Accidents and Close Calls Discussion on accidents, close calls, and other unplanned aviation events, so we can learn from them, and be better pilots ourselves.

What would YOU do?

Old 30th Jun 2022, 13:46
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What would YOU do?

What would YOU do?
Your aircraft suffers what was effectively a double engine failure at 200ft on take-off out of Sydney.
After weighing up all options and because of your training, you decide the only safe option is to ditch the aircraft.
All 25 souls onboard survive with one minor physical injury.
For a couple of days you are called a hero by the media.
You attend interviews by the investigating authorities but they do not want to listen to your version of events.
You were there - they weren't - but that makes no difference. They already have formed the conclusion (confirmed by a guest who was after one day asked to leave the investigation).

A few months prior to your accident, a Navajo tragically crashed at Young NSW killing all 7 onboard, instantly.
6 months after your accident, an Aero Commander crashes into the sea on its way to Lord Howe Island. 8 people tragically lost their lives there.
The Authority has been forced into a position (3 aircraft have fallen out of the sky) to act.
So, to appease the public they had to do something. They need a scapegoat, a fall guy. A guy who is not a member of a powerful union.

They suspend your pilot's licence some 9 weeks after the accident, because you decline to attend their counselling (which is your right).
You ask the Administrative Appeals Tribunal for a Stay Decision - they refuse.
You go to the Commonwealth Ombudsman Office to complain about the way you've been treated only to find that the Authority has drafted the letter for the Commonwealth Ombudsman to send you.
No need to guess the contents of that letter.
You submit 2 grievance procedures against the Authority. Naturally, they have done no wrong (the police investigating the police).

You find that in the official report into the accident, (page 14), they state "Right engine—With the exception of the propeller governor, no pre-existing abnormalities were found."
Yet you receive an interesting package of documents from BASI in early 1997, containing numerous revealing facts.
• Of the 28 left engine spark plugs, once they were cleaned and even regapped, five did either not fire or were found to be electrically breaking down.
• Only twenty-five spark plugs were recovered from the right engine (which had been immersed in salt water for two months). They were also cleaned, re-gapped and then tested and of these eleven were considered unserviceable for the same reasons.
• Of the fifty-six spark plugs, only 26 were deemed to be of the approved type of plug.
A 100 hourly maintenance inspection was (supposedly) carried out about 4 hours prior to the accident. Even BASI expressed concern at the condition of the spark plugs considering the recent 100 hourly.

Geez, could that be a reason the right engine (which should have kept you airborne) was not producing rated power.
You ask the then Minister for Transport to intervene. - Nothing.

The weight issue. You witness BASI weighing the personal luggage dripping wet on a set of old analogue bathroom scales. When challenged over this, they reply, "we factor it".
When the aircraft was previously weighed in 1992, the conditions did not comply with CAA requirements for weighing aircraft, and the resulting figures from both weight records were identical—8158 kg.
Each of the three jack-point figures showed identical weight readings as well—what are the chances of this? Impossible!
The CAA never questioned this. So the ACTUAL weight of the aircraft will forever be in doubt.

Recently you again ask a different Minister for transport to investigate. Nothing new found.
After requesting, under the Freedom Of Information Act, details of the mechanical condition of the aircraft, you are denied access.
Reasons given,"secrecy" and "not in the public interest".
Since when is an accident investigation SECRET?

You apply for flying jobs, only to be told that "you have an adverse BASI report against you" or the CAA has lied about you to employer.

If they had published an accurate and truthful report (as required under ICAO Convention) then perhaps PH-DDA (with remarkably similar problems) would not have crashed tragically killing all 32 onboard.

After a further 4 years with the Office of Australian Information Commissioner, some documents were finally released.
You find that the maintenance on the aircraft was atrocious or even non-existent.
At the time of the ditching, both engines had exceeded their 1,000hr TBO.
Extensions had been sought, but NOT granted, so a few recent flights were totally illegal and unknown to you.

A DC-3 simulator ride in the Netherlands confirmed the belief.
The right engine power had to be retarded by some 30% to replicate the descent into Botany Bay.

You find out that someone has edited the control tower tape recording to make the you look bad and incompetent. (Pilot's push to talk switch stuck on).
Certain phrases had been deleted from the tape and the transcript. - Tampering with evidence?
Remember the spark plugs - they were also cleaned, re-gapped and then tested. - Tampering with evidence?

Since becoming aware of the tampering and coverups, you contact a few Senior Accident Investigators who appear on the international media to advise them what you've found.
As soon as you tell them, they "circle the wagons" and stop communicating. Why?

Armchair critics state "in poor taste" when you tell the truth about your treatment on social media.
Perhaps those armchair critics can offer alternative ways to right a wrong.
Naturally you were promoting your book as it's the only way you can expose the truth.

So, what would YOU do?
Just roll over and accept the defamation, humiliation and loss of professional pride and integrity, together with loss of employment in your chosen passionate vocation OR fight for your rights?

I make no apologies to say that I value pride, integrity and honesty. Therefore the fight for vindication continues.

Flame me if you want to, but unless you've walked in my shoes.....
dogcharlietree is offline  
Old 30th Jun 2022, 17:30
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Join Date: Aug 2000
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Originally Posted by dogcharlietree View Post
What would YOU do?
Me personally? I think that after 25 years and everything being said, written and published I would let the whole matter rest in peace. And see to it that I get some good years out of my remaining lifetime with family and friends and not a single thought wasted on waters that have flowed down the river long ago.
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Old 30th Jun 2022, 17:39
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I am so sorry to hear of this, and I do not know what you can do. Why did you refuse the counselling - from your narrative, it seems that the wagons closed against you after this?

My guess is that the owner of the aircraft has powerful connections in politics?

A good reason to be a member of a union. Would a union be interested in you joining them now and supporting you - probably not.

Have you taken this to a barrister for their opinion of a court case being successful?

Or is there an investigative television programme in Australia you might be able to interest in this?

Have you taken this to your local minister of parliament?

edit to add: Oh....did not see it was that long ago. Bit late now surely?

Uplinker is offline  
Old 30th Jun 2022, 20:39
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What was the aircraft type? If it was a Navajo or an Aero Commander I’d sit back and enjoy the sunset as there might be some questions about 25 souls on board. If it was a DC4 there’ll be questions about the need to ditch. 😜😜

I’d fight but then I’m a stubborn idiot and would purely be doing it to waste other people’s time as I wouldn’t expect to get anything out of it. If you’ve got time and can compartmentalise this so it has ZERO affect on the rest of your life then why not?
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Old 30th Jun 2022, 20:49
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Originally Posted by Humpmedumpme View Post
What was the aircraft type?
https://en.wikipedia.org/wiki/1994_S...ive_DC-3_crash
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Old 30th Jun 2022, 23:53
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We studied that accident in our DC3 ground course - not to be critical, rather to learn of the pitfalls we might encounter, the options available, and the particular issues of an old airliner at MTOW on a single engine.

I consider myself fortunate not to have had need of that particular section of my education. However I have been subjected to a significant injustice thrust upon me be an 'authority' who, through no demonstration of competence nor independent oversight, have power over me and chose to exercise that power in a completely unreasonable way. Moreover they did so in such complete defiance of their own statements that individuals lied - at very least by omission - in a judicial process. All of this is a matter of record yet the injustice has not been addressed some years later.

That more than rankles today, and I suggest that while some people may be capable of suppressing their feelings should this sort of thing happen to them, it will not be everyone that can do that, and nor should they have to. We are meant to be living in an 'enlightened' society where such issues should not occur and, if they should, we expect justice to prevail with that issue being thoroughly investigated and addressed independently in a way that - even if we don't agree with the outcome - we can see our complaint has been properly considered.

The alternative, after which we might be able to let bygones be bygones, is the way such issues were dealt with in past times, going back to pistols at dawn and the like. Since that is no longer permitted the stand-in must be effective, and if it is not then you will end up with people whose lives could be destroyed by little people with too much power and no check or balance to be seen. Thus for those people, and those who may come after them - it could be you - it is very important that the utmost is done to ensure due and proper independent process where power is exerted by one person or persons in the name of the state over individuals. It is highly desirable this happen while that individual or individuals are alive and can enjoy their remaining time free of stigma, rather than some belated finding long after their demise.

So, dogcharlietree while there is little useful assistance I could give, and we have to acknowledge we only have your view on this, I can say that at least one person here understands your feelings and why they may remain strong even after 26 years. Perhaps the only practical thing one might offer is that I agree with Uplinker about seeking the advice of a barrister who has expertise in this area. And yes, you shouldn't have to pay, but maybe it is the only way forward at this point? One other thing I would say, there is nothing that focuses official's minds as enjoining them to proceedings as private individuals. At the end of the day it is individuals that make decisions, not a state machine, and if those individuals have acted - or not acted - in certain ways they could be held to be personally liable. The bar is probably high, but there are commonwealth cases possibly pertinent to this.

Finally, just to avoid doubt, I don't agree with Uplinker's implication that you should have subjected yourself to counselling simply because some person put it there as a test or a bar to jump over - unless there was some very good reason for it - and nor should it be 'too late' to address such a wrong, if there is a wrong.

FP.
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Old 1st Jul 2022, 03:47
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All 25 souls survived a textbook ditching immediately following low level EFATO in an old aircraft, I recall only one person suffered injury - flight attendant (broken arm?), PIC was last to leave the aircraft after supervising evacuation, I would say all crew did a good job IMO. I would fly with that crew.
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Old 1st Jul 2022, 10:07
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Originally Posted by jonkster View Post
All 25 souls survived a textbook ditching immediately following low level EFATO in an old aircraft, I recall only one person suffered injury - flight attendant (broken arm?), PIC was last to leave the aircraft after supervising evacuation, I would say all crew did a good job IMO. I would fly with that crew.
Yes, certainly. But this whole case is not about how the final stage of this emergency, the ditching and evacuation, was handled by the captain. It is about why there was no other option but to ditch after one engine failed shortly after takeoff. Because at the conditions of that day, a fully serviceable properly loaded DC3 flown by a competent pilot shold be able to continue flying and even perform a shallow climb. As the captain himself verified in the simulator. So why? To me it seems to be one of those cases where everybody involved tries to protect himself as much as he can and blame everything on others. Starting with the operator, their maintenance organisation and the authorities involved. In the end, as so often, the pilot in command, both the strongest link and the weakest link in the chain, is held responsible. Injust? Probably yes. But very difficult to prove, maybe impossible (I took the time to read the ivestigation report, it can be found following the link in the Wikipedia article above), especially after 25 years and with evidence that may have been tampered with.

What can we learn from it (this is the main reason why accident reports are published and discussed, isn't it)?
- Don't ever rely on others in our "industry" when problems arise. They will only look after themselves.
- Cover yourself as good as you can. Say "no" to your company if they ask you to perform impossible tasks.
- Don't trust anybody unless you know them very well. This includes maintenance and the other pilot next to you.
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Old 1st Jul 2022, 19:18
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Quote:
You find that in the official report into the accident, (page 14), they state "Right engine—With the exception of the propeller governor, no pre-existing abnormalities were found."
Yet you receive an interesting package of documents from BASI in early 1997, containing numerous revealing facts.
• Of the 28 left engine spark plugs, once they were cleaned and even regapped, five did either not fire or were found to be electrically breaking down.
• Only twenty-five spark plugs were recovered from the right engine (which had been immersed in salt water for two months). They were also cleaned, re-gapped and then tested and of these eleven were considered unserviceable for the same reasons.
• Of the fifty-six spark plugs, only 26 were deemed to be of the approved type of plug.
A 100 hourly maintenance inspection was (supposedly) carried out about 4 hours prior to the accident. Even BASI expressed concern at the condition of the spark plugs considering the recent 100 hourly.
Geez, could that be a reason the right engine (which should have kept you airborne) was not producing rated power.


I'm curious why excessive mag drops weren't detected on engine run-ups by the ground and air crews if that many spark plugs were in poor condition.
stevef is offline  
Old 1st Jul 2022, 23:26
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Obviously I can't speak for this specific situation but in our ops run-up testing was conducted at 1800RPM, with a max permissible mag drop of 100RPM.

Take-off RPM was 2700 (2200 after 1000'), with an engine max limit of 3050 for no more than 30sec. Manifold press is 48" at take off, I seem to recollect it was ~30" at run up.

Issues with plugs may not manifest themselves clearly at 1800RPM under light load. However if one engine fails and you firewall the remaining unit it will be requiring significantly more performance from the plugs than at run-up, therefore it's entirely possible that borderline faulty plugs could fall short to the extent of significantly reducing the max available power when you need it.

Although a DC-3 will fly on one engine it's not great. At MAUW with a good engine developing rated power climb rate at ISA+20C is just 14FPM with a windmilling prop on the failed engine. If you manage to get that useless prop feathered you might get a little under 200fpm, but add in a few other variables (including the remaining engine not producing rated power) and the only way is down :-(
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Old 2nd Jul 2022, 11:54
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Originally Posted by First_Principal View Post
Although a DC-3 will fly on one engine it's not great. At MAUW with a good engine developing rated power climb rate at ISA+20C is just 14FPM with a windmilling prop on the failed engine. If you manage to get that useless prop feathered you might get a little under 200fpm, but add in a few other variables (including the remaining engine not producing rated power) and the only way is down :-(
Looking at the accident report the aircraft was ~1250lbs overweight at the time of the engine failure. With that AUW it doesn't take much deterioration to end up with no positive climb rate at all. And at 81 kts the report states that already at 500lbs less than this no positive climb rate is to be expected anymore.unless everything is in optimum condition and all parameters being in optimum range. Together with the fact that the overweight situation was not known to the crew and thus wouldn't have been considered in the speeds the outcome seems pretty inevitable.
That said I do read more ciriticsism in the BASI report regarding operations of the whole outfit, of lack CAA oversight and of the operator and (check-/training) pilot for not thoroughly enough checking the credentials of the Co, the omission of a detailed weighing of freight and pax although being very close to MTOW and not taking over quickly enough from a Co with unclear asymmetry training state and who apparently applied visibly unsuitable correction technique (applying massive aileron). I do not see any condemnation of the PIC's flying itself. Rather the contrary.
How out of this report someone took such significant action against said Pilot in Command is somewhat of a mystery to me. I have seen lots and lots of much, much more condemning reports where the pilots haven't been grounded for good.
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