A year of mistakes. PPL/IR Europe AGM. Coventry, 9 April 2011

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1 PPL/IR Europe AGM A year of mistakes Coventry, 9 April 2011 Note: this material is private and for PPL/IR Europe members only, primarily those who attended the meeting. The slides were used as aids in a presentation and the content is not complete without the accompanying commentary.

2 Mistake (1) Preflight Failed to notice misadjusted Elevator trim 1.1 During inspection Following minor paint damage (see next mistake), Paint Shop had removed and refitted the elevator Subsequently, noticed that neutral Elevator trim indication was incorrect. Maintenance were asked dto adjust and advised dthey had ddone so Prior to a solo flight IFR, did not notice that with the pitch trim indicator in the Take-Off position, the trim tab was deflected up, rather than flush with the elevator The aircraft felt perhaps nose-heavy on the take-off roll, and distinctly nose-heavy after liftoff. The take-off was aborted after a few seconds airborne and the aircraft landed on the 7000 runway uneventfully Maintenance readjusted the pitch actuator at the tab, and the position and feel returned to normal Pitch trim indicator in normal T/O position (with parallax due camera angle) 2

3 Mistake (1) Preflight Failed to notice misadjusted Elevator trim 1.2 Lessons Learned It s easy to get complacent about the preflight inspection. Mine had reverted to really a check of oil-fuel-baggage lockers and no damage obvious Any maintenance event relating to the Primary Controls of the aircraft must be thoroughly checked by the pilot. A control problem is often life-threatening. All the warning flags were there, but I just ignored them. It was obvious a more thorough Trim check was needed. I had confidence in the maintenance people, but maintenance is not a deterministic science. I watched the engineers subsequently inspect the trim tab travel angle with a digital instrument and it was absolutely within limits and centred. Only a tiny adjustment was responsible for the very different control feel The take-off brief is important. The aircraft was controllable and a small trim adjustment would have neutralised the unusual pitch load. However, with plenty of dry runway ahead, I preferred to land. On a wetter or shorter runway, the right decision might have been a circuit to land...or to continue? Discuss. 3

4 Mistake (2) Taxiing Minor damage to own aircraft and parked PC Situation of parked aircraft Taxiway Desired direction of taxiing Wings totally clear mental box ticked Apron boundary, can not move forward without taxi clearance Tailplane well clear, especially given distance to taxiway, another mental box ticked Hangar 4

5 Mistake (2) Taxiing Minor paint damage to own and parked aircraft 2.2 Accident Taxiway Desired direction of taxiing 3. Taxis with Port Engine power and Stbd brake engaged, to minimise propwash p on the 2 SEP crew 4. Out of habit, taxis with yoke full aft 2. Waiting for taxi clearance, worried that propwash from Stbd engine is unfriendly to SEP crew 5. Outboard tip of raised elevator scrapes Radome lower surface of PC12 Hangar 1. After 421 engine start, two crew appear by parked SEP, fitting cover 5

6 Mistake (2) Taxiing Minor damage to own aircraft and parked PC Lessons Something is always there to catch you out, just when you are feeling good (great weather, easy solo trip...) Turning geometry of aircraft on the ground is not intuitive (especially twins with asymmetric power). Whilst parked parallel, the clearance between 421 tailplane and PC12 wing looked deceptively good Be careful not to tick mental boxes and dismiss risk elements too early Be careful not to let new factors introduced into a scenario distract from the existing factors they haven t gone away Do not let trying to be nice/friendly/airmanlike distract from your essential priorities as an aircraft commander 6

7 Mistake (3) Departure Departed on the wrong track from Milan Linate 3.1 Events I was very familiar with Linate, and expecting the SRN 7A, which I d always had previously Prior to receiving the clearance, I had the plate ready and loaded the departure into the GPS I received and read back SRN 6D I properly briefed and set-up the departure but for the SRN 7A ATC noticed the 340 track and queried it soon after take-off I acknowledged d the error and established on the SRN 6D 7

8 Mistake (3) Departure Departed on the wrong SID from Milan Linate 3.2 Lessons (In this example, Linate does not have a Clearance Delivery frequency, and it is possible for GND to give you a clearance late, as you are taxiing to the hold. At this point, you are under pressure to self-brief and set up the SID, with aircraft in sequence behind you) Do not over-stress a priority, it allowing it to overwhelm others. My over-stressing the be prepared and briefed priority led to failing in the priority to correctly understand and follow a clearance. Do not allow your mindset in respect of an ATC clearance to drift to a confirmation of what you expect The Select-Identify-Display discipline in loading a GPS procedure and pretakeoff checks should have helped, but only if you refer back to a correctly written note of the clearance Be careful when a alternative pair are easily muddled (obvious example is Engine failure left/right). I think this mistake was much easier to make than the wrong procedure from a list of dissimilar sounding ones. I should have been aware and seeking clarity of whether it was 7A or 6D, not seeking confirmation it was the expected one 8

9 Mistake (4) Enroute Engine vibration due to valve failure 4.1 Background (prior 9 months) Late 2009, the aircraft developed a faint, periodic light rumbling vibration in flight. Not specific to any power setting, but usually only noticeable in cruise. Source was guessed to be left engine/prop but uncertain Aircraft is particularly quiet and smooth, so by the standards of many piston aircraft, even with the light rumble, it felt very much within normal expectations Performance was unchanged JPI EDM760 Twin Engine monitor had been fitted in 2005, but data was never downloaded due to obsolete hardware interface of JPI unit. No indication of a problem from the inflight display (all EGTs/CHTs consistent with historical) Diagnostics included: - ignition (lean check at high altitude all good, but plugs changed anyway) - fuel flows all normal, rumble unrelated to mixture richness - engine inspected - airframe checked all OK (rumble perceived from Port engine but could have been drooping Landing Light, gear door etc) - Props dynamically balanced, balance was good 9

10 Mistake (4) Enroute Engine vibration due to valve failure 4.2 Failure of #5 Cylinder inflight Had flown from Dusseldorf earlier in the day. Flight was a night currency and refuelling trip from Bournemouth to Guernsey (40mins) Good night VMC, aircraft light (1300lbs below MTOW). Over 2.5hrs fuel onboard at point of failure. A few mins SW of ORTAC, at 2000, without warning, a significant vibration started from the port engine and there was a noticeable yaw to the left The failure of the Port engine #5 cylinder was immediately clear from the blank EGT bar on the JPI Failure of #5 Cylinder Port Engine EGT bar dark, all other indications normal 10

11 Mistake (4) Enroute Engine vibration due to valve failure 4.3 Decisions Decision: to continue to Guernsey (12mins flight time) - Alderney closed at night, so only a full emergency diversion - Return to Bournemouth would have added 10mins to the airborne time. It would have been more convenient and perhaps a not unacceptable decision, but it was right to land at the nearest suitable airport Decision: to operate Port engine at partial power with vibration reduced to reasonable level, rather than to shut down - Against shutdown: Port engine delivering useful power at acceptable vibration level. Engine T&Ps monitored and normal. Cylinder failure obvious from JPI. - For shutdown: Unknown nature of Cylinder failure. Ignition suspected, but Mag check preflight was normal, so why a double ignition failure? Fuel, weight and flight profile (over the sea, 12mins from a good ILS runway) would have allowed relatively easy single engine operation. A seized engine less so. POH recommends engine shutdown if roughness continues. On balance, I should have shut this engine down, unless circumstances meant there was a need for partial power. There wasn t. 11

12 Mistake (4) Enroute Engine vibration due to valve failure 4.4 Actions and Lessons Good Initial actions well handled Good/fair decisions taken under pressure Flew good arrival and approach, did not let the engine distract from SOPs Prudence in avoiding lower fuel state was useful (added fuel at EGHH) Not skipping checks on departure meant recent Mag check Lesson is training, SOPs and currency work Bad Allowed scan to lapse after initial actions and drifted down 250 to 1750 Lesson is NEVER ALLOW THE SCAN TO LAPSE (even at non-critical points) and do not tolerate deviations because it s OK and you are busy Did not refer to Emergency Procedure checklist after initial actions Lesson is: stay current on emergency procedures, but also use the checklist if possible 12

13 Mistake (4) Enroute Engine vibration due to valve failure 4.5 Emergency Procedure checklist Although all the other rough engine/live engine checks were well done from memory, I kept the rough engine at 1700rpm, not having referred to the checklist 13

14 Mistake (4) Enroute Engine vibration due to valve failure 4.6 Mistake: Not downloading JPI data Grey line is #5 Cylinder Port Engine. Sticky/failing valve is obvious, and was for weeks, if not months. However, e this oscillation o in EGT was not observable e from the instrument in-flight 14

15 Mistake (5) Approach Flying the EGKA (Shoreham) RNAV approaches 5.1 Errors on the RNAV 20 (not on the same approach!) 50kt tailwind gave >200kt GS BITLI ADURI leg was ~1min Missed the turn anticipation and was blown through the final approach track Descended to 800 MDA and levelled off. Towards the MAP, whilst working ATC to change to 02 approach, allowed altitude to drift to ~580 before recovering back to maintained until TAWS-B showed we were clear of the terrain north of Shoreham then relaxed. Terrain Awareness avionics must not be used to relax VNAV discipline, its value as a safeguard flips into being a risk factor if used this way. 15

16 Mistake (5) Approach Flying the EGKA (Shoreham) RNAV approaches 5.3 Lessons After the IAF, focus only on flying the approach - Approach checks and briefing complete; Flaps/Pumps/Lights set - Sterile Cockpit ; Single Pilot means avoid any distraction - Remaining actions beyond the IAF should be minimal Essential RTF Power/Flap/Gear at FAF 1000 checks (reds-blues-greens & ice) NOTHING ELSE EXCEPT SCAN AND PROCEDURE - Don t relax discipline, add secondary tasks to your work load and half fly the approach because wx is VMC or well above minima ATTITUDE, POWER and CONFIGURATION are the critical actions in departures, level-offs, go-arounds and missed approach procedures - Easy to pitch up initially but then allow the nose to drift down - Avoid tentative, incremental power application to protect the engines; immediately and smoothly set the power for the performance needed - It s vital to trim and maintain the scan, especially with the relatively high workload on a missed approach. Do nothing else for first 30s of go-around. - RTF, fiddling with GPS, finding the next plate etc etc etc are all secondary 16

17 Summary Overall Lessons Avoid complacency. More specifically, the comfort of the familiar, which relaxes you from normal disciplines Be alert to distractions that could divert your attention from priorities and risks that have not gone away Avoid Confirmation bias, a tendency for people to favour information that confirms their preconceptions or hypotheses. It s critical to watch for, especially in elements of an ATC clearance Most errors can be guarded against by 3 disciplines 1. Pre-flight: planning, preparation and inspection 2. In-flight: always maintain the scan (especially at workload peaks) 3. In-flight: always use simple and consistent SOPs/Checks Extra alertness on take-off, level-off and go-around (the sink back risk): set attitude, power, configuration, and then trim and maintain the scan Extra alertness before any descent step: check nav, charts/plates and altimetry 17

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