VH-PGW PA-31P-350 15 June 2010 Crash Investigation
Check Attitude
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had a long think about things after reading the preliminary report.
There was a loss of power on one engine, possible technical cause / failure.
There are some human factors issues inside and outside the aircraft.
With regard to the technical issues, the investigation will be hindered by the degree of intense fire damage, yet some clues may emerge.
Was the aircraft given a quick circuit after the recently completed 50 hrly or was this the first flight after maintenance?
Nothing like a leak check after a maintenance test flight. Was the daily inspection unintentionally interrupted and maybe an oil cap left off?
Was there an engine driven fuel pump failure and vital actions taken to switch on the electric fuel boost pumps to restore fuel flow?
We may never know because the switches are plastic and there was a fire.
Was the engine developing any power or was it shut down regardless.
Given that it seems the prop was feathered,
it must have been shut down before the RPM decayed to the RPM below which the pitch locks would have engaged to prevent feather.
ATSB will do their best to sort out the technical issues despite the fire damage.
The human factors side:
Loss of an engine in a twin engined aircraft removes the aircraft from the "Ops Normal" status.
Presented with an abnormal situation, a PAN call would have alerted ATC that there was an emergency potentially developing. A PAN call was not made.
This may have prevented the following happening:
Soon after, ATC instructed the pilot to descend to 2,500 ft
and advised that Richmond airport was two miles to the south of the aircraft if the pilot could not maintain height.
As other posters have commented, if it was the intention to get back to base at Bankstown, rather than attempt a landing at Richmond,
maintaining as much altitude as possible in a drift down till overhead Bankstown could have made a difference.
We all have the luxury of hindsight, and plenty of unpressured time to think out all the possible options in the comfort of our home or workplace,
with a cup of coffe nearby.
The PiC had the deck stacked against him and not much time or performance to explore options.
And yes, I have been in a similar scenario in a GA twin with a broken crankshaft. I made the PAN call and ATC responded very professionally.
I did not abdicate command of the aircraft, I communicated my intentions and flew my revised plan.
I drifted down to 6,000 ft and then was able to hold that until overhead a suitable aerodrome, then circled down and landed.
Good luck, good recurrent training and plenty of experience helped ensure a satisfactory outcome.
The TSIO 540 will run for a limited time at maximum power, then it will start to melt things, but needs about 10 to 15 minutes to do so.
The Whyalla Air Chieftain managed 15 minutes at Max Power on one before it finally gave up.
I still have faith that ATSB will come through with a factual report, although they did invoke junk science in the Whyalla report.
(Whyalla was ultimately found to have been one of many Lycomings suffering a broken crankshaft due to manufacturing changes.)
Keep the discussion going, regretably it won't help the deceased, but may prompt awareness and thinking that may save your own life in the future.
MF
There was a loss of power on one engine, possible technical cause / failure.
There are some human factors issues inside and outside the aircraft.
With regard to the technical issues, the investigation will be hindered by the degree of intense fire damage, yet some clues may emerge.
Was the aircraft given a quick circuit after the recently completed 50 hrly or was this the first flight after maintenance?
Nothing like a leak check after a maintenance test flight. Was the daily inspection unintentionally interrupted and maybe an oil cap left off?
Was there an engine driven fuel pump failure and vital actions taken to switch on the electric fuel boost pumps to restore fuel flow?
We may never know because the switches are plastic and there was a fire.
Was the engine developing any power or was it shut down regardless.
Given that it seems the prop was feathered,
it must have been shut down before the RPM decayed to the RPM below which the pitch locks would have engaged to prevent feather.
ATSB will do their best to sort out the technical issues despite the fire damage.
The human factors side:
Loss of an engine in a twin engined aircraft removes the aircraft from the "Ops Normal" status.
Presented with an abnormal situation, a PAN call would have alerted ATC that there was an emergency potentially developing. A PAN call was not made.
This may have prevented the following happening:
Soon after, ATC instructed the pilot to descend to 2,500 ft
and advised that Richmond airport was two miles to the south of the aircraft if the pilot could not maintain height.
maintaining as much altitude as possible in a drift down till overhead Bankstown could have made a difference.
We all have the luxury of hindsight, and plenty of unpressured time to think out all the possible options in the comfort of our home or workplace,
with a cup of coffe nearby.
The PiC had the deck stacked against him and not much time or performance to explore options.
And yes, I have been in a similar scenario in a GA twin with a broken crankshaft. I made the PAN call and ATC responded very professionally.
I did not abdicate command of the aircraft, I communicated my intentions and flew my revised plan.
I drifted down to 6,000 ft and then was able to hold that until overhead a suitable aerodrome, then circled down and landed.
Good luck, good recurrent training and plenty of experience helped ensure a satisfactory outcome.
The TSIO 540 will run for a limited time at maximum power, then it will start to melt things, but needs about 10 to 15 minutes to do so.
The Whyalla Air Chieftain managed 15 minutes at Max Power on one before it finally gave up.
I still have faith that ATSB will come through with a factual report, although they did invoke junk science in the Whyalla report.
(Whyalla was ultimately found to have been one of many Lycomings suffering a broken crankshaft due to manufacturing changes.)
Keep the discussion going, regretably it won't help the deceased, but may prompt awareness and thinking that may save your own life in the future.
MF
As Krusty has already pointed out after any loss of power (reduced power in a single or powerplant loss in a twin) you should find out how much performance you actually have. Set maximum continuous power, maintain altitude and if speed reduces to blue line (or best rate in a single) then allow the aircraft to descend and see what capabilities you have. This will be the best case scenario understanding that as gear, flap etc are added performance will suffer.
I use what i learn from this to ascertain the seriousness of the situation. If the aircraft can maintain safe altitude on the power available PAN call and land at nearest suitable (safe) aerodrome. If the aircraft can not maintain a safe altitude when the book says it should then an immediate MAYDAY is required with landing at the nearest available airport/clear area etc... With a piston like the PA31 there is additional management of the live engine to worry about with mixture and temperature control being critical if a longer flight on one engine is to be considered.
Never assume any multi-engined aircraft will maintain height or perform to book figures after a failure, jets and turbo-props included as history has proven time and again.
I use what i learn from this to ascertain the seriousness of the situation. If the aircraft can maintain safe altitude on the power available PAN call and land at nearest suitable (safe) aerodrome. If the aircraft can not maintain a safe altitude when the book says it should then an immediate MAYDAY is required with landing at the nearest available airport/clear area etc... With a piston like the PA31 there is additional management of the live engine to worry about with mixture and temperature control being critical if a longer flight on one engine is to be considered.
Never assume any multi-engined aircraft will maintain height or perform to book figures after a failure, jets and turbo-props included as history has proven time and again.
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I'm surprised no one else has seemed to considered this, what if the prop wasnt feathered, but seized with the engine failure? I'm thinking one engine performace would go out the window pretty fast, the report didnt confirm that it was feathered yet, just that one of the props wasnt turning from witness reports.
Last edited by Fly-by-Desire; 16th Jul 2010 at 03:13.
Another option is that the engine that was shut down wasn't in fact the failed one, this was masked by the power reduction for descent, and only became apparent when power was increased again to try and maintain height. Just a theory, but it certainly would not be unprecedented, in fact I know of another Mojave engine failure where exactly this happened. Luckily he got it restarted!
Gidday PA39,
0 feet at 3 nm but 1500 at 12 nm, when if on profile he should have been at around 4000! Sadly the die had been cast, you can see it in the inexorable decline back to vyse, and then below!!! but still no mayday! Of course a Mayday at that stage would have been academic, but it begs the question, just when did the pilot realise he didn't have performance on the "good" engine?
As I said, it just makes me want to cry. For the record, I probably would have headed to BK as well, especially if I had several thousand feet up my sleeve, and certainly if the Wx at RIC was suspect.
The decision not to adopt a driftdown as part of the initial action may have been the last or perhaps the second last hole in the cheese. Where I work, we don't have a choice. Fail to adopt a driftdown in a sim exercise and you run the risk of being stood down. On the surface it may seem that this policy is overly ridgid. I even find myself rolling my eyes at some of the more pedantic procedures, but they're enforced for a reason, and they've been developed on the back of previous accident statistics.
Does the PIC have the right to deviate from these procedures? Absolutely, but you need to have a good reason (taking stock). We all need a starting point when the **** hits the fan. In the heat of battle, we as human beings can sometimes jump to a less than optimun course of action. If pilots are trained to imediately adopt the safest course of action, then they will be in a better position to exploit that advantage when something else crops up. I know from my own training in G/A, there was the minimum Regulatory requirement, and then, if you were lucky, the initiatives of the training processes of your subsequent employers. If people learn from this, then hopefully Andrew and Kathy would not have gone down in vain.
0 feet at 3 nm but 1500 at 12 nm, when if on profile he should have been at around 4000! Sadly the die had been cast, you can see it in the inexorable decline back to vyse, and then below!!! but still no mayday! Of course a Mayday at that stage would have been academic, but it begs the question, just when did the pilot realise he didn't have performance on the "good" engine?
As I said, it just makes me want to cry. For the record, I probably would have headed to BK as well, especially if I had several thousand feet up my sleeve, and certainly if the Wx at RIC was suspect.
The decision not to adopt a driftdown as part of the initial action may have been the last or perhaps the second last hole in the cheese. Where I work, we don't have a choice. Fail to adopt a driftdown in a sim exercise and you run the risk of being stood down. On the surface it may seem that this policy is overly ridgid. I even find myself rolling my eyes at some of the more pedantic procedures, but they're enforced for a reason, and they've been developed on the back of previous accident statistics.
Does the PIC have the right to deviate from these procedures? Absolutely, but you need to have a good reason (taking stock). We all need a starting point when the **** hits the fan. In the heat of battle, we as human beings can sometimes jump to a less than optimun course of action. If pilots are trained to imediately adopt the safest course of action, then they will be in a better position to exploit that advantage when something else crops up. I know from my own training in G/A, there was the minimum Regulatory requirement, and then, if you were lucky, the initiatives of the training processes of your subsequent employers. If people learn from this, then hopefully Andrew and Kathy would not have gone down in vain.
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Bushy (post 28), 404 Titan (post 26),
You have summed up exactly what I was going to reply to in Jamairs post about the usefulness of piston twins in aeromed.
The line about 'tired old airframes from 30 years ago, certified back in the day' gets trotted out far to often, and nobody that has brung it out has defined why this is the case. An aircraft with 6000 hours would more than likely be on near new engines (assuming tbo 2000hrs) and the engineering tolerances in the airframe would not be so far gone to cause a negative climb performance. If you can explain to me why this should be the case, I am very willing to listen.
There are aeromed Kingairs out there with 20,000+ hours on them. And yet, Kingairs are able to crash just as poorly as anything that leaves the ground.
I have had a failure in a chieftain 700' high after takeoff with 6 pob, baggage and full mains in north west NSW in january in the rain, and the aircraft performed exactly as I expected. Once securing the engine, it was able to climb straight ahead until reaching 1000' where i returned for an uneventful landing.
In a perfect world with no financial constraints, I am sure that the government charged with transporting patients around the state for whatever reason would love to have everyone ferried around in the latest turbine/turboprop offering from Rayethon/Piaggio/Cessna/Pilatus/whoever but nobody in the government and the private sector can do that. The RFDS are a charity (one also well funded by the government) and mostly concern themselves with Pri-1's (yes, I know they do much more!). Pri-2/3's are sometimes carried by them and by other private sector companies charged with that duty by the state government. Much like the ambo's in sydney, there are also private companies driving around lesser (older/slower/lower medical equipment levels) 'patient transfer' vans that have government contracts.
I cannot say it better than bushy -
You have summed up exactly what I was going to reply to in Jamairs post about the usefulness of piston twins in aeromed.
The line about 'tired old airframes from 30 years ago, certified back in the day' gets trotted out far to often, and nobody that has brung it out has defined why this is the case. An aircraft with 6000 hours would more than likely be on near new engines (assuming tbo 2000hrs) and the engineering tolerances in the airframe would not be so far gone to cause a negative climb performance. If you can explain to me why this should be the case, I am very willing to listen.
There are aeromed Kingairs out there with 20,000+ hours on them. And yet, Kingairs are able to crash just as poorly as anything that leaves the ground.
I have had a failure in a chieftain 700' high after takeoff with 6 pob, baggage and full mains in north west NSW in january in the rain, and the aircraft performed exactly as I expected. Once securing the engine, it was able to climb straight ahead until reaching 1000' where i returned for an uneventful landing.
In a perfect world with no financial constraints, I am sure that the government charged with transporting patients around the state for whatever reason would love to have everyone ferried around in the latest turbine/turboprop offering from Rayethon/Piaggio/Cessna/Pilatus/whoever but nobody in the government and the private sector can do that. The RFDS are a charity (one also well funded by the government) and mostly concern themselves with Pri-1's (yes, I know they do much more!). Pri-2/3's are sometimes carried by them and by other private sector companies charged with that duty by the state government. Much like the ambo's in sydney, there are also private companies driving around lesser (older/slower/lower medical equipment levels) 'patient transfer' vans that have government contracts.
I cannot say it better than bushy -
I am saddened to see that some posts on here appear to to criticise the integrity of the operation, (dung heap etc) and by association, the people involved.
RatSore,
I don't think the NSW Government is bleeding with financial stress (correct me if I'm wrong, been a few years since I lived there). And it's more the WAY they are funding the aeromed side of NSW Health which is causing these transfers to happen in the way they are.
I am open to correction, but I have a family member involved in the scene, so I believe my info is quite correct.
When a patient requires transfer by air, the cost of the transfer is taken out of the budget of the health district where the patient is being taken from. So, as has been said, why do it the expensive way of RFDS'ing (Air Ambulance) the patient out, when a cheaper means of some charter company arriving in a Baron or a Chieftain for example, can be sourced?
As far as I know, this is the ONLY state where this occurs! What an absolute disgrace.
This is not the fault of the patient, it's not the fault of the nurses at the local hospitals, it's not the fault of the managers of the health districts, it is the fault of the bosses of NSW Health!
404 Titan,
Yes, that's probably the better way of wording it. Less Experienced, as opposed to Inexperienced.
morno
I don't think the NSW Government is bleeding with financial stress (correct me if I'm wrong, been a few years since I lived there). And it's more the WAY they are funding the aeromed side of NSW Health which is causing these transfers to happen in the way they are.
I am open to correction, but I have a family member involved in the scene, so I believe my info is quite correct.
When a patient requires transfer by air, the cost of the transfer is taken out of the budget of the health district where the patient is being taken from. So, as has been said, why do it the expensive way of RFDS'ing (Air Ambulance) the patient out, when a cheaper means of some charter company arriving in a Baron or a Chieftain for example, can be sourced?
As far as I know, this is the ONLY state where this occurs! What an absolute disgrace.
This is not the fault of the patient, it's not the fault of the nurses at the local hospitals, it's not the fault of the managers of the health districts, it is the fault of the bosses of NSW Health!
404 Titan,
Yes, that's probably the better way of wording it. Less Experienced, as opposed to Inexperienced.
morno
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Morno
When a patient requires transfer by air, the cost of the transfer is taken out of the budget of the health district where the patient is being taken from.
I don't think the NSW Government is bleeding with financial stress (correct me if I'm wrong, been a few years since I lived there).
The reason they are not bleeding is because they have been bled out! NSW health have anyway. My other half is a senior nurse (Nursing Unit Manager) and they have to bring their own cutlery to work, cos the dept can't afford disposable plastic knives and forks! Staff cutbacks, training budgets have up and disappeared. The doc's and nurses are all being forced to do more with less.
As I said, in my perfect world, if I scraped my knee out in the bush, the state government would rush a team of specialists out to my location in the lastest Avanti to patch me up. Whether we like it or not, everything has a cost to it, and the government will continue to apply the cost/benefit analysis to it.
All that aside, I still believe that a 6000hr Mojave is suitable for this job. I wouldn't be sending a busted old s$@tbox to do it (VH-SAO?!) but if the aircraft is not fit for flying paitent transfers, then in reality, it is not fit to fly full stop! The purpose of the flight and payload often has little bearing on why something went bad (overloading/DG/show-boating/etc aside, before everyone flames me!!) If PGW was full of the same weight of stuffed animals it wouldn't have made a difference.
Disclaimer - Just my opinion!
PS -
As far as I know, this is the ONLY state where this occurs!
Last edited by RatsoreA; 16th Jul 2010 at 01:33. Reason: Added PS
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More info needed...........
I don't think we can yet conclude that the pilot was actually 'throwing away altitude' to comply with ATC as has been suggested. If you read the sequence it states all the level clearances for descent as they were given, but the aircraft was already below the previous nominal altitude. It may be a case of the ATC clearance being given reprospectively as he had already descended through the previous cleared level. In other words ATC may have been watching the descent and just giving him the airspace so he didn't have to worry about the traffic/terrain at that point. I can't conclude whether the descent was dictated by lack of aircraft performance or by a decision of the pilot.
If I had no doubt about my aircraft's ability to hold height I wouldn't commit to an engine out landing in fog when there's an better airport a short distance away.
Conversely if I had an aircraft which was definately unable to maintain altitude I would then be very interested in a nearby runway even if it did have fog.
The variable of performance would be very much what determined my decision.
Piston twins do have very real performance limitations but for a simple failure and shutdown even if it wasn't performing I'd be thinking a descent rate of approx 200 fpm with everything secured, not the 800-1000 fpm we had here. (I've got just short of 2000 hours in Chieftains, albeit a long time ago.) Perhaps the failure was NOT so simple. I still think there is more to this than we know yet.
More info needed.............
If I had no doubt about my aircraft's ability to hold height I wouldn't commit to an engine out landing in fog when there's an better airport a short distance away.
Conversely if I had an aircraft which was definately unable to maintain altitude I would then be very interested in a nearby runway even if it did have fog.
The variable of performance would be very much what determined my decision.
Piston twins do have very real performance limitations but for a simple failure and shutdown even if it wasn't performing I'd be thinking a descent rate of approx 200 fpm with everything secured, not the 800-1000 fpm we had here. (I've got just short of 2000 hours in Chieftains, albeit a long time ago.) Perhaps the failure was NOT so simple. I still think there is more to this than we know yet.
More info needed.............
morno
Both NSW and QLD are in the largest financial mess since the Great Depression. Mix in corruption and incompetence and is it any wonder they are in the mess they are in.
Both NSW and QLD are in the largest financial mess since the Great Depression. Mix in corruption and incompetence and is it any wonder they are in the mess they are in.
Have a look at the speeds Nuthinondaclock. Not untill the A/C levelled off at 1500 feet and 12 miles did the speed even come within a bulls roar of vyse! If vyse was adopted from the biginning, the ROD would have to have been less, and probably significantly less.
I realise from ATC data that they were groundspeeds, but lets say vyse was adopted from the beginning and the A/C was experiencing a 50-60 knot tailwind at altitude. If the IAS was at or around vyse and the ROD's were around 700-1000 FPM then I would suggest in a PA31 you are essentially a glider, and any rational person would have told ATC such.
Whilst I agree that more info is needed, I cannot for the life of me conclude anything other than the pilot did in fact throw away altitude.
Hopefully the investigation may determine why?
I realise from ATC data that they were groundspeeds, but lets say vyse was adopted from the beginning and the A/C was experiencing a 50-60 knot tailwind at altitude. If the IAS was at or around vyse and the ROD's were around 700-1000 FPM then I would suggest in a PA31 you are essentially a glider, and any rational person would have told ATC such.
Whilst I agree that more info is needed, I cannot for the life of me conclude anything other than the pilot did in fact throw away altitude.
Hopefully the investigation may determine why?
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Removed due to having been falsely accused of being associated with the media. Thank you to those who may have understood what I saw and heard that day but this being the internet, I could protest my honesty about my employment until I am blue in the face and get nowhere.
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Additionally the tracking the aircraft took was not as direct as could have been, would have been wiser to request direct tracking to final approach for bk, and when approaching abeam RIC, after assessing performance output of the aircraft vs wx decision to continue or a turn onto the ILS as appropriate. I think if the remaining engine had a problem he also would have reported it so and as stated by krusty the ground speeds and rates of descent are fairly conclusive to the aircraft not being at vyse and the pilot descending to conform to ATC requests, anticipating the performance of his ship to be sufficient. Unfortunately bottom of descent is the worst place to find out where you stand performance wise.
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Oh Dear, this will be controversial....VYSE is best S/E ROC.....why would you wish to climb? Keeping clear of VMCA to maintain altitude is more important. He wanted to MAINTAIN altitude, not gain altitude. My point being, blue line is a book figure only, in reality it may not give you the best ROC or in this case ROD. Nurse the "good engine, don't flog it to death. MCP for extended periods in a 31 is inviting trouble. Doesn't take long for everything to go into the red. Look, this bloke had enough hours in them to know what goes on.....something was amiss with the live engine. It was all downhill for him. I reckon his fate was sealed very early in the situation.
FWIW, I have often failed outboard engines while turning inbound in a non precision approach and was always flabbergasted why some people applied full power (parrot fashion) to the live engine and adopt vyse.... and commence a climb....when in fact they are on approach and want the thing to go down!! Most of the time in the melee they end up in no mans land at some ungodly altitude when in fact the rwy was almost in front of them and not far away. Different circumstances call for different reactions.
Good posts Krusty!
FWIW, I have often failed outboard engines while turning inbound in a non precision approach and was always flabbergasted why some people applied full power (parrot fashion) to the live engine and adopt vyse.... and commence a climb....when in fact they are on approach and want the thing to go down!! Most of the time in the melee they end up in no mans land at some ungodly altitude when in fact the rwy was almost in front of them and not far away. Different circumstances call for different reactions.
Good posts Krusty!
Thanks for the endorsement PA39, but I think you're missing my point.
The Mojave will not maintain 7000 feet one engine at 165 Knots! If the "good engine" was performing correctly, then I agree that vyse would possibly create a climb, and I stress possibly. The time however to find out if the "good engine" is indeed good is whilst you have altitude to spare, assuming the sitution occurs at alitude as this one did.
A drift down should be at vyse. Vyse may not be required however to maintain height, but you must move towards vyse in order to determine the performance available. Also, I don't believe his fate was sealed from the beginning if the "good engine" was crook from the start. A performance check (vyse and MCP on the live engine) would have given him the information he needed to conduct a low power/glide aproach to RIC or even time to pick a more suitable landing place than Canley Vale road!
As far as having enough hours to know what's going on with the live engine? Very subjective statement I'm afraid. I like to think that the hours I had on that type, and my years of subsequent experience has helped me realise that it's not over untill it's off an chocked.
Tragically for this pilot and his passenger, the lesson, if he were to have learnt from it, has come at the ultimate price.
The Mojave will not maintain 7000 feet one engine at 165 Knots! If the "good engine" was performing correctly, then I agree that vyse would possibly create a climb, and I stress possibly. The time however to find out if the "good engine" is indeed good is whilst you have altitude to spare, assuming the sitution occurs at alitude as this one did.
A drift down should be at vyse. Vyse may not be required however to maintain height, but you must move towards vyse in order to determine the performance available. Also, I don't believe his fate was sealed from the beginning if the "good engine" was crook from the start. A performance check (vyse and MCP on the live engine) would have given him the information he needed to conduct a low power/glide aproach to RIC or even time to pick a more suitable landing place than Canley Vale road!
As far as having enough hours to know what's going on with the live engine? Very subjective statement I'm afraid. I like to think that the hours I had on that type, and my years of subsequent experience has helped me realise that it's not over untill it's off an chocked.
Tragically for this pilot and his passenger, the lesson, if he were to have learnt from it, has come at the ultimate price.
Last edited by KRUSTY 34; 16th Jul 2010 at 05:14.
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KRUSTY 34
I would have to agree. And it makes some sense - if you believe that you are in an aircraft that should easily maintain at least say, 1000' altitude on one engine, nowhere near max gross, with no weather issues. He was probably convinced that he would have no problems reaching Bankstown... so in that situation, it isn't entirely surprising that he would do so.
PA39
You don't... but you do need to establish that you can if you need to (missed approach for example). In any case it is close to the most efficient speed for the driftdown.
It will always be closer than anything else you can come up with in an emergency - that's why they put that nice easy blue line there!
Well maybe, but no all that relevant as all he had to do was descend... no need for MCP in the situation he was in (until it was too late, anyway).
That's really the only explanation that makes any sense... however it begs the question, why didn't he recognise the problem earlier and carry out a controlled forced landing? There are plenty of big green spaces along his track that would have been fine... better than trying to land on a narrow road filled with obstructions. He seems to have left it far too late to accept that he wasn't going to make Bankstown... and that was what got him (them) in the end.
I cannot for the life of me conclude anything other than the pilot did in fact throw away altitude.
PA39
VYSE is best S/E ROC.....why would you wish to climb?
My point being, blue line is a book figure only, in reality it may not give you the best ROC or in this case ROD.
Nurse the "good engine, don't flog it to death. MCP for extended periods in a 31 is inviting trouble. Doesn't take long for everything to go into the red.
something was amiss with the live engine. It was all downhill for him. I reckon his fate was sealed very early in the situation.
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Remoak and Krusty...good posts! points taken. Out of interest Whats the service ceiling for the Mojave on one? What altitude is it REQUIRED as per regs to be able to maintain on one engine??
When i said that he had enough hours to know whats going on i meant that he should have known his aircraft and its capabilities in all configurations and maybe situations.
Good on ya krusty....no charge for the endorsement (you're funny Muriel!)
Best regards to you both
When i said that he had enough hours to know whats going on i meant that he should have known his aircraft and its capabilities in all configurations and maybe situations.
Good on ya krusty....no charge for the endorsement (you're funny Muriel!)
Best regards to you both
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I still think there's a good chance there's more to it
G'day Krusty,
I'm not saying definatively that what I suggested occured I'm just pointing out that I believe it's too early to make hard conclusions. I saw the speeds and yes it is obvious that in the later stages of the flight they had run out of 'cash in the hand' and 'money in the bank'. Was the seriousness of the lack of performance not realised until too late or did the failure escalate. We don't know whether he was trying to deal with a significant controllability issue which may be good reason not to slow to Vyse or even what the specific failure was.
That he had problems holding a vector to final could again suggest controllability issues or equally have been to remain VMC or find a suitable forced landing area. Or it could be something else that none of us have even thought of. What I'm again getting at is that we only have a very small amount of information to go on and what I have seen repeatedly with many accident investigations is that there is usually much more to the event than is initially thought.
Look, maybe he did make an error of judgement in not realising the seriousness of the situation. If so we'll find out in good time but I hate seeing a bloke being pre-judged with insufficent info, particularly when he's not around to defend himself.
100.above,
I agree a reassesment passing RIC would be a top idea. Reassesment of a decision if circumstances change is always appropriate. As I said above I still don't agree that we can yet concluded that the descent was to conform to ATC, more so since the ATC assigned levels were given after he had already descended in all the given examples in the initial report.
I'm not saying definatively that what I suggested occured I'm just pointing out that I believe it's too early to make hard conclusions. I saw the speeds and yes it is obvious that in the later stages of the flight they had run out of 'cash in the hand' and 'money in the bank'. Was the seriousness of the lack of performance not realised until too late or did the failure escalate. We don't know whether he was trying to deal with a significant controllability issue which may be good reason not to slow to Vyse or even what the specific failure was.
That he had problems holding a vector to final could again suggest controllability issues or equally have been to remain VMC or find a suitable forced landing area. Or it could be something else that none of us have even thought of. What I'm again getting at is that we only have a very small amount of information to go on and what I have seen repeatedly with many accident investigations is that there is usually much more to the event than is initially thought.
Look, maybe he did make an error of judgement in not realising the seriousness of the situation. If so we'll find out in good time but I hate seeing a bloke being pre-judged with insufficent info, particularly when he's not around to defend himself.
100.above,
I agree a reassesment passing RIC would be a top idea. Reassesment of a decision if circumstances change is always appropriate. As I said above I still don't agree that we can yet concluded that the descent was to conform to ATC, more so since the ATC assigned levels were given after he had already descended in all the given examples in the initial report.
At The Time
Hopefully the investigation team to this sad event can get to the bottom of it quickly & with exact reasons so we can all learn from this.
Some good posts here so maybe we are all learning already.
What we train for & what we do in an actual situation can at times be totally different. I know of guys with 1000's of hrs on type get in a Sim for their 6 monthly check & shut down the wrong engine. Not saying this is the case here just an observation as to how we humans behave under duress.
Why we do something totally opposite to what we know is unknown & I reckon we shall never fully understand the human mind.
I've seen/heard of guys who have an engine fire (under Sim conditions) thrash around like a shark out of water just after T/of to shut down the engine. Shear madness! What you end up with is a high risk of shutting down the wrong donk, going from a fire with both engines still turning & climbing close to normal to a SE operation at low ALT on now one donk still with the fire! Just some Eg's how we can all react under stress.
This particular case where the Mojave lost an engine for whatever reason ended in tragedy thru like all accidents do it's a chain of events.
Okay what we seem to know so far is that the A/C started out with around 7000 ft left with one engine still running most likely fully serviceable at first. Whether that engine deteriorated during the next few minutes is still unknown. As has been mentioned here Vyse is just a book figure used under ideal conditions etc. It's for want of a better word the best L/D ratio to clb an A/C on one donk. Seeing as Alt wasn't a consideration here meaning that the guy was well above terrain the use of any excess pwr was needed only for maintaining level flt or to reduce the ROD to a Min. The A/C's grnd Spd as mentioned in the prem report was all over the place so no constant Spd was maintained during the subsequent decent for whatever reason this was probably the guys downfall. Something was amiss there.
More known facts. It's fairly obvious that given the dist to run to BK the height at the start of the sequence it was very doable but we don't have ALL the facts here yet.
With one engine left & quite possibly failing due the continuous high pwr setting left the pilot with a higher ROD than expected, this situation would have been overwhelming to him am sure, would have been to all of us.
Was Rich an option? Sure but going past Rich was I would say probably a good idea due wx...AT THE TIME, he made that decision right there & then, no turning back. I bet most of us would have done exactly the same thing, continue on 'cause remember at the time he was still high & not in a no win situation.
He would have had some commercial pressure on him ( nature of the beast) even if personal as in he wanted to get back to BK for reasons we shall never know so BK was the only destination he would have had in his mind, again AT THE TIME.
The guy didn't express the severe nature of the emergency thru a Mayday call, this usually means two things. He's fairly confident that he was going to make it or he was overwhelmed with what was going on under his ass & simply was prioritizing the situation meaning aviate nav & comms. We all 'default' to some level of handling a risky scenario.
When it became obvious that he wasn't going to make BK then raw instincts kick in. Bugga the rules & or trying to save face if indeed he was even thinking that but like him we are again all human so where am I going to put this thing down. At that very point in time when the situation became B&W (crash was minutes away) the stress levels & decision making went haywire, would for all of us especially in GA where training isn't as often or thorough as the Airlines
Now faced with a failing other engine (at a guess) & very low airspeed & very low Alt this guy just went along for the ride to the very end. I'm not saying he didn't keep trying to land safely but faced with virtually zero safe options we would all under the same circumstances just be part of the blur that he was faced with. This event would have been accelerating beyond belief at this point in time!
Nobody will ever know what this guy was thinking during the whole event other than what we know thru R/T etc but it must have been surreal for him & I gotta feel for the guy as he is no diff than the rest of us, fallible to all the things that we humans do under duress.
Right or wrong we all make mistakes in an ideal world we would be perfect specimens but aviation is one frontier that is far from perfect meaning we have to adapt & do what we can AT THE TIME:0).
We all await the last page to this story, the story for these two that is now closed so we can 'read' it learn from it to make our book of life last longer.
Wmk2
Some good posts here so maybe we are all learning already.
What we train for & what we do in an actual situation can at times be totally different. I know of guys with 1000's of hrs on type get in a Sim for their 6 monthly check & shut down the wrong engine. Not saying this is the case here just an observation as to how we humans behave under duress.
Why we do something totally opposite to what we know is unknown & I reckon we shall never fully understand the human mind.
I've seen/heard of guys who have an engine fire (under Sim conditions) thrash around like a shark out of water just after T/of to shut down the engine. Shear madness! What you end up with is a high risk of shutting down the wrong donk, going from a fire with both engines still turning & climbing close to normal to a SE operation at low ALT on now one donk still with the fire! Just some Eg's how we can all react under stress.
This particular case where the Mojave lost an engine for whatever reason ended in tragedy thru like all accidents do it's a chain of events.
Okay what we seem to know so far is that the A/C started out with around 7000 ft left with one engine still running most likely fully serviceable at first. Whether that engine deteriorated during the next few minutes is still unknown. As has been mentioned here Vyse is just a book figure used under ideal conditions etc. It's for want of a better word the best L/D ratio to clb an A/C on one donk. Seeing as Alt wasn't a consideration here meaning that the guy was well above terrain the use of any excess pwr was needed only for maintaining level flt or to reduce the ROD to a Min. The A/C's grnd Spd as mentioned in the prem report was all over the place so no constant Spd was maintained during the subsequent decent for whatever reason this was probably the guys downfall. Something was amiss there.
More known facts. It's fairly obvious that given the dist to run to BK the height at the start of the sequence it was very doable but we don't have ALL the facts here yet.
With one engine left & quite possibly failing due the continuous high pwr setting left the pilot with a higher ROD than expected, this situation would have been overwhelming to him am sure, would have been to all of us.
Was Rich an option? Sure but going past Rich was I would say probably a good idea due wx...AT THE TIME, he made that decision right there & then, no turning back. I bet most of us would have done exactly the same thing, continue on 'cause remember at the time he was still high & not in a no win situation.
He would have had some commercial pressure on him ( nature of the beast) even if personal as in he wanted to get back to BK for reasons we shall never know so BK was the only destination he would have had in his mind, again AT THE TIME.
The guy didn't express the severe nature of the emergency thru a Mayday call, this usually means two things. He's fairly confident that he was going to make it or he was overwhelmed with what was going on under his ass & simply was prioritizing the situation meaning aviate nav & comms. We all 'default' to some level of handling a risky scenario.
When it became obvious that he wasn't going to make BK then raw instincts kick in. Bugga the rules & or trying to save face if indeed he was even thinking that but like him we are again all human so where am I going to put this thing down. At that very point in time when the situation became B&W (crash was minutes away) the stress levels & decision making went haywire, would for all of us especially in GA where training isn't as often or thorough as the Airlines
Now faced with a failing other engine (at a guess) & very low airspeed & very low Alt this guy just went along for the ride to the very end. I'm not saying he didn't keep trying to land safely but faced with virtually zero safe options we would all under the same circumstances just be part of the blur that he was faced with. This event would have been accelerating beyond belief at this point in time!
Nobody will ever know what this guy was thinking during the whole event other than what we know thru R/T etc but it must have been surreal for him & I gotta feel for the guy as he is no diff than the rest of us, fallible to all the things that we humans do under duress.
Right or wrong we all make mistakes in an ideal world we would be perfect specimens but aviation is one frontier that is far from perfect meaning we have to adapt & do what we can AT THE TIME:0).
We all await the last page to this story, the story for these two that is now closed so we can 'read' it learn from it to make our book of life last longer.
Wmk2