The Bullshit factor.
One of several major shortcomings within the CASA FOI system may be found within the approval of operational material. There are countless anecdotes which relate to 'type specialists' in disagreement with experienced operators of an aircraft type. Some risible comments have been writ into a training system or manual, simply to 'satisfy' the FOI. Those who have experienced and understand this have no need of further explanation. It is a real existing problem which CASA must address should they wish to eliminate what I believe is a serious, concealed safety issue. That of an attitude toward 'CASA bullshit'. You can hear it a dozen times a week. “Nah, we don't do that, its just some CASA bullshit”. The problem being that as that approach becomes 'the norm' – often real safety issues within that area are treated in the same manner. You do see the problem, disregard for published material becomes a normalised deviance. Most chief pilots and check pilots in GA will confirm this. Airline training comes as a shock to a lot of GA pilots, when 'by the book and only the book' becomes the new norm.
ATSB - “The ATSB sought information from CASA regarding the circumstances under which the incorrect procedure was approved for use by the operator. Despite this request, no information was provided by CASA. Consequently, the ATSB was unable to determine whether the approval of incorrect information was an isolated human error or symptomatic of a systemic deficiency with the approval process.
Right there a classic. There is a great deal of difference between 'reading' a Flight Manual (AFM) and 'studying' it. In order to 'teach' (or pontificate) an aircraft type one must seriously study the relevant manuals. The end product should be a pilot who not only knows and understands not only the entire operational envelope, but how to keep the operation within safe, legal parameters. Take a simple thing like the following.
ATSB - Additionally, the likely power setting was less than the AIRSTART lever position detailed in the POH and had the potential to allow the aircraft’s right fuel computer to trip from the normal automated mode to the manual mode. If that occurred it could have affected that engine’s power level and/or been a distraction to the crew. As switching of the fuel computer from normal to manual was not recorded, it was not possible to determine if this occurred.
ATSB - “Manual mode refers to the engine power output being directly controlled by the power lever position rather than by a signal sent to the engine by the electronic engine control unit (EEC). The power system is designed so that fuel scheduling is lower in manual mode than it is in normal (automatic) mode. Higher power lever positions are therefore required to maintain engine power when in manual mode compared to normal mode. This means that if a fault is detected in the EEC and the engine operation automatically reverts to manual mode the engine will have a reduction in power for that particular power lever setting. If that occurs the power can be restored by advancing the power lever as required.
The workings, limitations and potential traps of this system should be acknowledged; a system to prevent inadvertent activation during abnormal operation must be prescribed and built into a C&T system ambit. Awareness of this possibility, through an 'approved' method of simulating an EFATO must be acknowledged. The CASA approved Ross Air system presented in both Part A and C of the operating manual fail to mention, let alone alert crew to this possibility, particularly in the simulated engine failure case. It may well be 'something-nothing' but, if the manufacturer has gone to the length of covering a possible 'loop hole' then either CASA or the operator should have picked it up and made it part of the 'approved' training system. If it can go wrong, etc..
ATSB - “Despite guidance in the CAAP to follow flight manual/POH recommended methods, on this occasion the exercise was conducted in accordance with the more general CAAP procedure at minimum practice height of 400 ft above the ground. The same procedure was also reflected in Part C of the company operations manual and, as such, had been approved by CASA. Practically, conducting the exercise in that manner resulted in it being conducted at a much lower safety height and via a different engine failure simulation method than detailed in the POH. That in turn reduced the overall safety margin for the activity.
Reverse bullshit this time – just because CASA say its OK don't necessarily make it so. A quick look through the performance charts and a read of the manufacturer notes would inform both regulator and pilot that they were on the raggedy edge of performance. One needs to be careful relying on the 'legal' weight of both the AFM and POH. The POH has 'legal grunt' only when it is included in the type certification data. Then there are parts of the AFM which carry serious legal weight and others which do not Depends on the manufacturer and the certifying authority (sort of – its complicated). However, IMO a case to answer is parked very squarely at the CASA front door. Parts of the CASA approved COM present operation out side of the POH; despite the CAAP and CASA approval. It is debatable as the 'Limitations' section of the AFM do not elaborate. But, for a classic example, take trip back in time to the Pel-Air 'approved' system – the more things change, the more they stay the same eh?
But stop and think for moment. What is the real purpose of asymmetric training? It is to develop and foster the 'drills' and methods for avoiding the inherent dangers. It is to promote early recognition of a danger area and initiate the actions taken to extricate the aircraft from a developing situation. Should the 'real deal' happen, once in a lifetime, the response and management from the crew should be almost 'routine'. This is essential in the lighter, FAR 23 certified aircraft. It is a difficult task when there is certified single engine performance; let alone in an aircraft with a single engine performance which will take you to the scene of the accident.
There's far too much bullshit floating about the place satisfying a perceived method of compliance. As most of this is treated with contempt and covertly undermined anyway, perhaps a reality check is needed. Beginning with making sure operations are conducted within the AFM specified limitations, acknowledged and not subject to the vagaries of individual, subjective preference.
I would very much like to know the trim settings of the accident aircraft. ATSB found them for the Essendon King Air crash in record time; but no mention made in this report. Its a curiosity; but then, almost everything in this gender neutral report generates questions. No matter we shall plod on.
Stand corrected. Sorry, missed the data; mea culpa and anyone who wants to borrow my phone may do – to ring anyone who gives a monkey's.
ATSB P.36 – Rudder trim.
The rudder trim actuator screw jack was found in a slightly over extended position which equated to a full nose-left trim position. The actuator displayed evidence of having been alternately driven toward the retracted and extended positions by impact forces. The ATSB could not determine the extent to which impact forces affected the screw jack’s pre-impact position.
The rudder trim indicator was found in the full nose left position. Although it is possible that impact forces may have affected the position of the indicator, it was considered that crushing, evident in the cockpit area probably captured the indicator in its pre-impact position.
On balance, the evidence supported the rudder trim being in the full nose-left position at impact. That position was consistent with pilot response to a simulated failure of the right engine.
Toot – toot.
One of several major shortcomings within the CASA FOI system may be found within the approval of operational material. There are countless anecdotes which relate to 'type specialists' in disagreement with experienced operators of an aircraft type. Some risible comments have been writ into a training system or manual, simply to 'satisfy' the FOI. Those who have experienced and understand this have no need of further explanation. It is a real existing problem which CASA must address should they wish to eliminate what I believe is a serious, concealed safety issue. That of an attitude toward 'CASA bullshit'. You can hear it a dozen times a week. “Nah, we don't do that, its just some CASA bullshit”. The problem being that as that approach becomes 'the norm' – often real safety issues within that area are treated in the same manner. You do see the problem, disregard for published material becomes a normalised deviance. Most chief pilots and check pilots in GA will confirm this. Airline training comes as a shock to a lot of GA pilots, when 'by the book and only the book' becomes the new norm.
ATSB - “The ATSB sought information from CASA regarding the circumstances under which the incorrect procedure was approved for use by the operator. Despite this request, no information was provided by CASA. Consequently, the ATSB was unable to determine whether the approval of incorrect information was an isolated human error or symptomatic of a systemic deficiency with the approval process.
Right there a classic. There is a great deal of difference between 'reading' a Flight Manual (AFM) and 'studying' it. In order to 'teach' (or pontificate) an aircraft type one must seriously study the relevant manuals. The end product should be a pilot who not only knows and understands not only the entire operational envelope, but how to keep the operation within safe, legal parameters. Take a simple thing like the following.
ATSB - Additionally, the likely power setting was less than the AIRSTART lever position detailed in the POH and had the potential to allow the aircraft’s right fuel computer to trip from the normal automated mode to the manual mode. If that occurred it could have affected that engine’s power level and/or been a distraction to the crew. As switching of the fuel computer from normal to manual was not recorded, it was not possible to determine if this occurred.
ATSB - “Manual mode refers to the engine power output being directly controlled by the power lever position rather than by a signal sent to the engine by the electronic engine control unit (EEC). The power system is designed so that fuel scheduling is lower in manual mode than it is in normal (automatic) mode. Higher power lever positions are therefore required to maintain engine power when in manual mode compared to normal mode. This means that if a fault is detected in the EEC and the engine operation automatically reverts to manual mode the engine will have a reduction in power for that particular power lever setting. If that occurs the power can be restored by advancing the power lever as required.
The workings, limitations and potential traps of this system should be acknowledged; a system to prevent inadvertent activation during abnormal operation must be prescribed and built into a C&T system ambit. Awareness of this possibility, through an 'approved' method of simulating an EFATO must be acknowledged. The CASA approved Ross Air system presented in both Part A and C of the operating manual fail to mention, let alone alert crew to this possibility, particularly in the simulated engine failure case. It may well be 'something-nothing' but, if the manufacturer has gone to the length of covering a possible 'loop hole' then either CASA or the operator should have picked it up and made it part of the 'approved' training system. If it can go wrong, etc..
ATSB - “Despite guidance in the CAAP to follow flight manual/POH recommended methods, on this occasion the exercise was conducted in accordance with the more general CAAP procedure at minimum practice height of 400 ft above the ground. The same procedure was also reflected in Part C of the company operations manual and, as such, had been approved by CASA. Practically, conducting the exercise in that manner resulted in it being conducted at a much lower safety height and via a different engine failure simulation method than detailed in the POH. That in turn reduced the overall safety margin for the activity.
Reverse bullshit this time – just because CASA say its OK don't necessarily make it so. A quick look through the performance charts and a read of the manufacturer notes would inform both regulator and pilot that they were on the raggedy edge of performance. One needs to be careful relying on the 'legal' weight of both the AFM and POH. The POH has 'legal grunt' only when it is included in the type certification data. Then there are parts of the AFM which carry serious legal weight and others which do not Depends on the manufacturer and the certifying authority (sort of – its complicated). However, IMO a case to answer is parked very squarely at the CASA front door. Parts of the CASA approved COM present operation out side of the POH; despite the CAAP and CASA approval. It is debatable as the 'Limitations' section of the AFM do not elaborate. But, for a classic example, take trip back in time to the Pel-Air 'approved' system – the more things change, the more they stay the same eh?
But stop and think for moment. What is the real purpose of asymmetric training? It is to develop and foster the 'drills' and methods for avoiding the inherent dangers. It is to promote early recognition of a danger area and initiate the actions taken to extricate the aircraft from a developing situation. Should the 'real deal' happen, once in a lifetime, the response and management from the crew should be almost 'routine'. This is essential in the lighter, FAR 23 certified aircraft. It is a difficult task when there is certified single engine performance; let alone in an aircraft with a single engine performance which will take you to the scene of the accident.
There's far too much bullshit floating about the place satisfying a perceived method of compliance. As most of this is treated with contempt and covertly undermined anyway, perhaps a reality check is needed. Beginning with making sure operations are conducted within the AFM specified limitations, acknowledged and not subject to the vagaries of individual, subjective preference.
I would very much like to know the trim settings of the accident aircraft. ATSB found them for the Essendon King Air crash in record time; but no mention made in this report. Its a curiosity; but then, almost everything in this gender neutral report generates questions. No matter we shall plod on.
Stand corrected. Sorry, missed the data; mea culpa and anyone who wants to borrow my phone may do – to ring anyone who gives a monkey's.
ATSB P.36 – Rudder trim.
The rudder trim actuator screw jack was found in a slightly over extended position which equated to a full nose-left trim position. The actuator displayed evidence of having been alternately driven toward the retracted and extended positions by impact forces. The ATSB could not determine the extent to which impact forces affected the screw jack’s pre-impact position.
The rudder trim indicator was found in the full nose left position. Although it is possible that impact forces may have affected the position of the indicator, it was considered that crushing, evident in the cockpit area probably captured the indicator in its pre-impact position.
On balance, the evidence supported the rudder trim being in the full nose-left position at impact. That position was consistent with pilot response to a simulated failure of the right engine.
Toot – toot.