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Every time I watch AOPA's Accident Case Study video Communication Breakdown, I'm left wondering. Here's an aircraft (in this case, '1DA) on final approach for landing on a towered airport, when another aircraft ('4SR) is cleared to enter the traffic pattern, and gets cleared to land before they turn base, without ATC mentioning the aircraft already on final. One could make an argument that the pilot of '4SR should be aware of '1DA, but somehow, they apparently weren't. Once the pilot of '4SR is made aware of the traffic already on final, they make what I can only describe as a hasty attempt at an evasive maneuver which results in '4SR crashing into the ground, killing everyone aboard '4SR.

Yes, this is a towered, controlled airport; ATC should be the one to inform the incoming aircraft about the one on final. But for some (here unimportant) reason, ATC fails to do so.

To make matters worse, '1DA is flown by a student pilot and instructor, so there's two people there, either of whom (and certainly the instructor) can use the radio.

In such a situation, why wouldn't the pilot of '1DA speak up?

'1DA was still some distance out from the airport. It seems to me that besides the obvious of maintaining situational awareness, there were several rather obvious options available here:

  • No later than when the pilot reported being on base, ATC could (maybe should) have instructed the pilot of '4SR to make a right turn to re-enter the downwind leg, and to then extend downwind and land behind '1DA. Yes, reentering the downwind leg from the inside would be unusual, but it seems as though it would have kept them well out of the path of '1DA on final.
  • ATC could have told '1DA to go around when the controller realized that '4SR was unaware of '1DA, allowing '4SR to land ahead of '1DA; things could be sorted out once both where on the ground (the video mentions this possibility).
  • The pilot of '1DA could have made a position report specifying being number one on final for the same runway, when ATC didn't mention them to '4SR.
  • The pilot of '1DA could have aborted their landing and executed a missed approach, announcing this, effectively letting '4SR land ahead of them.

Any of those (and probably a few other) options seem like it could have prevented the accident altogether, at the cost of a relatively minor inconvenience to either '4SR or '1DA. So why would no one do anything until it was (obviously in retrospect in this particular example case) too late?

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    $\begingroup$ I've been cleared to land (without saying "follow XYZ") while another aircraft was on final. It is expected that the aircraft will still follow the standard pattern which if 4SR had done, would have put them behind 1DA. Instead 4SR understood that as "land now" and turned immediately to base, which was very wrong. I can't listen to it now, but the controller should not have said (if I remember right): "Cut it in, cut it in tight for [rwy]". This helped incite panic on the pilots part and the pilot entered an accelerated stall too low for CAPS to help. $\endgroup$ – Ron Beyer Sep 26 '18 at 21:00
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    $\begingroup$ The crew of '1DA did not realise something was amiss any sooner than the controller did, when '4SR reported base. At that moment, it is still better to give the controller chance to react first as they usually have best idea of the overall situation. Meanwhile, '1DA was making sure they see '4SR as maintaining visual separation was their safest fallback solution (and they did see them as they confirm to tower they saw the '4SR's fatal manoeuvre). $\endgroup$ – Jan Hudec Sep 27 '18 at 21:44
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why wouldn't the pilot of '1DA speak up?

The simple answer is that you are not trained to "speak up" at a towered airport, you are trained to follow instructions from the tower and there is an assumption the tower will provide separation and appropriate clearances. As an ultimate fall back you are always supposed to "see and avoid".

For the official report you should reference the NTSB report but if you listen to the ATC audio in the linked video as well as their explanation of the link the pilots had no reason to think there was an issue and the clearances given were rushed but explicit. As I note above AOPA also notes

"it is a pilots responsibility to visually confirm final approach"

You can also hear that the pilot of '4SR was giving confusing instructions about base extension and clearance to land. The pilots was not incorrect in his approach actions but made a critical go-around error and may have been a low altitude, dirty config, stall.

Ultimately the lower aircraft on approach had the right of way so '1DA had no reason to speak up as they were in the right. AOPA states that the pilots may have thought "he was overtaking the aircraft from above" which is incorrect, or at least procedurally incorrect as '4SR would have had to yield to '1DA anyway.

In the end the controller should have simply issued

'4SR Go Around

Any time, you as a pilot hear that you should build the habit to just go around. As PIC you can ALWAYS execute a go around, controllers should be prepared for it and more importantly you as the PIC should be prepared for it.

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    $\begingroup$ Indeed, telling '4SR to go around is another option which I failed to include in my list. $\endgroup$ – a CVn Sep 26 '18 at 19:37
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It's the controller's responsibility to issue instructions and a pilot's responsibility to follow them unless doing so is unsafe. The pilot of 1DA didn't speak up because there was no reason to at that point; he didn't know of 4SR's intentions and probably thought that 4SR was going to fly a normal pattern just like the controller did. When he saw that 4SR was cutting the corner (obviously in a hurry, never a good thing) in front of him the instructor pilot of 1DA took control from the student and started a go around.

Going around is a busy time, you have to change pitch and power while maintaining airspeed and keeping the airplane in balance. The rule is Aviate, Navigate, Communicate, you don't make any radio communications until you have an established and controlled climb. 1DA would have made a going around call once that was done, but in any case the controller was, as the NTSB report says, "yelling" at 4SR so he wouldn't have been able to report anyway. 1DA wouldn't have reported number 1 because it's up to ATC to say who's #1, #2, etc.

4SR had multiple risk factors. According to the NTSB report it was 22 pounds under the weight limit (which incidentally meant it would have been over the limit on departure), and probably loaded with a C of G at or behind the rear limit. The pilot had elected to do a "slam dunk", close in approach rather than the normal pattern (probably intending to land long so there was less of a roll-out), was at a high approach speed and likely in a rush, with get-there-itis. The high weight would have increased stall speed and a rearward center of gravity would have decreased stability and control authority. The pilot jammed full throttle on quickly when at the limits of performance and couldn't maintain control.

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  • $\begingroup$ In the video, it's clearly tower instructing 1DA to go around after 4SR goes into the spin. Did you notice any indication they went around on their own already? $\endgroup$ – Jan Hudec Sep 27 '18 at 18:28
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    $\begingroup$ In the NTSB report the pilot of 1DA says he had already initiated a go-around before 4SR went into a spin @JanHudec $\endgroup$ – GdD Sep 27 '18 at 23:04
  • $\begingroup$ Ah, ok, then it makes sense. $\endgroup$ – Jan Hudec Sep 28 '18 at 8:57
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It was reasonable for 1DA to assume 4SR would fly a standard pattern, but Tower not explicitly telling 4SR they were #2 and/or confirming they had traffic in sight would have made me nervous enough to say something. Perhaps that's because my home airport is very busy and Tower always does both: they will not clear you to land until you report all preceding traffic in sight OR they call your base on extended downwind (the norm) when you pass abreast of the plane ahead of you on final. This sort of accident is exactly why they do that even though VFR rules don't require it.

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