Pilot & Passenger Lucky to Be Alive After Inverted Crash Landing at Abbots Bromley

Looking through the November AAIB bulletins this one in particular springs out at me

http://www.aaib.gov.uk/cms_resources.cfm?file=/Jodel%20D117A%20G-BEDD%2011-13.pdf

There are several lessons to be learned here. The first one  is that if  you are a low houred pilot and you are new on type, as this guy was,  you need to be very cautious especially with any approach that requires more skill or concentration than usual. Flying into short private strips needs skill and concentration. Distraction is always more likely with an aircraft you are not familiar with and you cannot afford much distraction on a challenging approach.  Always mentally self brief on your options if things should go wrong. Top of that ‘go wrong’ solution list is the go around.

You should never start an approach unless you are go around primed and ready to execute a go around at any moment. Sods law states that a go around will be called for when you are least expecting it.  BE READY!

Situation Awareness is thinking ahead, Threat and Error Management is knowing the approach threats (low airspeed – windshear -distraction-unfamiliarity) and knowing the errors (low airspeed- failing to initiate an early go around))

Another important lesson here although this wasn’t an engine failure accident, is that if you choose to just scrape over an obstacle in flight, such as a hedge or fence and get it wrong you are very likely to invert the aircraft. This is a very important consideration during an engine out forced landing if faced with the option of ‘just scraping over’.  So many students attempt to scrape over hedges into fields on engine out practice. Always be wary of the obstacles in the undershoot.

The safer option in my opinion is to push the aircraft down early into the unobstructed undershoot, get it on, or very close, to the ground and use the hedge or fence as a stopping device. A hedge or frangible fence (dont try this with a brick wall or ancient oak tree) will provide soft deceleration and a better option than the ‘scrape over’  were the aircraft will most likely be inverted and arrive with a large vertical forces on the other side of the hedge. If an aircraft does arrive onto the ground inverted there is more chance of a  serious impact,  more fuselage distortion and hence possible door jamming. There is also much more likelihood of a fire too because once you invert an aircraft  you can be sure there will be more fuel spillage.

The human body can generally stand more horizontal declarative forces than vertical forces so an inverted arrival is usually more serious in terms of injury. You also have the added complication of getting out of the aircraft from a hanging upside down in your straps position, believe me this is not the best way to start a rapid evacuation of an aircraft even though it will greatly encourage it!

A recent undershoot accident at Caenarfon were the aircraft was  inverted after hitting trees in the undershoot sadly killed the passenger. The aircraft arrived on the runway inverted.

carnarfon

I find it difficult to believe that this Abbots Bromley accident was caused by wind shear alone as the pilot reports the wind to be only gusting 10 knots. The pilot also stated that the airspeed dropped to 45 knots  which I would have said puts it on the wrong side of the drag curve which means you are going to need  a lot more power to recover airspeed and altitude. Unless you react very quickly in a situation like this, especially if there is any actual windshear, you can easily get into a non recoverable situation in a light low powered aircraft and even stall the aircraft.

Its at times like these that we are reminded why airspeed must be preserved at all costs on the final approach.

NEVER LET THE A/C DROP BELOW THE TARGET THRESHOLD SPEED ON THE APPROACH.

I recommend that you always use a 200 feet agl  stabilisation check. If the approach is not stable by 200 feet (airspeed, centreline and height correct)  GO AROUND.

CURSED ARE THOSE WITH THE LOW AIRSPEED FOR THE GROUND WILL COME UP AND SMITE THEM DEAD!

Night Rating Part Two- Things may not be what they seem!

Report No: 12/1977. Report on the accident to Piper PA31 Navajo, G-BBPC, at Walney Island Channel, Cumbria, 26 November 1976

PDF icon 12-1977 G-BBPC.pdf (2,727.56 kb)
The basis of Threat & Error Management (TEM) is learning from the mistakes of others. One of the greatest threats with flying at night is that you loose the normal visual cues you rely on for judging distance, flight path angle and height. You are also much more prone to nightime visual illusions which can catch out even the most experienced  pilots as we can see from this very sad Navajo accident at Walney Island. When you read this accident remember this was an experienced professional pilot at his home base. If he can get it very seriously wrong so can you and I!
What would you have done here, taken the into wind runway without approach angle guidance or taken the main runway with better lighting and  VASIS but with a crosswind on or just above limits?  I think I might have considered diverting to Carsisle but of course it’s always easy to be clever with hindsight. Notice the AIIB didn’t comment that a wet runway maximum crosswind landing is going to more tricky than the equivalent component on a dry runway.
Any night approach without approach angle guidance is certainly not my preferred approach but it would be definitely not an option for me with the ‘black hole’ that existed here and no approach lighting, together with the rain.
It’s also interesting that the AIIB did not comment on the inability of the passengers to initially locate the door opening mechanism. There is now much more emphasis on briefing passengers on how to get out in the event of an emergency in light aircraft but you always need to remember that you may have to get out in the dark, as in this case, (or even under water or upside down) if the normal exits jam or become unavailable. Most heavy impact arrivals distort the fuselage to such an extent that doors and hatches can jam. If your aircraft has only one normal exit how will you get out if it jams? It’s  best to think about this on the ground before the flight! Unlatching the door and even keeping it slightly ajar is a very good idea for an emergency arrival if this is action is approved by the aircraft manufacturer.

Note after this accident the airfield and aircraft operator banned the use of this runway for night approaches and in fact the complete runway is now out of use.

Find out more about visual illusions with this Airbus & FAA information

http://www.airbus.com/fileadmin/media_gallery/files/safety_library_items/AirbusSafetyLib_-FLT_OPS-HUM_PER-SEQ11.pdf

http://www.faa.gov/pilots/safety/pilotsafetybrochures/media/SpatialD_VisIllus.pdf

Gulfstream III aircraft struck a light pole about three miles southwest of the destination and crashed in poor weather while on an ILS approach- Possible fatigue, degraded situational awareness

Possible fatigue, degraded situational awareness

Don’t make the mistake of thinking that fatigue is something only likely to be suffered by professional pilots. If you have not had sufficient rest you should not fly an aircraft at any level, professional or amateur. Fatigue is a temporary illness only curable by quality sleep. Ensure over the previous 72 hours before you fly that you have had 3 periods of at least 6-8 hours interrupted sleap.

Research has shown that the effects of fatigue are similar to moderate alcohol consumption. The result is significantly delayed response and reaction times, impaired reasoning, reduced vigilance and impaired hand-eye coordination. Research has shown that after 17 hours of wakefulness, fatigue-related impairment is equivalent to a breath alcohol concentration (BAC) of 0.05 per cent. After 24 hours of wakefulness, this increases to a BAC of 0.10 per cent – well over the legally prescribed limit for operating a motor vehicle. For a pilot who only has four hours sleep a night, research has shown that just one beer can have the impact of a six-pack.

A chartered Gulfstream III aircraft struck a light pole about three miles southwest of the destination and crashed in poor weather while on an ILS approach. The aircraft was being repositioned from Dallas Love Field to Houston where it was scheduled to pick up former President, George H. W. Bush, and several other passengers. At the time of the accident, two pilots and a flight attendant were aboard the aircraft, and all three perished.

The investigation found the probable cause of this accident was the flight crew’s failure to monitor and cross-check the flight instruments adequately during the approach. Contributing to the accident was the flight crew’s failure to select the instrument landing system frequency in a timely manner and to adhere to approved company approach procedures, including the stabilised approach criteria.

The investigation report also mentioned fatigue. According to the captain’s wife, on  The night before the accident, the captain received about four hours less sleep than normal. A company employee stated that when the captain arrived for work on the morning of the accident, he looked as though he had just woken up. The first officer’s wife stated that the first officer did not have regular sleeping hours and that she was not sure how much he slept the night before the accident. Although the early reporting time for the accident flight might have resulted in flight crew fatigue, the actual amount and quality of sleep received by the captain and the first officer could not be determined.

Given the facts uncovered about crew sleep, the investigators found fatigue may have played a role in the flight crew’s degraded situational awareness.