Accident report: failure to climb

It sounds so simple: full power, pitch up and climb. What could possibly go wrong on takeoff, assuming the engine keeps running? The truth is, an awful lot, as a Cirrus accident from 2013 makes clear. We are at our most vulnerable just after takeoff, with little altitude or airspeed but lots to do in the cockpit. Throw in bad weather or dark skies and things can get overwhelming in a hurry.

On the day of this crash, the pilot and his 7-year old daughter were departing Spirit of St. Louis Airport (SUS) for Winslow, Arizona, with a fuel stop planned in Dalhart, Texas. The Cirrus took off on runway 26R, but as the NTSB report makes clear, the airplane didn’t make it far:

Approach control radar data indicated that the airplane did not climb more than 200 feet above ground level before impacting the trees. The examination of the wreckage debris field indicated that the airplane was in a shallow descent at impact.

Cirrus crash in trees
The Cirrus crashed into wooded terrain just a few miles off the end of the runway.

Further NTSB analysis showed that the engine was running, the controls were operating normally and the instruments were functional. While the airplane’s parachute had deployed, it was most likely due to post-crash fire, as the canopy was unopened. In other words, this sounds like a classic Controlled Flight Into Terrain (CFIT) accident, where the pilot flies a perfectly good airplane into the ground. Or, as the NTSB put it: “The pilot’s failure to establish and maintain a positive climb rate during the initial climb in night instrument meteorological conditions.”

The natural question in a CFIT accident is: how could this happen?

The weather was lousy, that’s for sure. The official METAR at the time of the crash reported a 400 ft. ceiling and 3 miles visibility with mist, and a SPECI just a few minutes after the crash reported visibility of less than 2 miles in mist. A witness reported “very foggy” conditions, and only seeing the airplane’s navigation lights for a few seconds as it flew past. But while the weather was bad, it certainly wasn’t unflyable–ceilings and visibilities were above the minimums for the ILS approach back into SUS.

The airplane, a 2001 model Cirrus, seems to have been operating normally. It was a very early SR22, so while many pilots think full glass cockpit when they hear “Cirrus,” this airplane came before the full Avidyne system was available. The primary flight instruments were mechanical, and the early model multi-function display (MFD) in the middle of the panel had recently been replaced by a newer EX5000. It’s not clear if the airplane had a full Terrain Awareness and Warning System (TAWS) or a flight director, but these were not standard on SR22s until a few years later, so it’s unlikely. The airplane was certainly well-equipped, with dual Garmin navigators and an autopilot, but the airlines haven proven that modern TAWS systems can virtually eliminate CFIT accidents.

That leaves, as usual, the human in the left seat. The 41-year old private pilot wasn’t brand new, but neither was he an old pro. Records indicate he had approximately 475 hours total time, with just over 150 hours in the Cirrus and a 6-month old instrument rating. This range of experience is often described as a dangerous time in the life of a pilot: when he leaves some of his beginner’s caution behind in pursuit of more demanding trips, but perhaps before he has accumulated enough experience to recognize when to stay on the ground. Many veteran pilots can remember making flights during the 400-1000 hour range that look less than safe with the benefit of hindsight.

Cirrus SR22 panel
A representative panel of an early SR22.

Taking off before 5am may have been the final straw. The pilot called Flight Service at 3:21am, so he was up very early. It’s possible he had a full night’s sleep, but it seems unlikely. At the very least, his natural body rhythms would have been off a bit. The NTSB report also mentions that the pilot had traces of cold medicine in his body, but it’s always difficult to determine how much of a factor this is.

One thing is certain: the early hour exacerbated the poor weather conditions. It was well before sunrise when the pilot called for his clearance, and SUS is located right in the bend of a river, making for dark and featureless terrain with few visual references when departing to the west. After rotating, the pilot would have been on instruments immediately, with a black hole below and gray scud above. Anyone who has been in this situation can describe how overwhelming it can feel–a safe climb takes total concentration and focus. In fact, TAWS systems have a “don’t sink” callout for exactly these scenarios.

In short, the pilot was taking on a huge challenge: departing very early in the morning, in poor weather, single pilot, with relatively low time. The airplane could handle the weather and the pilot was properly certificated for the flight, but that does not mean it was easy or safe. Richard Collins has famously said that single pilot IFR is all about flying with margins; this scenario had almost none.

Would a big, bright PFD with a flight director or a TAWS system have saved this pilot? They certainly could have helped. Pulling the airplane up into the V-bar and watching the red terrain fade away is reassuring, especially during those first few seconds after takeoff. But the basics are the same regardless of equipment: we must establish a positive rate of climb after takeoff and trust the instruments in front of us. It’s all that matters.

20 Comments

  • If the vehicle is TRIMMED for climb speed, and if takeoff power is applied, and if the wings remain level, the vehicle will climb smartly, even if the pilot uses both hands to eat a sandwich. Five-hour student pilots know this.

  • I guess I don’t have too much to say about this crash except I’m sorry it happened. Perhaps the only comment I could make is to urge others to be careful when flying in IMC. On the airline we teach that from brake release upon first taxi to climbing above FL180 is a “total concentration zone.” Actually, we never really relax until the VSI levels out at cruise. Keep your head in the game; be mentally and physically prepared for the sensations that come with flight in IMC; know what you’re looking for; make sure what you see is exactly that. Remember, the airplane doesn’t think; it simply responds to the laws of physics.

  • For low time instrument pilots, there is a tendency to flatten out the climb after take off in low visibility, especially at night. I think it comes from becoming slightly disoriented as the pilot makes the immediate transition to instruments.

    Personally, I don’t believe that v-bars would have made much difference. It takes training in low-viz conditions (real or simulated), continual practice, and real concentration whether it’s with v-bars, or an attitude indicator.

    Over the years, instructors always cautioned me to make sure I didn’t go over Vy or blueline (in a twin) until the plane was 500′ in the air when making low-viz (and night) takeoffs. The plane may not “know” that it’s low-viz, but the pilot sure does.

    • I agree with Larry. The immediate transition to full IFR just after lift off, particularly in darkness, can lead to a vertigo affect. Particularly with a recently minted instrument rating. The vertigo affect can lead a pilot to question what the instruments. And, it happens quick. The concentration that is needed once you “enter the soup” is intense, especially if the plan is to make an immediate turn. The NTSB report mentions the desire to use autopilot during training. We’ll never know, but if the autopilot was engaged immediately after lift off, with the assumption the autopilot would climb the airplane properly, that could be a contributing cause.

  • Addressing John’s question in the last paragraph, it is certainly POSSIBLE that more technology in the cockpit MIGHT have made some difference, but I think probably not.

    The accident pilot had plenty of information available on his panel to operate the aircraft safely in a challenging, but not unusual or egregious, weather environment. The pilot was legal, and with his recent IFR ticket was likely to be at least reasonably proficient with instrument flight. Along that line, the NTSB report says that the pilot had logged 24 flight hours in the previous 30 days, and 38 hours in the previous 90 days, but it is not known how many hours were logged under IFR since his check ride six months previous.

    We don’t know (and never will know) what went on in the pilot’s head just before and during that takeoff run. As John suggests, departing at such an early hour could have introduced an element of fatigue, depending upon how much sleep the pilot had gotten the previous evening.

    But there is also another potential factor here: With a young child in the right seat, it’s also possible that she had created some distraction in the cabin – just by her presence, if not also by her actions. Anybody familiar with 7 year old kids understands they often tend to fidget, or complain, and can be very inquisitive as well as talkative. Young children on the flight deck always represent a potential challenge for the pilot to maintain concentration on flying the airplane … especially if there is not another adult or older child on board to occupy the child’s attention. Sometimes adult passengers can pose a distraction too.

    What we do know is that all takeoffs, especially when flying on the gages in IMC, require the pilot to exercise total mental concentration within a “sterile cockpit”.

    Also, waiting even a couple of hours, to accommodate some additional pilot rest and possible improvement in the weather, could have made a big difference in the outcome of this tragic flight.

  • Don’t bother with this comment if you are an experienced IFR pilot. Newbies, there may be something here….

    I Love Tom’s comforting comment above. Really true of course and good to remember when you have someplace to go…

    At 700 hours, 620 in my TR182, right in John’s danger zone, I still shake a little (read “a lot”) on low vis takeoffs. I wouldn’t take off low vis in the dark; the yellow streak down my back is too big. I had 6 of them this spring, all daytime, between 300 and 600 feet and I can visualize every one of them.

    Vx is 72 and VY is 88 so I use 0 flaps on takeoff (normally 10 or 20 degrees), pull the gear once positive rate and try to stay visual till the gear stows. I almost always can (only once have not) because I won’t take off in less than 300′ agl and 3/4. Some low scud down the field surprised me once early morning near Augusta GA. Valuable experience and was no problem except for my heartbeat but the change in control feel I would rather have when I can see.

    Once clean I hold the heading on the heading bug set to runway heading and nail 80 knots (halfway VX to VY) to 1000 feet agl and refuse to do anything else before 500 feet. “UNABLE” is my response to anything before then. I have had tower complain once after trying to get me over to approach before 500 feet! “If you are ready now…” said a sarcastic tower guy in Bloomington IL after my refusal. Too bad. I will not turn right after takeoff, and very reluctant with any yellow on the TAWs. When forced to turn between 500 and 1000 outside DC this summer I put the autopilot on and let it do the turning and climbing.

    VERY IMPORTANT: at a non towered airport I have learned to not accept a clearance “upon entering controlled airspace turn to x” in low vis.
    Chicago departure took issue with me one day with 300′ and 3/4 mile, my limit. “You should have turned as soon as you were off the ground,” she complained. Not so.

    Now I tell clearance delivery that I won’t turn until X feet. Most times they put me back on hold and they’ll come back with “when able turn to” or “at x thousand turn to.”

    All of these procedures are super conservative I know. That’s where the margins are for me.

    As a father my heart breaks when a dad kills their kid. Nightmare.

    • Mark:

      As a confidence-builder, grab an instrument instructor and go practice some “instrument takeoffs.” Set the heading bug as you track the centerline, then hood on; smoothly but quickly apply takeoff power; rudder as necessary to maintain bug heading; monitor the localizer if you’ve got one and it makes you feel better, but the whole thing happens too fast to bother, anyway. With takeoff power applied, you’ll be airborne before long; then it becomes a pitch-and-airspeed game. You’ll need to know how to use your AI to nail the correct pitch angle for takeoff. Several methods are available; use whatever one you’re most comfortable with. As soon as the airborne bird accelerates to Vy, maintain that speed by adjusting the pitch angle. Gear up when you’re able, but save the first power change until you’ve got all of your ducks flying in formation – all of the GA engines out there are good for at least two minutes of full power.

      I’m not recommending that you routinely conduct actual zero-zero takeoffs, but this exercise is helpful in shortening the transition from visual to instrument cues – because it’s 100% reliant upon the latter.

      Trim is the most basic version of an “autopilot.” Regardless of flight conditions, the plane ALWAYS should be trimmed for your desired airspeed. Make the plane do the work, while you take the credit. As PIC, be a manager; not a worker.

      Fly safely and joyfully!

      -YARS

    • Mark, good advice. Sounds like you have a definitive line you won’t cross, and that can be hard to do at times. Too many pilots have let ATC unknowingly intimidate them right into a smoking hole.

  • Duane, you brought up a good point: Having loved ones in the cockpit with you changes your whole perspective. Didn’t think about it before, but I do remember having experience with this phenomenon years ago. I fly professionally, so I never have anyone but another company pilot in the cockpit with me. If I were allowed to bring my wife or young granddaughter onto the flight deck for an entire leg I know it would alter my abilities to keep my mind focused only on essential duties. Yes, you are 100% correct: In professional flying we have no such distractions; even jumpseaters know to be silent below 10,000 feet unless they see trouble brewing.

    • Dave – thanks. Even us non-professionals can benefit from professional methods when it comes to safety of flight.

      The better decision here would likely have been to delay departure to wait for better weather on takeoff. If for some reason it was necessary to depart in IMC, then it would be better to have the child sit in the back seats, to allow the pilot to concentrate on the job at hand up front. Explain to the child that she can come up front once the aircraft is up high and cruising “so that Daddy (or Mommy) can get us home safely”.

      Also, with today’s mobile entertainment technology (tablets and video players), it’s not difficult to occupy a child’s attention on things other than what Daddy or Mommy is doing at the controls, i.e., “what’s that do?”, etc.

      Finally, as all parents know, some kids are happier travelers than others, whether it be in an airplane or in the family car … if a kid who’s to be a passenger in your airplane is NOT a happy traveler, that represents a significant flight risk factor that the PIC has to take into account, especially when flying in challenging conditions (weather, traffic, unfamiliar or complex approaches or airports, etc.).

  • Positive rate of climb, wings level, proper airspeed, and directional control. What’s so very difficult about that? Every pilot controls those four things, even on nice, sunny days. And all of it is done with basic instruments with which every flying machine is equipped. The process shouldn’t change whether on a sunny day or during a zero-zero takeoff.

    This pilot seems to have been behind the mental power curve before he even added takeoff power. His pilot error had occurred even before he had started the engine.

  • All comments about basic flying aside. Is it also possible that the Cirrus side control stick makes precision flying more difficult? I’ve never flown one, so I have no basis for the question other than it has always looked a bit awkward to me with regards to fine pitch control.

  • Was this trip really necessary? If so, was the demand so great that one would have to depart in such marginal conditions–with a young child no less? Yeah, we all get instrument ratings to allow us to make more efficient our flying experience. I have been flying for over 45 years–since 17 years old. I had an instrument rating at 19. Yet, I never found a reason to depart in IFR, even mild IFR is there is such, at night. Most often I would delay a trip to wait for improvement. You can always give up a few hours for many years.

  • Half of my flying, these days, is at night in poorly lit areas with little visual references outside during takeoff. I will use my wing tip angle in relation to the horizon and I know what bar to set the AI for a Vx climb to 500′ then set attitude to Vy. In some instances , it is so dark that the outside references are not there. I always cross scan my AI with my VSI and airspeed during night takeoffs. I just traded up to a 400 that has flight director, so I will set the FD at the climb rate I need and set the heading bug on rwy heading, then engage the VS and heading modes on the FD. This gives me a reliable pitch attitude reference point for night takeoffs.

  • When I read this NTSB report, I often wonder if this pilot engaged the autopilot too early in flight. I have experience in a similar plane and too often I have found engaging VS when the Positive Rate of Climb is not stabilized can have the opposite effect intended. If this occurred and he was distracted, the autopilot could have taken him gradually into the ground. I fly out of this airport, and that end of the field near the river has zero lights. Very much like a black hole. You won’t see the ground coming, particularly in the fog.

    • I think autopilot usage is a piece of the puzzle here. The NTSB report doesn’t mention it, so I didn’t want to speculate too much. But you do wonder if that played a part – was it set correctly?

  • I have about the same amount of time as this pilot did and took off earlier this year in VFR conditions very early one morning. Even though I am IFR rated, current, and I like to think “ready”, I was startled at how dark everything suddenly got. I was immediately head down into my instruments. I can imagine how worse that would have been in Solid IFR conditions.

    A lesson to be learned for all of us. Taking off at night, VFR or IFR, you had better be instantly ready for possible disorientation or vertigo.

  • I had planned on departing from SUS to Airventure at 0600 the same morning of this accident but the low ceilings and darkness made my pleasure flight a ‘no go’. I have 2500+ hours in my C-182 but can’t maintain my own personal IFR comfort level flying only 60-80 hours per year. Instrument flying, especially zero-zero takeoffs into darkness require a level of proficiency that I could only achieve by doing it daily. I can’t imagine taking a pilot friend of mine out and over a relatively short period of time teaching him what I do on a daily basis…Pediatric Anesthesia. IFR proficiency cannot be maintained without ongoing training/practice/application. When I’m in the clouds and everything is clicking smoothly I still don’t relax until I’m VFR so I’ve decided to set my Instrument rating aside and enjoy myself more. I have twenty-one more years of flying before I reach my goal of joining The Flying Octagenarians and my chances are better if I log those hours VFR.

    • I note in the accident report that the winds were 010 at 4 knots. I’m not familiar with SUS — are there reasons one might opt for 26R under those conditions?

      It’s all Monday-morning quarterbacking, but there seem to be a lot of little warning signs in this scenario: night, IMC, quartering tailwind… I suppose that’s always the way. May we all be wise enough to see them ahead of time, instead of just in the postmortem.

  • Another possibility for this CFIT accident could have been that old gotcha, gyroscopic precession; the airplane did have the older mechanical instruments in it. Remember the intrinsic Achilles heel of acceleration and deceleration errors in gyros? They make it APPEAR as though the airplane is climbing or descending – depending on whether you are accelerating or decelerating – more steeply than it actually is. While the airplane is accelerating after takeoff – especially immediately after flap retraction – the attitude gyro will precess and “tell you” that you are climbing more and more steeply. As a reaction, because you are not looking at your altimeter and VSI, you lower the nose to counter the “increasingly excessive climb attitude”. And because you actually just lowered the nose of the aircraft you accelerate even more; and that just compounds the problem until you’re inevitably descending quite rapidly while your attitude gyro shows a climb – as long as you are accelerating; you’re really flying a big, increasingly faster arc right into the ground.) It is very commonplace for relatively new (or not current)instrument pilots to rely solely on the attitude gyro and disregard all other information. Because of acceleration (G) forces on the body there is the tendency for pilots to naturally want to lower the nose in the clouds after takeoff anyway – or anytime they are accelerating in the clouds. That plus the nasty precession property in the attitude gyro can easily cause the unaware pilot to fly the airplane into the ground shortly after takeoff. It’s happened countless times before. The only true guard against this phenomenon is a proper scan encompassing ALL the instruments. What’s the primary instrument for a climb? The altimeter – followed by the VSI. I don’t know why this aircraft crashed, but the above mentioned manifestations have brought many to their doom.

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