Aerodynamic Stall / Spin: Cirrus SR22 GTS G3, N544SR; fatal accident occurred February 29, 2012 in Melbourne, Florida

National Transportation Safety Board - Aviation Accident Final Report: http://app.ntsb.gov/pdf

National Transportation Safety Board - Docket And Docket Items: http://dms.ntsb.gov/pubdms

National Transportation Safety Board - Aviation Accident Data Summary: http://app.ntsb.gov/pdf


NTSB Identification: ERA12FA196
14 CFR Part 91: General Aviation
Accident occurred Wednesday, February 29, 2012 in Melbourne, FL
Probable Cause Approval Date: 12/19/2012
Aircraft: CIRRUS DESIGN CORP SR22, registration: N544SR
Injuries: 3 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

Several airplanes and a helicopter were in the traffic pattern at the tower-controlled airport performing simultaneous operations to parallel runways (9L and 9R) around the time of the accident. The accident pilot contacted the tower air traffic controller while south of the airport requesting a full-stop landing; the controller advised the pilot to report when the airplane entered the downwind leg of the traffic pattern. The controller subsequently cleared the accident airplane to land and expected the pilot complete a "normal" downwind traffic pattern and land behind the airplane already established on final approach for runway 9R; however, the controller did not provide sequencing instructions. The accident airplane proceeded directly to a tight right-base entry into the traffic pattern for landing on runway 9R, contrary to the controller’s original expectation but permissible based on the clearance to land. The controller radioed the accident pilot to confirm that he had visual contact with the airplane on a 1-mile final approach for runway 9R (the traffic was 300 feet below and 1 mile west). This was the first indication by the controller to the accident pilot that there was additional landing traffic sequenced to the same runway he had been cleared to land on. The accident pilot replied that he was on a "real short base" for runway 9R, and the controller responded, "no sir, I needed you to extend to follow the [airplane] out there on a mile final, cut it in tight now, cut it in tight for nine right." The two airplanes had closed within 1/2 mile of each other, but were still separated by 300 feet altitude. The pilot of the airplane on short final for 9R maintained situational awareness throughout, perceived the conflict before the controller or the accident pilot, and responded calmly and benignly to the conflict. The accident pilot needed only to arrest his descent, at a minimum, to avoid any collision. A flight instructor and an airline pilot both described seeing the accident airplane pitch up, bank left, then roll inverted. The flight instructor stated that this action occurred as the controller was "yelling at" the pilot. Both witnesses described what they saw as "an accelerated stall." Data extracted from the multifunction and primary flight displays revealed that the airplane pitched up and rolled inverted to the left at the same time that engine power was increased rapidly. When engine power is increased, a pilot must apply sufficient right rudder to counteract the left-rolling tendency, particularly if the airspeed is slow and the angle of attack is high, as it would be during landing. When instructed by the controller to "cut it in tight," the accident pilot over-controlled the airplane, lost control, and impacted terrain. Contributing to the traffic conflict was the controller’s lack of upfront sequencing instructions or subsequent sequencing instructions when the accident aircraft was cleared to land. Examination of the data and a postaccident examination of the wreckage revealed no preimpact mechanical anomalies that would have precluded normal operation.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's abrupt maneuver in response to a perceived traffic conflict, which resulted in an accelerated stall and a loss of airplane control at low altitude. Contributing to the accident was the air traffic controller's incomplete instructions, which resulted in improper sequencing of traffic landing on the same runway.

HISTORY OF FLIGHT

On February 29, 2012, about 1701 eastern standard time, a Cirrus SR22, N544SR, was substantially damaged when it collided with terrain following an uncontrolled descent while maneuvering for landing at the Melbourne International Airport (MLB), Melbourne, Florida. The certificated private pilot and two passengers were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.

Review of air traffic control information revealed that there were several airplanes and a helicopter in the traffic pattern at MLB, performing simultaneous operations to parallel runways, around the time of the accident. About 1658, the accident pilot contacted the MLB air traffic control tower (ATCT) from a position 5 miles south of the airport, and requested a full-stop landing. The pilot was instructed to report when the airplane was on the downwind leg of the traffic pattern for runway 9 Right (9R). Shortly after, a Cirrus SR20, which was on an approximate 5-mile final approach for runway 9R, was cleared for a touch-and-go landing. At 1700:02, the controller advised that the pilot could either land on runway 9R, or extend the downwind leg for approximately 6 miles to follow a Cessna landing on runway 9 Left. The accident pilot responded, “9 right’s fine,” and requested a long landing in order to reduce taxi time to the fixed-base operator (FBO). At 1700:16, the ATCT cleared the accident airplane for landing on runway 9R.

At 1700:47, the ATCT radioed the accident pilot to confirm that he had visual contact with the Cirrus SR20 on a one-mile final approach for runway 9R. The accident pilot replied that he was on a “real short base” for runway 9R. At 1700:57, the ATCT then instructed the accident pilot, “no sir, I needed you to extend to follow the Cirrus out there on a mile final, cut it in tight now, cut it in tight for nine right.”

At the time the accident airplane was advised of the landing traffic on final approach for the same runway, the conflicting traffic was about 300 feet below and 1 mile to its west. At the time the accident airplane was advised to "cut it in tight" to Runway 9R, the two airplanes had closed to within one-half mile of each other, but were still separated by 300 feet of altitude.

A flight instructor and a student pilot were flying the Cirrus SR20 on final approach for runway 9R at the time of the accident. According to the instructor, his airplane was on a one-mile final when he heard the accident airplane announce a "short right base" for runway 9R. He assumed control of the airplane from his student, increased engine power, and began a "shallow climb/turn" to the left towards the grass infield between the parallel runways.

The flight instructor further stated, "[The airplane] was northbound on a right base for 9R. He began a 30-45 degree bank turn to the left in front of us at our one o'clock. I didn't have to make any abrupt maneuvers to avoid the traffic but I continued my turn/climb to the left and started to go-around…[The controller] was yelling at him on the radio. I don't remember the exact words but the more tower yelled, the more the aircraft yanked and banked. I then witnessed an accelerated stall, 90 degree bank angle with a one to two turn spin that ended up nose first into the ground."

The first officer of an airliner witnessed the accident from the cockpit of his airplane while parked on taxiway Alpha, facing west, while waiting for a takeoff clearance from runway 9R. He said the accident airplane was "about 200-300 feet AGL, appeared slightly fast, and in a right turn of 30-40 degrees of bank descending for the runway.” The airplane then made an "abrupt" left turn, while simultaneously leveling or "attempting to climb" and "clearly initiated an accelerated stall" about 150-200 feet above the ground. The airplane continued to roll left until inverted, and then descended nose-down to ground contact.

The first officer, as well as other witnesses who gave similar accounts, observed the Cirrus Airframe Parachute System (CAPS) deploy from the airplane prior to ground contact.

PERSONNEL INFORMATION

According to FAA records, the pilot held a private pilot certificate with a rating for airplane single engine and instrument airplane. His most recent third-class FAA medical certificate was issued on June 24, 2010. He reported 365 total hours of flight experience on that date.

A review of the pilot’s logbook revealed that he had logged 515 total hours of flight experience, of which 296 were in the accident airplane make and model. The logbook showed that the pilot’s last biennial flight review was conducted on April 30, 2009.

AIRPLANE INFORMATION

According to FAA records, the airplane was manufactured in 2007. It was a four-seat, low-wing airplane of composite construction that was equipped with a Teledyne Continental IO-550-N, 310-hp reciprocating engine. The airplane’s most recent annual inspection was completed in August 2011, at which time the airframe had accumulated 1,250 total hours.

The maximum allowable gross weight for the airplane was 3,400 pounds. Based on occupant weights and the airplane’s fuel load, the estimated gross weight of the airplane at the time of the accident was 3,379 pounds.

METEOROLOGICAL INFORMATION

The 1753 recorded weather observation at MLB included wind from 130 degrees at 13 knots gusting to 18 knots, clear skies, 10 miles of visibility, temperature 24 degrees C, dew point 20 degrees C, and an altimeter setting of 30.11 inches of mercury.

FLIGHT RECORDERS

An Avidyne Primary Flight Display (PFD) and Multifunction Display (MFD) were recovered from the wreckage and forwarded to the NTSB Recorders Laboratory in Washington, DC.

An NTSB recorders specialist downloaded the data from both displays and prepared a Specialist's Factual Report. According to the report, the engine and flight data were consistent with the airplane descending on a northerly heading. During the last minute of the flight, the airplane was descending at about 500 feet per minute, as it slowed to about 100 knots airspeed.

At 17:00:56, engine rpm increased from about 1,500 to 2,000 rpm, and the airplane rolled left until it was inverted. At 17:00:59, the airplane began to pitch down, and reached an approximate 65-degree nose-down attitude and about 2,000 feet-per-minute rate of descent. The last data was recorded on the airplane at 17:01:04. Neither autopilot nor flight director were used during the accident flight.

WRECKAGE AND IMPACT INFORMATION

The airplane was examined at the accident site on March 1, 2012, and all major components were accounted for at the scene. The wreckage all closely surrounded the initial impact crater. The three-bladed propeller was buried in the crater, and separated from the engine at the propeller. Once unearthed, one blade was found separated, and two blades remained in the hub. All three blades displayed similar aft bending, leading edge gouging, and chordwise scratching. The engine was removed from the crater, separated from the wreckage, and moved to a hangar for examination.

The engine compartment, firewall, instrument panel, and cockpit and cabin area were all destroyed by impact. The empennage and tail section remained largely intact. Control cable continuity was established from the flight control surfaces in the tail to the cockpit area. Control cable continuity could not be established to the control surfaces in the wings due to multiple cable breaks; however, all cable breaks displayed signatures consistent with overload failure.

The CAPS parachute was found deployed, and entangled in the wreckage. Witness statements and the location of the CAPS components at the wreckage site were consistent with a low-altitude deployment.

The engine was examined at MLB on March 3, 2012. The engine was rotated through the secondary alternator drive pad, and approximately 180 degrees of rotation was achieved. Rotation was limited by impact damage to the crankshaft at the propeller flange, and several bent pushrod housings. The crankshaft separation exhibited overload signatures with cracking perpendicular to the longitudinal axis of the shaft. Fuel was observed at the fuel pump outlet, and inside the pump. The fuel manifold valve was removed, and disassembly revealed several ounces of fuel inside. All fuel was absent of water and debris.

The upper spark plugs were removed, and the electrodes were intact and ashen in color. A borescope examination of all six cylinders revealed normal wear, and no abnormal deposits. Both magnetos were removed, and the right magneto produced spark at all six towers. The left magneto was impact damaged, and could not be rotated. Disassembly revealed that the magneto driveshaft was bent by impact.

The oil pump displayed normal function when the engine crankshaft was rotated. The pump was removed, and the oil captured was clear and absent of debris. The interior of the oil pump housing did not reveal any evidence of hard particle passage.

ADDITIONAL INFORMATION

Air Traffic Control

On March 5, 2012, an air traffic control group was convened by an NTSB air safety investigator (air traffic) at the MLB air traffic control tower. The NTSB investigator toured the facility, conducted interviews, reviewed voice and radar recordings, and prepared a factual report.

According to the report, the controller expected the accident airplane to report when it entered the downwind leg of the traffic pattern as instructed, and subsequently complete a “normal” traffic pattern and land behind the Cirrus SR20 on final approach. However, examination of communications recordings revealed that the controller cleared the accident airplane to land, but did not provide sequencing instructions. The accident airplane then proceeded directly to a right-base entry into the traffic pattern for landing on Runway 9R.

According to FAA-H-8083-25, Pilot’s Handbook of Aeronautical Knowledge:

“The effect of torque increases in direct proportion to engine power, airspeed, and airplane attitude. If the power setting is high, the airspeed slow, and the angle of attack high, the effect of torque is greater. During takeoffs and climbs, when the effect of torque is most pronounced, the pilot must apply sufficient right rudder pressure to counteract the left-turning tendency and maintain a straight takeoff path.”

According to FAA Advisory Circular AC-61-67C Stall and Spin Awareness Training:

“Center of Gravity (CG). The CG location has a direct effect on the effective lift and AOA [angle of attack] of the wing, the amount and direction of force on the tail, and the degree of stabilizer deflection needed to supply the proper tail force for equilibrium. The CG position, therefore, has a significant effect on stability and stall/spin recovery. As the CG is moved aft, the amount of elevator deflection needed to stall the airplane at a given load factor will be reduced. An increased AOA will be achieved with less elevator control force. This could make the entry into inadvertent stalls easier, and during the subsequent recovery, it would be easier to generate higher load factors due to the reduced elevator control forces. In an airplane with an extremely aft CG, very light back elevator control forces may lead to inadvertent stall entries and if a spin is entered, the balance of forces on the airplane may result in a flat spin. Recovery from a flat spin is often impossible. A forward CG location will often cause the stalling AOA to be reached at a higher airspeed. Increased back elevator control force is generally required with a forward CG location.

“Weight. Although the distribution of weight has the most direct effect on stability, increased gross weight can also have an effect on an aircraft's flight characteristics, regardless of the CG position. As the weight of the airplane is increased, the stall speed increases. The increased weight requires a higher AOA to produce additional lift to support the weight.

“Accelerated Stalls. Accelerated stalls can occur at higher-than-normal airspeeds due to abrupt and/or excessive control applications. These stalls may occur in steep turns, pullups, or other abrupt changes in flightpath. Accelerated stalls usually are more severe than unaccelerated stalls and are often unexpected because they occur at higher-than-normal airspeeds”

 

11:46 AM, December 9, 2012
 Written by  Susanne Cervenka and Andrew Ford
FLORIDA TODAY

Federal investigators and outside observers have raised questions about the staffing levels and training at air traffic control towers run by private contractors, questions that were echoed in a recent report about a plane crash at Melbourne International in February that killed three Brevard County men.

Private companies, not the Federal Aviation Administration, provide air traffic control service at many airports around the country, including at Melbourne International Airport.

The cost of running a running an air traffic control under private contract is far lower than towers staffed by FAA employees. Studies have found that such contract towers provided an adequate level of service.

“Contract towers have their place, but under the current system they push the responsible limit of the margin of safety with short staffing, unreliable equipment, and a lack of technical support for the equipment,” National Air Traffic Controllers Association Executive Vice President Trisha Gilbert told a congressional panel this summer.

Among the concerns raised in the Department of Transportation’s Inspector General’ report released last month:

• Contract towers are staffed at lower levels than comparable FAA towers. An audit of similar airports showed that contract towers on average had about six air traffic personnel while FAA towers had 16. That — combined with lower pay for the private controllers — was the reason why the contract towers cost an average of $536,000 to run vs. $2 million for the FAA towers.

• Contract towers actually reported fewer safety issues than FAA tower in 2009 and 2010 studies. But the inspector general concluded that the main reason was because contract controllers didn’t know the definition of a “runway incursion” — an incident involving on unauthorized person, vehicle or aircraft on a runway — or the criteria for classifying such incursions. After the FAA emphasized the importance of runway-incursion prevention to contractors, reports of such incursions at contract towers jumped sharply.

The report also encouraged the inclusion of contract towers into the FAA’s voluntary reporting system that allows controllers to report safety issues without risking losing their jobs.

• Controller certification can take as little as 30 days at a contract tower, while at an FAA facility it could take from one to five years. The report did note that controllers at contract towers have to have the same certifications, and that contractors typically hire controllers who are already licensed and are former FAA or military controllers, while the FAA generally hires new employees with little or no air traffic experience and trains them.

“Thirty days is simply not sufficient to train a controller, regardless of experience,” Gilbert said in her testimony to Congress.

NTSB report

Last month, the National Transportation Safety Board released its factual report surrounding the February accident that killed pilot, Robert Kurrus, 44, owner of Premiere Theaters Oaks Stadium 10 in Melbourne, along with two of his theater managers James Franklin, 24, and Justin Gaines, 25, both of Palm Bay.

Kurrus’ Cirrus SR-22 plane crashed as it apparently attempted to avoid colliding with another small plane on final approach to Melbourne International. Both planes had been given permission to land on the same runway, but were not told the order in which they should land.

While the report didn’t identify a probable cause of the accident — that will come with the final report in a few weeks — it did paint a picture of an air traffic control tower operating below its typical staffing level and raised questions of whether a key piece of safety equipment was working at the time of the accident.

Typically there would have been three air traffic controllers working in the Melbourne tower at the time the accident occurred, but one had been given permission to leave early. The manager of the tower said it common to have only two controllers in the tower. When asked if the tower had enough controllers, the manager said the company had an additional controller “coming on board” and was awaiting a interim security clearance for the new controller.

Immediately following the accident, the controller who had working with the plane that crashed became distraught and could no longer function, leaving just one controller working. The tower manager arrived at the tower about 25 minutes after the accident. He began assisting the one remaining controller while also fielding phone calls, notifying other nearby airports and contacting all the required agencies.

He attempted to contact another controller to report to work, but was forced to leave a voicemail.

Investigators later questioned the manager about training procedures at the tower. The manager said that whenever supplemental or refresher training was required, the controllers would complete the online training on a computer in the break room and initial a list posted in the tower.

When asked if he could provide proof that the actual training had been completed, the manager said that all the previous records involving computerized training had been erased when the FAA switched to its new tracking system.

Investigators also asked why the training folders for all the controllers had the same completion date for the past four years. The manager, who splits his time between administrative duties and working as a controller in the tower, told the tower that “he was the training manager, quality assurance manager, secretary and everything else in between, so he just put the same date for all completed training events for the past six months.’’

Investigators asked if either of the two controllers in the tower at the time of the accident had heard the aural conflict alarm, which would have alerted them to two planes being too close together, going off.

The controller handling the plane that had crashed said he did not remember the alarm going off, but noted that “it goes off every day all day.” He said not remember what volume level he had the alarm set to. He said he did remember having received all of his refresher training on the alarm, even though his training indicated he had completed the required training on the same day every year.

The other controller said he did not hear the alarm go off, but said that it was normal not to hear it because it goes off so often that controllers have become desensitized to it.

The controller said he had never seen the alarm tested, but assumed that it was done on a day he doesn’t work. FAA rules require that alarm be tested prior to each shift.

Officials at Robinson Aviation, which runs the tower at Melbourne International Airport, declined to comment on the contract towers overall as well as the specifics regarding it local operations.

250 contract towers

The federal contract tower program began in 1982 as a result from an air traffic control strike the previous year, which ended when then-President Ronald Reagan fired thousands of controllers. The program was a way to return air traffic controllers to low-activity towers closed as a result of the strike.

In 1994, Congress approved funding to convert more low-activity, FAA-run towers to contract operations. Air traffic control operations at Melbourne International Airport joined the contract program in the mid 1990s.

The federal contract tower program has regularly been reviewed, most recently by the U.S. Department of Transportation Inspectors General, which deemed the program safe and cost-effective, but needing more oversight by the FAA.

About 250 air traffic control towers in 49 states operate under private contractors.

And one former air traffic controller who now works for a union that represents controllers who work for private contractors said that, while he considers the Federal Contract Tower program a good one, the glue that makes it work is often the on-duty controllers themselves.

“The controllers have made it work regardless of what they have to put up with,” said Jerry Tuso, president of the executive board for the Professional Air Traffic Control Organization. “They are very success-oriented, strong-ego types.”

The National Air Traffic Controllers Association said contract tower operations can’t be compared those run by the FAA because of differences in the principles of how each are run. The labor union represents air traffic controllers at FAA-run towers and 63 contract towers, including those who work for Robinson Aviation at Melbourne International.

In testimony before a Congressional committee this summer, NATCA executive vice president Gilbert said FAA operations are based on the idea of putting safety before all other factors, while contract towers have “incentive to prioritize the bottom line.” And that, she said, leads to differences between staffing levels and equipment and facility maintenance at contract and FAA towers as well as a potential for flawed safety data at contract towers.

Tuso described Robinson Aviation as being more “employee-oriented” than other air traffic control contractors. The flaw, he said, is that all of the contracts are competitively bid, so contractors risk losing awards if they push for additional funding .

“They don’t want to bring up anything to the FAA. It’s a pass-through situation,” he said.

“Would you want your surgeon to be selected by low bidders?”

The contract tower program has allowed more airports across the country to have controllers, as opposed to an uncontrolled runway where pilots are responsible for spacing, said Martin Rottler, lecturer at Ohio State Center for Aviation Studies.

“The contract tower program has been in place for many years and it is overseen by the FAA and the controllers that operate in that environment are held to the exact same standards.” Rottler said.

He stressed the importance of waiting for the final report from the NTSB, which will likely determine the probable cause for the crash.

“We have to wait and watch and see what the experts are saying,” he said.