Author: Stephen DaCosta, ASI, Charlotte FSDO; POC: AFS-850, Phil Randall, Greensboro FSDO, NC, Office Phone: 336-369-3948; Revision 1, 11/08/2012 by Pete Wilhelmson, AFS-850 2012/12/5-023 (I) PP
This presentation is based on an actual aviation accident which resulted in the fatality of a prominent doctor. We will see that many actions in the chain of events, any of which if handled differently, may have prevented the tragic ending. Our intent is to get……….. YOU………….. engaged in the discussion regarding positive safety thinking, safe behavior and of course recognizing the presence of Human Factors and effects on our performance. Finally to realize how a lack of a positive safety culture, poor behavior and how ignoring Human Factors can led to fatal results. Two options for this presentation: 1. Discuss culture, behavior and Human Factors throughout the scenario presentation 2. Present the raw scenario then conduct discussion of culture, behavior and Human Factors at the end.
Read Objectives: Presenter may add more supportive discussion if desired
This is a Mooney M20K. It is similar to the Mooney aircraft owned and operated by a prominent Doctor who had more than 4000 hours flying experience. We are going to tell you a tale about how procedures, maintenance and operational, were not followed and an experienced pilot, in a beautiful aircraft, similar to the one in this photo ………………(go next slide)
JULY 18, 2011, a tragic fatality that could have ………… and should have been prevented!!!
This is the engine prop configuration approved for Mooney M20K by the Type Certificate Data Sheet more commonly referred to as TCDS. The TCDS is issued upon FAA certification of aircraft, engines and propellers. The TCDS for an aircraft lists approved engine and propeller configurations as well as many other parameters, limitations, and equipment necessary to meet/retain airworthiness requirements. This McCauley propeller is two bladed model.
The accident Mooney was modified per a Supplemental Type Certificate commonly referred to as STC. An STC is issued by the FAA that allows an approved modification to be performed. This engine and prop combination were approved to be used on this particular aircraft by STC 5691NM. Note the HP increase from 210 hp to 305 and this propeller is a three bladed McCauley, feathering prop found on a lot of twin engine Cessna aircraft.
This tale begins at take-off …………... at 2 a.m., (Yes! ….wee hours of the morning!), on April 11, 2011, when Doctor X departed Shreveport, Louisiana in his (legally modified) Mooney M20, on a 600 mile trip to a small airport close to Augusta, GA. The weather at his destination was expected to be clear. Question? Do you think the Doctor was tired BEFORE he started his trip? Any other possible Human Factors having an effect on the trip?
When Doctor X arrived shortly after daybreak there was considerable morning fog. The Doctor X performed three missed approaches and was not able to land. Doctor X then decided to divert to Augusta Bush Field. Question: Do you think he should have tried to land three times BEFORE deciding to divert to another airport? Discuss the possible Human Factors i.e. pressure, complacency, lack of assertiveness……..Others??
The approach to runway 35, at Augusta Bush Field, was uneventful. Aircraft was lined up to land. When Doctor X flared at touchdown he felt a vibration and heard loud noise. As the aircraft was settling on the runway, Doctor X realized that the landing gear was NOT down. He attempted to pull up and applied full power and selected the landing gear down. By this time too much energy was dissipated and the aircraft settled and skidded approximately 700 feet. The engine stopped and the gear remained up.
First Bullet : On April 11, 2011, The aircraft received “substantial damage” to lower structure causing it to be an accident. The propeller blades were also curled from rotating contact with pavement resulting in sudden stoppage of the engine. Second Bullet : Doctor X did not follow procedures. He admitted that he did NOT use the checklist. He demonstrated poor safety culture by Failing to Follow the very basic procedures. HF1 Complacency Question: Do you think the Doctor’s more than 4000 hours in this aircraft made him a bit complacent in not using the checklist? Third Bullet: Doctor X also stated he was fatigued and weather and diversion distracted him. Do you think the Doctor’s own assessment regarding other human factors were pretty darn accurate!? We know fatigue is a Human Factor but what human factors are associated with weather and diversion? weather=“Stress”, any others? diversion=“Distraction”, “Stress”, any others? Do you think this accident should have changed his safety culture and behavior as well as his awareness of human factors? The aircraft and propeller display obvious physical damage…but what about the engine, it looks just fine? Continental Service Bulletin SB96-11 addresses PROPELLER STRIKE INSPECTIONS and says “Following any propeller strike, complete disassembly and inspection of all rotating engine components is mandatory and must be accomplished prior to further flight. Inspect all engine driven accessories in accordance with the manufacturer’s maintenance instructions. Remember this lead to Doctor X’s SECOND accident, just three months later! The FATAL accident on July18, 2011!
The Doctor’s business required he had to have an aircraft right away. Consequently, he purchased a Bonanza V tail 35. Nonetheless, his intention was to get the Mooney repaired and use it again. Reliance on an aircraft for business can result in “Pressure” that tend to push the envelop of safety to satisfy an immediate need…..especially in the General Aviation arena. Go to Next Slide:
As time passes, the Doctor realizes the insurance policy on the Mooney will soon expire. Although he tried, he could not find any local maintenance that wanted to repair the aircraft . So new “Pressure” is added. He has to move the aircraft. He decided to relocate the aircraft back home to Lake Norman, NC to have the repairs done. Now more “Pressure” to get this done. Recall the immediate need to get another aircraft for his business? This gives you a clue that this guy does not have lot’s of spare time. Now the movement of his damaged aircraft is in the chain of events and we could conclude he wants …or has to get this done quickly.
Recall the damaged aircraft is in Augusta, GA. It’s now the week of July 2011 and the Doctor could not obtain a local repair facility to fix his Mooney. He decides to relocate his aircraft on a Special Flight Permit commonly known as “ferry permit”. He makes arrangements with a local repair facility, at his home base, in Lake Norman, NC to repair aircraft and also to begin process to obtain a Ferry Permit for the Mooney for relocation flight back home. The Ferry Permit is received but it will expire July 18 th …………….not much time to prep aircraft……..more “Pressure”. So preparation begins.
Recall the Mooney, approved three bladed propeller, is severely damaged! It must be replaced for the ferry flight. BUT WAIT!!.....Doctor X owns a 2 bladed McCauley propeller . It was being stored by an acquaintance in Virginia. He contacted his acquaintance and asked if this propeller would work on the Mooney. The individual told Doctor X that the engine would start and run but was not the correct propeller for his engine per his STC . Nonetheless the doctor had the propeller shipped to Aircraft Repair Facility in Lake Norman, NC. What do you think the Doctor has in mind? One could question his safety culture at this time. The spare propeller 2AC34C50 is typically installed on Cessna 182. What would you have done if YOU were the acquaintance? The acquaintance displayed lack of assertiveness by not discouraging the Doctor from using the propeller!
It is now Friday (end of a work week!??) July 15 th , two mechanics, with prop “under arm”, are sent to Augusta do interim repairs for Ferry Flight. What kind of shape are the two mechanics in? (When does the ferry permit expire? July 18 th !...........not much time..right?). Quick Question: Does aircraft have to be airworthy for ferry flight? No! but it must be SAFE for the flight! One could question how much research was done by the repair facility to validate condition /applicability of propeller. Do you think this a human factor in the chain of events? The left landing gear would not lock in the down position so the gear was secured and physically locked down by mechanics and the circuit breaker was pulled. Do you think this might affect climb performance? Considering the Doctor’s safety culture or risky behavior do you think the Doctor even give this a second thought?
At some point, both mechanics were advised that Doctor X had spoken to an individual in Virginia and said the two bladed propeller would work BUT it was not the right one. (Should have been an alarm?). Mechanic 2 finishes final preparation to airframe. Mechanic 1 removes the 3 bladed propeller and attempts to install the 2 bladed McCauley but something is amiss!! The propeller bolts are too short! Question: What would you do at this point if you were the mechanic installing the propeller? Have discussion of behavior, safety culture, and human factors in effect. Well mechanic one presses on and removes the bulkhead, installs the propeller but must leave spinner off because that mounts to the bulkhead which is now removed! Propeller now installed. Mechanic 1, in subsequent interview, stated the propeller was installed using the Mooney Maintenance Manual . Discussion of facts: The replacement propeller is not approved for this aircraft per TCDS and remember this aircraft was modified with a different engine and propeller per STC! So use of Mooney manual is suspicious at best…………..do you agree?
A local maintenance facility support was sought to provide the Doctor’s mechanics with nitrogen service equipment to service the tires and nose strut. The local mechanic from the facility thought it was odd that the propeller tip was only 8 inches from the ground ( HF9 )…………….but nevertheless the servicing was completed. Why was the propeller tip clearance not further questioned or addressed? Anyone care to speculate on this? Afterwards, mechanic 1 and 2 attempted to run the engine. The engine started but power could not be obtained. Finally, it was late and the Doctor with both mechanics departed back to Lake Norman, NC.
It’s Monday July 18, 2011, the day the Ferry Permit will expire. Any Human Factors here? Mechanic 2 flew back with Doctor X in his Bonanza. The “plan” was that Mechanic 2, who was also a pilot, would fly the Bonanza back to Lake Norman, while the doctor flew the Mooney. Upon arrival Mechanic 2 began final preparation of the Mooney. He connected the battery then prepared to run the engine……………….again. Recall when they left on Friday the engine was started and ran but full power couldn’t be obtained.
The Mechanic 2 started the engine and ran it up. During the run up he noticed something was not quite right. The propeller control operated BACKWARDS! The correct propeller control is when the control is pulled out the engine RPM will decrease. However now the prop control INCREASED engine RPM when pulled out. What do you think Mechanic 2 did to remedy this? He advised Doctor X of this condition. It is not known how the Doctor reacted to this advisement……BUT is fully aware of the condition! What was the only thing on his mind? What HF influences were in effect?
Doctor X asked Mechanic 2 to service the spongy brakes. This is so bizarre ………….the Doc has a propeller control that operates backwards yet he is concerned over spongy brakes!! Nonetheless…..the Doctor presses on. The doctor told Mechanic 2 that he was going to take off and climb to 8000 feet over Bush Field and if everything was good he would proceed to Lake Norman. Well at this point we know that everything is NOT good……………….. mechanic 2 knows everything is not good. But the Doctor’s behavior, decisions, and actions are contrary to any that an experienced, safety conscious pilot should display.
Mechanic 2 recalls that he saw the doctor taxi the Mooney over to local fixed base operator (FBO) to be sure that he had the necessary fuel for the flight. About 2 PM, service is completed and Doctor X begins taxi to runway 17. Mechanic 2 is in the Bonanza and begins his taxi out. At 2:19, the Doctor receives clearance for take off and begins roll down the runway.
At this point one could ask what operating characteristics was the Doctor experiencing. Recall the engine power was an issue. Approximately one third down runway the aircraft lifted off. A ccording to witnesses, the engine was extremely loud and the aircraft was not climbing too fast . At the departure end of runway the aircraft began a shallow left turn and leveled off with the noise getting louder……………….then about 2:21 a loud POP was heard.
Can you guess what fell off the aircraft? The object was the propeller! The aircraft travelled another 200 yards. Entered into a steep left spiral! Then impacted the ground and exploded!
The Doctor perished in post fire impact!
The subsequent slides is post accident analysis and are optional to the presenter. Discuss the Human Factors that may have contributed this accident. Use the Dirty Dozen …………..or others that may have been in effect. Discuss the numerous opportunities that could have prevented not only the first accident but the fatal accident as well.
Complacency, Pressure, Others? How could/should they have been handled
Discuss acquaintance’s advice about propeller and how should the Doctor have reacted………….and possible reasons why he did not. What about the effects of the looming expiring ferry permit? Discuss the important fact about ferry permits. Although the aircraft does not meet certain airworthiness requirement it must be safe for flight and there must be a log entry stating this. A ferry permit is not permission to do what ever it takes. . Maybe if the mechanics had expressed some assertiveness and concerns with the owner and refused to sign off the aircraft, the accident could have been avoided. Or a call to the FSDO. Human Factors: Lack of Knowledge, Lack of Communication, Lack of Assertiveness, Pressure,……………………… Others??
Although it is common to ferry aircraft with gears locked down, do you think the increased drag and effects on performance was taken in consideration? Not necessarily by the mechanics but most definitely should have been by the Doctor? Discuss possible HF and mitigating actions The propeller did not fit properly! Bolts too short. Bulkhead and spinner left off to allow bolts to fit. This is absolutely mind boggling!! Notwithstanding all previous opportunities, this is where the everything should have come to a halt! Discuss the possible reasons it did not……………….i.e. culture, behavior, HF’s Lack of Knowledge, Lack of Assertiveness, Pressure…………..all others.
A local mechanic saw the propeller tips close to the ground………..…thought it was odd……………but did not express his concern. Lack of Communication Lack of Assertiveness Engine did not achieve full power………………accepted by mechanic and/or Doctor. Discuss possible reasons why . Propeller control…..operates backwards……….accepted by mechanic and/or Doctor. Discuss possible reasons why.
Review the summary bullets; Ask for any final thoughts from the attendee’s. Then ask the question to all in attendance – What, if anything would you have done different? Explain that the Number One Causal Factor of Fatal Accidents where maintenance is involved is “Failure to Follow the Proper Procedures.” Ask them: Do you follow procedures all the time? Give each attendee a copy of the “Maintenance Personal Minimum Checklist” and encourage them to use it. This means not just reading it but routinely and honestly reacting to each one of the checklist items.
Provide last chance for questions Promote faasafety.gov……………briefly discuss features, resources and location. Suggest hand out promotional business cards. Promote On-line AMT Program………..emphasize where, how……………………. and benefits (increased training, expand knowledge, obtain an award and finally enhancing a resume of self improvement………..i.e. a competitive edge.
Airworthiness: Doctoring maintenance
Federal AviationAdministrationAirworthinessPositive Safety CultureDoctoring MaintenanceA Discussion of HumanFactors and Behavior
Federal AviationAdministration2Introduction• Review a fatal accident scenario• Analyze chain of events leading up to the fatalclimax• Discuss how poor safety culture, unsafebehavior, and ignoring Human Factors causeda pilot to perish.
Federal AviationAdministration3Objectives• Emphasize thoughtless decisions and riskybehavior lead to undesirable consequence.• Recognize Human Factors and not to ignorethem.• Encourage embracing a more positive safetyculture that inspires safe behavior.
Federal AviationAdministration5Ended up like this!!
Federal AviationAdministration6Mooney M20K• Original Configuration per Type Certificate DataSheet (TCDS) 2A3.• Engine: Continental TSIO-360 (210 HP)• Prop: McCauley 2A34C216
Federal AviationAdministration7Accident Mooney M20K• Modified by Supplemental Type Certificate(STC) No. STC5691NM• Engine: Continental TSIO 520 (305 hp)• Propeller: McCauley 3AF32C505
Federal AviationAdministration8Departure• Departure, under visual flight rules, cross-country.• Destination airport expected to be VisualMeteorological Conditions (VMC).
Federal AviationAdministration9Arrival• Destination airport weather not as anticipated.• Unsuccessful attempts to land.• Diverted to another airport.
Federal AviationAdministration10LANDING• The approach to diversion airport wassuccessful.• At touchdown events began to unfold.• Failed attempt to pull up.• Unexpected climax
Federal AviationAdministration11Non Injury Accident• The Mooney was damaged .• Doctor X did not follow procedures• Doctor realized “Other” factors were in effect
Federal AviationAdministration12Heading to the fatal accident• Doctor X needed a replacement aircraft rightaway• Purchased a another aircraft• Mooney would be repaired and used again.
Federal AviationAdministration13Heading to the fatal accident• The Mooney insurance policy close to expiring.• No local area repair available.• Need to move the aircraft.
Federal AviationAdministration14On course to fatal accident• Doctor X decides to get Ferry Permit.• The Doctor makes arrangements with homebased aircraft repair facility.• Ferry Permit has time limit.
Federal AviationAdministration15Still on course to fatal accident• Mooney propeller must be replaced• Doctor X owns another McCauley propeller• Spare propeller not correct for the Mooney
Federal AviationAdministration16Course to fatal accident not altered• Mechanics sent to prepare damaged Mooney.• Problems encountered with the landing gear.
Federal AviationAdministration17Course to fatal accident still not altered• Mechanic 2 completes final repairs on fuselage• Mechanic 1 works on the propeller• Propeller installation problems• Propeller is installed
Federal AviationAdministration18Accident Course Slightly Delayed• Tires and nose strut gets serviced• Test run-up performed
Federal AviationAdministration19Back on the course to accident• Doctor and Mechanic 2 return to Augusta, GA.• Mechanic 2 was also a pilot• Final Ferry preparation began
Federal AviationAdministration20The Day of the Crash• Mechanic 2 began operational check of engine• More Problems…….now with the propeller• Doctor X knows the problem exists!
Federal AviationAdministration21The Day of the Crash• Flight preparation continues• Doctor X advises Mechanic 2 of his flight plan
Federal AviationAdministration22Shortly before the Crash• Doctor X taxies over to the FBO.• Doctor X taxies to the runway.• Mechanic 2 taxies Bonanza• Mooney is cleared for take-off
Federal AviationAdministration23Moments before crash• The Mooney lifts off• Witnesses observed the lift off.• Seconds before the crash
Federal AviationAdministration24The Crash:• Something fell off of the aircraft.• The aircraft continued a short distance more• Impacted the ground
Federal AviationAdministration25The Crash Scene
Federal AviationAdministration26Post Discussion Analysis:• What and why did things go wrong?• Human Factors (HF) were NOT recognized andWERE ignored.• Opportunities to prevent either/BOTHaccidents.
Federal AviationAdministration27Analysis:• HF1. The Doctor was very busy, used aircraftfor business and had logged more than 4000hours in his Mooney.• HF2: The Mooney insurance expiring.
Federal AviationAdministration28Analysis:• HF3: Acquaintance advice.• HF4: Ferry Permit expiration
Federal AviationAdministration29Analysis:• HF5: Landing gear problems.• HF6: The propeller problems
Federal AviationAdministration30Analysis:HF9: Propeller tips so close to the ground.HF10: Engine did not achieve powerHF11: Propeller control operates backwards.
Federal AviationAdministration31Summary• This scenario shows how thoughtless decisions andrisky behavior led to undesirable consequence.• We identified applicable Human Factors and why youshould not to ignore them.• Adopting a more positive safety culture will inspiressafe behavior in you as well as your associates.
Federal AviationAdministration32Before we close• Any questions or comments• www.FAAsafety.gov• AMT Awards Program