At first glance, there’s nothing particularly special about Part IV, Task L of the Private Pilot Practical Test Standards (PTS). That section focuses on go-arounds and rejected landings; examiner criteria for success begins by ensuring the applicant “makes a timely decision to discontinue the approach to landing.” No numbers here, just a judgment call based on experience. The instructor in the right seat can usually grade a go-around long before the maneuver’s complete, assuming the CFI is paying attention.
On February 6, 2013, at about 11:35 a.m. local time, a Beechcraft King Air E90 on a Part 91 training flight was destroyed following a loss of control and impact with terrain at the Casa Grande Airport (CGZ) in Casa Grande, Arizona—about 30 nautical miles southeast of Phoenix. The National Transportation Safety Board said the pilot most likely lost control after pitching the aircraft excessively nose up during a go-around, resulting in an aerodynamic stall/spin. The NTSB believed the pilot/owner was in the left seat, while an airline transport-rated instrument flight instructor occupied the right seat. The instructor had flown with the owner for 58 hours of dual instruction in the accident aircraft. The owner had 1,097 hours of total time, with about 51 hours as pilot in command in his E90. Both men died in the crash and post-impact fire.
On the morning of the accident, Casa Grande was reporting clear skies, good visibility, and light winds. The NTSB’s post-accident investigation also showed nothing unusual with the aircraft, either engine, or the propellers that might have led to the accident. The aircraft was relatively light, with only the two people aboard and a partial fuel load. Toxicology reports showed nothing unusual in the owner’s bloodstream.
The autopsy of the CFII, however, was not as benign. Physicians found levels of tetrahydrocannabinol (THC, the active ingredient in marijuana) in the instructor’s kidneys that convinced investigators he’d “used marijuana at least several hours before the accident,” according to the NTSB’s final report. The report also stated that the effects of marijuana use on the instructor’s judgment and performance at the time of the accident could not be determined.
The autopsy also revealed a number of conditions that could have been grounds for denying the instructor his airman medical certificate, including his use of benzodiazepine, a sedative. Investigators believed his last use of this medication could have been days or even weeks prior to the accident, however. That said, we can only guess how attentive the instructor was that morning on a routine training flight in good weather with a pilot he’d flown with dozens of times before.
Part 91 does not require a personal airplane to carry a flight data recorder. This 1977 King Air E90 had, however, been retrofitted with both a primary flight display (PFD) and a multifunction display (MFD) that normally allows for the storage of some operational data. Unfortunately, the NTSB said the nonvolatile memory of the King Air’s MFD was destroyed in the accident.
The majority of the flight hours logged by the pilot/owner—663 hours of his total of 1,097 hours—had been earned in multiengine aircraft, with 551 hours in a Cessna 414 and 112 hours in the accident aircraft. We can assume, then, that the pilot was used to flying an aircraft with two engines, but we don’t know how proficient he was in any maneuvers near the ground—other than successful takeoffs and landings—until the day of the accident.
This leaves us with very little in the way of facts other than that at some point on short final, something caused the pilot to attempt a go-around. At that point, things happened very quickly and not only did the pilot lose control, but the instructor was unable to recover the aircraft.
We don’t know whether the King Air was being hand-flown when things went wrong, or if it was being flown by the autopilot. Many an accident has occurred when a pilot mishandled the transition back to a climb using a combination of automation and manual inputs. Even though the airspeed of the aircraft would have been relatively slow, there can be precious little time to think about what to do next—on or off automation—when the ground is approaching quickly.
If the aircraft was on short final and slow, it most likely would have been trimmed nose-high to maintain the approach airspeed. Shove the throttles forward and there’s only one place the King Air’s nose would go without some immediate retrimming—up.
The FAA says the elements of a successful go-around include, first, recognizing the need for a go-around early in the approach. The pilot is expected to add climb power, pitch the aircraft to the correct climb attitude, and reduce drag by retracting flaps and landing gear. We know the pilot never reached this point in the go-around because the aircraft hit the ground with full flaps still extended. The NTSB said the landing gear was still in the down and locked position at the time of the accident.
A wild card in this accident is, of course, the instructor. We simply have no way of knowing how attentive he was to this particular landing. It’s not unusual for an instructor who has flown many hours with another pilot to assume the next arrival will be no different from any other. But could there have been some lingering effects of marijuana that may have caused the instructor to fail to notice the owner was getting in over his head?
The FAA, as well as the rest of the aviation community, has realized that instruction on how to perform go-around maneuvers has been inadequate. We have also come to learn that a go-around in a sophisticated, glass-cockpit, high-performance twin is more complicated than it is in simpler, less powerful aircraft.
In March 2015, two years after the Arizona King Air crash, the FAA’s Flight Standards Service issued Safety Alert for Operators (SAFO) Number 15004, which outlined new, scenario-based go-around training to address this deficiency. While the alert is aimed at airline pilots, it also has great relevance to general aviation pilots.
Robert P. Mark is president of CommAvia and publishes www.jetwhine.com.
Illustration by Brett Affrunti
SAFO 15004 highlights
Safety Alert for Operators (SAFO) Number 15004 urges ground instruction on somatogravic illusions that can produce false pitch-up or -down illusions during accelerations and decelerations, and recommends flight training emphasis on go-arounds under the following circumstances:
• From various stages of the approach, including configurations other than final landing configuration;
• From visual approaches followed by loss of visual references;
• With extreme pitch trim configuration, such as nose-up trim resulting from flight at speeds below approach speed with the autopilot engaged;
• In low-weight configuration with all engines at go-around thrust;
• After the initial touchdown, such as from a bounced or long landing;
• With air traffic control clearance change just after go-around is initiated.
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