Military cargo aircraft crash - Savannah, Georgia
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FE calls "power set" when it clearly wasn't before Vr. If he'd called "No 1 engine not responding" (or whatever) then they could have safely abandoned the take-off. Having got airborne the aircraft banks right to keep flying straight ahead, but left rudder is subsequently applied! This leads directly to the aircraft crashing (the left wing stalls in the sideslip). The very first thing you learn in asymmetric training is "Dead foot, dead engine". That simple slogan could have saved their lives. It had clearly been forgotten (for surely it was taught?). The after take off checks were not completed resulting in TO flaps remaining set.
As mentioned in the Accident Report, the first flight of the day was usually preceded by a standing start take off to ensure all engine parameters were normal. On RAF C-130Ks, this allowed setting the throttle lever gubbings to ensure max torque was not exceeded (though subsequent TOs from a different a/f would need it readjusting).
As mentioned in the Accident Report, the first flight of the day was usually preceded by a standing start take off to ensure all engine parameters were normal. On RAF C-130Ks, this allowed setting the throttle lever gubbings to ensure max torque was not exceeded (though subsequent TOs from a different a/f would need it readjusting).
Last edited by Chugalug2; 11th Nov 2018 at 16:25.
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It's quite possible that the engineer was focusing on TIT to the exclusion of everything else. I've seen this same thing where the FE is so focused on the power setting parameter, that he fails to monitor the other parameters. FWIW, the FE was fairly inexperienced. A little over a year as an FE, and less than 200 hours flight experience.
Indeed, A Squared. You have here the classic case of an experienced aircraft captain and a new/inexperienced co-pilot and FE. After the Staines Trident and the Kegworth 737, we still have crews not challenging the captain/flight deck when they clearly know that a situation is being mismanaged. Whatever happened to CRM?
The very first thing you learn in asymmetric training is "Dead foot, dead engine".
That said, this accident was the result of some inept aircraft handling combined with equally poor CRM.
HP:-
Agreed, and they had already identified the failed engine (#1) but an incorrect left rudder input was subsequently applied. The Report considers that P1 was suffering a sensory overload. If he had simply remembered that simple mantra he would have realised that his left foot should have been the 'dead' one, ie applying no rudder, and fed in right rudder instead. The sideslip that killed them could then have been avoided. Given how much else was going wrong it is by no means certain it would have saved them but it would have been a start, at least...
I'm not so sure that saying is used to help you decide which boot to move, rather than help you diagnose which engine has failed from the resultant rudder deflection!
Agreed, and they had already identified the failed engine (#1) but an incorrect left rudder input was subsequently applied. The Report considers that P1 was suffering a sensory overload. If he had simply remembered that simple mantra he would have realised that his left foot should have been the 'dead' one, ie applying no rudder, and fed in right rudder instead. The sideslip that killed them could then have been avoided. Given how much else was going wrong it is by no means certain it would have saved them but it would have been a start, at least...
Qualified 2004......made a captain in 2016.....and an instructor later in the year; that's a bit odd. Very few hours in recent months too. With a very inexperienced group around him in the front 3 seats, the captain's mishandling was unlikely to be picked up. I wonder who authorised the flight........in my day, I would have thought very carefully before doing so.....
The supervisory chain needs to conduct a fair amount of corporate investigation in my opinion.
A very sad end.
The supervisory chain needs to conduct a fair amount of corporate investigation in my opinion.
A very sad end.
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Well, I'm not sure what an "ex-albert driver" is, but if we assume that you at one time flew a c-130, we have to also assume that it was a while ago, because your systems knowledge is pretty lacking. Spouting the numerical specs for the prop is not the same as understanding how it works First the prop does not have "stop pins", I don't know where you got that but there's nothing in there that could be remotely described as a "pin". Regardless, the props go into reverse at high airspeeds on almost every flight. That's what you do on landing. It doesn't activate the NTS and it doesn't decouple the prop Besides, even if it *did* decouple, that doesn't prevent the prop from going into reverse. The safety coupling has nothing to do with prop function or control, All the safety coupling does is disconnect the reduction gearbox from the turbine, the prop is still out there in reverse. You may (or may not) recall that there is nothing to prevent you from moving the throttle into the beta range in flight. All you have to do is pick the throttle up over the flight idle gate and move it back into the ground range, and the prop will got to flat pitch, then reverse. It won't NTS because the NTS linkage is cammed out of engagement when you move the throttle into the ground range. Obviously that's a really bad thing to do in flight, so you don't do that. But, here's the thing; if you have a throttle cable break, the effect on the throttle coordinator out on the engine can be essentially the same, the throttle coordinator doesn't 'know" whether the cable broke or the throttle was moved into the ground range, all it knows is something just rotated it into the reverse range, and it does what it does in the reverse range ..whcih is this: it moves linkage to the valve housing whcih causes a prop pitch change into the reverse range and it cams the NTS linkage out of engagement. There you go: One single point of failure, and you have a prop reversing in flight. This isn't just speculation or theorizing this is the actual, real, cause of actual, real inflight prop reverse incidents. It seems odd that you claim to be a C-130 pilot and don't know about this. I thought that was one of those things that all Herc crews knew about. That's why you have a special Engine Shutdown Procedure which is different than a standard ESP when there's a known or suspected throttle or condition lever cable failure. You do remember that from your "albert" days, right? That a throttle cable failure had a special procedure? It's in all the Lockheed manuals, I don't know how you could have missed it. That's the reason, because it can cause the prop to reverse in flight.
Hope this clarified.
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A quick note about NTS. I'm not a C-130 driver, but was a P-3 driver which shares a lot of the propulsion systems with the C-130. NTS will NOT be engaged due to the props going into reverse whether in flight or on the ground. NTS is designed to decouple the prop from the engine when the prop drives the engine.
Anyway, all this is beside the point. It is pretty clear from the AIB report that this was not a case of in-flight prop reversal as we earlier speculated. It was simply a mishandling of an engine failure.
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Apparently the P-3 uses the same term with a different meaning. Perhaps because P-3s routinely loitered engines (in flight shut down with the intent to restart inflight later) to increase on-station loiter time.
Agreed. So sad that a crew was lost for what should have been a relatively simple and usually benign emergency.
Anyway, all this is beside the point. It is pretty clear from the AIB report that this was not a case of in-flight prop reversal as we earlier speculated. It was simply a mishandling of an engine failure.
One minor point that has been overlooked is the aircraft behaviour at rotate as it almost departed the runway. Normally the pilot will remove his hand from the nosewheel steering at around 60 kits. In this instance it was immediately before rotate at around 95kts, whereupon the aircraft began to veer to the left.
This sounds similar to the RAF incident during a practise windmill start where the pilot subconsciously/inadvertently was using nosewheel steering against the swing of the inoperative engine. At 60kts when he removed his hand to take the control column, the aircraft veered off the runway.
Incidentally, as I recall, normal practise was not to do a standing start to adjust ‘throttle gubbins’ as stated earlier - there was nothing to adjust. Not was it routine on the first flight of the day in the RAF. The only time I recall it being mandated other than for performance was when we had bleed air issues. However, I think most people would have carried out a standing start on an aircraft that had RPM problems on its last flight and had had work carried out to rectify the issue.
Inevitably a ‘chain’ of errors leading to a tragic loss of life. Very sad.
This sounds similar to the RAF incident during a practise windmill start where the pilot subconsciously/inadvertently was using nosewheel steering against the swing of the inoperative engine. At 60kts when he removed his hand to take the control column, the aircraft veered off the runway.
Incidentally, as I recall, normal practise was not to do a standing start to adjust ‘throttle gubbins’ as stated earlier - there was nothing to adjust. Not was it routine on the first flight of the day in the RAF. The only time I recall it being mandated other than for performance was when we had bleed air issues. However, I think most people would have carried out a standing start on an aircraft that had RPM problems on its last flight and had had work carried out to rectify the issue.
Inevitably a ‘chain’ of errors leading to a tragic loss of life. Very sad.
DCT:-
I think we might be both right (It was I that mentioned the 'gubbings'). My recollection is that the device was set for local flying prior to the first flight of that day. Obviously with different altitudes and OAT at other destinations a different torque output would result when the throttles were advanced to its stops, rendering it useless. Whether we then did a standing start first flight anyway to ensure all parameters normal I do not remember from that long ago (it was the early 70's for me). Perhaps others do? Was the gubbings dispensed with anyway?
I agree though that with previous engine performance issues a standing start was called for in this case.
Incidentally, as I recall, normal practise was not to do a standing start to adjust ‘throttle gubbins’ as stated earlier - there was nothing to adjust.
I agree though that with previous engine performance issues a standing start was called for in this case.
Very sad state of affairs all round, if the report is as accurate as it appears to be. The report makes some observations that I presume are more formally addressed in a classified version, can anyone say? I note that the documentation of aircrew records is incomplete. Also, the pathology reports are not supported by statistics and the alcohol measurement is not given. The actions of the maintenance crew appear to have been inept. The flightdeck crew seem to have been incapable of operating the aircraft. I would suggest that the report describes the performance you might expect of an untrained and unqualified crew. Bad
OAP
OAP
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The report makes some observations that I presume are more formally addressed in a classified version, can anyone say? I note that the documentation of aircrew records is incomplete. Also, the pathology reports are not supported by statistics and the alcohol measurement is not given.
OAP
Not being a pilot nor a Hercules engineer, air or ground, I have hesitated before raising my head above the parapet. However I did have a foot in two camps. I worked on the Javelin, Hunter and Lightning and flew for almost 30 years on the RAF C130K as a loadmaster . With my tech background I took an interest in the workings of the aeroplane. so I can follow well enough the technical discussion in the report.
That the maintenance team did not carry out the task in the prescribed manner is beyond doubt. But there is probably not a tradesman in any force in the world who has not had to 'work around' due to pressure to get the a/c back on line. The report highlighted the usual culprits of lack of tradesmen, spares (robbing is a wasteful and morale sapping necessity in most forces) and confusion about the paperwork qualifications. Often also the manuals do not reflect the actuality on the a/c. It also flagged up the disassociation some feel when the a/c do not 'belong' to them.
To my mind it was an implied criticism of the 'system' something I have never encountered in my experience of inquiries in the RAF. This of course in no way exonerates the tradesmen, it is just an attempt to understand from one who has been in analogous situations. Can we say that this situation is absent from the RAF today ? Are there any lessons to be learnt ?
As for the pilots and air engineer, I have struggled to understand the mindset. An Hercules crew knows that the propeller is a fickle friend who needs constant attention. They knew it had a valve housing change and the minimum of common sense would have required a very attentive run up as described by 'chugalug' and others. Then to get airborne with the a/c in the state it was in beggars belief. What was the engineer looking at ?
I have been in the a/c when we have taken it over after prop work. A fuselage rattling, tailplane shuddering run up was always the outcome to ensure that all was well..And a very careful monitor by the engineer as we rolled for T/O.
Time to duck before the sniping starts.
That the maintenance team did not carry out the task in the prescribed manner is beyond doubt. But there is probably not a tradesman in any force in the world who has not had to 'work around' due to pressure to get the a/c back on line. The report highlighted the usual culprits of lack of tradesmen, spares (robbing is a wasteful and morale sapping necessity in most forces) and confusion about the paperwork qualifications. Often also the manuals do not reflect the actuality on the a/c. It also flagged up the disassociation some feel when the a/c do not 'belong' to them.
To my mind it was an implied criticism of the 'system' something I have never encountered in my experience of inquiries in the RAF. This of course in no way exonerates the tradesmen, it is just an attempt to understand from one who has been in analogous situations. Can we say that this situation is absent from the RAF today ? Are there any lessons to be learnt ?
As for the pilots and air engineer, I have struggled to understand the mindset. An Hercules crew knows that the propeller is a fickle friend who needs constant attention. They knew it had a valve housing change and the minimum of common sense would have required a very attentive run up as described by 'chugalug' and others. Then to get airborne with the a/c in the state it was in beggars belief. What was the engineer looking at ?
I have been in the a/c when we have taken it over after prop work. A fuselage rattling, tailplane shuddering run up was always the outcome to ensure that all was well..And a very careful monitor by the engineer as we rolled for T/O.
Time to duck before the sniping starts.
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I don't think that applies in this case. The Aircraft was in Savannah for some fuel cell repair at that facility, but unless I badly misunderstand the the report, the maintainers who did the engine maintenance were from the Air National Guard Wing in Puerto Rico, so it would have been "their" aircraft.
AA62:-
Given that Sean Cunningham was killed by an inadvertent ejection from an unairworthy aircraft in a seat that had no Safety Case, the only lesson that comes to mind concerns Glasshouses and Stones. That MB should be fined for a death caused by a dysfunctional UK Military Air Safety System is a measure of how low we have sunk. As Aviation Professionals we should all feel shamed and dishonoured.
Can we say that this situation is absent from the RAF today ? Are there any lessons to be learnt ?
One thing that the investigators of this unfortunate accident had was recorders ! Those investigating the RAF C130K crashes were severely hampered by this vital lack of evidence as our a/c were never fitted with them.