ATSB Media Conference On Whyalla Airlines.
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ATSB Media Conference On Whyalla Airlines.
Thought this may be of interest to many PPRuNers? .......
(QUOTE)
MEDIA RELEASE
18 December 2001
Media Conference advice on the release of the Final Report on the Whyalla Airlines Piper Chieftain
ATTENTION
Editors/Chief of Staff
Aviation/transport writers
The Australian Transport Safety Bureau invites you to attend a MEDIA CONFERENCE hosted by the Executive Director, Kym Bills, to release the final report on the Whyalla Airlines Piper Chieftain accident on 31 May 2000 in which all eight occupants died.
WHEN : Wednesday 19 December 2001
TIME : 10.30 am. Please arrive at the foyer no later than 10.20 am as we need to escort you to our Fourth floor conference room
WHERE : The ATSB building at 15 Mort Street, Braddon, Canberra
A hard copy of the report will be available and some engine parts from the accident aircraft will be on display.
Media Contact: Peter Saint: Tel: (02) 6274 6590 Mobile: (0408) 497 016
(END QUOTE)
(QUOTE)
MEDIA RELEASE
18 December 2001
Media Conference advice on the release of the Final Report on the Whyalla Airlines Piper Chieftain
ATTENTION
Editors/Chief of Staff
Aviation/transport writers
The Australian Transport Safety Bureau invites you to attend a MEDIA CONFERENCE hosted by the Executive Director, Kym Bills, to release the final report on the Whyalla Airlines Piper Chieftain accident on 31 May 2000 in which all eight occupants died.
WHEN : Wednesday 19 December 2001
TIME : 10.30 am. Please arrive at the foyer no later than 10.20 am as we need to escort you to our Fourth floor conference room
WHERE : The ATSB building at 15 Mort Street, Braddon, Canberra
A hard copy of the report will be available and some engine parts from the accident aircraft will be on display.
Media Contact: Peter Saint: Tel: (02) 6274 6590 Mobile: (0408) 497 016
(END QUOTE)
Guest
Posts: n/a
This is the official media release, will post the actual report ASAP........
MEDIA RELEASE
19 December 2001
Release of the Whyalla Airlines Piper Chieftain, VH-MZK report
The final report on the Whyalla Airlines Piper Chieftain VH-MZK accident on 31 May 2000, in which all eight occupants died, was released today by the Australian Transport Safety Bureau.
ATSB Executive Director, Kym Bills, made the following statement: "The VH-MZK accident occurred after mechanical failures involving both engines forced the pilot to ditch the aircraft in Spencer Gulf, about 26km from Whyalla, on a dark, cloudy and moonless night.
Based on careful analysis of the engine failures and recorded radar and audio data, it is likely that the left engine failed first as a result of a fatigue crack in the crankshaft. This was initiated about 50 flights before the accident flight due to the breakdown of a connecting rod bearing insert. The combined effects of high combustion gas pressures developed as a result of deposit-induced pre-ignition, and lowered bearing insert retention forces due to an 'anti-galling' lubricating compound used during engine assembly by the manufacturer, led to this breakdown.
Lean fuel practices used by the operator increased the likelihood of lead oxybromide deposit-induced pre-ignition but were within the engine operating limits set by the aircraft manufacturer.
It is likely that because of the increased power demanded of the right engine after the left engine failed, abnormal combustion (detonation) occurred and rapidly raised the temperature of the pistons and cylinder heads. As a result, a hole melted in the number 6 piston causing loss of engine power and erratic engine operation. The subsequent ditching involved great pilot skill.
The ATSB examined components from a further ten similar engines that have failed since January 2000 (including two engines from another manufacturer) in order to better understand the failure mechanisms. Combustion chamber deposits that may create lead oxybromide deposit-induced pre-ignition were found in these engines. The Bureau concluded that engines that were operated at lean fuel-air mixtures during climb, and towards best economy mixtures during cruise flight, were more likely to show signs of such deposit-induced pre-ignition than those engines operated at full rich mixture during climb and at best power mixture during cruise.
On 30 October 2000 ATSB released recommendations about the risks of detonation and lean running and in relation to the desirability of life jackets and other life-saving equipment on smaller passenger aircraft flying over water. Today, we release further recommendations to:
the US FAA in relation to engine deposits that may cause pre-ignition;
the US FAA and the engine manufacturer on the use of anti-galling compounds between connecting rod bearing inserts and housings during engine assembly;
CASA in relation to high power piston engine reliability more generally; and
CASA in relation to providing guidance to pilots on ditching.
While there were deficiencies with the Whyalla Airlines safety culture and gaps with the extent of the regulator's surveillance of the operator, neither were significant accident factors.
No-one should be blamed for this accident, but if the lessons from it are learned, both in Australia and internationally, some good will have come from the tragic deaths of eight people."
MEDIA RELEASE
19 December 2001
Release of the Whyalla Airlines Piper Chieftain, VH-MZK report
The final report on the Whyalla Airlines Piper Chieftain VH-MZK accident on 31 May 2000, in which all eight occupants died, was released today by the Australian Transport Safety Bureau.
ATSB Executive Director, Kym Bills, made the following statement: "The VH-MZK accident occurred after mechanical failures involving both engines forced the pilot to ditch the aircraft in Spencer Gulf, about 26km from Whyalla, on a dark, cloudy and moonless night.
Based on careful analysis of the engine failures and recorded radar and audio data, it is likely that the left engine failed first as a result of a fatigue crack in the crankshaft. This was initiated about 50 flights before the accident flight due to the breakdown of a connecting rod bearing insert. The combined effects of high combustion gas pressures developed as a result of deposit-induced pre-ignition, and lowered bearing insert retention forces due to an 'anti-galling' lubricating compound used during engine assembly by the manufacturer, led to this breakdown.
Lean fuel practices used by the operator increased the likelihood of lead oxybromide deposit-induced pre-ignition but were within the engine operating limits set by the aircraft manufacturer.
It is likely that because of the increased power demanded of the right engine after the left engine failed, abnormal combustion (detonation) occurred and rapidly raised the temperature of the pistons and cylinder heads. As a result, a hole melted in the number 6 piston causing loss of engine power and erratic engine operation. The subsequent ditching involved great pilot skill.
The ATSB examined components from a further ten similar engines that have failed since January 2000 (including two engines from another manufacturer) in order to better understand the failure mechanisms. Combustion chamber deposits that may create lead oxybromide deposit-induced pre-ignition were found in these engines. The Bureau concluded that engines that were operated at lean fuel-air mixtures during climb, and towards best economy mixtures during cruise flight, were more likely to show signs of such deposit-induced pre-ignition than those engines operated at full rich mixture during climb and at best power mixture during cruise.
On 30 October 2000 ATSB released recommendations about the risks of detonation and lean running and in relation to the desirability of life jackets and other life-saving equipment on smaller passenger aircraft flying over water. Today, we release further recommendations to:
the US FAA in relation to engine deposits that may cause pre-ignition;
the US FAA and the engine manufacturer on the use of anti-galling compounds between connecting rod bearing inserts and housings during engine assembly;
CASA in relation to high power piston engine reliability more generally; and
CASA in relation to providing guidance to pilots on ditching.
While there were deficiencies with the Whyalla Airlines safety culture and gaps with the extent of the regulator's surveillance of the operator, neither were significant accident factors.
No-one should be blamed for this accident, but if the lessons from it are learned, both in Australia and internationally, some good will have come from the tragic deaths of eight people."
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This is the official ATSB Summary, I will see if I can also post the full report later.
(QUOTE)
MAJOR ACCIDENTS AND INVESTIGATIONS
31 May 2000
Whyalla Airlines Piper Chieftain VH-MZK accident on 31 May 2000
Summary
On the evening of 31 May 2000, Piper Chieftain, VH-MZK, was being operated by Whyalla Airlines as Flight WW904 on a regular public transport service from Adelaide to Whyalla, South Australia. One pilot and seven passengers were on board. The aircraft departed at 1823 central Standard Time (CST) and, after being radar vectored a short distance to the west of Adelaide for traffic separation purposes, the pilot was cleared to track direct to Whyalla at 6,000 ft. A significant proportion of the track from Adelaide to Whyalla passed over the waters of Gulf St Vincent and Spencer Gulf. The entire flight was conducted in darkness.
The aircraft reached 6,000 ft and proceeded apparently normally at that altitude on the direct track to Whyalla. At 1856 CST, the pilot reported to Adelaide Flight Information Service (FIS) that the aircraft was 35 NM south-south-east of Whyalla, commencing descent from 6,000 ft. Five minutes later the pilot transmitted a MAYDAY report to FIS. He indicated that both engines of the aircraft had failed, that there were eight persons on board and that he was going to have to ditch the aircraft, but was trying to reach Whyalla. He requested that assistance be arranged and that his company be advised of the situation. About three minutes later, the pilot reported his position as about 15 NM off the coast from Whyalla. FIS advised the pilot to communicate through another aircraft that was in the area if he lost contact with FIS. The pilot’s acknowledgment was the last transmission heard from the aircraft. A few minutes later, the crew of another aircraft heard an emergency locater transmitter (ELT) signal for 10–20 seconds.
Early the following morning, a search and rescue operation located two deceased persons and a small amount of wreckage in Spencer Gulf, near the last reported position of the aircraft. The aircraft, together with five deceased occupants, was located several days later on the sea–bed. One passenger remained missing.
On 9 June 2000, the wreckage of the aircraft was recovered for examination. Aside from the engines, no fault was found in the aircraft that might have contributed to the accident. Both engines had malfunctioned due to the failure of components of the engines.
The crankshaft of the left engine fractured at the Number 6 connecting rod journal. Fatigue cracking was initiated by the presence of a planar discontinuity in the journal surface. It was evident that the discontinuity had been caused by localised thermal expansion of the nitrided journal surface following contact with the edge of the Number 6 connecting rod big end bearing insert. The crankshaft failed approximately 50 flights after fatigue crack initiation.
The Number 6 bearing insert was damaged during engine operation through the combined effect of:
high bearing loads created by lead oxybromide deposit induced preignition, and
lowered bearing insert retention forces associated with the inclusion of an anti-galling compound between the bearing inserts and the housings.
Fatigue cracking in the Number 6 connecting rod big end housing had developed following the gradual destruction of the bearing insert. The left engine probably continued to operate for 8–10 minutes after the final fracture of the Number 6 connecting rod housing before the final disconnection of the Number 6 journal of the crankshaft. It is likely that the engine would have displayed signs of rough running and some power loss during this time. The final disconnection of the crankshaft resulted in a loss of drive to the magnetos, fuel pump, camshaft and, consequently, the sudden stoppage of the engine. The left propeller was in the feathered position when the aircraft struck the water, confirming that the engine was not operating at that time.
The physical damage sustained by the right engine was restricted to the localised melting of the Number 6 cylinder head and piston. The piston damage had allowed combustion gases to bypass the piston rings. The overheating of the right engine combustion chamber components was a result of changes in heat transfer to cylinder head and piston surfaces created by combustion end-gas detonation. The carbonaceous nature of the residual deposits on the piston crowns indicated that detonation had occurred under a rich fuel–air mixture setting. Rich mixture settings are used with high engine power settings.
The damaged piston would have caused a loss of engine oil and erratic engine operation, particularly at higher power settings. Engine lubrication was still effective at impact, indicating that oil loss was incomplete and that the piston holing occurred at a late stage of the flight.
Examination of the right propeller indicated that the blades were in a normal operating pitch range (i.e. not feathered) when the aircraft struck the water. It could not be confirmed that the right engine was operating when the aircraft struck the water, although it most probably was operating when radar contact was lost as the aircraft descended through 4,260 ft when 25.8 NM from Whyalla.
The aircraft was not fitted with a Flight Data Recorder (FDR) or a Cockpit Voice Recorder (CVR), nor was it required to be. Analysis of recorded radar data confirmed that the aircraft performed normally during the flight until the latter stages of the cruise segment when the speed gradually decreased. Speed variations, accompanied by track irregularities, then became more pronounced. Analysis of recorded voice transmissions revealed that propeller (and engine) RPM during the climb from Adelaide was 2,400. The RPM was 2,200 after the aircraft levelled at 6,000 ft. These were normal climb and cruise engine settings used by the company and the performance achieved by the aircraft during these segments was consistent with normal engine performance. Just prior to the commencement of descent, an RPM of 2,400 was identified. That was not a normal engine power setting for that stage of the flight.
The aircraft speed and propeller RPM information, coupled with the engine failure analysis, was consistent with the following likely sequence of events:
The power output from the left engine deteriorated during the first third of the cruise segment of the flight after the Number 6 connecting rod big end housing had fractured. The engine ceased operating completely 8–10 minutes later.
In response to the failure of the left engine, the pilot increased the power setting of the right engine.
Increased combustion chamber component temperatures via detonation within the right engine led to the Number 6 piston being holed. That resulted in the erratic operation of the right engine with reduced power and controllability and left the pilot with little alternative but to ditch the aircraft.
The double engine failure was a dependent failure.
Examination of eight failures of Textron Lycoming engines from a number of operators that had occurred over the period January 2000 to November 2001 revealed that deposits of lead oxybromide on combustion chamber surfaces were not restricted to the engines from MZK; seven other engines had such deposits. The inclusion of a copper–based anti-galling compound between the bearing insert and big end housing was noted in three of the engines examined. The quantity of anti-galling compound present varied between those engines.
Lead oxybromide deposits and anti-galling compounds act in different ways to weaken the defences for reliable engine operation. The relative contribution to engine failure of the factors cannot be predicted easily because of variations in the extent of each effect and the complexity inherent in engine assembly and operation. It is likely that the formation of lead oxybromides that cause deposit induced preignition is linked to the temperature of the fuel–air charge temperature in the combustion chamber just prior to the passing of the flame front. Leaning the mixture during climb, and using near ‘best economy’ cruise power settings appeared to favour the formation of lead oxybromide deposits that resulted in deposit induced preignition. Mixture settings of ‘full rich’ mixture during climb and ‘best power’ cruise settings appeared to favour reactions that resulted in less extensive and different deposits being formed. The Whyalla Airlines procedure was to lean the mixture during climb, and to use a cruise power setting close to ‘best economy’. Those procedures were in accordance with the US Federal Aviation Administration (FAA) approved Pilot’s Operating Handbook for the Piper Chieftain aircraft.
The combination of the use of leaded aviation gasoline, mixture leaning during climb, and leaning for best economy during cruise was not restricted to Lycoming engines. The ATSB also found evidence of high combustion loads and lead oxybromide deposits during the examination of components from two Teledyne Continental TIO-520 engines that were defective.
Anecdotal reports indicated that there were fewer engine problems (including component failures) in engines that were operated full rich during climb, and ‘best power’ during cruise, compared with those where the mixture was leaned during climb and ‘best economy’ cruise power was used. A comparison of the engine operating procedures of twelve other operators of Piper Chieftain aircraft revealed considerable disparity in procedures, particularly for climb and cruise. In fact, no two operators used the same procedure.
The incidence of lead oxybromide deposits in engines that had experienced defects, coupled with the range of fuel leaning techniques used, indicated a deficiency in the operation and maintenance of those engines, at least among some of the operators of high–powered piston engine aircraft in Australia.
On 30 October 2000, the ATSB issued a recommendation that the Civil Aviation Safety Authority alert operators regarding the risks of detonation, and encourage the adoption of conservative fuel leaning practices. This report includes further recommendations addressing the following:
the engine operating conditions under which combustion chamber deposits that may cause preignition are formed (addressed to the US Federal Aviation Administration);
the effect on engine reliability of the use of anti-galling compounds between connecting rod bearing inserts and housings (addressed to the US Federal Aviation Administration and the engine manufacturer); and
the reliability of high–powered aircraft piston engines operated in Australia (addressed to CASA).
This accident was the first recorded ditching involving a Piper Chieftain aircraft in Australia. Available records world–wide of previous Piper Chieftain engine failure/ditching events illustrate that, in most instances, successful night ditchings occurred in better visibility and weather conditions than those confronting the pilot of MZK. The relatively minor injuries suffered by the occupants of the aircraft indicated that the pilot demonstrated a high level of skill in ditching the aircraft. The report includes a recommendation to CASA regarding guidance material for pilots on ditching.
It is likely that the survival prospects of the occupants would have been enhanced had the passenger seats been fitted with upper body restraints, and life jackets or equivalent flotation devices had been available to the occupants. As a result of a separate investigation, the Bureau issued a recommendation concerning upper body restraints on 31 March 1999. On 30 October 2000, arising from the Whyalla investigation, the ATSB issued recommendations to the Civil Aviation Safety Authority concerning the provision of adequate emergency and life saving equipment for the protection of fare-paying passengers in smaller aircraft during over–water flights.
Full details of safety action including the CASA response to recommendations made on 31 March 1999 and 30 October 2000 are in Section 4 of this report.
The investigation included a detailed examination of the regulatory history of Whyalla Airlines from June 1997 to June 2000. In common with the published findings of other reports on CASA surveillance activities, there was a significant under-achievement of surveillance of the company against CASA’s planned levels during that period. However, there was insufficient information to conclude that the level of surveillance achieved was of significance with respect to the accident.
With regard to Whyalla Airlines itself, issues were identified in the company that had the potential to adversely influence safety. There was insufficient information to conclude that any of these issues were of significance with respect to the accident.
As a result of the accident and ATSB’s investigation, improved refuelling procedures were introduced nationally by the refuelling organisation to reduce the chance of error.
(QUOTE)
MAJOR ACCIDENTS AND INVESTIGATIONS
31 May 2000
Whyalla Airlines Piper Chieftain VH-MZK accident on 31 May 2000
Summary
On the evening of 31 May 2000, Piper Chieftain, VH-MZK, was being operated by Whyalla Airlines as Flight WW904 on a regular public transport service from Adelaide to Whyalla, South Australia. One pilot and seven passengers were on board. The aircraft departed at 1823 central Standard Time (CST) and, after being radar vectored a short distance to the west of Adelaide for traffic separation purposes, the pilot was cleared to track direct to Whyalla at 6,000 ft. A significant proportion of the track from Adelaide to Whyalla passed over the waters of Gulf St Vincent and Spencer Gulf. The entire flight was conducted in darkness.
The aircraft reached 6,000 ft and proceeded apparently normally at that altitude on the direct track to Whyalla. At 1856 CST, the pilot reported to Adelaide Flight Information Service (FIS) that the aircraft was 35 NM south-south-east of Whyalla, commencing descent from 6,000 ft. Five minutes later the pilot transmitted a MAYDAY report to FIS. He indicated that both engines of the aircraft had failed, that there were eight persons on board and that he was going to have to ditch the aircraft, but was trying to reach Whyalla. He requested that assistance be arranged and that his company be advised of the situation. About three minutes later, the pilot reported his position as about 15 NM off the coast from Whyalla. FIS advised the pilot to communicate through another aircraft that was in the area if he lost contact with FIS. The pilot’s acknowledgment was the last transmission heard from the aircraft. A few minutes later, the crew of another aircraft heard an emergency locater transmitter (ELT) signal for 10–20 seconds.
Early the following morning, a search and rescue operation located two deceased persons and a small amount of wreckage in Spencer Gulf, near the last reported position of the aircraft. The aircraft, together with five deceased occupants, was located several days later on the sea–bed. One passenger remained missing.
On 9 June 2000, the wreckage of the aircraft was recovered for examination. Aside from the engines, no fault was found in the aircraft that might have contributed to the accident. Both engines had malfunctioned due to the failure of components of the engines.
The crankshaft of the left engine fractured at the Number 6 connecting rod journal. Fatigue cracking was initiated by the presence of a planar discontinuity in the journal surface. It was evident that the discontinuity had been caused by localised thermal expansion of the nitrided journal surface following contact with the edge of the Number 6 connecting rod big end bearing insert. The crankshaft failed approximately 50 flights after fatigue crack initiation.
The Number 6 bearing insert was damaged during engine operation through the combined effect of:
high bearing loads created by lead oxybromide deposit induced preignition, and
lowered bearing insert retention forces associated with the inclusion of an anti-galling compound between the bearing inserts and the housings.
Fatigue cracking in the Number 6 connecting rod big end housing had developed following the gradual destruction of the bearing insert. The left engine probably continued to operate for 8–10 minutes after the final fracture of the Number 6 connecting rod housing before the final disconnection of the Number 6 journal of the crankshaft. It is likely that the engine would have displayed signs of rough running and some power loss during this time. The final disconnection of the crankshaft resulted in a loss of drive to the magnetos, fuel pump, camshaft and, consequently, the sudden stoppage of the engine. The left propeller was in the feathered position when the aircraft struck the water, confirming that the engine was not operating at that time.
The physical damage sustained by the right engine was restricted to the localised melting of the Number 6 cylinder head and piston. The piston damage had allowed combustion gases to bypass the piston rings. The overheating of the right engine combustion chamber components was a result of changes in heat transfer to cylinder head and piston surfaces created by combustion end-gas detonation. The carbonaceous nature of the residual deposits on the piston crowns indicated that detonation had occurred under a rich fuel–air mixture setting. Rich mixture settings are used with high engine power settings.
The damaged piston would have caused a loss of engine oil and erratic engine operation, particularly at higher power settings. Engine lubrication was still effective at impact, indicating that oil loss was incomplete and that the piston holing occurred at a late stage of the flight.
Examination of the right propeller indicated that the blades were in a normal operating pitch range (i.e. not feathered) when the aircraft struck the water. It could not be confirmed that the right engine was operating when the aircraft struck the water, although it most probably was operating when radar contact was lost as the aircraft descended through 4,260 ft when 25.8 NM from Whyalla.
The aircraft was not fitted with a Flight Data Recorder (FDR) or a Cockpit Voice Recorder (CVR), nor was it required to be. Analysis of recorded radar data confirmed that the aircraft performed normally during the flight until the latter stages of the cruise segment when the speed gradually decreased. Speed variations, accompanied by track irregularities, then became more pronounced. Analysis of recorded voice transmissions revealed that propeller (and engine) RPM during the climb from Adelaide was 2,400. The RPM was 2,200 after the aircraft levelled at 6,000 ft. These were normal climb and cruise engine settings used by the company and the performance achieved by the aircraft during these segments was consistent with normal engine performance. Just prior to the commencement of descent, an RPM of 2,400 was identified. That was not a normal engine power setting for that stage of the flight.
The aircraft speed and propeller RPM information, coupled with the engine failure analysis, was consistent with the following likely sequence of events:
The power output from the left engine deteriorated during the first third of the cruise segment of the flight after the Number 6 connecting rod big end housing had fractured. The engine ceased operating completely 8–10 minutes later.
In response to the failure of the left engine, the pilot increased the power setting of the right engine.
Increased combustion chamber component temperatures via detonation within the right engine led to the Number 6 piston being holed. That resulted in the erratic operation of the right engine with reduced power and controllability and left the pilot with little alternative but to ditch the aircraft.
The double engine failure was a dependent failure.
Examination of eight failures of Textron Lycoming engines from a number of operators that had occurred over the period January 2000 to November 2001 revealed that deposits of lead oxybromide on combustion chamber surfaces were not restricted to the engines from MZK; seven other engines had such deposits. The inclusion of a copper–based anti-galling compound between the bearing insert and big end housing was noted in three of the engines examined. The quantity of anti-galling compound present varied between those engines.
Lead oxybromide deposits and anti-galling compounds act in different ways to weaken the defences for reliable engine operation. The relative contribution to engine failure of the factors cannot be predicted easily because of variations in the extent of each effect and the complexity inherent in engine assembly and operation. It is likely that the formation of lead oxybromides that cause deposit induced preignition is linked to the temperature of the fuel–air charge temperature in the combustion chamber just prior to the passing of the flame front. Leaning the mixture during climb, and using near ‘best economy’ cruise power settings appeared to favour the formation of lead oxybromide deposits that resulted in deposit induced preignition. Mixture settings of ‘full rich’ mixture during climb and ‘best power’ cruise settings appeared to favour reactions that resulted in less extensive and different deposits being formed. The Whyalla Airlines procedure was to lean the mixture during climb, and to use a cruise power setting close to ‘best economy’. Those procedures were in accordance with the US Federal Aviation Administration (FAA) approved Pilot’s Operating Handbook for the Piper Chieftain aircraft.
The combination of the use of leaded aviation gasoline, mixture leaning during climb, and leaning for best economy during cruise was not restricted to Lycoming engines. The ATSB also found evidence of high combustion loads and lead oxybromide deposits during the examination of components from two Teledyne Continental TIO-520 engines that were defective.
Anecdotal reports indicated that there were fewer engine problems (including component failures) in engines that were operated full rich during climb, and ‘best power’ during cruise, compared with those where the mixture was leaned during climb and ‘best economy’ cruise power was used. A comparison of the engine operating procedures of twelve other operators of Piper Chieftain aircraft revealed considerable disparity in procedures, particularly for climb and cruise. In fact, no two operators used the same procedure.
The incidence of lead oxybromide deposits in engines that had experienced defects, coupled with the range of fuel leaning techniques used, indicated a deficiency in the operation and maintenance of those engines, at least among some of the operators of high–powered piston engine aircraft in Australia.
On 30 October 2000, the ATSB issued a recommendation that the Civil Aviation Safety Authority alert operators regarding the risks of detonation, and encourage the adoption of conservative fuel leaning practices. This report includes further recommendations addressing the following:
the engine operating conditions under which combustion chamber deposits that may cause preignition are formed (addressed to the US Federal Aviation Administration);
the effect on engine reliability of the use of anti-galling compounds between connecting rod bearing inserts and housings (addressed to the US Federal Aviation Administration and the engine manufacturer); and
the reliability of high–powered aircraft piston engines operated in Australia (addressed to CASA).
This accident was the first recorded ditching involving a Piper Chieftain aircraft in Australia. Available records world–wide of previous Piper Chieftain engine failure/ditching events illustrate that, in most instances, successful night ditchings occurred in better visibility and weather conditions than those confronting the pilot of MZK. The relatively minor injuries suffered by the occupants of the aircraft indicated that the pilot demonstrated a high level of skill in ditching the aircraft. The report includes a recommendation to CASA regarding guidance material for pilots on ditching.
It is likely that the survival prospects of the occupants would have been enhanced had the passenger seats been fitted with upper body restraints, and life jackets or equivalent flotation devices had been available to the occupants. As a result of a separate investigation, the Bureau issued a recommendation concerning upper body restraints on 31 March 1999. On 30 October 2000, arising from the Whyalla investigation, the ATSB issued recommendations to the Civil Aviation Safety Authority concerning the provision of adequate emergency and life saving equipment for the protection of fare-paying passengers in smaller aircraft during over–water flights.
Full details of safety action including the CASA response to recommendations made on 31 March 1999 and 30 October 2000 are in Section 4 of this report.
The investigation included a detailed examination of the regulatory history of Whyalla Airlines from June 1997 to June 2000. In common with the published findings of other reports on CASA surveillance activities, there was a significant under-achievement of surveillance of the company against CASA’s planned levels during that period. However, there was insufficient information to conclude that the level of surveillance achieved was of significance with respect to the accident.
With regard to Whyalla Airlines itself, issues were identified in the company that had the potential to adversely influence safety. There was insufficient information to conclude that any of these issues were of significance with respect to the accident.
As a result of the accident and ATSB’s investigation, improved refuelling procedures were introduced nationally by the refuelling organisation to reduce the chance of error.
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of particular importance, i believe:
and,
Was it just one of those crappy things that occasionally happen?
The relatively minor injuries suffered by the occupants of the aircraft indicated that the pilot demonstrated a high level of skill in ditching the aircraft. The report includes a recommendation to CASA regarding guidance material for pilots on ditching.
With regard to Whyalla Airlines itself, issues were identified in the company that had the potential to adversely influence safety. There was insufficient information to conclude that any of these issues were of significance with respect to the accident.
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Transferred from thread started by hunstman.Author Topic: Whyalla Airlines report due Wed 19/12
huntsman
Just another number
Member # 9779
posted 18 December 2001 21:24
--------------------------------------------------------------------------------
findings from the inquest due today
stay tuned
--------------------------------------------------------------------------------
From: NT, australia | Registered: Dec 1999 | IP: Logged
huntsman
Just another number
Member # 9779
posted 19 December 2001 00:00
--------------------------------------------------------------------------------
from the ABC website:
Mechanical failure blamed for Whyalla Airlines crash
An Australian Transport Safety Bureau (ATSB) report into last year's fatal Whyalla Airlines crash has found that mechanical failure caused the disaster.
The plane plunged into South Australia's Spencer Gulf in May last year, killing all eight people on board.
The ATSB report has ruled out pilot error, saying mechanical failures in both engines forced the pilot to ditch the aircraft into the sea.
The Civil Aviation Safety Authority says it is already acting on four safety recommendations contained within the report, with further details on regulation changes to be issued before the end of the year.
[ 19 December 2001: Message edited by: huntsman ]
--------------------------------------------------------------------------------
From: NT, australia | Registered: Dec 1999 | IP: Logged
huntsman
Just another number
Member # 9779
posted 18 December 2001 21:24
--------------------------------------------------------------------------------
findings from the inquest due today
stay tuned
--------------------------------------------------------------------------------
From: NT, australia | Registered: Dec 1999 | IP: Logged
huntsman
Just another number
Member # 9779
posted 19 December 2001 00:00
--------------------------------------------------------------------------------
from the ABC website:
Mechanical failure blamed for Whyalla Airlines crash
An Australian Transport Safety Bureau (ATSB) report into last year's fatal Whyalla Airlines crash has found that mechanical failure caused the disaster.
The plane plunged into South Australia's Spencer Gulf in May last year, killing all eight people on board.
The ATSB report has ruled out pilot error, saying mechanical failures in both engines forced the pilot to ditch the aircraft into the sea.
The Civil Aviation Safety Authority says it is already acting on four safety recommendations contained within the report, with further details on regulation changes to be issued before the end of the year.
[ 19 December 2001: Message edited by: huntsman ]
--------------------------------------------------------------------------------
From: NT, australia | Registered: Dec 1999 | IP: Logged
Guest
Posts: n/a
(QUOTE)
Wed, 19 Dec 2001 11:34 AEDT
CASA reiterates dangers addressed in Whyalla crash report
The Civil Aviation Safety Authority (CASA) says it has already warned operators of piston-engined aircraft of the potential dangers of running engines with an overly lean fuel mixture.
The recommendation is a key feature of the Transport Safety Bureau's main report into last year's fatal Whyalla Airlines crash in South Australia's Spencer Gulf.
The Australian Transport Safety Bureau today released its report into the crash, which killed eight people in May last year.
The report has ruled out pilot error, saying mechanical failures in both engines forced the pilot of the plane to ditch the aircraft.
The Civil Aviation Safety Authority says it is already acting on four safety improvement recommendations, with further regulation changes due before the end of the year.
The authority says it has also begun to encourage conservative fuel leaning.
Other recommendations relating to operating and maintenance procedures for high powered piston engines and procedures for ditching aircraft are still to be investigated by CASA, before a formal response is released.
(END QUOTE)
Also mentioned the Pilot by name, and about some of the families involved etc, I thought it better to leave that out?
[ 19 December 2001: Message edited by: lame ]
Wed, 19 Dec 2001 11:34 AEDT
CASA reiterates dangers addressed in Whyalla crash report
The Civil Aviation Safety Authority (CASA) says it has already warned operators of piston-engined aircraft of the potential dangers of running engines with an overly lean fuel mixture.
The recommendation is a key feature of the Transport Safety Bureau's main report into last year's fatal Whyalla Airlines crash in South Australia's Spencer Gulf.
The Australian Transport Safety Bureau today released its report into the crash, which killed eight people in May last year.
The report has ruled out pilot error, saying mechanical failures in both engines forced the pilot of the plane to ditch the aircraft.
The Civil Aviation Safety Authority says it is already acting on four safety improvement recommendations, with further regulation changes due before the end of the year.
The authority says it has also begun to encourage conservative fuel leaning.
Other recommendations relating to operating and maintenance procedures for high powered piston engines and procedures for ditching aircraft are still to be investigated by CASA, before a formal response is released.
(END QUOTE)
Also mentioned the Pilot by name, and about some of the families involved etc, I thought it better to leave that out?
[ 19 December 2001: Message edited by: lame ]
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Thank God, at last we have some closure on this tragedy. Yes DS, are you big enough to say sorry? Not only to the Lads family but also Chief Pilot, his family, and everyone else who you hurt.
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Wed, 19 Dec 2001 15:20 AEDT
CASA admits lax monitoring in lead-up to Whyalla crash
Australia's airline regulator, the Civil Aviation Safety Authority (CASA) has admitted it did not adequately monitor Whyalla Airlines in the lead-up to a fatal plane crash last year.
The final report into the accident, which killed all eight people on board, concludes lean fuel practices contributed to the plane's double engine failure.
But the Australian Transport Safety Bureau says the airline should not be blamed because this was a widespread practice at the time and it was in accordance with the aircraft manufacturer's guidelines.
The bureau also says there were major gaps in CASA's surveillance of the airline and CASA spokesman Peter Gibson has acknowledged that.
"It is true that the Civil Aviation Safety Authority up to a couple of years ago did have a poor record, in particular in meeting our surveillance targets," he said.
"The good news is since then, we have turned that right around.
"Now we are meeting about 100 per cent of our targets, that is for auditing and checking on airlines right around Australia."
CASA admits lax monitoring in lead-up to Whyalla crash
Australia's airline regulator, the Civil Aviation Safety Authority (CASA) has admitted it did not adequately monitor Whyalla Airlines in the lead-up to a fatal plane crash last year.
The final report into the accident, which killed all eight people on board, concludes lean fuel practices contributed to the plane's double engine failure.
But the Australian Transport Safety Bureau says the airline should not be blamed because this was a widespread practice at the time and it was in accordance with the aircraft manufacturer's guidelines.
The bureau also says there were major gaps in CASA's surveillance of the airline and CASA spokesman Peter Gibson has acknowledged that.
"It is true that the Civil Aviation Safety Authority up to a couple of years ago did have a poor record, in particular in meeting our surveillance targets," he said.
"The good news is since then, we have turned that right around.
"Now we are meeting about 100 per cent of our targets, that is for auditing and checking on airlines right around Australia."
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CASA Media Release - Wednesday, 19 December 2001
Whyalla accident report action
Australia's aviation safety standards are being raised following the tragic Whyalla Airlines accident in May 2000.
The Australian Transport Safety Bureau's report on the accident found the pilot of aircraft VH-MZK was forced to ditch into Spencer Gulf in South Australia after mechanical failures in both engines.
The ATSB says "no-one should be blamed for this accident", in which eight people died.
However, the report does contain recommendations in relation to passenger safety which are being addressed by CASA as a priority.
CASA is already acting on four safety improvement recommendations, with further details on changes to regulations to be issued before the end of this year.
Safety rules will be changed to require all aircraft carrying fare-paying passengers that take off or land over water to carry lifejackets or flotation devices.
Currently aircraft with nine seats or less are not required to carry lifejackets or flotation devices.
A separate recommendation relating to emergency equipment in aircraft flying over water will be addressed by issuing a discussion paper to gather the views of the aviation industry on the best ways to improve safety.
CASA is also proposing a requirement for shoulder harness seat belts to be fitted to all small passenger carrying aircraft, a move which will affect about 800 aircraft across Australia.
At present, shoulder harnesses are only required for the front seats of all small aircraft and for those aircraft built after 1986.
Action has been taken by CASA to alert the operators of piston engine aircraft to the potential risks of running engines lean and to encourage conservative fuel leaning.
Two further recommendations, relating to operating and maintenance procedures for high powered piston engines and procedures for ditching aircraft, are to be investigated by CASA before making a formal response.
CASA's Director of Aviation Safety, Mick Toller, says the report of the investigation of the Whyalla accident is constructive and will help to improve safety.
"The whole of the aviation industry can take important lessons from this tragedy and CASA is committed to achieving lasting safety improvements," Mr Toller says.
Whyalla accident report action
Australia's aviation safety standards are being raised following the tragic Whyalla Airlines accident in May 2000.
The Australian Transport Safety Bureau's report on the accident found the pilot of aircraft VH-MZK was forced to ditch into Spencer Gulf in South Australia after mechanical failures in both engines.
The ATSB says "no-one should be blamed for this accident", in which eight people died.
However, the report does contain recommendations in relation to passenger safety which are being addressed by CASA as a priority.
CASA is already acting on four safety improvement recommendations, with further details on changes to regulations to be issued before the end of this year.
Safety rules will be changed to require all aircraft carrying fare-paying passengers that take off or land over water to carry lifejackets or flotation devices.
Currently aircraft with nine seats or less are not required to carry lifejackets or flotation devices.
A separate recommendation relating to emergency equipment in aircraft flying over water will be addressed by issuing a discussion paper to gather the views of the aviation industry on the best ways to improve safety.
CASA is also proposing a requirement for shoulder harness seat belts to be fitted to all small passenger carrying aircraft, a move which will affect about 800 aircraft across Australia.
At present, shoulder harnesses are only required for the front seats of all small aircraft and for those aircraft built after 1986.
Action has been taken by CASA to alert the operators of piston engine aircraft to the potential risks of running engines lean and to encourage conservative fuel leaning.
Two further recommendations, relating to operating and maintenance procedures for high powered piston engines and procedures for ditching aircraft, are to be investigated by CASA before making a formal response.
CASA's Director of Aviation Safety, Mick Toller, says the report of the investigation of the Whyalla accident is constructive and will help to improve safety.
"The whole of the aviation industry can take important lessons from this tragedy and CASA is committed to achieving lasting safety improvements," Mr Toller says.
I flew MZK on many occasions when it (and I) was with Hazeltons.
Max had a very conservative leaning and cool-down policy.
From memory, full rich climb, back to a set (I think it was 1400deg) EGT for cruise, gradually enrich on descent and them cool down till EGTs were off the clocks before shutdown.
As a result, Hazos actually had an extended TBO on these notoriously finicky engines.
I'm not saying anything against Whyalla, sounds like they operated within manufacturers limits. But it highlights one of the great aviation truisms: -
THE CHEAPEST THING YOU WILL EVER PUT IN AN ENGINE IS FUEL AND OIL!!
I hope we can all learn something from tragedies such as this.
Max had a very conservative leaning and cool-down policy.
From memory, full rich climb, back to a set (I think it was 1400deg) EGT for cruise, gradually enrich on descent and them cool down till EGTs were off the clocks before shutdown.
As a result, Hazos actually had an extended TBO on these notoriously finicky engines.
I'm not saying anything against Whyalla, sounds like they operated within manufacturers limits. But it highlights one of the great aviation truisms: -
THE CHEAPEST THING YOU WILL EVER PUT IN AN ENGINE IS FUEL AND OIL!!
I hope we can all learn something from tragedies such as this.
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What were Dick's alleged disgraceful comments post accident surrounding the PIC? With libel and accuracy issues about it may be wise to quote only those references and links already in the public domain.
Thanks, I'd be interested to know.
Thanks, I'd be interested to know.
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Thanks Rainbow, fair call. Unfortunately post the Sept 14 AN debacle I have moved interstate and all the clippings/news tapes are in storage. Rest assured that if you want them, I can supply most, yet the post takes time!
Yes I most likely could be called biased. I Know the CP and knew the PIC and other people on the Aircraft. This fact obvoiusly caused me to take a more particular note of post accident comments than the casual aviation observor.
The sad fact is that we are all to willing to hang people prior to the trial. Comments before the bodies are found about the airline, the CP and the PIC's amount of experiance being a possible factor is not on!!
I don't know, there are a lot of things I want to say, problem is I think they may get me into trouble! There are the lucky one's and the unluckey one's. I honestly believe the short straw was drawn that night.
Imagine yourself, one just failed, yep compensated for that. Shortly after, the other starts to produce either low power or run down. Not good. OK auto-pilot on. Try to get first started while trying to restore/get fully started the other. S$$$ brief the pax, emerg ditch etc etc. Heck is the auto-pilot flying OK? I mean is there suction enough for the AH or do I have to hand fly manual on Turn and Slip. Getting busy now, people upset, through lower layer of cloud, no moon, cant see water. Still trying to start. Look down again, are we upright?
It's normally easy to say 'I could've done better.' Not for me this time.
No matter what the result, no matter what the cause. Some people should refrain from commenting, otherwise they may catch a severe dose of foot in mouth disease.
The general public does not remember or understand....But I do
Yes I most likely could be called biased. I Know the CP and knew the PIC and other people on the Aircraft. This fact obvoiusly caused me to take a more particular note of post accident comments than the casual aviation observor.
The sad fact is that we are all to willing to hang people prior to the trial. Comments before the bodies are found about the airline, the CP and the PIC's amount of experiance being a possible factor is not on!!
I don't know, there are a lot of things I want to say, problem is I think they may get me into trouble! There are the lucky one's and the unluckey one's. I honestly believe the short straw was drawn that night.
Imagine yourself, one just failed, yep compensated for that. Shortly after, the other starts to produce either low power or run down. Not good. OK auto-pilot on. Try to get first started while trying to restore/get fully started the other. S$$$ brief the pax, emerg ditch etc etc. Heck is the auto-pilot flying OK? I mean is there suction enough for the AH or do I have to hand fly manual on Turn and Slip. Getting busy now, people upset, through lower layer of cloud, no moon, cant see water. Still trying to start. Look down again, are we upright?
It's normally easy to say 'I could've done better.' Not for me this time.
No matter what the result, no matter what the cause. Some people should refrain from commenting, otherwise they may catch a severe dose of foot in mouth disease.
The general public does not remember or understand....But I do