Charlie's Blog

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27
Mar

Cessna 177A fatal accident in Magaliesberg Mountains

Written by Athol Franz. Synopsis by Charlie Marais. on Thursday, 27 March 2014 09:01.

The South African Civil Aviation Authority (SA CAA) accident report, CA18/2/3/8950,released in January that was filed by KoketjoBabili, assisted by Musa Maseko, is disappointing due to the fact that no realistic reasons (other than the obvious) have been identified for this accident.

On 30 July 2011 a flight instructor, who held a valid Airline Transport Pilot licence and who was accompanied by a pilot under training, took off from Grand Central Airport (FAGC) on a 'patter' training flight (for his instructor’s rating).They also flew under the auspices of an aviation training organisation (ATO). After take-off from FAGC the pair flew to Brits aerodrome (FABS) where an uneventful landing occurred. They then took-off from FABS on the return flight to FAGC, but whilst low-level they impacted terrain en route. Both occupants were fatally injured and the aircraft was destroyed during the impact.

Theprobable cause was failure to maintain flying speed or safe flying altitude in the vicinity of the Magaliesberg Mountains (GPS co-ordinates: S25°41.770' E027°54.890') at 5 000 feet. At the time of the accident the weather indications indicated a surface wind of three knots at 130° and clear visibility with no clouds. The Cessna 177A, registration ZS-FPK,was owned by Aviation Outsourcing Services (Pty) Ltd and operated by Flight Training Services based at FAGC.

According to an eye witness, who was outside his house, he identified a small white and blue aircraft pass overhead flying low level. After a short time he heard a loud bang, which drew his attention and when he checked the mountain, he noticed a crashed aircraft in the valley up the mountain. He contacted the neighbourhood watch radio and reported the accident to them. The police and the emergency services were also notified. The witness then hiked up the mountain and reached the plane at approximately 10h45. On arrival at the scene he found that the aircraft was upside down and being a medical doctor, he assessed that the two occupants had perished in the accident. Upon arrival of the emergency personnel and police at the scene, he handed over to the police services. The aircraft was destroyed during the accident sequence, but it did not catch fire.

The 26 year old instructor pilot, with total flying time of 3 342 hours,also held a valid ATPL with no restrictions. Prior to the accident the aircraft was flying in a southerly direction at a low altitude. It appears that the aircraft impacted a tree with the left-hand wing before it impacted with the ground and flipped over. The onsite investigation revealed no anomalies with the control surfaces or control cables.

Both pilots held valid pilot licences and were rated on the aircraft type. Both held valid medical certificates. The aircraft was properly maintained and the flight was duly authorised by the ATO. Weather was not a contributory factor to the accident, which was failure to maintain flying speed or safe flying height.

OBSERVATIONS

All accidents are unacceptable and all fatal accidents are extremely sad. However, we must learn from our fellow aviators so as to show due respect to them as well as to our profession. In this case there was enough experience in flying, but how experienced on type or mountain flying,we do not know. As with accidents where the information is scarce, I will from time to time make assumptions. This means that I will not be able to make all deductions using deductive reasoning, but as the amount of information decreases, I will use inductive reasoning which for the sake of this exercise will serve towards training or teaching purposes. Bear in mind all the time that this is not an investigation and only an analyses to glean valuable pointers to fellow aviators and not to apportion blame in any way, either directly or by implication.

For the sake of this analyses I will assume that they both, especially the student, had relatively few hours on type. This you may think has very little impact as the candidates had sufficient hours to be considered as very well qualified and prestigious pilots. That may be so and as I have no information on other types they have flown I will assume that they both flew some turbine, especially the instructor student pilot with over 3000 hours. Being an ATPL, it also means that he probably spent most of this time in the controlled environment of a charter organisation with strict flight routes and performance calculation either clearly researched by the company, or by himself to satisfy the CAA Charter requirements. Many times, and I do not state this as a fact in this case, the candidate will take up instructors training to utilise his spare time in instruction and this would also mean that in the future he may even be appointed as a line instructor for the company. This is very good, as it givesGeneral Aviation (GA) the chance to get experience, other than circuit and ab-initio, into the training arena.

In this case the instructor was junior to the student instructor, not only just in hours, but also probably in company context. The 23 year old instructor had around 1500 hours with an ATPL and the student also an ATPL had over 3300 hours and was 26 years old. We do not know if they worked for the same company, but as far as aviators are concerned, we always respect the ones higher up on the aviation ladder than ourselves. This would have had an influence on the cockpit gradient. There is a great possibility that the sortie was flown in a very relaxed atmosphere and that formal instruction was not at the desired level.

Instruction sorties are supposed to be very formal and intense flying periods and there is seldom enough time for lengthy transits and other sightseeing. As low level flying is part of the syllabus, I may argue in this case that low level training was indeed planned for and the accident happened during the execution thereof. If this was so, it must reflect in the authorisation book. We have no record on what content the sortie was authorised for. So, let us for now agree that this was part of the sortie outline. Hence we could or should safely assume that the sortie was planned accordingly, although not in depth.

When one looks at the performance graphs and aircraft operating manual for the C177A, the picture becomes worrisome to say the least. When facing a mountain range with an aircraft, the very first question should be if the mountain’s required rate of climb (ROC) is higher than that of the aircraft's rate of climb performance. The ROC in turn is dependent on excess power. That is the power that is in excess after the power available has satisfied the requirement to produce the minimum Kinetic Energy (½pV2), or, in simplerterms, the speed required for the specific stage of flight. In this case the requirement at around 5000 feet above mean sea level (AMSL) depends on the climb performance required, such as maximum rate of climb or maximum angle of climb. In practice when facing a mountain and deciding to fly the valley or kloof without planning for such an event,the normal approach would be to fly at cruise power and then when starting the climb to utilise excess KE (speed)for the first part, exchanging this for Potential Energy (Height) until the climbing speed is reached. The pilot would then fly firstly at normal climbing speed and as the mountain starts outperforming the aircraft, now with full throttle, the speed would be bled until the stall occurs. Some would apply optimal flap, but in this case it seems that flaps were not selected. The Cardinal does not necessarily have a complex speed and flap combination for the required performance, but nevertheless it also is not straight forward. Maximum angle of climb is at 77 mph and no flap selected. The stalling speed in no flap configuration is given as 62 mph at 5000 feet AMSL. The stalling speed reduces as flaps are added and with 30° flap the stalling speed is 52 mph. The rate of climb at 5000 feet AMSL with no flap selected in a max rate climb is interpolated at 630 fpm taken that the weight was between 2500 and 2200 lbs (assumed). Not too bad for a small piston at around 5000 feet AMSL. The fact that they did not use flap was therefore according to the book, but as you run out of performance, the lowest impact speed becomes a requirement. For this they needed flaps to reduce the speed to around 52 mph before impact, as speedis what would cause death and destruction.

Let us just consider performance for a moment. Besides turbine engine performance I have never seen a piston perform to specifications. The percentage deterioration of performance is flight-hour related and although under normal flight conditions where the performance may vary without consequence, this is not the case when flying on the edge as it was required in this instance. This is where pilots must know their machine’s performance under specific weight and density altitude conditions. However, I guess the ROC could not have been more than a steady 400 feet per minute. If the mountain requires more, the inevitable must happen. I suspect that in this case the mountain outperformed the aircraft, which is mostly the case in such accidents.

They were flying with the wind and when flying up the valley, this should aid the rate of climb as the air is also in rising motion. There was little to no wind, resulting in minimal help. The effect of the sun on the mountain face would be another factor, but with the vegetation on their approach side, again little to no rising air to help. Neither the sun nor the wind provided sufficient assistance in this case.

The question now is why they did not attempt a turnaround? We have to think this one through. Turning around in the climbing attitude requires either a type of "stall turn" if the speed is very low; a "chandelle" if the speed higher and energy still available, or the old fashioned "wingover" through 180° and not the normal 90° to position for an aerobatic manoeuvre. To be able to utilise any of the three manoeuvres one requires basic aerobatic training. These are not the kind of manoeuvres you attempt for the first time without height below you as your height loss the first few times would be catastrophic.

When flying up a valley or kloof, there is a very specific method to ensure the possibility of a successful turnaround when required. To turn around is pre-planned manoeuvre to be executed either to the right or left. Should you for instance prefer turning about to the right, then there must be enough space to the right. This means you must fly up the left slope of the kloof and leave enough space for such a contingency. Secondly, there must be enough height, as a turnabout manoeuvre will result in a loss of height. Difficult to predict, but here we talk about 300 to 500 feet, depending on aircraft type, power and low speed flight performance, wind and temperature conditions and so on. The point is that you need height for starters. Then lastly the decision to opt out of the climb must be taken preferably in the planning session on the ground prior to flight. In the air you must already know and anticipate that as the aircraft is steadily running out of energy (that is speed as you cannot trade height for speed because the height is required for the turnaround), when to start the turnaround. Every second the manoeuvre is initiated too late, means that desperately needed energy to successfully get you out of the tight spot is lost for ever.

During helicopter mountain flying training we teach this and we also practice it. One nightaround 02h00,whilst flying the Rooivalk Attack helicopter, I was flying up the valley of a mountain at around 7500 feet AMSL. It was a night vision sortie, better known as NVG and the helicopter weight around 7.8 metric tons. I had a headwind up the valley which meant that should I require a turnaround, much more height would be forfeited as the turn would result in a tail wind and also descending air. The wind was around 10 knots. Although there would be enough power for such a manoeuvre I was in doubt as the wind played a major role in this particular scenario. I gave myself 600 feet "fudge factor" on the radar altimeter just for in case. The last 10% of the height required to clear the ridge was the problem and soon the speed reduced to below 50 knots. My decision speed was 40 knots and at around 45 knots I started the turnaround manoeuvre. As soon as the helicopter was turned around, the rate of descent increased dramatically and I realised that this is tighter than what I anticipated. I then increased the power to the emergency levels, lowered the nose slightly as I needed more flow over the disc. We fell out of the sky and as the speed slowly increased and much need translational lift so produced, I managed to ease the nose up out of the dive. Now with less than 50 feet between the rock face and the helicopter, with the radar altimeter audio screaming in my ears, I managed to regain full flight control again. Yes it was a close shave, added a few years to my life and many more grey hairs.

Low flying is at the heart of attack helicopter flying and as we prepared for the expansion of low level tactical flight envelope of the Rooivalk, such manoeuvres were called for. Even when trained, planned for and expected, the margins were still too tight for anyone’s liking, how more so when you are not trained for the manoeuvre?

RECOMMENDATIONS

Instruction, and as such instructors course,requires a seriousapproach and it should be a tough and highlydisciplined course. All aspects must be covered aerodynamically during the pure theoretical phase, followed by the short or air briefing that builds the bridge between the theoretical and practical flying phase. This is followed by the patter flight phasewhere exposure hones the motorised and cognitive skills towards the finer art of assessment and debriefing. This should all be towards passing on the profession where the quality of our future pilots is decided. Be professional.

Sortie sequences must be planned. Planning is where any shortcomings in knowledge and skills are revealed. Without planning you simply would not have enough knowledge concerning what to expect during the execution of the sortie. This leads to surprises and as we know there are many cases during the dynamics of the sortie where there simply is little or no time to contemplate the complexity of the situation and formulate a reasonable course of action. Yes, I know you think you can think on your feet, but when you are in your office a little hesitation or mistake will seldom have disastrous effects. In the air,however, this is a luxury we cannot entertain. Plan.

I once flew jump-seat with two Captains in a Boeing 727. They were both Captains and when they changed command during the various flight legs, they always resorted to assume the role they then occupied. The acting co-pilot would always call the Capt so and the Capt would then call the co-pilot by his name. As they changed roles it sounded weird to say the least, but there was no guessing at any given time of the flightas to who the Captwas. Flight discipline was kept in strict airline protocol. Cockpit gradient is not a myth, it is real and especially during a training sortie we must learn to act our part. The mood and the mind of the cockpit is a very delicate climate and when you are senior, give the junior who is to be in charge the scope to carry out his work according to the strict discipline we expect from airline operators. It should be more so when we fly in the non-protected and little-oversight environment of GA. Fulfil your role.

'Spur of the moment' is not cool. Aviators must learn that when anything is perceived to be nice, it must be tested for right. Your emotions as seated in the part of the brain called the Amygdala, which will always react ahead of your Neo-Cortex, the thinking part of the brain. This is good when we need to react to danger, but when you get that feeling of excitement and you need to test your skills against the elements; you must measure against SOP’s and rationality. Think.

Mountain flying is an art that must be taught, planned and carefully assed during task performance. I have said this before, but here it is again; "low cloud, poor visibility, mountainous terrain and aircraft do not mix, theymash." Okay, in this case there was no cloud, but the mountains as a rule do not mix well with aircraft. Please understand that mountains are like wires and power lines, they are aircraft death traps. Respect the unknown and untrained.

Then I would like you to understand that flying high performance aircraft as a job and then expecting the same performance from the little ones is also way outside reality. Be extremely careful as you could subconsciously manoeuvre or expect performance due to your day job. As you become accustomed to the turbine,multi-engine world and high performance airliners, so the dangers of GA and its low performance aircraft becomea trap. Piston performance graphs are a best initial attempt, after that it deteriorates and we must compensate for this. Pay respect to the little ones, they kill.

Always leave yourself with a back door. To paint yourself into a corner on the ground is not always so bad, you can wait for the paint to dry, but in the dynamic environment of flying, the time to wait or think it through is simply not there. Anticipate.

In this case an innocent sortie ended up in a devastating tragedy. In South Africa we have beautiful mountain ranges and many of them look innocent, attractive and inviting. But let us get real for a change; just count the accidents where mountains have claimed lives. To date, mountains have been our biggest body claimer. If every pilot could just reflect on this for a moment and then do what is right, and not merely what is perceived as nice.Reflect.

Professionals think and plan, and then they execute the plan. As they say - "Failure to plan is planning to fail".

What is your plan?

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16
Jan

Brownout

Written by Charlie Marais on Thursday, 16 January 2014 10:44.

It is not that man has no respect for the machine; it is rather that the machine has no respect for man. For that matter so also the environment. When I ask what respect is, or how respect is shown, many answers will come forth, but the only truth is that it is man alone that can show respect. In the animal kingdom we will see respect towards other creatures andthe environment, but we are not discussing animal behaviour right now. In fact maybe we can learn from the animal kingdom; survival has a lot to do with respect, but again the environment shows no respect to man or beast.

Man must show respect. Before we can show anything or anyone respect, we first need to know the hazard or ramifications of non-respectful behaviour. Although we have certain instincts, most of our reasoning to show respect is taught from birth. I am convinced that it is not only during the formative years that we learn the rules of the game, but life itself is one continuum of cause and effect. Negative effect teaches us respect. Or at least, it should.

Before we interface with machine and environment, we show ourselves respect through proper knowledge and skills honed to useful effectiveness for the specific set of conditions. Applying the rules of the game is paramount. To elaborate, the rules of engagement are as such the key to respectfully interfacing with our machine while utilising it in a given environment.

Just a reminder, the difference between an error and a transgression is the possession of knowledge and skills pertaining to the specific task and task environment at hand. Only the wilful neglect of the application of knowledge and skills will lead to a transgression and inevitably, according to the law, will lead to punitive ramifications. The lowest form of knowing is not to know what you do not know. So, if you did not know, or you did not have the knowledge and skills to face the situation, you cannot, or should not attract punishment.

Let me clarify this statement; if you knew that you do not know, but still persist, you are committing a crime.When you do not know what you ought to know, then there is an excuse, but although man may pardon you, machine and environment will not reason with you.

The helicopter job environment is as vast as the fixed wing crafts, but as most take-offs and landings could be from and to unprepared surfaces, the three dimensional environment poses untold more risks.

Dust and snow landings are in many cases similar, but seeing that we have little snow, we will concentrate on dust. The so-called Brownout conditions are mainly encountered during the landing at the destination, followed by a take-off from that same location. Many factors must be taken into consideration such as; wind direction, size of the landing zone (LZ), surface slope, surface condition in terms of material ranging from rocks and boulders to soil in powder form and any loose article that can be blown up that can recirculate into the main rotor blades and so on.

Once the surface condition has been determined the approach and landing must be planned. The undershoot area becomes very important as that would determine the angle of the approach. The higher the undershoot obstacles, the steeper the approach.

Plan B is normally identified but not planned prior to attempting plan A. If plan A does not work out, there must be an escape route or escape plan. The escape plan will consist of when and how to break off the approach, the subsequent escape route and cockpit actions such as power application and referencingmust be discussed. The overshoot area, or break-off area now becomes crucial. Only if the escape and abandonment of plan A has been activated and accomplished, plan B will take all the planning, again with an escape plan. Typically in suspected Brownout condition approaches, the escape will entail going onto instruments as outside referencesare normally totally lost. Note that the decision of go or no-go is always taken in advance and activated as a rote response when certain predetermined conditions develop. The thinking is done in advance and not when in the corner.

Water as a dust settler is only effective if the soil is penetrated to a significant depth. One squirt will never do it. The helicopter in question weighed between 3 and 3.5 metric ton. This means that the rotor wash needs to displace sufficient air to decelerate and land this mass. This helicopter had sufficient power, but when one cannot see and the escape is no longer an option, you find yourself inside a blind confined nightmare.

In this case the pilots discussed the situation and had a plan B identified. I am not sure if the Captain beforehand decided on when and how to break off the approach, but it is clear that all of a sudden, they were unexpectedly caught inside a dust storm. I am sure that he and the passenger pilot in the other seat thought that the precautions taken were enough. According to the definition it was therefore an error and not a transgression, however, the environment did not find mitigation circumstances. The environmental judgement was quick and final.

One such an accident many years ago happened in Oshakati. The “bush War” was in the beginning years and flying in Northern Namibia, then still call South West Africa, consisted most of the time in desert sand to powder dust conditions. The only way to get on the ground in such conditions was called an “assault” landing. You would pick your spot, approached with a 10° nose up position in the Puma, and tried to land with a very slight forward speed maintaining the 10° nose up attitude on the AH till touch down, just enough to roll on for about half a meter to one meter. With the rear wheels on the ground the nose wheel was only lowered to the ground when the helicopter came to a stop. By that time the helicopter would be engulfed in a cloud of dust.

The techniques was taught, practiced and religiously applied. That was until this specific crew, both brand new in these conditions was tasked to take some people to Oshakati. The pad was made of cement and around six meters by three meters. The area around the pad was powder dust from all the vehicle and people movement. On entering the hover over the pad, the Puma was engulfed and the Commander (Captain) lost situational awareness. As the helicopter normally hovered slightly nose up attitude, the sensation when losing visual clues is that the helicopter is drifting rearwards. He continued pushing the nose forward and the resultant accident saw many lives lost.

As this pad was used quite a lot, we had asked numerous occasions that the surrounding area be settled with old vehicle oil. Oil is heavy and binds the soil, making it heavy enough not to blow up. Again, saturation is required. It was not done.

To my horror I also realised that the commander and the co-pilot had no previous experience in this kind of environment and their induction did not include training for the conditions. Crews came and went and we all expected everyone, at least the commanders, to be fully trained and capable of managing these conditions. The induction into flying in these conditions was quickly adapted, but someone had to pay the penalty.

RECOMMENDATIONS

Note that the recommendations are not focused on this particular accident. It is to sensitise those who perhaps do not know or those that need to know.

We must always respect those that learned the hard way by learning from them so that cause and effect is understood and properly negotiated.

Firstly we must be very aware that when we are fully aware or not remotely aware of the dangers during man, machine and medium interface, whether an error or a transgression, the end results is always without prejudice or favour. Always be educated to the end result of any interface.

Only through proper planning can you determine that which you actually do not know, are not capable of or not recent on. Always find out what you do not know and then take action to know. Note that it is invariably not possible for man to know what he does not know if he is not externally made aware of the lack of knowledge. Planning and consultation is such external eye openers.

Always have an escape route and actions planned prior to commencement with any approach.

Always make the decision when to break off before commencing with the approach.

When the conditions decided on for break-off realises, take action without reasoning further. All attention must shift to accommodate the break-off.

There are three basic approaches that can be used, depending if the helicopter have suitable skids or wheels. Such as:

  • High undershoot or high overshoot obstacles can make a flat approach or a break off during a constant path approach not possible hence the following method. One must get into a high hover (50 to 100 feet) over the LZ and then to slowly descend to ascertain the dust behaviour. A tower climb can then be used for an escape if required. Naturally enough out of ground effect hover-power plus a component of power for vertical climb is required, making power calculation and management extremely important. This approach will never be used in a clear flat area of operation, but only where a lot of obstacles prevail. Our game pilots will encounter dust many times and they must be aware on how to assess the situation, how to "test the water" and then how to escape when things go wrong.
  • When the undershoot area is clear a roll-on or skid-on low and flat approach can be used. On a dust runway for instance, a helicopter with wheels will attempt to touch down when the dust reaches the rear of the cockpit door. This means a very low height, ever decreasing speed depending on the dust severity, but for example say around 10 knots the dust would have crept up to the cockpit. The chopper is then landed. With wheels at the same attitude, with skids first level the platform and then land. An overshoot when already in the dust is extremely difficult and normally requires two crew. No two would then already be on instruments, the flying pilot declares that he has lost it; the other pilot then becomes the flying pilot by acknowledging that he has control. An instrument fly away is then done. The overshoot obstacles will determine the profile which will either be a 40 knots climb or a vertical tower climb.For single pilot operations this one becomes very difficult and good Instrument Flight recency may make the day.
  • The third one is the constant path approach with a zero/zero touchdown. This means you start off at around 200 feet above ground, when clear of the obstacle, enter into a constant path descent, maximum 300 feet ROD, as height decreases speed is decreased and the helicopter is never stopped until the touchdown at zero height and zero speed. This kind of approach is mainly used for multi-engine helicopter so that the approach may continue even if one engine fails. This is possible as the power required during the descent is lesser than for the other approaches. Oil rigs and heli deck landings normally consist of this kind of approach. Good for the smaller ones flying into stadiums and so an as well, but again, this is a taught and practised manoeuvre, to attempt this by yourself for the first time in adverse conditions may result in pain.

Please, do not attempt any of these methods described if you have not had proper training by a knowledgeable and capable instructor. My descriptions above are not complete in detail as writing space is limited.

I mention these so that helicopter pilots know that these methods exist and that without proper training, practicing under controlled conditions with a qualified safety pilot, being sharpened up in knowledge and skills prior to any job containing such conditions and good planning with advance escape planning done, gives you the best chance of task success.

Never assume that Captains are qualified in all aspects of helicopter applications. My ATPL does not make me capable of vertical reference cargo sling work, live wire work for Eskom or ship operations.

Always remember that in the comfort of reading this comment lays some general truths. It remains your decision on how you will apply them in preparing yourself.

Respect yourself by proper training, proper planning and honest application of the rules, you owe it to yourself.

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18
Nov

Beechcraft Baron controlled flight into terrain

Written by Athol Franz. Synopsis by Charlie Marais. on Monday, 18 November 2013 09:43.

On Saturday 28 January 2012, the pilot and owner of ZS-TVT delivered his aircraft at an Aircraft Maintenance Organization (AMO) at Port Elizabeth International Airport (FAPE) for a regular Mandatory Periodic Inspection (MPI). The AMO commenced with the MPI inspection on 31 January 2012 and released the aircraft to service on 16 February 2012. The aircraft was parked at the AMO’s hangar between 16 February 2012 and 17 April 2012. On 17 April 2012, the pilot arrived at FAPE to fetch his aircraft. This was to be the first flight after the MPI was completed two months earlier.

According to the AMO on 17 April 2012 a normal inspection and ground run were conducted during the presence of the owner/pilot and the aircraft was handed over to him for the flight back to Cape Town. The pilot accepted the aircraft and commenced with the thorough pre-flight inspection before the flight to Cape Town. It appeared that the pilot was happy and he filed a Visual Flight Rules (VFR) flight plan with the FAPE control tower. The flight plan was activated and the aircraft taxied to the runway 26 holding point where the run up checks were carried out. The pilot was cleared for take-off and requested to keep an altitude of 2000 feet above mean sea level (AMSL) and report at Sea View.

According to the air traffic controller who was communicating with the pilot before departure he appeared to be unsure of the location of Sea View, but after some explanation he understood and departed. Take-off and climb out was uneventful. Once ZS-TVT was airborne the approach controller was advised that ZS-TVT was routing towards the right side of the intended track. At 12h17 the approach controller established contact with ZS-TVT and advised him to remain at 2000 feet AMSL or below and standby for further climb. There was IFR traffic overhead ZS-TVT and the controller was waiting for the aircraft to be clear before further climb. The controller cleared the conflicting IFR traffic to descend to 3000 feet.

The controller observed TVT climbing to 2200feet and then 2600feet, still routing towardsthe right side of his intended track. ZS-TVT was advised to remain at 2000feet. The pilot apologised and slowly descended to 2400feet. He then requested to descend to 1000feet without indicating why. His request wasgranted. At 12h21 the controller observed ZS-TVT making a sharp turn to the right before the aircraft disappeared off the radar. The controller attempted to establish contact with the pilot, but there was no response. According to the controller due to the nature ofZS-TVT’s flight path he assumed that the aircraft may have experienced technical problems and landed at Progress airfield. The controller contactedProgress flight school asking whether ZS-TVT has not landed at their airfield andthe answer was negative.

The controller informed the airport pool manager and they started the initial phase of Search and Rescue. At this time, Progress flight school aircraft, call sign, ZSKHOwas in the air on a training flight and its pilot was requested to overfly thesurrounding area to see if they could see anything. They saw aircraft debrisscattered all over the area and was confirmed to be ZS-TVT aircraft. There was nodistress call made by ZS-TVT pilot and the aircraft crashed on a private farm nearthe Draaifontein road, approximately 24 kilometres North West of Port ElizabethInternational Airport. The South African Police Services (SAPS) and the localEmergency Medical Services (EMS) were notified and immediately drove to theaccident site. The aircraft was found to have been destroyed by impact during theaccident sequence and the pilot was fatally injured.

A witness, who is also a pilot, saw the aircraft flying overhead Progress airfieldrouting in the westerly direction at an altitude of approximately 2000feet AMSL. Hestated that he observed the aircraft taking a gradual bank to the left into a cloud.Immediately after the aircraft entered the cloud, the witness heard a high pitched noiseas if the engines were accelerating. A few moments later the witness heard animpact sound as the aircraft impacted the groundat an elevation of 594 feet above meansea level.

Wreckage and Impact Information
The accident site was a livestock grazing field on a private farm and the aircraft impacted blue gum trees before hitting the ground. It would seem like the aircraft impacted the ground at a very high speedand steep attitude. The is evidenced by the fact the initial impact with the ground iswhere one engine was found one metre underground and the second engine wasfound on top of the buried engine. The remainder of the wreckage was scattered over an area the size of a soccer field.

The wreckage distribution was a straight line trail that extended to approximately100 metres from the initial impact point. All control surfaces were accounted for atthe accident site. The cockpit/cabin area was destroyed and all instruments weredestroyed. All flight controls were destroyed by the impact forces and flight controlcable continuity and pre-impact control integrity could not be established. Both fueltanks ruptured during the accident sequence and there was no fuel available foranalysis. Theundercarriage was destroyed after impact. The extent of the damage to the aircraft and wreckage distribution revealed that theaircraft had struck the ground at high speed in a nose down attitude.

Post mortem results revealed that the pilot died as a result of multiple injuries associated with the accident. The pilot’s medical had expired.On-site inspection of the wreckage revealed that all of the structural damages wereconsistent with the impact at high speed in a nose down attitude and nothing wasfound to suggest that there had been any pre-impact failure of the primary structure.

Aircraft engines, serial numbers, 684414 and 684423 were recovered and taken toan approved engine overhaul facility based at Wonderboom (FAWB) aerodrome,Pretoria for further examination and analysis. Before that all relevant aircraftdocumentation e.g. Certificate of Registration (C of R), Certificate of Airworthiness(C of A), Radio Station Licence, Mass and Balance Certificate were inspected andwere found to be valid in accordance with requirements of applicable regulation.

The aircraft maintenance documentation such as airframe logbooks, engineslogbooks and work packages were obtained from the AMO and inspected and all maintenance entries made in thelogbooks were appropriately certified in terms of applicable regulations. A completeengine teardown inspection was conducted in the presence of a SA CAA accidentinvestigating team. It was found that all noted damage on both engines wasconsistent with that of accident damage. Disassembly and examination of bothengines revealed no evidence of any internal mechanical malfunction orcatastrophic failure. There was no evidence of detonation, piston/combustionchamber melting or oil starvation. Both engines’ ignition system components,including the magnetos, the spark plugs and the ignition harnesses were severelydamaged and could not be tested.

Probable Cause
The pilot appeared to have entered instrument meteorological conditions (IMC) andin an attempt to remain VFR, he failed to maintain adequate terrain clearanceresulting in the aircraft colliding with the ground.


ANALYSES BY CHARLIE MARAIS

When it comes to losing control of an aircraft it always seems that the pilot has not been paying enough attention to the correct things that would prevent precipitation of such an event.

Before I get into the accident purse, I would first like to do some observations and possible analyses to the factual information.

Firstly it is amazing how the past flying experiences of the pilots are just not available. This is normally very important to make some kind of judgement of currency, or then the recent exposure the pilot had to similar flying conditions. Pilots may fly one hour Instrument Flying prior to the next Instrument Commercial Test and that would be sufficient to ensure a revalidated licence depending on obviously passing the test. They normally do. Does this make you current? Legal yes, but capable? I believe not at all. At least not when it comes to the real thing.

Flying hours is not something to brag with or throw around to impress the ladies. Different flying hours will have different qualities to it. One hour on the autopilot, observing the machines compliance to a set requirement during an ILS, is not the same story as flying a Knife Edge at an air show, or for that matter flying 10 feet above the ground trying to understand the flying lesson a Tsetsibi (a buck species) is busy teaching you.

To have an Instrument rating and not be current and well-rehearsed in the procedures may be one thing, but another would be to fly without auto-pilot or auto-assistance. Show me an Instrument Landing Approach (ILS) assisted by a good auto-pilot such as found in the more sophisticated aircraft and I will show you how one and all struggles to do a CAT I approach without any assistance. We must get real about this; instrument flying is a tough business.

I will never forget the first time I was briefed about this. "If not competent you will lose the aircraft within the first 20 seconds!" What? Is this all the time we have? If this is true then if not trained and not current and very capable, the first few seconds could leave me alive, but theoretically dead until the inevitability of terrain strike.

There is some reading this that actually had the good luck, note not good skill, but luck, to get out. Yes that happens from time to time, but believe me, you were only lucky and should confess this like a man.

Let me say this; to get into an instrument flight situation inadvertently, is not only very surprising, but leads to many different reactions from different pilots.

I have been there. On the climb out to 16500 feet to drop parachutes from an Angel, old Kudu with turbine engine, I became entangled in setting the GPS, listening to the jump master, negotiating traffic entering the immediate area and receiving instructions from Johannesburg Central. There were lots of clouds around, around five eights, with vertical development between 2000 and 10 000 feet above ground. When I all of a sudden out of the corner of my eye I noticed the very pertinent colour grey, I knew I was in the cloud. Not 50 shades of grey guys, just grey! “Attitude, bank, DI, Attitude Bank VSI……”, and so on. I started scanning out loud. My mind was not listening to all the other interfering factors, I knew that with the instruments, a non-instrument rated aircraft and just old fashioned scans drilled into me, I must get into the clear.

I turned left through 90 degrees and hoped to exit, then to the right. During the steady turns I got the absolute sensation that I was flying straight and level, but the instruments did not confirm this. I fought the urge to follow my feelings and followed the instruments in great anticipation and with great effort. I eventually popped out at around 15 000 feet. I did the drop, landed and then faced myself with great honesty in the mirror.

Asshole was all that came to mind. Sorry ladies and sensitive readers, but how else do I describe such a foolish act?

I am current, recent and all the things when it comes to Instrument Flying. It is part of my job to teach and assess these phases of flight. The sheer realisation that I entered into cloud unplanned, unintentional, unprepared and totally by surprise, gave me a very real shock. It took a lot of discipline and I would dare to venture skill, which was thankfully engraved in me, to regain my composure and get out of trouble.

I will not for one moment pretend that there are none better than me, in fact, there are many, but entering into Instrument Conditions by surprise is a surprise that has killed many. There is no immunity clause you can sign.

A few other issues come to mind. A qualified IR pilot aged 57 with only around 736 hours? Sounds like this was not his day job.Coupled to this the aircraft was on the ground over two months. I do not know if he flew in those two months, probably not, but not the baron 58 in question. Therefore the question to recency, currency and all those fancy words that only describe if you are freshly mortised skills competentis very much relevant. If flying is then so much more difficult and so much more complex and so much more cognitively challenging, why is it that we treat it as a weekend or seasonal sport?

In April we get the aeroplane out to take the family to the sea, and then only in December we repeat this. We fly our family twice a year, nothing in between, and we confess that flying is more complex than driving a car. We never fly Instrument Flying and try our best to avoid it, yet when challenged we take to it without a second thought.

In this case it is very evident that the pilot expressed his opinion that he would like to stay clear of cloud. He expressed asked to remain right of track as he would have liked to stay clear of cloud. The met report stated scattered (3 to 4 Octas) and Broken (5 to 7 Octas) cloud. The cloud base veried, but it is clear from the tower tapes that the pilot wanted to stay clear of clouds.

I believe he was distracted due to flying, dodging clouds, adhering to heights and ATC instructions and so on. I then believe that he inadvertently and unintentionally found himself in the cloud.

None of the above is to blame, we as pilots just seem to be like normal people and when the attention is scattered, a slip may occur. I believe in this case the pilot was all aa sudden daced with the constant colour of grey.

The very natural thing that pilots do, and they most of the cases do it and they die in most of the cases, is to get back to where it was clear as quickly as possible. This leads to hard manoeuvring to go back to where we are comfortable and plainly, where we can see. Very natural and instinctive behaviour from us pilots. In this case I believe the pilot did the same.

Now we must bank hard to turn about, height maintenance becomes an immediate problem and power is normally induced to somehow correct what is happening. The result is a steep bank angle, probably running over Vne and with too little sky beneath the cloud to recover, the accident is brutal and final.

RECOMMENDATIONS

Firstly I would like qall of us for just one momemt to reflect on our status as pilots. Not comparing it to others, just to what is actually required and where do we stand. Am I capable to handle the situation? Am I recent and current and legal.

A lapsed medical do not cause any accidents, or at least I have not encountered that one. What is true though is that when the licence is not valid due to a lapsed medical or flight test or for whatever reason, the insurance of the aircraft and the personal insurance of the pilot will not pay out. Your passenger’s families will (not might), sue your estate leaving your family, already devastated because of losing you, penniless.

If you enter to where you are not allowed to such as in weather, night, mountains and so on, you are tempting fate irresponsibly. We all believe that it will never happen to us. We are all wrong. The only truth is that in a world of adversities, only the competent and disciplined will survive, or at least have the chance.

When unintentionally entering cloud he following is some good advice:

  1. When there are clouds about and you must stay clear due to any reason, beware of being distracted and by surprise find you in an area where you really did not what to be.
  2. The first thing when in a cloud is to stabilise the aircraft or helicopter. Straight and level controlled flight, if there are no mountains, must be achieved. Without this there is no second step. Get control by applying the scan you were taught. It not taught, get taught.
  3. If in mountainous terrain the level part must become a climb at 500 feet per minute. Naturally these depend on the rate of climb of the mountain, but get control in the pitch as well as the roll.
  4. Once initial control has been established and the adrenaline subsided to a level where your cognitive abilities return, go to the next step of turning about. This must be a level turn, or if terrain does not allow, a controlled climbing turn. A level turn is always advisable rather than climbing or descending, but circumstances may dictate.
  5. The reverse course must now once again be stabilised before a descend or a climb is attempted.
  6. The last step would be a controlled descend or further climb depending on the situation.

It would be irresponsible to give times and distances in the above, I merely need one to understand that every move must be started from a stable and controlled position. Yes I have procedures I can teach low flying helicopters inclusive of times, but there are so many variables that to fix time to any of the above would be untrue.

I am convinced that our pilot in this case wanted to stay clear of cloud, but was surprised to find himself inside the grey. This reasons that for starters we must all take a step back and always plan and pay attention to the unwanted reality of ending up in the grey.

Whether we intentionally or unintentionally end up inside a situation where we really did not want to be, the end result is normally the same.

To honour those pilots that departed, we must learn from their experiences, mistakes and sometimes just vey unlucky situations.

The greatest honour is to learn from them and then to apply that which we have learned, that is called self-respect.

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11
Jun

A REAL VIRTUAL(ity)

Written by Charlie Marais on Tuesday, 11 June 2013 11:57.

Johan turned onto heading 330 at three Nm after take-off from Cape Town International to intercept the CTV 354 radial adhering to the OKTED1A Standard Instrument Departure (SID).

After this interception, at 8 Nm, he turned on a heading of 060 to intercept RIV outbound on a radial of 090 degrees.

Everything has gone according to plan so far and although he is slightly tense, as concentration levels are high, I notice that his shoulders are drooping slightly as he starts to relax, as he was clearly flying on the numbers.

At first, he does not notice the left alternator annunciator light lighting up as his attention is fully on the instrument scan. The autopilot is not selected. After approximately thirty seconds he notices the light and immediately scans the Ammeter just to confirm that it is not charging. At that exact moment the left engine fails without warning.

The pronounced left yaw was a tell-tale sign and immediately his attention shifts from the alternator problem to the much more complex problem of the engine cut. Johan sorts it out in no time and contacts Cape Town informing them of the emergency and requests vectors back to CTV, planning for a procedure turn onto the ILS runway 01.

He can now see the front coming in and he elects to select the help of the auto-pilot. He then asks Cape Town for vectors onto the ILS onto runway 01. This is granted and as he enters the frontal system, the visibility quickly becomes zero. He is informed that the visibility on the ground has deteriorated to around 500 meters and that the cloud base is 500 feet AGL.

The autopilot cooperates, but mysteriously disengages just as he is intercepting the localiser. His knuckles become slightly whiter and I can see that his concentration levels have now peaked. With a single engine, very poor weather and no autopilot to help, the situation couldn’t possibly get any worse.

Maintaining the localiser and glide slope proves to be extremely hard work and finally the lead-in lights become visible just to the left of the aircraft nose.   As he intercepts the centre line of runway 01, there is a very loud bang as massive birds pound the cockpit, cracking the glass and the remaining engine fails.

With a multi-engine reduced to a super brick glider, Johan struggles to regain control and negotiate the landing. There is no first prize for the landing, but we are safely on the ground. As we come to a stop, he turns to me and says, “sh*t”.

The new FNPT II simulator as built by Simu Flight has performed yet another CPL annual Instrument and General Flying licence revalidation test. This simulation of reality was quite extreme, but then again I was not merely testing the candidate’s ability to fly. Nearly all pilots can fly, but the procedures and emergency decision-making is tested for realities that could not be simulated in real flight, let alone safely.

Westline Aviation, with its fourteen aircraft and three helicopters, does a lot of training. However, my work as DFE has suddenly become more fruitful as testing under IF conditions and Instructor Rating renewals are elevated to the next level.

Westline has expanded over the last eight years to accommodate local as well as international students. With accommodation, housing (same thing??) and personal attention for students struggling with ground subjects, Westline has built a reputation for going that extra mile.

The flying school offers PPL to ATPL, Single to Multi-Engine as well as Basic to Advanced helicopter flying. We also offer specialised training such as: Mountain Flying, Game Ratings, operational command and control, vehicle following, tactical navigations, formation flying as well as helicopter and aircraft turbine ratings.

I regularly lecture on Flight Safety and perform testing as a DFE Aeroplane and Helicopter. Normally in January of each year I also present the fully fledged Aircraft Accident Investigation Course over a four week period in Pretoria for the SAAF.

Fuel supply, fuel distribution and fuel placing are to name but a few of the extra services rendered at Westline. When you visit Tempe Airport, you will meet the friendly staff of Westline, with coffee and burgers on order. And with landing fees at half the normal rate, competitively priced fuel and no passenger tax, where else would you choose to stop on your way across South Africa?

Westline Aviation, where we help your flight dreams become a reality!

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07
May

Cessna 206 CFIT into the Magaliesberg Mountains

Written by Athol Franz. Synopsis by Charlie Marais. on Tuesday, 07 May 2013 11:52.

What should have been a routine flight to reposition a relatively new Cessna 206, from Krugersdorp airfield to Wonderboom airport for the purposes of a 50 hour oil change, resulted in tragedy when the aircraft flying in IMC conditions impacted the Magaliesberg Mountains close to the red and white radio masts east of Hartebeespoort Dam.

On 3 February 2010, the pilot accompanied by an instructor pilot departed from Krugersdorp airfield (FAKR) on a private flight to Wonderboom Airport (FAWB) when the aircraft collided with the Magaliesberg Mountains and the post-accident fire destroyed the aircraft. The weather conditions reported in the area were instrument metrological conditions (IMC) and from the information provided by witnesses, it appears that the aircraft was flying in adverse weather conditions at the time of the accident. According to another witness the mountain was covered in mist and fog. The mist reached down to the tree line of the mountain. Both occupants were fatally injured.

Owner/operator: Marshall Fowler (South Africa)(Pty) Ltd
Manufacturer: Cessna Aircraft Company Cessna T206H ZS PNM

Weather conditions at the departure airport were reported as acceptable for VFR flights. However, en route to FAWB, the aircraft flew into Instrument Meteorological Conditions (IMC). Clearly the pilots were flying far too low as they impacted terrain in the Magaliesberg Mountain range three nautical miles east of the red and white radio mast, at an elevation of 5 169 feet AMSL. A post-impact fire erupted that destroyed the aircraft and both occupants were fatally injured. The aircraft impacted the mountainside at an angle with a left wing tip impacting first, then the nose section and right wing. The maximum elevation of the Magaliesberg Mountains in the area of the accident is 5 319 feet and the aircraft should have been at least 1 000 feet higher to clear all obstacles including the very tall radio beacons close to the impact site.

Information received from the witness’s statement at the time of the accident suggest that the aircraft was flying in adverse IMC conditions prior to the accident. According a witnesses (who is also a pilot) who lives in the area, the mountain was covered in mist and fog and the mist reached down to the tree line of the mountain. The witness said he heard an aircraft passing over his house around 06h20 local time. He stated that he heard an aircraft with a constant RPM engine sound but about two seconds later heard an increase in RPM followed by the sound of an impact. He stated that prior to the increase in RPM sound, the engine sounded perfectly normal and it did not sound as if there were any problems. He called FAWB ATC, but there was no contact as the station is only manned from 07h00. He then called Johannesburg ATC to report the accident.

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