AOPA video • Traffic Pattern Tragedy: 2016 Cirrus stall-spin at Houston.

[Garfly]

Once again we learn from the tragedies of others; we can never, ever let task-saturation distract us from our one vital job as aeroplane pilots.

 

"On a June afternoon in 2016, a Cirrus SR20 carrying three occupants arrived in Houston’s busy Class B airspace to land at William P. Hobby airport. Miscommunication in the traffic pattern, three go-arounds, and ultimately, a departure from controlled flight resulted in a fatal crash near the airport. The AOPA Air Safety Institute examines the circumstances of this accident and discusses how to recognize and avoid the mistakes that led up to the tragedy."

 

 

 

Here is a link to Peter Garrison's analysis in Flying Magazine:

 

Examining the Aftermath of the June 2016 Crash of a Cirrus SR20

 

The concluding paragraphs:

 

"The real problem, I think, was one of airmanship. The accident report does not disclose the pilot’s experience level, but she had gotten her private license two years earlier. Her biannual flight review was out of date by a month — a discrepancy only a bureaucrat could love. Instructors who had worked with her said she was capable and did not get rattled in stressful situations. But the onboard flight data recorder suggests imperfect control of airspeed and altitude. In one instance, she selected full flap at 130 kias, ballooned upward and did not begin to descend until 40 seconds later. She seemed unable to manage her approaches in such a way that she was ready to touch down somewhere in the first half of the runway. The forward slip — an almost magical way to lose altitude — was evidently not in her repertory.

 

On the first of the three occasions on which she used flaps and then had to go around, she began to retract them at 76 kias; on the second, at 69 kias; on the third, at 62. The recommended go-around procedure in the SR20 is to accelerate to 81 to 83 kias before raising the flaps. On the third occasion, she began her go-around with full power, but reduced power to 80 percent at the same time as she began to retract the flaps. In principle, because full flap is a very draggy configuration, full power should be used and the airplane kept level or, in VMC, even allowed to sink, until reaching climbing speed. The first priority is to gain speed, not height.

 

A point that the NTSB does not mention is that a go-around from a full-flap approach is a delicate maneuver that pilots are seldom called upon to perform. A pilot making an instrument approach to minimums avoids using full flap, until landing is assured, for that very reason. It is quite possible that since her training, the pilot of the Cirrus had never had to perform such a go-around, and now, suddenly, she was given not one but three chances to fail."

 

 

[facthunter]

Wonder if she was taught to do things by rote and not analysis of her situation. (situational awareness)? Nev

 

 

[old man emu]

I have to take task with blaming the pilot for lack of assertiveness.

 

Let's look at the Human Factors at play here.

 

1. The pilot was a woman. We know that women often feel oppressed in male-dominated environments, especially as they appear to be in the USA.
    
    
   
2. The pilot appears not to have been used to operating in this type of traffic situation. It would be like someone flying into one of our Capital cities from their base at a country airport where traffic volumes were almost non-existent.
    
    
   
3. The pilot might have had impressed on her that if she was flying into this airport, she must do as she was directed to by ATC. She might not have known that as PIC she had the right to demand other solutions to the problem. This would be in accord with the behaviour of the pilot in Factor 2, above.
    
    
   
4. Maybe there was some Must-use-this-airport-itis. The pilot had undertaken a 3 hour cross-country for the purpose of visiting a sick relation in a major city hospital. Would you fly into, say The Oaks if you wanted to get to a hospital near the the Sydney CBD? Maybe the pilot had arranged car hire from this airport.
    
    
   

 

 

I reckon the lack of assertiveness was due to Factor 3. Don't forget that to the ATC blokes the Cirrus was just another aircraft amongst the hundreds they would deal with each week.

 

 

[Garfly]

But the problem is for a person to be 'assertive' in a given situation he/she really needs the confidence and the savvy as to what ought be asserted.

 

Failing that, one's likely to fall back on the relative comfort that a posture of compliance affords.

 

(I, myself have recurring nightmares where I'm in trouble with ATC ;-)

 

In her situation - with her experience level - I too, would have been keen to do anything and everything that I was told to. Yes, one could say "unable" if one had a clear idea of what exactly you were able to do, as an alternative. (e.g: "We'll be in the Hudson".) But yes, perhaps "Standby" is something we could and should learn to say in such situations; whenever we feel overloaded and in danger of losing it.

 

I tend to agree with Garrison (in his Flying article): "The pilot is unfailingly polite, composed and calm. She reads back clearances accurately, requests clarification when she needs to and does not appear to become flustered during the 18-minute-long attempt to land. I don’t know what the NTSB thinks she should have been more assertive about; perhaps they thought she should have been a man."

 

Personally, I take two main lessons from this misfortune befalling a pilot who, I'm pretty sure, on another day, would have been judged at least as competent and careful as I am, myself, in general flying. (i.e 'acceptable') The first is that whilst you can get away with sloppy airmanship most of the time, in a stressful situation the merely sloppy turns deadly in an instant. And the second: whilst growing in confidence and competence by extending one's comfort zone, is desirable, we really shouldn't push ourselves too far or too quick, lest we find ourselves in situations beyond our skill level. Then it ain't fun no more.

 

 

[fly_tornado]

I though Cirruss pilots were like Volvo drivers?

 

 

[cooperplace]

remind me to never fly a Cirrus, it sounds like it's a tricky, unforgiving plane.

 

 

[facthunter]

ALL aeroplanes are like that, to a certain extent. if you don't fly them right.. Any twin with an engine out would be far more difficult to manage. Everything becomes very critical then. Big power/performance deficit plus assymetry Nev

 

 

[Garfly]

Yeah, according to the report, she was fully 20 Kts under flap retraction speed - and with power coming off - at the time of the stall. So I'd say it was less a case of unforgiving plane and more about unforgiving human factors (in this case stress overload - including, I'd say, an awareness of her passengers' mounting anxiety). That's my takeaway.

 

 

[Garfly]

That being said, the above accident has several spooky similarities to the fatal Cirrus crash analysed in this video, below:

 

In any event, the well considered conclusion of this analysis applies equally to both.

 

 

 

Incidentally, I can't help thinking that the practice by US Tower controllers to issue landing clearances quite early in the sequence - and to more than one aircraft at a time - is unnecessary and likely to contribute to confusion - as it seems to have done in this case. I believe that in Australia, the usual terminology would be 'Continue approach' until the next-to-land aircraft was well established on final and the runway ahead was clear. Is that right? Can anyone enlighten us on this difference?

 

 

[antonts]

in Bankstown ATCs always clear only one, second plane gets "you are number 2", "follow **** on final" and so on, and cleared to land only when previous plane really leaves the runway, not only landed and braked.

 

 

[Downunder]

A slightly off-topic question, but can you talk to other aircraft or only atc?

 

 

[Sam the Swiss]

That is also what puzzled me when I saw the case: She gets landing clearance over and over again. If we get clearance it is only withdrawn very rarely, I wasn't in this situation myself up to now. Only one plane per runway is cleared at a time. If I follow an airliner I might already be in very short final until I get the clearance, as I only get it when the runway is vacated. Is this different in your places?

 

 

[Sam the Swiss]

@Downunder: All pilots on the same frequency can hear you, so you may talk to another pilot in approach. We use it when we are told to look out for traffic. When the other plane sees us, he/she tells so.

[fly_tornado]

an experienced pilot crashing like that does sounds like hypoxia

 

 

[Garfly]

Huh?

 

It was a stall spin, loss of control accident that could happen to any of us; that has happened to many of us.

 

[Thanks to Powerin for linking to this Coroner's Report on Ross Millard's accident on another thread.

 

https://www.courts.qld.gov.au/__data/assets/pdf_file/0003/578010/nif-millard-r-20180723.pdf ]

 

 

[Garfly]

By the way, there's a fair bit of discussion online about the use of "Clear to Land" in the US as opposed to the rest.

 

e.g:

 

Question about "clear to land" instruction [Archive] - PPRuNe Forums

 

Differences Between ATC In USA Vs UK - Airliners.net

 

Here's one comment (from a Brit on Airliners.net):

 

"In my 5 years of flying a 757 commercially I never experienced or saw any issues with ... late landing clearances. But I did have a problem wrapping my head around a landing clearance in the US, with 2 aircraft in front of you on final and one just about to vacate the runway. This shows another difference between the US and 'The World' - US controllers are very keen on pushing separation responsibility onto pilots. I prefer the 'talking traffic lights' to assume this responsibility, after all they're the ones sitting on the ground with the best overall view of the traffic situation. As we have been told more times than I care to remember, TCAS is not a separation tool, is not certified for such and not intended to be used as such. But in the US, pilots seem quite happy to report 'we've got the traffic on the fish finder', displaying both their love of slang and what seems to be a lack of understanding of what TCAS is designed to do."

 

 

[Sam the Swiss]

Thanks @Garfly, that was interesting. It will help me if I ever will have the chance to fly in the US.