KingAir crash near Chigwell?
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According to the report 57 defects were unofficaly recorded in e mails that should have been recorded in tech log or maintenance records in nine months preceding the accident......
As a consequence serious defects were being carried with no certainty that operating crews were familiar and alert to issues.
Sorry this is an apalljng reflect tion on the operator and points to a cowboy operation of the worst kind .
As a consequence serious defects were being carried with no certainty that operating crews were familiar and alert to issues.
Sorry this is an apalljng reflect tion on the operator and points to a cowboy operation of the worst kind .
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For what its worth I think the most likely scenario based on what the report reveals is that the long history ( as recorded in the dodgy dossier of unapproved e mails) of autopilot function and indication issues is what did for the guys.
Took off normally ....engaged autopilot at first opportunity as IMC. It didnt engage in vertical mode...and too late Rob realised it was not following flight director.
I make no aplogy for speculating as the report is so inconclusive........
Took off normally ....engaged autopilot at first opportunity as IMC. It didnt engage in vertical mode...and too late Rob realised it was not following flight director.
I make no aplogy for speculating as the report is so inconclusive........
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The flight profile was recreated in the sim.
'On one trial run, the autopilot was engaged with a lateral mode active (heading mode) but without a vertical mode. This simulated the possibility that the pilot attempted to use the autopilot but did not engage a vertical mode. When the turn was initiated, bank angle was limited to below 30°, power was sufficient to prevent a decrease in the nose attitude and the aircraft continued to climb.'
'On one trial run, the autopilot was engaged with a lateral mode active (heading mode) but without a vertical mode. This simulated the possibility that the pilot attempted to use the autopilot but did not engage a vertical mode. When the turn was initiated, bank angle was limited to below 30°, power was sufficient to prevent a decrease in the nose attitude and the aircraft continued to climb.'
the report reveals is that the long history ( as recorded in the dodgy dossier of unapproved e mails) of autopilot function and indication issues is what did for the guys.
When engaging an autopilot, it is prudent to ensure that the correct mode is activated and then monitor the aircrafts flight path to ensure that the aeroplane is being flown as you intended, in otherwords you watch the attitude and performance. This is even more important when single crew or , as suggested, there is a question of reliability of the autopilot. Then if it is not following the intended flight path hand fly the aeroplane.
Unfortunately we may never know what actually happened that led to the crash.
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'Section 2.7.3 of the operator’s Operations Manual Part B (OMB) stated that the autopilot should not normally be engaged below 1,000 ft (the minimum engagement height is 500 ft agl). The operator confirmed that, when departing from Stapleford, even in IMC, the autopilot would typically be engaged after the aircraft had turned towards its first navigation waypoint (in this case, Brookman’s Park VOR) at which point the aircraft would be at about 1,700 ft amsl.'
and also from the report
'If he believed the autopilot to be engaged when it was not, he would have noticed his error when he commanded the turn and the heading remained constant. Given that the operator expected the departure to be flown manually, it was concluded that the autopilot was probably not engaged.'
and also from the report
'If he believed the autopilot to be engaged when it was not, he would have noticed his error when he commanded the turn and the heading remained constant. Given that the operator expected the departure to be flown manually, it was concluded that the autopilot was probably not engaged.'
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So few facts and so much speculation. One fact clearly established is that LEA made up their own procedures for dealing with aircraft defects (presumably to get round the inconvenience of carrying out timely maintenance and avoiding AOG issues) as a consequence were both taking passengers in a defective aircraft and breaking the law. Considering the large presence LEA have with many different fleets the implications are horrendous. This company routinely flies the royal family including the queen as well as members of government. If ever there was a case for stripping its AOC and
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Much speculation and few facts....
What the report does do is shine a light on the perennial question that is at the heart of every GA operation....How do you deal with tech issues when, if properly recorded in the tech log as required by law, the effect is to ground an aircraft?
The catastrophic effect on scheduling charter flights...often from obscure destinations without engineering support, puts massive pressure on operators and as a consequence pilots to not properly record defects for fear of leaving important ( and certainly very rich) clients stranded. There is the added fact that GA companies often have scarce resources and as a consequence no ability to bring in alternative equipment without crippling financial penalty.
It is clear from this report that this operator had devised a system to try to diseminate technical information about aircraft serviceability which was in obvious breach of regulations and had the consequence that aircraft which should have had technical issues dealt with, continued flying.
Unairworthy in accordance with MEL and the terms of their C of A in other words.
An AAIB investigation is not about attributing blame but about establishing facts.
There is no evidence that this unofficial system of "engineering e mail reporting" killed our much respected and sorely missed colleagues but equally there is no evidence that it did not at least act as a contributing factor.....surely one or more of the many holes in the Swiss cheese that all lined up on that fateful day.
I would be interested to know how the CAA intended to deal with this......
So far as I can recall these were the first deaths of two pilots operating for a UK charter company for as long as I can remember (?)
Heads surely have to roll to make clear that this behaviour will not be tolerated and give reassurance to the rich public, government and royalty who use these services that a G registration charter aircraft is properly maintained and safe.
What the report does do is shine a light on the perennial question that is at the heart of every GA operation....How do you deal with tech issues when, if properly recorded in the tech log as required by law, the effect is to ground an aircraft?
The catastrophic effect on scheduling charter flights...often from obscure destinations without engineering support, puts massive pressure on operators and as a consequence pilots to not properly record defects for fear of leaving important ( and certainly very rich) clients stranded. There is the added fact that GA companies often have scarce resources and as a consequence no ability to bring in alternative equipment without crippling financial penalty.
It is clear from this report that this operator had devised a system to try to diseminate technical information about aircraft serviceability which was in obvious breach of regulations and had the consequence that aircraft which should have had technical issues dealt with, continued flying.
Unairworthy in accordance with MEL and the terms of their C of A in other words.
An AAIB investigation is not about attributing blame but about establishing facts.
There is no evidence that this unofficial system of "engineering e mail reporting" killed our much respected and sorely missed colleagues but equally there is no evidence that it did not at least act as a contributing factor.....surely one or more of the many holes in the Swiss cheese that all lined up on that fateful day.
I would be interested to know how the CAA intended to deal with this......
So far as I can recall these were the first deaths of two pilots operating for a UK charter company for as long as I can remember (?)
Heads surely have to roll to make clear that this behaviour will not be tolerated and give reassurance to the rich public, government and royalty who use these services that a G registration charter aircraft is properly maintained and safe.
Last edited by BuzzB; 15th Oct 2016 at 11:15.
The e-mail engineering reports are not intended to replace tech log entries, and they are not "unofficial". They are sent to ensure that any entries that have may been made are made known to the company asap so that arrangements for rectification can be put in place in advance - and they are a required, documented, part of the post-flight reporting procedure. They also serve to ensure that something unfortunate happens to the aircraft there is a full record, in one place, of any log entries that have recently been made.
LEA are not alone in this practice, which is not illegal. I have worked for quite a few operators over the years, and without exception crews were required to let Ops know, by some means or other, if there were any snags in addition to formally writing it up in the log.
Any system can be abused. I do not suggest that this is the case here; it is simply a fact.
LEA are not alone in this practice, which is not illegal. I have worked for quite a few operators over the years, and without exception crews were required to let Ops know, by some means or other, if there were any snags in addition to formally writing it up in the log.
Any system can be abused. I do not suggest that this is the case here; it is simply a fact.
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LEA are not alone in this practice, which is not illegal.
Read page 21 of the report.
57 items (!!) that either required immediate rectification or deferal in accordance with MEL for either three or ten days were not properly entered in the tech log in the preceding nine months!!! The report observes that the aircraft was flown with essential maintenance items outstanding because of this.
The first job of a competent Captain on entering the flight deck pre-flight is to read the tech log and check , amongst other matters, the engineering status of the aircraft including the status of any deferred defects. He is entitled to rely on that as the definitive source of information as to the status of the aircraft ( apart from anything he observes from his own pre flight checks)not wade through a stream of company e mails.....
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Although the aircraft had previously been flown with outstanding defects, this does not appear to be the case for the accident flight.
'In the week preceding the accident flight however, the aircraft had performed six flights and the email reporting system did not contain any significant defects apart from a worn main landing gear tyre. This was correctly recorded in the technical log and the tyre was replaced prior to the next flight.'
'In the week preceding the accident flight however, the aircraft had performed six flights and the email reporting system did not contain any significant defects apart from a worn main landing gear tyre. This was correctly recorded in the technical log and the tyre was replaced prior to the next flight.'
BuzzB - I have read the report, thank you, and with some interest as Francis was a friend as well as a talented colleague with whom I was privileged to fly.
I would point out that despite claiming "No one is suggesting the e mails themselves were illegal", you, yourself have claimed that the system is just that: "this operator had devised a system ... which was in obvious breach of regulations". Furthermore, you want action: "Heads surely have to roll to make clear that this behaviour will not be tolerated". I reiterate - the system, as intended, is not in breach of regulations and indeed is a great deal better than some alternatives with which I have been presented.
I cannot speak to the other fleets - I can only state that under the system being discussed I was not once presented with an aircraft that exhibited any undocumented defect. I therefore reiterate: any system can be abused. I do not suggest this is the case here; it is simply a fact.
I would point out that despite claiming "No one is suggesting the e mails themselves were illegal", you, yourself have claimed that the system is just that: "this operator had devised a system ... which was in obvious breach of regulations". Furthermore, you want action: "Heads surely have to roll to make clear that this behaviour will not be tolerated". I reiterate - the system, as intended, is not in breach of regulations and indeed is a great deal better than some alternatives with which I have been presented.
I cannot speak to the other fleets - I can only state that under the system being discussed I was not once presented with an aircraft that exhibited any undocumented defect. I therefore reiterate: any system can be abused. I do not suggest this is the case here; it is simply a fact.
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'The ‘Engineering Report’ emails also contained aircraft technical defects that were not recorded in the aircraft technical log or aircraft maintenance records.'
'None of these defects were recorded in the aircraft technical log, or the aircraft maintenance records, as required by M.A.403(d).'
'Part M regulation M.A.403 refers to the recording of aircraft defects:
(d) Any defect not rectified before flight shall be recorded in the M.A.305 aircraft maintenance record system or M.A.306 operator's technical log system as applicable.'
'None of these defects were recorded in the aircraft technical log, or the aircraft maintenance records, as required by M.A.403(d).'
'Part M regulation M.A.403 refers to the recording of aircraft defects:
(d) Any defect not rectified before flight shall be recorded in the M.A.305 aircraft maintenance record system or M.A.306 operator's technical log system as applicable.'
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The use of email ‘Engineering Reports’ to record aircraft technical defects circumvented the requirements of EASA Part M regulation M.A.403 for correctly recording defects in the aircraft technical log and aircraft maintenance records. A review of the ‘Engineering Report’ emails for G-BYCP, over nine months of operation immediately preceding the accident ight, revealed a high number of defects that were not recorded in the aircraft technical log, and for which recti cation actions were not recorded in the aircraft’s technical records. It was clear that the operator was aware of the aircraft’s defect history and that it used the content of the ‘Engineering Report’ emails to coordinate defect recti cation during the scheduled Phase 1 maintenance inspection in June 2015. Where defects were recti ed in this manner, the recti cation interval was well outside MEL allowable time limits.
Note the use of words "reports.......circumvented.....requirments of Part M"
And "high number if defects......not recorded"
Bottom line is this was a poorly maintained old aircraft with a long history of defects operated by a company that thought it knew better than the regulations.....or that it could get away without compliance.....( which , but for this accident, or a whistle blower it would have done)
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This culture and ethic came right from the top of this company and those of us who knew it well are not surprised by what happened. The arrival of luxaviation hasnt changed a thing I n this culture where blind loyalty to the will of the boss is valued far higher than professional ability or Integrity
Last edited by flybycheese; 16th Oct 2016 at 11:34.
I was very disappointed to read in the report the way in which a system was employed which appears to have circumvented the normal system of crews always making an appropriate entry in the Tech Log.
In the 1980s I was MD of a similar operation to LEA, although somewhat smaller, and as I was also a licensed engineer I fully appreciated the operational problems that entries in the Tech Log produced. At no time would I have countenanced a system which 'by-passed' the regulatory use of the Tech Log. I found that some crews wrote up items in the Tech Log in such a vague form that it was difficult for engineering to easily isolate the problem so we introduced a system whereby crews were encouraged to drop by engineering at the end of their flying duty in such cases to discuss the problem with an engineer. This also had the benefit of crews getting to know the engineers and strengthening the understanding between them of operational matters. It's a pity that the internet age means that face to face conversations are no longer the norm.
In the 1980s I was MD of a similar operation to LEA, although somewhat smaller, and as I was also a licensed engineer I fully appreciated the operational problems that entries in the Tech Log produced. At no time would I have countenanced a system which 'by-passed' the regulatory use of the Tech Log. I found that some crews wrote up items in the Tech Log in such a vague form that it was difficult for engineering to easily isolate the problem so we introduced a system whereby crews were encouraged to drop by engineering at the end of their flying duty in such cases to discuss the problem with an engineer. This also had the benefit of crews getting to know the engineers and strengthening the understanding between them of operational matters. It's a pity that the internet age means that face to face conversations are no longer the norm.
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The CAA don't exactly come out of this smelling of roses.
What's the point of a CAA audit if it doesn't expose these grubby practises that can cause or contribute to such lethal consequences?
What's the point of a CAA audit if it doesn't expose these grubby practises that can cause or contribute to such lethal consequences?
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If Patrick Hansen CEO at luxaviation is to restore any confidence in his LEA ( as was ) brand then Id strongly suggest that:-
He grounds every single LEA aircraft until it has had independant engineering inspection and its maintenance records are checked and verified with any defects signed off.
The remaining Kingair is upgraded with terrain warning and at least CVR.
He immediately dispense with his entire flight operations management team at LEA
Anything less would be to disrespect the memories of our dead colleagues and show inadequate appreciation for the reputational damage to the brand which has come out of this report.
He grounds every single LEA aircraft until it has had independant engineering inspection and its maintenance records are checked and verified with any defects signed off.
The remaining Kingair is upgraded with terrain warning and at least CVR.
He immediately dispense with his entire flight operations management team at LEA
Anything less would be to disrespect the memories of our dead colleagues and show inadequate appreciation for the reputational damage to the brand which has come out of this report.
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Interesting the report never mentioned Rob's training was carried out all by one Training Captain- who also signed him off on final line check. Contributing factor maybe? Who knows. Interesting that the certain TC is DCP now. Thanks goodness there's a good strong CP to take the lead and repair this mess... oh wait.
Commercial pressures consistently forced on crew members with no support from Ops management in the slightest, all create holes in the Swiss cheese.
Disgraceful mismanagement and oversight by LEA. Remaining King Air should be fitted with all the bells and whistles now out of respect. But again, what respect do LEA show for their crews?!
Anyone remember National Airways?
Commercial pressures consistently forced on crew members with no support from Ops management in the slightest, all create holes in the Swiss cheese.
Disgraceful mismanagement and oversight by LEA. Remaining King Air should be fitted with all the bells and whistles now out of respect. But again, what respect do LEA show for their crews?!
Anyone remember National Airways?