Originally Posted by
72856
I was only prompted to do so by the suggestion that the blame largely lay in not adhering to a checklist.
I disagree - I would say that the full blame lies with the crew who did not adhere to procedures. As a big jet driver you should know that the crew are the last line of defence against the shortcomings of the aeroplane and that following an SOP correctly will normally keep you out of trouble and almost never actually place you in peril.
My background is also big aeroplanes, although I am now associated with smaller ones whilst instructing in CRM/MCC. I know that ALL aeroplanes have potentially dangerous properties and that a properly written SOP (as in this case) correctly followed (as not here) will minimise the risk.
This incident has overtones of the British Midland B737-400 crash in the late 1980s - a design fault in the CFM 56 engine caused a blade failure but an incident was turned into an accident (with over 40 fatalities) because the crew did not follow the SOP. As crew it is our job to know the aeroplane, its characteristics, its drills and most important its shortcomings.
It's absolutely explicitly stated in the POH that you must not start the second engine from the GPU. This ensures that the battery has charged sufficiently to provide the necessary oomph to run the systems. It would be nice if the alternators produced enough juice to run everything, but they don't. However, there IS a procedure that mitigates the problem.
It's no worse than the fact that you can blow a Seneca engine apart by overboosting due to the fact that they are fitted with turbochargers without wastegates. The difference here is that, after a bit of a spat, Thielert and Diamond will get it sorted - but the Seneca still doesn't have wastegates after 20+ years.
The checklist on ANY aeroplane covers all sorts of actions which, if not followed correctly, can lead to disaster. Airline SOPs have to be written to take account of the fact that many turbine engines can flame out when anti-ice is switched on (CFM 56 and PT6 to name but two) but no-one wants the manufacturers head on a block, even though a friend of mine was killed by a double flameout on a PT6 powered Short 360.
No-one died here, lessons will be learned and the problem sorted. That's more than can be said for some aeroplanes.