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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 was attributed to a premature aerodynamic stall caused by ice accretion on the wings because the pilot failed to activate anti-ice systems during an approach in icing conditions.
  • The pilot selected an incorrect, lower approach speed (Vref) suitable for non-icing conditions, despite the need for anti-ice, which would have significantly increased the required Vref and resulted in an uncomfortably short landing distance margin on the available runway.
  • The NTSB theorized the pilot's failure to use anti-ice may have been driven by concerns over landing distance, task saturation, or an underestimation of ice's severe impact on the Phenom 100's stall characteristics.
  • The article suggests that the Phenom 100's substantial increase in required Vref when anti-ice is active, combined with broad anti-ice usage criteria, creates operational challenges and may incentivize pilots to make unsafe decisions.
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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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