Report on the Lancair fatality 31/3/06

[Guest Macnoz]

Report on the March 2006 Lancair crash near Archerfield.

 

There is much to reflect upon in this report for all of us

 

http://atsb.gov.au/publications/investigation_reports/2006/AAIR/aair200601640.aspx

 

 

[Guest High Plains Drifter]

Abstract

 

At 0728 Eastern Standard Time on 31 March 2006, an amateur-built Lancair 320 aircraft, registered VH-BST, departed Townsville, Qld, on a private flight to Archerfield, Qld. At 1058, shortly after flying past the destination airport, the aircraft departed controlled flight and impacted the ground. The aircraft was destroyed and the pilot sustained fatal injuries.

 

 

The loss of control was consistent with an accelerated aerodynamic stall, at a height from which it was not possible to recover, followed by the aircraft entering a spin to the left prior to impact. The loss of control occurred when the pilot was operating in adverse weather conditions of low cloud, was tracking towards an area of reduced visibility in rain and towards terrain that was higher than the aircraft.

 

 

The pilot’s decision to continue the flight into instrument meteorological conditions, even though neither he nor the aircraft were certified to operate is those conditions, increased safety risk. The pilot’s ability to fly the aircraft and manage the flight was limited by his relative lack of experience on high performance aircraft, and deficiencies in the training that he had received on the Lancair.

 

 

Some aerodynamic and flight control characteristics of the Lancair 320 aircraft increased the risk of an accident. However, those characteristics were largely a consequence of the role for which the aircraft had been designed. In order to operate Lancairs and other high-performance amateur-built experimental aircraft safely, pilots need to be aware of, and maintain the aircraft within, the safe operational envelope.

 

In response to this and other accidents involving amateur-built experimental aircraft, the ATSB is conducting further research on safety aspects of these types of aircraft.

 

 

 

[Guest High Plains Drifter]

Some interesting comments re GPS

 

..."the three GPS units on board the aircraft"

 

Logbook records and the records of the accident flight indicate that his total flying experience at the time of the accident was 302.1 hrs. He had accrued 29.5 hrs in Lancair aircraft (all in BST), of which 21.7 hrs were as pilot in command. He did not hold an instrument rating.

 

"The portable GPS unit... a ‘moving-map’ display and a terrain and obstacle alerting feature. The pilot was reported to have a high degree of confidence in using this unit for navigation"

 

 

[Guest Macnoz]

not the only one with 3 GPS involved in an accident.

 

Here is one from our own ranks

 

http://www.atsb.gov.au/publications/investigation_reports/2008/AAIR/aair2008028.aspx

 

 

[bushpilot]

Some interesting comments re GPS..."the three GPS units on board the aircraft"

 

Logbook records and the records of the accident flight indicate that his total flying experience at the time of the accident was 302.1 hrs. He had accrued 29.5 hrs in Lancair aircraft (all in BST), of which 21.7 hrs were as pilot in command. He did not hold an instrument rating.

 

"The portable GPS unit... a ‘moving-map’ display and a terrain and obstacle alerting feature. The pilot was reported to have a high degree of confidence in using this unit for navigation"

HPD. Just wondering what points you are making here...?

 

Cheers,

 

Chris

 

 

[motzartmerv]

A pilot having a high degree of confidance in useing a gps for navigation.. who'd a thought that aye. im wondering what the point of that comment is myself.

 

 

[Guest High Plains Drifter]

HPD. Just wondering what points you are making here

Points ? - more an observation of the ATSB report. What 'points' do you think the ATSB were making bushpilot ?

 

 

[motzartmerv]

Who highlighted the text?.. The atsb or you HPD.. is that you just making an observation? What extra relevance do you place on the highlighted parts??

 

 

[BLA82]

Points ? - more an observation of the ATSB report. What 'points' do you think the ATSB were making bushpilot ?

Don't let this thread go down the same road as others have in the past please!!!

 

And no HPD I am not slinging at you.

 

 

[Ben Longden]

My wild guess is the ATSB is not that impressed with VFR pilots who decide to fly into IMC using GPS as a sole means of navigating, believing that GPS will 'save the day' and keep them 'shiny side up'.

 

Also my wild guess they arent that impressed with VFR trained pilots deciding to go into IMC without any training - even a non current IFR ticket.

 

And a further wild guess, is the ATSB is not that impressed about folks who rely wholy and soley on GPS, when they do need, even as VFR pilots to check position and track using NDB and VOR.. oh and map and stopwatch..

 

Ben

 

 

[Guest Flyer40]

Points ? - more an observation of the ATSB report. What 'points' do you think the ATSB were making bushpilot ?

The ATSB don't make points. They report facts.

 

 

[Ewen McPhee]

It is good that we have access to the reports, we should not draw any conclusions based on the nuances of language regardless of whether we thought there was some intended slight or not.

 

The most important missing link is knowing what was going through the head of the pilot. Why did he entered IMC as a VFR pilot and suffered Spatial disorientation leading to a fatal accident. The psychology behind of these accidents remains a mystery to me.

 

Is there something fundamentally wrong with the system that put him in that aircraft at that time and with that level of training. We can all blame "Pilot error" but for the fact that so many of these accidents happen to experienced high time pilots; just as much as low hour pilots.

 

My son's first instructor was a highly regarded fellow with a wealth of experience and I personally flew an Introductory flight with him. Months later he CFIT in IMC condtion s while attempting to land in a Thunderstorm. Why he chose to fly that day and in those conditions we will never know but he was a careful and considerate instructor and I am sure had good reasons at least in his view to be there.

 

 

[facthunter]

Judgement & Decisions. IFR situation.

 

The most careful and meticulous pilot I ever knew (or so I thought) flew into cloud on climb and into a mountainside. Who knows what was the reason for the decision.

 

I know a few people who think it is easy but haven't done much (or none) and don't seem to comprehend what the dangers are, so they are liable to die. I for one, try to convince everybody that it is not on without the correct training, equipment, planning and recency, and I am speaking from experience here, it's not a hypothetical.

 

As they say ,"you can lead a horse to water, but you can't make it drink". Nev..

 

 

[Yenn]

It is easy to fly in cloud if you have a GPS. All you have to do is keep the wings level, using the turn and bank, keep the power and speed constant and stop any turn by watching the GPS and the whisky compass. That is what I have been told, but wether or not it is believable is up to you.

 

 

[Guest Flyer40]

Is that meant to be a joke Yenn? If so it's not a very funny one.

 

 

[Guest Macnoz]

WHAT have i started now

 

 

[Guest TOSGcentral]

Enlarging on what Yenn has said, but more with a leaning towards the psychological aspect indicated in other post – here are a few views.

 

 

No - Limited Panel (T/S, ASI, ALT, VSI & COMPASS) is not terribly difficult – providing things keep going well and you can keep it on an even keel – and the IMC does not persist for too long nor is it too rough.

 

 

Where things can come unglued is when you lose it and have to get it back – then back on course. That is where the essential instrument flying training in conjunction with pilot instrument flying currency steps right in. This is more underlined if the (hidden) surrounding country is close to you in any direction.

 

 

There is only one solution to this and that is DON’T DO IT unless you are instrument rated and current!

 

 

So why do people do it? As stated above the pilots concerned felt they had good reason and it would ‘be all right’ – but it was not!

 

 

‘Press-onitis’ is attributed as a major psychological factor where personal desires, or circumstances take over from practical airmanship. There may be many reasons for this. A lot of readers know that I am fond of replying to posts in personal experience terms – it gives them I feel a bit more of a ’being there’ ring to them. So here is another.

 

 

Last year I had just completed a conversion of a pilot to his new X-Air that he had built, did the airworthiness bit and test flying and then took him over to Watts Bridge for the conversion as his private strip (only five miles away) was a bit ‘tight’.

 

 

Everything went well but an increasing rain belt advanced from the South with cloud base coming down and light rain beginning to increase as it neared Watts.

 

 

We just finished the conversion to where we needed to be and then it was a case of getting the aircraft and its owner home – and me to my car. Did we have time to do so as it did not look too good – this was not a passing shower.

 

 

In fact there really was no great pressure. The owners wife could have got us by car in 20 minutes and taken me back with them to get my vehicle. The aircraft would have been safe tied down at Watts. I was interested to monitor my own reactions – I definitely wanted the day completed successfully and behind us but the weather was clamping down. How bad was it?

 

 

It was not raining at Watts yet and we had a 1300’ agl cloud base – no problem in flying and ‘taking a look’ and see if we could get in before the rain really increased and we went right out of VMC.

 

 

I watched carefully on the inbound flight. Horizontal vis was going down quickly and rain increasing just past the destination strip. I could see the strip and the hangar and was perfectly aligned for a straight in approach. I made sure that I hung out the cockpit several times to check that we had a clear route out still and it was not closing in behind us.

 

 

This was where I made the mistake (if a mistake was going to be made that would result in another of those loss of control situations or fly into a hill – as we were also flying into increasing hills).

 

 

I visually judged that we would get in with a few minutes to spare and the mistake was that I committed us. I made a decision that my experience in flying in far worse conditions would make it safe – but – I had to get the landing dead right first time or a go-around would have put us IMC with hills all around us. There was also the fact that the X-Air is most docile and easy to land, plus I had 2000’ of strip to play with. So I went for it but took over the flying as the increasing rain was stressing the guy I was with and his flying was deteriorating noticeably.

 

 

At the decision point all I had to do was a 180 and would have been back in clear air and at Watts in 5 minutes! If the decision had been wrong I would have given us nothing!

 

 

So it worked and it was all pretty much a non-event. But getting in my car five minutes later it was teemimg down and the cloud was nearly on the deck – that is what I would have had to take us into on a go-around.

 

 

On the drive back I thought things through quite a bit. There is no more staunch a supporter of steer well clear of cloud, hills and rain than I – yet I had taken us virtually into it. It was not bravado, or feelings of experienced superiority – it had primarily been a psychological driven desire for a bit of convenience. Well funerals are bloody inconvenient for everyone involved! I was surprised at myself and learned a little more.

 

 

I have been totally open and honest. If anyone wants to comment to open up discussion then go for it,

 

 

Tony

 

 

[Geoff]

No comment on the above, but recently I have been asked why don,t you put a wing leveler in your plane.Why I asked? its a safety device the mate said if you happen to fly in to cloud it could save you. I have though about this and I think it all so might make me make the wrong disunion,what do others think?

 

 

[Guest Flyer40]

No comment on the above, but recently I have been asked why don,t you put a wing leveler in your plane.Why I asked? its a safety device the mate said if you happen to fly in to cloud it could save you. I have though about this and I think it all so might make me make the wrong disunion,what do others think?

I think it depends on the risk taking pre-disposition of the individual.

 

CASA and ASA advocate the autopilot as a risk mitigation feature for VFR into IMC. If a VFR pilot asks a controller for assistance when inadvertently entering IMC the first thing the ATC will ask is if s/he has an autopilot.

 

There are plenty of stories about people who are still alive today thanks to an autopilot.

 

Aside from the safety aspect, once you have an autopilot you wont want to go back.

 

 

[Seal]

To Macnoz. Yeah, I have no idea but that was a spectacular blow up wasn't it.:raise_eyebrow:

 

Yenn, I don't know what was behind your post but if there is any sense of reality in it or if anyone else thinks its as simple as that sounds then I urge you to find an IFR instructor and go flying in real IFR, in cloud, in the dark and then tell us all what you think.

 

From experience I know it is hard and requires an enormous amount of discipline. I've never held a rating but I was working towards one years ago and I still remember an hour of holding patterns over Yarrowee when my brain was screaming that up was somewhere over my left shoulder. Two things stand out, the effort it took to believe what was in front of my eyes rather than what felt "right" and the speed with which the world righted itself with the first tiny glimpse of city lights as we came out of cloud on descent to Essendon.

 

Two things of relevance here come out of that. Unless you are some kind of superman you will not be able to follow the needles, GPS or otherwise, without some serious training and, doing it under the hood in VFR is mickey mouse practice at best. You just cannot stop the visual cues creeping in around the edges and it takes very little to keep your internal gyros from tumbling.

 

Be safe. Selwyn

 

 

[Guest High Plains Drifter]

The ATSB don't make points. They report facts.

Good point Flyer40 :thumb_up: (and thats not as in 'point' but maybe I should just say "comments")

 

...back to the thread subject.

 

 

[Guest pelorus32]

Tony,

 

firstly thank you for your candour...it's hard to maintain that clearly self evaluative attitude that ultimately keeps us safe.

 

There is a pattern that I think is out there: experienced or very experienced pilots coming to grief. We have seen a couple this year - the Yak accident in your part of the world and Col Pay are just two that come to mind. You are a very experienced pilot. Did that have anything to do with how you got yourself into that spot?

 

Also (and with no disrespect at all) they call holes in the cloud "sucker holes". My experience is that scud running is about, not so much "suckers" as being "sucked in". It's subtle and when you realise where you are it's often too late.

 

It makes me shudder to think how easy it is and the times I've nearly been there.

 

Kind regards

 

Mike

 

 

[Guest TOSGcentral]

Hi Mike,

 

Yes I believe experience played a large part in the decision making process plus self confidence, being in an easy aircraft and having a reasonable view of where I would be landing from a couple of miles out.

 

Equally a less experienced pilot, especially if high on personal confidence, could (and in many cases probably would) have made the same decision.

 

The critical factor is not where I was flying - I was still VMC (just) - but where I was heading. This was not into a hole in the clouds it was directly at an advancing wall of cloud and rain that definitely was IMC all the way to the ground - which itself was becoming increasingly hilly.

 

By making the decision to commit I then removed any alternative options if things had not gone exactly as I intended them to do. That is what kills you in this sort of circumstance.

 

I think this was the first time in my flying where I would have been in a position where I did not have any 'get out of it' options. And I had made the decision to go there while I did have a lot of very safe options at the time of making the choice.

 

This is the critical bit - this is no academic discussion on an isolated instance. Year after year, EVERY year, people kill themselves by deliberately flying into lowering cloud and rising ground!

 

I must admit to becoming impatient with comments and reasoning that revolve around 'if you find yourself in cloud'. Bollocks! You do not teleport there - you deliberately fly into it yourself! You therefore have plenty of prior time to decide not to fly yourself into it and do something else instead.

 

I personally feel that having just a few blind flying instruments, backed by NO IFR training only encourages the 'let's have look and see' syndrome. Equally all the autopilots or wing levellers in the world will not stop you flying into the side of a hill that you cannot see coming at you. Also a GPS encourages people to fly 'VMC on top" over extensive sheets of cloud - which is fine until the engine stops. You are then going to sample some cloud flying whether you want to or not.

 

T.

 

 

[facthunter]

My Little Bit here.

 

I am sure Ian (Yenn), is very tongue in cheek!

 

Collectively, a lot of good comments. Tony injects a real- life situation with his usual and welcome candour.

 

A short summary.

 

(a) Clouds can have rocks in them, even IF you are in control, you can't see the rocks. You Must know where you are. (The Lockhart river crash.)

 

(b) An auto-pilot does not know when you are in cloud, so it does the job just as well as when it is VFR. still refer to (a).Use autopilot to do a 180 back out, before you don't know where you are..

 

© Tony says you don't accidently get in cloud, True and when you push the boundaries, it may become inevitable. Heavy rainshower has the same effect, visibility-wise. Can be very sudden and noisy as well.

 

(d) Tony's situation. Generally he had an alternative course of action, and this is a necessary component of a good plan of action. In retrospect he may have placed too much emphasis on GETTING THERE and this is a common theme not confined to the low experience group of pilots.

 

(e) The use of GPS to fly over the top. IF you do have to descend, and it may not be just for engine failure, you will be in an IFR situation. You don't know what the cloud base will be. Indeed the cloud (in the worst case) may go right to the ground, so you will never see it . You will hit it blind, even if you are in control of the aircraft.

 

(f) There may be a feeling engendered by simulator "players" that they can handle this stuff, just by reacting to some instrument indications. This totally ignores the real-life accelerations which the body's sensory mechanisms receive and in the absence of a strong visual input, become dominant in giving overwhelming, and misleading feelings of the aircraft's motion. Nev...

 

 

[Guest brentc]

On the topic of the Lancair crash, they are a very fast machine and they are very quick to get you into the cloud especially if you're busy looking for an airfield below.

 

As a result of this crash and the one within weeks of it of a Lancair CASA are looking very closely at the type, AOPA have reported. It's not impossible that the type certificate will be pulled which may ground them permanently here in Australia.