Haste Makes Waste

Aviation has almost as many sayings and witticisms as there are pilots. One of my favorites is that pilots should never do anything in a cockpit quickly. To me, this means that responding to typical challenges—even an engine failure or fire—requires deliberate thought before acting, preferably along with the relevant checklist. Another way to state it, of course, is that haste makes waste: We easily can do the wrong thing in the cockpit at the wrong time.

Securing the perfectly good engine of a twin after the other one fails is a textbook example of the kinds of things that have happened when we’re in a hurry. Some might think that rushing through a procedure, especially in an emergency, is the hallmark of good airmanship. That’s rarely true even if the procedure is correct, successful and achieves the desired result. The problem is that there’s no way all of us can achieve that level of cockpit performance all the time.

According to the FAA’s Pilot’s Handbook of Aeronautical Knowledge (PHAK, FAA-H-8083-25c), “Risk management and risk intervention is much more than the simple definitions of the terms might suggest. Risk management and risk intervention are decision-making processes designed to systematically identify hazards, assess the degree of risk, and determine the best course of action. These processes involve the identification of hazards, followed by assessments of the risks, analysis of the controls, making control decisions, using the controls, and monitoring the results.” In other words, don’t rush through cockpit procedures.

How does this guidance translate to everyday challenges in the cockpit? Again, according to the PHAK, “While some situations, such as engine failure, require an immediate pilot response using established procedures, there is usually time during a flight to analyze any changes that occur, gather information, and assess risks before reaching a decision.”

“Immediate” is doing a lot of work here. “Reflexive” might be a better term. Actions like responding to a stall-warning indication, avoiding a bird or reacting after an engine fails are reflexive in nature. Meanwhile, the steps we take in response to a failed engine often can’t be performed immediately—we still have to fly the airplane. Our training requires us to have already considered such an event and practiced the steps to take. That doesn’t mean, however, that we should rush through them. A methodical process, backed up with a checklist, always is preferable and, to us, is the sign of good airmanship.

As we shall see, initiating a go-around or balked landing is one of the events when we should not make abrupt control inputs without anticipating and countering the airplane’s response.

Background

On April 24, 2021, at about 1312 Central time, a 2005 Cirrus SR22 was destroyed when it collided with terrain during an attempted go-around. The pilot (male, 76) was fatally injured, and the two passengers were seriously injured. The flight was returning to Mustang Beach Airport (RAS), Port Aransas, Texas, at the end of a Young Eagles flight sponsored by the Experimental Aircraft Association (EAA) to introduce children to aviation.

According to witnesses and ADS-B data, the accident pilot’s first Young Eagles flight that day departed Runway 30 at 1153 and concluded at 1221, after three approaches to Runway 12. At 1215, the wind was reported from 140 degrees at six knots. By 1315, the wind would change, blowing from 350 degrees at 10 knots.

The pilot’s second flight, the accident flight, departed Runway 30 at about 1305. As it returned to land at about 1312, witnesses stated the airplane was “low and slow” on the approach to Runway 30, and the airplane almost touched down short of the runway. Instead, the pilot appeared to initiate a go-around: engine power increased and the airplane’s nose pitched up sharply. Then the left wing dropped, engine power decreased and the airplane impacted the ground adjacent to the runway inverted in a nose-low attitude. The airplane was destroyed during the impact sequence.

Investigation

About eight seconds before impact, a cellphone video recorded by the front-seat passenger showed the flap selector switch in the fully retracted position. About five seconds before the impact, the video captured an increase in engine rpm, followed by a left roll and an immediate decrease in engine rpm, followed by terrain impact.

The initial impact point was located about 80 feet left of the runway centerline, with the main wreckage coming to rest about 90 feet further west. Fragmented fiberglass fuselage components and the nosewheel were located between the initial impact and main wreckage.

The upper cockpit and cabin structure was destroyed by impact forces and rescue efforts. Both outboard wing leading edges were crushed aft. Flight control continuity was established; the wing flap actuator’s position was consistent with the flaps in the retracted position.

No evidence of any pre-impact mechanical malfunctions or failures were noted with the airplane that would have precluded normal operation.

The pilot began his flight training in 2018 and earned his private pilot certificate about nine months later, with almost 100 hours of flight time. He started flying the accident airplane three days after his private pilot checkride and had a total of 72.5 hours in it as of approximately six weeks before the accident flight, including 17.3 hours of instruction.

The airplane was equipped with Avidyne primary flight display (PFD) and multifunction display (MFD) units. The memory chips from both displays were recovered in good condition and analyzed. The accident flight was about 14 minutes in duration, according to the data. Just prior to the accident, the airplane’s nose pitched up to about 22 degrees, as the airplane rolled to the left and then descended rapidly with a pitch of 30 degrees nose down. The airspeed at the time the data ended was 71 knots. The left roll continued until the data ended.

Probable Cause

The NTSB determined the probable cause(s) of this accident to include: “The pilot’s failure to maintain adequate airspeed during the go-around, which resulted in the airplane exceeding its critical angle of attack and a subsequent aerodynamic stall.”

There’s a lot going on here, including the pilot’s possible confusion. He used Runway 30 for both takeoffs and the accident flight’s approach, but it took him three tries to land on Runway 12 after the first flight. His trouble could have been because he was trying to land downwind. More confusion could be evidenced by the pilot’s failure to extend the wing flaps for the accident landing.

The pilot clearly failed to maintain adequate airspeed, as the NTSB notes. But his go-around actions seem to result from his immediate application of full power and failure to respond to the airplane’s left-turning tendency.

Instead of smoothly adding power, perhaps in increments, and managing the airplane’s reaction, he apparently quickly advanced the throttle to full power on deciding to go around. As the nose pitched up and he realized he was losing control, he reduced it but didn’t lower the nose. Because the flaps weren’t extended, the airplane stalled at a higher speed than anticipated.