Hawk XX204 Service Inquiry
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Hawk XX204 Service Inquiry
SI findings for Red Arrow accident - Practice Engine Flame-out on Take Off
https://assets.publishing.service.go...cted-Final.pdf
DV
https://assets.publishing.service.go...cted-Final.pdf
DV
Last edited by Distant Voice; 10th Oct 2019 at 12:58.
An interesting and sobering read.
Miraculous that he got out.
1.4.233. Within one second of the additional roll reversal the application of left aileron rapidly reduced from 7.4° to 1.2°, and the tailplane from -13.1° to 0.2°, indicating a control column movement close to the neutral position. In the Panel's opinion, the decision to actively push the control column towards neutral or release it, indicated that R3 was no longer attempting to pitch the aircraft up and recover the aircraft from its descending flightpath, and was probably reaching for the ejection handle'. This action occurred 0.85 sec before impact at a height of 62 ft
R3 ejected from the aircraft 0.52 sec before impact. The ejection was initiated at approximately 38 ft above ground level with 4.6° pitch nose up, 21° right AOB and at 148 kts; the aircraft was descending at 73 ft/sec. R3 perceived the situation dramatically switching from being 'okay' to not, with a realisation that the aircraft was going to hit the ground.
1.4.233. Within one second of the additional roll reversal the application of left aileron rapidly reduced from 7.4° to 1.2°, and the tailplane from -13.1° to 0.2°, indicating a control column movement close to the neutral position. In the Panel's opinion, the decision to actively push the control column towards neutral or release it, indicated that R3 was no longer attempting to pitch the aircraft up and recover the aircraft from its descending flightpath, and was probably reaching for the ejection handle'. This action occurred 0.85 sec before impact at a height of 62 ft
R3 ejected from the aircraft 0.52 sec before impact. The ejection was initiated at approximately 38 ft above ground level with 4.6° pitch nose up, 21° right AOB and at 148 kts; the aircraft was descending at 73 ft/sec. R3 perceived the situation dramatically switching from being 'okay' to not, with a realisation that the aircraft was going to hit the ground.
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What I do not understand is why R3 ever selected the flaps. If he meant to go round at 300 feet agl, he never needed to meet the “contract” requirement to select flaps down.
In deploying them, he washed all the speed margin he had. That left him at the bottom end of the recommended range of 170-150 Kts. That was made significant by the fact of his aircraft being so heavy.
A basic rule of glide approaches is to keep your speed up. What ever sort of landing you are destined for, you must harbour some energy with which to control the event. R3 seems, in effect if inadvertently, to have accepted the temptation to stretch his glide. Should he have trimmed nose down while he selected the flaps and did he forget ?
The SI sought to find human factors to explain his mistakes. They could still have wondered about the HF that is commonly called press-on-itis. If R3 felt he was rusty and had consciously set himself a difficult exercise, he really should have better prepared his escape plan – meaning he should have been ready to go around as soon as the exercise got difficult, rather than at the statutory 300 feet.
What the SI might have noticed is that, as he got to 300 feet, R3 had nearly met all the parameters of the “contract”, even as he lost control of his aircraft.
In deploying them, he washed all the speed margin he had. That left him at the bottom end of the recommended range of 170-150 Kts. That was made significant by the fact of his aircraft being so heavy.
A basic rule of glide approaches is to keep your speed up. What ever sort of landing you are destined for, you must harbour some energy with which to control the event. R3 seems, in effect if inadvertently, to have accepted the temptation to stretch his glide. Should he have trimmed nose down while he selected the flaps and did he forget ?
The SI sought to find human factors to explain his mistakes. They could still have wondered about the HF that is commonly called press-on-itis. If R3 felt he was rusty and had consciously set himself a difficult exercise, he really should have better prepared his escape plan – meaning he should have been ready to go around as soon as the exercise got difficult, rather than at the statutory 300 feet.
What the SI might have noticed is that, as he got to 300 feet, R3 had nearly met all the parameters of the “contract”, even as he lost control of his aircraft.
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rlsbutler,
He'd never have got around finals without them. As the report says.
That's why it's a range.
The report is clear, he was at the very bottom end of the energy state required to complete the manoeuvre.
It wasn't difficult. Report says so. And all service pilots are aware they can abandon approaches however dynamic in nature before the last contract/dh/stable gate/decision call.
He did indeed.
Please actually read the report before commenting incorrectly.
What I do not understand is why R3 ever selected the flaps. If he meant to go round at 300 feet agl, he never needed to meet the “contract” requirement to select flaps down.
In deploying them, he washed all the speed margin he had. That left him at the bottom end of the recommended range of 170-150 Kts. That was made significant by the fact of his aircraft being so heavy.
A basic rule of glide approaches is to keep your speed up. What ever sort of landing you are destined for, you must harbour some energy with which to control the event. R3 seems, in effect if inadvertently, to have accepted the temptation to stretch his glide. Should he have trimmed nose down while he selected the flaps and did he forget?
The SI sought to find human factors to explain his mistakes. They could still have wondered about the HF that is commonly called press-on-itis. If R3 felt he was rusty and had consciously set himself a difficult exercise, he really should have better prepared his escape plan – meaning he should have been ready to go around as soon as the exercise got difficult, rather than at the statutory 300 feet.
What the SI might have noticed is that, as he got to 300 feet, R3 had nearly met all the parameters of the “contract”, even as he lost control of his aircraft.
Please actually read the report before commenting incorrectly.
Last edited by T28B; 13th Oct 2019 at 17:51. Reason: Formatting add. Welcome
On the day of the accident, the first thing that struck me was:
Practise emergencies in the SIM, immediately afterwards practise an emergency in the real a/c early in the flight.
The use of emergency selections for gear / flap around the time of the ATC call ("distraction") might tend to confirm a capture of the wrong environment.
(Would those selections affect a go-around? eg Do those EMG selections now override normal selections?)
Clearly, there was overload and, as said above, an escape plan (simple gate?) would surely have helped.
lsh
Practise emergencies in the SIM, immediately afterwards practise an emergency in the real a/c early in the flight.
The use of emergency selections for gear / flap around the time of the ATC call ("distraction") might tend to confirm a capture of the wrong environment.
(Would those selections affect a go-around? eg Do those EMG selections now override normal selections?)
Clearly, there was overload and, as said above, an escape plan (simple gate?) would surely have helped.
lsh
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I have two questions relating to the death of Cpl Jonathan Bayliss.
Who authorised the carrying of passengers in the rear seat, when the command ejection system only operates from that position and is always selected OFF?
Who authorised the execution of 'live' emergency drills whilst carrying a passenger?
I my opinion, the risk associated with both conditions was not ALARP. Perhaps that will be brought out at the inquest when the ODH is called to give evidence iaw RA 1210.
DV
Who authorised the carrying of passengers in the rear seat, when the command ejection system only operates from that position and is always selected OFF?
Who authorised the execution of 'live' emergency drills whilst carrying a passenger?
I my opinion, the risk associated with both conditions was not ALARP. Perhaps that will be brought out at the inquest when the ODH is called to give evidence iaw RA 1210.
DV
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Cpl Bayliss was Supernumary Crew, not a passenger. Rules for passengers are different.
DV
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Timelord. I note that RA 2340 list the aircrew categories and states,
"Supernumerary Crew. A Supernumerary Crewmember is an individual, military or civilian, who is employed on an Air System and authorized to carry out a specific duty (that does not require an Aircrew qualification) while in flight or ground taxiing. This specific duty is to have an active role in achieving the purpose of the authorized flight and may involve the operation of Air System equipment/systems or authorized Equipment Not Basic to the Air System (ENBAS)2 under the supervision of the Air System’s Aircrew."
I am sure that the coroner will determine if Cpl Bayliss had undergone the necessary training for the authorized flight.
DV
"Supernumerary Crew. A Supernumerary Crewmember is an individual, military or civilian, who is employed on an Air System and authorized to carry out a specific duty (that does not require an Aircrew qualification) while in flight or ground taxiing. This specific duty is to have an active role in achieving the purpose of the authorized flight and may involve the operation of Air System equipment/systems or authorized Equipment Not Basic to the Air System (ENBAS)2 under the supervision of the Air System’s Aircrew."
I am sure that the coroner will determine if Cpl Bayliss had undergone the necessary training for the authorized flight.
DV
70deg AoB less than 600ft, through the centreline, 4000ft/min RoD, slow, throttle closed, Above Ave QFI. Must be our old friend Cognitive Impairment but not mentioned in nearly 150 pages.
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SI 1-4-84 to 1-4-119 discusses this in depth and makes recommendations.
DV
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On hearing of this accident my first questions were exactly as Distant Voice.
Why would such a risky drill be carried out whilst carrying someone who was without doubt a passenger (even though categorised as SC) on only their second flight in a Hawk, and why if that was to be the case was the PIC not flying from the rear seat, where command eject could be selected?
During my time as an engineer on Hawks at Chivenor this would never have been allowed. It would appear that the carrying of engineers on board should only be authorised on transit flights and not on any that impose additional risk to ground personnel who, not being pilots themselves, will have little or no situational awareness for which they are not trained. I get the strong feeling on reading the SI that the rules for the carrying of engineers on RAFAT have been allowed to erode to such an extent that they are almost considered to be aircrew -but of course they are not.
Why would such a risky drill be carried out whilst carrying someone who was without doubt a passenger (even though categorised as SC) on only their second flight in a Hawk, and why if that was to be the case was the PIC not flying from the rear seat, where command eject could be selected?
During my time as an engineer on Hawks at Chivenor this would never have been allowed. It would appear that the carrying of engineers on board should only be authorised on transit flights and not on any that impose additional risk to ground personnel who, not being pilots themselves, will have little or no situational awareness for which they are not trained. I get the strong feeling on reading the SI that the rules for the carrying of engineers on RAFAT have been allowed to erode to such an extent that they are almost considered to be aircrew -but of course they are not.
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A very long and detailed report, however, no mention that had the Hawk been retro fitted with an AoA system there would not need to be discussion about IAS, g, weight and configuration. Would be far safer and more relevant to the aircraft of today. I do accept that it would give the QFIs far less to talk about
I totally agree with the findings concerning the Command Eject system. Fundamentally flawed to cater for all different front/rear seat combinations. BAEs was naive to say the least and should have learnt from other 2 seat fast jets.
I find it very difficult to class the Circus crews as Supernumerary Crewmembers without caveat. There should be well defined regulations as to what is allowable with a Circus member in the rear seat. Supernumerary Crew was conceived to enable experienced aircrew fly in aircraft that they were not qualified on, not an easy way round the regulations for the Reds!!
There can be no doubt that Cpl Bayliss died needlessly. Yes, no matter how many hours you have, there is still something out there ready to bite. I do hope that Cognitive Impairment does not rear its head in the Inquest to follow!
I totally agree with the findings concerning the Command Eject system. Fundamentally flawed to cater for all different front/rear seat combinations. BAEs was naive to say the least and should have learnt from other 2 seat fast jets.
I find it very difficult to class the Circus crews as Supernumerary Crewmembers without caveat. There should be well defined regulations as to what is allowable with a Circus member in the rear seat. Supernumerary Crew was conceived to enable experienced aircrew fly in aircraft that they were not qualified on, not an easy way round the regulations for the Reds!!
There can be no doubt that Cpl Bayliss died needlessly. Yes, no matter how many hours you have, there is still something out there ready to bite. I do hope that Cognitive Impairment does not rear its head in the Inquest to follow!
I do agree though that an inexperienced pax should not be on board during turnbacks/efato etc.
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DV
You are quoting the current definition of Supernumerary Crew which was published on 30 Sept 19. But that was not the definition of Supernumerary crew on the day of the accident. I’m not sure whether it’s relevant to whatever point you are trying to make but I think it’s important to get your facts right.
You are quoting the current definition of Supernumerary Crew which was published on 30 Sept 19. But that was not the definition of Supernumerary crew on the day of the accident. I’m not sure whether it’s relevant to whatever point you are trying to make but I think it’s important to get your facts right.
Last edited by Homelover; 12th Oct 2019 at 07:44. Reason: Vocabulary
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Supernumerary Crew.(Prior to 30th Sept 19) Supernumerary crew are not classified as passengers. A supernumerary crewmember is an individual, military or civilian, who is temporarily attached to an air system crew for the purpose of carrying out a specific duty not involved with flying/operating the air system, as authorized by the appropriate Aviation Duty Holder or AM(MF).
DV
DV
Institutionalised Myopia
Thank you to all the Mr Hindsights who could have done better and can’t believe this happened; it did.
There’s an obsession with the outcome instead of dealing with the “Gorilla in the room”....Distraction and Tiredness (the word Fatigue is incorrectly used in the Report). These are the things we need to mitigate.
This is simply about Risk Management and Good Decision-Making; however, the system is, and never will be, perfect as long as we have humans involved in it.
A sad loss of life.
There’s an obsession with the outcome instead of dealing with the “Gorilla in the room”....Distraction and Tiredness (the word Fatigue is incorrectly used in the Report). These are the things we need to mitigate.
This is simply about Risk Management and Good Decision-Making; however, the system is, and never will be, perfect as long as we have humans involved in it.
A sad loss of life.