Obid,
Funny you should say this.
This report might well be grist to the mill for the likes of John Deakin and co. as had it just been a plugged injector blocking and un blocking and the A/C had (maybe it did??) a more comprehensive EIS the pilot may have seen it for what it was and elected to just reduce power on the R/H and return gracefully. Somewhat supposition though.
Well I was wondering if I should post the private correspondence I had over night with the very folk you mention. But seeing you make mention here goes, and to be fair I will post my email to the guys last night after I read the report.
Is this another ATSB report like the Whyalla report?
OK, not a bunch of fare paying pax, but a flight nurse, and an under trained pilot are dead.
Initial problem a “surging prop”
ATSB accept Lycomings response being surging from a fuel distribution problem.
Cause of the engine surging
The engine manufacturer advised that the surging identified by the spectral analysis of radio transmissions during the accident flight was ‘consistent with uneven fuel distribution to the cylinders’. The propeller manufacturer advised that it had ‘yet to find a causal factor in surging that was clearly identified as being from the propeller or governor, especially for a report of a large RPM excursion’.
I am perplexed at how this could be, in the climb with a TC engine surely full rich, the partial plugging of an injector would mean no noticeable power surging (if EMS equipped a rising EGT, TIT, and CHT on the affected cylinders) and not sufficient power loss that RPM variations occurred. If the injectors to one or more cylinders were such that they went excessively LOP and or beyond operational flows, it would have vibrated liked paint can mixer.
I find that hard to believe. Maybe I have a lot to learn.
In this case the PIC handled the whole event poorly, very poor on a number of fronts, and should not have shut it down completely and not descended at all until overhead YSBK. That aside….have the ATSB cocked this up like MZK?
Another good case for charter ops to have a fully functioning EMS and pilots educated to use and understand it.
And here is John Deakins reply, and I must say he has a few very interesting observations about what to do in such an emergency. If only I could learn half of what he has forgotten.
Your analysis is "spot on."
CASA (typo should be ATSB)discounts the effect of the landing gear warning horn (one throttle back, gear not down). From personal experience, I can tell you that can have a MAJOR effect on the human brain, and if loud enough, the noise alone can be utterly incapacitating. And I do mean incapacitating. I cannot help wondering if he'd just advanced the throttle on the feathered engine to get rid of the horn, the whole thing might have been avoided.
There's no mention at all of any ACTUAL shutdowns performed during training or proficiency checks, and a passing reference to the Chief Pilot not being an instructor, and therefore not authorized to conduct such training. The young pilot may not have been aware of what that horn was, or how to get rid of it.
Of course, there was apparently no reason to shut the engine down in the first place for the minor surging alone.
The surging sounds more like a problem with the prop governor or the flow of oil to/from the prop. Lycoming was willing to blame it on "something, anything else" to avoid liability.
They said that not having the correct bank angle probably would cost 20 to 30 feet per minute difference. I'd dispute that strongly, this alone might have had 200 to 500 fpm difference. The manual also suggests 5 degrees as optimum, which is not correct. That's a certification allowance for CONTROL at Vmc.
The whole report strikes me as self-serving for CASA. They have set forth massive requirements for Airmen of all levels, and specified paperwork and forms to be completed to show compliance. Many "Manuals", and other documents, most requiring some repetitive action within close time frames. They go into loving detail for all this, for 68 pages. It goes on and on, and it means nothing, distracting from the "real mission," which is to get there, safely.
Disgusting.
Best...
John Deakin
Advanced Pilot Seminars
So along with that one and a few others, who likewise are struggling to see what value there was in this report, as it was not helpful in preventing further crashes, it was more like a police report to a coroner, which makes me think, whose job are they doing here?
A pilot and a flight nurse lost their lives here...surely they deserve better than this???
There was this comment from from Walter Atkinson, John Deakins associate at APS, who understands my position on all commercial ops having an EMS and pilots specifically trained how to understand what they display and not just stare and blinking numbers and bars.
The presence of an engine monitor would have confirmed this and given the pilot useful info about a confusing situation. When are the Aussies gonna figure this EMS issue out?
Seems they share the same frustration.
‘consistent with uneven fuel distribution to the cylinders’.
Poor fuel distribution my arse, supply maybe
If the wreckage was that bad, that they could at best come up with that conclusion, they should not have been making any. Lycoming
I think the prop people are the only sensible ones in this bit.
Rant over for now....not happy Jaba is going home from the office to cool down. Merry Christmas Y'all.