ATSB Report C404 Jandakot

[Bill Smith]

http://www.atsb.gov.au/aviation/pdf/200303579.pdf

[Spotlight]

Frankly, the most savage report I have ever seen from the .
Australian tin kickers.
Gaunty of course has other ideas but to my mind, giving it away while he still had the chance, or continueing straight ahead until performance could be determined were the options.

Apart from the obvious of seeing fuel flow reducing and selecting high on the pump switch.

[gaunty]

Spotlight giving it away while he still had the chance, or continueing straight ahead until performance could be determined were IMHO the only options. my italics quite so, except maybe one other

the obvious of seeing fuel flow reducing and selecting high on the pump switch. seems to have slipped right through to the keeper??

I haven't printed the report down yet but I don't see any discussion of this and why this would be so.

Had this been selected as soon as a reduction in FF/power was sensed the engine would have regained a significant percentage if not 100% of TO power, certainly enough to keep everything upright and reduce the pucker factor to a tolerable level.

I do not have access to the aircrafts POH or Flt Manual but I would be interested to know whether the original POH or flight manual was revised to include a pre TO brief on it and selection of auxilliary pump to "high" as an immediate recall action for an EFATO, beyond the required placard.

It does not appear in the original manual as the "auto high", now disconnected, could be relied on to remove the "urgency" of the failure of an EDFP. The operation of the aux pump on high could usually be routinely confirmed as part of the prestart and starting and priming routine.

Can someone help us with this apparent and pretty obvious ommision by the ATSB?

The lack of pre TO climb gradient and obstacle clearance assesment and calculation beyond the subjective, "becoming concerned" and the pilots mistaken belief that because the aircraft was "old" it would not perform to the manufacturers calculations reveals a fundamental flaw in the CPL syllabus and the manner or mindset in the training and operation of these types.

The CASA response to the ATSB recommendation on Multi-engine training was an answer but not the complete one.

Unless the aircraft was seriously derelict and not maintained as it should be, and in this case it was, it will do what it is supposed to do and with an averagely competent pilot. The design, maintenance and certification rules demand that it must.

Otherwise why have the rules and performance manuals and why when the aircraft ceases to become "new" don't we simply disregard them or factor the results by, oh I don't know, let's say 10% eh but just to be safe how about .............:rolleyes:

The fundamental flaw is the lack of required understanding of the differences in design, maintenance, certification and performance requirement of the NORMAL FAR23 and TRANSPORT CATEGORY FAR 25 and the underlying concepts and philosophies.

Airline pilots or at least their ops through the manual routinely are before each flight required to satisfy engine inoperative climb gradient and obstacle clearance from V1 to return to the airport or continuation to an adequate airport or destination.

The mind set or "human factors" issue in CPL training is interesting but would make more sense in this context were it embedded in a detailed understanding of the FAR23/FAR25 above rather than simply an adherence to or application of whatever section of CAO 20.7 applies to your ops.

It is not a requirement for CPL and I find precious few ATPLs who understand it beyond the mere application of 20.7.1b.

FAR23 < 5700kg twins, including the turboprops have marginal EFATO performance, but you can calculate it, you can assess your options, plan your actions and do it. The FAR23 aircraft will deliver the goods, in the same manner as the FAR25 type, not as good perhaps but at least you have the escape route that is mandatory in FAR25 ops.

If all else fails <5700kg twins (including the turboprops) IMHO are single engine aircraft with dispersed power, in which you do much the same thing as you do in a single with an EFATO, give it away while you have the chance, continuing a TO is the least attractive option, keep it straight, find the least worst area in front of you, land the aircraft and keep flying it until the noise stops.

Never had to do it, but rumbling through the airport fence and doing some scrub bashing at maybe 30-40 knots is a more attractive proposition than the alternative. That's why God invented insurance companies.

[triadic]

An interesting and quite tragic report - have we not seen much of this before?

I continue to wonder at the level of training provided these days.

I did not see any mention of a passenger brief provided to the occupants prior to the flight (long day, may have missed it?) but for such operations in my experience it is SOPs. In my day for survey ops we all wore military style flying suits. Should be part of the deal and would have thought a contractor to the RAN would have done so. But then for some, it is not the "fashion" these day perhaps?

In over 2000 hrs on Titans I recall using flap for takeoff only a handful of times - the performance penalty was just not worth it. (Only short strips and light weights if I recall)

As some readers will recall, Titans were used in the RPT role by a major carrier in the '80's and '90's prior to the AFM changes. That carrier did the numbers and provided a flight manual supplement for single engine climb performance which demanded that the speeds used reflect the weight, runway and aerodrome as well as known obstacles. Those speeds were always below the marked blue line. In fact operators following those supplement numbers could always be identified on takeoff due to the relatively steep climb to a plateau height of (usually) 400ft.

Like many GA twins, the Titan will perform, but you must know the numbers and stay within the limits.

Hopefully lessons will be learnt and passed on as a result of this accident.

[Sunfish]

What a sad report.

The fuel pump switch check was not part of the EFATO procedure.


section 2.5 "The aircraft manufacturer’s emergency procedures stated that ............................................................ ................................
Above an airspeed of 91 KIAS and with the landing gear retracted or in transit, the procedure
recommended by the manufacturer and contained in the AFM, emphasised completion of
immediate action items to maximise aircraft performance, rather than conducting
troubleshooting of aircraft systems."

The report also states I think that the "Auto High" system was removed because inadvertant selection of high pressure on an engine with a with a working engine driven fuel pump could cause engine failure.

[gaunty]

Sunfish

If I recall it correctly the "auto high" function was removed from ALL Cessna twins by Service Letter/AD and the use of "hi" in the event of an EDFP placarded.

section 2.5 etc is correct in principle however..............
The fuel pump switch check was not part of the EFATO procedure but IMHO should have been.

Engine failure: first recall item training when I was a boy revolved around fuel pumps and fuel selection.

Granted it gets a bit busier in a FAR23 twin during that critical "few seconds" of transition, however it is also true that there is a tendency, some would say justified, to acting hastily rather than thoughtfully.

How many hasty misidentifications of lever or switch or confusion have caused a simple problem to become an accident?

IMHO the lessons we can learn from this accident is;
1: Do the gradient sums to satisfy obstacle clearance, plan the straight ahead escape to minimum 400ft AGL and have the confidence fly the aircraft accordingly.
2: Trust the aircraft, assumimg you know that it is properly maintained and is serviceable otherwise you shouldn't be flying it in the first place, beyond ones own personal perception of "oldness".
3: Review the fact that most engine failures engine have a very high probability of being fuel related and be prepared to take the simple and quick action (in this case "aux hi") to remove that first as a possibilty before shutting down a perfectly good engine.

The ATSB seem to be silent on this??

[YPJT]

And now the armchair experts are putting themselves on the stand at the coroners inquest.

One rather short gentleman with a track record of parking, or having his planes parked upside down barely within the JT CTR was giving evidence based on what he saw. Unfortunately for our intrepid aviator and eye witness expert, his efforts to assist the coroner were shot down in flames when counsel asked the question as to whether or not he is the same person who recently ran out of fuel and crashed in a nearby residents front yard.:E

Is there no end to this individuals attempts to seek publicity and purport himself to be something he clearly is not? :mad: