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Pursuit of excellence - the X-Factor in training accidents

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Pursuit of excellence - the X-Factor in training accidents

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Old 27th Feb 2012, 07:47
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So how do we get back to the 'good old days'?
That's easy. Simply cut the mixture just after lift off and risk losing the aircraft
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Old 27th Feb 2012, 08:03
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Pretty hard.

CASA will have to grow a spine and a brain.

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Old 27th Feb 2012, 08:33
  #23 (permalink)  
 
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A) Mandate 500 hours multi command for META and/or 200 hours on type or an equivalent type to teach on it.

B) Offer the professionals who possess these prerequisites a competitive salary.

C) Contract the role of FOI to industry professionals (such as ATO delegations) who are respected by their peers and work in the capacity or role that they are inspecting in other operations. If a guy is not performing, industry can vote them out.

D) If a or b can't work, open up CAR217 training departments to the industry.
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Old 27th Feb 2012, 14:04
  #24 (permalink)  

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sheppey how is it then that 10s of 1000s of hrs of safe ME training has happened over the last 5+ decades?

Yes there have been a bunch of accidents and people have been killed - I'd love to see a true and accurate break down of the overall accident rate for assy training but I very much doubt that statistic even exists. With huge effort you might be able to find out the number of accidents but you'd never come close to an accurate total number of twin training hours.

Too no one could ever seriously claim that reducing the accident rate to zero in training, absent piston twin 'Class D' sims, will reduce the overall rate of people killed in piston twins. People make claims along the lines of 'more people are killed training for EFATO than are killed in actual EFATO' - an utter BS statement because you could NEVER know how many people would die in piston twin actual EFATO if, to take the opposite extreme, NO EFATO training occurred close to the ground. How many people were saved by the training is also an unknowable number...but its not zero.

The numbers killed in accidents that result from no effective training would likely be larger/accident that in training accidents. In a typical assy training accident 2 people die. A pilot with only ineffective training could take anywhere from 1-9 others with him.

You just don't get to make statements along the lines of "If we stop training accidents we will save lives" because you will only save some lives 'over here' at the expense of other lives 'over there'. Anyone who makes such a statement can be immediately dismissed as a fool.

I can only go on personal experience as a line pilot and training pilot in piston twin (and light Turbine twin) airline operations in the 80s/early 90s in PNG. In those days airlines like Talair, Douglas and Airlink in PNG and Hazeltons, Kendals, Tillair, Easterns, Bushies etc in Oz ran fleets of 20-30+ piston twins and similar numbers of small turboprops.

I think in my time in Talair we had 35 odd Islanders/C402s/Barons and 26 Twin Otters and Bandits. When I worked for Airlink we had probably 10 piston twins (Islanders, 402s, 404s, Baron), 2 or 3 Twin Otters and 2 Bandits.

Over the years these airlines employed 1000s of pilots and conducted 10s of 1000s of hours of safe ME flying training. I can't speak for Australia in those years but I cannot remember a single fatal ME training accident in PNG in my decade in PNG GA. In fact off the top of my head I cannot remember a single ME training accident period let alone one that could be sheeted home to assy training.

About now my old mate Chimbu Warrior will come out of the woodwork with one

I could reel off the top of my head a half dozen actual EFATOs - and a bunch more en route type - that had happy endings - I had 2 just off the ground for starters...and not at training weights either

We have the resources - the John Chesterfields, Ray Villiermans and that nice fella at Ingham whose name escapes me - but they are not exactly in the first blush of youth - there are of course others.

I think CASA is addressing the issue slowly. The new Instructor rating they are mumbling about is a great start if they are smart about it and follow through with it. That would allow appropriately experienced and qualified people to put back into the industry we love on days off from airline flying or after retirement - or indeed after they lose their class one medicals - I know of several people who would very much like to get back into more advanced training if the barriers were lowered. ME, IFR training etc.

The first step is to raise the minimum experience requirements to conduct ME training. 500 hrs ME command (or as someone else suggested 2-300 on type) would be a good starting point.

And I want to stress this next point. The high minimum experience requirements are not ALL about what to do in the first 5-10 seconds after the engine fails - its as much or more about the 5-10 minutes after that.

Some of us who were ME training pilots in the old supplemental airline days are still around and 'only' in our early 50s and some remain current in light GA. Clearly still current in GA to some extent would need to be a requirement. I am not suggesting someone who last set foot in a Baron in 1990 and hasn't been near a light aeroplane since is a likely candidate for fast track back into a ME training. You'd probably want some sort of vetting system too - probably an informal one would work best.

CASA might be pleasantly surprised at the number (and I am not suggesting its scores, or even dozens, of people - you are probably looking at a small handful in each state) who would be quite happy to saddle up again part time...as long as the BS is kept to an absolute minimum.

Its actually easy - a one or two day (tops) ground course (could be waved if you are a current airline checker/trainer) and then a comprehensive practical test with someone like a John Chesterfield or a Ray Villierman for each area you were qualified in and want to do again.

CASA just has to want to...and I think they do.

Last edited by Chimbu chuckles; 27th Feb 2012 at 17:07.
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Old 27th Feb 2012, 22:23
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GG and CC excellent answers and ones that, if CASA had enough foresight, could quite easily be written into Part 61 before it gets 'officially' released!

Next question, CC said:
And yes it is also a disgrace that very experienced ME instructors who show ONGOING disdain for safe practices are not stripped of their approvals.
We have probably all had one or two of these rogue ATO, Checkies, Instructors even FOIs who have sailed through their careers till they have ended up in the seat beside you. They obviously meet all the min reqs but some how or another they escaped serious scrutiny (Bud Holland comes to mind!).

So my question is how do we weed out this rogue pilot element?
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Old 28th Feb 2012, 02:51
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Isn't it a shame the more practical ATOs like Chesterfield get chased out of the industry by CASA? And then they wonder where all of the experience goes...

Interesting how Mr. Chuckles talks about mixture cuts being ok and no one objects:

Whether you simulate failure by pulling throttle or mixture is a wash in my experience in both seats. What elevates the risk to unacceptably dangerous is the attitude, experience and skill of the instructor/examiner not whether you pull the mixture or throttle. I prefer the mixture for good engineering/physics reasons.
I agree with the above fully, but all the 'experts' came out swinging in a previous thread saying this was unacceptable. If a piston ME instructor sets themselves some ground rules they shouldn't run into too much trouble I.e. I won't fail an engine below 400ft, I won't let the speed drop below vmca+10 etc. A good preflight brief, about failure methods, CRM etc., goes a long way too, from light pistons to turbines. It's a shame many instructors and T&C captains forget this.
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Old 28th Feb 2012, 03:35
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Chesty was chased out of the industry?

I last flew with him probably 8 years ago - he was an awesome instructor/ATO. His set up at Cooly was very good.
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Old 28th Feb 2012, 04:30
  #28 (permalink)  
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but all the 'experts' came out swinging in a previous thread saying this was unacceptable

I think that the concerns were more with the philosophy of cuts at very low level on a GA twin rather than the actual technique adopted ?
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Old 28th Feb 2012, 05:04
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It did seem to me that there is lots of criticism of using the mixture lever for it's own sake.

I'm glad some experienced pilots are pointing out the danger of continuing the exercise down to zero feet AGL, independent of cockpit lever position.

I did some advanced training in western Europe (mixture cuts banned, EF at night &/or in IMC routine). They seem to have a very robust training system with an enviable training safety record. Perhaps it's worth looking at what they do right, in terms of culture rather than just minimum experience? I will say that the culture of the senior pilots was different to what I have sometimes observed in this corner of the Pacific. I never had the feeling that an examiner would let an asymmetric scenario continue down to tree top height for example. There are reasons why an examiner would do that, but only very bad ones.

Last edited by Oktas8; 28th Feb 2012 at 05:23.
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Old 28th Feb 2012, 06:33
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I did some advanced training in western Europe (mixture cuts banned, EF at night &/or in IMC routine). They seem to have a very robust training system with an enviable training safety record. Perhaps it's worth looking at what they do right, in terms of culture rather than just minimum experience? I will say that the culture of the senior pilots was different to what I have sometimes observed in this corner of the Pacific. I never had the feeling that an examiner would let an asymmetric scenario continue down to tree top height for example. There are reasons why an examiner would do that, but only very bad ones.
My thoughts and experience as well, moreover when I did my JAR multi-conversion on the Duchess, mixture cuts were mandated as verboten, the reason being as outlined in previous threads. I'm not saying don't practise/demonstrate it, but give yourself enough altitude to recover if it's screwed up.
All my multi piston s/e work was based around setting zero thrust.
On the BN2t as well as the B200 and bandit, it was the same thing....zero thrust, auto feather was demonstrated at higher altitudes.
We ran into a similar discussion on the F900 as to the cost vs safety implications of doing an LPC in the jet or in the sim, in the end it was harder and yet less expensive to head over to Le Bourget and get it done in Dassaults' lurching cave.
To me it's a simple equation of risk vs reward, nobody to the best of my knowledge has killed themselves in a sim practising s/e work, but on piston twins generally the sim option doesn't exist......so mitigate the risk, improve your margins and train people effectively based on evidencial and experience derived concepts....that have existed for a long time.
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Old 28th Feb 2012, 06:58
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So and Not so.


JAT - I think that the concerns were more with the philosophy of cuts at very low level on a GA twin rather than the actual technique adopted ?.

Spot on, despite much 'discussion' the argument sanity v black letter law has been beaten onto the back burner at various GA airports. Sad, but very true, don't believe me ask the 'experts' at your local GA airport.

Huaghtney - .so mitigate the risk, improve your margins and train people effectively based on evidential and experience derived concepts....that have existed for a long time.

Yup, but try to hold an ATO delaegation at ASBK and see what happens; 3 down 1 to go.
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Old 28th Feb 2012, 10:58
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My thoughts and experience as well, moreover when I did my JAR multi-conversion on the Duchess, mixture cuts were mandated as verboten, the reason being as outlined in previous threads. I'm not saying don't practise/demonstrate it, but give yourself enough altitude to recover if it's screwed up.
All my multi piston s/e work was based around setting zero thrust.
Like all things in flying there are different points of view based upon personal experience. But in a court case for instance,the legal eagles would quickly seize on such recommendations taken from Lycoming Flyer magazine (2002 issue) - edited extracts. Page 49 under the heading NTSB Warning On Simulated Engine-Out Maneuvers.

Quote: "The fatal crash of a light twin in which a flight instructor and an applicant for a multi-engine rating were killed prompted the NTSB to issue an urgent warning to all pilots simulating an engine-out condition on multi-engine airplanes. The Board's investigation revealed that some flight instructors do use the fuel selector or the mixture control to shut down an engine to test a multi-engine applicant. Although this is a recommended procedure, the urgent warning was aimed at flight instructors who were using this procedure at altitudes too low for continued safe flight. The NTSB observed that use of such procedures at traffic pattern altitudes may not permit instructors enough time to overcome possible errors on the part of the applicant.

The recommendation by the NTSB means that all simulated engine-out operation at the lower altitudes should be accomplished by retarding the throttle and this should be done slowly and carefully to avoid engine damage of failure. The current technique will protect the engine and at the same time provide for instant power if it is needed." Unquote.
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Personal comment only: The subject has been discussed numerous times in Pprune with good arguments for and against mixture cuts. The problem has always been the startled and possibly unpredictable reaction by students and this can happen equally with a throttle or mixture closure. One could argue that if it is safe to cut the mixture at low level to simulate an engine failure on a light twin, then why not do the same with a light single at say 500 feet agl after take off during ab-initio training as practice engine failure followed by a simulated forced landing glide?

After all, in all cases the instructor is counting on the engine to successfully restart when he opens the mixture control to rich and opens the closed throttle.

Few sane instructors will deliberately cut the mixture to simulate a low level engine failure in a single engine type simply because of the fear (risk) the engine may not pick up after the mixture is set to rich. That is a reasonable precaution. Same then with a twin because if the engine fails to pick up quickly after the mixture is returned to rich in a twin, then things quickly get serious with the inevitable loss of airspeed associated with a windmilling (not feathered) prop. Perhaps that is one reason for the NTSB recommendation of "The current technique will protect the engine and at the same time provide for instant power if it is needed."
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Old 28th Feb 2012, 22:22
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Sheppy.

For what it is worth,the only post EFATO engine I have had that failed to respond was after a throttle cut, fortunately there was a convenient paddock 30 degrees off the starboard bow.

Never, I say again Never, have I had a mixture cut fail to pick-up, and I have done literally thousands of them, in aircraft from new to totally clapped out.

Maui
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Old 29th Feb 2012, 02:41
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I have my own preference regarding mixture vs throttle. But it's a bit irrelevant these days, with so many regulators enforcing the "official line". It's only time before CASA does the same.

I think it's more important to address the reasons why instructors or examiners continue an asymmetric exercise down to an unsafe height or down to an unsafe speed - whatever that height or speed may be in the circumstances. It seems that the industry has not asked itself the tough questions - what skills the regulator actually asks to be measured, what the examiner intends to measure and what the examiner actually measures.

For example, what is gained by simulating an engine failure in a twin below 300' agl? What is gained by persisting with the exercise even though it looks like it's not going to work?
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Old 29th Feb 2012, 03:49
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Chesty was chased out of the industry?

I last flew with him probably 8 years ago - he was an awesome instructor/ATO. His set up at Cooly was very good.
Affirm. I only know the details third-hand, but from memory it happened about 4-5 years ago. I've been told CASA weren't happy with his 'lax' methods and his different view on certain CAOs, including when one could obtain a META (vs. use it).

but all the 'experts' came out swinging in a previous thread saying this was unacceptable

I think that the concerns were more with the philosophy of cuts at very low level on a GA twin rather than the actual technique adopted ?
The thread I was thinking of was in the GA forum about six months ago. I'm glad this thread has a lot more fact and less opinion than that one.

Never, I say again Never, have I had a mixture cut fail to pick-up, and I have done literally thousands of them, in aircraft from new to totally clapped out.
Me either. But there were plenty of times fouling was experienced when the throttle was opened, despite the normal warming/cycling of the throttle on the way down. Those that oppose mixture cuts the most seem to be the pilots who've never actually done it. There is a big difference between leaning the mixture vs. shutting off fuel systems.
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Old 29th Feb 2012, 05:11
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There is a big difference between leaning the mixture vs. shutting off fuel systems.
There is some confusion here. There is clearly a world of difference in leaning a mixture and selecting cut off with the mixture control.. Some years ago, at Tyabb in Victoria, an instructor on initial twin endorsement training with a student entered the circuit and cut the mixture (Seneca 2 I think) before entering downwind. In misplaced enthusiasm (the subject of the original post of this thread) he deliberately left the engine dead (mixture cut off) all the way around the circuit to simulate a windmilling prop (he didn't have to simulate it did it by itself). The purpose of the exercise in his mind was to give the female student the experience of the heavy foot force needed to maintain level flight on one engine while the other prop windmilled.

On final in the same configuration (windmilling dead engine prop) he told her to do a touch and go and that he would bring the mixture from cut off to rich on touchdown so when she opened both throttles to touch and go she would have symmetric power.

It didn't quite turn out as the instructor planned. Sod's Law in action. He opened the mixture on touch down and she pushed both throttles open to commence the touch and go. Unfortunately it appeared the prop had been windmilling sans power for so long that the fuel in the injector lines had diminished with the result that engine failed to deliver power when the throttles were positioned for take off.
The Seneca yawed under asymmetric power and neither the student or instructor (who belatedly took over as the aircraft went off the strip) were able to control the ensuing ground roll. It hit a log or something to one side of the strip and caught fire. Both pilots were lucky to escape with minor burns. There is a moral to this story somewhere but I am sure readers will think of something appropriate

Back in the old Mac Job DCA Air Safety Digest 1960-70 days, there was a report on a Chieftain that crashed into rising ground during a night take off when the check pilot cut the mixture soon after lift off at Port Lincoln. The prop was never set to zero thrust and the aircraft simply was unable to out-climb the invisible terrain ahead. One or both pilots were killed in that accident. Yet to this day throughout Australia, the mixture cut technique after lift off has continued for years and by the sound of it, still does. .

Of course we never get to hear about the close shaves. No names, no paperwork - therefore no CASA pack drill. As one contributor stated quite vehemently in an earlier post, in all his career he never had an engine fail to pick up following a mixture cut after take off. I am sure that applies to hundreds of flying instructors.

I can well believe that. And why do I believe that? Simply because it is a well known theory that these sort of accidents will never happen to you - but always only to some other poor doubtless incompetent sod.. The perception of danger diminishes in your mind the more you get away with it.

Last edited by sheppey; 29th Feb 2012 at 05:21.
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Old 29th Feb 2012, 06:11
  #37 (permalink)  

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sheppey both those stories are examples of egregious stupidity...nothing else.

Neither makes a case against using the mixture to simulate failure. Like maui I have never seen an engine not respond to the mixture being pushed back in. The engine was running fine before you pulled the mixture it will run fine when you reintroduce fuel 10-15 seconds later.

Yes a linkage could break - same with the throttle and the end result of either is identical.

The main reason for mixture cuts being uncommon in single engine EFATO training is simply that if the throttle linkage breaks in a SE aircraft the engine will go to full power whereas in a twin it will go to idle. In the larger piston engines, like the C404's GTSIO520 with its gearbox and counterweights, the mixture cut is much kinder to the engine whereas it is irrelevant with an O320.

With a mixture cut you also still have the pistons sucking air which cushions them as they slow down. You can't get plug fouling when there is no fuel.

The mixture cut is just more mechanically sympathetic to big bore engines and with no additional risk (in a twin) over a throttle chop - less in fact.

I have already expressed my opinion on night assy training in piston twins. Not setting zero thrust (or feathering the prop if that is the exercise) after demonstration of the correct memory items at any time is stupid - at night it is suicidal gross negligence. If someone pulled an engine in a piston twin on me in the dark I would break his fingers getting everything back against the stops.

Even when I was endorsing people on the Falcon 200 (no sim available) I didn't simulate engine failures during the night circuits portion of the endorsement - the brief was 'there will be NO simulated engine failures tonight. If one happens its real" - and that aircraft went like a dog shot up the ar$e on one engine. The rear pod mounted engines produced only minimal control challenges. In fact at training weights you had to pull the nose up around 15 degrees to stay at V2. At < 10 NU you were quickly through 200Kts, climbing and still accelerating fast, on one engine.

Re introducing the mixture to an engine that has been windmilling for 5 minutes or so on a touch and go and expecting the engine to pick right up - the way it does after windmilling for 10 seconds - just demonstrates a lack of understanding that is breathtaking. The pilot under training should have simply made it a full stop and argued about it later.

Last edited by Chimbu chuckles; 29th Feb 2012 at 06:59.
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Old 29th Feb 2012, 08:32
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The mixture should be enrichened to enable a zero thrust setting anyway, therefore the outcome two posts above shouldn't have happened.

I remember I started to become a bit overconfident after a couple of years of instructing and started to 'push' things a little further. I didn't really consider the risk vs reward in many sequences. Luckily I soon identified this mindset and went back to doing things by the book and only with prior planning (I.e. no knee jerk engine failing - planning out the sequence of events prior to departure after considering even little things such as how the crosswind would effect yaw during OEI landings). Hopefully most trainers or instructors pick this behavior up within themselves when it eventually surfaces before things go too far.
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Old 29th Feb 2012, 22:22
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When I did my ME endorsement my instructor was ex-military and had been CP for a regional airline. He stated right from the beginning that no simulated EFATO would be conducted below 400' as he had too many pilots stuff it up. When I started doing ME endorsements I kept his advise. He is still flying as am I. Is it because of his insistence on no EFATO below 400'? Who knows but given what has been written on this thread and on the Airnorth accident I thank him for his wisdom.
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