Steve Ayres

Accident Analysis

With Steve Ayres

SAFETY

Who’s in control?

While we all love to share our joy of flying with friends and colleagues, Steve Ayres examines why it’s worth looking at some of the possible consequences of handing over those precious flight controls – and why it’s important to get the cockpit ‘relationships’ right.

For all pilots making a bit of a ‘thing’ about ensuring they always know who has control of the aircraft at any one time, it IS really important. It’s obviously crucial in the instructional environment, but then it is usually quite obvious who should be taking control if things start to go wrong. It is the instructor, of course! But, is it always? And what if the aircraft owner is in the ‘command’ seat but his passenger in the other seat is much more experienced, more familiar or just ‘clear as day’ more capable! Add to this the stress of a serious emergency and the scene is set for some tricky decision making – even before the need for some nifty aircraft handling by the one left ‘in control’.

Accident 1

The Beechcraft B200 aircraft, equipped to perform medical evacuation flights, was conducting an instrument flight rules positioning flight, with two flight crew members and two flight nurses on board. While the aircraft was cruising at flight level 250, the flight crew declared an emergency due to a fuel issue, which the crew then realised meant they would not make it to the destination. It was at that moment that the First Officer (FO) remembered that he had forgotten to have the aircraft refuelled.

“It was at that moment that the FO recalled he had forgotten to have the aircraft refuelled”

The flight crew were ‘startled’ by the fuel exhaustion situation, and their management of the emergency subsequently deteriorated as they were faced with a higher and unexpected workload owing to the impending fuel exhaustion and imminent power loss of one, and eventually, both engines.

When the left engine lost power, the flight crew followed the procedure to shut down the engine. However, the left propeller continued to windmill at speeds between 1,300 and 2,000rpm.

It is likely that the propeller control lever had not been moved completely into the feather position. The FO had earlier programmed the FMS to display a track to the diversion airfield on the captain’s FMS and he instructed the captain to turn right and fly the new track. However, only when the FO moved the heading bug on the FMS display did the captain turn the aircraft, some two minutes after his initial call. Still feeling the effects of the startled response to the fuel emergency, the captain quickly became task-saturated.

The drag produced by the windmilling propeller explains the decaying airspeed and the difficulty the captain was experiencing controlling the aircraft. Although the captain was attempting to descend to intercept an acceptable approach angle, the windmilling propeller likely contributed to a rate of descent that was higher than expected, and at times approached 6,000fpm. Observing that the captain was encountering difficulty maintaining airspeed and controlling the descent rate, the FO took control.

When the aircraft was at 2,800ft above sea level (asl), the left propeller stopped rotating, indicating that the blades had moved to the feather angle.

The right engine then lost power due to fuel exhaustion when the aircraft was one nm from the threshold. From that position, a successful forced landing on the intended runway was no longer possible and, as a result, the aircraft touched down on the ice surface of Stephens Lake, short of the runway. The aircraft was severely damaged but there were no injuries and the occupants exited the aircraft.

The FO was a company line ‘indoctrination captain’, and on the occurrence flight he occupied the right-hand seat from where he was to perform the duties of a FO and provide line indoctrination training to the captain. The FO believed that the captain was the PIC, although in accordance with company policy it should have been the FO, as he was the one giving training to the captain.

Accident 2

The flight of the Cessna 172 was part of a three-plane, multi-day trip between Germany and France. The pilot (in the left seat) and the passenger, owner of the aircraft (in the right seat), took off from Dijon around noon for a flight to Tours. The accident pilot explained that he had met the owner of the aeroplane a few months before but that they had never flown together prior to this trip. As this three-day outing took place in several stages, they alternated in the role of captain. The day before the accident, the pilot flew one of the legs in Germany as a captain. On the day of the accident, he captained the Dijon-Tours leg from the left seat, while the owner provided radio communications in the right seat.

“Each assumed the other was in control, with neither of them actually piloting the aircraft”

On final for Runway 20 at Tours Aerodrome, the pilot said he had stabilised the speed at 70kt with the flaps configured in the landing position at 30°. After the flare and despite the reduced power, he had the impression that the aircraft was flying over the runway without touching the ground, as if it were floating on a cushion of warm air. For him, this effect was caused by the high air temperature just above the paved runway heated by the sun. He then decided to abort the landing and applied full power. At the same time, the passenger told him ‘go-around’. He estimated the speed at about 65kt and the available runway length at 1,500m.

The pilot’s intention then was to gain speed over the runway before gradually retracting the flaps. Seconds after the go-around, he perceived a change in nose-up attitude and pushed the yoke forward to maintain a level accelerating attitude. As that effort increased, he perceived a left turn and realised he was no longer above the runway. The pilot noticed that the passenger was also holding on to the controls. Startled, he stopped pushing the yoke and controlling the rudder pedals, believing that the passenger, the owner of the aircraft and more experienced than him, wanted to fly the manoeuvre himself. He thought that the owner might have wanted to make a quick left turn into the airfield circuit. He then passively accompanied the movement of the yoke without opposing it.

The pilot stated that when he noticed the speed was slowing he yelled at the owner to stop pulling as they were losing speed, but got no reaction from him. The aeroplane suddenly rolled over to the left and collided with the ground. With both occupants unharmed, they evacuated the aircraft.

He clarified that during the briefing given before the start of the trip, he and the owner agreed that if the owner was to take back control of the aircraft, then he should announce it using phraseology defined in advance. He did not hear this announcement during the accident flight.

Testimonies show that the situation was confused in the cockpit and that the two people each assumed the other was in control, with neither of them actually piloting the aircraft. The go-around procedure was therefore partially applied with only the throttle properly actioned. Control of the flight path, management of the engine effects and flap retraction were not.

Accident 3

Two experienced pilots began a flight in a two-seat glider near Briançon. The front seat pilot considered the other pilot to be the pilot-in-command because he had an instructor’s qualification and knew the area better than himself. The rear-seat pilot placed the flight in the context of a ‘mutual flight’, taking on the role of captain but leaving control and initiative to the other pilot. The two pilots did not, however, discuss the assignment of roles and functions before the flight.

At some point, the front seat pilot continued the flight in conditions disapproved of by the rear seat pilot, but he did not express this clearly and, although stressed, he left the controls and initiative with the front seat pilot.

When the front seat pilot could not find any lift, he decided to end the flight and land in the Rosier area. He prepared for the landing by commenting on his actions aloud. Thinking he was in difficulty, the rear-seat pilot took control and tried unsuccessfully to gain altitude, so he too resolved to land. He flew a downwind leg that was too close – and consequently was too high – on final.

Seeing that they had not descended sufficiently, he extended the spoilers fully, selected land flap and asked the front seat pilot to deploy the brake-chute. Immobilised since the rear seat pilot had taken control and after a few seconds hesitation, he pushed the release lever through the gate deploying, and then accidentally, jettisoning the brake-chute. The glider flew over the entire length of the field and in an attempt to avoid a tree line, the two pilots simultaneously retracted the spoilers and applied up elevator. The glider struck a tree and came to rest on its back in a river, submerging the occupants who were able to evacuate.

Ayres’ Analysis

Thankfully, it was mostly pride and airframes that were hurt in these accidents – but it could have been very different. And, although the relationships between crew members were not the principal cause, in each accident they certainly contributed. In the case of the Beech 200, the FO in his role as training pilot should have been the one in command and, given his greater experience, would most likely have been best placed to take decisions and to pilot the aircraft. As it was, confusion in the roles may well have compromised their ability to action the emergency drills correctly and then to reach the nearest airfield safely.

In the case of the Cessna 172, the skills of the pilot flying were almost unknown to the owner-pilot in the right-hand seat and when things got a bit fraught on landing there was a lot of confusion in the cockpit, ending up with no one piloting the go-around. And this was despite the control handover procedure being discussed previously! In the final example, there was no defined scope for the flight and the precise roles of each of the two pilots was not covered.

The flight took place based on presumptions around status (instructor/student) and experience (local knowledge/cross-country flights). This clearly had an impact on the ability of the two pilots to work effectively together. When things started to go wrong communication between the pilots suffered, they alternately adopted a passive attitude, which ultimately impeded their ability to carry out a safe landing.

Guarding against these kinds of accidents can be difficult and as the C172 accident demonstrates, even a pre-flight brief won’t necessarily keep us safe.

However, spending time discussing the flight profile and the roles each crew member is going to play during that flight is clearly important. Also, agree on who is going to take control if things go wrong and the role the non-flying pilot is to play (monitor speed, nav, radio etc). And finally, keep flying the aeroplane unless someone shouts very loudly in your ear: ‘I have control!’

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