Gremline Flight Safety Report: Checks Are Vital Actions & Thoughts for Flying Instructors

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the gremline digest — checks are vital / thoughts for instructors

Checks Are VITAL Actions

No matter how often you fly and no matter how many times per day you operate your aircraft it is VITAL that all checks are completed each and every time. A pilot taking off for his ELEVENTH virtually identical flight of the day neglected to complete his pre takeoff checks and paid for this oversight with his life.

The DHC-3 Turbo-Beaver is a single engine, high wing, tailwheel, STOL capable aircraft powered by a Pratt & Whitney PT6A-34 turboprop engine replacing the original P&W R-1340 Wasp piston engine. The Beaver was being flown by a 36 year old CPL who had a total of 932 hours with 27 hours on type. He had flown 22 hours in the previous 28 days. The aim of the flight was to drop 8 parachutists from 12,000 feet above Headcorn Airfield.
      There are two grass runways at Headcorn. The main runway is 11/29 which is 840m long by 30m wide. The secondary, unlicenced, runway is 21/03 and is 312m long.



The Accident
The pilot completed 13 lifts without incident on the day before the accident. He had completed five lifts from Runway 29 on the morning of the accident when the surface wind freshened from the south and the pilot requested the use of the shorter Runway 21. The air/ground operator refused this request because he believed that the pilot had not been checked out to use this runway, as required by the Headcorn Aerodrome Manual. The pilot approached a nominated check pilot who agreed to observe his next flight. The check pilot briefed on the procedures for the short runway, stressing the need to make an early decision to abort the takeoff if that became necessary. The check pilot observed that a thorough pre-takeoff check was completed using the full checklist available in the cockpit. The subsequent flight from the short runway was entirely satisfactory. A further five lifts were flown from Runway 21 without incident, although the check pilot commented that the climb gradient on one flight appeared shallower than normal. He put this down to a drop in the surface wind speed.

      The accident occurred on the pilot’s eleventh flight of the day. The aircraft taxied to Runway 21 and then appeared to accelerate normally but the tailwheel never left the ground. The experienced jump-master on board with seven other parachutists noticed that the aircraft was passing the point on the runway where it would normally be airborne. He heard the pilot shout “Abort”. Another parachutist shouted to the other occupants “Brace – Brace, everyone on the floor.” The Turbo-Beaver stopped abruptly when the left wing and cockpit collided with a camouflaged  North American F-100 Super Sabre static exhibit parked outside a museum to the left of the southern edge of Runway 21.
      The uninjured parachutists vacated the aircraft with mutual assistance. The aerodrome fire service extinguished a small fire in the area of the engine. The pilot remained unconscious in the cockpit. He was attended by paramedics and taken to hospital where he died.



The AAIB Investigation

A meticulous investigation by the Air Accidents Investigation Branch, Farnborough, looked at the wreckage in detail and examined the wheel mark on the grass runway as well as downloading GPS information from a unit recovered from the aircraft. The investigation noted that the Turbo-Beaver checklist requires that flaps be set to “Take-off” position for all take-offs but the flaps on the accident aircraft had not been extended for the fatal take-off. The wheel tracks showed that the tailwheel had been in heavy contact with the runway for the latter part of the take-off run while the mainwheels were only touching the grass intermittently until heavy braking was applied when the decision was made to abort. This indicated that the pilot was trying to pull the aircraft off the ground with the tailwheel still on the ground, and continued to do so until he realised that the aircraft was not going to take off.
      The facts regarding this fatal accident are taken from AAIB Field Investigation EW/C2007/03/03 which source is gratefully acknowledged. The aircraft registration was OY-JRR. The complete accident report may be seen at
      The following comments do not come from AAIB and do not seek to represent the views of AAIB. The Beaver Flight Manual requires that the flaps be set to 35 degrees for take off. When the flaps are lowered the ailerons also droop. This configuration considerably alters the aerofoil section of the wing and imparts the extra lift required during take off. The aircraft design authority was unable to provide data for takeoff with flaps UP, commenting that this configuration was outside the normal flight envelope. It appears that the pilot forgot to lower the flaps to the required take-off position prior to the last take-off. It also appears that he may have continued to attempt to haul the aircraft into the air when the take-off was not progressing normally. He did not abandon the take-off in time to stop the aircraft before it struck the parked F-100.



The Diagnosis - Repetitive Brain Syndrome?
It may be instructive to look for reasons for the pilot’s failures. He was engaged in a day long series of closely repeated short duration operations involving a short take-off, a climb to height, a rapid descent to landing and frequent repetitions of this profile. It is very easy to make a mistake, or to miss a check item, in this situation. Frequent repetition of a profile induces a mind-set where one is not really concentrating on the actions required but is just going through the motions. A fairly common example of this is when a trainee (or instructor) is flying a long sequence of visual circuits in a retractable gear aircraft and is amazed to eventually arrive on the runway with the gear up. When we have repeated something frequently over a short duration our brains can suffer from a low arousal level – which is psychobabble for our brains going into neutral. Think of someone performing a small, repeated action while standing beside a production line. You can bet they are unlikely to be concentrating fully on what they are doing. I suspect that is the trap that caught the Beaver pilot. He was on his eleventh sortie of the day. He had completed the take-off checks and lowered take-off flaps ten times. He simply didn’t do this for the eleventh flight. He was not highly experienced on type. He then fell into another trap. It is vital to consider your eleventh take-off of the day with just as much care as you dedicate to the first. He knew where his decision point was on the runway but on the fatal flight something went wrong and the aircraft was not performing normally. It is an understandable reaction in those circumstances to make some attempt to resolve the problem. THIS IS THE WRONG THING TO DO. He continued his futile attempt to haul the aircraft into the air. If something is going wrong during the take-off then abort as soon as you become aware of the problem, and certainly do not think about anything other than stopping the aircraft once you have arrived at your decision point on the runway.


Prevention is Better than Cure
If something goes wrong before your decision point during take-off then STOP THE AIRCRAFT first. Think about the problem after you have come to a halt.
      I have never flown a DHC-3 Beaver but I have flown the similarly configured Pilatus Turbo-Porter in its military guise, as well as several other STOL aircraft up to the size of the DHC-5D Buffalo and the Lockheed C-130 Hercules (which CAN be STOL). STOL operations involve flying close to the edges of the performance envelope. I believe that all STOL operations require a detailed and structured training programme and specific type training.
      A useful Flight Safety thought passed to me by a wise old pilot is,
“Learn from the mistakes of others. You won’t live long enough to make them all yourself.”



A Few Thoughts for Flying Instructors
I have gained the impression, perhaps wrongly, that quite a few club Flying Instructors feel antipathetic towards military instructors. Maybe the apparent present day antipathy by the younger generation is towards all things military. Old values like discipline, service, esprit de corps and striving to be best seem to have little place in modern life. Whenever I mention to younger people the possibility of joining one of the Armed Services the reaction is usually, “Oh! I couldn’t be bothered with the discipline and being told what to do.”
      Recognising the prevalence of these feelings I still think it worth printing an extract from Air Ministry Pamphlet 121 – published in March 1941. Below is an extract from
Hints on Flying Instructing. I believe the extract contains thoughts that are still valid today, 67 years after it was first published.

“When the Flying Instructor has been taught to fly accurately and to demonstrate his actions with synchronised ‘patter’, only the foundation of his profession has been provided for him. The most skilful pilot with the most perfect patter can still make a bad instructor, and the average pilot with good average patter can make an excellent instructor. The difference being that the one almost disregards the characteristics and foibles of his different pupils, while the other makes a constant study of his pupils in order that he may get the best out of them.
      “To his pupil the instructor is a demi-god. One well-known High Court Judge always used to call his old headmaster ‘Sir’ with profound respect, even when the judge was 60 years old and the headmaster was 85. In just the same way your pupils, we hope, will still regard you as the best pilot and instructor they have ever known, even when they have flown 2,000 or more hours. Don’t for one moment let a knowledge of this potential hero-worship go to your head, but by all means be worthy of its simple faith.
      “Already you may have heard it said that the pupil is the most slavish copyist there is; and this is true not only for work in the air, but for work on the ground as well.
      “It is a highly interesting fact that causes of flying accidents can be traced back to the original instructors of pilots. Some bad flying habit has been copied by a pupil, acquired and been allowed to persist in his flying until it has produced the inevitable result.
      “If you are slack in manner and appearance then you will inevitably breed a race of pilots, all your own, which tends to be slack in manner and appearance. Although you may not realise it, everything you do and say is mentally noted by your pupils, on duty and off duty. Your appearance in uniform should be good. Nobody should be able to teach you anything about punctuality. Move about as though you have a definite purpose in life. Don’t run down ground training. Some of it is admittedly dull, and lots of it may seem to you to smack of the kindergarten. Those in authority have good reason to believe that it has high value however, so support their authority and don’t undermine it. Don’t criticise superiors. Don’t discuss your own pupils, or other instructors or superior officers, with pupils. Along with priests and physicians you share a lot of confidences. Respect them.”

      Well, there it is. Archaic claptrap or a few nuggets worth thing about? Only you can decide.




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