Steve Ayres summarises and comments on accident reports from around the world and looks at the latest update of the CAA’s Safety Sense leaflets…
4 August 2021
The pilot reported that, while departing on a cross-country flight from the 2,738ft-long runway, the engine lost partial power about 100ft agl during the initial climb. He lowered the aeroplane’s nose, which appeared to restore engine power, then raised the nose again as the aeroplane approached the end of the runway. The engine then experienced a ‘severe’ loss of power and the aeroplane subsequently impacted a dirt field at the departure end of the runway.
Post-accident examination of the airframe and engine revealed no pre-impact anomalies that would have precluded normal operation, and review of data from the onboard engine monitor revealed that the engine was producing full power throughout the take-off. A Federal Aviation Administration inspector spoke to several witnesses who saw the pilot fill a truck bed with belongings from the accident aeroplane, including wooden crates full of avocados.
The pilot confirmed that he had a ‘substantial amount’ of cargo on board, and that he did not calculate the aeroplane’s weight and balance for the flight. Based on the available information, it is likely that the pilot’s inadequate pre-flight planning resulted in the aeroplane’s maximum gross weight being exceeded, which in turn lead to the aeroplane’s poor climb performance, the perceived loss of engine power, and the subsequent loss of control and impact with terrain.
Comment I must confess to a personal weakness for avocados but hopefully not to an extent that would lead me into this trap. Try as we might, most laws of physics cannot be cheated. Weigh everything – including avos!
The pilot reported that he last fuelled the aeroplane about five months before the accident. Before the flight, the pilot conducted a pre-flight inspection and sumped both wing fuel tanks. The left fuel tank had some sediment present, but as he continued sumping the fuel became clear. The fuel in the right fuel tank ran clear. After engine start, the left tank fuel gauge indicated near empty, and the right fuel tank gauge indicated about 1/4 full.
Subsequently, the pilot took off for a personal cross-country flight. After starting a right turn, and about 600ft agl, the engine sputtered and lost power. The pilot then attempted to turn back to the airport but realised that the aeroplane was too low, so he executed a forced landing to a field with small trees, during which the left wing struck a tree causing substantial damage. The pilot reported that after the accident he found more sediment in the left tank. He stated that he believed that the low fuel state and the sediment in the left tank may have starved the engine of fuel during the turn and that having more fuel onboard would have ‘probably been helpful’. However, it is more likely that, due to the low fuel state, when the pilot conducted the right turn, the fuel became un-ported, resulting in the loss of engine power due to fuel starvation.
Comment The pilot seemed a bit confused about the consequences of his actions. Low fuel states tend to amplify any pre-existing fuel issues and so taking off with what might only have amounted to 1/8 of maximum fuel capacity was unlikely to end well. Luckily the two children passengers, aged six and four escaped without injury.
The pilot stated that having bought the aircraft, he planned to fly it from Bedlands Gate Airfield, Cumbria, to relocate it. As the grass strip was wet after recent rain the pilot walked the length of Runway 16 with an experienced pilot friend and noted the surface was firm along the entire length.
“The aircraft’s right wheel sank into a patch of soft ground at the edge of the turning circle”
After start up, the pilot taxied the aircraft down Runway 34 and attempted a 180° left turn using the turning circle. While doing so, the aircraft’s right wheel sank into a patch of soft ground at the edge of the turning circle. The aircraft then slewed right and tipped onto its nose, damaging the propeller and stopping the engine. The pilot exited the aircraft normally and, with the help of his friend, removed the aircraft from the mud and towed it back to the hangar.
Although the main runway was firm, the pilot and his friend did not notice the soft ground at the extreme edge of the turning circle. The pilot added that he will never again take for granted the condition of the extreme edges and far ends of an unfamiliar grass strip.
Comment This is not the only UK accident of this type to report recently and reminds us that grass airfield conditions change all the time and can vary across the whole operating surface. Best stick to only those areas you have personally checked or asked someone else to do so on your behalf.
The pilot reported that he’d been conducting touch-and-go landings in the traffic pattern. During initial climb for the second touch-and-go landing and once the aeroplane reached between about 200 and 300ft agl, he smelled an unusual odour and noticed flames coming from the floor forward of his rudder pedals. The pilot added that he ‘immediately rejected the take-off’ and declared an emergency. He then landed the aeroplane on the departure runway, exited the runway onto a taxiway, and then stopped the aircraft.
“The pilot noticed flames coming from the floor forward of his rudder pedals”
The pilot subsequently shut down the engine by pulling the mixture to full lean, turned off the fuel valve and electrical power switches, and then exited the aeroplane. A post-crash fire ensued, which consumed the aircraft.
The pilot stated that he had installed all new fuel lines about one month, or 1.5 flight hours, before the accident flight. Post-accident engine examination revealed that all four fuel lines exhibited thermal damage and soot on their exteriors, consistent with exposure to fire.
An end of one of the fuel lines had soot deposits in the first three threads of the line’s attachment fitting. If the fuel line had been secured at the time of the fire, no soot deposits would have been inside the threaded fitting. Therefore, it is likely that the fuel line loosened during flight due to the pilot’s failure to apply adequate torque to the line during installation, which allowed fuel to enter the hot engine compartment and led to an in-flight fire.
Comment In many ways, it is how the pilot handled the fire which has some useful lessons. Cool head or what? Maintaining control of the aeroplane, getting on the ground asap and doing the right drills. It is just a shame that was not enough to save the aeroplane. I’m now off to re-check the fuel lines I’ve just installed…
The aircraft rotated about 1,300ft down the runway, which was about 75% of the normal ground roll distance for the aeroplane’s weight and the take-off environment. About two seconds after rotation, the aircraft rolled left. Three seconds later, the aeroplane had reached an altitude of about 80ft agl and was in a 90° left bank. The nose then dropped as the aeroplane rolled inverted and struck the ground. Review of surveillance video footage from before the accident revealed that the elevator was in the almost full nose-up position during the taxi and the beginning of the take-off roll.
Surveillance footage also showed that the pilot did not perform a pre-flight inspection of the aircraft or control check before the accident flight. The pilot’s friend, also in the hangar, stated as the accident pilot was pushing the aircraft back into his hangar the night before the accident, he manipulated and locked the elevator in the trailing edge up position to clear an obstacle in the hangar.
Comment Manipulating control surfaces to pass around obstacles in a hangar is not uncommon but using something to block them will get forgotten one day, and if not picked up in the pre-take-off checks will have entirely predictable results.
Civil Aviation Authority: Safety Sense leaflet on Care of Passengers
Free
Some months ago we looked in this column at the responsibilities we have towards our passengers and the CAA has taken this once step further with its new Safety Sense Leaflet on the ‘Care of Passengers’.
As the CAA identifies: “…there are some considerations for the health and safety of passengers and to ensure any associated risks are managed. Under the Air Navigation Order and the Air Operations Regulation, the pilot in command of any aircraft has responsibility for the safety of those onboard. While the legal responsibility starts after boarding with the intention of flight, you should also ensure that passenger safety is considered prior to and after the flight, for example when airside at the airfield.”
As with much information on the CAA website, finding it is the hardest part, so in addition to the link to the new leaflet above try this link for the other excellent Safety Sense leaflets.
