C-FNET C172S Investigation Report

[checkremarks]

Summary

The Cessna 172S (registration C-FNET, serial number 172S8544), owned by the Waterloo Wellington Flying Club, departed the Kitchener/Waterloo Airport, Ontario, at 1815 Eastern Daylight Time, under visual meteorological conditions. The aircraft flew to Niagara Falls, Ontario, then to the city of Toronto, Ontario, and back to a practice area north of Kitchener Waterloo. At approximately 2016 Eastern Daylight Time, the aircraft crashed into a field, 25 nautical miles north of the Kitchener/Waterloo Airport. The aircraft was destroyed; the pilot and 3 passengers were fatally injured. There was no post impact fire. The emergency locator transmitter activated upon impact.

Attached is a link to the Transportation Safety Board Investigation into this accident. RIP to all those who lost their lives on August 24, 2012.

Marko, I miss the days of Air Cadet Gliding in Borden and playing soccer with you, I'll see you again one day.

http://www.tsb.gc.ca/eng/rapports-repor ... 2o0138.asp

[BTyyj]

Sorry for your loss checkremarks.

[Colonel Sanders]

I hope the TSB didn't spend too much money on that report.

[checkremarks]

I hope the TSB didn't spend too much money on that report.

Why is that Andrew?

[Colonel Sanders]

Context: for years and years and years, accidents
happen. Various "crossing guards" jump on any
discussion, attempting to squelch it, and tell us
unctuously to wait for our elders and better at
the TSB with their crystal balls to tell us what
"really happened".

Then we have accidents like this one, and the
PC-12 at Calabogie, where the accident reports
are almost completely useless. They contain no
new information that wasn't available the day of
the accident.

This accident report, for example, is embarrassing.
Anyone knows, looking at the picture of the accident:



that airplane spun in.

The highly-paid geniuses at the TSB, with their fat
health benefits and indexed pension plans, years
after the accident, concluded that the 172 spun in,
having either entered an accidental spin, or an
intentional spin.

Thanks a lot, guys, for the brilliant insight. Now,
that was worth waiting years for. And squelching
any discussion.

As with any other government activity - eg health,
education, etc - the taxpayer gets very poor value
for his dollar.

[PilotDAR]

The report is necessary because our society demands it. We're too nosy, we can't "not know"- someone's lawyers, in particular. For this same reason, thousands of people will be inconvenienced while the police close a major highway for hours, because a driver rolls a perfectly serviceable car and kills himself.

We know again, for the umpteenth time, that a 172 crashed, and at the time it did, there were no significant detectable defects with the aircraft, so the fleet remains safe. It is sad that people have to die for the aircraft owner to get a taxpayer paid postmortem 100 hour inspection of the aircraft, but it's gonna keep happening as long as eager pilots fail to give due consideration to the laws of physics.

A Cessna 207 I highly modified was fatally crashed by the experienced pilot who I checked out in it. No significant defects were found with the aircraft during the investigation, he just went touring in a mountain valley, lost reference, and rolled it into the hillside. It's been done again and again. But the TSB was so interested in causal factors, they actually tasked satellite photos of the crash site, at different times of the day, to analyze shadows.

Even when they think no one is watching, pilots are still subject to physics, and there is nothing not already known about physics and a 172.

[pelmet]

I'm not sure what more the TSB can do. The reality is that these two accidents are pilots with poor judgement doing stupid things. Maybe a recommendation to revoke licences of pilots who exhibit poor judgement but how do you measure that.

[PilotDAR]

The TSB has done their job. They have investigated, determined the causes, and contributing factors, and reported the outcome. It's up to the industry to work with this information to make flying safer.

[peeelot]

One thing they did mention in the recommendation was decrease inspection times on the stall warning systems of c-172. TSB it was a problem but didn't give solutions just have pilot read more about stalls and introduce more on normal and utility category. TSB failed to do there job and just gave a smoke and mirrors solution. If anyone at the TSB reads this wondering if they can explain why they didn't recommend anything to do with the stall warning system?

[slam525i]

One thing they did mention in the recommendation was decrease inspection times on the stall warning systems of c-172. TSB it was a problem but didn't give solutions just have pilot read more about stalls and introduce more on normal and utility category. TSB failed to do there job and just gave a smoke and mirrors solution. If anyone at the TSB reads this wondering if they can explain why they didn't recommend anything to do with the stall warning system?

What solution is right? AD to replace every single stall horn on every single Cessna high-wing even though it passed the last 50-hour? Even though the airplane was most-probably spun/stalled intentionally?

There was no issue with the aircraft or its systems.The TSB did exactly the right thing: investigate and then do nothing.

[MUSKEG]

Isn't it ironic that society demands that the various arms of government keep them safe inspite of stupidity and incompetence. When government finally reacts with some weird law that is written to keep those that shouldn't be driving or flying or whatever, safe from themselves, society screams government interference. Darwin is almost dead.

[Posthumane]

That the aircraft spun in is obvious, but I think the purpose of an investigation is to see if they could figure out WHY the aircraft spun in. At the time that the investigation starts they don't know with any degree of certainty that this was not caused by a mechanical fault, or if it was simply pilot error, or some other cause. The fact that in this case there was no new information, that the aircraft was found serviceable, and that the spin may or may not have been intentional seems to make some people think that the investigation was a waste of money. But what if the investigation HAD found some major defect which could affect all 172 S models as they age and cause a stall/spin? Would it have been a waste of time and money then? How do you determine before you start an investigation whether or not your results will be conclusive and useful?

[CpnCrunch]

It's a good idea to occasionally check your stall warning if you can. The problem is that on some cessnas you have to suck on the hole to test it, which I don't particular want to do (and it's probably not good for the plane either!)

However if you're deliberately doing stalls (as seemed to be the case in this accident) I don't really see how the stall warning will make much difference - it's pretty obvious when the stall happens in a cessna even if the warning horn isn't working.

[pelmet]

It's a good idea to occasionally check your stall warning if you can. The problem is that on some cessnas you have to suck on the hole to test it, which I don't particular want to do (and it's probably not good for the plane either!)

However if you're deliberately doing stalls (as seemed to be the case in this accident) I don't really see how the stall warning will make much difference - it's pretty obvious when the stall happens in a cessna even if the warning horn isn't working.

While nice to have, it shouldn't really matter too much. I have done intentional stalls in quite a few aircraft that never had a stall warning system installed. A Cessna 172 has docile stall characteristics when in the Utility category and most likely in the normal category as well although I don't believe that I have ever done that. Intentional spins in outside the utility category would be a very foolish and irresponsible thing to do. It might endanger property and the lives of people.

It is interesting to note that the report says "Aircraft certified in the normal category, although not approved for intentional acrobatic manoeuvers (including spins), must be able to recover from a one-turn spin in not more than 1 additional turn, and it must be impossible to obtain unrecoverable spins with any use of the flight or engine power controls." Most likely, these tests were done by a very experienced pilot, not a newly licensed guy who might find himself well past that single turn in the spin prior to attempting a recovery with his limited experience.

[PilotDAR]

A few "knowns" and a few "ifs"...

The 172 is a very stable, well known aircraft, with not dark corners of handling.

The 172, when operated as a "normal category aircraft" will recover a one turn spin, in not more than one additional turn, if the recovery control inputs are prompt and correct. Unusual pilot skill and attention is not required. It is also not capable of entering an unrecoverable spin with any use of the controls = misuse. From this, there is an implicit understanding that if you exceed one turn in a spin, you are in territory where it can be recovered, but it will not be anywhere near as easy.

The 172, when operated as a "utility category aircraft" will recover a six turn spin in not more than one and a half additional turns, if the recovery control inputs are prompt and correct. Unusual pilot skill and attention is not required.

The occurrence pilot was flying the aircraft loaded in the normal category.

The occurrence pilot intended to do "airwork", which would normally be interpreted to include at least slow flight, and unusual pitch and bank angles, if not stalls. Spins should not be contemplated for a "normal category" 172.

If the occurrence pilot was intending to stall, and then found the stall warning system not working, no further stalls should have been entered.

If he approached the stall so rapidly, that the failure of the warning system to warn went un noticed to the point of the stall, the pilot was either not alert, or was not cautious. None the less, a normal stall would still be gentle enough that a recovery could be initiated with no difficulties.

If the pilot deliberately entered a spin, he did so outside the aircraft limitations, and air regulations.

If the pilot accidentally entered the spin, he was flying the aircraft in a way which left inadequate margin of safety.

If the pilot was unaware that the presence of back seat occupants put the aircraft in a category for which intentional spinning is prohibited, he was not applying due diligence to the flight.

If the pilot could not recover a spin, however entered, he either did not allow enough altitude to do it, or applied an inadequate technique (or both).

Cessna writes very good Flight Manuals, and they all contain spin recovery techniques, for every category the aircraft is approved in. The pilot is responsible for knowing the contents of the Flight Manual. Low altitude not withstanding, the spin was recoverable.

I remember the first time I was required to spin test a Cessna 206 at full gross weight, aft C of G. My recovery was poor, and delayed. I surprised myself, that a secondary recovery was needed. I told myself that I must be able to do better than that. Then I recalled the phrase "move the control wheel briskly forward" from the Flight Manual, and I did that. The recovery was text book. You just gotta follow the instructions. had I foolishly let the spin develop further, I could have had my hands full.

A Cessna 172 will do many things, and be many planes, but not all in the same flight. You must depart the flight, with the intent of the flight reasonably planned out, and fly that way. EITHER take four people, OR consider some properly executed air work!

[DonutHole]

That was one of the better posts I've seen PilotDAR.

I learned to fly in an aircraft with no warning system.

my question is. Barring mechanical failure.... how does one become inadvertently anywhere near a stall/spin scenario???

The aircraft get shifty when they slow down and it, at least to me, is quite noticeable when you're getting close to the aircraft letting go of the air.

If you were doing steep turns and it let go... that might sneak up on you.. especially with the extra weight.

[PilotDAR]

Thanks DonutHole. In my opinion, a 172 being flown into "airwork" has a pilot who is intending to fly unusual attitudes and accelerations, which makes the flight "aerobatic", and thus there should be no back seat passengers. Wisdom would suggest that "airwork" is not undertaken in poor weather, so it is very unlikely that at spin was entered because of loss of attitude awareness, unless as a part of another unusual attitude (which would be outside "normal category" anyway).

A normal spin can only be entered as a result of the entry into a stall of at least one wing. Yes, that could happen in a steep turn, but that would be an indicator that the pilot had very poor proficiency in turns. A spin could be entered from slow flight, were it to bee too slow, or roll and yaw control were very poorly managed. In such a case, that would be an indicator that to pilot was poor at slow flight, as its purpose is to maintain stable flight while flying slowly. In a long stretch, a spin could be entered because of the contribution of a passenger to distraction, or interference, in which case the pilot did not exercise command well.

The report does a good job of ruling out all the "other" factors which could be a cause, and puts our collective minds at rest that a 172 is a fine aircraft for many roles, with no skeletons in its closet. That leaves the cause of the accident at the feet of the pilot. We don't like to take on our peers, particularly after their fatal accident, but sometimes they simply screwed something up, and if you're going to inquire about the cause, that's the answer you're going to get.....

[CpnCrunch]

my question is. Barring mechanical failure.... how does one become inadvertently anywhere near a stall/spin scenario???

I think it's only really an issue close to the ground, when there might not be time to recover. I once was looking for the windsock and then realised my speed had decayed (not quite to the stall). Could also happen on base-to-final turn, or on approach, or if you're doing low-level sightseeing and not paying attention to airspeed. There have been quite a few accidents like these over the years, so it definitely happens.

[ReserveTank]

The corrective action was to install GPS tracking. How does this address poor judgement and lack of stick and rudder skills? At least they will be able to find their next crash a little quicker.

[trey kule]

That the aircraft spun in is obvious, but I think the purpose of an investigation is to see if they could figure out WHY the aircraft spun in. At the time that the investigation starts they don't know with any degree of certainty that this was not caused by a mechanical fault, or if it was simply pilot error, or some other cause. The fact that in this case there was no new information, that the aircraft was found serviceable, and that the spin may or may not have been intentional seems to make some people think that the investigation was a waste of money. But what if the investigation HAD found some major defect which could affect all 172 S models as they age and cause a stall/spin? Would it have been a waste of time and money then? How do you determine before you start an investigation whether or not your results will be conclusive and useful?

How indeed. Well, you simply post the accident as soon as possible on Avcanada, and in no time at all, you will have an accurate, in depth analysis with conclusive results.

BTW..I agree 100% with your post.

[flyinthebug]

That was one of the better posts I've seen PilotDAR.

my question is. Barring mechanical failure.... how does one become inadvertently anywhere near a stall/spin scenario???

-Low level (LIDAR) survey flying
-Aerial fire detection/attack.
-Moose/Elk count (low level, low AS)
-Pipeline patrol (low level, low AS)

Just to name a few. There are several segments of flying that include slow flight...approaching stall. On "moose count (MNR)" flights, we are at 500' AGL and as low as 85-90 MPH in a C337. That speed can deteriorate very quickly if you get distracted even for a few seconds. I have never stalled inadvertently, but I have to admit I got the buffet a couple times I didn't expect it...during this type of flying.

I agree completely with your assessment of PilotDARs post.

My condolences on your loss checkremarks.

Fly safe.

[MUSKEG]

Getting a visual on some stupid collared moose is not worth taking any aircraft to the buffet.

[Illya Kuryakin]

I'm not sure what more the TSB can do. The reality is that these two accidents are pilots with poor judgement doing stupid things. Maybe a recommendation to revoke licences of pilots who exhibit poor judgement but how do you measure that.

Perhaps they could take less than two years to state the obvious?
Illya

[flyinthebug]

Getting a visual on some stupid collared moose is not worth taking any aircraft to the buffet.

Agreed, but when you spend 12 hours a day everyday in slow flight, these things can and do happen. Staying ahead of the aircraft helps avoid this from ever occurring. I was just pointing out some segments of aviation that require slow flight, and can lead to an inadvertent stall if the PIC isn't paying full attention to what he or she is doing.

In most "moose counts" ive flown, there are two MNR guys in the back doing the observing, and the guy sitting beside me in the front seat marked the spots on his GPS. I was rarely ever doing anything more than flying the grid they handed me. It was when we would see a pack of wolves or coyotes chasing an Elk that I sometimes took a peek or maneuvered the aircraft for a better view. That's the type of distraction I was referring to that could potentially lead to a stall.

[aviate_77]

Friends that fly with their pilot friends generally want to see the 'stall'. My guess is a power on stall with a nasty wing drop, and obviously an out of whack C of G for recovery. Whatever happened, it is unfortunate. RIP to all.