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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 crash, which killed all onboard and three on the ground, was caused by a premature aerodynamic stall due to the pilot's failure to use anti-ice systems during an approach through icing conditions.
  • The pilot selected an insufficient approach speed (Vref) likely to achieve a shorter landing distance, as activating anti-ice would have significantly increased the required Vref and resulted in a landing distance nearly matching the runway length.
  • While the NTSB attributed the crash to pilot performance (omission of anti-ice), the article suggests a potential systemic issue where large anti-ice Vref increases and broad activation criteria might incentivize pilots to bypass safety protocols.
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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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