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-   -   DASH 8 accident in PNG (https://www.pprune.org/australia-new-zealand-pacific/466192-dash-8-accident-png.html)

Square Bear 17th Jun 2014 22:21


Reading the report,the Captain had been sick,the F/O had been called off reserve,the aircraft was not fully serviceable,flight controls not fully operational and no auto pilot;it had apparently been U/S for a number of days,
Don't call it pilot error,call it management error.
Not being an apologist for the Airlines management at all, but really, some of your points need looking at.

The report stated that the Captain HAD previously been sick, but reported as fit for the duty. No where does it indicate he was dragged out of a sick bed!! Don't you think that it was possible that he was no longer sick and that is why he went to work that day.

The F/O was called in from RESERVE. Actually that is why pilots are rostered on Reserve. In many, many airlines it is a bonus NOT to be called out on RESERVE

There was no Auto Pilot available due to the unserviceable Yaw Damper. I personally don't think it a smart idea at all flying an aircraft such as this in these circumstances without the help of an autopilot, but that is what the REGULATOR (and obviously the manufacturer) allowed, and allowed for it to up to 10 days.

The other MEL's were not so serious, and I whilst in the perfect world would not be carried, it is not perfect and again both the Regulator and Manufacturer allowed the MEL. So whilst the aircraft may not have been "fully serviceable" it was still legal.

There are a probably a lot of hands that are involved in this tragic event, but it is pointless putting the blame on one identity using normal (and perfectly legal) events to support your argument.

JammedStab 17th Jun 2014 22:56


Don't call it pilot error,call it management error.
Any pilot flying with these engines should know that you should keep your fingers well clear of the triggers whenever in the air. It is clearly written in the manuals about selection of power levers below flight idle in flight being prohibited.

There have been several cases of accidents happening for similar reasons and there is usually a common theme. The pilot was higher or faster than he wanted to be and somehow the two actions of pulling those triggers and then moving the power levers aft happened.

One has to wonder how much of a random coincidence it is that almost every time if not every time the triggers have been activated flowed by power lever movement aft beyond flight idle in the air leading to an accident, it just happened to be when the pilot really wanted to go down or slow down.

Hugh Jarse 18th Jun 2014 10:36

Jammedstab,

I'm not going to comment on the crew actions, but in response to the second paragraph of your last post I have to say that with the Dash 1 to 300, it's common knowledge among its pilots that "if you can see it, you can land on it". By that, I mean that if your landing runway is in view, any combination of flight idle, condition levers max, gear and flap will get you safely (and stable) to your proposed touchdown point without exception.

In over 6000hrs on the Dash, I never had to go around because of being too high/fast. The aeroplane is just so versatile and easy enough to fly to enable a stable approach in many unusual situations.

John Citizen 18th Jun 2014 12:54


One has to wonder how much of a random coincidence it is that almost every time if not every time the triggers have been activated in the air leading to an accident, it just happened to be when the pilot really wanted to go down or slow down.
Is this a common bush technique which works well in other turboprops (Twin Otter) but not so well in a Dash 8 ?

I am just wondering if the captain was using the "crack it into Beta" technique as it always worked so well in other types (if it ever did).

Has anyone heard of pilots successfully using this technique on another aircraft type (or even used the technique themself) ?

poncho73 18th Jun 2014 14:01

The bush technique of “cracking it into Beta” is not an approved method of operation in any of the Twin Otter, Dash 7 or Dash 8’s.The Dash 8 propeller is governed as far back as 2/3’s of the way between Flt Idle and DISCing, but unlike the PT6 controls, beyond that point, props are no longer governed and have what is referred to as ‘positive reverse’ in the PW100 series of engine/prop controls. At lower speeds during approach, there is insufficient airflow to drive the prop to overspeed. Reading between the lines of your (John Citizen’s) comments, is it possible that this particular pilot had used Beta without adverse effect on prior occasions, but didn’t know that the high speed characteristics of the prop were disastrous at Vmo?

swh 18th Jun 2014 15:24

poncho73

I dont think people realise you can be in beta RANGE without selecting reverse, they are not the same animal.

I think every person who has flown a PT6 powered aircraft has been in Beta RANGE totally legally. Beta RANGE is when the prop speed is controlled by the power lever, i.e. taxi, and often on final approach. Beta range is not the same as reverse range, however the reverse range can also be considered in the beta range.

Alfa RANGE is when the prop levers control blade angle.

I do not agree with your comments about "bush technique of “cracking it into Beta” is not an approved method of operation in any of the Twin Otter" as the aircraft is in flight idle". It happens every day, totally legal.

Sorry to digress, please continue.

poncho73 18th Jun 2014 16:24

Good point swh, I got excited when composing that response and forgot to include the word "GROUND" Beta. You are correct Beta is used in the air. I should also say....nothing below Flight Idle detent (considered GROUND Beta) is permitted while airborne, including the Twin Otter, it is not "legal" as you say to operate in this regime. I hope this does not happen everyday as you say, but I would like to continue the discussion.

Paragraph377 18th Jun 2014 22:38

APNG delay Annual Report
 
Have APNG sought an extension so that they can put some spin and waffle together to counteract the damning Dash 8 accident report? Of course they will. It is interesting how over the past 3 Annual reports the Chairman and Director have filled the report with page after page of financial jargon, and even financial risk, but there is virtually no statement about safety, commitment to safety, or a prioritisation of safety. No surprise really when you look back at around 9 crashes and 100 dead.
How do some people sleep at night???

http://www.apng.com/News.aspx

POMSOX ANNOUNCEMENT - 18TH JUNE 2014 - EXTENSIONS OF DATES FOR DISTRIBUTION OF 2013 ANNUAL REPORT, PREPARATION 2013 FINANCIAL STATEMENTS AND HOLDING 2014 GENERAL MEETING OF SHAREHOLDERS

Airlines of Papua New Guinea Limited (POMSoX: CGA) advises that:

a) the Registrar of Companies has granted extensions of the dates by or on which the company is to hold its annual general meeting of shareholders, prepare and /or finalise statements for 2013 and to prepare its annual report for 2013 to 29 August 2014; and

b)POMSoX has granted an extension of time to dispatch annual reports to shareholder as prescribed by Listing Rule 4.6 to 30 June 2014.

For further information contact:
Media Relations: Telephone: 302 3194 Email: [email protected]
Investor Relations: Telephone: 302 3234 Email: [email protected]

Let the spin begin.

JammedStab 19th Jun 2014 01:40


Originally Posted by John Citizen (Post 8527083)
Is this a common bush technique which works well in other turboprops (Twin Otter) but not so well in a Dash 8 ?

I was told to never even think about twisting the grips to go past the low pitch stops in the Twin Otter in flight. I only heard rumour that someone had tried it and there was a loss of aircraft control more to do with aerodynamics of airflow, perhaps over the tail. Perhaps right in the flare, this procedure might get done on offstrip landings.


Originally Posted by swh (Post 8527256)

I dont think people realise you can be in beta RANGE without selecting reverse, they are not the same animal.

I think every person who has flown a PT6 powered aircraft has been in Beta RANGE totally legally. Beta RANGE is when the prop speed is controlled by the power lever, i.e. taxi, and often on final approach. Beta range is not the same as reverse range, however the reverse range can also be considered in the beta range.

Alfa RANGE is when the prop levers control blade angle.

Correct,

At the finer pitch range at low power settings, the aircraft is in what is known as Approach Beta which simply means that Power lever movement is controlling blade angle. It could be from 10-17 degrees blade angle but I don't have the manual handy at the moment.


Originally Posted by Hugh Jarse (Post 8526903)
I'm not going to comment on the crew actions, but in response to the second paragraph of your last post I have to say that with the Dash 1 to 300, it's common knowledge among its pilots that "if you can see it, you can land on it". By that, I mean that if your landing runway is in view, any combination of flight idle, condition levers max, gear and flap will get you safely (and stable) to your proposed touchdown point without exception.

In over 6000hrs on the Dash, I never had to go around because of being too high/fast. The aeroplane is just so versatile and easy enough to fly to enable a stable approach in many unusual situations.

Thinking about it now, the accidents that I can remember off the top of my head were on the Fokker 50 and Saab 340 which has a GE engine. I flew the ATR and it seems similar in being able to get down quickly with those prop blades at flight idle.

In this accident, it appears that the scenario was different with a desire to get below a CB cloud combined with an overspeed.

saabsforever 19th Jun 2014 02:17

F50, S340.
 
The F50 has the same engine family as the Dash and ATR.
The Saab 340 has GE engines and with 200kt gear speed and 175 flap speed will get down and slow down much better than a Dash.
Interesting to note though that it had the same issue with double engine failure if the power levers were brought back below flight idle at high speed. One in the states deadsticked into an airfield below them at night and got away with it.
The first remedy was a physical block to prevent the levers coming back and later an electronic remedy.Both solved the problem at least they did something real not just putting a sticker on the panel.
Notes on both the F50 and Saabs are buried deep in the accident report.

JammedStab 19th Jun 2014 11:46


Originally Posted by Ret Sabala (Post 8528283)
what has to be asked is why? Why did a pilot with around 17,000 hours make such a silly mistake?

I did notice that the pilot only had 500 hours on type. Was he a jet guy that moved into the turboprop world and not particularly knowledgeable about them? Perhaps he had seen, as many have, the Pilatus Porter doing its thing straight down using beta inflight with a PT-6 and assumed the similar was possible with any free turbine engine.

Just a theory but someone could think that the warning not to do such a thing is more of an aerodynamic/high sink rate risk than a risk to destroying engines. I only knew about the real reason for the dangers by reading accident reports in which the same thing has happened.

Cactusjack 19th Jun 2014 12:25


PX has had accidents and its also unprofitable. It relies on AusAid to keep going. Its no better then apng in a lot of ways
Are you serious? To compare PX accident rate to that of APNG is ludicrous. There is no comparison.

Gemini Twin 19th Jun 2014 17:22

The outcome may have been different if they hadn't exceeded Vmo, the correction of which lead to the fatal chain of events.

poncho73 19th Jun 2014 18:39

Doing this at an airspeed of say 160kts or greater in the DHC-8 (1 - 3 series),without Beta Lockout protection, would have resulted in the same propeller overspeed condition. This is why aft of flight idle is prohibited at anytime while airborne, it's just something you never want to try.

Gemini Twin 19th Jun 2014 18:51

Agreed poncho but at slower speed the air forces may not have "wound it up" so fast. The rapid acceleration and huge increase in noise seems to have caused a huge element of surprise which could not be figured out, i.e. "what have we done", until it was too late.

poncho73 20th Jun 2014 15:12

That is what the report is saying, although wx might have been an issue:"When the propeller overspeeds occurred, the aircraft was at 10,090 ft AMSL 34 km south south east of Madang aerodrome. If we estimate it might have travelled two nautical miles towards Madang while losing 2,500 ft during the time the flight crew executed the emergency procedures and configured the aircraft to fly at 1.3 VS, it would have been approximately 17 nautical miles or approximately 31.5 km from Madang aerodrome by 7,500 ft AMSL. Prompt execution of the applicable emergency procedures would therefore have probably allowed the flight crew to glide to, or close to, Madang aerodrome. However, the flight crew could not see Madang and were also aware of a storm in the vicinity of the aerodrome."

ResumeOwnNav 23rd Jun 2014 14:23

The Finisterre Arrival is just over 5 degrees FPA.

In a Dash 8 100 it is done comfortably at flight idle, 900 RPM, with 1,600 ft/min RoD between 160-170 KIAS.

Constant descent profile from LSALT 15,000' down to MDA of 850'.

IAF 17 DME, FAF 10 DME.

Hugh Jarse 24th Jun 2014 21:02


The Finisterre Arrival is just over 5 degrees FPA.

In a Dash 8 100 it is done comfortably at flight idle, 900 RPM, with 1,600 ft/min RoD between 160-170 KIAS.

Constant descent profile from LSALT 15,000' down to MDA of 850'.

IAF 17 DME, FAF 10 DME.
Do you know what the performance of the aircraft would be with one or both propellors overspeeding, or in a combination of overspeed and feather?

At 900RPM and flight idle the PW120 is still providing forward thrust.

I suspect the crew would have been more concerned with controlling the aircraft...

Ret Sabala 25th Jun 2014 11:37

I personally can't wait for the annual report to be delivered on Monday I think? It should be hilarious.

Paragraph377 28th Jun 2014 13:16


I personally can't wait for the annual report to be delivered on Monday I think? It should be hilarious.
Maybe so, but of more importance than the humorous AG report bull**** will be the look on managements face if they are ever held to account over this accident. It probably won't happen, considering this mob have had close to a dozen crashes with 100 lives lost and still senior people remain enthroned.
Not even the most robust accident investigation report is complete until the root cause and contributing factors have been addressed, and as with this accident accountability heaped upon the accountable managers.

I just hope the lawyers are lined up over this, the families of the deceased are ready to take this airline to task, those accountable are locked up, the airlines insurance company pays dearly, and the CAA remain glued to this mob until such a day that the crashes and deaths are no longer a common theme. Here's to wishing.

Paragraph377 29th Jun 2014 08:39

APNG dismal record
 
The APNG Accident and death list:

• 15 December 1992. A Britten-Norman Islander aircraft struck a mountain near Alotau, Papua New Guinea. 6 people killed.

• 12 July 1995. Shortly after takeoff from Dagura Airport, the Twin Otter aircraft exploded and crashed into shallow water. 13 people killed.

• 11 May 1996. Britten-Norman Islander flew into a valley surrounded by high terrain near Oumba. Pilot attempted a 180 degree turn, but crashed into trees. 1 passenger killed.

• 9 July 1996. Twin Otter aircraft struck a mountain in cloudy conditions on approach to Mendi. 20 people killed.

• 29 July 2004. Twin Otter crashed near Ononge, in cloudy conditions. 2 people killed.

• 11 August 2009. Flight 4684, a Twin Otter, made a failed go-around in cloudy conditions near Kokoda. The aircraft crashed into a mountain at an altitude of 5500 feet (1676 metres). All 13 people killed.

• 13 October 2011. An Airlines PNG Dash 8-100, registration P2-MCJ, operating flight CG1600 from Lae to Madang (Papua New Guinea), crashed about 20 km south of Madang and caught fire, 28 of the 32 people aboard killed.

Plus;
• One incident in which a plane veered off the runaway during take off.

• An incident where a plane becoming bogged in wet ground.

• And another aircraft that had a flat tyre and damage to a wheel fairing.

Total = 82 dead.

I wonder whether some of these statistics are included in tomorrow's Board Report along with all the financial statistics? The last 2 accidents they have had has seen an increase in the amount of people killed. And the CAA is going to allow them to add ATR's?? The stakes get higher?

troppo 29th Jun 2014 21:07

without splitting hairs, there is a difference between MBA and APNG which is not mentioned in the APNG dismal record post

Mach E Avelli 29th Jun 2014 23:04

But, Troppo, was it not the same family directing the show in both cases?
APNG grew from MBA.
Corporate 'culture' begins at the very top. This includes pilot selection, training, checking, promotion, the application or otherwise of commercial pressure, and so on.
Not wishing to defend pilots when they make fatal errors of judgement, but all too often the investigators stop simply with 'pilot error' and don't delve far enough into other underlying causes.
Cynics may consider their fatality rate to be acceptable, given the domestic hours and number of passengers flown, but to the bereaved it is no doubt far from acceptable.

tolakuma manki 30th Jun 2014 01:19

paragraph377,
I have first hand knowledge of both the in flight fire accident in 1995 and the CFIT near Mendi in 1996.when the PF collided with the only piece of cumulus granite masked from view, the medical report stated the possibility of heart attack. The company I worked for recovered the body bags. In the Mendi case, 19 souls in 7 or 8 bags.

Niether of these can be slated to the Wild family or company.
The other accidents listed, especially the recent fatalaties at Madang and Kokoda were pilot error, no matter what the excuse for they making the error.
How can you make this the responsibility of the Wild family?

troppo 30th Jun 2014 02:25

Mach

APNG grew from MBA.
There was at the time more to it though and that statement is a bit of a stretch in some respects. There are however some lines being blurred. A company is a company, a legal entity. I don't see how any of the accidents prior to 1997 can be called APNG accidents.

Paragraph377 30th Jun 2014 04:48

Tolakuma manki

The other accidents listed, especially the recent fatalaties at Madang and Kokoda were pilot error, no matter what the excuse for they making the error.
How can you make this the responsibility of the Wild family?
Your lack of understanding about accountability and root cause and contributing causes is concerning. Both accidents in which you refer to as being 'crew error' being the cause, does not absolve a company's CEO or Board of directors from accountability under the corporations act. The causal factors in both of these accidents involves crew ability, training and other factors that lead up to their errors. For some of those errors the company is very accountable, namely its senior people.
As for the Wild family, I'm not singling them out. In fact I didn't even mention their names and I really don't care who owns, part owns, or doesn't own APNG. I'm talking about the company and its accountable people which as I said before includes a Board (not all are part of the Wild family), and the then serving CEO and the current CEO (also not Wild family members).

Even if we remove the MBA accidents you still have Madang and Kokoda with a total of 41 deaths, in 2 high profile accidents in just over a 2 year period and both under the APNG airline name.
By my books that is a shocking record, no matter how one might try to dress it up.

Paragraph377 30th Jun 2014 04:52

Finally somebody understands. Well done Mach E Avelli.

Mach E Avelli 30th Jun 2014 05:01

Sorry, I just deleted my post because you more or less beat me to it.
I have added a bit to post #220 to reflect original thoughts.

tolakuma manki 30th Jun 2014 21:47

Para377,
From researching your posts, it seems you have an inbuilt antaganism toward aviation operators and owners.
Be that as it may, you would be aware that the corporate entity is not the accountable manager for aviation.
APNG employs many PNG countrymen and women as well as foreigners, you may do well to temper your bias against them on this a public forum.

Most in the industry here know, understand what occured, you are being purposely obtuse.

JammedStab 1st Jul 2014 05:08


Originally Posted by Paragraph377 (Post 8543190)

Even if we remove the MBA accidents you still have Madang and Kokoda with a total of 41 deaths, in 2 high profile accidents in just over a 2 year period and both under the APNG airline name.
By my books that is a shocking record, no matter how one might try to dress it up.

Not familiar with the Kokoda accident but a manager should not be held responsible for intentional or stupid actions of a pilot unless there was real reason to believe that it was inevitable and the manager was aware.

I doubt you would be telling the authorities to put yourself in jail if your child decided to sexually assault someone.

Paragraph377 1st Jul 2014 10:03

tolakuma manki

From researching your posts, it seems you have an inbuilt antaganism toward aviation operators and owners.
No, wrong again. I have an inbuilt hatred of any government body or company that lies, deceives, twists, perverts or covers over the truth. Dead pilots can't speak. Dead passengers can't speak. I try to defend the innocent and if that means my comments about some airlines lack of accountability upset some folk then so be it, I make no apologies.
Also

APNG employs many PNG countrymen and women as well as foreigners, you may do well to temper your bias against them on this a public forum.
How dare you play that attempted trump card. I hold no bias against the good people at APNG, none whatsoever, never have and never will. And just in case the racist card gets played, I married someone from the middle east, have flown in Australia, NZ, PNG and the USA, and some of my best friends are from the same countries I have mentioned, as well as Singapore, Alaska and China.

JammedStab

Not familiar with the Kokoda accident but a manager should not be held responsible for intentional or stupid actions of a pilot unless there was real reason to believe that it was inevitable and the manager was aware.
Hard for you to make a comment about Kokoda if you are not familiar with it? So here we go again. Pilot error is rarely the sole cause of an accident. Just as an example only, if pilot error is determined to have been caused by fatigue (shoddy rostering), inadequate or incorrect training, organisational bullying or pressure, or other organisational factors then the organisation is accountable, not just the pilots.

To assist you, please refer back to the Concord crash (link below). An Air France Concord crashes in Paris, yet Continental Airlines and one of its Engineers narrowly escape jail;

Continental Airlines and engineer John Taylor fined over French Concorde crash | Mail Online

Sorry guys, you need to start looking outside the box and start drilling down. And while you are criticizing me, please don't forget the families, friends and loved ones who eternally mourn the loss of the forever departed. And yes, I do know how that feels.

I don't intend on starting a slinging match, but if you two guys serve in management roles in any airline....well something like this will happen again.

tolakuma manki 1st Jul 2014 21:07

Para377
You are wrong as well as being purposely obtuse.

Paragraph377 4th Jul 2014 12:37

APNG Voluntary suspension from official quotation 4/7/14
 
Latest update below:

http://www.pomsox.com.pg/dimages/com...fs/28_2326.pdf

Some other media reports on the accident:

http://mobile.abc.net.au/news/2014-0...-crash/5530664

http://www.emtv.com.pg/news-app/item/airlines-png

http://pidp.org/pireport/2014/June/06-17-14.htm

http://www.jacdec.de/2014/06/16/2011...of-madang-png/

JammedStab 9th Jul 2014 01:17


Originally Posted by Paragraph377 (Post 8544733)

I don't intend on starting a slinging match, but if you two guys serve in management roles in any airline....well something like this will happen again.

Now you are just making yourself look like an idiot with stupid statements.

Crackup 9th Jul 2014 07:27

As a former Dash 8 pilot and retired after 43 years of flying, I have been following this thread with great interest.
All I can say guys is; there but for the grace of god go I.
If lucky you will never be faced with anything like this in your entire career. If not so lucky, be ready for it, know your re-call drills and aircraft systems. Practice a glide approach occasionally. You are only as good as you are on the day. And that applies to all of us.

E&H 9th Jul 2014 09:58

Crackup...first sensible post I've seen...didn't know any one with common sense still existed...be careful the thought police will get you...

However what you say is very true we are only ever a nano second away from disaster, the real issue here in my view was that the aircraft should never have had the ability to do this in flight and when it was first brought to light it should have been fixed

Crackup 10th Jul 2014 00:01

E&H, I agree with you 100% that the real issue of this thread is the lack of corrective action taken as soon as the design fault was discovered. In fairness to the company I was flying for at the time, they started the process of fitting the beta lock-out system immediately after becoming aware of the severity of the problem. I do not wish to go into the debate regarding airworthiness bulletins and directives. The message of my previous posting was purely intended as helpful advice to the up-coming young guy, or young lady, who one day may be faced with having to deal with a catastrophic outcome resulting from a shortfall in the system they work under or any other cause.
Not saying that this is how it happened, but I can see how easy it would be to inadvertently select beta in the Dash 8, given the situation: Hand over the power leavers, large positive G bump, followed rapidly by a severe negative G bump. The out of control fingers would only have to catch under those latches and the rest is history. Prior to the APNG accident, like most, I was blissfully unaware of that potential.


The Big E 10th Jul 2014 01:11


the real issue here in my view was that the aircraft should never have had the ability to do this in flight and when it was first brought to light it should have been fixed
Hear Hear.

It makes you wonder about the original Type Certification, and then the subsequent reluctance of the OEM to address the situation when it became apparent. It took several years before the National Authority mandated a fix, which became available in the form of a Service Bulletin. The FAA required it much earlier, and with hindsight the other jurisdictions should have followed suit in the name of Safety.

Regards to ya all, Big E.

poncho73 10th Jul 2014 14:44

Some Common Sense
 
Gents

We must all realize that aircraft of this vintage, that were designed around the PW100 Series engines, were capable of this.
Some of these Types ran into problems in the early days when PT6 experienced pilots "assumed" the PW100 engines governed props all the way to max reverse as the PT6 did.
Fast forward 25 or so years...and BINGO, it happens again. While the decision to protect the pilot from inFlt Beta has been taken by the Regulators, it does not excuse the pilots who routinely use it during flight from being the cause. In the case of the PNG accident, there was no significant turbulence, and why would he have his fingers near the triggers at 10,000 ft anyways (not to mention it is an unnatural arm position to have your fingers grip the triggers). UNLESS, of course, that it was common practice.
If he had used this little 'trick' in the circuit, and didn't understand how the prop controls worked and repeats the 'trick' at Vmo...BOOM!
Let's use a little common sense and follow the instructions.
Pilots shouldn't ALWAYS need automation to be protected from themselves.

Crackup 10th Jul 2014 23:41

Hi Poncho73,
I was not aware that this “little trick” was ever practiced knowingly and willingly. Thanks for filling me in on it but I don’t think I’ll try it. I’m no fan of Airbus philosophy and heartily agree with you that pilots shouldn’t always need automation to be protected from themselves, but giving this particular design flaw to pilots to play with seems akin to giving a loaded pistol with no safety catch to children.


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