NTSB presents: Is your aircraft talking to you? Listen!


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NTSB presents: Is your aircraft talking to you? Listen!

  1. 1. Is Your AircraftTalking to You?Listen!1Cathy Gagne, AS-70
  2. 2. General Aviation (GA) Safety• About 1,500 accidents,475 people killed annually• GA on NTSB Most Wanted List• Personal flying sector of GA:greatest activity, proportion ofaccidents2
  3. 3. Top Occurrence Categories3Fatal accidents in GA personal flying sector, 2000-2011
  4. 4. Discussion of Accident Cases• Completed cases: commoncauses, factors, and scenarios• Used as educational tools• Not intended to admonish accidentpilots• Intended to help other pilots learn4
  5. 5. Scenario 1: Beech 365
  6. 6. Accident Synopsis• Pilot/owner planned personalround-trip night IFR flight• Complete engine power loss onreturn leg• Forced landing, pilot fatal6
  7. 7. Pilot• Sole owner/operator• About 2,300 total flight hours• Flight instructor, with multi-engineand instrument ratings7
  8. 8. Airplane History• Engine:10 hours since overhaulat time of pilot’s purchase• Pilot added about 50 hours priorto accident8
  9. 9. Airplane History• Engine oil pressure problemseveral weeks before accident• Mechanic: Overhaul issue• 1 week later, pilot said engine“seemed OK”• No evidence of corrective actions9
  10. 10. Accident Flight• No outbound leg problem reports• Midnight taxi out, return to FBO• Pilot requested mechanic(unavailable until morning)• Pilot then opted to depart, IFR10
  11. 11. Accident Flight• Complete loss of power 9 milesfrom destination• Night IMC forced landing• Engine examination: crankshaftfracture11
  12. 12. Bearing, Crankshaft Damage12
  13. 13. Missed Opportunities• Actively address problem• Maintenance troubleshooting• Do not fly until resolved• Take conservative approach• Take all indications seriously• Ground airplane until problemidentified and resolved13
  14. 14. What Pilots Can Learn• Resist external pressures to fly• Identify, assess all risks• Maintenance: Don’t talk self intobelieving what you want to hear• Problem indications not alwaysobvious14
  15. 15. What Pilots Can Learn• Conservative approach can beinconvenient, costly (but is safer!)• To avoid inappropriate choices:• Consider options and outcomes• Prevent outside factors fromadversely influencing decisions15
  16. 16. What Pilots Can Learn
  17. 17. Scenario 2 – Vans RV-617
  18. 18. Accident Flight• Vans RV-6• Departed 20 minutes beforeaccident• Private pilot was fatally injured• Maintenance test flight18
  19. 19. Airplane History• Oil leak discovered 6 weeks earlier• Source of leak: propeller governorhigh pressure oil line• Weld “repair” was made• Pilot departed for test flight, butchose to conduct cross-country flight19
  20. 20. Accident Site20
  21. 21. Wreckage Examination21
  22. 22. Missed Opportunities• Stick to maintenance test plan• Review service bulletins,airworthiness directive• Be prepared to executeemergency procedures22
  23. 23. What Pilots Can Learn• If signs of problem persist, beprepared to discontinue flight• Review, practice emergencyprocedures23
  24. 24. Scenario 3 – Beech G3524Photo from sales advertisement
  25. 25. Scenario 3 – Beech G35• 1956 Beech Bonanza (G model)• Recent purchase by two pilots• Lost engine at destination• Owner/pilot: 40 hours in BE3525
  26. 26. Airplane History• 3,350 hours total time airframe• 80 hours since major overhaul onContinental E-225 powerplant• Owners: Multiple mechanicstroubleshooting oil leaks26
  27. 27. Airplane History• Mechanics found,fixed some leaks;troubleshootingothers• Owners monitored;mechanicsrechecked daily• Oil temperature,oil pressure normal,no contamination27Photo from sales advertisement
  28. 28. Flight History• Owner/pilot (low time BE35) flewRYY to CHS (235 nm) day VFR• At CHS: remark about oil leak• Checked oil level, departed onreturn flight to RYY28
  29. 29. Flight History29
  30. 30. Flight History – Outcome?30
  31. 31. Flight History – Outcome31
  32. 32. Findings32• Engine teardown: No evidence ofcase fretting or bearing damage• Wrong type of case thread (notsilk) used at overhaul• Eventual consequences had itcontinued to fly? Depends …
  33. 33. What Pilots Can Learn33• Troubleshooting may take time• Even trusted sources mayprovide conflicting information• Decisions: not easy, not cheap,not always obvious what is right
  34. 34. In Conclusion• This issue, otherscovered in SAs• Hot links (or shorturls) to find reports,dockets, otherresources• www.ntsb.gov34
  35. 35. Thank You!Questions? Discussion?35