ATSB report on fatal C182 Go-Around at night

[Centaurus]

Investigation: AO-2013-163 - Loss of control and collision with terrain involving Cessna 182 VH-AUT, Hamilton Airport, VIC on 23 September 2013 (http://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-163.aspx)

In Cessna singles, a very low altitude go-around with full flap is a demanding exercise particularly with the strong pitch up that occurs at full throttle. To conduct the exercise under the hood or simulated IMC takes very sound instrument flying skills. On a dark night with no visible horizon, even an experienced pilot would need to be very careful during the initial change to climbing attitude and the change of trim that occurs as flaps are retracted to an intermediate setting and then up.

The nose down trim that occurs as the flaps retract needs to be countered lest the aircraft goes from the initial climb into a gentle descent because of poor instrument cross-reference by the pilot. This manoeuvre needs to be practiced under the hood to simulate loss of forward visibility such as rain or dark night conditions. It is a highly critical manoeuvre on instruments and no student should be sent solo until he has done several runway level go-arounds on instruments and judged to be perfectly competent.

Most pilots will recall the advice by their instructor on being sent for their first solo. It is usually something like "When in any doubt do not hesitate to go-around". That applies whether it is first daylight solo as well as first night solo. Most flying school instructors teach the go-around at around 200 feet and it is probable that very few teach go-arounds from the flare or during the float which is the most critical point with everything hanging out, speed bleeding and maybe even the first few bleats of the stall warning.

This runway level go-around is demanding but needs to be taught as should the recovery and landing ahead on the remaining length should a balloon or high hold off occur. A go-around from several bounces gets increasingly dangerous as speed is close to the stall. for that reason students need to be confident and competent to go-around again from a bounce before first solo day or night as well as equally competent to recover from a bounced landing and re-landing straight ahead.

Disregarding for the moment the ATSB medical report of the students heart condition, I believe ATSB missed a good opportunity to discuss the traps that can occur should a pilot have reason to go-around at very low altitude at night. Spatial disorientation is only one factor. A vitally important factor is the skill of the pilot and how he was taught by his various instructors.

Often, instructors do not adhere to the recommendations published in the manufacturer's AFM or Pilot handbook. Sometimes training schools publish their own procedures rather than the manufacturer's procedures. Physical handling of the go-around especially with regards to trim changes with flaps and the pitch up that occurs during a low speed full flap go-around need to be thoroughly understood by students One of the most effective teaching techniques is by doing the go-arounds at a safe height under the hood in simulated IMC/dark night.

In another era I was a RAAF QFI doing recurrent night flying training in a Lincoln bomber at Townsville on a experienced former wartime bomber pilot. He was much more experienced than me but out of currency on night circuits. After several touch and go landings on Townsville Runway 01, he was instructed to turn right 30 degrees after take off to track over the water east of Magnetic island. Apart from a few lights from houses at Magnetic island it was dark and we were on instruments.

At 800 feet after take off , the right turn was commenced and flap retraction took place. The QFI had no flight instruments in front of him (the Lincoln was designed for single pilot operation) and he had to lean to the left to monitor the pilots instruments which gave significant parallax error problems. As the flaps started to slowly retract from the take off setting, there was the usual nose-down change of trim. The pilot who was fully on instruments because of the dark night and no visible horizon, failed to counter the nose down change of trim and allowed the Lincoln to gently descend with the VSI changing from a 500fpm rate of climb at 5 degrees nose up to 2-300 fpm descent with his AH just below the horizon.

The radio altimeter showed a steady slow descent and it was obvious that the experienced bomber pilot was slow in his instrument scan as he said nothing. At around 500 ft radio altitude above the sea, I called and said "Watch your VSI "Sir". He was a squadron leader and therefore a "Sir" as I was junior in rank even though as QFI, I was captain of the aircraft.

With a muttered oath of surprise, the pilot swiftly pulled back on the control column arresting the descent and we resumed the climb. Nothing was said between us. it didn't have to be as it was clear that he would have allowed the aircraft to descend slowly into the sea. As mentioned earlier he was not current at night and not current on instrument flying which is why we were flying as dual instruction that Townsville night.

If a highly experienced pilot like the squadron leader had troubles on a night departure one can imagine the difficulty a Cessna student pilot at night doing a late go-around with full flap must have had...

[Jabawocky]

Centaurus, good post again.

I also find the balls to the wall go-around in many GA (high performance) singles to be inappropriate. Folk who just slam the power on, rather than bring on sufficient power and progressively manage power input and re-trimming /flap over a few seconds will often struggle with the transition.

I reckon this could start a fight….so I might just leave now :}, but my comments should be thought of with my favourite saying in mind, whatever you do…..it must do everything it should and nothing it shouldn't. And in some machines, that is not what you might do in a C152. Know your aeroplane!!

Thanks for the post :ok:

[Tee Emm]

The ATSB reproduced a copy of the company procedure for a go-around which stated the configuration should not be changed until a positive rate of climb is first achieved. This differs from the manufacture's procedure that states the flaps must be immediately retracted to 20 degrees from 40 degrees on commencing the go around.

The manufacturer's recommendation covers the various temperatures that may be encountered in normal service. At high ambient temperatures and other than sea level airports, the aircraft may not be able to maintain a positive rate of climb with full flap extended. Hence the advice to select 20 degrees immediately after full throttle which reduces drag significantly and approximates best lift flap. This technique applies in the POH to the C150, C172 and presumably the C182. Selection of flap up in ten degree stages is not a Cessna manufacturer SOP in the POH.

While it may sound laudable that a training provider wishes to tailor its training procedures to pilot experience level, the fact is students must be competent to operate the aircraft in accordance to the manufacture's POH if performance figures are to be met.

It is wrong to send a student solo day or night if he has not been taught to operate the aircraft correctly and safely to the manufacturer's recommendations. That includes a go-around procedure if approaching to land with full flap. Teaching students to land with partial flap invites a higher speed than recommended since there is less drag, and a longer float and possibility of a higher touch down speed. The higher touchdown speed brings with it, its own risks.

[Squawk7700]

The POH and training to a lesser extent go out the window when the proverbial hits the fan. How many of is have found this when something genuine has actually goes wrong? I remember my first solo flapped landing went horribly wrong and if it was at night when the same thing happened, I would hate to think what could have happened.

[ForkTailedDrKiller]

At high ambient temperatures and other than sea level airports, the aircraft may not be able to maintain a positive rate of climb with full flap extended.My experience - go-round from the flare, outside Mt Isa, middle of a summer day, C210 at near MTOW minus 30 min fuel, over the top of a BIG red buck roo - does not agree with this statement! :E

Dr :8

[andrewr]

Interesting that while the body of the report talks extensively about the effect of the 40 degree flap setting and spatial disorientation, the summary strongly imples that a medical condition contributed to the crash.

In reality the report says that "it could not be completely excluded" and no evidence was found to suggest that it actually happened.

I suspect that "could not be completely excluded" is pathologist code for "very unlikely but not impossible".

This isn't the first ATSB report where medical conditions have been suggested with very little evidence that they contributed to the accident. Is there an agenda here?

[flywatcher]

I have not had a lot of night time in 182's, certainly not more than 500 hours but I have always found 20 degrees of flap is enough for any electrically lit runway. Go rounds in this condition is always benign and transition to zero flaps at 200 hundred feet is easy. I believe some versions of the 182 handbook suggest usage of the 20 degree flap position on some occasions. It is a rare occasions when 40 degrees is absolutely necessary.

[Duck Pilot]

Good discussion about the aircraft configuration etc, however the report also mentioned that the pilot may have had a medical condition that may have attritrubited to the accident.

[PA39]

Some great posts. I agree the low level or bounce recovery go around should be taught thoroughly until proficient. I have noticed that many Grade 2 and certainly Gr 3's can't do it efficiently and effective themselves, let alone instruct on the procedure. That's my observation and 2 bobs worth.

[andrewr]

Good discussion about the aircraft configuration etc, however the report also mentioned that the pilot may have had a medical condition that may have attritrubited to the accident.

The report actually said there was no evidence that the medical condition contributed to the accident, but that it could not be completely ruled out.

Given the other factors in play what is more likely - loss of control due to spatial disorientation or aicraft configuration, or suddenly being affected by a medical condition that had not previously affected his flying?

According to Cessna (per the report), with 40 degrees of flap, 20 kg of forward pressure would be required to maintain 55 knots during the go around if trimmed for landing. That is a lot of control pressure. It seems to me that could very easily have contributed to a loss of control or situational awareness.

[Frank Arouet]

Mate just brought to my attention something I'd forgotten with the C182 and full flap. An increase in speed will generally arrest the situation to enable a reconfigure and climb out, but overly increasing speed past that required can result in a bubble buffet behind the flaps which actually makes the aircraft descend. I believe it is mentioned in the handling notes although I no longer have them. Someone with some may like to advise if this is so.

[andrewr]

Another interesting tidbit from the report, the report says that forward pressure to maintain 55 knots would be 20kg at 40 degrees, and 25kg at 20 degrees i.e. less pressure required at the greater flap setting.

Initially I thought this was probably a misprint, however it could be correct if e.g. the downwash over the hstab is cleaner at 20 degrees.

So this is one scenario:
- pilot inadvertently selects 40 degrees of flap instead of 20
- goes around
- doesn't retract flap because normally the flap is set correctly (20 degrees) for the initial stage of the go around
- tries to attain correct speed for go around (70 knots according to the report)
- at 40 degrees of flap, less forward pressure is required for level flight, but it is more difficult to attain 70 knots
- pilot applies forward pressure to try to achieve 70 knots, looses SA while watching the ASI and descends into the ground

How does a 182 fly with 40 degrees of flap? Will it achieve a positive rate of climb at 70 knots?

[uncle8]

I have noticed in recent ATSB reports, and other places, that plural pronouns are used where singular ones seem more appropriate.

From this report - "After four circuits,the instructor was satisfied with the student’s performance and instructed them to conduct a full stop landing" and " The student’s night circuit training was all conducted at Hamilton Airport and their logbook contained"

I have a feeling that it must be correct but it sounds awkward to me and is harder to understand. .

[triton140]

I have noticed in recent ATSB reports, and other places, that plural pronouns are used where singular ones seem more appropriate.

From this report - "After four circuits,the instructor was satisfied with the student’s performance and instructed them ...

Political correctness - avoids using "him" or "her" ...

[andrewr]

Found a 182 POH online to check some numbers.

The report says that the go around procedure in use was consistent with the procedure published by Cessna.

The go around procedure reported:
Flaps 20
Speed 70 knots
Retract flaps once clear of obstacles

Cessna's procedure

Flaps 20
Speed 55 knots

With that speed difference, I would not say that the procedure is consistent with Cessna's published procedure. When climbing with flaps extended, extra airspeed is not your friend. Every extra knot reduces your performance.

Cessna said that flaps 40 would have reduced climb performance by about 50% (presumably at the POH speed).

Power to overcome drag increases with the cube of airspeed, so the power to overcome flaps 40 at 70 knots would be (70/55)^3 = approximately double. So climb performance is degraded by double 50%, or 100%. Add the increase in other airframe drag and calculations suggest that you would be descending at 70 knots with flaps 40 set.

Obviously someone felt that the POH speed of 55 knots was too slow. But why would Cessna set such a low speed? My money says it was because at higher speeds a safe climb wasn't assured with flaps set at 40 degrees.

Easy enough to test this if you have a 182 - what rate of climb do you get at 70 knots with 40 degrees of flaps?

Go around performance with 40 degrees of flap using the operators procedures seems like an important area that the report should have investigated.

[IFEZ]

Andrew, I don't have a lot of time in a C182 but with full power and 20deg flap, it would have no problem maintaining a positive rate of climb, whether you're doing 55kts or 70kts. The problem here, is that it looks like the student had inadvertently selected 40deg flap when only 20deg was to be used for night circuits. Its hard to imagine he went from 20 to 40 during the go round. He must have (for some unknown reason) selected 40deg on final, and during the go round procedure either forgot he had done so, or possibly panicked when the aircraft didn't behave as expected, and whilst distracted trying to sort it out, became disoriented in the dark night conditions. Its all conjecture I know, and unfortunately we will never know for sure what happened. The whole thing is complicated further by the medical issues and the implication that these 'may' have contributed to the cause. There is no doubt that something as 'simple' as a go round procedure is made a lot harder in dark night conditions, especially for someone with low night hrs. Even a C150 will bite you if you haven't been taught correctly. Doing a go round with 40deg flap, with full power you are still descending, so you need to get rid of that 1st 10deg immediately, and the next 10deg soon after. That's after being aware of, and applying sufficient forward pressure on the controls to resist the nose pitch up that happens when you apply full power. The schools recommended procedure of only using 20deg flap for night landings seems appropriate, as it reduces both the angle & rate of descent, making it easier to attain consistency in approach and landing, and in the case of a go round, there is no need to be reaching for the flap lever straight away, just pitch full fine, full power, climb away, then once you're settled, raise the flaps and FINALLY make a radio call.

[andrewr]

Andrew, I don't have a lot of time in a C182 but with full power and 20deg flap, it would have no problem maintaining a positive rate of climb, whether you're doing 55kts or 70kts.

At 20 degrees flaps, certainly. But the question is about 40 degrees of flap and trying to achieve 70 knots.

Doing a go round with 40deg flap, with full power you are still descending, so you need to get rid of that 1st 10deg immediately

According to Cessna, it will climb with 40 degrees of flap - at 55 knots.

The question is whether you have a go around procedure that requires reconfiguring before you can get a positive rate of climb, or whether you are better off reconfiguring after you have a posistive rate of climb.

The schools recommended procedure of only using 20deg flap for night landings seems appropriate...in the case of a go round, there is no need to be reaching for the flap lever straight away, just pitch full fine, full power, climb away

No argument with the use of 20 degrees of flap, it is the go around procedure that should be examined. If you normally only use 20 degrees and can go around at 70 knots without touching the flap lever, if you inadvertently selected 40 degrees you will be looking for 70 knots, looking for positive rate of climb, wondering why it's not accellerating/climbing, checking engine gauges etc. - all while possibly descending.

If 55 knots (POH speed) is the target, at least you have your target speed and a positive rate of climb while you figure out why you haven't got the climb performance you expect. It buys you time.

[Centaurus]

Often, instructors do not adhere to the recommendations published in the manufacturer's AFM or Pilot handbook. Sometimes training schools publish their own procedures rather than the manufacturer's procedures.

The ATSB report is flawed. The flying school published procedure is someone's personal idea (usually the chief pilot or similar local authority) and published as fact. There is generally no caveat that the company procedure is at variance with the procedure published by the manufacturer.

The report says that the go around procedure in use was consistent with the procedure published by Cessna.

The go around procedure reported:
Flaps 20
Speed 70 knots
Retract flaps once clear of obstacles

Cessna's procedure

Flaps 20
Speed 55 knots

With that speed difference, I would not say that the procedure is consistent with Cessna's published procedure
............................................................ ............................................................ ............................................................ ......

Agree.


In the case of this accident, this includes the company procedure 70 knots climb on a go-around instead of the 55 knots published in the POH. The ATSB should have investigated this anomaly more closely as it may point towards why the aircraft hit the ground at 100 knots if the pilot was trying to maintain or reach the flying school published speed of 70 knots.

To reach 70 knots with flaps at 40 would require a heavy push down below the horizon and therefore descending, to reach 70 knots particularly with the considerable aft trim that would be there after 40 flap had extended. Of course the pilot may not have put any trim input in that short time.

For an inexperienced pilot with precious little IMC (read black night) experience it would be all too easy to shove the nose down and build up through 70 knots quite quickly before he realised it. As this writer said earlier, a go around with full flap at very low altitude on instruments is a tricky manoeuvre in daylight for an experienced instrument pilot which this unfortunate cadet wasn't.

To cap it all off there was no reason to further load up the already tense situation faced by the inexperienced pilot to make a radio call saying he was going around. He was following company procedure of course but that procedure was quite unnecessary near the ground on a black night. That could wait until the aircraft had been cleaned up and stabilised in a normal climb - not a full flap out of trim black night go-around. ATSB missed the opportunity to make that point re priorities of Aviate first.

Spatial disorientation, somatogravic illusion, or even possible heart attack cannot be ruled out - you name all the factors that could have caused the go-around to go wrong. But often in black night accidents like this one where no one knows what really started the chain events that finished in a 100 knot crash, the chances are absence or lack of correct training to manufacture's procedures during the endorsement stage. Either the POH/AFM is wrong or the company procedure is wrong. Place your bets..

In this reader's view, ATSB needs to bite the bullet and publish an honest non politically correct point of view rather than a bland basic account of an accident which leaves readers none the wiser. If that requires a change to legislation then so be it.

Of course, ATSB legal people have a significant say in what is finally published. While that is understandable, it should not be a handy excuse to avoid publishing of a most probable cause. In the absence of firm evidence as to the cause of an accident, ATSB should follow the US regulations and be required by law to publish a most probable cause.

At least that would encourage operators to look into their own procedures to see if there are any flaws in their training policies which should be rectified

[Brainy]

Would seem to me that part of the problem in the way we teach is that students are taught to chase an airspeed for a particular phase of flight's performance, and this airspeed varies enormously with configuration. eg Vy clean and with full flap (and or gear) will be significantly different values. How many students will be able to remember any other than one value for Vy when placed under stress?The pitch attitudes required are however usually very similar or the same, yet we don't teach students to fly an attitude. You want to go around? Pitch up to 10 degrees (or whatever) on that little horizon thingy, regardless of configuration, and the correct speed is likely to result. Clean up when you are away from the ground. Seems safer to me...

[Seabreeze]

So it seems we have a low-hour pilot, inexperienced in very dark conditions (not instrument rated), doing "visual" circuits on a moonless night in the western district of Vic with no significant ground lights visible.

Centaurus says "But often in black night accidents like this one where no one knows what really started the chain events that finished in a 100 knot crash, the chances are absence or lack of correct training to manufacture's procedures during the endorsement stage. Either the POH/AFM is wrong or the company procedure is wrong. Place your bets..

In this reader's view, ATSB needs to bite the bullet and publish an honest non politically correct point of view rather than a bland basic account of an accident which leaves readers none the wiser. "

Seems to me Centaurus is right: the ATSB report implies that the trainee pilot lost SA while trying to deal with possibly significant stick pressures and no visual reference. - i.e., he was not trained adequately to cope with the circumstances which could (perhaps should) have been foreseen. It is just that the report does not say that. . .....

I would be mad as hell if he were my son.
(the unproven medical matter is given undue relevance, IMO)