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SA Airlink J41 crash

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Old 1st Oct 2009, 09:18
  #101 (permalink)  
 
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To answer contractdog's question.

The aircraft was supposed to have nightstopped at Maritzburg the night before but was unable to land due to weather at the field. They diverted to Durban. The passengers were bussed through to Maritzburg.

The aircraft was returning to Maritzburg the following morning to pick up the schedule again.

It had nothing to do with maintenance.
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Old 1st Oct 2009, 11:40
  #102 (permalink)  
 
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No 2 engine rear turbine seal failed, hence the smoke on the t/o roll.
There are now two scenarios :
1) As the a/c crashed at 1.4nm and any crew who has had a complete oil loss will now the will not stop working instantly. There would have been plenty time to sort the problem out or straight engine failure. Unless with turbine seal failure lead to instant internal failure. The J41 is able to fly away with one engine NTS'ing not feathered etc specially with a/c empty at sea level. The may have been struggling to keep it straight hence the crash is to the right of centre line but should have flown away?
The only thing to think about then is they thought they were losing or couldn't control the a/c and decided on a controlled crash. Leading them into shutting the No.1 engine done. (But if the prop is feathered and stationary this doesn't stack up as it takes a good 30-45 sec for a -14 engine prop to stop?)

2) They shut the wrong one down?

Last edited by big buddah; 1st Oct 2009 at 13:55. Reason: spelling!
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Old 1st Oct 2009, 14:12
  #103 (permalink)  
 
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Avi8tor
Appologies.That was a bit ambiguous I meant for point b) The crew, in error shut down #1. But you have raised a question which may be relevant. Does the auto feather function work in flight when the stop switch is pushed?

Also the NTS function from what I understand is a rapid cyclic movement of the blade angle towards feather and then a reduction of the blade angle the opposite way. All this to reduce the drag, and in so doing, would, I imagine reduce the rotational velocity of the prop.
This could account for the condition of #1 prop.
Having said that, even if #1 prop was not in NTS mode and simply just wind milling, I am not too sure how much damage would be caused.

Supposing it was, as has been speculated, a turbine seal that caused smoke from #2.
This I understand is symptomatic. By RF’s own admission, Link has a history of these occurrences leading to engine shut downs. These as we hear are not necessary instantaneous
What is to say that #2 was in NTS mode at the time it impacted the ground. Looks pretty mangled to me as if there was a lot of power on at the time, so much so that it would be almost impossible to ascertain anything without analysing the FDR data.
Just another “blade angle”

Regards

S.D.
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Old 1st Oct 2009, 16:26
  #104 (permalink)  
 
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Quote: “For example, FlightSafety's motto is "Train to Proficiency". By this, they mean that as long as a candidate is making progress, the candidate will be given as much training as they require in order to achieve proficiency. No additional charge is ever made for this. I think FlightSafety has learned a few things about pilot training in the 60 years that they have been in the business.”

That may have been the situation in the past but it is certainly not correct now. FlightSafety now includes for a restricted number of hours in its courses and anything extra is definitely charged for. A recent quote from FlightSafety states:
“ Any additional hourly simulator training needed for course completion will be separately billed at the hourly price listed below.” The additional hourly price quoted for the simulator for that particular course is US$1,145 per hour with an additional US$265 per hour Crew Partner Fee if required.
There is a conflict of interest here. If business is slow, as in a recession, then it would be in the training company’s financial interest to ensure that as many students as possible need extra training that can be billed for. Individual ab initio flight instructors who are paid on an hourly rate by flight schools also sometimes resort to ensuring that students require extra training. One day back in the last century in Ontario the WX was too bad for student flying so one instructor actually gave a student an extra lesson in taxiing to keep the funds flowing. Fortunately the people who resort to these tricks are few and far between. Most instructors are honest and do their best to get students through at a fair rate of progress. However, I was surprised to discover that a leading training organisation would put itself in a conflict of interest position where such suspicions could fall upon it.
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Old 2nd Oct 2009, 12:54
  #105 (permalink)  
 
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I have learnt a lot reading this forum and hope you can help me. My questions are, if your family member/s had to fly and only this airline was available, would you let them fly? If you had the choice of having to fly or drive for business, what would you do? Hasn't this accident been a long time in the coming?
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Old 2nd Oct 2009, 14:23
  #106 (permalink)  
 
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I have never met a pilot who wants to crash. Personally I find your question an insult to my proffesionalism. Just because an aircraft crashes does not mean that it is a long time coming. The J41 is a safe aircraft. I have sent my family on it often and will tomorrow. if your accountant makes a mistake, does not mean he is a bad accountant or should not be trusted. if a car crashes does everybody get rid of that type? you newspaper people should stop over sensationalising aviation.
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Old 2nd Oct 2009, 16:20
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The Prelim Report is out on the CAA's website:

CAA Website here
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Old 2nd Oct 2009, 21:00
  #108 (permalink)  
 
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Anyone able to post the report. Unable to get past the link on the CAA website, nothing loads.
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Old 2nd Oct 2009, 21:58
  #109 (permalink)  
 
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Exclamation sacaa PRELIMINARY report

MEDIA STATEMENT 2 OCTOBER 2009
STATUS REPORT: INVESTIGATION INTO THE CAUSE OF AN ACCIDENT INVOLVING
A JETSTREAM 41 AIRCRAFT SHORTLY AFTER TAKE OFF FROM DURBAN
INTERNATIONAL AIRPORT ON 24 SEPTEMBER 2009
The objective of an accident investigation is to establish the cause (s) of the accident and
to take steps to prevent a further occurrence. As such the objective is not to apportion
blame or liability.
The purpose of this investigation is therefore to ensure that the investigation is conducted
in the most effective and comprehensive way to establish the cause(s). The investigation
team is committed to adhering to the International Provisions defined in Annex 13 to the
Convention on International Civil Aviation, of which South Africa is a signatory.
To date no evidence has been identified that requires the Commissioner for Civil Aviation
(CCA) to implement any action, such as the prohibition of further flight by Jetstream
aircraft, nor to suspend any approvals granted to the operator.
Passengers can continue to make use of South African operators with confidence in that
their safety is being overseen to the best of its ability by the South African Civil Aviation
Authority (SACAA).
The process followed to date and in future is in compliance with internationally accepted
practices. On arrival at the accident scene, the team of accident investigators, commenced
with the onsite investigation which included the photographing and video-taping of the
accident site and wreckage. It should be noted that the first priority following an accident is
to render assistance to injured parties. The investigators will await completion of this
process prior to taking control of the accident site, so as not to interfere with any rescue
operation.
Following completion of the initial assessment and documenting of the accident site, a
decision was made to remove the wreckage to a hangar at Johannesburg, where a more
detailed investigation and strip down of selected components could be made. This had
been done with the support and cooperation of the operator.
SA Civil Aviation Authority
Private Bag X73
Halfway House
1685
Tel: (011) 545 1000
Fax: (011) 545 1201
Website: CAA Website
2
The South African investigation team has since been joined by an Accredited
Representative (AR) from the Air Accident Investigation Branch (AAIB) of the United
Kingdom, who is being assisted by Advisors from the AIIB and the aircraft manufacturer.
The National Transportation Board (NTSB) of the United States of America (USA) has
nominated a non-travelling AR, but with an Advisor from the engine manufacturer on site.
Actions taken to date include:
· The aircraft wreckage is being examined in detail for defects and to exclude factors
that are not relevant to the cause of the accident;
· The Cockpit Voice Recorder (CVR) and Digital Flight Data Recorder (DFDR) have
been hand carried to the AAIB facilities in the UK and data has been successfully
downloaded. Both recorders were fully functional and data retrieved is of good
quality;
· The Air Traffic Control recordings have been obtained and are being transcribed
and analyzed;
· The engines have been removed from the airframe and will be shipped to the
manufacturer in the USA where they will be stripped down in the presence and
under supervision of the Investigators, accredited representatives, advisors and
observers from the operator;
· Compilation and review of relevant records in respect of the aircraft maintenance,
operational and crew records is ongoing.
Factual information obtained to date can be summarised as follows:
· Aircraft design and certification requirements for a multiple-engine aircraft are that it
should be able to continue take-off once passing the decision speed, climb, fly en
route and continue to a landing, should one engine become inoperative. This is
demonstrated during the aircraft certification process at maximum take-off mass.
· The Jetstream 41 aircraft requires an operating crew of two pilots and meets all of
the required certification criteria for a twin-engined turboprop aircraft, even at its
maximum certificated mass.
· It is a requirement that pilots be trained and competent to take-off, fly, and land such
aircraft with one engine inoperative. Pilots are required to maintain competency and
are assessed a minimum of every six months to ensure that such competency is
maintained.
· Operators define standard operating procedures (SOPs) which pilots are to follow
during the various emergencies that may occur. Such competency is again verified
during an actual flight test or in a simulator.
· Smoke was observed to originate from the no. 2 or right-hand engine during the
take-off roll and ATC advised the crew accordingly. This was only transmitted to the
pilot during take-off rotation, thus excluding the possibility of rejecting the take-off.
Duration of the take-off roll was about 18 seconds.
3
· The no.2 or right-hand engine failed on rotation and a power reduction occurred on
the no. 1 engine as the aircraft climbed to about 450 ft. above sea level.
· The aircraft was seen to climb and thereafter descend and impact terrain. (Total
time from start of the take-off roll until impact was about 50 seconds);
· Rescue and fire-fighting services responded appropriately;
· The three crew members on board received injuries to various degrees of severity
and a member of the public was also injured at the accident site;
· Investigators have as yet to interview the crew members and the bystander, due to
their medical conditions.
With reference to the above factual information, the aircraft’s mass was such that it should
have been able to have continued to climb and return to land on one engine. It is therefore
necessary to address the following factors that may shed further light as to the cause of the
accident:
· The reason for the power reduction experienced on the no.1 engine, which will
include continued analysis of the DFDR and CVR information;
· Analysis of any human factor aspects, such as whether the power reduction on
engine No. 1 resulted from an incorrect identification of the failed engine, or a
decision to land the aircraft as soon as possible, or other factors unknown at this
time, that necessitated a deviation from standard operating procedures to continue
the flight on one engine;
· Verification that the no.1 engine had in fact been serviceable throughout the flight by
means of a strip-down examination;
· Strip-down of the no 2. engine to establish the cause of this engine’s failure.
The investigation will be ongoing with participation by the accredited parties.
The Aircraft Accident and Incident Investigation Division (AIID) of the South African Civil
Aviation Authority (SACAA) wishes to acknowledge and thank the above participants and
the operator for their assistance and services rendered to date.
It is trusted that the investigation will lead to the introduction of corrective actions, should
any deficiencies be identified, to ensure the continued safety of passengers transported in
South African airspace and on South African aircraft.
-ENDSAbout
the SACAA:
The South African Civil Aviation Authority (SACAA) was established on 1 October 1998 following
the enactment of the South African Civil Aviation Authority Act, No.40, in September of the same
year. The SACAA promotes and maintains a safe, secure and sustainable civil aviation
environment, by regulating and overseeing the functioning and development of the industry in an
efficient, cost-effective, and customer-friendly manner according to international standards.
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Old 3rd Oct 2009, 05:32
  #110 (permalink)  
 
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Smoke was observed to originate from the no. 2 or right-hand engine during the
take-off roll

and

The no.2 or right-hand engine failed on rotation ?

The two statements are not compatible. An engine on fire can still produce take off thrust and there are many simulator scenarios, certainly within a 50 second period where, at rotation, you would leave a fire warning alone, apart from cancelling the devastatingly irritating bell, and fly the aircraft instead-normal drills until 400 feet.
If it has not auto feathered at that point in the take off and the fire is not catastrophic, it can be a fire drill not a failure drill.


This (the smoke information) was only transmitted to the
pilot during take-off rotation, thus excluding the possibility of rejecting the take-off.
Duration of the take-off roll was about 18 seconds.

Is ATC now going to be drawn in to the blame game? It is not their responsibility to point out that the engine needs a de coke.

From the armchair and, permit me to say, as a Jestream pilot with many hours on Garret/NTS/etc equipped aircraft, let me say that the initial hypothetical conclusions are absolutely inescapable in this accident.
Someone must regularily remind Airlink of their extreme good fortune. They have 'got away' with this because their were no passengers on board. Had the aircraft even had less fuel but more pax, to conform to MTOW/Performance TOWs-it would have had for sure some serious fatalities on its books to explain. Airlink has possibly-and I say only possibly with care-been given an opportunity to review all its training procedures with great attention. It is now its responsibility now to ensure that all its standards are reviewed, tightened up (there is always room for that) and perfected. Also perhaps some rostering procedures might need examination-but that is a differenc bottle of stale beer.

I imagine that the aircraft was on lease from BAES, which explains their involvement. The aircraft is certified in Perf A. BAES will be very desirous of ensuring that such certification is not put in danger. It would be very bad for their passenger customer airlines if that happened.

Whatever - There is a great deal for everyone to learn from this accident. so hop to it and do so!

Last edited by Der absolute Hammer; 3rd Oct 2009 at 05:48.
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Old 3rd Oct 2009, 05:57
  #111 (permalink)  
 
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I am really glad that the SACAA has accepted the help of the AAIB.

An engine on fire can still produce take off thrust and there are many simulator scenarios, certainly within a 50 second period where, at rotation, you would leave a fire warning alone, apart from cancelling the devastatingly irritating bell, and fly the aircraft instead-normal drills until 400 feet.
Nobody said it was on fire. The theory is that it lost a rear turbine seal, smoke was from oil in the exhaust.

such as whether the power reduction on engine No. 1 resulted from an incorrect identification of the failed engine, or a decision to land the aircraft as soon as possible, or other factors unknown at this time, that necessitated a deviation from standard operating procedures to continue the flight on one engine
If you reduce the power on the good engine, and the aircraft starts to head for terra firma, you increase it again. Why you do the verification with the thrust lever. But come to think about it, I have never demostrated that in the sim.

Might be a worthwhile 5min spent in the sim, any thoughts?

Last edited by Avi8tor; 3rd Oct 2009 at 06:09.
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Old 3rd Oct 2009, 06:42
  #112 (permalink)  
 
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Avi8tor
Nobody said it was on fire. The theory is that it lost a rear turbine seal, smoke was from oil in the exhaust.

If that is the case then the pilot still had take off power on two engines?
Below 400ft, why play around with power levers when the aircraft is equipped with auto feather and is a Perf A machine, It is capable of performing within the limitations of the Perf A envelope . Too many people are writing about the J41 as though it were a King Air 200 or an aircraft not certified in Perf A- as though it was a feline urinatory excretion machine.


Edit bit..

Do nothing below 400ft except silence the Fire Bell as applicable!

Last edited by Der absolute Hammer; 3rd Oct 2009 at 07:00.
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Old 3rd Oct 2009, 07:25
  #113 (permalink)  
 
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...And grip the seat cushion a little tighter with your sphincter.....
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Old 3rd Oct 2009, 11:27
  #114 (permalink)  
 
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NTS in a nut shell.

An engine flame out = negative torque, prop windmills and tries to turn the engine = large drag. The hydraulic NTS system lets prop move to an increased blade angle = less drag.

Negative torque ceases when windmilling engine drives prop again = NTS operation stops.

NTS system will not fully feather the prop it must be done by the PILOT if unable or doesn't want to relight the engine.

Feathering: "NTS/auto feather system gives prop feather operation together with an engine shutdown but only available when APR is armed" (which it always is as per SOP's and check list item)
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Old 3rd Oct 2009, 15:13
  #115 (permalink)  
 
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If the #1 engine was shut down, why did it not feather. And if #2 was producing power, why was it feathered? This is what is indicated in the crash photos as well.
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Old 3rd Oct 2009, 15:24
  #116 (permalink)  
 
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An excellent summation of the complex system and thank you for it !
As I can remember from the J32, there was one switch for the APR which, with both airlines for which I have had the doubtful pleasure of flying that not very aerodynamic wings goblin, was usually disconnected. As a matter of the fact, i do not remember that APR use figured much an any checklist . I cannot also remember whether APR was fitted on the original Astazu engined J31 - at least one was still flying from Cranfield quite recently.
Be such as it may, there is an article in today's Star newspaper which says that the SA CAA and the UK AIB are more or less saying that pilot error was the cause of the crash and that the operating engine suffereed a sudden loss of power. The article also says that ATC quite correctly informed the cockpit as to the engine that was smoking on rotation.
It will be seen in the future what any full results may be and it appears that no one had yet spoken (officially anyway) to the pilots who are still not well.
However-if pilot error is proved in this case -there would seem to be errors made in principle in regard to EFATO handling on that type of performance aircraft.
A shame and a worry for all concerned but I repeat the maxim-at the great risk of being shot down-do nothing until 400ft except silence the fire bell; segment climbs and all that stuff, which do not really apply to light twins but do apply to the category of aircraft in which the J41 finds itself.
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Old 4th Oct 2009, 00:07
  #117 (permalink)  
 
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There is a reasonably thoughtful article about this accident on the Flight International website - click here.
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Old 4th Oct 2009, 07:11
  #118 (permalink)  
 
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From PJ2 today in "Pilot handling skills under threat, says Airbus" item #187

Roger Coppid;
Quote:
is there iny info out there about the comparison between incidents such as deep/short/hard landings, stick-shakes, over-speeds, over-banking, bank angle on landing both with or without the use of automation.
Yes, all these events and more would be in an airline's FOQA/FDA/FDM (as the term might be) Program.

These are serious events which, if seen in trends, are precursors to an accident. The intent of a flight data monitoring program is to learn about these events and take preventative measures before an accident occurs.

But FOQA data must be used intelligently and with great integrity and comprehension to deliver on its promise of enhanced flight safety.

I have learned that senior management of a large airline has stated to its flight data people that the long landings being reported on the B777 are the result of its "big wing". Such a view is, in my opinion, an enabling one, excusing long landings, for whatever conceivable reason.

One supposes that the corollary to that view is, (because the wing is what it is), there is therefore nothing to be done and landings over 3000 to 4000ft down the runway are somehow acceptable (normalizing the deviance). The other excuse offered is, the runways that B777's typically use are "long".

Such a response (or denial) to the flight data places the organization at undue risk and subsequent liabilities because the "accident was in the data" before it occurred. The QANTAS overrun at Bangkok years ago is one example. The organization changed as a result of the accident and has championed flight data analysis as a primary preventative safety tool; in my opinion, QANTAS is a fine example of a learning organization which has been able to balance economics with safety.

Flight data monitoring programs will tell the airline if there are stick-shaker events which go unreported, hard landings, over-banking, (> 35deg), overspeeds and how the automation performs in comparison with manual flight.

Critically, the data derived from the QARs must be believed, (that is not always the case), kept confidential but never used to police or punish pilots. Ninety-nine percent of flight safety is about "what", not "who".

A "distributed archive" program was begun in the US some time ago, where de-identified flight data was made available to various airlines under a desire to share data to enhance safety. The idea was to see if carriers were experiencing the same issues. I don't know the present status of the program but such an approach, (very difficult to implement - those involve did a huge amount of work over a long time) goes directly to your question about industry experience.

FOQA programs are expensive to start and maintain, and the argument from the beancounters is always, "what does it produce that justifies the cost?" I have actually been told that the flight safety department was a "profit center" under some corporate business models. Such an approach reveals a high degree of ignorance first about aviation and second about how flight safety work is done. Some think that wearing reflective vests on the ramp is "doing flight safety" while others that I know have a full comprehension of the safety tools available to them, know their worth and are willing to invest the time and resources.

As always, the CEO leads and his or her "knights", (managers) will ride out and do and say exactly what the CEO wants. So if the CEO is ignorant about how to do aviation safety, the organization will likely be ignorant. All safety people have had experience pushing rope at one time or another. Some organizations learn by honest assessment of their strengths and weaknesses, others take their long-term success for granted, ostensibly waiting until an accident to teach them.
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Old 4th Oct 2009, 13:50
  #119 (permalink)  
 
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Sunday Times of today

For those of you who love RF dearly - check out today's Sunday Times REVIEW section (So Many Questions) where Chris Barron asked RF a few questions on Link's pilot selection criteria
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Old 5th Oct 2009, 06:07
  #120 (permalink)  
 
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sa airlink training

one of my IF renewals was done on a king air 200 sim (an aircraft i am still yrs later not rated on ) - interesting given i was flying a JS 41 for sa airlink at the time

fly safe
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