Cirrus SR22 Accident Nov. 16, 2008 off Cherbourg

[Wallace and Grommit]

I was talking to somebody recently who told me of an ATC tape recording of a fatal crash. Apparently, a lot of pilots hold the PTT button down when they know they are going to die, so ATC get to hear the whole lot, and in this case you could hear his family screaming in the background. The transcript (which I read) revealed nothing of the sort.

Yes they do, and I have listened to more than a few. But it rarely sheds light on why the accident occurs, just confirms the time of impact. The sounds live with you. Also you can get an uncommanded short open transmission at the moment of impact due to disruption of the electronics.

I spent a few years out of private flying. When I stopped the King KNS80 Rnav was the new boy on the block. When I returned something called a GNS430 had become the system of choice. My first thought was that this device needs configuring before you get airborne. There was loads of scope to fiddle in flight, head in cockpit, attention distracted from the primary function of controlling the aircraft. You could also screw settings up big time if the wrong button pushes were made.

A low hour PPL in a high tech machine trying to re-configure the electronics of a high tech device could easily lose the picture.

[IO540]

2 hours diff training for an SR22, assuming going from a spamcan, would be astonishing, if this is true.

[Kerling-Approsh KG]

IO540,

I really don't have time for this or wish to enter into debate, but...

Why would two hours training be astonishing? What do the regulations require?

What is your experience in radar track analysis?

No, an autopilot doesn't fly a heading. You clearly have no appreciation of how autopilots work (they fly asymptotic curves tending towards the determined track according to complex algorythms).

What makes the autopilot you mention 'very good'. Are you qualified to make this statement, or is it your observation?

Rebating controllers commenting on track keeping, are you a controller? Do you know what track jitter is?

Your words on pilots' final transmissions are particularly worthy of criticism: Pure sensationalist nonsense, without any foundation in fact at all.

And how are you qualified to say that OVC007 is not reason for a crash?

You're embarrassing yourself here. My advice is to bug out and stick to what you know, whatever that is...

[IO540]

No, an autopilot doesn't fly a heading

I will ignore most of your pompous rant, Mr "KG". But the above is actually how an AP works. It holds a heading, which is then continually adjusted according to the HSI deviation bar error (taking the simple non-GPSS NAV case, with a GPS or VOR source).

The basic "heading" is taken from the course pointer setting (if a mechanical HSI; the pilot turns the CP to the new track at each WP), or from an EHSI CP setting which is automatically slewed to the current GPS track at each WP.

A GA AP doesn't fly asymptotic curves

You can get more intelligent behaviour with GPSS, whereby the GPS directly controls the AP, bypassing the HSI. This can give you accurate fly-by WP behaviour. The GFC700 should have this in all G1000 installations.

He clearly had little regard for following the regulations as the report shows he busted so many.

Well, sure, but busting regs doesn't automatically get you killed. I still wonder why the investigators reckon he was flying on the AP when it seems obvious he was flying by hand (and not doing too great a job, especially at the very end).

I don't take the position that anybody busting regs deserves to simply die. If one could find out what was really going on, one might take something home from it.

[madlandrover]

Why would two hours training be astonishing? What do the regulations require?

No particular comment on the accident from me, but having spent nearly a year doing Cirrus conversions I would also be surprised at someone being let loose after only 2 hours training on the SR22 - it is a serious high performance single and while generally docile can have some surprises if pilots don't know what to expect. 2 hours circuits would be about right for a newish PPL... We generally found that current FIs would take 1.7-2 hours to train to a reasonable standard, most CPL holders were safe after 4-5, PPL holders were (by insurance) a minimum 6 hours which was generally fair, raised later on to 10 hours by insurance requirements.

Training on a modern glass cockpit aircraft is not purely about the handling of the aircraft, there is also mandatory differences training on the glass cockpit aspects. In a G1000 equipped aircraft people can get in and just look at it to have some basic familiarity but I would not regard that as safe to fly the machine solo, it should instead be a complete training solution to allow the prospective pilot to have reasonable familiarity with a) the instrument fit b) the capability c) failure options. The best way to do this in a Cirrus/other decent machine is to include some in-depth cross country flying in the training, with the focus on how to best use the automatic aids and avionics to free up spare capacity. They're great aircraft for distance flying when correctly used, but things can happen awfully quickly if the unexpected happens when single pilot IFR. Yes, even the humble SR20 can approach 200kt groundspeeds on a decent breezy day at altitude...

[Cows getting bigger]

Whilst the A/P Hdg hold argument is most fascinating.........

Anyway, time-on-type and differences training. Reading the report it seems to me that our chap completed his PPL then immediately went over to his new Cirrus. As one who trains pilots on G1000 aircraft, I would be a little intrigued if someone with so little apparent experience managed to get signed-off for glass panel (a differences training stipulation) in only 2 hours. That said, he could have previously trained on another G1000 type and therefore there may not have been any need for differences training. Regardless, he subsequently managed to 'survive' 23 hours of G1000 time and it would be reasonable to expect that, by the end of this time, he should have figured what most of the buttons did.

I believe all "Perspectives" have the magic blue button.

[Kerling-Approsh KG]

IO540,

No ranting here. Just facts and intelligent consideration of them. A shame you are so defensive about it, and yet so bull-headed about your own input to this dubious debate.

I don't intend to waste any more time here... You're the bloke in the pub I walk away from.

[yawningdog]

My hunch would be that he became distracted and intimidated by the controller's message to stay clear of Cherbourg restricted area. Whilst in descent he may have decided to disengage the AP to make a manual turn to the right to avoid the area. Feasibly quicker & easier to do this for a few moments rather than mess up a GPS flightplan by altering the AP to HDG. Perhaps coming from a high speed AP controlled descent into a manual turn could have induced disorientation and panic.

For the sake of arguement, the radar picture looks like the work of an AP, at least I couldn't fly that straight manually!

[Fuji Abound]

Yd

A good point but transitioning from gpss to heading is easy; press the heading button on the g1000 and heading on the ap assuming not gfc700 equipted and you are in heading mode with bug steer available at the twist of a knob.

The procedure does not disrupt the fp, you can either use the bug to steer back onto the magenta line when you are ready, or pull up the fp and use the d function to repaint the magenta line direct to the next wp in the fp. You can even resume gpss but it is not as elegant as using the bug to get back on track because of the greater bank angles the ap will generate.

There are times when the turn time is not as quick as you might wish in this mode. Lets say you are in the descent or for that matter s and l cruise, anxious to avoid imc for whatever reason and cloud is looming large but with attractive gaps. Maybe you think fine i can stay visual but disengage the ap to give yourself the required manoueverability; of course the danger is high rates and bank angles can ensue as you attempt to stay with the hole and then you find you cant avoid entering imc. Aiming at gaps can be a risky business unless you know what you are about but also like mermaids very attractive to a sailor that is missing home.

[mm_flynn]

Having read the report now and digested the added facts I suspect the most likely story is that the pilot either decided on a manual descent or mis-programmed when setting the altitude preselect and then faffed about fixing the issue and ended up disconnecting the autopilot. From that point it appears a standard loss of control.

My logic is
1 - 'Sam' who appeared to know the pilot personally (earlier in this thread) said he normally flew on autopilot, the BEA makes this statement
2 - Radar tracks do sometimes have the kind of small discontinuities seen in the bulk of the track (look at the G-EYES radar track)
3 - At the bottom of the track the aircraft clearly comes off the autopilot, with a nearly 30 degree turn to the left, then back on heading, then what looks like a 45 degree turn to the right, followed by the loss of control.

This last event happens just when the aircraft should be levelling at 3000 ft, probably just after transitioning to IMC. If one was planning on having the autopilot fly you to your destination, any unexpected manual intervention would be high stress.


As an aside, this accident report does clear up one of the issues that was hotly debated in 2008 - Do the French consider themselves to be part of the Country EASA/JAA? And of course they do not and have affirmed their understanding of 61.3.

[IO540]

You're the bloke in the pub I walk away from.

I'll save you the trouble: I almost never go to pubs Not having to do that is one of the luxuries of having a girlfriend. Not to mention one of the luxuries of the lifestyle choices which comes with middle age

A good point but transitioning from gpss to heading is easy; press the heading button on the g1000 and heading on the ap assuming not gfc700 equipted and you are in heading mode with bug steer available at the twist of a knob.

Indeed, but if he really had just 2 hrs conversion training for the SR22, it isn't terribly likely that he was all that familiar with the G1000 buttons.

Sadly, while "anybody" can get a PPL in a C152, there is a certain % of PPL holders who will never get their heads around the more advanced avionics. This may sound offensive to some but so be it. I take myself back to 2002 when I bought the TB20 with, hey, wait for it, an HSI, and could not find a single instructor who knew how it worked. I downloaded a load of manuals off the internet and went up to 5000ft over Kent, put the AP on, and gradually worked out what it did. A G1000 has another level of functionality. No extra capability as such (unless you count LPV which doesn't yet exist in Europe) but a whole lot more buttons and menus and submenus.

To operate an autopilot correctly, or even usefully, you need to understand where it gets its inputs from and what exactly it does in which mode. The GFC700 (at least in the TBM850 G1000 installation in which I have flown with it) has always-on GPSS so you enter a WP and press DCT and the CP auto-slews and the plane will go to the WP regardless of which way you are pointing, which is a lot simpler than more traditional AP installations where the CP interaction is required. But in this case, as suggested above, he may have wanted to go to a HDG mode and may have messed up.

Another possibility is that he stalled when he levelled off. If you do a descent at say -1000fpm (can anybody work out the ROD in that final long track?) your MP may well be too low for level flight when you finally level off. I tend to avoid descents below 18" MP for this reason if descending on AP.

Back to the G1000, there is a lot of functionality and it should have a mandatory classroom, which you can fail. But this has no support in the ICAO pilot paperwork structure, would play havoc with already painfully slow GA modernisation because many pilots would avoid doing business with a school which has decided to modernise, and we should never wish for extra regulation in this already grotesquely over-regulated game.

As an aside, this accident report does clear up one of the issues that was hotly debated in 2008 - Do the French consider themselves to be part of the Country EASA/JAA? And of course they do not and have affirmed their understanding of 61.3.

That one was cleared up earlier by the State of Registry (FAA chief counsel office) rulings which somebody found on the FAA website last year.

To me, there was never any doubt that a PPL issued in the UK was not issued in France

I wonder if the French writer actually knew about the FAA ruling. I bet he didn't (very few people do) but his opinion happens to be right.

[stevelup]

He may have done his training on G1000 equipped aircraft?

[bookworm]

Whether he was or was not using his AP is irrelevant as he should not have been where he was in the first instance - notably (1) in IMC (2) after dark (3) in France.

Issues (2) and (3) are really not significant as regulatory points. The report makes it clear that the only thing missing on (2) was that the physical piece of paper hadn't dropped through the door, and point (3) is a subtlety (almost certainly an unintended one) of FAR 61.3 the the vast majority of pilots and regulators neither know nor care about. French airspace is not more demanding than UK airspace. I'd be willing to wager that if it were not for the regular armchair-lawyer debates on Pprune and Flyer, and in particular post #36 in this thread, the BEA might not even be aware of the issue.

What is significant is that a pilot with no additional instrument training beyond the token amount in the PPL seemingly thought nothing of undertaking a night flight on top of a layer (albeit a fairly benign layer) of SC, knowing that at some point he would need to descend through it to land at his destination. This isn't the same as flying an ILS to minima on a dark and stormy night with a howling crosswind, but it does take a level of instrument competence. Is that, perhaps, another indication that Europe makes it too onerous to obtain the skills and privileges to do so legally?

[IO540]

When I returned something called a GNS430 had become the system of choice. My first thought was that this device needs configuring before you get airborne. There was loads of scope to fiddle in flight, head in cockpit, attention distracted from the primary function of controlling the aircraft. You could also screw settings up big time if the wrong button pushes were made.

A low hour PPL in a high tech machine trying to re-configure the electronics of a high tech device could easily lose the picture.

I think it is widely accepted that these avionics are indeed configured pre-flight.

On a few occassions, e.g. following ground delays but having filed a Eurocontrol IFR flight plan, one departs without loading up the entire route of say 20 waypoints, and then one loads up the waypoints when enroute, on the autopilot. Usually one would still ground-load the initial waypoints especially if e.g. flying a STAR departure, so one can see which way one is supposed to go after getting airborne

Whether this is obvious to a new PPL as it should be obvious to some old-timer, is a different matter. The PPL training business doesn't really teach cockpit procedures and GPS is rarely touched on. I think a lot of people discover this stuff as they go along.

But in this case the pilot should have had ground school on the G1000.

Is that, perhaps, another indication that Europe makes it too onerous to obtain the skills and privileges to do so legally?

Well, yes, obviously, but there are vast establishment interests which have always worked to keep the IR hard to get and they are still there today.

In the meantime we have EASA trying to ground the vast majority of IFR capable pilots, by screwing the IFR/N-reg community into getting the JAA IR with its mad 7-exam ground school. That crude anti-US move is really going to help safety IMHO, a lot of these pilots will not do the Euro IR but will just fly VFR in IMC. but at least they know how...

BTW it has been suggested on another forum that this pilot may have had more diff training hours than it may appear because some training may have been logged as P1.

[robin]

What is significant is that a pilot with no additional instrument training beyond the token amount in the PPL seemingly thought nothing of undertaking a night flight on top of a layer (albeit a fairly benign layer) of SC, knowing that at some point he would need to descend through it to land at his destination.

What is missing from this discussion is what the pilot's PPL experience was from those who carried it out.

It is quite possible the pilot was a natural with all the skils needed to convert to a Cirrus in 2 hours and come to terms with the glass cockpit and instrument flight.

On the other hand this could be another (of many) example of dynamic business folk taking their working styles into aviation.

[Fuji Abound]

Bookie

A good post. We are obsessed with regulatory issues; as has been said before the aircraft doesnt care what letter is on the side or what card is in the pilot's wallet. What we should care about is why we are forced to jump through more hoops than at Crufts instead of insisting on a joined up regulatory framework within Europe than enables pilots to concentrate on gaining the best training for the job in hand.

I first flew a Cirrus with already a lot of hours on glass and even more hours of flying time. I did two flights with a check pilot. It is a dangerous game second guessing what time a pilot needs but for a low hours pilot there is no doubt Cirrus's own recommendations should be closely followed. For any pilot accustom to flying at typical GA speeds the aircraft will get away from you quickly.

We will never know the exact sequence of events that ended with this tragedy. Some reasonably obvious possibilities have been mentioned. It serves as a another reminder that operating in marginal weather without instrument training can be a risky business even if this wasnt the whole explanation for this accident.

[bookworm]

Add that to flight in IMC and the odds starts to accumulate towards a certain mindset..

Fair point. I still think, however, that there's clear blue water between the technicalities, and deciding to fly in IMC, not just without the proper piece of paper, but, apparently, without any training to do so.

[maxred]

Exactly. Happened to me recently when I went to pick an aircraft up. There had been a delay in getting the CofA. I had confirmation e mail that it had been signed, that it had been posted, but I did not have the original signed hard copy. To check pre flight, I called the issuer, who reminded me that the cert had to be in my hand, and on board the aircraft to be legal.I booked into a hotel, and waited until the original was with me. I then collected the aircraft. Reason-if it all went pear shaped the insurers would not pay out, and secondly, it was not legal.

This guy really should not have undertaken that flight. His experience level was very low, the aircraft was challenging, even in daylight VFR, and he had no ratings.

At night, IMC, over water

[dont overfil]

I know you are all sky gods on here and maybe I'm thick but looking back 20 odd years what would I have done in this situation?
I would probably have crashed!
D.O.

[Fuji Abound]

Yes, but maybe he thought he could do it vfr.

The metar suggests it was scattered and broken; what did the tafs suggest. The weather was clearing from the north and would have been weakening south bound.

Optomistic there is no doubt but perhaps as i said earlier he was sliding a hole when he lost control. However was it pitch black by the time he arrived and if so was there a moon? If it was pitch black even if vmc was maintained did he realise descending over a black sea is very different to the night training work he did over the land.

Night vfr over the sea, no moon, patchy cloud and to all intensive purposes it is imc and an instrument flight the whole way with the risk of an upset if you try and transition to flying visually even for a pilot on the money.

Do

Just seen your post and an interesting observation. Actually i think if you really understand the systems AND nothing goes wrong with them the cirrus is sufficiently good that you could make the flight in imc with no instrument flight training. I have put the ap in at a few hundred feeg, flown a route, changed the route in flight, set up for a vectored ils and taken the ap out at dh touching nothing other than the power lever the whole way. There are two enormous caveats and you need to be 100% on the systems and the aircraft performance. Dont try it - ever.