Crash-Cork Airport

[BARKINGMAD]

All praise to AAIU for this report, it will have taken awesome resources and patient slogging to produce a damning indictment on those at the very top of the avation food chain, both corporate and regulatory.

Some in EASA and elsewhere should be seen in the dock under criminal charges for their negligence and compliance with the wishes of Big Corp & LittleCorp.

What a shame that some of our number refer to the horribly inexperienced crew as a pair of comedians in these pages.

Would you say the same to their grieving relatives face to face? I seriously doubt it, but if you did, I trust their understanable reaction might teach you a lesson. Typical thoughtless reaction to heap all the blame and opprobrium on the deceased flight crew whilst sparing the real villains some of the anger which should be directed at a higher level. Whoever you are, you should go far in the psychotic environment of corporate management!!

Incoming............................................!!! :sad:

[Big Pistons Forever]

Was the whole operation a total Shyt*e show.... Absolutely.
Should the little weasels in management face criminal sanctions...Yes if there was any justice

But

Nobody held a gun to the heads of the crew. The deliberately chose to put themselves and their passengers in a situation that was illegal and unsafe. This deliberate erosion of safety margins then made them fatally vulnerable to any malfunction, like the mis-rigged engine controls.

Pilots reading the report have a choice. They can say "other people" were responsible not the pilots, or they can use this as a wake up call on the fact that ultimately it is a pilots responsibility to resist the kinds of egregious work place pressures that reduce safety and vow not to make this kind of mistake. Learn from the accidents or be doomed to repeat them.....

[RatherBeFlying]

Nobody held a gun to the heads of the crew. The deliberately chose to put themselves and their passengers in a situation that was illegal and unsafe. This deliberate erosion of safety margins then made them fatally vulnerable to any malfunction, like the mis-rigged engine controls.

Pilots reading the report have a choice. They can say "other people" were responsible not the pilots, or they can use this as a wake up call on the fact that ultimately it is a pilots responsibility to resist the kinds of egregious work place pressures that reduce safety and vow not to make this kind of mistake. Learn from the accidents or be doomed to repeat them.....Operators can always find junior pilots desperate for any flying job. The CAAs nevercome down on operators where the culture encourages busting limits.

The dirty secret is that you can get away with busting limits -- quite a bit of the time. But the odds do catch up with folks from time to time.

[deefer dog]

If you read the report thoroughly, you will find that it was indeed caused by differential power, due to a fault in the sensing system for the engine power which was not picked up during maintenance because the full test was not carried out. When the thrust levers were moved back past the gate, the fault produced a negative torque in one engine which caused the aircraft to bank sharply 40 degrees to the left. The PF then attempted to correct this by pushing the levers forward and then overcorrected to the right. You are correct in that the aircraft was far too low at the point and so the roll to the right caused the right wingtip to impact with the ground. However, the actual cause was the differential in power between the two engines.Sunnyjohn, you must have read a different accident report. The differential power issue had been with that aircraft for some time, and certainly had been experienced and handled by the crew in the two preceding go-arounds. By all means it may have been a factor that contributed to the eventual cause, as was the wierd "combined" effort of flying the aircraft (PF on the yoke, and PNF on the power levers) and the mis-hadling that led to negative torque being commanded to the left engine, but the main cause of the crash was busting the approach minimums.

[perceval]

@Justanotherflyer : Duly noted and acknowleged . I got carried away there ...Apologies .

[mad_jock]

That power difference is pretty much common to all types that use those engines.

In fact I can't think of a single aircraft I flown in the last 6 years that hasn't had a bit of a split in either torque acceleration response or lever split.

I think the last time I flew one that didn't was when two aircraft got imported from Japan in 2004. Don't worry it only lasted for a week and then they were back to normal. Its one of the reasons why they gave us a rudder and we know how to use it.

http://www.aaib.gov.uk/cms_resources.cfm?file=/dft_avsafety_pdf_033317.pdf

Again a beta in the air accident.

I was always told that with these props that the big spring that drives the props to fine isn't strong enough to drive the props fine again against aerodynamic forces once in beta in the air so I am quite surprised they got any power back.

The dirty secret is that you can get away with busting limits

This is the problem. And one which is extremely hard to battle against once it becomes normal. And don't think that it just apply's to so called third world airlines and pilots. It is alive and kicking in the UK as well away from the big boys with there QDR's. Most have beaten the approach ban and landed in sub 550m off a CAT1 I think my lowest has been 250m RVR after being 600m RVR at 4 miles and 400m at 2 miles, all I can say is the CAT II lighting at Bristol is top notch. We only found out the RVR was 250m on touch down was when the tower told the aircraft behind. Once you get away with it once there is a tendency to do it again. And if its what you have seen throughout all your career you think its normal.

The UK is actually quite strong dealing with below RVR approaches there is set ATC RT which will be given and if you land anyway the **** hits the fan Most countries this is not the case and if you manage to land nothing more is said about it.

Of course busting DA there is no proof one way or the other on the ground and its perfectly legal to attempt an approach in VV000 550m RVR even though there isn't a chance in hell of getting in. I have always wondered why there hasn't been an approach ban for sub 100ft BKN or vv001 for cat 1 approaches. But if there isn't a robust ATC system from discouraging any attempt pilots will continue to try. To be honest if you had a look at the stats for different airports you might find its normal for local pilots to land in such conditions. And they have been doing so safely for years and years.

And also IOM would be a good place to start. I have diverted from there to Liverpool only to asked by ops why the hell didn't you get in. The Let410 front of us had and the Jetstream behind us even though the RVR had dropped another 100m an the VV gone from 200 down to 100 . We couldn't see Jack at 200ft not even a dim glow of the lights (it was at night) Top cover appeared from the CP and they got told in no uncertain terms to wind their necks in. But if your CP is the sort that he does that sort of thing your stuffed and its time to look for another job which your more than likely doing anyway working for that sort of company.

[NigelOnDraft]

Quote:
If you read the report thoroughly, you will find that it was indeed caused by differential power, due to a fault in the sensing system for the engine power which was not picked up during maintenance because the full test was not carried out. When the thrust levers were moved back past the gate, the fault produced a negative torque in one engine which caused the aircraft to bank sharply 40 degrees to the left. The PF then attempted to correct this by pushing the levers forward and then overcorrected to the right. You are correct in that the aircraft was far too low at the point and so the roll to the right caused the right wingtip to impact with the ground. However, the actual cause was the differential in power between the two engines.

Sunnyjohn, you must have read a different accident report. The differential power issue had been with that aircraft for some time, and certainly had been experienced and handled by the crew in the two preceding go-arounds. By all means it may have been a factor that contributed to the eventual cause, as was the wierd "combined" effort of flying the aircraft (PF on the yoke, and PNF on the power levers) and the mis-hadling that led to negative torque being commanded to the left engine, but the main cause of the crash was busting the approach minimums. My reading of the report, albeit recollection, as is Sunnyjohn says.

The torque "difference" was not a significant factor in normal ops, and an indication based issue. The trouble was, with the (partial) beta selection, the reduction in torque PLUS the error led to a "negative" torque being "sensed", in turn leading that prop (only) to feather. This led to a much more significant asymmetric issue than the original issue, and led to the roll (as warned about by the manual). This led to an immediate left roll, almost certainly countered by the PF (P2) with right aileron. When the PNF (P1) applied full power, the asymmetry was removed, but the right aileron not = right roll as at impact.

[PAX_Britannica]

The - generally manageable, as more knowledgeable folk have pointed out - power differential, and the - presumably - inadvertent engagement of beta mode were just the last holes in the cheese.

They busted minima three times, in spite of ATC suggesting EIKY.

We might as well blame ATC for not denying landing clearance, since they couldn't land without busting minima.

Inadvertent engagement of beta by experienced crews does seem a recurring theme in this class of aircraft.
2012/05 eng | sht (http://www.aibn.no/Luftfart/Rapporter/2012-05-eng)
"Last ned rapport"

But most of the holes were lined up for them before they signed up, never mind got up that morning.

[mad_jock]

There is a theory/practise out there that some lift the gate before landing.

Some have managed to jam the gate by applying pressure backwards at the same time as trying to lift them. This occurred mostly when they fitted the lock out solenoid linked to the squat switch to prevent beta in the air on the Jetstream.

The solution is just to release the pressure and try again.

But some so they can ram the levers into reverse as soon as the mains touch lift it with the power levers forward of flight idle.

I am struggling to see how the delta P system can have any effect on the NTS system.

The torque is sensed by either a strain gauge bridge on a metal ring or a hydraulic pressure sensor with a piston linked to the ring. Once it goes negative the NTS opens a valve which dumps the oil pressure out of the beta tube which then allows the spring to push the blades towards feather. Which I have always been told it is not strong enough to do against the aerodynamic forces with the aircraft in flight from the beta power regime.

If you are flying your ball its exactly the same as a single engine failure during go-around.

[Sunnyjohn]

From Page 110 of the report (on my PDF copy there are no page numbers; p 110 is the PDF location)
The CVR indicates that the Commander (PNF) took control of the power levers during the final approach, this action being acknowledged by the PF. This was significant, as both power levers were subsequently retarded below Flight Idle — an action which would have been unexpected by the PF.
The recorded data shows that the No. 1 engine reached a minimum torque value of -9% in Beta range, while No. 2 engine reached a minimum value of 0%. This thrust asymmetry was coincident with the aircraft commencing a roll to the left (maximum recorded value 40 degrees of bank). It is possible that the PF may have made a control wheel input to the right in response to the unanticipated left roll. However, without the FDR parameters of control wheel or control surface position the Investigation cannot determine if such input was made. The subsequent application of power to commence the go-around, at approximately 100 feet, coincided with the commencement of a rapid roll to the right and loss of control. This roll continued through the vertical, the right wingtip struck the runway and the aircraft inverted.
So although they had corrected from the known torque difference, at this point the asymmetry, due to the undetected thrust fault I previously mentioned was nine percent, sufficient to produce the 20 degree bank to the left.

[mad_jock]

9% is nothing to be honest.

The simulated feathered torque is 10% so in an engine failure the plane can have 90% torque split between the engines.

At 9% imbalance they will be well away from V minimum control airborne issues, Vmca.

The roll is just a secondary effect of yaw which was obviously not controlled. And to be honest with the experience level of the FO I can understand the reasons why as well.

[captjns]

Sunnyjohn... You need to look at the root cause of the accident. Electing to continue an approach to an airport where the weather was below minimums.

The AAIU reported that the captain (31, CPL, 1800 hours total, 1600 hours on type, 25 hours in command on type) was pilot monitoring, the first officer (27, CPL, 539 hours total, 289 hours on type) was pilot flying. Both pilots were certified for CAT I, however, were not certified for CAT II.

Crew pairing clearly was an issue too.

[NigelOnDraft]

mad_jock

9% is nothing to be honest.

The simulated feathered torque is 10% so in an engine failure the plane can have 90% torque split between the engines.

At 9% imbalance they will be well away from V minimum control airborne issues, Vmca.

The roll is just a secondary effect of yaw which was obviously not controlled. And to be honest with the experience level of the FO I can understand the reasons why as wellFrom the report, #1 went to -9% torque (indicated), then feathered and up to 22% torque / down to 96% RPM.

Torque might normally relate to thrust, but (not being a TP pilot), I suspect not with a feathered prop? Therefore the P2 had to handle whatever the effect was of a quickly / without warning feathered prop on the left - and then 3s later, having corrected, having that feathered engine / asymmetry suddenly restored to full symmetric power.

I am open to education about the relationship of torque to thrust, especially when a prop is feathered in flight with a running engine.

Edit: might not the prop going to feather, but at 100% RPM, produce a significant increase in thrust on #1 engine? i.e. as prop went from beta (flat) to feather... from Link (http://www.cast-safety.org/pdf/4_propeller_fundamentals.pdf)Uncommanded feather
Uncommanded feather is very similar to the overtorque condition noted above. The propeller pitch will abruptly increase, causing a rapid rise in torque with a rapid drop in RPM because the engine is still providing power to the propeller. While the pitch is changing, the thrust may increase and then decrease rapidly. The airplane will have asymmetric thrust

[Sunnyjohn]

Sunnyjohn... You need to look at the root cause of the accident. Electing to continue an approach to an airport where the weather was below minimums.I take your point. Because the crew were busy putting the seats back, as I previously mentioned, they left late. They made two attempts (below minimums, true) then held for twenty minutes while they looked at alternatives, all of which were also fogbound. However, ATC had suggested Kerry to them, which was above minimums and they were contemplating diverting when they heard another aircraft on approach told by ATC that the fog had lifted slightly. This may well have influenced them to try for the third time, instead of diverting to Kerry. Incidentally, for those of you who know the area, Kerry is literally just down the road from Cork but, being further west, was escaping most of the fog blanketing southern Ireland that morning. None of this, I agree, excuses their attempting to land below minimums, or their lack of experience, or their lack of CRM. I regret to say, being a resident of the country, that that all goes back to Spain, still, in many ways, a third world country. Those of you that have been party to the whole of this thread will remember that I did a bit of digging with regard to the dubiousness of the Spanish companies involved.

[mad_jock]

power is rpm times torque.

When the blade is feathered its zero torque. Its measured by the twisting moment applied against the mounting ring. But I don't think the blade can travel that fast to be honest and just from the torque values you can't really tell where the prop angle is you normally get negative torque when the props are disked as fine as they can get when shutting the power levers at Vmo and the flight idle is set to low. I can't see the blades going to fine then to feathered then back to fine again it would require a huge flow of oil and pressure.

The temperature torque limiting system is a fuel dump valve and it will drop your torque from 100% down to 40% in 0.5 of second. And its normal for the rpm to drop until the prop pitch controller sorts the blades out and restores the rpm.

I will see what diagrams I can find at work this afternoon for the engine prop combination.

[Bang Or West]

Sunnyjohn - your assertion that "Because the crew were busy putting the seats back, as I previously mentioned, they left late and did not obtain a Met report until they were airborne. Had they read it on the ground it might have turned out differently" is INCORRECT.

You have become absolutely hung up on the crew putting the seats back in at BFS/EGAA, they did have METAR and TAF information before they left BFS/EGAA first thing that morning.

The actual FACTS as reported by the AAIU (page 9) state that :

"The accident Flight Crew … commenced duty at EGAA at 06.15 hrs (and) downloaded flight documentation including meteorological information for Belfast City Airport (EGAC), Cork Airport (EICK) and Dublin (EIDW) in a handling agent's briefing office at 06.25 hrs.

The aircraft departed EGAA … at 06.40hrs on a short positioning sector to EGAC.."

A photo of the METAR and TAF they had in their possession is shown on page 31. The markings on the page (various circlings and underlinings) would indicate that time wasn't so short, as you seem to think, that they hadn't just printed it and put it in the FO's flightbag.

I'm going to make a suggestion, and there's no kind way to say this, but I suggest you put the kettle on, make a pot of coffee and sit down and actually READ the report from start to finish, wild fanciful speculation based on your own theories about what might have happened isn't really helping the flow of the debate here. IMHO.



[Trossie]

...I suggest you put the kettle on, make a pot of coffee and sit down and actually READ ... from start to finish...Best advice for many, many, many who post on PPRuNe!!!

[JW411]

Another worthwhile aspiration is:

Engage brain before opening mouth.

[jumpseater]

SJ may have got confused with the seat refit, as the previous crew fitted them. On arrival at EGAC the accident crew held boarding and were both seen at the back of the aircraft with torches appearing to be doing something with the seats.

Neither crew were authorised to carry out the seat swap and no tech log entries made to reflect the changes in aircraft configuration. The seating on the accident flight was a non standard config.

[Sunnyjohn]

I'm going to make a suggestion, and there's no kind way to say this, but I suggest you put the kettle on, make a pot of coffee and sit down and actually READ the report from start to finish, wild fanciful speculation based on your own theories about what might have happened isn't really helping the flow of the debate here. IMHO. Thanks, BangOrWest. I stand suitably chastised and have deleted the incorrect and wildly speculative part of my post.
I note that you have so far contributed three posts to this very long thread and so I look forward to reading more of your useful and informative contributions.

[blind pew]

It's ironic that around the same time the report was published yet another aircraft crashed after starting an approach when the airfield was below minimums.
Crash: Scat CRJ2 at Almaty on Jan 29th 2013, impacted ground near airport (http://avherald.com/h?article=45ce98f4&opt=0)
There are a variety of reasons why crews break the rules or ignor simple airmanship...until the authorities get their act together the accidents will continue.
Like MANY airline pilots I have broken the rules...mostly as a copilot without any choice except get a job elsewhere...and I have only worked for flag carriers.
A sad industry that hasn't progressed in certain aspects over the last 40 odd years when my mate died in Britain's worst disaster...not properly trained...captains forced to take us along...cr@p maintanence ...and authorities not doing their jobs.

[Chronus]

Have a look at my posts of 1st and 3rd September 2013. Thrust induced assymetry in one and assymetry previously reported on the accident aircraft the other. So all that was necessary for the ladies of fate to add an ill preprared crew who bust minima and for the PNF to compensate for the lack of automation and assume the role of an auto pilot and auto thrust system to bring about the fateful accident.
The question that we really need to debate is the lessons learned. In particular by operators which still appear to continue to allege that flight delays occasioned through technical problems are beyond their control and spend a fortune in the courts to defend claims for statutory compensation. Would it not be a lot better if they applied such resources to crew training and maintenance instead. Overworked, poor and inadequatly trained crews with ill maintained aircraft are a deadly combination.

[jetfour]

Co-incidence?

After three years in storage, Metroliner EC-GPS has left the IoM for Barcelona today.

[BARKINGMAD]

May I suggest that posters to this thread make an HONEST declaration, just as they would as professional flight crew signatories on public transport operations, as to how many pages they have read of the AAIU report?

I admit I'm only up to 145/244 and therefore NOT in a position to comment with enough knowledge and presumed authority on this awful tragedy.

Would the members of the lynching brigade like to 'fess up as to how much of the report they have digested before they spout about how allegedly wicked and evil and stupid they consider these unfortunate pilots were?

Dare they prefix their rantings with x/y pages read and considered, before they continue the outpouring of arrogant and complacent remarks implying their own professional perfection?

If the majority of posters are PROFESSIONAL pilots, I wonder have they lost the qualities of humility and awareness that we can ALL make mistakes under the incredible current commercial pressures.

Engage brain before opening mouth, as previously suggested!

[bookworm]

There is a theory/practise out there that some lift the gate before landing.

There's no explanation I can find in the report as to why the skipper might have selected reverse before touchdown, and MJ's is the only rationale I've seen. But is the 2100 m runway at Cork so limiting that the crew would feel it necessary to be so trigger-happy with reverse?

[BARKINGMAD]

"But is the 2100 m runway at Cork so limiting that the crew would feel it necessary to be so trigger-happy with reverse?"

If it's that sphincter cycling a length of runway, then the Ryr NG800s and Aerfungus 'buses would be having a sporting time?

The Capt's alleged enthusiasm for getting out of the detent should have been rectified during the inadequate preparation as per 2.17.2 of the report, for those too lazy to read it all.

[mad_jock]

Sorry no can do on diagrams the CAMO says there is copy right issues.

Anyway the NTS system on our versions as I thought is a completely separate system to the torque sensing system. Its a ring which slips and actuates a valve which opens a bypass valve which dumps the oil pressure from the beta tube which then the spring pushes the blades to feather.

The torque sensor is a strain gauge bridge on most aircraft with a rare old hydraulic system on one of them.

And as confirmed this very evening that negative torque can be obtained by disking the props and then it goes back to +2 again and then when you apply power again it goes to what ever you want without the NTS triggering and without the blades going to Feather and the power levers forward not in beta. The engineers are sorting the flight idle out as we speak up a couple of notches to +6 and I will do a flight idle check tomorrow to ensure it doesn't dip to zero or negative.

Negative torque is when the propeller is driving the engine not the engine driving the prop.

Its a single action prop BTW

I really don't think they were anywhere near feathered it could be that the negative was when the AOA of the blade was taken to negative value and the blade drove the engine then as fuel was increased to the engine it started driving the blades again. Even if you put the power levers forward again the spring isn't meant to be strong enough to rotate the blades back into a flight AoA. It could be that he put the lever forward again which increased the power but as the blade couldn't get into positive AoA it just gave more reverse which would been seen as a positive torque as the engine was driving the blades not the blades driving the engine. I can't really see how anyone can work out what angle the blades were in. You can't even look at them after the event because without the start locks engaged they will just go to feather as the oil pressure drops off.

If the spring isn't strong enough I can't see how the NTS system can even feather the props because all it does is dump the oil pressure out the beta tube. So even with zero pressure in the beta tube if the forces on the blade stopping it rotating back to flight AoA's are enough to defeat the spring it won't feather.

When we power back off stand the torques read positive in reverse then decrease to zero then increase again as you apply forward movement to the power levers bringing them out of the rev range.

[10Watt]

Beta range l think you meant.

mad - jock, l admire your fortitude.

[mad_jock]

The problem dealing with beta on the garette is that it means something different to the free turbine types.

Yes it means that reverse pitch on the blades is available but it also means there is a swap in shall we say dutys of various controllers.


So beta isn`t really a range its a engine prop control mode in which beta AoA of the prop blades can be used and is available. I think it also does something to the oil system supplying the beta tubes to increase the available pressure to protect against rev in the air with a prop pitch controller failure. But will check that tomorrow.

[10Watt]

l wouldn`t bother mate.

lf you`re happy that`ll do me.

Any news on the deaths ? l don`t check too often.

[mad_jock]

Its as good an excuse as any to read up on the engines. I try and do a sub system per month system revision anyway.

[NigelOnDraft]

mj

I've re-read the 2 sections of the report. My understanding of what they are saying:
The Temp sensor fault in #2 engine gave it higher fuel flow than #1 for matched power levers
Not an issue for normal Ops, albeit crews were seen to match Tq in cruise
From about -9s to -6s Beta range had been selected
Due to the Temp sensor this led #2 to 0% Tq, #1 to -9% Tq
#1 (not not #2) therefore triggered NTS, and (only started to?) feathered prop - seen by an increase in Tq to +22% and RPM drop
Manual states selecting Beta in the air can cause loss of control due drag / asymmetry - no doubt even more so given the mismatch as above NB one Beta interlock still found operated after crash, albeit a little movement and it "popped" back.
From my reading, if either Beta had not been selected, or possibly the sensor fault had not been present, the accident would not have occurred in this manner. Of course, other single event factors could also have prevented it, let alone the complete chain.

I see no implication from the report that the crews' skill (or not) were a factor in the loss of control i.e. given Beta/Sensor fault, the aircraft was "maybe/likely/probably" uncontrollable.

Clearly open to thoughts from those more familiar with TPs as to my misunderstandings or thoughts on what the report has said.

NoD

PS ATPL ~14Khrs, skim read 244 pages, detailed / multiple read of ~100 pages

[mad_jock]

The torque is a function of the propeller load. Not engine output which can only be worked out using rpm and fuel flow (which isn't recorded on those FDR's)

So when the engine is providing power either in reverse(beta) or forward it is a positive value.

If the airflow is driving the propeller its is a negative value.

So when you move the power levers on the ground during an engine run from fully forward to full reverse at 100% rpm the torque will start at 100% then reduce down to zero and then increase again up to about 30%.

The only thing which feathers the prop is the huge spring inside the hub you need positive oil pressure to stop it feathering.

I don't know about the metro but there is a very loud trill beta horn on my type which is operated by a microswitch on the pedestal for power lever position. And the only mention of alarms was the stall warner.

If the plane is horrendously rigged it is possible to get extremely low values of flight idle and negative torque.

The flight idle check is descending between 10k and 6K, flows off anti-ice off rpms 100% and then the power levers back to touch the gate at 140knts(might be a different speed I use a briefing sheet when I do it). Normal values are between 4 and 8%.

I have picked up a plane out of maint where the flight idle went down to -5%torque with the other at 10% which caused a lot of swearing when I got back and the plane in the hanger for 2 days getting re-rigged then another test flight. In general the more experienced you are on these types the lower you prefer the flight idle but -5% is a bit to much even for me even if both sides do it. You can quite happily be at 250 knts at 6 miles on a 3 degree glide and be back at 130 approach speed by 3 miles and hit your 500ft stabilised gate if the flight idle is about 4%.

So just from the torque readings I don't think you can read anything into if the power levers were brought back behind the gate or not. So just because its reading negative torques doesn't tell you where the power levers were. It all depends on the rigging. As for one of the gates being up I don't know what I would grab onto during a crash to try and brace myself.

You get to know individual aircraft as well and the old girls gotchas and I see they had just swapped to the standby aircraft. It could be that the normal one was rigged properly and in the heat of the moment he forgot that this ones flight idle was way out.

It would be interesting to know if a proper flight idle check was done after the heavy landing maint. I can only presume they had the engines out during that to check the main spar. There is no requirement to do a flight idle check on our type after an engine swap but a limitation is placed in the tech log "not to be used for training"

AT 6k hours and 5000ish hours on TP331's

[NigelOnDraft]

mj So just from the torque readings I don't think you can read anything into if the power levers were brought back behind the gate or not. So just because its reading negative torques doesn't tell you where the power levers were.I think we are at cross purposes here - have you read the report?

They are quite clear the power levers and the props went to Beta. I'm not going to repeat their findings / reasoning, but they are clear.

[mad_jock]

yes I have read the report.

And appendix L covers it.

The assumptions are taken from a brand new engine sitting on a test bed. Supplied by Honeywell who are getting there backsides sued off. Analysis done by an engineer who more than likely has never sat in a Metro never mind flown one.

If they had the actual fuel flows it might be more creditable.

But any one who has actually operated these engines in the old heaps they are fitted to can tell you that you can get negative torques in flight with the power levers forward of the beta gate depending on what the flight idle fuel flow is set at. I have lost count how many aircraft I teched because of flight idle being to low and going negative. Most of the time the NTS doesn't fire either as it takes 2-3 seconds to kick in and something like 85lbs of force on the actuator ring what that translates to in neg torque I don't have a clue.

These engines are not some fedec controlled monitored cross checking bits of kit.

They are an analogue control system with I think 16 different variables which the engineers have to tamper with to get them set up. Of course every time you change one variable it changes all the rest. The engineering term I believe is "utter bastard" but they give you a 20% fuel saving over the PT6 free turbines.

So the Honeywell engineers might like to believe they know where the power levers are and what mode the engines are in but any experienced user of the engines/props will tell you its a bit of fanciful make believe after the engine has been on the wing a couple of thousand hours after a hot section to be able to get anything useful from just rpm and torque.

Its pretty easy to set up on the engines you just need to turn the flight idle fuel flow back by 12 "clicks" on an engine set at 4% flight idle and you will get your -9% but then you won't get 100% torque for TO.

[BARKINGMAD]

244/244 pages read!

Surface temp/ dew point +5/+5 at elevation 502 feet.

If airmass was saturated, then the temp at 3000ft, 2500 above field elevation may have been approx +1.25 degrees, assuming lapse rate of 1.5/1000ft.

The aircraft was in this airmass for over 50 mins prior to the 3rd approach.

Any TP operators like to educate an ex-turbofan driver of the likelihood of engine icing in such conditions which might affect the Garrett?

I assume the investigation has looked at this but I have failed to find, or have missed, any reference to the possibility.

[mad_jock]

you have eng anti ice heaters which take air from the second turbine stage. There is a slight performance penalty due to increased egt for departure but nothing for landing or go-around.

I but its a good point because I didn't see anything about the flows settings.

Normally engine anti ice is on at +5 and off at +10 with visible moisture.

This isn't recorded in the FDR if you have them on or off.

Normally it gives a 10-20 degree increase in egt at cruise levels. At 5 degrees you will be torque limited not egt limited so will have 100% torque available with it turned on but the torque increase rate will be slightly less but nothing really noticeable.

[Livesinafield]

Sorry but I disagree...

This mode of operation might be distasteful to some, but as the report and subsequent to the accident shows, is perfectly legal. The CAA picked up Manx2 on some minor website breaches which they corrected, and the CAA continued oversight with seemingly no concern.

EASA and the Spanish CAA bear the responsibility for the "two bob tin pot operation" not being open to UK / Irish scrutiny. It's what our politicians have signed up to... and at heart that is where the basic cause lies, and I doubt will be changed.

In summary, what do you find Manx2 have done either illegally, or even just immorally?

Nothing i suppose, but anyone in their right mind wouldn't step withing 5 feet of a Citiwing/Manx2 flight

i have refused to allow my company to fly me on these flights in the past.....

[Sunnyjohn]

The accident Flight Crew … commenced duty at EGAA at 06.15 hrs (and) downloaded flight documentation including meteorological information for Belfast City Airport (EGAC), Cork Airport (EICK) and Dublin (EIDW) in a handling agent's briefing office at 06.25 hrs.
Correct, but: (report, p 142)
in any case, a departure was made without the Flight Crew having adequate information and a clear understanding of the overall weather conditions. which I think was in my mind when I made my previous comments.

[Bang Or West]

Sunnyjohn - I did actually see the paragraph you refer to on my first reading of the whole report (on the day it was released). It's one of the few parts of the report that initially made no sense, particularly with respect to what is written elsewhere.

However, I then re-read page 115, and it all made sense! Page 142 states that "In any case, a departure was made without the Flight Crew having adequate information and a clear understanding of the overall weather conditions". Read this in the context of Page 115 where we learn that "The evidence indicates that the Flight Crew were unaware of the forecast and actual weather conditions for their nominated alternate airport EIWF and both EINN and EIKY".

The "adequate information" referred to (or lack thereof) clearly relates to the lack of METAR or TAF for the alternate, or points beyond. I'd love to know what B-plan they were working to...assuming they did have a B-plan, didn't they?

[mad_jock]

This is another argument which is quite common with these sort of types of operation especially when tankering fuel.

You actually need two more alts and so load fuel for them or have enough in the tanks to get back to where you started from.

But..

Its a pain in the arse to get another plog printing it and even getting it and it will 9 times out of 10 make you late and ops is reluctant to generate you another one especially so if you paying a third party to produce them as they will charge an additional fee.

And if the crew think its normal to just choose one or two alts that work they tend to over look the requirement for the Alt to be with in 1 hour single engine speed to not contravene that regulation.

You can explain this to guys that have been in the game for 10-20 years that they need to have a PLog and flight plan for what they are actually planning and they just look at you and tell you to stop talking rubbish and walk off. And any comment that we don't have ETOPS approval is met with an equally blank look. And you only have to look at the number of TP aircraft going straight across the Bay of Biscay to realise that the 1 hour single engine is pretty much ignored.

[mad_jock]

Well if you have fuel for the furthest one you will have it for the nearest one won't you.

But that outstanding you need to have the ones your actually using nominated on your log and flight plan and not just say :mad: it here is alright I have round tripped my fuel so we will come back here if we can't get in and you cruise at 230knts for an hour to destination and your single engine cruise speed is 150knts. And on your log and flight plan you have alts which are 60 miles away from destination showing 400m rvr. Or neither are open yet and there is no TAF available just a AUTO METAR saying the wx is OK.

Even if you do get in if you get SAFA checked and they do there job properly you will get your arse in a sling quite rightly.

[Sunnyjohn]

Sunnyjohn - I did actually see the paragraph you refer to on my first reading of the whole report Thanks for the clarification, Bang Or West. It's a very detailed and thorough report and does take a lot of reading and digesting!

[deefer dog]

Forgive me, but did lack of fuel cause the accident? Was there any mention in the report that they did not meet the fuel planning requirements?

Which part of this accident is not understood by so many here? They busted their minimums three times, and ran out of luck on the third attempt.

This is not unlike the more recent accident at KASE where it would appear (subject to the final report being published) that the crew attempted to land while exceeding the certified limits of the aircraft.

[Jack1985]

The aircraft had 3,000lbs before departure from EGAC, more then sufficient for the aircraft to operate to EICK and back to EGAC.

I think trying to rule this down to one single cause, is what will actually see this accident happen again - there is never just one cause, its a series of ones which combine together to cause the accident and its from these from which we should learn.

The fact the No. 1 was retarded on the 3rd final approach also significantly contributed - As did the fact they were fatigued and there were numerous other factors, a statement of ''oh he bust the minima 3 times'' would be an insult to the investigation team of this accident.

As has been advised previously, please read all 244 pages.

[kapton]

Jack 1985 has it spot on about there being more than one cause to this accident. The professional pilots give an invaluable insight into the handling and operation of the aircraft during this tragic event, but I look at it from the angle of all the holes in the cheeses lining up. The pilots involved in this accident did not take off that morning with the intention of making the mistakes which led to the crash. I watched the Manx2 operation from the outside and was appalled at what I saw. Here was a collection of companies who we're doing everything on the cheap whilst giving the impression of being an airline.
Moreover, some of the people who worked for the operation were desperate to work in aviation, which, is one of those holes already lined up before you start. Almost every aspect of the operation was at fault. From the people who set the operation up the way they did, to avoid costs, to the various regulatory authorities, who knew the setup, but sat on their hands hiding behind EASA regulations.
In full view of people who ran the operation, pilots had periods when they weren't being paid, and even carrying out maintenance tasks. In 2 parts of the operation the maintenance back up so woefully inadequate that it was criminal. I think it will be some time for this report to be fully understood, if only for the incredulity one feels when reading it. It is for the lawyers and courts to decide whether legal sanction is taken against certain individuals. But, EASA need to stop existing to issue edicts and regulations, and act now to shut down operations such as what was manx2. Those who died, and their families, deserve that at the very least.

[His dudeness]

In 2 parts of the operation the maintenance back up so woefully inadequate that it was criminal.

I watched the Manx2 operation from the outside and was appalled at what I saw.


Are you saying you watched criminal behaviour and did not report it ?

Just asking....

But, EASA need to stop existing to issue edicts and regulations, and act now to shut down operations such as what was manx2.

In full view of people who ran the operation, pilots had periods when they weren't being paid, and even carrying out maintenance tasks.

So if I as a private person or as a company would charter an airplane from an AOC holder I would have to check their crews paycheck, the mx records and their operational procedures or lack thereof ?

There I was thinking that this what we have aviation authorities for....

[deefer dog]

The aircraft had 3,000lbs before departure from EGAC, more then sufficient for the aircraft to operate to EICK and back to EGAC.

I think trying to rule this down to one single cause, is what will actually see this accident happen again - there is never just one cause, its a series of ones which combine together to cause the accident and its from these from which we should learn.

The fact the No. 1 was retarded on the 3rd final approach also significantly contributed - As did the fact they were fatigued and there were numerous other factors, a statement of ''oh he bust the minima 3 times'' would be an insult to the investigation team of this accident.

As has been advised previously, please read all 244 pages.

I did read every page of the report. The accident would not have happened if the crew had not busted the minimums. Which bit of that is not clear to you, or the investigators (if they happen to be reading).

[NABLAG]

Question: If the crew had complied with the Cat 1 minima (200 ft AGL ?) and the Captain had handled the power in the same way would the crew have enough height to recover ?

[Sunnyjohn]

The accident would not have happened if the crew had not busted the minimums. From what I have read, and I have read the whole report, I don't see how you could know that. Could you explain?

[Big Pistons Forever]

From what I have read, and I have read the whole report, I don't see how you could know that. Could you explain?

Read the METAR's, vis was way below landable mins the whole morning.

[Jack1985]

I did read every page of the report. The accident would not have happened if the crew had not busted the minimums. Which bit of that is not clear to you, or the investigators (if they happen to be reading).

So you can say with certainty that following the application of -9% torque on the No. 1 engine and the left roll followed by the subsequent hard roll to the right which resulted in the loss of control had happened at minima it would not have crashed? Please could you do my lotto numbers when you get a chance? What rubbish.

The crew on both approaches 1 and 2 descended below minima to 101ft on approach 1 and to 91ft on approach 2 - It was a case of multiple factors combining on the 3rd approach that caused this accident not a single one.

[Sunnyjohn]

Thanks, Jack - that was the point I was seeking to clarify. With this hidden problem with the torque, it just seemed to me that this preponderance to roll sharply to left with certain flight settings could have happened at any time, regardless of the weather. Would that be correct?

[Jack1985]

Thanks, Jack - that was the point I was seeking to clarify. With this hidden problem with the torque, it just seemed to me that this preponderance to roll sharply to left with certain flight settings could have happened at any time, regardless of the weather. Would that be correct?

Basically in the latter stages of the final approach to 17 the Commander (PNF) took control of the Power Levers - Which was acknowledged by the Co-pilot (PF). This is an unusual move, as normally the PF handles both flight and engine controls in a coordinated manner to achieve the required flight path - When the PNF took control of the Power Levers they were subsequently retarded below Flight Idle - an action which would have been unexpected by the PF.

Recorded data showed that the No. 1 engine retarded to -9% torque in beta range, whilst the No. 2 engine stayed at 0%.

Then to quote the AAIU,

''This thrust asymmetry was coincident with the aircraft commencing a roll to the left (maximum recorded value of 40 degrees bank). It is possible that the PF may have made a control wheel input to the right in response to the unanticipated left roll. However, without FDR parameters of control wheel or control surface position the Investigation could not determine if such an input was made. The subsequent application of power to commence the go-around, at approximately 100 feet, coincided with the commencement of a rapid roll to the right and loss of control. The roll continued through the vertical, the right wingtip struck the runway and the aircraft inverted.''

And again to quote the AAIU,

''A torque split between the powerplants, caused by a defective Pt2/Tt2 sensor, became significant when the power levers were retarded below Flight Idle and the No. 1 powerplant entered negative torque regime. Subsequently, when the power levers were rapidly advanced during the attempted go-around, this probably further contributed to the roll behaviour as recorded on the FDR.''

So basically to answer you question Sunnyjohn, yes this could have happened in another situation - however as with all accidents its a number of factors which line up together to cause it and as the AAIU have provided 54 findings, a probable cause, 9 contributing factors and 11 safety recommendations to show this.

Again to Big Pistons Forever, trying to pin this down to a single factor is both nonsensical and dangerous - We need to learn from all the factors of which descending below minima is one.

[viren51]

Busting Minimas may not be very uncommon especially in operations where Flight Data Monitoring is not in vogue. One can see just such an example in the recently released investigation report of the CRJ accident, available in African Aviation Section of PPrune:
http://www.pprune.org/african-aviation/447794-un-plane-crash-dr-congo.html

While busting Minimas by a little bit, the crew may believe that he/she is not going to cause an accident, he/she may believes that it may be a way to get the job done.
But Minimas are supposed to provide the safety margin, hence any compromise on Minimas reduces the safety margin.
On most days, one may be able to get away but when chips are loaded against you, busting Minimas may be just another factor in the accident.

[mad_jock]

Perhaps you could explain your verbose and totally meaningless statement above too?

Its only meaningless if your a Microsoft flight sim ATPL.

[Big Pistons Forever]

Again to Big Pistons Forever, trying to pin this down to a single factor is both nonsensical and dangerous - We need to learn from all the factors of which descending below minima is one.

I respectfully disagree. The accident chain started with the deliberate decision to continue the approach below minimums. By removing all of the altitude margin they made a crash inevitable when the engine asymmetry caused the fatal roll.

The airplane may have still crashed if the missed approach had been commenced at the Cat 1 limit but the extra altitude may also have allowed a successful recovery. Where they started the go around there was no possible recovery.

You are correct in the fact that there are many lessons to be learned from this terrible tragedy but for professional pilots the primary take away should IMO be Do not descend below minimums EVER. We pilots can't control many of the mechanical and operational issues that contributed to this accident but not busting minimums is totally and completely under our control.

BTW the FAA accidents stats show that you are 15 times more likely to have a fatal crash on approach if you are flying your third attempt at the same approach.....

[mad_jock]

Have you got a link for that stat BPF I would like to include that stat in some training material.

[Chronus]

The all too important question for debate is why did this crew bust minima. The RT transcscrpit perhaps gives some clues, too many "Sirs" and the unsolicited offer of ATC of a suitable diversionary field.

Have a look at the following link which was published in February 2012, for the main contributory factor and for what now remains to follow.

Lawyer claims pilots' decisions were main cause of Cork air crash. (http://www.stewartslaw.com/lawyer-claims-pilots-decisions-were-main-cause-of-cork-air-crash.aspx)

[mad_jock]

There should be maybe be a change in the phraseology of Irish ATC.

In the UK there is no confusion if you try and bust the approach ban they won't give a landing clearance just "nothing know to affect" after a set phrase ending with "what are your intentions"

[reportyourlevel]

Not so any more, they changed that ages ago.

[mad_jock]

What's it these days?


Last time I heard it was 2011

[Jack1985]

I respectfully disagree. The accident chain started with the deliberate decision to continue the approach below minimums. By removing all of the altitude margin they made a crash inevitable when the engine asymmetry caused the fatal roll.

The airplane may have still crashed if the missed approach had been commenced at the Cat 1 limit but the extra altitude may also have allowed a successful recovery. Where they started the go around there was no possible recovery.

You are correct in the fact that there are many lessons to be learned from this terrible tragedy but for professional pilots the primary take away should IMO be Do not descend below minimums EVER. We pilots can't control many of the mechanical and operational issues that contributed to this accident but not busting minimums is totally and completely under our control.

So basically what you are saying they bust the minima 3 times and its pilot error?

And that's the precise reason you're view of the accident would actually contribute to it happening again - because in essence its a dismissal of every contributory part of the accident.

Look back through aviation - for every accident that the pilots are just blamed there is a repeat, one only has to look at Air France since AF447 in 2009 we've had 3 near stalls and about 5 major incidents which are directly attributable to training and understanding of in-flight upsets.

The reason your single view point will not stand is because;

Had the PF had full control the aircraft wouldn't have encountered the thrust issue or rolls and would have climbed away again - even when they bust the minima.

[reportyourlevel]

It was changed in 2011, we don't say anything at all now. I think this is to remove any ambiguity about responsibilities.

[Big Pistons Forever]

.

The reason your single view point will not stand is because;

Had the PF had full control the aircraft wouldn't have encountered the thrust issue or rolls and would have climbed away again - even when they bust the minima.

Yes but they did have a malfunction. So to me the question is if they had gone missed at the correct DH would they have not lost control even with the malfunction ? There is by no means certainty that this would be the case but I submit there is certainty that starting the miss approach from where he did made a crash inevitable when the engine malfunction occured.

I absolutely agree that there are many lessons here, but deliberately placing the aircraft in such a perilous position made it almost inevitable that any malfunction would doom the aircraft.

So I reiterate my central point. The lesson us pilots should take away from this is Never bust minimums !

[Jack1985]

Yes but they did have a malfunction. So to me the question is if they had gone missed at the correct DH would they have not lost control even with the malfunction ? There is by no means certainty that this would be the case but I submit there is certainty that starting the miss approach from where he did made a crash inevitable when the engine malfunction occured.

I absolutely agree that there are many lessons here, but deliberately placing the aircraft in such a perilous position made it almost inevitable that any malfunction would doom the aircraft.

So I reiterate my central point. The lesson us pilots should take away from this is Never bust minimums !

You're lack of reading of the report is now evident, the malfunction was only evident because the PNF retarded the Power Levers unbeknown to the PF, which resulted in the left roll and subsequent loss of control - So had the PF had absolute control on the 3rd approach and had they still decided to go-around as they did at approx 100ft the accident would not have happened - So you're view of they just bust the minima is wrong! That is a factor.

[Big Pistons Forever]

You're lack of reading of the report is now evident, the malfunction was only evident because the PNF retarded the Power Levers unbeknown to the PF, which resulted in the left roll and subsequent loss of control - So had the PF had absolute control on the 3rd approach and had they still decided to go-around as they did at approx 100ft the accident would not have happened - So you're view of they just bust the minima is wrong! That is a factor.

Or one could speculate that if the exact circumstances that led to the crash had occurred at the correct DH, not at the less than 100 feet AGL the aircraft was at at the time of the go around, would it still have crashed ?

Leaving aside the very poor CRM that had the Captain controlling the power levers with the copilot flying, the crew had no control or advance knowledge of the impending power asymmetry. They did have total control and knowledge of the DH though.

I guess we will have to agree to disagree on this one.

Finally I would like to make one general point aimed specifically at the newer less experienced commercial pilots reading this thread. Sadly the accident record has many examples of aircraft that crashed after busting minimums even when everything was working perfectly. It is just not worth it......

[Jack1985]

Or one could speculate that if the exact circumstances that led to the crash had occurred at the correct DH, not at the less than 100 feet AGL the aircraft was at at the time of the go around, would it still have crashed ?

Leaving aside the very poor CRM that had the Captain controlling the power levers with the copilot flying, the crew had no control or advance knowledge of the impending power asymmetry. They did have total control and knowledge of the DH though.

I guess we will have to agree to disagree on this one.

Finally I would like to make one general point aimed specifically at the newer less experienced commercial pilots reading this thread. Sadly the accident record has many examples of aircraft that crashed after busting minimums even when everything was working perfectly. It is just not worth it......

If I had been presented with an immediate 40 degree left roll but at the decision height with IRVR's of 500/400/400 I would have rejected as I'm sure the crew would have (The fact the crew even commenced the approach with those IRVR's on all 3 occasions is a factor - they shouldn't have), even at 200ft with 40 degree left roll followed by the command to execute the go-around and which resulted in an immediate hard right roll of over 70 degrees I'm pretty sure the aircraft would have crashed, especially with the terrain approaching 17. However that is speculation and as it happened 100ft the consequences were immediate, I agree breaking the DH was wrong of course it is, but to me its a factor in a litany of errors and contributory failings by other parties. But as you said we will have to agree to disagree.

[SloppyJoe]

Think about the events that happen when conducting an approach to minimums with the intention of going around if you are not visual at the DH. Would any of you just prior to DH reduce the power to idle whilst not visual or would you maintain a stable approach with stable power and speed until either visual or going around? I assume there was not much wind or a need to change power setting much due to the conditions in the final stages of the approach.

Having flown turboprops with splits in the power application I can tell you it is only really an issue when advancing from idle or near to it. If they were not land minded they would not have had the power at idle and going around at DH would not have caused a roll.

[mad_jock]

Its the half cocked busting of mins which has an effect.

I am sure most of the experienced TP drivers if they had decided that they were busting mins because they had to, would have just driven the thing to the ground with 20-30 % torque on sticking to the ILS then pitched the nose up slightly when the TWAS said 20 and taken the power off.

I know I have done it in LOFT exercises in the sim a few times in zero rvr.

But then again I think I have had significantly better training over the years. Well I have had training which it seems these two didn't.

There is loads of runway for an aircraft that size.

[Elephant and Castle]

That was not the plan as they did not keep a stable power setting until flare height but retarded the thrust levers below flight idle above 100 feet. These guys where winging it and pushing their luck big time, a luck which run out on them. The choices made by the commander where wrong and that cannot be glossed over. The only way this accident will not be repeated is if pilots in small unresourced outfits such at this one realize that going off piste for the sake of "getting the job done" is not worth loosing your life over. Procedures have a safety margin for a reason.

[mad_jock]

I am a 60 year old pilot, 14,500 hrs, no accidents, paid for all my training 35 years ago. One day I hope to have a job again!

http://www.pprune.org/terms-endearment/532172-stop-bashing-p2f-2.html#post8270983

500 hours since the 18th of January and not even working that's impressive.

Or your the resident village idiot walter mitty from the Instructors forum with yet another login.

But either way if you can't understand that I think the chances of you getting a job are pretty much nil.

[justanotherflyer]

This tragic and regrettable event, among its many complexities, illustrates the danger of permitting uncertainty about who has control.

Once the commander had taken control of the throttles, while leaving the co-pilot to control pitch and roll attitudes, the distinction between PF and PNF became essentially meaningless. Unless this was a specific, drilled SOP, both of them (i.e. neither of them) were now in control. Any ambiguity in their perceptions or intentions was now potentially disastrous.

With control of the flight path now split between two persons, conflicting communications could have played a further part in the accident:

<<speculation alert>>

The CVR dialogue would indicate that the co-pilot (still nominally but no longer fully the PF having deferred control of the throttles - a psychologically stressful situation) was expecting to go around in the event the commander was not visual at minimums. They had referred to an element of the missed approach procedure at 2:54 from the end of the recording: ("Okay missed approach three thousand") and subsequently in the final descent the commander called out heights to minimums as one would when prepared to go around if landing criteria were not met. Two missed approaches had already been made, and alternate fields had been discussed.

At 0:13 the commander made the call "Okay minimum... continue".

My speculation is that the co-pilot, primed mentally for another missed approach, interpreted this call as meaning "go around", whereas the commander, anxious to get in, meant it to signify "continue on the glide slope". As evidence for this contention, FDR data (fig. 5 in the report) shows that from about 0:12 altitude was held level (indeed at 0:11 it shows a slight increase); pitch attitude is increased slightly; and both are sustained until beyond the power reduction at 0:09. My guess: the co-pilot thought they were doing a go-around, but he couldn't do it fully, because the other guy had the throttles. Energy bled off while he sustained the pitch. At about 0:08 power is abruptly restored (likely although not necessarily by the commander) and suddenly the unexpected differential thrust aggravates the situation. A second later the stall warning sounds, and now they are trapped: low, slow, turning, asymmetric, devoid of useful energy (and at odds with what each other is doing?) and with no time, height, or visibility to react effectively.

One of the many lessons we may perhaps take from this event is to ensure that it is always clear "who has control".






Edited for spelling.

[LookingForAJob]

I respectfully disagree. The accident chain started with the deliberate decision to continue the approach below minimums. By removing all of the altitude margin they made a crash inevitable when the engine asymmetry caused the fatal roll.

....

You are correct in the fact that there are many lessons to be learned from this terrible tragedy but for professional pilots the primary take away should IMO be Do not descend below minimums EVER.
I haven't had time to read all of the report nor many of the recent posts on this thread yet but it seems to me that suggesting that the accident chain started on the aircraft is a huge misunderstanding of the events. The chain started way, way before.

There is no question that the crew made errors on the day of the accident. The report offers proposals to explain some of their actions. They were at the sharp end and sadly, along with some of the pax, paid for these errors with their lives. But the most important question is why/how they were put in a position for which they were so poorly equipped and supported. In the report there is a catalogue of weaknesses in the systems that put the crew where they were and which should have ensured that the Operator/Owner supported better the people at the front end. These weaknesses were there either because of incompetence or deliberate by unscrupulous people running the various organisations.

Yes, you may well be right that if the crew had not busted minimums, the accident may have been prevented. But if the chain of events had been broken at any opportunity - and there were many - the accident may not have happened.

Let's go right back to the start, or at least one starting point - Manx2, the virtual airline. You cannot blame anyone, let alone someone who thinks they are a businessman, for exploiting loopholes or grey areas in a legal system.

The report illustrates that there were many clear and, in some cases, blatant breaches of law and regulations but the existence of a 'virtual airline' wasn't one of them. As I read it, Manx 2 set themselves up as the ticket-seller and sold tickets; something that appears to be entirely legal. At the root of it all is the European Commission's desire to have a common and mutually recognised set of aviation regulations but in making it all legal the failed woefully to establish an oversight framework that was fit to deal with cross-border activities. Instead, we now see most opportunities for effective oversight missed by national agencies saying 'I thought it was their job' and pointing to any one of the others in the frame.

If you've got this far, please bear with me while I continue my rant by pointing out that the European Commission was actively aided by EASA which drafted the legislation. This is an agency that is happy to develop reams of sometimes barely comprehensible regulations for all parts of the aviation system.....and also happy to pass the buck to national oversight agencies when weaknesses in the regulatory system contribute to an accident like this.

Much of the reason we have safety regulation is to stop events of this sort. So that the fare-paying passenger, who knows very little about the business of aviation, doesn't need to be afraid of getting on an aircraft because there are experts overseeing what is happening on their behalf. But in this instance, almost all of the multitude of opportunities for the regulatory agencies to challenge the way in which the aircraft were operated were wasted. So yes, the crew made mistakes, and if they had the chance to relive the day with the benefit of hindsight, I have no doubt they would act differently. But though they may have held licenses and been 'legal' up to a point they could easily control, the licences prepare people to work in an environment where the rest of the rules are applied properly - and this, most certainly, wasn't the case in this organisation(s). This crew were working at the entry level to the business, and although fewer lives may be at risk, crews at this point in their careers may well be faced with many more difficult (given their level of experience) decisions and choices to make, and very different pressures, every day than a crew in an organisation where the proper support is provided. This shouldn't be a surprise for any professional working in aviation - and the same issues exist in other sectors of the industry - and it should mean that the regulators are more rigorous (and I don't mean inspect the small operators to death) and ensure that what the crew on the day have a right to expect from the organisation they work for is actually in place.

I could quite accept an argument that the accident chain started the day that Manx2 started up. And the report identifies plenty of holes in the cheese in just the latter parts of the chain.

[His dudeness]

I could quite accept an argument that the accident chain started the day that Manx2 started up. And the report identifies plenty of holes in the cheese in just the latter parts of the chain

What if Flightline would have sold the tickets themseves ? Do you honestly think it would have changed this flights fate ?

I doubt it.

[Henri737]

Dudeness, you completely missed the point made.

[LookingForAJob]

What if Flightline would have sold the tickets themseves ? Do you honestly think it would have changed this flights fate ?I'm not sure I see your point but, no, I doubt it also. But I'm not suggesting that the agency selling the tickets made a lot of difference. Even if that were the case, the Spanish NAA quite probably would have seen little greater justification for doing proper oversight of the flight because it did not take place within Spanish airspace.

But to use the Swiss cheese analogy (with thanks to Jim Reason), the fact that Manx2 sold the tickets was one more slice with a hole. Clearly some of the weaknesses in the system that allowed this accident to happen are more significant than others, but keeping to the simplistic analysis - that is to say, putting some of the dependencies to one side for the moment - plugging the hole in just one slice of the cheese could well have prevented this accident. Of course, on a different day the remaining holes could line up, which is why every weakness that we find needs to be fixed.

[Chronus]

This is simply a Human Factors accident. Unlike a high profile accident such as the THY Schipol crash where Human Factors were investigated, in this instance and in the abscence of a similar investigation, we shall never know why the crew made not one but three illegal attempts to land.

A salutary reminder is the 1989 incident at Heathrow of BA flight B741. The cost of busting approach and landing minima to the captain was a criminal conviction, followed by the very sad loss of his life by his own hand.

Command of an aircraft is a heavy responsibility, the duties of which must be discharged with great care and attention to every detail by all and every person who are concerned and involved in its operations. The person(s) who appoint a pilot to command carry in my humble view equal if not a greater degree of responsibility for his suitability and training for the task.

[Pappa Delta]

So I bought a ticket to Vienna from France on Saturday on the Lufthansa website. The flight was going to be performed by Austrian Airlines as it is a partner and in the end it was operated by Tyrolean Airways. Is this cause for an accident? No, not really.

Manx2 was acting as a ticket seller within their legal limits. They contract an Air Operator Company to supply them aircraft to fly their routes. They give their roster to the Air Operator company and the AOC holder is responsible by law to supply an airworthy aircraft with a trained, certified and current crew who are within their limitations regarding rest and duty times/fatigue and other limitations by law.

The AOC holder did not do this, thats why this outfit was flying around uncontrolled. And thats why the Spanish CAA got a kick for not catching it. The pilots were the last link. Sure, if they had not busted minimums, it would not have happened. But believe me, if people in the management of a company prefer to break limitations for the sake of making a profit and push this on the pilots, your chances that somewhere you will have an accident is many, many times bigger than when that same management kicks your butt if they found out you were breaking a regulation. Wether a pilot can resist those pressures or not is not really the case as it is always in the subconscious somewhere and influences decisions. Thats why I sadly conclude that if this accident had not happened, it would have happened (with this company) somewhere else anyways sooner or later. I'm 100% sure of that.

[Jack1985]

Pappa Delta, Manx2 acted inappropriately in its relationship with Flightline along with Air Lada.

The example you have given is neither noteworthy nor any bit helpful to this thread considering Tyrolean is Austrian now.

Please read the report before ranting off about something you clearly know absolutely nothing about.

Sure, if they had not busted minimums, it would not have happened.

And you know this HOW? what utter rubbish.

[Sunnyjohn]

This is simply a Human Factors accident.It is indeed a human factors accident, but a highly complex one. If you doubt this, read all 244 - repeat - 244 pages of the report, then read this entire thread of 1350 - repeat - 1350 posts. the crew made not one but three illegal attempts to land. and on the third attempt, a mechanical fault produced the crash.

[mad_jock]

I am afraid not sunnyjohn.

It is a handling factor but not the reason for the accident.

Even with the tech issue it should be within the ability's of a professional pilot to deal with it. In fact the crew had already dealt with it 2 times previously.

The cause of the accident was the crew placing the aircraft in a position and then mishandling the aircraft.

Most western pro pilots reading the report and seeing the busting of mins, two people putting primary control inputs in at the same time will see this as a recipe for an accident. The engine tech issue is a factor but not the cause of the accident. To be honest in the grand scope of things most Garret pilots would consider a lag and differences between the engines as normal.

[jumpseater]

SJ

Quote:

the crew made not one but three illegal attempts to land.


and on the third attempt, a mechanical fault produced the crash.


MJ
It is a handling factor but not the reason for the accident.

Even with the tech issue it should be within the ability's of a professional pilot to deal with it. In fact the crew had already dealt with it 2 times previously.



The key difference on this third approach as I read the report, is that only on this third approach did the Commander split the primary control functions, and only on this approach was Beta selected.

As far as the ATC factor in applying minima goes, in the UK since about 2010 (IIRC) the requirement to question crews instrument approach intentions when low visibility is occurring was changed. Many controllers won't know the variations between capability/fit of crew/avionics, for example a biz jet could have had a shed load of cash thrown at it to make it and its crew CatIII capable, whereas another similar aircraft may not. I'd be surprised to see a BE200/Jetstream for example, make a CatII approach (let alone CatIII), but only because of my background. I know others in ATC whom wouldn't get those alarm bells ringing, which is one of the reasons why ATC can't be policemen for crews/aircraft busting minima.

[mad_jock]

You see i ain`t convinced he did get it though the gate and into beta.

I don`t think they would have got the power back up.

And there was no beta horn sounding but i don`t know if they have one. I would be suprised if they didn`t.

I know ours tiggers with in a ball hair of going into beta the microswitch is just after the step that you have to lift the gate up to get behind and your not really into beta until you move the lever another ten degrees of arc.

There is a pic of it in that G-EEST report. It definately was in beta when it did its 5.6g landing.

[fireflybob]

and on the third attempt, a mechanical fault produced the crash.

That may be true but the error chain started when the decision was made to conduct an approach when the weather was below minima (Arguably the error chain started a lot earlier than that with the modus operandi of the "Company").

[mad_jock]

I would say that fireflybob.

It started when someone rostered them together.

And you could say it started when the Captain was a FO and was presumably exposed to this practise.

[10Watt]

Any news of the money men, aka, the "company" ?

l`m sorry that l haven`t checked all posts which may well reveal the answer

but l find it too depressing to stay there long.

There but for the grace of God go l, but l was lucky enough to be given

proper training by proper management and those poor sods weren't.

[wiggy]

A salutary reminder is the 1989 incident at Heathrow of BA flight B741. The cost of busting approach and landing minima to the captain was a criminal conviction, followed by the very sad loss of his life by his own hand.


Point of order about that particular incident Chronus. AFAIK the approach and landing minima, as in AOM, weren't "bust", the court case was brought because in the CAA's opinion the approach was continued when it should not have been (localiser deviation).

As you rightly say the final outcome for the captain was tragic.

[Chronus]

My thanks to Wiggy for his comments. Unless I am mistaken the following link may offer further enlightenment on whether the approach flown by Captain Glen Stewart did amount to bust of minima. Should he have descended below 1000ft agl. The crew of the inbound to Cork did.

http://theairlinewebsite.com/topic/384754-courtesy-don-h/

[fireflybob]

Also with the Heathrow incident the AIB were snowed under at the time with the Lockerbie and other inquiries. In my opinion there should have been a full AIB investigation and then a decision, if deemed necessary, to take the Captain to court.

As it was we had, if my memory serves me correct, a jury attempting to make judgements on aviation technical issues to determine whether or not Glen Stewart was guilty or not - for me, a travesty of the justice "system".

Also if I recall correctly, someone in management on the ground gave the authorisation for the approach after the crew had made this request whilst in the hold. Something like crew not in recency for CAT 2/3??

[virginblue]

Not sure why so many are obsessed with the issue of Manx2.com being a virtual airline. Sweden, for example, if full of them (just think of all those "xyz-flygs"). The criticism always seems to relate to the use of Spanish, German or Czech airlines - I have not seen Links Air being mentioned here. So one could get funny feeling that behind the criticism is the idea that only airlines from the UK can provide a decent, safe and proper service....

From my point of view (as far as the travelling public's perception is concerned), franchising is not much better that the manx2.com concept as the image is created that the passenger is doing business with someone else than he actually is . or maybe even worse as usually a much trusted brand is being franchised.

[Piltdown Man]

Virginblue - I don't think that anyone is saying that only UK airlines are capable of safe operations. What really matters is who is whom do you seek redress from in the case of delays, contractual issues and god forbid, injuries? In a franchising or sub-contracted operation, it's the name on the ticket. But when a ticket seller gets involved, they take the cash but not the risk. Manx2's website implied that it was an airline. Then following a crash with their logo on the tail, they ceased operations. Sloping sholders? Another similar organisation even has the cheek to say that its flights are on time. But they don't have any flights - or do they? I think ticket selling organisations must clearly state in big letters "WE ONLY TAKE CASH, NOT RESPONSIBILITY. FOR CLAIMS, CONTACT..." on the top of every communication. It's not sexy but there again, neither is their business style. It stinks!

[Cyrano]

Inquest to hear from survivors of Cork Airport crash (http://www.irishtimes.com/news/crime-and-law/courts/inquest-to-hear-from-survivors-of-cork-airport-crash-1.1826865)

[Sunnyjohn]

From the Irish Times - date below:

Coroner Court

Wed, Jun 11, 2014, 14:56

A jury has returned verdicts of accidental death at the inquest into the deaths of six people killed when their Manx2 flight crashed in thick fog as it was preparing to land at Cork Airport over three years ago.
The jury of six men and one woman took just over 40 minutes to return the verdicts of accidental death in the case of the two crew and four passengers killed when the Fairchild SA227-BC Metro crashed at Cork Airport on February 10th 2011.

[reefrat]

Have been following this thread from the beginging and not being able to fly a plane, I am a master mariner, I have a couple of questions.
Several posters have described the cause of the accident to being below minima.
Marine enquiriess ask 1. Cause of event, and 2. contributing causes.
Did the accident happen because the plane was too low, or did it happen because the plane acted like a bucking bull due to going astern on one engine.
And if the the former is the case, at what height could the plane be recovered from the violent rolls.
Lasltly would that height be greater than the permissable minima for this plane.

[darkbarly]

Interesting challenge to select a single cause. Perhaps easier to consider the primary hazard, the ground.

Continuing towards the ground, i.e; below minimums, without being able to see it should, for any reasonable person, introduce an escalation of risk that is unacceptable. In addition, proximity to the ground reduces the time available to diagnose and apply the correct recovery action.

Add inexperience, both pilots manipulating but not co-ordinating the aircrafts primary controls, increased stress levels, tiredness, etc this may well be classified by the coroner as an accident but to aviation, and maritime, proessionals this event was predictable albeit the magnitude was not.

Rolling or excessively banking this aircraft would take it beyond certified limits and into the realms of upset recovery (UR) for the crew. These are not practised in the real, commercial, world and not accurately modelled in the simulated world, but nevertheless should be recoverable with sufficient altitude. Generally, 'below minimums' is insufficient altitude to recover from such an upset.

[Piltdown Man]

Reefrat: The aircraft was not being flown correctly. It appears the last part of the approach, when they were lower than their discussion height, was flown too slowly. This resulted in a loss of control when they initiated a go-around. Never be low and slow.

Additionally, a public transport aircraft should be remain controllable at all times, when on the ground or in the air following the failure of any engine. So if an engine failed or spooled up at a different rate to the other, that still should not have been a problem. But a turboprop engine producing reverse is generally a terminal event (as ever, there are some exceptions). Because if this, interlocks are fitted to prevent reverse selection in flight. But when one engine does produce reverse thrust in flight, it will not produce a "bucking bronco." Something far more violent occurs: one wing stops flying, drops and the aircraft yaws and rolls after it. This is often unrecoverable even from thousands of feet (Luxair 9642), let alone close to the ground. I do not believe it is flight tested and there is no requirement to do so. And to put things in perspective, the decision height for a Cat I ILS is generally in the order 200' AGL.

Why this crew flew below the decision height on multiple occasions is the interesting question. Whatever the reason/s, there are certain failings we all suffer from. Amongst these, you'll often find that crews are often their own worst enemies and push things too far. Others work for dreadful employers who won't pay them for diversions or late arrivals. Others expect them to perform tasks which can only done by licensed engineers. Others work without proper supervision. The AAIU have prepared a very interesting report on this one.

[reefrat]

Thanks piltdown , low and slow, no go, high and reverse on one engine also not generally recoverable,,I think this also happened on a plane in PNG, Rabaul???

[mad_jock]

Its all about energy.

Low height you have low potential energy.

Low speed and you have low kinetic energy.

You need energy to recover from any mistake.

Up high you can recover, and if your going fast you can recover.

If you have neither you don't.

[Trossie]

This crash fundamentally had sod-all to do with 'energy' or anything like that.

It was all about decisions. Decisions to do a third approach when the visibility was below minimums for that approach, and then continue that approach busting two sets of minimums.

FULL STOP.

[mad_jock]

the thing is Trossie I am willing to bet that the skipper had done it several times before as a FO and survived.

I agree it wouldn't have happened to me because I would have never made an approach in the first place.

The comment was more for our Ship master to relate to his expert knowledge on ship handling which to be honest in my experience is far harder in confined spaces with a large vessel than landing an aircraft.

[Trossie]

You will find that that is very much what the AAIU reported, the problem is that when people bust these very clearly laid down rules that are there to AVOID crashes like this, organisations like the AAIU then have all the tedious extra work of trying to find contributing factors. And, of course, those comments are not 'for free', they are taken from information detailed in the AAIU report!

(You're not one of those 'limits busters' yourself are you?)

[darkbarly]

This crash fundamentally had sod-all to do with 'energy' or anything like that.

It was all about decisions. Decisions to do a third approach when the visibility was below minimums for that approach, and then continue that approach busting two sets of minimums.

FULL STOP.

Can't agree. Run the entire scenario again, same conditions, same pilot inputs, but this time the GA is initiated at 200`. Definitely recoverable?

I agree that busting limits is a no-no, but I would be mindful that other, less experienced aviators reading such emphatic thoughts might conclude that 200' is perfectly safe.

It provides for an acceptable level of safety, that's all. 300` is safer but unacceptable commercially. There's a trade off, of course.

What is clear is that any crew stepping out the box of standards, and there are many limits within this, increase significantly the likelihood of a bad outcome where there are other unforeseen system (organisational) failures.

To conclude that it was the crews actions alone sets us back 30 years and endorses poor crew training, poor operational control and supervision, inadequate state oversight and the need to apportion blame.

[reefrat]

Did the accident happen because the plane was too low, or did it happen because the plane acted like a bucking bull due to going astern on one engine.
And if the the former is the case, at what height could the plane be recovered from the violent rolls.
I am still a bit confused, my real question was how at what altitude could you recover from self induced stall of the port wing

[mad_jock]

Well in general if you screw up high up you can covert your potential energy into kinetic and get away with it.

But you do have certain situations such as spinning (http://en.wikipedia.org/wiki/Spin_(flight)).

Which require more height, a lot more height.

And to be honest it depends on who is on the stick how much you will use.

Similar to boats at lower speeds the controls are less effective. It is not a speed regime that commercial pilots are used to be in especially if they do their recurrent checks on the aircraft.

there is also a thing called Vmca (http://en.wikipedia.org/wiki/Minimum_Control_Speeds)

There are loads of factors, which as the Captain you have to make sure you don't put your self in the position of being exposed to these factors.

The development of a Captain starts the first day they step into a cockpit, it doesn't matter how much theory you pump into them they get led by the Captains they fly with. I very much doubt the Captain made what he did up on the day.

You also have to think about the time scale involved at the speeds and rates of decent we are talking about. At the normal 700-800ft per min approach decent rate 50ft is only 4 seconds. Which doesn't give you a lot of time to sort things out. Which is why most Captains would have been flying it themselves and not allowing a low houred FO to fly the approach.

Here is a video of a fully automated airbus doing a landing in better conditions than they had on the day.

CAT II ILS Approach Rwy 16 Thessaloniki LGTS-SKG, Airbus A319, manual landing at minimum conditions - YouTube.

And this one in slightly worse.

Cat 3 Landing Zurich...175m Vis - YouTube

It very hard to describe the final moments of a minimums approach, your adrenaline is up from 200ft its see the lights and 20 seconds later your on the ground. The beating your body gets from hormones just doing a successful approach once is quite high but, to then put it through the same thing 3 times they will have been in a form of battle shock getting low on energy and I wouldn't be surprised if the FO's limbs will have been twitching with having coming up and down off an adrenaline high so often with no real time to recover. He won't have been used to it with his experience he must have been terrified. Even after a minimums legal landing inexperienced FO's are buzzing on the adrenalin. Doing it three times will have used up all his ready energy and his body will have been in emergency mode with its reduction in reaction times and performance both physical and mental.

From the CVR recording it went from everything illegal but seeming OK to crash in 2 seconds.

[Trossie]

Direct from the AAIU report:The Investigation identified the following factors as being significant:

- The approach was continued in conditions of poor visibility below those required.

- The descent was continued below the Decision Height without adequate visual reference being acquired.

- Uncoordinated operation of the flight and engine controls when go-around was attempted. The engine power-levers were retarded below the normal in-flight operational range, an action prohibited in flight.

- A power difference between the engines became significant when the engine power levers were retarded below the normal in-flight range.

- Tiredness and fatigue on the part of the Flight Crew members.

- Inadequate command training and checking.

- Inappropriate pairing of Flight Crew members, and

- Inadequate oversight of the remote Operation by the Operator and the State of the Operator.


Please note the first two. Yes, the others are there too, but after those first two.

mad jock, I think that those videos are very good for putting this into context. Just to add to them, everyone should realise that in both of them the aeroplanes were being flown by autopilot, a requirement for those approaches. The aeroplane in the Cork crash incident had no autopilot.

[OVC002]

Wasn't this tragedy a result of the decision to go around with different pilots hands on throttle and stick.

But, possibly, an equal factor was the decision to go around at all. If you're stabilised and bang on gs and loc, why not just continue?

[Yankee Whisky]

Fairchild Swearingen Metroliner - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Fairchild_Swearingen_Metroliner#Accidents_and_incidents)


I seem to remember the Bearskin crash at Mirabel airport where there was a gear failure involved. See link above.........
I further remember that these aircraft when passing over my house on climb out had very noisy props and, according to one pilot I knew, it was a hot landing airplane.

[ehwatezedoing]

Fairchild Swearingen Metroliner - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Fairchild_Swearingen_Metroliner#Accidents_and_incidents)


I seem to remember the Bearskin crash at Mirabel airport where there was a gear failure involved. See link above.........
I further remember that these aircraft when passing over my house on climb out had very noisy props and, according to one pilot I knew, it was a hot landing airplane.
Propair, not Bearskin.
A totally different accident from the one involved in this long topic.
Weather was close to minimums but still within limits. They lost control because they....Lost a wing.

They had a fire who started in the wheel well just after taking off rwy 24L In Dorval. Fire extended to the engine, they shut it down.
Polemic at the time was their choice of runway for divertion in Mirabel since another one may have cut down their air time. This was proved wrong in the accident report, rwy 24 at CYMX was a good choice considering all the factors involved.

Never the less, fire did its job, eat up a spar and their left wing broke up on short final.

[slast]

"If you're stabilised and bang on gs and loc, why not just continue?"

I hope this isn't from someone who fits "PP" part of PPRuNe, as it seems to indicate a basic lack of understanding of what minima are for and how they are determined!!

Just because your instruments say you are "stabilised and bang on gs and loc" it does not follow that your flight trajectory is safe to continue below DH!

DH is simply the lowest altitude that the Loc and G/S accuracy can be assured such that a missed approach can be carried out on instruments, without infringing obstacle clearance criteria.

The decision the pilot is required to make at DH is that the visual cues from the "non-instrument" world have enabled him to finish assessing the aircraft's actual position AND actual trajectory, and concluding that BOTH are satisfactory to continue to a landing. If not a go-around is mandatory.

[mad_jock]

Its only ever been a sim situation for me and as I suspect it didn't matter what we did things would have been arranged that we would have a no options busting mins landing its all academic.

I have seen a mass mayday though after vfr taf at abz turned into 100m haar.

Helibuses were just dumping themselves where ever there was space and shutting down.

I don't think pants english had any effect on this incident.

[reefrat]

Thanks for the scary videos,, at sea if in danger or in doubt, slow her, stop her, or go about is the rule. The stop her bit is not possible for you blokes,, I reckon you are worth more money to do this sort of stuff.

[mad_jock]

It doesn't stop at that level though does it.


A NAA should be in the dock as well for not fullfilling its oversight dutys.

[Star monkey]

Sound familiar?

'Air Croatia is to start-up from Zagreb in early April with this ATR 42, leased from Denim Air and operated by cockpit crews provided by Spanish Aeronova'.


http://www.skyliner-aviation.de/showphotos.main?LC=nav2

[BigFrank]

Still no signs of anything at all from "los chicos del ministerio en Madrí " as far as I can see.

And the Isle of Man sails on oblivious too.

¡ Glad I don't live (or fly as a passenger) in a 3rd world regulatory environment, however !

[BARKINGMAD]

Reading the G-EUOE report, it would seem as if one pilot handling primary flight controls and the other handling the thrust is not confined to this sad accident at ORK?!?!:sad: