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-   -   Airtours C404 crash report (https://www.pprune.org/tech-log/10203-airtours-c404-crash-report.html)

overstress 2nd Aug 2001 04:42


To paraphrase your good self: if you have not been sufficiently well informed, then you have no business posting in this forum.

This forum can be very demanding, if not treated properly.

Please remember that the victims were well known to some on here.

BreakRight 2nd Aug 2001 06:06

Having read the report, which makes frightening reading when you put yourself in PIC`s shoes, I would have to agree with eeper, that as someone who is learning to fly, for my sake as well as the sake of any future collegues or pax I would like to have experienced any and every type of enginge failure in training, I would consider it money well spent supposing it was all on a sim even. Anything to reduce confusion in the situation and gain precious seconds.

As a footnote, I am convinced that PIC did his absolute best and I would never question his airmanship. I saw the immedeate aftermath of the crash, and that in itself was a lesson. RIP.

411A 2nd Aug 2001 06:18

If this concerned aircraft had been properly flown, then the passengers and most likely the crew would be with us today.
I wonder how many here have flown this particular model? I have, and certainly know what I am talking about. At heavy weights, it will have great difficulty achieving any kind of climb gradient on one engine.
However, would have to admit, sometimes even with the best of effort, s..t happens.

[ 02 August 2001: Message edited by: 411A ]

Jonty 2nd Aug 2001 12:38

Thanks Pilot Pete, you arguments demand respect as allways.

Just one or two points, the 404 is a single crew aircraft, the reason two pilots were on board was due to the request from Airtours. Only one of them had to be qualified on type, the commander.

Due to the nature of this failure it must ahve been very difficult to identify the failure in the time available. A bang was heard from the right side of the aircraft with possable fluctuations in power associated with possable water ingestion (mentioned in the report) at the same time there is a gradual loss in power from the left engine. The commander may have shut down the right engine thinking about a return to the airfield, then the problem with the left engine becomes apparent, but the right is already featherd. All this with conflicting yaw indications and the lack of time make this very difficult to recover from.

Eff Oh 2nd Aug 2001 15:56

Pilot Pete:- I agree 100%.
Den Dennis:- As for the being to the left of the centreline...Well, perhaps yes, however. Did they have a cross wind component(from the right)? This would also have caused drift to the left. As would not quite being on the centre line on take off. I think the report is well balanced. It was not an easy situation to be in. Perhaps this accident can be used as a teaching exercise, to show how situations are not as clearcut as they can seem!
Its always harder to read these things when you know someone involved.
Eff Oh.

Viscount Sussex 2nd Aug 2001 17:12

Have you heard the expression 'thick skin'?
Mallard had tried, politely, to explain!!, but just fell into 'deaf ears'. I get rather p*ssed off with people (self-oppinionated ones), you know, the ones that have a bl**dy answer to everything. Also with those that want to "learn", while seating in front the PC. I didn't know the Capt of the 404 and didn't have to. He was a professional, doing a job. Here we are wasting time (including myself replying) and trying to 'work out' (to put in a diplomatic manner) or to examine his actions. Have you got anything else to do apart from posting in PPRUNE?
Don't bother to reply. I am off flying tonight and the rest of the week and I won't get a chance to catch up with your 1000+ postings!

[ 02 August 2001: Message edited by: Viscount Sussex ]

Hudson 2nd Aug 2001 18:30

I noted that somewhere in the accident report it stated that the captain was in the habit of doing his run-up procedures, pitch exercising, magneto checks etc while actually taxying. In other words, on the run. I presume that this short-cut is to save time and money?

Is this a common procedure? And is this not a bit dodgy having to drag alternate brakes as each engine is run up? Can you really pay full attention to all the engine parameters while jockeying the engine levers as well as keeping the taxy speed down and keeping a sharp eye to where you are going?

Is it possible that the faulty engine may have showed a few signs of impending problems which would have been picked up on a careful static run up at a holding bay and perhaps was missed during the haste to do a run-up on the run, so to speak?

Perhaps there is indeed a hard lesson for other light twin GA operators to keep in mind..

gaunty 2nd Aug 2001 19:35

411A me old, I know what you're talking about if nobody else does.

Hopefully His Grace the Viscount will, when he recovers from his hissy fit, think a bit deeper about the real problems behind this sad event.

Search seems to have disappeared so I am unable to resurrect the original and very instructive threads on this subject. I hope they were'nt lost in the Great PPRuNe crash of 2000.

Pilot Pete 3rd Aug 2001 00:29

Just to reply to some of the points raised, IMHO that is;

Den Dennis - I don't think you can jump to the conclusion that being left of the centreline means that the left engine had failed/ was failing. You must agree that a vast number of factors could result in being left of the centre line, including drift induced by a crosswind (as pointed out by another post), incorrect tracking of a navaid, or quite possibly due to the distraction of a 'loud bang', who knows?

parkfell - yes, maybe the EGT gauges would have helped, but you're primarily taught (and get into the mindset) of putting in the rudder to counteract the yaw and identifying the failed engine that way. The manifold pressure gauges would be the next place I would look. Remember the time scale.

fireflybob - I'm not so sure they do have to retard the lever quickly.......it's just how they've all done it to me. I agree, the slow failure of an engine would be more difficult to identify if this the way you have always been trained.

eeper - I think you'll find that all instructors cover the quadrant with a map/ board etc to help the 'realism' of you having to identify the failure without just watching which lever he pulls. As regards sim training, you will understand that sims for this (and other light a/c) are usually uneconomical for small operators, and the report touched on this. I agree that there is no reason why it could not be incorporated into the a/c training.

Mallard - I thank you for your comments, and would not want you to not air your views about the subject.

411A - Read the report. Area Juliet has replied after obviously reading the report. Any piston twin aircraft is demanding if not
flown properly at MTOW.

Airboeing - Bang from the right. Possible loss of power (momentarily, but that wasn't known at the time) from the right engine due to the possibility of water ingestion, maybe confirmed by looking at the right engine instruments (that's just my own guess), and whilst dealing with this problem the gradual loss of thrust from the left engine without the commonly associated yaw (possibly counteracted by shutting the right?). The AAIB also mention how hard it is to read a gauge with two needles, one on top of the other - one with a small 'R' and the other with a small 'L'. Isn't that enough confusing/ conflicting indications bearing in mind the time scale and lack of altitude?

Hudson - you may well have a point there.

Gaunty - I recall your posts from before, and you may be surprised that I agree that with the limitations of perf 'e' and 'c' for public transport flying, passengers should be made aware of this.

Jonty and Eff Oh - as ever, thanks for you words.


gaunty 3rd Aug 2001 00:44

Pilot Pete
I was kinda hoping that the airlines would stop deadheading their personnel around in these types as a result of this accident.

They are not alllowed to put their passengers on these types, so why their staff?

Kiltie 3rd Aug 2001 14:20

Gaunty - as I recall the airline concerned who were chartering this aircraft consequently stopped all crew positioning on Perf C aircraft; indeed the task is now being performed by another Scottish based operator in a Perf A machine.

Parkfell -I wouldn't get in to the idea of looking at EGT guages to assist identifying failed engines, you'll open up a can of worms; stick to the rule book - identify with your feet, backed up AFTERWARDS by a look at the guages if you must; but remember! A failed engine will start to show increasing to near ambient manifold pressure, ie GREATER than that of the good engine! Trap!

411A - There are plenty of us who've flown 404s, including me, we all know Performance C types particularly of the piston variety can be awkward at MTOW; and it's not just limited to Cessna 400 series. I wouldn't say 404s were any trickier than other types.

I think what we need to take in to account the panic factor of an engine failure when it's unexpected. This wastes precious seconds of decision-making time, & it is only understandable for John Easson to perhaps have been led in to adrenaline-fuelled incorrect decision. I think we would all be likely to suffer from this. Yes; we're all aces during our Base / Line checks when we KNOW a failure is coming & have the drill anticipated in advance. No practice is given in the experience of surprise.

Though I haven't read the report in depth, I would suspect G-ILGW suffered such a hard impact because it went below VMCA whereafter control was lost, there is not much reference to this important parameter in the report, and I think it's an airspeed we should all be highly aware of.

[ 03 August 2001: Message edited by: Kiltie ]

gaunty 3rd Aug 2001 15:11

I am encouraged indeed, and I fervently hope that the others are following suit.
Crew should just plain flat out refuse to travel.
I should hasten to add that I spent a good part of my life selling these types new. They are fine aircraft for the use for which they were intended.
But they were designed and intended for private, business and recreational purposes. NOT charter and commuter ops.
Sadly everybody assumes that two engines and pilots is safer, regardless of the certification issues.
It is in fact, in this instance quite the opposite.

Capt Eason was operating in accordance with the rules and the level of skill required for the operation, the problem was the rules did not give them anywhere to go, the skill level was only interesting and the accident was almost inevitable after the engine failure.
The sooner the users understand the difference the sooner the "shock horror" will be replaced by, "just lets not go there"!

pterodactyl 3rd Aug 2001 16:10

I think Hudson has a point about the run up on the move. Elsewhere in the report it is mentioned that the Captain had a significant financial interest in the operation. This could suggest that the Captain also may have wanted to "save the engine" and in so doing acted more in haste than certainty. There have been many such instances of this previously where loss of the airframe and it's occupants ensued.
Gaunty's point is well made as to the adequacy of certification standards for this class of aircraft and the paucity of performance in the failure case.
But I have to say a "bang" does not a failure make and although the impression of witnesses is that it came from the right it is far from certain that this was correct. I have experienced bangs, backfires and the like on occasion and quite often both crew members were not able to identify from which engine it came.
As has been pointed out foot pressure is the primary method of identification and until there is a LOT of rudder input required it should not be assumed that complete failure has occurred. Bearing in mind the critical engine out performance in the failure case any usable power should be utilised until a more definite failure indication is evident. Continue to fly the aeroplane. On the other hand if there is a LOT of rudder input required at an early stage indicating power loss and a possibly windmilling prop then it is essential that positive identification and a TIMELY shut down be accomplished.
Time is critical but not so critical that the procedure is rushed. By that I mean that as each procedural step is actioned it's effect should be noted. The first item for instance after identification is to retard the throttle. At that point; did the yaw increase, stay the same, or reduce? If it increased markedly then there was significant power still being delivered which could be used if the situation warrants it. If the yaw is substantially the same then a complete power loss on that engine is indicated and proceed on with the next item. On the other hand if yaw REDUCED you have the WRONG one! Put it back up! Remember fly the aeroplane, maintain the correct speed even if losing height to maintain control if the worst happens rather than stall as seems likely in this case. Don't think VMCA was a factor with no power from either engine.
You may say that there is not ENOUGH time for all this...well there is if done in a deliberate and timely manner. The report indicates an altitude of about 600 feet was reached and there was a considerable time airborne. To identify and accomplish the drill in a deliberate manner with certainty only takes a few seconds longer.
The comment about always training for a complete engine failure on take off is a very pertinent one and I believe is led by the regulatory requirement. Generally that classic situation is handled very well since it is CHECKED on every licence proficiency check. But how many actual failures occur in exactly that manner at that time? Not a very high percentage really. All kinds of variations should be PRACTICED such as partial/slow engine failures, fire without thrust loss, fire with thrust loss, failure some time after take off such as during a turning departure and so on.
Please accept that this post is made not so much to reflect on the crew but rather as a little advice which may help someone else avoid a similar fate.

Several points need to me made about
practicing failures in a real aeroplane. Firstly the aircraft should never be placed in an irrecoverable situation by, for instance, pulling the mixture to Idle Cut Off.
Often we hear of "chopping the throttle". There is absolutely no need for rapid throttle chop....a smooth positive retardation is quite sufficient. Indeed if you "Chop" the throttle rapidly on a RR Dart powered aeroplane the prop coarsens off and the aircraft initially swings in the WRONG direction. A really spring loaded student reacting to this initial swing can present an interesting situation. Likewise the thrust lever on a DC8 was chopped so fiercely during a training take off that the engine reverser deployed with disastrous results. Seems I have wandered a little so with the final observation that just as in business corporate memory is lost so it is with aviation.

[ 04 August 2001: Message edited by: pterodactyl ]

Bally Heck 3rd Aug 2001 17:06

It might be worth pointing out that a number of years ago, a C404 operated by the Department of Agriculure and Fisheries for Scotland suffered an engine failure while on a low level fishery patrol.

Both the pilots were type and instrument rated. The aircraft's performance was such that they were compelled to ditch. Fortunately with no fatalities.

This aircraft was at high weight and had the added disadvantage of a radome installed on the belly which I assume didn't help the climb rate. Notwithstanding that, I think it says something about the performance of that type of aircraft on one engine.

It is also worth pointing out that 411A and his cronies seem to have regular access to the internet from whichever institution they are in and have the objective of saying black is white in the most offensive way they know how on whatever subject they know nothing about.

If you ignore them they go away :mad:

Hudson 3rd Aug 2001 18:12

Ptero D. You are dead right about the danger of pulling back a RR Dart engine.
During an instrument take off in an Avro 748 (yes!It was that long ago) I simulated an engine failure by quickly pulling back the throttle on one side. The student under conversion reacted very rapidly to the compass indication of yaw and whacked on full corrective rudder.
As you stated, the prop coarsening caused a momentary indication of yaw in the wrong direction. As this happened a few feet after lift off, we very nearly put a wing into the deck. My idiotic fault for not realising this could happen with a RR Dart. But then, the Avro test pilot at Woodford in Cheshire did not tell warn us about this either.

[ 03 August 2001: Message edited by: Hudson ]

411A 3rd Aug 2001 23:36

No Bally, not likely to go away.

Lets see, the Captain on this aircraft did the run-up while taxiing and then, once the engine had failed after takeoff, he feathered the operating engine propellor.
As I indicated before, altho he had passed a check in the recent past, he simply did not perform as he should have.
In simple terms even you should be able to understand, he stuffed it up.
I was being quite diplomatic when I mentioned poor training.

GlueBall 4th Aug 2001 02:00

It was mentioned a number of times now that during a C404 max weight takeoff/inital climb engine failure the engine must be feathered without delay....

I haven't flown the geared engine C404, but many moons ago I flew its smaller cousin, the C402C. Yes, I've had an engine failure with 9 pax and baggage during climb out at about 1,300 feet or so. The very first indication was a change in engine sound, followed by heading drift (yaw) corrected with gradual rudder and a slight push on the yoke to stop the climb. That was done instinctively. But because of fear and embarrassment of shutting down the wrong engine, I hesitated momentarily and glanced at the dual RPM needles and either the CHT or EGT, and it was clear that one side was less than the other. So, it wasn't until a good 5 seconds had passed before I pulled the throttle back, then waited another second before pulling the prop into feather.

My point is that the airplane has enough speed and inertia to give any pilot 6 seconds to think, identify and feather the bad engine.

Especially in IMC, engine failure sounds and airplane feel can play tricks on the pilot's mind, therefore it's imperative to also look at the engine instuments before making hurried and soley instinctive reactions.


pterodactyl 4th Aug 2001 05:10

Yes, Hudson, the Dart had a number of little idiosyncracies which could trap the unwary especially when setting up for a landing with prop feathered which was required for initial endorsement in those days.
There are still quite a few Dart powered aircraft operating and it has become apparent once or twice that a fair bit of knowlege has evaporated with passage of time.

[ 04 August 2001: Message edited by: pterodactyl ]

Kiltie 4th Aug 2001 06:15

411A without wishing to place any racial connotation to this thread you should realise that Pprune, being a UK originated site which welcomes global participation to further its popularity, does, as far as I'm concerned, tend to expect good manners perhaps unique to that of the country of its origin. Principally, remarks such as the late Captain "stuffed it up" may be what's on everyone's mind to a certain extent, but this is a comment which the majority would not be willing to put in to print simply out of respect for the deceased.

From some of your previous postings you seem to have a lot of constructive comment to contribute & long may it continue, but perhaps you should consider expressing your views in a more sensitive manner.

PS this is a polite hint & not intended to provoke argument to the extent this thread runs away in to petty squabble.

Pterodactyl -I see your point upon further reading of the accident report, Vmca can't have been a factor if neither engine was developing power BEFORE the turn -back;I stand corrected.

Bally Heck - regarding the DAFS 404, I am led to believe the reason they failed to climb away was that they were heavy on fuel but more importantly forgot to retract the first stage of flap, often used for low speed low level observation. Having flown the 404 in a similar role we were always taught to observe in a clean config weighted by that accident. Anyone that's in the know do correct me if I'm wrong regarding that particular incident.

Personally I see no fault with run-ups "on the move", so long as the full engine checks were performed on the first flight of the day. I don't know if this aircraft had flown previous to that of the accident flight on the same day, but if I was carrying passengers I would be inclined to abbreviate the run ups to a simple mag check and quick feather excercising at the holding point without undue "revving". This is commonplace in the charter environment and not inherently an unsafe corner-cutting measure.

I fly a Performance A category aircraft at the moment but have much experience in that of C. Some remarks, although justified, point toward Perf C machines being unsafe for passenger carrying but I'm not sure I'd want to agree thus far.

Interesting thread.......keep it going; this is beneficial to all of us.

[ 04 August 2001: Message edited by: Kiltie ]

[ 04 August 2001: Message edited by: Kiltie ]

pigboat 4th Aug 2001 06:34

The last sentence from para states: It was concluded that, while not fully feathered, the propeller was out of its normal range of operation at impact and was moving either towards feather or out of feather. (emphasis mine)
I wonder if, at the very last instant, he realized he had shut down the good engine, and was trying to restart it.

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