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-   -   DA40 crash Cranfield (https://www.pprune.org/accidents-close-calls/637381-da40-crash-cranfield.html)

treadigraph 21st Jul 2022 14:47

Here's the report...

https://assets.publishing.service.go...CTSB_08-22.pdf

Fostex 21st Jul 2022 16:08

Reading the report and seeing the tank of de-icer in the RHS foot well I was lost for words.

What sort of idiot does that?!

Hadley Rille 21st Jul 2022 16:36

As an aside it's odd that the AAIB think an aircraft has a "combing"

First_Principal 21st Jul 2022 22:02


Originally Posted by Fostex (Post 11265398)
Reading the report and seeing the tank of de-icer in the RHS foot well I was lost for words.

What sort of idiot does that?!

Such reports are intended to investigate the cause of accidents and incidents, and report on those dispassionately so that others may learn from them. They are not intended to lay blame nor prosecute a person, the quid pro quo being the full and frank disclosure from those involved - which may well reveal important facts that could otherwise remain undiscovered (thus possibly leading to others, unnecessarily, following the same path).

The pilot involved in this accident appears to have been a young person who did a whole lot of things right, who has learnt and operated within the company culture, but in trying to be helpful at the request of a senior person has implemented and experienced something that could have been avoided. Given what I read in the report I've every reason to think that all those involved will have learnt from this, and from their misfortune we are all reminded of something that may assist us the next time we think about loading some item into our 'plane, or car, or whatever.

Most certainly I don't consider this well qualified (albeit not highly experienced) young man to be an 'idiot', and I suggest to you that such a comment is particularly unhelpful as far as future disclosure is concerned, and nor is it justified from what I read.

First_Principal 21st Jul 2022 22:05


Originally Posted by Hadley Rille (Post 11265414)
As an aside it's odd that the AAIB think an aircraft has a "combing"

While I'd expect to see this word (and spelling) used more commonly in conjunction with maritime vessels it's not incorrect per se.

Fostex 21st Jul 2022 23:12

Basic common sense.

Never, ever would I place an item of luggage in the unoccupied footwell of an aircraft cockpit. To do so displays a staggering lack of judgement and inability to risk assess the hazards of loose luggage inside a cockpit.


punkalouver 22nd Jul 2022 06:58


Originally Posted by First_Principal (Post 11265560)
Such reports are intended to investigate the cause of accidents and incidents, and report on those dispassionately so that others may learn from them. They are not intended to lay blame nor prosecute a person, the quid pro quo being the full and frank disclosure from those involved - which may well reveal important facts that could otherwise remain undiscovered (thus possibly leading to others, unnecessarily, following the same path).

The pilot involved in this accident appears to have been a young person who did a whole lot of things right, who has learnt and operated within the company culture, but in trying to be helpful at the request of a senior person has implemented and experienced something that could have been avoided. Given what I read in the report I've every reason to think that all those involved will have learnt from this, and from their misfortune we are all reminded of something that may assist us the next time we think about loading some item into our 'plane, or car, or whatever.

Most certainly I don't consider this well qualified (albeit not highly experienced) young man to be an 'idiot', and I suggest to you that such a comment is particularly unhelpful as far as future disclosure is concerned, and nor is it justified from what I read.

The term idiot is not appropriate but would incompetent be appropriate?

The storage of the container near the control stick and subsequent jamming reminds me of a different type of situation I encountered last year that I thought I might share.

It involved a taildragger with tandem seating. It has limited space in the baggage compartment which was pretty much full. So I thought that I would strap some stuff in the aft seat using the lap belt and shoulder harness to keep it secure. The forward edge of the item was aft of the front edge of the seat. Which seemed safe.

Fortunately, I decided to move the control stick fully aft and discovered that it was being blocked by the item in the seat. The control stick is not straight but has a significant curve in it halfway up allowing the upper portion to overhang the seat when moved from neutral toward fully aft.

glush 22nd Jul 2022 07:46

A quote from the AAIB report… "Aspects of the approved training organisation’s operational management appear to have influenced behaviour in the organisation, contributing to the circumstances of the accident."

Notwithstanding the actions of the pilot, the culture is driven from the top. The management and operational aspects do not reflect well on L3 Harris. What a disgrace for a UK ATO to be referenced in this way… Additionally, CAA Level 2 findings that took months to address? Who on earth in their right would want to train with L3 Harris at Cranfield?

olster 22nd Jul 2022 12:32

My own dealings with L3 corroborates a spectacular level of incompetence @ middle management level not least the lack of experience, common sense and empathy usually required for these roles. Political in fighting, childish and personal vendettas, toxic atmospheres etc.The incompetence only matched by misplaced egos cashing cheques with no money in the bank. Training aspirant airline pilots would or should be an ideal, home every night job for pilots with previous airline experience with role model reference. However the few that have actually flown airliners previously are viewed by the aforementioned middle management instructors with a weird form of resentment and jealousy. A good question has been asked as to the regulatory oversight and of course that resonates with the popularly held belief in the big boy airline pilot world of the general uselessness of the U.K. CAA. I am very pleased that this young instructor made it out of the wreckage to fly another day. However, the Swiss cheese very nearly closed up which to those in the know was a worst case scenario prediction. As to sending your starry eyed sons and daughters to this flight school, avoid at all costs is my advice.

3wheels 22nd Jul 2022 14:54


Originally Posted by olster (Post 11265867)
Training aspirant airline pilots would or should be an ideal, home every night job for pilots with previous airline experience with role model reference. However the few that have actually flown airliners previously are viewed by the aforementioned middle management instructors with a weird form of resentment and jealousy. .

So very true.

The same applies to PPL Instructors with a few hundred hours. Looked up to by their students but barely one step ahead of them.

One had to file a flight plan and came to me asking me to do it for him as he had never done one before and didn’t know how to do it.

Another had an airprox and was hell bent on filing an MOR, until we put her straight.

I could give many other examples.

There is something very wrong with the Professional and Private Pilot systems that allows these sort of things.

djpil 22nd Jul 2022 23:30


Originally Posted by punkalouver (Post 11265692)
It involved a taildragger with tandem seating. It has limited space in the baggage compartment which was pretty much full. So I thought that I would strap some stuff in the aft seat using the lap belt and shoulder harness to keep it secure. The forward edge of the item was aft of the front edge of the seat. Which seemed safe.

Seems like a Decathlon. I often carry bags on the rear seat. Those who sit in the back know about the extent of the control stick.


Originally Posted by punkalouver (Post 11265692)
Fortunately, I decided to move the control stick fully aft and discovered that it was being blocked by the item in the seat. The control stick is not straight but has a significant curve in it halfway up allowing the upper portion to overhang the seat when moved from neutral toward fully aft.

Fortunately? Routine check perhaps? The Decathlon Operating Manual has a control check prior to start as well for this purpose - size of the passenger in the rear seat is limited by their stomach girth.

212man 24th Jul 2022 11:48


Originally Posted by First_Principal (Post 11265563)
While I'd expect to see this word (and spelling) used more commonly in conjunction with maritime vessels it's not incorrect per se.

Normally spelled 'coaming' though - surely?

punkalouver 24th Jul 2022 12:50


Originally Posted by djpil (Post 11266122)
Seems like a Decathlon. I often carry bags on the rear seat. Those who sit in the back know about the extent of the control stick.

Fortunately? Routine check perhaps? The Decathlon Operating Manual has a control check prior to start as well for this purpose - size of the passenger in the rear seat is limited by their stomach girth.

​​​​​​
Not a Decathlon. The type is not relevant but it had a much greater curve in the stick.

You are correct that this should be discovered as per checklist when checking control freedom which is typically performed after strapping oneself into the cockpit(on the Decathlon I flew, strapping in took me quite a while with those aerobatic seat belts installed).

Fortunately......I did this check during the loading process and discovered the issue while standing beside the aft open cockpit and realized there was a problem. Saved a good amount of time when I didn't have a lot of extra time.

Briefly off topic of thread:
Looking back on my Decathlon days(rental from a flight school), I seem to remember that during the control check, full aft stick had the rear stick rubbing against the rear seat crotch belt which could be felt in the control stick. Is it the same on you aircraft.

WideScreen 24th Jul 2022 16:18


Originally Posted by 3wheels (Post 11265929)
So very true.

The same applies to PPL Instructors with a few hundred hours. Looked up to by their students but barely one step ahead of them.

One had to file a flight plan and came to me asking me to do it for him as he had never done one before and didn’t know how to do it.

Another had an airprox and was hell bent on filing an MOR, until we put her straight.

I could give many other examples.

There is something very wrong with the Professional and Private Pilot systems that allows these sort of things.

Depends on your point of view.

There aren't many options to obtain experience, without bridging the gap between novice and expert, by making mistakes, probably a lot of mistakes, along that road. That's called "learning".

My kids don't like to go to school, though, I explain them, there is no alternative in the form of an "injection" or whatever, to acquire the knowledge and experience to obtain a school certificate. So there is no alternative than to attend school, learn the lessons and sit the exams. Which they accept, given their wish for a better future than working behind a garbage truck.

The same for flying experience. Unfortunately.


Fostex 24th Jul 2022 18:50

Make mistakes yes, but not ones that can cause danger to yourself or others.

Flying instruction should take the student up to the point of the mistake, allow them to recognise it and prevent the same occurrence happening in the future. It should absolutely NEVER put the student or others in danger.

There are many preventative checks and processes that should have prevented this incident occurring. Better to understand and practice those than find yourself in this situation in the first place.

djpil 24th Jul 2022 21:57


Originally Posted by punkalouver (Post 11266872)
​​​​​​Looking back on my Decathlon days(rental from a flight school), I seem to remember that during the control check, full aft stick had the rear stick rubbing against the rear seat crotch belt which could be felt in the control stick. Is it the same on you aircraft.

No, most are like this: https://www.covercraft.com/images/ar...hlon-front.jpg

alfaman 25th Jul 2022 12:51


Originally Posted by Fostex (Post 11266998)
Make mistakes yes, but not ones that can cause danger to yourself or others.

Flying instruction should take the student up to the point of the mistake, allow them to recognise it and prevent the same occurrence happening in the future. It should absolutely NEVER put the student or others in danger.

There are many preventative checks and processes that should have prevented this incident occurring. Better to understand and practice those than find yourself in this situation in the first place.

Sadly we don't get to chose the consequences of the mistakes we make: sometimes the tiniest slip has massive implications further down the track. I agree better instruction is probably the answer, but that hole in the cheese got missed.


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