One big oversight leads to........

[Jabawocky]

Has anyone read this.... :uhoh:

http://www.atsb.gov.au/publications/investigation_reports/2008/AAIR/pdf/AO2008048.pdf

easy to be an armchair expert but gee.... check your fuel tanks is a pretty easy one if you have plenty of height and time!:eek:

[AussieNick]

wonder if it could be a traning factor? a mate of mine got his twin endo and the engine failure action was mixture up pitch up power up gear up flap up dead leg dead engine confirm with throttle feather. he mentioned that there was no FMOST drill after an engine failure as everything was done in the circuit with nothing in the cruise therefore no oppertuinity to follow a full engine out drill without it been height critical (no i will not mention the school he went too) Now i know FMOST checks should be second nature as they are taught from GFPT but 3 twin endos in 2 months, maybe with so much engine out practise he had simply forgotten to do an FMOST check in its entirity and just done his engine out check as you would when doing asymetric training?

[bushy]

And things like that will keep happening until we get some stability and some experienced pilots in GA.
While we have a flood of newbies who either quit or move on after a short time we won't be able to change this.
Whether we like it or not, the apprenticeship taskes about 5000 hours.

[Lookleft]

It wasn't just the fuel management it was also that he didn't feather the engines either which led to the high RoD into the ground. Unfortunately the combination of low time and inadequate training has had unfortunate consequences for this bloke.

[Mr. Hat]

Does anyone know how the lad faired? Did he recover from the injuries? Is he back in the saddle? IMHO 500 hours is a bit low for a Navajo. I remember myself at 500 hours - i was learning in much less complex and more forgiving machines.

Its sad to read the report and see the pictures. It would have been a terrible time for someone just starting out.

I know several others that did this exact same thing (less time available though) and somehow they all ended up in very big airlines...hmm maybe thats where i went wrong ( i was/am fanatical about fuel)!

[freshy1234]

Was this Savannah Aviation???:confused:

[flywatcher]

I fail to understand how someone can total a perfectly good aircraft in this manner. It appears that even a most cursory glance at the fuel pressure or the fuel gauges or a change of tanks or almost anything would have made it a non-event.

[Koizi]

If a PA31 crashed every time the pilot had to be "reminded" by the engines to change tanks, there would be none left by now.
Having flown them for a while now, you would think it would be instinctive to change to mains. I know it is for me.

But I suppose mistakes happen and I can't help but feel sorry for the pilot. Pretty nasty wreck.

[Mr. Hat]

Human error for an inexperienced pilot on a relatively complex aircraft. Sometimes the career progression comes too early and given the right circumstances accidents can be the result.

[Lodown]

Correct me if I'm wrong because I haven't seen a training syllabus in years, but are students shown how to restart an engine in flight or is it deemed unnecessary risk? I know it made an impression on me when my instructor did two things in flight; pulled the mixture and then restarted a windmilling prop, and; took the effort to stop the prop completely near the stall, bunt, get it windmilling and started again. From memory, it took about 1200ft, but my memory is hazy on that subject. Besides being great fun, it was a good learning experience, but I can imagine CASA's reaction these days. I can understand in some way, a pilot who has never been shown otherwise, seeing a windmilling prop and thinking/hoping it still has some power.
If anyone sticks around in GA long enough, they'll eventually run a tank dry and lose power. Lucky the guy didn't have a full load of pax.

[Cessna Capt]

he mentioned that there was no FMOST drill after an engine failure

I was taught only to feather in a critical situation. (like low to the ground) In the cruise after identifying the engine out, i would stop before fethearing and conduct a restart. :ok:

[Chimbu chuckles]

500 hrs certainly isn't experienced....but what leads anyone to think the exact same things wouldn't have happened to this young man in almost any other aircraft?

Apart from (some of) the EFATO memory items being allegedly completed, and you have to ask why? (In cruise they would most likely make things worse), he appears to have sat there and done nothing meaningful.

By 'worse' I mean that pushing the props to full fine and then not feathering simply creates more drag - and maybe what led him to think the engines were producing 'some' power - Windmilling RPM being a product of airspeed and MP returning to somewhere close to ambient, say 22 inches at 8000'.

Mixtures to full rich would probably set him up for a 'too rich' condition if he suddenly remembered (he obviously didn't) to change tanks and flipped on boost pumps as well.

This pilot's actions seem to be a result of rote learning - he could peel off the EFATO memory items (inappropriately) while 'controlling' the aircraft but there was ZERO understanding...of what was happening to him or what happens in any engine failure in cruise vs one on takeoff.

A training issue?

Most likely. I don't think the guys 500 TT is the most important issue...it's what he didn't learn/wasn't taught in that 500 hrs.

Maybe he is one of those Gen Y who feel GA is a burden to be born for the least time possible and didn't WANT to learn his craft properly...maybe he's thick as pig****...or maybe he was just a victim of a deficient training system bereft of real experience/talent?

[Lookleft]

A training issue certainly but what was the experience of the CP who checked this bloke out and let him loose. As someone wrote it was fortunate that there were no passengers.

[AussieNick]

lodown i'm not sure if its in the training syllabus but I was shown and performed an air start.

Cessna Capt, was shown the same here mate. but as I said my mate said he was shown differently

[Horatio Leafblower]

As Koizi said... hasn't everyone run the aux tanks dry on a CheapTin?

I started flying Chieftains about a million years ago, with about 800 hours. I was very lucky to have a couple of very experienced Chieftain drivers around who were liberal in dispensing advice gained in RPT ops. Where is Bill Stokes now anyway? :ok: :}

[sms777]

The bad or perhaps good thing about Chieftain's fuel system is the location of the fuel gauges in the roof in full view of your pax. Always used to amuse me seeing eight pair of eyes transfixed to the guages minutes before switching to mains.
I used to leave it to the last moment to keep them all quiet.

[Jabawocky]

By 'worse' I mean that pushing the props to full fine and then not feathering simply creates more drag - and maybe what led him to think the engines were producing 'some' power - Windmilling RPM being a product of airspeed and MP returning to somewhere close to ambient, say 22 inches at 8000'

Yup.....but failed to nitice the VSI pointing exactly in the direction he was headed! :uhoh:

I reckon he must have been convinced in his own mind he was on the mains and that this was just another Whyalla so he went looking for the scene of the most likely survivable crash he could.

Hey, we are all fallable, I forgot the pitot cover the other day, usual cause, a distraction, was corrected before start up but all the same a simle error ....but it does NOT have to lead to a prang!

J

[PCFlyer]

Where is Bill Stokes now anyway?

RFDS Townsville?

Just a guess

[bushy]

The props would have gone to fine pitch to try to maintain rpm when the power failed even if the pitch controls were set for cruise rpm.

The important part is the psychology. What prevented him from looking further and finding the empty tanks? It seems this aircraft was fitted with digital fuel guages. Are the analogue guages simpler to read than digital ones. Would the empty tank be more obvious with an analogue guage reading empty than a digital one with numbers? The analogue guage indicates unambiguously that the tank is empty merely by the position of the pointer. There is no need to read numbers. I always found an analogue clock was much easier to use for timing approach patterns as you could just look at the angle of the pointer and just forget about the numbers.

Or maybe this situation was just too overwhelming and resulted in tunnel vision.
Whatever it was I feel sorry for the PIC. This sort of occurence is devastating. I'm sure he would have wanted to prevent this. I wish him well.

[Jabawocky]

I suppose one thing, apart from the fact nobody ever wants to see anyone get hurt..... he did learn a valuble lesson that will be with him for life, he nearly paid with it too!

Have a good weekend folks!

[sms777]

I can see only experienced Chieftain drivers can determine where he f@ckd up. The good thing is that he sort of walked away from it thanks to the the airframe built like a Shermann tank.
Jabba, you have a good weekend too and thanks for sharing your thoughts on this important subject.
I do hope you know how to play two-ups :}

[FGD135]

This accident seems to have many wise old pilots scratching their heads. The word "inexperienced" is cropping up in almost every post.

I think this accident had nothing to do with how experienced the pilot was.

I think it was a simple case of the pilot not having "the right stuff".

Not every individual can make a satisfactory pilot.

Those without the right stuff tend to get culled at some early stage of their flying career. For most, it probably comes when the frustration of repeated failure at gaining the PPL/CPL/CIR becomes too much and they just give it all away.

Some, like this individual, manage to defy the odds and get a good deal further - but I would doubt that any make it past the lowest levels of G.A.

So what, exactly, is "the right stuff"? We know it exists because we know that you can't just pluck any individual off the street and expect him to eventually be the captain of an airliner.

Here goes my description of what it is:

A certain attitude, or "mindset" towards your machine, how it works and the environment in which it flies. That attitude manifests itself as curiosity, caution, respect and pessimism - all of which come together to make you prepared for the wide range of contigencies that can arise.

If this pilot had been so prepared, he would have:

1. Been expecting an engine to fail from fuel starvation;
2. Had some idea of what the instrument indications of a failed engine would look like;
3. Realised the significance of the second engine failure;
4. Had an appreciation of the effects of a windmilling propeller;
5. Had better sense regarding undercarriage use during a forced landing;

Note that none of the above are things that require experience. A pilot with nothing but a bare CPL would have turned this incident into a non-event - provided he had the right stuff - and this point was effectively made, most succinctly, by Koizi with this statement:

If a PA31 crashed every time the pilot had to be "reminded" by the engines to change tanks, there would be none left by now.

All of this brings up the issue of the responsibility that instructors and ATOs have for recognising - and taking appropriate action - when a candidate demonstrates that he should really be pursuing a career in I.T., Pharmacy or Dentistry.

Is it impressed upon instructors and ATOs that they will have to, from time to time, seek to "terminate" a candidate's progress?

[Lodown]

Hands up the number of older pilots who, while learning to fly, had an instructor distract you and then surreptitiously select the empty tank or fuel off, and then let time take its course. Hands up all the pilots with 15 years or less experience who have had the same practical thing taught by instructors bent on sticking to a performance/outcome-based syllabus. I'll bet there's a big difference in relative numbers.

[Spotlight]

FGD,,, I agree.

I could count and maybe one day I will, the endorsesments I have conducted. The majority thankfully for 217 operations.

Two hours, the report has it for this fellows training. I tell you what! My signature doesn't come that cheap.

A predictable outcome in some ways.

[YoDawg]

A VERY similar incident took place out of Kalgoorlie a few years back in a 310 or a 402.

Pax on board suffered mightily, I believe, as did the pilot.

Apparently, the fuel on board in the mains was never used.

[Spotlight]

Been plenty more than Kalgoolie Yodawg. It is an ever present probability that if you do not manage your fuel you will have an engine failure, sometimes both.

Have you looked at the photo's of the prang? Well thats what a big mistake looks like. Broken legs I heard at the time. Probably worse I would guess now.

[Mr. Hat]

FGD I read your post and started thinking how i was going to give you a spray but then I found myself agreeing or even being harsher.

One could actually say that someone hasn't got the right stuff if they let an engine stop due to fuel starvation either deliberately or unexpectedly. But I'm not going to say that. It was my personal choice to calculate a buffer which i often refererred to as "mum and the kids".

Others i know chose not to and some suffered the consequences. I must point out though that major airlines felt that they had "the right stuff" perhaps because they had learned a lesson. Who knows?

Back to my original point, a few times in my career when i stuffed something up (no nothing major) i had some loser tell me that I was "no good" and should "give it up" didn't have "the right stuff" ect. I worked out that these people were fu{kwits that needed to put people down to make themselves feel good. They were taking the opportunity whilst i was new to the operation or on type to sink the boot in. Then within a short space of time i had the brain space to overtake them and observe all their mistakes.

I do find it strange that the pilot in question did not try to switch tanks but then again I wasn't there and don't know all the factors and therefore can't comment.

The one thing i remember about the early training in ga was that speed/rote was a focus. Now over time I'm unlearning this as I watch very experienced people do things in the exactly opposite fashion. I think this speed/rote might have been a contributng factor. As my mum often said "more hast less speed".

[morno]

Interesting read, but not surprisingly, it doesn't tell me much more than what was already known only days after the crash.

How a pilot can see two engines fail, and then effectively sit on your hands and do nothing, is beyond me. Whether you have "the right stuff" or not, wouldn't anyone try just about anything to prevent the plane from crashing!?

Maybe I'm just writing from the perspective of someone who was actually adequately trained, checked and uses common sense when things out of the ordinary occur in flight, :confused:.

Mind you, I sometimes question the level of experience of the pilots that the company concerned, constantly put's into their aircraft, even when there wasn't a shortage of experienced pilots. I know that you don't need 10,000hrs and 5 moon landings to fly a Chieftain (although, could have helped in this situation), but it's more the type of flying that you are most likely to do in that Chieftain, which I believe is where you need the experience. That being of course, single pilot, IFR operations.

As I watched an absolute cracker of a storm from the edge of my hangar one morning in North West QLD with my aircraft behind me in the hangar, thinking "**** that's a great storm. I'm glad I made the decision to wait around until it's safe to go", I watched as another aircraft from the same company as the crashed aircraft, took off into the murk, with lightning bolts everywhere for about 50nm's, and only minutes later a bolt hit the runway and created damage! What was even more disturbing, was that someone very close to me, was supposed to have been on that charter, but couldn't make it at the last minute. I now refuse to let them fly on any more charters operated by said company.

Anyway, the point I was trying to make, was perhaps it's a mix of both lack of experience and not having "the right stuff". Any experienced pilot who tell's you that they've never run a tank dry and made the engine splutter only to realise their mistake and change over, end of drama, is bull****ting you. It's experiences like this, that teach you over time, and can re-enforce those initial engine failure checks, that perhaps would have prevented this bloke from crashing.

morno

[FOD_Hazard]

Maybe I'm just writing from the perspective of someone who was actually adequately trained, checked and uses common sense when things out of the ordinary occur in flight


Its probably been said before, but I'll say it again.....common sense just aint that common anymore. Most pilots, no matter how much experience they have under their belt, when faced with a double engine failure would probably go straight for the fuel selector...There are probably a few more out there that wouldn't.

Sad truth is that this is not the first time it has happened but lets hope it is the last time we hear of such an avoidable accident.


but are students shown how to restart an engine in flight or is it deemed unnecessary risk

My instructor attempted to show me a restart during my initial multi training....No matter what we did we couldn't get the prop out of feather so my first landing in a partnavia was an assymetric.

[ReverseFlight]

A few things adopted at the school where I did my initial twin endorsement:

1. Regular instrument scan - left to right, top to bottom. Never leave anything out.

2. No restarts in training. This tended to loosen the engine mount bolts over time and may detach or shear off after repeated cycles. Best left for real emergencies. (However, I don't get to practice restarts.)

3. OEI in the cruise - don't feather straight away after closing the dead throttle. Go through FMOST checks first. At least you've got altitude and speed.

I presume the majority does the same ?

[Dorothy Dixer]

2. No restarts in training. This tended to loosen the engine mount bolts over time and may detach or shear off after repeated cycles. Best left for real emergencies. (However, I don't get to practice restarts.)

Errr.......ok.

[morno]

Riiiiight. So why didn't they just replace the engine mount bolts at regular intervals if they were that worried?

It's because of flying school's like that, that training standards continue to drop.

morno

[FGD135]

Maybe I'm just writing from the perspective of someone who was actually adequately trained, checked and uses common sense when things out of the ordinary occur in flight.
Actually, morno, you're writing and thinking from the perspective of someone who has the right stuff. You've always had it so you don't know any different, and this is the reason for the head scratching.

How do I know you have the RS? Well, from reading your posts, I can see you are a highly experienced pilot. But, to have become highly experienced, you have to have been a pilot for a long time - but you can't be a pilot for a long time unless you have the RS to begin with. Those without the RS get culled - in one way or another - early on in their flying career.

The RS is not something you can be taught. Nor is it something you acquire over time. You either have it or you don't. You, and probably the vast majority of our fellow PPRuners, have it.

To those of us with the RS, we tend to look at either lack of experience or training deficiencies whenever there is an accident or incident. But for this accident, neither of these usual suspects is to blame - hence the inordinate level of head scratching that is evident in this thread.

To better illustrate the significance of RS and how you either have it or you don't, consider the pilot selection and training that is conducted by the air forces of the world.

They spend substantial sums in assessing, selecting and training their pilots. The training is top notch, granted, but without the candidate having the RS to begin with, the training would be a waste of time.

Those pilots are highly inexperienced and the flying is far more demanding than a one hour day VMC sector in a PA31, but when they are finally let loose on their multi-million dollar jet fighters, the air force is able to rest assured the outcome will be satisfactory.

[ReverseFlight]

Further to Dorothy Dixer's post, apart from no restarts in my training, I was also told not to practice feathering it in flight either. Is this to avoid what FOD_Hazard experienced (unable to unfeather in flight) or is there something else I don't know about ? I am begining to doubt what I have been taught ... any advice is appreciated.

[Deepsea Racing Prawn]

Hey FGD135...this ones for you buddy.:ok:

YouTube - New Kids On The Block - You've Got It (The Right Stuff) (http://www.youtube.com/watch?v=SDAzP7BDHe4)

[YoDawg]

My instructor attempted to show me a restart during my initial multi training....No matter what we did we couldn't get the prop out of feather so my first landing in a partnavia was an assymetric.

I can't quite see the point in shutting down a piston engine just for practice at re-starting it. Has anyone in normal day to day operations ever had to RE-START a piston engine? We've all been caught out looking the wrong way when the fuel-flow guage begins to flicker, following which comes an embarrassing (if not alone) period of engine-surging, yawing, odd noises and red faced plucking at the fuel cock. In my own experience, the engine never fails to produce power for more than a maximum of maybe 10 seconds and never once stops wind-milling. Thus a "re-start" was never required.

I experienced a couple of engine failures which left me in no doubt that the engine would never operate again in its current state. Thus a "re-start" was never required in those cases, either.

In a bit over 6000 hours on pistons I never once had cause to attempt a re-start of an engine. Farting around shutting down a donk and feathering it is a nice demonstration that the world will not necessarily end following an engine failure. But without two pilots on board, it can start to get a little awkward keeping it neat and tidy for someone unfamiliar with the process of then unfeathering and re-starting the engine.

Spin training - yes I can see a real use for this. Practice in shutting down for the sake of re-starting a donk in a piston twin is, in my opinion, a waste of time. But I'm open to argument there, I guess.

I did lots of dumb things in GA and I suppose I was lucky not to have ended in an accident. Or was I? At a glance, and this is pure speculation based on experience with the PA31, systems knowledge (particularly with regard to the fuel system) may've prevented the reported flight from ending with a hull-loss.

Being interested enough to have a good standard of systems knowledge and applying the knowledge accurately and in a timely fashion when required is a part of The afore-mentioned Right Stuff** (imho).




** aka Airmanship

[Dog One]

Endorsed a lot of people over the years on PA31's and other twins. The engine mounting bolt issue is a new one to me. One could deuce that rough running from a cylinder failure would also cause the bolts to loosen? The only caution I can remember was stalling the aircraft, due to the extended crankshafts flexing.

People moving up from light twins in which they did their initial IRT's needed an attitude change when moving onto PA31 and C402 aircraft. System knowledge was very important.

One of the traits that had to be handled was on the asymmetric circuit, most of the light twins had electric undercarriages, so the training was gear down turning final, and unless a CB popped, the gear worked. In a PA31, the gear is hydraulic, driven by two engine driven pumps. Have an engine failure, you only have one pump, and it takes a lot longer to get the gear down. (you can bet that the remaining pump is a bit sick). I always trained people in the circuit to do everything in the normal spot whether normal or assymetric, except for the final flap extension. This way, other than a higher power setting on the live engine, the single pilot had time and altitude to handle a slow gear extension, traffic, and passengers and fly a normal approach.

[maui]

I was led to believe the principal argument against full feathering, was the rapid cooling that followed once you cut off the bang juice. As an occasional thing, not a big deal, but in a training situation, frequent shut-downs/rapid cooldowns, can produce problems.
Consequently I would only ever give one feathered approach and landing per endorsement.

BTW. With more than 40 years in the industry, I have never heard of FMOST. Can someone decode it for me. Must have been hiding under a cabbage all this time. I assume it is some cyber-gen version of some other mnemonic.

Maui

[Stationair8]

Sounds like another quick endorsement by some ace with little or no ICUS for the low time pilot.

[CharlieLimaX-Ray]

Hopefully the pilot made a recovery from his injuries.

Not the first Navajo to be run out of fuel in that part of the world, a coulpe from the memory bank:

PA-31/310 VH-UFO destroyed near Archerfield in 1993 due to loss of power,

PA-31/310 VH-??? a certain operater from Archerfield that was run out of fuel enroute on a rig pig crew transfer.

[PyroTek]

Maui:
FMOST:
Fuel (Check all tanks)
Mixture Rich
Oil T's and P's
Switches (L/R/Both, check them all)
Throttle (Cycle to see if you can attain partial power)

[Brian Abraham]

CLX, to add to the list, one many, many years ago near Cowell, SA, and at night, no injuries (paper run).

[RadioSaigon]

Thanks for posting that PyroTek -I too was wondering what the L a FMOST was...

In the scenario under discussion here, the FMOST check as indicated could have made the problem worse!!! The aircraft has/had turbocharged, injected engines, on which in some cases, it is necessary to lean the mixture from the cruise setting to achieve an engine-restart in flight, when fuel supply has (for whatever reason) been interrupted. I would expect that an appropriate in-flight restart procedure would have been discussed and demonstrated as a part of the endorsement training.

The FMOST check is quite probably very appropriate for a normally aspirated, carburetted engine. That does not mean it is necessarily appropriate for every reciprocating engine. A radial engine for example may well require yet another technique for an in-flight restart.

Worth keeping in mind.

[maui]

Thanks Pyro.
Always amazes me why we have to have a mnemonic for every activity. Sometimes it is harder to remember the mnemonic than it is to remember the actions.
In that one (FMOST).
The first action is instinctive.
The second not necessarily a good idea.
The third is a normal instinctive scan (where else would you be looking as that thing on the wing is coughing and farting).
Which leaves you two actions for which you have this strange word association.
Intriguing.
For years we managed to get around without the benefit of the Jacobsen Flare and all manner of new fandangles. Good luck I guess, cos we were obviously ignorant.

Maui

[BrokenConrod]

I would have thought that most PA31/C310/C402 drivers, knowing that they need to use fuel from mains and auxs to complete the flight, would have instantly realised their **** up when the first engined surged and gone - change tanks, pumps on - and the problem would have been solved almost instantaneously!

I always staggered my tank changes on multi-tank aeroplanes like Aztecs, older Barons, PA31, C310/402 to avoid the likelihood of draining both sides dry at the same time.

Should almost be a **** up of a bigone era with most drivers now carrying portable GPS's that can be programmed to remind you to attend to fuel needs at set intervals.

BC :cool:

[YoDawg]

If you switch to main tanks AND switch on the fuel pumps on a C310, the engine will flood.

[PercyWhino]

"Should almost be a **** up of a bigone era with most drivers now carrying portable GPS's that can be programmed to remind you to attend to fuel needs at set intervals."

Could even go 1 further than that. The most basic airmanship to begine with KEEP A FUEL LOG!. You know what is in their to start with, you know what your taxi and climb allowance is and in cruise with it all leaned out the FF gauge tells you what the motors are burning.

Only 3 things to keep a fire going which we all know, fuel air and spark take one away and it dont work no more! I was taught FMOST but really common sense should prevail. The motor has surged and stopped, now theres no oil all over the windscreen and no hole in the cowl where a piston has just shot through. So you would have to investigate the things that make the fire. Common sense?

[j3pipercub]

That's a pretty deep hole you're diggin there mate. So you're suggesting he was on something??

j3