Safety Accident Analysis
When trust is key…
F
or most of us, those early days with our flying instructor are hugely formative. A close bond is soon created as we learn to trust them to get us out of that proverbial hole which we have carefully dug for ourselves. How then, might we ever imagine it to be our instructor who is going to be the very person who takes us beyond even their ability to recover the situation? The following recent events show that it can and does sometimes happen.
Accident 1
The commercial pilot, a flight instructor with over 2,000 hours instructional experience, and the passenger, departed in the aerobatic aeroplane to an area established by the operator for accomplishing aerobatic manoeuvres. Although operating as a flight training company, the operator described itself as an ‘extreme aviation attraction’, providing a series of aviation-related experiences that included aerobatics, simulated air combat, and flight training, during which passengers had the opportunity to fly the aeroplane. The accident flight was 25 minutes long, which included aerobatics, high-g manoeuvres, and a low-level bombing run simulation. An aft-facing onboard camera, mounted in front of the passenger was recording throughout the flight and revealed that the aeroplane was performing aerobatic manoeuvres for about seven minutes, with both the pilot and passenger manipulating the controls. After the pilot completed a tumble manoeuvre, the aeroplane began to regain altitude. The
passenger then moved his hands away from the flight controls and appeared to be bracing his arms against the sides of the airframe in anticipation for an aerobatic manoeuvre. The aeroplane then pitched up and rolled right, and then rolled left, while the pilot made a ‘whooping’ sound, as the aeroplane transitioned into an inverted spin. The passenger experienced negative g forces and reached up with his right arm up to secure the headphones which were pulling away from his head. The manoeuvre progressed, and its direction of rotation then reversed, until the aircraft transitioned into an attitude so that only the sky was visible in the canopy. The wind noise began to increase, and a gap began to appear at the interface between the canopy frame and fuselage, indicating that the aeroplane was approaching its ‘never exceed’ speed. The passenger was then aggressively rocked from side to side. However, the sun could be seen gradually transitioning across the canopy, indicating that the aeroplane was no longer tumbling and its attitude had stabilised. Up until this point, the passenger appeared to be enjoying the flight, but his facial expression changed, and he looked down and reached forward with his right hand. At that moment, the pilot activated the canopy release handle and the canopy opened, although no bailout was attempted, before collision with the ground six seconds later. The aircraft was subject to two service bulletins (SB) pertaining to the flight controls, neither of which had been performed. The first required
“A gap began to appear at the interface between the canopy frame and fuselage” 46 | FLYER | November 2020
replacement of the rudder cable to prevent premature failure, however the aeroplane’s rudder cable did not display evidence of failure in the area documented by the SB. The other SB required the addition of a safety clamp to the transponder after a report that a transponder had slid out of its rack and jammed against the pilot control stick during aerobatic manoeuvres. It could not be determined if the transponder had moved during the accident flight and inhibited the control stick. Federal Aviation Regulations do not require compliance with SBs for aircraft operating under 14 Code of Federal Regulations (CFR) Part 91. The operator presented itself as a 14 CFR Part 61 flight school, and although it did provide upset recovery and tailwheel endorsement, flight training and all the company pilots held flight instructor certificates. The vast majority of customers (including the accident passenger) did not hold any type of pilot certificate, and bought flights for the aerobatic and air combat experience. By operating as a Part 61 flight training provider, the company was able to advertise its services, expose fee-paying passengers to high-risk flight profiles, while circumventing the regulations and oversight for operators who provide transportation for compensation or hire. Review of onboard video footage from the accident pilot’s previous flights revealed that, although considered to be a mentor and conservative in nature by his colleagues, the pilot routinely flew aeroplanes beyond their operating limitations (specifically their vertical acceleration, or g limitations) and at speeds very close to the ‘never-exceed’ speed, all with passengers on board. Review of footage taken with other pilots revealed a company-wide pattern of disregard for the aeroplane’s published operating limitations and the company’s own policies regarding airspeed and g limitations. Because both the accident aeroplane and other
Mark Mitchell
Choosing which organisation to provide the best airborne instructional experience can be more important than many realise, and should never be taken on cost alone. Steve Ayres looks at some incidents which might influence that ultimate decision…
