Jim Davis - ACCIDENT REPORT

AIRCRAFT ACCIDENT REPORT

• This report is to promote

aviation safety and not to establish legal liability.

• Unless stated otherwise all

times are local (Bravo time)

• The CAA’s report contains

padding, repetition, poor

English and incompetence.

So, in the interest of clarity and readability, I have had to correct and paraphrase extensively

SENECA FUEL CROSS FEEDS

ACCIDENT REPORT:

Aircraft Registration: ZS-KFT Date of Accident: 8 October 2012 Time of Accident: 1146Z Type of Aircraft: Piper-34-200T Type of Operation: Private (Part 91) Pilot-in-command Licence Type: Commercial Age: 20 Licence Valid: Yes Pilot-in-command Flying Experience Total Flying Hours: 531,0 Hours on Type 66,9 Last point of departure:

Runway 12 at Bethlehem Aerodrome (FABM).

Next point of intended landing:

Lanseria International Airport (FALA).

Location of the accident site:

Panorama residential area, Bethlehem 21’02 /20’10” at 5 561ft AMSL.

Met Info Wind: 090˚/11kt; Visibility: 10 km; Temperature: 23˚C; 1/8 Cloud cover. The density

altitude was 7 573 ft

Number of people on board: 1 + 0 No. of people injured: 0 No. of people killed: 0

SYNOPSIS

After take-off from Runway 12 the aircraft climbed to approximately 250 ft AGL when the left hand engine RPM suddenly decreased from 2450 rpm to 1500 rpm. The pilot reported that he then advanced both power levers, but the left engine failed completely. He executed a left turn in order to turn back towards the runway and executed a forced landing on an open field at the western side of the aerodrome. The aircraft rolled for approximately 400 metres before it which it went through a ditch and collided with a fence and a street light pole.

The landing gear was substantially damaged during the landing, and the left hand propeller separated from the engine during the impact sequence.

The investigation revealed that both the fuel selectors were found in the cross-feed position, this configuration is prohibited in accordance with the flight manual.

The pilot did not feather the engine following engine power loss as required by PHO.

PROBABLE CAUSE Fuel mismanagement

MASS AND BALANCE

Aircraft Basic Empty Weight: 2 823 Pilot: 185 Fuel on board: 416 Take-off weight: 3 424 The maximum take-off weight for this aircraft was 4 570 lb. The fuel was tested and found to be free from any contamination.

During the on-site inspection of the cockpit, the propeller pitch levers were found to be full forward. This is inconsistent with the settings of a feathered propeller. It was therefore concluded that the left propeller had not been feathered. The pilot could not explain why it was so.

The left Continental TSIO-360-EB, was removed from the wreckage and transported to a maintenance facility. It was not possible to subject the engine to a bench-test procedure, due to the impact damage. An engine teardown inspection was carried out. No anomalies were found that could have prevented the engine or its accessories from operating normally.

The fuel system components were benchtested. They were found to meet all the operating requirement limitations as contained

The Seneca after ripping off its undercarriage.

in the manufacturer’s manual and was found operating satisfactorily.

Irrespective of the reason for the power loss, the aircraft could still have been flown safely if the pilot feathered the left-hand propellor.

The pilot was licensed and current in accordance with existing regulations and had accumulated 39,9 hours on the aircraft within 90 days. He obtained a multi-piston engine rating on the Piper Seneca on 25 February 2012 at total flying hours of 131,3. That would have been the last time that he had completed emergency drills on this aircraft.

The pilot did not comply with the emergency procedures for an engine failure during takeoff as stipulated in the pilot’s handbook. However, it cannot be ignored from a human factor’s point of view that due to the aircraft’s height and the inoperative engine, the pilot’s workload had increased substantially, leaving him with no other option than to execute a forced landing.

FROM THE POH

The fuel selectors are on the floor between the front seats. Each selector has three positions: ON – OFF – X FEED.

ON causes each engine to feed from the tanks on its side. X FEED causes the engine to feed from the tanks on the opposite side. OFF shuts off the fuel from a side.

If one engine is inoperative the selector for that engine must be in the OFF position when the operative engine is selected to X FEED.

Taking-off with both selectors on “crossfeed” is prohibited.

Engine failure during take-off at 85 KIAS or more. (also from the POH)

If adequate runway remains CLOSE both throttles immediately, land if airborne, and stop straight ahead. If runway remaining is inadequate for stopping, decide whether to abort or continue. If decision is made to continue, maintain heading and airspeed, retract landing gear when climb is established and feather inoperative engine prop.

IMMEDIATE ACTIONS:

Maintain direction and airspeed above 76 KIAS Mixture controls.....................................forward Propeller controls...................................forward Throttle controls.....................................forward (40 in Hg max.) Flaps......................................................retract Gear.......................................................retract

To identify inoperative engine:

Throttle of inop. engine..........................retard to verify Mixture of inop. engine..........................idle cut-off Prop control of inop. engine...................feather

TIDYING UP:

Trim .......................................................as required Auxiliary fuel pumps ..............................OFF (except in case of engine driven-pump failure) Magnetos of inop. engine......................OFF Cowl flaps..............................................close on inop. engine, as required on operative engine Alternator of inop. engine ......................OFF Electrical load........................................reduce Fuel management..................................OFF inop. engine, consider crossfeed.

Minimum control speed .........................66 KIAS Best S.E. R/C ........................................89 KIAS

JIM’S COMMENTS

Where do I start - with the CAA’s incompetence, or the pilot’s? From the report it seems that the investigator simply failed to ask the right questions. The critical part of the flight, between sitting at the threshold, and the left engine losing power at 250 feet AGL, is blank. This means we can only guess at what happened. The same applies to the bit between losing the engine and hitting the ground. We know nothing about what the pilot did with the undercarriage, the flaps and the windmilling prop - all of which should have grabbed his immediate attention.

The best I can do is tell you what seems to have happened, and contrast that with

what should have happened. Briefly, the pilot seems to have become a very lucky passenger in a crash, and what should have happened is the aircraft should have climbed away comfortably to return for an uneventful single engine landing.

Let’s go through the flight from the pre-take-off checks to the crash.

Piper recommends that you test each engine individually on X-feed while taxying. I like the theory, but I have never done it because I have no idea how long the engine will run on the fuel in the pipes at taxi power. So that test seems pretty meaningless unless you have a hell of a long way to taxi. Besides it doesn’t feel good to be changing tanks or fiddling with fuel selection shortly before take-off. We can only guess at what the pilot did on the ground - but we know for certain two critical things he failed to do. I’m saying the accident started on the ground, and could have been prevented on the ground.

Here are the two things he failed to do.

He failed to check the fuel selection. Most aircraft will get into the air if that is the only check you do. The Senecas have the simplest fuel system I have ever seen on a twin. Each selector is either ON or OFF or on X-FEED. If you knew nothing about flying a twin - where would you put the selectors for take-off? Not difficult is it? I will explain more about that later.

If you lose power firewall the levers until you can identify the engine which has lost power.

And he didn’t brief himself on what he would do if an engine failed. Here is what he should have said - out loud. (We put far more value on instructions that we hear - even if they come from our own mouths.)

• If an engine fails - or if I have difficulty keeping straight - while there is usable runway ahead - I will throttle fully back on both engines and stop on the runway ahead. • If there is no usable runway I will: • Fly the aircraft by keeping straight with the rudder, and lower the nose if necessary to maintain at least 76 kts. • Take full power by moving all six power levers fully forward. • Retract the undercarriage. Heavy metal pilots like to do the flaps first in case the aircraft sinks on to the runway. (Light aircraft generally don’t have the inertia for this to be a problem. The undercarriage is a major drag contributor - it’s best to get rid of it asap.) • Retract the flaps • Identify - dead foot = dead engine • Confirm identification by throttling back the suspect engine • Bring the mixture on the dead engine to idle/ cutoff • Feather the dead engine. • I will then use 5 degrees of bank into the dead engine and trim as needed. • Finally I will replan my flight, notify ATC, tidy up - cowl flaps, mags, fuel pumps, alternators, etc.”

This may seem like a long list of things to remember at a critical stage of flight. And if you are not current and so suffer from the startle factor, it is indeed a formidable list. But think of it this way, if you can’t run through the immediate actions in less than 15 seconds, you should not be flying a twin.

The difference between just flying a light twin, and flying it safely, is largely defined by how you handle that crucial 15 seconds. When you convert to a light twin it’s not just another type in your license - it’s a massive step that separates a pilot with a professional attitude from the weekend warrior . It’s a very big deal if you are not current. This is when most out-of-practice multi-engine pilots kill all on board. And it is a total nonevent if you are current.

When I say current, I don’t mean current on twins - I mean current on EFATO actions. I have seen many accident reports where pilots who have thousands of hours in twins lose control and go inverted soon after an engine fails. You are either current and competent with an EFATO, or you are not. This is no time to scratch your head and try to remember what should do.

I advise all twin pilots to sit in the aircraft on the ground and go through those initial actions, up to feathering, time and time again. You will be surprised how quickly, smoothly and safely you can do everything once your muscle memory gets used to it.

So, to recap, this guy failed to switch the fuel on and he failed to prepare for an engine failure.

If I had been a passenger I would have climbed out before the pilot opened the throttles for take-off.

When the left engine lost power at 250 feet, the aeroplane did two things on its own - it turned left - into the dead engine and it lost height rapidly. At this stage the pilot had the presence of mind to level the wings before it ploughed into a field and ran for 400 metres before taking the gear off in a ditch and hitting a lamp post.

According to the POH a lightly loaded Seneca will easily land and stop in less than 400 meters - even at that density altitude. This aircraft was very light - 1,146 pounds below gross.

The report says nothing about flaps being used for the landing, and the photographs show no signs that they were used. This is a hobby-horse of mine. If you are going to land, or crash, do so at the slowest possible speed. Even a small reduction in speed causes a massive decrease in damage. As the inertia varies with the square of the speed, using flaps can make any crash much more survivable. Either way, this guy should have retracted the gear before he was at 250 ft. And it was certainly down when he landed - so perhaps he wasn’t entirely a passenger. But that immediate left turn - into the dead engine, and the immediate loss of height are exactly what the aeroplane will do on its own if you do nothing. Or perhaps the new young pilot was simply doing the instinctive thing that any low hour, single or multi, pilot tends to do - turn immediately back to the field.

We don’t know whether the undercarriage was retracted after take-off, but it was found to be There used to be a rule with twins that said extended for the landing. This is worth a bit of never turn into the dead engine, but this is consideration. There are not strictly correct - all two schools of thought on when to retract the sit in the asymmetric turns should be gentle, and there is a strong undercarriage after takeoff in a light twin. aircraft on the tendency for turns into the dead engine to tighten up The first, suggests ground and go and cause a rapid loss of height if you are not careful. that you leave the undercarriage down until there is no more usable runway ahead. This through those initial actions I see that the CAA’s final comment was that the pilot’s workload had increased seems eminently sensible substantially, leaving him - if there’s a problem and you simply throttle with no other option than to execute a forced everything right back and land straight ahead landing. What absolute rubbish. If the aircraft on the runway. was flown properly it would have had a rate of climb, at that density altitude, of 300 ft/min The second school of thought says - if you and a single engine ceiling of 14,000 feet. have stacks of runway ahead it seems stupid to drag the aeroplane slowly into the sky NEWS FLASH. I’m sitting in a coffee house with the gear hanging out. It’s more energy in Wilderness enjoying the palm trees and a efficient to pull up the gear once you are cool breeze off the sea. As I try to tidy up this clear of the ground and have a positive rate article I have a Eureka moment - I have just of climb. You can now accelerate and gain found out why the aircraft crashed. Have a height rapidly. If there is an engine failure you close look at these two photos of Seneca fuel have the advantage of a clean aeroplane and selectors. The one with a hand in it is from plenty of height and airspeed. the accident aircraft. Spot the difference? The plastic label for the ON position has been I use the second option - not because I have broken off. Although the pilot should have any figures on it but - because it just feels been familiar with the forward for ON position, right. If an engine fails, I want it to be when he obviously wasn’t. He had a brain-fart, or the aircraft is clean, accelerating and climbing. possibly worse - a hangover - and simply I really don’t want it to happen when I have a didn’t have his mind on the job. The rest is bag of drag at low speed and low altitude. history.

What the signage should look like. However, the accident aircraft had the 'On' sign broken off.

WHAT CAN WE LEARN?

• A light twin is only slightly more difficult to handle than a single - until an engine fails. It then demands immediate and professional action. • Fuel selection in any aircraft is a life-ordeath thing - it calls for more than casual attention. • Expect an engine failure on EVERY take-off, in any aircraft, and brief yourself for it. • In any emergency the rule is Aviate,

Navigate, and Communicate, in that order.

Aviate means fly the aeroplane no matter what. Navigate means point it in the most intelligent direction. Communicate means tell someone who can help - but only if you have plenty of time. • A turn into the dead engine on a twin must be planned and gentle. • Full flap during any landing will give you a slower touchdown and make it more survivable. • Moving up to a multi calls for moving up in professionalism.j

DECEMBER 22 is summer’s longest day and the low cloud over Joburg looked like it was going to burn off quickly, confirming my take on the favourable weather forecast. Haagie pulled out DHI (our trusty old Super Cub) and I was airborne at 10:15 in my fully ballasted ASW27. The task was a 1000 km out and return to a point near Olifantshoek. The day developed quickly and I was soon on my way. The thermals only got strong near Vryburg and the last 100 km into the turnpoint was in the blue; quite nerve-racking as there were no outlanding opportunities for hundreds of kilometres over the scrublands. The interminable ride to the turnpoint into wind is always greeted with a sigh of relief as you turn downwind on the homeward run. At 15:30 I still had 500 km to go, yet I felt confident thanks to a decent tailwind and the promise of a 16,000 foot cloud-base in the distance.

A large storm had formed near Sannieshof and the anvil’s shadow produced shade extending all the way home. The air was very turbulent at the top and the lift was hard to centre, so I decided to head for an intense localised storm over Hartebeesfontein in the hope that there may be enough lift to give me a speedy ride home. As I got closer I recognised the tell-tale signs of dead air around the storm and eventually landed near Buckingham, to record 940 km for my efforts. If only I had dumped my water and flown straight, I am sure I would have gotten home. Lessons: From 16,000 feet (11,000 feet above ground), I had about 1½ hours of gliding time. I could easily have headed to patches of sun in the north to connect with areas of re-cycling lift, instead of wasting time flying 35 degrees off course to a place where the wind was obviously blowing away from the storm. I have often puzzled as to why the outflowing air never created a convergence away from the storm- perhaps it occurs much further away than we think. The turbulence near cloud-base was caused by lateral wind shears and I could have possibly worked them had I been empty, but who wants to discard the energy stored by taking your ballast to cloud-base?

Uncle Ivan was my crew and recognised my exhausted state after 8 hours in the cockpit. He insisted on driving my car and trailer home. Lessons: There are many, but the most sage was Ivan’s comment that the drive home is the most dangerous part of the trip.j

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