[Peetwo]

The HVH YMEN DFO faery tale grows...    


Reference P7 Accidents - Domestic post: http://www.auntypru.com/forum/thread-103...ml#pid9398 

..I note, with some amusement, that the ‘experts’ on the UP are finally catching on. Shan’t bother you all with the posts – but, to further elaborate the abysmal ATSB performance in support of only the gods know what; a quote directly from the Be20 bible.

“The engine driven fuel pump (high pressure) is mounted on the accessory case in conjunction with the fuel control unit (FCU). Failure of this pump results in an immediate flame-out.” The primary boost pump (low pressure) is also engine driven and is mounted on the drive pad on the aft accessory section of the engine. This pump operates when the gas generator (N1) is turning and provides sufficient fuel for start, take-off all flight conditions except operation with hot aviation gasoline above 20, 000 feet altitude, and operation with cross-feed.

The minister should be asking his experts to clearly define what actually happened that day, at Essendon. They could, in turn, ask the ATSB what the hell they are playing at. Better yet, he could bring in the IIC and ask him; on oath, (in camera) if he can – hand on heart – provide a little more ‘fact’ than the Hood faery story. I’d expect some folk in the USA would value anything a little better than the current Wild Ass Guess (WAG) which claims, without any convincing supporting data or proof, 100% Pilot error. 

The simple truth minister is the ATSB management have NFI; the ‘tin-kickers’ might; but there is not enough evidence here to support any claim other than supposition. The bloody aircraft hit a building and burned, killing 5; that is fact – after that – well, you pay your money and take your chances...

Not exactly sure why but the last time I looked the mods over on the UP are still mulling over whether to approve Grogmonster's NTSB report attachment...

Grogmonster:

Some frightening similarities here people. Not Rudder Trim !!!!
Attachments Pending Approval
[img=16x0]https://www.pprune.org/images/attach/pdf.gif[/img]
 
NTSB report on Wichita Crash.pdf

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Lead Balloon: 

Pending approval, here’s some of the report:

The airline transport pilot was departing for a repositioning flight. During the initial climb, the pilot declared an emergency and stated that the airplane "lost the left engine." The airplane climbed to about 120 ft above ground level, and witnesses reported seeing it in a left turn with the landing gear extended. The airplane continued turning left and descended into a building on the airfield. A postimpact fired ensued and consumed a majority of the airplane.

Postaccident examinations of the airplane, engines, and propellers did not reveal any anomalies that would have precluded normal operation. Neither propeller was feathered before impact. Both engines exhibited multiple internal damage signatures consistent with engine operation at impact. Engine performance calculations using the preimpact propeller blade angles (derived from witness marks on the preload plates) and sound spectrum analysis revealed that the left engine was likely producing low to moderate power and that the right engine was likely producing moderate to high power when the airplane struck the building. A sudden, uncommanded engine power loss without flameout can result from a fuel control unit failure or a loose compressor discharge pressure (P3) line; thermal damage prevented a full assessment of the fuel control units and P3 lines. Although the left engine was producing some power at the time of the accident, the investigation could not rule out the possibility that a sudden left engine power loss, consistent with the pilot's report, occurred.
A sideslip thrust and rudder study determined that, during the last second of the flight, the airplane had a nose-left sideslip angle of 29°. It is likely that the pilot applied substantial left rudder input at the end of the flight. Because the airplane's rudder boost system was destroyed, the investigation could not determine if the system was on or working properly during the accident flight. Based on the available evidence, it is likely that the pilot failed to maintain lateral control of the airplane after he reported a problem with the left engine. The evidence also indicates that the pilot did not follow the emergency procedures for an engine failure during takeoff, which included retracting the landing gear and feathering the propeller.

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Old Akro:

The ATSB report of ZCR's recent flights / maintenance is sketchy. 


FlightAware shows ZCR returning to Essendon on Feb 4 at approx 2pm with a flight time of 1:24
But the ATSB does not show it flying on that day. 
The ATSB lists ZCR as flying 6 hours on Feb 5, but flight aware has nothing on that day. ZCR has ADSB. I don't understand how a 6 hour flight could be unrecorded by FlightAware. 

The RUMOUR I heard at the time was that it spent about 3 weeks in Adelaide unscheduled after a problem on the leg to Adelaide. The flight aware record supports this. The ATSB report does not mention this. although the flight it lists of Jan 13 when landing gear malfunction was reported may fit with this. At the time the 3rd hand rumour I had was that it was having work done on the FCU and that it was a repeat issue. I'll re-iterate that the rumour I had within days of the accident was 3rd hand. I cant vouch for it. But, it did spend time in Adelaide that corresponded with the rumour. 

An FCU failure has precedent and in many ways fits the facts. But, the ATSB report doesn't acknowledge it. 

and I don't understand why the 4 February flight in FlightAware returning from Adelaide does not appear in the list of recent flights in the report.

Anyway for the benefit of those IOS and BRB members interested, here is some links for the quoted NTSB final report into the 30 October 2014 B200 fatal accident at Wichita, Kansas (Report No. - CEN15FA034): 

1. https://www.ntsb.gov/_layouts/ntsb.aviat...4112&key=1
   
2. https://aviation-safety.net/database/rec...20141030-0
   
3. http://www.kathrynsreport.com/2016/02/be...g-air.html
   

NTSB Identification: CEN15FA034
14 CFR Part 91: General Aviation
Accident occurred Thursday, October 30, 2014 in Wichita, KS
Probable Cause Approval Date: 03/01/2016
Aircraft: RAYTHEON AIRCRAFT COMPANY B200, registration: N52SZ
Injuries: 4 Fatal, 2 Serious, 4 Minor.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The airline transport pilot was departing for a repositioning flight. During the initial climb, the pilot declared an emergency and stated that the airplane "lost the left engine." The airplane climbed to about 120 ft above ground level, and witnesses reported seeing it in a left turn with the landing gear extended. The airplane continued turning left and descended into a building on the airfield. A postimpact fired ensued and consumed a majority of the airplane. 

Postaccident examinations of the airplane, engines, and propellers did not reveal any anomalies that would have precluded normal operation. Neither propeller was feathered before impact. Both engines exhibited multiple internal damage signatures consistent with engine operation at impact. Engine performance calculations using the preimpact propeller blade angles (derived from witness marks on the preload plates) and sound spectrum analysis revealed that the left engine was likely producing low to moderate power and that the right engine was likely producing moderate to high power when the airplane struck the building. A sudden, uncommanded engine power loss without flameout can result from a fuel control unit failure or a loose compressor discharge pressure (P3) line; thermal damage prevented a full assessment of the fuel control units and P3 lines. Although the left engine was producing some power at the time of the accident, the investigation could not rule out the possibility that a sudden left engine power loss, consistent with the pilot's report, occurred.

A sideslip thrust and rudder study determined that, during the last second of the flight, the airplane had a nose-left sideslip angle of 29°. It is likely that the pilot applied substantial left rudder input at the end of the flight. Because the airplane's rudder boost system was destroyed, the investigation could not determine if the system was on or working properly during the accident flight. Based on the available evidence, it is likely that the pilot failed to maintain lateral control of the airplane after he reported a problem with the left engine. The evidence also indicates that the pilot did not follow the emergency procedures for an engine failure during takeoff, which included retracting the landing gear and feathering the propeller.

Although the pilot had a history of anxiety and depression, which he was treating with medication that he had not reported to the Federal Aviation Administration, analysis of the pilot's autopsy and medical records found no evidence suggesting that either his medical conditions or the drugs he was taking to treat them contributed to his inability to safely control the airplane in an emergency situation.


The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

• The pilot's failure to maintain lateral control of the airplane after a reduction in left engine power and his application of inappropriate rudder input. Contributing to the accident was the pilot's failure to follow the emergency procedures for an engine failure during takeoff. Also contributing to the accident was the left engine power reduction for reasons that could not be determined because a postaccident examination did not reveal any anomalies that would have precluded normal operation and thermal damage precluded a complete examination.
  

 
The first and most obvious question is why was this final report not listed in the ATSB's 'related occurrences' section of the VH-ZCR final report -   

Probably because it didn't fit the HVH faery tale:

Related occurrences

A review of the ATSB’s occurrence database and the United States’ National Transportation Safety Board’s (NTSB) online database identified three potentially similar accidents that involved an aircraft taking off with the rudder trim not correctly set.

  
After reviewing the NTSB accident reports, phots and video footage, IMO there is absolutely no debating the remarkable similarities in the two accidents. What makes it worse is that I suspect that the ATSB investigation team have actually referred to the NTSB report as some of the investigatory methodology is remarkably similar.

Example: 

..The NTSB conducted a sideslip thrust and rudder study based on information from the surveillance videos. This study evaluated the relationships between the airplane's sideslip angle, thrust differential, and rudder deflection. Calculations made using multiple rudder deflection angles showed that full right rudder deflection would have resulted in a sideslip angle near 0°, a neutral rudder would have resulted in an airplane sideslip angle between 14° and 19°, and a full left rudder deflection would have resulted in an airplane sideslip angle between 28° and 35° airplane nose left. Calculation of the airplane's sideslip angle as captured in the image of the airplane during the last second of flight showed that the airplane had a 29° nose-left sideslip, which would have required the application of a substantial left rudder input...

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https://www.atsb.gov.au/publications/inv...-2017-024/

...Following witness observations of a significant left yaw, the ATSB attempted to define the aircraft’s sideslip and roll angles at different points along the flight path using video footage from CCTV and a vehicle dashboard camera. Still images were extracted from the CCTV and dashboard camera footage, and the location of the aircraft was determined using ADS-B data at points A through G (Figure 16). ZCR’s track was determined at each point using ADS-B data...

...Analysis of the roof impact marks indicated that:

• the aircraft had a heading angle of about 86 ⁰ (T)
  
  
• the ground track was about 114 ⁰ (T)
  
  
• the aircraft was at a sideslip angle of about 28⁰ left of track
  
  
• the aircraft was slightly left-wing and nose-low with a shallow angle of descent at the initial roof impact
  
  
• after the initial impact, the aircraft rotated left on its vertical axis until the fuselage was about parallel with the rear parapet wall of the building...
  

P2 comment - I note in the case of the Wichita accident that on 26 October 2016 Flight Safety International filed a lawsuit against 12 different companies associated with the King Air crash: http://www.kathrynsreport.com/2016/10/be...g-air.html

FlightSafety files lawsuit over 2014 King Air crash 

WICHITA, Kan. FlightSafety International has filed a lawsuit, naming more than 12 companies (19 defendants total) it says contributed to the October 2014 fatal crash of a Beechcraft King Air near Wichita's Mid Continent Airport, now known as Dwight D. Eisenhower National Airport.

On Oct. 30, 2014, a Beechcraft B200 Super King Air crashed into a flight safety training center building near the airport, killing the pilot and three people inside the training center.

Among the defendants in the lawsuit are Textron Aviation, Yingling Aircraft, Beechcraft Corporation, Hartzell Propeller, Inc., Pratt and Whitney Engine Services, Inc. and the plane's previous owner.

Investigators say the pilot failed to maintain control of the King Air after a reduction in power to its left engine.

Source:  http://www.kwch.com

  
Finally on a somewhat related issue it would appear that Hoody is desperately trying to schmooze the APS review panel in the lead up to the ANAO audit of the ATSB (ref: https://www.anao.gov.au/work/performance...urrences-0 ) -  : https://uploadstorage.blob.core.windows....32d550.pdf

Thank you for providing the opportunity for the Australian Transport Safety Bureau (ATSB) to participate in the review of the Australian Public Service (APS) through this submission/case study.

As we discussed at the recent APSC-hosted forum for small agencies, I consider it important that we, as a small agency serving the Australian Government and people, provide a contemporary perspective to the review in relation to the manner in which we are evolving our business model and practices.

In facilitating this commitment, I would like to suggest that relevant panel members might wish to participate in the opportunity for an “experiential” visit to a small agency such as ours. In our case, this would be a timely venture as we are currently undergoing an efficiency audit by the Australian National Audit Office (ANAO). In preparing for this audit, we have taken the time to reflect on our past, present and future state in terms of achieving our primary function to improve transport safety with priority given to delivering the best safety outcomes for the travelling public.

As a backdrop and potentially an agenda for the visit, during the past two years, the ATSB has embarked on an “evolution” program that has resulted in fundamental changes to the way in which we operate. 

    
...“experiential” visit.. 

...Definition of experiential. - relating to, derived from, or providing experience : empirical experiential knowledge experiential lessons...

Perhaps definition should include...'greasing the wheels'...'gilding the lily'...'pulling the wool over one's eyes' etc..etc 


MTF...P2