Editor’s note: For our July 2021 accident investigation, Oshkosh Or Bust, we explored an accident involving a non-instrument rated pilot who took off from an IMC at night and crashed into an open field near the airport, causing his own and his passenger died. This month’s accident was eerily similar except that both passengers were instrument-rated commercial pilots. The root causes of the two accidents were somewhat different, but they shared a common goal: to fly to Oshkosh, Wisconsin, for the annual air show. Getting there is real.
FAA Pilot’s Aviation Knowledge Manual (PHAK, FAA-H-8083-25B) discusses five dangerous attitudes that a pilot may have. It defines “attitude” as “a motivated disposition to respond in a particular way to a person, situation, or event.” At the same time, according to PHAK, dangerous attitudes “can affect the ability to make good decisions and exercise power properly.” As we shall see, the dangerous attitude of “anti-authority” runs throughout this month’s incident.
But it also has a “get there” mentality, in which pilots ignore normal procedures and/or adverse conditions in an attempt to start or complete a planned flight. We’re sure this is more common than accident records reflect, in part because some combination of luck and skill allowed the task to be completed without filing an NTSB report.
There is a fine line between deftly navigating the many challenges that flying can present and negotiating irresponsibly (with potentially tragic consequences). Accident records tell us that this line is frequently crossed.
The real trick to all of this, to me, is the pilot’s ability to recognize when he or she is over their head, and make a decision only with the mission in mind, rather than consciously thinking about possible adverse outcomes. This is an example of the former.
background
On July 24, 2019, at approximately 0550 hours ET, a Cirrus SR22 was destroyed when it struck terrain near Americus, Georgia. The pilot and pilot-class passenger were seriously injured. Instrument conditions prevailed at night; no flight plan submitted.The pair are heading to Oshkosh, Wisconsin, for the
Annual air show.
The radar data included six targets over a one-minute period, tracing a 180-degree arc to the left. The first target is the aircraft approximately 1700 feet beyond the take-off end of the runway at 900 feet MSL/432 feet AGL. The last target showed the aircraft at about 1100 ft MSL.
A resident of the plane crash farm heard the sound of the engine at around 0550. He noticed it was cloudy and still dark outside, and it sounded like the plane was turning and the engine was “whooshing very loudly”. Then he heard an explosion.
investigation
The aircraft was at an altitude of 477 feet; all of its major components were inventoried on site. The wreckage path is about 400 feet long and faces south. Initial contact occurred with tree strike approximately 34 feet above the ground; ground scarring began approximately 50 feet after tree strike.
The fuselage and flight control surfaces were highly fragmented, including the rudder pedals and side sticks, but the continuity of the control cables from the cockpit to the associated bellcranks was confirmed and their overload interrupted and severed by first responders. Here’s an early, non-glass SR22: Its gyroscopes show spin notches, indicating they were running on impact.
The oil filter was dated July 7, 2017 and disassembled; no metal fragments were found. The propeller is detached from the aircraft; all three propeller blades remain attached to the hub. Each showed similar twisting, bending and chordal scraping, indicating that the engine was running at the time of impact. Cirrus Aircraft parachute systems still have safety pins on the activation handles, including a “Remove Before Flying” banner.
According to the aircraft logbook, the last annual inspection was completed on April 3, 2018. Annual inspections for the last three years are completed approximately every other year.
“The aircraft was not aware of any abnormalities that would prevent normal operation,” the NTSB said.
At 0550, weather observations were recorded at the departure airport approximately 2 miles south of the accident site, including a cloudy ceiling at 500 feet and a wind of 5 knots down the runway. Visibility is 10 miles. At 0445, an updated AIRMET Sierra was issued notifying the IMC of ceilings below 1000 feet, visibility below three miles, precipitation and mist. Weather satellite data indicated that the cloud tops at the accident site were approximately 6500 feet MSL. Civilian dawn begins at 0619 and sunrise at 0646. There is no record that the pilot of the flight received a weather briefing through Leidos or ForeFlight. It is unclear whether they obtained weather information from any other sources before the accidental flight.
The pilot/owner (male, 69) holds a commercial certificate and an instrument rating. (An earlier version of the NTSB report put his total flight time at 22,000 hours, down from the final figure.) The passenger (male, 63) with a pilot rating also holds a commercial certificate with an instrument rating.
possible reason
The NTSB determined that the probable causes of the accident included: “The pilot decided to take off in dark instrument weather conditions, which resulted in spatial disorientation and subsequent loss of control of the aircraft. pressure and the anti-authority attitude of the pilots.”
Given the pilot/owner’s failure to obtain weather briefings, submit IFR flight plans, or regularly inspect his aircraft, the NTSB said “it is likely that he has developed an anti-authoritative attitude, as evidenced by disregard of several rules and regulations” Additionally, the NTSB noted that the two may have experienced “rushing” while trying to get to the airshow.
The sidebar below highlights some details about anti-authority dangerous attitudes and “going there”. Acknowledging that you may be experiencing one or two emotional disturbances, or others, is the real key to avoiding the resulting bad decisions.
“Effective Risk Management Takes Practice”
According to the NTSB, “By identifying personal attitudes that are detrimental to safe flying, applying behavior modification techniques, recognizing and coping with stress, and using all resources effectively, pilots can significantly improve the safety of every flight. Remember, effective risk Management takes practice. It is a decision-making process by which pilots systematically identify hazards, assess the level of risk, and determine the best course of action. Pilots should plan ahead for flight diversions or cancel alternatives and not be afraid to change plans; sometimes it is safe to be late or There is no difference between arriving at all.”
Aircraft Profile: Cirrus SR22
Original engine: Continental IO-550-N
Empty weight: 2250 lbs.
Maximum takeoff gross weight: 3400 lbs.
Typical cruising speed: Chapter 175
Standard fuel capacity: 81 gallons
Service Cap: 17,500 feet
scope: 1049 nautical miles
VS0: 59 Korean Aeronautics and Space Administration
This article was originally published in the July 2022 issue aviation safety Magazine.
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