Cranfield crash, 5 June 2013
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Almost a two part report in some ways; the analysis of the accident itself and then the consequential findings regarding inappropriate fuel use, unqualified maintenance and record keeping at Hinton Pilot Flight Training.
It's just such a shame that it took the former to uncover the latter. BBC 3CR local radio did a piece on the AAIB report, somebody has posted it, together with a photo montage of their own making at:
BBC News report from BBC Radio - YouTube
I hope that those injured have recovered as best they can.
It's just such a shame that it took the former to uncover the latter. BBC 3CR local radio did a piece on the AAIB report, somebody has posted it, together with a photo montage of their own making at:
BBC News report from BBC Radio - YouTube
I hope that those injured have recovered as best they can.
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I hope that those injured have recovered as best they can.
That's the second PA38 in recent history where the driver (I hesitate to call them 'pilot') didn't fly the aeroplane after the engine failed.
I refer anyone interested to the 'Why has flying training gone assbackwards' thread.
Hmmm, impartial observations from someone with no knowledge of individuals (or axes to grind):
If there is any hair-raising going on then that should be the focus; presumably this same instructor taught others NOT to perform this maneuver at low level, and to select a spot dead ahead (and/or within 30deg of the nose), and land as best as able - yet he appears to have ignored such advice, at his and his student's peril. At ~75ft the land ahead should simply be a given, absolutely no question.
At the risk of repeating what has been said many, many, times before by those far more qualified than I: following EFATO get the nose down ASAP, if not before, maintain control speed and land ahead.
I'm not sure that getting the nose down and maintaining speed is given the emphasis that it should at times, hence my bolding this...
Disclaimer: I've never been in this situation, fortunately, and accept that despite all best intentions in the heat of the moment we may not act how we know we should at more rational times. I have however seen the results of a turnback at low level - skillful, but very lucky.
FP.
- An engineer cleaned the plugs and re-fitted them correctly, an engine check was performed, and a flight conducted with no issue prior to the crash flight. Although he may not have been officially authorised to maintain this aircraft he was an engineer, and nothing I read suggests his work contributed to any issue with the a/c.
- There were insufficient ethanol traces to have caused any issue, and upon being alerted to pilots incorrectly using Mogas the company advised them in staff notes that the a/c were not certified for such use.
- Although there were some anomalies in the record keeping it doesn't seem from what I read that these were serious misdemeanors and a check was correctly performed on the day of the crash with nil defects noted.
If there is any hair-raising going on then that should be the focus; presumably this same instructor taught others NOT to perform this maneuver at low level, and to select a spot dead ahead (and/or within 30deg of the nose), and land as best as able - yet he appears to have ignored such advice, at his and his student's peril. At ~75ft the land ahead should simply be a given, absolutely no question.
At the risk of repeating what has been said many, many, times before by those far more qualified than I: following EFATO get the nose down ASAP, if not before, maintain control speed and land ahead.
I'm not sure that getting the nose down and maintaining speed is given the emphasis that it should at times, hence my bolding this...
Disclaimer: I've never been in this situation, fortunately, and accept that despite all best intentions in the heat of the moment we may not act how we know we should at more rational times. I have however seen the results of a turnback at low level - skillful, but very lucky.
FP.
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From the report:
If my calcs are right that's 5 USG fuel burn an hour, those 0-235's must be pretty economical, especially when you figure a lot of short flights in the 15.6 hours at full power on T.O.
Recent fuel usage
G-BGBN operated from Cranfield between 26 May 2013 and 5 June 2013 when the accident
occurred. During this period it had flown 22 flights, uplifted 300 ltr of Avgas 100LL and the
engine had operated for 15.6 hours
G-BGBN operated from Cranfield between 26 May 2013 and 5 June 2013 when the accident
occurred. During this period it had flown 22 flights, uplifted 300 ltr of Avgas 100LL and the
engine had operated for 15.6 hours
An engineer cleaned the plugs and re-fitted them correctly, an engine check was performed, and a flight conducted with no issue prior to the crash flight. Although he may not have been officially authorised to maintain this aircraft he was an engineer, and nothing I read suggests his work contributed to any issue with the a/c.
An unqualified person cleaned the plugs and claimed to have re-fitted them correctly, an engine check was performed, and a flight conducted with no issue prior to the crash flight. He was not authorised to maintain this aircraft he was not an engineer, and nothing I read suggests his work contributed to any issue with the a/c apart from any long term damage potentially caused by unauthorised maintenance and fuel use over a long period of time.
he CAA later advised the investigation that the individual who carried out the work is not currently a Part 66 licensed engineer.
Although the individual reported that he had previously held an engineer’s licence issued by the CAA, the CAMO stated that he was not authorised to carry out maintenance on this aircraft.
Although the individual reported that he had previously held an engineer’s licence issued by the CAA, the CAMO stated that he was not authorised to carry out maintenance on this aircraft.
The bottom line is that the school owner was permitting an unauthorised person to maintain the aircraft, not all flights were being logged, and there was a track record of incorrect fuels being used in the school aircraft. And that is what AAIB found out and saw fit to report.
It remains the case that the cause of the accident was the way the engine failure was handled mind you - SEP engine failures happen and we're all trained for them, whether poor practice make them more likely, or not.
G
Last edited by Genghis the Engineer; 17th Mar 2014 at 08:21.
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What a terrible chain of events. Nothing much to add except good wishes and to note the shock value the first time the EFATO or partial failure happens for real. I am intensely grateful for all the good training and stern warnings about turning back but I must say, when it happened to me, I was surprised that I was so surprised!
One really useful thing to find out is the power your aircraft needs, in the take-off configuration, to maintain level flight. If that's (say) 1700 rpm and you're reasonably able to count on that power, it allows an informed choice about whether a turn of any type is feasible. It's also handy to know a bit about carb heat and mixture, and the juggling thereof, in the happy event that you find yourself with some level of consistent power. The partial failure case is never going to be an easy call but instincts like getting the nose down asap, and knowing the aircraft power requirements all help.
Perversely, the complete EFATO is easier - there's really only one way out, and that's to control the impact in the best way possible. And based on the Australian statistics previously quoted, I can see why some would say that the best chance of survival is just to pull the power off and treat all problems as complete engine failures. I'm glad I didn't but it would probably be the advice I'd give to a low time pilot or student.
Regardless of how the aircraft ended up in the situation it did, I would just urge an understanding thought for the instructor and his decision process. Until you've really been there, you haven't really been there.
One really useful thing to find out is the power your aircraft needs, in the take-off configuration, to maintain level flight. If that's (say) 1700 rpm and you're reasonably able to count on that power, it allows an informed choice about whether a turn of any type is feasible. It's also handy to know a bit about carb heat and mixture, and the juggling thereof, in the happy event that you find yourself with some level of consistent power. The partial failure case is never going to be an easy call but instincts like getting the nose down asap, and knowing the aircraft power requirements all help.
Perversely, the complete EFATO is easier - there's really only one way out, and that's to control the impact in the best way possible. And based on the Australian statistics previously quoted, I can see why some would say that the best chance of survival is just to pull the power off and treat all problems as complete engine failures. I'm glad I didn't but it would probably be the advice I'd give to a low time pilot or student.
Regardless of how the aircraft ended up in the situation it did, I would just urge an understanding thought for the instructor and his decision process. Until you've really been there, you haven't really been there.
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I've been there, and in a less forgiving aeroplane than a PA38. As someone else said, when it happens for the first time for real, the training kicks in, you act like Pavlov's dog, and you GET THE BLEEDIN NOSE DOWN!
This PA38 driver, and the one a couple of years back, didn't. Both got on the radio, though!
This PA38 driver, and the one a couple of years back, didn't. Both got on the radio, though!
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They don't say that CAA confirmed this fellow had ever held a licence, nor what sort it was, nor is there any indication of why that person had ceased to hold a licence.
Notwithstanding that, the fact is quite simple, the Instructor attempted a turn back that goes against everything we teach and he and the student paid a very high price for an act of stupidity.
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Sounds like the instructor was one of these pseudo airline ops types in light aircraft.
Touching down in the touchdown zone for the love of god in a light aircraft.
Cranfield is a 1800m runway if they had touched down on the numbers they would have been up in the air just after the big intersection. Engine starts giving you gip at 200ft power off stick the nose down full flap and your landing on tarmac and if your good you can roll taxi clear at Bravo if not roll it to the end.
I would have been at 600-700ft by the time I couldn't get it in on the runway and by that time no problems getting into the fields at the end.
Its a pity the AIBB aren't picking up on these sort of things as well.
When will these 3 deg glide PAPI pillocks not realise its a stupid thing to do in a light aircraft. Poor profile for engine failure during approach, runway behind you if your doing T&G's etc etc.
Was this instructer Integrated trained?
Touching down in the touchdown zone for the love of god in a light aircraft.
Cranfield is a 1800m runway if they had touched down on the numbers they would have been up in the air just after the big intersection. Engine starts giving you gip at 200ft power off stick the nose down full flap and your landing on tarmac and if your good you can roll taxi clear at Bravo if not roll it to the end.
I would have been at 600-700ft by the time I couldn't get it in on the runway and by that time no problems getting into the fields at the end.
Its a pity the AIBB aren't picking up on these sort of things as well.
When will these 3 deg glide PAPI pillocks not realise its a stupid thing to do in a light aircraft. Poor profile for engine failure during approach, runway behind you if your doing T&G's etc etc.
Was this instructer Integrated trained?
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Well we know that was lacking. But if these kids are taught ****e from the beginning that's all they know.
And to be honest I have about 300 hours operating tommys in that temperature and dew point range and never experienced carb icing to the point of ruff running, occasional grumble when the carb anti ice selected during cruise at just in the green arc power settings, but never ruff running. From memory the air gets routed from the intake over hot stuff to heat it up which is why the manual says you only need to use it when you think you have carb ice issues. I used to teach to use it anyway at the normal points because I wanted people in the habit of using it when they went to fly another type that it did matter.
Anyway after posting that, thought he will more than likely not fly again and he will have all his training debts to sort out and no real career to fall back on. So all in all he has been quite severely penalised for his inexperience/poor training/poor supervision.
And to be honest I have about 300 hours operating tommys in that temperature and dew point range and never experienced carb icing to the point of ruff running, occasional grumble when the carb anti ice selected during cruise at just in the green arc power settings, but never ruff running. From memory the air gets routed from the intake over hot stuff to heat it up which is why the manual says you only need to use it when you think you have carb ice issues. I used to teach to use it anyway at the normal points because I wanted people in the habit of using it when they went to fly another type that it did matter.
Anyway after posting that, thought he will more than likely not fly again and he will have all his training debts to sort out and no real career to fall back on. So all in all he has been quite severely penalised for his inexperience/poor training/poor supervision.
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Well said MJ. Spare a thought for the 21 year old instructor thrown into a highly responsible position, scratching 15 hours flying a month in a company that he probably knew was dodgy but probably also knew that challenging anything would lead to the dole.
NS
NS
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AAIB will find nothing wrong with the engine. There may be a dodgy mag or some oily plugs. One fuel tank will have evidence of residual fuel, the other no evidence but this will be caveated by there having been a post-crash fuel leak. Alternatively, there will be a question over carb ice/vapour lock.
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An unqualified person cleaned the plugs and claimed to have re-fitted them correctly
Is a Pilot not entitled to replace Spark Plugs - hence also remove, clean and refit same ones?
Obviously I do not know whether person mentioned in AAIB Report was a qualified Pilot.
Also, does the fact of removal, cleaning and replacing Spark Plugs really require an entry in the Maintenance Log?
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Originally Posted by piperboy84 View Post
From the report:
If my calcs are right that's 5 USG fuel burn an hour, those 0-235's must be pretty economical, especially when you figure a lot of short flights in the 15.6 hours at full power on T.O.
From the report:
If my calcs are right that's 5 USG fuel burn an hour, those 0-235's must be pretty economical, especially when you figure a lot of short flights in the 15.6 hours at full power on T.O.
GTE: Local rumour at the time was that the school owner was having his instructors conduct most flights, particularly trial flights, almost entirely below 60% power to keep tacho hours and fuel burn down.
Removing and refitting plugs should always require a logbook entry.
Pilot maintenance is not approved on an aeroplane being used for training. Even where it is, the pilot doing it must normally be a owner / part-owner of the aeroplane.
G
Pilot maintenance is not approved on an aeroplane being used for training. Even where it is, the pilot doing it must normally be a owner / part-owner of the aeroplane.
G
Easy rule of thumb for a pilot. If you have to use a tool to do the maintenance task, you can't do it.
thing.