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Aftermath: Failure to Focus on the Overall Situation

Accident analysis that goes behind and beyond the NTSB report. Flying
Gemini Sparkle

Key Takeaways:

  • A Phenom 100 jet crashed during approach, killing six, due to a premature aerodynamic stall caused by ice accretion on the wings.
  • The pilot failed to activate anti-ice systems and selected an incorrect, lower approach speed (Vref) that did not account for existing icing conditions.
  • The NTSB concluded the pilot's omission of anti-ice was likely driven by concern over landing distance, as anti-ice use would have significantly increased the required Vref and landing distance for the available runway.
  • The article suggests a potential systemic issue where the Phenom 100's substantial Vref increase with anti-ice and high sensitivity to ice accretion may incentivize pilots to deviate from safety procedures.
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“The entire normal operating checklist for the new Embraer Phenom 100 light business jet fits on both sides of a laminated card that you can slide into a shirt pocket,” former Flying editor Mac McClellan wrote approvingly in his 2009 report on the airplane. “The Phenom is designed to cut pilot workload to a minimum so there is time to focus on the overall situation while the airplane and its systems take care of themselves.”

Peter Garrison

Peter Garrison taught himself to use a slide rule and tin snips, built an airplane in his backyard, and flew it to Japan. He began contributing to FLYING in 1968, and he continues to share his columns, ""Technicalities"" and ""Aftermath,"" with FLYING readers.

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