Jandakot Crash Trial

[Diatryma]

Death pilot did not follow rules: expert : thewest.com.au (http://www.thewest.com.au/default.aspx?MenuID=77&ContentID=160161)

Death pilot did not follow rules: expert

5th August 2009, 7:00 WST

An aeronautical engineer suggested yesterday that a fatal crash at Jandakot airport in 2003 could have been avoided if the pilot of the twin-engine Cessna 404 followed emergency procedures after an engine failed seconds after take-off.

Robert MacGillivray, of Victoria, who has worked in the aviation industry since 1968, told the Supreme Court that pilot Alec Penberthy had only a few seconds to decide what to do.

Accepted practice was to minimise all manoeuvring after an engine failure but Mr Penberthy decided to turn left and head back to the airport.

“A series of left turns, or a continuous left turn, attempting to return to the airport would increase drag significantly so the pilot would not be able to maintain airspeed without sacrificing altitude, thereby making continuing flight impossible,” Mr MacGillivray said.
The Cessna 404 was in the air about 90 seconds on the afternoon of August 11, 2003, before it crashed into bush. The left wing was ripped off, causing a massive fuel spill and fire that destroyed the aircraft, killing two passengers and badly burning three others. Mr MacGillivray was giving evidence on the second day of a four-week trial.
Crash survivors Malcolm Cifuentes, Michael Knubley and Ozan Perincek are pursuing damages alongside Janet Graham, whose husband Harry Protoolis died in the crash, and Julie Warriner, whose husband Steven died of his injuries 12 weeks later.

The passengers worked for Fremantle technology company Nautronix Holdings, which claims its business was devastated by the loss of the employees.

They are suing Mr Penberthy and Fugro Spatial Solutions, which operated the aircraft.

Also being sued is engineer Aaron Barclay, who is accused of using the wrong alloy when repairing part of the fuel pump in the Cessna. It is alleged this caused the right engine to fail.

Mr MacGillivray said a well-trained pilot would need about 10 seconds to follow emergency procedures such as confirming the failure, shutting the engine and “feathering” the propeller.

He said the pilot should have banked the aircraft about five degrees to the left to compensate for the missing right engine and to ensure the aircraft continued to climb.

Asked if there was any realistic prospect that the aircraft could turn left and make a safe landing, he replied: “No.”



Bit harsh being called a "Death Pilot" ?

Di :sad:

[D-J]

could set a worrying precedent...

ATSB report
200303579 (http://atsb.gov.au/publications/investigation_reports/2003/aair/aair200303579.aspx)

[sockedunnecessarily]

He said the pilot should have banked the aircraft about five degrees

5 degrees gives the minimum Vmca under certification. It has nothing to do with maximum single engine performance which does NOT occur at 5 degrees bank.

This is a real court case with people's lives and repurations on the line - and the guy testifying obviously doesn't know what he is talking about.

Some expert.

[Checklist Charlie]

Some expert.

If he's from WSL, then he thinks he is.

Re-read the accident report and see what the pilot was confronted with, then perhaps the rationale for turning will become clearer.

Reporting of selective quotes by 'experts' at a court case can often be for 'effect' rather than for 'fact'.:=

[The Green Goblin]

I hope he is a member of the AFAP, at least they will provide legal representation for him else it could get expensive!

It is quite worrying that a Pilot can be sued for an accident (The Bali incident set a dangerous precedent to begin with). I'm sure he didn't plan on having an engine failure and when it happened, made a command decision and went with it unfortunatley not having the desired result.

If he landed the aeroplane safely he would have been considered a hero - not a death pilot, perhaps we should all reflect on this.

[D-J]

One would assume the cretins who brought about the case will be trying to prove negligence on the pilots behalf, from reading the ATSB report I don't think you could prove any on his behalf although maybe he could have done things better with good old hindsight.

The disturbing thing if this case is successful is the effect it will have on openness during accident reporting, from reading the report there's a couple of things the pilot said which can / will be use against him in this case. I see in the near future after an accident / incident when the accident investigator goes to get a statement from the pilot and all he'll get is "not with out my lawyer present"

[The Green Goblin]

Or the JAH for allowing a tree to be near the runway for them to hit, or God for not allowing the conditions of the day to be beneficial to single engine performance.

[Towering Q]

If he landed the aeroplane safely he would have been considered a hero - not a death pilot, perhaps we should all reflect on this.

Certainly a fine line between a 'hero pilot' and a 'death pilot'.:ugh:

[Mr. Hat]

Tragic indeed. Can't imagine how much post traumatic stress the survivors are living through.

"not with out my lawyer present" In today's world its not a bad idea actually. Best to not say anything at all.

Its a reminder to pilots to have their assets/cash structured for a worse case scenario.

[Diatryma]

One would assume the cretins who brought about the case will be trying to prove negligence on the pilots behalf

Bit harsh. I think the "cretins" are the injured passengers and the dependants of the not-so-lucky passengers.

Whats "WSL"?

So no one here thinks the pilot did anything wrong?

By the way, the pilot - whilst named on the Writ as a Defendant, is actually covered by and being represented by an insurer......as are the other defendants.....

Di :ok:

[QSK?]

I get very disheartened when I read these reports as they always make me question my ME training, my decision making capabilities and whether my reactions or decisions would have been any better than the pilot concerned.

My conclusion is that the quality of my multi training was probably no different, my experience is nowhere near this guy's and, therefore, my decision making and reaction would have probably been the same - or worse. How does a pilot train themselves to resist that overpowering urge not to crash following an engine failure by retarding the throttles and taking your chances on an overun?

There are many lessons here in this report, particularly with respect to take off planning and briefing, which I will take home and digest in the hope that that I can improve my approach and technique. But, to suggest this pilot was negligent is extremely harsh in my view and my heart goes out to him. I hope he comes out of this OK.

With respect to TO/LDG planning and briefing, do any of you airline or experienced GA ME operators have a good checklist or can suggest an appropriate TO/LDG performance card format suitable for GA ME ops? If you have suggestions, please PM me as I don't wish to hijack this thread. Thanks

[VH-XXX]

It doesn't matter who the "expert" is, the prosecution, defence or accuser will always find someone to support their argument either way, but that this does not mean that the expert is not an expert in his field. In this case, this particular expert is clearly that, with many years flying and engineering experience, ATPL, reg35, instructor rating etc etc. Remember that the 5 degrees is a comment of the reporter and may not reflect those words testified by the expert. The ONLY way to confirm this prior to pointing the finger and dismissing his opinion would be via the court transcripts.

[j3pipercub]

Love ya monday morning quarterbacking Di. If you can't see the slippery slope here, go away

[Diatryma]

QSK?:

.....as I don't wish to hijack this thread

Actually I think your post is what this thread should be all about really....



J3pipercub:

No "quarterbacking" here - I haven't expressed an opinion.....and am not qualified to do so


VH-XXX

Seen transcript - report accurate...



Whats WSL?

Di

[PA39]

Yep....theory and practise.Who the bloody hell can measure 5 degrees. What a load of absolute rubbish. All multi engine pilots should read "Flying the light twin" by Russ Evans. 5 degrees my a**e! All the figures quoted in the AFM are for certification purposes only.....a brand new aircraft with brand new engines delivering full stated HP flown by a test pilot under test conditions with instrumentation to dream of. Give the guy a break.....the darn thing wouldn't have climbed anyway.

[The Green Goblin]

You know what they say, the second engine takes you to your crash site!

[FRQ Charlie Bravo]

You know what they say, the second engine takes you to your crash site!

Anywhere near 75% of MTOW or greater I think of it more like a Cirrus parachute, it just lowers your rate of descent.

FRQ CB

PS I remember seeing that wreckage on what must have been my fourth or fifth training flight... and trying to not look at it on downwind on my first solo. A very sobering sight for a student pilot.

[pithblot]

Alec was a very level-headded, experienced and competent pilot.

Old (and new) FAR23 sh#t-boxes don't fly on one engine.

Thousands of pilots over millions of hours take a chance in them on every flight.

You play the cards you've got.

When things go wrong our legal system is designed to extract money.

If the pilot is killed in the accident our legal system will wring money from his estate, from his wife and children, if possible.

[Mr. Hat]

Hence my previous post.

[Barkly1992]

But then - you have to just accept that this is a court case.

It's about winners and losers - not the truth or the reality of how you handle an emergency when it all goes to worms and you are in the left hand seat.

It's about who gets paid.

Not really worth getting upset about.

:ugh:

[pithblot]

I agree with your first three points Barkley1992.

You might reconsider your' last if you were in the firing-line.


Pilate's question, John 18:38

[bushy]

Many a piston twin has flown home or to an aerodrome with only one engine going. And most of them were not new and they did not have test pilots flying them.

[Horatio Leafblower]

I have rarely disagreed with anything you have posted on this site, but you are ignoring the simple fact that the aircraft was on take-off, at low level, with a substantial load and with obstacles in the flight path.

Yeah I've had a shut down at 5000' and flown it home... but that's completely different. :ouch:

[remoak]

Green Goblin

I'm sure he didn't plan on having an engine failure and when it happened, made a command decision and went with it unfortunatley not having the desired result.

Unfortunately...???

Anyone flying a marginal twin should ALWAYS expect an engine failure and plan accordingly. The only reasonable plan is to put it down straight ahead, unless you can gain enough height and/or airspeed to ensure control.

If you want to be PIC, you have to accept responsibility for the lives of your pax, and how your actions affect them. If you aren't prepared to do that in a court of law, don't take the job, or join a union - not that it will necessarily help you.

If you get paid to fly pax, you have a duty of care, simple as that.

[The Green Goblin]

Green Goblin

Quote:
I'm sure he didn't plan on having an engine failure and when it happened, made a command decision and went with it unfortunatley not having the desired result.
Unfortunately...???

Anyone flying a marginal twin should ALWAYS expect an engine failure and plan accordingly. The only reasonable plan is to put it down straight ahead, unless you can gain enough height and/or airspeed to ensure control.

That is also one of the biggest mistakes people make, They run through EFATO drills, say "not climbing, landing ahead". I bet it will still maintain altitude! Accelerate it straight and level and use the inertia to get it up to 500 AGL not slipping below VMCA in the process (preferably not below VYSE)

What I meant to say or get across was everybody plans for an engine failure but does not expect it to happen, and when it does happen it can catch you by surprise! (especially during an important phase of flight) And may take a few seconds to gather your wits.

[PA39]

To quote the great Bob Hoover..."your two best friends in an aircraft are airspeed and altitude" If you have neither and something goes wrong.. you are in trouble.

The most critical phase of flight for a light twin is when it leaves terra firma and raises its nose to the heavens. You have a good chance of survival if you put it down in a controlled crash but you have absolutely no chance in an uncontrolled one. There is so much to consider outside of your parrot pre take off emergency drill. Density altitude, wx,wind,tow,tora,obstacles,aircraft age and condition and most of all YOUR own limitations! etc etc etc. If you do decide to power up gear up flap up etc etc what r you going to do? fly straight ahead? do a circuit? left or right? box or oval? what altitude are you going to aim for before you commence the turn, what are you going to do if you hit blue line and its going downhill? if you can't answer these questions before you open the taps, well you certainly won't be able to when s**t hits the fan. I talk through experience, I chose to keep going, the aircraft had brand new engines, new paint, but was heavy (freight) it was night and i was facing a 100' hill not far from the end of the rwy. I was doing a lot of m/e training in those days and was very very current at the time. Believe me I had my heart in my mouth doing a 300' r/h circuit....away from the town but into the abyss. My knees took a full day to stop shaking. :=

[FRQ Charlie Bravo]

Damn PA39, I've just had to change me knickers.

I hope that in a similar situation I'd be able to ignore the false security of the town lights (moth to the flame).

FRQ CB

[tubby one]

in reality the trial is not about whether the 'pilot go it right or not' it is about the law and the two are very different creatures. for a clear and unbiased understanding of what is happening in Perth I suggest the interested get their hands on and read "Just culture" by Sidney Dekker.
it is quite likely that the pilot will come out of this besmirched and sullied - but for that you cannot blame those who brought the action as it may be the only means by which they will achieve any compensation for injuries and loss.

if you read the book you will also realise that as an industry we do need to be vigilant if we are to retainany semblance of a 'just culture'.:ugh:

[Crew rest.]

This is a real court case with people's lives and repurations on the line - and the guy testifying obviously doesn't know what he is talking about.

Some expert.


With respect, I have been aquainted with Mr Mac Gillivray some time ago and he is most qualified for the "expert witness" role.

Aside from having a qualification in AEng, he is a qualified Test Pilot who worked extensively on the delevopment and certification of the Nomad (no jokes thanks!).

[remoak]

What I meant to say or get across was everybody plans for an engine failure but does not expect it to happen, and when it does happen it can catch you by surprise!I understand what you mean, but for myself, I always assume that something is about to happen until I have the altitude and airspeed to be safe.

I see a lot of young guys going "yeah yeah, I get how to handle an engine failure, she'll be right", and then stuff it up completely when it actually happens. Most of them end up dead, and I have lost a few acquaintances to light twin accidents. You just have to be ready, all the time.

Many moons ago, when I was flying the F27, a sim instructor remarked to us (after my colleague stuffed up an engine failure on approach) that the F27 would never be certified under the current regulations of the time, as it was simply too marginal on one engine, especially at high weight/temp/density altitude. I reckon most light twins are worse than the F27 was... funny how we put the most inexperienced pilots into the most dangerous aircraft...

On the jet I fly, the worst things that happen if we lose one are that the ROC drops to 2000 fpm and the ball marches out from the centre a bit. Easy-peasy. Trim it and whack the autopilot in while we figure out where to go. But when I'm flying a light twin, I'm very twitchy until through 1000' and at least blueline +20kts. YMMV of course.

[Diatryma]

I notice the ATSB report (Para 2.6 page 28) states:

The pilot reported that, during the accident flight, he initiated the turn from the runway heading because he was concerned about flight over residential areas and the high-tension powerlines ahead. Neither the pilot nor the aircraft operator’s chief pilot had considered the powerlines upwind from runway 24R as obstructions for the purpose of their pre-takeoff safety briefings.

I'm surprised that the powerlines were not considered as obstructions for the purpose of pre-flight safety briefings. I assume these briefings - being safety briefings - would include the EFATO scenario? I wonder if they are now considered to be obstructions?

Interesting how the mindset changes during an emergency.

Di

[Awol57]

The powerlines are a reasonable distance from the upwind threshold (I think its over 3km?), but I suspect they look might close at 100' with one engine out.

[Tmbstory]

QSK:

Thanks for the email.

You mentioned Aids for single and multi engine visual flying cues. A system that worked for me was to look at the obstacle ( or cloud or lights ) and if you could see features beyond the one you are looking at, then you are at a height to clear it. It works day and night and used to keep me in beers on overnights

Tmb.

[FRQ Charlie Bravo]

if you could see features beyond the one you are looking at, then you are at a height to clear it.
If you are maintaining height.

FRQ CB

[remoak]

if you could see features beyond the one you are looking at, then you are at a height to clear it.

Hmmm... what if the obstacle is power lines, and the features beyond are below the power lines...??? You might be at a height to clear the power lines... by flying under them... :=

[Joker 10]

This is probably one of the most accurate statements I have ever seen here

funny how we put the most inexperienced pilots into the most dangerous aircraft...

However in the case in point the pilot is a very experienced careful guy with good stick and rudder skills.

[goose89]

Qoute:
if you could see features beyond the one you are looking at, then you are at a height to clear it.

Another way of thinking about it and it's very simple it comes from looking a the threshold on final approach.

If the obstacle is moving upwards in the front windscreen your going into it or in the case of powerlines under them, If the obstacle is constant your flying directly for it and if the obstacle is moving downwards in the windsreen you are flying over it, Clear of it!!

I'm sure anyone with a lowlevel endorsement will be able to shed light on how the technique is taught.

[PA39]

(funny how we put the most inexperienced pilots into the most dangerous aircraft...)

Only incompetent Chief Pilots do such stupid things. One should never get ones ambitions mixed up with ones ability.

[Diatryma]

Judge finds pilot was negligent

Posted Wed Nov 11, 2009 1:49pm AEDT
http://www.abc.net.au/reslib/200908/r415095_1966404.jpg (http://www.abc.net.au/reslib/200908/r415095_1966409.jpg)
Alec Penberthy was the pilot of the twin engine Cessna with five passengers which crashed seconds after take-off in 2003.



A WA Supreme Court Judge has found a pilot involved in a fatal plane crash six years ago, was negligent in his duty of care.

http://www.abc.net.au/news/stories/2009/11/11/2739724.htm

Di :sad:

[Mach E Avelli]

Something missed by CASA in their surveillance of the operator would appear to be that they had a 'standard' flap setting for all takeoffs that was certainly not optimum for obstacle clearance. A bit of industry education would not have gone astray, as it is probable that neither the chief pilot or pilot on the day had specific understanding of the implications of using flap for takeoff with obstacles limiting. OK, so the info was in the AFM, but apparently the operator ignored it - possibly due lack of education. Yeah, I know, CASA is there to regulate, not educate.
In my short time operating the C404, I went to pains to educate pilots about the advantages of zero flap takeoffs whenever runway length permitted. This met with some resistance from the owner who thought it would wear the tyres out or damage the props or somesuch crap, and from some pilots "because it had never been done that way in the past and what would an ex-airline pilot know about light twins anyway?" Further, from the ATSB report :

"The investigation concluded that the pilot experienced an emergency situation, at a critical phase of flight, for which training in the aircraft had not been provided."

With no simulator, any engine-out training was likely done at light weights and with generous safety margins. This in itself gives pilots an unduly optimistic understanding of light twin capabilities. So how in all conscience can our so-called justice system lay blame on the unfortunate pilot faced with an impossible task not of his making?

[Windy_Pil0t]

you are all VICTIMS!

[gettin' there]

(funny how we put the most inexperienced pilots into the most dangerous aircraft...)

Only incompetent Chief Pilots do such stupid things. One should never get ones ambitions mixed up with ones ability.


So what are you suggesting GA multi engine pilots get their twin "experince" on? Something other than piston twins?

What is enough "experince" to fly a piston twin? 500 hrs? 1000hrs? 3000hrs? Much much single v twin time?

No disrespect or malice intended but i'm keen to hear what in your opinion is enough experience to fly a piston twin?

[FGD135]

All those posters that are saying that these aircraft don't perform - or that that particular aircraft wasn't performing - should just read the report.

The report very clearly shows that this aircraft was indeed performing.

The ONLY reason it crashed was because of that second turn. The pilot had gotten away with the first turn, so the supposed power line threat was no longer present.

But it was that second turn (taking it onto the northerly track) that robbed the aircraft of its performance and made the crash inevitable.

The engine failure had occurred before the aircraft had passed the upwind end of the runway. That it had continued to fly to a point on the other side of the aerodrome - and onto a heading opposite to that of takeoff - is surely proof that that aeroplane was performing.

[gordonfvckingramsay]

If the aeroplane wasn't performing then I would suggest that perhaps it should not have been uplifting the payload on the day. I understand that this category of aircraft does not have to comply with any sort of guaranteed performance requirements, however, Perth being as flat as it is, if power lines miles off the end of the runway are becoming a concern....

[Ex FSO GRIFFO]

2.63nm or 4.87 km from the brake release point........

As measured on Google Earth.....

[The Green Goblin]

If the aeroplane wasn't performing then I would suggest that perhaps it should not have been uplifting the payload on the day. I understand that this category of aircraft does not have to comply with any sort of guaranteed performance requirements, however, Perth being as flat as it is, if power lines miles off the end of the runway are becoming a concern....

With that logic every piston twin would be grounded and you would not be able to fly a single....

Back in yer box

[gordonfvckingramsay]

CAO 20.7.4

8 EN-ROUTE CLIMB PERFORMANCE
8.1 Multi-engined aeroplanes engaged in charter operations under the Instrument Flight Rules or aerial work operations under the Instrument Flight Rules must have the ability to climb with a critical engine inoperative at a gradient of 1% at all heights up to 5 000 feet in the standard atmosphere in the following configuration:
(a) propeller of inoperative engine stopped;
(b) undercarriage (if retractable) and flaps retracted;
(c) remaining engine(s) operating at maximum continuous power;
(d) airspeed not less than 1.2 VS.

Even if the day was not ISA, at sea level, the aeroplane should have been (and was) performing so that the second turn would not have been required until at a safe height. Additionally, it is good practise to reduce the TOW in order to achieve obstacle clearance if conditions require it. I doubt this would ground anything.

Not an attack on the PIC and no offence was intended. :ouch:

[The Green Goblin]

A C404 and most 10 seat cabin twins with 400L onboard and two crew (Instructor and Pilot) will barely climb with a failed engine in temps over 30 degrees.

It's all good to quote the regs bearing in mind these certification requirements were demonstrated by a test pilot in a new aeroplane under ISA or better than conditions.

The only way to make sure the aeroplane will perform is to remove all the payload and fly the pilot around with minimum fuel. The only aircraft I know that would achieve a mildly positive climb rate in the piston range was a Baron.

Those that fly or have flown these aeroplanes understand that the second engine is not a get out of jail free card. It simply gives you options. If you have an engine failure with a normal operating payload on take off it may as well be a single. Enroute at altitude you can consider your landing options and adopt a drift down procedure.

[Whiskey Oscar Golf]

While it would be remiss of me to discuss the appropriateness of the pilots actions in this case I would like to offer an experiment we once did.

We had 3 of the same type of aircraft, a GA piston twin very similar to the C404. We used the same day, same time, same terrain, same weights etc. We conducted a series of tests with either engine on all three aircraft. The results were, one of them climbed, albeit very slowly, one stayed relatively level and the other started dropping rather quickly. The difference was significant between the three aircraft and it taught us all a lesson on making assumptions based on what a manual says, what a type is supposed to do and what can really happen.

As another aside, we should all try and put ourselves in this pilots shoes and think of how we would feel if our own actions were put under the microscope in the way his have.

Regards

[Mach E Avelli]

Whiskey Oscar Golf makes a very valid point. At one stage I was involved in completing annual c of a air tests on a small fleet of DC3s for British CAA regulations.
This involved ballasting the aircraft to a certain weight then getting it airborne, feathering one engine just off the deck (really) and flogging the poor old thing at max takeoff power for five minutes while logging the climb rate etc. Then that engine was restarted and the other feathered and run at METO for 10 minutes for the en-route climb.
One aircraft in the fleet - which had suffered major damage in its early post-war career and been rebuilt - always made it comfortably. Another - which had no known major damage and was quite pretty to look at - was an absolute dog and required some creative paperwork to pass the required climb rate tests. Everything else checked out, fuel burn, cruise TAS, stall speeds etc but it just would not meet the climb gradient on one engine.
Pilot technique was not an issue (same pilot who became rather good at it if I do say so myself) and the weather was alway chosen to be most favourable - early morning, preferably just a bit foggy, so nice and stable etc.
Later I became involved in similar work on Fokker F27 aircraft and one in particular had us baffled for a while. It was brand new but just could not make the numbers. It turned out that the tail got a bit twisted in production due to some misalignment of a jig.
So, in the absence of a FDR we may never know whether the particular C404 in the accident was really able to make the numbers or not.

[FGD135]

So, in the absence of a FDR we may never know whether the particular C404 in the accident was really able to make the numbers or not.
No need for an FDR - you can just read the report. I thought I had made this point clear back at post #44.

Mach E Avelli, from your previous work with DC3s you would be well aware of the effect that TURNING has on an aircraft's marginal SE performance.

In the case of this C404, it is very clear from the report that:

1. The R engine failed 1-2 seconds after the aircraft left the runway;
2. The aircraft continued to fly for a further 2.5 miles;
3. The aircraft was successfully turned left through about 90 degrees (it regained the airspeed lost during the turn);
4. The aircraft crashed on a heading opposite to that of takeoff;

You think an aircraft that "wasn't performing" could have achieved what this aircraft did?

[Mach E Avelli]

FGD, I will go back and read the accident investigation more fully.
But I do know that I would do almost anything - including attempting to fly outside the envelope if painted into that corner - to avoid hitting power lines or buildings. Could he have flown under them? Could a survivable (we know it would have not been safe) flight path be maintained with 15 degrees angle of bank and say 50 ft of obstacle clearance all the way back to a landing ? I don't know, as I don't know the area well enough and certainly have not examined it at 50 ft. Did the aircraft go better in one direction of turn than the other? Local wind effects/subsidence/rotor?
I am trying to avoid coming across as an armchair expert, but I still believe that the pilot is carrying too much of the blame for a situation that we may all talk about when we do our emergency briefings, but few of us will ever experience in real life.

[pithblot]

Is this the famous Bob McG who worked for the then DCA in Vic/Tas in the early 80s?

I don't think "the famous Bob Mc G's" ...tag is Mach :ok:

But I do wish folks would take note of Mach E Avelli's words in post #41 especially CASA and those training 404 pilots to use flap for take off.