VH-PGW ATSB report
I will be interested to see what the CASA puts out in regard to the recommended additional OEI guidance material for engine handling.
The final report is,.. well a report, thorough in some areas wanting in others, no doubt the condition of the wreckage made it very difficult.
But the thoroughness seems focused on audit outcomes and C&T processes, relevant yes, but I really wanted to learn and understand more about the mechanical issues at play. Particularly in light of the history of so many in flight engine issues recorded in the last 4 years, including surging.
Uneven fuel distribution, perhaps, after all they did find one faulty injector, although undetermined as to what when it failed (pre/post crash) but I am not really buying it. FCU issue/fault seems more plausible, but you would possibly still have even distribution, just not the correct A/F ratios. No history on the FCU given in the report, or I missed it.
This report might well be grist to the mill for the likes of John Deakin and co. as had it just been a plugged injector blocking and un blocking and the A/C had (maybe it did??) a more comprehensive EIS the pilot may have seen it for what it was and elected to just reduce power on the R/H and return gracefully. Somewhat supposition though.
I cannot help but feel that the aircraft themselves should be subject to some form of compliance process other than just a CAO statement that it must achieve 1% gradient to 5000’. The pilots get grilled over and over again on performance, but what about the aircrafts performance.
Perhaps a phase in of a structured ongoing audit process on commercial low performance twins where they physically demonstrate the ability to achieve book figures. Those that fall short have a MTOW penalty imposed and an amended MTOW inserted into the AFM. Perhaps a two tier requirement non pax and pax services.
If I were a pax on board I would like to know that the young hour building pilot up front of a low performance twin had at least an aircraft that will afford him a modicum of performance on one.
The final report is,.. well a report, thorough in some areas wanting in others, no doubt the condition of the wreckage made it very difficult.
But the thoroughness seems focused on audit outcomes and C&T processes, relevant yes, but I really wanted to learn and understand more about the mechanical issues at play. Particularly in light of the history of so many in flight engine issues recorded in the last 4 years, including surging.
Uneven fuel distribution, perhaps, after all they did find one faulty injector, although undetermined as to what when it failed (pre/post crash) but I am not really buying it. FCU issue/fault seems more plausible, but you would possibly still have even distribution, just not the correct A/F ratios. No history on the FCU given in the report, or I missed it.
This report might well be grist to the mill for the likes of John Deakin and co. as had it just been a plugged injector blocking and un blocking and the A/C had (maybe it did??) a more comprehensive EIS the pilot may have seen it for what it was and elected to just reduce power on the R/H and return gracefully. Somewhat supposition though.
I cannot help but feel that the aircraft themselves should be subject to some form of compliance process other than just a CAO statement that it must achieve 1% gradient to 5000’. The pilots get grilled over and over again on performance, but what about the aircrafts performance.
Perhaps a phase in of a structured ongoing audit process on commercial low performance twins where they physically demonstrate the ability to achieve book figures. Those that fall short have a MTOW penalty imposed and an amended MTOW inserted into the AFM. Perhaps a two tier requirement non pax and pax services.
If I were a pax on board I would like to know that the young hour building pilot up front of a low performance twin had at least an aircraft that will afford him a modicum of performance on one.
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atsb and the validity of reports
I have read the report by atsb - Agree with Jabs - "FAIL"
Lets have a look at some of what is missing in the atsb report:
And from Obidah:
Well, the history that atsb reports should have identified maintenance problems, yet no reccomendations.
The reference by atsb to casa is as follows:
Yet the AOC is removed by casa.
Do we have yet another failure by casa to surveil, and an attempt to "cover up" the fact by "executing" the AOC holder in the AAT??
PLEASE EXPLAIN Mr. casa and Mrs casa [sorry - atsb]
Lets have a look at some of what is missing in the atsb report:
- Maintenance Issues
- The "surging engine";
- The effect of the regulator
And from Obidah:
Uneven fuel distribution, perhaps, after all they did find one faulty injector, although undetermined as to what when it failed (pre/post crash) but I am not really buying it. FCU issue/fault seems more plausible, but you would possibly still have even distribution, just not the correct A/F ratios. No history on the FCU given in the report, or I missed it.
The reference by atsb to casa is as follows:
CASA audit and surveillance
No organisational or systemic issue was identified in respect of CASA’s surveillance that might adversely affect the future safety of aviation operations.
However, during the investigation CASA advised that, in September 2010, it had commenced a Certificate Management Team approach to its audit and surveillance activities.
This change was intended to improve the evaluation capability across CASA, allow the more effective assignment of resources, increase knowledge sharing, clarify defined roles and responsibilities, and foster standardisation and consistency.
No organisational or systemic issue was identified in respect of CASA’s surveillance that might adversely affect the future safety of aviation operations.
However, during the investigation CASA advised that, in September 2010, it had commenced a Certificate Management Team approach to its audit and surveillance activities.
This change was intended to improve the evaluation capability across CASA, allow the more effective assignment of resources, increase knowledge sharing, clarify defined roles and responsibilities, and foster standardisation and consistency.
Do we have yet another failure by casa to surveil, and an attempt to "cover up" the fact by "executing" the AOC holder in the AAT??
PLEASE EXPLAIN Mr. casa and Mrs casa [sorry - atsb]
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Obid,
Funny you should say this.
Well I was wondering if I should post the private correspondence I had over night with the very folk you mention. But seeing you make mention here goes, and to be fair I will post my email to the guys last night after I read the report.
And here is John Deakins reply, and I must say he has a few very interesting observations about what to do in such an emergency. If only I could learn half of what he has forgotten.
So along with that one and a few others, who likewise are struggling to see what value there was in this report, as it was not helpful in preventing further crashes, it was more like a police report to a coroner, which makes me think, whose job are they doing here?
A pilot and a flight nurse lost their lives here...surely they deserve better than this???
There was this comment from from Walter Atkinson, John Deakins associate at APS, who understands my position on all commercial ops having an EMS and pilots specifically trained how to understand what they display and not just stare and blinking numbers and bars.
Seems they share the same frustration.
‘consistent with uneven fuel distribution to the cylinders’.
Poor fuel distribution my arse, supply maybe
If the wreckage was that bad, that they could at best come up with that conclusion, they should not have been making any. Lycoming I think the prop people are the only sensible ones in this bit.
Rant over for now....not happy Jaba is going home from the office to cool down. Merry Christmas Y'all.
Funny you should say this.
This report might well be grist to the mill for the likes of John Deakin and co. as had it just been a plugged injector blocking and un blocking and the A/C had (maybe it did??) a more comprehensive EIS the pilot may have seen it for what it was and elected to just reduce power on the R/H and return gracefully. Somewhat supposition though.
Is this another ATSB report like the Whyalla report?
OK, not a bunch of fare paying pax, but a flight nurse, and an under trained pilot are dead.
Initial problem a “surging prop”
ATSB accept Lycomings response being surging from a fuel distribution problem.
Cause of the engine surging
The engine manufacturer advised that the surging identified by the spectral analysis of radio transmissions during the accident flight was ‘consistent with uneven fuel distribution to the cylinders’. The propeller manufacturer advised that it had ‘yet to find a causal factor in surging that was clearly identified as being from the propeller or governor, especially for a report of a large RPM excursion’.
I am perplexed at how this could be, in the climb with a TC engine surely full rich, the partial plugging of an injector would mean no noticeable power surging (if EMS equipped a rising EGT, TIT, and CHT on the affected cylinders) and not sufficient power loss that RPM variations occurred. If the injectors to one or more cylinders were such that they went excessively LOP and or beyond operational flows, it would have vibrated liked paint can mixer.
I find that hard to believe. Maybe I have a lot to learn.
In this case the PIC handled the whole event poorly, very poor on a number of fronts, and should not have shut it down completely and not descended at all until overhead YSBK. That aside….have the ATSB cocked this up like MZK?
Another good case for charter ops to have a fully functioning EMS and pilots educated to use and understand it.
OK, not a bunch of fare paying pax, but a flight nurse, and an under trained pilot are dead.
Initial problem a “surging prop”
ATSB accept Lycomings response being surging from a fuel distribution problem.
Cause of the engine surging
The engine manufacturer advised that the surging identified by the spectral analysis of radio transmissions during the accident flight was ‘consistent with uneven fuel distribution to the cylinders’. The propeller manufacturer advised that it had ‘yet to find a causal factor in surging that was clearly identified as being from the propeller or governor, especially for a report of a large RPM excursion’.
I am perplexed at how this could be, in the climb with a TC engine surely full rich, the partial plugging of an injector would mean no noticeable power surging (if EMS equipped a rising EGT, TIT, and CHT on the affected cylinders) and not sufficient power loss that RPM variations occurred. If the injectors to one or more cylinders were such that they went excessively LOP and or beyond operational flows, it would have vibrated liked paint can mixer.
I find that hard to believe. Maybe I have a lot to learn.
In this case the PIC handled the whole event poorly, very poor on a number of fronts, and should not have shut it down completely and not descended at all until overhead YSBK. That aside….have the ATSB cocked this up like MZK?
Another good case for charter ops to have a fully functioning EMS and pilots educated to use and understand it.
Your analysis is "spot on."
CASA (typo should be ATSB)discounts the effect of the landing gear warning horn (one throttle back, gear not down). From personal experience, I can tell you that can have a MAJOR effect on the human brain, and if loud enough, the noise alone can be utterly incapacitating. And I do mean incapacitating. I cannot help wondering if he'd just advanced the throttle on the feathered engine to get rid of the horn, the whole thing might have been avoided.
There's no mention at all of any ACTUAL shutdowns performed during training or proficiency checks, and a passing reference to the Chief Pilot not being an instructor, and therefore not authorized to conduct such training. The young pilot may not have been aware of what that horn was, or how to get rid of it.
Of course, there was apparently no reason to shut the engine down in the first place for the minor surging alone.
The surging sounds more like a problem with the prop governor or the flow of oil to/from the prop. Lycoming was willing to blame it on "something, anything else" to avoid liability.
They said that not having the correct bank angle probably would cost 20 to 30 feet per minute difference. I'd dispute that strongly, this alone might have had 200 to 500 fpm difference. The manual also suggests 5 degrees as optimum, which is not correct. That's a certification allowance for CONTROL at Vmc.
The whole report strikes me as self-serving for CASA. They have set forth massive requirements for Airmen of all levels, and specified paperwork and forms to be completed to show compliance. Many "Manuals", and other documents, most requiring some repetitive action within close time frames. They go into loving detail for all this, for 68 pages. It goes on and on, and it means nothing, distracting from the "real mission," which is to get there, safely.
Disgusting.
Best...
John Deakin
Advanced Pilot Seminars
CASA (typo should be ATSB)discounts the effect of the landing gear warning horn (one throttle back, gear not down). From personal experience, I can tell you that can have a MAJOR effect on the human brain, and if loud enough, the noise alone can be utterly incapacitating. And I do mean incapacitating. I cannot help wondering if he'd just advanced the throttle on the feathered engine to get rid of the horn, the whole thing might have been avoided.
There's no mention at all of any ACTUAL shutdowns performed during training or proficiency checks, and a passing reference to the Chief Pilot not being an instructor, and therefore not authorized to conduct such training. The young pilot may not have been aware of what that horn was, or how to get rid of it.
Of course, there was apparently no reason to shut the engine down in the first place for the minor surging alone.
The surging sounds more like a problem with the prop governor or the flow of oil to/from the prop. Lycoming was willing to blame it on "something, anything else" to avoid liability.
They said that not having the correct bank angle probably would cost 20 to 30 feet per minute difference. I'd dispute that strongly, this alone might have had 200 to 500 fpm difference. The manual also suggests 5 degrees as optimum, which is not correct. That's a certification allowance for CONTROL at Vmc.
The whole report strikes me as self-serving for CASA. They have set forth massive requirements for Airmen of all levels, and specified paperwork and forms to be completed to show compliance. Many "Manuals", and other documents, most requiring some repetitive action within close time frames. They go into loving detail for all this, for 68 pages. It goes on and on, and it means nothing, distracting from the "real mission," which is to get there, safely.
Disgusting.
Best...
John Deakin
Advanced Pilot Seminars
A pilot and a flight nurse lost their lives here...surely they deserve better than this???
There was this comment from from Walter Atkinson, John Deakins associate at APS, who understands my position on all commercial ops having an EMS and pilots specifically trained how to understand what they display and not just stare and blinking numbers and bars.
The presence of an engine monitor would have confirmed this and given the pilot useful info about a confusing situation. When are the Aussies gonna figure this EMS issue out?
Seems they share the same frustration.
‘consistent with uneven fuel distribution to the cylinders’.
Poor fuel distribution my arse, supply maybe
If the wreckage was that bad, that they could at best come up with that conclusion, they should not have been making any. Lycoming I think the prop people are the only sensible ones in this bit.Rant over for now....not happy Jaba is going home from the office to cool down. Merry Christmas Y'all.
I have printed the report but not yet read it. On first glance, I suspect that the ATSB has side stepped the more difficult issues that might have delivered some lessons.
Top in my mind, is that I can't imagine a pilot who has been dealing with an issue for several minutes and has a descent rate that knows is a problem is not going to push the throttle forward at some point. You might start out trying to be nice to the engines, but at some point I struggle to believe that desperation won't kick in and you'll push everything forward. I'm expecting to see some gaping gaps in logic from the ATSB here.
I disagree with the EMS bit. It wouldn't have changed a thing. The experience of the engine surging is going to over-ride what any instrument says. Either you can deal with the engine misbehaving to gain whatever residual power it will produce or you wont. EGT's can't help assess that.
We tend to think of aircraft fuel injection as more complex than it is. It is what the car racing guys call "piss & dribble". The injector is a brass fitting with a hole in it. It continuously sprays fuel into the inlet manifold at the back of the inlet valve. I'm going to read the ATSB analysis of this with interest.
Top in my mind, is that I can't imagine a pilot who has been dealing with an issue for several minutes and has a descent rate that knows is a problem is not going to push the throttle forward at some point. You might start out trying to be nice to the engines, but at some point I struggle to believe that desperation won't kick in and you'll push everything forward. I'm expecting to see some gaping gaps in logic from the ATSB here.
I disagree with the EMS bit. It wouldn't have changed a thing. The experience of the engine surging is going to over-ride what any instrument says. Either you can deal with the engine misbehaving to gain whatever residual power it will produce or you wont. EGT's can't help assess that.
We tend to think of aircraft fuel injection as more complex than it is. It is what the car racing guys call "piss & dribble". The injector is a brass fitting with a hole in it. It continuously sprays fuel into the inlet manifold at the back of the inlet valve. I'm going to read the ATSB analysis of this with interest.
I was in Bankstown yesterday and heard a rumour ATSB could only find one LAME in Australia with enough knowledge of a Mojave engine to properly supervise the tear-down.
...the same guy who built it
We operate similar aeroplanes and the Chief Pilot yesterday took the ATSB report, made a copy for every pilot in the company, and went through all the salient points asking for the crew's imput on where we might be making the same mistakes.
How many other Chief Pilots have picked it up and done the same?
...the same guy who built it
We operate similar aeroplanes and the Chief Pilot yesterday took the ATSB report, made a copy for every pilot in the company, and went through all the salient points asking for the crew's imput on where we might be making the same mistakes.
How many other Chief Pilots have picked it up and done the same?
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Leafie,
I know a guy in Adelaide who would have been ideal for the ATSB to use. They did not look too hard did they?
Akro....I concur with the first line. Much is missed.
As for the EMS bit, I and many others strongly disagree with you. Having said that, pilots who are not trained properly on how to understand their EMS may well be a "Deer in the headlights" and I would say that is 95%.
If the ATSB report of the No6 injector being completely blocked happened in flight, what was the obstruction material? Had there ben any fuel system work done recently? Surging engine RPM does not seem likely from a blocked injector. And yes, an EMS that displayed all the typical parameters such as fuel pressure and flow, EGT/TIT/CHT, oil data, accurate tacho, would have made understanding the problem far easier and allowed for better decisions to be made. Assuming they were understood. If it were partially blocked, that would have stood out like a sore thumb on an EMS. Fully or almost fully blocked that also would have stood out, but the engine would have been shaking itself off the mounts almost.They don't feel smooth on 5.
Your description of the fuel injection is completely accurate
And not very easy to completely block unless someone introduces lint or sealant in recent times. Unlike a car.
Reading the report makes you ask more questions than were answered.
I know a guy in Adelaide who would have been ideal for the ATSB to use. They did not look too hard did they?
Akro....I concur with the first line. Much is missed.
As for the EMS bit, I and many others strongly disagree with you. Having said that, pilots who are not trained properly on how to understand their EMS may well be a "Deer in the headlights" and I would say that is 95%.
If the ATSB report of the No6 injector being completely blocked happened in flight, what was the obstruction material? Had there ben any fuel system work done recently? Surging engine RPM does not seem likely from a blocked injector. And yes, an EMS that displayed all the typical parameters such as fuel pressure and flow, EGT/TIT/CHT, oil data, accurate tacho, would have made understanding the problem far easier and allowed for better decisions to be made. Assuming they were understood. If it were partially blocked, that would have stood out like a sore thumb on an EMS. Fully or almost fully blocked that also would have stood out, but the engine would have been shaking itself off the mounts almost.They don't feel smooth on 5.
Your description of the fuel injection is completely accurate
And not very easy to completely block unless someone introduces lint or sealant in recent times. Unlike a car.Reading the report makes you ask more questions than were answered.
Here is another thought....
...I just pulled out my PA31 manual and it stipulates 49.0" MAP as the maximum value up to 15,000'. In fact I am trying to remember the last time I saw a Chieftain pulling anything above 44.0".
It is common practice to "dial back" the max MAP on Chieftain engines to protect them from over-boosting by the pilots.
Who, then, is going to be protecting the pilots and the passengers from the under-boosting?
What is the maximum MAP set up on OGW or IGW or the other remaining Luft-tex Mojaves, or for that matter their Chieftains?
...I just pulled out my PA31 manual and it stipulates 49.0" MAP as the maximum value up to 15,000'. In fact I am trying to remember the last time I saw a Chieftain pulling anything above 44.0".
It is common practice to "dial back" the max MAP on Chieftain engines to protect them from over-boosting by the pilots.
Who, then, is going to be protecting the pilots and the passengers from the under-boosting?
What is the maximum MAP set up on OGW or IGW or the other remaining Luft-tex Mojaves, or for that matter their Chieftains?
Last edited by Horatio Leafblower; 22nd Dec 2012 at 02:20.
I've just finished reading the report and I'm a bit dumbfounded. I regularly either write or supervise engineering reports for both clients and as court reports. Overall, I think the ATSB document fails as an engineering report and I would question whether the author has sufficient technical understanding for the job. I find it interesting that it has a range of human factors texts cited in full Harvard referencing discipline. However there is no reference to technical and measurement equipment used, its calibration, not a discussion on the limits of accuracy.
This is not a technical document.. It fails any basic test as an engineering report.
Furthermore, the references to surging RPM and engine roughness through "uneven fuel distribution"are prima facie contradictory. I am concerned that the author does not understand the operation of a CSU. If the statement that the RH engine was exceeding the maximum permissible RPM is correct, then this points to a CSU issue, not an engine issue. The engine should not be able to make the propeller go faster than redline. This also fits the history of that aeroplane (which is glossed over by the ATSB). I might come back and side with John Deakins a little, because if an engine monitor showed normal EGT's it would have allowed the pilot to immediately deduct a propeller issue. Although the standard equipment TIT should be adequate for this. A single non firing cylinder should cause an overall drop in TIT.
The reports inclusion of un-named pilots opinion of the PGW pilots flying ability makes me as mad as hell. This is nothing better than reporting on gossip and has no place in a professional report. If the ATSB saw value in collecting opinions of the pilots ability beyond that of those tasked with doing so by the CASA regulations (ie Chief Pilot, ATO, etc) then the correct way is to conduct structured interviews, disclose the position of the interviewees, append the list of questions and cite quotations from individuals and / or conclusions while keeping the identity of those question confidential. This is easy, routine and practiced by the market research industry daily. Frankly, it makes the ATSB look like hack amateurs in my opinion.
In my opinion, the report also seems to indulge in gratuitous criticism of the operator and its operating discipline that is not germane to the accident. If this is an accident investigation, lets stick to the accident. If its a witch hunt, then lets call it that.
Here is my hypothesis & take home lessons.
1. It looks like PGW lost a lot of height before the engine was feathered and the pilot was trying to diagnose the issue. I'm not sure that I've really seen this discussed, but it sounds real. Its possibly a reminder that in some situations you might be better to go straight to feathering an engine rather than diagnose it.
2. The pilot did not immediately go to VYSE and I think this might be a reminder that regardless of altitude or descent profile, that this is the best practice.
3. It looks like the pilot has tried to fly a normal descent profile back to Bankstown. I can absolutely see how one could be suckered into this. In part its an attempt to manage stress and make things closer to normal and potentially a fear of arriving too high. There is a joke about forced landings in Pitts that you choose the landing spot by throwing a brick out and following it down. I think this is a reminder that you need to plan to be way high. Its better to land at an airport fast & high and run off, than not land at an airport.
4. The pilot tried to follow the directions of ATC. Once we have a problem, the pilot should be assertive in telling ATC what he needs. I'm disappointed there is no discussion in the report of whether ATC might not have played a more supportive role. The stuff about not making a PAN call is bureaucratic mis-direction. The controller knew it was an emergency. Some of the US radio transcripts of emergencies we read in magazines show the controllers taking an active role in coaching or supporting the pilots. Should we encourage that here? Would the outcome have been different if PGW had not been directed to descend from 5,000ft to 2,500ft, but instead have been allowed to continue at the pilots discretion?
5. Trying partial power asymmetric is not something I have experienced in my training. "Fire, Fix or Feather" is drummed into us. Is there a role for trying a partial power setting first?
6. There but for the grace of god.... I'm not sure how well I'd stand up to the personal scrutiny that the ATSB gives pilots. I'd like to think I wouldn't make the same errors as this guy. But he seemed a pretty good diligent pilot and in quiet moments, I'm not really sure how much better I might have done. Which is why we deserve decent ATSB reports.
This is not a technical document.. It fails any basic test as an engineering report.
Furthermore, the references to surging RPM and engine roughness through "uneven fuel distribution"are prima facie contradictory. I am concerned that the author does not understand the operation of a CSU. If the statement that the RH engine was exceeding the maximum permissible RPM is correct, then this points to a CSU issue, not an engine issue. The engine should not be able to make the propeller go faster than redline. This also fits the history of that aeroplane (which is glossed over by the ATSB). I might come back and side with John Deakins a little, because if an engine monitor showed normal EGT's it would have allowed the pilot to immediately deduct a propeller issue. Although the standard equipment TIT should be adequate for this. A single non firing cylinder should cause an overall drop in TIT.
The reports inclusion of un-named pilots opinion of the PGW pilots flying ability makes me as mad as hell. This is nothing better than reporting on gossip and has no place in a professional report. If the ATSB saw value in collecting opinions of the pilots ability beyond that of those tasked with doing so by the CASA regulations (ie Chief Pilot, ATO, etc) then the correct way is to conduct structured interviews, disclose the position of the interviewees, append the list of questions and cite quotations from individuals and / or conclusions while keeping the identity of those question confidential. This is easy, routine and practiced by the market research industry daily. Frankly, it makes the ATSB look like hack amateurs in my opinion.
In my opinion, the report also seems to indulge in gratuitous criticism of the operator and its operating discipline that is not germane to the accident. If this is an accident investigation, lets stick to the accident. If its a witch hunt, then lets call it that.
Here is my hypothesis & take home lessons.
1. It looks like PGW lost a lot of height before the engine was feathered and the pilot was trying to diagnose the issue. I'm not sure that I've really seen this discussed, but it sounds real. Its possibly a reminder that in some situations you might be better to go straight to feathering an engine rather than diagnose it.
2. The pilot did not immediately go to VYSE and I think this might be a reminder that regardless of altitude or descent profile, that this is the best practice.
3. It looks like the pilot has tried to fly a normal descent profile back to Bankstown. I can absolutely see how one could be suckered into this. In part its an attempt to manage stress and make things closer to normal and potentially a fear of arriving too high. There is a joke about forced landings in Pitts that you choose the landing spot by throwing a brick out and following it down. I think this is a reminder that you need to plan to be way high. Its better to land at an airport fast & high and run off, than not land at an airport.
4. The pilot tried to follow the directions of ATC. Once we have a problem, the pilot should be assertive in telling ATC what he needs. I'm disappointed there is no discussion in the report of whether ATC might not have played a more supportive role. The stuff about not making a PAN call is bureaucratic mis-direction. The controller knew it was an emergency. Some of the US radio transcripts of emergencies we read in magazines show the controllers taking an active role in coaching or supporting the pilots. Should we encourage that here? Would the outcome have been different if PGW had not been directed to descend from 5,000ft to 2,500ft, but instead have been allowed to continue at the pilots discretion?
5. Trying partial power asymmetric is not something I have experienced in my training. "Fire, Fix or Feather" is drummed into us. Is there a role for trying a partial power setting first?
6. There but for the grace of god.... I'm not sure how well I'd stand up to the personal scrutiny that the ATSB gives pilots. I'd like to think I wouldn't make the same errors as this guy. But he seemed a pretty good diligent pilot and in quiet moments, I'm not really sure how much better I might have done. Which is why we deserve decent ATSB reports.
Akro
I wouldn't be to quick to draw that conclusion, it is not unusual for an engine surging toward full power in flight to briefly exceed the governors ability to catch it at red line, mass inertia and all that. The report did not state the magnitude of the exceedence due to the sprectral measuring apparently topping out at 2600 RPM.
The exceedence may have been only a 100 RPM, enough to generate the comment in the report but not enough to consider abnormal. Difficult to make conclusive statements.
I have no idea as to the natural limitations of the spectral analysis equipment in the circumstances, but I for one would like to know how large the exceedance was.
Can't help but wonder if the ATSB was shaken to the core over the Whyalla report that ever since they have shyed away from technical analysis of pistons. So many of us backyard experts quick to internationally embarrass them if they get it wrong. Humans are nothing if not predictable.
I hope that from all this the training environments are encouraged to remove the "bogey man" mentality surrounding OEI training and encourage a more thorough and relaxed familiaristion to this regime of flight.
If the statement that the RH engine was exceeding the maximum permissible RPM is correct, then this points to a CSU issue, not an engine issue
The exceedence may have been only a 100 RPM, enough to generate the comment in the report but not enough to consider abnormal. Difficult to make conclusive statements.
I have no idea as to the natural limitations of the spectral analysis equipment in the circumstances, but I for one would like to know how large the exceedance was.
Can't help but wonder if the ATSB was shaken to the core over the Whyalla report that ever since they have shyed away from technical analysis of pistons. So many of us backyard experts quick to internationally embarrass them if they get it wrong. Humans are nothing if not predictable.
I hope that from all this the training environments are encouraged to remove the "bogey man" mentality surrounding OEI training and encourage a more thorough and relaxed familiaristion to this regime of flight.
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Looks like we are all pretty much on the same page. You have summed up my thoughts very well Akro. Thank you for articulating your post so well.
Now how will things change?
Now how will things change?
I don't see why ATC could not have given a clearance direct to Bankstown with decent at the pilots discretion. Like all accidents, there are a number of factors at play here, any one of which could change the outcome. PGW needed what possibly may have been as little as an extra 500ft to have made the airport. You've got to wonder if there had been no requirement to descend to 2,500 ft whether it might have made the difference. The controller directed PGW to give up altitude it had no opportunity to regain for the sake of operational expediency. I'm not blaming the controller or saying it would have prevented the accident. Its just another piece of Swiss cheese that the report is deficient in not having examined.
Secondly, I said publish the questions, not the answers. Absolutely standard practice for qualitative research. Interview technique 101. It demonstrates an objective framework and allows peer review without compromising the confidentiality of the participants. Once again, not being across these techniques would question the authors qualification for the task.
Secondly, I said publish the questions, not the answers. Absolutely standard practice for qualitative research. Interview technique 101. It demonstrates an objective framework and allows peer review without compromising the confidentiality of the participants. Once again, not being across these techniques would question the authors qualification for the task.
Obidiah
I get your point. An aerobatic aircraft going vertically down will not exceed the propeller RPM, so I based my judgement that a CSU will controll RPM under duress on that experience. I think your point is that transient fluctuations in engine RPM might cause the CSU to "overshoot".
My response is it might have been nice to have seen a paragraph discussing this point in the report. A discussion that this was considered in the report would eliminate our (my) speculation. Its a lightweight report that should not have taken 131 weeks.
I get your point. An aerobatic aircraft going vertically down will not exceed the propeller RPM, so I based my judgement that a CSU will controll RPM under duress on that experience. I think your point is that transient fluctuations in engine RPM might cause the CSU to "overshoot".
My response is it might have been nice to have seen a paragraph discussing this point in the report. A discussion that this was considered in the report would eliminate our (my) speculation. Its a lightweight report that should not have taken 131 weeks.
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I am surprised that the ATSB ave discounted the role of the type rating training in the accident and have not even mentioned the ongoing training in the factors. If I am understanding their logic this is because the pilot had flown a lot of hours post training.
It is not my intention to be critical of the pilot as I know my ability to deal with in flight malfunctions is largely based on high quality training that I have received, not my innate skill. But I can't escape the conclusion that the aircraft ultimately crashed because of the way the malfunction was handled. If OEI operations was not taught well on the type rating, and/or was not well trained during subsequent ICUS flying, and not checked properly during the company's regular checks on the pilot, then when does the ATSB think that he would have attained this knowledge during the hours he accumulated? It certainly would not have developed all by itself during the almost 800 hours on type where both engines were working or the 1,700 hours multi where both engines were working.
It is not my intention to be critical of the pilot as I know my ability to deal with in flight malfunctions is largely based on high quality training that I have received, not my innate skill. But I can't escape the conclusion that the aircraft ultimately crashed because of the way the malfunction was handled. If OEI operations was not taught well on the type rating, and/or was not well trained during subsequent ICUS flying, and not checked properly during the company's regular checks on the pilot, then when does the ATSB think that he would have attained this knowledge during the hours he accumulated? It certainly would not have developed all by itself during the almost 800 hours on type where both engines were working or the 1,700 hours multi where both engines were working.
HL that would have to be a very enlightened CP to have done this:
Unfortunately too many people do not read anything to do with flight safety even a report that is thin on some aspects of the flight. The reduction in standards of flight safety information coming from CASA and the ATSB certainly doesn't help. Posting on Prune is only preaching to the converted. Even if this report was the most stunning breakthrough in accident investigation it would not reach the hands of most of the people who would benefit most and that is the majority of GA M/E pilots. I don't even consider that its apathy or a "Gen Y" thing. The message needs to be taken to where the pilots work and that requires some sort of adequately resourced education group be it private or government. Unfortunately there is probably no money in it for private enterprise and there is no interest from government in really making a difference to GA safety.
We operate similar aeroplanes and the Chief Pilot yesterday took the ATSB report, made a copy for every pilot in the company, and went through all the salient points asking for the crew's imput on where we might be making the same mistakes.
I found the report disgusting.
I could have written a better report in a fortnight of what happened.
Basically the cause of the accident goes right to the heart of the culture of general aviation and CASA in Australia.
Insufficient training.
Operating in an often reckless manner from operational pressure in aircraft that are dubiously maintained.
Should a mojave be operating single Pilot doing the work it was doing? I think a Kingair or PC12 would be the prefered option.
To me, the fact the gear warning horn was blaring throughout the entire accident sequence suggest Willow was so loaded up, he had nowhere to go (mentally). He would have been operating at his peak processing ability. He found himself in a situation, probably was second guessing his actions (no pan call), and dreading the return to base to be told there was nothing wrong with his ship. Or to be picked apart for his actions. (from the report he had been put through the ringer on a air return due to pitch lever movement).
The fact he didn't lower any flap prior to the accident re-enforces my opinion of his processing ability.
Another hole in the cheese was when he heard a reassuring voice on the other end of the radio telling him to descend, and he complied.
I think ATC should clear you to your diversion airport with the instruction to descend at will. Or at least 'when ready'.
Imagine his family reading that report. Going from the son who saved the kids at the school and being called a hero, to an incompetent operator with a dubious history (from his so called peers) and selected comments from his training file to support the case. I'm surprised they didn't throw in the accident he had in Kununurra hitting a tree with an airvan wing. That would have made the report really spicy!
I wouldn't wipe my arse with that report.
I could have written a better report in a fortnight of what happened.
Basically the cause of the accident goes right to the heart of the culture of general aviation and CASA in Australia.
Insufficient training.
Operating in an often reckless manner from operational pressure in aircraft that are dubiously maintained.
Should a mojave be operating single Pilot doing the work it was doing? I think a Kingair or PC12 would be the prefered option.
To me, the fact the gear warning horn was blaring throughout the entire accident sequence suggest Willow was so loaded up, he had nowhere to go (mentally). He would have been operating at his peak processing ability. He found himself in a situation, probably was second guessing his actions (no pan call), and dreading the return to base to be told there was nothing wrong with his ship. Or to be picked apart for his actions. (from the report he had been put through the ringer on a air return due to pitch lever movement).
The fact he didn't lower any flap prior to the accident re-enforces my opinion of his processing ability.
Another hole in the cheese was when he heard a reassuring voice on the other end of the radio telling him to descend, and he complied.
I think ATC should clear you to your diversion airport with the instruction to descend at will. Or at least 'when ready'.
Imagine his family reading that report. Going from the son who saved the kids at the school and being called a hero, to an incompetent operator with a dubious history (from his so called peers) and selected comments from his training file to support the case. I'm surprised they didn't throw in the accident he had in Kununurra hitting a tree with an airvan wing. That would have made the report really spicy!
I wouldn't wipe my arse with that report.
Lookleft - are you suggesting we need something like "Aviation Safety Digest" ? I'll step quickly away from the line of fire now!!!
Seriously, I was hoping to get some insight into the accident and lessons from this report, but its so superficial that I think it has little value.
The ill-fated pilot had done a bunch of check flights. They are summarised on pages 12-13. This raises the question of the efficacy of the CASA dictated check flight regime. This report had the opportunity to look at the check flight syllabus, but didn't.
An element of this accident is the diagnosis of a mechanical problem. 30-ish years ago when I learned to fly, most pilots had a strong mechanical bent. We poked around aeroplanes & workshops. This has largely changed now and mechanical aptitude is no longer as highly valued in pilots. This is the way of the world, but it does raise a question of whether fault diagnosis should become part of the training. That might have made an interesting discussion point in the report too!
Seriously, I was hoping to get some insight into the accident and lessons from this report, but its so superficial that I think it has little value.
The ill-fated pilot had done a bunch of check flights. They are summarised on pages 12-13. This raises the question of the efficacy of the CASA dictated check flight regime. This report had the opportunity to look at the check flight syllabus, but didn't.
An element of this accident is the diagnosis of a mechanical problem. 30-ish years ago when I learned to fly, most pilots had a strong mechanical bent. We poked around aeroplanes & workshops. This has largely changed now and mechanical aptitude is no longer as highly valued in pilots. This is the way of the world, but it does raise a question of whether fault diagnosis should become part of the training. That might have made an interesting discussion point in the report too!
I'm not even sure that would be enough anymore Akro, who reads stuff anymore and if its an electronic copy it has to compete with Angry Birds and You Tube for attention!
The safety message has to be taken to those who will benefit most from it. As you stated:
Its not even valued by the manufacturer when you look at the manuals that are supplied by the bigger manufacturers. Unfortunately even the format of the report highlights the general trend of keeping knowledge superficial.
The safety message has to be taken to those who will benefit most from it. As you stated:
most pilots had a strong mechanical bent. We poked around aeroplanes &
workshops. This has largely changed now and mechanical aptitude is no longer as highly valued in pilots.
workshops. This has largely changed now and mechanical aptitude is no longer as highly valued in pilots.
Interesting enough the question is being asked of with the surge should he have shut down, if you have read other reports you may remember a baron that crashed into Darwin that had a partial engine failure, he thought it was providing power so kept it running. It wouldn't perform on one and crashed, he was heavily critised for poor training and not understanding the amount of drag caused by a windmilling prop!
I'm not sure about his training but my MECIR training actually included situations like single engine g/a, climb to LSALT, discussion of what now in this situation, plus 2-3 other what ifs with a what then question mark, all whilst still hand flying on one, all discussions included maintaining height until as long as safely required.
Engineering analysis alone, crap report aside I think the big issues were in the report, and I guess known at the time were,
1. Lack of assertiveness with ATC
2. Lack of knowledge of the a/c (horn blaring in background and how to silence it) - perhaps back to his crap endorsement
3. Lack of discipline in handling of the engine failure, all things aside with this you can't deny it was mishandled.
Lets face it in all stages of GA pilots set their own standards, in GA it's not like the airlines were you are thrown in the sim and demanded to perform. Even in the airlines so guys are in the books brushing up weeks before a cyclic, others do a swat study the day before to cover the basics to get through it.
Sadly those guys that chase the 'easy' ATO for an endorsement or renewal are doing themself an injustice, it should always be a learning experience not a tick and flick exercise.
I'm not sure about his training but my MECIR training actually included situations like single engine g/a, climb to LSALT, discussion of what now in this situation, plus 2-3 other what ifs with a what then question mark, all whilst still hand flying on one, all discussions included maintaining height until as long as safely required.
Engineering analysis alone, crap report aside I think the big issues were in the report, and I guess known at the time were,
1. Lack of assertiveness with ATC
2. Lack of knowledge of the a/c (horn blaring in background and how to silence it) - perhaps back to his crap endorsement
3. Lack of discipline in handling of the engine failure, all things aside with this you can't deny it was mishandled.
Lets face it in all stages of GA pilots set their own standards, in GA it's not like the airlines were you are thrown in the sim and demanded to perform. Even in the airlines so guys are in the books brushing up weeks before a cyclic, others do a swat study the day before to cover the basics to get through it.
Sadly those guys that chase the 'easy' ATO for an endorsement or renewal are doing themself an injustice, it should always be a learning experience not a tick and flick exercise.
The stuff about not making a PAN call is bureaucratic mis-direction. The controller knew it was an emergency.
Sadly, in compliance land, compliance is everything, including pedantic compliance with "standard radio procedures". Initiative, enterprise and common sense is actively discouraged. It might lead to creating a liability, you know.
Cast your mind back to the last major loss of life at YSSY --- a Kingair that crashed on the seawall around the 34 (now 34L) threshold -- everybody died.
Despite the engine failure advised, the controller did not clear the aircraft No.1 because the pilot did not broadcast a Mayday or otherwise formally declare an emergency. It's all in the BASI report. Had he not been cleared No2 behind a B727, in all likelihood the aircraft would have made it.
Go even further back to the night the TAA B727 on takeoff hit the taxing CPA DC-8. Once again, pedantic and slavish Australian (and non-ICAO) "radio procedures" played a big part in the accident.
Or the Garuda DC-10 ( I think it was a 10) that nearly hit a domestic over Perth --- once again, failed "radio procedures" ---- but if the poor bleeding controller doesn't deviate --- he or she doesn't loose their jobs.
It's a long sad history of Australian "radio procedures" versus effective communications.
Tootle pip!!
Last edited by LeadSled; 22nd Dec 2012 at 14:22.