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Another Alpine crash - near LOWZ, SR22 D-EPRB

The IR learning objectives could be adapted and include training for approach ban,

They are already, and most SOP will have an explicit statement of whether an approach ban applies during the approach brief at the top of descent.

treat every approach as a planned go around / missed approach unless conditions permit a safe landing.

Again both the IR and the MCC/JOC will brief ‘gates’, not just the DA/MDA, when if conditions are not met the crew will initiate a go around. The IR check ride it is the examiner who states whether you are visual, the candidate only stating that as she approaches minima she is initiating a going around.

In the foggy Atlantic islands it is quite common that a student will fly to actual minima on several occasions and in icing during their IR.

Oxford (EGTK), United Kingdom

Snoopy wrote:

Perhaps it’s mental capacity / task saturation which inhibits rational thinking at the end of a flight / during an approach.

Common problem: Things go well and therefore apparently confirm prior decisions until they don’t. If you are at the end of a flight you obviously already survived a lot of your decisions so you are in a state of high confidence that you have a “good day”.
Unfortunately this is human nature.

Snoopy wrote:

and also to treat every approach as a planned go around / missed approach unless conditions permit a safe landing.

Does anyone teach/learn that differently?

Germany

@RobertL18C
If pilots that are described as conservative and well trained in an accident report have no concept and operational applicability of the rules then there is a problem.
99% of PPL IR guys do not shell out a few thousand € for extra training in a full motion SEP sim. So I wonder why a pilot that did it (and thereby did more than the norm) didn’t know about the concepts (and by know I mean apply them).
Maybe he should have gone to train at the foggy atl islands instead?

Yes, this particular accident is an extreme example (mountainous terrain, very bad weather) but I think a key point of the report is mentioning avionics/automation over reliance (i.e. “what can go wrong, I’ve got big screens”).

Single Pilot IFR in IMC is treading a thin red line.

Last Edited by Snoopy at 28 Jan 10:26
always learning
LO__, Austria

Malibuflyer wrote:

Does anyone teach/learn that differently?

Rephrasing: train it so as to enable this behavior subsequently during non training/checking flights.

I just want to understand the mental model of this flight…

always learning
LO__, Austria

Malibuflyer wrote:

I guess that is the limitation of METAR in mountainous terrain: The divergence between OVC004 and NOSIG can be one Cu at the wrong spot – that can form and dissolve very quickly in unstable conditions…

Even in the flatlands it can deteriorate and clear up fairly quickly. This is yesterday’s METAR snapshot from Zagreb:

METAR LDZA 271100Z 28005KT 230V330 CAVOK 02/M00 Q1017 NOSIG=
METAR LDZA 271030Z 25005KT 9999 FEW003 M00/M01 Q1018 NOSIG=
METAR LDZA 271000Z 24004KT 200V280 3000 BR SCT002 M01/M01 Q1018 BECMG 6000 NSW=
METAR COR LDZA 270930Z VRB02KT 1000 R04/1300U R22/1600U BCFG SCT002 M02/M02 Q1018 BECMG 6000 NSW=
METAR LDZA 270900Z 25005KT 210V280 0200 R04/0650N R22/1000U FZFG BKN001 M02/M03 Q1018 BECMG FM0930 6000 NSW NSC=
METAR LDZA 270830Z 25006KT 0300 R04/1300D R22/P2000N FZFG BKN001 M03/M04 Q1018 BECMG FM0930 6000 NSW NSC=
METAR LDZA 270800Z 00000KT 6000 NSC M03/M04 Q1018 NOSIG=
METAR LDZA 270730Z 27004KT 250V320 3000 BR FEW001 M03/M03 Q1018 TEMPO 1000 BCFG BKN002=
METAR LDZA 270700Z 26005KT 2500 BR BKN002 M03/M04 Q1018 TEMPO 1000 BCFG=
METAR LDZA 270630Z 00000KT 6000 NSC M04/M05 Q1017 TEMPO 2000 BR=
METAR LDZA 270600Z VRB02KT CAVOK M03/M04 Q1017 NOSIG=

From CAVOK to CAVOK in few hours, practically twice. At 0800 it looked like it was cleared (I was on the ground) but then it deteriorated quickly. I overflew the airport a bit later and several airliners went missed approach.

Last Edited by Emir at 28 Jan 08:58
LDZA LDVA, Croatia

Malibuflyer wrote:

Good example that ramp perception (and even the impression of instructors) can be completely disjoint from reality. Not only this flight, but also the long list of METARS from other flights of this pilot showed, that he was all but conservative about weather..

Are you referring to the list of METARs in the report or do you have information from other sources? From the list in the report I could find only one flight where the WX was in any way unsuitable. In fact, he seemed to not have much experience with landing in poor weather.

There was single case with LOWZ reporting OVC002 and even then the visibility was 8000 m. In fact none of his other landings at LOWZ had visibility less than 10 km or ceiling less than 4000’. The lowest cloudbase was FEW at 1500’

Of the samples of his landings at other airports, all were in VFR conditions. (Although in the EDDH case marginal.)

So I can see no evidence that he was “all but conservative about weather”, on the contrary I would say that his problem was that he was unaccustomed to approaches in poor visibility.

ESKC (Uppsala/Sundbro), Sweden

A self created waypoint and leg from the AD reference point to the missed approach leg could have helped him. He flew there 10 times mostly in good VFR, one might become creative in a DIY missed approach, not legal in the actual circumstances but if you were going to bust the rules (intentionally or not) at least build some additional guidance e.g if the weather is marginal VFR e.g 2 km. Probably he never thought or reflected seriously through the missed part and left his faith to the automation and resided in we will see when we get there…and clearly his mind was clouded somehow..we will never know what went on in his thinking logic when he passed the MAPt..very sad story.

I think indeed for instructors it would be good to have a look during IFR training and recurrent training and discuss a number of hypothetical holistic scenarios … what would you do if…in this cas, that case etc….including private …emotional state, kids on board..etc….For myself I know my risk assessment is different when I fly with pax and my own kids even more…….

In any case he for sure did not assess the FAA PAVE risks analysis:
The interaction between the pilot, airplane, and the environment is greatly influenced by the purpose of each flight operation. The pilot must evaluate the three previous areas to decide on the desirability of undertaking or continuing the flight as planned. It is worth asking why the flight is being made, how critical it is to maintain the schedule, and if the trip is worth the risks

Last Edited by Vref at 28 Jan 10:11
EBST

Vref wrote:

A self created waypoint and leg from the AD reference point to the missed approach leg could have helped him

What could have helped him is the ILS at LOWS. There is a reason airline ops PROHIBITS any manipulation of procedures in databases. I have no experience with these self stricken waypoint experiments, but I don’t think one should even go near them, especially at locations like LOWZ.

Vref wrote:

I think indeed for instructors it would be good to have a look during IFR training and recurrent training and discuss a number of hypothetical holistic scenarios … what would you do if…in this cas, that case etc….including private …emotional state, kids on board..etc….For myself I know my risk assessment is different when I fly with pax and my own kids even more…….

Discussing is easy, but is it effective? I think there needs to be some muscle memory in the form of “OVC004 – in LOWZ – no way – I’ll divert to the easiest option”.

Vref wrote:

.For myself I know my risk assessment is different when I fly with pax and my own kids even more…….

That is concerning. Imagine the horror you would bring to your family and kids. If you wouldn’t fly with your family, don’t fly alone!

Last Edited by Snoopy at 28 Jan 10:25
always learning
LO__, Austria

Snoopy wrote:

What could have helped him is the ILS at LOWS. There is a reason airline ops PROHIBITS any manipulation of procedures in databases. I have no experience with these self stricken waypoint experiments, but I don’t think one should even go near them, especially at locations like LOWZ.

Most airliners prohibit cancel IFR and fly VFR unless they have exemptions, so those comparaisons are rather moot…

I am sure the local guys used to flying VFR in LOWZ know well what they are doing, surely they operate just fine anywhere from 2200ft agl & 8km visbility to 500ft agl & 1.5km visbility which are way bellow the “required minima for the approach” and I hardly beleive they do that without GPS/FMS/Tablet waypoints

A vistor does not have that luxury and he should stick to the missed segment at the MAPt if no 2500ft agl & 10km visibility, if you want to get creative bellow these parameters at least ask some locals how they manage 500ft agl & 1.5km visbility over there (you may get surprised) or get few sunny visits or try in the sim yourself…

PS: in case it’s not obvious above, I am not talking about free-style IFR/IMC flying off-airways/approach or busting any rules or minimas here, just how to conduct a safe flight under plain legal VFR in class G in that valley, it’s not obvious to me it can be done on old school visual navigation (I really suck at this like most airliners pilots ) and one will surely need his GPS/Tablet with some VFR waypoints to find his way (and put his cut-loss & exit strategy), I know it’s hard to admit you need a tablet/GPS for VFR but I have flown some valleys with some weather, you definetly need GPS/Tablet with some identifiable waypoints (e.g. roads, railways) to confirm you will stay alive…

Last Edited by Ibra at 28 Jan 11:37
Paris/Essex, France/UK, United Kingdom

Presumably the fact that his two daughters were onboard was a big part of the decision making. There must have been a plan for an enjoyable day out with his children. It’s likely that he didn’t want to disappoint. That may have encouraged him to push further than he knew he should.

He might well have been a very capable and conservative pilot normally, and knew better, but on the day decided to push a bit further before giving up on a big day out. But that little bit further committed him to a path with tragic consequences.

I’m sure if the plan was just for a burger in the airport café, he’d have gone around at the MAP and gone somewhere else. But something made him push past it.

EIWT Weston, Ireland
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