P2 - Q&A.
• On 4 May 2017, the aircraft was erroneously released to service prior to in-flight FCU set-ups having occurred, with an endorsement in the deferred defect list that the left engine had to be operated in manual mode until the FCU set-up had been completed but could continue in service until no later than 14 May 2017 without the set-up being completed.
10 days. ATSB don't mention that as being a Minimum Equipment List (MEL) item. It probably is - but
• The Rossair chief pilot raised a concern on 8 May 2017 about the aircraft being released into service without the in-flight set-ups being completed, as the aircraft was more difficult than normal to operate with one engine in manual mode.
I could see it as being a 'get you home' item, even stretched out to a couple of days to allow for parts to be delivered. I wonder if the order to operate 'both' in Manual mode was issued. I can see a potentially 'unsafe' scenario or two developing there – there are times when 'split throttles' can create a distraction. Only a minor issue I admit but it speaks of a corporate mind set; a need to generate income and a chief pilot unable to impose his will on that mind set. A lack of parts, or the money to buy 'em is not a CP problem. Fix it or ground it is not a bad maxim. CP 's are paid to weather the storms of management bombast and have the full backing of CASA to do so. It is not a matter of can we keep it flying – it is a matter of should we – on risk analysis. I know we've all done it, nursed a sick aircraft about the place to get a job done – but only because we know that on return to base – it will be fixed.
2) Given the practice flight was operated 'private', supposedly because; a) the carriage of the observer would be defined as carrying a passenger and; b) the Chief Pilot didn't yet have CASA approval to conduct an OPC as a 'Check Pilot' on the C441, wouldn't that necessarily deem any simulated/practice asymmetric (OEI) as illegal, despite the fact the observer had extensive Cessna 441 check pilot experience?
Is the practice of OEI operations 'legal' with a 'passenger' inboard, no matter how well that 'passenger' is qualified? Then there is the small matter of being 'qualified' (officially) to simulate 'emergency' high risk operation? It takes us back to 'management' attitude and CP compliance with management dictates. As to the complete, black letter law 'legality' of that operation – I'd suggest asking CASA to explain. In fact, I'd add it a long list of 'please explain' questions for CASA to answer.
Quote: "..The observer stated that, based on his experience, zero thrust in the occurrence aircraft was about 150 ft.lbs of torque and lower than other company Cessna 441 aircraft. He also recalled that the chief pilot set a power lever position at or slightly above that torque value during the simulation..."
When there is a potential for 'confusion' which can be simply eradicated, there is little excuse for not doing so. The difference in torque settings between the three and four blade propellers is great – 150 and 350 – a 200 ft/lb difference. A pre flight briefing should always include 'words' to indicate the how and data related. Simulation will be through the power lever to a zero thrust setting of no less than XYZ. I even mark it down on the TOLD card – lest I forget. (I also always have a paw on the quadrant and boots on rudder pedals – just in case).
One further item intrigues me:- semantics I know, but nonetheless FWIW:-
While the pre-check briefing was not witnessed by anyone other than the participants, surveillance data and radio transmissions indicated the accident flight was conducted as per the briefed flight exercises, except that no single-engine go around was performed on arrival at Renmark.
If you intended to simulate an EFATO at a height of 400' or so; then why by-pass the operationally perfect situation of initiating an overshoot from an instrument approach minima? Not visual, go around, wallop – engine out. Minima at Renmark is (or was) 730'. An overshoot on one engine from that height provides obstacle clearance, a flight path, a 'real' scenario and a high work load – quite safely. Why bugger about at 300' with an artificial 'take-off' (not) when a much better, safer alternative means of testing is available? Just saying.
But back to P2's remarks -
5) I wonder if it would be worth requesting through FOI (or Senate order) a copy of the ATSB interview transcript of the practice flight observer who had extensive check pilot experience on the C441?
IMO, every scrap of paper should be collected and examined. This was a very messy operation, from top to bottom. This report highlights much that is 'wrong' within the system, from the MoU between ATSB and CASA, the CASA management of the company and of the company itself. How many more similar events, like Lockhart, Seaview and Pel_Air must we see, before someone gets a grip?
Toot - toot.
• On 4 May 2017, the aircraft was erroneously released to service prior to in-flight FCU set-ups having occurred, with an endorsement in the deferred defect list that the left engine had to be operated in manual mode until the FCU set-up had been completed but could continue in service until no later than 14 May 2017 without the set-up being completed.
10 days. ATSB don't mention that as being a Minimum Equipment List (MEL) item. It probably is - but
• The Rossair chief pilot raised a concern on 8 May 2017 about the aircraft being released into service without the in-flight set-ups being completed, as the aircraft was more difficult than normal to operate with one engine in manual mode.
I could see it as being a 'get you home' item, even stretched out to a couple of days to allow for parts to be delivered. I wonder if the order to operate 'both' in Manual mode was issued. I can see a potentially 'unsafe' scenario or two developing there – there are times when 'split throttles' can create a distraction. Only a minor issue I admit but it speaks of a corporate mind set; a need to generate income and a chief pilot unable to impose his will on that mind set. A lack of parts, or the money to buy 'em is not a CP problem. Fix it or ground it is not a bad maxim. CP 's are paid to weather the storms of management bombast and have the full backing of CASA to do so. It is not a matter of can we keep it flying – it is a matter of should we – on risk analysis. I know we've all done it, nursed a sick aircraft about the place to get a job done – but only because we know that on return to base – it will be fixed.
2) Given the practice flight was operated 'private', supposedly because; a) the carriage of the observer would be defined as carrying a passenger and; b) the Chief Pilot didn't yet have CASA approval to conduct an OPC as a 'Check Pilot' on the C441, wouldn't that necessarily deem any simulated/practice asymmetric (OEI) as illegal, despite the fact the observer had extensive Cessna 441 check pilot experience?
Is the practice of OEI operations 'legal' with a 'passenger' inboard, no matter how well that 'passenger' is qualified? Then there is the small matter of being 'qualified' (officially) to simulate 'emergency' high risk operation? It takes us back to 'management' attitude and CP compliance with management dictates. As to the complete, black letter law 'legality' of that operation – I'd suggest asking CASA to explain. In fact, I'd add it a long list of 'please explain' questions for CASA to answer.
Quote: "..The observer stated that, based on his experience, zero thrust in the occurrence aircraft was about 150 ft.lbs of torque and lower than other company Cessna 441 aircraft. He also recalled that the chief pilot set a power lever position at or slightly above that torque value during the simulation..."
When there is a potential for 'confusion' which can be simply eradicated, there is little excuse for not doing so. The difference in torque settings between the three and four blade propellers is great – 150 and 350 – a 200 ft/lb difference. A pre flight briefing should always include 'words' to indicate the how and data related. Simulation will be through the power lever to a zero thrust setting of no less than XYZ. I even mark it down on the TOLD card – lest I forget. (I also always have a paw on the quadrant and boots on rudder pedals – just in case).
One further item intrigues me:- semantics I know, but nonetheless FWIW:-
While the pre-check briefing was not witnessed by anyone other than the participants, surveillance data and radio transmissions indicated the accident flight was conducted as per the briefed flight exercises, except that no single-engine go around was performed on arrival at Renmark.
If you intended to simulate an EFATO at a height of 400' or so; then why by-pass the operationally perfect situation of initiating an overshoot from an instrument approach minima? Not visual, go around, wallop – engine out. Minima at Renmark is (or was) 730'. An overshoot on one engine from that height provides obstacle clearance, a flight path, a 'real' scenario and a high work load – quite safely. Why bugger about at 300' with an artificial 'take-off' (not) when a much better, safer alternative means of testing is available? Just saying.
But back to P2's remarks -
5) I wonder if it would be worth requesting through FOI (or Senate order) a copy of the ATSB interview transcript of the practice flight observer who had extensive check pilot experience on the C441?
IMO, every scrap of paper should be collected and examined. This was a very messy operation, from top to bottom. This report highlights much that is 'wrong' within the system, from the MoU between ATSB and CASA, the CASA management of the company and of the company itself. How many more similar events, like Lockhart, Seaview and Pel_Air must we see, before someone gets a grip?
Toot - toot.