Accident Case Study: Risk Stacking

It’s a cold spring morning on April 13, 2022, when a cargo pilot in a Cessna 208 Caravan departs Salt Lake City International Airport in Utah. Her IFR flight plan takes her 133 nautical miles to the northwest, where she plans to fly the RNAV Runway 20 approach into Burley, Idaho.

Join the AOPA Air Safety Institute as we examine the circumstances that led to a tragic outcome during the GPS approach at Burley Municipal Airport. We look at several risk factors - including weather conditions and a factory's steam stacks located below the flight path, close to the runway threshold - that turned out lethal during the final descent.

ASI’s Accident Case Studies seek to share critical lessons to make us all safer pilots.

NOTE: The video states that a new NOTAM has been issued for the Burley airport. Technically, it is a “Letter to Airmen” that was issued through the FAA’s NOTAM system. This LTA may not be found through all means of accessing NOTAMs, such as ForeFlight. We apologize for the discrepancy.

Check out the Air Safety Institute Website:

Follow AOPA on Twitter:

Follow AOPA on Instagram:

Follow AOPA on Facebook:

#aopa #flywithaopa #aviation #pilot #flying

[jimbobinfanger]

Just so there are not any questions about the validity of the video, every parent knows their child’s voice. The pilots voice you hear is my daughters voice, and the last words from her.

[blancolirio]

The design of the approach coupled with the FAA approval of Potato factory steam stacks was an accident waiting to happen.
The stacks and the increase in height of the stacks should have never been approved by the FAA.
This Approach should have NOT been approved by the FAA.

[flightinsight]

This series has represented the gold standard for years. A 3.75° VDA with minimums only 400 feet above ground, and obstacles in the visual segment is a tough approach to say the least. Throw a steam plume in on short final and it's one of the riskier ones out there. There are only subtle hints on the chart about the risks like the absence of the stipple as was mentioned.

[porkinsjunior]

Brittney was a friend of mine and a colleague in flight school. Thank you for making this video and being so respectful.

[Jimmy]

The narrator of these videos is absolutely the BEST!
He clearly explains all the factors facing the pilot and says it with the most respectful and caring tone I have ever heard!

[drzoltanvajo]

All accidents are sad, but this is especially heart breaking. Rest is peace, Brittany!

[gwilewiczjr]

Can we just give a shout out to the production squad? These are always produced beautifully. Grabs me in, every time. Keep up the good work.

[baylokcommanderoftheflagsh]

the most expensive video on YouTube, because you are saving lives by watching what mistake others have made that cost them their lives. RIP good pilot and condolences to the family, keep up the good work ASI in helping us pilots learn to fly safely.

[ryanheywood]

Brittney is my cousin and was one of the happiest, most caring, and optimistic girls I know. It pains me to watch this video. I’m a professional pilot of 8 years with my ATP flying as a captain on a private jet. The fact that the dangers of the smoke stacks and towers for the Burley airport weren’t on any NOTAMS or approach plates at the time and are currently only listed on “Letter to Airmen” is wrong in so many ways. Not many pilots use “Letter To Airman” or no where to find them. In order to take a proactive approach at letting others know about the dangers of this airport, it needs to actively be placed in both active NOTAMS and approach plates the dangers of the smoke stacks on the potato plant. Just having it on Letter to Airmen isn’t near enough to make other pilots aware of these dangers. This needs to be addressed and changed immediately and a more proactive approach needs to taken to prevent these kinds of accidents from occurring at Burley in the future. How come nothing is being done?

[Gilliganfrog]

Damn. Usually these videos present pilots making several bizarrely reckless, obviously foolish decisions. This case seems different. The pilot was careful, intelligent, communicative, extremely competent, and totally by-the-book: so much so that as I watched I started growing anxious wondering WHY (and where & when & how) the accident was going to happen, whereas usually these videos lack suspense because you can see the glaring mistakes quickly accumulating. By contrast the mistakes in this case were subtle, the risk-stacking was insidious, and the outcome uncertain. This is one of the scariest reconstruction presentations I've seen, and I'm deeply sorry this pilot lost her life.

[InfinityBassCannon]

I saw this specific aircraft often when doing flight training in Utah. Tragic accident. I agree with the other commenters that the steam stacks should never have been allowed to be built so close and so high right next to the final. I can also easily see how one could miss the clues mentioning the obstacles while flying single pilot IFR under a high workload.

[curtmurphree]

She was at or above the visibility approach minimums, data shows even better visibility reported at the airport on her second approach. The discussion of risk stacking is valid to all pilots but the safety of this approach goes from acceptable risk to unacceptable in a matter of seconds because of the HUGE variability of the plant steam that is produced intermittently and at varying quantities (16 different steam stacks). The reported airport visibility is meaningless when the steam cloud rapidly develops in front of you in less than 0.5 miles from the end of the runway. How do you plan for that? Old Faithful at the end of the runway would be much easier to manage because the eruption intervals are generally known. Did she make the decision to do the second approach because there was no steam cloud when she did the first approach? There should not be a steam emitting plant that is deadly roulette for pilots at the end of this runway. Let's get some sanity and move the airport or move the plant. The FAA should eliminate this instrument approach, and runway 20 / 2 should be closed immediately. Otherwise, pilots put their lives in danger.

[LanceRichards-otjr]

Thank you AOPA your safety foundation for releasing this video. I think it was extremely well done. There is just a couple points in my opinion that were omitted or not discussed in depth, which I believe are more likely the probable cause of this accident. The determination letter from the FAA in 2017 about the airport that was referenced in the video was only reference partly, as there are conditions that had to be met for the airport to be deemed safe, which were not met. The bigger issue in my mind are the plumes of steam. The steam that comes out of those stacks is 1500°F according to a factory employee, and according to the AIM, which was referenced in the video this can be extremely hazardous to Flight. AIM 7-5-15 states “ high temperature, exhaust plumes can cause significant air disturbances, such as turbulence and vertical shear. It further states that some studies predict that the significant turbulent affects can extend to a height of over 1000 feet above the stack or cooling tower(the stacks at Burley are 65 feet below the instrument glide path). And I believe that the steam released had a significant effect on the lift and performance of the aircraft at the most critical phase of flight on the approach near the runway. The wind at the time was blowing the steam directly into her flight path at 12 kts. The surveillance video of the crash, as well as eyewitness reports state that she spooled up the engine right before impact, because I believe she lost lift, in a steam cloud, she could not see because she was IMC. She did not get low on the approach, she lost lift. The interment approach should be removed immediately from Burley airport before this happens to another.

[gusmc]

Good God, those stacks aren't just close to the approach track to the runway, they are dead center on the final approach path. What a dangerous scenario, and with limited visibility the danger is compounded. As we too often see, someone had to lose their life before any action is taken. My condolences to the family for their loss. May this beautiful young woman rest in peace.

[AirSafetyInstitute]

NOTE: The video states that a new NOTAM has been issued for the Burley airport. Technically, it is a “Letter to Airmen” that was issued through the FAA’s NOTAM system. This LTA may not be found through all means of accessing NOTAMs, such as ForeFlight. We apologize for the discrepancy.

[randallthomas]

Reading through the comments, I feel it is important to state a couple of things: First the airport predates the potato plant by about fifty years. The airport, was originally an emergency landing field during WW-II. After the war, it was given to the County and city of Burley, who are now responsible for the operation. Second, the potato processing plant is across the river in a neighboring county. The airport board has protested the processing plant from the beginning. But the county across the river, has all control of planning and zoning on their side of the river. Finally the airport board, has no means to control the construction, operation and control of the processing plant. The plant was built below the approach clearance zone against the airport operators wishes. And expanded into the approach clearance zone, against the wishes of the airport.

And, quite frankly the person to sue is probably the design engineer for the steam stack. Engineers have a moral, ethical, and legal responsibility to consider safety first. I date myself with this but, I was taught an ethical standard of considering the safety in teh order of Mankind, Society, Client, then self. The engineer who designed the stack height increase violated their ethical obligation, when they put the desires of their client, ahead of those of the general society, and created an unsafe condition. It has been a while since I have designed anything near enough to an airport or landing strip, that I have had to reread teh standards. But, it used to be: start at the end of the runway exclusion, and project a prism, outward for two miles, which has a slope on the bottom of 15-degrees, and outward in both directions of 15-degrees. That is the exclusion zone. You do not deign anything which will protrude into it with out clearance from the FAA.

I think the first time the FAA knew of the intrusion, was when tehy came to do a physical inspection, and saw it. The FAA has no authority to make teh plant owner remove the stack, and took the only punitive action they could, and withheld Federal funding from the airport. They did fail to let pilots know of that action, and that is why they share some of the culpability.

[slayercessna]

The most perfect narrating voice that there ever could be for documentary that are so intriguing, sad, and informative at the same time. I learn a lot frome these.

[justinrodgers]

A potato plant that puts out a giant cloud of steam above a tall smoke stack right on final approach. What a genius idea…

[MarkJoseph]

"Spring weather in Idaho Is often unpredictable..."
Born, raised, and living still in Idaho here, I can attest to this 100%!

[RuggedGoodLooks]

This production value is outstanding. Keep this series alive. Important for aviators to learn from mistakes of others.