Airtours C404 crash report [Archive]

What_does_this_button_do?

31st Jul 2001, 11:12

from news.bbc.co.uk :(

The experienced pilot of a plane in which eight people were killed may have been misled into taking the wrong emergency action, a report has revealed.
Captain John Easson, 49, appeared to react initially to what he believed was a loss of power in the right-hand engine of the Cessna 404 Titan.

But it was the engine on the left side which had suffered failure in the accident near Glasgow Airport, the Air Accidents Investigation Branch (AAIB) said.

The victims
Captain John Easson, 49
Stewardess Pauline MacIver, 31
Stewardess Pauline Moyes, 38
Stewardess Linda Taylor, 29
Stewardess Helen Steven, 28
Stewardess Lynn McCulloch, 23
Pilot Colin Finnie, 32
Pilot Bill Henderson, 54

Out of the 11 on board, eight died and three, including Captain Hugh O'Brien, 39, Kevan MacKenzie, 32, and steward Derek Morrison survived.

The survivors told the Air Accident Investigation Branch that they heard a bang or a thud shortly after take-off in the Cessna 404 Titan.

They thought this had come from the right-hand side, but the AAIB report added: "It is possible that the bang came from the left engine but sounded as if it came from the right engine".

The AAIB said the right-hand propeller was put into the "feather" position - a manoeuvre in which the blade is adjusted to prevent further damage and to minimise drag.

But this left the propeller of the failed, left, engine unfeathered and so the aircraft was incapable of climbing on one engine alone.

When Capt Easson, of Bryde, Isle of Man, who was taking the Airtours' crew to Aberdeen, feathered the right-hand engine's propeller there was a total loss of thrust.

He tried to return to Glasgow, but the plane went down in a field, crashing through a hedge and bursting into flames.

Capt Easson had been confronted with "an unenviable emergency at a critical stage of his flight", the investigators said.

The report said: "Time for him to make the correct diagnosis and to take the correct action was short.

"He seems to have reacted initially to a perceived power loss from the right engine and then had to deal with a progressive loss of power from the left engine."

A post-accident inspection "did not reveal any mechanical evidence of a problem with the right engine".

Extreme conditions

Investigators also concluded that if Capt Easson had tried to carry out a forced landing in a field rather than deciding to return to Glasgow Airport, "the outcome might have been different".

The end of the flight might have been "far more survivable for all on board", added the AAIB.

However, the report said that, under extreme conditions the captain had "maintained the only option that occurred to him - returning to the airport".

The AAIB added that all of the passenger seats had come lose from the floor of the aircraft.

The passengers that perished in the fire "would have had improved survival prospects if the strengths of their seats had been to the latest airworthiness requirements".

The aircraft was operated by the Edinburgh Air Charter company and was taking the Airtours staff to Aberdeen to connect with a holiday flight to Majorca.

The plane did not have, nor was required to have, flight recorders.

The AAIB recommended that such aircraft should at least have a cockpit voice recorder and that the Civil Aviation Authority should look at the seats issue.

mallard

31st Jul 2001, 11:51

The information is doubtless interesting but there is something tasteless in the tone of the message.
Friends, relatives and colleagues of the deceased are likely to find the post hurtful.
The evidence must come out but I do urge sensitivity on the part of correspondents.
Please take into account those of us who still grieve.

bookworm

31st Jul 2001, 19:01

The report is available here (http://www.aaib.detr.gov.uk/formal/gilgw/gilgw.htm)

mallard

While I respect your grief, I am sure that you will also respect the need of those of us who still fly light twins to learn from this accident and try to avoid the fate of those who perished. I for one would rather see the odd comment that I found of questionable taste than see the debate become stifled from a need to avoid controversy.

Daifly

1st Aug 2001, 03:03

I agree Bookworm. It was a horrible accident which claimed more lives than it should have.

For once the Beeb's reporting of an accident report seems fairly factual, rather than tabloid. I am intrigued why the article goes on to quote "Aberdeen aviation expert, Jim Ferguson" (who seems to get rolled out for everything north of Hadrian's Wall) who is demanding CVR's be installed on all P/T flights - is this a general feeling? I guess it makes the AAIB's job easier.

I am more interested in what history Mr Ferguson has to make him an expert? Maybe it's a background in piston twin ops? If anyone knows I'd be interested to know.

BreakRight

1st Aug 2001, 03:28

Please feel free to tell me to shut up and go away.....

A few years ago I was a passenger in a Cessna 310 where the student was being taught engine failures. One of the things that was being done was to "fail" an engine without the student knowing which one it was, in order that they should correct the aircraft accordingly. So at glasgow despite hearing a bang from the wrong engine, would the aircraft not begin to yaw etc on the side which had in fact failed? Or did the bad engine fail gradually here so there was no sudden effect? Or did the pilot have no option but feather the "good" prop beacause the bang appeared to come from that side indicating a definite problem there. Could somebody please explain to me a bit of what happens here.

It is in not my intension to offend or upset anyone after what was undoubtedly a tragic accident. I just want to learn/understand.

GlueBall

1st Aug 2001, 03:45

The most important thing to remember is never to get into a big hurry when shutting down an engine.
Yes there will be yawing, and to correct that is rudder, and the dead foot is the dead engine. You can also take a quick glance at your EGT/RPM gauges before feathering, to make double sure that your sensations are not playing tricks on you.
:rolleyes:

mallard

1st Aug 2001, 04:24

My initial post was simply to urge a sense of respect for those no longer with us.
I learned on the Cessna 310 that dead leg meant dead engine.
Ever since I have corrected yaw with a foot on a rudder pedal. That gets the ship airborne (you hope) then you have time to investigate what might have gone wrong.
A scan of the engine instruments should give a clue.
Best now is to see if your colleague agrees, beware, he may agree to please.
Those of you on light piston twins will know far better than I that there may be an element of time involved to get a prop feathered which would otherwise create drag.
Even on jets which are not so critical I remember an MEA 707 crew training at Beirut when, presumably, the student hit the wrong rudder and screwed into the ground before the check pilot could take over.
Best advise is ... Correct the yaw, get it safely airborne under control and then say what went wrong.
OK! I know, it ain't always that simple.

gaunty

1st Aug 2001, 06:20

After this accident I got myself into a fair bit of trouble with this one, by raising the Airlines Duty of Care issue in allowing or booking their crew on this type, ie FAR23 v FAR25, I think you call it Perf B.
I was amazed at the lack of understanding by the airline community at large re the performance (or lack of) issues and the rush to defend the Captain and the organisation, when they were in fact not the issue.
I have printed off the report and will be studying it detail, but I do not expect to find anything very different to the usual results of misidentification and usually fatal "getting back to the airfield" syndrome.

I would be consoled by the loss if the airlines at large had learn't their lesson and were no longer using non transport category (FAR23 type) aircraft for dead heading their crew.

Nothing whatsoever to do with the "skill", "maintenance" or otherwise of the the operator.
Under the circumstances described it was almost inevitable.

Pilot Pete

1st Aug 2001, 18:43

Ladies and gentlemen,

Please read the report in full before posting questions/ comments.

Mallard - 'dead leg, dead engine, correct yaw with rudder - that gets the ship airborne(you hope) then you have time to investigate the problem. Best now is to see if your colleague agrees'

You are right, dead leg, dead engine, correct yaw with rudder. BUT, that's once you are airborne. The 404 is perf C and the 310 also mentioned is perf E which means that if you lose an engine during the T/O role you are not going to be able to get airborne and reach the single engine climb speed (assuming max T/O weight etc etc). If it happens on the runway you have one option - STOP - on what's left, be it runway or not. Additionally, this aircraft was operated single crew, the other pilot was a 'second pilot' not a co-pilot and was not trained on type, he was there at the request of the charterer and assisted with the RT etc etc. Therefore there would be no reason for the commander to seek his opinion as he knew he was not qualified to give one. Again, it's in the report.

Glue Ball - 'never be in a hurry to shut down an engine' - in principle this sounds like good advice, but it comes down to perception of 'hurry'. Works on a jet (generally), but again, read the report. On this type of piston twin without auto-feather you do not have long to get the prop feathered before it will not feather as the RPM drops too low and then you are faced with an aircraft with 'significantly less than 50% thrust' due to the increased drag. This is why ongoing training on the type requires you to identify and carry out the recall actions promptly. I do agree that it is better to spend what little time you have identifying the correct engine and carrying out the drill more slowly than shutting the incorrect engine down quickly. But, read the report. The commander percieved he had a problem with the right engine, there probably wasn't any great yawing moment due to the left engine failing slowly - the AAIB said he was in an unenviable position, not just because he was experiencing an engine failure, but because of the nature of it, with associated confusion and misleading signals he received and the very little time he had to do something about it and because of the performance of the 404 at MTOW.

Undoubtably, the wrong engine was shut down (but they didn't discount a possible problem with the right engine which was not evident), but it wasn't as cut and dried as in your initial twin training where the a/c only has two on board (therefore very light), you know it's coming and the instructor retards a throttle fairly quickly leading to the 'obvious' yaw, and you do have some time, although limited, from above 500' and the s/e climb speed to react and carry out the required actions. John Easson really couldn't have been faced with a much worse scenario apart from worse weather perhaps.

It may sound like I am trying to defend the PIC, what I am trying to put accross is the perspective. Read the report, put yourself in his shoes, consider it all without the hindsight and then make your judgement, like the AAIB have and then all of a sudden comments from 'your training days' of little snippets of how to fly a piston twin may not appear to be quite as relevant.

I speak with some authority having conducted the same flight as PIC in the weeks before the accident.

Safe flying to all, and RIP to friends.

PP

[ 01 August 2001: Message edited by: Pilot Pete ]

parkfell

1st Aug 2001, 18:55

I wonder if looking at the EGTs would have given a clue as to which engine had suffered a loss of power?

Den_Dennis

1st Aug 2001, 19:18

From what I understood from the report, two pilots did report that the aircraft upon T/O was to the left of the center line. This would indicate left engine failure.

It is interesting to note that all three surviving pax heard the bang from the right side of the a/c as well. I notice that this was addressed by the AAIB as a possible birdstrike - although ruled unlikely.

: DD :

fireflybob

1st Aug 2001, 19:23

Shutting down the "wrong" engine is the classic error on a two engine type - there but for the grace of God!

Pilot Pete - agree 100% with all your comments - well put.

<you know it's coming and the instructor retards a throttle fairly quickly leading to the 'obvious' yaw, and you do have some time, although limited, from above<

The only comment I would have on this is why, during pilot training, the instructor has to retard the throttle "fairly quickly"? Surely all types of failure should be simulated and I would venture to suggest that it is a slow loss of power which, in many ways, is far more "challenging" to deal with in terms of identification, etc.

As an aside, my father (who is no longer with us) was a veteran light aircraft instructor/examiner and I always remember that he often would retard the throttle slowly to simulate a gradual loss of power. I remember sitting in the back of a light twin (Apache I think) with my father testing the candidate for his twin rating. We knew that the instructor who had conducted the training was always keen on "slamming" the throttle closed and when my father retarded the (hidden) throttle slowly this confused him somewhat leading to application of too much corrective rudder and then considerable difficulty identifying the "failed" engine. Some time was spent in the debried on this topic!

Finally, in many ways pistons are more complex with the added complication of pitch and mixture levers - there are a lot more "wrong" levers to pull compared to a jet.

RIP

eeper

1st Aug 2001, 20:06

My IR instructor always covered the throttle quadrant with a clipboard before retarding a throttle. You knew the failure was coming, but it taught the technique of recognition better.

I sometimes think that too much reliance is placed during training on a "standard failure" i.e a sudden loss of power. Certainly it should be practiced as it is the worst case scenario, but engines do not always fail this way. I would like to see some emphasis placed in the sim on different sorts of failures eg slow failures, engine vibration with subsequent loss of power.

I would add that I am in no way criticising the actions of the unfortunate pilot in this incident who gave his very best in extremely trying circumstances.

mallard

1st Aug 2001, 20:18

Pilot Pete, that was a succinct, lucid and informative post and confirms what I said about trying to be sensitive to the feelings of others.
I, for one, shall say no more.

411A

2nd Aug 2001, 01:30

Twin Cessna aircraft....generally very reliable IF, and this is a very big IF, maintained properly and flown with a fair degree of accuracy. The 404 is a very heavy weight aircraft with CE421 power which equals, SLOW climb rate even with the CORRECT engine shutdown and feather procedure. If these guys had not been properly trained, then they had no business flying this aircraft. The 404 can be very demanding, if NOT flown properly.

Cisco Kid

2nd Aug 2001, 01:44

Gaunty is right on this one ,condolences to all.

Den_Dennis

2nd Aug 2001, 01:48

I think that it is obvious that the pilots were properly trained. It is not often that the AAIB make concessions to try to understand why a pilot made a wrong decision, but if they felt for one moment that the pilots lacked proper training, then it would have been in the report.

It is a truism that most accidents are not caused by lack of airmanship, and this applies to this case. - imho.

I know in the cold light of day it seems an easy decision to make - what engine to shut down, but as you said yourself, the 404 is known for it's 'interesting' handling - therefore, the pilot had very little time and under extreme stress to make the right decision.

As I stated earlier, it's very interesting that all three surviving pax also heard the bang from the rhs of the a/c.

: DD :

Area Juliet

2nd Aug 2001, 02:07

411A - INTERESTING POST!

Where exactly did you get your 'information' from.

The pilot was properly trained and did have the right to fly the aircraft.

quote from AAIB report:-

1.
The commander was qualified, well experienced, competent, adequately rested and medically fit to conduct the flight.

2.
The commander had satisfactorily passed a test of his ability to recognise and deal with a single engine emergency in this aircraft five days before the accident.

I don't think there can be any ambiguity as to whether he was qualified or not!

As for the maintenance aspect, there was no reference in the report to any irregularities in that respect.

So again where do you get your information from to post such blatantly arrogant accusations?

Perhaps you should read Pilot Pete's post (btw it's concerned with the practicalities of flying piston twins) and let those of us who fly piston twins learn from this tragedy.

tunturi

2nd Aug 2001, 02:34

Pilot Pete "Read the report" you exhort several times in your post. Well I have read the report and these posts and I am still a little confused. So a question:

Just exactly what were the confusing/conflicting indications that the pilot was faced with?. The only reference I have seen was to the bang which appeared to come from the right hand side. Were there other confusing indications such as yaw/roll in the opposite direction or conflicting engine or flight instrument indications? I have noted the AIIB's (and othres)comment about the need for speedy identification and action following such a failure but is the bang the only thing we are talking about here? Or have I missed something? This is a genuine serious question.
Thanks.

overstress

2nd Aug 2001, 03:42

412B:

To paraphrase your good self: if you have not been sufficiently well informed, then you have no business posting in this forum.

This forum can be very demanding, if not treated properly.

Please remember that the victims were well known to some on here.

BreakRight

2nd Aug 2001, 05:06

Having read the report, which makes frightening reading when you put yourself in PIC`s shoes, I would have to agree with eeper, that as someone who is learning to fly, for my sake as well as the sake of any future collegues or pax I would like to have experienced any and every type of enginge failure in training, I would consider it money well spent supposing it was all on a sim even. Anything to reduce confusion in the situation and gain precious seconds.

As a footnote, I am convinced that PIC did his absolute best and I would never question his airmanship. I saw the immedeate aftermath of the crash, and that in itself was a lesson. RIP.

411A

2nd Aug 2001, 05:18

If this concerned aircraft had been properly flown, then the passengers and most likely the crew would be with us today.
I wonder how many here have flown this particular model? I have, and certainly know what I am talking about. At heavy weights, it will have great difficulty achieving any kind of climb gradient on one engine.
However, would have to admit, sometimes even with the best of effort, s..t happens.

[ 02 August 2001: Message edited by: 411A ]

Jonty

2nd Aug 2001, 11:38

Thanks Pilot Pete, you arguments demand respect as allways.

Just one or two points, the 404 is a single crew aircraft, the reason two pilots were on board was due to the request from Airtours. Only one of them had to be qualified on type, the commander.

Due to the nature of this failure it must ahve been very difficult to identify the failure in the time available. A bang was heard from the right side of the aircraft with possable fluctuations in power associated with possable water ingestion (mentioned in the report) at the same time there is a gradual loss in power from the left engine. The commander may have shut down the right engine thinking about a return to the airfield, then the problem with the left engine becomes apparent, but the right is already featherd. All this with conflicting yaw indications and the lack of time make this very difficult to recover from.

Eff Oh

2nd Aug 2001, 14:56

Pilot Pete:- I agree 100%.
Den Dennis:- As for the being to the left of the centreline...Well, perhaps yes, however. Did they have a cross wind component(from the right)? This would also have caused drift to the left. As would not quite being on the centre line on take off. I think the report is well balanced. It was not an easy situation to be in. Perhaps this accident can be used as a teaching exercise, to show how situations are not as clearcut as they can seem!
Its always harder to read these things when you know someone involved.
Eff Oh.

Viscount Sussex

2nd Aug 2001, 16:12

411A,
Have you heard the expression 'thick skin'?
Mallard had tried, politely, to explain!!, but just fell into 'deaf ears'. I get rather p*ssed off with people (self-oppinionated ones), you know, the ones that have a bl**dy answer to everything. Also with those that want to "learn", while seating in front the PC. I didn't know the Capt of the 404 and didn't have to. He was a professional, doing a job. Here we are wasting time (including myself replying) and trying to 'work out' (to put in a diplomatic manner) or to examine his actions. Have you got anything else to do apart from posting in PPRUNE?
:mad:
Don't bother to reply. I am off flying tonight and the rest of the week and I won't get a chance to catch up with your 1000+ postings!

[ 02 August 2001: Message edited by: Viscount Sussex ]

Hudson

2nd Aug 2001, 17:30

I noted that somewhere in the accident report it stated that the captain was in the habit of doing his run-up procedures, pitch exercising, magneto checks etc while actually taxying. In other words, on the run. I presume that this short-cut is to save time and money?

Is this a common procedure? And is this not a bit dodgy having to drag alternate brakes as each engine is run up? Can you really pay full attention to all the engine parameters while jockeying the engine levers as well as keeping the taxy speed down and keeping a sharp eye to where you are going?

Is it possible that the faulty engine may have showed a few signs of impending problems which would have been picked up on a careful static run up at a holding bay and perhaps was missed during the haste to do a run-up on the run, so to speak?

Perhaps there is indeed a hard lesson for other light twin GA operators to keep in mind..

gaunty

2nd Aug 2001, 18:35

411A me old, I know what you're talking about if nobody else does.

Hopefully His Grace the Viscount will, when he recovers from his hissy fit, think a bit deeper about the real problems behind this sad event.

Search seems to have disappeared so I am unable to resurrect the original and very instructive threads on this subject. I hope they were'nt lost in the Great PPRuNe crash of 2000.

Pilot Pete

2nd Aug 2001, 23:29

Just to reply to some of the points raised, IMHO that is;

Den Dennis - I don't think you can jump to the conclusion that being left of the centreline means that the left engine had failed/ was failing. You must agree that a vast number of factors could result in being left of the centre line, including drift induced by a crosswind (as pointed out by another post), incorrect tracking of a navaid, or quite possibly due to the distraction of a 'loud bang', who knows?

parkfell - yes, maybe the EGT gauges would have helped, but you're primarily taught (and get into the mindset) of putting in the rudder to counteract the yaw and identifying the failed engine that way. The manifold pressure gauges would be the next place I would look. Remember the time scale.

fireflybob - I'm not so sure they do have to retard the lever quickly.......it's just how they've all done it to me. I agree, the slow failure of an engine would be more difficult to identify if this the way you have always been trained.

eeper - I think you'll find that all instructors cover the quadrant with a map/ board etc to help the 'realism' of you having to identify the failure without just watching which lever he pulls. As regards sim training, you will understand that sims for this (and other light a/c) are usually uneconomical for small operators, and the report touched on this. I agree that there is no reason why it could not be incorporated into the a/c training.

Mallard - I thank you for your comments, and would not want you to not air your views about the subject.

411A - Read the report. Area Juliet has replied after obviously reading the report. Any piston twin aircraft is demanding if not
flown properly at MTOW.

Airboeing - Bang from the right. Possible loss of power (momentarily, but that wasn't known at the time) from the right engine due to the possibility of water ingestion, maybe confirmed by looking at the right engine instruments (that's just my own guess), and whilst dealing with this problem the gradual loss of thrust from the left engine without the commonly associated yaw (possibly counteracted by shutting the right?). The AAIB also mention how hard it is to read a gauge with two needles, one on top of the other - one with a small 'R' and the other with a small 'L'. Isn't that enough confusing/ conflicting indications bearing in mind the time scale and lack of altitude?

Hudson - you may well have a point there.

Gaunty - I recall your posts from before, and you may be surprised that I agree that with the limitations of perf 'e' and 'c' for public transport flying, passengers should be made aware of this.

Jonty and Eff Oh - as ever, thanks for you words.

PP

gaunty

2nd Aug 2001, 23:44

Pilot Pete
I was kinda hoping that the airlines would stop deadheading their personnel around in these types as a result of this accident.

They are not alllowed to put their passengers on these types, so why their staff?

Kiltie

3rd Aug 2001, 13:20

Gaunty - as I recall the airline concerned who were chartering this aircraft consequently stopped all crew positioning on Perf C aircraft; indeed the task is now being performed by another Scottish based operator in a Perf A machine.

Parkfell -I wouldn't get in to the idea of looking at EGT guages to assist identifying failed engines, you'll open up a can of worms; stick to the rule book - identify with your feet, backed up AFTERWARDS by a look at the guages if you must; but remember! A failed engine will start to show increasing to near ambient manifold pressure, ie GREATER than that of the good engine! Trap!

411A - There are plenty of us who've flown 404s, including me, we all know Performance C types particularly of the piston variety can be awkward at MTOW; and it's not just limited to Cessna 400 series. I wouldn't say 404s were any trickier than other types.

I think what we need to take in to account the panic factor of an engine failure when it's unexpected. This wastes precious seconds of decision-making time, & it is only understandable for John Easson to perhaps have been led in to adrenaline-fuelled incorrect decision. I think we would all be likely to suffer from this. Yes; we're all aces during our Base / Line checks when we KNOW a failure is coming & have the drill anticipated in advance. No practice is given in the experience of surprise.

Though I haven't read the report in depth, I would suspect G-ILGW suffered such a hard impact because it went below VMCA whereafter control was lost, there is not much reference to this important parameter in the report, and I think it's an airspeed we should all be highly aware of.

[ 03 August 2001: Message edited by: Kiltie ]

gaunty

3rd Aug 2001, 14:11

Kiltie.
I am encouraged indeed, and I fervently hope that the others are following suit.
Crew should just plain flat out refuse to travel.
I should hasten to add that I spent a good part of my life selling these types new. They are fine aircraft for the use for which they were intended.
But they were designed and intended for private, business and recreational purposes. NOT charter and commuter ops.
Sadly everybody assumes that two engines and pilots is safer, regardless of the certification issues.
It is in fact, in this instance quite the opposite.

Capt Eason was operating in accordance with the rules and the level of skill required for the operation, the problem was the rules did not give them anywhere to go, the skill level was only interesting and the accident was almost inevitable after the engine failure.
The sooner the users understand the difference the sooner the "shock horror" will be replaced by, "just lets not go there"!

pterodactyl

3rd Aug 2001, 15:10

I think Hudson has a point about the run up on the move. Elsewhere in the report it is mentioned that the Captain had a significant financial interest in the operation. This could suggest that the Captain also may have wanted to "save the engine" and in so doing acted more in haste than certainty. There have been many such instances of this previously where loss of the airframe and it's occupants ensued.
Gaunty's point is well made as to the adequacy of certification standards for this class of aircraft and the paucity of performance in the failure case.
But I have to say a "bang" does not a failure make and although the impression of witnesses is that it came from the right it is far from certain that this was correct. I have experienced bangs, backfires and the like on occasion and quite often both crew members were not able to identify from which engine it came.
As has been pointed out foot pressure is the primary method of identification and until there is a LOT of rudder input required it should not be assumed that complete failure has occurred. Bearing in mind the critical engine out performance in the failure case any usable power should be utilised until a more definite failure indication is evident. Continue to fly the aeroplane. On the other hand if there is a LOT of rudder input required at an early stage indicating power loss and a possibly windmilling prop then it is essential that positive identification and a TIMELY shut down be accomplished.
Time is critical but not so critical that the procedure is rushed. By that I mean that as each procedural step is actioned it's effect should be noted. The first item for instance after identification is to retard the throttle. At that point; did the yaw increase, stay the same, or reduce? If it increased markedly then there was significant power still being delivered which could be used if the situation warrants it. If the yaw is substantially the same then a complete power loss on that engine is indicated and proceed on with the next item. On the other hand if yaw REDUCED you have the WRONG one! Put it back up! Remember fly the aeroplane, maintain the correct speed even if losing height to maintain control if the worst happens rather than stall as seems likely in this case. Don't think VMCA was a factor with no power from either engine.
You may say that there is not ENOUGH time for all this...well there is if done in a deliberate and timely manner. The report indicates an altitude of about 600 feet was reached and there was a considerable time airborne. To identify and accomplish the drill in a deliberate manner with certainty only takes a few seconds longer.
The comment about always training for a complete engine failure on take off is a very pertinent one and I believe is led by the regulatory requirement. Generally that classic situation is handled very well since it is CHECKED on every licence proficiency check. But how many actual failures occur in exactly that manner at that time? Not a very high percentage really. All kinds of variations should be PRACTICED such as partial/slow engine failures, fire without thrust loss, fire with thrust loss, failure some time after take off such as during a turning departure and so on.
Please accept that this post is made not so much to reflect on the crew but rather as a little advice which may help someone else avoid a similar fate.

Several points need to me made about
practicing failures in a real aeroplane. Firstly the aircraft should never be placed in an irrecoverable situation by, for instance, pulling the mixture to Idle Cut Off.
Often we hear of "chopping the throttle". There is absolutely no need for rapid throttle chop....a smooth positive retardation is quite sufficient. Indeed if you "Chop" the throttle rapidly on a RR Dart powered aeroplane the prop coarsens off and the aircraft initially swings in the WRONG direction. A really spring loaded student reacting to this initial swing can present an interesting situation. Likewise the thrust lever on a DC8 was chopped so fiercely during a training take off that the engine reverser deployed with disastrous results. Seems I have wandered a little so with the final observation that just as in business corporate memory is lost so it is with aviation.

[ 04 August 2001: Message edited by: pterodactyl ]

Bally Heck

3rd Aug 2001, 16:06

It might be worth pointing out that a number of years ago, a C404 operated by the Department of Agriculure and Fisheries for Scotland suffered an engine failure while on a low level fishery patrol.

Both the pilots were type and instrument rated. The aircraft's performance was such that they were compelled to ditch. Fortunately with no fatalities.

This aircraft was at high weight and had the added disadvantage of a radome installed on the belly which I assume didn't help the climb rate. Notwithstanding that, I think it says something about the performance of that type of aircraft on one engine.

It is also worth pointing out that 411A and his cronies seem to have regular access to the internet from whichever institution they are in and have the objective of saying black is white in the most offensive way they know how on whatever subject they know nothing about.

If you ignore them they go away :mad:

Hudson

3rd Aug 2001, 17:12

Ptero D. You are dead right about the danger of pulling back a RR Dart engine.
During an instrument take off in an Avro 748 (yes!It was that long ago) I simulated an engine failure by quickly pulling back the throttle on one side. The student under conversion reacted very rapidly to the compass indication of yaw and whacked on full corrective rudder.
As you stated, the prop coarsening caused a momentary indication of yaw in the wrong direction. As this happened a few feet after lift off, we very nearly put a wing into the deck. My idiotic fault for not realising this could happen with a RR Dart. But then, the Avro test pilot at Woodford in Cheshire did not tell warn us about this either.

[ 03 August 2001: Message edited by: Hudson ]

411A

3rd Aug 2001, 22:36

No Bally, not likely to go away.

Lets see, the Captain on this aircraft did the run-up while taxiing and then, once the engine had failed after takeoff, he feathered the operating engine propellor.
As I indicated before, altho he had passed a check in the recent past, he simply did not perform as he should have.
In simple terms even you should be able to understand, he stuffed it up.
I was being quite diplomatic when I mentioned poor training.

GlueBall

4th Aug 2001, 01:00

It was mentioned a number of times now that during a C404 max weight takeoff/inital climb engine failure the engine must be feathered without delay....

I haven't flown the geared engine C404, but many moons ago I flew its smaller cousin, the C402C. Yes, I've had an engine failure with 9 pax and baggage during climb out at about 1,300 feet or so. The very first indication was a change in engine sound, followed by heading drift (yaw) corrected with gradual rudder and a slight push on the yoke to stop the climb. That was done instinctively. But because of fear and embarrassment of shutting down the wrong engine, I hesitated momentarily and glanced at the dual RPM needles and either the CHT or EGT, and it was clear that one side was less than the other. So, it wasn't until a good 5 seconds had passed before I pulled the throttle back, then waited another second before pulling the prop into feather.

My point is that the airplane has enough speed and inertia to give any pilot 6 seconds to think, identify and feather the bad engine.

Especially in IMC, engine failure sounds and airplane feel can play tricks on the pilot's mind, therefore it's imperative to also look at the engine instuments before making hurried and soley instinctive reactions.

:cool:

pterodactyl

4th Aug 2001, 04:10

Yes, Hudson, the Dart had a number of little idiosyncracies which could trap the unwary especially when setting up for a landing with prop feathered which was required for initial endorsement in those days.
There are still quite a few Dart powered aircraft operating and it has become apparent once or twice that a fair bit of knowlege has evaporated with passage of time.

[ 04 August 2001: Message edited by: pterodactyl ]

Kiltie

4th Aug 2001, 05:15

411A without wishing to place any racial connotation to this thread you should realise that Pprune, being a UK originated site which welcomes global participation to further its popularity, does, as far as I'm concerned, tend to expect good manners perhaps unique to that of the country of its origin. Principally, remarks such as the late Captain "stuffed it up" may be what's on everyone's mind to a certain extent, but this is a comment which the majority would not be willing to put in to print simply out of respect for the deceased.

From some of your previous postings you seem to have a lot of constructive comment to contribute & long may it continue, but perhaps you should consider expressing your views in a more sensitive manner.

PS this is a polite hint & not intended to provoke argument to the extent this thread runs away in to petty squabble.

Pterodactyl -I see your point upon further reading of the accident report, Vmca can't have been a factor if neither engine was developing power BEFORE the turn -back;I stand corrected.

Bally Heck - regarding the DAFS 404, I am led to believe the reason they failed to climb away was that they were heavy on fuel but more importantly forgot to retract the first stage of flap, often used for low speed low level observation. Having flown the 404 in a similar role we were always taught to observe in a clean config weighted by that accident. Anyone that's in the know do correct me if I'm wrong regarding that particular incident.

Personally I see no fault with run-ups "on the move", so long as the full engine checks were performed on the first flight of the day. I don't know if this aircraft had flown previous to that of the accident flight on the same day, but if I was carrying passengers I would be inclined to abbreviate the run ups to a simple mag check and quick feather excercising at the holding point without undue "revving". This is commonplace in the charter environment and not inherently an unsafe corner-cutting measure.

I fly a Performance A category aircraft at the moment but have much experience in that of C. Some remarks, although justified, point toward Perf C machines being unsafe for passenger carrying but I'm not sure I'd want to agree thus far.

Interesting thread.......keep it going; this is beneficial to all of us.

[ 04 August 2001: Message edited by: Kiltie ]

[ 04 August 2001: Message edited by: Kiltie ]

pigboat

4th Aug 2001, 05:34

The last sentence from para 1.12.3.1 states: It was concluded that, while not fully feathered, the propeller was out of its normal range of operation at impact and was moving either towards feather or out of feather. (emphasis mine)
I wonder if, at the very last instant, he realized he had shut down the good engine, and was trying to restart it.

411A

4th Aug 2001, 07:13

Kiltie---
I would also not agree that these aircraft are not suitable for charter operations. They have proven over the years to be very reliable however, at MTOW they have very limited performance with an engine inop. The 404 has a large cabin with 11 seats but it is not always a good idea to fill them all. On the other hand, this same fuselage, when pressurised and fitted with Garret engines becomes a CE441, and this type DOES have good performance. My favorite machine, bar none.
With regard to run-up while taxiing, an incident I personally saw last week in which a CE414 tried this and ended up in the dirt with the left gear collapsed shows that it is, at best, ill advised. :eek:

gaunty

4th Aug 2001, 13:42

Listen to the wise words of pterodactyl, you do not get to be as old and wise as a pterodactyl without knowing a thing or two.

411A you may be surprised to learn that notwithstanding that I wholeheartedly agree with you about the C441 being an outstanding aircraft, it's actual EFATO performance at gross weights isn't all that much better if at all, than the C404, neither is it required to be. "measurably positve" is the go. It's the old FAR23 certification issue. There are no legal EFATO figures (beyond accelerate/stop/go distances 50 ft obstacle) for FAR 25 type climb gradient other than for Engine inop ROC. If you take the time it is possible to construct a defacto FAR25, 1 thru 4 climb segment obstacle clearance scenario, but it is not provided.
Like the C404 or any FAR 23 twin including the B200/MU2/Cheyenne. blah blah, especially the big MU2s and don't get me started on those, in the EFATO scenario you are just hanging out there damned if you do and damned if you don't.

Hudson

4th Aug 2001, 13:54

Kiltie.

I tend to differ with your opinion. I doubt if there can be any valid operational excuse for run-ups on the run, or a quickie feather check and quickie mag check at the hold. It is short cuts that kill people. If the ccompany cannot afford the time and money to operate the aircraft as per manufacturer's recommendations (and that includes a proper engine check as per POH) then they should not be in business.

Believe me, the short cuts which you state that there is nothing wrong with, would see you crucified in a court of inquiry and worse still in a court of law - if they resulted in an accident.

Quote from your post:
Personally I see no fault with run-ups "on the move", so long as the full engine checks were performed on the first flight of the day. I don't know if this aircraft had flown previous to that of the accident flight on the same day, but if I was carrying passengers I would be inclined to abbreviate the run ups to a simple mag check and quick feather excercising at the holding point without undue "revving". This is commonplace in the charter environment and not inherently an unsafe corner-cutting measure.
Unquote.

I hope for your sake that you never have a prang where your words could come back to haunt you. No offence met, old chap - and I really mean that. But so many accidents have been caused by short cuts rationalised in the name of legitimate cost savings.

"This is commonplace in the charter environment" is a clear indictment of the GA industry.

[ 04 August 2001: Message edited by: Hudson ]

Kiltie

4th Aug 2001, 13:54

Little to compare between Titans / Chancellors / Golden Eagles with Conquests or Caravans - gas turbine power will always vastly improve performance when matched to the same fuselage. Having flown turbine 400s alongside their piston variants I agree I'd rather be in a Conquest or whatever but the cost of purchase / operation of a PT6 or Garret powered machine over a TSIO-540 is prohibitive for most (UK at least) small charter operators, so I still think the 404 / 402 etc. has a role; but as you say at max AUW performance rarely matches that of the handbook when the aircraft is 20 years old.

Where do you stop at banning piston powered light twin charters? Do we keep Aztecs, Senecas, Barons & 310s etc.? Or would you say these were potential disasters as well?

PS when I was discussing taxiing run-ups I really meant a 30 sec stop at the holding point rather than continuing with forward motion; but not to the extent where long noisy power checks need to be endured.

Area Juliet

4th Aug 2001, 21:07

Regarding the run up/power checks required in the 404 for those of you who aren't aware of them:

engine gauges …………………………….. normal
both throttles …………………………….. 1500 RPM
magnetos …………………………….. check (max drop 100RPM, max difference
50RPM)
*propellors …………………………….. check feather
*mixture lever operation …..………………….… check
*pneumatic de-ice system ……………………… check (if required)
hydraulic flow lights …………………………….. check
engine gauges …………………………….. check
throttles …………………………….. *close/check idle, reset 1000 RPM

Hmmmmm........not exactly an awful lot to do.

Just two points for thought.

1.If done stationary (which is always going to be the best option) then the amount of time taken to complete this procedure is hardly going to have any significant implications on the duration of the flight, so to accuse the pilot (even if he did own the company) of cutting corners for financial reasons seems a bit extreme! We're not talking about a PPL who can't remember where the levers and guages are or where he is in the checklist!

2.As stated previously 'not exactly an awful lot to do'. Therefore if done on the move at a slow taxi speed it really should not be too much to cope with.

Area Juliet

4th Aug 2001, 21:16

Sorry, forgot to add this bit.

The run up/power check issue to the thread therefore seems to me to be a bit of a tenuous sideline to the analysis of what went wrong with this flight.

Kiltie

4th Aug 2001, 21:24

Area Juliet thanks for that breakdown; that proves that performing the actions quickly does not necessarily mean they are corner-cutting or unsafe. Familiarity with type will always see such checks done expeditiously without "missing bits out" for want of a better phrase.

Area Juliet

4th Aug 2001, 22:55

Exactly Kiltie, it's not exactly rocket science for those of us that fly the C404 regularly.

Puritan

5th Aug 2001, 03:26

W.r.t. 'sudden chop of the throttle' type engine failures we've all had during training / testing.

Many (many, many) moons ago when I was doing my MultiEngine rating, and during a cruise phase of flight, my learned instructor reached down between the seats of our Seneca and (unbeknown to me) turned off one of the fuel taps.

My subsequent reactions to what happened next where almost laughable, as the fuel starved engine coughed, spluttered, and surged its way towards stopping. My inexperienced feet were doing a veritable tango on the rudder pedals (making it worse), i.e. with the aircraft yawing about all over the place, plus the engine gauges bouncing up and down like whores-draws (there was a clue there somewhere, duh), I didn't have any bloody idea as to which engine had failed - and this was made all the worse by my instructor (simulating) total panic at what was going on.

It took (what seemed) ages before I was positively able to identify which engine was having the problem.

Yep, I (very thankfully) learnt a serious lesson from that about the insideous engine failure case, and how important it is to properly identify just what is the real problem, i.e. don't rush the drill.

That said, being in the cruise, with the luxury of time (or even from an armchair, with a beer alongside :) ) it's all very obvious, but in a heavy aircraft on takeoff, and one with crap s/e performance.......... uhm ? no thanks !

411A

5th Aug 2001, 04:27

gaunty---
Performance numbers for 404 & 441:

404: MTOW 8400lbs, engine out ROC: 230 ft/min.

441: MTOW 9850lbs, engine out ROC 715 ft/min.

As you can see, the 441 is just a tad better. Cessna figures, not mine.

'Course, you need at least $1.5 million to slide into a 441 in decent shape.

pterodactyl

5th Aug 2001, 06:36

Puritan
Don't know about the Seneca but it is quite possible in cruise flight depending on the airspeed in the case you mentioned for
the RPM to windmill at governed RPM and if the throttle has not been moved from cruise setting the manifold pressure would be the same as before. So you have both engine parameters of RPM and Manifold pressure the same. This would occur as long as the airspeed was high enough for the prop to reach governed RPM before it reached full fine blade angle. In due course as speed decayed as a result of the windmill drag RPM would reduce when full fine blade angle is reached. A good thing to be aware of don't you think?
At take off with lower airspeed windmill force would not be enough to do this in the case of a total failure. In any case Dead foot, dead engine is the PRIMARY way to identify the problem using other indicators only as a confirmation if appropriate.
Can't say that running a fuel tank dry or the like is good practice. :D

Puritan

5th Aug 2001, 12:45

W.r.t. 'Can't say that running a fuel tank dry or the like is good practice ', to some extent I disagree and would have to ask "why not ?". E.g. in the above, all that was actually done was to close the fuel tap and allow the engine to suck out the fuel downstream of the tap; and perhaps I should have mentioned that at the time we were several thousand feet over the sea and within site of the home airport - i.e. there's also a time and a place.

I accordingly then learnt a whole stack about how the engine actually behaves when it is starved of fuel, i.e. it doesn't, and contrary to many folks impression, just stop-dead. It surges, and that in turn causes the aircraft to yaw from one side to the other, making it harder to identify just which has failed. Plus, and as you say the wind-milling prop causes manifold pressure and RPM to remain pretty much static; Of course in this instance fuel flow was the clue - but with only 100 TT, and 6 on the aeroplane, plus way too confident, hot shot here learnt some very valuable lessons that day.

Similarly now, in the simulator with a V1 cut - it's very unlikely that the engine will actually stop dead in that manner (but that's the hoop that the authorities wish us to jump through, so we do). However imho we should practise a lot more failures of the insidious kind, e.g. early on in the departure during a complex SID and / or with an engine-out emergency turn procedure (e.g. a Barkway departure off R05 at London Stansted, straight ahead on 046 degrees to 2DME then left turn inbound to BKY. During takeoff roll the bloke in back provides an intermittent PMC failure (you get some very small engine surges, nothing above N1 limit, and you put the yaw down to the 30Kt crosswind that he's also given you coming off the terminal). During the climb out the PMC intermittently fails a few more times, but again you put the subtle yaw and engine indications down to the turbulence and / or maybe the auto-throttle buggering about. Just as you commence the big left turn to BKY with the flaps coming up and the autopilot going in, your mate in the back gives you a full PMC failure plus a blocked fuel filter on #1. This causes it to start surging big time - and it is also at the same moment when he chucks in a couple of distracting TCAS alerts - yep, it all becomes quite entertaining - but you haven't had an engine failure, at least not according to the QRH), or how about the classic run-down failure during a descent with thrust levers closed - i.e. you barely notice you've had an engine failure, until you need the engines.

The problem with failures, and as mentioned in many a subsequent board of enquiry, is that they are not always as cut & dried as we'd like them to be or have seen / tried in either training or examinations, i.e. it's nearly always a sequence of insidious events that lead to the scene of an accident - so the more exposure one gets to these less than clear types of failures the safer one should become - which is why we do our stuff in the sim - now is there a sim for the C404 ?

Ultimately - Aviate, Navigate, and Communicate.