AOPA Accident Case Study: Communication Breakdown

Dreadful: as a Cirrus pilot myself I found it awful to watch the tragedy unfold although I had previously read a lot about it when it was discussed on COPA at the time it happened. The animation and analysis really brings it home.

What I don’t understand is why the controller cleared the accident pilot to land with another aircraft on a one mile final. Surely he should have told him to continue downwind and, above all, that he was number two in traffic to another Cirrus on a one mile final. That’s what happens every time I fly a visual approach anywhere with ATC.

It’s different in the USA. There you can have multiple aircraft cleared to land.

“Cleared to land” in the USA, doesn’t mean that the runway is yours, but rather that it is expected to be yours by the time you get to it, but there may be other aircraft ahead of you who will use it before you.

I think that he is supposed to give him his number in traffic sequent though.

It’s different in the USA. There you can have multiple aircraft cleared to land.

Not only in the US. I can’t remember how often I’ve been ‘cleared to land behind the landing 737, maintain best speed, another 737 on 5 mile final’ at LEMG (Malaga). They would usually include the airline (Speedbird, Shamrock, Iberia, etc) in the call, so you know what to look for.

The other Cirrus on final was “essential local traffic” and the ATCO had to inform both.

An “ICAO” clearance to land can be issued at least when the preceding has passed the threshold. If reduced runway separation minima (7.11) apply then multiple a/c can occupy the runway, which is not normally the case (7.10.1).

4444 says the following

7.10.2 Clearance to land
An aircraft may be cleared to land when there is reasonable assurance that the separation in 7.10.1, or prescribed in
accordance with 7.11 will exist when the aircraft crosses the runway threshold, provided that a clearance to land shall not
be issued until a preceding landing aircraft has crossed the runway threshold. To reduce the potential for
misunderstanding, the landing clearance shall include the designator of the landing runway.

I wonder if the accident pilot was distracted by his passengers – for his hours, at his home base, he was not aware of the traffic situation. Was the controller fully qualified?
I’ve recently been RHS with a low hours NPPL who expected a RB join, and became very tense and uncertain when given a “right downwind” join from a position where he had not encountered that join before.
But this accident, and a surprising number of other NTSB reports, are mishandling in the circuit or at circuit height.

Just watched this video…

I could not understand most of the radio comms and would have had difficulty flying to that airport. I would said said to the controller “sorry but I cannot understand anything you are saying – please speak slowly”. I recall having some issues like that when doing the IR in Arizona but they weren’t as bad. Maybe it was a really crap recording.

As regards the SR22 crashing, that was just pointless. PROB99 the pilot was behind the aircraft and the ATC instructions pushed him over the edge. We had a similar thing here a year or two ago at Southend EGMC, where a student pilot crashed when asked to orbit. IMHO his instructor should have not sent him flying solo if he could not fly an orbit… would I send somebody I care about solo unless he/she was clearly able to do every possible thing they may be asked to do? No. This SR22 pilot was not a student but was probably right on his workload limit.

He had two IMHO equally reasonable options: turn left and continue downwind (as it appears he tried to do, with that 60+ degree bank turn) or turn right and go around overhead the runway. I would have probably done the latter, because I would have been already halfway there (having turned right a bit). Especially if I was not visual with the inbound traffic (and saw nothing on TCAS) .

There may have been a controller screwup of some sort, but you aren’t supposed to crash the plane just because ATC call you too many times…

Was he renting by any chance? A renter will be under far more pressure to land ASAP. I see that frequently.

I’ve been to various airfields where there was a complete manic situation (Stapleford is known for it in particular and I would probably not fly there on a nice weekend) and sometimes the best thing to do is to sod off and come back 10 mins later when there is peace and quiet. I have done that many times at my base (Shoreham) because while the ATC there are exemplary there is just no point in squeezing in as say #7, behind 6 planes flying at 70kt which I can do but only just about… Traffic is never solid (except at some airshow inbound stream) for much longer than that. Plus the chances of being visual with the 6 ahead of you is close to zero. On any nice weekend day, half of them will be nontransponding so you have no chance.

PROB99 the pilot was behind the aircraft

I sometimes wonder how you come to your conclusions sometimes. According to the information provided, this was reasonably experienced pilot, with lots of hours in make and model, flying a very simple VFR approach to his home airport. His radio calls sound totally calm…

There may have been a controller screwup of some sort

Now…nobody should stall and spin an aircraft in a traffic avoidance maneuver, BUT…the previous controller mistake is totally obvious here. The traffic he was supposed to follow was never mentioned to him, neither before his landing clearance, nor in conjunction with that landing clearance.
Up to the moment of the avoidance maneuver that led to the crash, the pilot didn’t do anything wrong. In fact, when ATC clears a pilot to land, at a busy airport but with no preceeding traffic, the pilot is supposed to fly a tight pattern, land and vacate the runway as quickly as possible. That’s good airmanship.

Would be too interesting to see what will happen with that controller…

With so much crap being talked on the radio its a wonder there was any communication. This is a good example of why we require RT discipline anf correct phraseology. This sounds like an episode of the Flintstones.

I sometimes wonder how you come to your conclusions sometimes.

nobody should stall and spin an aircraft in a traffic avoidance maneuver,

There you are! You have answered it yourself. No need to wonder anymore.

This is no rocket science. There is not much of a reason to just crash out of the airport circuit.

You can blame ATC but if a pilot crashes because of some ATC call then he would have probably crashed at some untowered airport, where the comms can get even more confusing if things are busy. This man’s flying hours might have been clocked up just flying between some easy airports where nothing happens.

One has to fly the plane first. Stuff like ATC is taken care of later.

Up to the moment of the avoidance maneuver that led to the crash, the pilot didn’t do anything wrong.

That’s true for most crashes… before whatever led to the crash, things were going OK

Why do you think the pilot put the plane into such a bank?

This sounds like an episode of the Flintstones.

I agree… US radio phraseology gets very slack at times. It seems to be OK in practice but that’s probably because when you do a PPL in the USA you graduate through such a system. Here in Europe pilots are much more used to being tightly controlled, and many fall apart when they don’t get that level of control. So ATC over here needs to be of a higher standard – because pilots are trained to have their hands held more. Then you get funny situations when a N European pilot flies to Spain or Italy and gets some of the ICAO Level Minus Two English language proficiency which is occasionally seen down there, and ends up having ATCOs screaming at him – or ignoring his calls because that doesn’t leave anything incriminating on the tape.