ATO responsible for Warrior accident - what is your verdict?
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ATO responsible for Warrior accident - what is your verdict?
Aviation Short Investigations Bulletin - Issue 28
On 15 January 2014, the pilot of a Piper PA‑28 aircraft, registered VH‑HVX, was undergoing a Commercial Pilot Licence test flight with a testing officer on board. At about 1500 Eastern Daylight-savings Time, the aircraft landed at Orange Airport, New South Wales. The aircraft had encountered moderate turbulence during the flight from Bankstown and the pilot reported a slight overshoot on landing at Orange due to fluctuating wind conditions.
During the time on the ground, the pilot observed the wind varying from an easterly to a westerly direction and the speed fluctuating from 0 to about 15 kt. The temperature at Orange was about 33 ºC, and the aerodrome elevation was 3,115 ft. The pilot had calculated the density altitude at Orange to be about 5,725 ft.
At about 1530, the pilot observed the wind to be from 110º at about 10-15 kt and configured the aircraft for a short field take-off from runway 11, selecting two stages of flaps. During the take-off run, the pilot and testing officer observed the aircraft performing normally and the pilot rotated the aircraft at about 55-60 kt indicated airspeed (IAS). The pilot then established the aircraft in an attitude to achieve a best angle-of-climb speed of about 72 kt IAS. The pilot reported that the stall warning horn sounded momentarily during the take-off due to turbulence.
When at about 50 ft above ground level (AGL) and about 65-70 kt IAS, the testing officer reduced the engine power to idle and stated “simulated engine failure”. The pilot immediately lowered the nose of the aircraft in an attempt to increase the airspeed and selected the third stage of flaps. At about 10 ft AGL, the pilot reported the aircraft was sinking and flared the aircraft for landing. However, the aircraft continued to sink and landed heavily. The pilots reported that the stall warning did not sound during the descent and that a shift in the wind direction was the most likely cause of the accident.
This incident highlights the critical importance of considering local conditions such as wind, elevation and temperature, as well as the inherent risks of conducting simulated engine failure at low altitude.
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Sheer folly by the ATO to have the candidate conduct a simulated engine failure at 50 feet after lift off from a short field take off with the only option to land straight ahead on the remaining field length. Blaming the weather conditions was a cop out. A simulated engine failure at that height would require lightning fast reaction by the candidate to not only literally bunt over to maintain safe gliding speed, but risk a heavy touchdown to be followed by heavy braking and risk of skidding and tyre failure. In other words he would have to get it right first time. There is no room for error and little time for the instructor (ATO) to take over from the candidate in the seconds available to touch down. By placing the candidate in a situation which would task even the most experienced pilots, the ATO exposed himself and the candidate to very high risk. To put it mildly he displayed poor airmanship.
In assessing a candidate's competence at conducting a forced landing procedure in a single engine aircraft following a simulated engine failure by throttle closure after lift off, it would be sensible to wait until at least 500 feet. That leaves a margin for slow reaction and also gives a reasonable amount of time for the ATO to make a fair assessment of the actions by the candidate. That includes, among other assessable items, the immediate lowering of the nose in order to maintain a safe gliding speed, correct selection of a landing area ahead and to the side, immediate simulated safety drills including warning any passengers and finally the correct method of going around again from the simulated emergency. Even then, simulating engine failure on take off in any single engine aircraft, is a high risk manoeuvre leaving little room for error by the candidate.
Some years ago, Point Cook was the scene of a fatal accident in a Tiger Moth when an experienced RAAF flying instructor was training another experienced RAAF pilot. The instructor had earlier briefed a wrong speed for climb in the Tiger Moth that was nearly 10 knots slower than the manufacturers recommended climbing speed of 58 knots.
As the pilot lifted off just above the power on stall speed and was climbing, the instructor pulled back the throttle at 100 feet to simulated engine failure with the intention the student should conduct a forced landing straight ahead on the remaining field length. Already 10 knots below best climb speed, the Tiger Moth stalled and entered an incipient spin before the experienced "student" could lower the nose to safe gliding speed attitude. The aircraft hit the ground in a steep nose down attitude and burst into flames. The student in the rear seat escaped with minor injuries while the instructor was killed on impact.
Tiger Moths are normally equipped with moveable slats on the top wing which lower the stall speed by about four knots and pop out just before the stall and the clacking noise of them popping out is an effective stall warning. This particular Tiger Moth had its slats permanently locked to minimise maintenance costs. To this day many Tiger Moths have this vital safety feature removed for the same reason.
The ATO in the previous Warrior accident displayed poor judgement in initiating the simulated engine failure after lift off at such a low altitude and in doing so accepted the risks involved. One wonders if CASA has since "reviewed' his Delegation?
On 15 January 2014, the pilot of a Piper PA‑28 aircraft, registered VH‑HVX, was undergoing a Commercial Pilot Licence test flight with a testing officer on board. At about 1500 Eastern Daylight-savings Time, the aircraft landed at Orange Airport, New South Wales. The aircraft had encountered moderate turbulence during the flight from Bankstown and the pilot reported a slight overshoot on landing at Orange due to fluctuating wind conditions.
During the time on the ground, the pilot observed the wind varying from an easterly to a westerly direction and the speed fluctuating from 0 to about 15 kt. The temperature at Orange was about 33 ºC, and the aerodrome elevation was 3,115 ft. The pilot had calculated the density altitude at Orange to be about 5,725 ft.
At about 1530, the pilot observed the wind to be from 110º at about 10-15 kt and configured the aircraft for a short field take-off from runway 11, selecting two stages of flaps. During the take-off run, the pilot and testing officer observed the aircraft performing normally and the pilot rotated the aircraft at about 55-60 kt indicated airspeed (IAS). The pilot then established the aircraft in an attitude to achieve a best angle-of-climb speed of about 72 kt IAS. The pilot reported that the stall warning horn sounded momentarily during the take-off due to turbulence.
When at about 50 ft above ground level (AGL) and about 65-70 kt IAS, the testing officer reduced the engine power to idle and stated “simulated engine failure”. The pilot immediately lowered the nose of the aircraft in an attempt to increase the airspeed and selected the third stage of flaps. At about 10 ft AGL, the pilot reported the aircraft was sinking and flared the aircraft for landing. However, the aircraft continued to sink and landed heavily. The pilots reported that the stall warning did not sound during the descent and that a shift in the wind direction was the most likely cause of the accident.
This incident highlights the critical importance of considering local conditions such as wind, elevation and temperature, as well as the inherent risks of conducting simulated engine failure at low altitude.
............................................................ .........................................................
Sheer folly by the ATO to have the candidate conduct a simulated engine failure at 50 feet after lift off from a short field take off with the only option to land straight ahead on the remaining field length. Blaming the weather conditions was a cop out. A simulated engine failure at that height would require lightning fast reaction by the candidate to not only literally bunt over to maintain safe gliding speed, but risk a heavy touchdown to be followed by heavy braking and risk of skidding and tyre failure. In other words he would have to get it right first time. There is no room for error and little time for the instructor (ATO) to take over from the candidate in the seconds available to touch down. By placing the candidate in a situation which would task even the most experienced pilots, the ATO exposed himself and the candidate to very high risk. To put it mildly he displayed poor airmanship.
In assessing a candidate's competence at conducting a forced landing procedure in a single engine aircraft following a simulated engine failure by throttle closure after lift off, it would be sensible to wait until at least 500 feet. That leaves a margin for slow reaction and also gives a reasonable amount of time for the ATO to make a fair assessment of the actions by the candidate. That includes, among other assessable items, the immediate lowering of the nose in order to maintain a safe gliding speed, correct selection of a landing area ahead and to the side, immediate simulated safety drills including warning any passengers and finally the correct method of going around again from the simulated emergency. Even then, simulating engine failure on take off in any single engine aircraft, is a high risk manoeuvre leaving little room for error by the candidate.
Some years ago, Point Cook was the scene of a fatal accident in a Tiger Moth when an experienced RAAF flying instructor was training another experienced RAAF pilot. The instructor had earlier briefed a wrong speed for climb in the Tiger Moth that was nearly 10 knots slower than the manufacturers recommended climbing speed of 58 knots.
As the pilot lifted off just above the power on stall speed and was climbing, the instructor pulled back the throttle at 100 feet to simulated engine failure with the intention the student should conduct a forced landing straight ahead on the remaining field length. Already 10 knots below best climb speed, the Tiger Moth stalled and entered an incipient spin before the experienced "student" could lower the nose to safe gliding speed attitude. The aircraft hit the ground in a steep nose down attitude and burst into flames. The student in the rear seat escaped with minor injuries while the instructor was killed on impact.
Tiger Moths are normally equipped with moveable slats on the top wing which lower the stall speed by about four knots and pop out just before the stall and the clacking noise of them popping out is an effective stall warning. This particular Tiger Moth had its slats permanently locked to minimise maintenance costs. To this day many Tiger Moths have this vital safety feature removed for the same reason.
The ATO in the previous Warrior accident displayed poor judgement in initiating the simulated engine failure after lift off at such a low altitude and in doing so accepted the risks involved. One wonders if CASA has since "reviewed' his Delegation?
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I won't specifically comment about whose to blame here, but having taken a warrior to Orange mid summer and struggled to get it off the ground and away from the hills at 38 deg C myself, I can very easily understand why the published glide speed and vref left the pilot hanging in the flare well above the ground. It way well have been exacerbated by the longer than expected take off run with less remaining runway than would normally been expected.
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Stupid thing to do.
No testing officer WILL EVER do that with me for a very simple reason. I brief them before hand. Simply if you want to see my reflex actions, do it at a height of 300' and we will not be landing off it, as it would be off field unless there is a very big runway or another suitable one involved.
That test's that aspect of an EFATO.
If you want me to demonstrate the ability to handle ground rush and land again from a low cut, we MUST do it after briefing before the take off. No 50' surprises. The ATO can pull the power at will during the climb out, but if under 300' only if we briefed the outcome prior to that takeoff. No negotiations entered into.
This way you can assess both aspects of the real event, but without the risk of the pilot stuffing up and proving they can't do it. Best to see they can and be able to recover if they can't.
This policy has a result which I measure all things with, "Does everything it should and Nothing it should not".
There may be some out there who disagree, that is fine but you will never test me or anyone I know or care about.
Failure to comply with my policy will involve a law suit if something or someone is damaged, physical harm from me if not, or at the very least being ordered to leave the aircraft and hopefully at some remote unserviced aerodrome, while I fly home. Again, not negotiable.
No ATO or CFI has ever argued with me, and they all agreed. But I bet there are a few out there that would.
Does this sound like a Polarair case or am I dreaming?
No testing officer WILL EVER do that with me for a very simple reason. I brief them before hand. Simply if you want to see my reflex actions, do it at a height of 300' and we will not be landing off it, as it would be off field unless there is a very big runway or another suitable one involved.
That test's that aspect of an EFATO.
If you want me to demonstrate the ability to handle ground rush and land again from a low cut, we MUST do it after briefing before the take off. No 50' surprises. The ATO can pull the power at will during the climb out, but if under 300' only if we briefed the outcome prior to that takeoff. No negotiations entered into.
This way you can assess both aspects of the real event, but without the risk of the pilot stuffing up and proving they can't do it. Best to see they can and be able to recover if they can't.
This policy has a result which I measure all things with, "Does everything it should and Nothing it should not".
There may be some out there who disagree, that is fine but you will never test me or anyone I know or care about.
Failure to comply with my policy will involve a law suit if something or someone is damaged, physical harm from me if not, or at the very least being ordered to leave the aircraft and hopefully at some remote unserviced aerodrome, while I fly home. Again, not negotiable.
No ATO or CFI has ever argued with me, and they all agreed. But I bet there are a few out there that would.
Does this sound like a Polarair case or am I dreaming?
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There was no mention of leaning for the vastly increased DA either, not that it was relevant to the ATo's actions but it would make a big difference to the actual take off performance and maybe better speed and then one less layer in the swiss cheese removed.
And why ohh why was a Best Angle speed used anyway? That was dumb too unless there was some REALLY good reason, and with such a high DA any good reason to NEED the Vx climb would have been enough to say....no, we are not doing it.
At the risk of being accused of advertising again, this demonstrates why my posting these links is relevant.
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And why ohh why was a Best Angle speed used anyway? That was dumb too unless there was some REALLY good reason, and with such a high DA any good reason to NEED the Vx climb would have been enough to say....no, we are not doing it.
At the risk of being accused of advertising again, this demonstrates why my posting these links is relevant.
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strangely enough I have no problem with what the ato did.
in reality an engine failure if it occurs will never occur at some convenient time.
however to pull an efato in gusty conditions was somewhat stupid.
interesting changes in law have meant that the ato is pilot in command and is liable for the damages caused.
that'll teach him.
in reality an engine failure if it occurs will never occur at some convenient time.
however to pull an efato in gusty conditions was somewhat stupid.
interesting changes in law have meant that the ato is pilot in command and is liable for the damages caused.
that'll teach him.
Just to be really pedantic you can't do a CPL test in a Warrior. I looked up the aircraft and it was an Arrow. I wonder what position the undercarriage was in.
Max angle climb, was there an obstacle?
But to pull an EFATO at 50 feet? Not something I would do on a test or in training unless there was sufficient runway remaining plus a lot
more for luck.
I once saw an ATO fail the left engine in a twin commanche with a whopping left crosswind at about the same height. The result was not pretty and the ATO allegedly blamed the student.
And I have been PIC on every flight test I have conducted as an ATO, are you referring to the proposed removal of liability which caused a fair bit of angst over Part 61?
Max angle climb, was there an obstacle?
But to pull an EFATO at 50 feet? Not something I would do on a test or in training unless there was sufficient runway remaining plus a lot
more for luck.
I once saw an ATO fail the left engine in a twin commanche with a whopping left crosswind at about the same height. The result was not pretty and the ATO allegedly blamed the student.
And I have been PIC on every flight test I have conducted as an ATO, are you referring to the proposed removal of liability which caused a fair bit of angst over Part 61?
iPad won't let me edit.I meant removal of indemnity cover
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If the instructor tried that in my aircraft my reflexes would include smacking his hand from the throttle back into place. As the PIC it's my job to remove any threats to the safety of the flight.
All that aside I've never had an instructor or ATO do a surprise move, there's no need to, they can advise they are going to and then do it. If you disagree for safety reasons you usually have time to stop the action, although a low time pilot would not have the luxury of experience to determine if safe or not.
All that aside I've never had an instructor or ATO do a surprise move, there's no need to, they can advise they are going to and then do it. If you disagree for safety reasons you usually have time to stop the action, although a low time pilot would not have the luxury of experience to determine if safe or not.
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strangely enough I have no problem with what the ato did.
in reality an engine failure if it occurs will never occur at some convenient time.
however to pull an EFATO in gusty conditions was somewhat stupid.
in reality an engine failure if it occurs will never occur at some convenient time.
however to pull an EFATO in gusty conditions was somewhat stupid.
I will cut some slack, I think we know what you really meant.
The point is very simply this. Any test/check is to assess various skills or attributes, and you can't do everything. So with EFATO you need to check for two things as I detailed above.
The argument of "if it was a real one you don't get to choose when or where" does not wash with me. If you actually have one from 50' in those conditions, and you bend nothing that is awesome, but if the failure resulted in the same outcome as in the report, because you did it mostly right but were caught out with gusts, well who cares. The object then is not to kill yourself.
There is no point trying to kill yourself or bend metal in a training/testing environment.
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putting myself in the CPL candidates shoes for a moment.
If an ATO does conduct a EFATO simulation at low altitude in conditions similar to the report. wouldn't the best course of action be for the candidate to abort the test apply full power and climb out?
what sort of reaction are you likely to get at the end of the assessment for doing that? obviously you might end up with an annoyed ATO for the rest of the flight, but are they likely to end the assessment there?
If an ATO does conduct a EFATO simulation at low altitude in conditions similar to the report. wouldn't the best course of action be for the candidate to abort the test apply full power and climb out?
what sort of reaction are you likely to get at the end of the assessment for doing that? obviously you might end up with an annoyed ATO for the rest of the flight, but are they likely to end the assessment there?
I agree Jaba and XXX. The last time some-one did that to me (although at a suitable height when I took my hand off the throttle to move another switch) I simply pushed the throttle forward again - he had omitted to announce the simulated engine failure.
I never teach Vx climbs in my airplane as it is only 7% above the stall speed. Short field take-off speed at 50 ft is the same "The aircraft must be pitched forward to a safe power off speed should a power failure occur during climb-out; failure to respond immediately may result in stall at low altitude."
CASA's draft Part 61 MOS mandates doing that in tailwheel endorsements from September.
It also mandates:
So, per my airplane's manual - approach at 10% above the stall speed. PPL tolerance allows touchdown up to 60 metres past nominated touchdown point (per the book) then apply maximum braking. And "stops aeroplane within calculated landing distance." Touching down 60 metres past the nominated touchdown point will not achieve book distances. I can see many bent tailwheel airplanes after September unless the MOS is improved.
I never teach Vx climbs in my airplane as it is only 7% above the stall speed. Short field take-off speed at 50 ft is the same "The aircraft must be pitched forward to a safe power off speed should a power failure occur during climb-out; failure to respond immediately may result in stall at low altitude."
CASA's draft Part 61 MOS mandates doing that in tailwheel endorsements from September.
It also mandates:
Short landing.
Calculates landing performance in accordance with performance chart.
Lands aeroplane at nominated touchdown point (+200ft/60 metres for PPL,
+100ft/30 metres for CPL) at minimum speed and applies maximum braking.
Touches down simultaneously on main wheels and tail wheel.
Controls aeroplane direction on the ground.
Stops aeroplane within calculated landing distance.
Calculates landing performance in accordance with performance chart.
Lands aeroplane at nominated touchdown point (+200ft/60 metres for PPL,
+100ft/30 metres for CPL) at minimum speed and applies maximum braking.
Touches down simultaneously on main wheels and tail wheel.
Controls aeroplane direction on the ground.
Stops aeroplane within calculated landing distance.
putting myself in the CPL candidates shoes for a moment.
If an ATO does conduct a EFATO simulation at low altitude in conditions similar to the report. wouldn't the best course of action be for the candidate to abort the test apply full power and climb out?
If an ATO does conduct a EFATO simulation at low altitude in conditions similar to the report. wouldn't the best course of action be for the candidate to abort the test apply full power and climb out?
First and foremost the pilot is responsible for the safety of the aircraft and the occupants of the aircraft, so you would assume that the CPL candidate would have applied power and aborted the EFATO.
But, that been said, realistically, the student would not have had the experience to recognise this as a dangerous situation. Putting myself in the students shoes I would have accepted that the ATO would not intentionally do something like this unless they thought it was . My thoughts would have been I'm sitting next to a testing officer, this guy/gal must have a heap of experience etc etc and would not have second guessed their call.
You would be hard pressed to find any young student pilot (young in experience, not age) who would be willing to countermand an action or request/order from an ATO for fear of failing the test flight.
In days gone past I used to pull the throttle on take off to simulate engine failure. I still pull the release in gliders for the same reason. I do this without warning ( on checks ).
The difference in the way I do it compared to this case is that I only do it in conditions where I can safely recover if the student stuffs it up!
It seems in this case the ATO did it too low, at too low a speed, in an unfamiliar aircraft?
The testing officer is the PIC and wears the prang.
The difference in the way I do it compared to this case is that I only do it in conditions where I can safely recover if the student stuffs it up!
It seems in this case the ATO did it too low, at too low a speed, in an unfamiliar aircraft?
The testing officer is the PIC and wears the prang.
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The most tragic outcome I ever heard about was at Camden NSW when the ATO cut the mixture on the right hand engine of a Duchess immediately the student (former B767 captain) had selected gear lever to up. This was at night or dusk. While during the briefing a couple of hours earlier at Bankstown the ATO (30,000 hours plus) told the student his intention was to conduct a simulated engine failure after take off at Camden, the student told the ATO he did not agree due night conditions on arrival. The ATO then agreed not to pull an engine. To cap it off, the ATO placed a map between the throttles and mixture lever as the student got airborne and then pulled the right hand mixture against his earlier agreement.
The student called for the ATO to reinstate the power quickly as he could not control the aircraft at such a low speed with windmilling prop. Soon after the Duchess clipped the top of a tree and stalled wheels up into rising ground and caught fire. The student survived but the ATO died of burns later.
A similar event but not tragic occurred in Victoria where an instructor conducting dual instruction failed the mixture on a student at 50 feet on take off in a Seneca? The student controlled the yaw correctly and continued the climb albeit with low gradient with gear still down . The speed fell below Blue Line in the confusion and the instructor told the student he should have landed straight head on the remaining runway length which is what the instructor had planned he should do. The student therefore did the bidding of the instructor and attempted to abandon the climb in order to put the aircraft back on the runway.
The instructor then grabbed the controls to salvage what was his stuff-up in the first place, and tried to land on the remaining length but landed very heavily and wiped out one wing. Both unhurt. As there was no property damage and no one hurt, ATSB did not investigate. The only report that went in to ATSB was by the instructor, in which he blamed the student for slow reaction and making the wrong decision to continue the single engine climb even though the student did well to control the aircraft until the instructor interfered.
The instructor thus self-exonerated himself for causing the problem in the first place. ATSB accepted the instructor's word for it without further comment leaving the student to wear the blame which was unfair. At no stage was either pilot interviewed by CASA or ATSB. And the student was never required to submit his version of the accident. I know all this because I saw the files...
The student called for the ATO to reinstate the power quickly as he could not control the aircraft at such a low speed with windmilling prop. Soon after the Duchess clipped the top of a tree and stalled wheels up into rising ground and caught fire. The student survived but the ATO died of burns later.
A similar event but not tragic occurred in Victoria where an instructor conducting dual instruction failed the mixture on a student at 50 feet on take off in a Seneca? The student controlled the yaw correctly and continued the climb albeit with low gradient with gear still down . The speed fell below Blue Line in the confusion and the instructor told the student he should have landed straight head on the remaining runway length which is what the instructor had planned he should do. The student therefore did the bidding of the instructor and attempted to abandon the climb in order to put the aircraft back on the runway.
The instructor then grabbed the controls to salvage what was his stuff-up in the first place, and tried to land on the remaining length but landed very heavily and wiped out one wing. Both unhurt. As there was no property damage and no one hurt, ATSB did not investigate. The only report that went in to ATSB was by the instructor, in which he blamed the student for slow reaction and making the wrong decision to continue the single engine climb even though the student did well to control the aircraft until the instructor interfered.
The instructor thus self-exonerated himself for causing the problem in the first place. ATSB accepted the instructor's word for it without further comment leaving the student to wear the blame which was unfair. At no stage was either pilot interviewed by CASA or ATSB. And the student was never required to submit his version of the accident. I know all this because I saw the files...
Unless a student is flying solo, or does some deliberate act of sabotage, such as pulling the gear up on the ground or switching off the ignition and throwing the keys on the floor, how can the ATSB find the student at fault?
In a training or testing situation it is the instructor/testing officer who is totally responsible.
Does instructor training no longer include learning what is a recoverable situation and what is not; how far to let a student go, when to patter gently, when to be firmly assertive and when to simply take over control?
In a training or testing situation it is the instructor/testing officer who is totally responsible.
Does instructor training no longer include learning what is a recoverable situation and what is not; how far to let a student go, when to patter gently, when to be firmly assertive and when to simply take over control?
All that aside I've never had an instructor or ATO do a surprise move, there's no need to, they can advise they are going to and then do it.
"Siht! What's happening??!?"
"I think we've just had an engine failure..."
"Whadda we do? Whadda we do? Whadda we do??!!"
It's turning into a sad state for aviation when we refuse to conduct emergency procedures because we're scared the student will fcuk it up. How do you expect students to learn if you have to give them two minutes notice the engine will fail?
A little pressure can produce much different outcomes.I will prep my students by reviewing the EFATO actions immediately before the take-off of TGL that it will occur and then announce the action with "engine failure". Still interesting how many need to be prompted to close both throttles when one fails while still on the runway in a twin.
Sure, it can be argued that the ATO's judgement may have been deficient in conducting the exercise under less than ideal conditions, but this was a CPL candidate, not a 50hr PPL. The failure was dealt with correctly by all accounts and the failure was initiated above the TOSS, which in itself has a safety margin over the stall.
I rue the day when the industry accepts the student dictating how the instructor will conduct assessments.