Pilot Debrief

CIRRUS DESIGN CORP SR22 near Melbourne, FL — 2012-02-29

Final reportERA12FA196
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Date
2012-02-29
Location
Melbourne, FL, USA
Airport
MLB
Aircraft
CIRRUS DESIGN CORP SR22
Registration
N544SR
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Approach

Probable cause

The pilot's abrupt maneuver in response to a perceived traffic conflict, which resulted in an accelerated stall and a loss of airplane control at low altitude. Contributing to the accident was the air traffic controller's incomplete instructions, which resulted in improper sequencing of traffic landing on the same runway.

Contributing factors

Contributing to the accident was the air traffic controller's incomplete instructions, which resulted in improper sequencing of traffic landing on the same runway.

NTSB narrative

Several airplanes and a helicopter were in the traffic pattern at the tower-controlled airport performing simultaneous operations to parallel runways (9L and 9R) around the time of the accident. The accident pilot contacted the tower air traffic controller while south of the airport requesting a full-stop landing; the controller advised the pilot to report when the airplane entered the downwind leg of the traffic pattern. The controller subsequently cleared the accident airplane to land and expected the pilot complete a "normal" downwind traffic pattern and land behind the airplane already established on final approach for runway 9R; however, the controller did not provide sequencing instructions. The accident airplane proceeded directly to a tight right-base entry into the traffic pattern for landing on runway 9R, contrary to the controller's original expectation but permissible based on the clearance to land. The controller radioed the accident pilot to confirm that he had visual contact with the airplane on a 1-mile final approach for runway 9R (the traffic was 300 feet below and 1 mile west). This was the first indication by the controller to the accident pilot that there was additional landing traffic sequenced to the same runway he had been cleared to land on. The accident pilot replied that he was on a "real short base" for runway 9R, and the controller responded, "no sir, I needed you to extend to follow the [airplane] out there on a mile final, cut it in tight now, cut it in tight for nine right." The two airplanes had closed within 1/2 mile of each other, but were still separated by 300 feet altitude. The pilot of the airplane on short final for 9R maintained situational awareness throughout, perceived the conflict before the controller or the accident pilot, and responded calmly and benignly to the conflict. The accident pilot needed only to arrest his descent, at a minimum, to avoid any collision. A flight instructor and an airline pilot both described seeing the accident airplane pitch up, bank left, then roll inverted. The flight instructor stated that this action occurred as the controller was "yelling at" the pilot. Both witnesses described what they saw as "an accelerated stall." Data extracted from the multifunction and primary flight displays revealed that the airplane pitched up and rolled inverted to the left at the same time that engine power was increased rapidly. When engine power is increased, a pilot must apply sufficient right rudder to counteract the left-rolling tendency, particularly if the airspeed is slow and the angle of attack is high, as it would be during landing. When instructed by the controller to "cut it in tight," the accident pilot over-controlled the airplane, lost control, and impacted terrain. Contributing to the traffic conflict was the controller's lack of upfront sequencing instructions or subsequent sequencing instructions when the accident aircraft was cleared to land. Examination of the data and a postaccident examination of the wreckage revealed no preimpact mechanical anomalies that would have precluded normal operation.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot could have extended downwind leg to avoid conflict with Cirrus SR20.

NTSB coding

Evidence available

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  • 17 docket documents
View NTSB final reportView NTSB docket

Docket documents17

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