Reflections on Cirrus fatal #61 near Buttonville Airport in Canada - Pull early, pull often! - Safety and Training Programs - Cirrus Owners and Pilots Association

Reflections on Cirrus fatal #61 near Buttonville Airport in Canada

Reflections on Cirrus fatal #61 near Buttonville Airport in Canada

SR20 C-GYPJ crashed into a building and two people died last 25 May, 2010.  The accident was extensively discussed on the COPA forums in two threads:

The SR20 departed Buttonville Aiport after avionics maintenance with two pilots aboard and encountered a loss of engine power due to a fracture of a cylinder.  The pilot attempted to turn back to the airport, lost control, attempted recovery, and impacted the roof of a commercial building.  Both people aboard died.

Loss of Engine Power Factor

The Transport Canada report details the failure of the cylinder in the engine.

Fractured cylinder #3 from the accident engine, with failure due to a fatigue crack in threads 4, 5 and 6, where the aluminum head screws onto the steel cylinder wall.  Photo: Transport Canada

Robert Apenis summarizes the report effectively.  The report indicates that this fatigue failure could not have been observed without destructive testing.  Apparently, this was the first occurrence in this type of IO-360 engine.  The cylinder did have 2221 hours in service, having been rehoned 715 hours before the accident.  Without further examples of failures, this seems like a single point of failure and not a fleet problem.

Lesson #1: Maintain your airplane diligently, but some failures are rare events.  Plan for them.

Mechanical Things Do Fail

Note that the failure of this cylinder was a factor in the accident chain, but not the ultimate cause of the fatal crash.  The pilot's actions after the engine lost power continued for some time and determined the sequence of events following the engine problem.  Dealing with a loss of engine power is a required task for the FAA Practical Test Standards for private pilot certification.  (I presume similar requirements are in place for Canada and other countries.)

Lesson #2: Mechanical things do fail, plan for them and practice your emergency procedures.

Two Pilots at the Controls

One detail from the accident report was that the passenger was also a private pilot with a license issued about 30 days prior to the accident.  No information indicates that this was a factor in the accident.

However, when an unusual situation arises, how do you handle it when a second pilot is in the front seat?

Did you and the other pilot discuss who was PIC?  Did you brief on the positive transfer of controls?  Recall that instructors check these things every time they fly with you.  Do you discuss it when you fly with another pilot?

The potential difficulty of another pilot attempting recovery may interfere with your actions.  Speaking up is one thing, acting on impulse is another.

Yet another possibility is for the second pilot to actually be given the opportunity to fly the plane.  Even the potential for them sitting in the left seat.  A couple of Cirrus fatal accidents involved uncertainty as to which pilot was in which front seat.  Are you familiar enough with your Cirrus that you can fly reliably from the right seat?  If not, don't do it on a whim, or to be generous.

Again, to emphasize, we have no evidence of this in the Buttonville accident investigation.  But I raise it as a lesson to learn.

Lesson #3: Two (or more) pilots in the plane can create confusion and different responses.  Brief on the ground who is PIC, who will make decisions in the event of an urgent situation, and how the other pilot(s) can contribute to the situation.

Back to Loss of Engine Power during Takeoff Climb

This accident involved reports of smoke coming from the airplane and an obvious mechanical fault -- the fracture of the #3 cylinder.  And it happened soon after takeoff, so the altitude was only a few hundred feet.

What would that sound and feel like?  One thing is certain -- you want to find out quickly if you still have any power left!

If it a complete loss of power -- silence is your best clue! -- then act immediately.  Otherwise, you can do a bit of troubleshooting.

The POH has a section on Engine Partial Power Loss in the Emergency Procedures section.  The emergency procedure steps through boost pump, fuel supply, mixture, power, alternate air and ignition.  At the CPPP, we recommend a flow by quadrant -- fuel, power, air, ignition -- moving swiftly at lower right upward to the left.  Practice these diagnostic steps so that you can find out if there is a quick resolution:

  • Fuel pump -- BOOST
  • Fuel selector -- SWITCH
  • Mixture -- SWEEP for conditions
  • Power lever -- SWEEP
  • Alternate Air -- ON
  • Ignition -- BOTH, L, R

Note that you have two magnetos in part because they fail often.  Also, turbo operators may lose the turbo boost but still operate as a normally aspirated engine, just at lower power for the altitude.  And your mixture may be changed by your passenger inadvertently.  Lots of possibilities.

Aim to accomplish all these tasks within a few seconds.  Realize that lingering on these steps uses up time that may result in a loss of altitude.

Lesson #4: If you don't have any power, act immediately.

Lesson #5: Practice the emergency procedures, especially Engine Partial Power Loss, such that you can correct the situation within seconds.

Departure Briefing

Here is the view of the departure end of Buttonville Airport (click for a larger image).

Looks like a lot of commercial and industrial buildings with some residential under the crosswind turn.  Note the wreckage was consistent with a turn downwind to return to the airport.

Lesson #6: When arriving at an unfamiliar airport, take a look at the terrain and land use off the ends of the runways, so you can see what will be underneath you on departure.

To maximize your alternatives, CPPP instructors recommend departing at Vy airspeed to gain the most altitude in the shortest time (not Vx that gets you the shortest altitude in the shortest distance, but at the risk of a significantly greater pitch angle and slower airspeed).  Aim to gain 500 feet AGL where CAPS becomes viable if activated immediately.

Otherwise, you need to determine where you would put the aircraft down if you have a loss of power at too low an altitude for a survivable CAPS deployment.

Lesson #7: Prepare a departure briefing for every airport and every departure, especially noting the CAPS altitude of 500 feet AGL.

Using CAPS during Takeoff Climb

Consider these choices for when to use CAPS during an emergency during takeoff and departure climb:

Below 500 feet AGL, you have few good options.  It takes time to recognize that you are in trouble.  It takes time to decide.  It takes time to act.  All that time may be costing you altitude.  COPA Pilots in the simulator consistently take 5-10 seconds to react and act.  Keep the wings level.  Avoid turns that will increase your chance of a stall at a higher airspeed in the banked turn.  Aim for the most suitable off-airport landing spot.  Good luck!  Wish you had climbed fast enough ...

Above 500 feet AGL, we know that CAPS is viable.  But you don't have much time to do anything else but decide to act.

Above 2000 feet AGL, you now have altitude to consider your options.  Maneuver to position your plane for the best outcome, which may be a CAPS pull.  Recall that survivable CAPS deployments have landed in trees, shrubs, residential streets, ponds, canals, rivers, oceans, powerlines, mountain slopes, etc.

Lesson #8: Think through your decision criteria for when you will use CAPS in an emergency during takeoff and departure.  No one has died when CAPS was activated above 1000' AGL and below 133 knots.

Low Altitude Options for CAPS

How low can you pull and still survive?

There are no limitations on using CAPS.  There are observations from the certification tests, but they are not limiting.  From level flight, activating CAPS lost 400 feet to level under canopy.  From a 1-1/2 turn spin, activating CAPS lost 920 feet from the initiation of the spin to level under canopy.

Accident investigations provide us with this additional data about what happens with low-altitude CAPS pulls:

  • ~500 feet when zooming up after a power-off glide was going to land short of the airport; 1 minor injury, 1 uninjured
  • 441 feet over the ocean after loss of engine power; 1 serious injury
  • ~400 feet during a power-off glide was going to land short of the runway; 1 serious injury, 3 uninjured
  • ~50 feet after first impact with trees during a failed go-around; 1 serious injury

Not all low-altitude CAPS activations are survivable:

  • 528 feet in a spin descending at 100 knots, CAPS activated just 4 seconds prior to impact and reduced vertical velocity to 58 knots; 1 fatal, 3 serious
  • ~50 feet in a spin, witnesses report CAPS observed partially opened; 2 fatal

Lesson #9: Pull Early!  If you have altitude and are faced with a risky off-airport landing, then use CAPS early enough to avoid serious injury.  You need 8 seconds.  That's only a few hundred feet of altitude above ground.

Why Crash with a Usable Rocket and Parachute?

The inventor of the ballistic parachute advocates that you should use CAPS whenever you face a potential high-energy impact.  Energy goes up as the square of your velocity.  Under CAPS, your vertical velocity is about 20 knots.  If you stall the aircraft and crash, your impact velocity is about 60 knots -- or 9 times more energy.  If you spin and crash, then the impact velocity may go up to 100 knots -- or 25 times more energy.  Lower energy in the crash is good.  Faced with landing in uncertain terrain or hitting something hard, pull the CAPS handle.  Even if you get the wheels rolling, hitting a stump, ditch, fence, or other hard object can ruin your day.

The CAPS deployment sequence will take 8 seconds, and part of that time will position the airframe in a nose-low attitude.  So, this is a consideration for the impact.  Fortunately, the Cirrus cockpit has proven to be very strong, and the seat restraints have proven to be very effective.  Consider reducing your impact energy as a trade-off for the risk of a nose-low impact.

Lesson #10: Plan to use CAPS to reduce your impact energy.

The Fatal Choice: Stall and Crash

When faced with a takeoff emergency, you have many choices of alternative actions and outcomes.

  • Land straight ahead
  • Maneuver with limited power to maintain airspeed and altitude towards a safer off-airport landing site
  • Pull CAPS handle

The worst possible choice is to stall the aircraft, lose control and impact the ground at flying speeds.

Lesson #11: Do everything you can to avoid stalling the aircraft and losing control.

 

Regretfully, these lessons come from a fatal Cirrus accident.  Please consider them in your recurrent training.  Don't make the same choices and have the safe fatal outcome.

 

Cheers
Rick

Comments
  • This is hard to write, so I am just going to say it, no doubt it will ruffle some feathers, and yes, I know the pilot is not here to defend himself, but this needs to be said and in the end is was not his fault.

    This accident has been a point of debate at the Buttonville Flying Club, local Cirrus pilots and among members of the Canadian Owners and Pilot Association ( The other COPA), for months.

    The key conclusion that myself and others have drawn from this debate and the TSB  report is that the pilot did not have adequate training on type. This is very controversial, so let me explain.

    First a quote from the “Politically Correct” transport report:

    “The pilot had accumulated approximately 225 hours of total flying time, including 100 hours on the SR20 aircraft. All of the pilot's initial training was completed on a Cessna 172, a slower aircraft with different handling characteristics than those of the Cirrus SR20. There is no indication that the pilot took any additional training on the Cirrus SR20.”  

    250 hours TT is low for any sort of advanced aircraft, but the real issue is the lack of conversion training. Every a many thousand hour pilot needs type training and any way you look at it 100 hours of self taught conversion doesn’t do it. Even highly experienced pilots have problems flying the cirrus when things begin to go wrong… and every indication is that the pilot simply let the plane get away from him.

    The scenario painted by the TSB report is that the aircraft turned back to the airport under partial power, but entered a stall at low level without enough altitude to recover. The report is clearly stating that the pilot did not maintain best glide speed ( 96 kts in an SR20 as loaded), but instead allowed the aircraft to enter SLOW FLIGHT under partial power, in a turn. Under this condition you are behind the power curve and require considerable more power just to remain level than at the best glide speed. This would have aggravated the partial power loss situation and made altitude loss or a stall much more likely, which is what happened.

     I have duplicated this in my own aircraft ( CGOPX, a SR20 of the same vintage as the crash aircraft) at  altitude.  Try it yourself, start out at 3000ft then use takeoff flaps and power to climb at 81kts to 3400ft (simulated take off) and then pull the power back to 16inches on Manifold pressure. Now try and turn back to the “runway”. You can turn around and make the runway if you maintain best glide.  But if you let the speed drop into slow flight you will start to loss height and you do not have the power or the altitude to exit slow flight.  This is a pilots worse nightmare and one easy enough to trap yourself into if you are thinking Cessna speeds rather than Cirrus speeds.

    It is also important to ask the question, Why turn back with two freeways in view (Hwy 404 & 407)?  Many pilots at our club are now performing take off briefings that require at least 1000ft of altitude before turning back after an engine failure.

    So we have a low time pilot, on a high end aircraft, forgoing any serious type training. He puts his money down, purchases a used aircraft beyond his ability to safely fly during an emergency.    

    Is the picture becoming clearer?

    The pilot in question was a nice guy and an able Cessna 172 Pilot who simply did not have easy access to or attempt to train with an experienced Cirrus instructor before flying the aircraft.  You may be able to get away with a quick type intro flight in the more forgiving Diamond or a Cessna 182, but not on a Cirrus.  Even 100 hours worth of self taught familiarization is not a substitute for proper training.  

    Local flight schools, such as Toronto Airways, do not have ANY flight instructors able to provide Cirrus training.  Only one local flight school (Canadian Flyers, at which I teach on a part time basis) and a handful of freelance Class one instructors, such as Ed Pasquale and John Chandler are currently providing this instruction, and they are all busy to say the least.

    As the Canadian dollar increases in value and the price of used Cirrus aircraft continues to drop, dozens of cirrus aircraft have recently been imported by Canadian pilots who are often first time aircraft owners with limited or no experience in flying high performance aircraft.  For example, In the Toronto area this has included low time pilots, as well as at least one student pilot.  It is my observation that, unlike the older high end singles for sale in Canada, the aircraft image, the CAPS system, advanced autopilot and avionics, makes the Cirrus especially appealing to the first time aircraft owner.

    This issue is augmented by an expectation level on the part of the new owner that an hour or two of instruction is all that is needed before being able to transistion from a cessna to a Cirrus.  Insurance companies also know that the higher the training requirements for the new owner, the less likely they are to get the business.

    Although local Insurance companies require some type specific training, safety may be taking a back seat to expediency in some cases   Given the shortage, the instructors providing type training are often not CSIP (Cirrus Standardized Instructor Program) certified or working thru a Cirrus Training Center, and in one case that I am aware of, had not even flown a Cirrus before.

    As used Cirrus aircraft begin to work their way from the US market place onto the world stage, lack of access to adequate training is a recipe for disaster that could make this accident the first of many to come.

    The question is, how to emulate the successful Cirrus training program in the US in Canada?

    Doug Morely has already approached Rick about holding a CPPP or similar training session in Canada, preferable Toronto.   What else can we do?

    If we are not proactive, we will be having this discussion again, and soon…

    Mark Brooks ( C-GOPX SR20)

    President Buttonville Flying Club

  • Mark, appreciate your extensive comments.  i will contact you to follow-up on several ideas in your post.

    Cheers

    Rick

  • Well said mark, I had been flying for over 30 years with over 400 hrs just on  T210 alone and hundreds in other types.

    I was supriseed to find out just how much I needed my training after buying my sr22.

    It was from a certified instructor and, after flying my plane for over 130 hrs and completing my IFR rating, I'm still finding out how to improve my skills.

    It was during my IFR training ( with you ) that I really started to think about emergency planning befor each and every take off.

    I just wanted to say that even after my transitional training, it was ongoing trainig and the  IFR course that showed me just how much I didn't know.

    Let's hope I never need to use all the emergancy training,  but always be ready just in case.

    Thank you for your patience.

    Izhak Hinitz

  • Unfortunately, this is a typical scenario of what does happen when the PIC is not trained to handle the emergency.  ALL pilots should be trained to accomplish these basic emergency procedures and it all starts with the proper mind set of properly aligning your flying skills and following the proper emergency checklist.  As a CSIP Instructor and Full Motion Simulator Instructor in Atlanta, I find most Cirrus pilots lazy in their knowledge of emergency procedure checklist including engine out, CAPS or other time critical emergency procedures.  There are memory items in the Cirrus checklist that are just that: memory items.  As an example, when the engine quits on climb out, this should not be the “first time” that the Cirrus Pilot experiences this situation.  Bottom line: If you have the money to purchase a Cirrus, money to maintain and keep fuel in the aircraft, you should have the money to properly be trained to fly the aircraft in any situation.

    Rich Hayes

  • Rick, exceptional blog...and Mark, your follow up comments are insightful and certainly additive to the review and analysis. This should be mandatory reading for everyone that is actively flying GA aircraft, not to mention our COPA members. I think currency vs proficiency is a major challenge throughout the industry. I personally have been trying to complete the Cirrus transition for over a year--bottom line: my business keeps me on the road with little time for flying. Having said that, I will finish the transition in April but staying proficient, post transition, is a concern of mine.

    Two years ago I got the itch to get back in the air after having not flown since my retirement from the Army in 2003. (5 years of inactivity)

    So while in Florida I called a local FBO/flight trng center and asked if I could receive some refresher training. They asked for my active duty flight records and scheduled refresher trng. To make a long story short. I received a very short oral, and a 1 hour flight. I was signed off to rent their aircraft. Haven't been back, because if that is their standardization program, I am certainly not comfortable with their maintenance program.

    I would like to think that this is an isolated scenario, but don't believe so. As Mark indicates 250 hours is low for an advanced aircraft, I couldn't agree more but I also believe that the proficiency, in type, and standardization program across GA is even a bigger issue. Rick, keep posting your reviews are invaluable to those of us trying to get back into the air. v/r Emmett

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