Fatigue theory over Islander air rescue deaths
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'Appendix 39' also here, on it's own web page:
http://www.publications.parliament.u...09we40.htm#n35
http://www.publications.parliament.u...09we40.htm#n35
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Regulators
What a very sad story and a preventable one too. Anyone who has done this type of work, will know only too well how easy it would be to get it wrong in the circumstances experienced by this guy.
The AAIB also clearly know it too yet see how reluctant the CAA is to take the obvious and recommended (2 crew) action. Because it is "only" a small aeroplane and 2 people, the tragedy recieves little public attention, in spite of the fact that it is the same regulator who deals with the larger operators.
The operator should not escape responsibility as cannot operators of lager aircraft who get away with rule abuse, entirely due to many factors we all know well enough.
Wake up CAA & stop letting the driver take the blame.
The AAIB also clearly know it too yet see how reluctant the CAA is to take the obvious and recommended (2 crew) action. Because it is "only" a small aeroplane and 2 people, the tragedy recieves little public attention, in spite of the fact that it is the same regulator who deals with the larger operators.
The operator should not escape responsibility as cannot operators of lager aircraft who get away with rule abuse, entirely due to many factors we all know well enough.
Wake up CAA & stop letting the driver take the blame.
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The G-BOMG Islander Crash (strange UK AAIB conclusions)
G-BOMG crashed into the sea during a non-precision night approach to Campbelltown, Ayrshire, Scotland.
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Within their Accident Report narrative the UK AAIB examined all possibilities but then in the analysis, conclusions and findings, proceeded to fail to mention the most likely cause (IMHO) - which they themselves had raised as a probability in their own precursor deliberations.
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I find this omission exceeding strange and an illogical non-sequitur.
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It's discussed here ( http://tinyurl.com/y9mo2e )
and there's also a link to the report.
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Possible explanations would be welcome.
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Within their Accident Report narrative the UK AAIB examined all possibilities but then in the analysis, conclusions and findings, proceeded to fail to mention the most likely cause (IMHO) - which they themselves had raised as a probability in their own precursor deliberations.
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I find this omission exceeding strange and an illogical non-sequitur.
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It's discussed here ( http://tinyurl.com/y9mo2e )
and there's also a link to the report.
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Possible explanations would be welcome.
Couldonlyaffordafiver
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Whether or not it turned out to be a factor in this case, I'm of the opinion that you will almost certainly never see the "F word" written in a UK commercial accident report.
The main reason being that as all UK operators are supposed to operate in accordance with CAP371 or a similar approved FTL scheme, which has been "scientifically" tested, any indication of fatigue as a causual factor would indicate that either CAP371 or the "Scheme" is flawed or that the company in question had been operating outside the "Scheme" or the spirit of it, in which case the Ops Inspectorate is flawed.
Just a thought.
The main reason being that as all UK operators are supposed to operate in accordance with CAP371 or a similar approved FTL scheme, which has been "scientifically" tested, any indication of fatigue as a causual factor would indicate that either CAP371 or the "Scheme" is flawed or that the company in question had been operating outside the "Scheme" or the spirit of it, in which case the Ops Inspectorate is flawed.
Just a thought.
Last edited by Human Factor; 1st Dec 2006 at 09:11.
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[QUOTEG-BOMG crashed into the sea during a non-precision night approach to Campbelltown, Ayrshire, Scotland.
][/QUOTE]
Just being pedantic but Campbeltown is not in Ayrshire, it's in Kintyre. Just a thought when the report contains a simple innacuracy like this.
][/QUOTE]
Just being pedantic but Campbeltown is not in Ayrshire, it's in Kintyre. Just a thought when the report contains a simple innacuracy like this.
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"The main reason being that as all UK operators are supposed to operate in accordance with CAP371 or a similar approved FTL scheme,.........."
Should read ".......are supposed to operate within the SPIRIT of CAP371........"
That has never been policed by the very organisation that wrote it, but has always been used as their 'get out' clause from doing anything. Imagine the chaos if the social legal system relied mostly on the good will and self discipline of the general public to uphold the law. No police force. It would be fun for a while, but then......? This abuse of the system has been going on for 30 years and getting worse.
Should read ".......are supposed to operate within the SPIRIT of CAP371........"
That has never been policed by the very organisation that wrote it, but has always been used as their 'get out' clause from doing anything. Imagine the chaos if the social legal system relied mostly on the good will and self discipline of the general public to uphold the law. No police force. It would be fun for a while, but then......? This abuse of the system has been going on for 30 years and getting worse.
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I think I agree with theShadow, having looked at his link.
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The AAIB Report introduced not the possibility of carby icing but the probability of it - and then went on to ignore it in their further analysis and findings.
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That seems to be puzzling at least. Perhaps BN2 operators MEEB and CORNFLAKE could comment after looking at theShadow's post and link.
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Extract:
The cause of this ditching is also possibly due to carburettor icing. This claims many pilots who just tend to forget about it (carby heat). The conditions certainly demanded it - but it wasn't being used. That type of icing can be insidious (the power simply not being there when you go for it).The possibility of carby ice affecting both engines equally and simultaneously is very high.
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The thing to remember is that if the conditions are conducive to carby ice forming, it WILL form in the carby throat. The only question is then whether enough will form to choke the gas flow and affect the engine's power output. In a low power descent Instrument Approach you're not likely to find out until you go to apply power. The surprise factor is then going to make carby icing possibly the last thing that you think of.
The other nasty aspect of carby icing is that by the time you get the symptoms (usually of power loss or failure to increase power on demand) it's too late. Why? because the engine by then isn't capable of generating sufficient heat fast enough to melt the icing build-up. A selection of HOT immediately after becoming aware of carby icing can also lead to a rich cut if the throttle is anyways OPEN (Ice dislodges and blocks all airflow past the venturi throat).
Although the report canvasses the possibility of carby icing, it's also given it insufficient analysis (i.e. no mention at all) as a probable cause.
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Almost unbelievably there's nothing whatsoever in the findings or causal factors about the possibility of carby icing having knocked out any power re-application from either engine. A double engine failure from carby icing is certainly a possibility. The engine doesn't really "fail" as such. It keeps running at low power but fails to produce any power on demand. I've seen that a number of times after a protracted descent in very humid conditions on a piston-powered machine without fuel injection.
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The crash position was around about where the pilot would have been going for power in the conditions (i.e. he needed a break-out of cloud at around 1000ft to be able to legally circle for r/way 25 - his expressed intention.). So he needed to level off at 1000ft and drive in. That's about when he would've found the power on demand just wasn't there. At that point he'd have been checking fuel and even if he had thought of carby icing as a cause, it wouldn't have made any difference at that late stage.
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The AAIB Report introduced not the possibility of carby icing but the probability of it - and then went on to ignore it in their further analysis and findings.
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That seems to be puzzling at least. Perhaps BN2 operators MEEB and CORNFLAKE could comment after looking at theShadow's post and link.
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Extract:
The cause of this ditching is also possibly due to carburettor icing. This claims many pilots who just tend to forget about it (carby heat). The conditions certainly demanded it - but it wasn't being used. That type of icing can be insidious (the power simply not being there when you go for it).The possibility of carby ice affecting both engines equally and simultaneously is very high.
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The thing to remember is that if the conditions are conducive to carby ice forming, it WILL form in the carby throat. The only question is then whether enough will form to choke the gas flow and affect the engine's power output. In a low power descent Instrument Approach you're not likely to find out until you go to apply power. The surprise factor is then going to make carby icing possibly the last thing that you think of.
The other nasty aspect of carby icing is that by the time you get the symptoms (usually of power loss or failure to increase power on demand) it's too late. Why? because the engine by then isn't capable of generating sufficient heat fast enough to melt the icing build-up. A selection of HOT immediately after becoming aware of carby icing can also lead to a rich cut if the throttle is anyways OPEN (Ice dislodges and blocks all airflow past the venturi throat).
Although the report canvasses the possibility of carby icing, it's also given it insufficient analysis (i.e. no mention at all) as a probable cause.
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Almost unbelievably there's nothing whatsoever in the findings or causal factors about the possibility of carby icing having knocked out any power re-application from either engine. A double engine failure from carby icing is certainly a possibility. The engine doesn't really "fail" as such. It keeps running at low power but fails to produce any power on demand. I've seen that a number of times after a protracted descent in very humid conditions on a piston-powered machine without fuel injection.
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The crash position was around about where the pilot would have been going for power in the conditions (i.e. he needed a break-out of cloud at around 1000ft to be able to legally circle for r/way 25 - his expressed intention.). So he needed to level off at 1000ft and drive in. That's about when he would've found the power on demand just wasn't there. At that point he'd have been checking fuel and even if he had thought of carby icing as a cause, it wouldn't have made any difference at that late stage.
Do a Hover - it avoids G
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Carb icing could well have been a distracting event in the overall process but the state of the wreckage does indicate a crash into the sea rather than a controlled ditching because there was not enough power to maintain height.
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AAIB assessed it as a CONTROLLED FLIGHT INTO THE SEA
pg 45 (53 of 81)
Don't agree John. Last sentence below reads:
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"Overall the impact damage and consequent breakup is consistent with a controlled flight into the sea at or close to a normal descent rate and speed."
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I think the AAIB uncharacteristically blew it on this one.
JS/TS
Don't agree John. Last sentence below reads:
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"Overall the impact damage and consequent breakup is consistent with a controlled flight into the sea at or close to a normal descent rate and speed."
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I think the AAIB uncharacteristically blew it on this one.
JS/TS
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Tend to agree with the Carby Ice Theory
From the Report
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The Report says that "neither carburettor heat selector was set to HOT"
These are gated controls (not likely to move during the accident).
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The Report says that "neither carburettor heat selector was set to HOT"
These are gated controls (not likely to move during the accident).
Do a Hover - it avoids G
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Point taken Shadow and I would not argue against your view. I just interpret the same words a little differently. My reading of them is that the aircraft was under control etc and doing the sort of manoeuvre to be expected at that inbound stage of the flight but at the wrong height. That to my mind is not quite the same thing as what it would have been doing if Guy was afraid of hitting the water (seen the altimeter at the last moment) or realised he had no choice but to land on the water (lack of power).
I am sure anybody who has real experience of flying at night single crew in the very special true darkness that exists low over the water knows how little it takes to distract one from the altimeter for those few seconds that are sadly all it takes. As to what the distraction might have been - well the list is bordering on endless.
I am sure anybody who has real experience of flying at night single crew in the very special true darkness that exists low over the water knows how little it takes to distract one from the altimeter for those few seconds that are sadly all it takes. As to what the distraction might have been - well the list is bordering on endless.
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Carburettor Icing on Both
It can all happen very quickly and confusingly
Meanwhile, the four student pilots on the plane forced to make an emergency landing in Hawke's Bay yesterday, 02 Dec 06, were unaware they were in danger.
Their six-seater Partenavia P68B plane ZK-LAL suffered a double engine failure, forcing their instructor to make an emergency landing in a small field about midday.
Instructor Ravindrah Singh said the students thought they were being tested on emergency procedures until the plane hit the ground.
"That's the time they realised it was the real thing."
The private students from the Manawatu Aero Club were returning to Palmerston North from Napier when their first engine failed about 760m above Takapau.
While running through emergency procedures, the second engine failed and Singh took over the controls to make the landing.
Singh said the students were in good spirits and the incident had been good for their emergency training.
Meanwhile, the four student pilots on the plane forced to make an emergency landing in Hawke's Bay yesterday, 02 Dec 06, were unaware they were in danger.
Their six-seater Partenavia P68B plane ZK-LAL suffered a double engine failure, forcing their instructor to make an emergency landing in a small field about midday.
Instructor Ravindrah Singh said the students thought they were being tested on emergency procedures until the plane hit the ground.
"That's the time they realised it was the real thing."
The private students from the Manawatu Aero Club were returning to Palmerston North from Napier when their first engine failed about 760m above Takapau.
While running through emergency procedures, the second engine failed and Singh took over the controls to make the landing.
Singh said the students were in good spirits and the incident had been good for their emergency training.
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Shows how much I know, I always thought the Islander had injected engines with no carb heat, only alternate air. Oh well. I wouldn't have thought the carb heat control positions were that significant anyway; from what little I know the system is designed for periodic use so could have been recently used and switched off. I flew with Guy on the Saab a couple of times and from what I saw wouldn't have thought that icing conditions would have been anything other than routine for him, unlikely even to have provided a distraction.
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Shadow,
From memory, the Partenavia came standard with injected engines. Was this one modified?
Of course my memory could be failing..............................
Snooze
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz
From memory, the Partenavia came standard with injected engines. Was this one modified?
Of course my memory could be failing..............................
Snooze
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz
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I only flew the Partenavia a few times, but on my conversion, by Pete Green, was told it was the air intakes that blocked, VERY quickly.
I've not flown the Islander, but did a year on the Trislander, and there the carb heat levers were at the bottom on the throttle pedestal, awkard inconvenient and invisible.
I've not flown the Islander, but did a year on the Trislander, and there the carb heat levers were at the bottom on the throttle pedestal, awkard inconvenient and invisible.
The BN2s used by LC were all carburetted with manual carb heat. Carb icing was so common it soon became routine select it on every 5 - 10 mins in cruise and for every power reduction - sometimes even at climb power. It became as automatic an action as changing power by using the throttle or leaning using the mixture control.
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1) The Islanders still used today by Loganair are carb'ed. Don't quite see the problem really. Do you really think that we ambulance drivers would've been taken by surprise with sudden carb icing....in Scotland....in the winter!? The levers are below the flap switch on the centre console. They're not hard to find, even with your eyes shut. As others have said, flying with your hands permanently fixed to the levers was common place and not something that would cause a distraction. It was when there was no carb icing that you didn't quite know what to do with the spare hand.
2) Flying a non-precision approach in the BN2 was not an issue either, especially with the 3-axis autopilot taking the workload off when IMC.
3) It has been mentioned about flying 120 kts down the approach in the same chat about possible carb icing and engine power loss. Do you know how much engine power the BN2 requires to be 'driven' down the approach at that speed? If it really was maintaining the slope and correct attitude at that speed to the water, then it would have been under power, not power loss. It isn't exactly a slick aerodynamic machine.
Cheers ACA
2) Flying a non-precision approach in the BN2 was not an issue either, especially with the 3-axis autopilot taking the workload off when IMC.
3) It has been mentioned about flying 120 kts down the approach in the same chat about possible carb icing and engine power loss. Do you know how much engine power the BN2 requires to be 'driven' down the approach at that speed? If it really was maintaining the slope and correct attitude at that speed to the water, then it would have been under power, not power loss. It isn't exactly a slick aerodynamic machine.
Cheers ACA
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Carb Ice
A freind of mine & his passengers all died in a Partenavia in very similar cicumstances to this one. Night approach over water and no carb heat selected. The engines stopped at low level on an SRA and in they went.
As a previous poster said, the aircraft was known for rapid ice build up in these circs.
As a previous poster said, the aircraft was known for rapid ice build up in these circs.
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Partenavias
At the risk of further thread drift........................
The discussion at this point centers around the possibility or probability of carburettor icing as a factor in the Islander accident. The Islander came equipped with either 260 hp carburetted engines, or 300 hp injected engines (or Allison 350 turbines), and apparently this one was carburetted.
In support of the carby ice possibility, two Partenavia apparent double engine failures have been cited as due to carby ice.
The P68B, P68C and P68 Observer aircraft were delivered with Lycoming IO-360 engines. Note the 'IO'. That's injected, not carburetted. The P68TC featured a turbocharged, injected engine from the same manufacturer. Various other engine / airframe combinations were mooted or marketted, but without much success. Before anyone asks, the P68A refers to the several pre-production aircraft.
Another poster has observed that during his conversion onto the Partenavia, he was advised that the (cooling) air intakes (located on the front of the engine cowling) were very prone to blocking with ice. This may or may not be so, but is in any case irrelevant to the Islander discussion, with different engines and cowls, and it's not carby icing.
The standard Partenavia, as delivered, does not suffer from carburettor icing. It doesn't have carburettors! (or carby heat, or carby heat selectors )-: )
Xploy Ted,
I'm sorry to hear that your friend and his passengers perished in a Partenavia accident. Like most light twins, it is not a forgiving aircraft to operate in adverse conditions. You can be assured though, that their demise was not due to his error in not selecting carby heat.
Now, can we get back to discussing Islanders please!
The discussion at this point centers around the possibility or probability of carburettor icing as a factor in the Islander accident. The Islander came equipped with either 260 hp carburetted engines, or 300 hp injected engines (or Allison 350 turbines), and apparently this one was carburetted.
In support of the carby ice possibility, two Partenavia apparent double engine failures have been cited as due to carby ice.
The P68B, P68C and P68 Observer aircraft were delivered with Lycoming IO-360 engines. Note the 'IO'. That's injected, not carburetted. The P68TC featured a turbocharged, injected engine from the same manufacturer. Various other engine / airframe combinations were mooted or marketted, but without much success. Before anyone asks, the P68A refers to the several pre-production aircraft.
Another poster has observed that during his conversion onto the Partenavia, he was advised that the (cooling) air intakes (located on the front of the engine cowling) were very prone to blocking with ice. This may or may not be so, but is in any case irrelevant to the Islander discussion, with different engines and cowls, and it's not carby icing.
The standard Partenavia, as delivered, does not suffer from carburettor icing. It doesn't have carburettors! (or carby heat, or carby heat selectors )-: )
Xploy Ted,
I'm sorry to hear that your friend and his passengers perished in a Partenavia accident. Like most light twins, it is not a forgiving aircraft to operate in adverse conditions. You can be assured though, that their demise was not due to his error in not selecting carby heat.
Now, can we get back to discussing Islanders please!