110/1980

-

Department of Transport •• Contents Beware of dehydration

3 Beware of dehydration Aviation Safety Digest is prepared in the Air Safety Investigation An inexperienced pilot set out to fly from Adelaide to Torn Price Branch and published for the Department of Transport through the with an overnight stop at Kalgoorlie. On the second day she twice Australian Government Publishing Service, in pursuance of Regula­ became lost and, during an unplanned landing, overturned the tion 283 of the Air Navigation Regulations. It is distributed by the aircraft. It became apparent that she was suffering from the Department free of charge to Australian licence holders (except effects of dehydration. student pilots), registered aircraft owners, and certain other persons and organisations having a vested operational interest in Australian 5 Visits to Airways Operations units civil aviation. Aviation Safety Digest is also available on subscription from the 6 Tie-down sense Australian Government Publishing Service. Enquiries should be ad­ Some points to remember when securing your aircraft after flight. dressed to the Assistant Director (Sales and Distribution), Australian Government Publishing Service, P. 0. Box 84, Canberra, ACT 2600. 9 The flight recorder system Subscriptions may also be lodged with AGPS Bookshops in all capital cities. 13 In brief A variation on Murphy's Law Change of address and distribution enquiries;' Subscribers should contact the Australian Government 14 How to plan a crash landing Publishing Service at the above address. A successful landing at Christchurch, N.Z. of a USAF C-141 Starlifter concluded a well-managed, seven hour operation after Readers on the free distribution list should contact the landing gear was damaged on take-off from McMurdo, The Publications Distribution Officer Antarctica. Department of Transport P.O. Box 18390, Melbourne, Victoria 3001 16 Unnecessary distraction - wheels up landing Poor operating habits developed to save time in his charter flying business led a pilot to omit to extend the landing gear. © Commonwealth of Australia 1980. The contents of this publication may not be reproduced in whole or in part, without the written author­ While studying for a Commercial Pilot licence, the a t the time, however, that application of the forecast 18 The Engine Doctor and density altitude ity of the Department of Transport. Where material is indicated to be extracted from or based on another publication, the authority of the pilot accepted the opportunity to ferry a Cessna 210 wind of 090/ 15 to the correct track did not produce originator should be sought. The views expressed by persons or aircraft from Adelaide to Tom Price, in north western the same amount of cha nge to th e heading. As a 21 Controls locked - remove before flight bodies in articles reproduced in the Aviation Safety Digest from other Failure to remove the control column lock in a Beech Baron led sources are not necessarily those of the Department. Australia. Although relatively inexperienced , with result the aircraft was seve n degrees left of the correct to a fatal accident. less than 150 hours total flight time, she saw this as a heading. The expected groundspeed had also been Reader contributions and correspondence on articles should be chance to build up her fl ying hours. reduced below the flight planned figure. 23 In brief addressed to: The flight was planned for mid November, with The first checkpoint, 1 I 0 nautical miles a long the The pilot of a Cessna 172, attempting a take-off before first light, route, was a homestead in relative featureless terrain. lost control of the aircraft as the result of lack of visual reference. The Assistant Secretary (Air Safety Investigation), refuelling stops at Ceduna, Kalgoorlie and Department of Transport, Meekatharra, remaining overnight at Kalgoorlie. The T his was missed and the pilot, believing the aircraft to 24 DC-9 lands short of runway P.O. Box 18390, Melbourne, Victoria 3001. first day's !lying was completed without incident, be r ight of track, altered heading 12 degrees to the During an ILS approach in heavy rain an Australian DC-9 touched although the pilot did esta blish that the radio compass le ft. At 1350 hours, whe n she estimated the aircra ft to down short of the runway at Melbourne Airport. RM77/30217(6) Cat. No. 79 92679 was unserviceable and she was required LO navigate by be 30 miles from Paraburdoo, the pilot broadcast an DR and visual reference. O n arrival at Kalgoorlie the 'all stati ons' call which was received by another 28 From the incident files Printed by Ruskin Press, 552-566 Victoria Street, North Melbourne, pilot arra nged LO refuel rh e a i1·c1·aft at 0730 hours the aircraft departing from that location. Three incident reports from the Air Safety Investigation Branch Victoria. files. next morning. By this time the pilot of the Cessna 210 had become Note: Metric units are used except for airspeed and wind speed She spent the night in a hotel and early next quite unsure of her position. Because of poor which are given in knots; and for elevation, height and altitude where 29 Survey of accidents to Australian civil aircraft measurements are given in feet. morning, when she went for breakfast, she was told communications, the other aircraft acted as a relay for 1978 that, because of a power strike, breakfast would not messages to Port Hedla nd Fligh t Service Unit. The be available until 0800 hours. Rather than disrupt the combined efforts of Airways Operations and the Cover refuelling an-angements, the pilot chose to have only other pilot were unable to fix th e position of the Water-colour by Peter Connor. a cup o f tea and then we nt to the airport. Cessna. At 1518 hours, afte r the declaration of an The a ircraft was refuelled and departed Kalgoorlie Alert phase, the pilot was instructed to land at a just after 0900 hou rs. The pilot had not obtained any sta ti on strip she had bee n circling. further food or drink and there was neithe1· rations After a successful landing th e pilot reported that nor water on board the aircra ft. After an uneventful she was at a homestead about 80 miles west of fligh t of about two and a half hours, the aircraft Paraburdoo. Because accommodation was considered landed at Meekatharra. Less than a n hour later it had to be unsu itable the pil ot d ecided to fl y to Paraburdoo Editor's note been re fud l ~d and departed for the final leg to T o m before last light. She drank half a cup of brackish Price. No refreshments were obtained by the pilot at water while flight planning and th en departed at Photographers and artists amongst our readers are invited to submit material suitable for the cover?' the Aviation Safety Meekatha rra. about 1700 hours. Digest. Illustrations of modern general aviation or airline activities will be favoured. Credits will be given for any photographs or artwork selected for reproduction. Shortly after Lake-off, the pilot realised that she had There were thunderstorms in the area a nd about made an errnr of l 00 degr ees on the flight planned four oktas cloud cover, the shadow of which made track (248 instead of 348) so she altered the aircraft navigation difficult. Ha lf an hour after de parture, at heading by the same a mount. The pilot did not realise the ETA for Parabur doo , the pilot again became lost

2 / Aviation Safety Digest 110 Aviation Safety Digest 11 O I 3 r but could see a homestead below. A Distress phase was evaporation from the skin and lungs. These normal declared and about 20 minutes later the pilot reported losses are balanced by drinking water. It is only when that because the aircraft was low on fuel she was the losses are greater than the intake that dehydration landing at the station strip. occurs. The aircraft was flown about 30 knots fast on the The symptoms of d ehydration include headache, approach and ultimately touched down about half weakness, drowsiness, nausea and impaired vision. way along the 730 metre strip. Heavy braking was Speaking distinctly and movement of any kind may • applied but the aircraft ran off the end and seem to require great effort. Water loss amounting to • overturned in a ditch. The pilot, fortunately, was only two per cent of body weight (about a litre) will uninjured. The accident had occurred at a station cause symptoms. A significant salt loss with T hi·-s boundary is identical with about 50 miles south west of Paraburdoo. dehydration can result in muscular cramps anywhere Western boundary of CTA. After the accident the pilot was taken to the in the body. The condition known as heat exhaustion homestead where she consumed a large quantity of is a state of collapse brought about by insufficient water. A commercial pilot who was there considered blood supply to the brain, following a period of heat her to be 'all in'. She was very distressed and stress. Heat exhaustion can occur at water losses as self-critical about the fact that she had twice become low as six per cel1l of body weight. l ISA Fl i. ght through these corridors shall~·· be lost. The association of flying and dehydration is based It was obvious from the circumstances of the flight partially upon the exposure of the human body to made within s ight of the railway o r and the accident, and the condition of the pilot, that lowered atmospheric pressures. When the highway concerned but in no case more than five mi les therefrom. she suffered from the effects of dehydration. atmospheric pressure decreases, water evaporates I Symptoms to be expected with dehydration include from the body al a higher rate. Rates of loss have been extreme thirst, headache, dizziness and studied at various altitudes and, even at cabin disorientation. Navigational difficulties, fatigue and pressures of 5-10 OOO feet, evaporation is significantly the apprehension experienced by the pilot would be increased. Under normal operating circumstances related to that condition. this loss is small, but under condition$ of prolonged The tern perature at the accident site at about 1800 flight the loss becomes very significant in the absence hours was 36 degrees Celsius so it can be assumed that of adequate water replacement. This loss will be through the day the temperature must have reached greatly increased if cabin temperatures are high or if at least 40 degrees. It is probable that the cockpit of the atmosphere is particularly dry - as it is at the aircraft was even hotter because of the 'green altitude. house' effect. Individual tolerance to dehydration varies, At rest, with an ambient temperature of 40 degrees, although it is a well established fact that no one can a person can expect to lose 3.26 kilograms per day as live much beyond three days without water. No pilot the result of sweat loss. Authorities agree that, for should attempt to fly an aircraft directly after any HOBART survival in arid areas with an average daytime prolonged activity in the sun that may have had temperature in excess of 32 degrees, the body needs deh ydrating consequences. Even where no obvious four litres of water per day. This is considerably in debilitating effects appear, a loss of mental initiative open boat, if water loss has not been replaced. encountered. Before undertaking-any such operation excess of the cup of tea and half a cup of brackish can be expected, and this is not a good frame of mind Vigorous exercise in h ot weather also speeds up be sure that you are mentally and physically water consumed by the pilot on the day of the for safe flying. the loss of water tremendously. The sweat rate of prepared. Read up on survival and ensure that you accident. It is probable that her water consumption on It is recommended that you incorporate th e men doing heavy work or playing a hard game of carry adequate food and rations for the occupants of the previous day was also well below the required following items into your flight planning for this and sport under very hot conditions can be over two the aircraft until help arrives, in the case of an amount. every other Australian summer, or when flying in the litres per hour, and the con current salt loss may be emergency. Seek guidance from experienced hot, dry conditions which can be e ncountered in equivalent to a normal day's intake. personnel if you are unsure of the safe way to embark Dehydration outback areas even during the winter: It was extremely fortunate for this pilot that the upon your trip . Ensure that you maintain an Dehydration is a severe imbalance of the water • Maintain a high body fluid level by regular intake accident occurred on a property with help close at adequate fluid intake to retain your mental processes content of the human system - a common, but not of suitable liquids. This can be supplemented by hand. If sh e had been forced down away from at a peak. If you do this you will be less likely to finish usu ally serious, summer complaint for most people. taking along a thermos of cool water in the aircraft civilisation it is extremely doubtful that, in her up in a survival situation. However, for pilots who fl y in spite of feeling and drinking frequently. Cool water is preferable condition and lacking any supply of water, she cou ld Although not through a Designated Remote Area obviously below par, dehydration can impair flight to iced water as it is easier to drink. The body have survived until a rescue party arrived. the planned route was over arid, sparsely inhabited performance to the extent that a serious accident can effecti vely loses more heat by warming the cool The AIP VFG discusses the requirements country. Planning for this flight should have result. water to body temperature. Realise that you lose applicable to flight in designated remote areas. obviously included consider ation of the normal needs Land animals evolved from water dwelling moisture constantly when you are out in the sun or However, it is not only in these designated areas that for food and water as well as preparation for the creatures and in that evolution retained the water warm air, even when you are unaware of sweating. hazardous conditions and situations can be possibility of a survival situation arising. • environment but c'nclosed it within the skin. The • Use normal salt with your meals, but check with a human body is over 60 per cent water by weight; doctor before taking salt pills. Some people have about seven per cent of the total body water is utilised bad reactions to them. Extra salt is seldom required as circulating fluid (blood plasma), with 33 per cent unless the individual is engaged in heavy manual bathing the body cells and 60 per cent contained labour in the sun. within the cells. We are dependent upon this fluid for • Recognise that caffeinated drinks (tea, coffee, Visits to Airways Operations units all physiological functions; food and oxygen are cola) tend to stimulate loss of water. dissolved and carried to the cells, waste products are • Avoid letting your aircraft cockpit be turned into ~~e. Dep~rtment .regularly receive.s letters from members of the aviation industry wh o are interested in carried away, and the very chemical reactions of life an oven by the sun. If you are unable to park it in a v1s1tmg Air TraffIC Control and Fhght Service units to learn more about their functions. Visits to units itself occur in water solution. This body of water is not hangar or in the shade, try to cover the upper appropriate to the individual's normal area of operations are encouraged. To arrange such visits interested static. T h ere is a constant flow from the cells into the windows with a tarpaulin. persons should contact the Superintendent of Airways Operations at the applicable regional office of the body and back, as well as exchange of water with the • Take time to open air vents before taxying. Department of Transport, or the officer in charge of the specific unit he wishes to visit • environment. The body takes advantage of normal • Be aware that dehydration can be accelerated by losses of water to the outside world for elimination of p re-fligh t activities - for example, it may well wastes by way of the kidneys, and for cooling by overtake a pilot in flight after a day's fishing in an

4 I Aviation Safety Digest 110 Aviation Safety Digest 110 I 5 T Tie-down sense

Each year aircraft are needlessly damaged by high Owners Manual, and in greater detail in the winds and storms because of negligence and Manufacturer's Service Manual. improper tie-down procedures. There is no doubt If an intended llight includes a landing away from that Mother Nature can turn the aircraft parking lot base, and the aircraft wi ll be left unattended fo r even into a junk yard in a matter of minutes. Whether you a sho rt time, a tie-down kit should be taken. This kit are willing to admit it or not, ifyour aeroplane, or one should include adequate stakes, ropes, fittings, a large ground becomes soaked from the heavy rain which study of the types and applications of simple knots for which you were responsible, has been damaged in hammer, control locks , chocks and covers for all accompanies storms. Metal 'star' pickets ar e much and practise tying th em in the comfort of your home; such circumstances, the chances are that it was external openings. better because they can be driven deeper and will do not wait until the storm hits. hold firmer as they do not break up the soil. T hey improperly secured, or not tied down at all. In an Tie-down considerations attempt to correct the situation this article is intended should be driven in with a heavy hammer so that the Securing the aircraft Ideally, an aircraft should be parked in an area to improve your knowledge on the correct way to tie angle between the picket and the Lie-down rope is Tie only at the proper tie-down rings. Never tie to a equipped with three poi nt tic-downs, and should be ~own an aircraft. about 90 degrees. 'Screw' pickets, although not strut as the rope may slip and result in bend ing of the tied down at the encl of each flight to preclude common, are p robably the most secure of all and do strut. Preventing damage damage from sudden weather changes. The direction not need a sledge ham mer to secure them in the Synthetic ropes are tied without slack but also The best protection against storm damage is, of in which the aircraft is tied down will ultimately be ground. without strain o n the aircraft. If using dry manila course, to fly the aircraft o ut of the impe nding storm determined by the location of the parking area and T ie-down ropes sh ould be capable of resisting a rope allow about 25mm (one inch) slack to allow area, provided you h ave sufficient warning time. The mooring points; however , whenever possible, the pull of approximately 1350 kg (3000 lb). Ropes shortening of the rope if it absorbs rain or dew. Wet next best protective measure is to secure the aircraft aircraft should be parked nose-into-wind regardless of suitable for use fa ll into two classes: manila (or sisal) manila ropes may be treated as synthetic rope but in a storm-proof hangar or other suitable shelter. The whether it is nosewheel or tailwheel equipped. ropes and synthetic fibre ropes. These two groups r emember that the knot may slip after the rope has remaining alternative is to ensure that the aircraft is Tail into wi nd is not a desirable situation for any have entirely d ifferent properties and should'be used d ried. tied down securely. Do not depend on the aircraft's aircraft as they are not stressed to take strong winds accordingly. T oo much slack will allow the aircraft to jerk weight to protect it from. wind damage; sudden and from the rear. The reasons offered for tail into wind As manila ropes are a vegetable fibre they are against the ropes, possibly loosening the tie-down and severe gusts, particularly associated with will y-w illies, tie-down arise from stories or aeroplanes '(l ying' on susceptible to rotting and attack by fungus, and will resulting in damage to the aircraft structure . T oo can destroy a parked aircraft in seconds. the ti e-down ropes; however, if' the aircraft is perish when affected by oil and grease. Their much strain can place inverted flight loads on the properly secured it cannot 'fly' on th e ropes. T he use strength deteriorates with age a nd they should be aircraft, greater than it is designed to take. Advance planning of temporary spoile rs on the wings, as discussed late r, Always be prepared for the worst conceivable storm inspected regularly. The main objection to manila Wing ropes sh ould be tied so that they splay will reduce any tendency to fl y and also reduce the ropes is that they shrink when wet. The reason is forward and outward about 45 degrees to the ground conditions: pouring rain, gusty winds exceeding 30 loads on the tie-clown syste m. knots and no hangar facilities available. With such simply that the individ ual fibres sweH out and shorten and the nose/ tail ropes sho uld be in th e fore and aft conditions in mind, aircraft owners and operators Tie-down facilities wh en they absorb m oisture. When the r ope dries out, line of the aeroplane. The nose and tail can have two should plan in advance by learning their aircraft Tie-down anchors for single-engine aircraft should the fibres r eturn to their normal size. This ropes each , both splayed outward from the aircraft manufacturer's recommendations for tying down, provide a minimum holding strength of characteristic ma kes it difficult to undo knots after centre line. If the ropes are knotted cor rectly, with location and/or installation of tie-down rings for approximately 1350 kg (3000 lb) each ; for the rope has become wet. the correct tension , the aircraft is secure. At attachment of ropes, special instructions for securing multi-engine aircraft this should be increased to Synthetic fibre ropes arc not affected by oil or aerod romes where p arallel tie-down cables are nosewheel type aircraft and tailwheel type aircraft, 1800 kg (4000 lb). T he type of anchor in use varies, moisture and a re reasonably stable in r egard to their installed, the ropes are tied vertically to the cables, charts and graphs denoting aircraft weights a nd depending upon the type o r parking area surface. le ngth, although they may stretch slightl y when hot. without slack. relative wind velocities that would make varied Owners a nd operators who wis h to obtain more Even so, they are preferable to manila ropes. T he All flight controls should be secured to prevent tie-down procedures necessary for pending weather information o n the type of ti e-down anchors available proble m with synthetic ropes is the te ndency for them banging against the stops. Some aircraft are e mergencies, correct fitment or control gust locks and should contact the Airports Engineering Sectio n at knots to loosen and slip. Extra care is required and equipped with integral gust locks operable from the covers, and the correct a ngles for ropes and chains their regional Department of Tra nsport office. knots that do not slip should be used. cockpit. O thers require the use of externally fitted, relative to the aircraft. T his information is given Wooden stakes driven in to the ground are not Remember that no matter how strong the tie-down padded control chocks. Some manufacturers briefly in the Pilots Operating Handbook or Aircraft dependable and will inva1-iably pull out whe n th e rope, it is only as good as the knot being used. Make a recommend securing the control column by u se or the

6 I Aviation Safety Digest 110 Aviation Safety Digest 110 I 7 pilot's seat belt, while others provide control locks per cent chord line along the full sp an and secured fitted inside the cockpit. against m ovem ent. An alternative sp oiler can be When using external chocks, covers and plugs, manufactured from a length of 50 x 50 mm timber ensure that red streamers are fitted to alert future with a strip of foam rubber glued along one sid e to p rotect the wing surface. T he spoiler is placed on the users of the aircraft. Ailerons and r udders should be oxes', more correctly known as the Flight Data and Cockpit Vojce secured in their neutral position, as should the top of the wing and secured by ropes or rubber elevator on nosewheel aircraft. Flap s should always be bungees. Pieces of cloth o r carpet should be used to 'up'. Tailwheel aircraft should have their elevators protect leading a nd trailing edges against chafing by secured in the full 'up' position. If it is absolutely the ties. unavoidable that a tailwheel aircraft has to be tied When securing an aircraft, it is good practice to down tail in to wind, the elevator should be in the full fasten all doors and windows properly, to minimise 'down ' position. damage inside the aeroplane. Both exhaust and intake openings for reciprocating and turbine Chocks should be placed fore and aft of each wheel engines sh ould be covered to prevent entry of foreign and secured by ropes or by nailing cleats from one matter. Picot-static vents and tubes should also be chock to the other. Housebricks and pieces of'four by covered to prevent damage. two' are poor excuses for chocks. Man y light aircraft Always secure the aircraft by ensuring doors and are equipped with collapsible chocks made from light windows are locked ; leave the keys with some weight m etal. As these ch ocks may be dislodged in a responsible person. strong wind or by the slipstream from other aircraft, Becom e familiar with local weather patterns and they should be secured by ropes on either side of each monitor weather r epor ts for high wind warnings, wheel. thunderstorms or other potential hazards. Learn the Spoilers can be made from lon g sandbags about correct tie-down proced ur es for your aircraft and 50-75 mm in diameter (Grandma's door draft remember that aircra ft parked ou tside, in the op en, excluders are ideal). They sh ould be placed at the 25 should always be tied down '

Whe n an airlin e aircraft is involved in an acciden t, the news med ia often refer to a search being cond ucted to recover the fligh t recorder 'black boxes'. T o many of their read ers this term has so me mystical conn otatio n but it is only a name given to many items of equipment fitted to aircraft, par ticularly th ose of complicated m echanical or electronic design which require specialist understanding. Radio and electronic equipment racks in modern ,, . aircraft are filled with black boxes most of which, in fact, are painted black. Flight recorders are also in boxes, of a similar size to man y other items of aircraft equipment, but they are painted red o r orange, not black. T his is to make them more conspicuous am ongst th e wreckage of a majo r aircraft accid ent. T h e recorder boxes are also of special construction to .. protect the r ecorder from high impact for ces, intense fire or a cor rosive en vi ronment. I n addition, some recorders are fitted with underwater location devices and reflective tape to assist in their recovery. T hat such precautions are necessary indicates the impor tance of fl ight recorde rs in an aircraft acciden t investigation . Modern aircraft are becoming more complex, and flying higher and faster than before. T hey are also much safer, but o n those infrequent occasions wh en there is an accident, the damage to the aircraft can be so gr eat that nor mal means of investigative examinatio n are made extremely d ifficult. In order to <;> bta(n a p ositive illus tration for the points made in this article, staff of the Digest went Another development that is ma king fligh t to Moorabbin A1rport to p hotograph a properly secured aircraft. They were not able to locate such recorde rs even more essential is th e incr easing use of an example, but were able to borrow wh eel chocks and a pitot cover to add to the aircraft cockpit instruments with various forms of electrical The FOR and CVR as fitted to the Boeing 727 aircraft, shown in illustra ted above which was well tied down. Although this aircraft provided the most suitable their pro(ective containers with the covers removed. They are p resentation. In th e event of an acciden t, a nd the located in the rear fuselage of the aircraft as indicated in the subject, the elevator trim tab had not been set in the neutral p osition. To satisfy the resultant loss of electrical power , all evidence of man u_ facturer 's recommendations it should also have had the cowl flaps closed, a s urface control diagram above. lock installed over the fin and rudder, and a tie-down rope securing the nose gea r torque link. It instrument read ings can be irretrievably lost - unless was also noted that wheel spats preclude the use of wh eel chocks of an effective size. • retained on a flight recorder.

8 I Aviation Safety Digest 110 Aviation Safety Digest 110 I 9 Flight recorders terms of the amount of information available to There are actually two separate and distinctly accident investigators. Australian aircraft with this different recorders which can be fitted to an aircraft. equipment are required to record a minimum of 20 These are the flight data recorder (FDR) and the parameters. These include the live previously cockpit voice recorder (CVR). The FDR is designed to mentioned for scratch recorders, plus certain engine record information concerning the aircraft's flight parameters, aircraft configuration, control angles, path. The CVR, perhaps better described as the pitch and roll attitude, longitudinal acceleration, etc. cockpit 'audio' recorder, provides a record of all Each of these parameters is recorded at least once sounds in the cockpit area. This, of course, includes every four seconds, but some information which can flight crew statements, both on intercom and over the change very rapidly, such as vertical acceleration, is radio but, of equal importance, also encompasses recorded as frequently as eight times per second. such sounds as warning alarms, equipment and DFDR equipment is capable or recording much engine operating noises, and even the background more than the required 20 parameters. Hence, many airflow. operators voluntarily wire other aircraft components Together, the two recorders provide a wealth of and systems into the DFDR. information that might not be available from any Readout of a DFDR tape is relative ly simple and other source. This data not only assists accident quick, as it is largely a n automated process. If the investigators to establish what happened but, more equipment is recovered intact it can be connected to importantly, why it happened. the readout station and its associated computer. If, on In Australia, it is a requirement that both types of the other· hand, the recorder is damaged, the flight recorder be fitted to all aircraft over 5700 kg protected magnetic tape can be removed a nd played maximum take-off weight which are turbine powered back on reel-to-reel equipment. It is then only or were first certified after 1 July 1965. This covers necessary to program the computer to be aware of most regular public transport aircraft, the those particular parameters recorded by the The stainless steel tape from a 'scratch' recorder showing the series of grooves cut in the foil. sophisticated executive jets and even the larger individual aircraft operator, and the•readout can turbine-powered helicopters. proceed. Within a few hours the accident investigation team can be provided with a printout of Flight data recorders tabulated data. In many cases this results in early There are several types of FDR available but only two elimination of those aircraft systems that were are common in Australia. The earlier models, which functioning normally and enables the team's efforts are fitted to the majority of aircraft, record altitude, to be concentrated on the systems which show airspeed, magnetic heading and vertical acceleration abnormal indications. Later in the investigation it is against a time base. Operation of a microphone common to convert the tabulated data to graphical transmission switch is also generally recorded, to form for easier understanding. permit accurate synchronisation between the FDR, the CVR and any ground-based communication Cockpit voice recorders recording facilities. The CVR is a four channel tape recorder, generally The information is engraved on a 12.5 cm wide roll using a continuous 30 minute loop of magnetic tape. of stainless steel foil as it moves from a supply spool, Normally, three of these channels are connected across a recording head, to a take-up spool. This directly into the captain's, first officer's and flight operation is similar to the movement of a film in a engineer's communication panels, whilst the fourth camera, except that instead of a picture the result is a channel is connected to an open microphone on the senes of grooves cut into the foil. The foil runs for centre or overhead instrument panel. Although the 200 hours of aircraft operation and then can be playback equipment appears different from domestic reversed to engrave on the other side. The tape decks it operates in much the same way. photograph of a typical FDR tape indicates why this However, to gain maximum benefit from audio type of equipment is generally referred to as a 'scratch' records it is necessary to have additional equipme nt recorder. so that the CVR output can be filtered and/or In the event of an accident the recorder foil is modulated to improve upon the original recording. placed on a special readout machine and held flat Other facilities, such as variable speed , repetitive under a sheet of glass. The position of each scratch is replay and spectrum analysis equipment, arc also measured using an electrically positioned microscope used to clarify distorted sounds and analyse the and the information fed into either an electric s.ourccs of various noises. typewriter or a digital computer. After correction for variables, such as calibration figures, the data is Use of data recorders presented in diagrammatic form, portraying the The development of detailed and accurate flight aircraft flight path prior to the accident. Much of this recorders, particularly the DFDR, has greatly work, such as positioning the microscope and tl1e simplified the accident investigation team's job of preparation of diagrams, must be done manually and reconstructing and analysing the events leading up to h ence readout of this type of recorder is a slow, the accident. One way in which this is done involves laborious task. the use of aircraft simulators. A simulator computer, The second type of FDR is fitted to the later of the appropriate aircraft type, ca n be programmed generation of aircraft, for example Boeing 74 7s. T he with the information obtained from a flight recorder information is recorded on a magnetic tape, similar to system to play back the accident flight. Not only does The FOR readout machine showing the recorder foil in place under the glass sheet. that used on hi-f'i reel-to-reel recorders, only in a this help establish what happened in the accident, but continuous loop of some 25 hours duration. These also permits experiments to be carried out to find the newer recorders, known as digital flight data best way to prevent another accident, should the same recorders (DFDR), represent a significant advance in circumstances occur again.

10 I Aviation Safety Digest 11 O Aviation Safety Digest 11 o I 11 .... - . ~·

..

., vJ!t~,. , ..

Audio equipment used to read out CVR and Airways Operations tape recordings.

If a n accident happened at night, or over played by the wind in many aircraft accide nts was mountains, a desert, a swamp or lhe sea, the flighl probably undereslimated. Thanks to flight recorders recorders m~ghl be the only means of eslablishing the sudden effects upon an aircraft flight path what happened. At the very least, the recorders save resulting from wind shear can be established. Also, in an investigation team many da ys, or weeks, of delay as the United States, the information obtained from they examine th e wreckage in an a ttempt to establish flighl recorders is being programmed into simulator the sequence of events. As a guide lo the time and computers to pe rmit a n evaluation of pilot and effort involved in wreckage examination , a recent aircraft response to wind shear on approach. In brief light aircraft accide nt in Australia required four Research and development of bolh equipmenl a nd • weeks for a lhree man investigation learn lo complele techniques, firstly to delect a nd then to counter the wreckage examination, establish a sequence of problems such as wi nd shear, is slill in progress. A variation on Murphy's Law: events, and isolate lhe probable cause of the accidenl. If there is a possibility of several things going wrong, lhe one that will go wrong is the one that will do the most Such an exercise with an aircraft of the size and Australian facilities damage! corn plexity of a wide-bodied j el would be vastly more The Air Safety Investigation Branch of the difficull. Depanment of Transport has FDR and CVR Because o f" a flat aircraf"t bauery, the owner of a and no earthi ng straps were used. After placing the Flight recorders have solved many 'm yslery' laboratories which are equipped lo read out all types Cessna 206 decided to use a spare battery and encl or the plaslic hose some 15 centimetres into the accidents. On the other hand, there have been many of recorders fi tted to Austr alian-registered aircraft jumper leads to start the aircraft's engine, and then tank, the owner climbed clown from the wing and accidents involving aircraft not equipped with flight and many of the recorders fitted to foreign-registered run the engine to recharge the installed bauery. He began to pump the l"uel. The vibration of the pump recorders in which, despite every possible effort, the aircraft. Accide nt prevention is an international positioned the spare battery 0 11 the ground j ust caused the hose to come out of" the fuel tank and cause still remains unknown. In one overseas accident endeavour and, in support of the International Civil fo rward of the le ft mainwheel, connected it to the fall to the ground. It fell on to either the battery or an aircral"l crashed into the sea and ve ry little of the Aviation Organisation recommendations, Australia aircraf"t battery, but then decided lo refuel the the jumper lead ter minals. A static discharge from wreckage was recovered. However, the CVR was provides a readout facility for a number of our South aircraft before he attempted to start the engine. the plastic hose or a short belween the lerminals found and this record alone was sufficient to establish East Asian neighbours. T he jumper leads were disconnected f"rom the provided a spark and ignited the spill Avgas. that the aircraft engines had not failed - as was Fli ght recorde rs will play an increasingly impo rtant aircra ft and we re left lying on the ground, still A large fire immediately broke out around the generall y expected - but rather the accidem resulled role in air safety as improved methods are d eveloped connected lo the spare baltery. nosewheel or the aircraft. The owner went to obtain from a flighl control malfunction. for the analysis and interpretation or the recorded T he owner brought. some 200 litre drums of lire fighting equipment and assistance, but on his The flight recorders are, of course, particularly information. In turn, this will provide the basis for Avgas to the aircra l"t and commenced refuell ing the 1·eturn only lwo or three minutes later the fire was valuable when the evidence is nebulous or transitory. more effective accident prevention and safety left tank. The refuelling equipment consisted of a too intense to be approached. As the fire Possibly the besl example of this.is the great increase education, thus aiding the whole aviation community double action hand pump and a plastic hose. The progressed an unopened 200 litre drum of fuel in awareness of wind shear problems in recent years. in its endeavours to improve safety in the air. • hose had no nozzle, and there were no metal benealh the right wing of the aircraft exploded. Prior to the develo pmenl of fl ighl recorders, the part fittings on the end of the hose. It was not bonded The aircraft was destroyed.

12 I Aviation Safety Digest 110 Aviation Safety Digest 110 I 13 In the past there have been many examples of problems caused by undesirable haste in dealing with (Photographs courtesy of the Christchurch Star) inflight emergencies. On other occasions pilots have dealt successfully with the inflight emergency, but have then caused further problems by not complying with standard procedures in their efforts to return to earth as soon as possible. This article relates the planning, co-operation and effective use of all available resources which prevented landing gear damage on an aircraft from causing a major accident. It is reprinted from the February 1980 issue of The MAC Flyer.

..

Although our goal is usually a smooth landing, this crew found themselves faced with the problem of ... How 'to plan a crash landing

touchdown in New Zealand. Extra drag from the efficiency at the higher altitudes assured landing "Not an experience I would recommend." T hat's how Starlifter , Sergeant Reynolds could not see inside the extended wheels was increasing fuel consumption somewhe re in New Zealand, and recovery at Captain Robert E. Colley described to reporters his gear well because or ice on the inspec6on window. significantly above the normal cruise fuel flow. After Christchurch became a possibility. The original flight crew's dramatic "planned" crash landing of a C- 14 1 Meamvhile th e navigators, Lt Col FrankJ.Jackson conferring with Major Ruppert and the experts had called fo r five h ours flying to their destination, Starlifter at Christchurch, New Zealand. Departing and Captain Lance W. Bachran, busily calculated assembled at Christchurch, Captain Colley decided to but because of their decreased speed, the mission Christchurch on 29 October 1979 for a round trip to their chances of getting to New Zealand. Without fu el retract th e functioning la nding gear. would stretch to over seven hours. Williams Field, McMurdo Station, Antarctica, the consumption cha rts available for gear d own cruise, it Working the engineer's panel, MSgt Alexander While the right-seater han dled the aircraft, the 349th Military Airlift Wing (Associate) crew's flight to was impossible lo determine for certain if MAC 249 Schneider prepared to depressurise the aircraft so pilot-in-command , the crew, and experts on the the frozen continent was routine until their landing could make landfall in Southern New Zealand. One that th e main gear could be pinned and electrically ground began planning for th e upcoming landing. As o n grid runway 26. During the roll out they option which seemed the most reasonable however, disconnected from the gear system. In the cargo time passed, they reviewed several checklists and experienced an extra rough r ide on the snow-covered was that they could cruise northward for about two compartment, TSgt William R. Friedrich , loadmaster, Dash One (Flight manual) discussions that seemed ice runway. Post flight inspection of the 14 1 revealed hours, see how things were going, and still be able to discussed the emer gency with the passengers and appropriate to their situation. Ahead at Christchurch, a shatte red taxi light a nd a broken brake line. With no return to McMurdo if need be . Based on this, and the • helped them d on oxygen masks. With the crew and MAC people were in contact with the 22nd Air Force en route maintenance available, the crew capped the generally inhospitable conditions in Antarctica, p assengers on oxygen, the cabin was deprcssurised, Standards and Evaluation and Lockheed , the lin e and refilled the number three hydraulic system. Captain Colley decided to continue on course for the scanner pinned the gear and then cabin pressure Starlifter's manufacturer, wh o provi ded expert Less than two hours later, 4 1 000 kilograms of fuel their original destination. He directed Maj o r Hartzell was restored. Finally, the left and nose landing gear ad vice and detailed technical information. T ogether, and 12 passengers were aboard for the return fligh t to start a climb at 235 knots, the gear limiting speed . were retracted . th e ground-bound advisors compiled a list of things to New Zealand. With Captain Colley in the left scat At FL 200, 235 knots equalled .55 Mach, so the Even with this decrease in d rag, the fuel flow for MAC 249's crew lo consider before landing. and Major John W'. H artzell fl ying as copilot, the Starlifter was cruising as fast as it could within remained high , a nd after consultation with the Captain Colley's ini6al plan was to land with the Starli!"ter started its take-off at 0615 hours GMT. .Just technical order limits. With the copilot controlling the experts in MAC 403 and at Christchurch, it became nose gear down and pinned, and the left main gear as Captain Colley barked, "Gear up," the copilot C- 141, Captain Colley worked the HF radio to get obvious that 249 wou ld have to climb to make it to up, because he believed the right gear truck would noticed an unsafe ind ication for the right main gear, more information on how to best handle the New Zealand. Because of the decreasi •~ g air density, separate from the plane upon touchdown. Generally, and did not raise the handle. At nearly the same time malfu nction. Because ol"their remote location, he was this option required increasing the Mach number and this seemed to be a way to keep the Starlifler on the McMurdo lee Tower called, "MAC 249, you lost your unable to set up a normal Conference Skyhook with thereby exceeding n ormal oper ating limits. runway and give the crew and passengers the best starboard wheels. T hey're hanging." the 22nd Air Force. Fortunately, another Sta rlif"ter, Experimenting with the Starlifter, Captain Colley chance for survival. Next he made sure every crew Captain Colley le velled the Starlifter at 3000 feet MAC 59403, had departed McMurdo two hours found that the cr ippled aircraft began to buffet at member understood the plan of action for the and kept the speed below 235 knots. He then earlier and that crew was in contact with the MAC sp eeds above .63 Mach. T herefore, the copilot kept u pcoming night app roach and emergency landing. I n transferred aircraft control to Major Hartzell and Operating Locatio n al Christchurch. Aboard MAC the speed below .62 d uring the climb to FL 300. Tb is the p ilot's words, "We made plans but still tried to be asked the scanner , MSgt Stephen E. Reynolds, to 403, Major Peter .J. Ruppert, 60 MAW Standards and action, coupled with a favourable wind shift, assured flexible and open to suggestions .. . (then) we check the gear. A ch eck by lee Tower confirmed that Evaluation, offered to relay messages for 249. them o r at least reaching one of the two airfields in 1·ehearsed it." the righ t main gear was positioned lower than The crew's most pressing problem was ensuring Southern New Zealand - Dunedin or I nvercargill. About 500 miles out, the fuel status gave the crew normal, and the controller speculated that it was that the fuel in their C-141 's tanks would provide As the plane consu med fuel, they were able to climb enough confidence to try for a landing at "hanging by h ydraulic lines". From inside the eno ugh endura nce for a landfall and a safe higher and eventually reach FL 350. Beller engine Christchurch . "(At this point) we had no doubt that

14 I Aviation Safety Digest 110 Aviation Safety Digest 11 O I 15 we could make landfall in New Zealand," recalled on its side, became trapped under the gear pod and Captain Colley, "but when we turned for helped for a while to support the aircraft's weight. Christchurch . .. we were committed." The copilot shut d~wn the outboard engines as "The radios hadn't been quiet for five minutes," the planned, and when the Starlifter's speed reached Captain remembered, and about 150 miles out he about 50 knots, the right main gear truck finally finished his consultations on HF and took control of separated. The big airlifter smoothly settled on to the the aircraft for descent and landing. As the Starlif"ter number four engine and the right wing tip. Although descended below 10 OOO feet, the engineer it veered to the right before grinding to a halt with depressurised the aircraft. For the first time, Sergeant 4000 feet of runway remaining, MAC 249 stayed on Reynolds was able to remove the gear pod access the pavement. In the 50 emergency vehicles that had panel and take a good look at the damaged bogey. He responded, crash crews·watched a momentary rooster saw the gear truck was still attached to the 14 1 by the tail of sparks fly clear above the Starlifter's T-tail as scissors assembly, and the crew estimated that the the right outboard engine and wing tip skidded along gear might stay with the aeropiane for part of the the ground. landing roll. After the C-141 stopp ed, Sergeant Reynolds Now aware of the right gear's true condition, the opened the crew entrance d oor and assisted the crew and the experts on the ground re-evaluated passengers and other crew members in departing the their plans. They decided that landing with all the aircraft. Captain Colley and Major H artzell were the wheels down might be the best course of action. Also, last to leave the flight d eck and checked the cargo the crew would pin the nose gear down so that the left compartment for possible stragglers before they main could be retracted if necessary to keep abandoned the crippled C-141. Fire department directional control after touchdown. vehicles were at the scene in seconds and started Air Traffic Control vectored the Starlifter for an pouring water and foam on the number four engine, ILS approach to Runway 20 at Christchurch. Gear right wing, and along the side of the fuselage. extension was delayed until they were on base leg to Fortunately, there was no fire. ' further conser ve fuel. As the 14 1 let down through · Captain Colley and his crew had worked their way the dark mist above the Waimakariri River on the ILS through an extremely serious emergency situation. glideslope, Captain Colley spotted the approach lights They were successful for many reasons: their own at two and a h alf miles out. The dangling right gear expertise, the aircraft commander's leadership, the touched the runway first, and a few seconds later the availability of experts on the ground to help, and the Captain set the Starlifter's weight on the left main and advice and co-operation of the crew of MAC 403. nose gears. Captain Colley held left aileron in to keep Some might contend a bit o f luck was also a factor. weight off the damaged right gear. As the aircraft But isn't luck, after all ,just the crossroads where slowed, the right main gear truck, which was laying opportunity and preparation meet? •

Unnecessary distraction - View of the aerodrome facing west, showing the approximate flight paths of the two aircraft during the circuit entry and approach to land. wheels up landing Meanwhile the Cessna 2 10 had entered the circuit On this occasion the pilot considered that he had and was !lying an abbreviated patte rn for the 27 fully completed all the checks. In fact he had gone strip. H e had in fact not flown over the fi eld, but through the lists mentall y without physically doing had turned crosswind prior to reaching the 27 or checking some o f the items. He realised on final T he chief pilot of a country based charte r company 1066 metres a few years before. It was the pilot's threshold . This meant that he turned away from that he had not extended any flap at the normal had developed a standard procedure of !lying habit to touch down on the disused portion of the the other traffic, and although he requested the downwind position , but did not realise that he had straight in approaches in his operations wherever strip when landing in to the west, especially when other's position twice, and was looking for the also omitted to extend the landing gear. possible. Subject to familia rity with the destination, operating with a downwind or crosswind, to allow a aircraf"t throughout the circuit, he still had not Thus the pilot's complacency and over-familiarity prevailing conditions and traffic, he would use the longer landing run and thus reduce brake wear. sighted it by the time he touched down . He fa iled with the aircraft and his company's operating strip or rumvay aligned closest to his inbound The Flight Service Uni t passed the wind velocity as to hear a taxying call from the aircraft some two procedures combin ed with his unorthodox practices track. He considered himself ver y familiar with the 'zero one zero degrees, one zero knots', but the minutes prior lo his landing. created unnecessary d ifficulties for him which led to aircraft and used this procedure irrespecti ve o r pilot read the directi on as one zero zero degrees. T he e nd result o f this continuous distraction was the omission. A further example of the pilot's wi nd direction, unless a downwind was too strong He intended to land straight in on the 27 strip, that the Cessna 210 landed wi th wheels up on the attitude lo his responsibilities is that at the time or fo r a short strip.T he sole reason for these even though he expected a 10 knot downwind. disused section o f' the 27 strip, over 380 metres the accident his Commercial Pilot Licence had operations was to save time. ln disregarding the At top of descent from 6500 feet, the pilot was short of the threshold. lapsed: the expiry d ate was over six weeks earlier. regulations relating to ope rations f'rom aerodromes, given traffic on a Cessna 182 inbound from the The pilot did not use a printed checklisr, but had T his accident demonstrates the necessity of the pilot chose to ignore procedures which have north west and estimating the circuit a rea about two committed downwind and final checks to memory. conformin g to established procedures for the good been develo ped for the safe a nd e fficient use of' minutes before him. He now decided to d elay his T he first ite m of the downwind check was to extend of all members of the aviation industry. In an effort f'a cilities by aircraft operators. final choice of landing direction until in the circuit the la nding gear and make the first selection or to save a few minutes, this operation cost a lot more O n this occasion the pilot was returning to base in with the other aircraft in sight. In the circuit area flap. T he last item was to check the landing gear than it could have gained. We can retrieve some a Cessna 2 10 from a charter flight to a town about the Cessna 182 pilot reported overfl ying for the 09 extended green li ght a nd visuall y confirm the value from the accident if we are prepared to learn 180 kilometres east of the base. T he cast-west strip strip, but shortly after advised changing to runway extension o r the left main gear . His prelanding from another's mistake. Bad habits do not just at the base had been shortened by 720 metres to 04. check on fi nal would also include the green li ght. appear. They are allowed to d evelop•

16 I Aviation Safety Digest 110 Aviation Safety Digest 110 I 17 --ij

The Engine Doctor and density altitude During the investigation of an aircraft accident which aircraft needs about 625 metres to get o ver a 50 foot occurred in Central Australia in midsummer, the obstacle, according to the book. Temperature was pilot revealed a distinct lack of knowledge on the about 24 degrees Celsius at noon and the field subject of density altitude. At the time of the accident, elevation was 2300 feet. On the chart that added up to 1700 hours local, the temperature was 39 degrees a 50 per cent increase in take-off distance, so I threw Celsius. With an aerodrome elevation of about 1700 in a little for good measure and added 300 metres to feet AMSL, this resulted in a density altitude of nearly the 625 - 925 was the number I pill down. Actually I 5000 feet. T he pilot was unaware of the possible figu red I could clear the obstacle in about 800, effects of this on his airci"aft performance and once considering the way that powerplant was purring again, as so often is heard, he had been told that when I left home. I would have, too, if the engine 'leaning the mixture is not done below 5000 feet'. hadn't let me down. Would you believe it, I was still T o help you better understand the effects of straining to get airborne when we passed under the density altitude on aircraft performance we present obstacle point? the third article in the Engine Doctor series, adapted Doctor: Hmmm. Anyone else have that problem? from the U.S. Federal Aviation Administration Owner: Yeah, there were several other pilots I magazine, General Aviation News. knew had a struggle, but no one overshot the mark as Aircraft Owner: Doctor, I've just had a shattering far as I did. According to the theodolite experience in my aeroplane. measurement, it took me 1260 metres from starting Doctor: Not literally, I hope. roll to get up to 50 feet above the runway. If those Owner: Worse! I've been humiliated, in a public judges hadn't been friends of my partner I would place. I don't know what I'm going to do. I may never have been sure som ebody was kidding. I was so fl y again. humiliated l almost flew straight h ome after I got into Doctor: A full hour later! Doctor: No, because gravity is also a facto r here. Doctor: I see. Well, that certainly seems to be a the air. Owner: So what? T he temper ature would be The h igher you go, the weake r the gravitational pull, problem. Is there a nything I can help you with? Doctor: A painful experience, I'm sure, but also a peaking at noon , would n't it? the fewer molecules per cu bic foot; above-standard Owner: T he re sure is. You can tell me what's learning experience. Doctor: Not at this time of the year, where you temperatures also thin out the number of molecules wrong with the engine in that aeropla ne of mine, Owner: What did I learn? Seem ed to me I just had were. Rem ember , on daylight saving time the sun has per cubic foot or air. T h inn er, or less dense air, makes which you certified just last month as being okay. It let a weak engine - I could feel it was not running another hour to reach its zenith. On a clear day the the aeroplane act as though it were higher than the me down when I needed it most. It had about as much smoothly during the take-off. temperature might peak around 1400 local or later. It altimeter (or p ressure) altitude . So de nsity altitude is power as a sick kitten. Doctor: Did you have any trouble with the engine so happens I a ttended a recent density altitude clinic the altitude environment in terms of the actual Doctor: Well, I remember it looke"c.i pr etty healthy once you became airborne? like this at a place where the temperature peaked out number of molecu les pe1· volume or air, compared to me. When did th e problem develop? Owner: No, n ot after I leaned it out. at 35 degrees Celsius between five and six o'clock. with the normal or standard number of molecules, in Owner: My partner and I went to a density altitude Doctor: Aha! Did you try leaning slightly before or One chap was nearly 700 metres beyond his mark a given volume at a given elevation. In even simpler seminar at one of the outback aero clubs and they during the take-off? before he got up lo 50 feet. T he actual temperature terms, it is the equivalen t altitude your e ngine were going to have this take-off contest on the next Owner: Well no, the airport elevation was only when you took off could easily have been 28 degrees breathes. day, lo see who could come closest to getting off in the 2300 feet. instead o l' 24. That would make it . . . uh, 17 degrees Owner: Isn't the rest or the aircraft affected? distance they p1·edicted. My partner introduced me Doctor: Ah, but what was the density altitude? above standard . If you check your chart I think you Doctor: Of course, the entire aircr aft behaves in around but then he got to saying that I was an ace Owner: How should I know? will find that woul d give you about 50 metres more accordance with the density of the air - rather than pilot when it came to fl ying by numbers, and I was Doctor: The re are formulas and prepared tables needed ror yo ur take-off run. according to the elevation. When density altitude is sure to win the take-off con test. He even offered to for computing density altitude. ICyo u have a fl ight Owner: How is that? Doesn't 15 from 28 equal 13? higher d1an pressure altitude, p ropeller thrust is bet anyone in sight, and give them odds. T here computer you can work it out yourself. It is D octor: Standard temperature varies according to· reduced (so is drag, on the oth er hand), and there is weren't any takers but I guess they were just being important. On the strength or the figures you alti tude. At 2000 feet AMSL it is not 15 but 11 less lift and less resistance to the air. T rue airspeed is polite. You beginning to get the picture? mentioned, I would say that you were al about 4000 degrees. much higher than indicated airspeed, but you may Doctor: I believe it's coming imo focus. I will foot d ensity altitude. That means that for best Owner: I don't think I will ever get that straight. I t not be aware of this because nor mal indicated assume that you d id not win. Where did you rinish - performance in your aircraft it may have been just doesn't make sense Lo me that the higher the airspeed readings are still applicable fo r virtually all second ? Third? A bit further back? necessary Lo lean yo ur engine slightly for take-off. temperallffe, the higher the density. operations - stall speed, climb speed , appr oach , etc. Owner: All the .way back. I was about fortieth in a Anything less than best pe rformance wou ld extend Doctor: T hat is not how it works. Density altitude, T he giveaway is the vertical speed indicator, which field of 40. the take-off. first of all , is a theor etical concept - not a point in reads below normal in a climb. Doctor: That is discouraging. What were the rules Owner: I can 't believe that would make me go 300 space or in the sky. It happens to be \lery useful. Let's O w ner: Is that why you seem to climb so slowly in of this competitio n? merres past the mark. No way. see if we can simpli fy . You know that at sea level, at the mountains in summer - it's not just your Owner: Well , they bad Runway 19 set up with Doctor: Oh, l agree, that is only one oflhe factors. wh at we call sta ndard temperature (15°C) and imagination, and the closeness of the cliff faces? judges alongside the field and instruments so that Let's look for some others. T emperature, for p ressure (I 0 13 .2 millibars) a block of air will always Doctor: Precisely. And with a higher true airspeed they could tell how much d istance from start it Look example, is critical. Where and when did you get your have the same d ensity - the same number of you need more lateral room for manoeuvring, you to clear a 50 foot obstacle. You were penalised for temperature read in g. molecules of air per cubic foot. You also know that in especially in valleys, a nd at aerodromes with runways every extra metre yo u allo wed yourself and Owner: I took it off the OAT gauge, right about o ur atmosphere te mperature declines about two of marginal length. Overshooting is always possible. disqualified if you clicln'Ld ear that imaginary barrier noon. degrees Celsius fo r every I OOO feet you climb - more If you try to avoid this by approaching to land at a in the distance you predicted . They had one category Doctor: I see. And how soon after that did you if the air is d ry. So at 5000 feel the standard subnormal indicated airspeed, you could easily land for private pilots, and another for commercial, etc. (){' take-off? Right away? tempera ture on this same cla y would be about rive short. course I had to go for broke. Owner: Well, no, not r ight away. I believe there was degrees, and the density of the air considerably less ? wner: Sou nds like they've got you, coming or Doctor: Of course. May I assume that you made all a little de lay, we had some problem with the than at sea level. gomg. the necessary computations correctly? communicatio ns. I think I got off about one o'clock, O wner: If the air temperature is down al higher Doctor: Not really. You simply have to make Owner: You bet. At standard conditions m y local time. altitudes, would n't d ensity go u p ? appropriate allowances for the environment your

18 I Aviation Safety Digest 11 O Aviation Safety Digest 110 I 19 ail-craft is experiencing, rather than for the altitude off firmly and smoothly, holding that speed. Now you read off your altimeter. what about the climbout - what was your airspeed ? Owner: Can you ever get such a thing as negative Owner: Strictly by the book. Ten degrees of flaps density altitude - say in winter? and 82 knots, for best rate of climb. Doctor: Certainly. And not just winter, but at night Doctor: Best rate? Oh, dear. Oh , dear. or whenever the temperature fa lls below standard. It Owner: What's the matter? is computed in terms of a theoretical point below sea Doctor: I'm afraid that's where you blew it. l level. Normally it presents no problem to fl ying and wonder how many unfortunate pilots have racked up we are not even aware of it, except perhaps in terms aircraft because they confused best rate of climb witl1 of increased engine performance. There is a best climb angle. It seems that the tighter the bind the possibility, with a controllable propeller, o f poor chap gets into, as concerns surrounding terrain, overspeeding the engine, but it is sligh t. On the other the more likely he is to go to excess airspeed in an hand, I recall one occasion where I was attempting to effort to outclimb the landscape. There is some take off in a 172 in the dead of winter. T he density fateful notion that safety lies in greater airspeed, but altitude was computed by the tower as just about 3000 actually every knot you add on over the best feet below sea level. Do yo u know, I was simply unable a ngle of climb speed reduced your chances o f getting to get a rich enough mixture into the carburettor to over the obstacle. I realise the terms may be less than get off the ground? But that's rare. indicative , but somehow you must get it straight that Owner: You know I was way under max gross best rate of climb means best ve rtical rise within a weight, which is what most or these performance given time' whereas best angle or climb (with a slower computations arc based on , so that should have given airspeed) means best rate of climb within a given me a big edge, shouldn't it? lateral distance. When it comes to clearing an obstacle, Doctor: It helps, but unless you know ~xac tl y how distance is the all-im portant factor, not time. It much difference it makes in your aeroplane - it doesn't matter if it takes you an hour to get over a varies a great deal from one to another - you don't ridge, as long as you dear it safely. If you get in a want to bank too heavily on it. Let's look at some other hurry about it, you may run out of room in a hurry. factors. I-low about the wind? Owner: I guess you're right. I got so impatient Owner: Negligible - three to five knots. finally I took the fla ps off. Doctor: Straight down the runway? Doctor: Another no-no. That cost you alrj tud e. Owner: No, we were taking off on 19, and the wind Your plane's best angle of climb configuration calls was from the west somewhere - we didn't pay any for 35 degrees of naps, and there is no way of getting attention to it because it was so light. around it. Doctor: Just the same, in a critical condition, even a Owner: Okay, what else did I do wrong? very light wind off the beam could affect your Doctor: Nothing, I suspect. All those things we take-off and climb performance if you are used to a mentioned may seem of li ttle consequence ta ken head wind. H ow about the slope? piecemeal, but when you put them together they Owner: Slope? There wasn't any runway slope - at could add up to quite a bundle - perhaps enough to least that I heard about. spell the difference between survival and disaster in a Doctor: Did you ask anyone? Many aerodromes real life situation. I suggest you set up a practice The Beech Baron D55 had been hired by a football was the last communication received from the have run ways with a small degree of slope which is course at your home aerodrome and see how close club to convey five of their players from Perth to aircraft. not mentioned in any of the o fficial publicati ons you can come to flying the aircraft according to its Norseman for a game at Kambalda. The aircraft Bystanders indicated that each en gine was run up, because no safety factor is involved. But when you are specified performance ability. I'm sure you would departed from Jandakot at 0805 hours local time and the navigation and land ing lights were trying to be precise on your take-off - or when the soon see a vast improvement. with the pilot and two of the players on board. It illuminated. Take-off commenced towards the south surrounding terrain actually does make the operation Owner: I'm not so sure. I'm a slow learner. landed at Perth Airport and the other three and the aircraft appeared to become airborne in a critical - even a slight uphill slant to the runway will Doctor: Perhaps they should have given you tl1c passengers boarded the aircraft for the flight to normal manner. At about 200 feet it commenced a extend your take-off. By and large, take-offs in hill same consolatio n p rize th C)' gave the cha p who Norseman. Shortly after arrival, at about 1000 left turn, initially maintaining height, but, as the angle country or from mountain airports are made recently finished last in one of these contests. At the hours, the passengers and the pilot were transported of bank increased, tl1e aircraft descended until it downhill by knowledgeable pilots, regardless of the Awards Banquet they presented him with a seedling by coach to Kambalda. struck the ground in a steep nose-down, left-wing wind. You don't ever want to try to outclimb the tree which he was to plant beyond the runway of his During the afternoon the pilot telephoned down attitude on a northerly heading. A fierce fire terrain on take-off. choice. The idea being that in 50 years the tree would Kalgoorlie Flight Service Unit to obtain the latest broke out on impact and all occupants were killed. Owner: Not in that crate of mine. grow to a h eight of about .10 f'ee t, and by that time, meteorological forecasts for the return flight to Perth. Detailed examination of the wreckage during th e Doctor: Come, come, let's not blame the with regular practice, he would be able to lly over it He was advised that there was a probability of fog subsequent investigation revealed no defects or equipment, unl e~s we're sure our own hands arc safely. It was quite funny, 1-eally. developing at Perth, so he nominated a departure time malfunctions which might have contributed to the clean . It's a good aeroplane o r you wouldn't own it. Owner: Goodbye, Doctor. from Norseman of2100 hours, with Meekatharra as accident. There was evidence which indicated that Let's look a little further. What about the climbout Doctor: Please don't go away angry. It was all in an alternate. both engines were producing substantial power at the profi le? l'un. As a matter of fact, I suspect that he - and you Arrangements were made for additional fuel to be time of impact. Owner: Strictly by the numbers. - were the real winners ol' these competitions. added to the aircraft because or the possible The investigation did, however, reveal that the Doctor: Very good . Do you re member the airspeed Owner: H ow do you figure that? diversion. On return to the Norseman aerodrome, at elevator and aileron control lock was at least partially whe n you lifted on ? Doctor: Well, I don't think the objective was really about 2000 hours, the pilot super vised the addition of engaged. This lock consisted of a steel pin normally Owner: Negative, but I took offj ust like always - to determine the pilot who could handle al titude and 195 litres of fuel to the aircraft tanks. inserted through an alloy lug on the instrument trimmed her up and let her fl y h erself off. l never obstacle clearance problems best, do you? Wasn't the After preparing the aircraft, the pilot and panel, below the control column shaft. It was also horse it up. point to learn something about one's fl ying passengers boarded and the engines were started. It possible to lock the aileron and elevator controls Doctor: Well, that's fine, under many techniques in a way that shook you up without was a clear, da rk night with no moon and a slight, together by inserting the pin into the control column circumstances. But if the problem is to get off and up actually exposing you to any danger? And who was southerly wind blowing. The aircraft proceeded to without first passing it through tl1e lug. In this case over a given terrain obstacle, in the shortest possible more shaken than you ? tl1e northern end of the main strip. Radio the aileron controls would be locked and the elevator d istance - which ofte n happens in mountain flying Owner: No one. Goodbye again. communications were established with Perth and the control could be moved rearward from about the mid - you want to hold the aircraft on the ground until Doctor: Keep smiling. Next please • pilot reported taxying. H e was advised that there was position but could not be moved forward. you reach the best angle of climb speed, and then lift no known traffic in the area. His acknowledgement Because the lug was destroyed by the fire it was not

20 I Aviation Safety Digest 110 Aviation Safety Digest 110 I 21 r

possible to determine if the pin had been inserted Above. Control column lock correctly fitted to the same type of Beech through it; however, the pin was in place in the Baron as the one featured in the accident report. Note that the pin is inserted through the aluminium Jug, thus preventing movement of control column. Nevertheless, with th e pin inser ted in both the aileron and elevator controls. Also note the separate hood either manner , the pilot would have been denied over the mixture control knobs. aileron and at least partial elevator con trol, during both ground and air operation of the aircra ft. T he Opposite. Control column lock notinserted in the lug. This position flight path of the aircraft as described by witnesses to Jocks the aileron control but allows movement of the elevator from the accident was consistent with the controls being about neutral to the full up position. locked by either of the two method s d escribed . Title illustration: The type of control lock ficted to later model Beech T he restriction to control surface operation sho uld Barons. Note that the aluminium lug is repositioned above the control have been obvio us if preflight, vital actions had been column and the one Jock operates on the aileron, elevator and engine performed . T he cause of th e accident was therefore controls. In brief considered to be that the pilo t did no t perform adequate p reflight procedures. Whether yo u call them pre-take-off checks, T he pilot of a Cessna 172 prepared to take off from a The aircraft had struck the ground shortly after the T here could be a number of reaso ns why the pilot, before-take-off vital actions or som e o ther name, the statio n strip before first light. His destination was the lurn was commenced , in a position that would who was apparently conscientious about his operation checks recommended by the manufacturer are the local township, 40 nautical miles south west, where h e approximate the beginning of a right downwind leg. of the aircraft, could become airborne with the minimum necessa ry to ensure that the aircraft will fl y was to assist with th e u nloading of a truck which was It then cartwheeled for about 70 metres, during control lock in place. T he tardiness of the last safely, provided nothing untoward occurs. Regardless required for back loading at 0700 hours local time. which the fuselage broke behind the cabin area. No passenger boarding the aircraft, concern about a of the type or make of aircraft they all call for a full The re were no r unway lights available and evidence was found to indicate that the aircraft had been other than ser viceable. p ossible diver sion d ue to fog at the destinati on , or a a nd free check of the primary control surfaces. conditions at 0550 hours were completely black but In turning on to cou rse the pilot did not refer to his number of o the r factors could have distracted him. Without such a check yo u cannot be sure that control the pilot, who d id not hold an instrument rating, was T h e actual reason or reasons for his failure to rem ove of the aircraft is going to be possible. Wherever quite confident knowing that he h ad cond ucted this .artificial horizon a nd the turn took him away from the lock will never be kn own. possible, the control surface itself should be checked , kind of oper ation in the past and would be flying into th e east where there may h ave been some glimmer of T he design of the control column lock was not as well as the moveme nt of the co ntrol colum n, to daylight. ligh t. It should be well known that without a visual altogether conducive to safe operatio n in that visual e nsure correct operation. In cases of low ambient horizon such an undertaking can lead to checks were inhibited by the lock being under the lighting, as on this fl ight, this check sho uld be A routine d aily inspection, including a fuel dr ain disorientation and loss of control, which probably co ntrol column. O n late r m odel aircr aft the pin is conducted with the a.id of a torch to see the control check, was carried out with the aid of a torch. T he h a p pe n e~ on this occasion. H ad the p ilot been inserted through a lug above the column wi th the su rfaces, or by ma king use of any available external pilot set the altimeter to zero feet and , using the for mally train ed in nigh t flying, he would have elevator control close to its full forward position. T he lig hting such as the security lights around the tarmac la nding lights, lined up the aircraft and took off to the ?iscovered that it consists to a lar ge extent of flying by control column lock pin in this aircraft was joined by area. It may take a little more time and effort, but will south, 36 minutes befor e first light. At 300 feet he instruments. wire to the r udder lock and the mixture control lock, be worthwh ile in the long run. visually comme nced a right hand turn towards the T he pilot m ay conside1· himself fortunate that in and it would appear tha t those locks were not in An accident such as this gives tragic emphasis to the town . T he next thing he remembered was scrambling th is case the only things broken were h is aircraft and a position d uring the final operation of th e aircraft. importa nce of these pre-take-off vital actions • ou t of his very bent aeroplane. few regulations •

22 I Aviation Safety Digest 110 Aviation Safety Digest 110 I 23

I ...:I As the Captain rotated the aircraft the F 10 sighted the right hand threshold lights and commented they DC-9 lands short of runway were 'looking a bit low'. He could not remember making any further comment but the Captain At approximately 1342 hours Eastern Summer Time on an afternoon in late Spring, a McDonnell Douglas recalled that,just before impact, the F/ 0 said 'You DC-9-31 aircraft landed 192 metres short of the threshold of Runway 27 at Melbourne Airport, Victoria. are going to hit the lights'. Both pilots thenfrlt the The aircraft was conducting an Instrument Landing System approach in conditions of reduced visibility landing gear strike the ground and the approach caused by heavy rain. During the ground roll to the threshold, the main landing gear of the aircraft struck lighting. and destroyed six lights in the high intensity approach lighting system serving the runway. 0 Touchdown was in a near normal landing attitude, The aircraft was operating a regular public transport flight and there were 91 passengers and a crew of 192 metres short of the runway threshold. Six approach lights, in the last four rows leading to the six on board. No one was injured and the damage sustained by the aircraft was minor. 0 threshold, were struck by the main wheels as the The flight was operating from Brisbane to Melbourne obtain an approach Reference Airspeed for 50 0 aircraft rolled across the grassed area. The nosewheel with an intermediate stop at Coolangatta. The aircraft degrees of flap of 122 knots. He added a 10 knot probably touched down on the runway j ust beyond departed Coolangatta at .] l 5 l on an Instrument increment to this figure to allow for the reduced flap the threshold. The aircraft remained on the runway Flight Rules category flight plan. Throughout this configuration, and a further 20 knot increment to as it slowed down and taxied to the terminal under its stage the Captain flew the aircraft from the left-hand compensate for the advised strong wind gradient and own power. T he passengers disembarked by normal pilot seat. gust effect. He thus arrived at a selected approach means. As the aircraft approached the destination area, speed of 152 knots. The Captain advised the First Melbourne Airport Automatic Terminal Information Officer of this decision, but did not otherwise Service was broadcasting information Papa. This elaborate upon the manner in which the approach Meteorological information contained the following: Runway 34, wind 340 and landing would be carried out. T he crew of the DC-9 had received all the relevant degrees at 25 knots, gusting to 35 knots, QNH 1001 Over Epping locator at about 3000 feet neither enroute and terminal forecasts, including an updated millibars, temperature 22 degrees Celsius, cloud six pilot could see the runway. At about 2000 feet they terminal forecast issued at 1102. This indicated a oktas at 2500 feet with lower patches and showers in could both see the airport terminal buildings and the surface wind of 340 degrees magnetic at 20 knots, area. first half of the runway, but not the control tower. with gusts to 45 knots, visibility of 10 kilometres or At 1339:58 Melbourne Tower ad vised the aircraft greater, rain, three oktas cumulus base 4000 feet and At 1334:06 the ai1·craft made contact with that it had n o idea of the cloud base but it was quite seven oktas altocumulus/ altostratus base 10 OOO feet. Melbourne Approach Control and was immediately low, visibility was 2000 metres in heavy rain, surface • Cl • A rapid chan ge would occur between 1400 and 1600 cleared to descend to 3000 feet on a QNH of 100 l SEALED wind 250 degrees magnetic, 20 knots gusting to 30 to: surface wind 200 degrees magnetic at 15 knots, millibars in accordance with the altitude restrictions BLAST AREA knots. Runway and apprnach lighting were on stage visibility 10 kilometres or greater, rain showers, six specified in the Distance Measuring Equipment five. oktas stratus base 700 feet and five oktas cum ulus Arrival Procedures. Approach Control also advised At about 1500 feet, in increasing rain, the crew base 2000 feet. During the period 1200 to 1900 there the aircraft it had 30 nautical miles to run to adopted full instrument flight procedures. Both would be temporary reductions of up to one h our Melbourne, that the runway had bee.n changed Lo 27, pilots referred to their ap proach charts and verbally duration in visibility to 3000 metres, associated with and that it was to track via the Epping locator and the con firmed the approach minima and overshoot thunderstorm activity and three oktas of Runway 27 localiser. Twenty seconds after procedure. T he r ain continued to increase in cumulo-nimbus, base 4000 feet. Surface temperature acknowled ging this instruction, the aircraft was intensity and at Giboul l OOO feel the wi ndshidd wipers and pressure over the forecast period were advised that the wind was coming around to the west 9• were turned on. Both pilots stated the aircraft was 23/ 16/ 15/ 14 degrees Celsius and at 30 knots. then aligned with the localiser and on glideslope. At 1002/1004/1006/ 1008 millibars respectively. GRASS The rapid change in surface wind was associated 800 feet (400 feet above ground level) the F/ 0 called Bureau of Meteorology procedures require that a with the passage of a cold front, crossing the the descent rate, in accordance with standard forecasting service be provided in respect of low level Melbourne area from west to east at about 30 knots. company procedures. To the best of his recall it was wind shear. Although conditions associated with the The front had been forecast to cross Melbourne about 650 feet p er minute. He also advised the frontal passage indicated a high probability of wind Airport between 1400 and 1600. ATC had issued an - shear a forecast to this effect was not issued. Captain that he h ad the high intensity approach lights LEFT AND RIGHT MAIN Operational Requirement for aircraft a rriving in sight. The Captain looked out and also saw th e LANDING GEAR GROUND Observations at Melbourne Airport at 1300 noted between l 130 and 1930 to carry additional fuel lights. MARKS conditions substantially the same as the forecast. By reserves because of the weather conditions associated From this point both pilots concentrated their 1330 the low level cloud had increased to seven oktas with the frontal passage. The DC-9 carried sufficient attention primarily outside the cockpit. The Captain at 3000 feet with lower patches. A marked roll cloud fuel to divert to Sydney. stated he supplemented this with instrument cross and heavy rain was visible approaching from the west. At 1336: 19 the aircraft was advised that the QNH checks down to about 200 feet AGL, while the F/ O About 1334 the front crossed the airport, the wind was now 1002.5 millibars, visibility 2000 metres in stated he stopped monitoring his instruments about backing to 240 degrees magnetic at 28 knots with heavy rain, wind from 240 degrees magnetic at 30 300 feet AGL. At this last instrume nt check the ' gusts to 39 knots. Approximately one minute later knots with gu sts .r.o 40 knots. The aircraft had 18 Captain recall ed the a ircraft was still close to glide -~- heavy rain commenced and a total of 12 millimetres nautical miles to run and was clear ed for ILS final on slope. H e also stated that about 400 feet AGL the was recorded in the next 20 minutes. At about 1336 Runway 27. Nine seconds later the aircraft was aircraft encountered wind shear. Both pilots recalled the surface pressure rose two millibars to 1005 further advised that QNH was 1005 millibars, cloud approximately 12 degrees left drift at this time. millibars over a 30 second inter val. cover six oktas at 1500 feet with lower patches and Visibility ah ead was poor. Despite operation of the • CJ - By 1400 conditions had moderated, and some 20 temperature 17 degrees. wipers, the rain on the windshield blurred the pilots' minutes later the rain reduced to occasional showers, As a result of the rapid ch anges in QNH and vision, a nd both stated the approach lights were badly l 0 0 l 0 20 30 40 with visibility of 25 kilometres and no cloud below surface wind, the Captain considered there was a diffused. Neither could see the runway ahead and METR E S 1500 feet. probability of encountering wind sh ear during the they concentrated on scanning for the green The aircraft was twice advised that visibility was approach. As a precaution he decided to make a threshold lights. 2000 metres. Aerodrome controllers and faster than normal approach with only 25 degrees of At an estimated J 00 feet AGL, still without visual meteorological observers refer to a series of flap extended. The calculated land ing weight was contact with the threshold lights, the Captain stated landmarks at known distances from the control tower 40518 kil ograms (2709 kilograms under maximum) he sensed the aircraft sinking rapidly. He attempted to estimate visibility. It is a requirement that when a nd the Captain referred to the 90 OOO pounds to counter this by pulling back on the control column, visibility is less than 2000 metres, Runway Visual (40 823 kilogr ams) landing weight Data Card to but did not increase power. Range is used. This information is obtained by

24 I Aviation Safety Digest 110 Aviation Safety Digest 110 I 25 despatching an officer to the runway threshoid to to 255 degrees mag netic was then made, and this the pilots regarded this sudden deterioration as a occasion the visibility from the tower was probably gauge RVR by reference to specific assessment lights. caused the aircr aft to deviate left of the localiser by transitory event. Subsequently they had the first half 1100 to J 500 metres. A specific reason for the There was evidence that for a period the visibility one dot on the course deviation indicator (each dot of the runway in sight from 2000 feet and this may incorrect advice was not established, but probably the reduced below 2000 metres. At about 1339 the equals 1.25 degrees oflocaliser deviation). have been an influence. Instrument procedures were Aerodrome Controller had restated his initial visibility from the tower was probably about 1100 Immediately after this turn the rate of descent not fully implemented at 1500 feet when the crew evaluation and had n ot assimilated the visual cues that metres to 1300 m etres, and at 1340 the increased to about 1500 feet per minute, and this accepted that a visual approach was not p ossible . This indicated the fi gure of2000 metres was no lo nger Meteorological Observer in the control tower expedited closure of Lhe glideslope. However as the was co n side r ~d a major facto r in the incident. The valid. As an RVR assessment was not made, it was not recorded the visibility as 1500 metres. However , the high descent rate was maintained the aircraft passed monitored approach proced ure was no t initiated, and establish ed ifthe minimum req uired 1200 meu-es Aerodrome Controller did not despatch an officer to through the glideslope at approximately 38 seconds. the lack of detailed alternate procedures in the existed at the time of the incid e nt. Had an RVR of less the Runway 27 threshold to assess the RVR. At this time a right turn to h eading 267 degrees Operations Manual cou ld possibly have been an than 1200 metres been determined , then the runway magnetic was commenced . influence in the resultant unco-ordinated actions by should have been closed. Alternatively, an assessment Ground facilities By 30 seconds the aircraft was some two dots below the fl ight crew. This omission was not classified as a of 1200 metres or greater would have permitted Runway 27 has a Calvert pattern high intensity glideslope and approaching the minimum altitude of factor in the incident in view of the crew's general authorisation of the approach a nd landing. The approach lighting system with associated runway 700 feel. The descent was halted and this altitude neglect of published procedures. advice of marginal RVR accompa nying such a lighting, variable over six stages, to ICAO Category 2 maintained until the aircraft was back on glideslope al [ t could not be establish ed what cross checks, if any, clearance might have provided a timely warning to standard. T he th1-eshold is marked by a row of green about 20 seconds. The d escent was then resumed at occurred as required by the Operations Manual. the crew of possible lack of outside reference below lights flush with the surface of the runway and spaced an initial 1-ate of900 feet per minute. Throughout Either the F/ O did not monitor the instruments, or he minimum altitude. It was concluded that the at intervals across it. The ILS is Category 1 standard this period the IAS remained in the 17 5- 180 knots noted the abnormal indicatio ns and elected not to Aerod rome Controller's omission contributed to the with a glideslope angle of three degrees. The range. alert the Captain, or, having issued the alerts, was incident, but only insofar as the flight crew was not associated middle and outer marker beacons and the During the last 20 seconds of fli ght the rate of ignored by the Captain . Whichever was the case, it provided with secondary information to ass ist in Epping locator are aligned with the centreline and are descent increased and averaged some I I 00 feet per was evidenL that a major breakdown in crew assessing the adequacy of landing visibility. I 074 metres, 6963 metres and 15760 metres minute over this period. The aircraft remained co-operation and co-ordination occurred during the There were no abnor mal pressures on the flight respectively from the threshold. approximately on localiser but rapidly dropped below approach . crew to complete the flight with out delay, but the All navigation aids and lighting systems were glideslope. The IAS fluctuated downwards, but at It was consid ered that fi nal approach shou ld have evidence suggests that ther e was some haste in the operating normally and the minima applicable to this touchdown was still 17 1 knots. been delayed, at least lo ng eno ugh to evaluate the manner in which the approach was flown. A approach were 700 feet ceiling (293 feet above rapidly changing weather situati on , and plan and non-sta ndard configuration of25 degrees of flap was Runway 27 threshold) and 12 00 metres visibility. Op_erating procedures brief appropriate instrument approach p rocedures. chosen and a high selected approach speed of 152 The Operations Manual implied that the approach knots calculated. T hroughou t the approach an IAS of Flight path Company operating p rocedures required cross should have been abandoned wh en stabili ty, some 20 to 30 knots higher than that selected was checking between the two pilots, and alerting by the From the Flight Data Record er trace and particularly in respecl of approach speed, had not pilot not fl ying of IAS variations of fi ve knots from maintained. meteorological analysis the a ircraft was determined to been established by 700 feet AGL. the selected approach speed and of r ates of descent in It is possible that the excessive airspeed reflected a have passed through the front at 1340: 50, 70 seconds The decision to continue beyond the minimu m excess of 800 feel per minute when below 1500 feet lack of familia1-ity with, or consideration of, the before to uchdown. altitude was dependent on the Captain's assessment above aerodrome level. Aircraft were also required to aircraft's performa nce in the 25 degrees flap T h e following reconstruction of the approach was that adeq uate conditions existed for visual fligh t, and be established o n glideslope in the landing configuration. Simulator tests indicated negligible made. All times are in seconds prior to touchdown. that forward visibility was 1200 metres or greater. difference in body angle and required power between The aircraft passed over Epping locator at 175 configuration at the selected airspeed not less than Flight visibility at the m inimu m altitude could not be 700 feet above airport level. the 25 degree fl ap/ 170 knot IAS and the 50 degree seconds, descending through 2950 feel on a heading precisely established but was considerably less tha n The Company's standard instrument approach flap/ 140 knots IAS approaches. If during the of 268 d egrees magnetic but closing the localiser from thaLn ecessary to fl y by external r eference a lone. It procedure was the monitored approach. In this approach the Captain had selected an attitude and the north under the influence of the strong northerly was conside1-ecl that failure Lo recognise that situatio n procedure the F/ O fl ies the approach a nd remain s power setting equating to the 50 degree flap wind. IAS was about 235 knots and decreasing. and to initiate a go-around was the primary causal 'on instruments' thr oughout the approach, even ifthe configuration with which he was more familiar, then Glideslope was captured from below at 165 seconds. factor in th e incidenl. aircraft e nters visual flight conditions and the Captain the aircra fL would have ach ieved an airspeed of the Descent continued with mino r deviations of about I n considering the circumstances of the fi nal large assumes physical control to complete the landing. order recorded on the FDR. half a dot on the glideslope (each dot equals 0.25 deviatiou belo w glideslo pe, it is significant that The Company Operations Manual covered this T he use of the reduced flap approach is not a degrees deviation) until 95 seconds. During this neither pilo t mo nito red the aircraft instruments. By procedure, reaffirming the cross ch eck requiremenls commo nly accepted counter for wind shear. This period the localiser was captured and maintained al atternpLing Lolly solely by reference to the runway laid out in the general section covering all particula r approach , with the wind backing from the an aircraft heading of 275 degrees magnetic. The IAS approach lights the crew risked theirj udgment being approaches. It also stated that the monitored no nh to the west, encountered a predictable had continued to decrease but al a slower rate and al influenced by illuso ry effects resulting from the heavy approach procedure could be d iscontinued any time overshoot shear cond ition. A reduced flap and higher 95 seconds was about I 80 knots, still some 30 knots rain o n the windshidd. Research in to this at the Captain's discretio n. airspeed would compound the problem of recovery as above the selected apprnach speed. T he aircraft phenomeno n indicates a depression of the 'horizon' T he Company Flight Training Manual instructed a g reater power reduction would be necessar y to altitude was about 1830 feet; an average rate of by up to I: 12. The gradient from the 'on glid eslope at that VRef be increased in stron g wind conditions by correct for the u nwanted e nergy gain. The lack of descent since passing Epping locator of 840 feet per minimum altitude' point to where the aircraft 50 per cent of the gradient wind plus I 00 pe r cent of 1-eference material on wind shear in th e operator's minute. T he re were still som e 8000 metres Lo run to tou ched d owu \\·as I: 14. Whilst no t concl usive the gust factor, Lo a maximum total of 15 knots. T his manuals lefl the fo rmation of the best approach the runway threshold. evidence of visual illusory effect, it was considered The rate of de.scent was then reduced and the maximum had been reduced from 20 knots some procedure to the Captain, possibly based on au this possibility could not be excluded. incomplete understa nding of the wind shear aircraft began to deviate above the glideslope. At the four weeks prior to the incident. same time a left turn of approximately fi ve degrees Both manuals indicated that landin gs were to be phenomeno n. was m ade and the aircraft also began to deviate left of made with 50 degrees of flap extended. The only Analysis The omissio n of a pre-approach briefing and the the localiser. T h e Outer Marker was crossed at 83 exception was for single-engine approaches when flap Ge neral meteorological conditions were essentially as delay in checking the approach charts until about seconds. At 75 seconds the aircraft encountered wind ·extension was to be limited to 25 degrees. In this case forecasl. Frontal passage was earlier than predicted . 1500 feet on final approach ind icated that the pilots sh ear associated with passage of the front. The IAS the VRe f for 50 degrees flap should be increased by Ground visibili ty was reduced to between 1100 a nd were largely employing non-instrument procedures:··· increased approximately 15 knots to 195 knots over a I 0 knots and there would be a markedly h igher body 1500 metres at the time the aircraft made its T heir in itial arrival expecta ncy was probably based on 10 second period. T his was accompa nied by a brief angle, of abouL six degrees, on approach . Neither approach , rather than the 3000 metres forecast. T h e infonnation Papa, which ind icated visual flight pause in descent which caused the aircraft to be manual contained inslructions lo be followed when Bureau of Meteorology omitted to issue a forecast of conditions could reasonably be expected no lower displaced some two dots above glideslope. wind shear was expected. wind shear as was required. This was not considered than 2500 feel. The aircraft then entered a descent at about 1200 T h e first information to indicate a need for IFR to be of sig nifican ce as the crew were aware of the T he Captain r eported that h e 'sensed' the aircr aft feet per minute and began to turn to the left. Drift to procedures was at 1336: 19 wh en the aircraft had probabili ty of wind shear on fi nal approach . sink. This was probably the resu lt of wind gust effects. the left had ceased and the localiser was closed at some 30 ki lo metres to run, and Approach Control T wice d uring the approach the aircraft was advised It seems likely that the Captain recognised a gust .approximately 60 seconds. A more rapid left turn on advised of reduced visibility and heavy rain. Possibly that visibility was 2000 metres. On the second induced sink in sufficient time to rotate the aircraft to

26 I Aviation Safety Digest 110 Aviation Safety Digest 110 I 27 approximately a normal landing attitude, but not pilot-in-command felt uneasy about d isagreeing, of the PA system and cabin attendants, if available, sufficiently early to significantly reduce the final rate particularly with the owner's wife also on board the will also ensure that instructions are complied with as of d escent. The F / O 's warning calls may also have From the aircraft. Consequently, he virtually relinquished his required. cau sed the Captain to apply back-control input. responsibilities as pilot-in-command, i.e. to ensure the The lesson to be learnt from this incident applies Consequently the touchdown was not sufficiently safety of the aircraft and its occupants. equally to private or commercial operations, in small severe, or in such an attitude, as to cause structural incident files It is essential that whenever there are two pilots or large aircraft. A pre-fl ight briefing or even a short failure. occupying the control seats of an aircraft, the division PA announcement may have prevented this of responsibilities must be clearly defined and, in passenger's injury. The incid ent could also serve as a Conclusions particular, it must be understood which pilot is in useful example for pilots to present to their The investigation into the incident reached the comman d. This aspect of flying safety is of paramount passengers as evidence of the degree of possible following conclusions: significance when a pilot, other than the injury which may be suffered if warning signs are not 1. A T C provided the aircraft with advice of the pilot-in-command, has some vested interest in the heeded • rapidly changing weather conditions at the airport, Who has control - the pilot-in-command or the aircraft or its operation. except that the minimum visibility advised was 2000 owner? If you are pilot-in-command, assert your authority Impati ent pilot plus fl at no sewh eel oleo results metres when actual ground visibility from the tower The aircraft was on a private VFR flight; on board whenever this is necessary and ensure that you retain in suspected control problem was probably in the range 1100 to 1500 metres. were the nominated pilot-in-command who held a control of the operation of the aircraft at all times • 2. ATC did not comply with procedures that private pilot licence, the aircraft owner who held a About five minutes after departing Parafield in his required the assessment of RVR when visibility was restricted PPL and the owner's wife, occupying a back Cessna 206, the pilot advised Adelaide Flight Service below 2000 metres, and the determination that RVR seat. that he was returning because of a suspected rudder was at or above the specified minimum of 1200 The flight proceeded normally from the departure Lack of briefing leads to passenger injury trim malfunction. He confirmed that operations were metres before authorising an approach and landing. point to an en route stop for fuel. One hour and 25 otherwise normal. In accord ance with standard 3. The company's manuals did not contain minutes after departing from the refuelling stop, the The Piper Navajo was on a scheduled service and was procedures, an Uncertainty SAR phase was declared procedures to be adopted when wind sh ear was pilot passed a position report to Flight Service with an cruising at 1500 feet when it encountered some and the Fire Service alerted. T he aircraft landed encountered or expected. Nor did they contain estimate for his destination in another 15 minutes. isolated, severe turbulence while passing between two normally and the phase was cancelled . procedures to be employed whe n a Captain elected Nineteen minutes later the pilot reported that he was rain showers. One of the passengers, an elderly During the investigation it was established that the not to carry out the monitored approach procedure. unsure of his position. After liaising with a cou ntry gentleman, was thrown up from his seat and struck pilot had unexpectedly arrived at the servicing 4. The Captain elected to make a landing approach police station, Flight Ser vice established that the his head on th e overhead lights, receiving a severe organisation, late in the day, to collect the aircraft and during the p eriod of frontal passage and selected a aircraft was over an aerodrome about 40 nautical gash. The passen ger was not wearing his seat belt. fly it back to base. Durin g his preflight inspection he non-standard configuration of 25 d egrees flap. This miles short of its destination. The aircraft landed Investigation of the incident revealed that the seat noticed that the nosewheel oleo strut was flat. The was unsuited to the predictable conditions met. there safely, nearly an h our after its ETA at the belt sign had been illuminated throughout the flight LAME, who had left for his home, was sent for but 5 .. A detailed approach briefing was not carried out destination. but the pilot had not briefed the passengers about the the pilot decided not to wait as the aircraft was loaded pnor to commencement of the approach , nor was the Subsequent investigation of the incident revealed use of seat belts either before flight or over the public with some refrigeration equipment which was specified Monitored Approach procedure ad opted. that, after the refuelling stop, there was a address system during flight. There was no cabin required urgently back at base. The LAME returned 6. The approach was unstable throughout, with IAS considerable amount of smoke haze which restricted attendant on board . T h e injured passenger suffered to the airport just as the aircraft was d ep arting. generally some 20 to 30 knots in excess of th e selected visibility along track. Because of this haze, the aircraft from poor vision as a result of a past double cataract When the aircraft returned after the incident, the approach speed. was ~limb ed to 6000 feet; the pilot informed Flight eye operation . H e wore dark glasses and could not see pilot reported that the rudder and pedals had gone over to one sid e. The system was thoroughly checked 7. Wind shear associated with the frontal passage was Service of the amendment from the planned altitude the seat belt sign. It appears that he had not worn his encountered at an altitude of approximately 1650 of below 5000 feet. The pilot-in-command was seat belt at any stage of the flight. After the aircraft and it was concluded that, because of th e flat oleo, the feet, about eight seconds after the aircraft passed over navigating the aircraft and the own er was flying from landed a doctor attended to tlle passenger's injury lower-than-normal pressure had prevented the nose the outer marke r beacon. As a result the aircraft the left hand seat. which required twelve stitches. strut from extending and locking in the fore-and-aft position after lift off. The fact that the nosewheel was became displaced from the glideslop e but the correct The two pilots believed they had identified the first T h e impor tant lesson arising from this unfortunate d escent profile was re-established at about the two check points; however, a subsequent examination incident is th at any pilot in charge of an aircraft still free to turn prevented the steering bungee from minimum altitude. of the flight plan sh owed that the first leg of 26 miles carrying passengers should ensure that all means providing a self-centring force to the rudder system, 8 . The approach was1continued below th e minimum was covered in 17 minutes, i.e. a grou ndspeed of 92 possible are used to alert them to hazardous possibly accentuated by air flow over the unlocked altitude although external reference to safely knots, while the second leg of 33 miles was supposedly situations. Preflight briefing on the use of seat belts, nosewheel. The nose oleo was inflated and the system operated complete a visual landing had not been established. covered in 13 minutes, i.e. a groundspeed of 152 observation of warning signs, use of emergency exits, T he existing flight visibility was less than the specified knots. On this basis it seems most unlikely that both etc., should be conducted before every flight. Never normally. New 'O' rings were subsequently fitted to 1200 metres minimum. check points could have been properly identified. assume that passengers know about these things. Use the oleo strut • 9. There was a major breakdown in crew It is questionable that, after the first check point, co-ordination. As a result the flight instruments were the pilots obtained a positive fix. Although the owner not monitored below the minimum altitude. had not commenced his navigation training he had 10. The aircraft's rate of descent increased to read about the radio compass and had been taking average approximately 1100 feet per minute during ADF bearings throughout the trip. Instead of ~ e final 15 seconds of flight. An illusory effect, maintaining fligh t planned headings and map DURSTIN by Russ Day (courtesy of Flight Crew magazine Spring 1979) ind uced by h eavy rain on the windscreen , and wind reading correctly, the owner was attempting to gust activity may have contributed to this high rate of navigate using the ADF. G~E.N eR.Ass... "-'f: descent. The pilot-in-command, although not formally WAR/<\ BREEZES . • ·:: trained on the u se of the radio compass, did know ' Cause that wh en tracking to a station it was not satisfactory T he probable cause of the incident was that the just to keep 'the needle on the nose'. This was approach to land was continued below the minimum apparently what the owner was doing. As the fl ight altitude, when external reference was insufficient to progressed, the pilot-in-command virtually gave away permit the completion of a safe la nding. • the navigation of th e aircraft to the owner. T h e situation in the aircraft was rather tense with the pilot-in-command wishing that the owner would (Condensed from Department of Trr111s/HH"l Incident !11vestigatio11 R port No. 79-2.) turn off the radio compass and concentrate on fl ying the correct headings. T he owner was rather insistent about the way the flight was to be conducted and the

28 I Aviation Safety Digest 110 Aviation Safety Digest 11 O I 29 Survey of accidents to Airline operations Accidents, aircraft damage, injuries and accident rates -1974-1978 Australian civil aircraft 1978 1974 1975 1976 1977 1978 The Australian aviation industry is obliged to report substantial random fluctuations in accident numbers Accidents all accidents a nd incidents involving civil aircraft, and from year to year, as may be seen from the tables. Involving fatalities 0 1 0 0 0 Involving serious injury 1 0 0 0 the Department's air safety investigation system is General aviation activity has increased at a rate of 2 Involving minor/no injury 1 3 0 0 based on this premise. The article 'Air Safety incident about six per cent per year ove1- th e period covered by Total 3 5 0 0 reporting - the Australian system' in Aviation Safl'ly the graph and the accident rate p er J 00 OOO hours Aircraft damage Digl'st I 09 explain ed the way in which accident and flown has decreased at about five per cent per year. Destroyed 0 1 0 0 0 incident reports arc stored and used. Provisional figures for 1979 indicate that this trend is Substantial 1 3 0 1 0 One source of accident prevention information is being maintained. Minor/none 2 0 0 0 the statistical analysis of recorded accident/ incident Fatalities data. A Survey ofAc cidents to Australian Civil Aircraft is The following data refers onl y Lo ai1-crart accidents, the Passengers 0 8 0 0 0 published annually by the Air Safety Investigation de finition of an accident being: Crew 0 3 0 0 0 Total 0 11 0 0 0 81-anch of the Department; the 1978 edition was Fire after impact recently released and is available from o utlets of the An occurrence associated with the operation or an Fatal accidents 0 0 0 0 0 Australian Government Publishing Service. IL aircraft ll'hich takes place between the time that any Non-fatal accidents 0 0 0 0 0 contains a wealth of statistical detail in respect of the person boards the a ircraft with the intention of flight Injuries 1978 accident record, including types of accident, until such time as all persons have disembarked, in Fatal 0 11 0 0 0 pilot experience, assigned factors and so on, for which, Serious 3 1 0 0 0 Minor/none 155 220 0 381 0 airline, general aviation and gliding operations. (a) a person is fatally or seriously i1~j ur ed as a result Hours flown {thousands) 399.4 393.1 357.0 362.6 370.4 The Survey also contains a section devoted to a of being in or upon the aircraft or by direct Accident rates review of accident rates and activity data over past contact with the aircraft or anything attached (per 100 OOO hours flown) years for all categories of airline a nd general aviation thereto, except when the injuries are from Total 0.80 1.35 0 0.29 0 fl ying, thus giving an indication of the changes which natural causes, are self-inflicted or inflicted by Fatal 0 0.27 0 0 0 have occurred in fl ying activity and accident rates other p ersons, or when the injuries are to Number of aircraft on over th e p ast ten years. The 1978 Survey marks a stowaways hiding outside the areas normally register at 30 June 157 156 151 145 136 departure from previous editions in that accidents to available to the passengers and crew; or , Australian registered aircraft based in Papua New (b) the aircraft incurs substantial damage or is Guinea prior to that country's independence in 197 5 destroyed; or, have now been removed from the statistical (c) the aircraft is missing or is completely inaccessible. General aviation operations p resentation. The result is a more accurate picture of (A n aircraft is considered to be missing when the Accidents, aircraft damage, injuries and accident rates - 197 4-78 trends applicable to p1-esent Australian operations, official search has been terminated and the and our reade rs may be imerested to see the graph wreckage has not been located.) 1974 1975 1976 1977 1978 and tables presented here. Accidents The graph in particular gives a picture of the Total overall trends in general aviation. Five year periods 234 190 243 221 249 Fatal 17 12 19 19' 27 are used for trend assessme nt because there can be Aircraft damage Destroyed 33 28 32 30 49 Substantial 199 162 21 4 188 199 Five year averages of general aviation accident and fatality rates. Minor/none 4 2 0 4 2 Fatalities 1969-78 Crew 18 12 21 18 26 Passengers 21 15 32 20 26 7.0 MILLIONS Others 0 0 0 5 6 HOURS •• Injuries 6.0 TOTAL •• •• In Aircraft 5.0 •• Fatal 39 27 53 38 52 Serious 18 21 13 12 31 Minor/none 489 405 542 457 544 4.0 On Ground Fatal 0 0 0 5 6 Serious 1 0 1 5 0 3.0 - Minor 3 0 0 3 Fire after impact Fatal accidents PER FATAL ACCIDENT 5 6 7 4 10 FATALITIES --~--._._ --~..-. ~--~~~--..--- Non-fatal accidents 6 4 5 2 6 ~ .._..._.._.,._ .__ ...... -- -.------~._, Hours flown (thousands) 1 150.8 1 206.8 1 346.6 1 512.8 1 518.4 2.0 -TOTAL Accident rates ACCIDENT (per 100 OOO hours flown) RATE PER 10 OOO Total 20.33 15.74 18.05 14.61 16.40 . HOURS FATAL Fatal 1.48 0.99 1.41 1.19 1.78 ACCIDENT--·- • RATE PER Number of aircraft on 100-·- ooo HOURS·- register at 30 June 3 887 4 113 4208 4 726 5 250 *Includes one suicide; not included in accident rates ..... 3 1970-7 1971-75 1972-76 1973-77 1974-78

28 · r1. viation Safety Digest 110 Aviation Sarety Digest 11L, · '29