Pursuit of excellence - the X-Factor in training accidents
With already 81,930 views and six Pprune pages on the Darwin Air North Brasilia crash, a fresh perspective is needed. Hence this point of view which it is hoped the Mods will not submerge literally with the current thread.
As it is, the Brasilia accident report should be vital reading for airline check pilots, flying instructors, and their ilk. In particular, the ATSB animated picture of the Brasilia flight path is a graphic example of the adage “A picture is worth a thousand words”
Several years ago, an ATO friend of mine died of injuries sustained in a similar asymmetric accident at Camden. In his undoubted enthusiasm to be realistic, he cut the mixture control to simulate engine failure on a Duchess shortly after lift-off. The student, himself a current Boeing 767 captain and flying instructor, was momentarily caught unawares and the aircraft yawed sharply. The ATO was too slow to set up zero thrust - the resulting drag from the windmilling propeller causing severe loss of climb performance. The Duchess clipped tree tops at the departure end of the runway and stalled wings level into rising terrain. The impact was not severe but during the ground slide the aircraft hit an unseen iron girder in long grass and a fuel tank ruptured. Both pilots evacuated the aircraft unhurt but were caught by fire. The student survived although badly burned. The instructor was not so fortunate and died in hospital of his injuries. He was a former student of mine in the RAAF where in 1959 I did his conversion to the Lincoln four engine bomber at Townsville. I remembered him as a keen and enthusiastic pilot.
Recently, I was reminiscing with another former Lincoln pilot about the good old days. He was a retired airline pilot and I was still involved in aviation training. He recalled that during his Lincoln training in 1957 it seemed to him we were rarely flying with four engines going– grumbling with good humour that I was always pulling engines on him. To be fair, in those days the Rolls Royce liquid cooled piston engines on the Lincoln were not as reliable as today’s power plants - engine failures being relatively common. For that reason, simulated engine failures were often practiced after lift-off while feathered propeller landings were part of conversion and recurrent training.
Despite over fifty years between our Lincoln flying and present conversation, I felt a twinge of guilt at what he perceived as my over-enthusiasm for practice engine failures. I wondered how many former students had felt the same way and why on earth didn’t someone tell me about it at the time? In those days, the squadron QFI worked almost single handed for conversion of new pilots to the Lincoln and with twenty or more pilots to worry about, he was a busy man. Commanding Officers ran the squadron while the QFI ran the training. If pilots privately felt the QFI’s enthusiasm for the job was a bit beyond a joke - especially with engine failures – it was a pity that their concerns never reached their Commanding Officer. As result, QFI’s often operated unsupervised in the job, except for an annual flight check at the RAAF Central Flying School.
There were a few hairy moments during conversion training on newly graduated 200 hour pilots who had never flown a multi-engine aircraft - let alone a big four engine tail-wheel bomber. All they had flown were Tiger Moths and Wirraways. Over-confidence is a close relation to over-enthusiasm and looking back at those years of instructing on Lincolns, I am sure over-enthusiasm for training excellence was a factor in close shaves some QFI’s experienced on other types over the years. The 1991 RAAF Boeing 707 fatal accident near East Sale was one such example, attributed to simulation of asymmetric flight training that resulted in a sudden and violent departure from controlled flight.
In later years, this scribe tried his hand at instructing in general aviation. One mellows with age and I soon became cautious of pulling engines at low speed and altitude - whether in a multi-engine type or a Cessna 172. From previous experience I was aware it takes only a momentarily wrong rudder or high nose attitude to cause an accident such as the Air North Brasilia.
Mixture cuts or sudden throttle closure to simulate engine failure at low speed after lift-off can be potentially dangerous, with any training value far outweighed by the risk of mishandling by the student or the instructor.
The two instructors on the Brasilia in Darwin, and the Duchess at Camden, were experienced on type. But I can’t help thinking that in the end their over-enthusiasm for the job may have led to their demise. If only someone in authority had pulled them up sharply when it was clear to others their very enthusiasm to impart knowledge was bordering on perilous for their students. It took 54 years before someone sorted out this writer and made him realise the potential dangers to which he had exposed his students in real aeroplanes all those years ago. Nowadays, simulators are the way to go. Yet, even in the safety of the simulator, instructors need to sit back sometimes and smell the roses, rather than overdo engine failures at V1. While an enthusiastic instructor is generally regarded as an asset to an organisation, over-enthusiasm has been known to lead to dangerous practices in flying training.