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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. |
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.
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"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. |
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. |
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 |
Nothing new here. The report more than a year ago indicated possible confusion over the engines as a contributory factor. Don't know why it's suddenly news again.
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:( One of the very few positive things to come out of this tragedy is that the airline bean counters no longer move crews about in perf c twins...........at least in the uk.
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A cockpit voice recorder in a single crew aircraft??
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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. |
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. |
Twistedenginestarter
You can't tell me all those pilots on the Korean 747 didn't notice the plane was going onto its side. |
>You can't tell me all those pilots on the Korean 747 didn't notice the plane was going onto its side.
< What the heck are you two talking about?:) |
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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?
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Activewaypoint,
I think you'll find air2000 are still using an aztec as a means of transporting crews when the need arises. |
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.
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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. |
:( 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.
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Oh Please! Get real will you....
clear prop!!!:
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). |
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. |
411a,
As far as I know the aircraft in question is not flown by a CPL when it is used to ferry crews around but I believe some of our capatins are checked out on it. I used to fly airline crews around in a PA31, sometimes out of Glasgow, and the incident in question made my blood run cold when I heard about. When I was doing these flights I was aware that the crews where not all that keen on the idea and one of the pilots often used to ask if they could sit in the right hand seat during the flight. Didn't bother me at all, I was quite pleased for the chance to chat and the pilots mostly had a go and seemed quite happy. At the time I could not see what they where bothered about but having flown 2 crew, perf A jet a/c in an airline operation for a good many years I can quite see thier point. I still fly G/A aircraft outside of work and I am quite happy to accept the risk that it involves but if the company want to position me by air they can do it on a 2 crew, perf A aircraft. |
From my old Perf 'C' briefing notes (two crew ops):
'In the event of an engine malfunction during or shortly after take-off, or at any other time that there is difficulty in continuing the flight on one engine for any reason, my intention is to close both throttles, and crash into the most suitable area ahead. My priorities will be keeping the wings level approaching touchdown and flying at the correct speed'. I never had to do the above, but I wonder whether the majority of Perf 'C' operators do consider this...? Finally, Perf 'C' <DOES NOT EQUAL> airline safety. Seriously, if you're a wealthy individual who wants an exciting aeroplane to fly yourself, buy a Perf 'C' twin. But no-one with a conscience should carry passengers in one. May they Rest in Peace. |
There's a lot of ill informed speculation being pandered around on this board over this accident. Read the definitive accident report from the AAIB. I was involved as a pilot for the said company at the time of the accident and John Easson was my boss and Chief Pilot.
I was also called as a witness to the fatal accident enquiry, sat around for two days and then sent home without giving evidence. The FAI is a strange element of Scottish Law, where someone not expert in the field passes his/her judgement on the causes of an accident and gives recommendations. The AAIB did not come to the conclusion of pilot error. In fact they said that John Easson was left in the 'unenviable position' of losing height with little time to react and conflicting information. If the AAIB cannot and do not pin the blame on John Easson then I fail to see how any of us can with our sweeping 'it's as simple as that' statements. It plainly was not as simple as that. The aircraft was certified for single crew operation and the airline insisted on a second crew member. They were made aware of the lack of legal requirement for this second crew member but wanted one just the same. activewaypoint; The company used to dress up various individuals as pilots and put them in the right seat in the guise of professional co-pilot. You are also wrong about crews not being positioned in the UK in these aircraft as already pointed out. Air2000 still do it occassionally as did jmc last summer (I had the pleasure of going to Newcastle in a Ravenair Aztec). For once I find myself agreing with 411A's comments, except that you will also find that the AAIB report found that all the maintenance requirements had been followed to the letter. We had a very close relationship to the in house engineering firm who were Cessna Concessionaires and extremely competent and skilled. One thing John Easson would not have is corners cut, especially on maintenance. The Chief Engineer had an open cheque book with regard to the fleet maintenance and they were all a pleasure to fly. Max Angle. You will find that the aircraft can (or could then) be flown by a CPL holder, again, if you read the report you will see that is the licence that John Easson held. That is all he needed to hold for the operation he had and who are we to question it? Would him studying the ATPL groundschool have made him any better a pilot? No. He had no need to get an ATPL and was a very busy, successful businessman who could not afford the time. What I agree with you on Max is that I always felt it a lot better if one of the positioning pilots sat up front (on other jobs). It was always interesting for them and good for us too. So, I know this is a rumour board but let's try and be informative with our view points......especially as the definitive document (the AAIB report) is out there for all to read. In my opinion the Fatal Accident Inquiry is a total waste of tax payers money, especially when they are drawing conclusions that the experts in the field did not draw and are recommending changes which they can not back up with technical reasoning (which they are not qualified to give). They put me in a hotel and paid me expenses for 2 days and sat me in a room and then didn't even bother to ask me any questions..............................facade. Rest in peace, good friends. PP |
PilotPete,
I was using the term CPL to indicate a commercially rated pilot. I was in no way suggesting that anybody who does this sort of flying should have an ATPL, I didn't when I did it. As far as I know our Baron is sometimes flown by a friend of Sir Mikes who does not hold a commercial licence at all. As I said I would be happy to fly, or fly in, a piston twin in my own time but if company want to position me by air then I and my colleagues deserve the protection and performance margins that a two crew, perf A aircraft provides. I freely admit that my opinion on the subject has changed since I was flying piston twins on passenger operations and the accident in question is main reason for that change. I have read the report and as you say they do not lay the blame at the foot of the pilot, he was in a dreadfull situation which I was lucky enough never to find myself in. |
Pilot Pete:
From the AAIB report: Shortly after take-off the commander reacted to a problem which he and some other occupants of the aircraft associated with the right engine. The commander feathered the propeller of the right-hand engine, which was mechanically capable of producing power resulting in a total loss of thrust. Post accident inspection did not reveal any mechanical evidence of a problem with the right hand engine. The left engine had suffered massive disruption to its accessory gear train resulting in the loss of magneto drives, valve timing, and engine fuel and oil pumps. Once the aircraft began to lose height a return to the airfield became impractical and a forced landing in the direction of flight should have been attempted. In a tightening turn it stalled I say again... he failed to correctly identify the failed engine (using stuff like rudder inputs and engine instruments to help him), and he stalled the aircraft in a turn back to the field. I'm sorry, but you can't get away from the FACTS . BTW I have no axe to grind with the pilot, who was faced with a difficult problem, what I do object to is the constant shifting of blame away from the pilot for what appear to be sentimental reasons. What progresses flight safety is a clear admission of what actually caused the crash, not some misguided loyalty to the pilot community. Let's be realistic, shall we? |
If a 737-400 can crash at EMA because the incorrect engine was identified and shut down and some years later a piston twin crashes at GLA for the same reason..
Perhaps it's time for more dedicated training on engine failure characteristics (as applicable to type), failed engine identifation, shut down drills and subsequent decision making. |
Like Max, I would not travel in a perf 'C' aircraft when positioning for my company.
Mind you, Max, have you tried our new, cheaper taxi firm! |
Pilot Pete
I'm afraid I have to agree with MOR. The "casual factors" if my understanding of English is correct, mean the factors that caused the accident. Here is the excerpt from the report:
Causal Factors The investigation identified the following causal factors: 1. The left engine suffered a catastrophic failure of its accessory gear train leading to a progressive but complete loss of power from that engine. 2. The propeller of the failed engine was not feathered and therefore the aircraft was incapable of climbing on the power of one engine alone. 3. The commander feathered the propeller of the right-hand engine, which was mechanically capable of producing power resulting in a total loss of thrust. 4. The commander attempted to return to the departure airfield but lost control of the aircraft during a turn to the right. It may make a tragic accident more painful if you know that it was avoidable, and it may open the door to blame and recrimination from people desperately searching for somewhere to assuage their grief, but it does not justify hiding from the truth. People make mistakes - we all do. Most of the time we are not forced to pay for those mistakes with our lives, but occasionally, and tragically, sometimes we do. |
Just to return to the subject of CVRs briefly: Maybe not such a bad idea after all - even with single crew, since they have many times played a key role in identifying noises associated with equipment malfunction, switch positioning and even the frequency of control flutter.
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Regarding the 737-400 crash years ago, was the crew concerned by an engine vibration gauge, or some such gauge? Is it also true that the Flight Attendants never reported to the cockpit that something appeared to be wrong with one of the engines?
Onboard the 747 (400) which departed San Francisco not too long ago and had numerous compressor stalls etc in an outboard engine, the flying pilot used aileron instead of rudder as the plane wandered from its initial departure heading. The heavily-loaded jumbo jet barely missed a high hill off the departure end of the airport. The crew at the controls stated that there was so much engine vibration that it shook both flight instrument panels, which might have made the "rudder ball", or a similar indicator, very difficult to read. The extra crew onboard were shouting from the back, that the flying pilot must use rudder inputs, from what I remember. This is not meant as criticism of any of those pilots at the controls, but haven't several major lessons been learned (not just more hand-flying currency for 747-4 FOs: both Captains fly so many legs on the very long flights that the FOs go to the simulator once each six months just for approach/landing currency...maybe even laymen can see the problem here) regarding both panel vibration and CRM from the cabin, so that cabin crewmembers don't just assume that the engine gauges in the cockpit always reflect what can be seen or heard from some passenger windows? Years ago at least six of us were ferried with flight bags in a very full Navaho from "Branch of Peace" airport up to Dubuque, Iowa, in order to ferry a few repossesed Bandeirantes back on a clear day. Two of our pilots, after takeoff, figured that our plane had been overloaded by about 800 pounds. The FBO owner (J. *.) was not known to be the most conscientious, and very many Part 135 airplanes would not have had a positive climb rate even with the correct engine feathered etc, at max gross weight-we could have ended up as dead meat. Do you think that the pilots on that flight would have refused to takeoff far overweight, if their jobs were at risk? A very young pilot who later ferried one of the Bandits solo had reportedly never even flown the type, which often required type ratings in the heavier series. |
after thousands of hrs flyin all sorts of twins around africa , hot high, (and thats just the pilot) any weight eqauls over weight.
if you are scheduled full and asked to cary a bit more it makes no difference you were landin staight ahead as soon as you loaded more than yerself into the aircraft. perf c and e is a caa joke. the only twins that can save yer ass are the otter and buffalo, both bush aircraft (the latter is perf a anyway). even in the buff alanding staight ahead was the required thing in cetain speed weight configs. african pilots operate in this world all the time and are upto speed on the pitfalls of piston twin flyin and still quite regularly go down. this guy may have made a mistake but as an ex bush piston twin driver , there but for the grace of god go i. leave him alone, hes dead and so are his pax, a toast in the aero club and move on. i,ve got five fatties and samsonites in a baron tomorrow and i need a drink. batty |
Pete
The operation was single crew and the pilots were trained for that ... so there was no requirement for that second pilot to be there at all, so as for the accident being a breakdown in crm or lack of input from the guy in the rhs ... not relevant in this case The whole thing about safety is if you blame the engine failure, or the poor performance of Cessna twins, or the pilot who just plain made a devastating mistake, you are missing the point. The point is for each adverse event, what can you do to neutralize the threat. |
just to echo the thought of CJ
a Sad day indeed for all involved. Our thoughs with the families of all involved. |
twistedenginestarter:
The whole thing about safety is if you blame the engine failure, or the poor performance of Cessna twins, or the pilot who just plain made a devastating mistake, you are missing the point. The point is for each adverse event, what can you do to neutralize the threat. The performance of the aircraft is not a variable (nor even an "adverse event")- the point is, that if you fly an aircraft with marginal performance, you have to be up to the challenge if it all goes wrong. Most piston twins leave little margin for error, so require far more skill and precision in an emergency. It has always amused me that, for every new type I have flown, the difficulty level of an emergency has reduced (and, paradoxically, the salary level has increased). You can't "neutralise the threat" of light twin performance unless you change the nature of light twins. The only thing you can do to reduce the risks is to ensure the pilot is fully up to the task, with an absolute commitment to carrying out the correct procedure (in this case, identify the failed engine correctly and/or put the aircraft down straight ahead, under control. Sadly, in the GA world (and I was no different when I was flying light twins), there is too often a tendency to try and save the aircraft by getting back to the field when it really isn't an option, with the predictable disasterous consequences. Very, very few light twin drivers have the depth of experience or training that their jobs require- I certainly didn't and count myself lucky to have got through that phase of my career unscathed. Hindsight... |
In the emotion of this tragic incident a lot of unnecessary things are being said. Those posters who are advocating learning the lessons, paying our respects and moving on armed with more life saving information have hit the nail on the head.
Comparisons with Kegworth are unfortunate and not relevant. The paucity of conversion training that those guys had, the insistance on disconnecting the autopilot on failures in the simulator at that time, the relatively youthful stage in crm evolution, the lack of understanding of the need for FC and CC to work as a team, the latent failure of the CFM56 which was NOT known and later had to be corrected, the lack of understanding by ATC that interruptions to crews by unnecessary transmissions can, and in this case DID, affect their ability to deal with the emergency, the poor engine instrument design leading to increased liklihood of confusion did not contribute to this light twin accident. The press have access to these web sites I worry what conclusions they may draw about our profession after reading some of the posts on this site. R.I.P. |
Predictably the pilot, who conveniently is not able to defend himself, is being given the blame.
Factually that may well be the case, or at least part of it. As many have commented, with these types of aircraft when an engine failure occurs, all too often a crash,controlled or otherwise is the end result. Part of the blame must lie with a system which allows these types of operations, without fully informing their passengers of their limitations. Many charterers, without specialist knowledge would be totally ignorant to the risks that they place themselves in by flying on piston twins. This was not the case with the Airtours management (of the time), who had been made well aware of the dangers and limitations by numerous pilots within their organisation who had experience on these types of aircraft. Indeed a number of them had been threatened with disciplinary procedures for voicing their concerns. Sadly it was a foregone conclusion that sooner or later an accident would happen, and only after the tragic waste of life was the company policy changed. Now under a new management team there is a robust quality control system in place, something that other organisations should be encouraged to follow before putting the lives of their employees at risk. May God bless those who perished. :( |
Glasgow
As an owner and pilot of my own GA aircraft I think that one aspect has not been examined in this thread. Whilst it is relatively straightforward to identify an engine failure in a piston twin in simulated situations (e.g. an examiner closing the throttle on an engine) it is much more difficult to identify in a real life emergency. The props' constant speed units will disguise a failing engine, and the surging from the failing engine will send the 'rudder ball' rolling fully from side to side with the plane yawing wildly. The pilot would have been left with very little direct information as to which engine had failed. The aircraft's performance figures for single engine operation, at max weight with failed engine feathered would have indicated a return to field. Other reports of the right hand engine's bang may have been all there was on which to make a decision.
The AAIB never shrink from apportioning blame. If the AAIB do not blame the pilot then that is good enough for me. |
fullyestablished, the AAIB never apportion blame, to say otherwise shows a distinct lack of knowledge of their sphere of operation.
In effect a fatal accident enquiry states what the AAIB are not permitted to say in public. |
The pilot believed the right engine had failed. He shut down the right engine. He started to make a right hand turn back to the airfield. I was always taught NOT to turn into the "dead" engine - any comments?
RIP - I agree with all those who say the important lesson is the one that is learnt from this unnecessary tragedy. |
If you look at the accident record of transport category aircraft in the late 1940's and 1950's there are many simularities to this story. I believe the great improvement in accident rate of large aircraft is largely due to depth and sophistication of aircraft simulation. I had an epiphany a few years ago when I was hired to fly a corporate Cessna 340 part time in the winter. The owner insisted I go with him to do a 3 day refresher at SIMCOM in Scottsdale. It was a non trivial expendature ( approx $ 3000 us ) but you got what you paid for. A excellent instructor with thousands of hours of Twin Cessna time and a 1.5 Million dollar sim with a state of the art visual system and a very realistic flight model. I arrived with considerable piston twin time and like virtually everyone before me crashed on the first EFATO. By the end of the 3 days I could fly away from the same scenario every time. In addition I experienced all sorts of problems that are either too dangerous or impossible to do in the real airplane. I think a program of training in a proper simulator should be mandatory. And for all those who say it is too expense and will ruin the industry , well I guess smoking holes becomes the cost of doing business, which is certainly no problem unless you are in one.
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