Centaurus
12th Feb 2016, 13:07
Well worth reading about this incident.
http://www.atsb.gov.au/media/5768552/ao2014147-final.pdf
In brief: Navigation event involving a Fairchild SA227 aircraft, VH-UUO, Brisbane Airport, Qld on 3 September 2014
On 3 September 2014, at about 0215 Eastern Standard Time (EST),[1] a Fairchild SA227 aircraft, registered VH-UUO, took off from Brisbane Airport, Queensland for a freight charter flight to Bankstown Airport, New South Wales, with one pilot on board. Following the take-off, when at about 200 ft above ground level, the pilot observed the horizontal situation indicator (HSI) indicating a right turn although the aircraft was still maintaining runway direction. The pilot reported that the attitude indicator (AI) displayed alternately a nose up and nose down attitude.
When at about 1,600 ft above ground level, the pilot advised air traffic control of a ‘minor problem with heading’ and was directed to conduct a right turn onto an easterly heading to avoid noise sensitive areas. The pilot turned the aircraft to the right, towards the Pacific Ocean, while referring to the HSI on the co-pilot’s instrument panel, which was providing more accurate heading information. The pilot was aware that the captain’s AI and HSI instruments were providing erroneous indications, but became disoriented by continuing to scan those instruments. The pilot looked out of the window in an attempt to gain a visual reference but could see only blackness.
The pilot continued a shallow right turn until the lights of runway 19 became visible. The aircraft landed back at Brisbane, on runway 19 about 150 kg above the aircraft’s maximum landing weight.
The ATSB found that the cockpit was not configured correctly prior to taxi, nor was the incorrect heading reference detected or corrected during the taxi or line up. The left gyro slaving switch was selected to ‘free’ instead of ‘slave’ mode, resulting in the captain’s HSI indicating about 50° left of actual heading throughout the flight.
The AI probably intermittently malfunctioned after take-off, and the pilot became distracted by the two erroneous instrument indications. These, combined with the dark night and flight over water without visual reference, contributed to the pilot’s difficulty in maintaining orientation and achieving the planned departure track. The pilot therefore elected to return to land at Brisbane.
Safety message
This incident highlights the importance of completing pre-flight checks and ensuring the cockpit is correctly configured prior to taxiing. Particularly when operating at night or into instrument meteorological conditions, it is imperative to verify all reference instruments are indicating correctly. This incident also highlights the importance of communication, especially as emergencies arise. If a pilot is having difficulty controlling an aircraft and maintaining instrument or visual reference, then alerting air traffic control enables them to provide the necessary and appropriate assistance.
............................................................ ....................................
Writer's Comment:
The report mentions the pilot experienced difficulty with erroneous indications on the captains artificial horizon as well as an apparent defective HSI. These problems compounded with dark night and no visible horizon, placed him in an unenviable situation and he did well to get back on the runway safely.
The investigation revealed, that, among other factors, the artificial horizon on his side was well overdue for servicing and it is probable that situation had been like that for several months. Hence its erroneous indications. The report did not say if pilots who had flown that aircraft had also noted the artificial horizon was unreliable or whether that defect had been had been snagged in the maintenance release by any of them.
............................................................ .........................................
Now read below and see the result of similar breach of maintenance that in this case led eventually to a fatal crash in a Mooney M20J. That was in October 1997 . In that accident the pilot's artificial horizon failed due a failed engine driven vacuum pump well overdue for servicing. The pilot lost control on a dark night due to lack of experience with flying on limited panel (ie using the Turn coordinator as an attitude instrument)
............................................................ ..........................................
The aircraft was being flown from Adelaide to Dubbo in accordance with instrument flight rules. At 1921 EST, the pilot reported over Mildura maintaining 9,000 ft, and estimating abeam Griffith at 2026 on a direct track to Dubbo.
The weather in the area was clear, with no restrictions to visibility, and scattered cloud at 30,000 ft. Sky conditions were dark, with no moon.
At 1958 the pilot made a routine frequency change, and 8 minutes later advised Melbourne Flight Service (FS) there had been a loss of vacuum and that he was returning to Mildura. In response to enquiries from FS the pilot advised that he had 'electric backups' and felt it safer to return to Mildura.
He also confirmed his approach and landing would not be affected, and that his estimated time of arrival would be 2029. At 2007 FS asked the pilot for his approximate distance from Mildura. The pilot asked FS to repeat the request, but subsequently failed to reply. Further attempts to contact the pilot were unsuccessful. The last recorded radio transmission from the pilot was at 2007:49.
An uncertainty phase was declared after communication and ground checks failed to establish the location of the aircraft. A local resident reported seeing the lights of an aircraft shortly after 2000, and then hearing the sounds of an impact. The wreckage of the aircraft was subsequently found some hours later. The accident was non-survivable.
An examination of the wreckage indicated the aircraft had impacted the ground at high speed, in a steep nose-down attitude, consistent with loss of control. With the exception of the vacuum system, the aircraft was considered to have been capable of normal operation prior to impact.
The aircraft was equipped with an attitude indicator and a directional indicator, each reliant on air-driven gyroscopes. An electrically powered turn co-ordinator was also fitted. Examination of the attitude indicator showed evidence of a witness mark consistent with the gyro-rotor being stationary at impact. The turn coordinator gyro-rotor was recovered and showed evidence of rotation at the time of impact.
The engine-driven vacuum pump and drive coupling were recovered from the wreckage. The impact resulted in separation of the pump body from its base. Only a few large pieces of the rotor and vanes were recovered. The frangible drive shaft coupling had sheared at some time prior to impact.
A specialist examination considered that either the carbon rotor, or one or more of its vanes, had failed, resulting in pump seizure and consequent shearing of the drive coupling.
An entry in the aircraft logbook indicated that the vacuum pump was installed in September 1991. From that date, until the last periodic inspection in August 1997, the pump had operated for some 1,248 hours. No evidence was found of vacuum pump replacement during that period.
The Mooney 20J Service and Maintenance Manual recommends that the schedule for the primary vacuum pump replacement be either on condition or at 500 hours, and at engine overhaul. The Civil Aviation Safety Authority provides no additional requirements regarding maintenance of the vacuum pump.
The pilot held a Private Pilot licence with a valid medical certificate. His command instrument rating had expired 3 days prior to the accident. Although no evidence could be found of the pilot having flown in instrument meteorological conditions in the previous 12 months, the pilot had conducted a night flight six weeks prior to the accident. A passenger on that flight reported they did not encounter cloud.
............................................................ ........................................
General Aviation Flight Training Devices (aircraft simulators) have been in use since after World War 2. They were often called Link Trainers. Nowadays these instrument flying training devices are in most flying schools and readily available to all pilots at a much cheaper cost per hour than flying the real aircraft. Their fidelity is excellent and often includes "glass cockpit" instrumentation. Failure of various instruments such as the Artificial Horizon and HSI can be simulated allowing skills at flying on `Limited Panel` to be practiced.
Despite the relatively low cost to pilots of practicing instrument flying on these simulators, it seems that they are used primarily by pilots training for their instrument ratings. It would appear that once pilots have obtained their PPL or CPL pilots with instrument ratings, they are happy to forego anymore simulator instrument flying practice. Complacency then sets in.
Even those individuals who enjoy keeping current on flying school FTD's, seem reluctant to practice limited panel manoeuvres which are much more demanding of their instrument flying ability than instrument approaches. This can be put down to `it will never happen to me` syndrome. Or sheer laziness. Or fear of failure. Or a combination of the lot.
This writer was fortunate to be trained by the RAAF in the early post war years. At flying training schools and operational squadrons, a Link Trainer was always available to the pilots and accent was placed on limited panel flying. That was because in those days, most multi-engine aircraft and all single aircraft had only one artificial horizon. If that failed at an inopportune time (Sods Law ensured they did fail then), pilots were well prepared and current on limited panel flying.
The Boy Scouts motto of "Be prepared" could equally apply to instrument flying currency; be it for student pilots and those with higher qualifications. Particularly on Limited Panel with no artificial horizon.:ok:
http://www.atsb.gov.au/media/5768552/ao2014147-final.pdf
In brief: Navigation event involving a Fairchild SA227 aircraft, VH-UUO, Brisbane Airport, Qld on 3 September 2014
On 3 September 2014, at about 0215 Eastern Standard Time (EST),[1] a Fairchild SA227 aircraft, registered VH-UUO, took off from Brisbane Airport, Queensland for a freight charter flight to Bankstown Airport, New South Wales, with one pilot on board. Following the take-off, when at about 200 ft above ground level, the pilot observed the horizontal situation indicator (HSI) indicating a right turn although the aircraft was still maintaining runway direction. The pilot reported that the attitude indicator (AI) displayed alternately a nose up and nose down attitude.
When at about 1,600 ft above ground level, the pilot advised air traffic control of a ‘minor problem with heading’ and was directed to conduct a right turn onto an easterly heading to avoid noise sensitive areas. The pilot turned the aircraft to the right, towards the Pacific Ocean, while referring to the HSI on the co-pilot’s instrument panel, which was providing more accurate heading information. The pilot was aware that the captain’s AI and HSI instruments were providing erroneous indications, but became disoriented by continuing to scan those instruments. The pilot looked out of the window in an attempt to gain a visual reference but could see only blackness.
The pilot continued a shallow right turn until the lights of runway 19 became visible. The aircraft landed back at Brisbane, on runway 19 about 150 kg above the aircraft’s maximum landing weight.
The ATSB found that the cockpit was not configured correctly prior to taxi, nor was the incorrect heading reference detected or corrected during the taxi or line up. The left gyro slaving switch was selected to ‘free’ instead of ‘slave’ mode, resulting in the captain’s HSI indicating about 50° left of actual heading throughout the flight.
The AI probably intermittently malfunctioned after take-off, and the pilot became distracted by the two erroneous instrument indications. These, combined with the dark night and flight over water without visual reference, contributed to the pilot’s difficulty in maintaining orientation and achieving the planned departure track. The pilot therefore elected to return to land at Brisbane.
Safety message
This incident highlights the importance of completing pre-flight checks and ensuring the cockpit is correctly configured prior to taxiing. Particularly when operating at night or into instrument meteorological conditions, it is imperative to verify all reference instruments are indicating correctly. This incident also highlights the importance of communication, especially as emergencies arise. If a pilot is having difficulty controlling an aircraft and maintaining instrument or visual reference, then alerting air traffic control enables them to provide the necessary and appropriate assistance.
............................................................ ....................................
Writer's Comment:
The report mentions the pilot experienced difficulty with erroneous indications on the captains artificial horizon as well as an apparent defective HSI. These problems compounded with dark night and no visible horizon, placed him in an unenviable situation and he did well to get back on the runway safely.
The investigation revealed, that, among other factors, the artificial horizon on his side was well overdue for servicing and it is probable that situation had been like that for several months. Hence its erroneous indications. The report did not say if pilots who had flown that aircraft had also noted the artificial horizon was unreliable or whether that defect had been had been snagged in the maintenance release by any of them.
............................................................ .........................................
Now read below and see the result of similar breach of maintenance that in this case led eventually to a fatal crash in a Mooney M20J. That was in October 1997 . In that accident the pilot's artificial horizon failed due a failed engine driven vacuum pump well overdue for servicing. The pilot lost control on a dark night due to lack of experience with flying on limited panel (ie using the Turn coordinator as an attitude instrument)
............................................................ ..........................................
The aircraft was being flown from Adelaide to Dubbo in accordance with instrument flight rules. At 1921 EST, the pilot reported over Mildura maintaining 9,000 ft, and estimating abeam Griffith at 2026 on a direct track to Dubbo.
The weather in the area was clear, with no restrictions to visibility, and scattered cloud at 30,000 ft. Sky conditions were dark, with no moon.
At 1958 the pilot made a routine frequency change, and 8 minutes later advised Melbourne Flight Service (FS) there had been a loss of vacuum and that he was returning to Mildura. In response to enquiries from FS the pilot advised that he had 'electric backups' and felt it safer to return to Mildura.
He also confirmed his approach and landing would not be affected, and that his estimated time of arrival would be 2029. At 2007 FS asked the pilot for his approximate distance from Mildura. The pilot asked FS to repeat the request, but subsequently failed to reply. Further attempts to contact the pilot were unsuccessful. The last recorded radio transmission from the pilot was at 2007:49.
An uncertainty phase was declared after communication and ground checks failed to establish the location of the aircraft. A local resident reported seeing the lights of an aircraft shortly after 2000, and then hearing the sounds of an impact. The wreckage of the aircraft was subsequently found some hours later. The accident was non-survivable.
An examination of the wreckage indicated the aircraft had impacted the ground at high speed, in a steep nose-down attitude, consistent with loss of control. With the exception of the vacuum system, the aircraft was considered to have been capable of normal operation prior to impact.
The aircraft was equipped with an attitude indicator and a directional indicator, each reliant on air-driven gyroscopes. An electrically powered turn co-ordinator was also fitted. Examination of the attitude indicator showed evidence of a witness mark consistent with the gyro-rotor being stationary at impact. The turn coordinator gyro-rotor was recovered and showed evidence of rotation at the time of impact.
The engine-driven vacuum pump and drive coupling were recovered from the wreckage. The impact resulted in separation of the pump body from its base. Only a few large pieces of the rotor and vanes were recovered. The frangible drive shaft coupling had sheared at some time prior to impact.
A specialist examination considered that either the carbon rotor, or one or more of its vanes, had failed, resulting in pump seizure and consequent shearing of the drive coupling.
An entry in the aircraft logbook indicated that the vacuum pump was installed in September 1991. From that date, until the last periodic inspection in August 1997, the pump had operated for some 1,248 hours. No evidence was found of vacuum pump replacement during that period.
The Mooney 20J Service and Maintenance Manual recommends that the schedule for the primary vacuum pump replacement be either on condition or at 500 hours, and at engine overhaul. The Civil Aviation Safety Authority provides no additional requirements regarding maintenance of the vacuum pump.
The pilot held a Private Pilot licence with a valid medical certificate. His command instrument rating had expired 3 days prior to the accident. Although no evidence could be found of the pilot having flown in instrument meteorological conditions in the previous 12 months, the pilot had conducted a night flight six weeks prior to the accident. A passenger on that flight reported they did not encounter cloud.
............................................................ ........................................
General Aviation Flight Training Devices (aircraft simulators) have been in use since after World War 2. They were often called Link Trainers. Nowadays these instrument flying training devices are in most flying schools and readily available to all pilots at a much cheaper cost per hour than flying the real aircraft. Their fidelity is excellent and often includes "glass cockpit" instrumentation. Failure of various instruments such as the Artificial Horizon and HSI can be simulated allowing skills at flying on `Limited Panel` to be practiced.
Despite the relatively low cost to pilots of practicing instrument flying on these simulators, it seems that they are used primarily by pilots training for their instrument ratings. It would appear that once pilots have obtained their PPL or CPL pilots with instrument ratings, they are happy to forego anymore simulator instrument flying practice. Complacency then sets in.
Even those individuals who enjoy keeping current on flying school FTD's, seem reluctant to practice limited panel manoeuvres which are much more demanding of their instrument flying ability than instrument approaches. This can be put down to `it will never happen to me` syndrome. Or sheer laziness. Or fear of failure. Or a combination of the lot.
This writer was fortunate to be trained by the RAAF in the early post war years. At flying training schools and operational squadrons, a Link Trainer was always available to the pilots and accent was placed on limited panel flying. That was because in those days, most multi-engine aircraft and all single aircraft had only one artificial horizon. If that failed at an inopportune time (Sods Law ensured they did fail then), pilots were well prepared and current on limited panel flying.
The Boy Scouts motto of "Be prepared" could equally apply to instrument flying currency; be it for student pilots and those with higher qualifications. Particularly on Limited Panel with no artificial horizon.:ok: