Accident Case Study: Traffic Pattern Tragedy

[dvm]

Every real world pilot should find this accident scenario and analysis worth a watch.

https://www.youtube.com/watch?v=mf3xhjXl454

[Les Parson]

As a former controller (TUS,JFK,LAX), I must state this was difficult to watch on many levels. This includes ATC sequencing, decision making and priorities as it relates to GA and AC (air carrier) traffic. I've been up to HOU ATCT and while it is a complex operation basic "first come, first serve" priorities still apply unless things have changed in the last few years.

[DHenriques_]

This is a good example of an accident we DO allow to be discussed on the forums. The NTSB report has been issued and a probable cause determined. Opinion on the forum is then not only allowed but encouraged, not for purient interest but rather for what might be useful as a safety data point for real world pilots in our A2A community.

The above having been said and since post accident back engineering is actually what I do I will offer a brief comment on this accident as I am familiar with it.

The scenario presented by the NTSB I felt at the time was accurate. Unlike the NTSB however I have less tendency toward over focusing on the confusion caused by the heavy traffic as other than a situation being capable of being handled to a successful conclusion by both ATC and the PIC of the Cirrus. Although convoluted and in a state of constant change, both ATC and the PF were handling the situation each in a professional manner.

I believe it is a mistake to focus heavily on the traffic situation in determining a cause for this accident. These were certainly contributing factors but I would go directly to the stall and the flap retraction as my area of main focus for cause. It was there where the fatal error occurred. Had this PF had more and better training in stall above 1g (accelerated stall) the PF would have known to expect the increased stall speed and avoided the flap retraction and turn combination that was the ACTUAL cause of these fatalities.

Post analysis;

There is a vast gap in our pilot training regimen today that leaves much to be desired as far as training in accelerated and cross control stall is concerned. This gap includes the CFI community as well, where many instructors themselves are not comfortable teaching in this area.
The real fault in this accident wasn't ATC, or the heavy traffic or the confusion. The REAL fault lies in a lapse in the basic stick and rudder skill set of the PF the Cirrus. Correct that lapse in the training curriculum and we go a long way toward avoiding accidents like this one down the line.

Dudley Henriques
Flight Safety Consultant
ICAS, EAA, EAC, and ASSA

[Les Parson]

This is a good example of an accident we DO allow to be discussed on the forums. The NTSB report has been issued and a probable cause determined. Opinion on the forum is then not only allowed but encouraged, not for purient interest but rather for what might be useful as a safety data point for real world pilots in our A2A community.

The above having been said and since post accident back engineering is actually what I do I will offer a brief comment on this accident as I am familiar with it.

The scenario presented by the NTSB I felt at the time was accurate. Unlike the NTSB however I have less tendency toward over focusing on the confusion caused by the heavy traffic as other than a situation being capable of being handled to a successful conclusion by both ATC and the PIC of the Cirrus. Although convoluted and in a state of constant change, both ATC and the PF were handling the situation each in a professional manner.

I believe it is a mistake to focus heavily on the traffic situation in determining a cause for this accident. These were certainly contributing factors but I would go directly to the stall and the flap retraction as my area of main focus for cause. It was there where the fatal error occurred. Had this PF had more and better training in stall above 1g (accelerated stall) the PF would have known to expect the increased stall speed and avoided the flap retraction and turn combination that was the ACTUAL cause of these fatalities.

Post analysis;

There is a vast gap in our pilot training regimen today that leaves much to be desired as far as training in accelerated and cross control stall is concerned. This gap includes the CFI community as well, where many instructors themselves are not comfortable teaching in this area.
The real fault in this accident wasn't ATC, or the heavy traffic or the confusion. The REAL fault lies in a lapse in the basic stick and rudder skill set of the PF the Cirrus. Correct that lapse in the training curriculum and we go a long way toward avoiding accidents like this one down the line.

Dudley Henriques
Flight Safety Consultant
ICAS, EAA, EAC, and ASSA

Well stated to which I agree 100% as it relates to the causal factor (s) of this accident. However, I standby the ATC handling comments. More importantly, this was a sad and tragic accident by any measure.

[DHenriques_]

This is a good example of an accident we DO allow to be discussed on the forums. The NTSB report has been issued and a probable cause determined. Opinion on the forum is then not only allowed but encouraged, not for purient interest but rather for what might be useful as a safety data point for real world pilots in our A2A community.

The above having been said and since post accident back engineering is actually what I do I will offer a brief comment on this accident as I am familiar with it.

The scenario presented by the NTSB I felt at the time was accurate. Unlike the NTSB however I have less tendency toward over focusing on the confusion caused by the heavy traffic as other than a situation being capable of being handled to a successful conclusion by both ATC and the PIC of the Cirrus. Although convoluted and in a state of constant change, both ATC and the PF were handling the situation each in a professional manner.

I believe it is a mistake to focus heavily on the traffic situation in determining a cause for this accident. These were certainly contributing factors but I would go directly to the stall and the flap retraction as my area of main focus for cause. It was there where the fatal error occurred. Had this PF had more and better training in stall above 1g (accelerated stall) the PF would have known to expect the increased stall speed and avoided the flap retraction and turn combination that was the ACTUAL cause of these fatalities.

Post analysis;

There is a vast gap in our pilot training regimen today that leaves much to be desired as far as training in accelerated and cross control stall is concerned. This gap includes the CFI community as well, where many instructors themselves are not comfortable teaching in this area.
The real fault in this accident wasn't ATC, or the heavy traffic or the confusion. The REAL fault lies in a lapse in the basic stick and rudder skill set of the PF the Cirrus. Correct that lapse in the training curriculum and we go a long way toward avoiding accidents like this one down the line.

Dudley Henriques
Flight Safety Consultant
ICAS, EAA, EAC, and ASSA

Well stated to which I agree 100% as it relates to the causal factor (s) of this accident. However, I standby the ATC handling comments. More importantly, this was a sad and tragic accident by any measure.

I have no problem with the ATC comments, just the priority in analyzing the accident. The bottom line is that regardless of the confusion and complexity involving the scenario, it all came down to a simple climbing turn and a decision to retract flaps. Had this PF had better instruction (and by better instruction I mean more THOROUGH instruction) in stall behavior above 1g, the decision to retract flaps at low airspeed in a climbing turn would have not been made. The turn would simply have been made at a higher airspeed and flap retraction been avoided until level flight had been achieved and angle of attack decreased
into a safe retraction zone.

Pilots flying in today's heavy traffic environment arriving at busy airports MUST expect and be able to handle a complex ATC environment. This PF was handling her interface with ATC professionally. Her failure involved a decision directly related to the aerodynamics surrounding her aircraft. Had her stall training been more thorough she would have avoided the stall.

It is common practice with the NTSB to "build" a set of contributing factors when back engineering an accident case. This is fine. The factors as stated are all pertinent. But the real failure in this accident wasn't the contributing factors. They added together don't relieve the PF from her decision to retract her flaps under conditions certain to cause a stall. It was THAT moment in time, and THAT decision where the failure lies.

The overwhelming post accident recommendation here points to a failure in the training path, and it is there the answer lies when we look to prevention.

Dudley Henriques

[CAPFlyer]

First, a link to the NTSB Full Narrative (since AOPA left it out) -

https://www.ntsb.gov/_layouts/ntsb.avia ... 211&akey=1

EDIT: I have since found the actual final report (apparently something wasn't working when I tried searching for the docket this morning but worked this afternoon).

The full final report is here -
https://app.ntsb.gov/pdfgenerator/Repor ... L&IType=FA

I will make a new response lower with my full thoughts based on this so as not to confuse too many who've already read this. Thanks!

[AKar]

One additional thing that concerned me was her untimely reduction of power while climbing at already low airspeed, just prior to equally untimely flaps retraction. This robbed some performance from the airplane already very low on it. While this was not particularly analyzed, personally I am not at all a fan of climb power fetish that has taken place in some schools of thought, based on what I understand from some discussions. By this I mean undue emphasis that sometimes appears to be placed on putting the engine to "climb power" as soon as possible. In my thinking, lowering the nose and accelerating should almost always take precedence over reducing power, when speaking of order in which the things are done. These engines are rated for continuous full power and there should be no compelling reasons to reduce power until comfortable climb airspeed and attitude are reached.

-Esa

[dvm]

Training is of course one of the most important parts of pilot competence. No matter how much training you have the confidence that comes with experience can be a real game changer in a high stress situations. That is at least my experience. No pun intended.

[dvm]

Here is example in my opinion where the overall experience and confidence as a pilot made a difference in the outcome of the accident. A complex situation with Lots of decision making in a very short time.

https://www.youtube.com/watch?v=BBpqvPujZgM

[CAPFlyer]

Okay, so I found the full report and not just the narrative. I've found the NTSB search to be a bit sensitive at times and even putting in good information doesn't always get the right return. This morning, I searched both the N-Number and the Docket Number and got no return for the full report. This afternoon, it popped up.

Here's a few things -

She got her PPL on 02 May 2014 (probably when she got checked out to fly the SR-20). At the time of the accident, that made her almost 30 days out of BFR. While yes that makes her legally out of limits, it doesn't mean she was. Additionally, she showed 300+ hours in the Cirrus. However, it still doesn't indicate if she completed the Cirrus Training Course or not, however it's possible based on her hours, that she did almost all of her training in the Cirrus as there's only 30 hours not in type. That would suggest she had a high level of comfort with the airplane itself because that's pretty much all she ever flew. Her currency and activity level seems to be fairly decent with 7 hours in the prior 30 days and 28 hours in the prior 90 days to the accident. For someone who isn't doing it as a job, that's a pretty good level of currency I think.

This brings me back to Dudley's point - the fact she pulled the flaps in a situation like that suggests that her training was lacking in some respects. She was familiar with the plane, she should have been pretty comfortable it as well. So that goes back to the initial point - the training was lacking somewhere that she didn't have to fall back on in a stressful situation.

[JeffKTPF]

This discussion reminded me of an event that happened to me last year.

I was flying to Zephyrhills Muni (KZPH) one beautiful Saturday morning from Peter O Knight (KTPF), and as was about 10 miles out (listening on CTAF) my stress level started to rise due to the fact that, not only was there a lot of traffic operating in and around the airport, but given that KZPH is untowered, and that winds were calm (it was a beautiful day, remember), it seemed pilots were using multiple runways all at once, rather than everyone using a preferred calm wind runway; hearing that (parachute) jumpers were in the air, and watching the PC-6 jump ship spiraling down from several thousand feet above me didn't help matters either.

Still I pressed on, and while on base for Rwy5, found I was a little high. Then, while turning final, I saw I was starting to overshoot the runway, and in response, steepened my bank angle more than I should have (while consciously unloading on the yoke, and letting the nose fall where it wanted), only to find myself too high and too fast on final.

Normally I would have gone around, but decided not too given the beehive of activity all around me (I heard someone a couple of minutes earlier announcing final for Rwy 19), as well as having a long runway ahead of me.

As I rounded out, things were looking good, and when I heard the squeak of my tires making contact, I thought the worst was over, and I'd have a chance to taxi clear of the runway and catch my breath. However that squeak was actually the beginning of a skip, which turned into a bounce, and then a second, harder bounce.

Since I knew I would rather not snap the nose gear off the rental Cessna I was flying (or worse), as soon as I was rebounding from the second bounce, I firewalled the throttle and elected a go-around (which turned into a "go-around and not come back").

The reason I'm bringing this all up is that, despite the stress I was under, as soon as I decided to go around instead of trying to save a botched landing, my sole focus was on flying the airplane, which including maintaining airspeed, pitch, directional control, and very methodically and carefully retracting the flaps, one step at time. I'm not in any way suggesting superior airmanship to the pilot who died (far from it, as I have only about 100 hours under my belt), but rather the importance of being able to focus one's limited attention under stress on the cardinal rule of "FLY THE PLANE!"

I also wonder if she was in the danger zone of having accumulated enough hours to no longer have a brand new pilot's healthy fear/paranoia (of all they ways things can go wrong), but not enough hours to constitute meaningful experience, wisdom and judgement.


This video isn't mine, but it does show just how crazy KZPH can be at times:

https://www.youtube.com/watch?v=8Ri4h4sQFUM

[DHenriques_]

I also wonder if she was in the danger zone of having accumulated enough hours to no longer have a brand new pilot's healthy fear/paranoia (of all they ways things can go wrong), but not enough hours to constitute meaningful experience, wisdom and judgement.

You're very close here.

The fail point was as she reached for the flap control to raise them. Had she the proper training coming through the system with her instructor, the decision path that guided her hand to the flap control considering the aerodynamics that existed at the time wouldn't have existed. Her training had it been sufficient, would have instinctively told her that raising the flaps at that moment was wrong. Denied that instinct, she raised them.
Granted there was stress involved but she was handling that well all through the ATC traffic diversions.
Granted also there are what we call "brain farts" where even trained, a pilot can perform an act totally unnatural and out of the norm. Such an act was performed by Chris Stricklin (Thunderbird Solo) at Mountain Home AFB.
But in this case her voice relayed total calm and command and she was following directions as dictated with the single error at the heading change which was a radio misunderstanding. She showed no sign of verbal stress even after that.
The indicators point simply to her not being aware of the angle of attack change with flap retraction; thus the stall and what ensued afterward.
Dudley Henriques

[clarkejw]

Very interesting and informative comments. May I just say, also, how moved I was when I watched that video, knowing what was about to happen. hearing the pilot's voice, employing what I would consider to be pretty good radio procedure, even a touch of self-deprecating humour.
I would like to think that her death was not in vain, and that those who have watched the video have learned, and will act up on what they have learned.

John

[DHenriques_]

Very interesting and informative comments. May I just say, also, how moved I was when I watched that video, knowing what was about to happen. hearing the pilot's voice, employing what I would consider to be pretty good radio procedure, even a touch of self-deprecating humour.
I would like to think that her death was not in vain, and that those who have watched the video have learned, and will act up on what they have learned.

John

I had a very good friend. He was internationally known and respected as one of the finest comedy act pilots in the world. He was killed flying a display when the stick in his J3 Cub came out of its base socket in his hand while he was doing a loop.
It turned out that the plane had been used for a photo shoot the day before and that required taking out the stick. When the stick was replaced they forgot to replace the cotter pin that secures the stick to the base. It wasn't a normal pre-flight check item but since it was known the stick had been removed it should have been included in the pre-flight to check for the pin being secured. It wasn't!

I have used this accident many times in safety lectures I've given that stress the importance of pre-flight inspection. Doing that I stress as well that using my friend's death as an example doesn't emphasize that he made a mistake. It means his death wasn't for nothing and that what happened to him might save someone's life.
THAT was his legacy ! We learn from our mistakes in life but in aviation it is important that we learn before we make the mistake. By using my friend's death in this way, BOTH lessons have been utilized and learning has taken place.
The learning curve in aviation can be quite painful !!!!!!!!!

Dudley Henriques

[KarelPatch]

As a former controller (TUS,JFK,LAX), I must state this was difficult to watch on many levels. This includes ATC sequencing, decision making and priorities as it relates to GA and AC (air carrier) traffic. I've been up to HOU ATCT and while it is a complex operation basic "first come, first serve" priorities still apply unless things have changed in the last few years.

Hi, I’m interested to know more about your opinion as a former controller.