Pilot Debrief

CIRRUS DESIGN CORP SR20 near Houston, TX — 2016-06-09

Final reportCEN16FA211
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Date
2016-06-09
Location
Houston, TX, USA
Airport
HOU
Aircraft
CIRRUS DESIGN CORP SR20
Registration
N4252G
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Go-around

Probable cause

The pilot's improper go-around procedure that did not ensure that the airplane was at a safe airspeed before raising the flaps, which resulted in exceedance of the critical angle of attack and resulted in an accelerated aerodynamic stall and spin into terrain. Contributing to the accident were the initial local controller's decision to keep the pilot in the traffic pattern, the second local controller's issuance of an unnecessarily complex clearance during a critical phase of flight. Also contributing was the pilot's lack of assertiveness.

Contributing factors

Contributing to the accident were the initial local controller's decision to keep the pilot in the traffic pattern, the second local controller's issuance of an unnecessarily complex clearance during a critical phase of flight. Also contributing was the pilot's lack of assertiveness.

NTSB narrative

The pilot was attempting to land the airplane at a busy airport with high volume airline traffic. While attempting to sequence the airplane between airplanes, the air traffic controller issued numerous instructions to the pilot, which included changing runways multiple times. The pilot was instructed to go around twice by the local controller; the first time because an air carrier airplane was overtaking the accident airplane and the second time because the airplane was too high to make a safe landing. During the airplane's third approach, a new local controller came on duty. On this approach, the pilot again had difficulty descending fast enough to make a safe landing, and she elected to perform another go-around. The new local controller then issued the pilot a lengthy clearance as the pilot was performing the go-around procedure. Data retrieved from the airplane revealed that, during the go-around, the pilot did not follow the recommended go-around procedure; specifically, the pilot did not attain a speed between 81 to 83 knots indicated airspeed (KIAS) before raising the flaps. Rather, the airplane's airspeed was 58 KIAS when the pilot raised the airplane's flaps while in a left turn, which resulted in exceedance of the critical angle of attack and a subsequent aerodynamic stall and spin into terrain. Postaccident examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. The air traffic control instructions given to the pilot during the three approaches were complex and potentially distracting. The initial local controller elected to keep the airplane in the traffic pattern rather than transferring the airplane to an approach controller for resequencing when airline traffic interrupted the pilot's first landing attempt and when the pilot displayed difficulty landing the airplane on her second landing attempt. The complex instructions from the second local controller during the pilot's go-around following her third landing attempt, were unnecessary at that time and likely distracted the pilot from monitoring critical flight parameters. The pilot was attempting to comply with ATC instructions throughout the flight and the pilot's actions are understandable as the instructions were largely consistent with the pilot's goal to land at the busy airport. However, compliance with ATC instructions greatly increased the pilot's workload as it led to an extended period of close-in maneuvering at a Class B airport due to the larger and faster airplanes converging on the airport. 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.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot could have executed a go-around earlier to avoid loss of control.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 15 docket documents
View NTSB final reportView NTSB docket

Docket documents15

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