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View Full Version : ATSB final report Bankstown 11Nov03 accident


Time Out
27th Jul 2005, 00:51
Summary
The circumstances of this occurrence are consistent with a loss of aircraft directional control during an attempted go-around manoeuvre with reduced right engine power. This is supported by the intention to include asymmetric flight in the training session, and by information related to the go-around. That information included:
• the three previous circuits were concluded by touch and go landings, but on this occasion the pilots initiated a go-around
• the pilots did not conduct a landing as would be expected if they had concerns about any aspect of the aircraft’s serviceability or performance
• the aircraft began to diverge right soon after commencing the go-around and that divergence was not corrected
• the aircraft’s performance deteriorated until it stalled at a height from which recovery was not possible
• at impact both engines were producing significant and comparable power.
However, because the investigation was unable to confirm the configuration of the aircraft during the approach and go-around, the reason the aircraft was not landed or restored to stable flight before control was lost could not be determined.

Findings
Aircraft
1. The aircraft had been fully fuelled with the correct fuel for normal engine operation before the flight.
2. The damage to the propellers indicates that the engines were producing significant and comparable power at impact.
3. Both propellers were assessed as being at their correct relative blade pitch angle for the take-off, go-around or early climb phase of flight.
4. The position of the wing flaps at impact could not be conclusively determined.
5. The position of the landing gear at impact could not be confirmed.
Flight Crew
6. The instructor was appropriately qualified to conduct the flight.
Air traffic control
7. The aerodrome controller saw the landing gear extend and issued a clearance for the pilots to conduct a touch and go landing.

Significant factors
1. The aircraft was not landed, or power restored to the right engine in sufficient time to regain stable flight.
2. The aircraft departed from controlled flight at a height from which recovery was not possible.

ATSB safety action
Following a number of accidents in recent years, involving twin-engine aircraft that incurred a loss of some or all engine power, the ATSB implemented a research project (B2005/0085) into power loss related accidents involving twin-engine aircraft. That report was approved for public release 27 June 2005 and concluded that:
• Power loss accident rates in twin-engine aircraft are almost half the rate in single-engine aircraft. However, a power loss accident in a twin-engine aircraft is more likely to be fatal than a power loss accident in a single-engine aircraft.
• Fatal accidents subsequent to a power loss in twin-engine aircraft are overwhelmingly a result of in-flight loss of control events.
• Just over one-third of power loss accidents in twin-engine aircraft occurred during a non-asymmetric power loss. The majority of these were related to fuel management, and no benefit was derived from the presence of a second engine.
• More accidents (46 per cent) occurred following an asymmetric power loss in the take-off phase than in any other phase of flight.
The research report is available on the Bureau’s website www.atsb.gov.au or from the Bureau on request.
Full Report (http://www.atsb.gov.au/aviation/pdf/200304589.pdf)

J430
27th Jul 2005, 03:04
Nasty prang, never seen a nice one. Makes you think twice about dangerous training close to the ground. Thats why you don't do stalls at 1000' AGL.

The single engine performance of most light twins really make you want to stick with your single engine bugsmasher. There is not much of a safety case for having the second engine is there.

I have read somewhere that the second engine usually takes you to the scene of the accident.

J:(

A37575
27th Jul 2005, 12:08
The maintenance release was destroyed in the fire. Therefore there would be no record of current defects on the aircraft - if they had been recorded in the first place.

Where fire destroys an aircraft, the maintenance release and thus any record of defects is usually destoyed as well, leaving ATSB with nothing to go on. That's a fat lot of good for the investigators. Why do CASA insist the maintenance release be carried on the aircraft for all flights, even if the flight may be just a local one? It doesn't make sense.

After all, if for legal reasons a copy of the passenger and cargo manifest is required by CASA to be left at the point of each departure, then it would be logical to leave a copy of the current maintenance release on the ground as well. I believe that for the big airlines, a copy of the applicable maintenance document is left with the agent at the point of each departure. Why not for GA aircraft?

For local flights, CASA should direct that there is no need to take the original of the maintenance release along for the ride, for the same reason there is no legal requirement for the pilots to carry their log books along.

Matt-YSBK
30th Jul 2005, 12:20
I think twins can be very safe great for night flight or imc. But some things need to be in mind.

a) recency You must be current on the twin. asymmetric should be practiced (i do a refresher every 3 months)
b) If in doubt close the throttles lower the nose trim for best glide and pick a field and pretend you have no working engines.
c) take of safety brief. Know what you are going to do if a fan stops.

You may survive a glide approach and emergency landing. You will not survive a VMCA event at low altitude.