Hey guys! John here from Fly8ma.com and today we're gonna go ahead
and take a look at a little bit of a tough topic here. We're gonna look at an
accident involving a Cirrus sr20 airplane with three people on board and
unfortunately it did not end well for any of the people on board that aircraft.
So we're gonna go ahead and look at the mistakes that were made on the part of
the pilot on the part of air traffic control. On all the external factors and,
well, there's nothing we can do to fix this accident now. Unfortunately those
three people are no longer here with us, but there are things we can do to learn from
the mistakes that were made and be able to recognize those mistakes in ourselves
and in others so that when we are pilot in command in our airplanes we know when
to assert our pilot command authority and never allow something like this to
happen to us or to anyone else. Now this entire accident case today is actually a
complete course online at fly8ma.com. You can log in to take that
course for free it's about a 15 to 20 minute course that'll give you a little
bit more in-depth knowledge about what happened with this accident. A little bit
more backstory. Let's go ahead and try to explain. See here the short version
anyways. So on June 9th of 2016 a Cirrus sr20 airplane took off from the
University of Oklahoma Airport in Norman Oklahoma and set out for about a 350
nautical mile cross-country flight. All the way down to the Houston Hobby
Airport. It is a nice day pretty clear skies and our pilot was a VFR rated Private
Pilot, so she had just gotten her private pilot's license about two years and a
month ago and had logged 332 hours total time about
250 hours pilot in command, so by no means was she an inexperienced pilot. Maybe not
an airline pilot, but certainly not inexperienced, certainly not a brand-new
pilot and for the last two years to fly 300 hours that's certainly not a rusty
pilot either. It's pretty competent pretty, should be pretty, proficient in
flying that airplane and in fact she had over 300 hours in that make and model so
by no means inexperienced here. This wasn't for lack of knowing how to fly
the aircraft. She had proven that she knew how to fly the aircraft very well
for over two years and over 300 flight hours. So how did a relatively routine
flight, although flying into a busy airport, how
did this turnout so badly? The visibility was 10 miles. the ceiling was broken at maybe
3,600 feet and the wind speed was 12 knots gusting to 16. Certainly well
within her capabilities of safely operating the aircraft and landing the
aircraft in those conditions. Now it's really important to note here that Dana
our pilot was flying her husband Tony and her brother-in-law Jerry down to the
Houston area to go see Tony and Jerry's sick father he was receiving cancer
treatment down there in Houston and so they were pretty intent on getting down
there to go see him. So there definitely was some external pressures making her
want to fly right into that Airport rather than maybe a less busy Airport
and aside from a long flight in 350 miles about three hours of flying it was
a pretty uneventful flight getting down to the Houston area into the Class B
airspace and starting talking to approach. Let's go ahead now and look at
what that first approach looked like.
Now after seeing that first attempt there, that first approach we can see that yeah she was getting into a little bit busy
airspace lot of other airplanes around so there's some threats popping up ATC
is telling her to go fast and we can see from the data recorder on the airplane
that once she configured a full flaps she started to slow the airplane down to
right around in the 80 to 90 knots range which might be a little fast for an
approach, but probably not fast enough to really make her fit in with all those
other faster jets those 737s doing 150 knots on final. The other important thing
to note here is that not only does she get go-around instructions, she also gets
a lot of instructions about switching to
different runway, a lot of wind information, can you accept that runway,
and a lot of stuff thrown at her all at once. Well she's in a pretty busy phase
of flight you're doing a go-around you're managing your airspeed managing
your pitch managing power managing your flaps that's a critical phase of flight
for any pilot not just an airline pilot flying a jet,
so is it appropriate for ATC to issue her all those instructions at that given
time? Not really. Are they used to dealing with little airplanes? Not really. Not at
that Airport. Although these controllers are incredibly competent and very good
controllers they're really good at dealing with big jets.
They're probably not very good at dealing with little airplanes like
Dana's. It's important for us to recognize that all those instructions
coming at us all at once while we're applying full power pitching to go
around retracting flaps and doing all these busy things on the airplane that's
not a good time to be listening to all those instructions. It's not a good time
to be replying to those instructions either and the best thing you can do is
simply fly the airplane first navigate the airplane where you hear them telling
you to put it and then communicate back with them and ask them to repeat if you
need to. While there's nothing glaring after this first go-around or after this
first missed approach, Dane is forced to make two more go
arounds after this and I think after watching this entire video and taking
the course you'll agree with me that at this point after the first go-around the
most appropriate thing to do if you were in this situation flying the airplane
would be to simply tell the tower you want to go back over to approach and be
resequenced for the approach so you can make a nice stable approach to the
runway maybe a different runway but ask for vectors back to a different runway
ask for a heading and an altitude and that is simple you can fly a heading in
an l2 you've been doing it since you had 15 hours in your logbook or even less as
a private pilot student. You can handle that, the runway changes, the wind, all
these other factors you can think about later on as you're being vector
back around for the approach. In the meantime fly a heading, fly an altitude,
go back over to approach get it away from the airport so that you can come
back in and try again. Staying too close it's gonna put you in too tight and
we'll see exactly how that plays out over the second approach here
Now that's a shortened version of what happened on
the second approach and if you want to see the full video go ahead and check
inside the course online at fly8ma.com but ultimately what we can
see here is ATC sending her all around in circles her getting a little confused
which is gonna happen to almost any pilot no matter how experienced you are
with all those different runway changes with all the traffic call-outs with all
those different confusing instructions and now she's left higher and faster
than she wants to be for the runway she's planning to land on and is forced
to execute another go-around it's important to note here though that ATC
isn't a bad guy for doing this they're actually trying to help her. They were
actually concerned for her safety right from the get-go and saying hey you look
a little high you look a little fast maybe you should go around she then
later on agrees with them it's important that you are the pilot and command that
you make those decisions and you should recognize that right early on
furthermore you should have realized earlier on out before making all those
circles and loops out there and making yourself dizzy flying in circles that
you need to speak up and tell ATC what you need you need a heading
you need an altitude you need to get box back around for the approach you need to
go back over to approach get Reve Ector get resequenced whatever freeze y'all do
you want to use they'll understand that and they understand what you're asking
for and you tell them what you want and you accept nothing less you are no less
important Dana her husband and her brother-in-law were no less important
than any of those other pilots or passengers flying into Hobby that day
flying in on Southwest flying it on the king air aircraft are handled by ATC
in the order in which they are received it's written in the ATC manual now we
know from experience of flying that obviously a little bit more priority is
given to airliners a little bit more priority is given to bigger jets they're
less maneuverable they're burning a lot more fuel they're a lot more expensive
to operate but that does not mean you are not important and does not mean that
you cannot speak up when you need to in be sequenced in front of Southwest make
Southwest do a go-around make Southwest enter a holding pattern make the king
air go around you are just as important and guess what Southwest has two pilots
and tons of extra fuel to be able to handle those situations you may not in
your Cessna or Cirrus or Piper now before we look at the third approach
there's something I really want to drive home here none of those air traffic
controllers she spoke to that day wanted her to get hurt in fact they
really truly care about her safety and her passenger safety but they're doing
their job and they're doing it the way they know how they've fallen into the
same complacency that we do as pilots and there's nothing lacking about Danis
skill here either as a pilot she had flown for hundreds of hours
successfully past check rides begun instrument training and was moving along
very well with her aviation career in her aviation goals all it takes however
though to become the next smoking hole in the ground is a momentary lapse of
judgment or a momentary lapse of skill or both and unfortunately that's what
we're going to see here on the third approach after the third go-around all
of these small lapses in judgment on the part of many people involved here in a
small lapse and skill to maintain proper airspeed what you're going to see is
that while flustered with lots of ATC instructions frustrated with a third
go-around and a third missed approach that Dana pitches the aircraft to a very
high nose attitude as the nose is pitching up to this attitude and she's
beginning her left turn to follow ATC's instructions to get boxed back around
for yet another approach airspeed decays down to 58 knots well below the
recommended go-around speed for a cirrus sr20 aircraft and while I receive is
dangerously low just above stall speed she retracts flaps from full to half and
then from half all the way up and as the flaps come all the way up had melted of
right around 600 feet just after retracting the last notch of flaps the
aircraft stalls begins to roll into a 70 degree left
bank full power is applied and unfortunately that correct inputs are
never applied to stop the aircraft from entering into that incipient phase of
the spin and developing into a full left turning nose down spin in the aircraft
hitting the ground just a few seconds later she's about to go loiter just okay
just you're just gonna make a right traffic now for runway 35 we'll come
back around we got at this par 5 to go down into runway 35 and you are clear to
land they'll be even no other traffic for only four so this one will be easy
play the lambs trying to get back okay or if you thought you dog
no problem okay yeah serious about five to go just go ahead and make the left
turn now to enter the downwind missed field downwind for all may for if you
can just keep me a nice low tight pattern I'm gonna have traffic for miles
behind you so I need you to just kind of keep it inside if you could and actually
I might end up sequencing you behind that traffic is on four miles a minute
it is going to be a little bit tight with one behind it
so when you get on that downwind stay on the downwind advise me when you have
that 737 in sight will either do four or we might swing you around at three five
up I'm a mammoth going up straight up we can see after this third approach here
that ATC wanted to help her they wanted to get her on the ground Dana was also
very set on landing at that Airport hitting the airplane on the ground
unfortunately a lot of factors environmental along with ATC factors and
factors with our pilot Dana led to the aircraft hitting the ground and everyone
on board dying in that crash in the NTSB final report they determined that the
probable cause of this accident was the pilots improper go-around procedure not
maintaining a safe air speed when retracting flaps exceeding the kurtik
line of attack the resulted in an accelerated stall and contributing to
the accident where the local controller is the tower controllers decision to
keep the pilot in the traffic pattern in the second local controller's issuance
of an unnecessarily complex clearance during a critical phase of flight that
go-around also contributing to the accident was the pilots lack of
assertiveness and the NTSB could not have hit the nail on the head any better
than that the NTSB identified that the pilot was attempting to comply with ATC
instructions throughout the entire flight and the pilots actions were very
understandable however that compliance with ATC instructions greatly increased
the pilots workload as a led to an extended period of closed and
maneuvering at a very busy Class B Airport during that extended period of
maneuvering around that airport the pilot did not just sir
the responsibilities that accompanying being a pilot in command and did not
awful the workload by either requesting to be resequenced telling the controller
to standby or stating unable this allowed for an increased likelihood of
the operational distractions associated with air traffic control communications
and affected the pilots ability to focus on aircraft control the biggest takeaway
point here is that this can happen to anyone
she was not an inexperienced pilot she was not a new pilot and she had landed
at class Bravo airports before this was not anything out of the realm of
ordinary this can happen to any of us that get into an airplane it's important
to recognize the key characteristics of what make this accident happen the
environmental factors along with ATC and pilot factors and to really do that I
would really strongly encourage you go take the free course online and fly at
my Cal comm of this accident case study also take the free course online of fly
Mike alpha comm of the spin awareness course understand how spins happen what
scenarios they might happen in and how to recover from spins how to get
yourself out of one and recover at the very first signs because at five to six
hundred feet you don't have a whole lot of time to figure that out and to try to
think back to the few moments of training you might have talked about
spins with your private pilot instructor you need to know how to do it right away
right off the top of your head and better yet after you do both of those
courses online at the website find an instructor find an airplane and go up
and do actual spin training at a good safe altitude and have them show you
what spins look like with the first signs of them are and how to recover
from one immediately before it ever develops. Thanks for watching this video
guys make sure you're always enhancing your skills always studying always
improving as a pilot never let your guard down and always be willing to
assert your pilot and command authority you are ultimately responsible for
ensuring that your aircraft every time it leaves the ground returns safely.
Every single time. Every single flight you make. Fly safe guys we'll see you
next time.