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Cirrus' "Failing Instruments In Rapid Succession"



 
 
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  #1  
Old April 12th 04, 03:43 PM
Marco Leon
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Default Cirrus' "Failing Instruments In Rapid Succession"

Sure the chute worked as advertised. Great.

What irks me is how and why the aircraft experienced all these instrument
failures one right after another. If any of our Pipers/Cessnas/Beechcrafts
had a propensity to experience near simultaneous failures of supposedly
separate systems there would be an uproar. Fresh off a maintenance visit or
not, sounds like a dangerous design of single-to-many points of failures.
With an airframe serial number of 80, I am assuming this was not a glass
cockpit.

Did this strike anyone else as bothersome?

Marco





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  #2  
Old April 15th 04, 12:26 PM
John Theune
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"Marco Leon" mleon(at)optonline.net wrote in
:

Sure the chute worked as advertised. Great.

What irks me is how and why the aircraft experienced all these
instrument failures one right after another. If any of our
Pipers/Cessnas/Beechcrafts had a propensity to experience near
simultaneous failures of supposedly separate systems there would be an
uproar. Fresh off a maintenance visit or not, sounds like a dangerous
design of single-to-many points of failures. With an airframe serial
number of 80, I am assuming this was not a glass cockpit.

Did this strike anyone else as bothersome?

Marco





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propensity

n 1: an inclination to do something; "he felt leanings toward frivolity"
[syn: leaning, tendency] 2: a natural inclination; "he has a proclivity
for exaggeration" [syn: proclivity, leaning] 3: a disposition to behave
in a certain way; "the aptness of iron to rust"; "the propensity of
disease to spread" [syn: aptness]


Source: WordNet ® 1.6, © 1997 Princeton University



I don't believe that the after action report of a single instance of a
action meets the definition of propensity. It also remains to be seen
just what happened here. Did the instruments fail, or did the pilot not
believe the indications?
  #3  
Old April 15th 04, 01:25 PM
Paul Tomblin
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In a previous article, "Marco Leon" mleon(at)optonline.net said:
What irks me is how and why the aircraft experienced all these instrument
failures one right after another. If any of our Pipers/Cessnas/Beechcrafts


You know, every time a pilot gets into a death spiral in IMC, if he
manages to report anything (like if he lives, or he says something over
the radio), he says that "all the instruments failed". But it's almost
never "all the instruments" that failed, it's the pilot that failed -
failed to trust the instruments, failed to cross check and identify if one
really had failed, failed to use the tools at his disposal (like pitot
heat and the autopilot and the checklist) and the skills he learned as a
student and never practiced again.

It's a sad thing to have to say, but most crashes are preventable and a
lot of the people who die in small planes have died for no reason other
than their pilot screwed up.

--
Paul Tomblin http://xcski.com/blogs/pt/
Some days violence is just a nice quick solution to a problem that
would need thought, planning and actual work to do justice to.
-- Wayne Pascoe
  #4  
Old April 15th 04, 02:48 PM
C J Campbell
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"Marco Leon" mleon(at)optonline.net wrote in message
...
Sure the chute worked as advertised. Great.

What irks me is how and why the aircraft experienced all these instrument
failures one right after another.


The man flew into IMC at 400 feet (I believe he was VFR and had no
instrument rating) and probably became disoriented. His instruments did not
fail. He did.


  #5  
Old April 15th 04, 03:10 PM
John Theune
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"C J Campbell" wrote in
:


"Marco Leon" mleon(at)optonline.net wrote in message
...
Sure the chute worked as advertised. Great.

What irks me is how and why the aircraft experienced all these
instrument failures one right after another.


The man flew into IMC at 400 feet (I believe he was VFR and had no
instrument rating) and probably became disoriented. His instruments
did not fail. He did.




************************************************** ***********************
*******
** Report created 4/15/2004 Record 7
**
************************************************** ***********************
*******

IDENTIFICATION
Regis#: 916LJ Make/Model: SR22 Description: SR-22
Date: 04/10/2004 Time: 1356

Event Type: Accident Highest Injury: None Mid Air: N Missing:
N
Damage: Substantial

LOCATION
City: FORT LAUDERDALE State: FL Country: US

DESCRIPTION
ACFT CRASHED UNDER UNKNOWN CIRCUMSTANCES 3 MILES NORTHWEST OF FORT
LAUDERDALE EXECUTIVE AIRPORT, FORT LAUDERDALE, FL

INJURY DATA Total Fatal: 0
# Crew: 1 Fat: 0 Ser: 0 Min: 0
Unk:
# Pass: 0 Fat: 0 Ser: 0 Min: 0
Unk:
# Grnd: Fat: 0 Ser: 0 Min: 0
Unk:

WEATHER: FXE 1353 UTX METAR 27004KT 2.5SM BR OVC006 24/22 A2991



OTHER DATA
Activity: Unknown Phase: Unknown Operation: General Aviation

Departed: FORT LAUDERDALE, FL Dep Date: 04/10/2004 Dep. Time:
1354
Destination: WEST PALM BEACH, FL Flt Plan: IFR Wx
Briefing: U
Last Radio Cont: APRX 5NM W OF FWE
Last Clearance: CONTRACT FXE TWR

FAA FSDO: FT LAUDERDALE, FL (SO17) Entry date: 04/12/2004
  #6  
Old April 15th 04, 03:24 PM
Peter R.
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C J Campbell ) wrote:

"Marco Leon" mleon(at)optonline.net wrote in message
...
Sure the chute worked as advertised. Great.

What irks me is how and why the aircraft experienced all these instrument
failures one right after another.


The man flew into IMC at 400 feet (I believe he was VFR and had no
instrument rating) and probably became disoriented. His instruments
did not fail. He did.


CJ, your conclusion does not appear to be the case, as the pilot is
instrument rated.

An interview with the pilot suggests that poor avionics maintenance may
have been the cause. However, flying into low IMC immediately after the
aircraft returned from maintenance may have been a bad decision.

From Aeronews 4/12 news (http://makeashorterlink.com/?T17252808)

--------------- start quote -------------------------------

ANN Exclusive: Cirrus SR22 BRS Survivor Describes Parachute Deployment
Mon, 12 Apr '04

Saturday should have been a good day for Jeff Ippoliti. And, ultimately,
we'd have to suggest that it was. Despite low scud and low visibility,
he was very comfortable with his SR22, an IFR-equipped aircraft that
he'd logged nearly 600 hours in, and one he'd come to depend on for an
unparalleled degree of freedom in getting where he wanted to go... swiftly.

A founding member of the highly regarded Cirrus Owner's and Pilot's
Association, Jeff had been flying a Cirrus Design SR22, Serial Number
80, for several years and simply wouldn't think of owning anything else.
He loved the speed, the looks, and the safety features and he'd gotten
quite comfortable with his personal bird, N916LJ.

He started the morning picking up his airplane at the local service
center, where he'd had it worked on, in order to deal with "some
electrical (and other) issues."

The shop assured him he was good to go, and after his usual preflight
and prep, Jeff launched out of Ft. Lauderdale Exec (FXE) enroute to Palm
Beach International, a short hop up the road. Weather was not all that
good. Broken bases at 400 feet and IFR visibility meant that much of the
trip would be conducted under IFR, though the scud reportedly had a
number of "occasionally broken" layers up to, and through, 6000 feet.

Ippoliti launched IFR, from FXE, and encountered "heavy IMC" shortly
after leaving the ground. Settling into this normal scan and IFR flying
patterns for the short trip up the coast, Jeff went into the soup at
only 400 feet AGL and continued the SR22's robust climb, now approved to
proceed to 2000 feet, as he switched over from tower freq's to the local
center.

From there, a pleasant effort requiring professional instrument flying
skills started tasking him in ways he had hoped to avoid. "Minutes after
departure, I started experiencing instrument failures, one after
another. No warning. No smoke. No clues. Just gauges going out one after
another." As the first gauge failed, Jeff told Center he wanted to turn
back. Center immediately gave him vectors for the return, but thereafter
the perceived succession of failures made the turn-around seem fairly iffy.

Ippoliti was stunned. Not only were gauges failing, but they were
failing in systems that didn't appear to be related. In a matter of
seconds, just hundreds of feet from the ground and untold obstacles
obscured by IMC, he really didn't know what to trust. This couldn't be
good.

With an unknown number of hazards looming, he informed ATC that he was
clearly in trouble. And after some initial hope of heading back, the
SR22 pilot realized that turning back to the airport was something he
wasn't sure he could do with his gauges continuing to fail in "rapid
succession."

"I told center I couldn't turn back... that I was going to pull the
chute." Jeff then told ANN that one of the few responses he remembered
from that moment on was center responding, "you're going to pull what?"

From there, Ippoliti's activities were quick and assured. "I'd thought
about this... but I never expected to have to do it." Jeff pulled the
power back, killed the engine and reached up for the BRS CAPS handle...
and pulled. Despite all his trepidation, Jeff noted that the pull went
well, "No problem with that, it pulled easily."

BANG!

The chute OPENED. Ippoliti then described feeling a little 'G' as the
plane slowed, swung around a bit, and then things calmed down remarkably
fast. "From there it was almost a non-event. The ELT went off right away
and prevented me from understanding Center because it was so loud, and
the pilot door came off as the chute fired... but the ride down lasted
only seconds as I came down on some trees and just... stopped."

Ippoliti was alive and had landed in a local park. The aircraft was not
only intact, but surprisingly suffered limited damage... "a lot less
than what might have been," he noted. He doesn't have much to say about
the landing impact, as the trees apparently absorbed most of the energy,
and turned history's third emergency CAPS landing into a "relative
non-event."

People who watched the plane land came immediately to the site and
Ippoliti soon found himself in the role of dutiful reporter (and
unwanted center of attention) to the numerous Law Enforcement, FAA and
other government agencies who converged on the scene. "FAA was
terrific," he said, and the support he got from Cirrus Design, shortly
thereafter (including a ride home), "was fantastic."

Jeff graciously called ANN less than 24 hours after his ordeal... a time
when there had to be a lot of things on his mind, though one thing
seemed certain. When asked if he was going to get another plane, he
answered quickly, "ABSOLUTELY... another Cirrus. I wouldn't fly anything
else."

As Ippoliti becomes the third pilot to experience what all Cirrus flyers
prepare for (and hope never to use), he joins the "informed unanimity"
that has developed from each of the survivors... a strong belief in a
safety system that was once looked down-upon by much of the rest of the
GA industry.. an industry who is now beginning to understand that this
technology has saved six lives so far and will, undoubtedly, keep doing
so far into the future.

Observers at the scene tell ANN that N916LJ seems in "Very good shape...
not as good as Lionel Morrison's aircraft (the first Cirrus to use the
CAPS system)... the leading edges of both wings scraped trees as it came
down but it looks like the landing gear never actually got to the
ground, since it was hung up in the trees."

ANN reached Cirrus CEO, Alan Klapmeier, just as he was returning from
the impact site, who was very pleased to be talking about incidents in
which no one came to harm. "First, in terms of preliminaries, no one
knows what really happened until NTSB makes final determination... but
obviously the whole purpose of the parachute was to give pilots one more
choice when they run out of options... and that sure appears to be the
case (in these incidents). These were tough situations for these guys
and we're glad the chute was there to give them a second chance."

[ANN Thanks Jeff Ippoliti and COPA's Mike Radomsky for their help in
preparing this article].


--
Peter










  #7  
Old April 15th 04, 04:02 PM
Michael
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"Marco Leon" mleon(at)optonline.net wrote
What irks me is how and why the aircraft experienced all these instrument
failures one right after another. If any of our Pipers/Cessnas/Beechcrafts
had a propensity to experience near simultaneous failures of supposedly
separate systems there would be an uproar. Fresh off a maintenance visit or
not


Is this the airplane that was flown in low IMC on the first flight
after maintenance? If that's the case, then as far as I'm concerned
we're looking at a case of gross pilot error. Test flights after
maintenance should never be in anything other than good day-VFR.

Michael
  #8  
Old April 15th 04, 05:39 PM
ArtP
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On Thu, 15 Apr 2004 11:26:33 GMT, John Theune
wrote:


I don't believe that the after action report of a single instance of a
action meets the definition of propensity. It also remains to be seen
just what happened here. Did the instruments fail, or did the pilot not
believe the indications?


The same thing happened in Lexington, Ky. Only that time the shut did
not work but the pilot was able to recover after he broke out of a low
cloud cover an land in a field.

If you have been following the COPA web site you will see a history of
a high rate of individual instrument failures so sooner or later
multiple failures are bound to occur.
  #10  
Old April 15th 04, 07:35 PM
Michael
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Peter R. wrote
An interview with the pilot suggests that poor avionics maintenance may
have been the cause.


I wonder how many of those "Loss of control in IMC" accidents,
generally attributed to pilot error, are really the result of multiple
failures. Face it, guys - we're flying old obsolete junk. I know
lots of pilots who tell stories of multiple failures on a single
flight. It happens.

However, flying into low IMC immediately after the
aircraft returned from maintenance may have been a bad decision.


In my opinion, it's an absolutely unacceptable decision. Test flights
are day-VFR events. I've had things go wrong on test flights before,
and they didn't always have an obvious connection to the maintenance
being performed. However, since I always landed the plane, I was
always able to do a detailed examination of the intact systems
afterwards - and in the end, it always turned out that the failures
were related to the maintenance, though in non-obvious ways that
generally pointed out previous marginal maintenance and/or very poor
design that clearly did not include a complete analysis of the failure
modes.

But of course he had a parachute. Would he have launched into low IMC
without a parachute immediately following maintenance?

Michael
 




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