[Peetwo]

Strange dissonance in the Hooded Canary's coop?

Top post Gobbles and I must admit I can relate to the man and machine bond etc.. -    

...I’m just saying, throwing it out there. Quite simply the phrase of “we’re going in, we’re dead” could be nothing more complex than a man and his machine working as one, being as one, acting as one. Hence the plural in the Captains final words?...

However in the Wichita accident if man and machine had such an affinity why didn't the pilot, in the interests of self-preservation for both man & machine, action the memory items for EFATO - you know...Pitch up...power up...flap up...gear up...identify dead leg..dead engine..etc..etc??

That is the point that I am trying to make the dis-associative behaviour by both pilots in the Wichita vs the Essendon DFO prang is a common element that - along with left bank, left yaw, loss of height and rudder issues - IMO needs some analysis and review to at least ascertain that there is no common element in the causal chain to both these accidents.

List of related occurrences:

Australian occurrence
Loss of control, 7km west-south-west of Tamworth Airport, New South Wales, on 7 March 2005, VH-FIN (ATSB investigation 200501000)
At about 1326 Eastern Daylight-saving Time on 7 March 2005, the pilot of a Cessna Aircraft Company 310R, registered VH-FIN, took off from runway 30 Right at Tamworth Airport, for Scone, New South Wales. Approximately 1 minute after becoming airborne, the pilot reported flight control difficulties. At about 1329, the aircraft impacted the ground in a cleared paddock about 7 km west-south-west of the airport. The pilot was fatally injured and the aircraft was destroyed by the impact forces and post-impact fire.
Examination of the aircraft's mechanical flight control systems, autopilot and electric trim system did not reveal any evidence of pre-impact malfunction. Those results, however, were inconclusive due to the extensive impact and fire damage.
A periodic maintenance inspection carried out in the days before the flight resulted in the rudder trim tab being set at the full right position and possibly aileron and elevator trim tabs being set at non-neutral positions prior to the flight. There were indications that the pilot was rushed and probably overlooked the rudder and aileron trim tab settings prior to takeoff. The aircraft flight path reported by witnesses was found to be consistent with the effect of abnormal rudder and/or aileron trim tab settings.
United States occurrences
Loss of control in-flight, Hayward, California, 16 September 2009, B200 N726CB, (NTSB accident number WPR09LA451)
The aircraft had just undergone routine maintenance and this was planned to be the first flight after the inspection. During the initial climb, the pilot observed that the aircraft was drifting to the left. The pilot attempted to counteract the drift by application of right aileron and right rudder, but the aircraft continued to the left. The pilot reported that, despite having both hands on the control yoke, he could not maintain directional control and the aircraft collided into a building. The aircraft subsequently came to rest on railroad tracks adjacent to the airport perimeter.
A post-accident examination revealed that the elevator trim wheel was located in the 9-degree NOSE-UP position; normal take-off range setting is between 2 and 3 degrees NOSE-UP. The rudder trim control knob was found in the full left position and the right propeller lever was found about one-half inch forward of the FEATHER position; these control inputs both resulted in the airplane yawing to the left.
The pilot did not adequately follow the aircraft manufacturer's checklist during the pre-flight, taxi, and before take-off, which resulted in the aircraft not being configured correctly for take-off. This incorrect configuration led to the loss of directional control immediately after rotation. A post‑accident examination of the airframe, engines, and propellers revealed no anomalies that would have precluded normal operation. The pilot was the only person on-board and he was uninjured.
Runway excursion, Oneida, Tennessee, 25 September 2014, Beech C90, N211PC (NTSB accident number ERA14CA458)
According to the pilot's written statement, he departed runway 05 and the airplane veered ‘sharply’ to the right. The pilot assumed a failure of the right engine and turned to initiate a landing on runway 23. Seconds after the aircraft touched down it began to veer to the left. The pilot applied power to the left engine and right rudder, but the aircraft departed the left side of the runway, the right main and nose landing gear collapsed and the aircraft came to rest resulting in substantial damage to the right wing. The pilot reported that he had failed to configure the rudder trim prior to take-off and that there were no pre-impact mechanical malfunctions or anomalies that would have precluded normal operation. The pilot was the only person on-board and he was uninjured.

There is also the fact that the Wichita accident was not even included as a 'related occurrence'. This apparently was because it did not fit the ATSB hypothesis that the sole cause of the DFO accident was the pilot Max Quartermain's lack of checklist discipline which led to him not identifying that the rudder trim was fully deflected to the left prior to take off - UDB!  

Okay, even with the total lack of physical evidence/proof that this was the case, if we take the examples used to paint the commonality in lack of 'checklist discipline' causal to these occurrences, why then is not the classic accident for these type of human factor pilot error and lack of SOP discipline included in the accident report related occurrence list? Of course I am referring to, the much publicised and commonly referred to by a multitude of AAI Human factors experts, the Runway Overrun During Rejected Takeoff of G-IV - https://www.ntsb.gov/investigations/Acci...R1503.aspx - on May 31 2014?

Even the CASA Flying Safety publication did an article on this occurrence: https://www.flightsafetyaustralia.com/20...nto-error/

THE NTSB SAID, ‘ALTHOUGH ONE OF THE PILOTS COULD HAVE COMPLETED ONE OR MORE OF THESE CHECKLISTS SILENTLY, THE PILOTS DID NOT DISCUSS OR CALL FOR ANY OF THESE CHECKLISTS, EXECUTE ANY OF THE CHECKLIST ITEMS USING STANDARD VERBAL CALLOUTS, OR VERBALLY ACKNOWLEDGE THE COMPLETION OF ANY OF THESE CHECKLISTS.’

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Also of interest: .... a few terse words revealed the immediate cause of the crash.


At 21.39.59 the pilot said, ‘Steer lock is on,’ a remark he repeated six more times in the remaining 20 seconds of the flight. Fourteen seconds later he said, ‘I can’t stop it’.

There was no other discussion of the situation and the only other words before the recording stops were one of the flight crew saying, ‘Oh no, no’ as the aircraft sped towards the ravine that would trap it. Fire broke out ‘almost instantaneously’, in the words of a witness...

   
 I can only assume that the ATSB regarded the GIV Massachusetts accident as not relevant because it was a multi-crew jet accident and not a single pilot B200 or equivalent turboprop accident? In other words it did not again fit the Hooded Canary's singular causal slice of Swiss cheese. Which is a pity because there is much to take away from the GIV prang especially under the safety recommendation part of the report: https://www.ntsb.gov/investigations/Acci...c=A-15-034

...The NTSB determines that the probable cause of this accident was the flight crewmembers’ failure to perform the flight control check before takeoff, their attempt to take off with the gust lock system engaged, and their delayed execution of a rejected takeoff after they became aware that the controls were locked. Contributing to the accident were the flight crew’s habitual noncompliance with checklists, Gulfstream Aerospace Corporation’s failure to ensure that the G-IV gust lock/throttle lever interlock system would prevent an attempted takeoff with the gust lock engaged, and the Federal Aviation Administration’s failure to detect this inadequacy during the G-IV’s certification.

Recommendation: TO THE NATIONAL BUSINESS AVIATION ASSOCIATION: Work with existing business aviation flight operational quality assurance groups, such as the Corporate Flight Operational Quality Assurance Centerline Steering Committee, to analyze existing data for noncompliance with manufacturer-required routine flight control checks before takeoff and provide the results of this analysis to your members as part of your data-driven safety agenda for business aviation.

 
Ah yes, unless it is absolutely positively PC and won't have any blow back for the miniscule, the Hooded Canary's flock, unlike the rest of the 1st world AAI organisations, doesn't do safety recommendations and I guess that includes reading the ones from peer organisations like the NTSB? - FDS!   
  

MTF? - Yes MUCH...P2