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IT SHOULD NOT HAPPEN TO YOU COMANCHE ACCIDENTS, 12.2002 By Omri Talmon Comanche Accidents, 12.2002 1.12 Date: 12/12/2002. Acft: PA-30. Descr: ACFT GEAR COLLAPSED ON LANDING. Damage: Minor. One POB, no injuries. 2.12 Date: 12/14/2002. Acft: PA-24-180. Descr: ACFT LANDING GEAR COLLAPSED ON LANDING . Damage: Minor . Three POB, no injuries. 3.12 Date: 12/15/2002. Acft: PA-30. Descr: ACFT EXPERIENCED LANDING GEAR MALFUNCTION, LANDED AIRPORT PERIMETER ROAD. Damage: Substantial. Two POB, both suffered minor injuries. 4.12 Date: 12/16/2002. Acft: PA-24-250. Descr: ACFT ON EIGHT MILE FINAL LOST RADAR AND RADIO CONTACT WITH ATC AND CRASHED INTO TWO RESIDENT HOUSES, 2 POB FATALLY INJURIED, NO GROUND INJURIES, OTHER CIRCUMSTANCES ARE UNKNOWN. Damage: Destroyed .Two POB, both fatally injured.
A CASE This accident report comes from Australia (ATSB is the Australian transportation Safety Bureau). The composition and language are different from the NTSB reports.
ATSB Report FACTUAL INFORMATION Sequence of events The co-owners of the Piper Twin Comanche aircraft, both of whom were pilots, were conducting the flight to test a newly fitted left propeller governor. At about 1650 EST, one of the owners telephoned the aircraft refueller and requested fuel for VH-CNZ. When the refueller arrived at the aircraft a short time later, he was requested by the other pilot to refuel the aircraft to full tanks. The refueller reported that this pilot appeared to be conducting a preflight check of the aircraft while the other pilot was seated in the cockpit, possibly in the left seat. The refueller noticed that the fuel filler flap covers were open and that the fuel tank filler caps, two on each wing, one on either side of the engine nacelles, had each been removed and placed on the wing adjacent to the filler points. After adding fuel to the right auxiliary fuel tank, the refueller placed the cap in the filler port. The pilot who was doing the external inspection approached him and said that he would secure the caps because they had a locking mechanism that was different from those fitted to many other aircraft types. The refueller then filled the right main tank and placed the cap in the filler port. As he moved away, he saw the pilot move to the tank. The refueller then moved to the left side of the aircraft and filled the left auxiliary and left main tanks, again placing the caps in the filler port of each tank. He did not secure the caps and left the flap covers open. At this stage, he saw the pilot lying beneath the fuselage, apparently conducting a fuel drain check. The refueller recorded in the refuelling register that 179 litres of fuel had been added to the aircraft at 1700. He then told the pilot seated in the aircraft the amount of fuel he had added, and reminded her that he had not secured the fuel caps. The refueller then moved to refuel another aircraft. A short time later, the aircraft taxied for takeoff. Visual meteorological conditions existed with scattered light cloud at 3500 feet. The wind was from the southeast, gusting to 5 knots. Sunset on the day of the accident was at 1658. At the time of the accident, the sun was 3.5 degrees below the horizon, bearing 292 degrees True. The following is a summary of the pertinent communications between the aircraft (CNZ) and Archerfield Tower (Tower), which commenced at 1714.14.
Several witnesses observed the progress of the aircraft. Their observations confirmed that a cloud of what appeared to be 'greyish black smoke' coming from both sides of the left engine. The aircraft yawed sharply left and right just after becoming airborne and then commenced a left circuit at very low level, estimated to have been 100 ft above ground level. The landing gear remained extended throughout the circuit. Approaching the western boundary of the airport, the aircraft entered another left turn, passing low over some buildings. Part way through the turn, the aircraft's angle of bank suddenly increased and it descended rapidly into the ground. Both occupants were fatally injured. Wreckage and impact information Initial examination at the accident site revealed that the fuel filler flap covers of the two left wing tanks were open, and both filler caps were missing. The caps were recovered the following day from runway 10 right and the adjoining clear way. Fuel wetting was evident on the ground below the open fuel caps of the inverted left wing. A total of approximately 35 litres of fuel was recovered from the damaged right wing fuel tanks. The recovered fuel was confirmed as the correct type and grade for the aircraft. The accident aircraft was the thirteenth of sixteen refuelled from the same batch and tanker on the day. The records show that the fuelling agent had sample tested the fuel on three previous occasions throughout the day. Given that there were no reports of fuel related problems from any other aircraft and because of the obvious level of performance from the right engine. The quality of the fuel as a factor in the development of the accident was discounted. The aircraft wreckage was located in an open area adjacent to the western boundary fence of the aerodrome, approximately 250 metres north-northwest of the threshold of runway 10 left. Impact marks indicated that the aircraft was inverted and rolling left when it struck the ground. The aircraft attitude was 55 - 60 degrees nose down and 25 - 30 degrees left wing low. The main wreckage came to rest about 17 m beyond the initial impact point. The tail section was right way up and the main wing section was folded back on top of the rear fuselage. The cabin area was severely distorted, with the instrument panel and cockpit floor displaced rearward. Specific points noted during the wreckage examination included the following: There was no evidence of either pre-impact or post impact fire including to the left engine. (PA30-160 aircraft, along with most other light twin engine aircraft, were not equipped with fire detection or suppressant systems.) The landing gear was locked in the extended position and the wing flaps were fully retracted. Impact damage prevented the serviceability of the stall warning system being assessed. The nature and extent of damage to the cockpit engine control pedestal prevented any useful witness mark information being obtained regarding the pre-impact position of the controls. Ground contact marks and the condition of the right propeller blades indicated that the right engine was developing significant power at impact. Ground contact marks and the condition of the left propeller blades indicated that the left propeller was rotating at impact but that the engine was not developing power. The constant speed governor from the left engine was recovered; the only obvious damage being slight bending to the control-input shaft which was consistent with impact damage. The governor was functionally tested at an approved overhaul facility. The tests met all the manufacturer's specifications, with the exception of the maximum RPM setting that indicated 2285. This was 45 RPM below the specification. Specialist opinion was that this discrepancy could be attributed to the damage to the control-input shaft. Disassembly of the left and right propellers found no evidence of any pre-existing fault or defect. Disassembly of the left propeller confirmed the blades were at fine pitch and not in the feathered position at impact. Disassembly of both engines did not reveal any pre-existing fault or defect that would have affected normal engine operation. Fuel tank filler points The two fuel tank filler points on each wing were located on either side of the engine nacelles. The filler points consisted of filler port, a cap to seal the port, and a flap covering the cap access. The cap consisted of a black rubber insert that compressed to seal the fuel filler tank port by the action of a screw grip on top of the cap. The flap cover was secured with a winged slotted 'dzus' type fastener and, when locked, was flush with the upper surface of the wing. Locking the flap cover required deliberate action, and could not be achieved by slamming the cover down. The flap covers were hinged parallel to the longitudinal axis of the aircraft, and opened away from the engine nacelles. The slotted 'dzus' fasteners had to be locked for the flap covers to be closed flush with the wing surface. If not locked, the flap covers would stand slightly proud of the wing surface. The left and right wing filler points, inboard of the engine nacelles, were visible from the left and right cockpit seats, respectively. They may have been visible in the pilot's peripheral vision, depending on the pilot's seating position. With the flap covers open, there was a high level of contrast between the white painted upper surface of the wing and the dark underside of the flap covers and filler cavity. In reduced light conditions, the level of contrast would have been lower. When in the open position, the outboard flap covers were partly visible from the cockpit. If those covers were down, but not locked, they were not visible from the cockpit. The 'dzus' fastener locking mechanism for the flap covers on the left wing tanks functioned normally. Aside from damage caused to one cap when it was struck by an aerodrome mower operating on the runway 10R flight strip on the morning following the accident, both fuel caps from the left wing tanks were in a serviceable condition. The pilots Both pilots were appropriately licensed and held current medical certificates. Toxicological and Post-mortem analysis did not reveal the presence of any compound or pre-existing medical condition that may have affected the performance of either pilot. Aerodrome information Runway 10 Right was 1100 m long. Beyond the runway end was a flat area extending for more than 400 m, and free of major obstacles, to the aerodrome boundary fence. The distance from a position on the runway abeam the control tower to the boundary fence was about 800 m. The control tower cab was 65 ft above ground level. The controller reported that when the aircraft passed abeam the tower, its level appeared to be slightly below that of the tower cab. With respect to the control tower, the remaining light or glow from the sun was behind and slightly left of the position of the aircraft, as it became airborne. Aircraft performance The aircraft flight manual performance charts indicated that, in the prevailing conditions, the take-off ground run distance required was about 350 m, depending on the flap setting used. The observations of the tower controller indicated that the actual take-off performance of the aircraft was not substantially different from that figure. The landing distance over a 50-ft obstacle was approximately 500 m, depending on the aircraft flap setting and approach speed. Single engine performance The sea level single engine climb performance of light twin engine aeroplanes certified in accordance with United States Federal Aviation Regulation 23 requirements can be up to 70 to 90 percent less than the twin engine performance. Many factors can contribute to this performance loss such as aircraft age and condition, leaving the landing gear extended, not feathering a propeller, not maintaining the correct airspeed, and not turning towards the live engine. The Pilot's Operating Manual for the aircraft included information on propeller feathering procedures and single engine flight. That information included the statement that, when climbing with one engine inoperative, the landing gear and wing flaps must be retracted.
The aircraft took off with the fuel caps for the left wing tanks not secured, and the flap covers unlocked. It could not be established if the flap covers remained in the opened (up) position where they were left by the refueller, or whether they moved to the closed/not locked position because of aircraft movement or vibration, or airflow. There may have been some perceived time pressure regarding the pre-flight inspection because of the deteriorating light. Further, the light may have reduced the visual prominence of the open flap covers. Either, or both of those influences could have contributed to the pilots not being aware that the left wing fuel caps were not secured. As the aircraft accelerated during the takeoff roll, the caps fell from the left wing filler ports, probably as a result of vibration and/or aerodynamic forces. The 'smoke' observed by the tower controller and a witness was fuel venting from the open tank filler ports. It was unlikely that any other interpretation of the venting fuel would reasonably have been made in the circumstances, particularly in the deteriorating ambient light conditions, coupled with the position of the filler ports on either side of the engine nacelle. Other than the tower controller's transmission regarding the 'smoke', it could not be determined what other information the pilots of the aircraft used in reaching the decisions to shut down the left engine and attempt a left turnback. However, based on the examination of the left engine and propeller, there would most probably have been no indication from the cockpit instruments that the left engine was malfunctioning in any way. Whether the pilots were able to observe the 'smoke', or became aware of the situation regarding the fuel caps, could not be determined. It was apparent from the record of communications with the control tower that the pilot who initiated communications with the air traffic controller prior to take off was not the same person who communicated with the tower controller following the advice that there was 'smoke' coming from the left engine. However, which pilot manipulated the aircraft controls during that period could not be determined. At the time the aircraft passed abeam the control tower, there was adequate runway and overrun distance available for the aircraft to land and decelerate significantly before reaching the boundary fence. Whether the pilots considered the option of landing straight ahead after being notified of the 'smoke' could not be determined. The flight path taken by the aircraft (the turn away from the live engine) and the aircraft configuration at impact (left propeller not feathered, landing gear extended) indicated that aspects critical to maintaining single engine performance were not accomplished. The final flight path and impact attitude of the aircraft were typical of what might be expected following loss of control when the airspeed falls below the minimum single engine control speed.
1.The left wing fuel tank filler caps were not secured before takeoff. 2.Fuel vented from the left wing fuel tanks and had the appearance of smoke coming from the left engine. 3.The pilot(s) did not take the appropriate actions to maintain aircraft performance after shutting down the left engine. 4.The pilot(s) were unable to maintain control of the aircraft.
MY FURTHER INVESTIGATION According to an Australian friend and pilot who knows the case, the pilots were experienced. The woman pilot must have had some 12,000 hours and was a CFI, teaching multi engine flying. The man pilot had some 2,500 hours. No information was obtained as to the experience in type, but it may have been quite low.
MY DISCUSSION The accident report points out several basic errors in flying a twin with one engine inoperative, and there is no use to repeat it. I would like to discuss a few other points. My habit, and my recommendation, is for the pilot to follow, in person and without interruption, the refueling process. This includes opening the fuel tanks, and, more important, closing them. I never let a line person touch my fuel caps. This accident demonstrates how critical this issue may become. Due to the lower air pressure above the wing, the fuel, or most of it, will be sucked out in no time. The second issue is the assessment of risk vs. benefit in taking this or other steps in an emergency. In this case, should an engine which caught fire (this must have been what the pilot assumed) but still delivers full power be shut off at 50 ft if the intention is to proceed with the flight, or rather let the engine pull for another 30 seconds in order to gain some more precious altitude and speed. The third issue is the situation in the cockpit, of which we know little. The radio communication shows that there was a personal change in handling the radio, 15 seconds after the tower advised about the smoke (and made another call). Is this a sign of a conflict on the flight deck, with the resulting disorder never to be expected from such experienced pilots, one of them a multi engine instructor? It should be noted that the report does not refer to the fuel selector. Was the left one placed on the OFF position? The forth issue: If the instructor had indeed low experience on Comanches, and high experience on other types, what was the real knowledge and imprinted response to asymmetric handling on an aircraft with a Vmc which is well above the stall? The fifth issue: What was the impact of the quite incorrect call by the tower? Should he not have used less prescriptive wording - "There appears to be something streaming from the left of the aircraft" or similar. Is it not possible that the direct advice from ATC may contributed to the tragedy by limiting a pilot's analysis of the possibilities? LESSONS Follow very strictly the refueling checklist and always secure in person the fuel caps. Even the aces among us do require periodic training in single engine operation of the twin. Emergencies are nearly never the same, and good judgement is necessary before action is taken. There should be only one PIC in the cockpit.
PROVERB Speed is life; altitude is life insurance. Omri Talmon, born 1936, lives in Tel Aviv, Israel. He holds degrees in engineering, business administration and accounting. Presently a consultant, he worked for many years as an executive for several Hi-Tech companies. Omri is a private pilot with both Israeli and U.S. certificates. His ratings include SEL, MEL, Instrument, Glider, and CFI (glider). Since 1974 he owns and flies a 1966 PA-30-B, registration 4X-CAO. |
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