Different Accident, No Lesson

71

Over the weekend, a highly experienced skydiver acquaintance of mine died in an accident that was, for all intents and purposes, the equivalent of last week’s midair collision in Colorado. It was a midair canopy collision that the other skydiver survived.

This news reached me on Sunday morning as I was thinking about the Centennial midair and watching comments scroll by on social media suggesting there’s much to learn from the Colorado accident. I can be as thick as a mud fence sometimes, but I can’t think of single thing to learn from either of these mishaps, other than if you lose the bubble in a high-risk environment, you can die in an instant. But did we not already know this? Is this now some kind of Eureka moment?

We published this news story the day the accident occurred and a couple of days later, Juan Browne pulled together a nice summary on his YouTube channel. He’s got the fact pattern well illuminated and absent the NTSB’s investigation, the results of which we probably won’t see for months and with no probable cause for three years, you can readily see what happened here. And see it well enough to draw your own conclusions.

Do we not, by now, know that when entering a traffic pattern, we have to be hyper alert for other traffic? Is this a new awareness? Raise your hand if you didn’t know that the second part of see and avoid is not to hit the traffic you say you have in sight. (The tape has the Cirrus pilot saying he had the ATC-pointed-out traffic in sight, the airplane he eventually collided with.) Is it news to anyone that a visual tower just provides sequencing and point outs, but not separation? Do people who’ve actually passed a checkride understand—or at least remember—that the faster the airplane is flying, the larger its turn radius will be? And that’s one reason you slow down in the pattern? As this accident is dissected, will further flaying of the thing tell us something we haven’t seen a thousand times before?

If the answer to these questions is no, our training edifice is even more rickety than I imagined. But increasingly, the more I cover and write about accidents, the less effective I think that coverage is in preventing the next one because we’re not seeing much new in how people wreck airplanes. How they die doing it. That may not be equally true of the why, but I suspect not much has changed there, either. We continue to implore pilots not to do certain things in the interest of accident avoidance or to do other things in the same pursuit, but, despite a lower accident rate,  some of us keep doing and not doing the same things anyway.  I wonder if we delude ourselves into believing we can procedureilize our way to a lower accident rate.

What may actually be needed is training in thinking about thinking instead of thinking about flying. Back to the skydiving connection. I jumped on Saturday and had a minor revelation. At the end of the freefall part of a jump, we track off to gain some separation for canopy deployment. After the canopy is out, there’s 10 seconds of housekeeping: collapse the slider; open the chest strap; slide back in the leg straps; release the brakes. For years, it has been my habit to look around for my teammates immediately before and after doing this. I hold the rear risers in case I need a quick avoidance turn. My teammates are likely to be hundreds of feet away, but we all like to confirm that and that everyone is under a good canopy. It’s just basic survival situational awareness. It’s habitual.

After the third jump Saturday, I realized I hadn’t done this all day. And I couldn’t remember when I stopped doing it. This is complacency setting in and it’s what kills people in any high-risk endeavor. I had lost the habitual discipline on which survival turns. I wasn’t paying attention to the hierarchy of risk in the various phases of a risky activity. That I thought about it snapped me out of it.

In flying—especially in a modern airplane—your eyes can’t be outside the cockpit constantly, nor do they need to be. Given that the majority of midairs happen in the traffic pattern and there are between six and eight midairs a year, the risk away from the airport justifies a more relaxed scan. You’d exhaust yourself to dysfunction if you didn’t fly with relaxed awareness some of the time. Approaching the airport, however, the reverse is true. There’s little or no time for anything but eyes outside; not using ADS-B to find traffic you should acquire visually, because visually is how you’re going to avoid it. And not relying on a tower for accurate point outs or blabbering on the radio in the misguided belief that it’s anything other than a supplement to a pair of vigilant eyes.

Do people not have this sense of elevated risk? I think they know it intuitively and have it reinforced in training. Maybe what we need is to figure out not how to beat more specific procedures and memory tasks into pilots, but how to get them to self-diagnose complacency to keep it from eroding basic survival awareness. In other words, we all know what to do to confront the risks; we just have to know when we’re faced with them.

If I figure that out, I’ll let you know.

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71 COMMENTS

  1. We don’t need anymore training. We don’t need anymore information. We don’t need anymore technology. We don’t need anymore airplanes with parachutes. We are all human and that appears to be fact for the foreseeable future, I think. Part of being human is to error and that’s not going away any time soon. Somehow people seem to think they can eradicate error from humanity. It’s not going to happen boys and girls.

    • More airplanes with whole-frame parachutes wouldn’t be a terrible thing. There’s no reason a pilot needs to die because of a stupid mistake (either by them, or by a maintenance-induced failure). It’s not about eradicating error, it’s about mitigating the results of error. So it’s always worth asking “is there anything we can learn from X”, even if the answer is objectively “no, not really”.

      • Exactly! The purpose of CAPS is not to prevent pilots from screwing up, it is to prevent them from paying with their lives (and the lives of their passengers) when they do screw up! CAPS is there to take the death penalty off the table.

  2. This was a 2016 Cirrus, best cockpit displays around. ADS-B and big screens to see it on, big windshield to see it in. Big brain to think it through. All went wrong. Why? I think a lot of pilots do not have a good overall 3D situational awareness. If 3 minutes before the accident, he had taken 7 seconds to look at all the moving traffic targets and plan your entry into it, we might have had a different outcome, like say a near miss.

    Oh, it’s Monday morning…….I could have won the big game easily.

    • Let’s not forget that the Metroliner was also on a visual approach! It seems from his radio calls that the Metroliner pilot was 100% absolutely clueless about any other planes near him. See and AVOID is for everyone.

      • Art, if you look at the Metroliner’s ADS-B track, he was already firmly established on final for 17L and his final approach ADS-B courseline looks like it was drawn with a straight edge. The Cirrus’ ADS-B courseline looks like a kamikaze TRYING to hit the Metroliner.

        Paul’s link to Juan Brown’s summary on You Tube plainly shows that. The Cirrus pilot said he “had the traffic,” overshot HIS runway 17R centerline and clunked into the Metroliner.

        • Yea, that’s the problem. The Metroliner lined up with autopilot on a long visual approach. As you can hear in his transmissions, he could care less about other traffic… and then it hit him.

          • The metroliner was broadsided by the cirrus who overshot his final. The metroliner pilot did remarkably well flying a crippled airplane to safety. The only thing he was clueless about was how much damage he had sustained.

      • How did you reach the conclusion that the Metroliner was clueless to other traffic? To me, the two tower frequencies sounded like any other tower frequency, until the collision.

        It’s not a unique situation that one pilot thought they saw the correct traffic, or made a call that caused the tower controller to believe the pilot had the correct traffic in sight, but didn’t actually. I know even in my own flying, I have occasionally picked out the wrong target and later realize the one that was being pointed out was someone much closer.

        What is a fact is that the Cirrus pilot apparently overshot the parallel runway it was assigned to and flew into the Metroliner.

        • The Metroliner ads-b track is straight as an arrow (no evasive maneuvering) and the pilots initial report was erroneous (reported engine problem).

          Just because the Metroliner was cleared did NOT remove his PIC responsibility to keep an eye on other traffic that my pop up due to error or circumstance. Having “I had the right of way” on your gravestone means little.

          • I’m not sure what data you think supports this opinion. To the Metro, the Cirrus was at 2 o’clock trending toward 4 and almost 1000 feet lower. If the Metro had a co-pilot, he or she might have seen the traffic, but from the left seat, hard to see how that would have been possible. Also, according to the tapes, the Metro pilot never got a call out on the Cirrus for the parallel. He did get a callout for the Cessna.

          • Paul, Yes! And the Cirrus was looking toward the airport (to follow traffic and to gauge his lineup to final). Point being is that it’s a far more complex situation than we see on first blush.

          • The Metroliner pilot probably thought he had an engine problem because of asymmetric drag preceded by a bang/shudder (note side of fuselage hanging out).

            I am puzzled as to why there were two frequencies in use for parallel runways with (I presume) close spacing. (For IMC landings there are criteria for runway spacing, SEATAC had to spend for a new runway to the west in order to get spacing.)

    • I’m baffled on why the Cirrus wasn’t paying attention to his ADS-B display showing the other aircraft in the pattern. Wouldn’t he also have received a traffic warning for the Metroliner?

      It would be interesting to find out if the Metroliner had ADS-B IN.

      Bottom line is that see and avoid is way over rated. I’ve been flying with ADS-B IN for 5 years, and half the time, I can never visually see traffic that is less than a mile away from me, even though my ADS-B display shows me exactly where the traffic is.

  3. As the quote goes, “Aviation itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect”.

    We can do everything possible to attempt to reduce the most common accidents, but ultimately if the person behind the controls doesn’t give aviation the respect it deserves, nothing will eliminate these accidents. Fully autonomous aircraft probably will, but if we’re talking about aviation as an activity people like to do (as opposed to just ride in), that misses the point.

    More training might help, but only if a) the person receiving the training is actually ready to hear the lesson (FOI “law of readiness”) and b) the person teaching is effectively communicating the lesson. And just like pilots, there are good CFIs and less-dedicated CFIs.

  4. I didn’t think of it this way before reading this article but it’s a good point. There truly is nothing to be learned from that crash other than that metroliners don’t fall apart if decapped while flying slowly and that it’s incredible nobody was killed.

    Don’t go 150kts in the pattern unless you’re in a fast mover. Everyone knows that

    Don’t overshoot your turn on parallel approaches. Everyone knows that.

    Watch for traffic during visual approaches. Everyone knows that.

    There’s no big lesson here; grievous pilot error was the cause, and the person responsible is the cirrus pilot. Case closed. The metroliner pilot could not have even seen the cirrus approaching him from above and to the right because the cockpit structure is in the way. Hopefully the cirrus pilot will be compelled to stick to the ground from now on given his chain of grossly negligent action. And for all of the good cirrus pilots out there this was another exasperation inducing, stereotype reinforcing crash, and I don’t hold it against you. I’ll still perk up a little more when I hear a cirrus is near me while in the pattern though.

  5. I dunno … I learned a lot from watching the video links you provided plus others. As YOU said about your jumps, we know the way things work yet complacency often enters the equation. In this case, two airplanes (and an insurance company) paid the price but no lives were lost. Great and not so great. I’ll be more careful as a result.

    One thing about local controllers has always bothered me, however. If I’m cleared to land on final, the runway is “mine.” Why do they clear another airplane to land behind me? It’s NOT clear … I’m in the way. Even if they say, “Cleared #2 behind the Cessna,” the runway isn’t clear. SOME pilots just chug along fat dumb and happy and would probably be happy to land on top of me or hit me from the rear. IN FACT, MY CESSNA WAS REAR ENDED BY A PITTS WHEN IT WAS NEW !! I even went to far as to look in the Order JO7110.65V … which no one ever taught me 50 years ago. I only learned of its existence when I had a job in Flight Test Ops for a large Company. I think an alternative command for the number two airplane ought to be evolved. I ‘get’ that the number 2 airplane cleared is now responsible for spacing once they acknowledge the command but … in this case, the Cirrus acknowledged the centerline command but screwed it up anyhow. Some controllers bear responsibility in these evolutions, too. They talk too fast, hear what they “expect” to hear and keep on yakking. Sequencing is only part of their job; spacing is, too.

    I’ve had two very close calls among the half dozen or so in my time defying gravity. The one that chased me away from the environs of Bumble Bee AFB was SO close that I could see the two pilots yakking at each other and not looking IN the pattern. As someone said about your Bristell demo article, can’t they talk without looking at each other? Had I not anticipated their actions, they woulda probably run right over the top of me. What flew out of my mouth on the radio cannot be printed here despite the fact that I know better. My wife was SO scared that she rarely flies with me anymore over that one.

    • Maybe the real lesson from this is a reminder of the lesson that sometimes pilots give too much of their PIC authority to controllers, and that controllers sometimes assume more authority over pilots than they actually have. Pilots and controllers alike have to realize that they operate at the lowest common denominator: sometimes it’s the controller, and sometimes it’s the pilot.

      Maybe another lesson is that it should be ok for controllers to use a phrase like “newly certified” just like it’s ok for pilots to say “student pilot”. Saying “student pilot” (even if one isn’t technically still a “student”, because we’re all students of aviation) is short-hand for “go easy on me, please” so if they’re not feeling up to the particular challenge, they are given a little more leeway to remain within their safety comfort zone. But there is no similar phrase for controllers, and I think too many take a bit of a macho attitude and sequence aircraft closer together than they should.

    • Question: Just how does a controller expect you to use just your eyeballs from 4 miles out from the airport to “not overshoot the final”? It’s a serious question; not only about phraseology but also what accuracy is humanly possible only using eyeballs and perception.

      • Seeing another traffic target at 4 miles is difficult. Seeing the extended centerline of a runway 4 miles out is not.

        Basic geometry means if the two sides of the runway appear to converge in the distance at the midpoint of the runway (i.e. where the centerline is: / \ ), you are lined up. If one side or the other appears different ( | \ or / | ) you are displaced to the left or right (respectively as “drawn” here). The Cirrus pilot would have seen the former, indicating he overshot the final. This is basic visual perception that all post-solo students and up should (but sometimes don’t) have an understanding of.

        But if basic visual geometry doesn’t suffice, the Cirrus has a very capable glass panel that can easily be set up to show the extended centerline. This is particularly helpful in reduced visibility or when there are obstructions (like terrain) that obscure the runway.

        • Yea… and the Metroliner has ADS-B as well. Just saying that being fat dumb and happy on a long visual final is NOT the way I would play it. Perhaps the split frequency also contributed to the pilot(s) complacency?

          • Why do you keep insisting he was fat, dumb and happy? He was flying the airplane as he was supposed to, he was on the approach where he was supposed to be and he got hit from the right rear quarter by another airplane.

          • Hey Arthur, please bless us with your knowledge and enlighten us as to why the Metroliner having ADS-B increases his liability in this accident.

            And how exactly WOULD you play it on final? S-turns for safety all the way to touchdown while adjacent another extended runway centerline?!

            Please tell us, we need to know how it should be done!!

        • Let’s back up… Just how good are your eyes? What was the background for the Metro or the Cirrus that you can so easily and assuredly pick ’em out and identify them as a potential threat (while maintaining alignment with a runway to assure YOU don’t meander where you don’t belong (i.e. on 17R?)? I know the light has to be just right for me to see a typical GA airplane way off center to right or left at even 1-2 miles. Four miles? You are kidding, right?

    • Mark II eyeballs, experience, double checking where all the pertinent airplanes are and KEEPING track of ’em, anticipating a potential conflict so staying WELL right (west) of 17R centerline until closer in, checking your ADS-B screen in a busy environment (if you have one [I’ll be interested in knowing if the Cirrus go an aural warning]), slowing to pattern speeds well in advance of the pattern (at one point just prior to the collision, the Cirrus pilot was at 188 kts and descending rapidly while the Key Lyme pilot was below 140 in a normal stabilized approach descent), sterile cockpit (just like the airlines), asking for controller verification of traffic and/or requesting a longer downwind to allow for automatic conflict resolution, anticipating winds aloft off the Rockies might push you further east if you don’t compensate. There’s likely more ? I’d also like to know who the r/h passenger was in the Cirrus? (Pax or CFI).

      In THIS case, the Cirrus pilot basically ran down the Metroliner from the side … period. Wasn’t a darned thing the Metroliner coulda done different; he did everything right after the crash, however.

      I’ll also be interested in knowing if conversations INSIDE the tower cab are recorded? Were the L and R local controllers talking to each other making sure there wasn’t a conflict. Did someone look out w/ binoculars or look at a brightscope? IF they saw the excessive speed of the Cirrus, they should have steered him further north to establish a stabilized approach.

      I’m betting there’ll be some big changes to parallel runway ops as a result of this one. I’m also betting that the final NTSB report will have a laundry list of contributing factors and the JO7110.65 will change, too.

      • “IF they saw the excessive speed of the Cirrus, they should have steered him further north to establish a stabilized approach.”

        Visual towers sequence, they don’t separate, other than on the runway. PIC is supposed to do his part. They might have staggered them a little more, but I’ll bet you a beer no changes to the .65.

      • “IF they saw the excessive speed of the Cirrus, they should have steered him further north to establish a stabilized approach.”
        Be careful what you ask for. Controllers are not the airplane’s PIC. They provide the service of telling you who to follow and point out other traffic that they might consider a factor.. again, they point it out only. Once you advise them you “have the big flick” they assume you actually do or you would not have said so. At this point you are permitted to fly the airplane as you see fit. If how you are then flying it (too fast, too high, whatever), they will assume that you as the PIC of that aircraft still knows what you’re doing. Do you want new rules to get them more into the cockpit with you? In my many years as both a pilot and an ATC kinda guy, I’ve seen every imaginable kind of flying occur, some pilots flying like Chuck Yeager, others like they have never flown before. So therefore, as controllers, we really don’t know what a pilot is doing if it looks a bit different this time, except we assume that he/she being PIC is doing the whatever by choice.
        Reference two being cleared to land at the same time, “anticipated separation” is used all the time for convenience. Assume is a bad word, but we all, pilots and controllers, must make certain assumptions based on the many, many times we’ve seen a particular event happen before. Even though you’re landing first (you own the runway), well yea you do, up to a point, and assumption come into play here. Because there is no reason to expect you to “own that runway” any longer than you safely need it. We all know that someone else is going to need it very shortly, and the tower expects a normal and safe exit of it at the first opportunity. However, if you either screw up and miss a turn off, or just decide “I own the runway” and delay for no good reason, then the tower controller is still monitoring the runway and can cancel the next guy’s landing clearance with a go around….who, both the next pilot and the controller, will now be pissed at you because he/she now thinks that you are one sorry ass pilot. The system works well millions of times a year. Unfortunately, being the humans that we are, there will be a mistake by one of us occasionally. Making a controller more of you copilot is still not a good idea though….my opinion.

  6. Challenge accepted. Problem is, by the time the dust settles, we’ll probably both be lawn food. 🙂

    If local controllers only job is to sequence and not separate, why do they sometimes tell you to “go around” or “sidestep?” And why do they say, “Clear to land?” They could get a recording for that. I’d have to sit down and ready the 7110 to understand a bit more about what the heck their job is because if that’s it, we don’t need ’em. We can have some guy with a TV set and a bright scope doing the task remotely. And what would give them the right to “yell” at someone who isn’t doing what they direct? There’s more to this story I think. I’m gonna be doing some digging into this when I have time.

    • That’s all related to runway separation. The .65 covers. There’s a little diagram of it in section 3-9-6. If the controller determines that the landing airplane will compromise the required minimum, go around is an option.

      • I forgot to mention two things a couple of controller friends told me. Normally, in a situation like this, the controllers would be relieved immediately to keep the distraction from causing more errors. It’s possible they don’t have the staffing, made worse by COVID.

        Second, the runway should have been closed for a FOD inspection. You hear the Lear pilot told of possible FOD, express dismay, but apparently charge on. That could lead to follow up incident or accident if the runway is really a mess. We assume he continued; not evident on the tapes.

    • A tower controller does indeed have separation responsibility but only insuring .65 separation on THE RUNWAY. He /she is required to insure that the separation, as Paul pointed out in the .65, is provided for each and every airplane that either is going to takeoff on that runway or land on that runway. Therefore, “cleared to land” and my favorite as an ATC guy “go around” (hey..just joking) are very specific actual separation providing phrases. But runway separation is all the tower provides. In the pattern, sequencing and traffic point out when possible are all they do. They have absolutely no responsibility to keep you separated from each other, other than they will sure do their best to help you if it doesn’t seem like you’re doing it for yourself. But that’s only a, “them doing the best they can”, not a guarantee. And don’t forget that chapter 3 in the .65 will show you how two aircraft can use the runway at the same time, as long as on is not a jet.

      • Sorry, Roger … I ain’t buying it. See .65Y 3-8-1:

        Section 8. Spacing and Sequencing
        3−8−1. SEQUENCE/SPACING
        APPLICATION
        Establish the sequence of arriving and departing
        aircraft by requiring them to adjust flight or ground
        operation, as necessary, to achieve proper spacing.

        I don’t see any words in that paragraph intro that says, “On The Runway.”

        Maybe I don’t understand the words “spacing” and “separate?” Seems to me they’re darned near interchangeable? Proper sequencing ensures proper spacing. How is a local controller supposed to do that without looking outside his tower cab w/ binoc’s or on a brightscope. If HE can claim he can’t see the airplanes, then how are the pilots supposed to do that?

        I would like to think of myself as an active, well-versed and current pilot. I take scads of webinars and other training all the time. And in my previous two lines of work, I was also similarly involved. 50 years ago, no one EVER told me about the 7110.65 (if it even existed?).. And, I doubt if any current students get any training in it, either. They study the AIM.

        • Spacing is not separation, Larry.

          If you page through the .65–usual reference is to call it the “point 65,” you’ll find standard required separation for IFR and for VFR in certain kinds of airspace. You can find much of the same information and similar language in the AIM and this is by intent.

          IFR *requires* separation, variable with airspace by 3 miles and 1000 feet in the terminal airspace. This is what ATC provides. A visual tower provides sequencing, point outs and spacing to assure what the controller thinks will provide the *required* runway separation when the whole shebang comes together at the end. It could be sequencing that puts an airplane in a mile in trail or two.

          For IFR separation, it *will* be no less than three, absent visual approaches. That’s the difference. The .65, by the way, has been around since the earth was cooling. At least since 1990 when I started writing about this stuff. I seem to recall the order existed quite some time ago but the name of it was changed. Around that time, the language in the AIM and .65 were somewhat merged in an attempt to reduce confusion.

          But the more I think about this relevant to this accident, it doesn’t matter if you understand it or not. If you know it or not. All you need to know is that it’s your job to see called traffic and avoid it. I don’t think it’s any more complicated than that.

          • I will concede that real IFR handling has to be different and more stringent in all sorts of ways. But as others have opined, I still don’t see references to VFR handling being different other than if a pilot says he has traffic, then he better damned well HAVE the traffic. That’s why when a local controller talks too fast, he’s inviting trouble. In all MY 50 years aviating, I never ever — not once — heard a CFI, a Captain, a Test Pilot, a webinar (in recent years) or anyone refer to terminal air traffic handling being different for VFR or IFR. The tower is the tower and that’s that.

            One thing IS for sure … I think your original premise of “No Lesson” wasn’t correct. I think all this jibber jabber has opened a lot of eyes. You can bet I’ll be leaning on those books once I get to my northern outpost next week.

        • Hey Larry. You’re not alone. Controllers spend their entire career arguing the point sixty five in facility break rooms. And Paul, I until recently though I was a recent ATCer kinda guy, but now realize I’m old as dirt having hire in ’68 following 4 years of ATC in the USAF. However, as I remember, prior to the .65, we had the .8 and the .9. One was terminal and the other enroute. Can’t remember which was which. But Larry, sequencing, as Paul said, isn’t separation. It is only telling you who to follow. You say”ok” and it is now totally incumbent on you to separate yourself from that traffic. And as I previously said, the tower controller, if time and attention permits (tower guy or gal frequently doing a bunch of other stuff and looking at many different situations) would certainly try their best to assist you if things start to look ugly to him/her. It is amazing to me, anyhow, how many folks just do not understand the responsibilities, or lack there of, of a tower controller. You know what I see? It’s Paul writing an article absolutely setting the record straight! How ’bout that Paul! And.. I didn’t just fall off the ATC or pilot turnip truck. I learned to fly, soloing in ’59 in the L.A basin. Got all the ratings, thanks mostly to the VA bill, and been an ATC kind guy from ’64 (USAF) until FAA retirement in ’02. And I gotta say, I was an ass kicker for some number of years as a controller at ORD. If we ain’t got ego, we ain’t got nothing. But…I really enjoy these types of discussions.

          • By your seniority, I suspect you are “old” O’Hare. So I’m sure you can explain the joke about an O’Hare 3 miles.

          • Paul. I did hear one of our ORD guys say this. “American two eighty three, slow to one seventy now, do it quick, you’re just a skinny three behind the traffic you’re following!” American said, “OK. Two eighty three is slowing. But’s what’s the difference between three and a skinny three?” Controller casually said, “About a mile and a half.”

          • I grew up less than 2 miles east of O’Hare starting in ’56. I remember Constellations rumbling by into the early 60’s when jets became de rigueur. I wonder how many people know why the ICAO for the place is ORD or who its named after.

            Next time some tower puke tells me to do something landing under VFR after I’m in line, I’m gonna unload on ’em. PB said it was OK 🙂

  7. Oh, Paul : For a guy who refused to look outside the Bristell during your entire video flight review of it on a blazing sun VFR day in busy GA Paradise Florida airspace and then shat on the guy who constructively mentioned that in the comments complete with FAA Advisory Circular refs, you sure are fixated on midairs lately! Your form of penance?

      • Well that’s a start. But I followed the link and watched the video and NEVER flew with “anyone else” who did not even show curiosity about what was going on outside the cockpit, much less demonstrate vigilance. Or who so scatalogically derided someone who pointed it out…and still no apology for that aspect. Focused on your assignment I guess… more than your survival. I’m Sure you’re not that way flying solo in the Cub but then there are far fewer panel distractions in that.

  8. The parachute accident description is very similar to one experienced by an old boy (79 — sorry that makes him a young lad here) I have got to know recently while he was in the paratroopers.
    In a routine large-scale training excercise, similar to the couple of hundred he had already done in his career, one trooper, for what ever reason, started moving across the line of the descending stick. My friend heard shouts from near misses but did not see, and did not believe what was happening till his chute and the other one, collided.
    His went into trailing rag mode and he fell, very heavily into a luckily muddy field.
    Being young and dumb he jumped up, was told he was fine by the sgt, and went back to barracks, only to wake in extremis with internal bleeding and terribly wrenched shoulder, hips and spine in the evening and spending the next four months in hospital.
    End of parachute regiment — probably a good thing as he was retrained with the much more moneyable skill of diesel mechanic.
    Now though he cannot sit for more than a couple of minutes before having to move to relieve his aching body.
    The other chap fell like a stone and died.
    Moral of the story is, I suppose, sometime accidents happen.

  9. Oddly, some people don’t know the tower doesn’t provide separation for VFR aircraft.
    Really, I’ve asked instructors, even controllers, and they dismissed me as a dumb pilot.

    There really is a problem with instruction. Many things I see as obvious are completely foreign, even to some designated flight examiners (DPEs). Because of the clear issue of IIMC crashes, I like to ask what should you do if you (or your student) goes IIMC. I ask ‘your student’ because I always get the answer, “I will never go IIMC”. I almost always get the same response, “I’ll just do a 180”, which is the worst thing you could possibly do, again for reasons I think are completely obvious, but are completely foreign to these student pilots, pilots, instructors, and pilot examiners until I explain all the reasons it is a very very bad idea to do a 180.

    As bad as it sounds, I think pilots should have to take a written exam every 1 or 2 years, not just a check ride with your local instructor. Even if that exam is just done on the FAA website, much like what is being required for Drone pilots, permitting the pilots to see the correct answer if they get it wrong. I also believe this should be combined with addressing and giving pilots remedial flight instruction in areas of obvious deficiencies. Sounds like this would suck… but it might save lives and slow the ever rising cost of insurance, going up due to poorly trained pilots.
    Drone pilots are being required to do these tests because the rules and regulations are changing almost daily. Yea, this is a bit exaggerated, but they are rapidly changing and it is the only way to make sure they are getting good correct up to date information.

    I got my first certificate several decades ago, and I still remember back then people joking about an older pilot that hadn’t flown in a while, renting an airplane, asking where a good place to fly to for lunch. He was told to fly to the Manassas airport. ‘Just fly west until you see two parallel runways. The field is uncontrolled so you didn’t need to talk to anyone’. He landed at Washington Dulles International on a taxiway.
    Things change, and he didn’t keep up with them. He didn’t know of the large Terminal Control Area (TCA) around Washington National, Dulles, and Baltimore… yes, even that is now Bravo airspace. Something obvious to every new pilot today, but not so obvious to a 1980s pilot. This seems like something that would be obviously caught during a flight review. But not all things are this obvious to all pilots.
    It use to be obvious, you don’t want to stall a plane. People stalled planes and crashed and died. So we taught people to recognize a stall and how to recover from a stall or a spin. The same isn’t done for IIMC. It is obvious you don’t want to go IIMC, but what should you do if it does happen?

    • Can you expand on why a “180 when IIMC” occurs? I recall doing exactly that manever one evening south of KRDM when I entered an invisible cloud while enroute abt 2,500′ above the highest terrain within 10 nm E or W of my southerly flight path. Obviously the maneuver worked. So, what’s the flaw?

      You wrote: “…“I’ll just do a 180”, which is the worst thing you could possibly do, again for reasons I think are completely obvious, but are completely foreign to these student pilots, pilots, instructors, and pilot examiners until I explain all the reasons it is a very very bad idea to do a 180.”

      Sorry for the thread drift… but, I’d really like to see

      • Unless the 180 turn is practiced regularly or flown by an autopilot (or you are a natural IMC pilot – some pilots are, some pilots are not), there is a good chance that the aircraft will not be in a stable attitude passing 90 degrees (most likely nose low, airspeed increasing, and load factor also increasing as the pilot pulls back harder on the yoke to raise the nose).

        If it is done well as a level, standard (or even half-standard) rate turn, 180 degrees is also around the point that your inner ear fluid will have stabilized, so when you roll out you will feel as though you are actually turning and be tempted to “correct” that turn and thus steepen the bank.

        That’s not to say continuing forward in IIMC is risk-free either. It just means that the “180 degree turn” is not the magic bullet it is often made out to be, and that it has its own risks. It needs to be practiced regularly with a competent CFI for it to be successful.

  10. After reading about this crash, I looked up the details on Cory Lidle’s fatal SR20 crash in 2006. In that one, the NTSB calculated how steep their bank angle needed to be in order to successfully make the turn. I hope they run that calculation on this one. I’m betting it’s more than 30 degrees..

  11. Great article, Paul. Safety begins and ends with the pilot. For good reasons all the FARs point in this direction. A couple of phrases that I have found useful: “You are the only thinker in your universe” meaning nobody else can do your thinking for you, so do it right. And, to borrow one from dog training, “The dog is managed by a jerk at the end of the leash” Sometimes the jerk is at the airplane’s controls.

  12. This thread has strayed away from a very important point Paul made about teaching pilots to think and build a mental 3-D picture of our environment.

    Situation awareness is what allows us to safely operate in proximity to other airplanes whether we gain that awareness with our eyes or our ears and preferably both. The ability to synthesize these inputs into an accurate and actionable mental picture is a skill all pilots need to develop and practice to stay proficient.

    Consistent pattern operations, a pilot’s personal Standard Operating Procedures if you will, frees up brain capacity to build the mental picture because you don’t have to think about power settings, speeds, and all the other standard things that apply to every traffic pattern and landing operation. You do it the same way every time, with exceptions as conditions dictate based on your awareness of the situation.

    Everything we do as pilots, from flight planning to weather interpretation to communication and execution risk mitigation revolves around our ability and capacity to think, synthesize information, make good decisions, and take appropriate actions.

    My take-away from this accident is reinforcement of the need to fly a consistent airplane in a predictable manner, look and listen to keep my mental picture fresh, and recognize when the hair starts standing up on the back of my neck I need to execute my Plan B to exit the situation and try it again. But the last parts relies on having situation awareness, and we have to be able to think to develop and maintain that.

    • Holy damn smoke! Mike, of TOA and Champ 2982E fame! Yes…me…only 57 years since we last saw each other. Hope you are doing great! Here’s a kinda unused email address of mine. So if it gets spammed, I don’t really care. Give me a holler there and let me know what’s going on with you these days. Roger 11ac@comcast.net

    • Holy damn smoke! Mike, of TOA and Champ 2982E fame! Yes…me…only 57 years since we last saw each other. Hope you are doing great! Here’s a kinda unused email address of mine. So if it gets spammed, I don’t really care. Give me a holler there and let me know what’s going on with you these days. Roger

      Mike. This might be posted twice or not at all. I tried to put and email address in it and got bounced. Let me try this.
      eleven alpha charlie at comcast dot net

  13. After viewing and reviewing all the links offered by Paul and others, I looked at Dan Gryder’s conclusions recently posted on YouTube. One glaring observation that I was unaware of at this airport is the centerlines of 17L and 17R are only 700ft apart. He pointed out that it only takes 2.8 seconds to travel that 700ft at the ground speed the Cirrus was traveling because of the current density altitude including the prevailing tailwind at that time. Draw your centerline out a couple of miles and it becomes more difficult to “see” a 400-700 ft overshoot.

    Since both runways were being controlled by two controllers on separate frequencies, my understanding of what I heard from ATC to the Cirrus pilot did not include the Metroliner as a target aircraft of conflicting traffic. It was the Cessna ahead that was the focus of attention for the Cirrus pilot and the controller working 17R. There was a lot of emphasis on following that particular airplane. The Cirrus acknowledged that airplane a couple of times. Likewise, the Metroliner was the focus of the controller handling 17L. But I don’t remember if the controller handling 17L mentioned anything about the proximity of the Cirrus to the Metroliner.

    I know Key Lime’s airplanes very well including their single pilot operation. Key Lime’s Metroliners do NOT have autopilots installed. They are entirely hand flown. As demonstrated by this particular pilot, he knows how to precisely hand-fly his airplane. He had no idea he was involved with a mid-air collision. All he knew was the right engine had quit for an unknown reason. There was no possible way to visually see the position of the Cirrus above and behind him other than potentially seeing him while the Cirrus was still on right downwind, still higher than him going the opposite direction. I would have never expected the controller to permit a right base turn before the Metroliner had passed while still on opposing courses. Once again, I don’t think the Metroliner driver knew about the Cirrus on a right base for 17R.

    It is hard to see and avoid if you already think you have seen all the airplanes close to you and have so far, identified, confirmed, and are following the airplane you are assigned to follow. With such tight parallel runways, an overshoot on a VFR day, with a known tailwind component for one runway, at the normally high density altitude has been a well known problem for a long time by the local controllers. Enough so that they were in the process of advising the Cirrus not to overshoot the center line of 17R when the two tangled. The Metroliner’s pilot is on short final, hand flying his airplane like it was on rails, making sure one more time his GUMP checks, while doing a perfect VFR approach, I believe never knowing about the Cirrus. How do you avoid what you don’t know is there. I get on short final, I am not looking at my ADS-B display. I am looking out the window with all that my cockpit allows for anything including birds, animals, and other airplanes on the ground. That is a lousy time to do a clearing turn to “see” if someone is performing right traffic above and behind me in my blind spot and come up with an avoidance maneuver just in case.

    Gryder claims ATC has already implemented changes in protocol at that airport to mitigate future repeats of this accident. He did not say what they are. There is enough information stored on that Cirrus’s glass panel that has offered a lot of information that we are currently unaware of. There is all the tower recordings to go through. And the ADS-B readouts in the Metroliner. In this case Gryder lays the bulk of the blame on the tower controllers.

    “Do people not have this sense of elevated risk? I think they know it intuitively and have it reinforced in training. Maybe what we need is to figure out not how to beat more specific procedures and memory tasks into pilots, but how to get them to self-diagnose complacency to keep it from eroding basic survival awareness. In other words, we all know what to do to confront the risks; we just have to know when we’re faced with them.” Sage comment to say the least. I think the this need for self-diagnosis of complacency also extends to ATC personnel as well. We all need to know when we are faced with elevating risks. Easy to spot from the comfort of home in the easy chair looking at YouTube videos of various sources looking for probable cause. Not so easy when we are flying airplanes including intertwining with ATC who is charged with assisting us as we do what we do.

    I never got the impression, from any of the pilots involved, or from what I could hear from the two tower personnel in charge of VFR arrivals on 17L and 17R at that time, they were aware of any elevated risks until the advisement to the Cirrus pilot not to overshoot. It certainly got my attention when the Cirrus was cleared to land as number two making an immediate right base for 17R in response to that clearance before he passed the Metroliner. My first impression is why the controller allowed for that.

    I don’t remember any training discussion about the different responsibilities for the tower based on VFR or IFR arrivals when I learned to fly. I never studied the FAR’s regarding these differences because I never thought about asking the question is there different criteria based on VFR vs IFR arrivals at a tower controlled airport. I took my check-ride at a tower controlled airport. If it was busy for whatever reasons VFR ( I don’t fly IFR other than following roads) , they called an airplane’s base or extended a downwind to maintain adequate spacing. Sometimes I saw the conflicting traffic, sometimes I did not. As I have stated before, I would make a lousy fighter pilot because spotting little or big airplanes from my little airplane is not intuitive nor easy for me. I am no Chuck Yeager by any stretch of the imagination. While I will perform an evasive maneuver to avoid being hit should I see a problem first and ask questions later, I was never aware there are different ATC traffic separation rules dependent upon a VFR or IFR arrival. Now I know.

    That will slightly change my strategy when arriving at my local airport of cross country destination tower controlled or not. My expectations of the tower and myself is no slightly changed, too. So, for me, this was a learning experience…a teaching moment. I appreciate all the comments and Paul’s candor in writing this blog. I have learned something new and am thankful for it. I am thankful no one got hurt in this learning curve. Keep up the good work Paul. Keep checking those buckles, risers, chute, and proximity checks too.

  14. If bored, here is the FAA Order 7110.65. It is the ATC instruction book for controllers. It covers every type of ATC operation. However, chapter 3 pertains to control tower VFR type operations. Just scroll down to chapter three, thumb through the subsections, click on one, and it will take you there. Actually, the entire chapter isn’t really that long or complex compared to some of the rest of the Order. It is best enjoyed while sipping an adult beverage.

    https://www.faa.gov/documentLibrary/media/Order/7110.65Z_ATC_Bsc_dtd_6-17-21.pdf

  15. “Errare humanum est.” Yes, the pilots made serious mistakes. However, the environment invited the accident. Two parallel runways (probably separated by a short distance), a mix of airplanes (including a jet), lack of radar…

    The only way, in my opinion, to improve safety in small planes is technology and training. Does anyone truly think that the airline pilots pilots of yesteryear were less competent? The scheduled flight accident rate is zero because technology and good management have made flying safer. Technology alone is not enough (read any of the recent Tesla accidents), and indeed pilots need to be correctly trained, but let us not go crazy blaming the pilots.

  16. “OUR” positions agree 100%, Jim. The tower controllers ARE fallible. And the systems employed to operate a parallel runway airport are fallible. The use of two different frequencies and focusing the Cirrus’ pilot on the Cessna are contributing factors in this accident. They shoulda been steering him away from that Metroliner and THEN turning him … whether they could see him, or not. IF they couldn’t see him, then they should never have turned him toward Cherry Creek reservoir. That’s MY position.

    On one of MY very close NMAC’s taking off from the Gaston’s White River Resort, AR (3M0) runway 6, the unicom for the nearby airline destination at Baxter County airport (KBPK) runway 5 is different and the course lines intersect because of close proximity. I was pilot flying in a friend’s Bonanza from the right seat. Looking at instruments to the left, I saw a fast moving shadow cross the L wing and instinctively went into a Linda Blair move looking for it. Right next to us on the right wing was a Lone Star airlines Metroliner in a very high rate of descent. I could tell you what color shirts and ties they were wearing. It was VERY close. THEY never saw us and neither of us knew of the other’s existence. I later called the Ops Officer at that airline (this is nearly 30 years ago) and you know what he said … “Our crews are used to doing ‘slam/dunk’ approaches.” I guess close only counts if you’re playing horseshoes. My point is, being on different frequencies for runways THAT close is an accident waiting to happen. In my case, we lived. In this case, they lived too … but two airplanes died. I made a recommendation to the FAA about putting both airports on the same frequency and now I see — 30 years later — they’re STILL not??

    I would like to know more about what changes you’ve heard about at Centennial tower. I already said that, “I’m betting there’ll be some big changes to parallel runway ops as a result of this one.”

    I think a LOT of us have learned something from this article. Airplane engines have TWO mags and spark plugs/cyl for a reason … redundancy. If someone tries to tell me a singular command to watch out not to overshoot 17R’s centerline is sufficient to relieve tower of safety responsibility … I’ve got a bridge I’d like to sell. You can sit near LAX on a cold, clear winter night and see airliners lined up from 150 miles east for a reason. You didn’t hear me say it was OK for the Cirrus pilot to be descending and moving at 188kts, but there are / were other factors in play here.

  17. Aren’t check rides and constant study all about reminding us again and again for the sake of safety? I worked with a fellow who was the chief safety officer aboard two or three aircraft carriers. He conducted fire drills once a week.

    I asked him how his crew would react when there was a real emergency. Here’s what he said, “Ha! They’d forget everything and run around like chickens with their heads chopped off!”

    It’s his opinion, as well as mine, that you cannot be reminded too often of the dangers inherent in any task..

    • Realize the quote relayed from the Safety(O) was meant to illustrate the point that training helps focus response, but I never saw anyone on a flight deck running around like a headless chicken, even when putting out a fatal post-mishap fire. Most dangerous place I’ve ever been was a flightdeck at night, more ways to die in a instant than any of us faced in the cockpit…oh, and most are give/take 20 years old, my hats off to any of them who may be reading.

      They were focused because they understood that if they screwed up, people, and likely they too, would die. Maybe that focus is the missing ingredient in our GA flying.

      I’ll save the comments for another day comparing 15-20 aircraft not smacking into each other over a moving airfield in non-radar “uncontrolled” no comms 400 kt arrivals…suffice it to say “focus” and the desire not to be “that guy”.

  18. My home airport for the last 30 years has two sets of parallel runways and back a few years they were so busy that there were always 5 or 6 aircraft in each pattern and they were almost always on different frequency’s. None of us ever had to be told not to over run centerline….it was a given especially if you expected to live to fly another day. In those thirty years there was no midair. The cirrus pilot had his head up his —– on all counts if you have traffic you follow it period. I have often had to reply “Looking for traffic” or “Traffic in sight” I fly a high performance Cessna 210 and surly do not enter a pattern at 188knts.

    • I used to be at one of the busiest fields in the USA; with parallel runways and split frequencies. You learned early that people “training” don’t always do things perfectly. Just because you did not hear the trainers heading for the parallel did not mean you did not constantly check/verify in that direction. Constantly.

      Today with ads-b, I still have that “trust but verify” attitude anytime I’m knowingly elbow-to-elbow with training aircraft. So called controllers, as in this case, issued instruction to the Cirrus only as the impact was happening. Zero caution was issued to the Metroliner and the controller on that frequency did not seem to even realize what had happened even as the “engine problem” was reported.

  19. Good article, but I think your best point comes in the seventh paragraph when you made the observation that you had not taken the proper steps for a safe jump, even though you had done it dozens of times before. To me the biggest dangers we face in any complex and hazardous activity are complacency and distraction – what you call thinking about thinking. Flying has several components that are repetitive, at least on the surface, but never identical. Landing is one of them. We follow the same steps on every landing, but each one is different than the last, or the next. You can proceduralize the steps, but never make it totally mechanical. Sometimes, complacency creeps in and we start getting a little sloppy in the process. Then a distraction pops up. Maybe the Cirrus pilot was used to flying into a single runway airport and the importance of not overshooting the centerline did not fully register. Or, looking for another airplane off to the side rather than in front of or behind him caused him to drift over the centerline while looking out sideways. In a retractable gear airplane, distraction is the proximate cause of most gear-up landings. Anything that takes us out of the norm should be a point for us to pause and think about where we are and what is going on, then think about what needs to be done. Years ago, I was watching a football game on TV where one of the teams was about to try a field goal. As the kicker got ready, he walked up and tapped the holder on the helmet, then took position. The commentator said that in a pre-game interview he asked the kicker why he did that. The kicker replied that in the noise and chaos of an actual game, the holder tended to get distracted and not concentrate on ball placement. The tap on the helmet caused him to think about the process and shut out the outside distractions. At the time I though it was funny, but I have come to realize that all of us could use a tap on the head whenever we are dealing with a complex situation.

  20. “Approaching the airport, however, the reverse is true. There’s little or no time for anything but eyes outside; not using ADS-B to find traffic you should acquire visually, because visually is how you’re going to avoid it.”

    Funny thing… recently I was doing pattern work. I extended the downwind at the tower’s request because of traffic on final. I had just gotten visual on the traffic on final when tower called my turn to left base. About two seconds later the Glasair that had taken off behind me, blew past my left wingtip (very likely hadn’t seen me). I thought, “mental note – check the ADS-B more often when in the pattern.”