Accident Case Study: Communication Breakdown

Vitalik Larry you have a heavy to extreme cell at your 1 to 2 o'clock the reports of pilot of the plane may have been doing aerial acrobatics just by no stretch of the imagination are we healed and we may never be it's the afternoon of February 29th 2012 a sunny breezy day in Melbourne Florida on the state's Atlantic coast at the local Class D Airport the parallel east-west runways are buzzing with a steady stream of private and commercial traffic shortly before 5:00 p.m. November 5 for for Sierra Romeo a Cirrus sr22 based on the field is a few miles south of the airport inbound for landing its pilot the owner of a local theater multiplex is accompanied by two young employees with a little over 500 hours total time 300 of it in the sr22 the instrument-rated private pilot stays reasonably active flying about 75 hours a year it's 4:58 p.m. when the pilot makes his initial call to Melbourne tower over radiation a visual check point five miles south of the field his is one of several aircraft operating near the airport powered higher spirits are 40 Romeo over radiation and Balfour . first area near Melbourne the radiation good time radiation westbound 1052 and report right mrs. Vallon filming on the right right men build on one four nine four do remember the controller then mentions he'll try to sequence the aircraft for runway Niner left if possible presumably since the general aviation ramp is on the north side of the airport this night welcome like animal busy right now all right fine put the earlier just over a minute after that first exchange with the Cirrus two miles out on a heading roughly appropriate for a midfield downwind pattern entry the controller calls back understand lady on my right there with the 20 Bachelor Ambrose I'm an athlete it's about this mom first time right fine and uh if I get a long landing I'm Lorna Barrett that'd be great for sir Romeo with the news that the pilot is headed for Bayer air which is on the east end of the airport and actually closer to 9:00 or right given a long landing the controller seems glad that the matter of runway selection has been resolved have person when the other one learnings of for every matter right and third was clear the land mine right for therapy on in the cockpit the pilot turns left positioning the aircraft to enter the pattern on a tight right base rather than the midfield downwind specified earlier just as he's coming even with the approach end of the runway however there's a startling transmission from the tower would be a mile per night unbeknownst to the pilot another sirits this one flown by an instructor and student has been on a straight-in approach to Niner right the whole time I'm on a real short base for night rising land now port de Romeo you're only on this but I need to do to extend upon the stairs up at my apartment taken out of context the first few interactions between for Sierra Romeo and Melbourne tower seemed relatively normal in light of the actual situation that day however there were dangerous errors most notably the controller's failure to mention the aircraft on final or the fact that he expected for Sierra Romeo to land behind it why the mistakes there's some indication that the controller's focus on a matter of secondary importance for Sierra Romeo's destination on the airport played a role from the beginning it was clear he assumed the pilot would prefer to land on runway Niner left the GA side of the airport this was a reasonable assumption but for some reason it persisted after the pilot clearly stated that Niner Wright was acceptable when the pilot finally mentioned his actual destination the controller seemed primarily relieved that he could stop worrying about the runway issue the rest of the exchange which included the clearance to land seemed hurried almost an afterthought matter I observe it was later the controller would state that he felt it unnecessary to specify a landing sequence because aircraft like for Sierra Romeo typically turned base a mile or more from the end of the runway and because he hadn't cleared it for a short approach shaky assumptions at best was the controller feeling overloaded only two controllers were on duty that afternoon one handling tower and one handling ground but according to later statements the staffing level was not unusual and the traffic that afternoon while brisk was not particularly heavy the pilots actions also deserve scrutiny although the clearance to land technically superseded the towers earlier instructions to fly a downwind to base entry at a busy Airport it was arguably unwise to interpret the clearance as permission to proceed directly to a tight base leg given the vagaries of the situation a call for clarification would have been entirely appropriate in addition despite the controller's failure to point it out the pilot could have been aware of the traffic on final the other aircraft was cleared to land on runway 9 or right well after 4cr romeo started listening to tower frequency and as every primary student learns it's a good practice to visually clear final approach tower or no tower finally it's worth noting that Melbourne was the pilots home airport there's no way to be sure but given the issues just discussed it seems likely that a degree of complacency had set in familiarity breeds contempt a dangerous thing around airplanes for sir Rubio she had the fair fair he's armed I'll file for my right I'm on a real short base when I try to land now Corsa Romeo zero me unless I needed you to extend the file the tiers up there mile final come to excite now from big banks and anguish the pilot clearly surprised reacts immediately to the urgent instruction he throws the aircraft into a sharp left bank while simultaneously increasing power from 1,500 to 2,000 rpm and raising the nose witnesses watch helplessly as the events of the next few seconds unfold the aircraft now headed due west rolls inverted before pitching down and entering a spin it's altitude is roughly 300 AGL the Cirrus ballistic parachute deploys but it's too late to slow the descent and the aircraft hits the ground in a vertical dive coming to rest in a crater four feet deep I push the window I'm going around oneself oh gosh yes I did at the time of the accident the aircraft was calculated to be only 31 pounds below max gross weight prior to the final manoeuvre sequence it was flying at an airspeed of roughly 100 knots telemetry data recovered from avionics confirmed eyewitness reports by aggressively banking left while raising the nose and increasing power in other words by raising the angle of attack while bringing strong left-hand turning tendencies into play the pilot put the aircraft in a classic pre spin situation with its stall speed already on the high side of normal because of the high gross weight and perhaps as much as 50% higher than that due to the increased wing loading caused by the abrupt maneuver there was no margin for error but if the causes of the spinner straightforward the other circumstances are less so why did the pilot respond so aggressively and why did he turn left rather than right as one witness the captain of a Delta Airlines flight waiting to depart runway Niner Wright put it I was astonished at such a hotdog maneuver anywhere outside of an airshow as he was very low and must have been at at least sixty degrees of bank it just made no sense for him to be turning that aggressively and in the opposite direction of traffic we'll never know for certain but perhaps based on the urgency in the controller's voice the pilot imagined the traffic to be so close that a left turn would have taken him more quickly away from danger in the moment for example he may have thought he was overtaking the other aircraft from above and behind it's also possible given the controller statement about extending downwind to follow the other aircraft that the pilot was attempting to fix the situation by turning outbound trying to get back to the downwind leg so that the other aircraft could land first whatever the case there's one indisputable fact the actual positions of the aircraft did not merit a panic response the aircraft on final was a mile away and 300 feet below the accident aircraft when the tower first mentioned its presence and still a half mile away with the traffic in sight at the time of the fatal spin given that it's interesting to contemplate alternatives rather than giving hurried confusing instructions to foresee our Romeo the controller could simply have told the other aircraft to go around arguments about who was wrong and who should have done what could have waited until both aircraft were safely on the ground the crash of November 5 4-4 Sierra Romeo is a startling example of how a series of miscommunications unfounded assumptions and snap judgments can combine to disastrous effect even in an apparently benign situation at towered fields we expect ATC to keep track of the big picture and make sure things flow smoothly but as pilots we also have responsibilities it's not enough to sit in our little cocoons do as we're told and speak when spoken to staying vigilant building a mental picture of the traffic situation keeping an eye out for potential misunderstandings speaking up if instructions are unclear these are the things that keep us safe and they're equally important whether it's our first landing in an airport or our 500th it's also important to remember who's ultimately in charge we refer to ATC specialists as controllers but in truth a more apt term would probably be coordinators or perhaps directors because as important as their role is controllers don't really control aircraft pilots do that being said on a day-to-day operational basis its ATC that has the authority and while there are times when it's clearly necessary for pilots to speak up we have to be careful not to overuse our veto power as it were the appropriate balance is perhaps best summed up by the old saying trust but verify of course that's all for naught if we fail to control the aircraft short of a bona fide imminent mid-air collision nothing justifies the kind of abrupt low altitude low airspeed maneuvering that led to for Sierra Romeo's demise this accident holds important lessons about communication low altitude maneuvering and traffic pattern operations but perhaps its most critical lesson has to do with our fundamental responsibilities as pilots when all said and done we don't answer to ATC we answer to ourselves and to the passengers who entrust their lives to us you

Channel: Air Safety Institute

Views: 773,129

Rating: 4.8940077 out of 5

Keywords: Melbourne, general aviation, Cirrus, stall, spin, ATC, phraseology, comm, see and avoid, MLB, KMLB, AOPA, Air Safety Institute, Aircraft Owners And Pilots Association (Organization), Landing, accident, crash, airplane, plane, aopa, asi, analysis, investigation, ntsb, cirrus, sr22, pilot, student, florida, flight

Id: pAWy9mjnrYM

Length: 13min 10sec (790 seconds)

Published: Wed Dec 18 2013