Report on the Lancair fatality 31/3/06

[Guest Flyer40]

Once again we find ourselves wondering how a pilot got it so wrong. This is not so much about skill or equipment as it is about decision making and personal responsibility.

 

On my score card there are more canceled flights (due to weather) than completed flights. I don't fly VFR on top unless I can actually see my descent point and it's clear. I've turned back where others wouldn't, because having AN escape route is not enough for me. I need multiple escape routes in case one or more closes over.

 

That's me, I'm proud to be a chicken, being a ckicken keeps me alive. But there are a lot of people at the opposite end of the risk-tolerability spectrum. There's a fine line between having the confidence to handle difficult situations and having so much confidence that it becomes an impediment to objective self-critical thinking.

 

In my view ego is probably the biggest killer in aviation.

 

Ego is a direct cause of risk taking behaviour and offers an explaination for why some professional and military pilots come to grief in ways that leave their colleagues baffled. It's also the root cause of the poor decision making that leads some private and rec pilots into unrecoverable sitiuations.

 

Take this personality test:

 

When you read an accident report do you think (a) "I hope that never happens to me" or do you think (b) "that would never happen to me".

 

Personality (a), without realising it, has taken the key message from the report and filed it away somewhere in their sub-consious to contribute to their risk awareness. One day that information might bubble up into their conscious mind in the middle of some white-knuckle moment and save their life. Personality (b) took nothing away from the report. In fact I doubt personality (b) reads many reports.

 

It's also important to think about the effect of time on decision making. If there are potentially adverse consequences to a decision, but they wont manifest until some time in the future, some people will defer the acceptance or non-acceptance of those consequences, but by then it may be too late. Those people need to shorten the gap to improve their risk avoidance, at least conceptually.

 

As for equipment, GPS and autopilot actually make people safer when used as intended. These are potentially life-saving devices and it disappoints me when someone labels them inappropriately because some pilots use them do the wrong thing. When a pilot chooses to use his GPS to fly VFR in IMC, that's another example of poor decision making. The equipment didn't make him do it.

 

I know I'm preaching to the converted here, but I'd still like to see people being encouraged to be responsibile for the consequences of their decisions, at the time of their decision.

 

 

[facthunter]

Like it!.

 

Good stuff flyer 40. I don't think ego is all it is, but it is close. It is a question of distorted priorities perhaps, where one facet of the picture assumes an importance above what it should, so the final judgement is in error. (Like having to be there because you have arranged to be met at a specific time).

 

Whenever I have got into a bad situation it is usually a combination of several factors rather than one particular issue. It sort of "sneaks" up on you.

 

Brentc, how fast is fast? You CAN slow aeroplanes up safely by "dirtying" them up, and that is the normal thing to do when you are in a precautionary situation, (or holding). Isn't the problem with the Lancair, the need to appreciate what kind of aircraft it is and be trained properly? There are a lot of aircraft that are faster than a Lancair per se, so surely there is more to it than speed. (like keeping ahead of the plane, and knowing where you are) There would be a much higher workload in a Piper Navajo (for an example) Nev...

 

 

[Guest brentc]

That's one of the problems with the Lancair, is that it doesn't slow well, especially when dirty and it has violent stall characteristics. They are a 90-95 knots over the fence machine, like a Chieftain. Some Lancairs are capable of a comfortable 200+ knot cruise and that's just the piston ones.

 

Low cloud, rain, limited visibility, not being able to spot the airfield, inexperience and indecision are all contributing factors to this crash and the Lancair is NOT the kind of machine for this set of conditions. Ironically this guys instructor Ron Bertram also died in a Lancair within 2 weeks of this crash when he took the first flight after maintenance at Bankstown.

 

 

[Guest pelorus32]

A very experienced friend of mine keeps saying to my daughter: "don't take an aircraft anywhere your brain hasn't been 5 minutes before!"

 

Just another way of saying keep ahead of the aircraft but one that strikes home with the budding aviator.

 

Regards

 

Mike

 

 

[vk3auu]

Tony said "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 can't quite agree with you there .

 

On a flight north, somewhere above Euroa, at around 4500 feet on what was generally a fine day with a few scattered clouds, I observed quite a large shadow on the ground immediately in front and almost below me. To the front, the cloud looked to be a few miles away at about my level with clear air below. That had me a bit puzzled.

 

Suddenly, I was in it. My immediate action was to do a careful left hand descending turn as I knew that the bottom of the cloud was fairly close and there was plenty of clear air below and I would be back out of it. By the time I had turned 180 degrees I was out of it, so I continued the turn and proceeded at a lower altitude.

 

In retrospect, I probably should have just throttled back and lost height.

 

David

 

 

[antzx6r]

It will be a sad day if CASA pull the type certificate on the lancairs. A perfect example of knee jerk simplistic reaction to a compounded problem. The fact that it's fast and requires proper respect and training shouldn't render it grounded.

 

We see this kind of reaction more often these days.

 

Kids are killing themselves in cars so we see rules on car size/type and log books and 3year provisional licences. Kids are still killing themselves.

 

Gun laws are introduced because of the number of violent crimes. Now the criminals have easier access to guns and farmers and recreational hunters need to jump through hoops. Usually unsuccessfully.

 

And of course there's ASIC cards and airport security.

 

For a dominant species we really do make some childish decisions as a community. Individually intelligent but dumb as sheep in a herd.

 

There are some good points comeing from this thread however. I remember an issue of Flying mag discussing VFR into IMC. It brought this idea of always having an alternate. If followed correctly, like Tony says, VFR into IMC... bollocks! You should allways have an airfield within range with VMC enroute. Why experienced pilots still get caught is a mystery. Maybe its a case of minor incursions on the edge of bad weather building up to the one that flanks you and cuts you off from home. Apart from maintaining our own vigilence theres not much that can be done.

 

On the autopilot discussion. I'm a firm believer in being over prepared and capable of more than you plan on getting yourself in for. I'd love to Get IFR trained but the upkeep i think would be beyond my means for recreational flying (GA of course). So the only option is to just stay out of it. But good sence tells me that being prepared to survive if something beyond my control puts me there is smart. That doesn't give me a licence to be less diligent about staying out of IMC.

 

Autopilots don't kill people, people(bad decisions) kill people.

 

 

[Guest TOSGcentral]

Yeah well VK3 let us talk about clouds in very simple terms – not the real nasty variety that are all over the place with big walls of the things.

 

 

Forgive me if I use your example and yourself for descriptive purposes – no attack or denigration intended at all. In your described situation you were plenty high with a lot of clear air under you and the cloud sounds as if it was more or less isolated?

 

 

OK what you seemed to have missed is the run in to the cloud and picking up the early warning signs.

 

 

The main problems with even an isolated cloud let alone the edge of a cloud mass, is that you have no horizontal references or scaling. You have no clue how large the cloud is and therefore exactly how far in front of you it is.

 

 

Your best clue is the vertical view. You should be able to see entirely below the cloud for a long distance as you approach it. In your case VK3 at 4.500’ you may well have been able to see the horizon but that may not cut the mustard.

 

 

Generally if the cloud seems to be ‘in front of you’, rather than definitely above you, but not that high that you are obviously going to hit it – then chances are you will go into it.

 

 

What it looks like is this. You are approaching the cloud and realise that you will be close to the base. But it all seems OK. Very abruptly (and it does happen damn quickly) the cloud seems to sink in front of you as your forward slant visibility abruptly drops quite unexpectedly as you did not realise how close you were. You are now probably within less than a couple of hundred metres or so to entry.

 

 

That is still enough for you to get in an enthusiastic turn in to prevent going in, but I would rather advise a full closure of the throttle immediately, get the nose down to stabilise the airspeed and quite deliberately ‘freeze’ on the controls.

 

 

If you still enter the cloud then you should be close to the base and the blind ‘flying’ will not last for more than a few seconds and you will be out of the bottom – a bit wiser.

 

 

[Barefootpilot]

Just a quick add-on to Tony's post. A general rule of thumb I was tought, more for out climbing terrain than clouds but it works just the same. If the cloud moves up the windscreen you will go under it. If it moves down the windscreen you will go under it and if it remains in a fixed position your going to go through it.

 

As a working GA pilot I've flown in some pretty bad conditions some while IFR and some marginal VFR and I've had the it will be ok I'll just sneak up the coast and it wasn't! I have my own stories but I think Tony's has made all the points that need to be made.

 

If anyone out there thinks flying at night or flying through cloud is easy just let me know and I'll organize a flight one NOT so fine day and get you to show me how its done!

 

Adam.

 

 

[motzartmerv]

haha, i like it Adam. I imagine you'd get some soup on that sydney newcastle run, infact i think ive watched you appear out of the grey out on arrival there once.

 

Some exellent stuff in this thread. And indeed Adams post resembles what ive been taught (and teach) regarding cloud infront of you. A simple one is that if you can't see the horizen beneath it then you are at least level with it.(the cloud)

 

I think Flyers points are quite valid, its ego that is a big player, and its more a personality type rather then a particular trait.

 

All this is easy to test without flying into cloud. Next time your up, try shutting your eyes and holding the wings level for 2 minutes. Take note of yor heading. oh, and make sure ya have someone with you that can tell you when to open your eyes and watch for traffic for you.

 

I can hear some of you already saying, " but i have an A/H and a turn co-ordinator" and this is where the trap lays, ive seen it posted athousand times but i will post it again. YOU WILL NOT BELIEVE THE INSTRUMENTS. The feelings in your bum are to strong and your brain is programmed to respond top them. Up can feel like down, and down can feel like up.

 

cheers

 

 

[Guest High Plains Drifter]

Hmmm... all good stuff and sound thinking, but, I'm wondering if anyone had a look at the ATSB Figure 2: Radar track, and, Figure 3: Aircraft altitude and groundspeed ?

 

Now that we have a factual report supplied by the ATSB, and the thread started by Macnoz, should we look more closely at this incident ? The don't fly in cloud bit is obvious, though - what exactly was this aviator thinking on the day ?

 

 

[facthunter]

Bertram crash.

 

Without going right back to the intricate details of this, the aeroplane suffered an engine failure shortly after take-off at Bankstown. NO single engined aircraft would have been assured of a good outcome under those circumstances.. To pull the aircraft off the list of certified aircraft is ridiculous. What about a bit of sanity here. Nev..

 

 

[motzartmerv]

I reckon pulling the type is ridiculous. where does it end? pull all fast types??

 

That's just knee-jerk stupidity. And where will it end, ban all fast types?? mandate instrument ratings for those flying fast types??

 

 

[Guest pelorus32]

Just continuing from Adam's post: one of the things you learn racing yachts - and it's equally useful here - is collision avoidance.

 

In a situation where you are crossing with another a/c if the other aircraft stays "still" against the background then you are going to hit it. If it moves ahead against the background then it is passing ahead. If it moves backwards against the background then you are passing ahead.

 

Regards

 

Mike

 

 

[Guest brentc]

It's not unheard of for CASA to pull a type cert. Didn't the Vickers Viking suffer this fate for it's tenenct to lose a wing in flight or something along those lines back in CAA days?

 

If an aircraft has violent tendencies and suffers let's say 12 fatalities in 5 years and there are only a few out there on the register, then it would surely warrant closer inspection, you would think.

 

A 90-95 knot over the machine requires a very experienced pilot and it's hard to stop them getting into a low time pilots hands with the current system. Not unlike the fork-tailed-doctor-killer.

 

 

[antzx6r]

Hmmm... all good stuff and sound thinking, but, I'm wondering if anyone had a look at the ATSB Figure 2: Radar track, and, Figure 3: Aircraft altitude and groundspeed ?Now that we have a factual report supplied by the ATSB, and the thread started by Macnoz, should we look more closely at this incident ? The don't fly in cloud bit is obvious, though - what exactly was this aviator thinking on the day ?

I read through it and agree we should discuss the events and possible causes to get others ideas on it. One thing I noticed was that when he dropped below 1000ft the airspeed showed two distinct dips down to near 100kts. This is still within the envelope of aircraft but the fact it showes the dips tells me that being closer to the ground and close to cloud, he may have felt the terrain and cloud rushing at him. That together with not having sighted the airfield yet (getting worried) and thus not thinking to setup for slow flight may have led to a steep(er) turn with not enough airspeed to execute the turn. This poor fellows over confidence may not have been in entering the near IMC but maybe back in the planning stages (IMO). The compounded conditions (wx, low hrs on type, unfamiliar with the area) should have told him to leave it for another day(or later) or take someone experienced in as many of the three conditions as possible (or at least one).

 

But after saying that, at the time of the broadcasts, it looks as though he has (a) not believed the tower when they told him he was over the wrong bridge and (b) turned in toward the bad weather and built up areas and brisbane CTA when he thought he'd over shot the field. There are some confusing decisions being made. A lot could have been done to ease the situation right up to the accident.

 

Not to speak ill of the dead, but at 300 odd hrs I'd of thought just one of those decisions could have been made better and thus saved his life. I guess when things get busy, the mind has a hard time making the same decisions we would have made in a comfy class room or sunny day with the instructor in the right seat.

 

Moral to this might be to build ones experience up to these types of conditions slowly. Don't think "I should be able to do this" and press on. I've been guilty of that myself. (In my defence, I do tend to chicken out of things I have been adequitely trained for. It took me three tries to do my first solo nav to an away airfield.)

 

But it is something to keep in mind.

 

Ant

 

 

[Barefootpilot]

It would be sad to see the type cert pulled. It would be more sensable to mandate training and currency training by a quilified instuctor to a set sylibus (note the comments from the atsb regarding no stalls or slow flight were demostrated in his check flights) for the type. This has been done for the MU-2 which is a perfectly safe aircraft if flown as the flight manual instructs. If you can teach a 200hr pilot to fly a Metro single pilot surely a PPL with 200hrs can be tought to fly a Lancair.

 

Adam.

 

 

[Guest brentc]

I've been in a similar situation before, disoriented, near cloud, near the ground and got through it ok, thus stimulating a bit of thinking on the return leg to the field think about how to avoid it next time. If I had had another 80 knots on the dial like this guy had, I fear it may have been a different outcome. It's the speed that does the damage and in an aircraft that doesn't fly well when slow, it's a dangerous combination. There's definitely a difference in training in your comparison Adam, with one probably having completed a commercial course, but the other one possibly have started in a backyard flying with little exposure to anything.

 

The other problem is that there are only very few instructors out there with Lancair / Glasair experience. Most of your 20-25 yr olds at Moorabin and those places have only ever cruised around the circuit in a bug smasher 172 and perhaps an Arrow for their CSU rating. The best pilots on type are probably the owner builders that have been banging around in them for years, however they are rarely instructors.

 

 

[Barefootpilot]

I agree that the two groups discribed above come from different backgrounds but my point (probably not written clearly) is that with the proper training anyone can fly anything safely. I agree there probably arn't many if any instructors out there with enough experiance on type to do a proper aircraft introduction and maybe this is something the lancair people can look at fixing by training some.

 

The MU-2 Factory (now out of buisness) still do a yearly (possibly two years) refreasher course for all MU-2 pilots which the FAA requires all type rated pilots to attend if they want to fly the aircraft. This has stopped the high accident rate that was associated with the aircraft type and it is now one of the safest twins out there (all be it not to many flying anymore)

 

I won't even touch the subject about experianced instructors as once I start I would probably never stop!

 

 

[facthunter]

Cause.

 

The principal problem here was the weather conditions which the pilot flew into, and the pilots lack of experience and ability to operate IFR. There is no doubt he was overloaded ( Mentally) and while the aircraft type is more demanding than most, it would not have been a problem in better weather. If you "lose it" it's a bit academic whether you spin in, or spiral in. The outcome is much the same. The spiral dive is possibly more common and the velocities achieved can be very high. Nev.

 

 

[Barefootpilot]

Agreed Nev but with better training it could be possible that he would have slowed the aircraft up in a better configuration (flap a gear were up) he may also have been more aware of the feel of the aircraft as it approached the stall.

 

But you are right if he had of been in 8/8th's of blue sky we wouldn't be talking about it today.

 

 

[antzx6r]

Conversly, if he'd known the area, he wouldn't have mistaken bridges (notice the vear to left to cross over top the wrong bridge) and slid straight down to join base 10L.

 

Also, albeit less significant, if he'd had more time on type, he may have set up for slow flight more instinctively and had less attention drawn from looking out for the field. Any of these factors could have made it a non-event. Weather is is just the most unforgiving. And as a side point, the most fear inspiring. Hence the discussion.

 

 

[kevinfrost]

Jabiru down at Jamestown SA. Bit of a mess.Pilot with suspected spinal injuries. Taken to Adelaide.

 

 

[facthunter]

More.

 

Adam and ant, I agree with ALL those things that you say. I don't want to see the aeroplane blamed because the weather was the situation that wasn't coped with. I have several friends and acquaintances who own these aircraft, and they ALL have BIG experience on fast and/ or aerobatic aircraft. These A/C are not for the inexperienced or pilot lacking recency. The conversion was a bit light-on, and some recommendations were not complied with.

 

Education and training & awareness, are what is required here for the pilots who fly these types of aircraft. We don't want to encourage a Nanny-state approach to what is allowed and what is not allowed, by banning them, when the human element (Operation/ maintenance) plays the major part. If you go down that road where do you stop?

 

100 Kts gives a good margin over the stall (clean) but it should have been configured differently. (I have mentioned this earlier) . In this instance, the dynamic loading caused the stall/spin event. I would see the concept of emergency manoeuver training being appropriate to this kind of aircraft (not that it would definately have helped here, in isolation) ,but Stick Stall Position is a concept that I see as pretty basic to the philosophy of safe flying, in all but the most benign of aircraft.(perhaps).

 

Note, I do not have a particular love for the Mitsubishi MU-2. It is deadly in icing conditions, because of the lateral control system , but that is another story that has little relevance to us here. Nev..

 

 

[youngmic]

Classic Lancair accident by the sound of it, low and slow with flaps in reflex, very light stick forces, then throw in 300 hrs TT and marginal VMC into an unfamiliar destination.

 

Unfortunatley any other outcome would've only been based on luck.

 

Didn't know the fellow but I bet he was doing the best he could under the circumstances. And under those conditions in that type of aircraft it would be a big test of metal for even highly experienced drivers.

 

Was it not the case that the ATSB are simply looking into the safety margins of this and some other high performance homebuilts.

 

And not a case of CASA pulling type certificates.

 

 

[Guest J430]

A bit of a sad tale this story. People have commented on some last minute bad decissions. Let me add a slightly expanded view.

 

This man was not a stupid man, he was a pharmacist from TL going to a conference on the Gold Coast. He may have made the coast in one shot but its a long haul and fuel would and bladder would be marginal, so he was to stop somewhere.

 

Now his bad decissions started not at YBAF, nor YBTL, but more like between Gympie and Redcliffe.

 

The weather was getting worse and could be seen, yet he continued on past YBMC, YCDR, YCAB and YRED all with fuel and facilities. From there a choice of route could be made, or hire a car! For that matter YBBN has more hire cars than anywhere in Brisbane.

 

Sometimes the decissions we could make earlier will have a big impact on those we have to make later.

 

Prior to getting into the hills in western Brisbane would have been a good time to turn back to YCAB/YRED.

 

J

 

PS..... how can CASA pull a type certificate on an Experimental which does not have a type certificate?