Glasgow Accident Inquiry Findings
Ecce Homo! Loquitur...
Thread Starter
Glasgow Accident Inquiry Findings
BBC - Tuesday, 24 September, 2002, 12:16 GMT 13:16 UK:
Crash pilot switched off wrong engine
An air crash near Glasgow Airport which left eight people dead was caused when the pilot mistakenly switched off the wrong engine, an inquiry has found.
The Cessna 404, which was carrying nine Airtours staff from Glasgow to Aberdeen, nosedived minutes after taking off on 3 September, 1999.
A fatal accident inquiry at Paisley Sheriff Court concluded that the pilot, Captain John Easson, realised that one of the engines had malfunctioned but was unable to tell which one.
The victims
Captain John Easson, 49
Stewardess Pauline MacIver, 31
Stewardess Pauline Moyes, 38
Stewardess Linda Taylor, 29
Stewardess Helen Steven, 28
Stewardess Lynn McCulloch, 25
Pilot Colin Finnie, 32
Pilot Bill Henderson, 54
The report by Sheriff Principal Bruce Kerr said that Capt Easson's judgment could have been hampered by the fact that a "bang" was heard from the right engine, which was in fact the good one, early on in the flight.
The report stated: "The commander decided to adhere to his original intention to return to the airfield and did not consider (or may have decided against) the possibility of a gradual descent to a forced landing.
"This was, as it turned out, a misjudgement, albeit made under great stress, at low height in a necessarily very limited period of time."
Sheriff Kerr said the decision was "born of the commander's predisposition from his training and experience to resolve such an emergency by closing down the malfunctioning engine and proceeding to an airport on the remaining engine".
The report said the pilot ought to have considered making an emergency landing in nearby fields rather than attempting to return to Glasgow Airport.
It also lists a series of recommendations:
Cockpit voice recorders in all aircraft regardless of size
Extra pilot training
Mechanical inspections every 200 flying hours
A reduction in the effects of engine vibration
A study into safety of seats on small planes
The sheriff underlined the need for small aircraft to carry cockpit flight recorders.
He said: "It is highly probable, indeed almost certain, that we would all have known immeasurably more about this accident and the reasons for it had there been a cockpit voice recorder on board."
A spokesman for MyTravel Airways, the new name for Airtours, said: "Following the publishing of Fatal Accident Inquiry findings today into the tragic accident, our thoughts remain with the survivors and the families of the deceased at this time."
Five stewardesses, the pilot and co-pilot and an Airtours pilot travelling as a passenger were killed, while three other staff members only survived after being pulled from the burning wreckage by a man who was working nearby.
The rescuer, John Connell, 24, later received a British Red Cross humanity award for his heroism.
Crash pilot switched off wrong engine
An air crash near Glasgow Airport which left eight people dead was caused when the pilot mistakenly switched off the wrong engine, an inquiry has found.
The Cessna 404, which was carrying nine Airtours staff from Glasgow to Aberdeen, nosedived minutes after taking off on 3 September, 1999.
A fatal accident inquiry at Paisley Sheriff Court concluded that the pilot, Captain John Easson, realised that one of the engines had malfunctioned but was unable to tell which one.
The victims
Captain John Easson, 49
Stewardess Pauline MacIver, 31
Stewardess Pauline Moyes, 38
Stewardess Linda Taylor, 29
Stewardess Helen Steven, 28
Stewardess Lynn McCulloch, 25
Pilot Colin Finnie, 32
Pilot Bill Henderson, 54
The report by Sheriff Principal Bruce Kerr said that Capt Easson's judgment could have been hampered by the fact that a "bang" was heard from the right engine, which was in fact the good one, early on in the flight.
The report stated: "The commander decided to adhere to his original intention to return to the airfield and did not consider (or may have decided against) the possibility of a gradual descent to a forced landing.
"This was, as it turned out, a misjudgement, albeit made under great stress, at low height in a necessarily very limited period of time."
Sheriff Kerr said the decision was "born of the commander's predisposition from his training and experience to resolve such an emergency by closing down the malfunctioning engine and proceeding to an airport on the remaining engine".
The report said the pilot ought to have considered making an emergency landing in nearby fields rather than attempting to return to Glasgow Airport.
It also lists a series of recommendations:
Cockpit voice recorders in all aircraft regardless of size
Extra pilot training
Mechanical inspections every 200 flying hours
A reduction in the effects of engine vibration
A study into safety of seats on small planes
The sheriff underlined the need for small aircraft to carry cockpit flight recorders.
He said: "It is highly probable, indeed almost certain, that we would all have known immeasurably more about this accident and the reasons for it had there been a cockpit voice recorder on board."
A spokesman for MyTravel Airways, the new name for Airtours, said: "Following the publishing of Fatal Accident Inquiry findings today into the tragic accident, our thoughts remain with the survivors and the families of the deceased at this time."
Five stewardesses, the pilot and co-pilot and an Airtours pilot travelling as a passenger were killed, while three other staff members only survived after being pulled from the burning wreckage by a man who was working nearby.
The rescuer, John Connell, 24, later received a British Red Cross humanity award for his heroism.
Guest
Posts: n/a
Having flown the 404 all I can say it has marginal performance (Performance class C) at max gross weights. When I did my conversion, my instructor was emphatic that you must feather the failed engine within 5 seconds or you've had it. I remember his words,'dead leg... dead engine'. All very sad for those concerned.
Join Date: Mar 2000
Location: Arizona USA
Posts: 8,571
Likes: 0
Received 0 Likes
on
0 Posts
"Sheriff Principal"...?
One wonders, has this fellow had any training in aircraft accident investigations?
CVR's in all already under-performing piston twins?
Is this guy nuts...or what?
OTOH, better training might be a very good idea.
One wonders, has this fellow had any training in aircraft accident investigations?
CVR's in all already under-performing piston twins?
Is this guy nuts...or what?
OTOH, better training might be a very good idea.
Join Date: Apr 2001
Posts: 355
Likes: 0
Received 0 Likes
on
0 Posts
Well, I don’t know what the press and TV coverage is like South of the Border, but up here it is diabolical, misinformed sensationalism.
It is very sad for John’s family that it is being suggested that the whole thing is down to pilot error and, that the Sheriff feels that the pilot should have considered a forced landing…. I’ll bet that informed statement came from first hand experience???!!!
I did not have the pleasure of meeting John, but I’m sure from what I have heard of him that he considered everything in the very short time available. As for further pilot training…are these guys on the same planet!!
A very sad result for the family of the crew, and I’m sure all our thoughts are again with them and those of the passengers.
It is very sad for John’s family that it is being suggested that the whole thing is down to pilot error and, that the Sheriff feels that the pilot should have considered a forced landing…. I’ll bet that informed statement came from first hand experience???!!!
I did not have the pleasure of meeting John, but I’m sure from what I have heard of him that he considered everything in the very short time available. As for further pilot training…are these guys on the same planet!!
A very sad result for the family of the crew, and I’m sure all our thoughts are again with them and those of the passengers.
Join Date: Dec 1999
Location: Wilmslow and North Yorks
Age: 53
Posts: 402
Likes: 0
Received 0 Likes
on
0 Posts
I lost a friend and colleague in the accident, brings it all back. 
As for the reports recommendations:
"CVRs in all aircraft regardless of size", good idea, never happen, too expensive.
"Extra pilot training", why? Surely we all do enough, tragic mistakes will happen regardless of how much training we do. We can't be perfect.
"A reduction in the effects of engine vibration".........?
Thoughts with the families of all involved,
CJ
As for the reports recommendations:
"CVRs in all aircraft regardless of size", good idea, never happen, too expensive.
"Extra pilot training", why? Surely we all do enough, tragic mistakes will happen regardless of how much training we do. We can't be perfect.
"A reduction in the effects of engine vibration".........?
Thoughts with the families of all involved,
CJ
ENTREPPRUNEUR
Join Date: Jun 2001
Location: The 60s
Posts: 566
Likes: 0
Received 0 Likes
on
0 Posts
This is an interesting case. What you have is an aircraft that in the event of an engine failure on take-off you have only seconds to feather an engine. On the other hand you have two pilots (presumably they were used to having two pilots in these situations). Engine failure is a likely event and it is an extremely dangerous one. So wouldn't you expect them to have a high-speed drill that tried to get input from both pilots albeit squeezed into a few seconds?
I think this is a failure to train and to embrace CRM.
I've said this before but I believe there is insufficient encouragement for non-flying pilots to veto the actions of the flying pilot in the event of emergencies. You can't tell me all those pilots on the Korean 747 didn't notice the plane was going onto its side.
I think this is a failure to train and to embrace CRM.
I've said this before but I believe there is insufficient encouragement for non-flying pilots to veto the actions of the flying pilot in the event of emergencies. You can't tell me all those pilots on the Korean 747 didn't notice the plane was going onto its side.
Join Date: May 2002
Location: Middle East
Posts: 806
Likes: 0
Received 0 Likes
on
0 Posts
Ballyheck - why not have CVR in a single crew aircraft. Take Egyptair 763 crash in the USA a few years ago. Although a multiple crew aircraft, the CVR picked up critical information from the pilot who was ALONE in the aircraft cockpit at the time, and who is "reputed" to have nosedived the aircraft into the sea.
I am not a pilot, but doesn't it make sense to have a CVR on all commercial or passenger carrying aircraft?
Surely any mis-communications between cockpit and ground would also be identified on later playback?
Excuse my naivety.........maybe I am talking bollocks but this is logic as I see it.
I am not a pilot, but doesn't it make sense to have a CVR on all commercial or passenger carrying aircraft?
Surely any mis-communications between cockpit and ground would also be identified on later playback?
Excuse my naivety.........maybe I am talking bollocks but this is logic as I see it.
Guest
Posts: n/a
Join Date: Oct 1999
Location: ex EGNM, now NZRO
Posts: 551
Likes: 0
Received 0 Likes
on
0 Posts
Low cost CVR??
Surely in this technological age there must be a cheap way of making a cheap CVR for light aircraft. You can buy those memo type digital recorders for say £100 that record about 20 mins of audio. Perhaps some bright spark could harness that technology and apply it to aviation?
And bmi have an old Baron at EMA which has been used within the last year or two to position the odd pilot, more normally it flies Sir Mike or spares around. I for one would not get onboard on the companies time.
Join Date: Mar 2000
Location: Arizona USA
Posts: 8,571
Likes: 0
Received 0 Likes
on
0 Posts
Max Angle,
Would rather depend, would it not, if that "old Baron" was maintained and flown professionally? Or, are you simply being elitist?
Nothing wrong with higher powered light twin-engined aeroplanes to move one or two crew members from time to time IMHO. Having said this however, these aeroplanes must not be packed to the gills with larger numbers and operated at max weights, or in very poor weather.
And, most important, must be properly maintained. Note for example the 404 concerned. According to the AAIB report, the engine failed due to starter adapter (and related accessory gear) failure. This is a very well known problem area with these geared Continental engines, and is covered extensively by a TCM critical service bulletin which requires careful repetative inspections, which CANNOT be ignored.
Would rather depend, would it not, if that "old Baron" was maintained and flown professionally? Or, are you simply being elitist?
Nothing wrong with higher powered light twin-engined aeroplanes to move one or two crew members from time to time IMHO. Having said this however, these aeroplanes must not be packed to the gills with larger numbers and operated at max weights, or in very poor weather.
And, most important, must be properly maintained. Note for example the 404 concerned. According to the AAIB report, the engine failed due to starter adapter (and related accessory gear) failure. This is a very well known problem area with these geared Continental engines, and is covered extensively by a TCM critical service bulletin which requires careful repetative inspections, which CANNOT be ignored.
Join Date: Jul 2001
Location: europe
Posts: 85
Likes: 0
Received 0 Likes
on
0 Posts
discussion won't wind the clock back but I have it on good authority that Airtours wanted it to be a 2 crew operation. The company operating the 404 used to dress up various individuals as pilots and put them in the right seat in the guise of professional co-pilot. It was in reality a single crew operation. The aircraft was certified as such, but the clients were not getting what they had requested.
Join Date: Feb 2000
Location: Euroland
Posts: 959
Likes: 0
Received 0 Likes
on
0 Posts
Oh Please! Get real will you....
clear prop!!!:
Sorry you feel unable to accept it, but the whole thing IS down to pilot error.
Two fundamentals of flying twins:
1)In an engine failure, it is imperative to identify the failed engine correctly (dead leg, dead engine- not rocket science).
2)If you cannot maintain altitude and are losing control, trade height for speed and put the aircraft down in a controlled fashion, in a clear area. There were plenty of clear areas available in this case (the aircraft crashed into one of them).
This pilot neither correctly identified the failed engine, nor maintained control of his aircraft. That, I am afraid, is the simple, hard truth.
And before anybody says "there but for the grace of God..." CRAP. If you fly the emergency with even reasonable competency, you generally live to tell the tale.
It is sad that his family should have to endure further pain, but better that than pretending the crash was caused by some other, unidentified, factor (which hinders flight safety).
It is very sad for John’s family that it is being suggested that the whole thing is down to pilot error and, that the Sheriff feels that the pilot should have considered a forced landing
Two fundamentals of flying twins:
1)In an engine failure, it is imperative to identify the failed engine correctly (dead leg, dead engine- not rocket science).
2)If you cannot maintain altitude and are losing control, trade height for speed and put the aircraft down in a controlled fashion, in a clear area. There were plenty of clear areas available in this case (the aircraft crashed into one of them).
This pilot neither correctly identified the failed engine, nor maintained control of his aircraft. That, I am afraid, is the simple, hard truth.
And before anybody says "there but for the grace of God..." CRAP. If you fly the emergency with even reasonable competency, you generally live to tell the tale.
It is sad that his family should have to endure further pain, but better that than pretending the crash was caused by some other, unidentified, factor (which hinders flight safety).
Join Date: Jun 2000
Location: Co.Durham UK
Posts: 185
Likes: 0
Received 0 Likes
on
0 Posts
I believe after reading the report about a year ago the thought that passed through my little brain was more about the weight aspect and the ability to climb with a 757 crew all their crew bags and any other weight on board this Cessna. The importance of feathering etc is also very important but mass & balance is something that should be looked at closely before we even get airborne. Pressure from the airlines to get crew from A to B no questions asked was also a cotributing factor. My girlfriend flies with Mytravel/Airtours and I am pleased they have changed the way in which they position crew-such a damn shame it took this accident for the suits to look up and change things.
May they rest in peace.
May they rest in peace.