For years, safety advocates have preached that pilots need to deal with loss of control in aviation accidents, but what does that mean? How does it happen? How does it apply to our Cirrus fleet, and what do we do about it?
(This blog entry first appeared as the Safety Talk column in COPA Pilot magazine, Jan/Feb 2016, pages 46-50)
by Rick Beach, COPA Safety Chair
The Focus on Loss of Control
Recently, there has been a lot of attention by many aviation groups focused on pilots losing control and causing fatal accidents. The NTSB has added loss of control to its Most Wanted List. The General Aviation Joint Steering Committee (GAJSC) published their recommendations. That’s where the Angle of Attack suggestion arose.
Loss of control describes what happened – the pilot failed to maintain altitude, failed to maintain airspeed, etc. It does not, however, describe why it happened. Even worse, big buckets, like loss of control or maneuvering, often result in fallacious advice. Do not maneuver! Do not lose control! That really doesn’t work as a teaching or learning emphasis.
We need more fine-grain detail. What was the pilot doing? What factors led to something bad? Only then can we determine how to intervene, what safety program can address these factors, and what pilots can do to be safer.
At the Cirrus Training Partner Symposium held in mid-October 2015, Brad Miller presented a study about loss of control accidents in the Cirrus fleet. Brad has been an air safety investigator at Cirrus for over 10 years; he and his team have investigated many Cirrus accidents. He has also collaborated with COPA on providing helpful guidance to our safety efforts.
Brad maintains a database of all Cirrus events, accidents and incidents that come to their attention. For this study of loss of control accidents, he filtered a query on the following details:
These are the most complete investigation reports of Cirrus accidents. They also will be easily accessible to instructors and pilots who have an interest in learning more details. With these accidents, Brad looked for loss of control (LOC) occurrence in the NTSB investigation. He excluded accidents that were not loss of control, including midair collisions, CFIT (controlled flight into terrain), and pilot incapacitation.
The resulting data set contained 56 fatal Cirrus accidents with a loss of control occurrence.
To break down the variety of accidents, each was placed in a bucket (see Figure 1).
The first breakdown was into rules of flight, either visual (VFR) or instrument (IFR). Then further broken down into the phase of flight when the loss of control happened. These included the standard phases: takeoff and departure, enroute, instrument approach, missed approach and landing phases. Because of the high frequency of loss of control during landing accidents, further breakdown helped with traffic pattern approach, final approach, flare/ runway contact/rollout, and go-arounds.
Figure 1: Buckets of Cirrus fatal accidents used to analyze the phase of flight where loss of control happened and what the pilot was doing.
The first breakdown into rules of flight (Figure 2) suggests that both VFR and IFR flights involve loss of control. Slightly more than half of the accidents involve VFR flights.
Figure 2: Breakdown of 56 Cirrus fatal accidents into rules of flight: VFR (31) versus IFR (25).
If we wish to reduce Cirrus loss of control accidents, we will need to pay attention to both VFR and IFR flight.
Analyzing the phases of flight for VFR loss of control accidents begins to shed some light on where things go badly (Figure 3). Many more VFR enroute and landing accidents happen than during takeoff.
Figure 3: Loss of control in VFR flight involves takeoff (2), en route (14) and landing (15).
This suggests that we need to focus on aircraft control during visual flight enroute and landing.
Breaking down the IFR loss of control accidents (Figure 4) shows a much different breakdown than VFR flight. As expected, instrument procedures become more involved, with more takeoff and departure accidents (7), along with instrument approach (6) and missed approach (1) accidents. Interestingly, IFR loss of control involves a smaller proportion of enroute accidents (8), yet there remain a few landing accidents (3).
Figure 4: Loss of control during IFR flight.
This suggests that we need to focus on proficiency with instrument flying to maintain control during instrument procedures.
Figure 5: Takeoff and departure accidents.
VFR takeoff loss of control accidents (Figure 5) involve basic decisions:
IFR takeoff and departure loss of control accidents (Figure 5) involve two groups of factors:
The VFR accidents suggest the need for better pre-flight planning to avoid return to airport maneuvers and ensure configuration for the performance required for takeoff and departure.
The IFR accidents suggest the importance of understanding your avionics, both the navigation and autopilot systems. Furthermore, pilots need to maintain situational awareness during abnormal situations, especially the need to consider CAPS.
Loss of control during enroute flight (Figure 6) has more accidents (22) than any other phase of flight, even landing (18). Of course, the long duration of enroute flight phase creates more opportunities for problems to arise. Let’s review what situations COPA Pilots encountered.
Figure 6: Enroute loss of control.
The breakdown suggests factors that point to pilot discipline and aeronautical decision-making:
These enroute loss of control accidents suggest the need for better aeronautical decision-making, especially for weather, pre-flight inspections and planning, as well as improved ability in handling abnormal situations.
The Cirrus fatal accidents in this bucket of instrument approach procedures (Figure 7) involved some basic instrument flying proficiency tasks:
Figure 7: Loss of control during IFR approach.
These instrument procedure loss of control accidents suggest the need for improved proficiency during instrument flying.
Figure 8: Landing loss of control accidents.
We already know that landing accidents in the Cirrus fleet merits special attention and effort. The number of fatal landing accidents surprised me when Brad presented his analysis (Figure 8). Breaking down accidents into each of those landing buckets reveals some surprising details about what contributes to loss of control.
First, the traffic pattern accidents involve maneuvering low to the ground:
The only final-approach accident involved loss of control between 500 feet and the flare for landing:
The single flare/rollout accident involved loss of control during the flare, runway contact and rollout phase:
The biggest bucket of landing loss of control accidents in the Cirrus fleet occur during go-arounds:
These landing loss of control accidents suggest the need to address the sequence of maneuvers what we now call Approach-to-Landing-and-Go-Around. The flow of maneuvers needed to maintain control and situational awareness whenever something does not appear or go right.
As you may know, COPA and Cirrus Aircraft have collaborated on a Landing Standardization Course that addresses most of these aspects of landing loss of control accidents. COPA will be including this Landing Standardization syllabus during our recurrent flight training events.
During Brad’s presentation to the Cirrus Training Partner Symposium, he compared the list of big targets from both his analysis and what COPA found. His big targets:
He also noted the big targets from the previous COPA analysis of Cirrus accidents that led to the Command and Control course:
First, you can reflect on your envelope of experience. When you read these analyses, ask yourself where do your tendencies fall into these buckets? Do you have sufficient weather knowledge? Do you assess risks of your flight while planning? Are you a little rusty with your crosswind landings or instrument procedures? Do you know of weaknesses in your flight proficiency, especially in tasks that show up in these loss of control accidents?
Second, seek out resources to help increase your proficiency. Obviously, COPA offers safety resources such as the preflight risk assessment seminar called Critical Decision Making (CDM). We also offer recurrent training through our COPA Pilot Proficiency Program (CPPP). Cirrus training partners offer standardized transition, recurrent, and landing syllabi.
Third, talk with other COPA Pilots. Ask them what they do to ensure their safety. Encourage them to take advantage of these safety resources.
Most of all, know that we can all be safer pilots. Participate in our culture of safety, and enjoy flying your Cirrus.
Discussions of Cirrus accidents and safety issues are prominent on the COPA forums. Additional safety resources appear under the Safety tab.
Accident reports and information can be found on the NTSB website by searching for “NTSB aviation database”. More detailed reports, photos and data can be found in the NTSB Document Management System website.
COPA publishes video materials on the YouTube channel copasafety. These include safety keynote talks from past Migrations, video animations that reconstruct accident flights, and occasional safety briefings.
You can also follow COPA safety events, resources, and dialogues on Twitter @copasafety.
Rick Beach joined COPA in 2001 and bought his Cirrus SR22 because of the community of owners and their focus on safety. He regularly posts online as the COPA de facto “accident historian” and is the COPA Safety Chair. In his spare time, he works with educational non-profits to improve K-12 math and science education
Great post Rick
Putting it all together in a clear, easy to digest summary provides a means to absorb a lot of history in one sitting. When done reading and thinking, a question hung in my mind; Why?
With 1400+ Cirrus hours in both avionics platforms, normally aspirated and turbo, I'm comfortable saying that the airplane is just not hard to fly well and the avionics provide more than ample decision making and guidance information to avoid any problem. Also, the preflight briefing resources available with ForeFlight and WSI weather to name two I use take the mystery out of planning.
In all of the accidents there is a common factor; pilot self assessment and decision making. Regardless of how the airplane got to the accident site, a pilot took it there, and I wonder why?
Putting aside the pilots who are accidents waiting to happen, I wonder about the diligent, reasonably proficient pilots who's decision making put them in a position where they were beyond either their own capability or that of the airframe.
I think there is another level of analysis worth investigation. What was each accident pilot's procilivity toward risk. As a pilot I find my self facing two kinds of risk mentally. The first is that which Jimmy Doolittle famously labeled the calculated risk. It's inherent in every flight planned and every unanticipated phase of flight encountered until touchdown. Handling it is a mindful process that involves weighing information against risk. If I think I have the means to manage the risk then the flight is a go. If not, then no.
The second kind of risk is that which cannot be evaluated mindfully. Some find it exciting to anticipate entering that risk, I find it gut churning.
So I think part of understanding accidents is understanding how the pilot as a person dealt with risky situations both anticipated and unanticipated. If that is something that can be measured, it might be a good addition to a CPPP event to help pilots understand their proclivity toward getting into weather or attitudes beyond their or the airframes capability.
I've known a few pilots who's extraordinary behavior eventually killed them, and I've know a few who I considered reasonably prudent and proficient who came to a sad end. It is the latter that interest me because in each case the pilot was not ambushed by an outside factor such as a gross mechanical failure or stroke, but somehow, at some critical moment, was offered a chance to take a risk and their mental process broke down; or maybe it happened often and I just never saw it.
As a pilot who has so far managed the calculated risk, I'd like to understand those who went a bridge too far and why so it does not happen to me.
This is a very informative report. As I reflect on the recent accidents I see, " there is nothing new under the sun." We continue to make the same mistakes.
Thank you for your continued efforts.
Rick, Really nice, concise and helpful article reviewing the data.
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