Accident Case Study: Final Approach

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Brought to you by AOPA Insurance ( 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.

Shaun Daskam
The biggest lesson I've learned: You never want to be featured in any of these videos.
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.
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.
No matter how old I get or how many hours I accumulate, I will always be a student pilot. Really appreciate these videos.
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
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
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.
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.
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 feeling is that they would have been easier to deal with then the FAA.
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.
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.
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.
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.
The Jason Knight Fiasco Band
I hope God had mercy on his soul. He sounded like a very nice man.
Lord Sandwich
The sound of his voice when the plane was going down almost had me in tears. :'(
This was horrible to listen to...the guy's last minutes. "Keep talking to me, please!"
Riley Raine
He must not of known there was an ILS approach option. Its sad that the ATC did not offer that option.
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.
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.
If it wasn't for airplanes the country would be overrun with doctors and lawyers.
Bret Fugate
I hope that female ATC knows that she killed this guy
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
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.
If he has asked for ILS assistance he would have been talked down and would be alive today.
Vic Wiseman
Currently training to be a controller. I found this very informative.
This guy was way to passive.
C Riley
ATC really failed
Luca Brazi
Wish he asked for the ILS. I think he would have got in.
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.
Ben Kolbeck
Keep doing these - they are excellent.
Bob M.
Plain and simple, He’s the PIC and should have declared an Dover and say “I have an emergency and I am landing” sad.
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.
henry dumor
really poor piloting indecisive and unskilled
This is a great an AOPA member I'm glad they are making good use of funds. A terribly sad story though...sorry.
Truly a sad case, with a lot of lessons to be learned.
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.
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.
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.
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.
Andrew Squitiro
Very well done video. Learned a lot.
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.
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.
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.
King Beef
Sad story!
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.
Scotty Weißmüller
Poor guy, you can hear the fear he had in his voice.....
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..
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,
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.
in the house of the blacksmith a wooden knife
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.
Steven Ramos
RIP doctor..
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?
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.
The sheer amount of accidents that result from pilot inaction, leads me to believe that training is at fault here. Flight instructors must be failing to teach their students to swallow their ego, and declare an emergency before the situation gets lethal. So very sad.
Dyl Connaway
These are just incredible videos. Wonderful teaching tool and I am sure the AOPA is responsible for saving many lives. Thank you.
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!" ;-)
dude just had to be the pilot surgeon, couldn't just stick to surgeon
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.
Milt Farrow
This is truly sad, but the truth be known ( I am an 8000hr pilot with single and multi time -with many cross country flights) It has recently been posted by FedEx that that had a near miss with USAF aircraft coming out of Military flight zone  descending into civil aircraft area ( Apparently Military aircraft KC!130 Tankers carrying Chemical dump material) are permitted to fly In our airspace with No squawking of their transponders ( The want NO VISIBILITY)  we are bound to have a huge accident coming to a city near you soon-
Fred Rohlfing
With an instrument ticket, he has to have some ILS experience doesn't he? It's hard to get 3 different types of approaches without an ILS and the examiner can ask for that. My CFII taught that if you get into even a zero zero pickle with limited fuel, fly the ILS right down to the runway - it offers far better consequences than crashing off airport. We did it in training (under the hood) and it was no big deal. I would rather crash at 5 feet per second descent to a runway that off airport with limited visibility. And there is always some visibility.
Christopher B. Jack
The lesson for flight trainers is a bit subtle but equally relevant: Perhaps at least once a CFI should be required to cut power and have the trainee pilot perform a mayday (these should come unannounced so only perform these drills after ground school confirms the pilot does indeed know the procedure for declaring emergencies). Try to desensitize pilots from the deadly allergy (as in it has killed many pilots both GA and Transport) to calling maydays even when they are more in an emergency than they realize. I suspect the medical culture of strict rules in the surgical colleges played a part in this instance. Something that would have saved this man's life were mayday training runs to unlearn that habit when flying.
The ACS's are so well done. Very sobering indeed but a great learning tool.
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.
Ronald Monsen
Yeah he made a zillion mistakes which of course it the real takeaway. However one puzzling part of this tragedy I did not see addressed was why he was having trouble shooting those first GPS approaches? He said his GPS wasn't working correctly and he aborted both approaches hundreds of feet above MDA. Did the NTSB look at that? Was there something wrong with his 430?
Red Bluesome
*Dr. Clifford H. Turen* - an internationally recognized orthopaedic traumatologist, died Sunday, January 13, 2013 in an airplane accident. He was 55. Dr. Turen was employed as an orthopaedic trauma surgeon at Bayhealth Medical Center in Dover. Previously, he worked at Shock Trauma Center in Baltimore for 20 years, serving as the Chief of Orthopaedic Trauma Services and the Director of its Orthopaedic Traumatology Fellowship Program. As Director of that program he trained countless fellows and residents who rotated through Shock Trauma. He was friend and mentor to many of the orthopaedic traumatologists now serving as faculty and program directors throughout the US and abroad. He served as President of the AO North American Membership and as a Senior Trustee of the AO Foundation, a global-non-profit organization led by trauma surgeons. Through this work he was internationally recognized for his teaching and clinical acumen. Dr. Turen served for 28 years as a Commander in the Medical Corps of the US Navy Reserve. While on active duty he was medical officer for the Navy Seals. Professionally and personally Dr. Turen thrived in challenging situations. He was active in the Emergency Medical Service community as an educator, provider and medical director, serving with the Maryland Fire and Rescue Institute, the Washington DC Fire Department and the Howard County, MD Fire and Rescue Department. He contributed as a dive team member and instructor, firefighter, and fire officer. He was a former Special Deputy US Marshal and led the development of the tactical EMS program for the National Capital Region Antiterrorism Task Force. He is survived by his wife Bethanne; sons Jonathan and Jason Turen; stepchildren Jessica Webster, Margaret Sutton (William)and Zach Webster; step-grandson Alex Webster; his mother Georgia Lo Prete; and sister Anita Davidson (Robert Friedman). His father, Sidney Turen, died in 1970.
sad, and scary situation
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.
Peter Lake
First-rate video in all respects. Very sad to hear the rising anxiety in the pilot's voice. I fear he may have gotten tunnel vision as things progressed, paying too much attention to his navigation and not enough to fuel. I recall flying into an unpredicted sandstorm in a Stearman and thinking of the old phrase, "A crash site is where the pilot ran out of altitude, airspeed and ideas." This pilot ran out of ideas first and got none from ATC.
ali xena
What a shame the Dover ATC chose to word her negative response that way. He asked if there was any chance that he could land at Dover. Her response should have been in the affirmative, if there was an emergency, not a negative response, followed up by a "no way". Talk about gate keeping...
Milt Farrow
Military aircraft are flying missions without transponders  LOOK OUT  MAJOR CRASH COMING courtesy of USAF
Liam B
R.I.P Dr. Clifford Turen 1957-2013
Bob Beals
Fantastic video. So sad, but a learning experience to be sure!
Aviation Nut
The problem is that doctors got lots of money and they always buy a lot more plane then they can handle.
Liberalist D
Sad indeed. Rest in Peace.
Karl Tusing
This is profoundly sad.  Take whatever repercussions come and live to see your loved ones.  Perhaps the controller could have said, "Yes, you can land here - just declare an emergency".
Jorge Salvatori
Thanks for this amazing videos. I really appreciate what you teach here.
garcha perez
what a sad loss...
Sean McKinnon
The controller at Dover should have asked "are you declaring an emergency?" When he asked about landing there instead of being confrontational.
Steve Holstein
I'm disappointed in the indifferent attitude the Dover approach controller had.
Is that p3d, fsx or X-plane?
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!
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.
Jimmy Haley
Never,,, Ever fly with a Dr. or Lawyer,,,, doom ,,,,, ole USN vet
Dave B
It's impossible to get into his head but why he didn't even attempt the IFC approach at Salisbury seems strange and his repeated decisions to continue to the north.. And not communicating the urgency to controllers.. hard to understand, and too bad for him.
aAaa aAaa
Best advice....avoid flying at night if there is ANY change of IMC....or heck, avoid flying at night, period.
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.
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.
Paul Dutton
Poor guy...
Eddie Cifuentes
This case made me cry. May his soul be at peace.
Should have just spoken up, geez.....
Im confused, I saw this video i believe two weeks ago. And its published on June 30? I know i saw it before .
After the war everybody is smart and knowledgeable
it is sad to listen to him knowing the end result….