Air North Brasilia Crash in Darwin (Merged)
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Report released on VH-ANB Darwin Brasilia
The report was released today.
Just a quick grab:
Contributing safety factors
• The pilot in command initiated a simulated left engine failure just after becoming airborne and at a speed that did not allow adequate margin for error.
• The pilot in command simulated a failure of the left engine by selecting flight idle instead of zero thrust, thereby simulating a simultaneous failure of the left engine and its propeller autofeather system, instead of a failure of the engine alone.
• The pilot under check operated the aircraft at a speed and attitude (bank angle) that when uncorrected, resulted in a loss of control.
• The pilot under check increased his workload by increasing torque on the right engine and selecting the yaw damper.
• The pilot in command probably became preoccupied and did not abandon the simulated engine failure after the heading and speed tolerance for the manoeuvre were exceeded and before control of the aircraft was lost.
Discuss
Just a quick grab:
Contributing safety factors
• The pilot in command initiated a simulated left engine failure just after becoming airborne and at a speed that did not allow adequate margin for error.
• The pilot in command simulated a failure of the left engine by selecting flight idle instead of zero thrust, thereby simulating a simultaneous failure of the left engine and its propeller autofeather system, instead of a failure of the engine alone.
• The pilot under check operated the aircraft at a speed and attitude (bank angle) that when uncorrected, resulted in a loss of control.
• The pilot under check increased his workload by increasing torque on the right engine and selecting the yaw damper.
• The pilot in command probably became preoccupied and did not abandon the simulated engine failure after the heading and speed tolerance for the manoeuvre were exceeded and before control of the aircraft was lost.
Discuss
Moderator
All other issues aside, the report and in particular the animation shows how quicly things can go wrong.
I have never flown anything other than a single so have no appreciation for assymetic training. But I am shocked to see how litle time elapsed between the flight idle and the aircraft rolling onto its back
Nasty indeed.
I have never flown anything other than a single so have no appreciation for assymetic training. But I am shocked to see how litle time elapsed between the flight idle and the aircraft rolling onto its back
Nasty indeed.
There is a short movie (avi) that is very sobering. I spent years as a ME instructor, simulating engine failures after take-off, as required in the syllabus. I do not miss that part of the job one little bit.
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Gung ho checkies.
Very few of them appreciate just how dicey these exercises are. This checkie learned this, but with only a few seconds of his life left.
Most of them would be blissfully ignorant of the fact that more accidents happen in assymetric training than real assymetric emergencies.
Very few of them appreciate just how dicey these exercises are. This checkie learned this, but with only a few seconds of his life left.
Most of them would be blissfully ignorant of the fact that more accidents happen in assymetric training than real assymetric emergencies.
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A wise old instructor in ME training said to me once that accidents, particularly with EFATO's occur through errors in conducting drills with haste. This may not be the case with turbines as my twin time is in pistons.
Ofcourse the actions must be prompt but not instant, I wonder how many accidents can be attributed to these kinds reactions??
rocket
Ofcourse the actions must be prompt but not instant, I wonder how many accidents can be attributed to these kinds reactions??
rocket
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Very very sobering.
At the risk of sounding ignorant can I ask a very basic question of the more experienced pilots reading this? Can I assume that in a nutshell the two biggest errors here were:
FRQ CB
At the risk of sounding ignorant can I ask a very basic question of the more experienced pilots reading this? Can I assume that in a nutshell the two biggest errors here were:
- Pitching to allow the aircraft to decrease below Red Line (or was Red Line not applicable due to the double failure including the feathering system?)
- Not reducing the power on the good engine when direction could not be maintained.
FRQ CB
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FRQ
I think the biggest mistake was not advancing the power lever when it started going pear shaped. But the power control on the right and not keeping the nose down seemed to be the start of it for sure.
FGD has a point too, knowing Shane and his family, gung ho is not what I would expect at all, maybe he was this day, but if I know the folk (him and his family) as well as anyone I doubt it was significant. More likely he had a belief the very experienced pilot being checked would not make a mess of it. Only a couple of seconds from belief-non belief - rolled on ya back and dead.
Reading how hard they are to control in a sim, the heavy control forces, and when you know what is coming and why you are doing the experiment, that makes for eye opening reading too.
Very sad event.
I think the biggest mistake was not advancing the power lever when it started going pear shaped. But the power control on the right and not keeping the nose down seemed to be the start of it for sure.
FGD has a point too, knowing Shane and his family, gung ho is not what I would expect at all, maybe he was this day, but if I know the folk (him and his family) as well as anyone I doubt it was significant. More likely he had a belief the very experienced pilot being checked would not make a mess of it. Only a couple of seconds from belief-non belief - rolled on ya back and dead.
Reading how hard they are to control in a sim, the heavy control forces, and when you know what is coming and why you are doing the experiment, that makes for eye opening reading too.
Very sad event.
Nasty business this is.VMCA is something that should be avoided at all costs.
Notice in the animated sim that the rudder was not held at full deflection all the time especially when it started to roll on it's back. AS slowly decayed.The primary instrument to watch in these events apart from keeping wings reasonably level is airspeed. Airspeed is everything. You can go off course a fair bit and even lose a little Alt but losing AS & it's game over full stop! If you have to sacrifice anything make it Alt even if yr down at fence height a wings level crash is far more survivable than spinning in due going beyond VMCA.
I did many renewals in the old Beech 'till we got an old Sim to use. Man was that an eye opener! Old heap of junk Sim it was/is but it taught you to fly the numbers & had you as sharp as a razor blade in the end
Wmk2
Notice in the animated sim that the rudder was not held at full deflection all the time especially when it started to roll on it's back. AS slowly decayed.The primary instrument to watch in these events apart from keeping wings reasonably level is airspeed. Airspeed is everything. You can go off course a fair bit and even lose a little Alt but losing AS & it's game over full stop! If you have to sacrifice anything make it Alt even if yr down at fence height a wings level crash is far more survivable than spinning in due going beyond VMCA.
I did many renewals in the old Beech 'till we got an old Sim to use. Man was that an eye opener! Old heap of junk Sim it was/is but it taught you to fly the numbers & had you as sharp as a razor blade in the end
Wmk2
I've just had a quick flick thru, but my take on the major issues the lead them into the trap (besides the culture of not doing itin the sim) are:
Checkie pulls per lever too far back, disabling autofeather and increasing actual min control speed. 25.149 from memory talks about vmc being certified with auto feather.
Checkee pull nose up too high. Speed loss. Puts in correct rudder, but not enough due to more adverse yawing than normal Puts aileron the correct way, but not enough and fails to stop increasing bank the wrong way (coming from the aforementioned yaw), further increasing actual min control speed
Aircraft gets towards the actual min control speed quickly which is now much higher than the normal 97 given the above (and this possibly caught the checkie out) and it's all over.
May we all learn from this.
RIP.
Checkie pulls per lever too far back, disabling autofeather and increasing actual min control speed. 25.149 from memory talks about vmc being certified with auto feather.
Checkee pull nose up too high. Speed loss. Puts in correct rudder, but not enough due to more adverse yawing than normal Puts aileron the correct way, but not enough and fails to stop increasing bank the wrong way (coming from the aforementioned yaw), further increasing actual min control speed
Aircraft gets towards the actual min control speed quickly which is now much higher than the normal 97 given the above (and this possibly caught the checkie out) and it's all over.
May we all learn from this.
RIP.
Last edited by compressor stall; 23rd Feb 2012 at 18:57. Reason: Clarification
So what has happened to the 'mandatory sim' NPRM, has it been shelved till we have another EFATO training accident?Join Date: Oct 2011
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In October 1954 TAA lost a Viscount (VH-TVA) on a training mission at Mangalore. Three pilots died. VMCA was at the core of this.
PROBABLE CAUSE: "An error of judgement on the part of the pilot-in-command in that he took the aircraft into the air at a speed below the minimum control speed....
They didn't have simulators of adequate fidelity then, but that was nearly 60 years ago. I have no idea exactly how many pilots have died in engine-out training since but it is not a small number I am sure.
The sooner this activity takes place where it can be done safely, that is in the simulator only, the better.
PROBABLE CAUSE: "An error of judgement on the part of the pilot-in-command in that he took the aircraft into the air at a speed below the minimum control speed....
They didn't have simulators of adequate fidelity then, but that was nearly 60 years ago. I have no idea exactly how many pilots have died in engine-out training since but it is not a small number I am sure.
The sooner this activity takes place where it can be done safely, that is in the simulator only, the better.
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Very sobering! So what has happened to the 'mandatory sim' NPRM, has it been shelved till we have another EFATO training accident?
Moderator
One of the factors (in this case with a static departure) so pointedly obvious from the ATSB's animation is the typical small spread of IAS between "still under control" and "lost it" - it can all happen in the space of several knots and can be very dramatic as shown in the animation.
This phenomenon ought to be in the forefront of everyone's mind when playing in the asymmetric sandpit at or near the real Vmc for the day.
It brings a tear to the eye to recall a fatal (in which I was involved subsequently) which was a near mirror image to the present flight path - while the precipitating circumstances differed, the sequence and results were the same (albeit with a full load of passengers). That particular Type was not quite as dramatic as the present case, exhibiting a significant steady yaw prior to departure .. but the end result was the same.
At the expense of repeating oneself, Vmc is test pilot territory and one ought to maintain a comfortably wide margin from it for routine training operations.
This phenomenon ought to be in the forefront of everyone's mind when playing in the asymmetric sandpit at or near the real Vmc for the day.
It brings a tear to the eye to recall a fatal (in which I was involved subsequently) which was a near mirror image to the present flight path - while the precipitating circumstances differed, the sequence and results were the same (albeit with a full load of passengers). That particular Type was not quite as dramatic as the present case, exhibiting a significant steady yaw prior to departure .. but the end result was the same.
At the expense of repeating oneself, Vmc is test pilot territory and one ought to maintain a comfortably wide margin from it for routine training operations.
Checkie pulls per lever too far back, disabling autofeather and increasing actual min control speed. 25.149 from memory talks about vmc being certified with auto feather.
The auto feather isn't activated when simulating an engine failure by moving the thrust lever.
There were other requirements to make it auto feather, and I can't recall what they were. So the way I read it, the check pilot reduced the thrust below the zero thrust setting which creates extra drag and isn't an accurate simulation of auto feather, which in turn increases VMCa.
I raised that question late last year on a separate forum and no-one here knew anything. I quick search of the CASA website and all the literature points to a release of the CAO mid last year...
Anyway if anyone can enlighten us it would be much appreciated!!
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For a "real" view of what the EMB120 would have looked like, take a look at this video:
This was a Queen Air in the Philippines, only a few months ago, that also experienced a loss of power on the port engine. Hard to tell from the video, but it appears the prop was not feathered.
Like the EMB120 animation, there is a large amount of left bank immediately before the LOC.
The flight path of the Queen Air is almost identical to the EMB120. The result was identical.
This was a Queen Air in the Philippines, only a few months ago, that also experienced a loss of power on the port engine. Hard to tell from the video, but it appears the prop was not feathered.
Like the EMB120 animation, there is a large amount of left bank immediately before the LOC.
The flight path of the Queen Air is almost identical to the EMB120. The result was identical.
Compounding the tragedy is that it's textbook.
There are few new ways to die in aviation; someone's almost always succumbed to the same errors before.
There are few new ways to die in aviation; someone's almost always succumbed to the same errors before.
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Something that I noticed on the animation that does not make sense to me.
When stationary prior to take-off the asi is reading 30kts, the wind according to the report was 5kts. Can somebody explain this to me?
Could the asi have been overreading?
BSB
When stationary prior to take-off the asi is reading 30kts, the wind according to the report was 5kts. Can somebody explain this to me?
Could the asi have been overreading?
BSB