Kenora District

This report covers the period from recognition of the stopped engine to impact. I have always been interested in reading other accident reports, trying to glean anything that could learn to help me if faced with a similar situation. Evidently it is my turn to supply a case.

I have noticed two general types of pilots: those who say "the engine does not know if it is over water" when discussing crossing water and those who believe in Murphy's Law " If anything than can go wrong it will go wrong". I fall into the latter group so have been concerned with how to react in various emergency situations.

One's reaction to a situation is affected by one's background. I am a classic nerdy engineer who approaches everything with that mindset. Much of my career has been spent either designing things to work better or in quality assurance trying to determine why and how things can fail and to make them better. Because of a software background I often find it useful to think of the mind as a limited resource computer trying to share one mind with several tasks

Another significant aspect for this case is that my initial flying was in gliders. I became fanatical and got heavily involved in teaching gliding. At one time I was chief flying instructor for my club.

For this incident there is an additional opportunity as a learning tool. My instruments recorded a breadcrumb file containing position, speed and heading at one second intervals. With confidence I can say there are 3 aspects of looking at emergency: how I planned my actions, how I thought I performed my actions, and what actions actually happened. All were different.

In this note, a few notations have been adopted. Occasionally a quote would come to mind. Where not specified, I was remembering a line I said somewhere in the past. Ponderings made after the fact are within angle brackets <>.

Abandoned engine restart attempts, and recognized I had to shift to forced landing mode. Set aircraft speed to 75 knot and zero flaps for (near) maximum glide range. Established a mental mode where part of me tried to deal with the emergency directly, another 'observer task' tried to assess the quality of the decisions made and be on the alert for panic. I decided to make choices based on which way required the least finesse and precision: adrenalin would degrade skill and lead to excessive control motions.

Called Red Lake radio and declared an emergency. A nearby twin aircraft told the operator that they would look for me. The observer in me noted that after taking the initial parameters from me, he never contacted me directly although frequently talking with the twin. I was impressed: he was not trying to divert my attention. The exception was at one point I decided he needed my coordinates so gave the GPS values to him. He requested clarification of the latitude.

<This brings up one serious error I made. My attention got diverted to listening to the radio and 'correcting' them when I felt they got my location wrong. I should have concentrated on Aviating the plane while Navigating to a good landing location not Communicating. This was an especially significant blunder for me since I am easily distracted by a radio. When driving a car in town I turn the radio off as it it distracts from my attention. Significant brain capacity was wasted by not turning the radio off. My observer task eventually noticed my foolishness and I managed to ignore the radio from that point.>

Places to land were either small diameter trees, logging roads and lakes. I decide I would make choices based on what would be the most easy approach to adjust if needed.

I immediately eliminated the single lane logging roads as possibly too narrow to negotiate: I did not want to catch a wing tip at speed. “Choose northern trees before water”, from a conversation with a bush pilot a few years ago. I was not experienced enough to judge the massiveness of those trees. Ultimately since the trees were big enough for logging roads, I would look for alternatives. Looked for wider logging road sections and found an offshoot that had an uphill grade into wind. Selected that. Would make a downwind/base/final circuit to land there.

Then I began to stare a the selected landing area. I noticed that the end of the area sloped up more sharply than I originally thought. Became fixated keeping it in constant view. Zombie mode (became totally consumed with its form, sucking down all my mental capacity, observer task getting no time to break in).

<This fixation might be similar to what happened when an airliner went into a swamp in the Everglades in 1972 while the crew fixated on trying to understand why a minor alarm light was on.>

Finally noticed tree tops were closer to me than I wanted and that I had drifted too close to the landing site for a proper circuit pattern. I was amazed and annoyed I had fallen for the newby error of setting up a circuit to close the field. This was a big deal for me since from my gliding instruction days it had become almost a prime directive to “Watch the attitide (angles) to the flare point. Started to ponder how I had become so inept. Promised to practice circuits after the trip. Zombie mode. Found myself having finished both a base and final turn and was now lined up on final. These were not conscious decisions but mechanical motions that I knew had to be made. It was very steep angle to the threshold of the field. The far end was at a more reasonable angle to meet. Perhaps my earlier fixation with the hill at the far end had either affected where I should turn to base or I just made a base and final turn automatically without thinking. “Make good turns in the circuit” i.e. looking out of front for good attitude/speed control and coordination. I don't remember the turns at all but suspect they were well executed... just in the wrong place.

Angle judged too steep to land in the space available. Contemplated full spoilers with side slip vs a figure 8 S turn. Rejected the full spoilers because if that was insufficient there would be no room for another maneuver.

Also a steep turn figure 8 was a common practice maneuver I made when working on coordination and speed control. In fact, during the flight previous to starting on my trip, I performed some to evaluate and hone my skills.

Began my S turn to the right. I estimated I got about 45 degrees beyond a right angle (135 degrees) when “Don't turn away from the field” was remembered form an instructor while practicing forced approaches. Banked left to form the right hand loop. Zombie mode. Noticed speed had dropped 10 knots on asi. “Tweak stick forward to reduce angle of attack” from my instructing days. I was half way through the the left hand loop and was over trees with the field at at a shallow angle. Straightened the bank and took the shortest distance to the clearing. Zombie mode.

I mentally heard, “Cleared the trees now let see where I can land. Oh, I'm here”. The observer noted the words which were of a common thought when clearing trees to get into a small field. There was probably a fixation on clearing the tree tops. The aircraft altitude was below the flare point. Impact was imminent. "Freeze the stick”. Was concerned about a panic jerk back of the stick so locked stick in current position. The thought would have been fortified by the instructing tip of freezing the stick after ballooning or bouncing while landing to let the aircraft settle is almost always a safe response.

Impact. The observer was back noting the behaviour of the aircraft during the crash particularly windshield destruction.

The attached image is the final two and a half minutes of the breadcrumb trail. The little hook at the end should be ignored as an artifact of the gps coordinates becoming more accurate while being stationary. The landing site differs significantly from when the aerial photography was done. The terrain is semi-soft sand surrounded by a trees and a few more logging roads.

Note my attempted S turn near the top. The admonition to not turn away from the field did not happen at 135 degrees. It was 45 degrees. The intent was for the S turn to not consume much landing length. Because it was so skewed, final touchdown was at the far end area, perhaps less than 200 ft remaining. Fortunately (?) I had zero rollout,

By the way, if you look are trying to find the impact point from my Inreach track (https://share.garmin.com/RayStl), the final point is at the Red Lake hospital. that was where my Inreach satellite device was returned to me and I shut it off. Impact point was further east, just south of Little Trout Lake at the point labelled 4:22 pm on June 12. That is Atlantic time while the impact point was in the Central Time zone.Читать далее