1/2 required? Yes it was. If he was having problems with his GPS, why in the hell did he not just ask for GCA vectors to an ILS pickup? Was he uncomfortable with ILS approaches? Who knows. I practice ILS approaches in perfectly VMC conditions just for practice. I inform approach I want vectors to the GCA box for a practice ILS all the time, I have never been told no. ILS approaches are easy, you intercept the glide path until you hit tipover, set a 300 fpm rate of descent at your approach speed and fly the needles down to DH and then proceed VFR. The more you practice, te more it becomes second nature when you have to do it. Granted, I flew A-6's and ALL night recoveries at the ship were ACLS Mode 2 (ILS) but still, PRACTICE, PRACTICE PRACTICE,
Chris Saindon
Declare, report souls and put it in Dover, regardless of protocol. Prayers go out to the family and my the pilot R.I.P.
Jean-Philippe Bélanger
These videos are great. They really make you think and run through scenarios in your head.
SMaze17
The ACS's are so well done. Very sobering indeed but a great learning tool.
Nathan Rohrbough
So has any pilot ever lost there license after declaring and emergency? I think this might be one reason pilots seldom do. Sad out come. Keep uploading videos. These are life savers!
Zapper CD
Pilots are required by law to use ATC and follow their directions. Where the hell were they. Any controller worth his salt would have known the guy would be running low on fuel and were in a MUCH BETTER position to see the big weather picture than the pilot. As for the pilot, where was that god like take charge attitude they have in surgery...nowhere to be found. Pilot tried to take on a flight he was not qualified for (maybe on paper but NOT IRL). Everyone screwed up on this one. It's stuff like this that gives general aviation a bad name. 20/20 hindsight is always a bitch.
Dyl Connaway
These are just incredible videos. Wonderful teaching tool and I am sure the AOPA is responsible for saving many lives. Thank you.
captain757747
this sounds like the pilot had a lack of confidence in flying an ILS rather than fooling around with an R-Nav system that he was apparently having trouble with. On the 757 we had the map and hole ball of wax but when it came to landing in minimums the ILS was always used. For those not familiar with the 757 we could and DID shoot Cat III approaches down to min's.  Min's for a Cat III   were 50 ft ceiling and 800 rvr. We had to hand fly these in the sim with one eng inop. The first time I actually flew a Cat II approach I was real close to needing a change of underwear. As we had to fly these approaches going into KSAN and Montreal Canada you learn to trust the instruments and gain confidence as well as experience. It is sad the doc didn't have a more experienced pilot with him. Also the controller should have sensed a change in the pilots voice and lack of what to do. If it would have been suggested to fly the ILS and give him vectors all he would have had to do was fly the localizer and glide scope like in the sim.a procedure that he was probably more familiar with than the R-Nav.
ANTI ASMR
Is that p3d, fsx or X-plane?
Scotty Weißmüller
Poor guy, you can hear the fear he had in his voice.....
Jorge Salvatori
Thanks for this amazing videos. I really appreciate what you teach here.
King Beef
Sad
sanforce
sad, and scary situation
J Shepard
One of the saddest crash videos I've seen. You can hear the fear in his voice. Condolences to Dr. Turen's family.
mazpr2025
in the house of the blacksmith a wooden knife
aAaa aAaa
Best advice....avoid flying at night if there is ANY change of IMC....or heck, avoid flying at night, period.
Eric Taylor
Doctor, especially very good doctors are often over confident in other ventures. Just because you can handle a scalpel with near perfect precision doesn't mean those skills in an airplane.
Centurion Wizofid
That is sad, gifted man,but lost to bad weather and negative choices. in the end it is just terribly sad to lose such a person.
KrisRaps
After the war everybody is smart and knowledgeable
Bill Fife
"Doctors get to bury their mistakes; "Pilots get buried with theirs." Slogan learned while on military flight crew.
Homefront
Should have just spoken up, geez.....
fuzzypaws17
Sad story!
wise ken
It is sad that he was not aware that he could have contacted Dover much earlier and declared an emergency. The controller would have never said no. I assuming you're still able to request a no gyro GCA.
Peter Lewellyn
I can't be sure of course, but I am guessing that the ATC rep was an enlisted person who might have been in the Air Force for four years or less. Working in the Air Force she would not have been exposed to the kind of experience a civilian ATC would be subjected to. It also indicates that the Air Force folks should be given more training in respect to the use of the air base for civilian aircraft. I am sure they have an SOP which covers the arrival of a civilian aircraft under emergency procedures. I am guessing that the ATC supervisor had the book thrown at him/her for this failure to provide the kind of support to the pilot that was necessary. At least that is what should have happened.
irgski
These are very well done. This pilot may have been a doctor but he wasn't very smart nor a very good pilot.
chuckschilling
Thank you for publishing this. What a sad and unnecessary tragedy - as usual, multiple compounding factors worked in conjunction to create the accident. I hope all private/general aviation pilots will take advantage of these videos and use them to improve their own safety consciousness and flying behavior.
greasemonkey981
I disagree with some of the "lessons learned" from this video. Loading up with twice as much fuel as necessary just makes your airplane heavier and, at best, increases your fuel burn. Being constantly skeptical of every weather briefing is okay, but there comes a point in that logic train where you cease to believe anything the briefer tells you then you might as well skip the briefing all together. Rather than those two points, simply examine the possibility of all available approaches at your selected destination. Going around isn't always digging a deeper hole. It may give that massive cloud deck on approach enough time to thin slightly or it may just give the pilot enough time to do the approach better; both of which offer better outcomes. I do, however, agree that it is justified in declaring an emergency, if there is one or you perceive one.
Paul Dutton
Poor guy...
JLDoctorWho
"Propeller windmilling"? Doesn't everyone consider "feather the prop" to be the first step after deciding the engine won't come back? It radically improves glide performance.
Tony Duncan
That had high production values.  Bravo.
Christopher DuBois
I was a member of the Dover AFB Aero Club when I was stationed there about 10 years ago. You can tell that there is a much different tone between military controllers and civilian FAA controllers such as Potomac approach to the West. Military controllers are a little more rigid and a little more by the book and are not trained to give suggestions. One thing about military controllers is they are very professional and the Dover approach controller very clearly told this pilot he can only land there if it's an emergency. Based on my experience with military controllers as a pilot I don't see them suggesting anything otherwise unless the pilot declares an emergency.
Karl H
I don't know the limitations of the equipment. Was he flying manually or trying to use the autopilot? Are these WAAS GPS' slaved to the needles like the NAV radio or was he trying to use indicators on the GPS screen. Needles in front of you are hard enough.
DC-8 Tailpost
Watching some of these vids you hear ATC telling us 'we're there for your safety'...yet in real life reality sets in: Govt Employees.
BLS2001
Im confused, I saw this video i believe two weeks ago. And its published on June 30? I know i saw it before .
Dixfer
I am certain that this pilot has run more than a few cars off the road in his lifetime.
dieselrotor
Sadly I have heard several ATC that sound as if they are eating a sandwich and barely speaking loud enough to hear. At that point I simply say, Can You please speak up and more clearly. I've had a few then that take it personally and almost yell into the mich. We would be lost (Literally) without ATC and Bless them all, but.
Solomon Pilot
I FEEL SAD 4 THE PILOT AND HE SHOULD HAVE LANDED AT DOVER !
Max Flight
Chilling.....Such a powerful video.
William Dukane
Some prior experience with ILS could have helped him out in this situation.
Bruce Wachta
Male ego problem! If you can't fly ILS then you should not be allowed to fly an airplane! He should have declared an emergency, and landed at Dover AFB but there is something about the male ego that seems to prevent that!
Bobby Paluga
The pilot lost his life as a result of poor decision making, but that warning from the military controller seemed very definitive and strong. I may have felt the same way. This man had incredible skills as a trauma surgeon and we don't have a surplus of trauma surgeons. 4 years to get his BS, 4 years med school and internship, 5 years surgical training as a resident physician, 2-4 years training in his specialty trauma. All wasted, he should have flown Commercial given the weather. RIP Doctor
dirtyfred1
Glad I had a fear of heights and never wanted to learn to fly.
Evan S
Hey!!! 15:45 KIXD that's where I train at!