Misinterpreted Engine Situation

Similar documents
Turboprop Propulsion System Malfunction Recog i n titi ion on an d R d Response

ONE-ENGINE INOPERATIVE FLIGHT

AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY

LOFT A/B-90 SIM PRE/POST

Simulated engine failure during a check ride led to a loss of control.

causalfactors Despite several warnings, the Garuda 737 pilot stayed focused on landing.

Amateur-Built Aircraft Safety Record Brian Poole

(ii) Weight. Maximum gross weight for all tests, except where otherwise described in subparagraph (iii) below.

National Transportation Safety Board Aviation Accident Final Report

For the purposes of this guidance material the following definitions are used:

National Transportation Safety Board Aviation Accident Final Report

Ron Ridenour CFIG and SSF Trustee

Transportation Safety Board of Canada Daily Notification Log MODE: AIR HO Review Date: 2018/11/01

From London to Athens : how a fuel imbalance lead to control difficulty!

Introduction. Table of Contents. Chapter 1: Airplane General I. Airspeeds... 2

REPORT A-024/2012 DATA SUMMARY

IATA Air Carrier Self Audit Checklist Analysis Questionnaire

National Transportation Safety Board Aviation Accident Final Report

FNPT II MEP IFR STANDARD OPERATIONAL PROCEDURES

CAA MMEL POLICY ITEM: GEN-7

This page intentionally left blank.

National Transportation Safety Board Aviation Accident Final Report

National Transportation Safety Board Aviation Accident Final Report

Cessna Citation CE500 Series Training Course FOCUSED SINGLE PILOT EXEMPTION TRAINING PROGRAM

FINAL REPORT ON ACCIDENT

ISLAMIC RE-PUBLIC OF PAKISTAN OFFICE OF THE DIRECTOR GENERAL PAKISTAN CIVIL AVIATION AUTHORITY

Airmen s Academic Examination

This is the third of a series of Atlantic Sun Airways CAT A pilot procedures and checklists for our fleet. Use them with good judgment.

N7579P (PA24-250) Checklist

National Transportation Safety Board Aviation Accident Final Report

AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY

NEW FAA REPORTS THIS WEEK

IT S NOT ALL BAD NEWS

SAFETY HIGHLIGHTS CESSNA CITATION AOPA AIR SAFETY INSTITUTE 1 SAFETY HIGHLIGHTS CESSNA CITATION

March 2016 Safety Meeting

THE WEEKLY ACCIDENT UPDATE IS AN INDEPENDENT PRODUCT OF MASTERY FLIGHT TRAINING, INC. Update 2: 1/13/2016

F1 Rocket. Recurrent Training Program

Airmen s Academic Examination

Automation Dependency. Ensuring Robust Performance in Unexpected Situations Sunjoo Advani, IDT

National Transportation Safety Board Aviation Accident Final Report

REPORT IN-038/2010 DATA SUMMARY

A Human Factors Approach to Preventing Tail Strikes. Captain Vern Jeremica Senior Safety Pilot Boeing Commercial Airplanes May 2004

Recurrent Training & Checking Form

CoreLock. flightops. Investigators consider possibility of a condition that could prevent an in-flight restart.

TEACHING EMERGENCIES: Preparing Pilots For The Unthinkable and The Worst Using Scenario- Based Training

National Transportation Safety Board Aviation Accident Final Report

Valley Fliers 1402 Auburn Way North, #223 Auburn WA 98002

National Transportation Safety Board Aviation Accident Final Report

July 17, Mr. Joe Sedor Investigator in Charge National Transportation Safety Board 490 L'Enfant Plaza, SW Washington, DC 20594

National Transportation Safety Board Aviation Accident Final Report

Airmen s Academic Examination

CIVIL AVIATION AUTHORITY CZECH REPUBLIC

2) The maximum gross weight for your airplane is Ib. 3) The maximum takeoff weight for your airplane is Ib

National Transportation Safety Board Aviation Accident Final Report

FLIGHT REVIEW February 1, 2018

National Transportation Safety Board Aviation Accident Final Report

Federal Aviation Regulations (including accident reporting, TSA security and light sport)

National Transportation Safety Board Aviation Accident Final Report

Update to Airline Transport Pilot and Type Rating Airplane and Aircraft Dispatcher Practical Test Standards

Tire failure and systems damage on takeoff, Airbus A , G-JDFW, 10 July 1996

Launch and Recovery Procedures and Flight Maneuvers

HARD. Preventing. Nosegear Touchdowns

National Transportation Safety Board Aviation Accident Final Report

National Transportation Safety Board Aviation Accident Final Report

Tire debris disabled sensors, causing a Learjet 60 to accelerate during a high-speed rejected takeoff.

MANDATORY OCCURRENCE REPORTING

AIRCRAFT ACCIDENT REPORT OCCURRENCE NUMBER 03/1675 RAND KR-2 ZK-CSR 25 KM SOUTH WEST OF WOODBOURNE 8 JUNE 2003

AVIATION OCCURRENCE REPORT A98W0216 LOSS OF SEPARATION

National Transportation Safety Board Aviation Accident Final Report

Newcastle Airport. 36 years

This is the fifth of a series of Atlantic Sun Airways CAT B pilot procedures and checklists for our fleet. Use them with good judgment.

National Transportation Safety Board Aviation Accident Final Report

NEW FAA REPORTS THIS WEEK

AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY

Diamond Star DA40 Pre-Solo Written Exam

REPORT ACCIDENT. In-flight loss of control in a turbulent atmosphere, collision with vegetation, then the ground 1 - HISTORY OF FLIGHT

Flight Design CT-LSA Flight Training Supplement CTSW

National Transportation Safety Board Aviation Accident Final Report

F I N A L R E P O R T ON SERIOUS INCIDENT OF THE AIRCRAFT SR-20, REGISTRATION D-ELLT, WHICH OCCURED ON MAY , AT ZADAR AIRPORT

FACTUAL REPORT AVIATION

Indonesia AirAsia Flight Accident. Investigation

Nosewheel stuck 90, Airbus A320, N536JB, September 21, 2005

National Transportation Safety Board Aviation Accident Final Report

AVIATION OCCURRENCE REPORT FLIGHT INTO TERRAIN PIPER COMANCHE PA N6541P (USA) PELICAN NARROWS, SASKATCHEWAN 15 JUNE 1996 REPORT NUMBER A96C0092

National Transportation Safety Board Aviation Accident Final Report

National Transportation Safety Board - Aircraft Accident/Incident Database

Indiana State University Aerospace Technology

Piper Arrow PA 28 RT-201T (Turbo) - Checkout Sheet

AVIATION OCCURRENCE REPORT

AIRCRAFT ACCIDENT REPORT OCCURRENCE NUMBER 03/249 PIPER TOMAHAWK PA ZK-USA RAUMATI SOUTH 31 JANUARY 2003

National Transportation Safety Board Aviation Accident Final Report

FLIGHT LESSON RECORD

Investigation Report

BRIDGEWATER STATE UNIVERSITY PIPER SENECA PA

AVIATION INVESTIGATION REPORT A10Q0098 ENGINE PROBLEM - COLLISION WITH TERRAIN

National Transportation Safety Board Aviation Accident Final Report

RFC Dallas, Inc. AIRCRAFT QUESTIONNAIRE

National Transportation Safety Board Aviation Accident Final Report

601 XL SLSA FLIGHT TEST AUTHORIZATION THIS AIRCRAFT IS RELEASED FOR FLIGHT TEST

National Transportation Safety Board Aviation Accident Final Report

Transcription:

Misinterpreted Engine Situation Morrisville, NC December 13, 1994 Engine self-recovery light misinterpreted. Control lost on attempted goaround. Fatal crash. The aircraft crashed while executing an ILS approach into Raleigh-Durham. The captain misinterpreted a momentary ignition light to be an engine failure and did not crosscheck the other engine instruments. The aircraft stalled during attempted go-around from a single-engine approach even though the other engine was operating normally. The ground impact and post-crash fire destroyed the aircraft. There were 15 fatalities, including the 2 crewmembers. Thirteen additional passengers received serious injuries.

Attempted Single-Engine Go-Around with Propeller Unfeathered Schiphol, Netherlands April 4, 1994 Commuter flight. Attempted go-around below V MCA. 3 fatalities; 9 serious injuries. The pilot reduced power to flight idle on the right engine after observing a (false) low oil pressure light in cruise, and returned to Schiphol. The pilot did not feather the propeller. At an altitude of 45 ft, the crew determined the approach was not stabilized and declared a go-around. Airspeed was 110 kt, close to V MCA (103 kts). The pilot used aileron input to combat the airplane yaw; no rudder input was used. Airspeed dropped, and the airplane rolled and yawed to the right until it crashed.

Engine Stoppage during Takeoff due to Fuel Contamination Perris, California April 22, 1992 Sport parachute flight. Inappropriate pilot action following engine failure during takeoff. 16 fatalities; 4 serious injures. Accident scene picture The No. 2 engine stopped at or immediately following liftoff on the second flight of the day. Eight gallons of water had mistakenly been pumped into the airplane s forward fuel tank prior to the occurrence flight. The lowtime pilot did not correctly identify the malfunction and failed to fly the airplane. None of the occupants, other than those in the cockpit (pilot and passenger) were wearing seatbelts. A number of aircraft airworthiness issues were also identified during the on-scene accident investigation. The autofeather and beta back-up systems were inoperative at the time of takeoff, contrary to Minimum Equipment List dispatch requirements.

Valens, Ontario, Canada February 27, 1981 Fatal Training Accident Training flight. Struck ground. 2 fatalities; 1 seriously injured. sister aircraft The purpose of the flight was an instrument and proficiency check (IFC/PPC) on the left-seat pilot (PF) in VMC conditions. The check pilot was sitting in the right seat. Part of the check included a simulated overshoot at an altitude (greater than 3,000 ASL) with a simulated engine failure. Engine failures were simulated by shutting down the engine by pulling the fuel lever to the fully aft or to the OFF position. The PF was wearing instrument goggles, which simulated IMC conditions and also restricted visibility inside the cockpit. Therefore, the PF was not able to determine the manner in which the right engine was shut down. The third crew member reported seeing the right fuel lever in the OFF position upon feeling a yaw movement and observing that the right propeller was windmilling. Shortly after unusual cockpit activity, it became abnormally quiet, and the crew member observed that the left fuel lever was also in the OFF position. Approximately 600 ft AGL, the crew attempted a restart of the left engine by hitting the starter and placing the fuel lever in the fully forward or ON position. Time did not permit a complete start prior to the aircraft hitting the ground. A ground witness observed that right propeller was stopped and a stream of black smoke was coming from the left engine prior the aircraft striking the ground. The accident was not survivable for the front crew members. The flight deck was crushed back almost to the sloping bulkhead. The third crew member survived with serious injuries.

Birdstrike on Final Approach Schiphol, Netherlands July 15th, 1996 Bird ingestion on final approach. Crashed during attempted goaround. Accident scene picture Engines 1 and 2 ingested birds at the runway threshold. The #3 engine was shut down by the crew; engines 1 and 2 were no longer operating. The crew decided to initiate a go-around at 100 kts; this was below the goaround speed of 134 kts. The airplane yawed and rolled slowly to the left, and then departed controlled flight.

Forced Landing Baton Rouge, LA February 1, 1994 Dual engine propeller overspeed and shutdown. Forced landing, runway over-run. No injuries. During the descent, the airplane encountered turbulence. The DFDR shows that the power levers on both engines were then retarded to 15 degrees PLA, below flight idle. At this point, both propellers oversped, resulting in some power turbine damage. Since the engines were unable to produce torque, the pilot shut them both down and made an unpowered landing. The airplane overran the runway and sustained substantial damage.

Uncommanded Autofeather on Takeoff Bremen, Germany 1992 Aircraft performance issue due to inappropriate pilot action. Airplane landed uneventfully. Accident scene picture The airplane s No. 2 engine experienced an uncommanded autofeather immediately after liftoff, with takeoff power selected. The flight crew inappropriately reduced power on both engines, in contradiction to AFM procedures. The reduction in engine power deselected the autofeather system and unfeathered the No. 2 propeller. The crew inappropriately responded by reselecting takeoff power on the No. 1 engine, and attempted to climb with idle power on the No. 2 engine and a windmilling, unfeathered propeller. Aircraft performance was significantly reduced by the flight crew s action.

Birdstrike during Approach at V MO Broome, Australia May 17, 1996 Loss of directional control during single-engine landing. Airplane departed runway. No injuries. Accident scene picture The aircraft struck a 25-pound sea eagle during a V MO descent into Broome, Australia. Due to an erroneous engine indication, the flight crew elected to shut down the No. 1 engine. Upon selecting landing gear down, the left main landing gear indicated an unsafe condition. The crew failed to notify Broome of the engine shutdown, ignored the alternate landing gear indication system (which indicated that the left MLG was down and locked), and continued for over 30 minutes to discuss the landing gear issue with ground personnel. The flight crew ultimately elected to perform a low-altitude, low-energy single-engine flypast of the control tower to ascertain left MLG position. Aircraft performance was significantly reduced during the single-engine flypast. The airplane ultimately landed and departed the runway due to inappropriate use of single-engine reverse thrust and braking.