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SR20 N4252G down after two failed landing attempts...

I don’t agree with the comments that the pilot wasn’t coping and needed to be more assertive. Seems to me that she was coping just fine, but been given a constantly changing plan, and asked to make base turns that were way to close to the threshold to work. It seems to me that it was ATC that wasn’t coping.

Note that there are no missed called and no incorrect read backs (hearing is usually the first thing to go when stressed).

I think that ATC really over estimated what a slippery light aircraft can do. Not every light aircraft can descend really quickly in a short distance without gaining speed.

She simply needed more room for a final approach than they gave, and she needed a consistent plan.

But in the end, I think what really got her was the instruction to keep it low and tight for another runway change, followed by an irrelevant monologue. Just as she’s climbing out, after getting another new plan, ATC start into a monologue that was of no relevance. When ATC start such a monologue, you tend to concentrate of it, waiting on the relevant bits to note. Climbout really isn’t the time for that. As a result her brain was concentrating on putting into action the recent previous instruction for a tight, low circuit, while also concentrating on the monolouge to pick out any important points in it. When that happens, your hand and legs tend to move on motor memory. I strongly suspect that she never even realised she was reducing the flaps….it’s just something she did automatically on climbout while her mind was elsewhere. Normally she would have gotten away with that mistake, as she would have been straight and level at that point.

Normally ATC don’t given pilots new instructions during the landing or take off stage for good reason. This was ATC giving her task saturation at a critical stage of flight, and as a result she fell back on motor memory.

Would anyone think it acceptable for a airliner to be given complicated new instructions and a verbal monologue in the 15 seconds before touchdown or 15 seconds after take off?

There is a lot wrong here, but I think you could slice off all of the recording before the final go-around, and still have a lot to critise ATC for.

When I used to fly out of Dublin, they way they handled busy traffic situations was either
a) give the light aircraft a different runway (one of the other two runways might have been more suitable so that the approach paths didn’t cross)
b) have the light aircraft orbit abeam the final approach (at a safe distance), and sequence in the light aircraft in a suitable gap when visual contact with the traffic was confirmed.

dp

EIWT Weston, Ireland

Spot on, @dublinpilot. ATC was waaaaay below standard here.

EBST, Belgium

I would not be able to fly in the US, with such atrocious ATC. About 10x too fast for me and a lot of waffle. I would just be saying “say again slowly” and wind them up

When I was out there in 2006 doing the IR (Arizona) it wasn’t like that at all, especially with Phoenix (KPHX) which was very professional… they have to be due to all the international traffic.

Administrator
Shoreham EGKA, United Kingdom

From the NTSB:

>>During this extended period of maneuvering the pilot did not assert the responsibilities that accompany being a pilot-in-command and did not offload the workload by either requesting to be re-sequenced, telling the controller to standby, or stating “unable.” This allowed for an increased likelihood of operational distractions associated with air traffic communications and affected the pilot’s ability to focus on aircraft control.<<

ATC is like ping pong. At a busy airport with commercial jets you either fit in or you tell them you don’t and need it differently. It’s not ATC‘s job to analyze every traffic – they treat everyone the same. Just my opinion!
UNABLE is a word that needs more attention!

Last Edited by Snoopy at 05 Dec 16:14
always learning
LO__, Austria

Peter wrote:

I would not be able to fly in the US, with such atrocious ATC. About 10x too fast for me and a lot of waffle. I would just be saying “say again slowly” and wind them up

I am sure you would be fine

However, the first time the combination of ascent, phraesology and speed of delivery takes some getting use to. As usual, when dealing with those that cant speak English, speak very slowly and loudly – that usually does the trick.

Agree with @dublinpilot. Since I’m an ATCO and a PPL pilot I have learned to concentrate on the most urgent things first and leave everything else behind (but monitor for any urgent messages). E.g. an ATCO in single-man shift (such as in the shifts at all small-medium Greek airports) has 1-2 frequencies or more (TWR – APP, emergency, military etc) and 3+ telephones (neighboring ATS units – ACC – FIC – military, airport internal landline, airport external landline etc), so imagine what happens when you have to separate 2-3 a/c in the air, 3 on the ground that want to startup, the airport’s vehicles calling, and some telephones ringing.
What I do is automatic prioritization. If things happen at the same time I concentrate on the traffic in the air, then leave everything else unanswered (eg pick the phone and leave it on the desk). Everything unanswered, but as I said monitoring for any urgent calls, maydays etc. If the aircraft on the ground keeps calling back, “standby”. If the vehicle talks, “standby”. After the most urgent thing has passed, everybody is told to “pass their message”.
The same happens in the air. Somebody makes a g/a. Acknowledge and leave him do whatever he’ll do or follow a very simple instruction, gain altitude, seem stable, then talk to him, ask for intentions etc. If I’m the pilot, I’ll aviate first, keep monitoring for any urgent messages, but first finish the urgent task. The pilot may indeed have flown the last part out of muscle memory. But if the controllers kept changing their plans so quickly I would argue with them politely and ask for a straight and simple solution.

LGMT (Mytilene, Lesvos, Greece), Greece

This (ATC overtasking you) can happen to any pilot. It’s why being assertive and offloading workload should be trained before heading out into busy commercial airports. What a useless way to die because of distraction due to radio communications when a simple „negative, unable, request vectors“ would have shown ATC that enough is enough!

always learning
LO__, Austria
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