Get me to the Game on Time

September 19, 2012 by Bruce Landsberg

A recurring accident theme is the use of GA aircraft to get to sporting events. It can be a great way to travel, but sometimes it can’t. Pilots are often traveling with friends or family so there is a social commitment of delivering passengers to a special, possibly prestigious, event. Tickets are pricey and often hard to get, adding to the pressure of an irreplaceable loss if the trip is canceled or delayed. Off the top of my head I can think of three “sports-induced” mishaps involving GA, and there are sure to be many more in the files.

Two involved VFR pilots who just had to get to a game when the weather was clearly IMC. The third one occurred this past weekend when a Cirrus SR22 with two adults, a child, and two teens wound up about five miles short of the airport on the trip home from a baseball game. We know very little at this point other than the pilot was instrument-rated, and the weather appeared to be IMC,, just after midnight with a close temperature/dew point spread.

Five people in a four place aircraft is considered bad form in any case, but they flew to the game that way so, presumably, flight was possible—if not legal or smart.

Arriving back after the midnight hour means fatigue may have been a factor. The airplane handling may have been squirrelly due to weight/balance problems. Five fatalities, however, (especially for the young people) seems like a very poor tradeoff to sleep in one’s own bed. So, as usual, we’re back to the judgment, decision-making aspect.

This just in from NTSB: “The pilot contacted Springfield Approach about 0002 as the flight entered their airspace. About 0017, the pilot was cleared for an Instrument Landing System (ILS) approach to runway 14 at SGF. The pilot was instructed to contact the control tower at that time. At 0020, about 3 minutes after establishing contact with the control tower, the pilot requested radar vectors in order to execute a second ILS approach. About 30 seconds later, radar contact was lost.”

So, a few questions/observations:

  • What potential  aerodynamic degradations might have occurred and would the pilot notice?
  • Night IMC and a missed approach can be stressful but when we choose to play in that environment on must be prepared.
  • The pilot, in his mid-40s, was a successful businessman. How might fatigue have played into this mishap?
  • Perhaps there was a mechanical malfunction and the pilot was not directly to blame, although the 5/4 seating arrangement still bothers me.

The aftermath, as you might suspect, was devastating to the community, and it’s going to take a long time to recover. The reporter I spoke to for an interview was sympathetic to GA and said she really liked flying in small planes. That’s an unusual twist, but too many of her viewers won’t understand that it’s not the activity that caused the problem—any more than they’d understand that automobile or motorcycle accidents are usually the result of some human failure that could have easily been prevented.

From a systems analysis perspective, I’m hard-pressed to see how these situations are to be prevented without drastically reducing the freedom of those who use aircraft responsibly.

Your thoughts?

 

Bruce Landsberg
President, AOPA Foundation

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11 Responses to “Get me to the Game on Time”

  1. Brian Turrisi Says:

    Bruce;
    The late night SR22 crash coming home from the baseball game is an accident discussed at length on the Cirrus Owners forum. There are too few details at this point but amazing the thoughts with so little information. The weather, by the way, was IFR by the time he was trying to land well after midnight.
    What disturbs me is the division of thinking on this accident by a large number of folks who fly the same plane. Too many think this has to be the plane causing the wreck. It is suggested that it is too easy to stall of spin a Cirrus and that is the problem.
    I have been flying airplanes for 40 years. The Cirrus is no more likely to stall spin that any other legacy aircraft; having flown many of them. But this is a classic accident scenario with layers of issues leading to the accident.
    Putting 5 people in a Cirrus? Leaving late at night? Marginal and then IFR weather?
    I could list others but this speaks of a decision process ignoring the true risk and the need to be totally “at the top of your game” to handle a flight like this. Yes, it can be done but should it be done? When was his last IFR night approach? The Nall report on night IMC is pretty eye opening!
    My concern is if we continue to blame the machine instead of the one controlling it, we will never improve safety. But I am seeing pilots arguing it the other way!

  2. L Waters Says:

    Bruce,

    Thanks for your ongoing focus on safety and the complex questions surrounding it. I am a new pilot and read your magazine with great interest. This accident is a true tragedy, especially for those young passengers.

    Through the complex questions and overlapping causes, the simple truth is that flying a plane carries risks, and it is our job as pilots to weigh those risks and make decisions based first on safety. This is no more or less critical in other walks of life, from driving a car to making management decisions in companies. Assuming there was not a catastrophic mechanical failure, would that Cirrus have crashed on any other day?

    Some planes are more stable than others. Some pilots are more capable than others. I fly a Cessna 206, which is an incredibly forgiving airplane. The Cirrus is a more demanding plane but carries performance benefits accordingly. Pilots have many choices in the market, and the relationship between stability and performance is well understood. Design of a plane also influences the overall envelope. Choosing an aircraft, right up front, is part of the decision set a pilot is responsible for. I think Cirrus makes a wonderful plane, but I don’t feel qualified to step into one yet. It is interesting that some Cirrus owners blame the plane — a different plane could be (or for some, possibly should be) chosen!

    The idea that accidents can be eliminated — or even substantially reduced — by “regulating” all aspects of a pilot’s choices is a losing path. Choosing to be a pilot acknowledges the risks. We must accept that responsibility for ourselves and for the passengers that depend on us. We’ll never fully eliminate accidents but each of us can individually choose a low-risk path every time we begin (or delay) a flight.

  3. John Ylinen Says:

    Bruce;
    Thanks for your continued focus on safety and your service to our community.

    A few details you have left out. Listening to ATCLive; the pilot got a popup IFR clearance so was on an IFR flight plan. Just shortly before the accident; the pilot had radio the FBO to request a taxi since he was not landing at his home airport as there were no IFR approaches.

    Your point about flying when you have an important event is valid, but would like that you have suggested the use of Critical Decision Making rather than suggest that we should not fly. In this case; he was returning from the event. We don’t know what agenda he or the passengers had the next day. In this case, it might have been better to stay in KC and come back the next morning.

    One thing that you could do to help the pilot community as they review these accidents is see if we can get the NTSB to release the preliminary and factual reports faster. In this case; I think it would have been better for you to wait till at least the prelimnary report was released so you have more of the details to base your questions/observatons on.

  4. Bruce Landsberg Says:

    John….

    Thanks much for your note. I omitted my usual disclaimer that all my comments are speculative at this early stage. When this was written we did not have the weather and latest Metar that we had showed VFR although the dew point was close.

    The idea to get the NTSB move more quickly is enticing. Given the reality of gov’t budgets that may be a bit optimistic.

    Brian, I can only imagine what’s going on in the Cirrus forums! Barring a mechanical malfunction the machines do pretty much what we tell them to. Since, this was an older model SR22, if I recall, the Flight Data Monitoring equipment may not be installed which gives us less to go on.

    Hope to learnmore but I really interested in seeing how to communicate and navigate the risk – reward – skill issues.

    Appreciates everyone’s thoughts.

  5. Rick Beach Says:

    Bruce, appreciate your contributions to the news articles that followed this accident. Glad to have articulate spokespeople involved.

    An area to emphasize with the NTSB investigators, should you have access to them and can influence their focus, would be the human factors analysis of this accident. You raise several very important and useful questions. I would add information about the pilot’s proficiency and currency with the circumstances of this flight — night, IMC, family passengers, transition training, CAPS parachute training, etc.

    But will the NTSB factual report contain a “HUMAN FACTORS” section to answer them? Apparently, commercial airline investigations have such a section, but few if any GA investigations seem to include these details.

    Cheers
    Rick

  6. Bruce Landsberg Says:

    Rick….

    Great suggestion and already passed to the NTSB!

  7. Kevin Wardlaw Says:

    As a Non-Instrument Private Pilot, I have a hard time understanding WHY some Pilots will subject themselves and their unfortuante innocent trusting passengers to such indiscretion.

    Basic Pilot training teaches first and formost to build saftey margins in all flights with Fuel reserves, Physical Judgment, trip planning, take off and landing safety technics, Weight and Balance and of course Weather.

    I continue to watch and read accounts of Pilots “pushing the envelope” whether it’s trying to impress observers of their Aircraft’s steep climb out and turn technics, how slow they can get it and still manuever or how they can do it all in one day…….There’s alot of VFR space and daylight out there and room to build in safety margins with every flight not to mention plenty of Hotels with comfortable beds to wait for such if the day gets away from you………

  8. Kip Glass Says:

    I am based at the accident airport, the preliminary report is now out. The weather at the time of the accident was 700 ovc and light winds out of the east. The report said he was cleared for the ILS 14 approach and 3 minutes after the switching to the tower he asked for vectors for a second attempt. 30 seconds after that radar contact lost.
    This leads me to believe that a climb and a vector was issued and the transition to a heading and climb, if hand flying, possible spatial disorientation. Or CG issues in the transition leading to a stall he could not recover from. The reason for the confusion? Did he select the GPS 14 approach instead of the ILS 14 approach.
    Time will tell. Tragedy anyway you look at it.

  9. Chaz Burnett Says:

    Bruce:Great commentary.Appears that another pilot violated commonsense rules.Mechanical problems would appear to be unlikely.

    My preflight checklist consists of a mnemonic (7 P’s)of major flight risks.This simple mental checklist can be used for both VFR& IFR flights, and by GA pilots of different skillsets to help “Go-No Go” decision-making.Not rocket science,but complements ASF stuff and regular preflight planning.I consider the following “risk factors”:
    1.PERSONS(ie pilot (proficient?)& passengers(source of distraction)
    2.PLANE(ie any recent powerplant/ prop or fuselage issues)eg.broken pitot heat or recent annual
    3.PANEL(capability,including pilot’s proficiency; recent squaks)eg.nonfunctioning autopilot is a “no-go” item for cross country IFR in a Bonanza vs a Cessna 310
    4.PLAN(not just the flight plan,but stuff like day vs night flight,urgency of the trip,wt/balance,weather,fuel….understandably requiring a pilot to “step back” and take a look at the big picture)
    5.PLACES(terrain&runway friendliness enroute and @destination,FBO services,IFR approaches,etc)eg.descent and approach over mountainous terrain @night in IMC increases risk
    6.PRECIPITATION(ie IMC,weather and wind,icing forecasts)
    7.POSSIBILITIES(this is required by FAR’s -as an alternate course of action;more than having an alternate destination airport)
    I suspect the Cirrus pilot violated several of his own rules,had he stopped to consider them.In my opinion,everybody would benefit by using his own preflight mnemonic for rapid risk assessment.

  10. Bruce Landsberg Says:

    Please note we just rec’d NTSB preliminary, as Kip stated. Field was IMC

  11. Don Sutherland Says:

    Bruce, I need to ask a question: How much of our day-to-day pilot flight training, do you think, focuses on the pilot evaluating the risk factors and doing go/no-go decision making for a flight? Have you ever had a check pilot on a proficiency check ride ask for your risk analysis before the flight and then follow up during the flight with a question like “Are the risk factors for this flight under control? Discussion, please!”. I don’t believe that this is a common training practice.

    CFIs get risk analyis and decision making training as part of the FIRC (Flight Instructor Refresher Clinic) but my guess is that very little of this gets incorporated into daily activity or practiced regularly with GA pilots.

    One last opinion: Scenario training is of tremendous value however it tends to be reactionary; That is, an instructor creates a situation that needs solving, the student then reacts. … Risk management should be an ongoing observation and thought process which begins with flight planning and continues until the plane is secured after the flight. When a risk is perceived, decision making begins.

    By the way of decision making, the AOPA on-line course “Do the Right Thing-Decision Making for Pilots” is excellent. Thank you.

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