ATSB Report C90 fatal at Toowoomba November 2001.
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ATSB Report C90 fatal at Toowoomba November 2001.
The ATSB report has just been published on the fatal accident to a Beech King Air at Toowoomba in November 2001.
An engine failed at lift-off near Vmca and the pilot lost control.
A salient point was that according to the report the company operations manual stated a 6 knot lower lift off speed than the manufacturer's recommendation. This placed the aircraft closer to Vmca with all that implies.
Without knowing all the facts, it would suggest that operators who change or omit manufacturer's figures or recommendations when writing their own operations manual, need to ensure the revised company procedures have been subject to measured flight tests by a competent authority - rather than have their pilots follow someone else's personal opinion. This certainly would be an issue in any litigation.
This type of discrepancy between operations manual personal opinion and manufacturer's advice would (should?) normally be picked up by the routine CASA audit?
An engine failed at lift-off near Vmca and the pilot lost control.
A salient point was that according to the report the company operations manual stated a 6 knot lower lift off speed than the manufacturer's recommendation. This placed the aircraft closer to Vmca with all that implies.
Without knowing all the facts, it would suggest that operators who change or omit manufacturer's figures or recommendations when writing their own operations manual, need to ensure the revised company procedures have been subject to measured flight tests by a competent authority - rather than have their pilots follow someone else's personal opinion. This certainly would be an issue in any litigation.
This type of discrepancy between operations manual personal opinion and manufacturer's advice would (should?) normally be picked up by the routine CASA audit?
It seems there were a few concerns with the operator. This item was fairly concerning I thought...
I guess it shows that trend monitoring works - If analysed.
The pattern of ECTM data from the left engine indicated that a potentially safety-critical problem existed in that engine for several weeks prior to the accident. For a variety of reasons, that evidence was not detected and analysed, nor was appropriate remedial action initiated.
This type of discrepancy between operations manual personal opinion and manufacturer's advice would (should?) normally be picked up by the routine CASA audit?
With an engine failure or malfunction near Vmca, the safest course of action would be to reject the takeoff due to the likelihood of the aircraft not being able to accelerate to Vyse. Although in some cases this will mean that the aircraft will overrun the runway and perhaps sustain substantial damage, the consequences associated with such an accident will generally be less serious than a loss of control after becoming airborne.
Why is there a culture of blaming the pilot if such an action (abort and overrun) is carried out? One has to just think back to comments on this forum on a recent overrun in a Baron due to an aborted take off.
I remember another Baron incident (engine surging and coughing on takeoff) up in the Territory a few years ago that lead to it going into a fence at a few knots causing some damage. Said pilot was dismissed and left Aus for overseas. That pilot's actions possibly saved the lives of 4 others, and was punished not rewarded.
Non transport category aircraft do not have balanced field lengths, calculated V speeds. They were NEVER designed to accelerate to Vyse after engine failure at or immediately after rotation. (Where is Gaunty these days?
)Maybe it's from our instructors who tried to teach us in pistons how the big jets fly cos that's where they wanted to be, maybe not. But until we realise it as a community, when that engine (be it turbine or piston) goes t!ts up, we won't be tempted to keep going with something that can't fly.
report link here
Last edited by compressor stall; 25th Jun 2004 at 14:39.
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What is not realised by many instructors who teach multi-engine flying is that a very fast almost lightning quick action is needed by the pilot if a decision is made to continue a take off shortly after engine failure at lift off and if a reasonable chance of success is required.
The drastic reduction in airspeed that occurs immediately the total engine failure occurs requires instant feathering and drag reduction. There may be little time to revert to the dual training mantra so beloved by ME instructors of dead side, dead leg - pitch up power up gear up flap up, identify, confirm with slow throttle and finally get around to feather.
The prop must be feathered in seconds and gear selected up to stand any hope of maintaining safe speed above Vmca and some positive climb rate. Of course in the perfect world there is all the time in the world to mutter your way through the drills described earlier - but as the unfortunate King Air pilot found out, he needed to make an instantaneous decision to stop or go and it wasn't his day.
The confirm with throttle check would have been the last thing he needed if the auto-feather had done its job as this cancels auto feathering. It would be ever so easy to revert back to his early flying school instruction that the throttle of the dead engine must be pulled back as confirmation - when in fact in aircraft equipped with autofeather this action could be deadly.
Wasn't his instrument rating done on a light piston twin where confirming with throttle is all the go? Fine if the failure occurs at a safe altitude, but absolutely critical in a very low level engine failure where valuable feathering time is lost while fiddling and pulling back the throttle on a dead engine.
The drastic reduction in airspeed that occurs immediately the total engine failure occurs requires instant feathering and drag reduction. There may be little time to revert to the dual training mantra so beloved by ME instructors of dead side, dead leg - pitch up power up gear up flap up, identify, confirm with slow throttle and finally get around to feather.
The prop must be feathered in seconds and gear selected up to stand any hope of maintaining safe speed above Vmca and some positive climb rate. Of course in the perfect world there is all the time in the world to mutter your way through the drills described earlier - but as the unfortunate King Air pilot found out, he needed to make an instantaneous decision to stop or go and it wasn't his day.
The confirm with throttle check would have been the last thing he needed if the auto-feather had done its job as this cancels auto feathering. It would be ever so easy to revert back to his early flying school instruction that the throttle of the dead engine must be pulled back as confirmation - when in fact in aircraft equipped with autofeather this action could be deadly.
Wasn't his instrument rating done on a light piston twin where confirming with throttle is all the go? Fine if the failure occurs at a safe altitude, but absolutely critical in a very low level engine failure where valuable feathering time is lost while fiddling and pulling back the throttle on a dead engine.
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I have heard suggested a much simplified Pilot Take-Off Briefing for light twins: If an engine fails with the gear down, I will cut the power and land. If an engine fails with the gear up, I will identify and feather the failed engine and fly the aeroplane.
Makes sense - if the gear's up you should already be past the critical speed, if it's down you probably never will be. If you're taking off, the aircraft is already configured; so the max rich, full-fine, max power mantra is somewhat pointless. If you have reached a point where you may have leaned the mixture (such as in a Baron) or coarsened the pitch, or reduced power (why would you though?) then it is no longer an engine failure during take-off, but an engine failure in the climb, with substantially more room to manouvre (literally & figuratively).
There are a number of aircraft that require a positive rate of climb BEFORE attempting to raise the gear, due to the substantial increase in drag that gear operation causes. Add in the delay of the 'Oh Sh!t' factor and the head-down element of trying to clean up the aeroplane while checking the power configuration and mumbling 'dead engine dead leg', it can be seen that the narrow envelope of possibility that theoretically existed (when the aircraft was new, with new motors in an ISA atmosphere and being flown by a test pilot at sea level ) rapidly dwindles to a near certainty of an inverted nose down high vertical speed and universally fatal impact.
Bruce was a good pilot and genuinely nice guy. Vale Bruce and the Qld Health passengers.
Makes sense - if the gear's up you should already be past the critical speed, if it's down you probably never will be. If you're taking off, the aircraft is already configured; so the max rich, full-fine, max power mantra is somewhat pointless. If you have reached a point where you may have leaned the mixture (such as in a Baron) or coarsened the pitch, or reduced power (why would you though?) then it is no longer an engine failure during take-off, but an engine failure in the climb, with substantially more room to manouvre (literally & figuratively).
There are a number of aircraft that require a positive rate of climb BEFORE attempting to raise the gear, due to the substantial increase in drag that gear operation causes. Add in the delay of the 'Oh Sh!t' factor and the head-down element of trying to clean up the aeroplane while checking the power configuration and mumbling 'dead engine dead leg', it can be seen that the narrow envelope of possibility that theoretically existed (when the aircraft was new, with new motors in an ISA atmosphere and being flown by a test pilot at sea level ) rapidly dwindles to a near certainty of an inverted nose down high vertical speed and universally fatal impact.
Bruce was a good pilot and genuinely nice guy. Vale Bruce and the Qld Health passengers.
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Hudson and Jamair,
Very good posts,you have obviously been there done that, that is very much in evidence. However to change the instructional technique on this class of aircraft will be almost impossible. As you say it works with an empty aircraft, but at max gross or any reasonable load it must be firmly implanted that if gear is still down then accept what is in front and close throttles and accept controlled reunion with the ground, if the gear is up then it must be dead leg, feather, blue line if max rate will suffice, or a few knots slower for max angle, clean up any drag on the dead one, cowl flaps mainly, and if you are lucky and it is a cold day, and there are no lumps in the way, you may get to plan further actions when rectum contractus has settled.
Prospector
Very good posts,you have obviously been there done that, that is very much in evidence. However to change the instructional technique on this class of aircraft will be almost impossible. As you say it works with an empty aircraft, but at max gross or any reasonable load it must be firmly implanted that if gear is still down then accept what is in front and close throttles and accept controlled reunion with the ground, if the gear is up then it must be dead leg, feather, blue line if max rate will suffice, or a few knots slower for max angle, clean up any drag on the dead one, cowl flaps mainly, and if you are lucky and it is a cold day, and there are no lumps in the way, you may get to plan further actions when rectum contractus has settled.
Prospector
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Follow the link to the report, yes they do, but if you follow the instructional technique that gives majority of drivers initial multi rating, and teaches close throttle to confirm dead engine then the auto feather is disabled. Technique should be ignored when flying aircraft such as C90. Easy to say, but harder to ignore initial teaching in a very stressed situation.
Prospector
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Bottums Up
Prospector,
It's been a while since I flew an autofeather equipped turbo prop (DH8), about 5 years, so my systems memory is possibly not up to scratch.
But if memory serves me the recalls for an engine failure on take off, include retarding the offending power lever to flight idle, even after the autofeather has activated. I don't recall that this caused the prop to unfeather.
It's been a while since I flew an autofeather equipped turbo prop (DH8), about 5 years, so my systems memory is possibly not up to scratch.
But if memory serves me the recalls for an engine failure on take off, include retarding the offending power lever to flight idle, even after the autofeather has activated. I don't recall that this caused the prop to unfeather.
For the C90's bigger stablemates with -41/2 engines, the autofeather is inoperative when either power lever is retarded below 90%n1.
From the flight manual...
No mention is made anywhere in the initial emergency actions of the clean up secondary actions of moving the power lever.
It is important to identify the engine for the subsequent clean up. I use the ingrained dead leg dead engine mantra followed by "Confirm ITT, Torque, Fuel flow."
But that is secondary to flying the aircraft.
It is all pretty irrelevant though...what is the issue is that the aircraft still probably would have not climbed out even if the prop had feathered, and the gear retracted.
From the flight manual...
If the autofeather system (if installed) is being used, do not retard the failed engine power lever until the autofeather system has completely stopped propeller rotation. To do so will deactivate the autofeather circuit and prevent automatic feathering.
It is important to identify the engine for the subsequent clean up. I use the ingrained dead leg dead engine mantra followed by "Confirm ITT, Torque, Fuel flow."
But that is secondary to flying the aircraft.
It is all pretty irrelevant though...what is the issue is that the aircraft still probably would have not climbed out even if the prop had feathered, and the gear retracted.
Last edited by compressor stall; 26th Jun 2004 at 16:29.
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Stallie old chap, still around, been up to my a&se in alligators lately but I think I'm in remission now.
Haven't had a moment to look at the ATSB report but I dont expect any surprises.
I had a bit to say when it happened and I hope the passengers leagles get their act together. I gaurantee the pax and probably whoever in the QLD Govt Tender Board thingy, thought because it burnt kero it was "different" and "better" than those piston thingies.
prospector that instructors offer any hope beyond picking the least worst area in front of you and using the live engine very carefully to maybe broaden your opportunities to make the best of it, is the real problem.
How many times has the pilot rolled right into hell and damnation with the live one going flat out when ALL he had to was pull it back and keep flying the ship onto the ground and keep on flying it until the noise has stopped and the dust has settled.
Believe it or not I have run into more than the odd instructor and FOI who thinks because it has got two it will get you out of trouble, when in fact the opposite is the case.
And then they go and put a Vg or Raisbeck kit on em (piston or turbine) and instead of accepting the performance "gain" ?? as an extra safety buffer go use it as an operational bonus.
Show me the pilot who can have an engine failure when the new whizbang kit "blue line", VS and VMCA are within knots of each other and, keep it all together whilst he holds airspeed plus or minus 0 KTS whilst cleaning up, because if he has electric flaps and gear on the old clunker he is going to have maybe +200-950= -750 fpm ROC for the 15-20 secs whilst he does.
Do the math on that.
E still =mc2. and the higher TOW means a higher AoA for the same speeds = higher drag with the same HP already, hell is where you're goin, do I need to go on.
It was Richard Collins I think who got it absolutely right when he described FAR23 twins as "a single engine aircraft with dispersed power".
aint dat de troof.
Haven't had a moment to look at the ATSB report but I dont expect any surprises.
I had a bit to say when it happened and I hope the passengers leagles get their act together. I gaurantee the pax and probably whoever in the QLD Govt Tender Board thingy, thought because it burnt kero it was "different" and "better" than those piston thingies.
prospector that instructors offer any hope beyond picking the least worst area in front of you and using the live engine very carefully to maybe broaden your opportunities to make the best of it, is the real problem.
How many times has the pilot rolled right into hell and damnation with the live one going flat out when ALL he had to was pull it back and keep flying the ship onto the ground and keep on flying it until the noise has stopped and the dust has settled.
Believe it or not I have run into more than the odd instructor and FOI who thinks because it has got two it will get you out of trouble, when in fact the opposite is the case.
And then they go and put a Vg or Raisbeck kit on em (piston or turbine) and instead of accepting the performance "gain" ?? as an extra safety buffer go use it as an operational bonus.
Show me the pilot who can have an engine failure when the new whizbang kit "blue line", VS and VMCA are within knots of each other and, keep it all together whilst he holds airspeed plus or minus 0 KTS whilst cleaning up, because if he has electric flaps and gear on the old clunker he is going to have maybe +200-950= -750 fpm ROC for the 15-20 secs whilst he does.
Do the math on that.
E still =mc2. and the higher TOW means a higher AoA for the same speeds = higher drag with the same HP already, hell is where you're goin, do I need to go on. It was Richard Collins I think who got it absolutely right when he described FAR23 twins as "a single engine aircraft with dispersed power".
t is all pretty irrelevant though...what is the issue is that the aircraft still would have not gone anywhere.
Props are for boats!
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Hi Stallie,
You are right on the buzzer with the AutoFeather and it is the same operation in the 90 except with the PT6A-20 its 88%N1. But something tells me this particular Aircraft didnt have Auto Feather fitted. I flew its sister once and it didnt have autofeather VH-NQH. So I am asssuming it didnt have it either. And this maybe the linch pin in the whole disastrous occurence. AutoFeather was an option on early King Airs and infact the ex US ARMY ones I fly it was an add as a mod later in its service.
One of our machines had an inop failure just recently the Captain left his autofeather on until the cruise. Going through FL140 on climb out, he noted an loud pop from the left engine looked outside and she was allready feathered, he returned ok to point of origin. We are still awaiting the final verdict from the engineers with the cause. But in his experience the autofeather definitely sorted it out. If you have the autofeather off in a turbo prop your just increasing your workload for no reason. Because as turbines run, they go or they dont , you will hardly get partial power situation, if anything as opposed to a rollback ,youll get a runaway than anything else.
Sheep
You are right on the buzzer with the AutoFeather and it is the same operation in the 90 except with the PT6A-20 its 88%N1. But something tells me this particular Aircraft didnt have Auto Feather fitted. I flew its sister once and it didnt have autofeather VH-NQH. So I am asssuming it didnt have it either. And this maybe the linch pin in the whole disastrous occurence. AutoFeather was an option on early King Airs and infact the ex US ARMY ones I fly it was an add as a mod later in its service.
One of our machines had an inop failure just recently the Captain left his autofeather on until the cruise. Going through FL140 on climb out, he noted an loud pop from the left engine looked outside and she was allready feathered, he returned ok to point of origin. We are still awaiting the final verdict from the engineers with the cause. But in his experience the autofeather definitely sorted it out. If you have the autofeather off in a turbo prop your just increasing your workload for no reason. Because as turbines run, they go or they dont , you will hardly get partial power situation, if anything as opposed to a rollback ,youll get a runaway than anything else.
Sheep
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One must seriously ask why the contract was awarded to 30 plus year old aircraft, powered by temperature limited PT6A-20 engines, on operations where ambient temps were regularly at 40 plus degrees Celsius for a significant part of the year?
For many years the contract operated, incident free, with more appropriate Cessna 310 and Beech 58 aircraft. It is now being operated with PT6A-42 powered King Air 200 an Piper Cheyenne aircraft.
For many years the contract operated, incident free, with more appropriate Cessna 310 and Beech 58 aircraft. It is now being operated with PT6A-42 powered King Air 200 an Piper Cheyenne aircraft.
G'Day Sheep
From the long investigation report.
(And check your PM's mate )
Air Ace
Reference B200 being more appropriate...consider the following.
Let’s simulate the exact takeoff situation for a B200C.
All data straight from the flight manual of a 6yo aircraft (non Raisbeck). Beech do use V1 (take off decision speed) and V2 (take off safety speed) but only to “meet FAR 25 takeoff climb requirements”.
Conditions on that day were Wind 249/5 Temp 20C QNH1011 headwind 2kts. Rwy elev 2086’ Rwy length 1121m.
I have calculated a B200C TOW at the same percentage of MTOW as the C90 was…4170/4377*5670=5350kg=11770lbs.
Let’s make the point straight away….the Accelerate –Stop-Flaps up graph.
Enter the following Data…OAT 20, Palt 2146’, 11770lbs, 2kt headwind….
The Accelerate Stop distance is 3600 feet. That is 1181m. That’s LONGER than the Toowoomba Runway.
So an engine failure at V1, max braking and reverse on operating engine, on a paved runway and an abort, a brand new KingAir would still run off the end of the strip at Toowoomba.
So, what about keeping on going after the engine failure at V1. Well, sure there is a chart for that Accelerate-Go
Enter the above data and you get a figure of 6200 feet = 2034 metres. Note 3 to this chart says that a useable clearway cannot exceed 25% of the runway length.
Even a spankin’ new King Air won’t do it.
And putting a Raisbeck kit on it barely changes the Acc-go distance. It does however have a rotation speed 3kts above Vmca 
From the long investigation report.
The investigation was
unable to determine whether the auto-feather system was armed at the time of the accident. The
investigation was also unable to determine if the left power lever was retarded during the accident
flight, or whether manual feathering of the left propeller had been attempted.
unable to determine whether the auto-feather system was armed at the time of the accident. The
investigation was also unable to determine if the left power lever was retarded during the accident
flight, or whether manual feathering of the left propeller had been attempted.
)Air Ace
more appropriate Cessna 310 and Beech 58 aircraft
Reference B200 being more appropriate...consider the following.
Let’s simulate the exact takeoff situation for a B200C.
All data straight from the flight manual of a 6yo aircraft (non Raisbeck). Beech do use V1 (take off decision speed) and V2 (take off safety speed) but only to “meet FAR 25 takeoff climb requirements”.
Conditions on that day were Wind 249/5 Temp 20C QNH1011 headwind 2kts. Rwy elev 2086’ Rwy length 1121m.
I have calculated a B200C TOW at the same percentage of MTOW as the C90 was…4170/4377*5670=5350kg=11770lbs.
Let’s make the point straight away….the Accelerate –Stop-Flaps up graph.
Enter the following Data…OAT 20, Palt 2146’, 11770lbs, 2kt headwind….
The Accelerate Stop distance is 3600 feet. That is 1181m. That’s LONGER than the Toowoomba Runway.
So an engine failure at V1, max braking and reverse on operating engine, on a paved runway and an abort, a brand new KingAir would still run off the end of the strip at Toowoomba.
So, what about keeping on going after the engine failure at V1. Well, sure there is a chart for that Accelerate-Go
Enter the above data and you get a figure of 6200 feet = 2034 metres. Note 3 to this chart says that a useable clearway cannot exceed 25% of the runway length.
Even a spankin’ new King Air won’t do it.
And putting a Raisbeck kit on it barely changes the Acc-go distance. It does however have a rotation speed 3kts above Vmca
Last edited by compressor stall; 27th Jun 2004 at 02:29.
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Stallie thanks for that
exactly 
The lot that run the WA Govt contract over here won it (twice) with a Raisbeck B200 out of strips that would not otherwise be available to them. It's cheaper to play casinos than lengthen strips you know.
They had to retender the second round after the financiers wouldn't finance on the rates quoted, guess who won the retender, yup, a bit nearer the rates the pros quoted in the first place.
The "consultant" who advised them was ex regulator, I spent a great deal of time trying to educate him on the FAR23/25 bit, his only response being that "it was legal". The ONLY reason they went to a Citation later was because it was "faster".
That the Citation COULD ROUTINELY go into/out of the "Raisbeck" limited strips was only "interesting".
Still they are only pollies.
Don't get me wrong Raisbeck and Vg kits are clever mods, but you have to understand the limitations and philosphy behind them. If you are using them for anything other than safety buffer and the occasional odd problem strip here 'n there, then you IMHO, deserve what's coming to you.
Duty of Care?
Just make sure you explain to your passengers, in writing (if properly prepared it will be about a 2 kg document that will require their signatures to be notarised and left with a responsible person), that you are going to operate the aircaft they are to go flying in at the very extreme boundaries of the performance envelope and it is going to require extraordinary skill on your part to cope with an emergency of any sort.
"Is that OK with you folks?"
it does have a rotation speed about 3 KTS above VMCA.
The lot that run the WA Govt contract over here won it (twice) with a Raisbeck B200 out of strips that would not otherwise be available to them. It's cheaper to play casinos than lengthen strips you know.
They had to retender the second round after the financiers wouldn't finance on the rates quoted, guess who won the retender, yup, a bit nearer the rates the pros quoted in the first place.
The "consultant" who advised them was ex regulator, I spent a great deal of time trying to educate him on the FAR23/25 bit, his only response being that "it was legal". The ONLY reason they went to a Citation later was because it was "faster".
That the Citation COULD ROUTINELY go into/out of the "Raisbeck" limited strips was only "interesting".
Still they are only pollies.
Don't get me wrong Raisbeck and Vg kits are clever mods, but you have to understand the limitations and philosphy behind them. If you are using them for anything other than safety buffer and the occasional odd problem strip here 'n there, then you IMHO, deserve what's coming to you.
Duty of Care?
Just make sure you explain to your passengers, in writing (if properly prepared it will be about a 2 kg document that will require their signatures to be notarised and left with a responsible person), that you are going to operate the aircaft they are to go flying in at the very extreme boundaries of the performance envelope and it is going to require extraordinary skill on your part to cope with an emergency of any sort.
"Is that OK with you folks?"
it does have a rotation speed about 3 KTS above VMCA.
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Gaunty et al,
I'm with you on Raisbeck and VGs all the way.
I was really very fortunate in that my B200 training was on a Raisbeck 200 with a guy who was an extremely competent and capable TPE as well as an instructor. He ran a really tight outfit where everyone was well aware of the potential cost of squeezing paper performance from lower rotation and climb-out speeds that relied on reduced stalling speeds despite an even greater reduction in controllability margins. In his game, Raisbeck just provided money in the bank, not competitive advantage!
However, I also understand the consultant's dilemma (young M?) in that the great god FAA has given the legal imprimatur to the new performance figures. Given that most of our industry has clamoured for CASA to stop paying attention to performance issues (hence the demise of CAO 101.5/6 etc and the introduction of CAR 22A and now CASR 23/25...), the poor old consultant is faced with satisfying the client in regard to the number one priority - competitive advantage - with only lip service being paid to the smoke and mirrors that are used to get there. If he doesn't do it, there are plenty who are more ignorant waiting in the wings.
In the end, they (the clients) all believe that "it won't happen to me"!!!
But I think I was more frightened by Hudson and his thing about instant feathering before selecting gear up:
There is more about instructors and what they teach in an overall context of "they know not what they do".
But the reality is that they are teaching a mantra that, while respecting that the available timeframe may vary, is designed to cover both EFATO and EFITGR (engine failure in the go-round) and is further intended to prevent inadvertant shutdown of the wrong engine when survival is just around the corner.
At least in Hudson's version, if you shut down the wrong engine, then your decision to crash straight ahead is made for you and the gear is still down. However, if you have already made the decision that your best chance of survival is to continue the take-off, then that boring old mantra may well be the thing that keeps your arse out of the grass.
In most cases, the instantaneous decisions are the worst.
If you fly an auto-feather equipped aircraft, your conversion and your procedures should be very specific about identifying "engine failure - negative autofeather!" rather than do whatever you think in the heat of the moment. In the normal course of events, the "arrgh, shet!" factor will allow autofeather to do its thing or be clearly identified as requiring manual over-ride. There will be situations where recognition of the failure of one or both systems time will consume all of the available time - but the crime will not be the procedures, it will be in accepting that risk in the first place.
I have made quite a few instantaneous handling or procedural decisions in my time - almost every one has been either a failure or at best a very untidy and unprofessional result. On other occasions I have been taken by surprise and the good old rote learning has kicked in and at least kept me out of the weeds long enough to make another more informed decision.
So I am an unabashed fan of consolidated learning of good "mantras" and the like, simply because I know that they are not "silver bullets" and that they need to applied in a sensible and considered sense or abandoned if circumstances dictate. The alternative, the various forms of TALR (that looks about right)and MIUAYGA (make it up as you go along) are just aviation anarchy unless sequenced as the last resort.
Stay Alive,
I'm with you on Raisbeck and VGs all the way.
I was really very fortunate in that my B200 training was on a Raisbeck 200 with a guy who was an extremely competent and capable TPE as well as an instructor. He ran a really tight outfit where everyone was well aware of the potential cost of squeezing paper performance from lower rotation and climb-out speeds that relied on reduced stalling speeds despite an even greater reduction in controllability margins. In his game, Raisbeck just provided money in the bank, not competitive advantage!
However, I also understand the consultant's dilemma (young M?) in that the great god FAA has given the legal imprimatur to the new performance figures. Given that most of our industry has clamoured for CASA to stop paying attention to performance issues (hence the demise of CAO 101.5/6 etc and the introduction of CAR 22A and now CASR 23/25...), the poor old consultant is faced with satisfying the client in regard to the number one priority - competitive advantage - with only lip service being paid to the smoke and mirrors that are used to get there. If he doesn't do it, there are plenty who are more ignorant waiting in the wings.
In the end, they (the clients) all believe that "it won't happen to me"!!!
But I think I was more frightened by Hudson and his thing about instant feathering before selecting gear up:
"The prop must be feathered in seconds and gear selected up to stand any hope of maintaining safe speed above Vmca and some positive climb rate."
But the reality is that they are teaching a mantra that, while respecting that the available timeframe may vary, is designed to cover both EFATO and EFITGR (engine failure in the go-round) and is further intended to prevent inadvertant shutdown of the wrong engine when survival is just around the corner.
At least in Hudson's version, if you shut down the wrong engine, then your decision to crash straight ahead is made for you and the gear is still down. However, if you have already made the decision that your best chance of survival is to continue the take-off, then that boring old mantra may well be the thing that keeps your arse out of the grass.
In most cases, the instantaneous decisions are the worst.
If you fly an auto-feather equipped aircraft, your conversion and your procedures should be very specific about identifying "engine failure - negative autofeather!" rather than do whatever you think in the heat of the moment. In the normal course of events, the "arrgh, shet!" factor will allow autofeather to do its thing or be clearly identified as requiring manual over-ride. There will be situations where recognition of the failure of one or both systems time will consume all of the available time - but the crime will not be the procedures, it will be in accepting that risk in the first place.
I have made quite a few instantaneous handling or procedural decisions in my time - almost every one has been either a failure or at best a very untidy and unprofessional result. On other occasions I have been taken by surprise and the good old rote learning has kicked in and at least kept me out of the weeds long enough to make another more informed decision.
So I am an unabashed fan of consolidated learning of good "mantras" and the like, simply because I know that they are not "silver bullets" and that they need to applied in a sensible and considered sense or abandoned if circumstances dictate. The alternative, the various forms of TALR (that looks about right)and MIUAYGA (make it up as you go along) are just aviation anarchy unless sequenced as the last resort.
Stay Alive,
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Stallie, I accept your point and agree but I think you missed the my point. The contract requires three aircraft based at Longreach and Roma, to service surrounding rural airports on relatively short haul sectors. The service provides Surgeon transport only, not medivac.
Toowoomba was the operator’s home base. Toowoomba would normally be a "rare occurrence" for the contract operation.
Toowoomba runway would be longer and cooler than many of the rural airports serviced.
I was simply suggesting that many of the operations, particularly in Summer, would be in ambient temperatures at which the engines were limited, add a defective ECTM system (both in manual recording and interpretation – the aircraft were not fitted with electronic ECTM data recorders) and one has an operation which is very much on the edge of the envelope.
But isn’t that the usually case with the lowest bidder??
I stand by my comment that the airports involved in the contract, short sectors (50 to 150 NM) and one to three passengers maximum were more suited to Cessna 310 and Beech 58 aircraft (which operated the contract for many years, incident free, with Bushies, TAA and Flight West), than old, low cost and somewhat inappropriate Beech C90 aircraft.
Toowoomba was the operator’s home base. Toowoomba would normally be a "rare occurrence" for the contract operation.
Toowoomba runway would be longer and cooler than many of the rural airports serviced.
I was simply suggesting that many of the operations, particularly in Summer, would be in ambient temperatures at which the engines were limited, add a defective ECTM system (both in manual recording and interpretation – the aircraft were not fitted with electronic ECTM data recorders) and one has an operation which is very much on the edge of the envelope.
But isn’t that the usually case with the lowest bidder??
I stand by my comment that the airports involved in the contract, short sectors (50 to 150 NM) and one to three passengers maximum were more suited to Cessna 310 and Beech 58 aircraft (which operated the contract for many years, incident free, with Bushies, TAA and Flight West), than old, low cost and somewhat inappropriate Beech C90 aircraft.
Air Ace
Think you'll find that EA no longer had the Flying Surgeon contract out at Roma and Longreach at time of accident.
The flight in mention was for Mental Health Staff, with which used to be done in the PA31
Think you'll find that EA no longer had the Flying Surgeon contract out at Roma and Longreach at time of accident.
The flight in mention was for Mental Health Staff, with which used to be done in the PA31
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The Chronicle (Toowoomba)
Monday, June 28, 2004.
A GLITCH!
An oversight allowed Eastland Air to operate for seven weeks without CASA Certification.
On November 27, 2001, an Eastland Air plane crashed with the loss of four lives.
A “GLITCH” allowed Eastland Air to operate for seven weeks withourt CASA certification.
When safety certification was hurriedly issued five days before the fatal crash in November 2001, it was based on an inspection months earlier.
A Freedom of Information search by The Chronicle shows that July-August inspection was not exactly glowing.
Among other things, it found:
* Overall maintenance performance was “somewhat worse” than the previous inspection;
* The Company did not have a mature, well-functioning safety system;
* Safety had not been identified as a major organisational priority; and
* Eastland Air had showed signs of suffering financial stress.
CASA had also issued a number of requests for action, which were outstanding as of the July/August inspection.
A senior CASA official requested the Brisbane office of the organisation investigate how the company was allowed to operate without a Certificate of Approval (COA) for seven weeks.
A CASA spokesman told The Chronicle the oversight “boiled down to a glitch in the paperwork”.
“The company believed the renewal was an automatic process, where they infact had to apply for a renewal, and it was also a time where we were making changes to the way we were administering Certificates of Approvals and that also led to confusion,” the spokesman said. “The airworthiness inspector who had been looking at the company said the work quality had not deteriorated in the seven weeks and therefore decided recertification was not necessary.
“We don’t believe it had anything to do with the fall in standard of maintenance being carried out by the company at that period.”
The spokesman said the outstanding requests for action by CASA were “of a minor nature” and had been acted on, while it was not mandatory for the company to act on “observations”.
Monday, June 28, 2004.
A GLITCH!
An oversight allowed Eastland Air to operate for seven weeks without CASA Certification.
On November 27, 2001, an Eastland Air plane crashed with the loss of four lives.
A “GLITCH” allowed Eastland Air to operate for seven weeks withourt CASA certification.
When safety certification was hurriedly issued five days before the fatal crash in November 2001, it was based on an inspection months earlier.
A Freedom of Information search by The Chronicle shows that July-August inspection was not exactly glowing.
Among other things, it found:
* Overall maintenance performance was “somewhat worse” than the previous inspection;
* The Company did not have a mature, well-functioning safety system;
* Safety had not been identified as a major organisational priority; and
* Eastland Air had showed signs of suffering financial stress.
CASA had also issued a number of requests for action, which were outstanding as of the July/August inspection.
A senior CASA official requested the Brisbane office of the organisation investigate how the company was allowed to operate without a Certificate of Approval (COA) for seven weeks.
A CASA spokesman told The Chronicle the oversight “boiled down to a glitch in the paperwork”.
“The company believed the renewal was an automatic process, where they infact had to apply for a renewal, and it was also a time where we were making changes to the way we were administering Certificates of Approvals and that also led to confusion,” the spokesman said. “The airworthiness inspector who had been looking at the company said the work quality had not deteriorated in the seven weeks and therefore decided recertification was not necessary.
“We don’t believe it had anything to do with the fall in standard of maintenance being carried out by the company at that period.”
The spokesman said the outstanding requests for action by CASA were “of a minor nature” and had been acted on, while it was not mandatory for the company to act on “observations”.
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Air Ace -
Nope, there was a C421 rolled into a ball of pulped, barbequed aluminium at the end of YROM RWY 18 on this task, subsequent to an EFATO (managed perfectly by the very experienced pilot who without a doubt saved the lives of everyone on board that day by planting the thing back on the deck and accepting the controlled prang) which was why the Flying Obstetrician Team moved to the C90 - a decision based on what the RFDS was using at the time (and were still using until just three years ago when the CV mob changed to the PC12). The change from Baron to 421 Cessna was in consideration of the environmental conditions of the area (hot & turbulent) and passenger comfort, for the folks who spend every day flying in the things; not a performance issue per se.
Eastland had lost the Contract before the TWB crash. There were 3 C90s, 2 at Roma (LQH & NQH) and one at LRE (SQH?). The crashed one DID had autofeather, at least one of the others did not.
Deciding to retard the power lever is AFTER checking whether Autofeather has functioned by LOOKING AT THE PROP and FLYING THE AEROPLANE, then checking the ITT/TQ/FF/ dead leg/ manual feather etc
For many years the contract operated, incident free, with more appropriate Cessna 310 and Beech 58 aircraft.
Eastland had lost the Contract before the TWB crash. There were 3 C90s, 2 at Roma (LQH & NQH) and one at LRE (SQH?). The crashed one DID had autofeather, at least one of the others did not.
Deciding to retard the power lever is AFTER checking whether Autofeather has functioned by LOOKING AT THE PROP and FLYING THE AEROPLANE, then checking the ITT/TQ/FF/ dead leg/ manual feather etc