Checks
Are VITAL Actions
No matter how often you fly and
no matter how many times per day you operate your aircraft it is VITAL that
all checks are completed each and every time. A pilot taking off for his
ELEVENTH virtually identical flight of the day neglected to complete his pre
takeoff checks and paid for this oversight with his life.
The DHC-3
Turbo-Beaver is a single engine, high wing, tailwheel, STOL capable aircraft
powered by a Pratt & Whitney PT6A-34 turboprop engine replacing the
original P&W R-1340 Wasp piston engine. The Beaver was being flown by a
36 year old CPL who had a total of 932 hours with 27 hours on type. He had
flown 22 hours in the previous 28 days. The aim of the flight was to drop 8
parachutists from 12,000 feet above Headcorn Airfield.
There are two grass runways at Headcorn. The main runway is 11/29
which is 840m long by 30m wide. The secondary, unlicenced, runway is 21/03
and is 312m long.
The Accident
The pilot
completed 13 lifts without incident on the day before the accident. He had
completed five lifts from Runway 29 on the morning of the accident when the
surface wind freshened from the south and the pilot requested the use of the
shorter Runway 21. The air/ground operator refused this request because he
believed that the pilot had not been checked out to use this runway, as
required by the Headcorn Aerodrome Manual. The pilot approached a nominated
check pilot who agreed to observe his next flight. The check pilot briefed on
the procedures for the short runway, stressing the need to make an early
decision to abort the takeoff if that became necessary. The check pilot
observed that a thorough pre-takeoff check was completed using the full
checklist available in the cockpit. The subsequent flight from the short
runway was entirely satisfactory. A further five lifts were flown from Runway
21 without incident, although the check pilot commented that the climb
gradient on one flight appeared shallower than normal. He put this down to a
drop in the surface wind speed.
The accident occurred on the pilot’s
eleventh flight of the day. The aircraft taxied to Runway 21 and then
appeared to accelerate normally but the tailwheel never left the ground. The
experienced jump-master on board with seven other parachutists noticed that
the aircraft was passing the point on the runway where it would normally be
airborne. He heard the pilot shout “Abort”. Another parachutist
shouted to the other occupants “Brace – Brace, everyone on the
floor.” The Turbo-Beaver stopped abruptly when the left wing and
cockpit collided with a camouflaged North American F-100 Super Sabre static
exhibit parked outside a museum to the left of the southern edge of Runway
21.
The uninjured parachutists vacated the aircraft with mutual
assistance. The aerodrome fire service extinguished a small fire in the area
of the engine. The pilot remained unconscious in the cockpit. He was attended
by paramedics and taken to hospital where he died.
The AAIB Investigation
A meticulous investigation by the Air Accidents
Investigation Branch, Farnborough, looked at the wreckage in detail and
examined the wheel mark on the grass runway as well as downloading GPS
information from a unit recovered from the aircraft. The investigation noted
that the Turbo-Beaver checklist requires that flaps be set to
“Take-off” position for all take-offs but the flaps on the
accident aircraft had not been extended for the fatal take-off. The wheel
tracks showed that the tailwheel had been in heavy contact with the runway
for the latter part of the take-off run while the mainwheels were only
touching the grass intermittently until heavy braking was applied when the
decision was made to abort. This indicated that the pilot was trying to pull
the aircraft off the ground with the tailwheel still on the ground, and
continued to do so until he realised that the aircraft was not going to take
off.
The facts regarding this fatal accident are taken from AAIB Field
Investigation EW/C2007/03/03 which source is gratefully acknowledged. The
aircraft registration was OY-JRR. The complete accident report may be seen at
http://www.aaib.gov.uk
The following comments do not come from AAIB and do not seek to
represent the views of AAIB. The Beaver Flight Manual requires that the flaps
be set to 35 degrees for take off. When the flaps are lowered the ailerons
also droop. This configuration considerably alters the aerofoil section of
the wing and imparts the extra lift required during take off. The aircraft
design authority was unable to provide data for takeoff with flaps UP,
commenting that this configuration was outside the normal flight envelope. It
appears that the pilot forgot to lower the flaps to the required take-off
position prior to the last take-off. It also appears that he may have
continued to attempt to haul the aircraft into the air when the take-off was
not progressing normally. He did not abandon the take-off in time to stop the
aircraft before it struck the parked F-100.
The Diagnosis - Repetitive Brain
Syndrome?
It may be
instructive to look for reasons for the pilot’s failures. He was
engaged in a day long series of closely repeated short duration operations
involving a short take-off, a climb to height, a rapid descent to landing and
frequent repetitions of this profile. It is very easy to make a mistake, or
to miss a check item, in this situation. Frequent repetition of a profile
induces a mind-set where one is not really concentrating on the actions
required but is just going through the motions. A fairly common example of
this is when a trainee (or instructor) is flying a long sequence of visual
circuits in a retractable gear aircraft and is amazed to eventually arrive on
the runway with the gear up. When we have repeated something frequently over
a short duration our brains can suffer from a low arousal level – which
is psychobabble for our brains going into neutral. Think of someone
performing a small, repeated action while standing beside a production line.
You can bet they are unlikely to be concentrating fully on what they are
doing. I suspect that is the trap that caught the Beaver pilot. He was on his
eleventh sortie of the day. He had completed the take-off checks and lowered
take-off flaps ten times. He simply didn’t do this for the eleventh
flight. He was not highly experienced on type. He then fell into another
trap. It is vital to consider your eleventh take-off of the day with just as
much care as you dedicate to the first. He knew where his decision point was
on the runway but on the fatal flight something went wrong and the aircraft
was not performing normally. It is an understandable reaction in those
circumstances to make some attempt to resolve the problem. THIS IS
THE WRONG THING TO DO. He continued his futile attempt to haul the aircraft into
the air. If something is going wrong during the take-off then abort as soon
as you become aware of the problem, and certainly do not think about anything
other than stopping the aircraft once you have arrived at your decision point
on the runway.
Prevention is Better than Cure
If
something goes wrong before your decision point during take-off then STOP THE
AIRCRAFT
first. Think about the problem after you have come to a halt.
I have never flown a DHC-3 Beaver but I have flown the similarly
configured Pilatus Turbo-Porter in its military guise, as well as several
other STOL aircraft up to the size of the DHC-5D Buffalo and the Lockheed
C-130 Hercules (which CAN be STOL). STOL operations involve flying close to
the edges of the performance envelope. I believe that all STOL operations
require a detailed and structured training programme and specific type
training.
A useful Flight Safety thought passed to me by a wise old pilot is, “Learn
from the mistakes of others. You won’t live long enough to make them
all yourself.”
A
Few Thoughts for Flying Instructors
I have gained the impression, perhaps wrongly, that quite a
few club Flying Instructors feel antipathetic towards military instructors.
Maybe the apparent present day antipathy by the younger generation is towards
all things military. Old values like discipline, service, esprit de corps and
striving to be best seem to have little place in modern life. Whenever I
mention to younger people the possibility of joining one of the Armed
Services the reaction is usually, “Oh! I couldn’t be bothered
with the discipline and being told what to do.”
Recognising the prevalence of these feelings I still think it worth
printing an extract from Air Ministry Pamphlet 121 – published in March
1941. Below is an extract from Hints on Flying
Instructing. I believe the extract contains thoughts that are still
valid today, 67 years after it was first published.
“When
the Flying Instructor has been taught to fly accurately and to demonstrate
his actions with synchronised ‘patter’, only the foundation of
his profession has been provided for him. The most skilful pilot with the
most perfect patter can still make a bad instructor, and the average pilot
with good average patter can make an excellent instructor. The difference
being that the one almost disregards the characteristics and foibles of his
different pupils, while the other makes a constant study of his pupils in
order that he may get the best out of them.
“To his pupil the instructor is a demi-god. One well-known High
Court Judge always used to call his old headmaster ‘Sir’ with
profound respect, even when the judge was 60 years old and the headmaster was
85. In just the same way your pupils, we hope, will still regard you as the
best pilot and instructor they have ever known, even when they have flown
2,000 or more hours. Don’t for one moment let a knowledge of this
potential hero-worship go to your head, but by all means be worthy of its
simple faith.
“Already you may have heard it said that the pupil is the most
slavish copyist there is; and this is true not only for work in the air, but
for work on the ground as well.
“It is a highly interesting fact that causes of flying
accidents can be traced back to the original instructors of pilots. Some bad
flying habit has been copied by a pupil, acquired and been allowed to persist
in his flying until it has produced the inevitable result.
“If you are slack in manner and appearance then you will
inevitably breed a race of pilots, all your own, which tends to be slack in
manner and appearance. Although you may not realise it, everything you do and
say is mentally noted by your pupils, on duty and off duty. Your appearance
in uniform should be good. Nobody should be able to teach you anything about
punctuality. Move about as though you have a definite purpose in life.
Don’t run down ground training. Some of it is admittedly dull, and lots
of it may seem to you to smack of the kindergarten. Those in authority have
good reason to believe that it has high value however, so support their authority
and don’t undermine it. Don’t criticise superiors. Don’t
discuss your own pupils, or other instructors or superior officers, with
pupils. Along with priests and physicians you share a lot of confidences.
Respect them.”
Well, there it is. Archaic
claptrap or a few nuggets worth thing about? Only you can decide.
Text and Photographs © 2008 Gremline & Hill House
Publications, unless otherwise stated.
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