The NTSB has completed its investigation into the loss of Asiana Airlines Flight 214 — a Boeing 777 that crashed into a seawall then cartwheeled on Runway 28L at San Francisco International Airport (SFO) on July 6, 2013 — with a widely anticipated probable cause finding that the crew let the airplane get low and slow during an unstabilized visual approach.
The National Transportation Safety Board said in its determination of probable cause for the loss of Beech E90, N987GM, that “Contributing to the accident was the failure of air traffic control personnel to use available radar information to provide the pilot with a timely warning that he was about to encounter extreme precipitation and weather along his route of flight or to provide alternative routing to the pilot.”
The 52-year-old pilot of Beech King Air N987GM, an E90 model, was certainly experienced — the FAA's airman records showed he reported 5,300 hr. total time at his most recent second-class physical examination even though, inexplicably, his personal logbooks showed over 9,000 hr., 6,500 hr. of that in multiengine airplanes. The logbooks also indicated the pilot had accumulated 718 actual instrument flight hours. Whatever the case, he had spent a good amount of time in the cockpit.
According to the DC-6 emergency checklist, the proper procedure for an engine fire is to ensure the engine is feathered first before pulling the fire-extinguishing handle. The checklist notes the effectiveness of the fire extinguisher system is greater after engine rotation has stopped. A letter submitted to the NTSB by the operator, says, in part:
“Engine rotation may be the source of the engine fire. Feathering and stopping engine rotation may remove that source.”
This month, we'll look at two NTSB investigations —one recent, one many years past — both involving inflight fire. One tells of the importance of maintenance follow-up; the other demonstrates how a small deviation from checklist procedures can lead to disaster.
Cessna 401 (N9DM) was lost on May 11, 2012 in Chanute, Kan. Four persons died and one was seriously injured.
During the final approach and landing phase, it is essential that the activities of the Pilot Flying be closely monitored. The approach shall be stabilized no later than 1,000 ft. above field elevation. Boeing defines a stabilized approach as follows:
Aircraft in the final landing configuration
Power setting appropriate for aircraft configuration
Airspeed no greater than target +20 kt. and trending toward target
On glidepath or assumed 3-deg. glidepath
Note: Descent rates above 1,000 fpm should be avoided.
The autothrottle system provides automatic thrust control from the start of takeoff through climb, cruise, descent, approach and go-around or landing. In normal operation, the flight management computer provides the A/T system with engine N1 limit values. The A/T moves the thrust levers with a separate servomotor on each thrust lever. Following manual positioning, the A/T may reposition the thrust levers to comply with computed thrust requirements except while in the THR HLD and ARM modes.
There's been much talk recently in aviation regulatory circles about three issues — fatigue, aircraft automation and basic airmanship. The incident we're discussing this month has a happy ending with no injures and no significant damage to the aircraft. But it does shine a light on the dangers of fatigue when dealing with the complexities of modern flight management/control systems.
The fire-related survival aspects in the loss of a Beechcraft King Air 100 (C-GXRX) on Oct. 27, 2011, especially concerned TSB investigators. Spilled jet fuel burned after ignition during the crash sequence. However, arcing electrical elements kept the fire going even after the engines had stopped. A fire was concentrated on the right wing and in the areas where the aircraft's electrical-system wiring was routed.
A Beechcraft King Air 100 piloted by a well-experienced captain crashed on Oct. 27, 2011, about a half mile short of Runway 26L at Vancouver International Airport. Observers said the airplane simply spun out on short final from a position 300 ft. above the ground. Both pilots were killed and all seven passengers were seriously injured by the impact and subsequent fire.
The amphibious de Havilland DHC-2 MK 1 Beaver (C-GCZA) departed on wheels from Pitt Meadows Airport, B.C., just east of Vancouver, at 1620 on May 13, 2012, with the pilot and three passengers on board, for a day VFR flight to Okanagan Lake, B.C., some 150 sm to the northeast. It touched down at the lake about 1 hr. and 40 min. later where a single passenger deplaned, as planned.
In mid-December 2011, NTSB investigators viewed black and white video images recorded on Nov. 23 by an outdoor security surveillance camera located about 6 mi. south of Superstition Mountain at Apache Junction, Ariz. The video file contained about 50 min. of image data covering the period from about 1810 to 1900.
While the final report on the loss of Aero Commander N690SM had not been released at this writing, it is certain to make mention of controlled flight into terrain (CFIT) accidents.
These are incidents in which a properly functioning aircraft is flown under the control of a qualified pilot into terrain (water or obstacles) with inadequate awareness on the part of the pilot of the impending collision.
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