ATSB Report Camden Duchess fatal accident
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ATSB Report Camden Duchess fatal accident
The report is on the ATSB website. Much could have been learned from this accident, but the report seemed more concerned with regulatory side issues and detailed discussion of previous accidents rather than the nitty gritty of who pulled what on whom.
The instructor was a well known highly experienced ATO who had conducted many instrument rating tests involving simulated engine failures at take off.
Yet the ATSB report said nothing about his usual method of simulating an engine failure on multi-engine aircraft during lift off or shortly afterwards. There must have been many pilots who had personally experienced his method of engine failure simulation. That being so, then why was this not brought out in the report? Fears of litigation maybe?
In essence, all we know from the ATSB report was that something happened at lift off to cause the aircraft to fly back into the ground on a night take off. And also that other aircraft have crashed under similar circumstances. So what's new?
The instructor's method of engine failure simulation may well have been the real answer to why the aircraft crashed. Anecdotal evidence existed that before simulating an engine failure at take off, this particular instructor would often place a map between the throttles and the mixture controls before cutting an engine. One wonders his motive for this?
Often there is no firm evidence of what specific actions took place in the cockpit immediately before a crash. This should not prevent the ATSB from at least discussing the most plausible explanations that may have precipitated the final outcome.
Instead ATSB spend nearly two years carefully drafting a report which tells the industry nothing that was not known before, but does say that it is not a good thing to pull an engine on take off in a multi-engine aeroplane unless you have first checked all clear left - ahead - and right for a safe area to crash if there is a stuff up. An interesting discussion point on its own? How?
The instructor was a well known highly experienced ATO who had conducted many instrument rating tests involving simulated engine failures at take off.
Yet the ATSB report said nothing about his usual method of simulating an engine failure on multi-engine aircraft during lift off or shortly afterwards. There must have been many pilots who had personally experienced his method of engine failure simulation. That being so, then why was this not brought out in the report? Fears of litigation maybe?
In essence, all we know from the ATSB report was that something happened at lift off to cause the aircraft to fly back into the ground on a night take off. And also that other aircraft have crashed under similar circumstances. So what's new?
The instructor's method of engine failure simulation may well have been the real answer to why the aircraft crashed. Anecdotal evidence existed that before simulating an engine failure at take off, this particular instructor would often place a map between the throttles and the mixture controls before cutting an engine. One wonders his motive for this?
Often there is no firm evidence of what specific actions took place in the cockpit immediately before a crash. This should not prevent the ATSB from at least discussing the most plausible explanations that may have precipitated the final outcome.
Instead ATSB spend nearly two years carefully drafting a report which tells the industry nothing that was not known before, but does say that it is not a good thing to pull an engine on take off in a multi-engine aeroplane unless you have first checked all clear left - ahead - and right for a safe area to crash if there is a stuff up. An interesting discussion point on its own? How?
Mixture with engine failure just airborne.... right. It should be an interesting read. Maybe it would be pure speculation to say he did do that during that flight..
saying that, the other "student" pilot (not so student) would have something to say aswell but its not uncommon in situations like these to not remember what happened... especially when you wouldn't want to.
ooohhh well.... let us all learn, let us learn
saying that, the other "student" pilot (not so student) would have something to say aswell but its not uncommon in situations like these to not remember what happened... especially when you wouldn't want to.
ooohhh well.... let us all learn, let us learn
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Surprise, surprise, there was more than just anecdotal evidence in the possession of the ATSB as to the why's and hows. Once again the opportunity of the industry learning something that would probably save lives has been denied us. I do know, as I had a "discussion" with the man in question a matter of days before.
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Maybe most other pilots are far more skilful than I am ... I was always too busy flying the thing to find time to look at the disposition of levers ..and the map trick always strikes me as a silly and unnecessary potential for confusion ?
Determining the failed engine by flying the AH/DG, advancing all throttles, correcting the yaw delta, and closing to confirm, takes but a second or two ... and is done quite reliably and repeatably in a simple twin ...
Having said that, and having done a couple of renewals with the fellow concerned in years long gone by .. I can't recall his using a map or similar to cover the quadrant ? Perhaps this was a technique he adopted in more recent years ?
Determining the failed engine by flying the AH/DG, advancing all throttles, correcting the yaw delta, and closing to confirm, takes but a second or two ... and is done quite reliably and repeatably in a simple twin ...
Having said that, and having done a couple of renewals with the fellow concerned in years long gone by .. I can't recall his using a map or similar to cover the quadrant ? Perhaps this was a technique he adopted in more recent years ?
I personally use a chart or something similar to cover the mixture controls during simulated engine failures. I also know plenty of other Multi-engine Instructors (& ATOs) who do the same.
To those that have asked, many pilots during twin or IFR training use the adage " a sneaky peak is worth a hundred scans", therefore visually masking the mixture controls prevents "cheating". And no most people probably would not even bother to look as they realise their life and the lives of their passengers are at stake, by being able to correctly identify and confirm the failed engine.
Whether he covered the mixture controls or not is hardly the point. He knew which engine he had failed and he was PIC so should "bloggs" get it wrong at the "confirm left" stage then there should be no issue.
I always do a runway abort with initial twin students and if the strip is suitable possibly a below Vyse failure (immediately after becoming airborne) hoping the student closes both throttles as they have briefed that they will do. Surprising how often they decide to go below the go speed.
John Where is the potential for confusion by covering the mixture controls? I find it has the added benefit that the student knows it is not a "real one" and also my hand is close to the action in case the student trys to do something silly, like close the other mixture control!
To those that have asked, many pilots during twin or IFR training use the adage " a sneaky peak is worth a hundred scans", therefore visually masking the mixture controls prevents "cheating". And no most people probably would not even bother to look as they realise their life and the lives of their passengers are at stake, by being able to correctly identify and confirm the failed engine.
Whether he covered the mixture controls or not is hardly the point. He knew which engine he had failed and he was PIC so should "bloggs" get it wrong at the "confirm left" stage then there should be no issue.
I always do a runway abort with initial twin students and if the strip is suitable possibly a below Vyse failure (immediately after becoming airborne) hoping the student closes both throttles as they have briefed that they will do. Surprising how often they decide to go below the go speed.
John Where is the potential for confusion by covering the mixture controls? I find it has the added benefit that the student knows it is not a "real one" and also my hand is close to the action in case the student trys to do something silly, like close the other mixture control!
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Icarus 2001,
I respect your views but we must agree to disagree.
Coming mainly from a larger aircraft IFR background and being able to load the pilot up a bit in the simulator, I have long left worrying about pilots "having a sneaky look".
In any case, it should be fairly obvious to the GA I/F instructor/examiner if the student or pilot under renewal test is "cheating". By choosing the time of the simulated failure and keeping a reasonably high workload involved . .. if the pilot drops his/her scan then other things will fall in a heap and it all becomes a bit obvious to blind Freddy. The more experienced pilot wouldn't waste his/her time scanning the throttle quadrant when it is easier and quicker to do it right first time.
I don't have any knowledge of what Les did or did not do on this occasion and I have flown with him enough over the years to respect his overall ability .. even if I might disagree on some specifics. But, I agree, that isn't the point in question.
In general we could take the view that, in any situation where there is room for the student to do something silly (for whatever reason), and the instructor/examiner hasn't left enough fat in the scenario to recover from something out of left field .... the situation ..... sooner or later .... is going to turn to custard and bite you on the exposed bits ....
I suggest that failing engines during the takeoff flare at low speeds is just such a scenario. I am reminded of an airline for whom I did some contract sim training work a few years ago ... during recurrent training exercises, I introduced a similar exercise during spare time just for interest value .... it was far more interesting to see that some of the pilots got it very wrong first time round .... in the aircraft (presuming that the aircraft and sim were similar in response) there wouldn't have been a second time to try it again ... this sort of thing always provides a sobering point for debriefing discussions ...
"Where is the potential for confusion by covering the mixture controls?" The training setup doesn't match the real world ... does that difference create a potential problem in the case of a real world failure ? In my view it does ... for no real benefit. If you chose a different point of view, then I accept that.
The history of training accidents suggests that it is a bit silly to kill more people by training for an event ... than are killed in the real world situation ..... the use of high fidelity full flight simulators provides the opportunity to play and refine skills .... without the risks associated with doing it for make-believe real.
I agree with Menen's philosophies .... why stick one's neck out playing with low level failures for questionable benefit. While there are arguments for and against, it seems to me that most of the training needs can be addressed by playing at a reasonable altitude.
My standard brief for GA renewals was along the lines of "pull an engine below X ft agl and I will assume that it is a real failure and close both throttles" ... no examiner ever called my bluff, Les included. Because my airline placed considerable emphasis on simulator practice and I did a fair bit of personal sim practice over and above minimum licence and training requirements .... I wasn't concerned about my ability to fly the aeroplane during a simulated failure ... I just wasn't prepared to risk my neck doing something which, in my view, was unnecessary.
I respect your views but we must agree to disagree.
Coming mainly from a larger aircraft IFR background and being able to load the pilot up a bit in the simulator, I have long left worrying about pilots "having a sneaky look".
In any case, it should be fairly obvious to the GA I/F instructor/examiner if the student or pilot under renewal test is "cheating". By choosing the time of the simulated failure and keeping a reasonably high workload involved . .. if the pilot drops his/her scan then other things will fall in a heap and it all becomes a bit obvious to blind Freddy. The more experienced pilot wouldn't waste his/her time scanning the throttle quadrant when it is easier and quicker to do it right first time.
I don't have any knowledge of what Les did or did not do on this occasion and I have flown with him enough over the years to respect his overall ability .. even if I might disagree on some specifics. But, I agree, that isn't the point in question.
In general we could take the view that, in any situation where there is room for the student to do something silly (for whatever reason), and the instructor/examiner hasn't left enough fat in the scenario to recover from something out of left field .... the situation ..... sooner or later .... is going to turn to custard and bite you on the exposed bits ....
I suggest that failing engines during the takeoff flare at low speeds is just such a scenario. I am reminded of an airline for whom I did some contract sim training work a few years ago ... during recurrent training exercises, I introduced a similar exercise during spare time just for interest value .... it was far more interesting to see that some of the pilots got it very wrong first time round .... in the aircraft (presuming that the aircraft and sim were similar in response) there wouldn't have been a second time to try it again ... this sort of thing always provides a sobering point for debriefing discussions ...
"Where is the potential for confusion by covering the mixture controls?" The training setup doesn't match the real world ... does that difference create a potential problem in the case of a real world failure ? In my view it does ... for no real benefit. If you chose a different point of view, then I accept that.
The history of training accidents suggests that it is a bit silly to kill more people by training for an event ... than are killed in the real world situation ..... the use of high fidelity full flight simulators provides the opportunity to play and refine skills .... without the risks associated with doing it for make-believe real.
I agree with Menen's philosophies .... why stick one's neck out playing with low level failures for questionable benefit. While there are arguments for and against, it seems to me that most of the training needs can be addressed by playing at a reasonable altitude.
My standard brief for GA renewals was along the lines of "pull an engine below X ft agl and I will assume that it is a real failure and close both throttles" ... no examiner ever called my bluff, Les included. Because my airline placed considerable emphasis on simulator practice and I did a fair bit of personal sim practice over and above minimum licence and training requirements .... I wasn't concerned about my ability to fly the aeroplane during a simulated failure ... I just wasn't prepared to risk my neck doing something which, in my view, was unnecessary.
Last edited by john_tullamarine; 4th Sep 2004 at 10:46.
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I'd like to know where there is a high fidelity full flight simulator for a Duchess, tell me and in future I'll spend my money there. Why has no one mentioned that in Australia engine failures at night below 1500' are illegal. Most Ops Manuals would have a minimum height below which you don't use the mixture but the throttle. Above that height I do use something to cover the mixtures. I do not want to get into the student's subconscious mind "it's always the mixture or it's always the throttle". I have operated Duchesses in and out of Camden for many years and have always found them capable to outperform that hill.
When a pilot sits in the runup bay and goes through the safety drill, s/he needs to know precisely what the aircraft can do and can't do. If you don't, how are you going to make a realistic decision? But do it in daytime with someone who does know.
When a pilot sits in the runup bay and goes through the safety drill, s/he needs to know precisely what the aircraft can do and can't do. If you don't, how are you going to make a realistic decision? But do it in daytime with someone who does know.
John I agree with most of what you say. However I still believe covering the mixture controls is worthwhile. I think the crux of the issue is instructors/ATOs crossing the line of their ability to recover if "bloggs" gets it wrong. I only got to fly with Les once and I concur that the outcome is surprising.
Hudson your personal attack has added very little to an important thread about an issue which is poorly taught and understood and has killed more than once. What do you actually think about the issue being discussed, rather than what you think you know about me?
I am always happy to learn and modify what I do based on new ideas or another persons viewpoint which is valid. However what can I get from your post Hudson?
Hudson your personal attack has added very little to an important thread about an issue which is poorly taught and understood and has killed more than once. What do you actually think about the issue being discussed, rather than what you think you know about me?
I am always happy to learn and modify what I do based on new ideas or another persons viewpoint which is valid. However what can I get from your post Hudson?
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Icarus. No offence meant - it was meant to be a humorous quip.
There is however a fine line between risking life and limb of your student to prove that engine failures can be dangerous - and genuinely believing that by doing so, you will make them a safer pilot.
Having said that, I must say that cutting a mixture a few seconds after getting airborne with the intention that the student should close both throttles and bunt over to land on the remaining length of runway, is arguably one of the most dangerous practices that I have ever read about.
One thing is for sure, and that is the lawyers (and CASA)would have your guts for garters if you bent the aircraft and student in the process of showing your student how good you are. Only cowboys and the irresponsible would put lives at risk for the purposes of simulating realism. This, my lad, is not another humorous quip...
There is however a fine line between risking life and limb of your student to prove that engine failures can be dangerous - and genuinely believing that by doing so, you will make them a safer pilot.
Having said that, I must say that cutting a mixture a few seconds after getting airborne with the intention that the student should close both throttles and bunt over to land on the remaining length of runway, is arguably one of the most dangerous practices that I have ever read about.
One thing is for sure, and that is the lawyers (and CASA)would have your guts for garters if you bent the aircraft and student in the process of showing your student how good you are. Only cowboys and the irresponsible would put lives at risk for the purposes of simulating realism. This, my lad, is not another humorous quip...
Hudson yes I did take offence, as I consider myself at the other end of the spectrum to the cowboy, young & bold pilots.However I accept the limitations of the medium and the lack of a humour button on the posts.
I agree entirely that the line is very fine. I never intentionally go up to it as I wish to be the oldest pilot in Australia, perhaps not the best. Let me explain further. The standard GA light twin brief as you probably know includes something along the lines of " if I have an engine failure below X I will close both throttles and land straight ahead". This is often spoken as a mantra, losing it's effectiveness, and it is surprising how often pilots suffering an engine failure on the runway do not do as they have briefed for and close both throttles. As I said I always do an engine failure on the runway to prove this point to the student and also to show them how quickly the aircraft will head for the green bits! Most of the schools I have worked for show this as part of their training syllabus.
You will note that as for a below Vyse failure immediately after becoming airborne I said "if the strip is suitable I will possibly do..." Suitable for me is around 2000 metres of bitumen. I do not undertake this procedure lightly or very often. In fact I have probably done it three times in twelve years of multi-engine training. Usually a failure early in the ground roll is sufficient to make the point to the student that they should be ready for an engine failure on every take-off and that they have to move very quickly. I am talking about a simulated failure at around 10 feet off the ground. Incidentally I am talking here about Duchess, Seminole type aircraft. I also agree with you that it is probably the most dangerous sequence of training that I do, (hence three times only) and that includes plently of aerobatics training!
Hudson do you use phrases like "my lad" and "old chap" in your spoken communication? I find it very patronising, you assume I am younger than you? You may like to peruse this document...
http://www.casa.gov.au/download/CAAPs/ops/5_23.pdf
I think I fly raises a valid question. Simulated engine failures at night are not permitted below 1500'. (AIP ENR 80.3.1)
I agree entirely that the line is very fine. I never intentionally go up to it as I wish to be the oldest pilot in Australia, perhaps not the best. Let me explain further. The standard GA light twin brief as you probably know includes something along the lines of " if I have an engine failure below X I will close both throttles and land straight ahead". This is often spoken as a mantra, losing it's effectiveness, and it is surprising how often pilots suffering an engine failure on the runway do not do as they have briefed for and close both throttles. As I said I always do an engine failure on the runway to prove this point to the student and also to show them how quickly the aircraft will head for the green bits! Most of the schools I have worked for show this as part of their training syllabus.
You will note that as for a below Vyse failure immediately after becoming airborne I said "if the strip is suitable I will possibly do..." Suitable for me is around 2000 metres of bitumen. I do not undertake this procedure lightly or very often. In fact I have probably done it three times in twelve years of multi-engine training. Usually a failure early in the ground roll is sufficient to make the point to the student that they should be ready for an engine failure on every take-off and that they have to move very quickly. I am talking about a simulated failure at around 10 feet off the ground. Incidentally I am talking here about Duchess, Seminole type aircraft. I also agree with you that it is probably the most dangerous sequence of training that I do, (hence three times only) and that includes plently of aerobatics training!
Hudson do you use phrases like "my lad" and "old chap" in your spoken communication? I find it very patronising, you assume I am younger than you? You may like to peruse this document...
http://www.casa.gov.au/download/CAAPs/ops/5_23.pdf
I think I fly raises a valid question. Simulated engine failures at night are not permitted below 1500'. (AIP ENR 80.3.1)
Last edited by Icarus2001; 5th Sep 2004 at 06:36.
I have a question for the twin training guys...
If you dont think that it is important to cover the mixtures for the failure, why use the mixture below 1000' when the throttle could be just as effective?
Also regarding the AIP for engine failure at night below 1500' AGL i thought this comment and the use of the word "guidance" was very intersting in the ATSB report.
Asymmetric flight at night was not precluded by regulation. However, guidance provided to pilots contained in the Aeronautical Information Publication (AIP) stated that simulated asymmetric flight at night must not be conducted below 1,500 ft AGL. Civil Aviation Advisory Publication (CAAP) 5.23-1 (0) provided guidance on a syllabus of training, which included night asymmetric circuits.
If you dont think that it is important to cover the mixtures for the failure, why use the mixture below 1000' when the throttle could be just as effective?
Also regarding the AIP for engine failure at night below 1500' AGL i thought this comment and the use of the word "guidance" was very intersting in the ATSB report.
Asymmetric flight at night was not precluded by regulation. However, guidance provided to pilots contained in the Aeronautical Information Publication (AIP) stated that simulated asymmetric flight at night must not be conducted below 1,500 ft AGL. Civil Aviation Advisory Publication (CAAP) 5.23-1 (0) provided guidance on a syllabus of training, which included night asymmetric circuits.
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"I think I fly raises a valid question. Simulated engine failures at night are not permitted below 1500'. (AIP ENR 80.3.1)"
The whole bloody point!!!
One Metro at Tamworth springs to mind...
The whole bloody point!!!
One Metro at Tamworth springs to mind...
80.3 Circuit Training Operations at Night
80.3.1 Aircraft engaged in training operations at night in the circuit area must not, when below 1,500FT AGL, carry out any manoeuvres which involve:
a. the simulation of an engine failure;or
b. flight in a simulated one engine inoperative condition;or
c. the intentional shut down of a serviceable engine.
Pretty strong guidance! Okay so when CASA prosecutes it is for an offence against the ACT or the CAR. Surely the wording of the AIP carries legislative weight. Creampuff?
80.3.1 Aircraft engaged in training operations at night in the circuit area must not, when below 1,500FT AGL, carry out any manoeuvres which involve:
a. the simulation of an engine failure;or
b. flight in a simulated one engine inoperative condition;or
c. the intentional shut down of a serviceable engine.
Asymmetric flight at night was not precluded by regulation. However, guidance provided to pilots contained in the Aeronautical Information Publication (AIP) stated that simulated asymmetric flight at night must not be conducted below 1,500 ft AGL. Civil Aviation Advisory Publication (CAAP) 5.23-1 (0) provided guidance on a syllabus of training, which included night asymmetric circuits.
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Icarus. You may have a point re the patronising bit - so I will try and be more concise.
Most multi-engine light twin instructors will agree that cutting an engine at low speeds and close to the ground is risky. How risky is a matter of personal opinion.
It is interesting to note that the British CAA are against simulated engine failures by cutting the mixture of fuel at any altitude (AIC/1999 dated 6th May 1999.
In addition the NTSB in 1976, issued an urgent warning on simulated engine-out manoeuvres which was published following a fatal accident where the instructor and student were killed after a mixture control was used to shut down an engine. An interesting paragraph included in the NTSB warning, could well apply to your own stated reasons for such a practice on take off.
It stated that "Many flight instructors down through the years used the technique of abruptly cutting an engine with a multi-engine candidate to test his emotional reaction and judgement with this extreme technique."
Finally the Piper Seminole Information Manual at Section 10, entitled Training Tips, states that "experience has shown that the training advantage gained by pulling the mixture control or turning off the fuel to simulate engine failure at low altitude is not worth the risk assumed - therefore it is recommended that instead of using either of these procedures to simulate loss of power at low altitude, the throttle be retarded slowly to idle position".
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. If the purpose of the map between the throttles and mixture trick is to give practice at identification then why not practice this above 2000 ft until the pilot is competent at correct and speedy identification.
Having now demonstrated his competence you can then use the throttle method at lower altitudes which is demonstrably a safer technique. But as I said earlier the policy of bunting over to land straight ahead is really beyond the pale for any sensible instructor.
All this reminds me of that wonderful pithy saying coined by some
wise aviator of yesteryear:
"A superior pilot is one who stays out of trouble by using his superior judgement to avoid situations that might require the use of his superior skills". A lesson there for you perhaps, Icarus?
Most multi-engine light twin instructors will agree that cutting an engine at low speeds and close to the ground is risky. How risky is a matter of personal opinion.
It is interesting to note that the British CAA are against simulated engine failures by cutting the mixture of fuel at any altitude (AIC/1999 dated 6th May 1999.
In addition the NTSB in 1976, issued an urgent warning on simulated engine-out manoeuvres which was published following a fatal accident where the instructor and student were killed after a mixture control was used to shut down an engine. An interesting paragraph included in the NTSB warning, could well apply to your own stated reasons for such a practice on take off.
It stated that "Many flight instructors down through the years used the technique of abruptly cutting an engine with a multi-engine candidate to test his emotional reaction and judgement with this extreme technique."
Finally the Piper Seminole Information Manual at Section 10, entitled Training Tips, states that "experience has shown that the training advantage gained by pulling the mixture control or turning off the fuel to simulate engine failure at low altitude is not worth the risk assumed - therefore it is recommended that instead of using either of these procedures to simulate loss of power at low altitude, the throttle be retarded slowly to idle position".
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. If the purpose of the map between the throttles and mixture trick is to give practice at identification then why not practice this above 2000 ft until the pilot is competent at correct and speedy identification.
Having now demonstrated his competence you can then use the throttle method at lower altitudes which is demonstrably a safer technique. But as I said earlier the policy of bunting over to land straight ahead is really beyond the pale for any sensible instructor.
All this reminds me of that wonderful pithy saying coined by some
wise aviator of yesteryear:
"A superior pilot is one who stays out of trouble by using his superior judgement to avoid situations that might require the use of his superior skills". A lesson there for you perhaps, Icarus?
Anyone of the Multi instructors here actually read Pub 45 re night asymmetrics???
"Asymmetric operations shall not be carried out at night."
Full Stop. No Argument........Essendon, Tamworth, Camden........History repeating itself!!
"Asymmetric operations shall not be carried out at night."
Full Stop. No Argument........Essendon, Tamworth, Camden........History repeating itself!!