Airtours C404 crash report
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Airtours C404 crash report
Due out tomorrow but I understand will highlight port engine failure, subsequent confusion about whether port or starboard engine had a problem, resulting in feathering of starboard prop rather than port. Awful accident.
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from news.bbc.co.uk 
The experienced pilot of a plane in which eight people were killed may have been misled into taking the wrong emergency action, a report has revealed.
Captain John Easson, 49, appeared to react initially to what he believed was a loss of power in the right-hand engine of the Cessna 404 Titan.
But it was the engine on the left side which had suffered failure in the accident near Glasgow Airport, the Air Accidents Investigation Branch (AAIB) said.
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, 23
Pilot Colin Finnie, 32
Pilot Bill Henderson, 54
Out of the 11 on board, eight died and three, including Captain Hugh O'Brien, 39, Kevan MacKenzie, 32, and steward Derek Morrison survived.
The survivors told the Air Accident Investigation Branch that they heard a bang or a thud shortly after take-off in the Cessna 404 Titan.
They thought this had come from the right-hand side, but the AAIB report added: "It is possible that the bang came from the left engine but sounded as if it came from the right engine".
The AAIB said the right-hand propeller was put into the "feather" position - a manoeuvre in which the blade is adjusted to prevent further damage and to minimise drag.
But this left the propeller of the failed, left, engine unfeathered and so the aircraft was incapable of climbing on one engine alone.
When Capt Easson, of Bryde, Isle of Man, who was taking the Airtours' crew to Aberdeen, feathered the right-hand engine's propeller there was a total loss of thrust.
He tried to return to Glasgow, but the plane went down in a field, crashing through a hedge and bursting into flames.
Capt Easson had been confronted with "an unenviable emergency at a critical stage of his flight", the investigators said.
The report said: "Time for him to make the correct diagnosis and to take the correct action was short.
"He seems to have reacted initially to a perceived power loss from the right engine and then had to deal with a progressive loss of power from the left engine."
A post-accident inspection "did not reveal any mechanical evidence of a problem with the right engine".
Extreme conditions
Investigators also concluded that if Capt Easson had tried to carry out a forced landing in a field rather than deciding to return to Glasgow Airport, "the outcome might have been different".
The end of the flight might have been "far more survivable for all on board", added the AAIB.
However, the report said that, under extreme conditions the captain had "maintained the only option that occurred to him - returning to the airport".
The AAIB added that all of the passenger seats had come lose from the floor of the aircraft.
The passengers that perished in the fire "would have had improved survival prospects if the strengths of their seats had been to the latest airworthiness requirements".
The aircraft was operated by the Edinburgh Air Charter company and was taking the Airtours staff to Aberdeen to connect with a holiday flight to Majorca.
The plane did not have, nor was required to have, flight recorders.
The AAIB recommended that such aircraft should at least have a cockpit voice recorder and that the Civil Aviation Authority should look at the seats issue.
Captain John Easson, 49, appeared to react initially to what he believed was a loss of power in the right-hand engine of the Cessna 404 Titan.
But it was the engine on the left side which had suffered failure in the accident near Glasgow Airport, the Air Accidents Investigation Branch (AAIB) said.
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, 23
Pilot Colin Finnie, 32
Pilot Bill Henderson, 54
Out of the 11 on board, eight died and three, including Captain Hugh O'Brien, 39, Kevan MacKenzie, 32, and steward Derek Morrison survived.
The survivors told the Air Accident Investigation Branch that they heard a bang or a thud shortly after take-off in the Cessna 404 Titan.
They thought this had come from the right-hand side, but the AAIB report added: "It is possible that the bang came from the left engine but sounded as if it came from the right engine".
The AAIB said the right-hand propeller was put into the "feather" position - a manoeuvre in which the blade is adjusted to prevent further damage and to minimise drag.
But this left the propeller of the failed, left, engine unfeathered and so the aircraft was incapable of climbing on one engine alone.
When Capt Easson, of Bryde, Isle of Man, who was taking the Airtours' crew to Aberdeen, feathered the right-hand engine's propeller there was a total loss of thrust.
He tried to return to Glasgow, but the plane went down in a field, crashing through a hedge and bursting into flames.
Capt Easson had been confronted with "an unenviable emergency at a critical stage of his flight", the investigators said.
The report said: "Time for him to make the correct diagnosis and to take the correct action was short.
"He seems to have reacted initially to a perceived power loss from the right engine and then had to deal with a progressive loss of power from the left engine."
A post-accident inspection "did not reveal any mechanical evidence of a problem with the right engine".
Extreme conditions
Investigators also concluded that if Capt Easson had tried to carry out a forced landing in a field rather than deciding to return to Glasgow Airport, "the outcome might have been different".
The end of the flight might have been "far more survivable for all on board", added the AAIB.
However, the report said that, under extreme conditions the captain had "maintained the only option that occurred to him - returning to the airport".
The AAIB added that all of the passenger seats had come lose from the floor of the aircraft.
The passengers that perished in the fire "would have had improved survival prospects if the strengths of their seats had been to the latest airworthiness requirements".
The aircraft was operated by the Edinburgh Air Charter company and was taking the Airtours staff to Aberdeen to connect with a holiday flight to Majorca.
The plane did not have, nor was required to have, flight recorders.
The AAIB recommended that such aircraft should at least have a cockpit voice recorder and that the Civil Aviation Authority should look at the seats issue.
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The information is doubtless interesting but there is something tasteless in the tone of the message.
Friends, relatives and colleagues of the deceased are likely to find the post hurtful.
The evidence must come out but I do urge sensitivity on the part of correspondents.
Please take into account those of us who still grieve.
Friends, relatives and colleagues of the deceased are likely to find the post hurtful.
The evidence must come out but I do urge sensitivity on the part of correspondents.
Please take into account those of us who still grieve.
The report is available here
mallard
While I respect your grief, I am sure that you will also respect the need of those of us who still fly light twins to learn from this accident and try to avoid the fate of those who perished. I for one would rather see the odd comment that I found of questionable taste than see the debate become stifled from a need to avoid controversy.
mallard
While I respect your grief, I am sure that you will also respect the need of those of us who still fly light twins to learn from this accident and try to avoid the fate of those who perished. I for one would rather see the odd comment that I found of questionable taste than see the debate become stifled from a need to avoid controversy.
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I agree Bookworm. It was a horrible accident which claimed more lives than it should have.
For once the Beeb's reporting of an accident report seems fairly factual, rather than tabloid. I am intrigued why the article goes on to quote "Aberdeen aviation expert, Jim Ferguson" (who seems to get rolled out for everything north of Hadrian's Wall) who is demanding CVR's be installed on all P/T flights - is this a general feeling? I guess it makes the AAIB's job easier.
I am more interested in what history Mr Ferguson has to make him an expert? Maybe it's a background in piston twin ops? If anyone knows I'd be interested to know.
For once the Beeb's reporting of an accident report seems fairly factual, rather than tabloid. I am intrigued why the article goes on to quote "Aberdeen aviation expert, Jim Ferguson" (who seems to get rolled out for everything north of Hadrian's Wall) who is demanding CVR's be installed on all P/T flights - is this a general feeling? I guess it makes the AAIB's job easier.
I am more interested in what history Mr Ferguson has to make him an expert? Maybe it's a background in piston twin ops? If anyone knows I'd be interested to know.
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Please feel free to tell me to shut up and go away.....
A few years ago I was a passenger in a Cessna 310 where the student was being taught engine failures. One of the things that was being done was to "fail" an engine without the student knowing which one it was, in order that they should correct the aircraft accordingly. So at glasgow despite hearing a bang from the wrong engine, would the aircraft not begin to yaw etc on the side which had in fact failed? Or did the bad engine fail gradually here so there was no sudden effect? Or did the pilot have no option but feather the "good" prop beacause the bang appeared to come from that side indicating a definite problem there. Could somebody please explain to me a bit of what happens here.
It is in not my intension to offend or upset anyone after what was undoubtedly a tragic accident. I just want to learn/understand.
A few years ago I was a passenger in a Cessna 310 where the student was being taught engine failures. One of the things that was being done was to "fail" an engine without the student knowing which one it was, in order that they should correct the aircraft accordingly. So at glasgow despite hearing a bang from the wrong engine, would the aircraft not begin to yaw etc on the side which had in fact failed? Or did the bad engine fail gradually here so there was no sudden effect? Or did the pilot have no option but feather the "good" prop beacause the bang appeared to come from that side indicating a definite problem there. Could somebody please explain to me a bit of what happens here.
It is in not my intension to offend or upset anyone after what was undoubtedly a tragic accident. I just want to learn/understand.
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The most important thing to remember is never to get into a big hurry when shutting down an engine.
Yes there will be yawing, and to correct that is rudder, and the dead foot is the dead engine. You can also take a quick glance at your EGT/RPM gauges before feathering, to make double sure that your sensations are not playing tricks on you.
Yes there will be yawing, and to correct that is rudder, and the dead foot is the dead engine. You can also take a quick glance at your EGT/RPM gauges before feathering, to make double sure that your sensations are not playing tricks on you.
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My initial post was simply to urge a sense of respect for those no longer with us.
I learned on the Cessna 310 that dead leg meant dead engine.
Ever since I have corrected yaw with a foot on a rudder pedal. That gets the ship airborne (you hope) then you have time to investigate what might have gone wrong.
A scan of the engine instruments should give a clue.
Best now is to see if your colleague agrees, beware, he may agree to please.
Those of you on light piston twins will know far better than I that there may be an element of time involved to get a prop feathered which would otherwise create drag.
Even on jets which are not so critical I remember an MEA 707 crew training at Beirut when, presumably, the student hit the wrong rudder and screwed into the ground before the check pilot could take over.
Best advise is ... Correct the yaw, get it safely airborne under control and then say what went wrong.
OK! I know, it ain't always that simple.
I learned on the Cessna 310 that dead leg meant dead engine.
Ever since I have corrected yaw with a foot on a rudder pedal. That gets the ship airborne (you hope) then you have time to investigate what might have gone wrong.
A scan of the engine instruments should give a clue.
Best now is to see if your colleague agrees, beware, he may agree to please.
Those of you on light piston twins will know far better than I that there may be an element of time involved to get a prop feathered which would otherwise create drag.
Even on jets which are not so critical I remember an MEA 707 crew training at Beirut when, presumably, the student hit the wrong rudder and screwed into the ground before the check pilot could take over.
Best advise is ... Correct the yaw, get it safely airborne under control and then say what went wrong.
OK! I know, it ain't always that simple.
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After this accident I got myself into a fair bit of trouble with this one, by raising the Airlines Duty of Care issue in allowing or booking their crew on this type, ie FAR23 v FAR25, I think you call it Perf B.
I was amazed at the lack of understanding by the airline community at large re the performance (or lack of) issues and the rush to defend the Captain and the organisation, when they were in fact not the issue.
I have printed off the report and will be studying it detail, but I do not expect to find anything very different to the usual results of misidentification and usually fatal "getting back to the airfield" syndrome.
I would be consoled by the loss if the airlines at large had learn't their lesson and were no longer using non transport category (FAR23 type) aircraft for dead heading their crew.
Nothing whatsoever to do with the "skill", "maintenance" or otherwise of the the operator.
Under the circumstances described it was almost inevitable.
I was amazed at the lack of understanding by the airline community at large re the performance (or lack of) issues and the rush to defend the Captain and the organisation, when they were in fact not the issue.
I have printed off the report and will be studying it detail, but I do not expect to find anything very different to the usual results of misidentification and usually fatal "getting back to the airfield" syndrome.
I would be consoled by the loss if the airlines at large had learn't their lesson and were no longer using non transport category (FAR23 type) aircraft for dead heading their crew.
Nothing whatsoever to do with the "skill", "maintenance" or otherwise of the the operator.
Under the circumstances described it was almost inevitable.
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Ladies and gentlemen,
Please read the report in full before posting questions/ comments.
Mallard - 'dead leg, dead engine, correct yaw with rudder - that gets the ship airborne(you hope) then you have time to investigate the problem. Best now is to see if your colleague agrees'
You are right, dead leg, dead engine, correct yaw with rudder. BUT, that's once you are airborne. The 404 is perf C and the 310 also mentioned is perf E which means that if you lose an engine during the T/O role you are not going to be able to get airborne and reach the single engine climb speed (assuming max T/O weight etc etc). If it happens on the runway you have one option - STOP - on what's left, be it runway or not. Additionally, this aircraft was operated single crew, the other pilot was a 'second pilot' not a co-pilot and was not trained on type, he was there at the request of the charterer and assisted with the RT etc etc. Therefore there would be no reason for the commander to seek his opinion as he knew he was not qualified to give one. Again, it's in the report.
Glue Ball - 'never be in a hurry to shut down an engine' - in principle this sounds like good advice, but it comes down to perception of 'hurry'. Works on a jet (generally), but again, read the report. On this type of piston twin without auto-feather you do not have long to get the prop feathered before it will not feather as the RPM drops too low and then you are faced with an aircraft with 'significantly less than 50% thrust' due to the increased drag. This is why ongoing training on the type requires you to identify and carry out the recall actions promptly. I do agree that it is better to spend what little time you have identifying the correct engine and carrying out the drill more slowly than shutting the incorrect engine down quickly. But, read the report. The commander percieved he had a problem with the right engine, there probably wasn't any great yawing moment due to the left engine failing slowly - the AAIB said he was in an unenviable position, not just because he was experiencing an engine failure, but because of the nature of it, with associated confusion and misleading signals he received and the very little time he had to do something about it and because of the performance of the 404 at MTOW.
Undoubtably, the wrong engine was shut down (but they didn't discount a possible problem with the right engine which was not evident), but it wasn't as cut and dried as in your initial twin training where the a/c only has two on board (therefore very light), you know it's coming and the instructor retards a throttle fairly quickly leading to the 'obvious' yaw, and you do have some time, although limited, from above 500' and the s/e climb speed to react and carry out the required actions. John Easson really couldn't have been faced with a much worse scenario apart from worse weather perhaps.
It may sound like I am trying to defend the PIC, what I am trying to put accross is the perspective. Read the report, put yourself in his shoes, consider it all without the hindsight and then make your judgement, like the AAIB have and then all of a sudden comments from 'your training days' of little snippets of how to fly a piston twin may not appear to be quite as relevant.
I speak with some authority having conducted the same flight as PIC in the weeks before the accident.
Safe flying to all, and RIP to friends.
PP
[ 01 August 2001: Message edited by: Pilot Pete ]
Please read the report in full before posting questions/ comments.
Mallard - 'dead leg, dead engine, correct yaw with rudder - that gets the ship airborne(you hope) then you have time to investigate the problem. Best now is to see if your colleague agrees'
You are right, dead leg, dead engine, correct yaw with rudder. BUT, that's once you are airborne. The 404 is perf C and the 310 also mentioned is perf E which means that if you lose an engine during the T/O role you are not going to be able to get airborne and reach the single engine climb speed (assuming max T/O weight etc etc). If it happens on the runway you have one option - STOP - on what's left, be it runway or not. Additionally, this aircraft was operated single crew, the other pilot was a 'second pilot' not a co-pilot and was not trained on type, he was there at the request of the charterer and assisted with the RT etc etc. Therefore there would be no reason for the commander to seek his opinion as he knew he was not qualified to give one. Again, it's in the report.
Glue Ball - 'never be in a hurry to shut down an engine' - in principle this sounds like good advice, but it comes down to perception of 'hurry'. Works on a jet (generally), but again, read the report. On this type of piston twin without auto-feather you do not have long to get the prop feathered before it will not feather as the RPM drops too low and then you are faced with an aircraft with 'significantly less than 50% thrust' due to the increased drag. This is why ongoing training on the type requires you to identify and carry out the recall actions promptly. I do agree that it is better to spend what little time you have identifying the correct engine and carrying out the drill more slowly than shutting the incorrect engine down quickly. But, read the report. The commander percieved he had a problem with the right engine, there probably wasn't any great yawing moment due to the left engine failing slowly - the AAIB said he was in an unenviable position, not just because he was experiencing an engine failure, but because of the nature of it, with associated confusion and misleading signals he received and the very little time he had to do something about it and because of the performance of the 404 at MTOW.
Undoubtably, the wrong engine was shut down (but they didn't discount a possible problem with the right engine which was not evident), but it wasn't as cut and dried as in your initial twin training where the a/c only has two on board (therefore very light), you know it's coming and the instructor retards a throttle fairly quickly leading to the 'obvious' yaw, and you do have some time, although limited, from above 500' and the s/e climb speed to react and carry out the required actions. John Easson really couldn't have been faced with a much worse scenario apart from worse weather perhaps.
It may sound like I am trying to defend the PIC, what I am trying to put accross is the perspective. Read the report, put yourself in his shoes, consider it all without the hindsight and then make your judgement, like the AAIB have and then all of a sudden comments from 'your training days' of little snippets of how to fly a piston twin may not appear to be quite as relevant.
I speak with some authority having conducted the same flight as PIC in the weeks before the accident.
Safe flying to all, and RIP to friends.
PP
[ 01 August 2001: Message edited by: Pilot Pete ]
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From what I understood from the report, two pilots did report that the aircraft upon T/O was to the left of the center line. This would indicate left engine failure.
It is interesting to note that all three surviving pax heard the bang from the right side of the a/c as well. I notice that this was addressed by the AAIB as a possible birdstrike - although ruled unlikely.
: DD :
It is interesting to note that all three surviving pax heard the bang from the right side of the a/c as well. I notice that this was addressed by the AAIB as a possible birdstrike - although ruled unlikely.
: DD :
Shutting down the "wrong" engine is the classic error on a two engine type - there but for the grace of God!
Pilot Pete - agree 100% with all your comments - well put.
<you know it's coming and the instructor retards a throttle fairly quickly leading to the 'obvious' yaw, and you do have some time, although limited, from above<
The only comment I would have on this is why, during pilot training, the instructor has to retard the throttle "fairly quickly"? Surely all types of failure should be simulated and I would venture to suggest that it is a slow loss of power which, in many ways, is far more "challenging" to deal with in terms of identification, etc.
As an aside, my father (who is no longer with us) was a veteran light aircraft instructor/examiner and I always remember that he often would retard the throttle slowly to simulate a gradual loss of power. I remember sitting in the back of a light twin (Apache I think) with my father testing the candidate for his twin rating. We knew that the instructor who had conducted the training was always keen on "slamming" the throttle closed and when my father retarded the (hidden) throttle slowly this confused him somewhat leading to application of too much corrective rudder and then considerable difficulty identifying the "failed" engine. Some time was spent in the debried on this topic!
Finally, in many ways pistons are more complex with the added complication of pitch and mixture levers - there are a lot more "wrong" levers to pull compared to a jet.
RIP
Pilot Pete - agree 100% with all your comments - well put.
<you know it's coming and the instructor retards a throttle fairly quickly leading to the 'obvious' yaw, and you do have some time, although limited, from above<
The only comment I would have on this is why, during pilot training, the instructor has to retard the throttle "fairly quickly"? Surely all types of failure should be simulated and I would venture to suggest that it is a slow loss of power which, in many ways, is far more "challenging" to deal with in terms of identification, etc.
As an aside, my father (who is no longer with us) was a veteran light aircraft instructor/examiner and I always remember that he often would retard the throttle slowly to simulate a gradual loss of power. I remember sitting in the back of a light twin (Apache I think) with my father testing the candidate for his twin rating. We knew that the instructor who had conducted the training was always keen on "slamming" the throttle closed and when my father retarded the (hidden) throttle slowly this confused him somewhat leading to application of too much corrective rudder and then considerable difficulty identifying the "failed" engine. Some time was spent in the debried on this topic!
Finally, in many ways pistons are more complex with the added complication of pitch and mixture levers - there are a lot more "wrong" levers to pull compared to a jet.
RIP
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My IR instructor always covered the throttle quadrant with a clipboard before retarding a throttle. You knew the failure was coming, but it taught the technique of recognition better.
I sometimes think that too much reliance is placed during training on a "standard failure" i.e a sudden loss of power. Certainly it should be practiced as it is the worst case scenario, but engines do not always fail this way. I would like to see some emphasis placed in the sim on different sorts of failures eg slow failures, engine vibration with subsequent loss of power.
I would add that I am in no way criticising the actions of the unfortunate pilot in this incident who gave his very best in extremely trying circumstances.
I sometimes think that too much reliance is placed during training on a "standard failure" i.e a sudden loss of power. Certainly it should be practiced as it is the worst case scenario, but engines do not always fail this way. I would like to see some emphasis placed in the sim on different sorts of failures eg slow failures, engine vibration with subsequent loss of power.
I would add that I am in no way criticising the actions of the unfortunate pilot in this incident who gave his very best in extremely trying circumstances.
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Twin Cessna aircraft....generally very reliable IF, and this is a very big IF, maintained properly and flown with a fair degree of accuracy. The 404 is a very heavy weight aircraft with CE421 power which equals, SLOW climb rate even with the CORRECT engine shutdown and feather procedure. If these guys had not been properly trained, then they had no business flying this aircraft. The 404 can be very demanding, if NOT flown properly.
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I think that it is obvious that the pilots were properly trained. It is not often that the AAIB make concessions to try to understand why a pilot made a wrong decision, but if they felt for one moment that the pilots lacked proper training, then it would have been in the report.
It is a truism that most accidents are not caused by lack of airmanship, and this applies to this case. - imho.
I know in the cold light of day it seems an easy decision to make - what engine to shut down, but as you said yourself, the 404 is known for it's 'interesting' handling - therefore, the pilot had very little time and under extreme stress to make the right decision.
As I stated earlier, it's very interesting that all three surviving pax also heard the bang from the rhs of the a/c.
: DD :
It is a truism that most accidents are not caused by lack of airmanship, and this applies to this case. - imho.
I know in the cold light of day it seems an easy decision to make - what engine to shut down, but as you said yourself, the 404 is known for it's 'interesting' handling - therefore, the pilot had very little time and under extreme stress to make the right decision.
As I stated earlier, it's very interesting that all three surviving pax also heard the bang from the rhs of the a/c.
: DD :
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411A - INTERESTING POST!
Where exactly did you get your 'information' from.
The pilot was properly trained and did have the right to fly the aircraft.
quote from AAIB report:-
1.
The commander was qualified, well experienced, competent, adequately rested and medically fit to conduct the flight.
2.
The commander had satisfactorily passed a test of his ability to recognise and deal with a single engine emergency in this aircraft five days before the accident.
I don't think there can be any ambiguity as to whether he was qualified or not!
As for the maintenance aspect, there was no reference in the report to any irregularities in that respect.
So again where do you get your information from to post such blatantly arrogant accusations?
Perhaps you should read Pilot Pete's post (btw it's concerned with the practicalities of flying piston twins) and let those of us who fly piston twins learn from this tragedy.
Where exactly did you get your 'information' from.
The pilot was properly trained and did have the right to fly the aircraft.
quote from AAIB report:-
1.
The commander was qualified, well experienced, competent, adequately rested and medically fit to conduct the flight.
2.
The commander had satisfactorily passed a test of his ability to recognise and deal with a single engine emergency in this aircraft five days before the accident.
I don't think there can be any ambiguity as to whether he was qualified or not!
As for the maintenance aspect, there was no reference in the report to any irregularities in that respect.
So again where do you get your information from to post such blatantly arrogant accusations?
Perhaps you should read Pilot Pete's post (btw it's concerned with the practicalities of flying piston twins) and let those of us who fly piston twins learn from this tragedy.
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Pilot Pete "Read the report" you exhort several times in your post. Well I have read the report and these posts and I am still a little confused. So a question:
Just exactly what were the confusing/conflicting indications that the pilot was faced with?. The only reference I have seen was to the bang which appeared to come from the right hand side. Were there other confusing indications such as yaw/roll in the opposite direction or conflicting engine or flight instrument indications? I have noted the AIIB's (and othres)comment about the need for speedy identification and action following such a failure but is the bang the only thing we are talking about here? Or have I missed something? This is a genuine serious question.
Thanks.
Just exactly what were the confusing/conflicting indications that the pilot was faced with?. The only reference I have seen was to the bang which appeared to come from the right hand side. Were there other confusing indications such as yaw/roll in the opposite direction or conflicting engine or flight instrument indications? I have noted the AIIB's (and othres)comment about the need for speedy identification and action following such a failure but is the bang the only thing we are talking about here? Or have I missed something? This is a genuine serious question.
Thanks.