Cooler heads observed that the majority of unintentional spins occurred in the traffic pattern, particularly on the base-to-final turn, where there was no room to recover even if the pilot knew how to. So knowing how to spin and recover served no purpose, besides its entertainment value—which, to be sure, was considerable.

Under the new dispensation, pilots were taught, in theory at least, not how to recover from a spin but how to avoid one. Nevertheless, stall spins, usually in the traffic pattern, still account for more than a tenth of all airplane accidents and around a fifth of all fatalities. Because they involve a vertical descent, stall spins are about twice as likely to be fatal as other kinds of airplane accidents.

• READ MORE: A Cautionary Tale About Pilot Freelancing

Why has the FAA’s emphasis on stall avoidance not done more to reduce the number of stall spin accidents? There are probably many reasons, but I think the lack of realism in the training environment deserves some blame. The training stall is a controlled maneuver, briefed in advance, approached gradually, calmly narrated, and recovered from without delay. The real-life, inadvertent stall is sudden, unexpected, and disorienting.

The pilot does not see it coming and so does nothing to prevent it. The training stall is so reassuring that pilots fail to develop a healthy fear of the real thing. After this preamble, you may guess that I am going to talk about a fatal stall spin.

The airplane was a Van’s RV-4, an amateur-built two-seat taildragger with a 150 hp Lycoming engine. It had first been licensed 13 years earlier and later sold by its builder to the 48-year-old pilot, a 1,300-hour ATP with single- and multiengine fixed-wing, helicopter, and instrument ratings. For the past six months, the pilot had been on furlough from regional carrier Envoy Air, where he had logged 954 hours in 70-seat Embraer ERJ-175 regional jets.

On the day of the accident, he added 24 gallons of fuel to the RV and flew from Telluride (KTEX) to Durango (KDRO), Colorado, a 25-minute trip, to pick up a friend. They then flew back to Telluride, where the temperature was 1 degree Fahrenheit, and a 10-knot breeze was blowing straight down Runway 27. The density altitude at the runway was about 9,600 feet.

Entering a wide left-downwind leg at about 100 knots, the pilot gradually decelerated and descended. By the time he began his base-to-final turn, he was about 200 feet above the runway and was going to slightly overshoot the extended centerline if he didn’t tighten his turn. His airspeed dropped to 50 knots, and the airplane stalled and spun. An airport surveillance camera caught the moment—a blur, then a swiftly corkscrewing descent. It was over in a few seconds. Both pilot and passenger died in the crash.

• READ MORE: Two Fatal Cases of the Simply Inexperienced

The National Transportation Safety Board’s finding of probable cause was forthright, though it put the cart before the horse: “The pilot’s failure to maintain adequate airspeed…which resulted in the airplane exceeding its critical angle of attack…” Actually, the opposite happened: The pilot allowed the angle of attack to get too large, and that resulted in a loss of airspeed. It was the angle of attack, not the airspeed, that caused the stall.

Still, it was an airspeed indicator the pilot had in front of him and not an angle-of-attack indicator, so to the extent that the pilot was consciously avoiding a stall, he would have had to use airspeed to do so. 

The published stalling speed of the RV-4 at gross weight is 47 knots. In a 30-degree bank, without loss of altitude, that goes up to 50.5. Individual airplanes may differ.

But in any case it’s misleading to make a direct, mathematical link between bank angle and stalling speed, although the NTSB frequently does just that. When you perform a wingover, your bank angle may be 90 degrees, but your stalling speed is certainly not infinite. In the pattern, you can relieve the excess G-force loading associated with banking by allowing the airplane’s downward velocity to increase—assuming that you have sufficient altitude.

On the other hand, with your attention focused on the simultaneous equations of height, position, glide angle, and speed that your mental computer is solving in the traffic pattern, you may not even be aware of a momentary excursion to 1.2 or 1.3 Gs.

• READ MORE: Three-Mile Limit: Novice Pilots Succumb to the Perils of Total Darkness

The RV-4, with a rectangular wing of comparatively low aspect ratio and no washout, stalls without warning in coordinated flight but is well-behaved and recovers readily. Uncoordinated, it can depart with startling abruptness. It resembles all other airplanes in being less stable when the center of gravity is farther aft, so maneuvering at a speed just a few knots above the stall may be more perilous when there is a passenger in the back seat. Like most small homebuilts, the RV-4 is sensitive to fingertip pressure on the stick and easily overcontrolled.

The NTSB’s report on this accident does not include any information about how many hours the pilot had flown the airplane or how many of those were with a passenger. The FAA registry puts the cancellation of the previous owner/builder’s registration just one month prior to the accident, suggesting the pilot may not have had the airplane for long.

The pilot never stabilized his approach. He descended more or less continuously after entering the downwind leg several hundred feet below pattern altitude—to be sure, the pattern at Telluride is 400 feet higher than normal—and never maintained a steady speed even momentarily. His speed decreased more rapidly as he entered the final turn, perhaps because he felt he was a little too low and instinctively raised the nose. Besides, the terrain rises steeply toward the approach end of Runway 27, possibly making him feel he was descending more rapidly than he really was.

A final factor that may have played a part in this accident is the altitude. The runway elevation at Telluride is at about 9,100 feet. Density altitude doesn’t matter for speed control in the pattern if you pay attention to the airspeed indicator, because all the relevant speeds are indicated airspeeds. But your true airspeed, which is 10 knots greater than indicated, can still create the illusion that you have more speed in reserve than you really do when you are making a low turn to final.

There’s a reason that students are taught to establish 1.3 V_s on the downwind leg, begin the descent abeam of the threshold, and maintain a good speed margin throughout the approach. It helps keep the stall-spin numbers down.

Note: This article is based on the National Transportation Safety Board’s report of the accident and is intended to bring the issues raised to our readers’ attention. It is not intended to judge or reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.

This column first appeared in the Summer 2024 Ultimate Issue print edition.

The post Ultimate Issue: Analyzing a Fatal Final Turn appeared first on FLYING Magazine.

In a preliminary report released Tuesday detailing the January 2023 near collision, NTSB said confusion on the part of the crew of a London-bound Boeing 777 led to mistakenly crossing a runway occupied by the Delta Airlines 737 that had been given clearance for takeoff. The aircraft came within 1,000 feet of each other.

Numerous Factors

On the evening of January 13, 2023, Delta Airlines Flight 1943 bound for the Dominican Republic was cleared for takeoff from Runway 4L at KJFK. The jet was carrying 145 passengers and 14 crew. Runway 4 is perpendicular to Runway 31.

Shortly before 9 p.m., the B-777 moved along a taxiway when it approached the area where two runways cross perpendicularly, Ross Feinstein, a former spokesman for both the Transportation Security Administration and American Airlines, said at the time after reviewing radar and audio recordings.

An audio recording of an air traffic controller can be heard telling the B-777 to “cross Runway 31 Left,” which would require it to turn right before coming around to line up for departure on Runway 4 Left behind the Delta B-737.

The B-777 made a wrong turn, putting it on Runway 4.

As the B-737 accelerated, Airport Surface Detection Equipment, Model X (ASDE-X) issued aural and visual alerts in the ATC tower, warning of a potential collision. Five seconds after the alerts, the controller canceled the takeoff clearance of the Delta B-737, which quickly decelerated from its top speed of 121 mph as the American Airlines B-777 was crossing in front of it.

The NTSB investigation found the ground controller who provided the taxi instructions to the American B-777 crew didn’t notice the aircraft turned onto the wrong taxiway because he was performing a lesser priority task that involved looking down. The ATC tower team, which was involved with operations related to switching runways, also didn’t prioritize its duties to continuously scan the airport operations environment and did not notice the B-777 on the runway.

NTSB investigators cited numerous factors that contributed to the American Airlines captain’s mistake in continuing along the wrong taxiway and crossing the occupied runway without a clearance, including interruptions and multitasking that were happening on the flight deck during critical moments of ground navigation. The other two flight crewmembers didn’t catch the captain’s error because they were both engaged in tasks that diverted their visual attention from outside the airplane.

The investigation also identified safety issues with air traffic control.

NTSB Safety Recommendations

As a result of the event and subsequent investigation, the NTSB made the following recommendations to the FAA to address the risks identified in this investigation:

• Encourage flight crews to verbalize the number of the runway they are about to cross, unless an automated system already provides an advisory.
• Encourage air carriers to use their safety management systems to identify flight crew surface navigation errors and develop effective mitigation strategies.
• Evaluate the effectiveness of the activation logic for runway status light systems, and update the logic as necessary to improve its effectiveness.
• Collaborate with aircraft and avionics manufacturers to develop a system that would alert flight crews of traffic on a runway or taxiway and traffic on approach to land, and require that both newly manufactured and existing transport category airplanes have such a system installed.
• Update a long-standing recommendation to require all airplanes be fitted with a cockpit voice recorder (CVR) capable of covering the last 25 hours of audio, up from the current standard of two hours.

The CVR information was not available for this incident because the data was overwritten. As a result, the NTSB had to rely exclusively on flight crew recollections about the incident, however, these were not documented until a month after the incident occurred.

A cockpit voice recording would likely have provided additional details about the content and timing of crew communications, shed light on the crew’s minute-by-minute focus of attention, and revealed any unreported, nonpertinent conversations or other distractions.

“The whole reason U.S. aviation has such an exemplary safety record is because we’ve built in extra layers of protection, which is why we need lifesaving technology at more of the nation’s airports,” NTSB Chair Jennifer Homendy said in a statement. “Our investigation also makes clear why we’ve long supported systems that warn flight crews of risks directly: because every second matters. Thankfully, the controllers acted quickly in this case, but safety shouldn’t be all on their shoulders. Instead, we must back up every single component of the system; direct crew alerts do just that.”

The investigation abstract is available here. The NTSB expects the final report to be published later this year.

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As you will have guessed, since you are reading about this in Aftermath and not in I Learned About Flying From That, the flight did not end well. About 25 minutes after takeoff and shortly after crossing the Arkansas border, the 31-year-old pilot, whose in-command time amounted to 75 hours, lost control of the airplane and went down in a remote woodland. All aboard perished.

A few minutes before the impact, as he was climbing to 9,500 feet msl, the pilot contacted ATC and requested flight following. The weather along his route—which, notably, he had last checked with ForeFlight 17 hours earlier—was generally VFR, with a chance of scattered convective activity. There was, however, one patch of rainy weather just to the left of his course, and the controller advised him to turn right to avoid it.

On the controller’s display, the target of the Cirrus crept eastward just below the edge of the weather. Radar paints rain, however, not cloud. The flight was over a remote area with few ground lights and the harvest moon had not yet risen, but its hidden glow may have faintly defined an eastern horizon. In the inspissated blackness of the night, the pilot, whose instrument experience was limited to what little was required for the private certificate, probably could not tell clear air from cloud.

As the Cirrus reached 9,500 feet, it began to turn to the left toward the area of weather. Perhaps the tasks of trimming and setting the mixture for cruise distracted the pilot from his heading. The controller noticed the change and pointed it out to the pilot, who replied he intended to return to Muskogee. He now began a turn to the right. Rather than reverse course, however, he continued the turn until he was heading northward back into the weather. The controller, who by now sensed trouble, said to the pilot that he showed him on a heading of 340 degrees and asked whether he concurred. The pilot, whose voice until this point had betrayed no sense of unease, replied somewhat incoherently that “the wind caught me, [but now] I’m out of it.”

With a tone of increasing urgency, the controller instructed the pilot to turn left to a heading of 270. The pilot acknowledged the instruction, but he did not comply. Instead, he continued turning to the right. At the same time, he was descending at an increasing rate and was now at 6,000 feet. “I show you losing serious altitude,” the controller said. “Level your wings if able and fly directly southbound…Add power if you can.”

It was already too late. In a turning dive, its speed increasing past 220 knots, the Cirrus continued downward. Moments later, its radar target disappeared.

In its discussion of the accident, the National Transportation Safety Board (NTSB) focused upon the pilot’s preparedness—in the broadest sense—for the flight. A former Marine, he should have been semper paratus—always ready—but his history suggested a headstrong personality with a certain tendency to ignore loose ends as he plunged ahead.

He had failed his first private pilot test on questions related to airplane systems; he passed on a retest the following week. But this little glitch tells us nothing about his airmanship. His instructor reported he responded calmly and reasonably to turbulence, and was “good” at simulated instrument flight. He had enrolled in Cirrus Embark transition training shortly before acquiring the airplane. He completed all of the flight training lessons, but—again, a hint of impatience with tiresome minutiae—may not have completed the online self-study lessons. The flight training was strictly VFR and did not include night or instrument components.

The airplane was extremely well equipped for instrument flying, but it was a 2001 model, and its avionics were, according to the Cirrus Embark instructors, “old technology” and “not easy to use.” In other words, it did not have a glass panel, and its classical instruments, which included a flight director, were sophisticated and possibly confusing to a novice. The airplane was equipped with an autopilot, and the pilot had been trained in at least the elements of its use.

The airplane was also equipped with an airframe parachute, but it was not deployed during the loss of control. In any case, its use is limited to indicated speeds below 133 kias, and it might not have functioned properly in a spiral dive.

• READ MORE: Dissecting a Tragedy in the Third Dimension

An instructor familiar with the pilot and his airplane—whether this was the same instructor as the one whom he called on the night of the fatal flight is not clear—wrote to the NTSB that the pilot had made the night flight to South Carolina at least once before, and he had called her at midnight before departing to come help him fix a flat tire. She declined and urged him to get some sleep and make the trip in the morning.

“I told him he was starting down the ‘accident chain,’” she wrote. “New pilot, new plane, late start, nighttime, bad terrain, etc….To me, he seemed a little overly self-confident in his piloting skills, but he didn’t know enough to know what he didn’t know.”

He fixed the tire himself and made the trip safely that night. Undoubtedly, that success encouraged him to go again.

We have seen over and over how capable pilots, including ones with much more experience than this pilot, fail to perform at their usual level when they encounter weather emergencies. A sudden, unexpected plunge into IMC—which, on a dark night, can happen very easily—opens the door to a Pandora’s box of fear, confusion, and disorientation for which training cannot prepare you.

There are two clear avenues of escape. One is the autopilot. Switch it on, take your hands off the controls, breathe, and count to 20. The fact the pilot did not take this step suggests how paralyzed his mental faculties may have become.

The other is the attitude indicator. It’s a simple mechanical game. Put the toy airplane on the horizon line and align the wings with it. That’s all. It’s so simple. Yet in a crisis, apparently, it’s terribly hard to do. The fact that so many pilots have lost control of their airplanes in IMC should be a warning to every noninstrument-rated pilot to treat clouds—and, above all, clouds in darkness—with extreme respect.

This column first appeared in the November 2023/Issue 943 of FLYING’s print edition.

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