Watch List

July 24, 2008 by Bruce Landsberg

Many accidents, while not boring to the participants, have a predictable regularity – Crosswind landings or gear-ups, for example. There’s not much we don’t know about the cause and cure for either. They get cataloged in Air Safety Foundation’s database where they form the basis for topic and initiative areas for future education or awareness. But others pique our curiosity.

What brought this to mind was a fatal Cessna 441 accident in Oregon last week. Obviously, it’s way too soon to know why things went sour but a normal landing in light winds turned into a disaster. Witnesses saw the Conquest porpoise a few times and then saw what looked like an attempted go-around. What’s unusual about this? Two things: First, pilots flying turboprops usually know how to land especially without confounding factors, such as night, IMC, short runways or adverse winds. Secondly, how did what is usually just an embarrassing, if somewhat expensive, incident become a fatality.

The coding on this accident for our database will be challenging because the initial event occurred on landing, from what we now know. The fatality occurred on go-around which is five times more likely to result in a fatality than landing where there are seldom any serious injuries. The NTSB also has difficulty with this and we sometimes code something differently if we think there is compelling logic

We don’t yet know the pilot’s background or training but this accident is now on the ASF Watch List. When more information comes in we’ll revisit to see what may be learned and passed along.

As communications becomes more encompassing – web for example – I ‘d invite your thoughts on the watch list. Is there a better way to communicate the lessons learned than what we’re currently doing?

Bruce Landsberg
Senior Safety Advisor, Air Safety Institute

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  • Rich Bond

    For many years, I was involved with studying accident reports on 18 wheeler brakes. A common theme with looking at aircraft accident reports is that there always seemed to be some question that was not answered in the report. Of course motor vehicle accident investigations are usually conducted at the state or local level, where training in accident investigation may be questionable. However, in GA investigations, the same may be true. The investigation is handed to some field office, where the investigator has a whole slew of other responsibilities, so the investigation may fall short. Compound that with the usual lack of data recorders on GA aircraft, and add on that it was a single pilot, and the probable cause becomes a probable guess.

    To make the report meaningful from a safety standpoint, it may take looking into factors other than the accident itself as part of the analysis. Input from one very knowledgeable in this aircraft, such as a company test pilot, may be required. Questions such as how critical is Vref in this aircraft, or how critical is tire pressure or strut pressure to landing energy absorbtion may need to be part of the report?

  • bob reid

    Sounds like pure pilot error..But…Maybe he was ill and kept silent figuring he could make it to the airport ..or maybe the airplane broke somehow..this is a mystery..not enough information ..except for guessing..

  • Charles Severs

    Seems to be a typical landing with nose too low and above stall speed. The second bounce is bad and the third is catastrophic if the nose is not raised and power added to cushion the next bounce on the nose strut..Pilot error? likely

  • Don Morris

    Many years ago, prior to my becoming a pilot, I was subjected to a long and impassioned lesson on “go arounds” from one of the Air force’s most experienced and senior accident investigators. He had just returned from the Philipines after the DC-8 from Viet Nam crashed on landing.

    His lesson is very contrary to what we are taught in flight school and per the FAA regimen. Namely, once the plane is on the ground in a manner that the people will most likely survive, chop the throttle and never try to retrieve anything in the name of pride or bent metal.

    He gave numerous examples and reasons, and I have always operated that way. When my judgement and skills were inadequate to provide a respectable landing, then my judgement is inadequate to determine whether a higher airspeed and more power is actually safer. Of course, bouncing high and and being nose high, might require intervention with the throttle. Though this has happened more when I am in the safety pilot position than otherwise.

  • Stephen W. Teal

    I was at Sunriver shortly after this tragic mishap occured. The consenus of those who witnessed it said that he apparently hit his nosewheel first and then began to porpoise.

    I can’t help it but wonder if, since he was landing a high-performance turbocharged airplane at a fairly high field elevation (4164 feet) that perhaps he flared, if at all, too late to avoid hitting the nosewheel.

    In the high, thin air of Sunriver, it’s a density altitude trap each and every Summer and the possibility that he did not anticipate the need to flare a bit earlier in this thinner Summer air may have caused this terrible mishap, witnessed by lots of people.

    Stephen W. Teal

  • R. Clement

    A trend is starting. It also appears that after the first bounce the pilot relaxed or applied forward elevator and probably was at idle, which would cause the repeated uncontrolled bounces. After the propeller strike any go around attempt, would probably not be successful. Since the aircraft stayed on the runway, the crosswind, probably wasn’t a factor.

    In the past two years there have been two other fatal accidents involving more complex aircraft being operated by under qualified pilots. Lack of training will undoubtedly be a contributing cause in this accident.

  • G. Newcombe

    Were there others on board the aircraft? Perhaps the pilot(s) were allowing a novice to land the airplane in “benevolent” conditions. Hard to imagine an experienced pilot getting caught in something like this. Or perhaps as Bob Reid said perhaps the pilot was ill.

  • G. Newcombe

    Were there others on board the aircraft? Perhaps the pilot(s) were allowing a novice to land the airplane in “benevolent” conditions. Hard to imagine an experienced pilot getting caught in something like this. Or, as Bob Reid said, perhaps the pilot was ill.

  • J Mac

    Not enough information obviously for other than speculation but it is hard to believe an experienced TP pilot would lose the landing picture enough even at high density altitude to go so far as getting airborne upon nose wheel contact unless the pilot flew a very hot final and perceived the need to slam the nose down for max braking or possibly tracked the flaps just before or on touchdown. With just under 5500 ft available and landing on the numbers, the runway length should have been sufficient for the conditions present to not create the need for slamming the nose down and getting on brakes right away. The resulting pilot induced oscillation after landing is not indicative of an experienced pilot flying an on-speed routine landing with no configuration changes. Purely opinion but the synopsis sounds like flying too hot on final/landing (maybe no-flap speeds or above) coupled with a possible configuration change (tracked flaps) on or just before touchdown resulting in excessive nose low trim forces which were difficult to overcome for the situation

  • Barry camp

    I have flown with pilots that want to raise the flaps the instant the wheels touch.
    I think this is a bad habit. I think the airbrake advantage of the flaps is as good as
    the wheelbrake advantage with the flaps up. As a copilot I have endured the displeasure of pic’s by waiting until the aircraft was firmly on the ground to
    retract flaps.

  • Phil Browning

    I still remember the disquieting sensation of being much too fast on short final at Carson City, NV one hot summer afternoon. The gauges said I was fine, but my peripheral and forward vision said “way too fast”: I went around. The next approach was slightly slower and I planted the PA28-140 with a firmness I’ve not since repeated.

    High DA adds groundspeed. A modest runway length at high DA adds challenge, sometimes fear. The pilot of the 414 might have felt some motivation to get the landing roll started asap. Still, I’d like to see more concrete information.

  • Bruce Landsberg

    As usual, you are making some good points. Obviously we’ll wait to see what the investigation shows – at this point it appears that the pilot was by himself.

    Don’s comment on not going around is perhaps as much about timing as anything. One you’ve damaged the aircraft, staying on the ground is better but that takes a very good sense of what is actually happening and better judgment than many accident pilots likely have.

    Thanks for your thoughts….

  • Victor Raymond

    As a long time CE-441 Conquest pilot I can attest that is and easy airplane to land but things can and will go wrong.
    One time the PIC (not me) flared too high and tried to go around with the aircraft way too high and way too slow. A small application of power and slight nose down by the co-pilot recovered the landing.
    Another time the same pilot tried to put the props in beta while still flying because he was too fast. Again the SEC was quick enough the move his hands forward enough to get the props out of beta before something untoward occurred.