Convair 340 (C-131D) ZS-BRV crash Pretoria, South Africa
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I noticed a a few discrepancies like that in the report. It stated the propellers were Composite, which they are not, they're aluminum. The position of hte accident was given as S26°67.031" E028°28.461" which is just gibberish, not a valid set of coordinates. The actual position of the crash was about S25 40' E28 17'
Double Back. Good post that.
let us remind ourselves.
Accident reports are very informative of what happened and when. WHY it was allowed to happen is a whole new ball game.
It is possible the P in C faced time constraints and faced pressure deriving from that.
let us not be too critical of the crew, as anyone with any sort of substancual and varied experience will agree, it can happen to anyone, given the circumstances. 20/20 hindsight is a wonderful thing. Let's all try and learn from this, as in all accidents. Their luck ran out. If we fly often and long enough, by the law of averages, our luck will desert us also. More so of course, in a ferry or test flying environment.
let us remind ourselves.
Accident reports are very informative of what happened and when. WHY it was allowed to happen is a whole new ball game.
It is possible the P in C faced time constraints and faced pressure deriving from that.
let us not be too critical of the crew, as anyone with any sort of substancual and varied experience will agree, it can happen to anyone, given the circumstances. 20/20 hindsight is a wonderful thing. Let's all try and learn from this, as in all accidents. Their luck ran out. If we fly often and long enough, by the law of averages, our luck will desert us also. More so of course, in a ferry or test flying environment.
This appears to have been a short, local, VFR flight. The closed field had been NOTAM'd for a while and was only 60nm from the departure point with alternates available.
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The GOPRO recording also shows the control wheel deflected to the right and the captain indicating that they had lost aileron, and requesting rudder input from the FO.
Great to have Centaurus back in the discussion. IIRC he's the only poster with CV-340 pilot experience on the thread.
Yes, "TRAIL" is also used for take-off on the C-47 with its R1830 (Twin Wasp) engines, and now see selector panel in post by uncle8 above.
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As I posted in my first reaction to the report, "The report suggests that the L/H propellor was receiving much less power and/or rotating slower than the R/H at impact, but that no shut down had been performed by the crew. In the absence of any explanation, it seems incredible that, faced with a failure and fire on the L/H engine and an accompanying loss of climb performance, the captain would wish to keep it running."
Indeed, showing a critical parameter for two engines on a single gauge is an ergonomic nightmare although - from his position behind the pilots, and with only the engines to handle - the LAME was in a good position dispassionately to interpret the gauges. OTOH, unlike the PF, he would not know how much yaw (if any) was accompanying the engine problem, i.e., how much rudder/control-wheel was being applied, and the forces needed to do it.
Yes, although I don't need to remind you that all large and long-haul aircraft employed a flight engineer to mind the engines and most other systems from the 1940s to the early-1980s, culminating in the L-1011, DC-10 and B747 Classic. And, of course, the Airbus A300B. When Airbus redesigned and automated the A300 cockpit and introduced the glass-cockpit A310 and A300-600 - with all systems-switches within reach of both pilots - the design was euphemistically referred to as the forward-facing crew cockpit. Airbus really meant it was a two-pilot cockpit, but was trying not to antagonise the flight-engineers' unions. So Air France introduced the A310 with two pilots and a forward-facing F/E. That didn't last long, and meanwhile Boeing had introduced the two-pilot B767. When any member of a cockpit crew is relegated to a monitoring role, (s)he loses motivation and can even be a liability in an emergency.
In this case, it's possible that the captain had tacitly delegated any decision-making process on engine handling to the experienced LAME, who regarded the aircraft as his baby. The LAME, on the other hand, may have been waiting simply for the captain to call for the engine fire drill. This, and a lack of communication, could have led to a mutual paralysis in decision-making and nothing was done. Very soon after, both pilots became preoccupied with trying to maintain control of the aircraft.
This preliminary report, as previously stated by me and others, contains minor anomalies. More significantly, there is no mention of fuel analysis. Perhaps that will follow.
...Photos accompanying the official report prove beyond doubt the accident aircraft departed with the top and bottom cowl flaps fully open. See above previous highlighted comment. The photo shows a fire that can be seen through the open top cowl flap. Is it possible that the intensity of the fire could be made worse by the airflow through the open cowl flap?
The drag would be significant. I was a QFI on the RAAF Convair 440 Metropolitan based at Canberra in the 1960's era. As far as I recall it was unheard of to take off with the cowl flaps fully open.
...if my memory serves me correctly, for take off we selected the cowl flaps selector switches to a position called "Trail" or similar name and the cowl flaps would then close to a position about two inches open. This gave minimum drag commensurate with keeping the CHT within take off limits.
The drag would be significant. I was a QFI on the RAAF Convair 440 Metropolitan based at Canberra in the 1960's era. As far as I recall it was unheard of to take off with the cowl flaps fully open.
...if my memory serves me correctly, for take off we selected the cowl flaps selector switches to a position called "Trail" or similar name and the cowl flaps would then close to a position about two inches open. This gave minimum drag commensurate with keeping the CHT within take off limits.
The report states the propeller of the engine on fire was not feathered; indeed the fire drill was not actioned either. At impact, evidence indicated the engine was delivering very little power. It is no wonder the aircraft was unable to maintain height on one engine given the high density altitude, the drag from a windmilling propeller and the fully open cowl flaps on the engine.
As I posted in my first reaction to the report, "The report suggests that the L/H propellor was receiving much less power and/or rotating slower than the R/H at impact, but that no shut down had been performed by the crew. In the absence of any explanation, it seems incredible that, faced with a failure and fire on the L/H engine and an accompanying loss of climb performance, the captain would wish to keep it running."
The single manifold pressure gauge with twin needles marked 1 and 2 and the single RPM gauge with its twin needles marked 1 and 2 which were on the Convair 340 and 440, could be a bit of a trap for the unwary. [...] The South African report reveals there was initial uncertainty among crew members which engine was the problem. With the single manifold pressure and single RPM gauge design, I can understand that.
The report stated the LAME was handling the engine controls. That is another trap IMHO. Too many cooks spoiling the broth, as the saying goes. I saw this happen once. [...]
[...] Afterwards I pondered this situation and came to the conclusion there were too many hands on the flight deck sharing simple tasks and if there were already two pilots in a two crew aircraft it was superfluous to have someone else, no matter how qualified, reaching between them operating engine controls.
[...] Afterwards I pondered this situation and came to the conclusion there were too many hands on the flight deck sharing simple tasks and if there were already two pilots in a two crew aircraft it was superfluous to have someone else, no matter how qualified, reaching between them operating engine controls.
In this case, it's possible that the captain had tacitly delegated any decision-making process on engine handling to the experienced LAME, who regarded the aircraft as his baby. The LAME, on the other hand, may have been waiting simply for the captain to call for the engine fire drill. This, and a lack of communication, could have led to a mutual paralysis in decision-making and nothing was done. Very soon after, both pilots became preoccupied with trying to maintain control of the aircraft.
This preliminary report, as previously stated by me and others, contains minor anomalies. More significantly, there is no mention of fuel analysis. Perhaps that will follow.
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What a depressing report. As others have pointed out there are some contradictions in the report itself but these tend to be cleared up and get worse, not better, by the time of the final report.
Lawyers will have a field day with this and so they should.
Lawyers will have a field day with this and so they should.
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So from video evidence through the cabin window the left aileron was in the maximum up position, earlier conjecture suggesting the fire could have stretched or severed the control linkage (as had happened during another Convair engine fire). That aileron up would tend to a left wing drop / turn - but a left turn wasn't evident in the cabin video. Now it appears from the GoPro footage that the control wheel was deflected to the right which would cause right aileron up, maybe in an attempt to counter an uncommanded left aileron up condition? Both ailerons up, drag from an unfeathered prop, loss of power on the left hand side. I guess if all that was so the only way was down?
Marcus
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Another factor could be the single engine performance capabilities that the CV 340 was certificated under. Under ideal conditions they are marginal at best, throw in a rats nest of engine/control/cockpit confusion and the odds were long.
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Yup.
I for one would have gladly signed a waiver to fly this bird (or the JU-52 for that matter) but would have been reluctant to do it straight out of maintenance...
Maybe someone with more knowledge of this operation will chime in.
I for one would have gladly signed a waiver to fly this bird (or the JU-52 for that matter) but would have been reluctant to do it straight out of maintenance...
Maybe someone with more knowledge of this operation will chime in.
Save the moralizing. In case you haven't noticed, dozens of people have been killed or injured in the last month in crashes of vintage aircraft where innocent people (mostly aviation enthusiasts) put their trust in skilled, experienced cockpit crews. The crashes of the Convair 340, the JU-52, the Dakota, and the de Havilland Dragon Rapide, may not have any common cause but they all share the elements of vintage aircraft being flown for the delight of aviation enthusiasts. This isn't about "versions of events," it's about reducing the chances of more people being unnecessarily killed if the failures can be identified and avoided. And that includes human failings.
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I'm very surprised by certain aspects of the preliminary report and would love to get some clarification. My understanding is that the PIC and FO are both very senior pilots from the same airline (hence culture), the PIC being a very senior line officer (for lack of a better term).
From the report I got no sense of any command presence, no radio call, no briefing/statement of intent to the FO or LAME...I find that both confusing and disturbing. This event unfolded over minutes....not seconds. Once the balloon went up I would have expected the captain to exercise
command authority? They specifically mention the rudder issue but no mention of any briefing on mechanical or other issues and emergency procedures? If this has been a "professional" flight for the two of them wouldn't you brief the takeoff and then wouldn't the PIC clearly state his intentions when
the engine failed? My very limited understanding is that you always brief alternative options for engine or other failure. Obviously in modern commercial multi-engine jets your expectation is to be able to return and land but in single engine and some GA light twins that's not always possible. I'd assume in
an older plane like this there was/should be a clear assessment of what options would be available for an engine failure outlining both the optimal return path and the best alternative for ditching if that's the only option.
That had to be the PIC's responsibility and it needed to be done quickly with whatever input he required from the FO or LAME. The lack of a quick and concise summery and course of action from the PIC is perplexing to say the least....
From the report I got no sense of any command presence, no radio call, no briefing/statement of intent to the FO or LAME...I find that both confusing and disturbing. This event unfolded over minutes....not seconds. Once the balloon went up I would have expected the captain to exercise
command authority? They specifically mention the rudder issue but no mention of any briefing on mechanical or other issues and emergency procedures? If this has been a "professional" flight for the two of them wouldn't you brief the takeoff and then wouldn't the PIC clearly state his intentions when
the engine failed? My very limited understanding is that you always brief alternative options for engine or other failure. Obviously in modern commercial multi-engine jets your expectation is to be able to return and land but in single engine and some GA light twins that's not always possible. I'd assume in
an older plane like this there was/should be a clear assessment of what options would be available for an engine failure outlining both the optimal return path and the best alternative for ditching if that's the only option.
That had to be the PIC's responsibility and it needed to be done quickly with whatever input he required from the FO or LAME. The lack of a quick and concise summery and course of action from the PIC is perplexing to say the least....
If this has been a "professional" flight for the two of them wouldn't you brief the takeoff and then wouldn't the PIC clearly state his intentions when
the engine failed?
the engine failed?
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Originally Posted by SLFinAZ
From the report I got no sense of any command presence, no radio call, no briefing/statement of intent to the FO or LAME...I find that both confusing and disturbing.
-- Mike Tyson
We can plan for all sorts of eventualities. However as the report hints at, there may have been some underlying flight control issue (both pilots required for rudder input, taxiing off centreline, para 1.1.16 Preliminary report). Until the investigators get to interview the crew or find some other mechanical defect we just don't know. Were one, two or three issues with the aircraft (engine fire, flight controls and engine instruments)? Did the engine fire cause the control problem? We don't know.
However, what I can tell you is that simply hand flying an airworthy aircraft during normal manoeuvring a consumes a large proportion of cognitive resources. That is why we have two pilots and use the autopilot when things get busy. Hand flying whilst potentially having multiple confusing failures makes it very easy to get to cognitive overload. Once in that state we rapidly lose the ability to perceive what is going on around us, we don't hear, we don't see very well, and we load-shed tasks. But here is the kicker, we don't get to choose what tasks we drop, it just happens automagically.
So we can plan for all sort of things, then we get airborne and nothing happens the way we think it will. Modern certification standard ensure that you can get away from the ground under the prevailing conditions with a safe plan. But this wasn't a modern aircraft. You only need to look at the list of Convair Accidents to see quite a number where people on the ground were killed people (five by my count). The inference is that many accidents happened as the aircraft simply could not out climb nearby populated terrain.
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Without being too simplistic, is it possible that this aircraft was past it's use by date? No matter what inspection or maintenance showed or was performed some other mechanical gremlin was about to surface. As it did in this case. A fubar.