NTSB presents: Is your aircraft talking to you? Listen!
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Transcript of NTSB presents: Is your aircraft talking to you? Listen!
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Is Your Aircraft Talking to You? Listen!
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Cathy Gagne, AS-70
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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 of accidents
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Top Occurrence Categories
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Fatal accidents in GA personal flying sector, 2000-2011
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Discussion of Accident Cases
• Completed cases: common causes, factors, and scenarios
• Used as educational tools• Not intended to admonish accident
pilots
• Intended to help other pilots learn
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Scenario 1: Beech 36
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Accident Synopsis
• Pilot/owner planned personal round-trip night IFR flight
• Complete engine power loss on return leg
• Forced landing, pilot fatal
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Pilot
• Sole owner/operator
• About 2,300 total flight hours
• Flight instructor, with multi-engine and instrument ratings
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Airplane History
• Engine:10 hours since overhaul at time of pilot’s purchase
• Pilot added about 50 hours prior to accident
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Airplane History
• Engine oil pressure problem several weeks before accident
• Mechanic: Overhaul issue
• 1 week later, pilot said engine “seemed OK”
• No evidence of corrective actions
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Accident Flight
• No outbound leg problem reports
• Midnight taxi out, return to FBO
• Pilot requested mechanic (unavailable until morning)
• Pilot then opted to depart, IFR
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Accident Flight
• Complete loss of power 9 miles from destination
• Night IMC forced landing
• Engine examination: crankshaft fracture
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Bearing, Crankshaft Damage
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Missed Opportunities
• Actively address problem • Maintenance troubleshooting
• Do not fly until resolved
• Take conservative approach• Take all indications seriously
• Ground airplane until problem identified and resolved
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What Pilots Can Learn
• Resist external pressures to fly
• Identify, assess all risks
• Maintenance: Don’t talk self into believing what you want to hear
• Problem indications not always obvious
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What Pilots Can Learn
• Conservative approach can be inconvenient, costly (but is safer!)
• To avoid inappropriate choices:• Consider options and outcomes
• Prevent outside factors from adversely influencing decisions
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What Pilots Can Learn
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Scenario 2 – Vans RV-6
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Accident Flight
• Vans RV-6
• Departed 20 minutes before accident
• Private pilot was fatally injured
• Maintenance test flight
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Airplane History
• Oil leak discovered 6 weeks earlier
• Source of leak: propeller governor high pressure oil line
• Weld “repair” was made
• Pilot departed for test flight, but chose to conduct cross-country flight
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Accident Site
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Wreckage Examination
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Missed Opportunities
• Stick to maintenance test plan
• Review service bulletins, airworthiness directive
• Be prepared to execute emergency procedures
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What Pilots Can Learn
• If signs of problem persist, be prepared to discontinue flight
• Review, practice emergency procedures
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Scenario 3 – Beech G35
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Photo from sales advertisement
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Scenario 3 – Beech G35
• 1956 Beech Bonanza (G model)
• Recent purchase by two pilots
• Lost engine at destination
• Owner/pilot: 40 hours in BE35
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Airplane History
• 3,350 hours total time airframe
• 80 hours since major overhaul on Continental E-225 powerplant
• Owners: Multiple mechanics troubleshooting oil leaks
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Airplane History
• Mechanics found, fixed some leaks; troubleshooting others
• Owners monitored; mechanics rechecked daily
• Oil temperature, oil pressure normal, no contamination
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Photo from sales advertisement
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Flight History
• Owner/pilot (low time BE35) flew RYY to CHS (235 nm) day VFR
• At CHS: remark about oil leak
• Checked oil level, departed on return flight to RYY
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Flight History
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Flight History – Outcome?
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Flight History – Outcome
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Findings
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• Engine teardown: No evidence of case fretting or bearing damage
• Wrong type of case thread (not silk) used at overhaul
• Eventual consequences had it continued to fly? Depends …
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What Pilots Can Learn
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• Troubleshooting may take time
• Even trusted sources may provide conflicting information
• Decisions: not easy, not cheap, not always obvious what is right
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In Conclusion
• This issue, others covered in SAs
• Hot links (or short urls) to find reports, dockets, other resources
• www.ntsb.gov
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Thank You!
Questions? Discussion?
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