Convair 340 (C-131D) ZS-BRV crash Pretoria, South Africa
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This is the link to the report: http://www.caa.co.za/Accidents%20and...rts/ZS-BRV.pdf
Very detailed for a preliminary report and certainly worth reading.
It also contains a high res capture from the video showing the burning engine. This pic clearly shows the left aileron all the way up. It even looks like it is deflected past the normal operating range.
Very detailed for a preliminary report and certainly worth reading.
It also contains a high res capture from the video showing the burning engine. This pic clearly shows the left aileron all the way up. It even looks like it is deflected past the normal operating range.
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The FO had a valid Australian Air Transport, Commercial and Private Pilot Licence, however he was not type rated on the aircraft (Convair 340/440).
The Aircraft Flight Manual requires two pilots to operate the aircraft and both need to be rated on the aircraft, however the documents and licenses made available to Investigation team indicates only Captain rated on the aircraft (Convair 330/440).
Yes that seems a contradiction but did not cause the crash IMHO.
Two things got just a passing comment, stiff or heavy rudder and loss of aileron control.
Also mention that it was not climbing well.
I can only guess that putting out the known fire was not the priority at the time.
Two things got just a passing comment, stiff or heavy rudder and loss of aileron control.
Also mention that it was not climbing well.
I can only guess that putting out the known fire was not the priority at the time.
Quote
oug ferried the Hars Convair out from South Africa last year.
000
oug ferried the Hars Convair out from South Africa last year. 000My thought was maybe the cowl flap motor was inoperative and the crew had perhaps mechanically wound the cowl flap to the full open position for a ferry flight due lack of spares at the point of departure. That would be inconceivable to me as the CHT on that engine would be very low with all that cooling airflow through the engine and effect on the cylinders. I wrote to HARS for their comment but received no acknowledgement
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.
Again 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. It is difficult to know why the company policy required the cowl flaps to be set fully open for take off. It was the same cowl flap policy apparently that HARS used for the first Convair ferried to Australia.
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. I experienced a runaway left propeller at 500 feet after take off at Canberra in a Convair 440. The very first indication was the very loud increase in noise from the left side of the aircraft. A quick glance at the RPM gauge showed a rapid "split" occurring between the number one and number two needles and for a few seconds it was difficult to confirm if one needle was indeed reducing in RPM and the other increasing in RPM. I would imagine the same would apply to a manifold pressure gauge with its dual needles. 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. During my time as QFI at Canberra on the Convair 440, I was tasked to test the pilot of a USAF Convair 340 for his instrument rating. The Convair 340 (or maybe it was a Convair 240 I am unsure now) was based at Canberra for the use of the United States Consul General and his staff. The pilot was a Major in the USAF and it was policy to carry a "Crew Chief" who had the rank of Staff Sergeant I think. In other words he was an LAME who was primarily responsible for the servicing of the US Embassy aircraft. The crew chief sat in the jump seat and among other duties he started the engines (which could be a quite complicated procedure involving multi-fingered switch flicking and lever operation). He also handled the throttles, pitch and mixture levers, and cowl flaps - even though a co-pilot might be present.
During the instrument rating test, one engine was shut down in cruise and checklists followed. Except I noticed the mixture on the live engine was still in lean even though the live engine was at METO power. The crew chief who was doing the engine handling did not notice the lean mixture. The captain missed it as well. He was relying 100 percent on the crew chief to push and pull the appropriate levers and knobs. When I pointed out to the captain the mixture on the live engine was not placed in rich he got very cranky and harsh words were exchanged between the hapless crew chief and the captain. The captain refused to accept he was equally to blame for the missing checklist item.
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.
Last edited by Centaurus; 12th Aug 2018 at 05:52.
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we selected the cowl flaps selector switches to a position called "Trail"
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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
Jet A1 is removed as a issue, as seems a R/H engine failure.
There seems to be a large amount of audio/video evidence including in the cockpit.
Type rating
Assuming they had no technical issue what would have happened ? Divert to where ?
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From the interim report
Since the first flight after maintenance is basically a test flight I'm surprised they'd be taking passengers. Since it's unknown what issues will occur it makes more sense to have the minimum number of people on board and to keep the weight as low as possible.
I wonder if the outcome would have been different if they'd done this.
1.1.3 On 06 July 2018 maintenance checks (A, B & C) were performed on the aircraft at 18115.1 airframe hours The accident flight was the first flight post maintenance.
I wonder if the outcome would have been different if they'd done this.
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The FO had a valid Australian Air Transport, Commercial and Private Pilot Licence, however he was not type rated on the aircraft (Convair 340/440).
the FO had a valid Australian license with the appropriate type rating.
Very puzzling.
2.2 The FO had a valid Australian Air Transport, Commercial and Private Pilot Licence, however he was not type rated on the aircraft (Convair 340/440).
2.3 The FO’s validation of his foreign license was only limited to Single Engine Landing aircraft with the following aircraft types (C150, C172, C182 PA 28 A/B) this is based on his foreign license validation application and skill test report dated 9th of May 2016 and the validation was valid until 05 May 2021.
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That was my take-away as well ... the "Type Endorsed" notation in the personnel matrix notwithstanding.
it's not a good read sadly - especially when the injured crew and pax are still recovering in hospital
test flight but with load of 17 pax (first flight since A B and C checks) although pax had signed indemnities - so the report states.
operating to a notam'd closed field - although flight was described as a ''scenic flight'' -- had they intended to land or simply return to their originator?
flight crew (F/O) not seemingly type rated for this a/c type in RSA or his home country nor for ME classification in RSA.
auto feather light inop (LAME says bulb u/s)
engine on fire seemingly not positively identified by the flight crew and the fire check list was not initiated.
handling issues were prevalent
CRM concerns - as noted in the report
Rovos Rail still officially owned this aircraft and it was still registered to them - due to hand over to the Dutch air museum on arrival at AMS.
The LAME on board was employed by them.
we have lost 3 vintage airliners in a few weeks - all with pax on board and 2 with serious fatalities - for the preservation movement this is very sad
test flight but with load of 17 pax (first flight since A B and C checks) although pax had signed indemnities - so the report states.
operating to a notam'd closed field - although flight was described as a ''scenic flight'' -- had they intended to land or simply return to their originator?
flight crew (F/O) not seemingly type rated for this a/c type in RSA or his home country nor for ME classification in RSA.
auto feather light inop (LAME says bulb u/s)
engine on fire seemingly not positively identified by the flight crew and the fire check list was not initiated.
handling issues were prevalent
CRM concerns - as noted in the report
Rovos Rail still officially owned this aircraft and it was still registered to them - due to hand over to the Dutch air museum on arrival at AMS.
The LAME on board was employed by them.
we have lost 3 vintage airliners in a few weeks - all with pax on board and 2 with serious fatalities - for the preservation movement this is very sad
Last edited by rog747; 12th Aug 2018 at 08:14.
In the report, 1.6.1 "The minimum permissible cylinder head temperature is 260°C (500°F); the minimum permissible oil-in temperature is 100°C (212°F)," should read "Maximum" for those two conditions. Overall, seems like a well presented prelim report. Expect the final version to include more specifics, particularly a more thorough analysis of the engine fire/fail and actions of all responsible in the whole sad saga.
OAP
OAP
an update from the Pprune Ozzie forum about the injured crew posted 4 days ago....
quote:
They are coming back probably in the next ten days, states as being repatriated by QF. (does not state whether on stretchers on a QF flight or by med-vac flight)
a pilot who saw them in hospital - Doug is responding with hand squeezes, but Ross is still critical.
they were both in induced comas since the accident.
One of the pilots had his wife onboard and she is recovering well so the thread states....
quote:
They are coming back probably in the next ten days, states as being repatriated by QF. (does not state whether on stretchers on a QF flight or by med-vac flight)
a pilot who saw them in hospital - Doug is responding with hand squeezes, but Ross is still critical.
they were both in induced comas since the accident.
One of the pilots had his wife onboard and she is recovering well so the thread states....
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I see quite a few drivers that can be a problem with a "go minded" attitude.
With all the folks on board, who had been contributing to the restoration, all were eager to fly, included the crew.
The limited time available before the actual ferry flight.
Possible the limited time the crew had (one was still on active duty with the airline) to complete the whole schedule, before needing to return the long way home.
And who knows what more.
That reflects in decisions like not returning to the hangar to investigate the stiffness of the rudder and the drifting during taxy. Especially from a test flight crew You might expect a critical attitude. Long time ago a very experienced colleague learned me that You can fly with nearly any problem, as long as You know the source and be able to make a risk assessment.
In all they had to operate in what I would call an 'hostile environment` with many distracting elements. Were this same flight to be flown at their home turf (including SL altitude and w/o pax), the outcome would have been different.
On the SA "validation" part: long time ago I used my (Dutch)ATPL as a basis to get a simple PPL (VFR) validation to use for renting a SE for sightseeing trips when I had a layover in JNB. I cannot describe the procedure other than terrible bureaucratic. It involved a trip to a field to do an early morning checkout and drive to Pretoria (office closed at 13.00hrs) with all the paperwork. My normal license which was valid for 2 Years, it included an IF rating with a due date always less that 6 months away, and the SA validation got limited to that date, no matter I said I did not want to include IF in my PPL. In practice every time I got there, I had to go over the same procedure every time, so after 3 times I gave up.
But maybe things have changed.
And for my flying abroad: I flew at many stops we had layovers: like in Alaska, LAX, Houston, Atlanta, NY, Chicago, Curacao, Nairobi, Santiago and even Thailand. Besides the XX thousands of airline hours have some 5500 hours on GA planes, but sometimes I just rented with a local instructor, to have someone O/B who knew all about local stuff. Having experience on a plane alone is not the whole story.
With all the folks on board, who had been contributing to the restoration, all were eager to fly, included the crew.
The limited time available before the actual ferry flight.
Possible the limited time the crew had (one was still on active duty with the airline) to complete the whole schedule, before needing to return the long way home.
And who knows what more.
That reflects in decisions like not returning to the hangar to investigate the stiffness of the rudder and the drifting during taxy. Especially from a test flight crew You might expect a critical attitude. Long time ago a very experienced colleague learned me that You can fly with nearly any problem, as long as You know the source and be able to make a risk assessment.
In all they had to operate in what I would call an 'hostile environment` with many distracting elements. Were this same flight to be flown at their home turf (including SL altitude and w/o pax), the outcome would have been different.
On the SA "validation" part: long time ago I used my (Dutch)ATPL as a basis to get a simple PPL (VFR) validation to use for renting a SE for sightseeing trips when I had a layover in JNB. I cannot describe the procedure other than terrible bureaucratic. It involved a trip to a field to do an early morning checkout and drive to Pretoria (office closed at 13.00hrs) with all the paperwork. My normal license which was valid for 2 Years, it included an IF rating with a due date always less that 6 months away, and the SA validation got limited to that date, no matter I said I did not want to include IF in my PPL. In practice every time I got there, I had to go over the same procedure every time, so after 3 times I gave up.
But maybe things have changed.
And for my flying abroad: I flew at many stops we had layovers: like in Alaska, LAX, Houston, Atlanta, NY, Chicago, Curacao, Nairobi, Santiago and even Thailand. Besides the XX thousands of airline hours have some 5500 hours on GA planes, but sometimes I just rented with a local instructor, to have someone O/B who knew all about local stuff. Having experience on a plane alone is not the whole story.