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ATSB Report Camden Duchess fatal accident

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Old 6th Sep 2004, 07:50
  #21 (permalink)  
 
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Icarus2001

And there you were thinking that the AIP contained rules!

You'd be amazed at how much of AIP is somebody's bright but legally invalid idea.

A direction in the AIP is binding if, and only to the extent that, it is the product of a valid exercise of a power to make the particular direction.

The problem is that you don't know which bits of AIP are valid and which bits are invalid. However, unless you are on notice that a particular bit of AIP is invalid, I suggest it is reasonable (and indeed prudent) for you to presume that all of AIP is valid.

You would have a defence of honest and reasonable mistake of fact if, for example, you did a right hand circuit at an aerodrome because ERSA said it was right hand circuits at that aerodrome, when in fact the 'requirement' in ERSA was someone's 'bright idea' instead of the result of a direction given by a delegate of CASA's power under reg 166.

Conversely, if someone is prosecuted for failing to comply with a 'direction' in AIP, it will be up to the prosecution to show that the 'direction' was a valid exercise of some power to make that particular direction. If, for example, you did a left hand circuit when ERSA said it was right hand circuits at a particular aerodrome, the prosecution would have to prove that a delegate of CASA's power under reg 166 had given a valid direction in relation to that aerodrome.



Reg 92 deals with aerodromes. It confers on CASA the power to issue directions relating to the safety of air navigation, in relation to an aerodrome. If CASA has given a direction under reg 92 to the effect set out in AIP 80.3, and if reg 92 is wide enough to support such a direction, and if that direction remains in force, a failure to comply with that direction would be an offence under reg 92(3).

If an operation is being conducted under the authority of an AOC and the company ops manual prohibits the activity mentioned in AIP 80.3, failure to comply with the ops manual would be a breach or reg 215(9).

That's a lot of "ifs".

Reg 166 deals with operations on and in the vicinity of aerodromes. It's very difficult to construe reg 166 as conferring power other than with respect to circuit directions.

Reg 249 covers pax-carrying emergency practice, and does not confer a direction-making power on CASA.

Beyond that, it's hard to identify the source of the power to give a direction in terms of AIP 80.3.

It seems that the ATSB has come to the view that AIP 80.3 is a 'bright idea' rather than a legally valid direction – a very, very untidy state of affairs. If it's only 'guidance', the AIP should say so in words of one syllable.
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Old 6th Sep 2004, 08:19
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It never fails to amaze how this little 'gem' from CAAP 5.23-1(0) Syllabus Of Training - Multi Engine Aircraft made it through:

Flight # F8 - Night Asymmetric Circuits

With a nice little pointer :" Note: The conditions of AIP OPS – 77 apply."

Still builds an expectency of legitimacy of the excercise.

I mean, why bother putting that in the CAAP???
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Old 6th Sep 2004, 09:28
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Hudson
If you feel so strongly about using the mixture as a good training policy then it might be safer to do this above circuit altitude where there is more time to recover from stuff-ups by either yourself or the hapless student.
once again you patronise me. Of course almost all of the simulated failures are done at a "safe" altitude. You need to read the requirements for the CIR Renewal test to see that two engine failures at 8000' does not meet the requirements!

I note that the topic has now changed to using the mixture control to simulate an engine failure. I am simply following the standard practise in regard to this. Ring any CASA field office on 131 757 and ask what technique the local FOIs use for simulating an engine failure. Moving the mixture control to ICO is almost universally used by ATOs for the pupose of simulating an engine failure.

You quote from selected sources. I can quote some selected sources back at you if you like? Aircraft manufacturers write many things to protect their legal position. For example does a new C172R really need 13 fuel drain points?

I have had a read through some of your posts in an attempt to understand your point of view. It seems you have plenty of heavy metal time, am I correct? Much of what we do in GA is scorned by the RPT end of town. For example we fly single engine aircraft at night on moonless nights over tiger country. This is fully endorsed by CASA but strangely most CASA FOIs refuse to fly at night in singles. I have friends in the airlines who consider anything below 5700 Kg an ultralight.

We also fly aircraft with unreliable 1950s technology fuel gauges, some that have fuel tanks that are impossible to dip because of their design. We manage this risk in various ways. Coming from your world of guaranteed performance and triple redundancy this would be frightening no doubt but until the regulator actually does something to enhance safety in this country like requiring reliable gauges and fuel flow computers in say, all twins, we live with it.

Most of the engine failures I give pilots are conducted above LSALT or MSA but "the system" requires engine failures lower down. For example inside the OM on an ILS. Do you consider a simulated engine failure at 800' on the ILS to be folly also?

Creampuff Thanks for your input. Clear as mud isn't it. I deal with CASA on an almost weekly basis where what they want me to do and what they can legally compel me to do are very different.

So if the industry does not know which AIP "rules" (guidance) are backed by an instrument or other legal "direction" should we just obey the AIP assuming we are then protected?

barleyhi Interestingly I heard an RFDS aircraft advise the tower that they were going to go assymetric the other evening, about half an hour after last light. I wonder what their Operations Manual says?
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Old 7th Sep 2004, 00:05
  #24 (permalink)  
 
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Icarus2001

You are 'protected' to the extent that it is reasonable for you to assume that the AIP is valid, and the 'protection' would be in the form of allowing you to set up a defence of honest and reasonable mistake of fact in the event that a provision of AIP with which you complied was found to be invalid.

In almost all circumstances it will be reasonable for you to assume AIP is valid, because you will not have any knowledge of or means to determine whether and if so which parts are not valid, and you will have specific obligations to comply with various parts of AIP and therefore no reasonable alternative but to comply. In rare cases there may be a patent error in AIP, or you may be on reasonable notice of an error in AIP, in which case it may not be reasonable for you to comply with the erroneous requirement.

AIP 80.3 raises some very tricky issues, because it seems (from the ATSB's statement) that we're not talking about a failure to comply with a valid direction, but a failure to comply with 'guidance'.

If AIP 80.3 is not the product of a valid exercise of a power to make a direction in those terms (to which conclusion the ATSB appears to have come), what effect does it have?

If you 'comply' with it, you're evidently not breaking any rules, because you'll simply be doing what you would be otherwise be entitled to do: doing circuits at night without practising engine emergencies. If you don't 'comply' with it, you're still not breaking any rules, because (we've assumed) it's not a valid direction.

However, AIP 80.3 may still be relevant in determining whether the duty of care which is undoubtedly owed by the participants in the activity to each other and to innocent third parties, has been breached. The fact that an activity is carried out in compliance with, or without breaching any, regulatory requirements, does not preclude a finding that the activity was nonetheless carried out negligently. Whatever other effects AIP 80.3 may have, it has the effect of putting people on reasonable notice that there are particular and special risks that arise in the specific activities to which it applies, and there are consequent effects upon what must reasonably be done by participants in those activities in order to discharge their duty of care. (A simple analogy would be driving at the speed limit on a road that had roadworks and warning signs about gravel and the consequent sliding risks. The fact that the road rules did not prohibit you from driving at that speed would be no answer to a claim in negligence against you when you slid on gravel into on coming traffic.)

There's no way I'd be doing anything contrary to AIP 80.3, unless I had confirmation, in writing from CASA, to the effect that it is merely 'guidance' rather than a direction, and even then, only in the context of a very clear understanding of the special risks and consequent steps I needed to take to ensure I discharged my duty of care to those put at risk by the activity.
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Old 7th Sep 2004, 04:17
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I think that simulated engine failures in situations described in the JWW accident report and NEJ accident report (Tamair Metro) should be authority enough to show that it is unsafe to perform that exercises at night below circuit height - especially in the case of a light training twin with marginal single engine climb performance.

In both of those accidents the aircraft had take-off power being delivered on one engine, this has the obvious effect of a large yaw force that requires a quick response to correct.

Of course, a simulated engine failure during, say, a turn from an outbound leg to an inbound leg on an NDB approach or at the outer marker of an ILS is completely different, due to the active engine only delivering approach power. The yaw force is much less and therefore there is a greater margin of safety (although the effects of an engine failure during this phase of flight can be insidious).

I would be interested to read the accident report regarding CTT, what factors were contributory.

For those interested, here is the link to the ATSB report of the NEJ accident: http://www.atsb.gov.au/aviation/pdf/vh-nej.pdf

Last edited by NAMPS; 7th Sep 2004 at 05:16.
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Old 7th Sep 2004, 07:43
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Creampuff,

Good posts ..... Thanks

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Old 7th Sep 2004, 14:39
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Creampuff, I suggest you talk to the ATSB. I talked to the person that wrote the report. He/she states that the bit about the AIP being only 'guidance' is NOT his / her opinion, it IS THE INTERPRETATION GIVEN BY CASA. I thought that when we got the CAAPs, all the advise was to be written there on coloured paper. White paper was to contain the law and nothing but the law. Perhaps the CASA legal eagles write the law so they know where the loopholes are that the rest of us is blissfully ignorant and just complies anyway.
I understand that the pre-flight safety briefing spelled out that NO simulated engine failures will be carried out below 500'. In that case the pilot flying should (MUST) have assumed it to be a REAL engine failure (bits of paper or not) AND FLOWN ACCORDING TO HIS PRE TAKE-OFF SAFETY BRIEF. If they had done a full stop landing, returned to the run-up bay, and done a FULL AND PROPER pre take -off brief, they might still be alive.
Shortcuts only shortcut your life.
IF there was a real engine failure at 12' and IF the pilots had operated the aircraft correctly, (the BE67 at Camden, only 2 up, not full tanks,) the aircraft HAS the performance to fly away. Have a look at the accelerate go distance, in those conditions, in the POH. NOTE: The accelerate go distance is based on 71 kts. I doubt they were as slow as that at 12', therefore the accelerate go distance is less.
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Old 7th Sep 2004, 20:57
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I'm not surprised ATSB checked with CASA.

That means that CASA takes the view that AIP 80.3 is not the subject of a legally valid direction.

The fact that it remains in the AIP in its misleading mandatory terms, or has not been made mandatory by a valid supporting direction with consistent complementary guidance material, is, I am afraid, typical of the two and half ringed political circus that passes as your aviation regulators.
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Old 8th Sep 2004, 12:22
  #29 (permalink)  
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I Fly. The fact that a safety brief was given which stated that no simulated engine failures would be given below 500 ft doesn't mean a thing. One would be very naive to then assume that a real engine failure has occurred if the instructor had pulled an engine below 500 ft - in this case just on lift-off. The PF would have seen the instructor pulling the engine (by whatever means) as there would be hands all over the mixture controls. Clearly in this case the instructor pressed his luck once too far as he had been known to get away with this sort of thing for ages -albeit with a couple of close shaves.

The assertion that a full stop landing followed by a run-up and nice little take off brief would have prevented the accident from happening is hopeful speculation and exceedingly unlikely given the most probable method of simulating the engine failure.

While the Duchess may have had the performance to climb away with the gear retracted and the prop feathered this does no take into account the rising terrain on the projected take off flight path from that runway at Camden.
 
Old 8th Sep 2004, 13:12
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And I seem to recall that a DH Dove crashed under similar circumstances, ie an engine pulled on t/o going up the hill at Camden in 1954.
Aircraft was a write off. DCA test officers on board as was another pilot, the name Dalton, comes to mind. Daylight hours.

Do we learn with age & experience ?
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Old 9th Sep 2004, 00:11
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Hudson the point I was trying to make. If they had done a 'proper safety brief'. With that aircraft, that load, those pilots, that airport, that time of day(night) - the go - no go discission would have been at least 85kts with gear in transit (if not a height as well). So IF a real engine failure had occurred BEFORE that point, both throttles would have been closed and landed straight ahead (possibly still on the runway, had they started the take-off roll from the beginning of the runway). NO SIMULATED ENGINE FAILURE SHOULD BE DONE BEFORE THAT POINT unless you are well within your accelerate stop distance available. Pub. 45 also states not to do engine failures 10 kts either side of Vmca. So it's simulated engine failures below 55 kts and still on the ground, or simulated engine failures AFTER the pilot said "we are in the go mode".
CurtissJenny I don't think we can compare this to the accident in 1954. Aircraft then had NO requirement for performing on one engine.
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Old 9th Sep 2004, 05:20
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Why use the throttle?? Its because the piston being a large hunk of alloy stays warm and the cylinder cools very quickly (just check CHT) and therefore the cylinder shrinks onto piston and simulated emergency now becomes the real thing .



I also cover the mixtures as in accordance with the ops manual and also Lycoming/Contonental have issued guidelines on the subject.

Engine failures below 300' if I really want to prove a point I will do so with throttle only but this is very rare. EFATO below 500' in daytime is dangerous enough people.

It was only recently practising Vmca at 3500' that a student said to me "I havent got any more rudder" and rolled full aileron and took the Baron after almost half a rotation and 1000' till I recovered (first 500' was just adrenalin) Multi training is dangerous enough without testing the limits of the flight envelope
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Old 9th Sep 2004, 08:55
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Cool

Ah, Creampuff,

I have missed your precise and well constructed passages....

I have always argued about the validity of AIP 80.3, simply because of its generality. As you have pointed out, it is indeed the product of someone's good idea on one hand and lack of regulatory knowledge on the other.

I believe that your approach (duty of care) is most appropriate, simply because it does not prohibit something that is capable of being risk-managed in certain aircraft types to a better risk profile than some other practices currently accepted. Practice failures in CAO 20.7.1B compliance-capable aircraft and many multi-engine helicopters spring immediately to mind.

The other problem for the regulator is finding an appropriate regulation under which to ban the practice, if that is what is required in the public interest. My quick scan of CAR(88) didn't pop up too many options that I thought appropriate - do you have any ideas about what piece of existing legislation might support a proper direction?

Stay Alive,
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Old 9th Sep 2004, 13:37
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Curtis Jenny. The Dove accident was fatal - I think one or two DCA Examiners of Airmen were killed. That was a practice engine failure at rotation and the prop was feathered I think. I never flew the Dove but like the Duchess I think it was quite flyable providing the gear was up and prop feathered. In the case of the Dove I believe the mixture is cut to ICO and then the prop feather button pushed. Same as DC3. But until that prop is feathered the aircraft is going nowhere fast.

Also on January 1st 1950 around midnight a Lockheed Hudson VH-SMK crashed at Camden under similar circumstances to the Duchess, except that it may have been a real engine failure but this was not proven. It cleared nearby trees but stalled flat into the rising ground a few hundred yards beyond the end and 100 yards to one side of the extended centre line of runway 06. It caught fire and both pilots were killed.

Again a similar fatal accident at Port Lincoln about 20 years ago in a Chieftain. The instructor was known to pull the mixture to simulate engine failure at night and in this case he failed to put the mixture back to rich an set the throttle for zero thrust. The aircraft impacted gently rising ground - no visible horizon - and both pilots were killed. Mixture cuts and cowboy instructors have been proved to be a sometimes fatal combination.
 
Old 9th Sep 2004, 20:43
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4dogs – you’re too kind.

If I wanted to be hairy-chested about it, I’d probably:

- give it a go under 92, and let someone have a go at challenging its validity;

- use 215(3) to direct all AOC holders to put a prohibition, to the effect set out in AIP 80.3, in all Ops Manuals;

- use 5.11 and 5.16 to impose conditions, to the effect set out in AIP 80.3, on all licences and ratings

All of these could build in exceptions for specifically qualified people in specified circumstances.

(There was a time when a range of posters on this forum would say - do as they do under the FARs.)
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Old 9th Sep 2004, 22:56
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I don't know any instructors who use anything but the mixture (or in some circumstances the fuel selector) to simulate an engine failure. This is a perfectly safe practice if it's done under suitable conditions (I use 300' min, day VMC only).

This is how it's done by testing officers in NZ also. Mixture controls are usually sheilded from view, mainly to stop the student using anything other than rudder pressure to identify the dead donky, but also to let the student know that it is a simulated engine failure and not the real thing (they are briefed as such).
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Old 10th Sep 2004, 01:18
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Ah - so they have cowboys in New Zealand as well as sheep.....
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Old 10th Sep 2004, 02:55
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No, I fail to see how simulating with the mixture is any different to the throttle. Speaking of cowboys, intentionally failing an engine on or just after rotation should (IMHO) not be done in ANY aircraft, that's what simulators are for. No there aren't any duchess sims, but as this type of aircraft (group C) is not required to be able to continue a takeoff after engine failure below 50 feet, there is no need to try.

It's quite simple: EF below blue line/with gear down/below 50 ft = rejected takeoff.
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Old 10th Sep 2004, 06:37
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So Centaurus & Hudson, using the mixture controls to simulate an engine failure makes one a cowboy? Then I must be one along with most CASA FOIs and all the ATO's that have done my renewals for the last 14 years!

I would really like to know how much light twin training time you guys have in the last ten years.
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Old 10th Sep 2004, 06:46
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Rudder - My Foot!

Naughty S:
It was only recently practising Vmca at 3500' that a student said to me "I havent got any more rudder" and rolled full aileron and took the Baron after almost half a rotation and 1000' till I recovered (first 500' was just adrenalin) Multi training is dangerous enough without testing the limits of the flight envelope
When demonstrating the effects of Vmca to a student, put your foot under the relevant rudder so that the student can see the aerodynamic effect of approaching Vmca but can't go below Vmca and put the aircraft into an uncontrollable stall. The pain in your foot will be significantly less than hitting the ground at Mach 1.0 in a nose down attitude.
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