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Latest from Accidents - Domestic:

"Pilots untrained to deal with 'feathering' failure that may have caused DFO crash: experts"

Bollocks – sentence 1.

Failures in both the engine and 'feathering' system, that pilots are not trained to deal with, may be behind Tuesday's fatal plane crash, experts say.

Complete utter rubbish; the first class ‘auto-feather’ and ‘rudder boost’ system are ‘assist’ only. They are categorically not to replace a well trained pilot.  Nor should these systems  ever be totally relied on as the ‘definitive answer’ to an engine failure in the ‘low-slow’ configuration. Even if both systems failed, simultaneously at the most critical moment it would matter little to any pilot who had been ‘trained’ to actually fly the aircraft, rather one only trained to pedal ‘the box’ around the sim exercise garden circuit.

Item one – failed engine – big yaw – big rudder; balance is all. Rudder boost failed – so what, use muscle and trim, but do NOT allow the ‘yaw’ to continue.

Item two – failed engine – balanced aircraft – failed unit identified; feather and fuel off – or Fuel off and feather for fire –no matter – reduce the drag – quickly; after correctly identifying the ‘failed’ power unit.

Item three – Speed – must have – and the ‘right’ one then maintain that speed until clear of obstacles – power available from live engine; performance available from setting up the right ‘asymmetric balance’ take height with speed stabilised; clean up; sort it out then get on the radio and back to earth a.s.a.p.

There are several items which must be considered during this difficult first thirty seconds; e.g. what is there to bang into and how best to avoid it – in terms of given altitude and rate of climb being produced; it is important to remember that the undercarriage will take a longer period of time to retract, (hydraulics question) which will delay accelerating to and achieving the Single engine best rate of climb speed (SEBROC). In fact SEBROC may not be achieved initially; but, a well managed take off takes the aircraft very quickly through the ‘speed gates’. A Be 20 should, on a runway like Essendon be doing 110 -120 knots as the gear comes up before the end of the runway. The old Dash 41 models rotated at 92 (ish) knots and went very quickly through safe single engine speed 104 achieving 115 Kias* (single engine best rate of climb) with the gear retracting SEBROC 121 Kias came within seconds, followed swiftly by Multi engine best rate of climb speed @125 Kias.  In not technical short, from 80 Kias through to 160 Kias (normal climb) happens very swiftly, the only real ‘grey’ period is between 90 and 115 Kias.  ( Sorry P&W- 41 numbers; 42 not to hand). *KIAS – Knots indicated Air Speed.

It is a great mistake to sit back and do nothing while relying on rudder boost, auto feather and the gods to drag you through the very short ‘grey’ period. It is reprehensible for this reliance to become normal; it is completely irresponsible to teach this dependence as a requirement.

I want to know who trained this pilot, I want to know where his ‘retraining’ was done after the Hotham scare. I particularly want to examine the sim print outs and the check list procedures and who’s sim was used to execute these procedures.

FFS someone; get into a Be20 with a camera and a stopwatch; watch the airspeed and altimeter; you will be amazed at the speed which the aircraft achieves safe flight speeds; then do it again for an EFATO with a ‘proper’ King air pilot; use the RFDS, and, be even more amazed as the aircraft, properly handled, breezes through the event; even with the rudder boost and auto-feather disabled.

Lord I am tired to my very bones of bloody ‘experts’ and their empty headed rational.

Aye well – what can you do – except try to explain it to the ‘media’ again and again and again. The up side is they’ll have forgotten it all by next week and we can have a real look at this accident.

Toot toot.

Not wanting to pre-empt any of the good folk on the coal face of this tragic CFIT accident but I see some disturbing similarities to the fatal Darwin Brasilia training accident, that the Dr 'Ghost who walks' Walker took issue with in relation to the PelAir cover-up:  

"There's a hole in the cheese dear Liza, dear Liza??" 

Who'd of thought? The Ferryman doing 'an evening twiddle' just short of the 'witching hour' on a Sunday night? Maybe like the rest of us mere mortals, this bollocks daylight savings has disturbed his evening routine..

Anyway job well done Mr "K"...   (Ps & TY for the edit I was bit rushed with my last - )

Ok onwards & downwards with the dot joining...

Quote from: Opinion :-ATSB since 2003.

We have also examined the final reports on the Pel Air ditching event off Norfolk Island and the fatal Sydney 'Canley Vale' and Darwin Brasilia fatal accidents; we believe they provide further examples of compromised ATSB Final Reports.

In case you need a reminder of the circumstances of the Darwin Brasilia accident, here is a disturbing ATSB simulator animation of that tragic C&T accident: 

From earlier post#33 "K" said:

..History then shows a clear shift in the approach of the ATSB to a ‘softly softly’ approach where organizational issues are brushed aside. A classic is the Air North Brasilia fatal where a whole string of ‘organizational’ matters of great import were written out of the script.  In short, a routine check and training flight ended with two deaths. The question left begging is why two experienced, qualified pilots died that day. The ‘new’ procedures being used were ‘approved’ by CASA, have to be. The practices used in the simulator take the aircraft into ‘borderline’ dangerous situations; which is fine, and; in theory, those practices should translate into in-flight scenario. Well, they did not. There is a CASA FOI who we believe has much to answer for, still gainfully employed, at the well hidden roots of this accident. Part of the ‘organizational’ causal chain; sure, but acknowledged? Don’t be naïve...

And just before the Senate PelAir inquiry, on the 6th August 2012, a certain 'senior' ATSB Transport Safety Investigator (who I believe was actually Dr (BASR) Walker), said this about the Braz tragedy:


{P2 comment - To put this in context this was just prior to the release of the original nearly 3 year, totally shambolic, politically & bureaucratically obfuscated VH-NGA ditching investigation final report}

Now in an effort to track down the 'unflattering comments' that so offended Dr (BASR) Ghost-Who-Walks, I raided the UP archives based on the timing and this is (much to my amusement..) was what I discovered: Air North Brasilia Crash in Darwin (Merged) #446

Without this diverging into a mixture vs closed throttle vs Flight idle vs zero thrust debate has anyone noticed the gradual decay of the quality of investigation reports coming out of the ATSB?

Besides the Hempel Inquest, where the ATSB appears to have abrogated all responsibility to investigate at all, the ATSB report into the Brasilia accident in Darwin is nothing short of totally spare in its conclusions!

There also appears to be no 'Safety Recommendations' generated from a training accident that I think we could have all learnt a lot more from.

Take a look at a couple of extracts from the report:

Quote:
Terminology used in training and checking
The operator’s documentation did not contain any specific terminology for discontinuing a manoeuvre, but did provide clear instruction as to how control of an aircraft was to be changed between crew members.
To take over control from the pilot flying, or for the pilot flying to relinquish control to the other pilot in a multi-crew aircraft, very specific terminology was used. To avoid any confusion as to which pilot was manipulating the controls, the operator’s General Policy and Procedures Manual, section 4.7.2.2 Crew Communication - Handing Over and Taking Over stated:
The process of handing over control of the aircraft shall always be conducted in a positive manner. To minimise confusion or operational risk, the following terminology shall be used.
To assume control, the pilot monitoring shall call "taking over". To relinquish control, the pilot flying shall call "handing over".
Control of the aircraft cannot be handed over until the pilot monitoring has called "taking over"...
The term ‘disengage’ that was used by the PIC during this simulated engine failure was not standard phraseology. Other EMB-120 pilots reported that they had never heard the term ‘disengage’ used for any action other than deselecting the autopilot/yaw damper and had never heard it used to discontinue a manoeuvre.
They also reported that if a training or check pilot decided to discontinue a simulated engine failure procedure, they would expect that check pilot to restore power to the ‘failed’ engine. Alternately, if the training or check pilot wanted to assume control of the aircraft, they would expect to hear the term ‘taking over’.

Which is pretty basic stuff in a multi-crew aircraft....and then in regards to the Yaw Damper....

Quote:
The operator’s flight operations manual for the EMB-120 stated that the yaw damper was not to be used for takeoff or landing, and that the minimum speed for its use during one engine inoperative (OEI) flight was 120 kts indicated airspeed (KIAS).

.....and then more in relation to the apparent Yaw Damper activation...

Quote:
The use of the yaw damper during asymmetric flight was introduced to the simulator testing following consideration of the cockpit voice recording references to the PIC’s command ‘disengage’ and the pilot under check’s response, ‘yeah, disengaging’. It was assumed that the reference was to the yaw damper and not the autopilot because the chime that sounds when the autopilot was disengaged was not heard on the CVR recording. Additionally, the simulator instructor reported having previously observed pilots engage the yaw damper during simulated engine failures in the EMB-120 in response to pilots ‘overcontrolling’ rudder and aileron following a simulated engine failure.

All of the above is all good factual investigative methodology a lot of which points to a number of operational issues (company SOPs etc) and regulator oversight issues....right?? Wrong, take a look at the first paragraph of the ATSB conclusion.

Quote:
No organisational or systemic issues that might adversely affect the future safety of aviation operations were identified as a result of this investigation.

Maybe this conclusion is a result of the regulator putting in place the Mandatory Simulator program and subsequent NPRM leading to the current NFRM, but does it excuse glossing over what was a particularly significant training accident event that, although tragic, we could all have learnt from!

ps ....and what gives with the no 'Safety Recommendations' issued!

http://www.atsb.gov.au/media/3546615/ao-2010-019.pdf

With "K" in tow, the discussion went on down the page:

Now I'm curious

---

I find I am once again forced to read between the lines of an ATSB report. Technically it's spot on; for example, reading the time line analysis, there is a temptation to question the rudder v aileron input, however this is clearly resolved in the computer simulation graphics. Not having operated a Braz – there are a couple of points of interest which perhaps can be explained by someone who has.
Disengage ?? –could this refer to the Flight Director or is it the Yaw Damper ?. I note the AFM mentions –(paraphrased) FD Before take off (SET), expanded to PF select GA and check 7° pitch up; and, that the AP or YD may not be engaged during TOFF and LAND manoeuvres.

Has it been SOP for the PF to engage the YD as part of an EFATO or was this a recent innovation ?.

The V1, Vr and V2, V2 +10, etc. schedule. The AFM seems to be clear about the speed schedule and the acceleration to V2 +, then flaps up then Vfs (paraphrased). There appears to be a deliberate reduction from V2 + 4 (at – 23 seconds) to V2 (at -20.7 seconds). Is this a norm for the type or a new innovation ?.

Is the un monitored management of the OE, the over torque (124%) and the corresponding rudder/aileron excursions normal for the airborne exercise being conducted ?.

It is suggested by the ATSB final analysis that the BASI recommendations made after an investigation into the Flight Idle v Zero thrust (auto feather) scenario have been ignored. There is much documented proof that CASA have been enforcing 'black letter' CAO 40.1 requirements which conflict with both the AFM (see CAR 138) and a common sense approach to airborne EFATO exercises.

It is noteworthy that simulator based training had been recently introduced; and, conversely that Air North have safely, successfully conducted many 'in flight' simulated failures prior to the introduction of 'simulator' techniques. It is of concern that several things occurred which should give a check pilot the screaming heebie jeebies, airborne.

Perhaps we could ask of the ATSB to investigate 'in depth' the contributing factors to this situation occurring. We have the almost self evident facts of the accident, we have the why, but maybe it would be nice to know the wherefores.

P.S. Categorically not having a pot shot at the crew, the company or the simulator. Just seeking a satisfactory explanation of why and how this 'abnormal' chain of events occurred. If this was a new ME instructor and an initial twin conversion, perhaps this event may have occurred, but it wasn't – was it.

   
Which I followed with:

Quote:
It is noteworthy that simulator based training had been recently introduced; and, conversely that Air North have safely, successfully conducted many 'in flight' simulated failures prior to the introduction of 'simulator' techniques. It is of concern that several things occurred which should give a check pilot the screaming heebie jeebies, airborne.

Perhaps we could ask of the ATSB to investigate 'in depth' the contributing factors to this situation occurring. We have the almost self evident facts of the accident, we have the why, but maybe it would be nice to know the wherefores.

A lot of what was covered in the ATSB report touched on the areas of operational concern and hinted to several differences in history where the Check Pilot had started to diverge from his 'norm'. This quote from page 54 of the report is significant:

Quote:
Two of the pilots who were recently assessed by the PIC reported that he selected flight idle (zero torque) to simulate an engine failure after takeoff in their check flights. It was possible that the PIC had decided to deviate from the operator’s approved procedure in order to test the recognition by the candidate of the additional failure of the autofeather, before setting zero thrust.

 
However it isn't clear whether this 'divergence' from his 'norm' started after he had been to the simulator or before. If it was after then one may suggest that he was operating in a 'simulator induced complacency' manner i.e. it was proven that Flight idle (aircraft) or 'Autofeather Failed' engine failure (simulator) could be successfully recovered from while conducting a V1 cut.

This also appears to have been an area of concern for the regulator, as they used this accident as an example in Annex A of the NFRM for Mandatory Simulator, see here:

Quote:
From CASA NFRM Mandatory Simulator training Annex A:

COMMENT 1.2
Some respondents proposed adding wording to allow training and checking to occur in the aircraft provided the exercise had been conducted by all pilots in a simulator in the preceding 12 months.
CASA Response
CASA is firmly of the view that where a qualified STD is available for aircraft of this size, this should be used for all training and checking activities. The ATSB has reported that the training captain of the aircraft involved in an accident in Darwin in March 2010 had undergone training and checking in a flight simulator, however the actions by the training captain in simulating an engine failure in the actual aircraft during the accident flight was not consistent with the training received during the simulator course. This suggests that doing one session of training and one check per year in an STD (with the subsequent session/check in an actual aircraft) does not satisfactorily address the risk of conducting non-normal exercises in an actual aircraft.

If the Check Captain was inducing this scenario (FI V1 cuts) prior to having gone to the simulator, whereas previously he always only induced a Zero Thrust EFATO scenario, then there must have been input from somewhere/someone to change him to suddenly start breaching the company T&C SOPs??

As 'K' suggests there has been many takes, ambiguity and debate..etc..etc..on the regulatory requirements of CAO 40.1.0:

Quote:
There is much documented proof that CASA have been enforcing 'black letter' CAO 40.1 requirements which conflict with both the AFM (see CAR 138) and a common sense approach to airborne EFATO exercises.

Maybe there is an element of rogue FOI's, that lack the necessary industry experience, that insist on adhering to the letter of the law in CAO 40.1.0. Instead of applying practical safeguards and risk management to high risk training and checking scenarios!!

 
So am I offended that 'his nibs' Dr W#*ker believes that I have no idea about what an "..organisational issue actually is, and when it is, or is not important.?"  - Not on your life I luv it... 

In light of the Kharon post and considering it is still way to early to really speculate, but reflect that this is not realistically about some spurious lack of training in a 1 in a million auto fx or rudder boost failure after EFATO. Potentially this is about why two experienced professional aviators - one a senior Training & Check Pilot with years of experience instructing and C&T; the other a 38 year experienced Charter Pilot with presumably much experience on type (B200) that was recently checked (& re-checked) by CASA - would appear to have deviated from what would be regarded as their baseline 'normal' for dealing with (simulated or real) abnormal or emergency twin turbo-prop aircraft operations - just saying...


MTF? - Definitely...P2