What can we learn?
Sorry – nothing new.
Just a reinforcement
of the same old, same old:- Stick to the rules.
- RTFM.
- Understand the machinery
that keeps you aloft. - Instructors – your pen can
be an executioner’s axe.
Aiming to make safer pilots of us, here veteran instructor Jim Davis looks at extracts
from official CAA Accident Reports from his homeland of South Africa and analyses
why things went wrong and how we may all avoid making similar mistakes.
australianflying.com.au 79
November – December 2017 AUSTRALIAN FLYINGJim’s Analysis
Does dropping one’s jaw and
gaping at the report count
as a comment? If not, see my
comments below, in italics.
Oh dear, oh dear, oh dear, what
a terrible mess. Both the pilot and
the accident report.
Remember the old saying: “there
are old pilots, and there are bold
pilots – but there are no old bold
pilots”? This guy has gone out of
his way to prove it stone wrong.
I do have one question. It says
the pilot’s licence was valid. Who
did his last renewal test? This sort
of sloppiness, and disregard for the
law, simply has to be noticed by a
half-way vigilant testing officer.
Instructors – signing your name
on your mate’s f light-test form,
may be signing his death warrant.
Extracts from the
full report, with
Jim's comments
The pilot was given clearance
to taxi to the holding point of
runway 29.
(For crying in a bucket – why 29?
It is further to taxy, and it is directly
downwind.)
The information available in
the pilot’s file and logbook shows
that the pilot was not rated on this
aircraft type, nor did he have a
multi-engine rating on his licence.
There is also no information to
show that the pilot had ever f lown
this type of aircraft.
(Do I need to comment or just
bang my head on the f loor?)
The last recorded MPI on this
aircraft was on 28 March 2002 at
a total of 5662.57 airframe hours.
The left engine had 1805.97
hours since overhaul and the right
engine also had 1805.97 hours
since overhaul.(This simply has to be logbook
gyppoing. Show me two engines that
have exactly the same time, and I
will show you a Parker pen.)
The Certificate of
Airworthiness of this aircraft
had been cancelled due to a lack
of maintenance records for the
aircraft. This was also done due
to non-payment of fees owed
to SACAA by the owner of the
aircraft.
(This sounds like a shortage of
bucks could have been the reason for
lack of maintenance.)
An application for a special
f light permit was completed
on 4 April 2003, requesting
that the aircraft be f lown
from Krugersdorp (FAKR) to
Wonderboom (FAWB) in order
to carry out an MPI. The SACAAissued the special f light permit
Number J15/DTK on 4 April
2003 with an expiry date of 16
April 2003.
(So the crash happened more than
five years after the Permit to Fly
expired.)
There is no record of such f light
taking place and there also is no
record of the MPI. In the engine
log books there is a record of the
overhauling of two carburetors
(serial numbers R-6B-2217 and
R-9-5509) from the accident
aircraft, and this is dated 27
March 2008.
(Ah, so the carbs were overhauled
two months before the accident.
Good move Mr Pilot.)
The aircraft veered to the right
of runway 29, entered into an
uncontrollable spiral dive and
impacted with the ground with
the right wing followed by the
nose dome.
(Come CAA – did a spiral dive
really occur as the aircraft lifted off
the runway?)
The aircraft travelled for 30.3
metres from the point of initial
contact with the ground to the
final point of coming to rest.
(Talk about the luck of the devil.
The aircraft would have made a
neat hole in the ground had the fuel
held out for another minute and
taken him to a thousand feet or
more. Then there would indeed have
been a spiral dive.)
When the wreckage was
examined at the time of the
accident, it was noted that both
fuel selectors were selected to the
outboard main fuel tanks. The
outboard main were empty as
evidenced by the fact that there
was no fuel in both carburetor
bowls.
The abovementioned factors
point to both engines losing power
at about the same time, due to fuel
exhaustion.
(Wake up Mr CAA – the Aztec
has no such things as “outboardmain tanks” – there are mains and
auxiliaries. You are making the same
unforgivable mistake the pilot made.)
The pilot was not rated on this
aircraft, nor is there any evidence
of him ever having f lown the type
before the accident.
The pilot therefore did not
understand the fuel system, hence
the wrong selection of the fuel
tanks.
(This is the bit that really gets
to me. The CAA feels that a
licenced pilot, who owns an aircraft
maintenance setup, wouldn’t
understand the fuel system on an
Aztec. Really? Folks, look at my
photo of the fuel selector. And the
fuel gauges automatically indicate
the contents of the tanks selected.
The General’s dog could get it right.)
On-site investigation revealed
that the f laps had been selected
down (landing position).
The f laps on this aircraft have
two position settings, i.e. either
in the up or in the down position
and according to the owner’s
handbook, the f laps should not be
used on take-off, thus should be
selected to an up position. Page 30
last paragraph, “Take-Off ’ in the
Owner’s Handbook.
(A simple case of RTFM – Read
The Flight Manual. Actually it
makes pretty much no difference on
an Aztec – particularly a light one.
She leaps off the ground happily –
with or without flaps.)The aircraft
would have
made a neat hole
in the ground
had the fuel held
out for another
minute.