Cirrus down Gundaroo, 06/10/23
No. Because you are not likely to just 'pop the chute' without having a good long think about it. In a car, there is nothing to lose by pulling over straight away. If it's a false alarm, you just drive off!
Just registered here to clear up a few things:
I’ve spent many hours in cockpits with Peter, the deceased pilot. And many years on the ground with him also.
Not a “student” pilot. He had many hundreds of hours including much recent time in Cirrus aircraft.
He had completed many IFR renewals over the years including one in the last month.
I found him to be careful, thoughtful, competent and meticulous in his approach to flying.
In my experience, he always briefed his passengers - including the kids - on deploying CAPS, even when I/we had heard it all before.
Also we talked about the old ‘Aviate/Navigate/Communicate’ priorities quite a few times over the years.
I spoke with him on Wednesday morning for 5 minutes and he was in a very positive frame of mind, having just filed his flight plan.
We arranged to meet next week when he was back in town. I’ve also been informed that after the ARM to CB leg he advised another friend that the “plane was perfect”
I’m reliably informed that a “new” / repacked (?) chute was fitted to the aircraft in January.
I won’t be replying/ posting further.
Clearly atm none of us know what happened.
Just wanted to inject some facts into the discussion.
I’ve spent many hours in cockpits with Peter, the deceased pilot. And many years on the ground with him also.
Not a “student” pilot. He had many hundreds of hours including much recent time in Cirrus aircraft.
He had completed many IFR renewals over the years including one in the last month.
I found him to be careful, thoughtful, competent and meticulous in his approach to flying.
In my experience, he always briefed his passengers - including the kids - on deploying CAPS, even when I/we had heard it all before.
Also we talked about the old ‘Aviate/Navigate/Communicate’ priorities quite a few times over the years.
I spoke with him on Wednesday morning for 5 minutes and he was in a very positive frame of mind, having just filed his flight plan.
We arranged to meet next week when he was back in town. I’ve also been informed that after the ARM to CB leg he advised another friend that the “plane was perfect”
I’m reliably informed that a “new” / repacked (?) chute was fitted to the aircraft in January.
I won’t be replying/ posting further.
Clearly atm none of us know what happened.
Just wanted to inject some facts into the discussion.
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IndianaOceans post appears pretty quick for a first post (thankfully).
And Grey head's post doesn't appear at all to me,
Let's hope that both these identities are in contact with ATSB and Cirrus.
And Grey head's post doesn't appear at all to me,
Let's hope that both these identities are in contact with ATSB and Cirrus.
Sometimes medical events happen that are fatal, even when the person is in otherwise good health.
All the comments in there are reflective of what's been said second hand about the pilot, so no surprises there and nothing of interest to the ATSB. Keep in mind that the pilot was not the owner of the aircraft, so any maintenance or relevant info is well known.
I do question people when I hear them say "just pull the chute" or "I briefed my 8 year old on how to pull the chute"... it would simply be a HUGE step for someone to mentally pull that handle, especially an adult with any life awareness, but expecting a child to is a huge ask and that's not even before they see if they actually physically try and pull it. For a young child to process a medical episode of the pilot, try to triage the situation, panic, attempt to make a radio call, attempt to level off and gain control, comfort the patient and decide to pull the chute in a short space of time seems incredibly unlikely. I know my 9 and 10 year old would probably discuss it for way too long, argue about something and not truly process that I wasn't going to be able to help them.
Last edited by Squawk7700; 9th Oct 2023 at 06:32.
Does anyone have the QNH from the day?
With the data based on 1013 it would be interesting to know what altitude actually is actually applying the delta.
With the data based on 1013 it would be interesting to know what altitude actually is actually applying the delta.
In discussions about incapacitation and the fact pattern of this accident, I want to add that it may confuse the analysis to presume that incapacitation and loss of control were simultaneous. If it was incapacitation, all we can know is that the state came on sometime between the last radio response from the pilot and the loss of control. Once it had, the only other person at the controls was a child. That might have been the situation for five seconds, or several minutes with an incapacitated or dead pilot in the left seat. In the second case, we may be seeing the best efforts of a child to do something. i.e. the heading changes, etc. ,
Under the assumption that there's a consistent wind velocity, there's a lot going on in this red box.
A consistent climb followed by a sharp reduction in airspeed caused by occurrence X.
Presumably the autopilot cannot climb at the ~800fpm vertical climb speed which appears to be set on the autopilot VS dial.
A sharp decrease in airspeed follows.
The aircraft pitches forward and the speed increases by around 10 knots, at which point the climb rate increases again, back to normal levels.
What is interesting, is that the if the graph is correct, the climb rate continues at what it was, if not even a little higher, right to the point of stall, even as the airspeed decays dramatically, like the autopilot is pulling back hard for all it's worth, trying to climb the aircraft. Keeping in mind that as far as we are all advised, the stec autopilot doesn't run off IAS, but rather Vertical Speed.
Was the pilot potentially blissfully unaware that the aircraft was teetering on the edge of a stall for potentially a couple minutes, even after a seemingly similar occurrence barely a minute earlier?
A consistent climb followed by a sharp reduction in airspeed caused by occurrence X.
Presumably the autopilot cannot climb at the ~800fpm vertical climb speed which appears to be set on the autopilot VS dial.
A sharp decrease in airspeed follows.
The aircraft pitches forward and the speed increases by around 10 knots, at which point the climb rate increases again, back to normal levels.
What is interesting, is that the if the graph is correct, the climb rate continues at what it was, if not even a little higher, right to the point of stall, even as the airspeed decays dramatically, like the autopilot is pulling back hard for all it's worth, trying to climb the aircraft. Keeping in mind that as far as we are all advised, the stec autopilot doesn't run off IAS, but rather Vertical Speed.
Was the pilot potentially blissfully unaware that the aircraft was teetering on the edge of a stall for potentially a couple minutes, even after a seemingly similar occurrence barely a minute earlier?
Caveat, FR data is heavily smoothed and obviously granular but….
The same behavior is also exhibited through 8000’ as well which could suggest close to the aircraft’s performance capacity. Especially if heavy.
I have no experience with that autopilot but I do with more modern setups in similarly capable aircraft and obv can’t just peg it at 1000fpm and close your eyes. You need to use IAS/FLCH or dial the VS down as you climb.
the thought of climbing through 8000’ in IMC with the FZL at 5000’ at pretty much Vy while potentially accumulating to me would have my pucker meter in the red. He could have been very keen to get on top quickly. Or not conscious.
that leg LSALT is 4600.
The same behavior is also exhibited through 8000’ as well which could suggest close to the aircraft’s performance capacity. Especially if heavy.
I have no experience with that autopilot but I do with more modern setups in similarly capable aircraft and obv can’t just peg it at 1000fpm and close your eyes. You need to use IAS/FLCH or dial the VS down as you climb.
the thought of climbing through 8000’ in IMC with the FZL at 5000’ at pretty much Vy while potentially accumulating to me would have my pucker meter in the red. He could have been very keen to get on top quickly. Or not conscious.
that leg LSALT is 4600.
Last edited by BronteExperimental; 9th Oct 2023 at 09:52.
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I remain by my belief that the aircraft stalled due to ice, that was the start of the incident.
Yes you did say that. However, you said that you couldn't accept speculation which put the entire blame on the pilot yet in my eyes, a stall and subsequent spin usually ARE typically caused by pilot error..... except with severe icing; here, any pilot aware of the danger would typically be looking for a way out - higher or lower - and whilst on an IFR flight plan, he's not going to depart from his assigned altitude without clearance. Maybe the pilot thought: at 10000 feet he would be on top and could get the ice burnt off but as soon as he's starting to descend due to icing, I can pretty much guarantee he'd be calling up the controllers - this has happened with multiple aircraft suffering icing, they didn't stay silent and accept their fates....
At the same time, I wouldn't blame a pilot who became incapacitated due to an unknown medical condition as being guilty of pilot error because, after all, none of us know when our time has come. It's not a crime to become involuntarily incapacitated, it's not as if the pilot said "yes please, I want a massive stroke / heart attack right now...." If it happens, it happens - why do you believe we mustn't consider such issues as most likely but rather want to suggest BRS malfunction or some other mechanical reason for the accident?
Quote:
Why did the pilot not react?
The fact that the aircraft departed controlled flight so abruptly would indicate otherwise.... from 800fpm climb to 3700feet descent rate within 15 seconds is a pretty rapid change, wouldn't you say? The descent rate then only increased as the ground speed decreased. My first thoughts were that the plane was descending in a flat spin but that would mean the aircraft would have had to have stalled extremely tail heavy, beyond its aft CG limits - however with 3 small children aboard, I think we can safely rule that out....
Quote:
Why did he not recover or at least pull the chute?
Again, the fact that the aircraft descended so rapidly and crashed whereas BRS are rightly proud of their records for deployments within the recommended flight envelope would indicate that he did neither.....the plane was already dropping like a stone, just 15 seconds after the last datapoint showing a cruise climb was transmitted. What "recovery actions" would cause a plane in a cruise climb suddenly descend at a terrifying rate, so quickly? If the Chute was the cause of the issue, why was it deployed in the first instance? If it deployed accidentally, they would have been within normal operating parameters, why would it have suddenly caused the plane to drop? Assuming it was pulled whilst inverted or whilst at an unusual attitude, what caused the upset in the first place?
I'm pretty sure that based on the wreckage left that they have available to investigate, they won't be able to define a clear root cause for the accident because the plane was completely destroyed and burnt - unless, of course, they find parts of it which detached in flight which would point to an in flight breakup or perhaps a video capturing it's last moments of descent.... Also, I doubt a coroner would be able to carry out an autopsy on the remains of the pilot either to identify whether he had any unknown medical conditions which could have caused his sudden incapacitation.....
But again. let's look to Occam's Razor or, if you prefer, the Swiss cheese model. What scenario needs fewest number of slices of Swiss cheese to line up for the outcome we have seen? We know the plane wasn't flying on autopilot, we know that there was moderate freezing forecasted in clouds between 5000 and 10000 feet, we know he was climbing to 10000 when the incident started. Icing was therefore likely to have been present.
I'd love for it to be the result of poor maintenance or something like that - maybe he lost an aileron, the plane then rolled inverted, the pilot then triggered caps whilst inverted which led to the chute wrapping itself around the aircraft whilst ripping off his communication antenna - you know, something like that - but that requires multiple layers of cheese to line up. How likely do you believe that scenario is?
With my scenario, all I need is the icing to be a little more severe than forecasted with the pilot unable to react, for whatever reason.....
I remain by my belief that the aircraft stalled due to ice, that was the start of the incident.
Yes you did say that. However, you said that you couldn't accept speculation which put the entire blame on the pilot yet in my eyes, a stall and subsequent spin usually ARE typically caused by pilot error..... except with severe icing; here, any pilot aware of the danger would typically be looking for a way out - higher or lower - and whilst on an IFR flight plan, he's not going to depart from his assigned altitude without clearance. Maybe the pilot thought: at 10000 feet he would be on top and could get the ice burnt off but as soon as he's starting to descend due to icing, I can pretty much guarantee he'd be calling up the controllers - this has happened with multiple aircraft suffering icing, they didn't stay silent and accept their fates....
At the same time, I wouldn't blame a pilot who became incapacitated due to an unknown medical condition as being guilty of pilot error because, after all, none of us know when our time has come. It's not a crime to become involuntarily incapacitated, it's not as if the pilot said "yes please, I want a massive stroke / heart attack right now...." If it happens, it happens - why do you believe we mustn't consider such issues as most likely but rather want to suggest BRS malfunction or some other mechanical reason for the accident?
Quote:
Why did the pilot not react?
The fact that the aircraft departed controlled flight so abruptly would indicate otherwise.... from 800fpm climb to 3700feet descent rate within 15 seconds is a pretty rapid change, wouldn't you say? The descent rate then only increased as the ground speed decreased. My first thoughts were that the plane was descending in a flat spin but that would mean the aircraft would have had to have stalled extremely tail heavy, beyond its aft CG limits - however with 3 small children aboard, I think we can safely rule that out....
Quote:
Why did he not recover or at least pull the chute?
Again, the fact that the aircraft descended so rapidly and crashed whereas BRS are rightly proud of their records for deployments within the recommended flight envelope would indicate that he did neither.....the plane was already dropping like a stone, just 15 seconds after the last datapoint showing a cruise climb was transmitted. What "recovery actions" would cause a plane in a cruise climb suddenly descend at a terrifying rate, so quickly? If the Chute was the cause of the issue, why was it deployed in the first instance? If it deployed accidentally, they would have been within normal operating parameters, why would it have suddenly caused the plane to drop? Assuming it was pulled whilst inverted or whilst at an unusual attitude, what caused the upset in the first place?
I'm pretty sure that based on the wreckage left that they have available to investigate, they won't be able to define a clear root cause for the accident because the plane was completely destroyed and burnt - unless, of course, they find parts of it which detached in flight which would point to an in flight breakup or perhaps a video capturing it's last moments of descent.... Also, I doubt a coroner would be able to carry out an autopsy on the remains of the pilot either to identify whether he had any unknown medical conditions which could have caused his sudden incapacitation.....
But again. let's look to Occam's Razor or, if you prefer, the Swiss cheese model. What scenario needs fewest number of slices of Swiss cheese to line up for the outcome we have seen? We know the plane wasn't flying on autopilot, we know that there was moderate freezing forecasted in clouds between 5000 and 10000 feet, we know he was climbing to 10000 when the incident started. Icing was therefore likely to have been present.
I'd love for it to be the result of poor maintenance or something like that - maybe he lost an aileron, the plane then rolled inverted, the pilot then triggered caps whilst inverted which led to the chute wrapping itself around the aircraft whilst ripping off his communication antenna - you know, something like that - but that requires multiple layers of cheese to line up. How likely do you believe that scenario is?
With my scenario, all I need is the icing to be a little more severe than forecasted with the pilot unable to react, for whatever reason.....
"Wandering heading could be the pilot using heading mode to avoid small buildups, the fluctuations in speed and rate of climb could be mechanical turbulence"
Speed fluctuations may also mean very little other than using a little inertia energy to zoom climb over a few taller build ups on your way up, the kids probably would have enjoyed such a thing too.
.....(all types and yes)....
Speed fluctuations may also mean very little other than using a little inertia energy to zoom climb over a few taller build ups on your way up, the kids probably would have enjoyed such a thing too.
.....(all types and yes)....
You were saying? Here the thoughts of the investigators are that the driver became incapacitated at the wheel. He had plenty of time to pull over, right..... oh wait......
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What about a Cirrus trim runaway (relay failure)? It has caused loss of control and fatalities before. Those it has happened to who managed to recover report that a full up trim event at circuit or climb speeds has them in a stall in just a few seconds if not immediately recognised and countered (overpowered until the circuit breaker can be identified and pulled).
Last edited by Mark__; 9th Oct 2023 at 15:12.
nothing of interest to the ATSB.
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Analysis
The pilot reported that he lost airplane control during cruise flight in instrument meteorological conditions (IMC) and turbulence. He subsequently activated the airplane's parachute system, but the parachute failed to deploy. The pilot regained control of the airplane after exiting IMC and landed the airplane without further incident.
Certification tests were performed from level flight at speeds ranging from 62 to 137 knots indicated airspeed, and one test included deployment of the parachute system after a one-turn spin. The testing showed that to minimize the chances of parachute entanglement and reduce aircraft oscillations under the parachute, the parachute system should be activated from a wings-level, upright attitude if possible.
Postincident examination of the parachute system did not reveal any system component failure. Postincident testing showed that off-axis deployment of the parachute could exceed the forces required for a successful deployment of the parachute. If the airplane has a large pitch or bank angle or angular rates (or a combination of these) as the parachute rocket leaves the airplane, the airplane will rotate and cause the rocket tether to pull at an angle other than that intended, and the parachute will fail to deploy.
Radar data showed that the airplane was in a very dynamic flight pattern with extreme pitch and bank angles when the parachute system was activated. Thus, the parachute likely failed to deploy when activated due to the dynamic maneuvering of the airplane at the time of the activation, which exceeded the parachute system's certification requirements.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this incident to be:
The failure of the airplane's parachute to deploy when activated during a loss of control in cruise flight due to the dynamic maneuvering of the airplane at the time of the activation, which exceeded the parachute system's certification requirements.
A pdf copy of the whole NTSB investigation report is available here.
If the base of the IMC had been granite rather than clear air in that incident, the Monday Morning Quarterbacks would be asking why the pilot didn’t transmit a mayday and pull the chute.
Last edited by Lead Balloon; 9th Oct 2023 at 22:31. Reason: To correct the link. Thanks KR!
Thread Starter
LB, The linked report does not align with the quoted text. Got the wrong URL?
From the linked report:
From the linked report:
Analysis
The instrument rated pilot and passenger departed into instrument meteorological conditions (IMC) and intended to practice some instrument approaches. Shortly after takeoff, the pilot reported a turn coordinator failure. The turn coordinator indicated a left bank regardless of control inputs and the pilot became disoriented. The airplane was equipped with a Cirrus Airplane Parachute System (CAPS). The pilot stated he pulled the CAPS activation handle repeatedly; however, the cable did not extend and "nothing seemed to happen."
The airplane broke out of the cloud layer, and the pilot performed an emergency landing to a field. Witnesses near the accident site reported that the CAPS parachute deployed after ground contact. Post accident testing of the wreckage did not reveal any pre-impact instrumentation, or autopilot failures. The CAPS system also functioned normally; however, it was noted that the pull forces to activate the CAPS parachute varied significantly
The instrument rated pilot and passenger departed into instrument meteorological conditions (IMC) and intended to practice some instrument approaches. Shortly after takeoff, the pilot reported a turn coordinator failure. The turn coordinator indicated a left bank regardless of control inputs and the pilot became disoriented. The airplane was equipped with a Cirrus Airplane Parachute System (CAPS). The pilot stated he pulled the CAPS activation handle repeatedly; however, the cable did not extend and "nothing seemed to happen."
The airplane broke out of the cloud layer, and the pilot performed an emergency landing to a field. Witnesses near the accident site reported that the CAPS parachute deployed after ground contact. Post accident testing of the wreckage did not reveal any pre-impact instrumentation, or autopilot failures. The CAPS system also functioned normally; however, it was noted that the pull forces to activate the CAPS parachute varied significantly
For me, there are few things about this tragic accident that I can take to heart.
The state of the residual wreckage is one which will likely not enable any definite conclusions to be drawn regarding the causal factors, unless there is other structure that exists outside the impact site yet to be found. No comms from the pilot cannot be pinned to a specific reason.
Whilst there are numerous possibilities, sifting through these to formulate probabilities requires some pretty speculative narrative constructs that some commentators seem to cling tenaciously to, without definitive evidence.
There are several 'facts', but I don't see the connections that some others do, we see nothing that really links these in a cogent manner that is supported with real evidence.
It is frustrating to many in this industry/recreation/field of interest that a clear explanation does not connect all of the dots. The aviators mind generally likes to create order from the chaos to complete the story and close the narrative, and to apply some confirmation bias. To accept that there are too many unknowns to complete and package the open ended is difficult to embrace, so we seek plausibility to make up for evidence or even proof that "this would not happen to me". I have a few thought of my own about what MAY have happened, but without evidence these are notional and I respect that others experiences (or inexperiences) will lead them to different theories of cause and outcome, some better informed than others but all speculative, including my own, and so I will refrain from commentary.
So what are the lessons to be learned:
- Always communicate during any/every emergency?
- Deploy Caps as soon as issue is recognized?
- Maintain control in severe turbulence?
- Be aware of icing potential?
- Recognize departure symptoms, and associated recovery inputs, for Spiral dive and incipient spin?
- Be competent at spin recovery technique applicable for type?
- Don't carry passengers when unpredictable/unforeseen medical conditions may manifest?!?
- Carry a safety pilot/flight competent passenger?
Most of us should be at least reasonably competent in all these aspects so that when flying a certified aircraft we remain in control and can safely complete the task. Does this mean that a similar fate cannot befall us skilled and experienced in these considerations? These are the knowns, and known unknowns. As Donald Rumsfeld once observed, "its the unknown unknowns that will get you" (paraphrased), Dunning and Kruger also had some thoughts about this.
My reflection is that the evidence indicates this was an experienced and capable pilot, with the added responsibility of his grandchildren on board, who departed on a well planned flight that went amiss in the most terrible way, telling me that the lesson I must take from this is that whilst all due care is exercised there may be interventions that can steal the care and skill in an instant from such a person in a manner that can be terminal and terrible.
Rather than attempting to solve the riddle, I contemplate more the outcome and aftermath in this case. Sad and tragic, currently unexplained, this accident serves to illustrates to me that observation and introspection, rather than supposition based explanation, may be a better approach to some resolution and acceptance of mortality could be the 'lesson learned' that may make us all a little bit better at aviation in our own way.
I do not expect that this will in any way dampen the the wild and varied posting of the to and fro by the proponents of the pet theories, I'm just throwing my own two cents worth into the pot FWIW.
HD2
The state of the residual wreckage is one which will likely not enable any definite conclusions to be drawn regarding the causal factors, unless there is other structure that exists outside the impact site yet to be found. No comms from the pilot cannot be pinned to a specific reason.
Whilst there are numerous possibilities, sifting through these to formulate probabilities requires some pretty speculative narrative constructs that some commentators seem to cling tenaciously to, without definitive evidence.
There are several 'facts', but I don't see the connections that some others do, we see nothing that really links these in a cogent manner that is supported with real evidence.
It is frustrating to many in this industry/recreation/field of interest that a clear explanation does not connect all of the dots. The aviators mind generally likes to create order from the chaos to complete the story and close the narrative, and to apply some confirmation bias. To accept that there are too many unknowns to complete and package the open ended is difficult to embrace, so we seek plausibility to make up for evidence or even proof that "this would not happen to me". I have a few thought of my own about what MAY have happened, but without evidence these are notional and I respect that others experiences (or inexperiences) will lead them to different theories of cause and outcome, some better informed than others but all speculative, including my own, and so I will refrain from commentary.
So what are the lessons to be learned:
- Always communicate during any/every emergency?
- Deploy Caps as soon as issue is recognized?
- Maintain control in severe turbulence?
- Be aware of icing potential?
- Recognize departure symptoms, and associated recovery inputs, for Spiral dive and incipient spin?
- Be competent at spin recovery technique applicable for type?
- Don't carry passengers when unpredictable/unforeseen medical conditions may manifest?!?
- Carry a safety pilot/flight competent passenger?
Most of us should be at least reasonably competent in all these aspects so that when flying a certified aircraft we remain in control and can safely complete the task. Does this mean that a similar fate cannot befall us skilled and experienced in these considerations? These are the knowns, and known unknowns. As Donald Rumsfeld once observed, "its the unknown unknowns that will get you" (paraphrased), Dunning and Kruger also had some thoughts about this.
My reflection is that the evidence indicates this was an experienced and capable pilot, with the added responsibility of his grandchildren on board, who departed on a well planned flight that went amiss in the most terrible way, telling me that the lesson I must take from this is that whilst all due care is exercised there may be interventions that can steal the care and skill in an instant from such a person in a manner that can be terminal and terrible.
Rather than attempting to solve the riddle, I contemplate more the outcome and aftermath in this case. Sad and tragic, currently unexplained, this accident serves to illustrates to me that observation and introspection, rather than supposition based explanation, may be a better approach to some resolution and acceptance of mortality could be the 'lesson learned' that may make us all a little bit better at aviation in our own way.
I do not expect that this will in any way dampen the the wild and varied posting of the to and fro by the proponents of the pet theories, I'm just throwing my own two cents worth into the pot FWIW.
HD2
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Last edited by Lead Balloon; 9th Oct 2023 at 22:42.