These are great questions, and difficult to wrap your mind around and answer as well. The hardest part of this accident is the fact that the pilot, was actually a very good pilot. She was by no means a “new pilot”, having held her certificate for a couple years and logged over 300 hours of flight time (most of which was in Cirrus aircraft). She was certainly capable and competent to complete such a flight as she set out to do. What is so tough and insidious about this accident is a string of seemingly minor “threats” or issues occurred, and somehow manifested into a terrible accident. The risks accepted by our accident pilot were well in line with risks accepted by many GA pilots. Most pilots with 300+ hours of flight time have allowed themselves to be placed into at least one of “traps” or issues our accident pilot did.
The problem with understanding this accident is that while pilots are told by ATC to “go around” and “make it tight” on a fairly regular basis, that usually does not lead to pilots dying, however this time it did. The “threats” or issues mounted and mounted to some undefined point and it only took one more little straw to break the camel’s back (or in this case cause the accident). We all accept risk when we fly, and much of the risk Dana accepted with ATC’s instructions and embarking on this flight under the given conditions is the exact same risk’s we’d be willing to accept any day as pilots. Unfortunately here, that level of risk hit the “invisible tipping point”, and in just a few seconds after flipping a flap switch to the “up” position, three lives abruptly ended.
While some pilots may not always agree with the findings of the NTSB after an accident. I really do not think that the NTSB could have been any more on-point with their findings this time. The probable cause below sums almost perfectly why this tragedy occurred. The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot’s improper go-around procedure that did not ensure that the airplane was at a safe airspeed before raising the flaps, which resulted in exceedance of the critical angle of attack and resulted in an accelerated aerodynamic stall and spin into terrain. Contributing to the accident were the initial local controller’s decision to keep the pilot in the traffic pattern, the second local controller’s issuance of an unnecessarily complex clearance during a critical phase of flight. Also contributing was the pilot’s lack of assertiveness.
What we can take away from this accident is this:
If anything of these things occurred below, we wouldn’t be having this conversation, the accident would not have occurred. A chain of minor “threats” and “errors” formed, and if at any time we could have done any of the things on the list below, we could break the chain, and stop the accident from occurring (at least you would stop THIS accident from occurring, breaking just one link in an accident chain may still leave enough links to form a different accident down the line).
All these people constantly say “use good ADM’ and “ADM is really important”. Well, thanks, now I know something that doesn’t really make sense to me is really important, but how the heck is that useful tidbit going to keep me alive? ADM is any decision you make in the air, and the ability to recognize “threats” that pose a hazard to the safety of flight, or increase the risk of that flight (usually both). So let’s make this less abstract and talk about actual examples from this accident. We’ll give examples of “threats” that you should be alert to as a pilot and realize when these things start happening, you need to stop, re-focus, and get the airplane back to a happy place you are comfortable with that doesn’t have all of these “threats” popping up. The quiz will give you ten example threats that occurred during this flight, and your job will be to select any and all things that could be done to counter it.
Well no perfect answer there. In this accident, about 20 things went wrong before anyone died. In some accidents, it only takes one thing. The vast majority of the time, it will take 3 or more “threats” (note: sometimes the “treats” are extremely trivial) to get you killed. Personally, I use the “three strikes and you’re out rule”, meaning once I have two things go wrong in an airplane, I “abort” and go back to my safe happy place (a.k.a. “Plan B” and get the heck away from the “threats”). You’ll have to develop your own personal minimums, and they may change over time.
One of my first flights as a certificated private pilot was in a 152 that had a slight radio problem right after takeoff at a non-towered airport. I landed immediately and had the mechanic take a look at it. Today I would probably just keep flying if nothing else was wrong and not worry too much about that particular “threat”, your comfort zone will change over time and experience. Just remember there’s a fine line between “comfort zone growth” and complacency that will get you killed.
Take the quiz below and see how likely you are to fall into the same traps as our pilot in this accident case study. (note: the higher you score on the quiz, the more likely you are to make the same errors that lead to this accident).