Cessna 172 Accident in Colorado in 2022
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To avoid any misconception my comment wasn't an attack on punkalouver, far from it, down here if someone said something similar in a group discussion and someone else pointed it out we'd all have a good laugh and no-one would think worse of anyone else.
Sadly that happened here; a good man who'd been doing aero's in his 'plane dislodged a 7/16" spanner that had been laying about the fuselage post maintenance,
I've had some control jams in my time, and the first thing you do is get the plane to a place in the sky where you have room, and lessened distraction to deal with it. Buzzing a boat, and flying into a canyon are not that! As I remarked, do what will sound best in the report you may have to write later, I've had to write a couple over the years, and the truth seemed decent on paper after the fact!
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Anyways, the pilot I was talking about was flying an aircraft, not a boat. He buzzed a boat that was on a river, a fairly large river actually. His parents were in the boat. He got a little too low and subsequently met up with his parents in the boat.
Sorry for the earlier errors. Fast typing.
As for the accident on this thread, I remember starting a thread in a different accident forum titled..."Are The Pilots Lying To The Investigators" after reading several incidents in a row in the U.S. where it was obvious that the pilots reports were inaccurate and most likely intentionally inaccurate.
Sadly, the idea that if the pilot can be interviewed, the investigators are guaranteed to get an honest report is frequently not the case.
It is a long post so I will show it separately.
Last edited by punkalouver; 20th Mar 2023 at 04:36.
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Written a few years ago.
Are the Pilots Lying to the Investigators
Last week I read 6 accident reports. Five of them came to my attention from a magazine that I get monthly which provides a bit of info on recently released reports. Those five were quite small accident briefs by the NTSB. The sixth one was a well publicized foreign airline accident last year that had been sitting on my computer for a while.
Of the six, I was very surprised to get the distinct feeling that the pilots in 5 of the accidents were giving false statements to the investigators. The pilot of the sixth accident did not survive. Of course, I wasn’t “there” so it is just a feeling based on what the reports say, but you be the judge. To save space I will just post what I think is the critical info but a link to each report is provided.
The first one was a turbine powered Air Tractor down in Texas. According to the report…
http://www.ntsb.gov/_layouts/ntsb.aviat ... &pgsize=50
“The pilot reported that prior to departure the airplane was filled with fuel. After engine start, he taxied to runway 18, and conducted an engine run-up with no anomalies noted. The initial takeoff appeared normal; however, about half way down the runway, he noticed a "lack of airspeed" and the engine monitor was flashing "several red lights". About this time, the airplane became airborne. The pilot added that he was able to climb to about 150 feet, before he noticed an additional power loss. He kept adding throttle and even with full power selected, the airplane lost altitude.”
“The pilot added that the engine never developed full power, even after adding full throttle.”
“The engine examination did not reveal any pre-impact anomalies that would have precluded normal engine operation.”
“the Electronics International Inc., MVP-50T, engine monitor's installation, was completed on January 30, 2015.”
“The accident flight was the airplane's first flight after installation of the engine monitor. Review of the monitor's setup revealed the unit's clock was set to one hour earlier then local time, and the fuel flow calibration factor, was off by a factor of 10, meaning the monitor would indicate fuel flow ten times the actual fuel flow.”
“During the takeoff run, the propeller rpm reached 1,730 rpm at an engine torque of 1,304 ft-lbs. About 21 seconds after power was applied for the takeoff, the torque reached 1,492 ft-lbs, and was the maximum seen for the entire flight. The torque then dropped to about 1,200 ft-lbs and remained there for about 20 seconds before further reduction was noted. The propeller rpm remained at 1,730 rpm for about 32 seconds after maximum torque was reached, then dropped below 1,700 rpm, with a torque reading of 736 ft-lbs, The torque then dropped into the 500 ft-lbs range, before a slight increase was noted about 10 seconds before the crash; the rise was followed by a decrease in the torque.”
But wait a minute, the pilot told the investigators that he kept adding throttle but still lost altitude. Or was the truth that he kept reducing power to try to stop the engine warning indications while continually losing airspeed and not paying attention to flying resulting in a crash. All systems tested OK except the new engine monitor which was flashing due to a false warning. In the end the NTSB said......
“The National Transportation Safety Board determines the probable cause(s) of this accident as follows: Maintenance personnel’s improper installation of the engine data monitor (EDM), which was not in accordance with the supplemental type certificate instructions and resulted in engine warning indications and the pilot’s subsequent reaction to the warning indications due to his lack of experience with the EDM and airplane.”
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The second accident is a Cessna 550 Citation crash in Alaska after both engines flamed out after ice ingestion on an icing research flight. http://www.ntsb.gov/_layouts/ntsb.aviat ... 150&akey=1
“N77ND, sustained substantial damage during an off airport, gear-up emergency landing, following a complete and simultaneous loss of engine power in both engines, about 60 miles west of Fort Yukon, Alaska.”
“The inboard section of each wing is provided with anti-ice protection via electrically heated mats in the leading edge. The main wing sections are deiced by the activation of pneumatic leading edge boots. The engines are protected from ice accumulation by heated air inlets, and are operated by the same switch as the wing's inboard anti-ice.”
“On October 1, the IIC received a telephone call from a passenger who stated he was the onboard representative of the company that contracted the flight. The passenger said he was monitoring icing test equipment in the rear of the airplane during the accident flight. He further stated he took a series of photographs, which show both wing's leading edges prior to the loss of engine power. He forwarded the pictures to the IIC. The passenger said the captain announced that he was going to activate the wing's deice boots, and he took the series of pictures prior to and after the deice boot activation. The pictures taken prior to the boot activation show an accumulation of about 1 inch of ice on both the deiced and anti-iced, inboard portion of the wing. The pictures taken after the boot activation show the ice removed from the deiced (booted) section of the wing, but the ice remained on the anti-iced, inboard portion of the wing. The scientist said a few minutes after the boot activation, he heard a loud bang, and both engines lost power.”
“During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on October 4, the captain said while in instrument meteorological conditions (IMC), the airplane accumulated about seven-eights inch of ice on the wing leading edge surfaces. He stated he cycled the deice boots to remove the ice accumulation, and several minutes later he heard a loud "bang" at the rear of the airplane, and both engines lost power. He said he initiated an emergency descent, and attempted to restart the engines without success.”
“Procedures for flight into icing conditions for the accident airplane are contained in the FAA approved Airplane Flight Manual, Section III, Operating Procedures. The icing section states: "All anti-ice systems should be turned on when operating in visible moisture, and the indicated air temperature is +10 degrees C or below," and further warns that "failure to switch on the system before ice accumulation has begun may result in engine damage due to ice ingestion." During a previous telephone conversation with the IIC, a representative of the manufacturer stated that if the anti-ice equipment was inadvertently left off, and subsequently turned on after entering icing conditions, it would take 2-4 minutes before the anti-iced surfaces (in-board wing leading edges, and engine inlets) would heat up enough to shed the already accumulated ice.”
“During a telephone conference, which included the director of aviation safety for the operator, the captain, and the IIC on October 17, the captain stated that he operated the anti-ice equipment in accordance with the airplane's flight manual, and never intentionally flew the airplane in icing conditions with the icing equipment turned off. The pilot said he was familiar with the photographs of the airplane parked on the ramp with ice buildup on the anti-ice surfaces, but said he did not report a malfunction of the anti-ice system. He said during the next preflight inspection, there was no indication of an anti-icing or deicing system malfunction. He further stated that prior to the loss of engine power during the accident flight, there were no indications of any anti-icing or deicing system malfunction. The pilot reiterated the general procedure for the operation of the anti-ice/deice systems of the airplane pursuant to the Airplane Flight Manual, but could not definitively say he turned the anti-ice on prior to entering icing conditions or prior to the loss of engine power.”
“The co-pilot did say that during icing missions he and the captain talked a lot about the subject of airframe icing. He further stated that during the accident flight he did not operate the icing protection controls. He also said he remembered the captain announced that he was going to cycle the deice boots. He said a few minutes after the captain cycled the boots, both engines lost power. In a written statement to the NTSB dated October 10, 2005, the co-pilot wrote that during the accident flight while in clouds, the captain said he was going to turn off the anti-ice. The co-pilot reported that as the anti-ice system was turned off, the captain was looking over his shoulder at a computer screen that displayed atmospheric instrumentation data, and the captain remarked that they were not in icing conditions. He wrote that this procedure of referring to the instrument data was different from his usual procedure of turning the engine anti-ice on when in cloud, and turning if off when out of cloud.”
“The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's improper use of anti-icing equipment during cruise flight, which resulted in ice ingestion into both engines (foreign object damage), the complete loss of engine power in both engines, and an emergency descent and landing on tree covered terrain. Factors associated with the accident were the icing conditions, inadequate crew resource management, and failure to use a checklist.”
So the captain told the investigators that he operated the anti-ice in accordance with the AFM. The NTSB doesn’t seem to agree. Looks like he took off with some ice already on the wings and then accumulated more ice. Then he operated the de/anti-icing equipment improperly and flamed out both engines. Kinda looks like he doesn't want to incriminate himself with the FAA.
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The third report is an incident involving a GIV that did a high speed RTO leading to a wheel fire.
http://www.ntsb.gov/_layouts/ntsb.aviat ... 139&akey=1
“The pilot reported that before taxing the airplane a flight control check was performed. He noted that the flight control check was "normal," with "no binding or resistance issues." He added that the flight control forces seemed "normally loaded."
"During the initial takeoff attempt, the pilot engaged the auto-throttles. He stated that about 75 knots, a triple chime sounded and a master warning illuminated. He immediately rejected the takeoff with "light" brake pressure and coasted to the end of the runway. The flight crew reported that they did not observe any message on the Crew Alert System (CAS), nor were there any exceedance events recorded. In addition, they did not observe any tripped circuit breakers. Based on this information, the pilot elected to attempt another takeoff. During this takeoff, he did not use the auto-throttles, electing to set the engine power manually. He reported that as the airplane accelerated through approximately 75 knots, the triple chime/master warning activated again. He observed that the engine low pressure (LP) turbine speed indicated within the yellow arc. He subsequently reduced engine thrust slightly in order to return the LP turbine speed to the white arc (normal operating range). The pilot continued the takeoff. At rotation speed, he pulled back on the control yoke but the flight controls did not seem to respond normally. He added that the controls had no "noticeable pressure resistance and felt unloaded with hydraulic pressure." He noted that the yoke was moved "forward and then back further aft" with the same result. The pilot subsequently rejected the takeoff, applying maximum braking and full reverse thrust.”
“A postincident examination was conducted under the direct supervision of Federal Aviation Administration (FAA) Flight Standards inspectors. The examination was directed and monitored by an NTSB aircraft systems engineering specialist.”
“An inspection of the flight control system was conducted without any electrical or hydraulic power supplied to the airplane. Movement of the cockpit control column and control yoke was smooth throughout the required range of motion (stop-to-stop). Movement of the flight control surfaces corresponded to the inputs from the cockpit controls. With the elevator rig pins installed, the control cable tensions measured 113 lbs. and 160 lbs. at the inboard and outboard cables, respectively. The required minimum cable tension was 135 lbs. [Aircraft Maintenance Manual (AMM) 27-01-00]. The rig pins were subsequently removed in order to allow the system to balance. With the rig pins removed, the control cable tensions measured 129 lbs. and 140 lbs., respectively. The elevator trim cable tensions measured 40 lbs., which was within the specifications (AMM 27-04-00).
An operational test of the gust lock was completed without any anomalies or adverse findings (AMM 27-05-00). A general examination of the elevator gust lock hook was unremarkable. Inspection of the elevator input bungee, input bungee attachment bolt, elevator actuator load relief bungee assembly, and elevator actuator damper shaft (AMM 27-01-00) revealed no anomalies. Indexing of the horizontal stabilizer corresponded correctly at all flap settings in accordance with the Wing Flap/Stabilizer Operational Test (AMM 27-06-01). Operational testing of the stall barrier/angle of attack system and the stall barrier dump valve (AMM 27-01-01) did not reveal any anomalies. The FPSOV operated normally in accordance with the Flight Control Manual Shut-off Valve – Operational Test (AMM 27-08-00).”
“On March 3, 2015, an evaluation flight was completed by Gulfstream Aerospace Corporation Production Test Pilots. The evaluation flight was conducted without any adjustments to the flight control system following the rejected takeoff event. A maintenance preflight inspection and ground engine run-up were performed the day before the flight. During the engine run-up, at a takeoff engine pressure ratio (EPR) of 1.75, the left engine low pressure (LP) turbine speed approach the exceedance limit of 95.5-percent, which would intermittently trigger a master warning. The flight crew elected to complete the takeoff with a slightly reduced EPR of 1.73 in order to avoid the possibility of a nuisance warning message on takeoff. The flight control check conducted before takeoff was normal. Airplane flight manual procedures specify an elevator control check at 60 knots during the takeoff roll. Specifically, the airplane flight manual included a note with the Line Up checklist stating, "At sixty (60) knots, the pilot shall confirm that the elevators are free and the yoke has reached the neutral position." Due to the flight control issues reported as part of the incident, the evaluation flight crew elected to conduct an additional control check at 80 knots. During the takeoff roll, at both 60 and 80 knots, the elevator response was "positive, obvious, and 100% normal." The takeoff continued normally and the flight crew completed a left-hand traffic pattern to return for a full stop landing. The pilot subsequently executed a landing without any anomalies; the brakes and thrust reversers functioned normally during the rollout. No anomalies were identified during the evaluation test flight. The airplane was subsequently released to the owner/operator for return to service.”
“The National Transportation Safety Board determines the probable cause(s) of this incident as follows:
• The pilot's rejected takeoff due to perceived flight control system anomalies, which led to excessive brake temperatures and resulted in a right main landing gear brake fire.”
The pilot rejected the first takeoff due to the triple chime of unknown origin. And decided to try another takeoff. Why did the PIC perform the second RTO which was after Vr. Was it due to a flight control anomaly as the pilot told the investigators or was it perhaps due to that nuisance engine warning(in which case you should continue if at high speed). Only a flight control anomaly might justify a high-speed RTO above V1. Yet there was no flight control anomaly on the subsequent test flight and there had been no adjustment to the flight controls. Was a flight control anomaly story made up to justify an second RTO at high speed instead of admitting it was done due to a previously known issue?
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The fourth flight was a Gulfstream 200 bizjet landing on a 5300 foot runway in New York state that overran the runway. There was an FAA inspector on board.
http://www.ntsb.gov/_layouts/ntsb.aviat ... 294&akey=1
“The 1415 recorded weather observation at JHW, included calm wind, 10 miles visibility, clear skies, temperature 23 degrees C, dew point 09 degrees C; barometric altimeter 30.25 inches of mercury.”
“The pilot flying stated that during the incident flight, the airplane landed within the touchdown zone of runway 25, about 1,000 feet past the threshold, following a "normal stabilized approach." After touchdown, the pilot flying deployed the engine thrust reversers and applied steady brake pressure; however, the "braking/stopping ability was nil."
“The FAA inspector seated in the cockpit jumpseat reported in a written statement, "the touchdown was normal and within the 1000 foot markers, the PIC [pilot in command] activated the thrust reversers, but no power increase was noted. The braking action or deceleration was noted as 'smooth.' The second-in-command [SIC] was calling out the airspeeds and runway remaining and was noted to be alarmed by the last 2000 foot markers, it was also noted that the SIC, attempted to stand on the brakes just prior to the end of the runway. The PIC was noted as alarmed and applying maximum braking pressure and attempted to steer the aircraft to the right towards the taxiway at the end of the runway, but then straighten the aircraft out just prior to the end of the runway."
“According to the recording, the airplane touched down at 1410:00 and 3 seconds later the thrust reversers were first deployed at a Throttle Lever Angle (TLA) of 16 degrees, which corresponded to a thrust reverser idle power lever selection. Then 20 seconds after touchdown, a TLA of 20 degrees was recorded, which corresponded to maximum thrust reverser power lever selection. 24 seconds after touchdown, the N1 (engine fan speed) increased to the maximum recorded value of 55 percent. Finally, 32 seconds after touchdown, N1 began to decrease, an indication consistent with the thrust reversers being stowed."
“1409:33 the pilot monitoring stated "before landing checklist complete and you're ref plus ten"
1409:37 the PIC stated "correcting"
1409:44 the pilot monitoring stated "runway's clear ref plus fifteen don't let it increase it's a short runway"
1409:47 the PIC stated "ahh great correcting"
1409:49 the EGPWS alerted "one hundred"
1409:51 the EGPWS alerted "fifty"
1409:52 the EGPWS alerted "thirty"
1409:53 the EGPWS alerted "twenty"
1409:55 the EGPWS alerted "ten"
1410:00 the airplane touched down on runway 25 at JHW
1410:00 the PIC stated "your tops"
1410:01 the pilot monitoring stated "my tops"
1410:02 the pilot monitoring stated "one twenty"
1410:04 the pilot monitoring stated "one fifteen two thousand remaining"
1410:06 the pilot monitoring stated "more brakes"
1410:08 the pilot monitoring stated "one hundred"
1410:09 the pilot monitoring stated "a little to the right"
1410:10 the pilot monitoring stated "ninety knots one thousand remaining"
“There was no indication that the crew utilized the emergency braking system. In addition, the FAA inspector on the jumpseat reported debriefing the flight crew on the emergency brake system and that it "was not used by the flight crew."
“The National Transportation Safety Board determines the probable cause(s) of this incident as follows:
• The pilots’ failure to effectively use the airplane's primary (brakes), secondary (thrust reversers), and emergency braking systems to decelerate the airplane, which resulted in a runway excursion. Contributing to the accident was the pilots’ failure to conduct a go-around maneuver upon recognizing that the airplane had excessive airspeed while on final approach to the runway.”
But the PIC said the approach was stable(which includes proper airspeed control) and that braking/stopping ability was nil(on a bare, dry runway). Really? The CVR shows that he was fast on approach according to the FO. Both the PIC and the FAA inspector claimed a touchdown at 1000 feet. Well, they touched down at 1410:00 supposedly 1000 feet down the runway. Four seconds later, the FO said "one fifteen, two thousand remaining". That means they travelled 2300' in 4 seconds which require an average ground speed of 340 knots. Not too likely. It is more likely that they landed much further down the runway than 1000 feet(it was 5 seconds from the 10 foot autocall to touchdown) which is why it only took 4 seconds to have two thousand feet remaining. As well, it took three seconds before for initiation of reverse thrust, with only idle reverse selected and then, 20 seconds after touchdown, max reverse was selected. It appears that braking was not utilized as well as it could have been as the FO asked for more brakes to be used.
The claim was made by the PIC that the bare dry runway had no braking/stopping ability on this nice sunny day but it looks more like someone trying to minimize wear and tear on the aircraft by minimizing brake use and minimizing reverse thrust. That may be a good idea sometimes but not on a short runway after an unstable(fast) approach.
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The last accident was a Turkish Airlines A330 in Khatmandu. After the first missed approach due to fog, another approach was initiated. The F/A had told the captain about the difficulties that would be encountered if they diverted. The aircraft flew an autopilot coupled RNP approach. Unknown to the crew, the runway waypoint coordinates were in error and located slightly to the left of the runway but the coordinates for the approach were accurate. The autopilot was disconnected at a low altitude of 14 feet and the aircraft touched down partially off the runway resulting in a nosegear collapse and significant other damage. A video of the landing can be seen at this link starting around 1:45.
http://www.tourism.gov.np/uploaded/TURK ... alcopy.pdf
“During the interview after the accident for post flight incident report the pilots stated that they were visual with the approach lights of the runway at the Decision Altitude and continued the approach below the DA. According to the PF, during the final approach he momentarily lost visual contact with the runway but before he initiated a missed approach the runway became visual again and he decided to land.”
“The CCTV footage showed that at 01:58 hrs when the aircraft was approaching and landing during second approach, the visibility was almost zero. This visibility was much worse than the visibility when the aircraft was executing go-around at 01:22 hrs during first approach. “
“Four seconds before the “MINIMUMS” auto-callout, the PM stated “it will appear when we descend below…””
“When the “MINIMUM” auto-call out was annunciated at 01:58:30 hrs the PF responded “continue until 300 ft””
“Had he established visual contact with approach lights at decision altitude, the response to the “MINIMUM” auto-call out would have been “visual and continue” in accordance with SOP.”
"Approximately 5 seconds before touchdown the PF states “appearing” which was the first mention of the runway being visual."
“The aircraft descent below the DA, towards the amended runway threshold coordinates, the approach lights and the runway would have been offset to the right of the aircraft nose. Had the flight crew been visual with the runway they should have noticed this offset.”
“The auto-pilots remained coupled to the aircraft until 14 ft AGL, when it was disconnected, a flare was attempted. The maximum vertical acceleration recorded on the flight data recorder was approximately 2.7 G. The aircraft pitch at touchdown was 1.8 degree nose up up which is lower than a normal flare attitude for other landings”
“Causal Factor
The probable cause of this accident is the decision of the flight crew to continue approach and landing below the minima with inadequate visual reference and not to perform a missed approach in accordance to the published approach procedure.”
So are the pilots telling the truth to the investigators. Did they really have the required visual references at the DA? Maybe, but not too likely. Now you know why it is good to have CVR's and FDR's. Even if the pilots survive, it appears that more is needed to discover the truth sometimes.
Am I right to be suspicious in all these accidents or am I way out of line. Something for the accident investigators to think about.
Are the Pilots Lying to the Investigators
Last week I read 6 accident reports. Five of them came to my attention from a magazine that I get monthly which provides a bit of info on recently released reports. Those five were quite small accident briefs by the NTSB. The sixth one was a well publicized foreign airline accident last year that had been sitting on my computer for a while.
Of the six, I was very surprised to get the distinct feeling that the pilots in 5 of the accidents were giving false statements to the investigators. The pilot of the sixth accident did not survive. Of course, I wasn’t “there” so it is just a feeling based on what the reports say, but you be the judge. To save space I will just post what I think is the critical info but a link to each report is provided.
The first one was a turbine powered Air Tractor down in Texas. According to the report…
http://www.ntsb.gov/_layouts/ntsb.aviat ... &pgsize=50
“The pilot reported that prior to departure the airplane was filled with fuel. After engine start, he taxied to runway 18, and conducted an engine run-up with no anomalies noted. The initial takeoff appeared normal; however, about half way down the runway, he noticed a "lack of airspeed" and the engine monitor was flashing "several red lights". About this time, the airplane became airborne. The pilot added that he was able to climb to about 150 feet, before he noticed an additional power loss. He kept adding throttle and even with full power selected, the airplane lost altitude.”
“The pilot added that the engine never developed full power, even after adding full throttle.”
“The engine examination did not reveal any pre-impact anomalies that would have precluded normal engine operation.”
“the Electronics International Inc., MVP-50T, engine monitor's installation, was completed on January 30, 2015.”
“The accident flight was the airplane's first flight after installation of the engine monitor. Review of the monitor's setup revealed the unit's clock was set to one hour earlier then local time, and the fuel flow calibration factor, was off by a factor of 10, meaning the monitor would indicate fuel flow ten times the actual fuel flow.”
“During the takeoff run, the propeller rpm reached 1,730 rpm at an engine torque of 1,304 ft-lbs. About 21 seconds after power was applied for the takeoff, the torque reached 1,492 ft-lbs, and was the maximum seen for the entire flight. The torque then dropped to about 1,200 ft-lbs and remained there for about 20 seconds before further reduction was noted. The propeller rpm remained at 1,730 rpm for about 32 seconds after maximum torque was reached, then dropped below 1,700 rpm, with a torque reading of 736 ft-lbs, The torque then dropped into the 500 ft-lbs range, before a slight increase was noted about 10 seconds before the crash; the rise was followed by a decrease in the torque.”
But wait a minute, the pilot told the investigators that he kept adding throttle but still lost altitude. Or was the truth that he kept reducing power to try to stop the engine warning indications while continually losing airspeed and not paying attention to flying resulting in a crash. All systems tested OK except the new engine monitor which was flashing due to a false warning. In the end the NTSB said......
“The National Transportation Safety Board determines the probable cause(s) of this accident as follows: Maintenance personnel’s improper installation of the engine data monitor (EDM), which was not in accordance with the supplemental type certificate instructions and resulted in engine warning indications and the pilot’s subsequent reaction to the warning indications due to his lack of experience with the EDM and airplane.”
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The second accident is a Cessna 550 Citation crash in Alaska after both engines flamed out after ice ingestion on an icing research flight. http://www.ntsb.gov/_layouts/ntsb.aviat ... 150&akey=1
“N77ND, sustained substantial damage during an off airport, gear-up emergency landing, following a complete and simultaneous loss of engine power in both engines, about 60 miles west of Fort Yukon, Alaska.”
“The inboard section of each wing is provided with anti-ice protection via electrically heated mats in the leading edge. The main wing sections are deiced by the activation of pneumatic leading edge boots. The engines are protected from ice accumulation by heated air inlets, and are operated by the same switch as the wing's inboard anti-ice.”
“On October 1, the IIC received a telephone call from a passenger who stated he was the onboard representative of the company that contracted the flight. The passenger said he was monitoring icing test equipment in the rear of the airplane during the accident flight. He further stated he took a series of photographs, which show both wing's leading edges prior to the loss of engine power. He forwarded the pictures to the IIC. The passenger said the captain announced that he was going to activate the wing's deice boots, and he took the series of pictures prior to and after the deice boot activation. The pictures taken prior to the boot activation show an accumulation of about 1 inch of ice on both the deiced and anti-iced, inboard portion of the wing. The pictures taken after the boot activation show the ice removed from the deiced (booted) section of the wing, but the ice remained on the anti-iced, inboard portion of the wing. The scientist said a few minutes after the boot activation, he heard a loud bang, and both engines lost power.”
“During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on October 4, the captain said while in instrument meteorological conditions (IMC), the airplane accumulated about seven-eights inch of ice on the wing leading edge surfaces. He stated he cycled the deice boots to remove the ice accumulation, and several minutes later he heard a loud "bang" at the rear of the airplane, and both engines lost power. He said he initiated an emergency descent, and attempted to restart the engines without success.”
“Procedures for flight into icing conditions for the accident airplane are contained in the FAA approved Airplane Flight Manual, Section III, Operating Procedures. The icing section states: "All anti-ice systems should be turned on when operating in visible moisture, and the indicated air temperature is +10 degrees C or below," and further warns that "failure to switch on the system before ice accumulation has begun may result in engine damage due to ice ingestion." During a previous telephone conversation with the IIC, a representative of the manufacturer stated that if the anti-ice equipment was inadvertently left off, and subsequently turned on after entering icing conditions, it would take 2-4 minutes before the anti-iced surfaces (in-board wing leading edges, and engine inlets) would heat up enough to shed the already accumulated ice.”
“During a telephone conference, which included the director of aviation safety for the operator, the captain, and the IIC on October 17, the captain stated that he operated the anti-ice equipment in accordance with the airplane's flight manual, and never intentionally flew the airplane in icing conditions with the icing equipment turned off. The pilot said he was familiar with the photographs of the airplane parked on the ramp with ice buildup on the anti-ice surfaces, but said he did not report a malfunction of the anti-ice system. He said during the next preflight inspection, there was no indication of an anti-icing or deicing system malfunction. He further stated that prior to the loss of engine power during the accident flight, there were no indications of any anti-icing or deicing system malfunction. The pilot reiterated the general procedure for the operation of the anti-ice/deice systems of the airplane pursuant to the Airplane Flight Manual, but could not definitively say he turned the anti-ice on prior to entering icing conditions or prior to the loss of engine power.”
“The co-pilot did say that during icing missions he and the captain talked a lot about the subject of airframe icing. He further stated that during the accident flight he did not operate the icing protection controls. He also said he remembered the captain announced that he was going to cycle the deice boots. He said a few minutes after the captain cycled the boots, both engines lost power. In a written statement to the NTSB dated October 10, 2005, the co-pilot wrote that during the accident flight while in clouds, the captain said he was going to turn off the anti-ice. The co-pilot reported that as the anti-ice system was turned off, the captain was looking over his shoulder at a computer screen that displayed atmospheric instrumentation data, and the captain remarked that they were not in icing conditions. He wrote that this procedure of referring to the instrument data was different from his usual procedure of turning the engine anti-ice on when in cloud, and turning if off when out of cloud.”
“The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot's improper use of anti-icing equipment during cruise flight, which resulted in ice ingestion into both engines (foreign object damage), the complete loss of engine power in both engines, and an emergency descent and landing on tree covered terrain. Factors associated with the accident were the icing conditions, inadequate crew resource management, and failure to use a checklist.”
So the captain told the investigators that he operated the anti-ice in accordance with the AFM. The NTSB doesn’t seem to agree. Looks like he took off with some ice already on the wings and then accumulated more ice. Then he operated the de/anti-icing equipment improperly and flamed out both engines. Kinda looks like he doesn't want to incriminate himself with the FAA.
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The third report is an incident involving a GIV that did a high speed RTO leading to a wheel fire.
http://www.ntsb.gov/_layouts/ntsb.aviat ... 139&akey=1
“The pilot reported that before taxing the airplane a flight control check was performed. He noted that the flight control check was "normal," with "no binding or resistance issues." He added that the flight control forces seemed "normally loaded."
"During the initial takeoff attempt, the pilot engaged the auto-throttles. He stated that about 75 knots, a triple chime sounded and a master warning illuminated. He immediately rejected the takeoff with "light" brake pressure and coasted to the end of the runway. The flight crew reported that they did not observe any message on the Crew Alert System (CAS), nor were there any exceedance events recorded. In addition, they did not observe any tripped circuit breakers. Based on this information, the pilot elected to attempt another takeoff. During this takeoff, he did not use the auto-throttles, electing to set the engine power manually. He reported that as the airplane accelerated through approximately 75 knots, the triple chime/master warning activated again. He observed that the engine low pressure (LP) turbine speed indicated within the yellow arc. He subsequently reduced engine thrust slightly in order to return the LP turbine speed to the white arc (normal operating range). The pilot continued the takeoff. At rotation speed, he pulled back on the control yoke but the flight controls did not seem to respond normally. He added that the controls had no "noticeable pressure resistance and felt unloaded with hydraulic pressure." He noted that the yoke was moved "forward and then back further aft" with the same result. The pilot subsequently rejected the takeoff, applying maximum braking and full reverse thrust.”
“A postincident examination was conducted under the direct supervision of Federal Aviation Administration (FAA) Flight Standards inspectors. The examination was directed and monitored by an NTSB aircraft systems engineering specialist.”
“An inspection of the flight control system was conducted without any electrical or hydraulic power supplied to the airplane. Movement of the cockpit control column and control yoke was smooth throughout the required range of motion (stop-to-stop). Movement of the flight control surfaces corresponded to the inputs from the cockpit controls. With the elevator rig pins installed, the control cable tensions measured 113 lbs. and 160 lbs. at the inboard and outboard cables, respectively. The required minimum cable tension was 135 lbs. [Aircraft Maintenance Manual (AMM) 27-01-00]. The rig pins were subsequently removed in order to allow the system to balance. With the rig pins removed, the control cable tensions measured 129 lbs. and 140 lbs., respectively. The elevator trim cable tensions measured 40 lbs., which was within the specifications (AMM 27-04-00).
An operational test of the gust lock was completed without any anomalies or adverse findings (AMM 27-05-00). A general examination of the elevator gust lock hook was unremarkable. Inspection of the elevator input bungee, input bungee attachment bolt, elevator actuator load relief bungee assembly, and elevator actuator damper shaft (AMM 27-01-00) revealed no anomalies. Indexing of the horizontal stabilizer corresponded correctly at all flap settings in accordance with the Wing Flap/Stabilizer Operational Test (AMM 27-06-01). Operational testing of the stall barrier/angle of attack system and the stall barrier dump valve (AMM 27-01-01) did not reveal any anomalies. The FPSOV operated normally in accordance with the Flight Control Manual Shut-off Valve – Operational Test (AMM 27-08-00).”
“On March 3, 2015, an evaluation flight was completed by Gulfstream Aerospace Corporation Production Test Pilots. The evaluation flight was conducted without any adjustments to the flight control system following the rejected takeoff event. A maintenance preflight inspection and ground engine run-up were performed the day before the flight. During the engine run-up, at a takeoff engine pressure ratio (EPR) of 1.75, the left engine low pressure (LP) turbine speed approach the exceedance limit of 95.5-percent, which would intermittently trigger a master warning. The flight crew elected to complete the takeoff with a slightly reduced EPR of 1.73 in order to avoid the possibility of a nuisance warning message on takeoff. The flight control check conducted before takeoff was normal. Airplane flight manual procedures specify an elevator control check at 60 knots during the takeoff roll. Specifically, the airplane flight manual included a note with the Line Up checklist stating, "At sixty (60) knots, the pilot shall confirm that the elevators are free and the yoke has reached the neutral position." Due to the flight control issues reported as part of the incident, the evaluation flight crew elected to conduct an additional control check at 80 knots. During the takeoff roll, at both 60 and 80 knots, the elevator response was "positive, obvious, and 100% normal." The takeoff continued normally and the flight crew completed a left-hand traffic pattern to return for a full stop landing. The pilot subsequently executed a landing without any anomalies; the brakes and thrust reversers functioned normally during the rollout. No anomalies were identified during the evaluation test flight. The airplane was subsequently released to the owner/operator for return to service.”
“The National Transportation Safety Board determines the probable cause(s) of this incident as follows:
• The pilot's rejected takeoff due to perceived flight control system anomalies, which led to excessive brake temperatures and resulted in a right main landing gear brake fire.”
The pilot rejected the first takeoff due to the triple chime of unknown origin. And decided to try another takeoff. Why did the PIC perform the second RTO which was after Vr. Was it due to a flight control anomaly as the pilot told the investigators or was it perhaps due to that nuisance engine warning(in which case you should continue if at high speed). Only a flight control anomaly might justify a high-speed RTO above V1. Yet there was no flight control anomaly on the subsequent test flight and there had been no adjustment to the flight controls. Was a flight control anomaly story made up to justify an second RTO at high speed instead of admitting it was done due to a previously known issue?
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The fourth flight was a Gulfstream 200 bizjet landing on a 5300 foot runway in New York state that overran the runway. There was an FAA inspector on board.
http://www.ntsb.gov/_layouts/ntsb.aviat ... 294&akey=1
“The 1415 recorded weather observation at JHW, included calm wind, 10 miles visibility, clear skies, temperature 23 degrees C, dew point 09 degrees C; barometric altimeter 30.25 inches of mercury.”
“The pilot flying stated that during the incident flight, the airplane landed within the touchdown zone of runway 25, about 1,000 feet past the threshold, following a "normal stabilized approach." After touchdown, the pilot flying deployed the engine thrust reversers and applied steady brake pressure; however, the "braking/stopping ability was nil."
“The FAA inspector seated in the cockpit jumpseat reported in a written statement, "the touchdown was normal and within the 1000 foot markers, the PIC [pilot in command] activated the thrust reversers, but no power increase was noted. The braking action or deceleration was noted as 'smooth.' The second-in-command [SIC] was calling out the airspeeds and runway remaining and was noted to be alarmed by the last 2000 foot markers, it was also noted that the SIC, attempted to stand on the brakes just prior to the end of the runway. The PIC was noted as alarmed and applying maximum braking pressure and attempted to steer the aircraft to the right towards the taxiway at the end of the runway, but then straighten the aircraft out just prior to the end of the runway."
“According to the recording, the airplane touched down at 1410:00 and 3 seconds later the thrust reversers were first deployed at a Throttle Lever Angle (TLA) of 16 degrees, which corresponded to a thrust reverser idle power lever selection. Then 20 seconds after touchdown, a TLA of 20 degrees was recorded, which corresponded to maximum thrust reverser power lever selection. 24 seconds after touchdown, the N1 (engine fan speed) increased to the maximum recorded value of 55 percent. Finally, 32 seconds after touchdown, N1 began to decrease, an indication consistent with the thrust reversers being stowed."
“1409:33 the pilot monitoring stated "before landing checklist complete and you're ref plus ten"
1409:37 the PIC stated "correcting"
1409:44 the pilot monitoring stated "runway's clear ref plus fifteen don't let it increase it's a short runway"
1409:47 the PIC stated "ahh great correcting"
1409:49 the EGPWS alerted "one hundred"
1409:51 the EGPWS alerted "fifty"
1409:52 the EGPWS alerted "thirty"
1409:53 the EGPWS alerted "twenty"
1409:55 the EGPWS alerted "ten"
1410:00 the airplane touched down on runway 25 at JHW
1410:00 the PIC stated "your tops"
1410:01 the pilot monitoring stated "my tops"
1410:02 the pilot monitoring stated "one twenty"
1410:04 the pilot monitoring stated "one fifteen two thousand remaining"
1410:06 the pilot monitoring stated "more brakes"
1410:08 the pilot monitoring stated "one hundred"
1410:09 the pilot monitoring stated "a little to the right"
1410:10 the pilot monitoring stated "ninety knots one thousand remaining"
“There was no indication that the crew utilized the emergency braking system. In addition, the FAA inspector on the jumpseat reported debriefing the flight crew on the emergency brake system and that it "was not used by the flight crew."
“The National Transportation Safety Board determines the probable cause(s) of this incident as follows:
• The pilots’ failure to effectively use the airplane's primary (brakes), secondary (thrust reversers), and emergency braking systems to decelerate the airplane, which resulted in a runway excursion. Contributing to the accident was the pilots’ failure to conduct a go-around maneuver upon recognizing that the airplane had excessive airspeed while on final approach to the runway.”
But the PIC said the approach was stable(which includes proper airspeed control) and that braking/stopping ability was nil(on a bare, dry runway). Really? The CVR shows that he was fast on approach according to the FO. Both the PIC and the FAA inspector claimed a touchdown at 1000 feet. Well, they touched down at 1410:00 supposedly 1000 feet down the runway. Four seconds later, the FO said "one fifteen, two thousand remaining". That means they travelled 2300' in 4 seconds which require an average ground speed of 340 knots. Not too likely. It is more likely that they landed much further down the runway than 1000 feet(it was 5 seconds from the 10 foot autocall to touchdown) which is why it only took 4 seconds to have two thousand feet remaining. As well, it took three seconds before for initiation of reverse thrust, with only idle reverse selected and then, 20 seconds after touchdown, max reverse was selected. It appears that braking was not utilized as well as it could have been as the FO asked for more brakes to be used.
The claim was made by the PIC that the bare dry runway had no braking/stopping ability on this nice sunny day but it looks more like someone trying to minimize wear and tear on the aircraft by minimizing brake use and minimizing reverse thrust. That may be a good idea sometimes but not on a short runway after an unstable(fast) approach.
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The last accident was a Turkish Airlines A330 in Khatmandu. After the first missed approach due to fog, another approach was initiated. The F/A had told the captain about the difficulties that would be encountered if they diverted. The aircraft flew an autopilot coupled RNP approach. Unknown to the crew, the runway waypoint coordinates were in error and located slightly to the left of the runway but the coordinates for the approach were accurate. The autopilot was disconnected at a low altitude of 14 feet and the aircraft touched down partially off the runway resulting in a nosegear collapse and significant other damage. A video of the landing can be seen at this link starting around 1:45.
“During the interview after the accident for post flight incident report the pilots stated that they were visual with the approach lights of the runway at the Decision Altitude and continued the approach below the DA. According to the PF, during the final approach he momentarily lost visual contact with the runway but before he initiated a missed approach the runway became visual again and he decided to land.”
“The CCTV footage showed that at 01:58 hrs when the aircraft was approaching and landing during second approach, the visibility was almost zero. This visibility was much worse than the visibility when the aircraft was executing go-around at 01:22 hrs during first approach. “
“Four seconds before the “MINIMUMS” auto-callout, the PM stated “it will appear when we descend below…””
“When the “MINIMUM” auto-call out was annunciated at 01:58:30 hrs the PF responded “continue until 300 ft””
“Had he established visual contact with approach lights at decision altitude, the response to the “MINIMUM” auto-call out would have been “visual and continue” in accordance with SOP.”
"Approximately 5 seconds before touchdown the PF states “appearing” which was the first mention of the runway being visual."
“The aircraft descent below the DA, towards the amended runway threshold coordinates, the approach lights and the runway would have been offset to the right of the aircraft nose. Had the flight crew been visual with the runway they should have noticed this offset.”
“The auto-pilots remained coupled to the aircraft until 14 ft AGL, when it was disconnected, a flare was attempted. The maximum vertical acceleration recorded on the flight data recorder was approximately 2.7 G. The aircraft pitch at touchdown was 1.8 degree nose up up which is lower than a normal flare attitude for other landings”
“Causal Factor
The probable cause of this accident is the decision of the flight crew to continue approach and landing below the minima with inadequate visual reference and not to perform a missed approach in accordance to the published approach procedure.”
So are the pilots telling the truth to the investigators. Did they really have the required visual references at the DA? Maybe, but not too likely. Now you know why it is good to have CVR's and FDR's. Even if the pilots survive, it appears that more is needed to discover the truth sometimes.
Am I right to be suspicious in all these accidents or am I way out of line. Something for the accident investigators to think about.
Last edited by punkalouver; 20th Mar 2023 at 04:54.
