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One big oversight leads to........

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One big oversight leads to........

Old 23rd Apr 2009, 05:48
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One big oversight leads to........

Has anyone read this....

http://www.atsb.gov.au/publications/.../AO2008048.pdf

easy to be an armchair expert but gee.... check your fuel tanks is a pretty easy one if you have plenty of height and time!
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Old 23rd Apr 2009, 06:13
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wonder if it could be a traning factor? a mate of mine got his twin endo and the engine failure action was mixture up pitch up power up gear up flap up dead leg dead engine confirm with throttle feather. he mentioned that there was no FMOST drill after an engine failure as everything was done in the circuit with nothing in the cruise therefore no oppertuinity to follow a full engine out drill without it been height critical (no i will not mention the school he went too) Now i know FMOST checks should be second nature as they are taught from GFPT but 3 twin endos in 2 months, maybe with so much engine out practise he had simply forgotten to do an FMOST check in its entirity and just done his engine out check as you would when doing asymetric training?
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Old 23rd Apr 2009, 07:30
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And things like that will keep happening until we get some stability and some experienced pilots in GA.
While we have a flood of newbies who either quit or move on after a short time we won't be able to change this.
Whether we like it or not, the apprenticeship taskes about 5000 hours.
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Old 23rd Apr 2009, 12:19
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It wasn't just the fuel management it was also that he didn't feather the engines either which led to the high RoD into the ground. Unfortunately the combination of low time and inadequate training has had unfortunate consequences for this bloke.
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Old 23rd Apr 2009, 13:17
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tough times

Does anyone know how the lad faired? Did he recover from the injuries? Is he back in the saddle? IMHO 500 hours is a bit low for a Navajo. I remember myself at 500 hours - i was learning in much less complex and more forgiving machines.

Its sad to read the report and see the pictures. It would have been a terrible time for someone just starting out.

I know several others that did this exact same thing (less time available though) and somehow they all ended up in very big airlines...hmm maybe thats where i went wrong ( i was/am fanatical about fuel)!
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Old 23rd Apr 2009, 19:18
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Was this Savannah Aviation???

Last edited by freshy1234; 23rd Apr 2009 at 19:18. Reason: typo
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Old 23rd Apr 2009, 22:18
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I fail to understand how someone can total a perfectly good aircraft in this manner. It appears that even a most cursory glance at the fuel pressure or the fuel gauges or a change of tanks or almost anything would have made it a non-event.
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Old 23rd Apr 2009, 22:43
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If a PA31 crashed every time the pilot had to be "reminded" by the engines to change tanks, there would be none left by now.
Having flown them for a while now, you would think it would be instinctive to change to mains. I know it is for me.

But I suppose mistakes happen and I can't help but feel sorry for the pilot. Pretty nasty wreck.
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Old 23rd Apr 2009, 23:53
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Human error for an inexperienced pilot on a relatively complex aircraft. Sometimes the career progression comes too early and given the right circumstances accidents can be the result.
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Old 24th Apr 2009, 00:23
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Correct me if I'm wrong because I haven't seen a training syllabus in years, but are students shown how to restart an engine in flight or is it deemed unnecessary risk? I know it made an impression on me when my instructor did two things in flight; pulled the mixture and then restarted a windmilling prop, and; took the effort to stop the prop completely near the stall, bunt, get it windmilling and started again. From memory, it took about 1200ft, but my memory is hazy on that subject. Besides being great fun, it was a good learning experience, but I can imagine CASA's reaction these days. I can understand in some way, a pilot who has never been shown otherwise, seeing a windmilling prop and thinking/hoping it still has some power.
If anyone sticks around in GA long enough, they'll eventually run a tank dry and lose power. Lucky the guy didn't have a full load of pax.
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Old 24th Apr 2009, 00:40
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he mentioned that there was no FMOST drill after an engine failure
I was taught only to feather in a critical situation. (like low to the ground) In the cruise after identifying the engine out, i would stop before fethearing and conduct a restart.
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Old 24th Apr 2009, 00:43
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500 hrs certainly isn't experienced....but what leads anyone to think the exact same things wouldn't have happened to this young man in almost any other aircraft?

Apart from (some of) the EFATO memory items being allegedly completed, and you have to ask why? (In cruise they would most likely make things worse), he appears to have sat there and done nothing meaningful.

By 'worse' I mean that pushing the props to full fine and then not feathering simply creates more drag - and maybe what led him to think the engines were producing 'some' power - Windmilling RPM being a product of airspeed and MP returning to somewhere close to ambient, say 22 inches at 8000'.

Mixtures to full rich would probably set him up for a 'too rich' condition if he suddenly remembered (he obviously didn't) to change tanks and flipped on boost pumps as well.

This pilot's actions seem to be a result of rote learning - he could peel off the EFATO memory items (inappropriately) while 'controlling' the aircraft but there was ZERO understanding...of what was happening to him or what happens in any engine failure in cruise vs one on takeoff.

A training issue?

Most likely. I don't think the guys 500 TT is the most important issue...it's what he didn't learn/wasn't taught in that 500 hrs.

Maybe he is one of those Gen Y who feel GA is a burden to be born for the least time possible and didn't WANT to learn his craft properly...maybe he's thick as pigshit...or maybe he was just a victim of a deficient training system bereft of real experience/talent?
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Old 24th Apr 2009, 01:09
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A training issue certainly but what was the experience of the CP who checked this bloke out and let him loose. As someone wrote it was fortunate that there were no passengers.
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Old 24th Apr 2009, 01:17
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lodown i'm not sure if its in the training syllabus but I was shown and performed an air start.

Cessna Capt, was shown the same here mate. but as I said my mate said he was shown differently
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Old 24th Apr 2009, 01:52
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As Koizi said... hasn't everyone run the aux tanks dry on a CheapTin?

I started flying Chieftains about a million years ago, with about 800 hours. I was very lucky to have a couple of very experienced Chieftain drivers around who were liberal in dispensing advice gained in RPT ops. Where is Bill Stokes now anyway?
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Old 24th Apr 2009, 02:28
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The bad or perhaps good thing about Chieftain's fuel system is the location of the fuel gauges in the roof in full view of your pax. Always used to amuse me seeing eight pair of eyes transfixed to the guages minutes before switching to mains.
I used to leave it to the last moment to keep them all quiet.
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Old 24th Apr 2009, 02:32
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By 'worse' I mean that pushing the props to full fine and then not feathering simply creates more drag - and maybe what led him to think the engines were producing 'some' power - Windmilling RPM being a product of airspeed and MP returning to somewhere close to ambient, say 22 inches at 8000'
Yup.....but failed to nitice the VSI pointing exactly in the direction he was headed!

I reckon he must have been convinced in his own mind he was on the mains and that this was just another Whyalla so he went looking for the scene of the most likely survivable crash he could.

Hey, we are all fallable, I forgot the pitot cover the other day, usual cause, a distraction, was corrected before start up but all the same a simle error ....but it does NOT have to lead to a prang!

J
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Old 24th Apr 2009, 05:54
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Where is Bill Stokes now anyway?
RFDS Townsville?

Just a guess
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Old 24th Apr 2009, 06:06
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The props would have gone to fine pitch to try to maintain rpm when the power failed even if the pitch controls were set for cruise rpm.

The important part is the psychology. What prevented him from looking further and finding the empty tanks? It seems this aircraft was fitted with digital fuel guages. Are the analogue guages simpler to read than digital ones. Would the empty tank be more obvious with an analogue guage reading empty than a digital one with numbers? The analogue guage indicates unambiguously that the tank is empty merely by the position of the pointer. There is no need to read numbers. I always found an analogue clock was much easier to use for timing approach patterns as you could just look at the angle of the pointer and just forget about the numbers.

Or maybe this situation was just too overwhelming and resulted in tunnel vision.
Whatever it was I feel sorry for the PIC. This sort of occurence is devastating. I'm sure he would have wanted to prevent this. I wish him well.
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Old 24th Apr 2009, 08:45
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I suppose one thing, apart from the fact nobody ever wants to see anyone get hurt..... he did learn a valuble lesson that will be with him for life, he nearly paid with it too!

Have a good weekend folks!
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