NT Air King Air Accident - Pilot Discussion Thread

[pelmet]

Oldtimer there was an F-27 in the hangar next to ours that landed with the HP cocks in Fuel On and cooked both engines on the ground when he came up on the power to taxi off the runway. It was in Reading PA, they were training a new F/O and trying to beat a CB to the airport. No one noticed the HP cocks weren't in Cruise Pitch Lock Out and the props had hung on the locks. My cousin was there waiting for them to arrive, he said he could chin himself on the props, both engines seized solid. Allegheny lost a 227 due to hung props, in Albany or Erie, I forget which. Some oil company lost a G1 in Texas the same way. They were training and forgot the HP cocks in Fuel On on the approach. The props had hung on the Cruise Pitch locks and both engines were on fire before they hit the ground. I seem to recall another G1, CF-MMM was lost in YZ the same way, many years ago.

I do remember(although it wasn't really explained) that if you did not get your lights for a prop going to ground fine after landing, it is essential not to even add a bit of power to it to taxi or you will overtemp the engine. Just shut it down. To be honest, I am not sure of the whole background reason for this. Anyone care to explain. Too much fuel perhaps. Is the FCU reset to a lower fuelflow at ground fine.

I remember hearing that the 8X engine had those cruise pitch lockouts that were not on the 534/535's(at least not on the planes I flew). Possibly because they flew faster but any explanation is welcome.

For those of you that miss the sound of the Dart starting up, have no fear....youtube can rekindle those wonderful memories.

Actually, pretty much all the different turbines I have been associated with have at least one portion of engine operation that sounds cool.

http://www.youtube.com/watch?v=xijQ-XYEWzo

http://www.youtube.com/watch?v=kDlsbbEm ... r_embedded

[Siddley Hawker]

All G1's, the F-227 and some of the Fairchild built F-27's, notably the F and I believe the J models with the 532 engines, had two stop props. In addition to the flight fine stop at what, 16 degrees? there was a mechanical cruise pitch stop at 32 degrees. There was an extra forward position on the F-27 quadrant detents for the HP cocks that read cruise lock out. Grumman demanded the cruise pitch lock when they built the G1 because they were worried in the case of a runaway prop at high speed - read over 250 kt - control of the airplane could be lost if the prop was allowed to fine off to the flight fine position. Dowty added a mechanical pitch lock at the 32 degree position to preclude this. The F-27F had a similar arrangement although I have no idea why. The Turbo Blimp was anything but high speed. Problems arose if an electrical fault occurred in the cruise pitch circuit and the cruise pitch locks did not remove automatically, and the crew missed the HP Cocks Lockout position call on the checklist as well as the Cruise Pitch Lock lights on the panic panel not being illuminated. The first indication the props were hung on the CPL's would be an increase in TGT's as you set power on the approach. That would get your attention right smartly, but if the props had jammed in the locks usually setting the HP cocks in the Lock Out position was enough to resolve it. In cases where this procedure didn't work you had to increase speed and or bump the feathering buttons to knock the props off the lock. The airplane could be landed with the props hung on the CPL's but you had to shut down both engines after landing to avoid an overheat. While the system was pretty well foolproof and worked mostly as advertised, I had an instructor at USAir who said the cruise pitch locks had killed more people than it ever saved.

The Flight Fine Pitch Lock was another kettle of fish. To remove the FFPL on the ground on the F-27 there was a selector switch on the quadrant connected to the Captains right hand power lever. You selected Ground Fine with the switch, then lifted the power lever to activate the ground fine pitch circuit. If the switch had failed, you could also remove the FFPL's by engaging the gust lock.

When Dowty was creating the props for the Dart engine application there was a great deal of discussion of what degree of pitch should the props be set for ground operation. Experiments were carried out using a Viscount. They couldn't use 0 degrees for reasons I have forgotten, so they took an arbitrary figure - I seem to remember it was 10 degrees - and tried that. With all four engines running they found the Viscount would trundle merrily off all by itself at idle RPM if the brakes weren't applied. They then came up with another figure, 8 or 6 degrees I forget which and I'm too lazy to go look it up, and that figure worked, so the operating range of the propeller was 6 degrees at idle to 87 degrees at full feather.

[oldtimer]

One must remember that the Dowty Rotol props were not like a modern propeller that has springs and counterweights to bring the prop blades to feather if oil pressure is lost. In the Dowty, engine oil pressure through the prop control simply acted on an internal piston connected to all 4 blades to push the piston, and hence the blades, to every intemediate position.
In the G1, starting had to be at zero pitch which was indicated by stripes painted on the blades and spinner. The Gulfstream had a slightly better system for the FFPL, which was a honking big lever in between the power levers which flopped forward as one applied full power to both engines and on landing, the pilot released a big catch and the lever flopped rearward, releasing the flight fine pitch locks which otherwise would hold the props at 13 degrees. The pilot could do it by feel rather than looking for a switch. Cruise lockout held the prop at a minimum of 36 degrees on case of governor failure which would limit engine RPM to 16.300 RPM which would create engine damage but was supposed to stop bits and pieces from flying off.
Another interesting piece on the Gulfstream, (and the F27) were the speed brakes. On the Gulfstream, selecting the speed brakes extended the main landing gear but held the nose wheel retracted. VMO for the airplane was .54M but below 12,000 ft, VNE was 290 KIAS. The speed brakes had a maximum extension speed of 310 KIAS. Had to slow to 199 KIAS to retract them. The main gear doors would open, the main gear would extend and the doors would close. If the doors were opened hydraulically for a walkaround or maintenance, we were supposed to put a strut in between because if the doors closed accidently, injury or death could result if anyone was unlucky to be in the wells when the doors closed.
Grumman got it's knickname the Grumman Iron Works because they built the Navy fighters the same way, tough as all getout.

Trying not to hijack this thread, I wonder if the fact that the King Air 100 modified with the Raisbeck mod had any influence on the outcome?
For those new to airplane flight characteristics, it has been my experience that increasing the number of blade on a propeller changes the amount of drag produced when the power lever/throttles are brought to idle, which will affect the way the airplane lands.
My first experience was with a Norseman which had a 3 blade prop. The prop was out for overhaul so a 2 blade prop was installed and my first landing almost put me in the weeds because the airplane floated more than what I was used to. I had the opposite experience with a Cessna 310 when for the same reason we installed a 3 blade in place of the original 2 blade. Now, I flew GXVX, a sister ship, first with the original 3 blade prop and then later with the 4 blade Raisebeck and I could no longer go directly to flight idle during the flair.

[flyinthebug]

Trying not to hijack this thread, I wonder if the fact that the King Air 100 modified with the Raisbeck mod had any influence on the outcome?

We did the Raisbeck mods (strakes, wing lockers, and VG kit) on our A100. Increased our MTOW by a nominal amount, but handled very nice. The VGs reduced VS/VMC and the strakes just made it an overall more stable aircraft to fly. I could not see how that mod would have any negative affect on this outcome. That said, i`m no engineer and maybe those strakes could have an affect during engine failure at low ASI?

Fly safe.

[rigpiggy]

The raisbeck strakes are probably the best mod aerodynamically you can do for any king air. Any yaw is met with a deadbeat response. It also reduces the altitude restriction without yaw damp. There is areason why a lot of raisbeck kits are installed at the factory.

[pelmet]

Trying not to hijack this thread, I wonder if the fact that the King Air 100 modified with the Raisbeck mod had any influence on the outcome?

We did the Raisbeck mods (strakes, wing lockers, and VG kit) on our A100. Increased our MTOW by a nominal amount, but handled very nice. The VGs reduced VS/VMC and the strakes just made it an overall more stable aircraft to fly. I could not see how that mod would have any negative affect on this outcome. That said, i`m no engineer and maybe those strakes could have an affect during engine failure at low ASI?

I believe there was an earlier discussion about the effect of the for bladed quiet turbofan propeller modification and the increased drag they cause when windmilling. Didn't realize how quiet these props were until I flew the three bladed Beech 99. Pretty loud machine.

What about the King Air wing fence? Is that a Raisbeck mod as well or from someone else.

[oldtimer]

The wing fence on the upper surface of the wing was added to the Beech A100 because of the higher gross weight. Not installed on the 100, with or without the Raisbeck. I guess the aft body strakes were enough.

[wallflower]

Interesting article in Business and Commercial Aviation about this accident.
maint left the oil cap loose, pilots lost control on final.

[magic wand]

Interesting article in Business and Commercial Aviation about this accident.
maint left the oil cap loose, pilots lost control on final.

Maint could leave a wing off. The final decision as to whether the aircraft is airworthy or not rest with the PIC.
Low tire pressure, no trim tab, loose oil cap, they all fall in the same category.
The PIC is responsible for the decision to fly it.

[Brantford Beech Boy]

The wing fence on the upper surface of the wing was added to the Beech A100 because of the higher gross weight. Not installed on the 100, with or without the Raisbeck. I guess the aft body strakes were enough.

not true.
All 100s have the wing fence.

or at least all 7 of them I have operated.

Cheers
BBB

[cncpc]

Maint could leave a wing off. The final decision as to whether the aircraft is airworthy or not rest with the PIC.
Low tire pressure, no trim tab, loose oil cap, they all fall in the same category.
The PIC is responsible for the decision to fly it.

Well, that's a nice thought from an armchair, but it doesn't always hold up in practice.

There is no evidence this pilot made the decision to fly with the cap off.

And, though the cap being off was one of the holes in the cheese, it wasn't directly the cause of the accident.

[human garbage]

Maint could leave a wing off. The final decision as to whether the aircraft is airworthy or not rest with the PIC.
Low tire pressure, no trim tab, loose oil cap, they all fall in the same category.
The PIC is responsible for the decision to fly it.

Well, that's a nice thought from an armchair, but it doesn't always hold up in practice.

There is no evidence this pilot made the decision to fly with the cap off.

And, though the cap being off was one of the holes in the cheese, it wasn't directly the cause of the accident.

The TSB said in the report:

During the loading of the passengers, a small puddle of oil under the left engine was pointed out to the pilots. The captain acknowledged the oil, but no further action was taken.

If you see a puddle of oil and don't investigate the root cause of that defect, then you are choosing to fly with said defect. Loose oil cap in this case. Nothing armchair about that.

I have to disagree about the cheese. Loose cap -> loss of oil -> loss of engine -> loss of control at a critical juncture -> crash. I'd say it was about the only factor involved, not an alignment of many factors as in the cheese model.

Feel free to disagree of course, but I agree with magic wand on this one.

[CpnCrunch]

Also the report says "A complete preflight inspection of the aircraft was not conducted" (the pilot spent "2 minutes" before pulling the plane out of the hangar).

I think there was a discussion a while ago about the difficulty in checking the oil caps on a king air. However it seems that this pilot had a number of opportunities to discover the problem.

[cncpc]

.
The TSB said in the report:

During the loading of the passengers, a small puddle of oil under the left engine was pointed out to the pilots. The captain acknowledged the oil, but no further action was taken.

If you see a puddle of oil and don't investigate the root cause of that defect, then you are choosing to fly with said defect. Loose oil cap in this case. Nothing armchair about that.

I have to disagree about the cheese. Loose cap -> loss of oil -> loss of engine -> loss of control at a critical juncture -> crash. I'd say it was about the only factor involved, not an alignment of many factors as in the cheese model.

Feel free to disagree of course, but I agree with magic wand on this one.

A puddle of oil is not a defect. If this puddle of oil came about because of the loose oil cap, then the cap must have been loose on a previous flight.

There was sufficient oil in the left engine for it to operate. It was not shut down, but brought to flight idle. The aircraft crashed because it rolled to the left on the application of power, whether it was to both engines or to just the right isn't clear. If the left was brought out of flight idle and powered up, then something must have caused assymetric thrust in those final few seconds. I would imagine that it hit level because as his last act, the captain reduced the power on the right and was able to roll level.

In doing so, he saved the lives of all his passengers, whatever negatives may be thrown out as to what happened in the minutes before.

I respectfully disagree about the cheese model. This was a classic example of that model and there were a considerable number of points in which a slight change would have resulted in no thread here at all.

[magic wand]

A puddle of oil is not a defect. If this puddle of oil came about because of the loose oil cap, then the cap must have been loose on a previous flight.

Are you serious? A puddle of oil under a turbine engine is a defect.. a big one..!
A puddle of oil under a R2800 should be investigated.

Have you even read the report. As pointed out ..they didn't even do a full DI. Kicked the tires and lit the fire.

There is no cheese model.
Failure to ensure your aircraft is serviceable prior to flight usually leads to undesirable flight characteristics.

[pelmet]

A puddle of oil is not a defect. If this puddle of oil came about because of the loose oil cap, then the cap must have been loose on a previous flight.

Actually, you would probably fail your private pilot flight test if there was a puddle of oil coming from your Cessna 150 and you then didn't do much of a pre-flight and didn't follow up when the examiner mentioned something about it.

I'm afraid that this was a key reason for the eventual result.

It was termed in the report as a small puddle, but how much oil is normally coming from a PT-6 on your walkaround. A few drips may be reasonable.

[Brown Bear]

I had a puddle of oil under a turbine one time. I dumped a litre into the engine, and MISSED the filler spout! Someday I will hear the last of it....perhaps not.

[rolly117]

There is no doubt that Luke fought his way to survive this situation. I
Worked with him with borek at harbour air @ coal harbour/ richmond, and the guy had his shit together. if you cyber idiot's like to fantasize about what you think what went wrong,then you should get out of your cocoon and experience the real world . Pilots go North then become Aviators. Luke was one of them

[brownbear]

This thread has runs it's course and is time to be closed.

Luc did have his shit together as mentioned above. He wasn't a 5000 hr pilot he was in the 14k range. With 9 of it in Pt6 world. He flew around the world. He had incredible flying skills. With years of float flying landing in big swells he honed his low speed skills. Which I am sure played a big part in survival for their passengers.

He also came from an environment that wasn't corporate. He had AMEs when the plane was at base giving the plane full DI's. How much of a DI these pilots do after such an inspection might vary from pilot to pilot. A missed oil cap might occur. But he would always presume the oil was topped up and the tires had air. He would have done a run up. Oil pressure would have been solid. How many -6 or -8 pilots check their own oil? You go with the AME who just inspected the plane. This was a borek way too, but depends on the pilot for sure.

As far as oil under a Pt6. These NT birds are hard worked machines that fly along side 1900Cs and Ds. While it is true oil leaks under -28s are rare, they are not on 1900s. 1900s have tubing systems specifically for draining oil when seals start to fail. The backs of the nacelles are always dripping oil. If you look at any airline larger turbine they are wet with oil. -8's etc. So for a company with 100's to see oil would not bring about any panic.

Luc went back and forth between the 1900 and the 100's at NT. Im sure the planes behave differently with low speed and one engine producing torque. Now there is training given to pilots who fly 100's on this event.

I think while its important to look at accidents and learn from them to avoid repeating mistakes, one thing we cannot do is prevent them entirely.

Luc was not complacent, and I feel that no matter how many hours or level of skill you have, how careful you are, when it's your time it might not be preventable. We've all seen a lot go bad to some very good pilots. At the end of the day you have exposure and risk levels. Cheese model for sure, but remember we might be chatting about you when you finally go...

[cncpc]

There is no doubt that Luke fought his way to survive this situation. I
Worked with him with borek at harbour air @ coal harbour/ richmond, and the guy had his shit together. if you cyber idiot's like to fantasize about what you think what went wrong,then you should get out of your cocoon and experience the real world . Pilots go North then become Aviators. Luke was one of them

Thanks for saving me the effort of saying the same thing.

I didn't fail my private flight test, or any other flight test. If I'd seen a puddle of oil and described it as a defect, I'm sure the examiner would have thought I perhaps wasn't yet ready for a flight test.

[pelmet]

There is no doubt that Luke fought his way to survive this situation. I
Worked with him with borek at harbour air @ coal harbour/ richmond, and the guy had his shit together. if you cyber idiot's like to fantasize about what you think what went wrong,then you should get out of your cocoon and experience the real world . Pilots go North then become Aviators. Luke was one of them

Thanks for saving me the effort of saying the same thing.

I didn't fail my private flight test, or any other flight test. If I'd seen a puddle of oil and described it as a defect, I'm sure the examiner would have thought I perhaps wasn't yet ready for a flight test.

Maybe if you had asked a maintenance person for a look you would have impressed the examiner if such a situation were to occur. You would have shown that you have something called airmanship about suspecting a potential defect.

Do you really feel that this kind of recommended action/opinion is "cyber-idiot" like? This wasn't at a remote location without any maintenance around was it. I believe it was in a hangar in YVR. Perhaps a quick phone call if no one is around to see if it is unusual if you are not sure.

I remember being new on a turboprop type a few years back. I was on a sched flight with pax and ended up shutting down the aircraft after start and getting maintenance to check something on a because of an indication that turned out to be normal under certain situations. Not a big deal. It only takes a few minutes. Had to fill out a delay form later on but there was no consequence to doing this. (I was worried about a hydraulic pump possibly running when not powered). But there can be a hesitancy to ask or delay a few minutes sometimes.

A puddle of oil is not a defect. If this puddle of oil came about because of the loose oil cap, then the cap must have been loose on a previous flight.

Think about what you are saying here. Has it not occurred to you that if a cap was loose on the last flight, it might come off on the next flight or maybe there was maintenance done with an engine run. In the end, while more information is nice, the last flight doesn't really matter when you encounter this sort of situation.

I suspect the readers of this thread on the same aircraft type will look into things further if this happens to them in the near future. Lesson learned but who wants to be the one teaching the lesson by example.

[Diadem]

I think it needs to be pointed out that the puddle of oil wasn't on the hangar floor after being left overnight, it was found after the aircraft had taxied to pick up the passengers. I don't know about you, but if I found a pool of oil under my aircraft after it had been sitting for just a few minutes I'd investigate further. I fly aircraft equipped with PT-6s, none of which are particularly new, and I've never seen a puddle of oil, even after being left for days. That kind of thing would draw my attention.
Regardless of whether the captain should have checked the oil caps, he allowed an aircraft that was perfectly capable of maintaining flight to get out of control. He let the speed decay below Vref quite a ways back from the threshold, which would be poor airmanship in a perfectly-functioning airplane. Even if he didn't know that the mod would affect the minimum control speed, he still should have never gotten below ref speed; this is especially true if he was only ten knots above normal Vmca and already had an engine issue. Under those circumstances, with a 10000' runway, I would raise my ref speed to give myself a good margin of error just the same as I would on a gusty day or under any other unusual circumstances.
The fact that the captain had almost 14000 hours doesn't mean he was infallible. He was complacent about the oil issue, and sloppy with his handling of the aircraft. It's a cautionary tale that even the most experienced pilot can make mistakes.

[angry inch]

Well Said Brown Bear.

[leftoftrack]

Can we not say that Luc fucked up? I sat beside the man for a portion of my line indoc he was an amazing person who knew a lot.

The biggest change that I have seen is the EMS response. Despite what a pilot declares if he returns it is considered an emergency and ARFF service's are dedicated to the response. ARFF at Vancouver international are tied to the Richmond EMS system which is tied to the greater Vancouver system ultimately thru the requirement of having to maintain a level of service available to all residents the unnesacarry responses are costing tax payers money.

[pelmet]

Can we not say that Luc fucked up? I sat beside the man for a portion of my line indoc he was an amazing person who knew a lot.

The best thing to do in a case like this is to ignore who the person was and focus on the actual events that occurred to prevent bias from entering the picture. You will find that a TSB investigator will have restrictions in an investigation if they know the person involved well or were employed recently by a company involved in an accident.

While knowing the pilot can help come to an unbiased conclusion it can be very easy to have objectivity impaired based on the personality of the pilot.

Based on the comments on this thread, it is a good reminder for all of us that even really good pilots can make significant mistakes. All we can do is try to learn.