Fatal accident in Vic 27 June
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Final report released...
Investigation: AO-2013-104 - Collision with terrain involving Cirrus SR22, VH-CKS, Boxwood, Victoria on 27 June 2013
The final approach to land was made after last light, with a family member positioned in a motor vehicle ‘at the end of the strip’. The vehicle’s headlights were intended to illuminate the upwind end of the strip, facing the oncoming aircraft. However, this lighting was inadequate and provided insufficient guidance for the approach and landing. This increased the risk of a collision with terrain.
Investigation: AO-2013-104 - Collision with terrain involving Cirrus SR22, VH-CKS, Boxwood, Victoria on 27 June 2013
The final approach to land was made after last light, with a family member positioned in a motor vehicle ‘at the end of the strip’. The vehicle’s headlights were intended to illuminate the upwind end of the strip, facing the oncoming aircraft. However, this lighting was inadequate and provided insufficient guidance for the approach and landing. This increased the risk of a collision with terrain.
Man Bilong Balus long PNG
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So if I read that report correctly, the Pilot was VFR rated only, with no Night VMC rating (or whatever it is called nowadays) and attempted to land at a strip with which he was not overly familiar, had no runway lighting system and indeed was unsuitable for night operations, after last light.
Someone please correct me if I have stated anything incorrectly.
I will refrain from further comment.
Someone please correct me if I have stated anything incorrectly.
I will refrain from further comment.
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Not trying to be smart or cute, but how does someone first on scene know to look up this manual? Wouldn't most rescue personnel be hard pressed knowing it is a Cirrus and not just a "Cessna"?
Speaking as someone who did road crash rescue in a country NSW SES unit for many years, it's a lot of work just keeping up with the nasty surprises modern (particularly luxury) cars hold, let alone aircraft.
Extra batteries in unexpected places, airbags everywhere, and let's not mention hybrids...
When you live....
Someone please correct me if I have stated anything incorrectly.
From the report intro:
The pilot was appropriately licensed to operate the visual
flight rules category aircraft at night
flight rules category aircraft at night
Whilst it's easy to look on and say wow, what an idiot, I must then surmise that there are a lot of idiots around this isn't the first time I've seen/heard this done.
Learning from the report...
From reading the report it looks to me that the pilot put some thought and planning into the landing...
Via the ATSB report. My bolding:
Pg 2: "The pilot held a Commercial Pilot (Aeroplane) Licence, a valid Command Instrument Rating (Single-engine aeroplanes) and a valid Class 1 Medical Certificate ... The pilot renewed his instrument rating on 25 May 2013. (one month before accident) The pilot’s application for renewal indicated that a significant proportion of his flying since his last renewal was at night ... The pilot had flown the accident aircraft for a total of 267 flight hours, 34 hours of which were at night. During the last 90 days the pilot accumulated 59 flying hours..."
Pg. 5: "...It was reported that the pilot’s previous landings at Boxwood were all in daylight..."
Pg 7: "...the pilot planned his final approach using two pre-selected waypoints and with vehicular headlights illuminating the airstrip. This contrasted with the pilot’s recorded night flying experience, which showed that all previous night landings were on licenced aerodromes that were equipped with appropriate runway and obstruction lighting..."
Pg 7: "The approach was consistent with reliance by the pilot on the provision of lateral and vertical guidance from the course deviation and vertical speed indications on the aircraft’s primary flight display. In this context, although the decent path was relatively constant, the turn onto final was commenced overhead the 4 NM (7 km) waypoint, resulting in the aircraft overshooting the extended centre-line. As a result, the aircraft was to the north of the intended track to the airstrip and required the pilot to track back to the centre-line during the remainder of the approach. This increased the risk that, given the inadequate lighting, the aircraft would strike the trees north-adjacent to the airstrip.
The use of Global Positioning System-derived waypoints for the final approach may have given the pilot a false sense of accuracy and an expectation that a single-point light source was adequate for the attempted night approach and landing. In contrast, the only means of judging the latter stages of the approach, flare and touchdown was by the aircraft’s landing light. Together with the closer-than-recommended location of the trees to the runway, this sole reliance on the landing light increased the risk of the pilot not comprehending the trees in time to take avoiding action."
http://atsb.gov.au/media/5244139/ao2013104_final.pdf
.
Via the ATSB report. My bolding:
Pg 2: "The pilot held a Commercial Pilot (Aeroplane) Licence, a valid Command Instrument Rating (Single-engine aeroplanes) and a valid Class 1 Medical Certificate ... The pilot renewed his instrument rating on 25 May 2013. (one month before accident) The pilot’s application for renewal indicated that a significant proportion of his flying since his last renewal was at night ... The pilot had flown the accident aircraft for a total of 267 flight hours, 34 hours of which were at night. During the last 90 days the pilot accumulated 59 flying hours..."
Pg. 5: "...It was reported that the pilot’s previous landings at Boxwood were all in daylight..."
Pg 7: "...the pilot planned his final approach using two pre-selected waypoints and with vehicular headlights illuminating the airstrip. This contrasted with the pilot’s recorded night flying experience, which showed that all previous night landings were on licenced aerodromes that were equipped with appropriate runway and obstruction lighting..."
Pg 7: "The approach was consistent with reliance by the pilot on the provision of lateral and vertical guidance from the course deviation and vertical speed indications on the aircraft’s primary flight display. In this context, although the decent path was relatively constant, the turn onto final was commenced overhead the 4 NM (7 km) waypoint, resulting in the aircraft overshooting the extended centre-line. As a result, the aircraft was to the north of the intended track to the airstrip and required the pilot to track back to the centre-line during the remainder of the approach. This increased the risk that, given the inadequate lighting, the aircraft would strike the trees north-adjacent to the airstrip.
The use of Global Positioning System-derived waypoints for the final approach may have given the pilot a false sense of accuracy and an expectation that a single-point light source was adequate for the attempted night approach and landing. In contrast, the only means of judging the latter stages of the approach, flare and touchdown was by the aircraft’s landing light. Together with the closer-than-recommended location of the trees to the runway, this sole reliance on the landing light increased the risk of the pilot not comprehending the trees in time to take avoiding action."
http://atsb.gov.au/media/5244139/ao2013104_final.pdf
.
It's amazing what humans will do when (& this is just a guess in this case) "get-home-itis" is in the back of their minds.
Familiarity with the airstrip (due it was his own property I understand)obviously worked against him in this case & along with the high level of automation in the A/C meant he was led into a false sense of security being able to complete the landing even though it was against the rules & obviously against all common sense.
I just like to think that these sad events & the following reports & discussions etc that are found amongst these pages are going to make someone else in the future faced with a similar so called ability to think twice & save a life or two. All the laws & rules in the book don't mean a damned thing if common sense isn't alive & well in a pilots head at all times.
Wmk2
Familiarity with the airstrip (due it was his own property I understand)obviously worked against him in this case & along with the high level of automation in the A/C meant he was led into a false sense of security being able to complete the landing even though it was against the rules & obviously against all common sense.
I just like to think that these sad events & the following reports & discussions etc that are found amongst these pages are going to make someone else in the future faced with a similar so called ability to think twice & save a life or two. All the laws & rules in the book don't mean a damned thing if common sense isn't alive & well in a pilots head at all times.
Wmk2
Last edited by Wally Mk2; 1st Jul 2014 at 16:02.
The odd thing is, there is now another Cirrus that carries that rego, & to an owner in Boxwood! I often hear it on the airwaves.
DF.
DF.
Whilst it's easy to look on and say wow, what an idiot, I must then surmise that there are a lot of idiots around this isn't the first time I've seen/heard this done.
But let's add to the challenge - make it a 600 M, up hill, one way strip, and me in a Mooney! Landed there lots of occasions in daylight but never before at night. Kero flares marking the four corners of the strip and a Tojo parked off to one side of the approach end with its head lights shining up the strip.
I can still hear the "THWACK" - as I ran the aeroplane through the top of a prickly bush short of the threshold!
Only once - never again!
If any young pilots read this - DON"T TRY IT!
I got away with it - he didn't!
Dr
Last edited by ForkTailedDrKiller; 2nd Jul 2014 at 00:00.
On page three of the ATSB report there is a picture of the accident aircraft panel.
"...2 Avidyne integrated flight displays ... The brightness of the screens is controlled manually for night operations..." "...an Embedded Terrain Awareness Warning System..."
The panel photo shows a green terrain on the MFD and a red/brown earth colour on the PFD.
Not being familiar with the Avidyne i'm wondering what the displays would have shown during the night approach to the Boxwood airfield. Noting the experience and currency of the pilot i would guess the displays were dimmed during flight to suit the apparently fairly dark night thus retaining the pilots night vision.
Would the Avidynes automatically go bright yellow or similar due to a terrain alert ? Between a possibly suddenly brightening panel on approach and the vehicle lights the pilot would lose a lot of his night vision.
.
"...2 Avidyne integrated flight displays ... The brightness of the screens is controlled manually for night operations..." "...an Embedded Terrain Awareness Warning System..."
The panel photo shows a green terrain on the MFD and a red/brown earth colour on the PFD.
Not being familiar with the Avidyne i'm wondering what the displays would have shown during the night approach to the Boxwood airfield. Noting the experience and currency of the pilot i would guess the displays were dimmed during flight to suit the apparently fairly dark night thus retaining the pilots night vision.
Would the Avidynes automatically go bright yellow or similar due to a terrain alert ? Between a possibly suddenly brightening panel on approach and the vehicle lights the pilot would lose a lot of his night vision.
.
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Not being familiar with the Avidyne i'm wondering what the displays would have shown during the night approach to the Boxwood airfield.
There is no synthetic vision on the GPS / Avidyne screen either so that wouldn't have helped.
FTDK - I recall doing something similar only to find a flock of sheep on my one way strip. I had another option only 7 nm away but it seemed to difficult at the time. Bunny hopped the sheep, landed solidly and got down successfully, but... never again.
Lateral thinking and had already been studied at Embrey-Riddle( goes to show, there is no such thing as an original idea) Using passive reflector panels to mark an unlit runway. Regardless of legality...if you are going to do something stupid, at least, give yourself a fighting chance. ER's study showed the panels were visible from 5nm away, allowing maneuvering to land, lit only by landing lights. My personal addition would be to survey in something like an aircraft carrier meatball like glideslope indicator to give some amount of obstacle clearance. When I mean survey, I mean simple measurements, erect panels at measured heights a measured distance apart aligned with the strip.
Stupid it may be, but if it saves one life....
Stupid it may be, but if it saves one life....
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i
The odd thing is, there is now another Cirrus that carries that rego, & to an owner in Boxwood! I often hear it on the airwaves.
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this scenario happens more than you think.
(landing in the dark on a home strip)
I know of a guy who thinks nothing of having the wife park on the downwind end of his strip, hazard lights flashing and high beam pointing down the runway.
lands over the top of her in absolutely crap weather.
has done it many times.
in my little garmin gps I can set the display to show an "ADF" needle or a "CDI".
I use the simple ADF (automatic direction finder) needle on the display but I wonder in cases like these if the CDI (course direction indicator) doesn't offer a better display since the offset from the straight-line track is also indicated.
might have told this guy he was off to the side of the intended track.
(landing in the dark on a home strip)
I know of a guy who thinks nothing of having the wife park on the downwind end of his strip, hazard lights flashing and high beam pointing down the runway.
lands over the top of her in absolutely crap weather.
has done it many times.
in my little garmin gps I can set the display to show an "ADF" needle or a "CDI".
I use the simple ADF (automatic direction finder) needle on the display but I wonder in cases like these if the CDI (course direction indicator) doesn't offer a better display since the offset from the straight-line track is also indicated.
might have told this guy he was off to the side of the intended track.
Man Bilong Balus long PNG
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Underneath The Radar and Binghi; Thanks. I stand corrected.
Teach me to read properly.
Teach me to read properly.
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Seems as though an overshoot would have been the order of the day given the crash location with respect to the airstrip. Crash site red diamond, tree yellow oval.
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Owns a Cirrus and a strip but not willing to spend a few hundred dollars on some cable and low voltage garden lights?
Sometimes it is actually easier to do it properly.
Sometimes it is actually easier to do it properly.
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400 to 1000 hours
This incident brought home for me the truth of something that I was told by one of the ex RAAF pilots out at Temora.
His view was that the most dangerous time for pilots is between 400 hours IC and 1000 hours. Over 400 hours and you think you are on top of your game and are therefore prepared to do things that you perhaps wouldn't have before then. It takes you till 1000 hours before you learn just how many things can go wrong. You're either lucky and make it through or unlucky and don't.
Pilot had 600 hours or so.
With just a few less than that, I know I am a beginner but I also know that I have become more bold than I was before. I will be thinking about this poor guy and his family and taking extra caution for the next 400 hours or so.
His view was that the most dangerous time for pilots is between 400 hours IC and 1000 hours. Over 400 hours and you think you are on top of your game and are therefore prepared to do things that you perhaps wouldn't have before then. It takes you till 1000 hours before you learn just how many things can go wrong. You're either lucky and make it through or unlucky and don't.
Pilot had 600 hours or so.
With just a few less than that, I know I am a beginner but I also know that I have become more bold than I was before. I will be thinking about this poor guy and his family and taking extra caution for the next 400 hours or so.
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Owns a Cirrus and a strip but not willing to spend a few hundred dollars on some cable and low voltage garden lights?
Sometimes it is actually easier to do it properly.
Sometimes it is actually easier to do it properly.
the lights have to be above a threshold brightness or you can't see them.
it would be rather sad to find that your lights were inadequate when you most needed them.
led lighting is available now that is bright enough.