Accident Case Study: Final Approach


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.



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.
skyviper1973
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
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.
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
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.
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...
Sean McKinnon
The controller at Dover should have asked "are you declaring an emergency?" When he asked about landing there instead of being confrontational.
PassiveSmoking
His two biggest mistakes were putting too much faith in weather predictions and in not declaring a fuel emergency when talking about landing at the military base.
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.
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.
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
Bartonovich52
Rule of thumb: If you can’t accept a 30 minute hold in your aircraft’s current state, declare an emergency.
TCPUDPATM PORTS
Despite being a video about being lessons learned, I like that you closed out the video with the doctor in a positive light. Cheers.
Riley Raine
He must not of known there was an ILS approach option. Its sad that the ATC did not offer that option.
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".
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.
Vic Wiseman
Currently training to be a controller. I found this very informative.
Bill Fife
"Doctors get to bury their mistakes; "Pilots get buried with theirs." Slogan learned while on military flight crew.
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.
Luca Brazi
Wish he asked for the ILS. I think he would have got in.
Ben Kolbeck
Keep doing these - they are excellent.
FlyGirl V
I always feel my heart drop when they play the final transmission.
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.
smoothvirus
In ground school our instructor was a former Marine, and he absolutely encouraged us that if we ever got in a situation like that, declare an emergency, contact the nearest military airfield, and request a GCA approach.
ThePurpleUFO
This was horrible to listen to...the guy's last minutes. "Keep talking to me, please!"
Lord Sandwich
The sound of his voice when the plane was going down almost had me in tears. :'(
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.
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.
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.
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.
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...
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.
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.
Scott Hillary
Notice how many of these videos feature Doctor pilots? Something tells me hubris and ego involved......
Nicholas Littlejohn
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.
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.
TheMonkini
The controllers should have been more helpful. They did not care much from the communication and support provided.
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.
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.
UaAviator
Truly a sad case, with a lot of lessons to be learned.
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!" ;-)
Liam B
R.I.P Dr. Clifford Turen 1957-2013
MrTeotwawki
This guy was way to passive.
German Aviation
When there’s an ILS option at your airport, take it. It’s better than RNAV or VFR approaches.
B Laws
Your plane will always find the ground, with or without your help
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.
MegaBakerdude
I knew it was an emergency when she said "unless it is an emergency". Sad that the pilot didn't.
Faras Khan
I am so sad for this Pilot and so glad to have watched this great video. I love to fly but I take it very seriously! It is always a matter of life and death if things go wrong!
Tommy Petraglia
Like my tugboat captains would when towing oil and conditions were sketchy: The schedule is more flexible than the bow.... then the log entry would be Wx, meaning 'Weatherbound' as we stayed anchored or tied to the pier.
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.
bcflys
I have heard many "sayings" about aviation in my years of flying, but one that has always stuck with me is: " They don't look for your wreckage until the weather improves" This video is a classic case.
Toby McVinn
Sometimes while flying and going through a certain situation I imagine myself on one of these videos. That’s when I really look to make the smart choice.
Greg
Question: Apart from „shame” what is stoping people from declaring emergencies? Is is paperwork required to fill after?
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.
Stephen Smith
A clever skilled man Who was out of his depth,in this situation. God Bless You And R.I.P.
Steinwaygrande
If he has asked for ILS assistance he would have been talked down and would be alive today.
Andrew Squitiro
Very well done video. Learned a lot.
Jean-Philippe Bélanger
These videos are great. They really make you think and run through scenarios in your head.
Chris
"In a case with many ironies, he was unable to extend the same care to himself, is perhaps the saddest." Yeesh, cut the poor guy and his family some slack would you, that's a bit dis-respectful. He's still dead and his family and colleges still have to live with that, and I doubt they would appreciate that comment. Good lesson to be learned here but no need to trash the guy at the ending.
Doug Hanchard
Lots of very valuable lessons learned in this video. A pilots license (endorsement) is simply the first step in gaining experience. Was the GPS actually faulty, or was the operator rusty or inexperienced in how to use it. We will never fully know. I can't stress enough the importance of the video's message about using US Air Force bases in an emergency landing situation. The same I true for almost all NATO bases worldwide. They *will* help you. In fact, they are eager to help when the situation is dire. They are some of the very best trained Air Traffic Controllers in the world. It's up to you, the pilot, to be aware of your options. I dare say, even if Air Force One was on a 10 mile approach, if a Cessna C-150 was in trouble and declared an emergency, AF1 would be instructed to go around and wait. That's how serious military controllers take their job.
Coeur de tigre
imo these are some of the most powerful videos on YT; because they are real, and because they save lives.
Milt Farrow
Military aircraft are flying missions without transponders  LOOK OUT  MAJOR CRASH COMING courtesy of USAF
KrisRaps
After the war everybody is smart and knowledgeable
Nick Breeze
Now how do I get my WINGS credit for this as ALC-425??? The link appears to be incorrect
Jorge Salvatori
Thanks for this amazing videos. I really appreciate what you teach here.
dsriggs
"The aero's pilot..." Ok. "...an orthopaedic trauma surgeon" Uh-oh.
The Jason Knight Fiasco Band
I hope God had mercy on his soul. He sounded like a very nice man.
Bob Beals
Fantastic video. So sad, but a learning experience to be sure!
Jon Hartley
God I can hear the panic in his voice after that 3rd airfield attempt :(
Dyl Connaway
These are just incredible videos. Wonderful teaching tool and I am sure the AOPA is responsible for saving many lives. Thank you.
fuzzypaws17
Sad story!
Allan62T
Anticipation building, excitement so thick! An endeavor to peek at Heaven, on a magically flown brick!! Up There, by Terry Allan!......
Greg1 McIntosh
This is a very very sad story. God Bless this good sole.
Art Houston
I had a situation flying a part 91 trip to OSU, where the controller was using an RNAV approach. I wanted the ILS, and he grudgingly let me have vectors for it. Never be afraid to ask for what you want to stay safe. The weather was deteriorating, and I popped out just above ILS minimums.
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..
Eddie Cifuentes
This case made me cry. May his soul be at peace.
YouTube Addict-18
I'm no pilot, but having a backup plan seems like priority. Here on the ground dealing with weather is challenging enough. I can only imagine it being a top priority in flying.
Brad Hampton
A tragedy he lost his life over weather conditions and low fuel. Sometimes you have to reconsider a flight into IMC.
Noor Elahi
Two things: 1) These videos are addictive and fantastic! 2) Flying is still a million times safer than my motorcycle.
Pen Name
If yur feet are over ten feet off the ground and you're not a bird you are defacto exigent circumstances.
C Riley
ATC really failed
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.
michael flegel
One more thing. This is important because it wasn't even mentioned in the review that I heard. For a three almost four hour flight plan the review never included to check weather in route. Keep checking it every 55 past the hour.
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.
Computer Whisperer
7:36 "We'll never know for certain..." What do you..... .... Oh.... 😞
Tommy Petraglia
From Sandersville Georgia to Dover Delaware is a 10-hour drive, a $100 flight (somebody else flies you) or a $225 train ticket ... you decide Prolly one of those adrenaline junky, A type personalities necessary to be able to cut and fix anf stitch a person's body.
qqqqq qqqqq
Your criticism of the pilot immediately diverting instead of trying to force an approach is absurd. On the other hand, this guy obviously should never have trapped himself into a night landing. That's what happened.
sanforce
sad, and scary situation
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.
Jan Leunissen
The quality of the sound communication and the gnawing of words on top... Bound to lead to disaster if it hasn't already.
SMaze17
The ACS's are so well done. Very sobering indeed but a great learning tool.
Darren Munsell
Is it me but despite his built-in GPS and his onboard advance transponder when the engine quit did he not just lose his gyro instruments? Because as far as I know most chiro instruments are run off vacuum pressure supplied by the engine! When he lost his engine did he also lose his artificial horizon and Direction indicator? The GPS failed him however his confidence also failed him. Would that be an accurate assessment of the situation when he lost power?
VideoDreamer
That military ATC sounded lumpen, dogmatic, resentful and slow witted. A more lively intelligent operator would have probably got that pilot onto the ground safely.
Rhyme& Reason
The last controller certainly should have done more. The stress in the pilot's voice was clearly evident - they should have inquired more about the nature of his request and helped to assess whether he was in an emergency situation.
TheBeingReal
Overconfident Dr.
wjatube
Can you at least try and change your voice when reading both sides of the earlier conversation?