Safety Accident Analysis When trust is key…

Choosing which organisation to provide the best airborne instructional experience can be more important than many realise, and should never be taken on cost alone.

Steve Ayres looks at some incidents which might influence that ultimate decision…

For most of us, those early days with our flying instructor are hugely formative. A close bond is soon created as we learn to trust them to get us out of that proverbial hole which we have carefully dug for ourselves. How then, might we ever imagine it to be our instructor who is going to be the very person who takes us beyond even their ability to recover the situation? The following recent events show that it can and does sometimes happen.

Accident 1

The commercial pilot, a flight instructor with over 2,000 hours instructional experience, and the passenger, departed in the aerobatic aeroplane to an area established by the operator for accomplishing aerobatic manoeuvres. Although operating as a flight training company, the operator described itself as an ‘extreme aviation attraction’, providing a series of aviation-related experiences that included aerobatics, simulated air combat, and flight training, during which passengers had the opportunity to fly the aeroplane. The accident flight was 25 minutes long, which included aerobatics, high-g manoeuvres, and a low-level bombing run simulation.

An aft-facing onboard camera, mounted in front of the passenger was recording throughout the flight and revealed that the aeroplane was performing aerobatic manoeuvres for about seven minutes, with both the pilot and passenger manipulating the controls. After the pilot completed a tumble manoeuvre, the aeroplane began to regain altitude. The passenger then moved his hands away from the flight controls and appeared to be bracing his arms against the sides of the airframe in anticipation for an aerobatic manoeuvre. The aeroplane then pitched up and rolled right, and then rolled left, while the pilot made a ‘whooping’ sound, as the aeroplane transitioned into an inverted spin.

The passenger experienced negative g forces and reached up with his right arm up to secure the headphones which were pulling away from his head. The manoeuvre progressed, and its direction of rotation then reversed, until the aircraft transitioned into an attitude so that only the sky was visible in the canopy.

The wind noise began to increase, and a gap began to appear at the interface between the canopy frame and fuselage, indicating that the aeroplane was approaching its ‘never exceed’ speed. The passenger was then aggressively rocked from side to side.

However, the sun could be seen gradually transitioning across the canopy, indicating that the aeroplane was no longer tumbling and its attitude had stabilised. Up until this point, the passenger appeared to be enjoying the flight, but his facial expression changed, and he looked down and reached forward with his right hand. At that moment, the pilot activated the canopy release handle and the canopy opened, although no bailout was attempted, before collision with the ground six seconds later.

The aircraft was subject to two service bulletins (SB) pertaining to the flight controls, neither of which had been performed. The first required replacement of the rudder cable to prevent premature failure, however the aeroplane’s rudder cable did not display evidence of failure in the area documented by the SB. The other SB required the addition of a safety clamp to the transponder after a report that a transponder had slid out of its rack and jammed against the pilot control stick during aerobatic manoeuvres. It could not be determined if the transponder had moved during the accident flight and inhibited the control stick. Federal Aviation Regulations do not require compliance with SBs for aircraft operating under 14 Code of Federal Regulations (CFR) Part 91.

The operator presented itself as a 14 CFR Part 61 flight school, and although it did provide upset recovery and tailwheel endorsement, flight training and all the company pilots held flight instructor certificates. The vast majority of customers (including the accident passenger) did not hold any type of pilot certificate, and bought flights for the aerobatic and air combat experience. By operating as a Part 61 flight training provider, the company was able to advertise its services, expose fee-paying passengers to high-risk flight profiles, while circumventing the regulations and oversight for operators who provide transportation for compensation or hire.

Review of onboard video footage from the accident pilot’s previous flights revealed that, although considered to be a mentor and conservative in nature by his colleagues, the pilot routinely flew aeroplanes beyond their operating limitations (specifically their vertical acceleration, or g limitations) and at speeds very close to the ‘never-exceed’ speed, all with passengers on board.

“A gap began to appear at the interface between the canopy frame and fuselage”

Review of footage taken with other pilots revealed a company-wide pattern of disregard for the aeroplane’s published operating limitations and the company’s own policies regarding airspeed and g limitations. Because both the accident aeroplane and other aircraft in the company fleet had been flown beyond their rated g limits, it would have been required to undergo additional maintenance checks. There was no evidence that such checks had been performed on the accident aircraft, as such, the aeroplane was likely un-airworthy at the time of the accident.

Accident 2

The flight instructor picked up the private pilot and passenger for a cross-country flight. The instructor requested VFR flight following services from ATC and indicated a planned climb to 8,500ft mean sea level (msl).

However, the aeroplane continued to climb past that altitude. During the climb, the instructor indicated to the ATC controller, in separate transmissions, that he was climbing to reach ‘VFR on-top’, he was experiencing problems with an ‘unreliable’ attitude indicator, and that the aeroplane was ‘in and out of IMC’. Based on weather sounding and satellite imagery, it is likely that the aeroplane was operating in IMC above 4,100ft.

About 20 minutes after the aeroplane departed, the controller declared an emergency on behalf of the pilot and provided multiple radar vectors for the aeroplane to return to visual meteorological conditions (VMC). However, the aeroplane’s radar track showed that the aircraft continued climbing to 19,400ft msl before it entered a series of figure-eight turns followed by a steep, turning descent.

The pilot demonstrated several lapses in judgment. Specifically, the instructor did not appear to recognise the significance of widespread ceilings along his route of flight and planned a cruise altitude that took him into instrument conditions.

The instructor likely did not carry supplemental oxygen onboard the non-pressurised aeroplane and continued to climb the aeroplane to altitudes that required the use of oxygen. Without oxygen he risked becoming susceptible to the effects of hypoxia.

Further, another pilot who had flown the accident aeroplane, before the accident flight, stated that the aeroplane had a known problem with the directional gyro, yet the instructor flew the aeroplane in instrument conditions. Based on the instructor’s failure to follow the controllers’ directional instructions, it is likely the directional gyro was still not working.

“He wanted to show the student that there was more to flying than just training”

Lastly, review of the instructor’s logbook and an interview with another flight instructor indicated that the instructor was likely not ‘instrument current’, so his ability to safely manoeuvre the aeroplane in cloud during the flight would have been negatively impacted by the broken gyro and his lack of currency.

Accident 3

According to the flight instructor, they had planned a three-hour instructional flight to the training airfield. While en route, the flight instructor stated that he wanted to show the student that there was more to flying than just training. In his words flying was also ‘fun’. Subsequently, the aircraft was turned west towards a valley in the Olympic Mountain range. While flying in the valley, the flight instructor stated that he believed their altitude was at least 2,000ft agl and that no wind or turbulence was present. However, at some point, the pilots realised they needed to climb to avoid terrain and the flight instructor applied full power and pitched the aeroplane up into a climb.

However, he realised that even with these control inputs, the terrain was rising faster than the aeroplane was climbing. The flight instructor instructed the student pilot to start a right turn. Shortly thereafter, he felt the turn was too slow and just as the student pilot was increasing the bank of the turn, he took control of the aeroplane. The flight instructor stated things were happening too fast for him to recover the aeroplane and he knew that they were going to crash. In due course, the aeroplane impacted terrain.

Ayres’ Analysis

In the first accident there is recognition that lack of proper regulatory oversight made the accident more likely. That is surely the case, but it is as much about an organisation’s approach to safety that matters. When this is lacking at the very top of a company then it will inevitably permeate throughout the organisation. Such flagrant and systemic disregard for rules and aircraft limitations was never going to end well.

In the two other cases, personal judgement is clearly called into question, but the reader is still left wondering how such events could occur in a properly run training organisation with such elementary aspects of instruction. Observance of rules and regulations have to be instilled and then reinforced from the outset, as must the absolute respect of airframe limitations – by staff and students alike. And hopefully, fostering in one’s student the sort of behaviour that is going to keep them safe and able to enjoy a lifetime of fun flying.

From an instructor’s perspective, demonstrating the sort of behaviour you would want your students to emulate, is key. This isn’t to say that those of us who instruct haven’t pushed the bounds of regulations at some time or another, but hopefully with good reason and with safety in mind. Forever mindful that a culture of ‘do as I say, not as I do’ will likely leave itself embedded in the consciousness of a student and may well perpetuate itself across future generations…

The aspect of trust is, of course, absolutely key in these accidents. The student or passenger in each case had very little aviation experience and was never likely to influence the outcome once they had paid their money and flight preparation was under way. Their only real prospect of doing so was well before that point; in their choice of training organisation and even, perhaps, their choice of instructor.

Time spent on carrying out due diligence of those training organisations under consideration has to be time well spent in making that airborne experience a memorable one for all the right reasons. And it is not just about the cost. It is as much about the feel of the organisation, the state of the hangar, the condition of the aeroplanes and the background and experience of the instructors. It all plays a part in making sure they turn out to be heroes – not villains!

Safety Accident Reports When checking is key…

Steve Ayres summarises and comments on accident reports from around the world and puts his best foot forward with the Sparco race boot, which might help keep feet light on rudder pedals…

Stay focused…

Cessna P210N N3896P Detroit, MI Injuries: Two fatal, one serious

As the pilot approached his destination after a cross-country flight, the aeroplane’s landing gear did not fully extend. Over the next seven minutes the pilot attempted to troubleshoot the landing gear in the airport traffic pattern before he reported to the tower controller, “Well, I just burnt outta fuel, we’re totally out bud.”

The tower controller immediately cleared the pilot to land. However, there was no additional communication from the pilot and the final radar return was recorded about 180ft agl and about a mile north-west of the runway. The aeroplane impacted trees and an electricity service line in an urban residential area.

A post-crash fire destroyed most of the forward fuselage and cockpit area and the extensive impact and fire damage to the landing gear extension / retraction components precluded determination as to why the landing gear did not fully extend during the flight.

Although the pilot had departed on the flight with enough fuel to reach his intended destination, he did not have enough fuel remaining to adequately address the landing gear malfunction before the aeroplane had a total loss of engine power due to fuel exhaustion.

Based on the recorded transmissions between the pilot and the tower controller, the aeroplane only had about seven minutes of fuel remaining when the pilot first reported the landing gear malfunction to the tower controller.

Comment

This emergency should not have ended the way it did, but in becoming preoccupied by an undercarriage that refused to lower, the pilot missed the real threat to life – running out of fuel. Of course, the pilot should have diverted due to low fuel well before this situation arose. Even without the undercarriage emergency, a bulked approach or some other unforeseen event at the destination airfield may well have ended with the same outcome.

Loose canopy

SubSonex N224P Latrobe, PA Injuries: None

The pilot reported that after take-off in a homebuilt jet, the canopy ‘shimmied open about two foot aft’ and that he immediately reached for the canopy with his left hand while his right hand was on the control stick. The aeroplane was a few feet above the runway surface when he applied slight forward pressure on the control stick. The aeroplane’s nose pitched down, and the nose landing gear impacted the ground. The aeroplane veered right, the main landing gear collapsed, and the aeroplane then slid to a stop on the runway. The pilot reported that he did not complete the predeparture checklist to secure the canopy because he was adjusting the recently installed radio and headset. The aeroplane sustained substantial damage to the left wing.

“While troubleshooting the landing gear problem, the aircraft ran out of fuel”

Comment

Once airborne the pilot was faced with a choice of two evils, hold on to the canopy or risk letting it continue to open, where it most likely would have separated. As the aircraft was a jet, with the engine located on the upper rear aft fuselage, any debris from the separation may have been ingested by the engine.

Unfamiliar approach

Van’s RV-9 G-CDXT Private airstrip, Whippingham, Isle of Wight Injuries: None

The pilot had planned to fly on an overseas trip in G-CDXT, an aircraft owned by a friend. Most of the pilot’s flying experience had been gained on taildragging aircraft and he owned a Piper Cub, which he operated from a 580-metre long private grass airstrip on the Isle of Wight.

A few weeks prior to the accident, the pilot had flown G-CDXT with the owner to familiarise himself with it. The flight had taken place at Clacton Airfield which has a grass runway just over 500m in length. The dual flight was uneventful and the pilot then undertook a solo flight in the aircraft, with no problems.

On the day of the accident, the pilot had flown in his Piper Cub to a private airstrip in Sussex to collect G-CDXT and fly it back to the airstrip he used on the Isle of Wight.

On his return, the weather was good with a westerly wind of about 10kt. The pilot positioned G-CDXT for an approach to the grass strip, which was orientated into wind. He reported he had been deliberately low on the approach and that just prior to landing the aircraft had encountered wind shear, causing it to lose height. The pilot thought the aircraft would hit a low hedge situated at the boundary of the airfield and applied a nose-up elevator to avoid it. He did not apply power at the same time. The aircraft stalled, hitting the ground near the start of the airstrip sufficiently hard to cause the undercarriage to collapse and damaging the propeller, wing leading edges and fuel tank.

The pilot considered that had he flown the normal approach path he would have had sufficient height to lower the nose of the aircraft when encountering the wind shear in order to maintain speed. He further commented that the Piper Cub he normally flew had the throttle on the left, whereas the throttle on G-CDXT was on the right. He believes this contributed to him not applying power when he applied a nose-up elevator to avoid the hedge.

Comment

Operating into confined strips brings with it a whole load of stress, and the pilot rightly commented after the event that ‘it may have been beneficial to have gained more experience at a larger airfield before trying to operate to the more challenging airstrip’.

Lowering the nose in the event of wind shear might have its place but only when height and a choice of touchdown point allows.

Forced landing…

Reims Cessna F152 G-BTAL Shobdon Aerodrome, Herefordshire Injuries: None

The pilot had not flown for several months due to public health restrictions and on the day of the incident was planning to complete three circuits to regain recency.

The first two circuits were uneventful. He took off for the third circuit with the flaps up and full power. As the aircraft reached 300-400ft the engine lost all power. The pilot described it feeling like ‘someone had pulled the throttle to idle’. He immediately lowered the nose and selected a field slightly to his left. He recalled that the power returned briefly then reduced again but he decided to close the throttle and treat the engine as completely failed. He made a Mayday call then focused on the landing.

“Having read about previous accidents he was not tempted to turn back”

The pilot landed the aircraft with the flaps up in a slight crosswind. As the aircraft touched down he noticed a ditch crossing the aircraft’s track and decided to pull back on the control column to pass over it. Once clear of the ditch he brought the aircraft to a halt and shut the engine down. The aircraft was not damaged and the pilot was able to exit the aircraft normally.

The pilot reported that he had been trained to think through all possible outcomes and had considered different engine failure scenarios at the airfield prior to the event. He also always briefed himself on his actions in the event of an engine failure prior to each take-off.

He believed this helped him manage the situation on the day. He had recently completed ATPL ground exams and had read various articles and reports about managing engine failures and potential pitfalls. These had taught him to treat a partial engine failure as a complete engine failure, not to try to turn back to the airfield, and the importance of flying the aircraft first.

The maintenance organisation recovered the aircraft and conducted a detailed inspection. It was unable to identify the cause of the loss of power but suspected carburettor icing. The air temperature was 29°C with a dew point of 17°C, suggesting serious carburettor icing was likely at descent power. The pilot reported that he used the carburettor heat for at least 10 seconds while flying downwind and did not detect any icing. He selected the carburettor heat again before he reduced power for descent and kept it on until landing.

The aircraft was returned to flying and at the time of writing no further engine problems had been encountered.

Comment

The pilot attributed the safe outcome to having planned and reviewed his actions in the event of an engine failure prior to taking off.

This freed sufficient capacity such that, when the event occurred, he could focus on flying the aircraft. He also treated the partial failure as a complete failure. Having read about previous accidents he was not tempted to turn back and instead selected a field ahead and focused on landing.

Safety kit

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