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Centaurus
24th Jun 2012, 09:56
Pprune readers may remember the Air Disaster series of books first published in 1994 by the Australian author Macarthur Job. The illustrator was Martin Tesch and his graphic drawings were proof of the adage “A picture is worth a thousand words.”

Recently I was browsing Air Disaster Volume 2; the first chapter being about a DC-9 of Southern Airways (USA) that penetrated a severe thunderstorm that caused both engines to flame-out. As you can image the crew worked feverishly to get the engines started and during the many exchanges between them and ATC, one particular call chilled me. It was from the DC9 and the pilot said: “All right, listen – we’ve lost both engines and…I can’t tell you the implication of this…we’ve…only got two engines.”

Hail had caused severe damage to the engines and the crew were unable to re-start them. The aircraft forced landed on a road and was destroyed with the loss of 60 lives. That was in April 1977, the same year that I first flew the Boeing 737 which had similar Pratt & Whitney JT8D engines. Hence, the close interest on the reason for the flameouts taken by pilots of our airline. In those days the Quick Reference Handbook (QRH) did not include a checklist that covered loss of both engines. While there have been cases where fuel exhaustion has caused flame-outs in jet engines, the purpose of this article is to discuss weather related flame-outs. Impending fuel exhaustion will normally give the crew time to prepare for an engine failure, but it’s a different story when heavy rain often encountered in a thunderstorm, may cause a flameout. If that happens without warning, then it may well be the professional skill on the part of both pilots that makes the difference between disaster and survival.

The most recent example of a double flameout was in January 2009 when a successful dead stick ditching made into the Hudson River New York, by Captain B. Sullenberger flying an A320. Both engines failed due to bird ingestion shortly after take off and severe engine damage prevented successful relights.

Other examples of dual engine failures caused by thunderstorm penetration include an Air Europe B737-300 in 1987 and TACA Airline Boeing 737 in 1988. In the latter the aircraft encountered heavy rain and turbulence at 16,000 feet on descent. Although the APU was started at 10,000ft and both engines relit, they would not accelerate. Advancing the throttles resulted in overheating of both engines so they were shut down to avoid catastrophic failure. The aircraft was successfully forced landed.

In January 2002, a Garuda Indonesia Boeing 737-300 inadvertently penetrated a thunderstorm cell with tops measured at 63,000ft. Both engines flamed out. Efforts to start the APU failed because unknown to the crew the aircraft battery was defective. The aircraft became clear of cloud at 8000 ft enabling the crew to conduct a no electrical power, no flaps and landing gear up ditching into a river. With a touchdown speed of 190 knots it was a miracle only one person was killed. A representative of the engine manufacturer told the investigators it would be very hard to relight an engine if the aircraft was in still in extremely heavy rain which had caused the flameout in the first place. Adverse weather and a decrease in engine rotational speed could induce more water into the engine core. Such attempts to re-start the engine would be unsuccessful. In the case of the Garuda 737 it was found the aircraft had experienced rain more than ten times the maximum tested used for certification.

Many operators meet operational regulatory requirements by cyclic training. Each non-normal checklist must be tested at least once every three years since it is not practical to cover every emergency procedure on one or two simulator sessions. Loss of both engines is one such sequence to be tested. In the case of the Boeing 737, the QRH Loss of all Engines checklist covers six pages including the first four items known as Memory Items. Pilots are expected to have a sound working knowledge of these non-normal checklists – not just the few items that constitute the immediate memory items. From simulator experience it is clear that some crews cannot be bothered to study the QRH contents unless they are coming up for a simulator session. Even then the subjects to be covered in the next simulator session are usually well known beforehand and pilots have been known to simply concentrate on only those specific subjects to be tested. Often pilots take an inordinate time to even find the required pages in the QRH and this is primarily because they are lazy in their professional duties.

Engine flameouts caused by inadvertent penetration into extremely heavy rain inside a super-cell thunderstorm are rare. Sometimes defective weather radar or lack of knowledge by the crew of optimum radar settings, can lead into flight through a severe storm. In the case of the Garuda Boeing 737 flameout mentioned previously, investigators discovered the aircraft radome had been damaged in earlier weeks and the damage remained unrectified. This reduced the radar beam efficiency to such a degree as to be virtually useless. Over many years defective weather radar was a common complaint by general aviation pilots in Australia. This was particularly noticeable in turbo-prop freight aircraft cruising in the medium altitude levels. Leaking seals or pin-hole size cracks characteristic of a poorly maintained radome, allowed moisture to freeze inside the radome, drastically affecting radar range efficiency. For various reasons, pilots seemed reluctant to write up the snags.

One thing is for sure. A dual flameout in adverse weather is no laughing matter. It does not help if the crew waste valuable time trying to find the right pages in the QRH while the aircraft is gliding in turbulence at 2000 feet per minute in a thunderstorm. Leaving the study of the QRH and associated operational manuals only when the next cyclic simulator session is due, is certainly not the wisest decision and displays a slack professional attitude.

Enough said of the grim stuff. Allow me to finish off with the story of an RAAF Lincoln bomber that in 1955 lost all four engines over the Arafura Sea at night. The captain was Flight Lieutenant Rick Tate. In later years he became a DCA Examiner of Airmen based at Moorabbin. Ppruners of that vintage would remember him well and with great affection. Here is the story as it happened:

On 29th May 1955, our crew took part in an anti-submarine exercise in the Arafura Sea. On board that night were navigators Warren Agnew, Ash Clarke and Len McTaggert. Peter Hays was second pilot, while Alf Harrison, Des Barratt, John Nicholson, Nat Thompson and John Edmonds were the signallers. With the exception of Warren "Bunny"Agnew, we were all non-commissioned officers (NCO's). Bunny had previously flown in Beaufighters on operations against Japanese forces in Timor during the war.

Two RAN submarines and three frigates also took part in the exercise which was code named Operation Anzex. Our job was to hunt the submarines, while their job was to attack a convoy of ships escorted by the frigates. Our search pattern took us within 50 miles of Timor.
There were several Lincolns involved, one of which was flown by Flight Lieutenant Ricky Tate. These aircraft were equipped with additional fuel tanks in the bomb bay, giving the aircraft 14 hours endurance. These bomb bay tanks required fancy plumbing and it was the job of the duty signaller to keep an eye on the fuel tank contents gauges. He would then manipulate the various cross-feed cocks under the wing spar near his radio operator position. On this occasion, due to an oversight by the ground staff at Darwin, and unknown to the crew, the bomb bay tanks had not been filled.

Students undergoing RAAF pilot training at No 1 Advanced Flying Training School at Point Cook were taught to avoid changing fuel tanks when flying on low level (200 ft) cross-country flights. Good airmanship dictated a climb to at least 1500 feet before changing fuel cocks to a fresh tank. This would give more time to cope with any engine failure caused by air in the fuel lines, or simply because of faulty fuel cock selection. For this reason at midnight during the anti-submarine patrol, Ricky Tate increased power to the four engines and climbed from 500 feet to 1500 feet prior to fuel transfer from the bomb bay tanks. The duty signaller was then directed by the captain to commence fuel feed from the bomb bay tanks. This was done by switching on the high pressure fuel pump switches situated on the cockpit wall behind the navigator. These switches were out of reach of the pilot.

Shortly afterwards one engine stopped, quickly followed by the remaining three engines. Tate called that all four engines had failed and ordered his crew to take up ditching stations. Meanwhile the Lincoln had rapidly become a 30 ton glider and began to lose height towards the sea. Sergeant Jim Chataway (the second pilot), who had been on rest next to the signaller, leapt to his feet and headed for the cockpit where Rick Tate was preparing for ditching. There was no checklist or QRH to cover four engines failing at once.

Behind the pilot was the navigator and radar operator positions. The radar screen is viewed from under a canvas cover similar to that used by photographers in the old days. Ray Parkin was the radar operator and as he attempted to take up ditching positions he found his face being un-ceremoniously pushed into the radar screen by Chataway's size 10 boot. The signaller meanwhile tapped out a fast Mayday on HF with his morse key.

Chataway managed to turn off the high pressure fuel pump switches situated out of reach of the captain. Meanwhile Rick Tate while still hand flying, attempted to re-start the engines. Once the fuel pump switches were turned off, each engine slowly came back to life - the last one at 500 feet above the waves. No one knew why the engines had failed and it was a relieved crew that finally touched down at Darwin two hours later. An inquiry revealed that the two bomb bay fuel tank contents gauges were unserviceable with their needles stuck at full. When the ground staff went to fill the fuel tanks prior to the flight they first checked the fuel gauges in the cockpit. On seeing that both tanks indicated full capacity, they decided the tanks must have already been filled. In fact, both tanks were empty, and the engines had failed when air from these tanks was drawn into the fuel system by the high pressure pumps.

The wise precaution by the captain to gain height before switching fuel tanks, almost certainly saved the aircraft from the perils of a black night ditching. Nearly 60 years later, for the crew of a jet transport experiencing a simultaneous failure of all engines, good knowledge of the QRH might also do the trick and save aircraft and passengers from disaster. It is worth thinking about

redsnail
24th Jun 2012, 12:21
Thanks for posting. Good story and food for thought. :)

Trojan1981
25th Jun 2012, 04:30
Great info there Centaurus. Do you rember this one?

http://www.pprune.org/rumours-news/229559-qatar-airways-a330-dual-engine-flameout.html

Centaurus
25th Jun 2012, 13:37
Great info there Centaurus. Do you rember this one?

Qatar Airways A330 Dual Engine Flameout

Redsnail and Trojan. Thank you for the replies. The link to the Qatar 767 flameouts was very good and I have forwarded it to a 767 friend overseas.
I have often wondered if technically it was possible for Pprune management to start a new forum dedicated to aircraft incidents/accidents by aircraft type. The search engine has its limitations in this regard.

With so many operators employing recently graduated cadet pilots straight into the RH seat of big aircraft, I would have thought these pilots would be interested in learning more of the type of aircraft they are flying. There is so much of technical value from past Pprune posts in this regard-if you know they existed of course. For example, the link to the Qatar 767 flameouts would be invaluable to those pilots keen enough to want to add to their knowledge of engine handling. Or am I being naive in thinking most pilots of the current generation would be seriously interested? The cynic in me is coming out I'm afraid...:ugh:

sleeve of wizard
25th Jun 2012, 15:18
Centaurus, a small correction, it was a brand new A330 that had the dual engine failure with Qatar not the 767. But I completely agree with your comments.

Kharon
25th Jun 2012, 21:20
Another enjoyable first coffee; you make a couple of points early in the piece:-

Centaurus – From simulator experience it is clear that some crews cannot be bothered to study the QRH contents unless they are coming up for a simulator session.

and - Even then the subjects to be covered in the next simulator session are usually well known beforehand and pilots have been known to simply concentrate on only those specific subjects to be tested.Given this a lot of thought over the years – and wonder if this is not the fault of younger crew coming through but the 'way' they are trained at ground school. It seems to me that the 'modern' method is to train them to pass an exam, rather than 'learn' and explore the subject matter, this attitude then pervades from basic training to 'on line'. I find the 'younger' crew will happily 'learn their craft' when the reasons for study are made clear; but if they come from a 'tick a box' background, into a 'tick a box' TCO system, one can hardly blame them for being 'slack'. Just a thought. (not bagging Flight Schools).

We need a return to the old style 'crash comic', the amount of knowledge distribution triggered by 'smoko/ pub' discussion of the latest issue is legendary, hardly seem hear any these days.

morno
25th Jun 2012, 21:37
Whenever possible, I try to put my new found/learned skills to use and practice them, so that I'm not just learning it to pass a test. Who know's when you'll need it down the track!

Interesting reads Cent, thanks very much.

morno

PLovett
25th Jun 2012, 23:33
Given this a lot of thought over the years – and wonder if this is not the fault of younger crew coming through but the 'way' they are trained at ground school.

Not sure that it is the way they are trained. I have had the opportunity to watch a lot of students over the years in a variety of settings (both aviation and non-aviation) and an overwhelming impression has been that the majority of male students (not so prevalent among females) want to be told what they need to know for the exam/test/assessment, nothing more. In fact they will actively switch off if it is not directly related to why they are there no matter how beneficial it may be otherwise.

Centaurus
26th Jun 2012, 12:40
and an overwhelming impression has been that the majority of male students (not so prevalent among females) want to be told what they need to know for the exam/test/assessment, nothing more. In fact they will actively switch off if it is not directly related to why they are there no matter how beneficial it may be otherwise.

In his fine book "Handling the Big Jets" David Davies the former UK Air Registration Board test pilot, had this advice to airline pilots:

"Finally do not become lazy in your professional lives. The autopilot is a great comfort, so are the flight director and approach coupler. But do not get into the position where you need these devices to complete the flight. Keep in practice in raw data ILS, particularly in crosswinds. Keep in practice at hand flying the aeroplane at altitude and in making purely visual approaches.

Airline flying really is money for old rope most of the time; but when things get hairy then you earn your pay. The old saying that `Flying is years and years of utter boredom punctuated by moments of sheer terror` is always true. As we get older we all become slightly lazy, slightly more tired- and this is a bit of a trap. The demand of jet transport flying can be best met by enthusiasm. Personal enthusiasm for the job is beyond value because it is a built-in productive force, and those who have it do not have to be pushed into practice and the search for knowledge. Enthusiasm thus generates its own protection. This is the frame of mind which needs to be developed for the best execution of the airline pilot's task"

His advice is just as pertinent now as it was when he wrote it in 1967, forty-five years years ago.

Keg
26th Jun 2012, 14:05
Not sure that it is the way they are trained. I have had the opportunity to watch a lot of students over the years in a variety of settings (both aviation and non-aviation) and an overwhelming impression has been that the majority of male students (not so prevalent among females) want to be told what they need to know for the exam/test/assessment, nothing more. In fact they will actively switch off if it is not directly related to why they are there no matter how beneficial it may be otherwise.


I wonder if time is a function of that. The aircraft manufacturers have shortened their courses considerably but reducing the amount of content. The airlines want their candidates out of the training system and being productive. The combination of the two results in ticking the box to get the person out and flying. Whilst I agree that some of it can probably be levelled at some candidates, I do wonder whether the 'system' is actually moving in that direction anyway as the system is the one that wants the tick in the box (in the shortest amount of time possible) so that they can pass the person on to the next phase of training.

As an example, a major airline supposedly reduced the number of simulators conducted during initial endorsement. They went from virtually no one failing initial training to now having about a 30% failure rate. The logic (again, allegedly) was that it was cheaper to give 30% of crew the extra two sims needed to get them up to speed than give 100% of crew those extra two sims. Of course, the 'system' doesn't count the additional stress on those crews, the lack of confidence by someone who scraped through in the bare minimum, etc, etc.

Anyway, an interesting read. Thanks Centaurus.

B772
27th Jun 2012, 00:30
The solitary casualty in the GA B737-300 crash was not killed as such. She was a junior stewardess who opened a rear exit and drowned after jumping into the river. There were some photos of the aircraft 'moored' after the high speed landing in the river showing little signs of damage.

BTW. Is it true the engines the US Air A320 (Hudson River) could not be relit due to them being auto shutdown after the bird ingestion. I believe QF also experienced an auto shutdown on a A330 a number of years ago in S.E Asia.

Centaurus
27th Jun 2012, 11:39
B772. Thanks for the correction.

I took my quote from the Garuda accident report which stated nothing about drowning after jumping from the aircraft:

1.13 Medical and Pathological Information
The fatally injured cabin crew was lacerated on her face, left part of the necks (i.e. fracture of the neck), fracture of the both upper arms, right femur, left lower leg, and all toes were missing.
The cabin crew death is presumably due to impact with the bottom of the river of the aircraft against the river.

aditya104
27th Jun 2012, 19:27
Thanks for sharing this gem, Centaurus. :D

Your cynicism about professionalism among the young pilots is justified. Have economic benefits taken precedence over other important aspects only recently, & was it different in the past?