Convair 340 (C-131D) ZS-BRV crash Pretoria, South Africa

[andrasz]

... perhaps being Senior Check Pilot with Qantas isn't so impressive or reassuring title for paying pax.

If my memory is correct, it was also a Senior Check Pilot who drove the golf cart at Don Muang...

[A Squared]

Yes, it's unclear from the report if the cockpit-mounted Go-Pro showed the RPM and Manifold Pressure gauges, and indeed whether the readings from the L/H Manifold Pressure gauge were erroneous.

I'd say that it was indeed clear from the report that at least the tachometers were visible in the footage:

The cockpit GOPRO recording also shows that the left engine RPM gauge was fluctuating and that later the left engine fire master caution light was illuminating and an audible warning sound was heard. The GOPRO recording also shows the control wheel deflected to the right and the captain indicating that they had lost aileron, and requesting rudder input from the FO.

[Bleve]

... perhaps being Senior Check Pilot with Qantas isn't so impressive or reassuring title for paying pax.

That is a grossly offensive comment. The two pilots are still in hospital in a critical condition, unable to give their version of events and you want to take the opportunity to put the boot into Qantas? Shame, shame on you.

[Airbubba]

Was he required to? I have no idea what the SA laws are, but I know that for a non-revenue non-airline flight like this in the US, the FO would not be required to have a type rating, just have received certain type specific training. On the other hand, some countries require a "type rating" in a duchess. I have no idea where South Africa falls in this range.

From the preliminary findings posted above:

2.7 The Aircraft Flight Manual requires two pilots to operate the aircraft and both need to be rated on the aircraft, however the documents and licenses made available to Investigation team indicates only Captain rated on the aircraft (Convair 330/440).

[A Squared]

Agreed.
Would be interesting to know if it was a deliberate decision (not to go through the fire checklist, and if so why) or if they just froze...

Well, the report says: It also shows that though the pilots and LAME were informed of the left engine fire, they were asking each other which engine was on fire. At no stage did the pilots or the LAME discuss or attempt to extinguish the left engine fire, as the left engine fire extinguishing system was never activated.

Other parts of the report indicate that the cockpit GoPro footage picked up the crews conversation. The absence of a discussion on whether to shut down the engine seems to suggest that it was not a conscious decision. If they had made a choice to not shut down the burning engine because they needed the thrust for performance, I would have expected there to have been at least some discussion or statement between the crew about that.

[A Squared]

From the preliminary findings posted above:



Thanks, missed that in my earlier perusal.

[A Squared]

That is a grossly offensive comment. The two pilots are still in hospital in a critical condition, unable to give their version of events and you want to take the opportunity to put the boot into Qantas? Shame, shame on you.

Well, to be fair, there are a number of facts, not subject to the pilots' version of the accident, which appear not to reflect well on them here.

[The Ancient Geek]

They didn't have the right licenses, they didn't use the right procedures and they flight planned to a closed airport. Then they crashed the plane. Other than that Mrs. Lincoln, they did a terrific job.

The closed airfield was notified in a new NOTAM which did not reach the FAWB controller until after the flight
had departed.
They had valid Australian licenses which had not been fully validated for the SA registered aircraft. A paperwork issue.

[A Squared]

They had valid Australian licenses which had not been fully validated for the SA registered aircraft. A paperwork issue.

The FO had a valid Australian Air Transport, Commercial and Private Pilot Licence, however he was not type rated on the aircraft (Convair 340/440).

Looks like more than a "paperwork" issue. Looks like the FO needed a CV340 type rating and didn't have one, on any license.

[Chris Scott]

I'd say that it was indeed clear from the report that at least the tachometers were visible in the footage:
Thanks A Squared, I shouldn't have included RPM gauges in that sentence. But my comment on the Manifold Pressure gauge stands. Yes, the report seems to confirm the fluctuating RPM of the L/H engine that I originally inferred from the video taken from the airport boundary.

Unfortunately I can't pick out the specific engine gauges in the nice cockpit photo that megan posted here:
https://www.pprune.org/showthread.php?p=10201954

I also infer that the crew had little confidence in the L/H Manifold Pressure gauge, and that might have contributed to any loss of awareness of engine performance.

[EDML]

This is the link to the report: http://www.caa.co.za/Accidents%20and%20Incidents%20Reports/ZS-BRV.pdf

Very detailed for a preliminary report and certainly worth reading.

It also contains a high res capture from the video showing the burning engine. This pic clearly shows the left aileron all the way up. It even looks like it is deflected past the normal operating range.

[Capn Bloggs]

Re the type-rating of the FO, page 13 says that he was "type endorsed: Yes" :confused:

[A Squared]

Re the type-rating of the FO, page 13 says that he was "type endorsed: Yes" :confused:

Hmmm, so it does. But then page 28 says:

The FO had a valid Australian Air Transport, Commercial and Private Pilot Licence, however he was not type rated on the aircraft (Convair 340/440).

and

The Aircraft Flight Manual requires two pilots to operate the aircraft and both need to be rated on the aircraft, however the documents and licenses made available to Investigation team indicates only Captain rated on the aircraft (Convair 330/440).

The report seems to be contradicting itself

[Bend alot]

Yes that seems a contradiction but did not cause the crash IMHO.

Two things got just a passing comment, stiff or heavy rudder and loss of aileron control.

Also mention that it was not climbing well.

I can only guess that putting out the known fire was not the priority at the time.

[Rodney Rotorslap]

I can only guess that putting out the known fire was not the priority at the time.

I think Bendy has hit the nail on the head. Things must have been dire.

[Centaurus]

Quote:Doug ferried the Hars Convair out from South Africa last year.https://www.pprune.org/images/statusicon/user_offline.gif https://www.pprune.org/images/buttons/report.gif (https://www.pprune.org/report.php?p=10194676) 000



I saw a media photo last year of that HARS Convair taken during its initial take off climb. As a former Convair 440 pilot from over 50 years ago, I noticed that one upper cowl flap was fully open on one engine. The angle of the photo restricted the view of both upper cowl flaps. Normally that would be a serious event as the drag from a fully open upper cowl flap would be prohibitive in event of an engine failure at that stage.
My thought was maybe the cowl flap motor was inoperative and the crew had perhaps mechanically wound the cowl flap to the full open position for a ferry flight due lack of spares at the point of departure. That would be inconceivable to me as the CHT on that engine would be very low with all that cooling airflow through the engine and effect on the cylinders. I wrote to HARS for their comment but received no acknowledgement



Please forgive the longish high-lighting of a previous post. Photos accompanying the official report prove beyond doubt the accident aircraft departed with the top and bottom cowl flaps fully open. See above previous highlighted comment. The photo shows a fire that can be seen through the open top cowl flap. Is it possible that the intensity of the fire could be made worse by the airflow through the open cowl flap?
The drag would be significant. I was a QFI on the RAAF Convair 440 Metropolitan based at Canberra in the 1960's era. As far as I recall it was unheard of to take off with the cowl flaps fully open.

Again if my memory serves me correctly, for take off we selected the cowl flaps selector switches to a position called "Trail" or similar name and the cowl flaps would then close to a position about two inches open. This gave minimum drag commensurate with keeping the CHT within take off limits.
The report states the propeller of the engine on fire was not feathered; indeed the fire drill was not actioned either. At impact, evidence indicated the engine was delivering very little power. It is no wonder the aircraft was unable to maintain height on one engine given the high density altitude, the drag from a windmilling propeller and the fully open cowl flaps on the engine. It is difficult to know why the company policy required the cowl flaps to be set fully open for take off. It was the same cowl flap policy apparently that HARS used for the first Convair ferried to Australia.

The single manifold pressure gauge with twin needles marked 1 and 2 and the single RPM gauge with its twin needles marked 1 and 2 which were on the Convair 340 and 440, could be a bit of a trap for the unwary. I experienced a runaway left propeller at 500 feet after take off at Canberra in a Convair 440. The very first indication was the very loud increase in noise from the left side of the aircraft. A quick glance at the RPM gauge showed a rapid "split" occurring between the number one and number two needles and for a few seconds it was difficult to confirm if one needle was indeed reducing in RPM and the other increasing in RPM. I would imagine the same would apply to a manifold pressure gauge with its dual needles. The South African report reveals there was initial uncertainty among crew members which engine was the problem. With the single manifold pressure and single RPM gauge design, I can understand that.

The report stated the LAME was handling the engine controls. That is another trap IMHO. Too many cooks spoiling the broth, as the saying goes. I saw this happen once. During my time as QFI at Canberra on the Convair 440, I was tasked to test the pilot of a USAF Convair 340 for his instrument rating. The Convair 340 (or maybe it was a Convair 240 I am unsure now) was based at Canberra for the use of the United States Consul General and his staff. The pilot was a Major in the USAF and it was policy to carry a "Crew Chief" who had the rank of Staff Sergeant I think. In other words he was an LAME who was primarily responsible for the servicing of the US Embassy aircraft. The crew chief sat in the jump seat and among other duties he started the engines (which could be a quite complicated procedure involving multi-fingered switch flicking and lever operation). He also handled the throttles, pitch and mixture levers, and cowl flaps - even though a co-pilot might be present.

During the instrument rating test, one engine was shut down in cruise and checklists followed. Except I noticed the mixture on the live engine was still in lean even though the live engine was at METO power. The crew chief who was doing the engine handling did not notice the lean mixture. The captain missed it as well. He was relying 100 percent on the crew chief to push and pull the appropriate levers and knobs. When I pointed out to the captain the mixture on the live engine was not placed in rich he got very cranky and harsh words were exchanged between the hapless crew chief and the captain. The captain refused to accept he was equally to blame for the missing checklist item.
Afterwards I pondered this situation and came to the conclusion there were too many hands on the flight deck sharing simple tasks and if there were already two pilots in a two crew aircraft it was superfluous to have someone else, no matter how qualified, reaching between them operating engine controls.

[uncle8]

we selected the cowl flaps selector switches to a position called "Trail"
"Trail" and "Trial" are shown on the cowl flap panel gauges and switch position? in Fig. 3

[uncle8]

https://cimg0.ibsrv.net/gimg/www.gmforum.com-vbulletin/276x213/cowl_962672d0df42e8d4b8e1793e8da2d7e5c32848d3.jpg
cowl flaps selector switches to a position called "Trail" or similar name and the cowl flaps would then close to a position about two inches open. This gave minimum drag commensurate

[Capt Fathom]

Just as all the wild theories were petering out, up comes the Preliminary Report....
And off we go again!
:}

[Bend alot]

Just as all the wild theories were petering out, up comes the Preliminary Report....
And off we go again!
:}
Except now there are evidenced factors that bring in primary control surface problems and a L/H engine issue.

Jet A1 is removed as a issue, as seems a R/H engine failure.

There seems to be a large amount of audio/video evidence including in the cockpit.

[andrasz]

The report seems to be contradicting itself
The way I read it, the FO had a valid Australian license with the appropriate type rating. However to operate a ZS registered aircraft that license must be endorsed by the SA CAA. Apparently this endorsement was lacking.

[atakacs]

The closed airfield was notified in a new NOTAM which did not reach the FAWB controller until after the flight
had departed.
Sorry for the slight thread drift but is it common practice to close an airport for maintenance in what seems to be very short notice ?
Assuming they had no technical issue what would have happened ? Divert to where ?

[Eric Janson]

From the interim report

1.1.3 On 06 July 2018 maintenance checks (A, B & C) were performed on the aircraft at 18115.1 airframe hours The accident flight was the first flight post maintenance.

Since the first flight after maintenance is basically a test flight I'm surprised they'd be taking passengers. Since it's unknown what issues will occur it makes more sense to have the minimum number of people on board and to keep the weight as low as possible.

I wonder if the outcome would have been different if they'd done this.

[A Squared]

The way I read it, the FO had a valid Australian license with the appropriate type rating. However to operate a ZS registered aircraft that license must be endorsed by the SA CAA. Apparently this endorsement was lacking.

I'm not sure how you read: The FO had a valid Australian Air Transport, Commercial and Private Pilot Licence, however he was not type rated on the aircraft (Convair 340/440).

...and conclude: the FO had a valid Australian license with the appropriate type rating.


Very puzzling.

[PukinDog]

The way I read it, the FO had a valid Australian license with the appropriate type rating. However to operate a ZS registered aircraft that license must be endorsed by the SA CAA. Apparently this endorsement was lacking.

2.2 of the prelim states, referring to his Australian license..
2.2 The FO had a valid Australian Air Transport, Commercial and Private Pilot Licence, however he was not type rated on the aircraft (Convair 340/440).

2.3 deals with his SA validations...
2.3 The FO’s validation of his foreign license was only limited to Single Engine Landing aircraft with the following aircraft types (C150, C172, C182 PA 28 A/B) this is based on his foreign license validation application and skill test report dated 9th of May 2016 and the validation was valid until 05 May 2021.

The way I read the above, he wasn't type-rated on the Convair in Australia (or SA), and his SA validation was limited to SE only (limited to the light aircraft types listed), yet he was operating as crew on a ZS-reg ME aircraft.

[A Squared]

The way I read the above, he wasn't type-rated on the Convair in Australia (or SA), and his SA validation was limited to SE only (limited to the light aircraft types listed), yet he was operating as crew on a ZS-reg ME aircraft.

That was my take-away as well ... the "Type Endorsed" notation in the personnel matrix notwithstanding.

[rog747]

it's not a good read sadly - especially when the injured crew and pax are still recovering in hospital

test flight but with load of 17 pax (first flight since A B and C checks) although pax had signed indemnities - so the report states.
operating to a notam'd closed field - although flight was described as a ''scenic flight'' -- had they intended to land or simply return to their originator?
flight crew (F/O) not seemingly type rated for this a/c type in RSA or his home country nor for ME classification in RSA.
auto feather light inop (LAME says bulb u/s)
engine on fire seemingly not positively identified by the flight crew and the fire check list was not initiated.
handling issues were prevalent
CRM concerns - as noted in the report

Rovos Rail still officially owned this aircraft and it was still registered to them - due to hand over to the Dutch air museum on arrival at AMS.
The LAME on board was employed by them.

we have lost 3 vintage airliners in a few weeks - all with pax on board and 2 with serious fatalities - for the preservation movement this is very sad

[Onceapilot]

In the report, 1.6.1 "The minimum permissible cylinder head temperature is 260°C (500°F); the minimum permissible oil-in temperature is 100°C (212°F)," should read "Maximum" for those two conditions. Overall, seems like a well presented prelim report. Expect the final version to include more specifics, particularly a more thorough analysis of the engine fire/fail and actions of all responsible in the whole sad saga.

OAP

[rog747]

an update from the Pprune Ozzie forum about the injured crew posted 4 days ago....

quote:
They are coming back probably in the next ten days, states as being repatriated by QF. (does not state whether on stretchers on a QF flight or by med-vac flight)
a pilot who saw them in hospital - Doug is responding with hand squeezes, but Ross is still critical.
they were both in induced comas since the accident.

One of the pilots had his wife onboard and she is recovering well so the thread states....

[Double Back]

I see quite a few drivers that can be a problem with a "go minded" attitude.
With all the folks on board, who had been contributing to the restoration, all were eager to fly, included the crew.
The limited time available before the actual ferry flight.
Possible the limited time the crew had (one was still on active duty with the airline) to complete the whole schedule, before needing to return the long way home.
And who knows what more.

That reflects in decisions like not returning to the hangar to investigate the stiffness of the rudder and the drifting during taxy. Especially from a test flight crew You might expect a critical attitude. Long time ago a very experienced colleague learned me that You can fly with nearly any problem, as long as You know the source and be able to make a risk assessment.
In all they had to operate in what I would call an 'hostile environment` with many distracting elements. Were this same flight to be flown at their home turf (including SL altitude and w/o pax), the outcome would have been different.

On the SA "validation" part: long time ago I used my (Dutch)ATPL as a basis to get a simple PPL (VFR) validation to use for renting a SE for sightseeing trips when I had a layover in JNB. I cannot describe the procedure other than terrible bureaucratic. It involved a trip to a field to do an early morning checkout and drive to Pretoria (office closed at 13.00hrs) with all the paperwork. My normal license which was valid for 2 Years, it included an IF rating with a due date always less that 6 months away, and the SA validation got limited to that date, no matter I said I did not want to include IF in my PPL. In practice every time I got there, I had to go over the same procedure every time, so after 3 times I gave up.
But maybe things have changed.

And for my flying abroad: I flew at many stops we had layovers: like in Alaska, LAX, Houston, Atlanta, NY, Chicago, Curacao, Nairobi, Santiago and even Thailand. Besides the XX thousands of airline hours have some 5500 hours on GA planes, but sometimes I just rented with a local instructor, to have someone O/B who knew all about local stuff. Having experience on a plane alone is not the whole story.

[A Squared]

In the report, 1.6.1 "The minimum permissible cylinder head temperature is 260°C (500°F); the minimum permissible oil-in temperature is 100°C (212°F)," should read "Maximum" for those two conditions.
OAP

I noticed a a few discrepancies like that in the report. It stated the propellers were Composite, which they are not, they're aluminum. The position of hte accident was given as S26°67.031" E028°28.461" which is just gibberish, not a valid set of coordinates. The actual position of the crash was about S25 40' E28 17'

[sycamore]

Another cockpit photo can be found on `Jetphotos.com-N8042W `..Different layout ,but clearer..

[Dan_Brown]

Double Back. Good post that.

let us remind ourselves.

Accident reports are very informative of what happened and when. WHY it was allowed to happen is a whole new ball game.

It is possible the P in C faced time constraints and faced pressure deriving from that.

let us not be too critical of the crew, as anyone with any sort of substancual and varied experience will agree, it can happen to anyone, given the circumstances. 20/20 hindsight is a wonderful thing. Let's all try and learn from this, as in all accidents. Their luck ran out. If we fly often and long enough, by the law of averages, our luck will desert us also. More so of course, in a ferry or test flying environment.

[Bell_ringer]

Sorry for the slight thread drift but is it common practice to close an airport for maintenance in what seems to be very short notice ?
Assuming they had no technical issue what would have happened ? Divert to where ?

This appears to have been a short, local, VFR flight. The closed field had been NOTAM'd for a while and was only 60nm from the departure point with alternates available.

[The Ancient Geek]

They probably had no intention of landing, it is common practice to use a suitable field as a waypoint in the flight plan for a round trip pleasure flight.

[EastMids]

The GOPRO recording also shows the control wheel deflected to the right and the captain indicating that they had lost aileron, and requesting rudder input from the FO.
So from video evidence through the cabin window the left aileron was in the maximum up position, earlier conjecture suggesting the fire could have stretched or severed the control linkage (as had happened during another Convair engine fire). That aileron up would tend to a left wing drop / turn - but a left turn wasn't evident in the cabin video. Now it appears from the GoPro footage that the control wheel was deflected to the right which would cause right aileron up, maybe in an attempt to counter an uncommanded left aileron up condition? Both ailerons up, drag from an unfeathered prop, loss of power on the left hand side. I guess if all that was so the only way was down?

[atakacs]

I guess if all that was so the only way was down?

Well eventually....

More seriously it would seem that they were pretty much comited to a return to the departure airport and never considered an emergency landing. That so many walked away is just sheer luck.

[Chris Scott]

Great to have Centaurus back in the discussion. IIRC he's the only poster with CV-340 pilot experience on the thread.

...Photos accompanying the official report prove beyond doubt the accident aircraft departed with the top and bottom cowl flaps fully open. See above previous highlighted comment. The photo shows a fire that can be seen through the open top cowl flap. Is it possible that the intensity of the fire could be made worse by the airflow through the open cowl flap?
The drag would be significant. I was a QFI on the RAAF Convair 440 Metropolitan based at Canberra in the 1960's era. As far as I recall it was unheard of to take off with the cowl flaps fully open.
...if my memory serves me correctly, for take off we selected the cowl flaps selector switches to a position called "Trail" or similar name and the cowl flaps would then close to a position about two inches open. This gave minimum drag commensurate with keeping the CHT within take off limits.
Yes, "TRAIL" is also used for take-off on the C-47 with its R1830 (Twin Wasp) engines, and now see selector panel in post by uncle8 above.

The report states the propeller of the engine on fire was not feathered; indeed the fire drill was not actioned either. At impact, evidence indicated the engine was delivering very little power. It is no wonder the aircraft was unable to maintain height on one engine given the high density altitude, the drag from a windmilling propeller and the fully open cowl flaps on the engine..
As I posted in my first reaction to the report (https://www.pprune.org/rumours-news/610956-convair-340-c-131d-zs-brv-crash-pretoria-south-africa-13.html#post10221120), "The report suggests that the L/H propellor was receiving much less power and/or rotating slower than the R/H at impact, but that no shut down had been performed by the crew. In the absence of any explanation, it seems incredible that, faced with a failure and fire on the L/H engine and an accompanying loss of climb performance, the captain would wish to keep it running."

The single manifold pressure gauge with twin needles marked 1 and 2 and the single RPM gauge with its twin needles marked 1 and 2 which were on the Convair 340 and 440, could be a bit of a trap for the unwary. [...] The South African report reveals there was initial uncertainty among crew members which engine was the problem. With the single manifold pressure and single RPM gauge design, I can understand that.
Indeed, showing a critical parameter for two engines on a single gauge is an ergonomic nightmare although - from his position behind the pilots, and with only the engines to handle - the LAME was in a good position dispassionately to interpret the gauges. OTOH, unlike the PF, he would not know how much yaw (if any) was accompanying the engine problem, i.e., how much rudder/control-wheel was being applied, and the forces needed to do it.

The report stated the LAME was handling the engine controls. That is another trap IMHO. Too many cooks spoiling the broth, as the saying goes. I saw this happen once. [...]
[...] Afterwards I pondered this situation and came to the conclusion there were too many hands on the flight deck sharing simple tasks and if there were already two pilots in a two crew aircraft it was superfluous to have someone else, no matter how qualified, reaching between them operating engine controls.
Yes, although I don't need to remind you that all large and long-haul aircraft employed a flight engineer to mind the engines and most other systems from the 1940s to the early-1980s, culminating in the L-1011, DC-10 and B747 Classic. And, of course, the Airbus A300B. When Airbus redesigned and automated the A300 cockpit and introduced the glass-cockpit A310 and A300-600 - with all systems-switches within reach of both pilots - the design was euphemistically referred to as the forward-facing crew cockpit. Airbus really meant it was a two-pilot cockpit, but was trying not to antagonise the flight-engineers' unions. So Air France introduced the A310 with two pilots and a forward-facing F/E. That didn't last long, and meanwhile Boeing had introduced the two-pilot B767. When any member of a cockpit crew is relegated to a monitoring role, (s)he loses motivation and can even be a liability in an emergency.

In this case, it's possible that the captain had tacitly delegated any decision-making process on engine handling to the experienced LAME, who regarded the aircraft as his baby. The LAME, on the other hand, may have been waiting simply for the captain to call for the engine fire drill. This, and a lack of communication, could have led to a mutual paralysis in decision-making and nothing was done. Very soon after, both pilots became preoccupied with trying to maintain control of the aircraft.

This preliminary report, as previously stated by me and others, contains minor anomalies. More significantly, there is no mention of fuel analysis. Perhaps that will follow.

[Daysleeper]

What a depressing report. As others have pointed out there are some contradictions in the report itself but these tend to be cleared up and get worse, not better, by the time of the final report.

Lawyers will have a field day with this and so they should.

[EDML]

So from video evidence through the cabin window the left aileron was in the maximum up position, earlier conjecture suggesting the fire could have stretched or severed the control linkage (as had happened during another Convair engine fire). That aileron up would tend to a left wing drop / turn - but a left turn wasn't evident in the cabin video. Now it appears from the GoPro footage that the control wheel was deflected to the right which would cause right aileron up, maybe in an attempt to counter an uncommanded left aileron up condition? Both ailerons up, drag from an unfeathered prop, loss of power on the left hand side. I guess if all that was so the only way was down?


When the cable is severed or stretched, both ailerons will be up. Of course that will be a lot of additional drag.

Marcus

[Marty33]

Another factor could be the single engine performance capabilities that the CV 340 was certificated under. Under ideal conditions they are marginal at best, throw in a rats nest of engine/control/cockpit confusion and the odds were long.

[atakacs]

Wondering: where the passengers made aware that this was a test flight out of fairly significant maintenance?

[sgs233a]

Wondering: where the passengers made aware that this was a test flight out of fairly significant maintenance?

The report mentions that the passengers signed waivers, but doesn't seem to go into more depth.

[atakacs]

Yup.

I for one would have gladly signed a waiver to fly this bird (or the JU-52 for that matter) but would have been reluctant to do it straight out of maintenance...

Maybe someone with more knowledge of this operation will chime in.

[voyageur9]

That is a grossly offensive comment. The two pilots are still in hospital in a critical condition, unable to give their version of events and you want to take the opportunity to put the boot into Qantas? Shame, shame on you.

Save the moralizing. In case you haven't noticed, dozens of people have been killed or injured in the last month in crashes of vintage aircraft where innocent people (mostly aviation enthusiasts) put their trust in skilled, experienced cockpit crews. The crashes of the Convair 340, the JU-52, the Dakota, and the de Havilland Dragon Rapide, may not have any common cause but they all share the elements of vintage aircraft being flown for the delight of aviation enthusiasts. This isn't about "versions of events," it's about reducing the chances of more people being unnecessarily killed if the failures can be identified and avoided. And that includes human failings.

[megan]

Better photos. Thanks for the pointer sycamore.

https://cimg5.ibsrv.net/gimg/www.gmforum.com-vbulletin/1020x763/24997_1165766039_d266d917c6ab5e6874c9657632abfa513c7f1fe5.jp g
https://cimg2.ibsrv.net/gimg/www.gmforum.com-vbulletin/1200x822/54593_1436467891_f378ce960e39f198d37f2fc288c0b68d9cb2100d.jp g

[SLFinAZ]

I'm very surprised by certain aspects of the preliminary report and would love to get some clarification. My understanding is that the PIC and FO are both very senior pilots from the same airline (hence culture), the PIC being a very senior line officer (for lack of a better term).

From the report I got no sense of any command presence, no radio call, no briefing/statement of intent to the FO or LAME...I find that both confusing and disturbing. This event unfolded over minutes....not seconds. Once the balloon went up I would have expected the captain to exercise
command authority? They specifically mention the rudder issue but no mention of any briefing on mechanical or other issues and emergency procedures? If this has been a "professional" flight for the two of them wouldn't you brief the takeoff and then wouldn't the PIC clearly state his intentions when
the engine failed? My very limited understanding is that you always brief alternative options for engine or other failure. Obviously in modern commercial multi-engine jets your expectation is to be able to return and land but in single engine and some GA light twins that's not always possible. I'd assume in
an older plane like this there was/should be a clear assessment of what options would be available for an engine failure outlining both the optimal return path and the best alternative for ditching if that's the only option.

That had to be the PIC's responsibility and it needed to be done quickly with whatever input he required from the FO or LAME. The lack of a quick and concise summery and course of action from the PIC is perplexing to say the least....

[Centaurus]

If this has been a "professional" flight for the two of them wouldn't you brief the takeoff and then wouldn't the PIC clearly state his intentions when
the engine failed?
On the other hand, it is also quite possible the before takeoff safety brief was covered in full detail before engine start but not necessarily covered on camera?. No doubt that will be cleared up once both pilots have fully recovered from their injuries.

[CurtainTwitcher]

From the report I got no sense of any command presence, no radio call, no briefing/statement of intent to the FO or LAME...I find that both confusing and disturbing.
"Everybody has a plan until they get punched in the mouth."
-- Mike Tyson

We can plan for all sorts of eventualities. However as the report hints at, there may have been some underlying flight control issue (both pilots required for rudder input, taxiing off centreline, para 1.1.16 Preliminary report (http://www.caa.co.za/Accidents%20and%20Incidents%20Reports/ZS-BRV.pdf)). Until the investigators get to interview the crew or find some other mechanical defect we just don't know. Were one, two or three issues with the aircraft (engine fire, flight controls and engine instruments)? Did the engine fire cause the control problem? We don't know.

However, what I can tell you is that simply hand flying an airworthy aircraft during normal manoeuvring a consumes a large proportion of cognitive resources. That is why we have two pilots and use the autopilot when things get busy. Hand flying whilst potentially having multiple confusing failures makes it very easy to get to cognitive overload. Once in that state we rapidly lose the ability to perceive what is going on around us, we don't hear, we don't see very well, and we load-shed tasks. But here is the kicker, we don't get to choose what tasks we drop, it just happens automagically.

So we can plan for all sort of things, then we get airborne and nothing happens the way we think it will. Modern certification standard ensure that you can get away from the ground under the prevailing conditions with a safe plan. But this wasn't a modern aircraft. You only need to look at the list of Convair Accidents (https://en.wikipedia.org/wiki/List_of_accidents_and_incidents_involving_the_Convair_CV-240_family) to see quite a number where people on the ground were killed people (five by my count). The inference is that many accidents happened as the aircraft simply could not out climb nearby populated terrain.

[garpal gumnut]

Without being too simplistic, is it possible that this aircraft was past it's use by date? No matter what inspection or maintenance showed or was performed some other mechanical gremlin was about to surface. As it did in this case. A fubar.

[Old Fella]

Without being too simplistic, is it possible that this aircraft was past it's use by date? No matter what inspection or maintenance showed or was performed some other mechanical gremlin was about to surface. As it did in this case. A fubar.


Yes gg, it is too simplistic. With proper maintenance there is absolutely no reason this aircraft should not have been flown. It was a relatively low hour airframe.

[atakacs]

That had to be the PIC's responsibility and it needed to be done quickly with whatever input he required from the FO or LAME. The lack of a quick and concise summery and course of action from the PIC is perplexing to say the least....
They might or might not have briefed their contingency plans but from the "uber CVR" we had here it seems that execution was lacking, to say the least.
If what is described in the report is a fair representation I'd say we are faced with very poor airmanship. I don't know if that flight could have been saved (seems they had a lot going against them) but it would appear that amazing luck was their only redeeming quality.

[Dan_Brown]

Has carbinmonoxside been ruled out, as a contributory factor. Unlikely I know, insidious and no warning whatsoever of course.

[The Old Fat One]

I do hope that accident report (and the full one to come) gets the widest possible circulation wherever aviation takes place.

Once more, so many lessons...for those that want to learn.

[Chris Scott]

Thanks for the superb cockpit photos, megan, although an even closer shot of the engine instruments would be even better. I'm going to try and describe them in case it helps anyone and, perhaps, prompts a discussion on the problem of failure identification.

As expected, on the L/H side of the centre panel, the design and layout of the primary engine instruments - typical of the period - is an ergonomic nightmare.
There seems to be one BMEP gauge per engine (a parameter with which I',m not familiar), side by side.
Underneath the left BMEP gauge is a single manifold-pressure gauge, employing two concentric needles; one for each engine.
Underneath the right BMEP gauge is a single RPM gauge, employing two concentric needles; one for each engine.
All these gauges would be difficult to read from the co-pilot's seat, and subject to parallax error (particularly on the twin-needle gauges).

Further right on the centre panel, the gauges for the other engine parameters are of a similar size. Being for piston engines, they cover a far greater range of parameters than pilots have to deal with on modern turbine engines. Although a gauge - such as the one for cylinder-head temperature - covers both engines on one gauge, the twin needles are in most cases separate - typical of the period. This reduces the sweep of the needle, but reduces the chance of misidentifying which engine is which.

[jimjim1]

I noticed a a few discrepancies like that in the report. It stated the propellers were Composite, which they are not, they're aluminum. The position of hte accident was given as S26°67.031" E028°28.461" which is just gibberish, not a valid set of coordinates. The actual position of the crash was about S25 40' E28 17'

Re - Composite. As I recall the preliminary report goes on to detail that the hub was one particular alloy and the blades a different one. I think that they mean composite as more than one piece or material. Perhaps an older use of the word but perhaps one time common in aviation to differentiate from a one piece propeller.

Re - co-ordinates.
A typo here. Supposed to be decimal degrees I guess. The number are all correct, someone stuck in the degrees symbol and moved the decimal point. Degrees Minutes.DecimalMinutes is quite a common way to write coordinates. It was used in a sailing course that I was on recently.

S26.67031 E028.28461

Notice 67.031 is very close to 40/60 x 100 and
28.461 is very close to 17/60 x 100

All very confusing.

In the UK the best maps (not aviation or marine) use a local co-ordinate system that dates from 1936. https://en.wikipedia.org/wiki/Ordnance_Survey_National_Grid. Must have seemed a good idea at the time. The maps were created for military purposes originally. Google Maps does not understand it at all:-) The maps though are very good.

[TWT]

jimjim1, those co-ordinates are also incorrect ( for what's it's worth).

The crash occurred at the Moorddrift Dairy Plant (long green roof building), see here :

https://goo.gl/maps/JWntJvbdipC2

[GordonR_Cape]

The coordinates given by avherald.com are S25.6711 E28.2838, which can easily be confirmed in Google Maps.

[aterpster]

In the UK the best maps (not aviation or marine) use a local co-ordinate system that dates from 1936. https://en.wikipedia.org/wiki/Ordnance_Survey_National_Grid. Must have seemed a good idea at the time. The maps were created for military purposes originally. Google Maps does not understand it at all:-) The maps though are very good.And, not WGS84 compliant.

[A Squared]

There seems to be one BMEP gauge per engine (a parameter with which I',m not familiar), side by side.

Chris, the BMEP gauges are simply torquemeters. For whatever reason Pratt&Whitney decided to lable them as psi of Brake Mean Effective Pressure, an abstract theoretical quantity representing the average pressure in the cylinders during the power stroke. Ultimately I guess it doesn’t matter whether ithe units are psi bmep or inch-pounds, you learn the numbers and apply them in operation. Thats why i said earlier that it would be interesting to know what the bmep gauge for the left engine showed, bmep is the best indication of how much power is being developed, whether it was producing more thrust or more drag.

[A Squared]

Re - co-ordinates.
A typo here. Supposed to be decimal degrees I guess. The number are all correct, someone stuck in the degrees symbol and moved the decimal point. Degrees Minutes.DecimalMinutes is quite a common way to write coordinates. It was used in a sailing course that I was on recently.

S26.67031 E028.28461

Notice 67.031 is very close to 40/60 x 100 and
28.461 is very close to 17/60 x 100

All very confusing.



Jimjim, good catch. I know about decimal degrees, but from the format of the coordinates it didn’t occur to me that’s what was intended. It’s worth noting though that S26.67 degrees is about 60 NM south of the crash site.

[Chris Scott]

Chris, the BMEP gauges are simply torquemeters. For whatever reason Pratt&Whitney decided to lable them as psi of Brake Mean Effective Pressure, an abstract theoretical quantity representing the average pressure in the cylinders during the power stroke. Ultimately I guess it doesn’t matter whether ithe units are psi bmep or inch-pounds, you learn the numbers and apply them in operation. Thats why i said earlier that it would be interesting to know what the bmep gauge for the left engine showed, bmep is the best indication of how much power is being developed, whether it was producing more thrust or more drag


Yes, as you say, the precise meaning of the numbers on a torquemeter are of little significance, provided the crew can confirm that they are within the normal range for the phase of flight.

I imagine the auto-feathering system would look at BMEP and throttle angle? On take-off, with the throttle at or somewhere near the gate, a critical loss of BMEP would presumably activate auto-feathering. But we know the captain commented that the auto-feathering light was not working [report, 1.1.12]. I'm unable to identify the light he was referring to on the photo posted by megan, but would there not be a separate one for each engine? Maybe the auto-feathering system was inoperative, at least on the No.1 (L/H) engine.

[atakacs]

A slight thread drift but in light of the potentially missing certification of one of the pilots: how would someone get qualified on a Convair 340/440 in 2018 ?

[Mach E Avelli]

Some people here are too quick to suggest poor airmanship. We do not know how thorough the pre take off briefing was, but given the background of the two pilots I expect it covered the usual engine failure actions. The stiffness of the rudder could have been due to some binding or friction in the aileron circuit (interconnect on this airframe) but given the age of this old beast perhaps not unusual in itself. Whether or not the autofeather light was working should not have interfered with the system. If the system tested OK they probably considered a faulty light acceptable.
But for autofeather to work the engine must lose power with the throttle near wide open. Autofeather does not detect fire, and fire does not necessarily cause a loss of power. Cross wiring of fire warning circuits, failure of circuits to detect a fire and false warnings are not unknown. I can attest to an engine fire in which the circuit completely failed within seconds of the fire starting, leading us initially to assume a false warning.
They appear to have had a combination of control degradation tending to turn the aircraft one way and fire on the opposite side. That would take some analysis which would not be easy while simultaneously trying to maintain controlled flight in an aircraft that neither had flown extensively. Most of us would struggle with that combination on an aircraft with which we were intimately familiar. I would like to spring this nightmare scenario as an unrehearsed exercise on keyboard experts who cry "poor airmanship" or "lack of command decision making" in the simulator to see what they would do.
While the Flight Manual says the first action of the engine failure/fire drill is to feather, given the control problem it is understandable (to me at least) that they would be reluctant to do this.
Most jet pilots would probably retard the throttle on the side that they assumed was on fire, as this is a fairly universal initial procedure on jets.. Do that in a large prop driven aircraft and not only will autofeather be inhibited, but it won't fly very well, if at all.
They did the best that they could to get it on the ground and were just unlucky because of the obstacles..

.

[roundsounds]

A slight thread drift but in light of the potentially missing certification of one of the pilots: how would someone get qualified on a Convair 340/440 in 2018 ?
The same way these guys did. They obtained a certificate of validation in SA, then did a type rating with an approved pilot / instructor.

[A Squared]

I imagine the auto-feathering system would look at BMEP and throttle angle?

Probably, no direct Convair knowledge but on the DC-6, which had the same engines and same props, the Autofeather actuated when BMEP dropped below a certain reading for more than one second with the throttles pushed up. It's pretty likely the Convair had the same system.

[MarkerInbound]

I imagine the auto-feathering system would look at BMEP and throttle angle? On take-off, with the throttle at or somewhere near the gate, a critical loss of BMEP would presumably activate auto-feathering. But we know the captain commented that the auto-feathering light was not working [report, 1.1.12]. I'm unable to identify the light he was referring to on the photo posted by megan, but would there not be a separate one for each engine? Maybe the auto-feathering system was inoperative, at least on the No.1 (L/H) engine.

The autofeather system is armed by raising the guard and then the switch under it found at the center of the pedestal aft of the prop controls. There is one green light to the left of the switch that indicates the system is armed. When the throttles are advanced to a point that equates to ~45 inches MAP and the BMEP drops below ~70 for more than one second a solenoid pulls the feather button in and the prop feathers as if the feather button was pushed. The system also then disarms to prevent autofeathering the other prop.

[A Squared]

A slight thread drift but in light of the potentially missing certification of one of the pilots: how would someone get qualified on a Convair 340/440 in 2018 ?


Same way get any type rating when there's no Simulator: Get some ground training. Get some flight training in in a CV 340 or 440. Take a check ride in a CV 340 or 440 with an examiner who has the authorization to issue type ratings.

Finding the airplane and the examiner might be problematic. I'm not sure if there are any recip convairs still operating commercially in the US, I believe the Commemorative Air Force operates a C-131. I would imagine that someone within that organization is a FAA designee for CV240/340/440 type ratings.




The same way these guys did. They obtained a certificate of validation in SA, then did a type rating with an approved pilot / instructor.


Well, actually, one of them *didn't*

[Capt Fathom]

maybe tied to a lack of familiarity with flying a big piston, versus a modern jet.
Just because you're a superdooper jet jockey doesn't mean you can fly a vintage airliner

I don't think they were totally clueless!

From an earlier post:
Both have been heavily involved for a number of years with the Historical Aircraft Restoration Society (HARS) south of Sydney. Together, the aircraft they have flown are the DC3, Caribou, Convair 440, Lockheed Super Constellation, Lockheed Neptune, PBY Catalina plus others.

I would be surprised if the copilot had been flying a Convair for the last 2 years if not rated. Plus the upcoming ferry flight to Holland. Just doesn't make sense!

[A Squared]

I would be surprised if the copilot had been flying a Convair for the last 2 years if not rated. Plus the upcoming ferry flight to Holland. Just doesn't make sense!


The FO had a valid Australian Air Transport, Commercial and Private Pilot Licence, however he was not type rated on the aircraft (Convair 340/440).

So, what's your working theory here? That the South African Civil Aviation Authority is clueless when it comes to determining which type ratings a pilot holds?

[EDML]

There might be countries in Africa where no one really cares about rules and legislation - that does not apply to South Africa, though. CAA works pretty good as one can see reading preliminary report.

[megan]

BMEP gauges are simply torquemeters. For whatever reason Pratt&Whitney decided to lable them as psi of Brake Mean Effective Pressure, an abstract theoretical quantity representing the average pressure in the cylinders during the power stroke As an aside the BHP can be calculated from the formula BHP = BMEP(PSI)*Engine Displacement*RPM/792,000 As the quote cites, BMEP is not the actual pressure within the cylinder, but an effective pressure representing the mean gas load acting on the piston during the power stroke.

[roundsounds]

Sorry, it doesn't work that way.
As someone who went through the process of getting a South African validation some years ago, the SA CAA don't work it like that.
A validation is basically an authorisation to use a foreign licence, and its included ratings and endorsements, as if it were a local licence. Type ratings must be included in a licence, and then a validation allows you to use them on a local aircraft. You can't include a new type rating on a validation,its only an approval certificate for another CAA's qualification.

Getting a little perturbed by those who are rushing in to defend the pilots with "Oh they work for Q... therefore they knew what they were doing".
1. These are senior heavy jet drivers, used to flying aircraft that are immaculately maintained. The potential of failure is significantly less in a modern airliner, and when it does happen the flight profile of an A330 with an engine out on take-off is better than the normal flight profile of the CV. Then consider the automation of modern jet systems in the event of a failure - versus the almost complete lack thereof (autofeather if it works) in the CV. The GoPro footage reveals an almost complete lack of CRM, maybe tied to a lack of familiarity with flying a big piston, versus a modern jet.
Just because you're a superdooper jet jockey doesn't mean you can fly a vintage airliner, especially on a test flight after heavy maintenance with passengers on board.
2. Coming from Oz where pedantic bureaucracy in pilot licensing is the normal, it is inconceivable that either pilot could not understand if they did not have the correct licences/validations/type-ratings to legally fly the aircraft on the ZS- register. To hold a validation certificate that allows flight of PPL, single-engine only, and then go blasting off in the CV beggars belief. Couple this with the fact that there were fatalities, if this had been in Oz with a South African pilot the media and Australian CAA would be baying for blood.
Are you saying obtaining a certificate of validation and type rating issued by the South African CAA doesn’t work?
Both the PF and PNF went through the same process with the same SA instructor. I’d suggest the table on page 13 of the report is corrrect, the PNF did hold a valid licence and type rating to operate the aircraft.
id suggest this is an error in the report or CAA licencing records system.
The following extract from SA news report (https://citizen.co.za)supports this understanding:

Aviation expert Karl Jenson strongly repudiated the report’s preliminary finding that the Convair co-pilot was not licensed.
“A friend who trained him on the aircraft refutes this claim vehemently,” he told The Citizen. “The Sacaa report is preliminary only and there are glaring omissions and claims which cannot possibly be substantiated,” Jenson said.

Reference your suggestions these pilots aren’t familiar with large piston engine operations, you need to do some research before commenting. Extensive and recent experience in Caribou, Constellation, Convair 340, P51 and Catalina to mention some of their experience.

[A Squared]

Are you saying obtaining a certificate of validation and type rating issued by the South African CAA doesn’t work?


No, he's saying that if you don't have the type rating on your foreign license, you can't then *add* it to your certificate of validation of that license.

[Volume]

Without being too simplistic, is it possible that this aircraft was past it's use by date? No matter what inspection or maintenance showed or was performed some other mechanical gremlin was about to surface.
This is what we call "limit of validity" (LOV) these days...
From FAA AC 120-104:
3. WHY DO YOU NEED AN LOV? If you properly maintain an airplane, theoretically you could operate it indefinitely. But structural maintenance tasks for an airplane are not constant with time. Tasks are typically added to the maintenance program as the airplane ages. It is reasonable to expect, then, that the current structural maintenance tasks may not, at some future point, be sufficient for continued operation. Maintenance tasks for a particular airplane can only be determined based on what is known about that airplane model at any given time—from analyses, tests, service experience, and teardown inspections.
Same philosophy applies to systems, although it is much easier to completely replace all parts, as long as spares are still available...

[The Ancient Geek]

The report states that the P2 had a type endorsement rather than a type rating.
An endorsement requires type specific training signed off by a suitably qualified instructor whereas a type rating requires a specially designated examiner. Such examiners would be hard or impossible to find for such an old type.

[Double Back]

Without any pointing to the crew, which is hopefully recovering, we may discuss the playing field in which they had to operate and make decisions. Not to blame, but to learn from it.
All pilots have been in situations where they were "forced" to fly, and after many years concluded how in the world they'd accepted that then. But got away with it with luck. At least I had my share.

Initially I thought the flight was one of a series of flight testing and at one moment they decided to load the contributors of the restoration.
What I read in the report is that de bird did not fly any more since beginning of 2018, that means it did not fly for about half a Year before the accident flight. And was repainted shortly before. That really scared me. There is also no indication if it was sitting outside or hangared during those months.
Given all the other factors I mentioned earlier, this long idle time is a grave one. Even well maintained airliners, if they were parked outside for a week, You could come across some strange defects, mostly electrical/electronic though.

For a while I was a company test F/O for the flight(s) after heavy maintenance (D check) that also included a repaint job. The capt was also a dedicated test pilot, so normal cockpit structures ruled. We were specially trained for it, including non-STD manoeuvres and operations. And were expecting anything out of the ordinary, anytime.
The number of items we found were sometimes "countless", although many/most were minor. Add to that we sometimes were flying airliners from other carriers that had completely different instrument setups, different engines, etc. It took its toll on cockpit operations. But we were in the position to have "unlimited" time available to complete all tests, the flight took around 5-6 hours. That is longer than a test flight Boeing does on a new plane. If needed we redid a shorter test flight till all were satisfied. The first flight only mechanics/specialists that had some task to do in flight were allowed.

The Convair was sold under the "as is" condition. That leaves little room for the seller to spend a lot on test flying (fuel and other costs) and/or costly repairs.
That must have weighed heavily in the crew's decision process.

In all I do not envy the flight crew that was faced with so many contributing factors. You can only guess at what time one personally would have called it quits. IF you would have done.

[Volume]

The Convair was sold under the "as is" condition. That leaves little room for the seller to spend a lot on test flying (fuel and other costs) and/or costly repairs.
That must have weighed heavily in the crew's decision process.
I think if you expect as a pilot to fly this plane from South Africa to the Netherlands, you would spend anything it requires to make this trip safe. If you would like to detect issues, you probably want it at your origin of the trip, not somewhere over the raiforest, desert, grasslands or war zones of Africa...
As the mechanic was expected to join the trip, I would expect him to make damn sure everything is working fine. I can not believe in enough "adventure spirit" to start the long trip without spending anything it takes to make it safe.

If the report is right, it is really hard to understand why they never bothered to address the engine fire...

the BMEP gauges are simply torquemeters.
How does this fit the current replacement/repair of one of them? For me the report sounds like they suspect some sort of leak in the MAP sensor line as contributing factor for the power loss/fire, but maybe I misunderstand that point.

[rog747]

DOUBLEBACK
the a/c was not yet officially 'sold' - it was still maintained by Rovos Rail the owners and registered keeper - it was (the a/c) to be handed over once at the Museum in Holland.

it had just had A B and C checks and this was its first flight post this mx.

Rovos Rail's LAME was as you know, on board the test (scenic) flight and would accompany the a/c to Holland on its delivery flight

There is a thread about the 2 QF crew members welfare on the Ozzie pages - and these chaps were involved in flying with the HARS heavy piston fleet for some years

[Chris Scott]

The autofeather system is armed by raising the guard and then the switch under it found at the center of the pedestal aft of the prop controls. There is one green light to the left of the switch that indicates the system is armed. When the throttles are advanced to a point that equates to ~45 inches MAP and the BMEP drops below ~70 for more than one second a solenoid pulls the feather button in and the prop feathers as if the feather button was pushed. The system also then disarms to prevent autofeathering the other prop.
Thanks to you and others for the added detail on the operation of the R2800 auto-feathering system, which sounds comparable with that fitted to the Rolls Royce Dart turboprop engine some years later.

This preliminary report does not discuss the background to the captain's statement that the "auto-feather light was not illuminating" [1.1.12]. That begs a few questions, some or all of which may be answered by the Go-Pro recording.
Was this light failure revealed during some kind of pre-take-off test of the auto-feathering system?
Was the light failure simply due to a defective bulb, which presumably could have been quickly changed by the LAME, or did it imply a fault in the system?
Was any pre-take-off check made of the manual feathering system on the #1 (L/H) engine?

Mach E Avelli rightly points out that, on jets, the first action on receipt of any fire warning is normally to retard the throttle to idle, which action may in itself put the fire out. In this case, that action would immediately inhibit auto-feathering, as well as creating a lot of drag from a propellor in full-fine pitch.These were jet pilots but, fortunately, the Go-Pro recording should settle that argument.

[atakacs]

What I really have a hard time accepting is that during the whole flight they apparently did not communicate about the situation developing. I for sure would have engaged my fellow crew members about our options. Be it the LAME (captain, are you intentions? Should I do something about that engine fire?) or the pilots (and don't think the PIC ever communicated want he wanted to do, apparently a return to base).

[Old Fella]

If this is how professional airline radial engine drivers behave in an abnormal situation, then heaven help us all!

People DIED because this crew were not situationally aware/unprofessional/inept/incompetent (choose your own adjective).


Grizzly, your comments are inappropriate, certainly at this time I think, before anything more than a preliminary report with contradictions within is all we have to inform us.
Both pilots are still critically ill, neither has been able to relate their side of this story and we do not know the full extent of the problems they encountered. Hasty
condemnation of the crew is unwise and unfair, in my view. At least have the decency to wait until the full and final report is available before being so willing to
crucify the crew. I note you do not give any hint as to your qualifications, if any, to make such judgments.

[SLFinAZ]

Grizzly, your comments are inappropriate, certainly at this time I think, before anything more than a preliminary report with contradictions within is all we have to inform us.
Both pilots are still critically ill, neither has been able to relate their side of this story and we do not know the full extent of the problems they encountered. Hasty
condemnation of the crew is unwise and unfair, in my view. At least have the decency to wait until the full and final report is available before being so willing to
crucify the crew. I note you do not give any hint as to your qualifications, if any, to make such judgments.

I don't think the comments are inappropriate or unfounded in any way specific to what we know. Without question the preliminary report is by it's nature both incomplete and does not paint an entirely accurate picture....however.

I do think that it is within reason to assume that had the PIC declared an emergency and stated both his intentions and instructions it would be noted in the report. Without question the engine failure itself is simply fate but the PIC's apparent
failure to exercise command is something entirely different. Had he announced his intentions to return to both and then instructed the LAME to deal with the engine/fire and the PM to handle the radio/look for alternative spots to ditch this flight might have had a different outcome...

At least for the unfortunate souls on the ground who perished. With command comes responsibility and regardless of all the other variables involved it appears that the PIC failed to meet this burden....again it's a harsh subjective (at this point) but not unreasoned observation. More so
if in fact there was no clear prefight brief for mechanic or other emergencies....

[His dudeness]

I don't think the comments are inappropriate or unfounded in any way specific to what we know. Without question the preliminary report is by it's nature both incomplete and does not paint an entirely accurate picture....however.

I do think that it is within reason to assume that had the PIC declared an emergency and stated both his intentions and instructions it would be noted in the report. Without question the engine failure itself is simply fate but the PIC's apparent
failure to exercise command is something entirely different. Had he announced his intentions to return to both and then instructed the LAME to deal with the engine/fire and the PM to handle the radio/look for alternative spots to ditch this flight might have had a different outcome...

At least for the unfortunate souls on the ground who perished. With command comes responsibility and regardless of all the other variables involved it appears that the PIC failed to meet this burden....again it's a harsh subjective (at this point) but not unreasoned observation. More so
if in fact there was no clear prefight brief for mechanic or other emergencies...

So you essentially know more or less nothing but reach a conclusion from a prelim report that doesn´t even get the date on it right ?

Your words: if, might , regardless of all other variables, appears....

[EDML]

According to the preliminary report no one on the ground died.

[Onceapilot]

Can I ask, does anyone have the details of how the BMEP indicator system on the Convair operated? I understand the function of the BMEP indication but, I have drawn a blank on what parameters the indicator or the system used to calculate the BMEP that was displayed. Thanks for any detail or reference. :)

OAP

[SLFinAZ]

So you essentially know more or less nothing but reach a conclusion from a prelim report that doesn´t even get the date on it right ?

Your words: if, might , regardless of all other variables, appears....

That's an absolute over simplification....here is what we do "know"...

1) At no point did the PIC declare an emergency to the other two
2) At no point did he assign tasks or ask for the appropriate checklist
3) At no time did he clearly state his intentions

Given the apparent detail specific to the video recording that was disclosed any of these would seem merit a mention.

We do not know if the above actions would have changed the outcome, and we do not know if the LAME did or did not act unilaterally in managing the engine fire
but we do know that the report does not mention a single specific command action from the PIC....so either you have a gross misrepresentation of events or there
simply was not an expected appropriate response to the engine fire....

[A Squared]

Can I ask, does anyone have the details of how the BMEP indicator system on the Convair operated? I understand the function of the BMEP indication but, I have drawn a blank on what parameters the indicator or the system used to calculate the BMEP that was displayed. Thanks for any detail or reference. :)

OAP

As I said in a previous post, its really a torquemeter. The way it measures torque is the outer ringgear of the planetary gear reduction unit has helical splines around it's rim. These fit into helical splines in the nose case of the engine. the reaction to engine torque tend to shift this ring gear backward (Or is it forward?, it's been a while) opposing that axial thrust are a series of hydraulic pistons which operate off engine oil pressure from the nose case scavenge pump. there's some sort of metering mechanism so that the pistons exactly offset the axial thrust of the ring gear, and the actual measurement is of the oil pressure required in the pistons to balance that axial force, the signal from the oil pressure transducer is displayed on the BMEP gauge. As a side note, on other radial engine installations, the torque meter was calibrated in units of "Torque oil pressure" which is a more accurate description of what is actually being measured that BMEP, But again, the units are arbitrary, learn what numbers you should see for what power setting on your engine and it doesn't matter the actual units are.

[A Squared]

The autofeather system is armed by raising the guard and then the switch under it found at the center of the pedestal aft of the prop controls. There is one green light to the left of the switch that indicates the system is armed. When the throttles are advanced to a point that equates to ~45 inches MAP and the BMEP drops below ~70 for more than one second a solenoid pulls the feather button in and the prop feathers as if the feather button was pushed. The system also then disarms to prevent autofeathering the other prop.

Sounds like it's likely the identical system which was installed on the DC-6.

[A Squared]

... the BMEP gauges are simply torquemeters.

How does this fit the current replacement/repair of one of them? For me the report sounds like they suspect some sort of leak in the MAP sensor line as contributing factor for the power loss/fire, but maybe I misunderstand that point.


I'm not sure I understand what you're asking. There are shops which specialize in repairing and overhauling obsolete gauges, just like there are still engine shops which overhaul R-2800's

Bear in mind, there was no mention of BMEP in the report, it's only been a point of discussion in this thread.

[Onceapilot]

As I said in a previous post, its really a torquemeter. The way it measures torque is the outer ringgear of the planetary gear reduction unit has helical splines around it's rim. These fit into helical splines in the nose case of the engine. the reaction to engine torque tend to shift this ring gear backward (Or is it forward?, it's been a while) opposing that axial thrust are a series of hydraulic pistons which operate off engine oil pressure from the nose case scavenge pump. there's some sort of metering mechanism so that the pistons exactly offset the axial thrust of the ring gear, and the actual measurement is of the oil pressure required in the pistons to balance that axial force, the signal from the oil pressure transducer is displayed on the BMEP gauge. As a side note, on other radial engine installations, the torque meter was calibrated in units of "Torque oil pressure" which is a more accurate description of what is actually being measured that BMEP, But again, the units are arbitrary, learn what numbers you should see for what power setting on your engine and it doesn't matter the actual units are.

Thanks, A Squared. Yes, no probs with the torquemeter oil pressure system. I was just interested if there was anything different in the Convair BMEP type of indication. Thanks very much again for your info. :ok:

OAP

[Murexway]

I flew/instructed on the C-131B before I left the Air Force 45 years ago. We operated the C-131's through Albuquerque, NM all year long at much higher density altitudes than this takeoff, so it's certainly within the capabilities of the airplane - it all depends upon the weight, of course. There are a LOT of things that could have happened on this takeoff - none of them good; some of them beyond the pilots' ability to do much of anything. We'll just have to wait and see how good the accident investigation is and what it turns up. Hopefully, the pilots will recover and be able to fill in the blanks.

[Bell_ringer]

So you essentially know more or less nothing but reach a conclusion from a prelim report that doesn´t even get the date on it right ?

Your words: if, might , regardless of all other variables, appears....

The date is when this document template was created. It's the format used in all of the SA CAA documents, not the accident date.

[A Squared]

The date is when this document template was created. It's the format used in all of the SA CAA documents, not the accident date.


Yeah, this. I said "huh????" when I first saw that date, but it didn't take a lot of advanced thinking to figure out what that date represented.

[Chris Scott]

Bit early to be apportioning blame, chaps?

The investigation has a long way to go and minor anomalies in the preliminary report to clear up. The two flight crew have yet to be interviewed, AFAIK, and the unofficial third man is sadly deceased. With a crew debrief still pending, even if a recording of all cockpit conversations is available from the Go-Pro camera it's quite right that its transcript be withheld at the preliminary report stage.

Right now we can try and work out what may have happened, and what the crew probably did. We may also like to form an opinion, from the unhurried comfort of our armchairs, on what might have been done to mitigate the effects of the failure(s).

[Murexway]

With regard to the apparent left aileron anomaly, I once picked up a Gulfstream G-I turboprop from a heavy "C" check at a busy, well-known, U.S. maintenance facility that was very familiar with Gulfstreams. During the preflight, we noticed that when the control yokes were turned to the right, the left aileron went up and the right aileron went down (and vice-versa) - that was the end of the day's flying. A left engine fire on takeoff would be a bad time to discover that.

[A Squared]

With regard to the apparent left aileron anomaly, I once picked up a Gulfstream G-I turboprop from a heavy "C" check at a busy, well-known, U.S. maintenance facility that was very familiar with Gulfstreams. During the preflight, we noticed that when the control yokes were turned to the right, the left aileron went up and the right aileron went down (and vice-versa) - that was the end of the day's flying. A left engine fire on takeoff would be a bad time to discover that.

If the ailerons were rigged backward on this Convair, they would have crashed immediately upon lifting off. That's what happened in both instances I know of where the ailerons were connected backward. It's extremely unlikely that any pilot would be able to recognize what was going on and have enough time at low level to apply control input opposite everything he'd learned and practiced his entire life.

[Dan_Brown]

Yes they probably would have crashed immediately after lift off if the ailerons were connected wrong way round. The video of the departure of the a/c that is being discussed, showed normal lateral control after lift off.

I know of a light a/c years ago, with the ailerons reconnected incorrectly, after heavy maintenance.. The company chief pilot was the PF on the test flight and a senior pilot in the RHS. At lift off, the inevitable occurred. The authorities tried to blame the PIC. (Yes they survived) They were unable to make it stick, as the Pre t/o check list in the approved FM stated, " controls full and free". The words. "In the correct sense" we're omitted. That Chief pilot had close to 20k hours stick time. I doubt if he ever used an A/P as the entire fleet was never equipped with them. AG aircraft.

[Murexway]

If the ailerons were rigged backward on this Convair, they would have crashed immediately upon lifting off. That's what happened in both instances I know of where the ailerons were connected backward. It's extremely unlikely that any pilot would be able to recognize what was going on and have enough time at low level to apply control input opposite everything he'd learned and practiced his entire life.I might buy "likely would have", but "would have"? Despite everything less than flattering that's been mentioned about these guys, they weren't exactly novices. Plus, the Convair wasn't exactly light on the controls, from my recollection - it certainly was a lot slower and heavier than a light airplane. Given that the left engine was apparently the initial problem, the video of the left aileron certainly looks a bit odd. And courtesy of Vietnam, I discovered that you can learn awfully fast when you think you're going to die.

[A Squared]

I might buy "likely would have", but "would have"?

Yeah, "would have". That close to the ground there simply isn't enough time or space to figure out why the airplane is rolling uncontrollably despite your aileron inputs. If there was a way to initiate this at altitude, perhaps some good pilots could figure it out and overcome a lifetime of practice and control roll with "backward" inputs. 10 ft off the runway? Not a chance. Your wing is in the ground before you have time to think anything other than " whoa! I'm really rolling left, I need more right aileron. "

Regardless, we have ample video of the takeoff it took off without a wobble in roll. Whatever the cause of the raised aileron in the video, it wasn't from them being rigged backward in Mx.

[Murexway]

Who said it was rolling uncontrollably? He had control for quite awhile. But If he needed aileron and it went the wrong way, turn the yoke the other way. Just because previous instances turned out poorly doesn't mean they will all automatically result in an immediate crash.

[A Squared]

In any case, you're probably right - the ailerons weren't the problem. I was just brainstorming.

Well, obviously on the video from inside the plane in flight, there's some problem with the aileron. I'm just saying that I think it's really unlikely that it was a Mx Reversal of the ailerons prior to takeoff. .

[Murexway]

Well, obviously on the video from inside the plane in flight, there's some problem with the aileron. I'm just saying that I think it's really unlikely that it was a Mx Reversal of the ailerons prior to takeoff. .Yeah, something sure wasn't right, unfortunately.

[Murexway]

The C-131 was old and slow, but it was a very comfortable, stable airplane. In 1972-73 when Bendix was developing the first TCAS, we used one with specially calibrated altimeters to run head on passes against a C-135 starting with 2,000 ft. vertical separation, and working our way down to 500 ft. It was an eye opener.

But I digress. Hope both the guys in the hospital do well.

[WhoFlungDung]

If this is how professional airline radial engine drivers behave in an abnormal situation, then heaven help us all!

People DIED because this crew were not situationally aware/unprofessional/inept/incompetent (choose your own adjective).

Bare, I read your comment with utter disgust. How dare you slander these pilots before the investigation is complete. What right do you have to judge and condemn anyone involved in this tragic accident on the basis of a preliminary report? Who knows what this crew were faced with on the day. Controllability issues? Engine shutdown? How would you feel about intentionally destabilizing an aircraft that was maybe marginally controllable - immediately after take off? Gear? These guys know whether the gear has been selected up or not - but perhaps the fire had destroyed the gear indication circuitry. Would that not be cause for confusion and or discussion about the gear position? The fire is clearly evident below the wing and in the LH main gear area. Convairs have a history of Aileron issues associated with engine fires. And tell me Bare, which non normal checklist would you call for? The one titled "Crew Are Struggling to Control Aircraft - Shutdown Engine and Lose Control Totally"? Or would you expect the crew to muster their combined 37000 hrs of experience to try and manage a situation for which there is no checklist or training.Or perhaps you have some magical technique that neither Boeing or Airbus have mastered for dealing with multiple failures? The tragedy of this event is that two people lost there lives. It could have been so much worse. By all means speculate on the cause of this horrific event, but don't you dare condemn two men who have arguably saved the lives of 18 people on board, on the basis of a preliminary report.

[megan]

Hopefully, the pilots will recover and be able to fill in the blanks Even though they may regain their physical health they may have absolutely no memory of the accident flight.

Post-Traumatic Amnesia - Memory Disorders - The Human Memory (http://www.human-memory.net/disorders_traumatic.html)

[4 Holer]

WFD post 358. I would go the engine shutdown and fire checklist from memory items close cowl flaps while on the way to land empty in about a 3 seconds pattern as it is an out of heavy maintenance test flight with nil pax/weight....... Is this answer ok, but Im not an Australian top gun so might be a bit simple.

OH I would have run the engines up with the LAME looking from the outside shutdown checked for leaks restarted etc before he jumped aboard rather than " started the left engine once the LAME was onboard per report ".

[WhoFlungDung]

There are no Top Guns here 4 Holer. Just want to make sure two guys get a fair hearing. Can it be any simpler?

[Murexway]

None of us know what was really going on in that cockpit. We can speculate all we want, but let's wait a bit before we castigate our fellow professional airmen, who are still in the hospital.

[b1lanc]

There is a thread about the 2 QF crew members welfare on the Ozzie pages - and these chaps were involved in flying with the HARS heavy piston fleet for some years

Is this the same HARS crew that ferried the PBY from Portugal? There was a YT documentary on that which I can no longer find. I was somewhat surprised at the condition that the PBY was ferried with and the relatively cavalier attitude of the crew to potential problems - even to themselves (caveat, I don't know who narrated it).

[Volume]

Bear in mind, there was no mention of BMEP in the report, it's only been a point of discussion in this thread.
Is that another inaccuracy of the (interim) report? Do they actually mean the BMEP when they say "the captain stated that the manifold pressure was low" ?
Do they mean the BMEP indicators when they say "the manifold pressure gauge, which is a dual indicator for the left and right engine, was removed, repaired and refitted to the Aircraft" ?
Does manifold pressure mean anything on these high power piston engines? Is it as important as on a typical SEP with CS Propeller? Or is BMEP the parameter you use to manage engine power?
Is the removed and repaired unit somehow linked to the autofeather system?

[LeadSled]

None of us know what was really going on in that cockpit. We can speculate all we want, but let's wait a bit before we castigate our fellow professional airmen, who are still in the hospital.
Murexway,
Well said, preliminary guesses based on the GoPro and little else will NOT be the whole story.
As for whether the crew were "legal" or not, firstly it has no bearing on the reasons for this terrible accident, and sounds more like a bureaucratic balls up than anything else, to me. Nowhere (but particularly in Australia) is aviation law straight forward and unambiguous.
Tootle pip!!

[rog747]

good news is one of the pilots (Doug) has been repatriated home by QF

also one of his QF colleagues has stated the pilots were def typed rated for the a/c (Ok but maybe not for flying in RSA as reported?)

please see the thread on the pacific forum for more details re the pilots and news

https://www.pprune.org/australia-new-zealand-pacific/611016-douglas-haywood-ross-kelly-4.html#post10224003

[Dan_Brown]

First iteration:
"Sorry, our documentation is not yet in place, so we can't legally fly yet."
That night everyone is still alive.

Professional airline pilots know when they are legally allowed to fly, and know when they can't. Many thousands of birthdays/anniversaries have been missed because crews have reached duty limits and can't fly home in time - even though they desperately wanted too. QF pilots would not deliberately bust mere duty hours to get home, and yet this flight happened in Africa. This is so much a worse violation. An attitude of "I don't have the legal authorisation to fly this airplane in this country on this registration, but what-the-hell I'll violate the law and do it anyway, it's only South Africa - not like it's a real country and a real CAA" by any chance?

"Let whom without sin cast the first stone"

[sycamore]

Can anyone confirm whether the aileron controls are cable ,or pushrod operated.Also a`routing` diagram along the wing/fuselage would be useful...

[steamchicken]

As I said in a previous post, its really a torquemeter. The way it measures torque is the outer ringgear of the planetary gear reduction unit has helical splines around it's rim. These fit into helical splines in the nose case of the engine. the reaction to engine torque tend to shift this ring gear backward (Or is it forward?, it's been a while) opposing that axial thrust are a series of hydraulic pistons which operate off engine oil pressure from the nose case scavenge pump. there's some sort of metering mechanism so that the pistons exactly offset the axial thrust of the ring gear, and the actual measurement is of the oil pressure required in the pistons to balance that axial force, the signal from the oil pressure transducer is displayed on the BMEP gauge. As a side note, on other radial engine installations, the torque meter was calibrated in units of "Torque oil pressure" which is a more accurate description of what is actually being measured that BMEP, But again, the units are arbitrary, learn what numbers you should see for what power setting on your engine and it doesn't matter the actual units are.

Originally Posted by MarkerInbound https://www.pprune.org/images/buttons/viewpost.gif (https://www.pprune.org/rumours-news/610956-convair-340-c-131d-zs-brv-crash-pretoria-south-africa-post10222964.html#post10222964)The autofeather system is armed by raising the guard and then the switch under it found at the center of the pedestal aft of the prop controls. There is one green light to the left of the switch that indicates the system is armed. When the throttles are advanced to a point that equates to ~45 inches MAP and the BMEP drops below ~70 for more than one second a solenoid pulls the feather button in and the prop feathers as if the feather button was pushed. The system also then disarms to prevent autofeathering the other prop.

And to think there are people on here who talk about the simple aircraft of the 1950s!

[junior.VH-LFA]

First iteration:
"Sorry, our documentation is not yet in place, so we can't legally fly yet."
That night everyone is still alive.

Professional airline pilots know when they are legally allowed to fly, and know when they can't. Many thousands of birthdays/anniversaries have been missed because crews have reached duty limits and can't fly home in time - even though they desperately wanted too. QF pilots would not deliberately bust mere duty hours to get home, and yet this flight happened in Africa. This is so much a worse violation. An attitude of "I don't have the legal authorisation to fly this airplane in this country on this registration, but what-the-hell I'll violate the law and do it anyway, it's only South Africa - not like it's a real country and a real CAA" by any chance?

Knowing that they were both (clearly) trained on type, you are focusing on easily the most irrelevant and insignificant aspect of this tragedy, paperwork on the day wouldn't have stopped what happened from happened. For what purpose or agenda remains to be seen.

[Volume]

The flight crew were not licenced to pilot this aircraft. Simple.
Really simple? Are there still training organisations around which have instructors current on this type? Are there training aircraft available? (approved) Flight simulators? Are there any examiners current on the type? Is the manufacturer maintaining the training material up to date? Or even the pilot handbooks? Does the licence mean anything?
It might be a pure beurocratic paperwork issue, you can probably have pilots which can perfectly handle such aircraft but are lacking the paperwork, you probably can also have pilots perfectly licenced but havin no clue how to operate them.
For 1950s vintage aircraft it does not make much sense to aply 2018s regulation for flight crew licencing.

So it is a simple fact with a difficult truth behind...

[climber314]

[QUOTE=The Ancient Geek;10193854]The SACAA can be relied upon to publish a full investigation is due course, their work is always to a very high standard.
/QUOTE]

Paperwork seems to be a legitimate concern.
CRM is another issue, as is NOT running the EFTO/Fire Checklists amongst others.
A GoPro video is a pretty good substitute for the lack of CVFDR in this incident.
What is the alternative theory here?
That SACAA has it "in" for the crew due to a regulatory issue?
Seems like an unbiased and fact-based PRELIMINARY report IMO.
It appears some here don't like the facts as presented by SACAA?

[Feathers McGraw]

Something from the other thread that I had not seen mentioned before

https://www.pprune.org/showthread.php?p=10195432

It is stated that the FO on the accident flight, Ross Kelly, had an engine failure in another Convair last year. So one of the flight crew had first hand experience of the CV-340 on one engine even if at a very light weight.

Not sure how that would manifest itself in this case, but surely better than having no experience of engine problems.

[Murexway]

For 1950s vintage aircraft it does not make much sense to apply 2018s regulation for flight crew licensing.So it is a simple fact with a difficult truth behind...Well, it's true that regulations can't prevent accidents, but they're the best thing we have (in addition to currency) to try and insure that the people flying the airplane have some familiarity with what they're doing.

I must say that after reading the preliminary report twice, and looking at what the result was, it's hard to understand why nothing was apparently being done in the cockpit other than to try and maneuver the airplane back to the field. It's especially baffling in light of the fact that both gentlemen are very experienced A380 captains and one of them is apparently a check airman - a training captain, and they apparently ferried the same type aircraft to Australia previously.

The A380 is a marvelous aircraft, but with all of today's automation and heavy reliance upon flight management systems, do the old, basic flying skills and mindset erode?

[Murexway]

Can anyone confirm whether the aileron controls are cable ,or pushrod operated.Also a`routing` diagram along the wing/fuselage would be useful...Cable operated. Someone may have already posted this, but here's a link to a left engine fire incident on a C-131F. The report noted... "The examination revealed significant heat damage to the rear spar of the left wing, and to a flexible hose associated with the left brakes. Additionally, the left aileron primary control cable was noted to be drooping."

https://www.ntsb.gov/about/employment/_layouts/ntsb.aviation/brief2.aspx?ev_id=20110118X45001&ntsbno=ERA11LA117&akey=1

[climber314]

Something from the other thread that I had not seen mentioned before

https://www.pprune.org/showthread.php?p=10195432

It is stated that the FO on the accident flight, Ross Kelly, had an engine failure in another Convair last year. So one of the flight crew had first hand experience of the CV-340 on one engine even if at a very light weight.

Not sure how that would manifest itself in this case, but surely better than having no experience of engine problems.

So is there an ATSB TRANSPORT SAFETY REPORT on the Engine Failure Incident with VH-TAA mentioned?
It would seem VERY relevant given this incident IMO.

[A Squared]

Is that another inaccuracy of the (interim) report? Do they actually mean the BMEP when they say "the captain stated that the manifold pressure was low" ?
Do they mean the BMEP indicators when they say "the manifold pressure gauge, which is a dual indicator for the left and right engine, was removed, repaired and refitted to the Aircraft" ?

There's nothing which suggests that mix up. I only pointed out that the BMEP wasn't mentioned in the report to keep readers from assuming that our discussion of BMEP gauges indicated there was reason to believe that there was a problem involving BMEP.

Does manifold pressure mean anything on these high power piston engines? Is it as important as on a typical SEP with CS Propeller?

Yes, it is every bit as important as it is on a simpler, normally aspirated piston engine with a CS prop. MAP is the primary indication for setting power.

Or is BMEP the parameter you use to manage engine power?

Not really, power settings are made by MAP and RPM. BMEP is useful as it is a measurement of output, vs MAP which is a measurement of input. Input doesn't necessarily equate to output, depending on condition of the engine, etc. As an example, if you were to turn off the magnetos in cruise in the DC-6, the RPM would tend to remain the same because of the CS prop. MAP is a function of supercharger speed and throttle opening, and because the RPM is the same and you haven't changed the throttle setting, MAP indication will remain the same. and fuel flow would remain the same. But obviously, even though you have the same manifold pressure, you aren't getting the output you want. Aside from aircraft feel/handling/performance, the only instrument indications of the power loss would be BMEP and your cylinder heat temps would be decreasing. BMEP was used to verify power output, and on the DC-6, if you had the same MAP and RPM on all 4, and one BMEP was noticeably lower than the other 3, that was an indication something wasn't right. Also, BMEP was used as a primary indication for leaning the fuel mixture in cruise. We would lean until BMEP peaked, then decreased by 12 psi. That represented about a 10% drop, when meant we were operating Lean of Peak, but that's a whole separate discussion.



Is the removed and repaired unit somehow linked to the autofeather system?

Not exactly, as I said, there's no indication that the references to the MAP gauge were in error. There's no direct link to the Autofeather System, so an MAP gauge error wouldn't affect the operation of the autofeather system.

[A Squared]

And to think there are people on here who talk about the simple aircraft of the 1950s!

Yeah, ain't that the truth. Having flown in all 3 seats of the DC-6, there was nothing simple about that airplane ... or aeroplane, as you like ...

[Feathers McGraw]

So is there an ATSB TRANSPORT SAFETY REPORT on the Engine Failure Incident with VH-TAA mentioned?
It would seem VERY relevant given this incident IMO.

I had a look around the ATSB site but I have not found anything about it. Bulletins seem to be only up to mid-2017, maybe it will be in a later one.

[PAXboy]

Let me throw a hand grenade: Are we going to keep restoring and crashing these machines - until there are none left? Since the Convair there was the Ju-52.

It was my late father who asked this question when the last airworthy Beaufighter went in. He was in Beaufighters and Mosquitos for 4.5 yearsin WWII and thought it better to have something original to show the next generation rather than reproductions.

[A Squared]

Let me throw a hand grenade: Are we going to keep restoring and crashing these machines - until there are none left? Since the Convair there was the Ju-52.

It was my late father who asked this question when the last airworthy Beaufighter went in. He was in Beaufighters and Mosquitos for 4.5 yearsin WWII and thought it better to have something original to show the next generation rather than reproductions.


Ehhh, it's not like we're talking about a rare, priceless historical artifact. There's rows of them sitting in the desert. We're a loooong way from running out of Convairs.

[Chu Chu]

If the aircraft are fully documented (a big if, I know), we don't really lose much knowledge if one goes in. Certainly, looking at photos is not the same as walking around an aircraft in a museum. But to me, walking around one doesn't hold a candle to actually seeing it fly. Obviously a there's a trade off to be made, but I'd say we'd lose more than we'd gain from a strict prohibition on flying historic aircraft.

[Centaurus]

BMEP was used to verify power output, and on the DC-6, if you had the same MAP and RPM on all 4, and one BMEP was noticeably lower than the other 3, that was an indication something wasn't right

The operative word is "noticeably." In the Convair (assuming my memory is correct from over 50 years ago since I flew the Convair 440) there was usually around 15 BMEP difference between the two engines on take off. That was because one of the engines was used for operating the air-conditioning /pressurisation systems and that stole power from that engine, for want of a better term. I forget which engine. However manifold pressure and RPM indications displayed equal for both engines. It was only the BMEP for one engine that was slightly down on the other engine

[A Squared]

The operative word is "noticeably." In the Convair (assuming my memory is correct from over 50 years ago since I flew the Convair 440) there was usually around 15 BMEP difference between the two engines on take off. That was because one of the engines was used for operating the air-conditioning /pressurisation systems and that stole power from that engine, for want of a better term. I forget which engine. However manifold pressure and RPM indications displayed equal for both engines. It was only the BMEP for one engine that was slightly down on the other engine

That's true centaurus, The DC-6 had pressurization on 2 engines, and the company I was with had the pressurization systems removed anyway, but there was always some variation due to engine condition, indicator system inaccuracy, etc. But once you had a feel for what was "normal", an indication outside of normal usually meant something.

[MarkerInbound]

The operative word is "noticeably." In the Convair (assuming my memory is correct from over 50 years ago since I flew the Convair 440) there was usually around 15 BMEP difference between the two engines on take off. That was because one of the engines was used for operating the air-conditioning /pressurisation systems and that stole power from that engine, for want of a better term. I forget which engine. However manifold pressure and RPM indications displayed equal for both engines. It was only the BMEP for one engine that was slightly down on the other engine

At least in FAA land there is an AD concerning the windshield. The simple solution to deactivate the pressurization system. So thirty some years ago all the CVs I flew had the pressurization inop. We bought a 240 that had been sitting for years mainly for the engine cowls to switch one plane from CA engines to CBs. During the ferry flight I look over and all the pressurization stuff on the FO's side panel appears to be working. So then we had to try to remember how to make it work.


And to think there are people on here who talk about the simple aircraft of the 1950s!

I still remember my first leg as PIC after 15-20 hours of OE with a line check airman. The FO and I had both come off DC-3s. Lining up on the runway I asked "Are you ready for this?" BMEP gauges and auto-feather lights. CHT selector switches and water pressure lights and gauges. We even had engine analyzers on some of the planes if you wanted to get up and play with them.

[climber314]

We even had engine analyzers on some of the planes if you wanted to get up and play with them.

Engine Analyzer in Aircraft after overhaul good idea.
PAX in OLD Airplane after EO.
Not so such.
IMO.

[PAXboy]

Ehhh, it's not like we're talking about a rare, priceless historical artifact. There's rows of them sitting in the desert. We're a loooong way from running out of Convairs.

My point was: do we keep on crashing old aircraft until there are none left? There might be Convairs lining up to crashed buy not so many Ju-52s and old warbirds.

[climber314]

My point was: do we keep on crashing old aircraft until there are none left? There might be Convairs lining up to crashed buy not so many Ju-52s and old warbirds.

I'm not sure GROUNDING sound historical aircraft being operated in revenue service makes a lot of sense.
Especially if there of plenty of types available for static display in a museum.
This isn't the Wright Flyer.
Better to BE a part of history than to just SEE history.

[PAXboy]

Since I was told that Convair are 'a dime a dozen' (sort of) I replied that it's fine to go on breaking them. But, at what point do you stop - when there are only three exampes left? One?

[Herod]

Agreed, paxboy. They said the same thing about Spits, Hurricanes and Lancasters after WWII.

[Centaurus]

Agreed, paxboy. They said the same thing about Spits, Hurricanes and Lancasters after WWII
Aerobatic displays by these precious old aircraft should be banned. OK to have a reasonably low flypast so spectators can hear the sound of a Merlin and admire the beautiful lines of a Spitfire, Mustang and similar warbirds, but showing off by performing a slow roll, steep wingover or barrel roll at low altitude is quite risky and totally unnecessary. Over-enthusiasm often leads to pilot error.

[AerocatS2A]

You may as well ban all aerobatic displays then Centaurus. The machines are privately owned and I don't see why the owners shouldn't do whatever they like with them. If someone wants to make sure there is a non-flying but airworthy museum piece then they are welcome to buy one and store it.

[PukinDog]

The tragedy of this event is that two people lost there lives. It could have been so much worse. By all means speculate on the cause of this horrific event, but don't you dare condemn two men who have arguably saved the lives of 18 people on board, on the basis of a preliminary report.

Yes, it could have easily been much worse, so before you start arguing that the crew "saved the lives of 18 people on board" once airborne, one must make the case that deciding to accept those 18 pax on board for a maintenance test flight of an aircraft after prolonged down time/ just out of heavy maintenance was prudent or a wise decision in the first place, regardless of what papers those in back signed. That's a question of crew judgement that can't be ignored.

[Chris Scott]

WhoFlungDung writes that two people lost their lives in this accident, whereas the Preliminary Report (http://www.caa.co.za/Accidents%20and%20Incidents%20Reports/ZS-BRV.pdf) states one, who I understand was the LAME. I'm hoping no one else has died since?

The circumstances of the sad death of the LAME will presumably be covered in a later report. Considering he was charged with operating the engine controls, was he able to wear a harness on whatever he was seated?

[Carbon Bootprint]

WhoFlungDung writes that two people lost their lives in this accident, whereas the Preliminary Report (http://www.caa.co.za/Accidents%20and%20Incidents%20Reports/ZS-BRV.pdf) states one, who I understand was the LAME. I'm hoping no one else has died since?
I believe somewhere earlier in this thread it was mentioned a person who was in the building the aircraft struck died a couple of days after the incident.

[Chris Scott]

I believe somewhere earlier in this thread it was mentioned a person who was in the building the aircraft struck died a couple of days after the incident.
Yes, that was posted by Hotel Tango on 11th July, the day after the accident, citing a Dutch news source. The date of the Preliminary Report is corrupt ("01 FEBRUARY 2017" [sic]). but I imagine it was compiled well after that. It clearly states that 8 people on the ground were injured, 4 seriously, but no fatalities at that stage.

[Gigajoules]

Yes, that was posted by Hotel Tango on 11th July, the day after the accident, citing a Dutch news source. The date of the Preliminary Report is corrupt ("01 FEBRUARY 2017" [sic]). but I imagine it was compiled well after that. It clearly states that 8 people on the ground were injured, 4 seriously, but no fatalities at that stage.

The date of the report is not corrupt. The "01 February 2017" refers to the report template date (some type of version control). Nobody on the ground died, it was a mix-up in the media...

[deSitter]

I think the thing that stands out most here is that the cowl flaps were wide open.

-drl

[Carbon Bootprint]

The date of the report is not corrupt. The "01 February 2017" refers to the report template date (some type of version control). Nobody on the ground died, it was a mix-up in the media...I was unaware the ground fatality report was erroneous. I'm glad to hear that, this was bad enough as is.

[Chris Scott]

The date of the report is not corrupt. The "01 February 2017" refers to the report template date (some type of version control). Nobody on the ground died, it was a mix-up in the media...
Yes, that it was a template date was evident! But I think it's normal to append a specific date to any report.

Relieved to have confirmation that no one died on the ground, thanks.

[Down and Welded]

voyageur9 (#246) highlights a critical factor and asks a reasonable question. My thoughts on these historic aircraft operations are that, inevitably, a small clique of pilots become type-rated (not a small achievement in the modern era, given the flying that must be involved) and from that, they become 'legends'... their celebrity, of course, being promoted by such people as personnel within their historic aircraft organisation, the media, and various airshow commentators. It IS beginning to sound as if the captain was not quite as competent--including in managing CRM--as some have suggested by pointing out his pedigree. It is also looking as if that old-hand LAME might have been extended slightly excessive deference due to his acknowledged familiarity with the aircraft and to the captain's previous experience of flying with him. There was also--apparently--a supernumerary STANDING on the flightdeck or in the doorway during the flight. These matters also go to the question of the degree of precision of captaincy and management of CRM displayed (or not) by the PF that day.

The ATSB's FindIT tool shows the crash site at 25' 40"/28' 17".

[The Old Fat One]

I think this whole warbird/vintage debate is derailing this thread. Whatever the antiquity of the aircraft is, it was operating in a passenger-carrying role with some clear risks involved.

Whether or not those risks were correctly managed is currently speculative; whether or not those risks associated with passenger carrying needed to be incurred in the first place, is not.

[currawong]

Has anyone been able to ascertain, from the footage available, if the cowl flap position matches the cowl flap setting?

[His dudeness]

And the relevance of that statement to this accident is what exactly.........??

:confused:

Zilch, nothing, nada.

Over here, there is an airshow called "Oldtimertreffen Hahnweide" (OTT), that regularly attracts many thousand of spectators and dozens, if not hundreds of old birds. The only accident I recall was an Extra, (NOT an oldtimer!) losing power after T/O and going into a field. The A/C displayed range from Ryans to DC-3s, they also had fly bys by a Connie, a B-17, a ME 262 etcetc. The displays are done by Stearmans, Cubs, Bückers, Warbirds (P-40,47,51, Spits, Hurricanes, Yaks, Sea Furies, ME 109s and a lot others)

This ban and forbid reflex is just....

[Mach E Avelli]

Dudeness, sadly we are headed for a ban and forbid reaction from the various regulators - certainly in regard to carrying passengers in old aircraft . I believe it already exists for commercial operations in Europe. The three most recent crashes (DC3 in the USA, Convair in South Africa and Junkers in Switzerland) can only accelerate the usual knee jerk response from regulators as they move to cover their public service backsides.
Down here in Oz and the Shaky Islands we are still lucky enough to occasionally see a DC 3 on a commercial flight carrying passengers to the vineyards, or doing scenic flights, evening dinner over the city lights etc. The safety record is OK because the few operators are sufficiently diligent in their maintenance and pilot training. It is doubtful that they actually make a profit from such operations, but they persist for the love of it and recover as much of their costs as they can by flogging tickets to the public.
Do the public know the potential risks? Of course not! No one will market a joy flight in a DC3 by stating that if it suffers an engine failure there is a chance it won’t be landing back at the departure airfield, or indeed may not actually land on any airfield but possibly on a convenient beach.
Therefore, I fear these grand old birds will be soon be legislated out of commercial operation by the imposition of modern performance standards, requirements for ADS B, flight recorders etc.which will make them unaffordable for all but the most wealthy private collectors.

[Volume]

The only accident I recall was an Extra, (NOT an oldtimer!) losing power after T/O and going into a field.
That very same year a Bücker or Stampe biplane also went into a field (http://www.feuerwehr-kirchheim.de/node/3234)after engine failure...

With no people injured, such incidents typically do not attract too much attention. With warbird display pilots being typically very skilled, most of the airshow incidents do not result in injuries or fatalities.

Everybody should know that preserving our aviation heritage in flying condition is not without risk. Everybody involved should accept this. We are not talking commercial air transport of customers without a clue.
Restoring an ancient castle is also not without risk..

It looks like the people involved in the Convair preservation and transfer to the Netherlands did basically know what they were doing, they were skilled, they did it before. What exactly went wrong will most probably be discovered and all people in this relatively small community will learn from it. I know many people dealing with vintage and classic aircraft, all of them follow such threads carefully. Most of them are aware that they do not know everything, and are eager to learn more. It is a pitty that a lot of knowledge gets lost constantly, but many people are working hard to preserve as much of it as possible.

[The Old Fat One]

We are not talking commercial air transport of customers without a clue.


Well actually that's exactly what we are (or should be) talking about in this thread. Amongst other things that should be pertinent and thought-provoking to professional aviators everywhere. As opposed to a whole load of spraff as to whether or not vintage aircraft should be allowed in the sky, which a great many people who make (or in my case, made) a living out of aviation could not care less about.

Oh well, time for me to go, I'll read the accident report when it comes out. I doubt it will contain many surprises.

[Judd]

You may as well ban all aerobatic displays then
That was never even hinted at. Nothing wrong with aircraft owners of aerobatics approved modern flying machines spinning and flying upside down leaving coloured smoke all over the sky. But please let the rare old warbirds fly sedately past the crowd so that those of us still alive who either flew them during WW2 or even post war, can watch them with affection without wondering if the owner pilot is going to suddenly show off and lose control with the inevitable result

[Mach E Avelli]

I am not quite sure how we got from an engine fire and loss of control in a Convair to aerobatics in this thread. Relevance is?

[climber314]

I am not quite sure how we got from an engine fire and loss of control in a Convair to aerobatics in this thread. Relevance is?

Yeah... no kidding!
MAJOR thread drift.
Create a new thread to discuss other issues?

[Fris B. Fairing]

Time for some balanced reporting?

THE AUSSIE CONVAIR PILOTS WERE HEROESI have been reading the Preliminary Report of the Convair Pretoria Accident.
This report was issued by the Accident and Incident Investigative Division of the South African Civil Aviation Authority.
The 3 Investigators responsible for the report were local engineers of which only the lead engineer " had done some flying ".
The report basically tries to blame the Australian pilots but it is full of errors, inaccuracies and unwarranted opinion.
For example the First Officer, a highly regarded Qantas A380 training captain, was accused of not being type rated on the Convair. Yet I can see on page 4 of his Australian ATPL under Type Qualifications - C340/440 above A380 and B747. Also this same crew two years previously had ferried the same model Convair to Australia.
What is most disturbing however is that the 3 engineer investigators appear to have no understanding of twin piston engine aircraft climb performance in the event of an engine failure.
Twin engine jet aircraft have a required climb performance capability in the event of an engine failure after takeoff. Piston twin engine aircraft however may not climb safely away on one engine.The single biggest improvement in aviation safety has been the switch from piston to jet engines. Jet engine stress is rotational inertia unlike the harsh reciprocating forces in a piston engine. In two thousands hours on RNZAF Sunderland flying boats I experienced 4 engines failures 2 of which were partial. In 20,000 plus subsequent hours on jet aircraft I have up to date only experienced 1 failure which was a bearing failure in a Learjet engine and which I immediately shutdown to avoid damage.
The elevation of 4,100 feet at Pretoria and a temperature of 20 degrees C meant a reduced engine power output from a density altitude of 4,700 feet. Plus 19 passengers and nearly 4000 lb of fuel suggests that there was insufficient performance available on one engine to safely climb away.Pilots of piston twin aircraft are taught that if an engine fails before selection of gear up then close the throttle of the remaining engine and land straight ahead. If the engine fails after selection of gear up, which appears to be the Convair case, then the pilot is committed to climb away at the safety speed.
The Convair engine was a partial failure that progressively got worse. Pilots are taught before all else to fly the aircraft and airmanship in this case meant using what power was available from the failing engine, even if it was on fire, to assist in getting to a safe altitude to perform an emergency return to the field for landing. That they managed to get to 800 feet is testament to this fact.
The report slays the pilots for not carrying out the emergency procedure of shutting down the engine. To do so as the investigators state would probably have resulted in a more rapid performance decay and possibly loss of control and crash with the death of all on board. That the pilots managed, in a no win situation, to mitigate the forthcoming consequences by keeping control means they should be lauded. They importantly crashed under control in a nearly wings level attitude that unfortunately resulted in only the one fatality of the Flight Engineer, but saved the rest.
Another disturbing feature of the report is that the investigators, with no formal CRM training, confused the standard airline identification and confirming procedure ( avoids error ) as the pilots being unsure of what was happening. These 2 pilots are Senior Qantas Check and Training captains which includes them teaching human factors and CRM.
This report is severely flawed. The investigators should have sought the advice from experienced airline pilots. That they did not do not means in my opinion that the report is worthless.
CAS should request to the South African CAA a formal review of the report with a view of ensure the final report does not contain these many errors and unqualified opinions.
BYRON BAILEY

www.captainbyronbailey.com (http://www.captainbyronbailey.com)

[rcsa]

Fris - look. No one familiar with South African aviation authorities would assume to get a competent first report these days. It happens, but less and less often. I fully expect the final report to be much more professional. Politics, unfortunately.

I don't think anyone here is really over-exercised about the paperwork - licenses, validations, certificates... we know these guys could fly the plane, and we know they know that their careers depend on them following the rules of Air Law.

I doubt anyone really doubts the capability, experience and airmanship of the flight deck team.

Pretty much everyone here understands that old machines break more often than new ones, and that when they break, the safety systems in place to mitigate consequences are generally not as good as modern safety systems.

There's really only one major bone of contention left - what on earth did they think they were doing taking passengers on that flight? First flight out of major overhaul, challenging density altitude (for the type), unfamiliar ground... Honestly. I wouldn't take passengers in my car, in the equivalent circumstances.

That, sadly, is the decision upon which the case for the defence falls apart. Everything else is irrelevant, or a distraction.

[Fris B. Fairing]

First flight out of major overhaul

Do we know this as fact? Could it have been the aircraft's first flight since it was painted? To some, a new paint job alone might constitute a major overhaul.

[Grizzly Bare]

Balanced reporting ... I don't think so.
These pilots were not heroes.
They were not legally entitled to pilot that aeroplane on that registration at that time. As senior Q training pilots they know full well the law, and as noted in Oz, it is a strict liability offence. If foreign pilots conducted this flight in Australia they would be prosecuted and the Q pilots union would have been fully supportive of the prosecution. However Australians coming to Africa and behaving like amateur cowboys is somehow acceptable? Remember, by choosing to conduct this illegal flight the pilots' actions led to DEATH.

Again, as far as "doubt(ing) the capability, experience and airmanship of the flight deck team" ... I wait to see and hear the GoPro footage. Good airman would not have flown an illegal flight. Good airmen would not have carried passengers on the test flight. But as reported by the SACAA they behaved in a thoroughly unprofessional manner for the aircraft type they were flying in, and again because of their actions people DIED.

[A Squared]

Do we know this as fact? Could it have been the aircraft's first flight since it was painted? To some, a new paint job alone might constitute a major overhaul.

If the investigators were in fact engineers, couldn't they be presumed to know the difference between painting and cunducting lettered checks?

According to the report:

Aircraft was painted and weighed February 2017
"Rebranded" in December 2017
Flown in February 2018
A, B and C checks performed July 2018.

[Volume]

A, B and C checks performed July 2018.
which does not make much sense as it is stated... If you do the C Check, it includes the A and B Check tasks anyway. Painting is out of that logic anyway.
I do not even know whether Convair has ever published letter checks, this policy was introduced later in the industry around the mid 60s. But maybe Convair was pioneering this.
Probably the former owner/maintenance organisation called it that way.

They were not legally entitled to pilot that aeroplane on that registration at that time.
This looks neglectable to me compared to not reacting to an engine fire...

because of their actions people DIED.
Probably both opposites as well...
Because they did not take certain actions, people died.
Because of some of their actions many people SURVIVED.

What they did perfectly is "fly the plane" and "control the plane as far as possible into a crash", this for sure saved lives. But it does not make them heroes.
They should have probably realized earlier that they will not make it back to the airport and perform an emergency landing in a suitable flield. There were several along their flight path.

Thanks to GoPro we will probably receive a great final report.

[Rated De]

Every pilot ever having graced a 'crash comic' started the day assuming it was not going to happen to them.
Perhaps human nature as it applies to the individual means we as a species consider those fallen lesser than ourselves, maybe this is what helps humans do things, including flying which carry real risk: It is always that guy not me.


The fact that the overwhelming majority of the occupants exited the aircraft still breathing is testament to many factors.

Best to leave it for the fullness of time to reveal what transpired.

[atakacs]

We shall definitely wait for the full report but there is little reason to doubt the preliminary findings.
We have a "super" CVR in the form of the GoPro. As far as we know they did not communicate during the emergency, which is is not good airmanship. And "controlled flight" into a dairy factory is very suspect to me. Until proven otherwise there was nothing controlled here and they just happen to crash into power lines then into the building pretty much as passengers. As I wrote earlier their only redeeming quality was to be incredibly lucky: good on them!

Now I don't know if this fight was recoverable: they were most likely going down anyway. But there is zero indication so far that crew performance was above par.

[Dan_Brown]

Whom would you prefer to fly this machine? Someone with all the boxes ticked and the I's all dotted, that has f all experience on type and overall? Or would you prefer these guys that were in the accident?

As said above #408, most of us, having been dealt a hand such as they were dealt, would probably have died along with all on board, given the same senerio.

[atakacs]

As said above #408, most of us, having been dealt a hand such as they were dealt, would probably have died along with all on board, given the same senerio.
I am not too much bothered about the paperwork shortcomings as I don't think it had much of an impact on the final outcome.

I certainly question the wisdom of flying paxes in a test flight after apparently an extensive maintenance.

I have many reservations on the crew performance (or lack of) during the emergency but I'll wait for the final report.

But I am happy that whoever was flying this aircraft was immensely lucky!

[EDML]

Of course it might have been a viable plan to keep the engine running as long as possible due to the OEI performance of this aircraft.

However, I would have expected that this plan is discussed by the flight crew members.

Furthermore, due to the topologie the traffic pattern to the north is very long - they where in the air for 9min until they crashed. With just 4kt of wind a procedure turn and a downwind landing would have been an option to get the plane on the ground ASAP. Maybe there was a reason not to do that but it should have been discussed.

Also, they should have been aware that an engine fire in a piston engine might quickly compromise the structural integrity of the aircraft. Again, that was not discussed.

[A Squared]

I do not even know whether Convair has ever published letter checks, this policy was introduced later in the industry around the mid 60s. But maybe Convair was pioneering this.

I don’t know about the Convair, but the DC-6 has letter checks, so it doesn’t seem out of the question that the Convair might also.

[papa_sierra]

I can quite see why people climb into aircraft of a previous age to relive nostalgia, (I would myself) but there is a history of things going wrong. There is a parallel with this accident - https://www.gov.uk/aaib-reports/2-1986-vickers-varsity-t1-g-bdft-19-august-1984 which I would hope the operators of older aircraft would take on board.

[Chris Scott]

Of course it might have been a viable plan to keep the engine running as long as possible due to the OEI performance of this aircraft.
However, I would have expected that this plan is discussed by the flight crew members.
Furthermore, due to the topologie the traffic pattern to the north is very long - they where in the air for 9min until they crashed. With just 4kt of wind a procedure turn and a downwind landing would have been an option to get the plane on the ground ASAP. Maybe there was a reason not to do that but it should have been discussed.
Also, they should have been aware that an engine fire in a piston engine might quickly compromise the structural integrity of the aircraft. Again, that was not discussed.

Hi EDML,
No doubt the wind conditions would have permitted a downwind landing, particularly in an emergency such as pertained.The problem, however, seems to have been keeping the a/c in the air at all. Normally, a procedure turn on a slow aeroplane like the Convair would be executed at Rate-One. That would involve nearly 20 degrees of bank, which - as we can infer from the report that they only climbed 800 ft with wings level - would inevitably have involved a loss of height. You probably know that here are two types of procedure turn in common use? At a turn-rate of Rate-One, the absolute minimum time to turn an aircraft round is 2 minutes - more likely 2 mins 30 seconds.

Apart from the possibility of a forced landing, which could easily have lead to fatalities and probably written the a/c off anyway, the only option was to nurse the airplane around a wide circuit, using minimal bank. That's what they seem to have been attempting. And don't forget that they were apparently experiencing serious flight-control problems.

By the way, I'm not expressing an opinion on flight-crew performance, because there are currently too many unknowns. I'll await a transcript of the GoPro recording, and hope that the investigators will be able to shed light on possible aileron and rudder anomalies, as well as the engine-cowl configuration.

[climber314]

EXPANDED EMERGENCY CHECKLIST
Convair C-131 N131CW
Convair Serial Number 205
USAF Serial Number 54-2809
CV-340 (with all 440 mods)

https://www.avweb.com/news/pelican/182145-1.html

"For ANY fire in-flight, the first thought must be to GET DOWN. Major fires in these old airplanes can cause structural failures in less than 60 seconds (there is film to prove it), and it will take not less than three minutes to get this airplane down to sea level from 9,000 feet or so. If the fire is brought under control, it's easy enough to stop the descent, and then evaluate the options.

With a serious fire on board, DO NOT attempt to "stretch" the flight to some airport that is even a short distance away. Put the airplane down in the water, or anywhere, under control."

[atakacs]

Hmm pretty damning....

Any specifics about this document? Pardon my ignorance but who is that Deakin?

[Dan_Brown]

Can we be sure the crew knew the no 1 engine was on fire? The pax down the back on the port side,along with those filming would have know of course. The flames were not "great in lenght" compared with say, avgas pouring from the engine and igniting, with the results of flame as long as the length of the a/c.

My gut tells me it was an oil feed fire.

They obviously knew they were done on power.
Down on power checklist? Best option, attempt to land at nearest suitable.

[Capt Fathom]

Climber, checklists are designed by aircraft manufacturers (people in an office) writing checklists based on one failure at a time. All very straight forward... from the office.
It often does not happen that way in the real world.
Not so good when you have multiple problems. You then need to prioritise.
So it’s a little different when you’re sitting at your desk pointing out what should have been done verses actually being in an aircraft faced with multiple problems.
Easy to comment in hindsight.

[Chris Scott]

Hmm pretty damning....

Any specifics about this document? Pardon my ignorance but who is that Deakin?

Well Mr Deakin's opinion is as legitimate as any, I guess. I don't share it, except in the instance when the fire cannot be extinguished promptly. If it has been extinguished, one's choice of a landing site probably depends on how the airplane is performing on the remaining donk. Forgive me for harping back to the Dakota again, but, fifty years ago, plan A was to extinguish the fire and land at the nearest aerodrome. Plan B is open to what desk-occupants call "airmanship".

Quote from climber314:
"You run the checklist and put it down in an open field ASAP.
Statistically speaking, that would result in fewer/less severe injuries than (partially) controlled flight into overhead wires and a ground structure and vehicles."

Your second sentence is un-contestable, but even the best-executed forced landings can end badly. An example was an Air Rhodesia Viscount in 1978. The aeroplane had been hit in the #3 engine by a heat-seeking missile, causing an non-extinguishable fire in that engine and the failure of #4. Having no alternative to a forced landing, the skipper selected a large, apparently unobstructed cotton field. The approach and belly landing were good by all accounts. Shortly after touchdown the a/c encountered an irrigation ditch. It cartwheeled, broke-up and caught fire. Of the 56 SoB, 18 survived. I imagine the Viscount's approach speed may be slightly higher than the CV-340, but in a similar ballpark.

[A Squared]

Can we be sure the crew knew the no 1 engine was on fire?

Do you mean other than the cockpit engine fire warning lights illuminated and the (engineer rated, I believe) passenger coming forward to the cockpit and telling them the left engine was on fire?

[Dan_Brown]

Oh I stand corrected. I didnt read all the posts. Thanks for the correction.

[megan]

Pardon my ignorance but who is that Deakin? John was the check and trainer on the CAF's big pistons, C-131, B-24, Connie, C-46, B-29 to name a few, and flew a few WWII single engine fighters, including the Zero. Had extensive C-46 experience in Asia early in his career with Air America. At time of retirement was the worlds highest time 747 driver. Mr Deakin's opinion is as legitimate as any, I guess. I don't share it But I'd sure listen Chris, and of course context, aircraft type etc may be influencers. Light twins have had the wing fail as a result of engine fire impacting spar integrity, no fire bottles to help.

[Dan_Brown]

Very impressive CV.

He didn't buy his job but got there on ability and drive.

I would very surprised, if he ever addresses himself as "Captain" outside work. Not like a lot of pratts who do. I know at least one who has his name, prefixed by Captain, in his passport. You see he, among others have been brought up in a country where aviation is common place and encouraged. not like Europe for example where the authorities are trying to destroy aviation and making a damned good job of it too.

Sorry I digress.

[ehwatezedoing]

This accident reminded me of a very good story narrated by late con-pilot
Hangar flying in a bar can save your life. (https://www.pprune.org/accidents-close-calls/563987-hangar-flying-bar-can-save-your-life.html)
Piston Convair’s exaust manifold fail, leading to a (hidden) fire with structural damage.




Lots of lessons there, it is worth the reading...

[climber314]

This accident reminded me of a very good story narrated by late con-pilot
Hangar flying in a bar can save your life. (https://www.pprune.org/accidents-close-calls/563987-hangar-flying-bar-can-save-your-life.html)
Piston Convair’s exaust manifold fail, leading to a (hidden) fire with structural damage.
Lots of lessons there, it is worth the reading...

WOW! I would have tossed my cookies after that too!

Certainly makes one wonder what structural damage this fire may have done?
"Ground witnesses observed and collected melted metal debris, that fell off the aircraft while it remained airborne."

Fortunate they made it back to terra firma with only one fatality.
It could have been A LOT worse.
Hoping all others recover fully in due course.

[Webby737]

Climber, checklists are designed by aircraft manufacturers (people in an office) writing checklists based on one failure at a time. All very straight forward... from the office.
It often does not happen that way in the real world.
Not so good when you have multiple problems. You then need to prioritise.
So it’s a little different when you’re sitting at your desk pointing out what should have been done verses actually being in an aircraft faced with multiple problems.
Easy to comment in hindsight.

Well said Capt Fathom,
From an Engineers opinion, this is where the pilots earn their money (it's not enough!).
It's all well and good blaming the crew, but how would those criticising the crew react if faced with a similar situation ?
I for one will wait for the official report before pointing the finger !

[AN2 Driver]

Pardon my ignorance but who is that Deakin?

John Deakin (https://www.advancedpilot.com/staff.html)is one guy a lot of people listen to and for a reason to: When he sais something it usually is very true.


John is one of the original Air America pilots (DC3, Curtiss Commando) followed by a distinguished career with JAL as a 747 commander. After retiring he has flown several biz jets but also was one of the top pilots of the CAF, flying the Commando again plus many other airplanes including the B29 FIFI as commander. He used to own a Beech Bonanza for a long time too until he lost his medical a few years ago. Currently he teaches engine seminars (https://www.advancedpilot.com/). He is probably one of the people alive who know this kind of engines and airplanes better than most others.

His book, "Full Throttle" is probably one of the most entertaining aviation reads available.

[Volume]

hang around airport bars, you might save your life.
Or visit forums like this regularly, it may do the same job :ok:

[BEACH KING]

Well said Capt Fathom,
From an Engineers opinion, this is where the pilots earn their money (it's not enough!).
It's all well and good blaming the crew, but how would those criticising the crew react if faced with a similar situation ?
I for one will wait for the official report before pointing the finger !
I agree Webby.
It would be interesting to see if the outcome differed any if 4 assholer and Grizzly Bare were crewing

[climber314]

John Deakin (https://www.advancedpilot.com/staff.html)is one guy a lot of people listen to and for a reason to: When he sais something it usually is very true.

His book, "Full Throttle (https://www.amazon.com/Full-Throttle-John-R-Deakin/dp/0974977004)" is probably one of the most entertaining aviation reads available.

Just finished reading his book. I'd highly recommend it to anyone interested interested in historical piston aircraft from a pilot's perspective.

[A Squared]

I would very surprised, if he ever addresses himself as "Captain" outside work. Not like a lot of pratts who do.


You'd be right. He was still flying for JAL when he started writing Pelican's Perch fore AvWeb. He hit the age at which he could no longer fly as PIC, but continued to fly as a first officer. He mentioned in one if his columns having to instruct some of his co-workers to quite addressing him as "Captain" as he wasn't serving in that role any more.

[aterpster]

John Deakin (https://www.advancedpilot.com/staff.html)is one guy a lot of people listen to and for a reason to: When he sais something it usually is very true.


John is one of the original Air America pilots (DC3, Curtiss Commando) followed by a distinguished career with JAL as a 747 commander. After retiring he has flown several biz jets but also was one of the top pilots of the CAF, flying the Commando again plus many other airplanes including the B29 FIFI as commander. He used to own a Beech Bonanza for a long time too until he lost his medical a few years ago. Currently he teaches engine seminars (https://www.advancedpilot.com/). He is probably one of the people alive who know this kind of engines and airplanes better than most others.

His book, "Full Throttle (https://www.amazon.com/Full-Throttle-John-R-Deakin/dp/0974977004)" is probably one of the most entertaining aviation reads available.

I know John. Very knowledgeable and a good guy. He's forgotten more about aircraft engines than most of us will ever know.

[gcal]

Well Mr Deakin's opinion is as legitimate as any, I guess. I don't share it, except in the instance when the fire cannot be extinguished promptly. If it has been extinguished, one's choice of a landing site probably depends on how the airplane is performing on the remaining donk. Forgive me for harping back to the Dakota again, but, fifty years ago, plan A was to extinguish the fire and land at the nearest aerodrome. Plan B is open to what desk-occupants call "airmanship".

Quote from climber314:
"You run the checklist and put it down in an open field ASAP.
Statistically speaking, that would result in fewer/less severe injuries than (partially) controlled flight into overhead wires and a ground structure and vehicles."

Your second sentence is un-contestable, but even the best-executed forced landings can end badly. An example was an Air Rhodesia Viscount in 1978. The aeroplane had been hit in the #3 engine by a heat-seeking missile, causing an non-extinguishable fire in that engine and the failure of #4. Having no alternative to a forced landing, the skipper selected a large, apparently unobstructed cotton field. The approach and belly landing were good by all accounts. Shortly after touchdown the a/c encountered an irrigation ditch. It cartwheeled, broke-up and caught fire. Of the 56 SoB, 18 survived. I imagine the Viscount's approach speed may be slightly higher than the CV-340, but in a similar ballpark.
Of those that did survive many were killed by the fighters responsible for the missile; the few that survived entirely had taken shelter in the bush or going in search of help.

[Chris Scott]

John was the check and trainer on the CAF's big pistons, C-131, B-24, Connie, C-46, B-29 to name a few, and flew a few WWII single engine fighters, including the Zero. Had extensive C-46 experience in Asia early in his career with Air America. At time of retirement was the worlds highest time 747 driver.
But I'd sure listen Chris, and of course context, aircraft type etc may be influencers. Light twins have had the wing fail as a result of engine fire impacting spar integrity, no fire bottles to help.
FWIW I've read John Deakin's expanded emergency checklist for the C-131 (CV-340) and, admittedly from my perspective of zero experience on type, it looks to be an excellent contribution.

Some posters seem to have inferred that, following any in-flight fire, Mr Deakin's policy is to force-land on land or water regardless of the outcome of the fire drill. This, however, is what he has written - as previously quoted by climber314:

"For ANY fire in-flight, the first thought must be to GET DOWN. Major fires in these old airplanes can cause structural failures in less than 60 seconds (there is film to prove it), and it will take not less than three minutes to get this airplane down to sea level from 9,000 feet or so. If the fire is brought under control, it's easy enough to stop the descent, and then evaluate the options.
With a serious fire on board, DO NOT attempt to "stretch" the flight to some airport that is even a short distance away. Put the airplane down in the water, or anywhere, under control.
Even without fire, water is by far the best bet for an emergency landing. With a fire, you're carrying a major fire to the scene, where fuel tanks are very likely to burst. A water landing can only help."

Note that he is addressing the event of a "major" or "serious" fire. Well, I think we would agree that ANY fire is a serious matter. His advice to descend immediately is to cover the case in which, subsequently, the fire cannot be extinguished. At the same time, he emphasises the need not to rush the engine fire drill:
"Both crewmembers should agree that the failure warrants a shutdown, and should confirm with each other which engine it is. It is far better to take it slowly, than to get it wrong."

His advice not to "stretch" the flight to the nearest airport evidently refers to the case where the fire has not been promptly extinguished and/or there is reason to suspect the airframe is structurally compromised. Otherwise:
"If the fire is brought under control, it's easy enough to stop the descent, and then evaluate the options."

Returning to the case in question, IMHO we do not yet have sufficient information to explain either why the crew of ZS-BRV apparently decided to leave the #1 engine running on fire, or why they decided to stay airborne as long as they did. Mr Deakin's preferred option of a landing on water was not available.

Hi gcal,
Yes, the shocking fate of many of the 18 who survived the Viscount forced-landing to which I referred is well documented, and I felt it was not relevant to this thread.

[megan]

The mention of Viscount and fire brings to mind Viscount VH-RMI, in cruise at FL175 reported "on emergency descent" with fire warnings on both #1 and #2 engines, one was "out" and they were unable to feather the other engine (#2). Caused by the break up of the rotor in the No. 2 cabin pressurisation blower, which then ignited the lubricating oil. Airflow through the wing caused a breach in the No. 2 fuel tank and the fuel fed fire was directed by airflow to the spar upper boom. At 4,000' on descent to the airport the wing failed. 24 died. Entire process encompassed 15 minutes.

[PAXboy]

They had valid Australian licenses which had not been fully validated for the SA registered aircraft. A paperwork issue.
Knowing that they were both (clearly) trained on type, you are focusing on easily the most irrelevant and insignificant aspect of this tragedy, paperwork on the day wouldn't have stopped what happened from happened. For what purpose or agenda remains to be seen.
I don't think anyone here is really over-exercised about the paperwork - licenses, validations, certificates... we know these guys could fly the plane, and we know they know that their careers depend on them following the rules of Air Law.
I am not too much bothered about the paperwork shortcomings as I don't think it had much of an impact on the final outcome.

None of you maybe concerned about the paperwork but the lawyers and insurance companies sure are ...

[voyageur9]

None of you maybe concerned about the paperwork but the lawyers and insurance companies sure are ...

As well as the maimed and the families of the dead. If the pilots were not legal to fly (no matter that some dismiss it as trivial paperwork) then there may arise issues of personal liability for the pain, suffering, loss and ongoing care for anyone who was disabled. Much will depend on the jurisdiction and whether insurers are willing to overlook what some regard as technicalities. But insurers rarely pay out what could be huge settlements if there were wrongful acts or omissions unless that coverage was purchased. Signed waivers may not be valid in such circumstances.

[rcsa]

Of course it matters before and after the fact, and surely there will be expensive consequences if the paperwork wasn't correct. I won't speak for anyone else, but what I meant was simply that in the moment of managing the crisis, the paperwork wasn't relevant.

[The Old Fat One]

"For ANY fire in-flight, the first thought must be to GET DOWN. Major fires in these old airplanes can cause structural failures in less than 60 seconds (there is film to prove it), and it will take not less than three minutes to get this airplane down to sea level from 9,000 feet or so. If the fire is brought under control, it's easy enough to stop the descent, and then evaluate the options.
With a serious fire on board, DO NOT attempt to "stretch" the flight to some airport that is even a short distance away. Put the airplane down in the water, or anywhere, under control.
Even without fire, water is by far the best bet for an emergency landing. With a fire, you're carrying a major fire to the scene, where fuel tanks are very likely to burst. A water landing can only help."

Outstanding guidance, albeit, second nature to every professional aviator on here (hopefully).

There is an old early CRM video of the Nimrod ditching in the Moray Firth (uncontained engine fire) which depicts this exact scenario perfectly...the skipper (who I knew well) stuck it in the oggin, even though the runway was a few minutes away. Structural analysis later showed that ballsy call saved all onboard. Well played AS.

And as for the document/insurance thing...check out why Damien Hill (the racing driver) grew up poor.

[PAXboy]

Damon Hill.
Wikipedia Graham Hill (https://en.wikipedia.org/wiki/Graham_Hill)
Wikipedia Graham Hill plane crash (https://en.wikipedia.org/wiki/Graham_Hill_plane_crash)

[Pilot DAR]

With a fire, you're carrying a major fire to the scene, where fuel tanks are very likely to burst. A water landing can only help.

I can't agree that a water landing with a fire is preferable. Of course, no landing with fire is good, and you gotta do what you gotta do, but... considering occupant safety as the primary objective, a water landing will introduce more hazards. If there is a choice between water and decent land for an on fire crash landing, I'd take the land. My reasons: You have a better chance of maintaining control of an intact aircraft to the stop on land, than on water, there is no risk of drowning, if it's been a fuel fed fire, the fuel will spread the fire over a larger area on water than land, and people can't run away from it in the water, it'll be easier for emergency services to reach you on land, a person's injuries will be more likely to become infected in the water, than on land.

I have more experience with this that I would like to have had.

[climber314]

I can't agree that a water landing with a fire is preferable. Of course, no landing with fire is good, and you gotta do what you gotta do, but... considering occupant safety as the primary objective, a water landing will introduce more hazards. If there is a choice between water and decent land for an on fire crash landing, I'd take the land. My reasons: You have a better chance of maintaining control of an intact aircraft to the stop on land, than on water, there is no risk of drowning, if it's been a fuel fed fire, the fuel will spread the fire over a larger area on water than land, and people can't run away from it in the water, it'll be easier for emergency services to reach you on land, a person's injuries will be more likely to become infected in the water, than on land.

I have more experience with this that I would like to have had.

Can't say I disagree Pilot DAR (https://www.pprune.org/members/150561-pilot-dar). All good points. In fact, my original comment was deleted for some reason, but remains quoted in another post?
Quote from climber314:
"You run the [fire] checklist and put it down in an open field ASAP.
Statistically speaking, that would result in fewer/less severe injuries than (partially) controlled flight into overhead wires and a ground structure and vehicles."
Perhaps the water landing reference had/has something to do with the specific type/age of the plane in question? IDK. I'm going to leave the final analysis to the experts and John Deakin is certainly one of the few remaining. Further, I am hoping that the surviving pilots are able to shed some light on their thoughts and intents.

[WhoFlungDung]

Does anyone know when the final report will be released? Is there any news on the investigation?

WFD

[atakacs]

Will be released when ready. Seriously!

These investigations take time and this one is probably not the easiest while not the most urgent (there are not that many Convair 340 in service). I wouldn't be surprised to wait a few more years to get the final report.

[The Ancient Geek]

SACAA usually aim to get a final report published in around a year but this is not an easy case so it could take a while longer.

[jojo1977]

Apparently the report has been obtained by the Dutch museum that purchased the Convair. I've been trying to look for it but can;t see it officially published on the SACAA website yet. link to a dutch newspaper article http://www.omroepflevoland.nl/nieuws/173635/piloten-mochten-crashtoestel-aviodrome-niet-besturen (https://www.omroepflevoland.nl/nieuws/173635/piloten-mochten-crashtoestel-aviodrome-niet-besturen)

[Bell_ringer]

http://www.caa.co.za/Accidents%20and%20Incidents%20Reports/9722.pdf

[Cloudee]

Not a good read for both the flight and maintenance crews.

3.4. Contributory Factors:
3.4.1 Pre-existing damage to the cylinder No 13 piston and ring pack deformation and, most probably, the cylinder No 7’s fractured exhaust valve head that were not detected during maintenance of the aircraft.
3.4.2 Substandard maintenance for failing to conduct compression tests on all cylinders during the scheduled maintenance prior to the accident.
3.4.3 Misdiagnosis of the left engine manifold pressure defect as it was reported twice prior to the accident.
3.4.4 The crew not aborting take-off at 50kts prior to reaching V1; manifold pressure fluctuation was observed by the crew at 50kts and that should have resulted in an aborted take-off.
3.4.6 Lack of crew resource management; this was evident as the crew ignored using the emergency checklist to respond to the in-flight left engine fire.
3.4.7 Lack of recency training for both the PF and PM, as well as the LAME.
3.4.8 Non-compliance to Civil Aviation Regulations by both the crew and the maintenance organisation.

[atakacs]

Not a good read for both the flight and maintenance crews
Pretty damning indeed.
And they actually wanted to fly this aircraft to the Netherlands!? Amazing.

Do we have any news of the recovery of the survivors?

[Double Back]

Hmmm, reeks like, let's get this crate flying again as soon and as cheap as possible, then send it off to NL, who will (probably) use it only as a non-flying piece of static display. Possibly the price was already hammered, meaning in flying condition. So not much eagerness for extra costs from the side of the vendor.
And who takes a load full of pax with You during a test flight with old stuff, after "maintenance" and a long idle period. And only ONE test flight was planned due to possibly a few time constraints. Like the return flight was already planned, with all that comes with it.
I wonder how much the pilots were pressed to accept the conditions as they were. But OK, finally they made the decision to accept it as presented.

I love to see those old planes fly but long time ago I decided not to fly them myself, however I was and am still active in GA.
There is just too many accidents with those old planes. I flew 18.000plus hours on heavy metal, most of it 3 and 4 holers. NEVER lost ONE engine (mostly GE CF6)

[Airbubba]

As suspected earlier, neither one of these so-called 'professional pilots' was legal to fly a ZS registered Convair. :ugh:

1.5.1.2 The PF’s validation of his foreign licence, which was valid until 5 May 2021, was only limited to Single Engine Land aircraft with the following aircraft types: C150, C172, C182 and PA 28 A/B. This information is based on his foreign licence validation application and skills test report dated 9 May 2016.

1.5.1.3 The PF was not authorised to operate a South African registered Convair 340/440, as he had not done a skills test on a Convair 340/440 as required by CAR 2011, Part 61.01.13.

1.5.2.3 The PM’s validation of his foreign licence, which was valid until 5 May 2021, was only limited to a Single Engine Land aircraft with the following aircraft types: C150, C172, C182 and PA 28 A/B. This information is based on his foreign licence validation application and skills test report dated 6 May 2016.

1.5.2.5 The PM was not authorised to operate a South African registered Convair 340/440 as he had not done a skills test on a Convair 340/440 as required by CAR 2011, Part 61.01.13.

[atakacs]

To be honest the licensing part of this mess is relatively minor when put into the perspective of the glaring mistakes and negligences otherwise comited.

[Airbubba]

To be honest the licensing part of this mess is relatively minor when put into the perspective of the glaring mistakes and negligences otherwise comited.

I guess you are right, these 'senior QF check pilots' apparently never did a checklist or fired an extinguisher bottle with the left engine on fire. I'm sure some will call this 'technique'.

1.1.14 Throughout the flight, the left engine was on fire. The cockpit GoPro video recording
showed that the left engine’s revolutions per minute (RPM) indicator was fluctuating
and, later, the left engine’s fire master caution light illuminated and an audible
warning sound came on confirming that the left engine was on fire. The GoPro
video recording also showed that prior to impact, the control wheel was being
deflected to the right by the PF and he indicated that they had lost aileron control.
He also requested the PM (first officer) for the rudder input.

1.1.15 The GoPro video recording further showed that the PF was not sure if they had
retracted the landing gears as he could be heard asking the PM if the gears were
retracted or not. Moreover, the video recording revealed that although the crew was
informed of the left engine being on fire by one of the passengers, they were still not
sure which engine was on fire. At no stage did the crew discuss or attempt to
extinguish the fire in the left engine. As a result, the left engine fire extinguishing
system was never activated and the left engine remained operating and on fire until
the aircraft impacted the building.

[fdr]

To be honest the licensing part of this mess is relatively minor when put into the perspective of the glaring mistakes and negligences otherwise comited.


Maybe... but it is untidy. A while ago, two other AUS pilots were flying an N rego B737 around in Africa under similar circumstances, the "PIC" had a valid FAA PPL, but a CASA ATPL, and the copilot had a CPL/IR/ME AUS, no FAA license. Flying out of an interesting mid lattitude country not well known for its high standards, these guys were so on the nose that they were given hours to get out of town... taking their toy with them. When there was some concern raised on the operation by the southern african CAA, the "PIC" commented in response to the regulator that the FO was in fact the typed PIC.... The "FO" picked up his type on the baby Boeing 90 days after they were booted out of mid africa, after having flown for a month doing RPT.

There is an underlying complacency with meeting any semblance of compliance that occurred then, nearly 10 years before the Convair event.

Of light relief, reportedly the "PIC" involved in this had to phone home on a borrowed cell phone to work out how to start the 73 before departing on the adventure. To give the PIC his due, once upon a time he was a very good Checker on B747s with a major carrier, but retirement seems to have altered his view on standards and compliance matters.

FAA was aware of the issue, as was SA CAA, and as was CASA... and no one did a thing about it. FAA has enough work on their plate with other items to be worried about cloned jets, or the same Antonov being used on contract to the UN, 2,305nm apart at the same moment, registered to a country that doesn't have an Antonov on its register. One colourful vignette came from a recovery crew picking up a 737 on a lease that was delinquent, which was parked beside the cloned B737, showing the same registration. The crew were impressed enough to take happy snaps of the twins. The regulators did... nothing.

[Jhieminga]

As suspected earlier, neither one of these so-called 'professional pilots' was legal to fly a ZS registered Convair. :ugh:
Not very professional at first sight, but the report does show that both pilots were rated on the CV-330/340 (on their AUS licences) and had experience on the type. The problem was that these ratings were not copied across to their SA licences. This may have been because of a restriction in the SA rules (specifically the skills test mentioned in the report). If (I don't know if that's the case) they had instructor or examiner privileges, they may have been operating on a waiver, with the intention to use the flight to tick the 'skills test' box. This may seem odd, but in the case of historic aircraft it is not unheard of. The options for doing a skills test on a Convair in SA are not that abundant so sometimes you have to come up with a different solution.

Please note that I'm only playing devil's advocate with regard to the licencing issue. I'm not commenting on the other aspects of this accident.

[Double Back]

In support of the crew, to get a validation in SA, was (and is?) extremely bureaucratic and cumbersome, at least that was it 15 Yrs ago.
I did it a few times to get my SAA PPL, to rent a Cessna whenever I had a layover.
One of the irritating and stubborn views of the office was that the expiry date of part of my ATPL's IF rating was of course sooner than the ATPL itself.
They insisted that that date was then also the expiry date of my validation, even while it was a VFR PPL validation only! So with some luck I had it valid for 3-4 months.
After doing that a few times (my next trip was always after the expiry date...) I got fed up and never rented again.
Bureaucracy at its worst, thinking in hurdles in stead of possibilities.
Of course the government tries to "protect" the local pilots of not giving away an ATPL too easily, but they could have stated on it, that is was only for a few test flights on that specific plane plus the outward bound.
Try that with a driver's license of a foreign visitor and the local rental car businesses would be crying out...

The report does not state why the crew did not/could not obtain a suitable validation, I am sure they tried!. If this was because of a missing check flight, I swallow my words, but they might not have gotten even close to this point. Instead the report mentions the missing licensing several times. But no word WHY it was missing...

[voyageur9]

In support of the crew, to get a validation in SA, was (and is?) extremely bureaucratic and cumbersome, ..... I am sure they tried!. ..

Really, how sure ... as sure as you are that they wouldn't break rules and procedures, wouldn't fail to follow checklists or display basic airmanship, wouldn't recklessly endanger the lives of others by turning a test flight into a sightseeing jaunt. Sadly the dead and the injured may have shared your misplaced confidence but paid a far higher price.

[atakacs]

Well, formally licensed or not, ignoring a defective (or at the very least extremely suspect) then burning engine was extremely poor aimanship. That people walked form this crash as sheer luck.

[Braam]

Sad day when senior captains operate planes for which they have no foreign validation....

[KRviator]

The report does not state why the crew did not/could not obtain a suitable validation, I am sure they tried!. If this was because of a missing check flight, I swallow my words, but they might not have gotten even close to this point. Instead the report mentions the missing licensing several times. But no word WHY it was missing...IF they tried to obtain a validation, but couldn't or didn't, and flew the flight knowing they were technically unlicensed makes it worse than simply thinking, or assuming as the case may be, that the CAA blindly accepted their Australian qualifications. The report doesn't seem to go into either their attempts to obtain such a validation, or their reasoning for crewing the flight without it, either knowingly or not.

[Double Back]

The current owners MUST have known the crew failed to get the corresponding licenses. If not, they were quite sloppy in their preparations. Normally, getting a validation for these kind of flights, the "locals" will be helping with all the paperwork and the national licensing department.
And if they DID know, that makes them culpable as well, willingly letting an incomplete licensed crew fly their plane.
I rented planes all over the world, but I never got a simple C172 from the FBO/Club w/o them checking my license..... Plus a checkout of course...

[Cloudee]

IF they tried to obtain a validation, but couldn't or didn't, and flew the flight knowing they were technically unlicensed makes it worse than simply thinking, or assuming as the case may be, that the CAA blindly accepted their Australian qualifications. The report doesn't seem to go into either their attempts to obtain such a validation, or their reasoning for crewing the flight without it, either knowingly or not.
Maybe they will leave that part of the investigation to the police.

[PerPurumTonantes]

To be honest the licensing part of this mess is relatively minor when put into the perspective of the glaring mistakes and negligences otherwise comited.


Having flown N, VH and G - reg aircraft, and had to deal with the US, Aus and UK licensing, I'd agree - it's a bureaucratic tick in the box. It is the same aircraft and the same air, and that license certification will not help you to keep it flying. (Having said this, it is worth getting additional training on procedures / airspace etc in each country. Especially the UK, things are a bit weird here ;) )

But: Failing to get the certification shows a "she'll be right" attitude. Which is confirmed by the rest of the narrative. Taking passengers when not current, in an old crate, and not having the engine fire checklist drilled into memory... :rolleyes:

I can't see anything in the accident report about why they didn't pull the fire suppression. Were they reluctant to shut an engine down if they were still getting power out of it?

[atakacs]

I can't see anything in the accident report about why they didn't pull the fire suppression. Were they reluctant to shut an engine down if they were still getting power out of it?
From the various reports of the in-flight footage and accident report my take is that they froze, possibly not even recognizing an engine fire and the seriousness of it...

[EDML]

I can't see anything in the accident report about why they didn't pull the fire suppression. Were they reluctant to shut an engine down if they were still getting power out of it?

Maybe - but then it should have been briefed. Not just continue the flight doing a very wide (> 10min) pattern while the engine fire burns through the wing & flight controls.
Being rated on the CV340 they should have been aware that an engine fire on such a radial engine quickly affects the structural integrity of the aircraft.

[Down and Welded]

The investigation report makes no mention of interview evidence. Were the investigators unable to speak to them at any time while still in-country - even as they were eventually preparing to travel back to Australia? One wonders if the SA investigators will ever be able to ask these two the requisite questions... or is it that they will lay low in Australia, have a memory lapse, and choose to make no contribution whatever to the advancement of aviation safety?

[bobdh478]

Really, arguing the toss about whether things are merely "untidy" or it's merely because bureaucratic obstacles simply prevent compliance with rules is a complete red herring. The bottom line is that it was an unsound operation in almost every respect. To even contemplate flying to the Netherlands is even more worrying. This type of thing only ensures that the difficulties facing preservation and operation of old aircraft become even more stringent. Many would say rightly so, after reading the accident report.

[JW411]

I am led to believe that both of the pilots were senior QF captains (one of them was on the A380). I am also led to believe that they had successfully delivered ZS-ARV to Australia previously? They were both very seriously injured in the accident and ended up in hospital in induced comas. One, I have heard, ended up with a double amputation. So, perhaps those of you out there who can't understand why they did not give a comprehensive debrief before they were medivaced back to Oz might just give them a little bit of latitude.

[medod]

I am led to believe that both of the pilots were senior QF captains (one of them was on the A380). I am also led to believe that they had successfully delivered ZS-ARV to Australia previously? They were both very seriously injured in the accident and ended up in hospital in induced commas. One, I have heard, ended up with a double amputation. So, perhaps those of you out there who can't understand why they did not give a comprehensive debrief before they were medivaced back to Oz might just give them a little bit of latitude. ​​​​​​I am sure the family of the person who died, and the families of and the individuals themselves who were seriously injured, feel just the same.

[roundsounds]

The current owners MUST have known the crew failed to get the corresponding licenses. If not, they were quite sloppy in their preparations. Normally, getting a validation for these kind of flights, the "locals" will be helping with all the paperwork and the national licensing department.
And if they DID know, that makes them culpable as well, willingly letting an incomplete licensed crew fly their plane.
I rented planes all over the world, but I never got a simple C172 from the FBO/Club w/o them checking my license..... Plus a checkout of course...
Both of these pilots gained their type ratings on the sister ship in SA by a local instructor / examiner. There seems to be some information missing or misinformation in the report.

[Surlybonds]

I can't see anything in the accident report about why they didn't pull the fire suppression.

Within the report published earlier in the thread, I noticed there's a picture of the Fire Control Panel from the aircraft, and that, notably the T handle for the left engine is broken off, and the No1 engine Fire Detection lamps are smashed.

https://cimg6.ibsrv.net/gimg/pprune.org-vbulletin/1043x410/convair_f_c_panel_16763a3bb9ef69bc527740a6685fcdb1cc3c7277.p ng

So the question is, did this damage occur during the final impact, during the flight, or was this panel like that before the flight?

If the T handle was missing, that might explain why the crew couldn't address the fire.

[ehwatezedoing]

So the question is, did this damage occur during the final impact, during the flight, or was this panel like that before the flight?

If the T handle was missing, that might explain why the crew couldn't address the fire.
Would you take off with a missing T-handle :confused:
If it had broken on their hands, I think it would have been mentioned on the report. Or words would have gone out about it one way or another.

[EDML]

Well, having seen the pictures of the cockpit area after the crash and seeing the broken and bent fire panel in the dirt with shards of glas it is pretty obvious that the T-handle was ripped of in the accident sequence.
Furthermore, if you look closely at the picture it is obvious that panel is distorted and the switch holding the T-handle is dislodged. That has surely torn off the T-handle.

[ATC Watcher]

Both of these pilots gained their type ratings on the sister ship in SA by a local instructor / examiner. There seems to be some information missing or misinformation in the report.

If true it is indeed not really what the report says : 1.5.1.3 The PF (and PM) ..... had not done a skills test on a Convair 340/440 as required

[JW411]

They did their type ratings with an SA instructor in order to have the aircraft put on their Australian licences.

[mustafagander]

Is not the "skills test" an annual requirement?
It was when I was doing a bit of flying in Africa "North of the Limpopo".

[Mariner]

Skilltest is the first checkride for the type rating as far as I know.
After that it's yearly LPC's isn't it?

[JW411]

Mariner is absolutely correct in his statement. However, it should be remembered that this aircraft was being operated as a private aircraft on a private flight. It was not being operated as a public transport category flight, Therefore, "PPL" rules applied. (You could fly a 747 on a PPL if you could find someone to insure you). By the way, I hear that one of the pilots has made a reasonable recovery but has no memory of the accident. The other still has serious medical problems.

[EDML]

Even if the plane is operated privately the type rating is only valid for one year.

There are no operational requirements like a line check but the validity of the TR is the same.

[medod]

The report is clear that neither pilot had flown a Convair 340 for 17 months before the accident flight.

[MarcK]

It occurs to me to ask: How does one do a check ride on a type when there are no flying instances of that type in the country, and possibly no examiner rated on the type?

[Wunwing]

I suspect that the answer to the last questions are to be answered by the fact that the sister ship to the accident aircraft is currently operating in Australia and both pilots may be the normal crew on the Australian aircraft???

If the accident report says that they hadn't flown a Convair for 17 months ,then it seems wrong. Maybe not an SA registered Convair?

In the world of rare historic aircraft operations, its normal for crews to keep recent on foreign aircraft. I know that both the Swiss Connie and Lufthansa 1649 crews kept recent on the HARS Connie.

Wunwing

[The AvgasDinosaur]

Learned contributors,
Wasn’t it a similar engine fire that finally closed Air Atlantique’s efforts to put a Convair twin on to the U.K. register G-CONV was I believe a CV-440?
Is this a known problem on Convair CV-340/440 aircraft?
Be lucky
David

[The AvgasDinosaur]

Learned contributors,
Wasn’t it a similar engine fire that finally closed Air Atlantique’s efforts to put a Convair twin on to the U.K. register G-CONV was I believe a CV-440?
Is this a known problem on Convair CV-340/440 aircraft?
Be lucky
David
Having now had a chance to get fully on line, and check ASN I see the answer is a definite YES.
Sorry to trouble you
David

[Centaurus]

Is this a known problem on Convair CV-340/440 aircraft?
I flew the Convair 440 Metropolitan as QFI on the RAAF No 34 (VIP) Squadron for several years 1963-68. Apart from the occasional induction fires caused by over-priming during engine start, I do not recall any in-flight engine fires. The over-priming fires were caused by inexperienced ground engineers starting the Convair engines for the first time without adequate supervision.

[medod]

I suspect that the answer to the last questions are to be answered by the fact that the sister ship to the accident aircraft is currently operating in Australia and both pilots may be the normal crew on the Australian aircraft???

If the accident report says that they hadn't flown a Convair for 17 months ,then it seems wrong. Maybe not an SA registered Convair?

In the world of rare historic aircraft operations, its normal for crews to keep recent on foreign aircraft. I know that both the Swiss Connie and Lufthansa 1649 crews kept recent on the HARS Connie.

Wunwing

The report isn't clear. For example, in the conclusions:

3.2.4 Both pilots last flew the Convair 340/440 aircraft 17 months prior to the accident flight, therefore, none of the crew complied with the 12-month competency check.

But in the flight crew information section contradictory information is given; the PFs logbook indicated 5.9 hours on type in the last 90 days (the PM's logbook wasn't found). But the same section also says According to the PF’s logbook, the PF last flew the Convair 340/440 on 27 February 2017. ??

Still, none of this takes away from the fact that the pilots were fully aware the left engine was on fire but took no actions to deal with it. They had observed that the engine had low MAP before V1 but elected to continue. Once the fire was obvious, the LAME handed the PM the AFM QRH but the PM "ignored it", to quote the report. It must be said though that the LAME was manipulating the engine controls, not the pilots. The fire melted out the rivets securing the left wing's aileron cable pulleys which resulted in the cable going slack and the left aileron rising, as seen in the video. They lost roll control & lift, on top of the drag of the burning engine which they never feathered or secured.

The engine caught fire because the LAME didn't service it properly, missing that no. 7 cylinder's exhaust valve was cracked and partly missing its head. The cylinder head cooling fins softened and failed and the combustion flame escaped the engine. No 13's piston rings had also failed and were no longer sealing; that didn't cause the fire but it and no. 7's damaged exhaust valve did drop the MAP.

The programmed maintenance performed a few days before the flight called for compression testing of each cylinder on both engines but the LAME patently didn't do this.

The engine had been showing low MAP on two previous flights but the LAME removed the gauge each time and sent them to another AMO, who both times recorded that it was blocked with carbon deposits and cleaned it out, rather than compression testing the engine.

[Jhieminga]

Still, none of this takes away from the fact that the pilots were fully aware the left engine was on fire but took no actions to deal with it. They had observed that the engine had low MAP before V1 but elected to continue. Once the fire was obvious, the LAME handed the PM the AFM QRH but the PM "ignored it", to quote the report. It must be said though that the LAME was manipulating the engine controls, not the pilots.
For me, this is one of the main questions that remains after reading the report; why did they not take any action to deal with the engine? Was this because of a CRM arrangement where they expected the LAME to deal with it? Were they too overwhelmed by the flying qualities of the aircraft with one engine low on power to take on any other tasks? Did the events unfold with such speed that they didn't have time to take action (I cannot find a timeline in the report)? I realise that we may never know the answer, but a bit more attention to this particular question by the investigating team would have been appropriate in my view.

[IcePack]

Very odd response by two experienced aviators. I would look into what may have been known about the port engine prior to departure. Speculating but if they knew it was down on power that might go some way to explain lack of response initially.
Shame that a gracious old lady had to be so miss handled to cause her demise.

[Double Back]

During my airline years we were drilled to call ENGINE FAILURE/FIRE, LOUD and clear. This was to "reset" the crew (including Yrself) to start one's memory items/actions, whatever You were doing otherwise. More or less the same effect You will see when calling "Mayday 3X" , it will get anyone's attention (ATC and other A/C) and get everyone into high gear and do the job one was trained for.
It looks like this was not done here, plus the presence of the LAME had eroded the strict 2-man crew operation. It was NOT a three man crew with a fully trained FE, notwithstanding his knowledge of the engines. The LAME did probably all his best from a technical standpoint, but did not fit into CRM at that moment.
The pilots were leaning (too)heavily on his presence/actions.

For ones who might wonder why the aileron went upwards, when the aileron control cables break the pressure difference below and above the wing will force it upward. Possibly, when speed would be rising, it would blow back into a more trailing position, but if the net result would be the same rollrate, I have no cue. Anyone here to have an idea?
In this case they were already trading height for minimum speed, for not getting the prop into feathering, and there was no more energy to accelerate. Getting more speed would have given them more control, like with the rudder to assist in roll.
Nevertheless, as with many other accidents, not a scenario I'd like to be in and play hero. And I do have mixed feelings talking about the subject with the crew still recovering, But that is aviation.
And wishing them all the best.

[EDML]

During my airline years we were drilled to call ENGINE FAILURE/FIRE, LOUD and clear. This was to "reset" the crew (including Yrself) to start one's memory items/actions, whatever You were doing otherwise. More or less the same effect You will see when calling "Mayday 3X" , it will get anyone's attention (ATC and other A/C) and get everyone into high gear and do the job one was trained for.
It looks like this was not done here, plus the presence of the LAME had eroded the strict 2-man crew operation. It was NOT a three man crew with a fully trained FE, notwithstanding his knowledge of the engines. The LAME did probably all his best from a technical standpoint, but did not fit into CRM at that moment.
The pilots were leaning (too)heavily on his presence/actions.

For ones who might wonder why the aileron went upwards, when the aileron control cables break the pressure difference below and above the wing will force it upward. Possibly, when speed would be rising, it would blow back into a more trailing position, but if the net result would be the same rollrate, I have no cue. Anyone here to have an idea?
In this case they were already trading height for minimum speed, for not getting the prop into feathering, and there was no more energy to accelerate. Getting more speed would have given them more control, like with the rudder to assist in roll.
Nevertheless, as with many other accidents, not a scenario I'd like to be in and play hero. And I do have mixed feelings talking about the subject with the crew still recovering, But that is aviation.
And wishing them all the best.

Lift moves the aileron up when it’s no longer firmly connected to the other side. It will move up until a balance between lift and loss of lift due to the aileron position is reached. More speed won’t change that as the lift increases as well.
Depending on the way the cables are connected the other side will move up as well. That would keep things symmetrical with no roll rate. However, roll control would be very limited or lost altogether.

[megan]

the presence of the LAME had eroded the strict 2-man crew operation. It was NOT a three man crew with a fully trained FEThe USAF operated the aircraft with a three man cockpit crew, two pilots and a flight mechanic. The mechanic has his duties/responsibilities spelled out in the flight manual, among items he operated were ignition switches, cowl flaps, flaps (on pilots call). Were they operating in accordance with USAF procedures perhaps, or utilising a form of carry over from their Constellation practices?

[Australopithecus]

Did the accident aircraft have brake mean effective power gauges? More than MAP + RPM, BMEP shows a direct torque (and hence h.p.) output. I have a very few long-ago hours on CV440, and am no expert on the R-2800, hence I probably would defer to the superior technical knowledge of the engineer when it came to nuances. Once you do that though it might be too easy to rely on that knowledge past the point of (operational, pilot sh*t) prudence.

I think the US Navy crashed a 440 in similar circumstances in the 70’s. Engines mounted in the wing present fire-related issues that we moderns have not had to consider for several generations of aircraft.

[megan]

Did the accident aircraft have brake mean effective power gaugesYes, has torquemeters.