Turning Fatals into CAPS Saves and Avoiding CAPS Deployments - Pull early, pull often! - Safety and Training Programs - Cirrus Owners and Pilots Association

Turning Fatals into CAPS Saves and Avoiding CAPS Deployments

In a recent discussion of the survivable CAPS deployment last week, much commentary addressed our desire to reduce accidents. One poster put it as "Once we figure out how to turn all fatals in to chute pulls, we still need to figure out how to stop the chute pulls."

From reviewing all of the Cirrus fatal accidents and CAPS saves in 2014, here are some thoughts on how to accomplish those goals -- fewer fatal accidents and avoidable CAPS deployments.

Recent Fatal Accidents

We still have a few (very few, actually) fatal accidents. Just 2 in the US and 1 more in Brazil for 2014.

BAD WEATHER FLYING

The first in Brazil involved stormy weather over inhospitable jungle terrain (see Cirrus fatal #104 in SR22 PR-JHR near Mato Grasso, Brazil [19 Feb 2014] https://www.cirruspilots.org/copa/member/cirrus_general/cirrus_flying/f/4/t/139412.aspx)

No parachute activation in this one. Hence, we need to continue to work with all COPA Pilots to encourage them to plan for the use of CAPS and help them determine when they will use it.

PILOT INCAPACITATION

One was an incapacitation of the pilot at high altitude followed by an unsuccessful descent (See Cirrus fatal #105 in SR22T N930RH in Atlantic Ocean near Washington DC [30 August 2014] https://www.cirruspilots.org/copa/member/cirrus_general/cirrus_flying/f/4/t/144222.aspx)

Hence, we need to think about our health, our hypoxia symptoms, our oxygen delivery systems, and our use of avionics to get us down safely.

DESCENT THROUGH ICING CONDITIONS

Another was a very rapid and high-speed descent from on-top and through conditions conducive to icing (See Cirrus fatal #106 in SR22 N811CD near Findlay, OH [6 Nov 2014] https://www.cirruspilots.org/copa/member/cirrus_general/cirrus_flying/f/4/t/145189.aspx) We don't know much more than the loss of radar contact and an unusual debris field without a CAPS deployment. But we do know the weather forecasts and radar depictions, as well as concern for the pilot's determination to use CAPS.

Hence, we need to think about our weather knowledge, our pre-flight planning, our crew resource management when flying with another experienced pilot, our escape outs when flying near icing conditions, and our determination to use CAPS in situations where our outs don't work.

Recent CAPS Deployments

Turning our attention to chute pulls, we have a much happier outcome -- no one has died in 2014 after 12 CAPS saves with 23 survivors.

Yet, we still have numerous situations that command our attention. One area is loss of engine power. See the blog Reviewing the causes of loss of engine power in survivable CAPS saves (https://www.cirruspilots.org/copa/safety_programs/b/pull_early_pull_often/archive/2014/11/24/reviewing-the-causes-of-loss-of-engine-power-in-survivable-caps-saves.aspx)

Those causes break down into several areas that we can address.

MAINTENANCE INDUCED FAILURES (MIF)

While we don't maintain the engine ourselves, we do select the shop where the maintenance gets done. Choose wisely. Confirm that work performed is inspected as required. Assess if the workplace and the workload are well organized, such that few distractions interrupt critical tasks.

Mike Busch has written extensively about maintenance failures. A couple of his articles in COPA Pilot and his book, Manifesto, tell the stories of MIF.

FUEL MISMANAGEMENT

Flying without fuel is tough to do. You don't get very far. So, preflight procedures need to ensure that you have planned for sufficient fuel for all contingencies and diversions, as well as having on board the fuel you expected.

FUEL STARVATION

Harder to explain are the few accidents where the plane landed with fuel in the tanks, just not getting to the engine. Task saturation and task fixation can overwhelm us. Switching fuel tanks would have kept the fuel flowing. But are we prepared to follow a checklist in an emergency? Or to remember to find the checklist?

DETONATION or PRE-IGNITION

If you see the cylinder temps rising quickly, then you only have a brief time, perhaps less than a minute, to do something to address the cause. You do watch the CHT display, right? You do have alarms that tell you when CHT has exceeded a threshold of safety, right?

Two key actions: one is to cool the cylinder and the other is prepare to abandon flight. See the interview with Tom Brooks Glass shown at M12 about his engine failure. See http://youtu.be/YgOKRe7Bb2M

OIL QUANTITY and OIL PRESSURE

As some have noted, the Cirrus IO-550N engine configuration uses a rather small sump with about 8 quarts capacity. Lose oil and your engine will fail.

One investigation found that flying with the oil dipstick not fully inserted and clamped shut can cause oil to leave the engine, causing loss of oil pressure and ultimate catastrophic engine failure.

Another investigation found that high oil consumption can leave your engine with insufficient oil quantity. Several engine overhauls have dealt with stuck oil-control rings. When your engine starts blowing lots of oil overboard, you have only a few good options.

Fly with your own oil supply in a case in the baggage compartment. Depart with a full oil sump, especially on long legs. Use the ring flush technique to attempt to unstick the stuck oil-control rings. Consider a top overhaul (carefully due to MIF reasons above) to perform a ring and valve job.

GO-AROUND POWER LOSS

A suspicion about a couple of scenarios involves the engine failing to make the power demanded. When you need to go-around, you need power. To get power, you need fuel-air-spark in sufficient quantities to make max power.

Review your go-around procedure. Do you have the boost pump on? Best to avoid vapor lock; best to avoid insufficient fuel quantity; best to indicate that you are cleared to land (a habit i formed a long time ago).

Do you advance the throttle and the mixture together? If you operated LOP or even ROP, you may not have sufficient fuel flow into the engine for max power. With an SR20 or turbo, max power comes from full rich mixture. With an NA SR22, max power comes from the fuel flow on the placard by altitude. My personal technique in my NA SR22 is to advance both throttle and mixture fully forward then lean the mixture to the placard fuel flow (this needs you to brief the density altitude for the landing approach, since you will need that info to adjust the mixture).

FATIGUE FAILURES of ENGINE COMPONENTS

Okay, finally, we reach a set of causes that we can't do much about. The failure of an internal engine component, such as a piston skirt, a connecting rod, a crankshaft. Whenever a systemic failure is discovered, such as the episode of spalled lifters, there are vigorous discussions among the many affected parties. However, recent examples are so idosyncratic that we don't have any good ways to prevent failures.

EMERGENCY PROCEDURES

Finally, we need to ensure that when something bad happens, we have prepared ourselves to follow memorized emergency procedures. See Top 10 Emergency Memory Items (https://www.cirruspilots.org/copa/non_member/marketplace/b/tips_from_csips/archive/2012/09/14/top-10-emergency-memory-items.aspx)

Summary

The COPA Culture of Safety illustrates how COPA members succeed with these actions. COPA discussions of accidents include many exhortations to do these things. Participants at our  COPA Pilot Proficiency Program (CPPP) regularly comment on the valuable impact of those ground courses and recurrent flight training segments. Participants at our Critical Decision Making (CDM) seminars experience the value and intensity of pre-flight planning to address risks we undertake on every flight. And the results are trending in the best direction -- fewer fatal accidents and fewer fatalities. (See the summary CAPS Saves and Fatal Accidents and then review the Cirrus Accident Rates discussion.

Have a great Cirrus day!

Cheers
Rick

Comments
  • just watched the video with tom brooks nice to hear the story time line and the outcome.thanks for a great article Wes banks

  • I just watched the video as well. It is a great account of real coolness under pressure and a well handled emergency.

    I do have one criticism, though. After pulling CAPS, Tom said that he put on his life jacket. IMHO if flying over water beyond glide range of land you really should wear the life jacket.

  • Excellent work, Rick, thanks for the effort of compiling this. Good stuff for discussions with Cirrus pilots (and others as well). Happy New Year! Timm

  • Rick,

    I fly a 2006 SR22 with Avidyne.  You wrote:  You do have alarms that tell you when CHT has exceeded a threshold of safety, right?   I am not sure where these are set.

    thanks

    larry

  • Just attended my first CPPP at Houston two weeks ago.  I found out firsthand what a wonderful fraternity I have found in Cirrus ownership.  Thank you Rick Beach and all of the other instructors for sharing a wealth of knowledge about my airplane specifically and flying in general to make me a better pilot.  There is no excuse for not attending a CPPP if you are flying a Cirrus aircraft.  One weekend could save your life.

    Richard Payne

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