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Lesson Learned from Tragedy

by Bruce MacKinnon, Wildlife Control Specialist, Aerodrome Safety, Transport Canada

In the business of risk management, we frequently discuss abstract concepts such as active failures, latent conditions, causal effects as well as links in the chain of events that contribute to an accident. On July 15, 1996, a Belgian Air Force C-130 Hercules crashed at Eindhoven Air Base in the Netherlands, resulting in 34 fatalities and 7 serious injuries. The tragic circumstances surrounding this accident provide a poignant message that dramatically shifts abstract concepts into gut-wrenching reality.

The Hercules departed Melsbroek, Belgium, for Eindhoven Air Base via Villafranca and Rimini in Italy. On board were 37 passengers and 4 crew members. Of the 37 passengers, 36 were armed forces musicians who had given several performances in Italy. It was during the flight from Italy to Eindhoven that a chain of events began that, when examined carefully, can provide a valuable lesson.

The Hercules arrived ahead of schedule at Eindhoven, and was cleared for a visual approach to Runway 04. The airport bird control officer had previously been asked to report to the tower when it was assumed that the Hercules would arrive later in the day, although normal procedure required him to be on the field monitoring bird activity during flight operations. These circumstances required the bird control officer and air traffic control (ATC) staff to fire pyrotechnics from the tower to disperse a flock of birds that was observed shortly before the Hercules was due to land. The bird control officer and ATC staff failed to detect that a large, mixed flock of lapwings and starlings was sitting near the runway in grass, which had recently been mowed but had not been raked.

Just prior to touchdown, approximately 500 to 600 of these small birds were observed by the flight crew, who elected to carry out a missed approach. During the overshoot, the No. 1 and No. 2 engines were severely damaged by bird ingestion. The crew also feathered the No. 3 engine, likely believing that this engine was also damaged. With only the No. 4 engine producing power, the aircraft yawed approximately 70 degrees to the left, banked approximately 35 degrees to the left, lost altitude and crashed into the ground. The fuel tanks ruptured and flames engulfed the aircraft.

While the aircraft was still airborne, ATC staff activated the crash alarm, and emergency response staff reacted immediately. A misunderstanding during the initial calls resulted in the assumption that only the flight crew was on board the aircraft, with the result that backup fire fighters did not respond. A further assumption that the flight crew could not have survived the fire led to the decision not to enter the severely damaged aircraft (see photo). Because of these assumptions, more than 25 min were lost in the rescue effort. Meanwhile, survivors were unable to evacuate the aircraft because the doors had been damaged in the crash. Survivors were evacuated to the local hospitals 40 min after the accident.

It appears from the available information that quite a few links in the chain of events could have been broken to prevent this accident. For instance, the bird control officer could have been sent back to the field prior to ATC giving a landing clearance to the aircraft. Aircraft arriving early or departing late are common to any operation and the short delay that would result from the bird control officer returning to the field would have been a minor one.

Freshly mowed grass that is left unraked near a runway is an inviting site for birds. Had the mowed grass been properly disposed of, the probability of having a large flock of birds resting there would have been reduced, and it may also have offered a better view of the birds from the tower. Had more effective communications taken place during the initial calls, especially regarding the number of people on board, the fire fighters would have responded accordingly and possibly reduced the number of casualties.

Finally, the initiation of a missed approach in such a situation is something to reflect on seriously, and perhaps this issue could be discussed among pilot groups. We have received a number of reports describing incidents in Canada where pilots initiate an overshoot once they see birds in the runway environment, often resulting in aircraft control problems. Harm to turbine engines involved in bird-strike incidents is greater when the engines are operating at high power settings.

Although we fully realize that the critical decision to either overshoot or continue with the landing rests with the aircraft captain, bird-strike reports suggest that it may be advisable to continue with an assured landing, instead of applying full power and flying through a "cloud" of birds.

Perhaps the Eindhoven tragedy may have been prevented had one link in the chain of events been broken. The fact that the Dutch military has a state-of-the-art bird control program proves that if such an accident can happen there, it can happen anywhere.

by Rod Ridley, Regional System Safety Officer, Prairie and Northern Region

Anyone who flies has heard the old rhyming phrase that is the title of this article. These three words form the fundamentals of safely piloting an airplane - fly the airplane; get to where you want to go safely; and talk to people about where you are going. Unless you are flying circuits from your own grass strip in the country and never fly anywhere else, chances are you will eventually fly into and out of airports that have a control tower, or a mandatory frequency (MF) that has certain basic requirements as outlined in sections 602.97 to 602.104 of the Canadian Aviation Regulations (CARs).

At these times, talking to people takes on a high degree of importance because you must share the airspace with other folks in large and small aircraft. If you don’t talk to others about where you are, or if others don’t tell you where they are, the risk of problems arising increases, with dramatic results. Take these recent cases in point:

Case 1: The instructor and student were conducting circuits in a single-engine aircraft at a satellite airport, and were descending on the base leg. Pre-landing checks had been completed and a position report made on the MF. Just seconds before turning final, a twin-engine executive aircraft passed right in front of the training aircraft, on a straight-in approach to the active runway without so much as a word on the MF. Fortunately the instructor and student saw the other aircraft before a risk of collision could occur, but this incident could have had a different outcome.

Case 2: During another dual training flight in a single-engine airplane, the instructor and student were performing circuits at an uncontrolled airport with an MF. As the aircraft levelled out on the downwind leg, the instructor saw an air force jet trainer joining the circuit at the same altitude at his 3 o’clock position, closing fast and just a few hundred feet away, which made evasive action imperative. Again, not a word was broadcast by the jet aircraft.

Case 3: The twin-engine turboprop commuter plane had just taken off from an airport with an MF in effect, and was climbing out over the adjacent lake, when a single-engine float aircraft flew through the departure path of the active runway, causing the commuter plane to have to quickly manoeuvre away from the other traffic. Was there any communication from the float aircraft? You know the answer by now.

The risks inherent in a mid-air collision are well known to pilots, and to the travelling public as well, yet why are the required communication practices are often ignored by pilots flying in MF areas. We have all heard the phrase "big sky, little airplane" and can be lulled into believing that the chances of a collision are so remote that we relax our need to be vigilant. The regulations described in the CARs are clear and meant to be helpful. In fact, they reflect common sense and are designed to minimize the risk of a mid-air collision.

For the purposes of simply illustrating the importance of communication while flying, let’s use the analogy of driving our car through an intersection. While communicating by radio doesn’t apply when driving, the need for controls at intersections does, and we can fully understand the need for stop or yield signs or traffic lights. Imagine driving straight through any intersection without obeying a traffic sign or light. The consequences could be catastrophic given the right timing with another vehicle.

Now, extend the analogy to an airport, with the MF as our traffic control. Traffic converges at airports, just as it does at intersections, and airports are statistically the sites of the majority of mid-air collisions. In places where air traffic control towers or terminal control centres are not warranted, the pilot has a great deal more freedom from rules and procedures. But, as with any extension of freedom comes added personal responsibility, and in the case of flying in MF areas, the price is a relatively small one - tell people where you are and where you are going. Failing to do that in the sky with its extra dimension of space, and in multiples of the speeds of vehicles on a road, makes the price of not talking to one another potentially deadly.

Flying is, for most pilots, a joyful and highly satisfying activity, whether it’s done for business or pleasure. Playing by the rules when we fly allows for maximum safety, and assures that all of us can continue to experience the benefits of air travel. Remember the three fundamentals and, please, when you’re in an MF area, TALK TO US, WE WANT TO HEAR FROM YOU!

To The Letter

Directional Control on Runway

Dear Editor:

After reading Transportation Safety Board of Canada Final Report A97Q0015, referenced in your "CRM Classic - Takeoff Gone Awry" article published in ASL 4/98, I was struck by the brief mention of, but not the emphasis on, what I believe may have really triggered the accident.

It is true from the crew resource management (CRM) aspect that a bad chain of events was set up by the crew. The trigger, however, was the directional control on the runway. I would bet that the pilot flying did not have enough, or, more likely, any aileron deflection into wind. I came to this conclusion before going back and checking the runway alignment and wind direction and, sure enough, there it was, a 50 degree crosswind at 20 kt. gusting to 30 kt.

Over the years, while supervising pilots, I have been astonished at the total lack of attention to deflecting ailerons while taking off and landing. It seems to be the very first thing that pilots forget after their private licence, yet it is critical input if proper directional control is to be maintained. On wet, icy, muddy surfaces with a crosswind, aircraft will drift downwind on the roll, both taking off and landing. The application of ailerons counteracts this. In extreme cases, full aileron is insufficient, but this generally coincides with exceeding the maximum crosswind tolerance of the aircraft.

Even on the most icy surface, proper application of ailerons enables good direction control in a crosswind, coupled with proper technique. Most aircraft that are not high-lift types are more forgiving under these circumstances. If you perceive that most newer pilots are flying nosewheel, non-high-lift aircraft and encountering crosswinds and slippery runway surfaces on an infrequent basis, then it is apparent that their level of competency is not too high. Associated with wrong technique, they are a set-up for disaster.

An argument may be made for differential power to correct drift, but this is application of a yawing technique that produces some weathercocking. The power settings are altered, and, assuming full power is set and required, the pilot is decreasing power on the upwind engine at a critical time, and increasing his ground roll. The proper application of ailerons will normally negate the need to adjust the power.

The report mentions only "...It appears that the loss of directional control was caused by the condition of the runway, the environmental conditions, and the late application of corrective measures." It does not mention what kind of control input the PF (pilot flying) was making (or not making). I don't like second-guessing without the facts, but if I am correct, if he is typical of what I have observed, then I am wondering if he has figured it out yet, ready for next time. To all pilots who drift unaccountably on runways in crosswinds, check the position of your ailerons!

Sincerely,
John Warner
Leduc, Alberta

Dear Editor:

In ASL 4/98, "CRM Classic - Takeoff Gone Awry," there is much talk of the first officer (F/O) giving an insufficient take-off briefing, not informing the pilot-in-command (PIC) of his difficulties maintaining directional control, and making the non-standard call "I have reached the speed." With phrases like, "It is possible that the PIC would not have cut power if the F/O had clearly and precisely communicated the loss of directional control of the aircraft and his intention to continue the takeoff," and "...the PIC had very little time to analyze the situation...," the reader is left with the impression that the poor PIC is simply a victim of a bad situation.

Based on your account, the PIC was the major cause of this accident. The first thing I learned in my two-crew training is that, at the command of the PF (pilot flying), in this case the F/O, the PNF (pilot not flying), in this case the PIC, sets and maintains take-off power, monitors the engine instruments and airspeed, and makes any calls covered in the take-off briefing loudly and clearly enough for the PF to hear them. The PNF is not relieved of these duties until after climb power has been set. Had the PIC followed this most basic rule of crew resource management (CRM) there would have been no incident no matter what deficiencies there were on the part of the F/O. This incident happened only because the PIC did not call V1 loudly and clearly enough, and then made the cardinal sin of abandoning his duties altogether by looking out the window. It makes this reader wonder how much of the directional control problems were caused by an asymmetrical power setting by a PNF who was looking out the window instead of doing his job.

Sincerely,
Ian Shipmaker
Salmon Arm, B.C.

Take Five - Winter Tips

Winter brings changeable weather with fast-moving fronts, strong and gusty winds, blowing and drifting snow, and icing.

This calls for good judgment, caution, changing some habits, and caring for your aircraft.

So much for the generalities; let's get down to specifics.

Winter Care

  • Follow the manufacturer’s recommendations for winterizing.
  • Use recommended baffling and covers.
  • Check all hoses, flexible tubing, and seals for the signs of deterioration: cracks, hardening and lumps. Tighten loose clamps and fittings.
  • Adjust control cables to compensate for cold contraction.
  • Remove wheel covers to reduce the chance of frozen slush locking the wheels and brakes.
  • Inspect the heater system for leaks (carbon monoxide).
  • Use covers for at least the pitot, engine and wings if your aircraft is parked outdoors.
  • Top up the fuel after landing - this will reduce condensation icing in the fuel system.
  • Keep the battery charged, or remove it if your aircraft is parked outside. (Take the same care of the emergency locator transmitter (ELT) battery. If you need it, you’ll want it to perform properly.)

Be Weather Wise

  • Winter weather is not more hazardous; it's just different - and a trifle unforgiving.
  • Plan carefully.(Do you really understand that forecast? Have you prepared alternate ways out in case you run into a problem or unexpected weather? Have you allowed for the shorter day?)
  • Carry a safe margin of fuel for any change in plans.
  • File a flight plan or itinerary, and forward any amendments to air traffic control.
  • Dress for the weather outside the cockpit. (You could have heater failure, or even an emergency landing).
  • Monitor weather broadcasts, request PIREPS (and give them), and get forecast updates en route.
  • Watch for the warning signs of weather ahead: clouds, indefinite horizon, wind and temperature changes, and cars using headlights during the day (blowing surface snow).
  • Know what a whiteout is, especially if you fly over large frozen lakes or snow-covered terrain with no contrasting features. It happens when snow-covered, featureless terrain blends into an overcast sky: the horizon disappears, disorientation sets in quickly and height perception is lost. Can you handle instrument flight?
  • Be alert for carburetor icing around the freezing mark.
  • Warm the engine periodically during low-power descents and approaches.
  • Set reasonable limits and stick to them; otherwise you could be tempted into pressing on.

Pre-Flight Additions

  • Make sure the oil breather tubes are ice-free.
  • Drain enough fuel for a proper contamination check (if it doesn’t drain freely, suspect ice in the line or sump).
  • Clear the pitot tube, heater intake, fuel vents, and carburetor intake of snow or ice.
  • Make sure the gear is ice-free.
  • Clear ice, snow and frost from lift and control surfaces. (Even a little frost can destroy lift!)
  • Bring adequate survival gear.
  • Check the ELT transmission.
  • Make sure the ski safety cables and shock cords are in place.
  • Preheat the engine and cockpit, if possible.
  • Follow oil dilute directions, if equipped.

Carbon Monoxide

Don’t count on fumes from a leaky heater to warn you of carbon monoxide. Here are some of the symptoms: sluggishness, warmth, tightness across the forehead and headaches, ringing in the ears, nausea, dizziness, and dimming of vision. If any of these occur, shut off the cabin heat, open a fresh air source, don’t smoke (it will aggravate your condition), use 100 percent oxygen if available, and land as soon as possible.

Scary Checklist, eh? Well, it’s just a summary of what has happened to others. Keep this handy, and you’ll go places — all the way!

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