Accident Case Study: Risk Stacking 

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.

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.

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

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.

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.

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!

the most expensive video on RU-vid, 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.

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

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?

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.

I never knew that about the grey "stipple" indicating clear line of sight from the MDA. That's good to know.

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.

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

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.

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.

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.

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.

I'm a VFR pilot with limited IFR training. For a few seconds at 6:37, I thought smoke along with two blinking lights was the runway, even though it looks a bit strange. I would have followed it momentarily. Hope that smoke stacks are removed.

This is one of the most haunting ASI Case Studies yet. The pilot was about my age, experience level, sounds like me, and flying in actual IMC... something I do with some regularity as a CFII in the Pacific Northwest. How many tiny-footnote obstacles populate the path between the MDA and threshold on the approaches I fly? I will look now, instead of finding out the hard way in 1sm visibility.

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.

Wow the increase in density altitude from the steam is a fascinating theory. Rest In Peace to this pilot.

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

This series should be a standard in new pilot training. Simple verbiage, great video production, and respectful to the deceased. Though I hate terribly seeing another pilot/crew/passenger fatality, I throughly enjoy seeing another installment in the series. Also a big shout out to the narrator. Great voice and inflection.

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.

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

Flew freight in the van for years. Not a fancy G1000 like this one, but still. It's a solid airplane and we flew it into some really nasty weather. Been sitting in the same seat, not an easy job. I wonder if the lights of the stacks (White) could have tricked her into thinking they were REIL. I've descended below MDA before after seeing what I thought was the VASI, but turned out it was a gas station price board, illuminated with the gas in red and three white prices. Made a missed approach and I'm still here, wish she'd have been as lucky.

Reading, reviewing all incident/accident reports can only increase your awareness. This channel certainly helps toward that goal.

This was a sad loss of a young aviatrix. A sad loss to her family, colleagues, and to her friends, indeed.

That plant with stacks that actively reduce visibility of the runway was such and obvious risk, that was graveyard mandating there.

The grandfather of aviation RU-vid provides us with essential knowledge yet again. Thank you for making everyone who watches these videos safer pilots.

Thank you for returning to this format. It is much easier to follow.

Thank you for taking the time to detail the factors causing this tragic accident.

Nice video. I'm glad you're still doing this series, it's one of the best in the genre

These videos are very well done. Very informative. Please keep making them!

Thank you AOPA for another accident case study. I love them and they are life saving for us pilots. Please never stop doing them!

I could probably watch thousands of these videos, and im not even a pilot. Fascinated, incredible effort in production quality. Keep it up aop

AOPA ASI, thank you for publishing these videos and analysis’ of the accidents. They are always very informative and provide more tools to the ADM tool box no matter the pilot skills/levels.

Thank you Air Safety Institute for creating such high quality videos. Specifically, the narrator delivers information so that it’s easily understood. Great work.

These are sooo good, my fave flight education video series, amazing narrator, graphics, editing, and lessons to learn.

Aside from the "stacks" issue, these videos are great because they also give tips on things us pilots might not know or remember, bringing them back to light and hopefully sticking the knowledge into our heads not to forget. I watch these videos for these tips just as much as I do for the overall lesson being conveyed. Well done!

I earned my private license at the age of 17. Today, I'm 67. I never stepped out of a VFR flight because I had too much respect for mother nature and only enjoy clear, non turbulent days of flight. I would have issues with those stacks even on a perfect day! I've just never wanted to be in a poor weather situation. For me, private flying was all about clear skies, tons of touch and go's and then owning an amphibious Searey.

Another sad loss. Thank you ASI for your amazing work. And the masterful narrator, a golden voice for this

Always fascinating to watch these. Thanks for the great production quality.

Whenever I see one of these new videos come out, I suspend everything I am doing to watch it. I love them. Keep up the good work!

A magnificently compiled video. Many thanks indeed.

Glad these are back. I LOVE these case studies

Its always bittersweet to see these videos pop up in my feed.... I know I will learn something important... but also that often someone paid for that knowledge with their life. RIP to all pilots that have been lost. Just a small gesture for such a large sacrifice.

Fantastic video. Thank you for producing it.

Amazing presentations every time. Best on the net.

Need more of these videos!! Thanks guys!!

I really missed this series. I’ve been waiting for months for it. Thanks.

One of my favorite videos by you guys! Great lessons learned.

Always well done ASI. Appreciate your professionalism in the pursuit to improving air safety which unfortunately often leaves us learning from regrettable incidents... Horrible for the families and loved ones affected by this incident.

These videos are a fascinating and sobering experience, I hope the narrator sticks around - such a warm but cautionary tone and no obnoxious music or embellishments.

Finally one more of this great videos it has been so long since one was released, and they are great.

So excited to see another one of these after so long. These are my favorite part of the channel. Not what happened, but how much I can learn. The narrator is also wonderful.

This does a good job explaining the “stacking “ of independent issues that significantly increased the probability of a significant event. The video helps those unfamiliar with the problems at the Burley airport see the big picture.

Excellent video,keep up the good work and please,produce more of the kind!

Crucial concept there, risk stacking. As with the accident chain it's not a matter of a moment gone awry as people tend to believe. A bit awkward in the telling here, given that there were other *stacks* involved. And it's not easy to listen to the recorded voice of someone who's about to die. But these videos are invaluable. Thank you.

I loved this documentary. Well done with production!

Very classy presentation. Thank you for this.

I wish these Case Study videos are more frequent

Excellent video, thank you.

Great content as always.

Another great video. Thank you.

Thx a lot for your service

Brittney Infanger, Fly to the sky fellow pilot, condolences to the family

This is a fabulous video with many excellent points that every IFR pilot should pay attention to.

I wait and wait and wait for new episodes. Can you please make more! Why are they too far apart😢

Very sad story. Excellent presentation.

Pleasw we need more videos like this!!!

So excited for a new one

Another great video for pilots to watch and a lot of things to learn from this tragedy.

These videos are so well done. Thank you for the effort!

I liked the old intro music better. Thanks for posting.

These videos are excellent , very well produced and informative but ironically my wish is that no more of them have to be made. It's so sad to see there tragedies unfold.

MSFS is a great recreational sim, and a visualization tool!

New subscriber. ...excellent video...these videos are Awesome learning tools

While obviously sad, these are your best videos! The accident case study. Great teaching tool for us young pilots!

Thanks for the good explaining video. I hope that such a failure doesn't happen again

Great video !!!

Oh snap, Case Study! So excite! So excite!

Thank you AOPA for producing these high quality educational videos. The production quality, storyline, video editing and voiceover are spot on perfect and it presents the message in a very easy to understand yet very powerful manner. Please continue to produce these Accident Case Study videos!

Heart breaking.

Sorry to hear about the crash :( and beautifully explained. Thanks for spreading the awareness about the stipple on the charts

Very sad. Well done. Thx

Tragic. RIP brave pilot

Here’s a suggestion for amateur pilots; don’t fly in bad weather, especially in mountainous areas.

So sorry for your loss. I can not imagine. ❤️ A pilot myself, I'm now questioning my daughter's quest for her own pilot's license...

Finally another case study! Love these!

Excellent production. So sad.

RIP to the deceased, and may her accident, tragic as it is, save lives in the future, however possible.

Brillant! - stacks on approach and not mention by tower

I feel like the narrators voice is in many videos of my feed currently. I like it.

There is no way at my local area that you would EVER see smoke stacks allowed to be built anywhere near the approach path for a runway. This is precisely the reason too, there just is not enough margin for error and factoring in the types of weather conditions you see in that area you need extra broad margins. A very tragic cost for this lack of forethought.

Good information…thank you

God be with her

Mr. Narrator, whoever you are, you do an exquisite job of narration. I just saw a photograph of this pilot. She was stunningly beautiful. My heart breaks for her family.

That was an accident waiting to happen. Terrible spot for steam stacks, directly in the approach path. Even if the height of the stacks themselves are accounted for. The huge plumes of warm MOIST air that extend a couple hundred feet higher are bound to intersect the approach path. Sudden loss of density? possible icing at a critical phase could easily push the aircraft lower. Definite risk stacking. Excellent video on how these things can easily compound.

This narrator is top notch as well as the production series