Cirrus Design Corporation SR22T accident at Canberra Airport, Australian Capital Territory, 2 Oct 2025 (VH-XXO)

Accident narrative

Pilot cognitive workload The arrival and approach was conducted at night, in turbulence, and initially in cloud, while the pilot had only flown one approach into a major airport (Canberra) in the last 12 months. These conditions are conducive to a high workload. For example, a study conducted by Dodd and others (2014) found that while operating in moderate turbulence, it took pilots over 2 minutes longer to complete a given task when compared to operating in no turbulence. In this case, the pilot reported experiencing a high workload (9 out of 10) during the latter part of the STAR when they received the unexpected ILS clearance and were attempting to reprogram the aircraft’s flight management system (FMS).Contributing factorThe pilot was experiencing high cognitive workload demands during the arrival and approach as a result of severe turbulence, a night approach in instrument meteorological conditions, a controlled airport with which the pilot was not highly familiar, and being issued an approach type that the pilot was not expecting. Missed turn at waypoint MENZI The aircraft made a left turn at waypoint DALEY as required, and levelled out, but did not make the required turn at waypoint MENZI (the initial approach point). Two minutes before the aircraft reached MENZI, the controller cleared the pilot for an ILS approach for runway 35. As per the AIP requirements, the controller issued the first available procedure listed on the chart for that runway, which was an ILS approach, as the pilot had not requested a different approach through the flight plan or verbally to the controller. However, even though the pilot had not informed air traffic control of their preference, they were not expecting to fly an ILS approach and had pre-programmed the FMS for a different approach. Instead of asking the controller for a different approach the pilot attempted to comply with the clearance and tried to reprogram the FMS in addition to managing a further stepped descent using the autopilot. Possibly in an attempt to reduce workload, the pilot then changed the autopilot modes to maintain the current altitude with wings level. While doing all these tasks in turbulence and experiencing a very high workload, the pilot likely became task focused on the FMS and the aircraft flew through the waypoint without turning.Contributing factorThe pilot did not inform air traffic control of their instrument approach preference, and then accepted an approach for which they had not prepared. The pilot then focused their attention on managing autopilot modes and programming the flight management system. As a result, the aircraft did not turn as required at the initial approach point. Controller’s use of daytime procedures at night During daytime operations an air traffic controller can issue a clearance that allows a pilot to descend visually. However, at night or in instrument meteorological conditions, the degraded visual environment limits the ability for a pilot to identify obstacles and terrain. Consequently, procedures and ATC phraseology differ at night in comparison to the day. A controller is not permitted to vector the aircraft below the minimum vectoring altitude (MVA) at night. In this case, the approach controller cleared the aircraft to descent below the MVA about 8 minutes after the point at which night procedures applied, and continued to vector the aircraft below the MVA for about 5 minutes during the approach. In addition, the approach controller used daytime phraseology to issue the visual approach clearance instead of the nighttime phraseology. Unlike the daytime clearance, the nighttime clearance for a visual approach reminds a pilot to maintain their assigned altitude until established on the PAPI. The controller had the intention to use the phraseology once night came into effect, but did not realise that it was now night in Canberra.The controller’s intention to switch to night procedures at the appropriate time is an example of prospective memory. Prospective memory, or ‘remembering to remember’, is an intention to perform an action in the future. In prospective memory, the main challenge is not remembering intentions but recalling them when they need to be carried out. Research has indicated that an individual is unlikely to remember to do so unless they get a timely retrieval cue from the environment (Dismukes 2010; Harrison and others, 2014). In this case, the controller had not set up a reminder cue. Their physical location and different local time for the end of civil twilight would have made their environmental cues inaccurate. In addition, the controller reported that managing the occurrence aircraft resulted in a high workload, which can increase the likelihood of error. Contributing factorLikely associated with a high workload, the approach controller was not aware that the time of transition from daytime to nighttime procedures had passed and, as a result, provided clearances and vectors for the aircraf