PC-12 close shave at night

[A37575]

http://www.atsb.gov.au/media/5777834/ao-2019-019_final.pdf

Well worth reading by all general aviation pilots regardless of aircraft type. To have a runway pitch trim going to full nose down shortly after takeoff at night on instruments is a scary situation and the pilot is to be commended for his actions in preventing a crash. To have it happen at a most critical time makes interesting study of the pilots immediate actions. There was no time to drag out an emergency procedures manual as he needed two hands on the elevator control to prevent the aircraft spearing into the ground. While groping for the trim cut-out switch which was adjacent to a flap cut-out switch he inadvertently selected the wrong switch.

Many students of today's flying schools are taught from the time they step into the cockpit to use written checklists for almost all phases of flight from walk around preflight to line up checks. These are CASA mandated policy. It does not prepare you for situations where control difficulties in the air may not allow the luxury of reading an emergency checklist from a book. During wartime days it was Royal Air Force training policy when pilots converted to fighters was the pilot under conversion had to know where cockpit controls were while blindfolded.

While such measures are unnecessary in peacetime, the blind use of read and do checklists instead of memory has its drawbacks. In the example of the PC-12 incident where the pilot was forced to feel for a particular switch at night and the subsequent delay in locating the switch allowed the runaway trim to operate un-checked, there is a lesson to be heeded. Instant knowledge of the position of every switch and control in the cockpit is good airmanship. Relying on a written checklist for almost everything is not good airmanship.

Instructors should not only keep this in mind when training ab-initio student pilots, but encourage students to read ATSB reports and learn from them. After all, they are free..

[kangaroota]

. These are CASA mandated policy. It does not prepare you for situations where control difficulties in the air may not allow the luxury of reading an emergency checklist from a book.


Instructors should not only keep this in mind when training ab-initio student pilots, but encourage students to read ATSB reports and learn from them. After all, they are free..[/QUOTE]
It's a while back a Swiss Air DC10 came to grief after an on board fire off the Canadian east coast. IIRC is was posited that if the crew had diverted their attention from the checklist which took at least 20 minutes to getting the aircraft on the ground there was a theoretical chance they may have made Halifax.

[Ixixly]

I don't entirely agree with what you've said in regards to a culture of Checklists used for every situation. I don't think there are any Flight Schools that would teach this and am pretty sure they teach memory items that need to be known off by heart designed to get the Aircraft under control which are then backed up with a checklist to confirm all steps have been taken properly. I'd dare say if there is a school that teaches that the very first action should be to take out a checklist they should be taken to task and would be interested to hear of any such out there.

[machtuk]

Check list or no check list self preservation kicks in under extreme duress, you become a test pilot in some ways, trial & error!

[atakacs]

Well with the benefit of hindsight we (myself included) often ponder about the incredible boneheaded things pilots do. Congrats to this pilot for saving a potentially very bad situation!

[roundsounds]

This whole written read and do checklist fever is wrong. The trend is based on a research paper which was based on multi-crew operations. Written checklists are valuable, but should be as the title implies - a checklist, not a do list! A runaway trim should be a memory item, completed by recall and followed up with a written checklist only after the aircraft is under control and not in a critical phase of flight. Well done to this aviator.

[drpixie]

Part of the problem is that we (aviators) have used the term "checklist" for two completely different things: #1 is a check of routine things, #2 is instructions for unusual abnormal situations.

#1 is a genuine check-list. And even CASA (yes even CASA) will be happy for an organisation to use mnemonics (memory checks) for parts of #1.

But #2 (say diagnosing/sorting a systems issue) is not checking, it is an instruction manual for abnormals. (And just a few of those are "memory items" that require quick response - eg. cabin altitude.)

It might help students all around if we separated "checklists" from "abnormal procedures".

[Tee Emm]

I recall taking over a student who had flown eight hours dual in a Cessna 152. His instructor was away on holiday. We went to the aircraft and strapped in until he said he had left his checklist at home.
I said no problem just go ahead and scan the set up and start the engine. There was silence. "What the problem" says I?
"I don't know how to start the engine without the checklist" says the student "My instructor always told me to use the checklist and I don't know what to do."

I showed him the left to right scan. We got airborne. He flew quite well and did a credible landing. We parked. I waited for him to conduct the shut down. Silence. "Sorry, I have never shut down the engine without using a checklist to tell me what to do next." he said.
In eight hours he had never made a move without using a written checklist and his instructor was a Grade 2 who had been brought up from CPL training to always use a read and do checklist

[kangaroota]

One of the shiboleths in aviation training is that before V1, thou shalt stop, and after V1, thou shalt go for an abnormality.
How would you judge someone who aborts a takeoff between V1 and Vr with X amount of runway left (X=more than enough required to stop) if they spotted a flock of birds on the centre line capable of doing a Sullenberger on them.

[Ascend Charlie]

Top to bottom, left to right was always the way I did my normal checks.

And because of the Law of Primacy, the first one you learn will be the one that sticks in your head. I found that the checks for a Huey were applicable to every other chopper I flew, including the S76, by expanding the one-word Huey chex to allow for things like autopilot, lots more radios and navaids, and aircon.

An emergency has the BOLD items which are from memory, and then when the time is available, run the rest of the chex.

[KRUSTY 34]

I would have thought a relatively sophisticated aircraft like a PC12 would have a Master Disconnect button on the column?

[Capt Fathom]

I was surprised the RFDS employed Pilots with such low aeronautical experience!

No one available or no one wants to do it?

[VH-MLE]

Captain Fathom, it’s unfortunately a case of demand outstripping supply. For now, at least, it’s going back the other way due to this virus...

As an edit, it might be the other way around - airlines were taking so many pilots which meant that generally, only pilots with low experience levels were available. As a consequence, training needs to be modified accordingly...

[Centaurus]

One of the shiboleths in aviation training is that before V1, thou shalt stop, and after V1, thou shalt go for an abnormality.

How would you judge someone who aborts a takeoff between V1 and Vr with X amount of runway left (X=more than enough required to stop) if they spotted a flock of birds on the centre line capable of doing a Sullenberger on them.
I think the answer to your comment can be found in the preface to the Boeing 737 Flight Crew Training Manual which states:
"Conditions beyond the control of the flight crew may preclude following a maneuver exactly. The maneuvers are not intended to replace good judgement."

For an example of this, study the actions of the captain of an Emerald Airways HS 748 that experienced a catastrophic failure of No 2 engine after rotation. He made the instant and ultimately correct decision to abort the takeoff not only beyond V1 but also after VR.
https://aviation-safety.net/database/record.php?id=19980331-1

[KRUSTY 34]

I was surprised the RFDS employed Pilots with such low aeronautical experience!

No one available or no one wants to do it?

Recently another Aeromedical operator using King Air equipment (not RFDS) had problems with candidates passing initial induction training. This was despite several very experienced pilots not being successful during the interview process?

Tricky business trying to get the right people based on a 30 minute Q&A. Being slick and polished during an interview may not necessarily tell the whole story?

[Tee Emm]

tricky business trying to get the right people based on a 30 minute Q&A.

The HR people run the interview process. Take Jetstar interviews for example. Interview panel normally consist of two people. One who is usually the Jetstar HR person who leads the interview and asks 90% of the questions most of which are the “tell me the time when you disagreed with the captain” style. There are no aeronautical or technical questions. The priority is clearly Human Factors

The other person on the interview panel is normally a first officer who has been briefed to keep his mouth shut and only to ask occasional set questions and not to go beyond those questions. Virtually it is a one man (female HR person) band interview

In contrast, Cathay Pacific and Cathay Dragon interviews are heavily weighted towards in-depth technical knowledge and include close study of the applicants log book looking for bogus hours which can be discovered by judicious questioning.

[machtuk]

Recently another Aeromedical operator using King Air equipment (not RFDS) had problems with candidates passing initial induction training. This was despite several very experienced pilots not being successful during the interview process?

Tricky business trying to get the right people based on a 30 minute Q&A. Being slick and polished during an interview may not necessarily tell the whole story?

spot on! Suitable driver for the RFDS isn't found at the interview stage!

[Warped Wings]

When you read the way that some other RFDS crew also incorrectly responded to the same failure on previous occasions, you would have to think that the RFDS training systems was the biggest contribution to this incident.

Surely with so many PC-12's they should be investing in simulator training and checking. Touch drill training/checking for failures is a cheap but poor substitute. And if experience levels are dropping, sim training/checking is even more valuable.

I imagine that if this event had ended with fatalities, they would be getting a simulator quick smart!

Well done to the pilot for getting it down.

[Towering Q]

the pilot is to be commended for his actions in preventing a crash.

Her actions, in this case.

[jmmoric]

They fired the pilot?

Wouldn't it be better flying with 2 pilots instead.... From what I understand the aircraft can be difficult to handle if you hit the wrong button.

Oh, and I always fly with manual trim, don't like the electric trim in smaller aircraft anyway (don't fly anything larger).

[Douche]

They fired the pilot?

Wouldn't it be better flying with 2 pilots instead.... From what I understand the aircraft can be difficult to handle if you hit the wrong button.

Oh, and I always fly with manual trim, don't like the electric trim in smaller aircraft anyway (don't fly anything larger).


Yes, 2 pilots is better. But that reduces the number of patients or fuel you can carry (payload) which is already limited. Plus I believe it already costs about $2500 per hour to operate one of these RFDS PC12's with just one pilot. (plus doc & nurse)

When you find the manual trim wheel in a PC12 let me know!! ;) ;)
(Seriously it doesn't even have one :ok:)