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Old 27th Mar 2014, 11:24
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sheppey
 
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ATO responsible for Warrior accident - what is your verdict?

Aviation Short Investigations Bulletin - Issue 28

On 15 January 2014, the pilot of a Piper PA‑28 aircraft, registered VH‑HVX, was undergoing a Commercial Pilot Licence test flight with a testing officer on board. At about 1500 Eastern Daylight-savings Time, the aircraft landed at Orange Airport, New South Wales. The aircraft had encountered moderate turbulence during the flight from Bankstown and the pilot reported a slight overshoot on landing at Orange due to fluctuating wind conditions.

During the time on the ground, the pilot observed the wind varying from an easterly to a westerly direction and the speed fluctuating from 0 to about 15 kt. The temperature at Orange was about 33 ºC, and the aerodrome elevation was 3,115 ft. The pilot had calculated the density altitude at Orange to be about 5,725 ft.

At about 1530, the pilot observed the wind to be from 110º at about 10-15 kt and configured the aircraft for a short field take-off from runway 11, selecting two stages of flaps. During the take-off run, the pilot and testing officer observed the aircraft performing normally and the pilot rotated the aircraft at about 55-60 kt indicated airspeed (IAS). The pilot then established the aircraft in an attitude to achieve a best angle-of-climb speed of about 72 kt IAS. The pilot reported that the stall warning horn sounded momentarily during the take-off due to turbulence.

When at about 50 ft above ground level (AGL) and about 65-70 kt IAS, the testing officer reduced the engine power to idle and stated “simulated engine failure”. The pilot immediately lowered the nose of the aircraft in an attempt to increase the airspeed and selected the third stage of flaps. At about 10 ft AGL, the pilot reported the aircraft was sinking and flared the aircraft for landing. However, the aircraft continued to sink and landed heavily. The pilots reported that the stall warning did not sound during the descent and that a shift in the wind direction was the most likely cause of the accident.

This incident highlights the critical importance of considering local conditions such as wind, elevation and temperature, as well as the inherent risks of conducting simulated engine failure at low altitude.
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Sheer folly by the ATO to have the candidate conduct a simulated engine failure at 50 feet after lift off from a short field take off with the only option to land straight ahead on the remaining field length. Blaming the weather conditions was a cop out. A simulated engine failure at that height would require lightning fast reaction by the candidate to not only literally bunt over to maintain safe gliding speed, but risk a heavy touchdown to be followed by heavy braking and risk of skidding and tyre failure. In other words he would have to get it right first time. There is no room for error and little time for the instructor (ATO) to take over from the candidate in the seconds available to touch down. By placing the candidate in a situation which would task even the most experienced pilots, the ATO exposed himself and the candidate to very high risk. To put it mildly he displayed poor airmanship.

In assessing a candidate's competence at conducting a forced landing procedure in a single engine aircraft following a simulated engine failure by throttle closure after lift off, it would be sensible to wait until at least 500 feet. That leaves a margin for slow reaction and also gives a reasonable amount of time for the ATO to make a fair assessment of the actions by the candidate. That includes, among other assessable items, the immediate lowering of the nose in order to maintain a safe gliding speed, correct selection of a landing area ahead and to the side, immediate simulated safety drills including warning any passengers and finally the correct method of going around again from the simulated emergency. Even then, simulating engine failure on take off in any single engine aircraft, is a high risk manoeuvre leaving little room for error by the candidate.

Some years ago, Point Cook was the scene of a fatal accident in a Tiger Moth when an experienced RAAF flying instructor was training another experienced RAAF pilot. The instructor had earlier briefed a wrong speed for climb in the Tiger Moth that was nearly 10 knots slower than the manufacturers recommended climbing speed of 58 knots.

As the pilot lifted off just above the power on stall speed and was climbing, the instructor pulled back the throttle at 100 feet to simulated engine failure with the intention the student should conduct a forced landing straight ahead on the remaining field length. Already 10 knots below best climb speed, the Tiger Moth stalled and entered an incipient spin before the experienced "student" could lower the nose to safe gliding speed attitude. The aircraft hit the ground in a steep nose down attitude and burst into flames. The student in the rear seat escaped with minor injuries while the instructor was killed on impact.

Tiger Moths are normally equipped with moveable slats on the top wing which lower the stall speed by about four knots and pop out just before the stall and the clacking noise of them popping out is an effective stall warning. This particular Tiger Moth had its slats permanently locked to minimise maintenance costs. To this day many Tiger Moths have this vital safety feature removed for the same reason.

The ATO in the previous Warrior accident displayed poor judgement in initiating the simulated engine failure after lift off at such a low altitude and in doing so accepted the risks involved. One wonders if CASA has since "reviewed' his Delegation?
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