Cirrus SR20 Incident Analysis (June 9, 2016)

Flight Details

• Aircraft: Cirrus SR20, N4252G
• Route: Norman, Oklahoma to William P. Hobby Airport, Houston, Texas
• Occupants: 3 (46-year-old private pilot, her husband, brother-in-law)
• Purpose: Visit a relative receiving cancer treatment
• Weather: East winds 12 knots, gusts up to 16 knots
• ATC communication: Key in busy Class B airspace; interaction with Boeing 737s

Key Events

1. Initial Clearance
   • Cleared to land following a 737 on approach to Runway 4.
   • Instructed to maintain maximum forward speed due to another 737 approaching quickly.
2. First Go-Around
   • Directed to go around due to separation issues with the 737.
   • Given more instructions and alternate runway assignment (Runway 35) not ideal due to crosswind.
   • Correct actions by pilot but interpreted instructions led to confusion.

ATC and Pilot Communications

• Complex Instructions: Received lengthy and complex instructions from ATC.
• Initial Go-Around: Maintained instructions properly but interpreted 'turn left heading 30 degrees' as turning to a heading of 030.
• Runway Assignment Changes: Frequent changes between Runway 4 and 35 caused confusion.
• Altitudes & Winds: Encountered difficulties lowering altitude, winds contributing to challenges.
• Attempts to land: Multiple attempts to line up and land failed due to altitude and confusion.
• Task Saturation: Increased pressure and workload for the pilot; task saturation evident.

Incident Cause Analysis

Immediate Causes

• Flap Retraction: Retracted flaps at inadequate airspeeds during go-arounds, leading to stalls.
  • First go-around: Retracted at 76 knots (marginal).
  • Second go-around: Retracted at 69 knots (below safe speed).
  • Third go-around: Retracted at 62 knots (well below safe speed).
• Airspeeds: Critical airspeed for SR20 in 15-degree bank is 70-75 knots; began go-around flaps at 62 knots.

Contributing Factors

• ATC Decisions: Complexity and distraction from instructions.
• Approach Resequencing: Not transferred to approach control when needed.
• Ambiguity: Confusing instructions, e.g., ‘turn left heading thirty degrees.'
• Fatigue and Stress: Possible stress due to deteriorating situation and time pressures contributed to poor decision-making.
• Flight Review: The pilot's flight review was one month overdue.
• Complex Instructions: Lengthy and non-standard ATC instructions likely increased pilot's workload.

Pilot Factors

• Lack of Assertiveness: Did not request resequencing or communicate clearly; tried to follow ATC under pressure.
• Task Saturation: High workload environment, increased pressure to land.
• Bypassing Procedures: Retracted flaps at insufficient speeds.
• Miscommunication: Several misunderstandings with ATC led to confusion.
  • E.g., ATC's “turn left thirty degrees” interpreted as heading 030.

Recommendations and Learning Points

• PIC Authority: Use Pilot in Command authority to communicate clearly, request resequencing if necessary.
• Prioritization: Focus on maintaining flying airspeed and clear flight path before tackling less critical tasks.
• Manage Workload: Recognize signs of task saturation and stress; don’t hesitate to ask for a reset.
• Proper Training: Reinforce go-around and communication procedures through regular training and reviews.
• Assertiveness in Communication: Remember that clarity in communication is key to ensuring safe outcomes.

Summary

This incident highlights the importance of clear communication, assertiveness in flight decisions, and the necessity of maintaining proper procedures and airspeeds during critical flight phases. Proper prioritization and recognition of task saturation can make a significant difference in safely managing flight operations in busy airspace.