ATSB Report on Cessna 210 Fatal in WA - A must read report.
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ATSB Report on Cessna 210 Fatal in WA - A must read report.
AO-2007-047
ATSB accident report just out. Cessna 210 fatal at night on 17 October 2007 at 255 kms SW of Warburton, WA.
This is chilling reading. Low suction caused unreliable AH and DG readings and pilot lost control. Every general aviation pilot should read this report. Although the aircraft had a serviceable Turn Coordinator, the pilot was probably not current on using that instrument in IMC or night.
Make no mistake about it, a loss of gyroscopic instruments in IMC is deadly serious stuff and having to switch to basic instrument flying on airspeed, altimeter VSI and only the Turn Coordinator, is not for the faint-hearted. Most pilots would quickly get disorientated and lose control.
This accident shows the importance of keeping current on basic instrument flying by using regular synthetic trainer training. Yet it's a good bet that very few commercial pilots once having their first instrument rating, and now flying general aviation aircraft, ever consider spending a few dollars to buy an hour every few months (minimum) on a flying school synthetic trainer to practice limited panel manoeuvres on the Turn Coordinator. This could be a life-saving practice.
The ATSB report stated the suction in this aircraft had been found to be only 3 inches HG - which is not enough to provide reliable gyroscopic instrument integrity - meaning the AH and DG would have displayed sloppy indications. Yet, strangely enough, previous pilots who flew the same aircraft attested the suction was always in tolerances.
But it is hard to understand why suddenly in this case the suction was found to be at only 3"HG when the investigators delved into the wreckage. Usually, when suction is indicating outside tolerances it has been like that for a long time with some pilots shrugging it off as not worth writing up. There is always the danger that failing to write up defects in a maintenance release means the next unsuspecting pilots cops the problem. It is hoped this wasn't the case with this unfortunate soul.
In this accident the MR was destroyed and any defects on it that happened to have been recorded by previous pilots that could have had a bearing on the cause of the accident, are lost for good. It is a good bet that 90 percent of MR's are destroyed in post crash fires and with them valuable evidence is lost to the investigators. It is a crazy rule that the original of the MR must be carried in the aircraft at all times in general aviation aircraft - even on local training.
ATSB accident report just out. Cessna 210 fatal at night on 17 October 2007 at 255 kms SW of Warburton, WA.
This is chilling reading. Low suction caused unreliable AH and DG readings and pilot lost control. Every general aviation pilot should read this report. Although the aircraft had a serviceable Turn Coordinator, the pilot was probably not current on using that instrument in IMC or night.
Make no mistake about it, a loss of gyroscopic instruments in IMC is deadly serious stuff and having to switch to basic instrument flying on airspeed, altimeter VSI and only the Turn Coordinator, is not for the faint-hearted. Most pilots would quickly get disorientated and lose control.
This accident shows the importance of keeping current on basic instrument flying by using regular synthetic trainer training. Yet it's a good bet that very few commercial pilots once having their first instrument rating, and now flying general aviation aircraft, ever consider spending a few dollars to buy an hour every few months (minimum) on a flying school synthetic trainer to practice limited panel manoeuvres on the Turn Coordinator. This could be a life-saving practice.
The ATSB report stated the suction in this aircraft had been found to be only 3 inches HG - which is not enough to provide reliable gyroscopic instrument integrity - meaning the AH and DG would have displayed sloppy indications. Yet, strangely enough, previous pilots who flew the same aircraft attested the suction was always in tolerances.
But it is hard to understand why suddenly in this case the suction was found to be at only 3"HG when the investigators delved into the wreckage. Usually, when suction is indicating outside tolerances it has been like that for a long time with some pilots shrugging it off as not worth writing up. There is always the danger that failing to write up defects in a maintenance release means the next unsuspecting pilots cops the problem. It is hoped this wasn't the case with this unfortunate soul.
In this accident the MR was destroyed and any defects on it that happened to have been recorded by previous pilots that could have had a bearing on the cause of the accident, are lost for good. It is a good bet that 90 percent of MR's are destroyed in post crash fires and with them valuable evidence is lost to the investigators. It is a crazy rule that the original of the MR must be carried in the aircraft at all times in general aviation aircraft - even on local training.
I don't disagree with anything said above.
Any accident that results in loss of life or serious injury is a tragedy, however, the circumstances described in the ATSB report should not have resulted in loss of the aircraft.
In this case, the pilot had completed a MECIR some 5 months prior to the accident. It is hard to believe that he was not proficient in flying on limited panel. If he wasn't - then he should have been. Ditto to having an effective instrument scan.
ATSB reports state the facts, but there is often more to what actually happened that can be gleaned from the ATSB report on first reading.
The AP in the aircraft was U/S and therefore the pilot would have been hand flying. That being the case, it is hard to imagine that he would not have picked up discrepancies in his instrument scan if the low suction was having an effect on the reliable function of the AH and DG.
AS, AH, Alt, GD, T&B, compass ......... hmmmmmm!! What's the deal here?
I have had 3 vacuum pump failures and one AH failure in SE aircraft in IMC. With the vac pump failures, in all cases, continued slight discrepancies between flight instruments alerted me to the problem - before the low suction light came on or I noticed the low reading on the suction guage. For the AH failure, I just happened to be looking at it when it rolled upside down.
Look at the whole picture:
1) Night VMC flight
2) No AP
3) Dark night
4) Suspect suction for primary flight instruments
5) Surface trough with CBs in the vicinity of the aircrafts track
6) Slippery aeroplane
7) "I got out here OK, I should be able to get back"
.... and the deck is starting to get stacked against you!
Nobody could accuse me of being faint-hearted when it comes to single pilot Night VFR/IFR/night flying in an SE aircraft, but I doubt that I would have made the flight, unappealling though a night at the Warburton aerodrome may have been.
Early start - back next morning - live to fly another day!
Dr
Any accident that results in loss of life or serious injury is a tragedy, however, the circumstances described in the ATSB report should not have resulted in loss of the aircraft.
In this case, the pilot had completed a MECIR some 5 months prior to the accident. It is hard to believe that he was not proficient in flying on limited panel. If he wasn't - then he should have been. Ditto to having an effective instrument scan.
ATSB reports state the facts, but there is often more to what actually happened that can be gleaned from the ATSB report on first reading.
The AP in the aircraft was U/S and therefore the pilot would have been hand flying. That being the case, it is hard to imagine that he would not have picked up discrepancies in his instrument scan if the low suction was having an effect on the reliable function of the AH and DG.
AS, AH, Alt, GD, T&B, compass ......... hmmmmmm!! What's the deal here?
I have had 3 vacuum pump failures and one AH failure in SE aircraft in IMC. With the vac pump failures, in all cases, continued slight discrepancies between flight instruments alerted me to the problem - before the low suction light came on or I noticed the low reading on the suction guage. For the AH failure, I just happened to be looking at it when it rolled upside down.
Look at the whole picture:
1) Night VMC flight
2) No AP
3) Dark night
4) Suspect suction for primary flight instruments
5) Surface trough with CBs in the vicinity of the aircrafts track
6) Slippery aeroplane
7) "I got out here OK, I should be able to get back"
.... and the deck is starting to get stacked against you!
Nobody could accuse me of being faint-hearted when it comes to single pilot Night VFR/IFR/night flying in an SE aircraft, but I doubt that I would have made the flight, unappealling though a night at the Warburton aerodrome may have been.
Early start - back next morning - live to fly another day!
Dr
Last edited by ForkTailedDrKiller; 23rd Apr 2010 at 23:47.
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Don't be too hasty in blaming the vac pump and its setting for the low vacuum. Just over a year ago I had major autopilot work done on my C210M. On return to service I noticed that the vacuum was reading low. I had the pump adjusted to its maximum which brought the reading into the green but on the low side. I assumed the vac pump was on its last legs.
All went well for 300 hours with no changes to the vac reading and with the AH and DG functioning properly. Then one morning on startup the AH wouldn't strut its stuff. As best I could, I shone a torch on the vac lines looking for cracks or disconnects. I also had a grope around the fittings going into the instruments. All seemed well. Assuming I had an expensive AH replacement problem I took it to the nearest aircraft workshop. Thank goodness there was a knowledgeable and experienced LAME available. He checked the lines, then put a spanner on the fittings. Shock Horror!! These fittings which felt tight by hand were quite loose. After he tightened them the instruments worked just fine. The vac pump went up to the middle of the green, better than it had ever been since the autopilot work. Probably they had been leaking ever since that AP job.
We shouldn't jump to conclusions that previous pilots didn't report a fault on the maintenance release. There may well have been none to report. The vac lines or the fittings may have chosen a very bad time to start leaking. It would be very difficult to find any evidence of this after a fire. Even after 38 years of flying it amazes me how planes seem to be able to come up with new GOTCHAS.
Cheers, RA
All went well for 300 hours with no changes to the vac reading and with the AH and DG functioning properly. Then one morning on startup the AH wouldn't strut its stuff. As best I could, I shone a torch on the vac lines looking for cracks or disconnects. I also had a grope around the fittings going into the instruments. All seemed well. Assuming I had an expensive AH replacement problem I took it to the nearest aircraft workshop. Thank goodness there was a knowledgeable and experienced LAME available. He checked the lines, then put a spanner on the fittings. Shock Horror!! These fittings which felt tight by hand were quite loose. After he tightened them the instruments worked just fine. The vac pump went up to the middle of the green, better than it had ever been since the autopilot work. Probably they had been leaking ever since that AP job.
We shouldn't jump to conclusions that previous pilots didn't report a fault on the maintenance release. There may well have been none to report. The vac lines or the fittings may have chosen a very bad time to start leaking. It would be very difficult to find any evidence of this after a fire. Even after 38 years of flying it amazes me how planes seem to be able to come up with new GOTCHAS.
Cheers, RA
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Back in the days when men were men and sheep were scared, I always thought the military had some salient points to teach us and one of these involved limited panel instrument flying. I will never forget the gradual failing of an AI (in the simulator) and the way in which I was still drawn to information, even though I knew it was incorrect. The solution was SO simple, yet immediately effective; cover up the affected instrument. Now I know I'm teaching you all to suck eggs. We ALL know this and some silly old git, waxing lyrical about the 'old days' doesn't help, but sometimes a gentle reminder might be useful. In this particular instance I slapped a bit of paper on the glass, held in place by a good dose of tongue lickage. Straight away that instrument is no longer compelling and you're forced to start scanning the performance instruments, just as you've always been taught. It actually becomes significantly easier as the old training kicks in.
After that session in the 'box' I managed to procure some of that non-sticky, sticky plastic (you know, the stuff they use for sticking on car windows to keep the sun from burning your bits) and cut it to fit the AIs and HSI. Fortunately, I never had to use it for real but did have cause to drag it out again in the simulator and it works.
This is, perhaps, related to the accident in question but not at all a comment on the pilot's handling of the event. As you know, spotting the failure is the most difficult part, as often the indications are insiduous and can be masked by other factors; being bumped around in turbulence being an obvious one. However, once you do notice your AI is knackered it is important that you ignore it and that's why I bore you and insult your intelligence by relating my obvious yet, hopefully, useful reminder of the uses of a bit of spit, licked onto a piece of paper and stuck to the offending instrument.
After that session in the 'box' I managed to procure some of that non-sticky, sticky plastic (you know, the stuff they use for sticking on car windows to keep the sun from burning your bits) and cut it to fit the AIs and HSI. Fortunately, I never had to use it for real but did have cause to drag it out again in the simulator and it works.
This is, perhaps, related to the accident in question but not at all a comment on the pilot's handling of the event. As you know, spotting the failure is the most difficult part, as often the indications are insiduous and can be masked by other factors; being bumped around in turbulence being an obvious one. However, once you do notice your AI is knackered it is important that you ignore it and that's why I bore you and insult your intelligence by relating my obvious yet, hopefully, useful reminder of the uses of a bit of spit, licked onto a piece of paper and stuck to the offending instrument.
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I remember loosing the suction pump on 210 one night around top of climb between Port Hedland and Broome. The hardest thing, was once I discovered the failure, was trying NOT to look at the HSI, and DG. I ended up pulling out the post lights around the 2 said instruments and that made it a lot easier to concentrate on the Turn co-ord, VSI, ALT and compass.
I accept the Dr's commence regarding his I.R., he's should have had all the training tools in his shed's, But ONLY 5 months was my thought. He had barely bedded his techniques, I've had mine for 15 years, and I still get bitten if I've not practiced for a while. My limited panel is a bit like wrestling a bore into a stock trailer.
L/dog.
I accept the Dr's commence regarding his I.R., he's should have had all the training tools in his shed's, But ONLY 5 months was my thought. He had barely bedded his techniques, I've had mine for 15 years, and I still get bitten if I've not practiced for a while. My limited panel is a bit like wrestling a bore into a stock trailer.
L/dog.
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Pontius,
"We ALL know this and some silly old git, waxing lyrical about the 'old days' doesn't help"
As someone starting out on the journey, you have taught me something.
Keep waxing lyrical please... It's the reason I come here.
"We ALL know this and some silly old git, waxing lyrical about the 'old days' doesn't help"
As someone starting out on the journey, you have taught me something.
Keep waxing lyrical please... It's the reason I come here.
I've only lost vaccum in a single once - I was in VMC, but it was a very dark night that seemed to get even darker 
. Picked it up when the AH started to show a gentle bank to the right while the DG started turning gently to the left. (What if they'd both started showing a 'phantom' turn in the same direction ...?? )
The one good thing about it happening at night was that this aircraft had post lights, and I could turn them away from the AH and DG so I didn't keep seeing them. It is bloody hard to ignore an AH which looks 'normal' and is showing a gentle turn ...
Since then, I carry a packet of cardboard instrument covers that fit into the steam gauges, clipped on my knee board. Still got the price tag on 'em: $2.50 (admittedly 10 years ago - but I haven't needed to use 'em since). Well worth the investment!
Ted
. Picked it up when the AH started to show a gentle bank to the right while the DG started turning gently to the left. (What if they'd both started showing a 'phantom' turn in the same direction ...?? )The one good thing about it happening at night was that this aircraft had post lights, and I could turn them away from the AH and DG so I didn't keep seeing them. It is bloody hard to ignore an AH which looks 'normal' and is showing a gentle turn ...
Since then, I carry a packet of cardboard instrument covers that fit into the steam gauges, clipped on my knee board. Still got the price tag on 'em: $2.50 (admittedly 10 years ago - but I haven't needed to use 'em since). Well worth the investment!
Ted
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I also find it curious that the suction guage was on the far right of the panel, well out of the easily scanned area. No mention of whether it was lit or could otherwise be easily seen with ambient light.
Ever since my own GA IFR flying, I have always wondered why they put such an important instrument so far away. Especially as the instuments involved were reported to not have failure flags.
Do they teach the periodic "SADIE" check to CIR students in Aussie?
"Suction, Amps, DI, Ice, Engine (parameters)"
Ever since my own GA IFR flying, I have always wondered why they put such an important instrument so far away. Especially as the instuments involved were reported to not have failure flags.
Do they teach the periodic "SADIE" check to CIR students in Aussie?
"Suction, Amps, DI, Ice, Engine (parameters)"
The hardest thing, was once I discovered the failure, was trying NOT to look at the HSI, and DG
The other thing that I now know, with the value of hindsight, is that the vac pump was not delivering full suck (or "blow" in the case of the V35B) for maybe 10 hrs before it failed. Still in the green range but well below what it normally did - particularly at low power settings.
I also find it curious that the suction guage was on the far right of the panel, well out of the easily scanned area.
Dr
Last edited by ForkTailedDrKiller; 24th Apr 2010 at 04:19.
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Great thread.
I don't have much experience to add except that if you fly an aeroplane equipped with glass (G1000 or Aspen style) it is really worth practicing the scan on standby instruments before you need to do it in anger. Often the analog instruments are placed in a shotgun arrangement all over the panel wherever they'll fit.
I once had an Aspen drop out in the clag before needing to fly an NDB approach to the minima. Thankfully, I was proficient on the standby scan or it would have really got the blood pumping.
I don't have much experience to add except that if you fly an aeroplane equipped with glass (G1000 or Aspen style) it is really worth practicing the scan on standby instruments before you need to do it in anger. Often the analog instruments are placed in a shotgun arrangement all over the panel wherever they'll fit.
I once had an Aspen drop out in the clag before needing to fly an NDB approach to the minima. Thankfully, I was proficient on the standby scan or it would have really got the blood pumping.
once had an Aspen drop
One thing about the vac instruments, the giros themselves usualy give a bit of warning.... slowly increasing windup/down noises for several hundred hours.
.
A feature of the old Cessna 300A autopilot is that in the event of a vacumn failure it will hold the wings level by reference to the turn co-ordinator if the turn knob is pulled out. Makes flying on the primary panel a lot more foregiving.
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U/S Flight Instruments.
Just wanted to reinforce the advice from Pontius regarding covering up a defective Flight Instrument. There have been a number of times during my flying career where this method of ensuring false info was not used has been employed. I trust all will be as willing as Aussiefan to learn from the post of Pontius.
I've seen the Aspen units lose its **** countless times. More than enough times in IMC also... Don't get sucked into thinking that because you are operating new and fancy equipment that they wont fail. They can and do.
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In the ATC book for the BAK, it says if you smash the glass in one of the instruments you will get enough pressure for it to work, it did specify which instrument but I dont remember and I don't have the book with me. I also assume this is for non pressurised aircraft.
Anyone tried this? Heard of it?
Anyone tried this? Heard of it?
aussiefan, just have a think about the physics that are involved with your statement and you should be able to work it out yourself.
What will smashing the glass give the instrument in question?- Static air pressure. What instruments need a static source to function......Not the A/H or DG.
What will smashing the glass give the instrument in question?- Static air pressure. What instruments need a static source to function......Not the A/H or DG.