Safety: Accident Case Study – Missing Over The North Sea

The Cirrus SR20, with its single pilot and occupant, departed Gloucestershire in the UK for a flight to Osnabruck-Atterheide in Germany.  The aircraft dissapeard from radar enroute.  During the search and recovery efforts the pilot was found.  He did not survive.  Several floating pieces were recovered.  In cooperation with Rijkswaterstaat, several pieces of wreckage were recovered from the sea bed, including the engine and the emergency parachute of the aircraft.

Dutch Safety Board (2016)

Aim

The aim of accident investigation is, in general, to develop an understanding of the causes and effects that had a contributing factor to the accident occurring.  Furthermore, its aim is to  subsequently develop and implement actions and procedures such as to mitigate, thereby preventing, or otherwise minimising the risk of a reoccurrence of the conditions that contributed to the accident.  As such, accident investigation is  an important factor in developing safety systems, thereby in the process making aviation safer.

Although the Dutch Safety Board is yet to publish its findings regarding the crash of a Cirrus SR20, callsign G-ZOGT, it is however likely that the prevailing weather conditions were a major factor that contributed to the accident.  Although little is known about the qualifications of the pilot, the flight was conducted under visual flight rules.  The poor visibility in the area in particular, and secondary the icing conditions that were likely, are probably the two major factors.

This briefing goes back in time to consider the expected weather conditions at the time of pre-flight preparation, and the knowledge the pilot could have had at that stage, as well as the prevailing weather conditions at the time that the flight took place, given the chosen route, and under VFR (Visual Flight Rules).  It further explores safety issues that are of importance when dealing with weather.

Introduction

This briefing is organised according to the ICAO SHELL Model.

In the SHELL Model, the pilot is said to interface with several areas, each of these will be discussed in this briefing.

  • Software: the rules, procedures, written documents etc., which are part of the standard operating procedures.
  • Hardware: the Air Traffic Control suites, their configuration, controls and surfaces, displays and functional systems.
  • Environment: the situation in which the L-H-S system must function, the social and economic climate as well as the natural environment.
  • Liveware: the human beings – the controller with other controllers, flight crews, engineers and maintenance personnel, management and administration people – within in the system.

Software

Flight planning

Weather

Every pilot considers the prevailing and expected weather conditions as a essential part of the flight planning process.  Indeed, theoretical and practical training places an important emphasis on weather.  Through a variety of official sources, it is possible to develop an understanding of the weather at the departure and destination, as well as the expected weather that is to be encountered en-route.

The usage of the type of weather information differs according to the type of flight to be conducted.  For instance, for a local flight, the weather conditions found around the airport of departure and arrival will be of more relevance, than the en-route weather with a cross-country flight.  Although it remains unknown what weather briefing the pilot received prior to departure, the following sections considers the primary sources most likely used by pilots in determining the expected weather conditions.  In cases where the weather is more complex, it is common that pilots would dig deeper such as to get a better understanding of the underlying risks.

Unfortunately it was not possible to retrieve the SIGWX (Significant Weather Chart) that was valid for the period, as there is no digital archive available  with this information.  A SIGWX is an important source of information, particularly for IFR flight planning.  It describes the weather for a particular altitude, in the case of Europe mostly as from FL100.  As the accident flight was conducted in VFR, it is unlikely that the flight took place at this altitude.  Although flying VFR at this altitude in the UK is possible, it is not in the Netherlands and Germany, where flying at or above FL100 would imply entering airspace class A.

Metar

Metar’s provide a description of the actual weather conditions, and are generally issued in Europe every half an hour for larger airports.

As radar contact was lost at around 14:00 UTC, and considering the distance and speed of the SR20, it is likely the aircraft departed about 2 hours before that, at around 12:00 UTC.  The pilot therefore likely had access to the weather information that was published at around the time.

For Gloucestershire, the airport of departure, there are two Metar’s issued around that time, one at 11:50 UTC, and one at 12:20 UTC:

METAR EGBJ 041150Z 20006KT 9999 -SHRA FEW007 SCT010 BKN020 08/07 Q0980=
METAR EGBJ 041220Z 20006KT 9999 SCT012 BKN045 08/07 Q0980=

For Osnabruck-Atterheide, at around the same times, the following Metar’s were issued.

METAR EDDG 041150Z 08005KT 030V150 2800 -SN BR BKN006 00/M00 Q0990 BECMG 3500=
METAR EDDG 041220Z VRB03KT 2800 -SN BR BKN006 00/00 Q0990 BECMG 3500=

At the airport of departure, the Metar from 11:50 indicates light showers and rain, with few clouds at 700 feet, a scattered layer at 1.000 feet and broken at 2.000 feet.

The second Metar from 12:20 shows some improvement with a scattered layer of 1.200 feet, and a broken layer at 4.500 feet.  The improvement seems to be temporary in nature however.  Subsequent Metars, which the pilot is unlikely to have received considering his time of departure, shows a worsening of conditions with reference to showers in the vincity of the airport, and towering cumulus and cumulonimbus clouds in the area.  Though the slight improvement in weather conditions may initially give the impression of better weather approaching, most pilots would seek further information as to determine if the improvement is temporary in nature or not.

Both Metars show difference of only 1 degree between the temperature and the due point.  Although the visibility was reported as to be in excess of 10 km at the time, the temperatures indicate, considering the large amount of moisture in the air, that a decrease in visibility, or in other words an increase in cloud formation at all levels including the possibility of mist, was likely and probable.

Furthermore, the low pressure at the time, of 980 hpa, while on itself cannot provide a direct indication as to the weather as its relevance needs to be seen in comparison with the area, it does however provide a signal to at least develop a deeper understanding of the weather, in particular with regard to frontal weather to be encountered.

The airspace around the airport of departure, and for the vast majority of the UK, is of class G.  In this class, aircraft are to remain free of clouds, but no specific distance that aircraft are to remain free from clouds is prescribed.  While it is legally possible to fly at 500 feet, insofar as one does not fly over inhabited and built areas, the conditions at the time of departure were at the least very  marginal for a VFR flight.

Osnabruck-Atterheide at the same time shows weather that is a lot worse than at the airfield of departure.  Both Metars, which do not differ much from each other, show light snow, with a very low visibility of 2.8 km, and  low clouds with a broken layer at 600 feet.  The Metar does show an improvement of the visibility to 3.5 km. Even with the improvement, the conditions are the time were far from which a VFR flight could safely take place.

Considering the prevailing weather at the time of departure, the weather is far from suitable for a safe VFR flight, and at the very least, the weather is extremely marginal.  Even for a IFR flight, the weather would be unsuitable in the type of aircraft that was flown.  The SR20 is not equipt with equipment that allows flight into known icing conditions.  Considering the weather, it was extremely likely that these were to be encountered, even at low levels, because the temperature is sufficiently low, and the moisture content high, that along the route temperatures of below 0 degrees would be encountered, with visual moisture and rain.

TAF

TAF’s (Terminal Area Forecasts) are a forecast of the expected meteorological conditions in forthcoming hours, and are coded in a manner similar to Metar’s.  In Europe the TAF’s have different time periods.

At the time of departure, the TAF for the departure airfield was:

TAF EGBJ 041400Z 0415/0420 18008KT 9999 SCT030 PROB40 TEMPO 0415/0420 8000 SHRA BKN014=

As for  Osnabruck-Atterheide, the TAF is as follows:

TAF EDDG 041100Z 0412/0512 10005KT 2500 -SNRA BR BKN006 BECMG 0422/0501 5000 BR BKN013=

The TAF for the airfield of departure was issued at midnight on the day of departure, and showed a scattered layer of 3.000 feet, with 40% probability of showers/rain from 15:00 UTC, during which the clouds would descend to a broken layer of 1.400 feet.    The weather during the period covered in the TAF shows, outside of the showers/rain, although not good, acceptable VFR weather.  Such a weather pattern is common when cumulonimbus clouds create temporary and local showers.  Considering the Metar’s that showed a lot worse weather conditions, it is clear that further investigation is neccesary as to the reasons for the apparent difference in weather conditions.

The TAF for the airfield of arrival shows a situation that is a lot more worrying, with 2.5 km visibility, light snow/rain, and broken clouds at 600 feet. The weather is not expected to improve until the evening and following morning, when the visibility is expected to increase to 5 km and with a broken layer at 1.300 feet.   These weather conditions, while technically legal for class G airspace, are unsuitable for a VFR flight.

Both the Metar’s and the TAF’s at the destination airfield, indicate that VFR flight is not advisable in these weather conditions and dangerous.  The poor visibility creates a high risk for spacial disorientation, especially as the flight is conducted over water and under visual flight rules.  The high moisture content and low temperatures also increase the risk for icing.  Even if it is possible to avoid low visibility areas, icing in areas of precipitation is also a risk. The high moisture level also indicates that it is hard to predict where the poor visibility is likely to prevail.

The Metar’s and TAF’s alone, without considering further information, should be enough indication for the vast majority of pilots as to cancel or postpone this flight.

Precipitation Radar

The precipitation radar for Europe before departure, at 11:00 UTC, was as follows:

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Figure 1: Precipitation Radar, 11:00 UTC

The precipitation radar shows that areas of heavy precipitation en-route would first be encountered shortly after crossing the north-sea all the way through to the coast of the Netherlands (dark blue areas).  To the south of the UK these is even more intense weather.  The pattern shows that the weather is most likely cause by different air masses joining together, and is therefore likely to be frontal weather.

Furthermore, precipitation is also found over a large area extending around the destination aerodrome.  It is unlikely, als considering that the weather is mostly stationary when looking at the animated image (not available here), that a significant improvement is unlikely.

In combination with the low pressures, cloud bases and low visibility as previously seen in the Metar’s and TAF’s, there is ample indication that the weather condition will prevail over a large area of the route towards the destination aerodrome, without sign of improvement.  In combination with the low temperatures, particularly over the northern part of continental Europe, there is also likelihood of encountering icing or freezing rain.

Satellite Image

The satellite image at 11:00 UTC, was as follows:

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Figure 2: Satellite image, 11:00 UTC

The satellite image shows areas of clouds to the east of the UK, extending from the north sea all the way to the area of destination.  The clouds over the UK and Netherlands do not seem very dense, as it is possible to see the underlying ground beneath it.  They do however hold precipitation as previously seen on the weather radar and as indicated by the Metar’s.  The majority of the clouds extending from the Dutch coast to the airfield of destination look like nimbostratus, similar to that which is common by warm fronts. This weather type of weather is often associated with low visibility and low ceilings with brume / mist.  The Metar therefore confirms what we see.

There are however some larger cloud formation that are very dense, probably CB’s, just off the coast of the Netherlands extending to the south of the UK.  These cloud formations seem to be largely present over the north sea and is one of the riskier areas.  These clouds are likely to have showery properties, als also seen in the Metar and weather radar, that shows them as moderate to heavy areas of precipitation.

Based on the imagery, one can see larger clouds around the airfield of departure.  These clouds are likely to be producing the light showers/rain as referenced in the Metar.  A slight improvement is then seen along the initial part of the route, before heading of the other sea when further cloud formations are expected to be encountered.  Thereafter the clouds to be encountered seem more widespread, but less dense, most likely nimbostratus type of clouds with low visibilities and mist.  The most risky weather are the dense clouds that can be seen over the north sea that have moderate to heavy precipitation. Secondly, the low visibilities to be encountered over continental Europe could make a VFR flight at the very least marginal, and maybe even impossible.

Fronts and Pressure Charts

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Figure 3: Front and pressure chart, 00:00 UTC

A low pressure area can be seen to the west of Ireland, with a warm front occlusion developing as the colder continental air from the high pressure area meets the cold (but warmer) maritime air.

The weather associated with an occlusion generally has elements that are common to both cold and warm fronts, including moist and unstable air that may form thunderstorms, and generally includes precipitation and a decreased visibility.  Cold-front occlusions are often more severe than warm-front occlusions, but considering the closeness of the isobars that can be observed in the chart, including the large number of fronts that are visible, the weather may be expected too nevertheless be strong.  The reason for this is that the rapid change in pressure of a relative small surface causes a more aggressive front than if the isobars are loosely spaced.

Furthermore, a trough can be observed to the south of the UK, roughly halfway between France and the UK over the north sea.  Troughs mark areas where the air is particularly unstable.  Such a boundary is often associated with showery activities.  The troughs coincide with the heavy cloud formations as seen on the satellite imagery and the moderate-heavy precipitation areas as seen om the weather radar.

The front and pressure chart shows that upon departure, the aircraft would initially be flying away from the warm front occlusion lying to the west.  A periode of apparent improvement may then be expected to be visible over the UK, until approaching the warm front occlusion lying over the north sea.  The occlusion just off the coast of the Netherlands is located in an area where the isobars are closely spaced together.  The weather here is expected to be poor.

In any case, there is no route possible without passing through weather.  The areas of the worst weather are to the south of the UK, and then over the North sea in the warm front occlusions.  VFR flight in these areas is likely to be ill-advisable.

Routing

Particularly when flying VFR, pilots have a lot of freedom to choose a route to the destination airfield to their liking.  Several aspects form part of the decision making process as to the route to be flown.

Part of the flight from the UK to Germany will have to be flown over the North sea.  With single engine piston aircraft, pilots general would want to decrease the amount of time flown over large areas of water, due to the limited possibilities of conducting a successful emergency landing (or ditching) should an engine failure occur.  Particularly the North sea during January is very cold, and even being exposed to the cold water for a short period, can already induce severe hypothermia.  Furthermore, rescue in the North sea is difficult, as it is hard to see a person in a large body of water, particularly if water is choppy and bad weather prevails in the area.

Safety equipment does exist to increase the chances of survival.  These include wearing a dry suit such that it is possible to remain in the water for a longer period of time without hypothermia, a life raft, life jackets and a personal locator beacon such that resume services can track the position.  However, this equipment is cumbersome and expensive, and not without risks.  A predicate is at least a successful ditching, and being able to successfully inflate the life raft. For this reason, pilots often have a strong preference to reduce the time spent of large bodies of water.

As for this specific flight,  and considering routing alone, it is possible to reduce the time spent flying of the North sea by first flying south, and crossing from the UK to France where the distance across the channel is least.   Time spent of water is reduced dramatically,  with maybe only about 15 minutes during which ditching would be necessary in case of an engine failure.  The flight could then proceed along the French and Belgium coast initially, before crossing boarders to Germany.

Considering the weather however, one can see the precipitation radar and satellite imagery, that the heavier areas of precipitation and weather are encounter over the channel.   The front and pressure charts also showed a trough extending over the entire channel.  As the weather is particularly bad here, choosing an alternate route that would fly the aircraft for a longer period of the North sea might be the lesser evil, than comforting the bad weather over the channel.

However, whenever one is found choosing the lesser evil between two or more evils, a pilot should also consider the option of cancelling the flight and waiting for better weather conditions to arrive, particularly as most flights GA pilots fly for fun.  While an extra night in a hotel might be of inconvenience,  the inconvenience should not preclude over taking big risks.

Weather at the Time of the Accident

The aircraft lost control and impacted the North sea about 5 NM off the coast of Campeduin (see map below), just south of the Dutch town of Petten.

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Figure 4: Accident location

The following video shows the flightpath of the accident aircraft.


Around the time of the accident several SIGMET’s had been issued that icing was present in the area. Unfortunately, it has not been possible to find these in the archives.

At the time of the accident, at around 14:00 UTC, the following precipitation radar image was issued.

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Figure 5: Precipitation radar image at time of accident

Considering the radar image, there seems to be no precipitation over the accident area.  The pilot had just passed the precipitation  area and was now flying in the area just of the coast of the Netherlands which does not show any precipitation activity.  It is therefore unlikely that the CB clouds formed a major factor in the accident.

When considering the satellite image, we can see another danger, however.

Figure 6: Satellite image at time of accident
Figure 6: Satellite image at time of accident

In the satellite image we can see the cloud formations that we previously discussed, most likely nimbostratus with low visibility, similar to the weather described in the Metar at the destination airfield.  It is therefore likely that the visibility was very poor, and this was indeed confirmed by the rescue team who reported a visibility of 400 metres at the area of the accident.  At the time of the accident, the Schiphol Metar, which lies just south east of the accident location, reported  the following:

METAR EHAM 041355Z 14005KT 9999 FEW008 BKN011 OVC015 07/06 Q0987 TEMPO 5000 -SHRA BKN008 SCT015CB=

The Metar on land is not always representative of the prevailing conditions above a large body of water, however, we can see that low ceilings prevailed with a broken cloud layer at 1.100 feet, temporarily reducing to a broken layer of 800 feet with a reduction in visibility of 5 km. Furthermore scattered cumulonimbus clouds were also reported at 1.500 feet, though looking at the precipitation radar at the tie of the accident, these are unlikely to be a primary cause.

It is apparently evident that, in so far as the weather conditions played a role in the accident, this would in all likelihood have been caused by the rapid reduction is visibility, mostly likely making VFR flight and in particular maintaining visual cues impossible.  The large body of water, which provides little contrast from clouds, provides for further challenges in maintaining a visual horizon.

Hardware

The aircraft flown as a Cirrus SR20.

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Figure 7 – Picture of accident aircraft

The Cirrus SR20 is a new generation aircraft that differentiates itself from traditional aircraft with a carbon fibre body and wing, and a modern, car-like interior.  The aircraft is designed to be comfortable, and is suitable for long trips, which dues to its efficient wing, generally cruises at speeds of around 140 kts.

The SR20 has significantly higher performance than the Cessna 172, the involved pilot  transitioned from, and therefore requires additional training to safely fly.   The aerodynamic efficiency with which the aircraft is built, which allows it to fly at much higher speeds than equivalent aircraft with the same power plant, also means the aircraft has a much smaller margin of error.  In effect, it is a much more complex aircraft.  It is unclear if the involved pilot actually received adequate transition training, however the CEO of the flight club where the pilot flew, Wilfried Bockbreder,  stated that “to upgrade from the Cessna to Cirrus – would be equivalent as to switching from a VW to Opel.”.  He further states that it is possible that this was a factor in the accident.

The Cirrus flight controls are controlled by a side stick that has a system of springs.  The advantage is that this allows for a clean cockpit with more room that would otherwise be occupied by a flight yoke or stick.  The disadvantage of this system, is that the side stick has a significantly lower amount of freedom of movement to traditional flight controls, and the springs limit being able to directly feel the flight loads.   This design different can be very important when flying in reduced visibility, where a ‘feel’ of the aircraft provides important cues as to the flight attitude and speed of the aircraft.  It is certainly a big difference for a pilot transitioning from more traditional controls that have a more direct feel for the flight loads and greater degrees of movement.

Due to the efficiency of the Cirrus wing, it is also susceptible to even a small amount of icing significantly disrupting the flow over the wing.  While it is unclear if this was a factor in the accident, as the temperature at ground level was 7 degrees centigrade, and therefore approximately at about 4 degrees centigrade at 1.500 ft where the aircraft was flying, icing, even at low levels, is at the least something that should be considered with this flight.

There is no indication as for an engine failure.  The Cirrus SR20 is also equips with a power plant with a fuel injection system.  In de absence for a carburator, there is no risk of forgetting to activate carburator heat for this flight.  Carburator icing would have been the most likely cause of engine failure, but can in this case be ruled out.

Finally, all models of Cirrus aircraft are equipt with a ballistic parachutes that may be deployed in case of emergencies. The parachute, when deployed, allows for a controlled descent of 1.600 – 1.800 feet per minute, and may be particularly useful above areas of water, where an emergency landing with forward speed would flip the aircraft on its back due to the immediate drag created by the landing gear upon impacting the water.   Deploying the parachute however does have a drawback, which is that the aircraft will most likely be irreparable and need to be scrapped, as the repair costs often outweigh the value.  While the choice is easy when considering that loosing an aircraft is a small price to pay versus loosing a life, making it in effect a insurance matter, the choice becomes much more complex when considering that the pilot had just bought the aircraft, and was flying it back home.

Liveware

Livewire considers the pilot.  While it is unclear if the pilot possessed an IR (Instrument Rating), on this flight where low visibilities and little contrast between the horizon and the sea was to be expected, training in Instrument Meterological Conditions would have been very important such as to avoid spacial disorientation.  In marginal conditions, a pilot must be able to switch from outside visual cues to the artificial horizon or/and turn coordinator, should conditions become insufficient such as to safely maintain attitude based on outside visual cues alone.

VFR flight into Instrument Meterological Conditions remains an important source of accidents for pilots, particularly those that are not instrument rated.

The pilot was also aged 76, and had received his flight certificated approximately 10 years prior, at the are of around 66.  While older people can certainly become and are good pilots, one needs to at least appreciate the effect of ageing on proficiency.  The law for acting as a pilot in passenger transport indeed poses limits on age.  For private flights, there are no limits imposed, because the law expects the pilot to make this decision himself.

We already considered the effects of flying in marginal VFR conditions and upon VFR flight into IMC.  However, pilot experience is also much broader than this, in particular when flying larger distances when different weather conditions can be found.   Certainly in the winter in Northern Europe weather can be unpredictable, and even relatively small distances, can have a great effect on the weather encountered.  With cross-country flights, it is likely that several weather conditions are found.  A thorough understanding of these conditions is required in order to safely conduct the flight, and this requires experience and training.

Finally, it is clear that the pilot wanted to go home.  This is commonly referred to as get-there-itis.  The pressure to get home may become so large, that too high risks are taken. The risks taken may become so high that personal minimums, legal minimums and aircraft capabilities may be overcome.  It is important to consider that no flight is obligatory, while it may be inconvenient to stay another night in the hotel, this is a small price to pay.  A pilot must always ask himself ‘do I want to fly in these conditions?’, ‘am I legally allowed to fly in these conditions?’ and ‘is it indeed possible to fly in these conditions?’.

A final note that may be indicative of get-there-itis, or perhaps poor flight planning, is the time at which the accident occurred.  The accident is said to have occurred at 15:00 local time, or 14:00 UTC.  The end of daylight period for the 4th of January 2016 is at 15:57, in other words, in about 2 hours time.  While the flight is to be expected to be completed before end of daylight, this may be indicative of the pilot having waited before departure for better weather conditions.

Environment

Environment considers the context in which system resources (software, hardware and liveware) operate as a whole.  Little is known about the accident in this regard, however, it is possible to discuss several elements that may be of importance, whether or not they are applicable in this case.

Livewire – Livewire

ATC

Most single engine GA aircraft, including the SR20, do not (in Europe), have a system that allows the tracking of weather once airborne.  Larger aircraft often have on-board weather  radar systems and can see and therefore avoid areas of heavy precipitation and turbulence.  However, an important resource can however be ATC, in this case Amsterdam Information.  ATC often has information of prevailing weather conditions.  Should this information not be directly available by ATC, they can usually call upon resources to provide at least some information regarding the weather.  One example of this is asking a nearby aircraft to use their weather radar system to describe the weather at a particular area.  Other pilots, that may also include passenger planes, are generally more than willing to help a helping hand.

Recently on a flight from Prague to Rotterdam, unstable weather produced several cumulonimbus clouds around the area of Hannover.  The weather was significantly poorer to the north of Hannover than southwards where I was flying.  Overhearing a conversation with ATC and another pilot who was fighting weather just north of Hannover, I provided information on the cloud ceilings and tops just south of Hannover, which was significantly better.  This is an example of pilots working together with ATC for the safety of everyone.

Other examples include flying over central France and Mallorca where overlying Boeing 737 pilots were kind enough to provide information of the weather conditions at the lower altitudes that was vital for developing a understanding of the conditions prevailing at the time.

ATC often has access to weather radar, and can also provide for directions as to avoid the worst.  Also when lost, ATC can direct an aircraft back on the flight path.  It is important not to wait too long to call upon ATC for help.  They are often more than willing to do so, and are there to ensure flight safety.

Safety Pilot

Considering that the liveware, or the pilot, is a weak link in the chain due to limited or no experience in the Cirrus SR20,  low visibility that might require or at least greatly benefit from an instrument rating, and lastly the age of the pilot (76),  a safety pilot may have been a smart choice and had a very different outcome with this accident.

A safety pilot, whenever their role is to take over control of the aircraft whenever conditions require, should at least be a certified flight instructor. An experienced pilot, that has not received formal training in flight instruction, may not be able to adequately, and in a timely manner, take control of the aircraft when the situation requires this.  The reason is that quick decisions may be necessary if conditions predict.  Without training on flight instruction, there may be a too long delay in taking control of the aircraft.

An alternative method is of taking an experienced pilot who acts as pilot in command (PIC) if the conditions are above personal minimums of the other pilot.  In this case, the experience pilot is responsible for the flight, but the other pilot may assist, by for instance taking care of radios.

Conducting a complex flight with two pilots also allows the work load to be spread out.  For instance, one pilot may focus on flying the aircraft, whilst the other takes care of the radios.  This often has the effect that due to the increased attention on the task at hand, the outcome of the flight as a whole becomes better.  This is indeed also a requirement for larger aircraft.

Plan ‘B’

One of the most important aspects of flying in conditions that may impose danger, is to be sure to always have a way out, or a plan ‘b’.   In other words, one must have a ‘what if…?’ strategy.  In the case of the accident the pilot, once the pilot started flying over the north sea, he quickly lost the option of returning to the airfield of departure, as the fronts were building behind him.

Furthermore, poor visibility and low ceilings were expected once flying over continental Europe.  Should these conditions be met, what would be the strategy to return to visual meteorological conditions?.  By that time the building front behind that aircraft was already building in intensity.

It is important to note that if we are unable to find a plan ‘B’ should certain conditions become reality, then we are committed to those conditions.  These may exceed the capability of the pilot and the aircraft.

Livewire – Hardware

Already touched upon in the hardware section, it is unlikely that the pilot has received sufficient transition training in the Cirrus SR20.  This would have created an increasingly complex environment in which to operate, in additional to the challenges imposed by weather.

The lack of experience with the aircraft, could in this case have been easily overcome by taking onboard a safety pilot, or an experienced pilot to conduct the flight.  Another option would have been to receive formal flight instructor prior to flying the aircraft.

Livewire – Software

As discussed in the software section, flight planning, particularly with regard to weather, is an important  process before conducting a flight.  Meteorology is a subject in pilot training, requiring a sound theoretical base in order to pass the exams.  However, interpreting weather based on meteorological reports requires not only sound theoretical knowledge, but also experience.  The experience and flying around weather should be built up gradually.  It is also always possible to seek help from more experienced pilots or flight instructors if you are unsure about whether the weather conditions are above your, or your aircraft minima.

Summary

While it is impossible to fully understand the causes of the accident as a thorough investigation for this is necessary, and is still to be published, several aspects do stand out.

  • The weather was far from ideal for a VFR flight under visual meteorological conditions:
    • Low visibilities were expected at the airfield of departure, at the airfield of destination and enroute.
    • Icing was also a risk, as the aircraft was flying at temperatures close to freezing level.
    • Cumulonimbus clouds were in the area that could cause significant and dangerous weather conditions
    • The Metar’s and TAF’s showed conditions that were not suitable for VFR flights.  Furthermore, the precipitation radar, satellite imagery and pressure and fronts charts, all showed significant weather along the route as wel as the departure and destination airfield.
  • The pilot is likely to have flown in conditions that were above his personal minima
    • Whether unclear, it is likely that the pilot did not have an Instrument Rating, and therefore had no formal training in flying in Instrument Meterological Conditions.  Disorientation would have been a major risk considering the deteriorating visibility.
    • The pilot had not likely received transition training when this would have been required when transitioning from a Cessna 172 to a Cirrus S20 that has very different flight characteristics.
    • The experience level of the pilot might have played a role in the accident, particularly with regard to understanding the expected weather conditions to be encountered enroute.  It is likely that the weather conditions were grossly underestimated.
    • The pilot was also of an age of 76, and may not posses the same reaction as younger pilots may have.  Furthermore the pilot first started flying 10 years, at the age of 66, and while it is possible to become a good pilot at a later age, a pilot that has learnt flying at a younger ages is likely to be more proficient.
    • Get-There-Itis is likely to have played a role, as delaying or postponing the flight, as weather conditions were not improving, would have been the right decision.
    • It is unlikely that the pilot had a plan B.  Without an exit strategy, the pilot was committed to the weather ahead.

When considering the tracking by the SSR (secondary surveillance radar), one can see that in the final phase the aircraft mad several turns.  A gradual left turn to the south, preceded by a rapid turn towards the west, and finally a sharp turn towards the east.  Disorientation due to VFR flight into IMC (instrument meteorological conditions), often leads to a spiral dive caused by a too large bank angle as a result of spacial disorientation. The final sharp left turn seems to be indicative of this taking place.  The aircraft would then impact the sea at a high speed.  Due to the aircraft having been disintegrated into many pieces, provides further evidence that this has taken place.

The sad thing of this accident, is that it preventable.  The weather was clearly not suitable for a VFR flight.  This was indicated by almost all weather information, with the exception of the TAF (which was too outdated being issued almost 12 hours prior).  Why then did the pilot still press on when the weather conditions were so poor?.  The answer may lie in an underestimation of the weather conditions, possibly due to a lack of experience.  Get-there-itis is likely to have played a major role.

The flight was planned such that arrival would take place close to the end of daylight period.  It is likely that the pilot at the departure airfield would have felt pressure to get home.  The pilot might had wrongly interpreted the slight improvement in weather conditions at the airfield of departure, as a signal to get into the air.  The pilot is then likely to have pressed on, despite deteriorating weather conditions, until his capabilities were exceeded when he lost visual cues and entered VFR flight into instrument meteorological conditions (IMC).

Conclusion

Flying is a very safe when it is done responsibly.  Indien from the 100.000 flights that take place in small aircraft in the Netherlands, only 2,6 of these end in an incident (of which only 0,4 is fatal), mostly cause by pilot error.

This briefing aims to show and explain the determining factors that likely played an important role in the accident, such that it may be prevented from occurring in the future.

If you know any other factors that may have played an important role, or agree of disagree with any of my conclusions, please drop me a comment below.

References

Dutch Safety Board (2016), Quarterly report aviation – jaunary – march 2016, www.onderzoeksraad.nl

LZ.de, Ex-Claas-Chef Gernot Schäfer tödlich verunglückt, http://www.lz.de/ueberregional/owl/20674020_Ex-Claas-Chef-Gernot-Schaefer-ueber-der-Nordsee-abgestuerzt.html?em_cnt=20674020

One comment

  1. I completely agree!. The regulations place primary focus on flight exercises during the training towards a PPL. However, a safe pilot requires additional skills, in particular for dealing with unexpected situations. This includes retrieving and interpreting information from different sources, including tools such as Skydemon that have the advantage of integrating a lot of the information. For longer cross-country flights these skills are essential, as weather and operational conditions more likely require deviating from the initial plan, or developing contingencies even before the flight takes place in order to reduce and manage the risk.

    In the Netherlands, I believe that insufficient focus is placed on developing captaincy in new pilots. The reason for this may be that the type of flying that most private pilots do here, primary consists of relatively short flights (of around 1 hour), where unexpected flight conditions are rare. Most of these flights also take place in next to ideal operational conditions, and few student pilots are ever exposed to poor weather or other complex operational conditions during training. Longer cross country flights are a whole different ballgame, and some pilots underestimate them.

    In defence of instructors and regulators, it is also a big challenge to develop these skills in training alone, as the 25 dual hours required for a PPL are just about sufficient for teaching the basic flying skills and maneuvres, let alone captaincy. Pilots will also have to appreciate that personal limitations exist. At the very least, a private pilot should be able to retrieve and interpret the information that allows him to make a judgement of the conditions, and whether these exceed personal limitations.

    Hopefully the Dutch Investigation Board and CAA do a thorough investigation so that lessons can be learnt. I am often saddened by the fact that all too often accidents are dismissed and labelled as ‘inadvertent flight into IMC’ without investigating the true underlying causes.

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