Aeronautical Decision Making, a post crash critique

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poadeleted3

Pattern Altitude
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I came across an accident report in the Air Safety Foundation's database that I thought might make for interesting discussion. A pilot had engine trouble en route and is vectored to an airport. At the airport he flies the approach too fast, and on rollout realizes he is going to overrun the runway. He chooses to try to go around, even with a sick engine. He doesn't make it, and crashes.

Now me, once I've got the plane on the ground, there is no way I'm taking off again, especially with a sick engine. If I realize I'm going to overrun, I'll slow down as much as I can before I hit anything, and the insurance company just bought themselves a plane. Would ya'll try to take off again with a sick engine, or keep it on the ground?


http://www.ntsb.gov/ntsb/brief.asp?ev_id=20040622X00845&key=1

NTSB Identification: MIA04LA097.
The docket is stored in the Docket Management System (DMS). Please contact Public Inquiries
14 CFR Part 91: General Aviation
Accident occurred Monday, June 14, 2004 in Crystal River, FL
Probable Cause Approval Date: 3/30/2005
Aircraft: Gulfstream American AA5B, registration: N4516V
Injuries: 4 Uninjured.

The pilot stated that he was en route to Athens, Georgia, and the airplane was in level cruise flight at 8,000 feet, when all of a sudden the engine started running roughly. He stated that he was unable to maintain altitude, so he declared an emergency with FAA Jacksonville Air Route Traffic Control Center, and was given vectors for Crystal River Airport, Crystal River, Florida. He stated that he flew the subsequent approach to a forced landing with too much speed, and was unable to stop the airplane on the runway. As he was nearing the end of the runway, he stated that he thought he had enough power to execute a go-around, but as he was attempting to do so, he was able to avoid the fence, but collided with some trees. Post crash examination of the airplane's engine showed no compression was noted in the No. 3 cylinder. Further examination revealed that the No. 3 cylinder exhaust valve head was missing and that the cylinder head and top of the piston had incurred mechanical damage. The center electrode of No. 3's upper spark plug showed evidence of physical contact, and was found pushed against the side electrodes. Two pieces of metal appearing to be pieces of the valve head were found in the exhaust system. According to information obtained from the pilot, the engine had accumulated a total of 1,547 total flight hours since overhaul, and 56 flight hours since its last annual inspection, which had been conducted in October 2003. The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

The failure of the number three cylinder exhaust valve which resulted in the partial loss of engine power. The pilot's misjudgment of speed and distance resulted in an overrun of the runway.
 
Joe Williams said:
Now me, once I've got the plane on the ground, there is no way I'm taking off again, especially with a sick engine.
Click to expand...

Joe, if you and I had in that plane together, we would not have been fighting over the controls due to any significant conflict of interest. Depending on conditions at the time, I would have likely taken it off the side of the runway to use the grass to help slow down. More friction is good when trying to stop. Also careful S-turns once you're slow enough could make the runway longer than it actually is.

IMHO foregoing any blatant in my face way bad threat, once the wheels are on the ground with engine problems, it stays on the ground and I'll take my lumps for my decision if need be.
 
The pilot was probably very anxious which accounts for his coming in too hot. Gee, not like I've ever done that. And like Frank said, once the wheels were on the ground, I'd do my damnedest to keep them there.
 
Reminds me of a favorite Rod Machado question:

Q: What's the most expensive aircraft you've ever flown?



A: Look at your insurance policy for the deductible amount.

Absolutely - once I'm on the ground with a sick bird I'm staying on the ground. I'm pretty certain I'll survive hitting chain link fence at 20 mph. Alternatively, if you're pretty sure you can pull it off without flipping over or hitting something hard, a ground loop will lose a lot of energy too, though I wonder if the seat belt will protect you better in a head-on vs. getting knocked around sideways (?).

Jeff
 
I witnessed the pilot of a twin land gear up- well almost. Before I could get to my handheld, I was hearing the ting-ting-ting. He powered up and went around, got the gear down, and landed. The engine mounts had to be replaced, the props, governors, and because he did not have engine stoppage, the TCM bulletin suggests but does not demand magnafluxing and bearing inspection....so he didn't have it done.

Now me, at that point, it's open the door, shutoff the fuel, and finish the landing...unless I'm in deepest darkest Africa. That pilot- he got discovered and got remanded to remedial training.
 
I'm familiar with this one -- the guy was over 30 knots fast crossing the fence. Problem is that folks sometimes get so boresighted on not coming up short that they show up over the approach end with WAY too much energy. That's why the FAA has that power-off 180 approach task in the Private and Commercial PTS's. So the real answer is to do like they say in the paragraph of the C-5 flight manual dealing with a three-engine-inoperative go-around, which says, "Plan your approach so a go-around is not necessary." But in that instance, if you do screw it up, it's better to run off the end of the runway at 30 knots than to crash out of control at 70.
 
bbchien said:
I witnessed the pilot of a twin land gear up- well almost. Before I could get to my handheld, I was hearing the ting-ting-ting. He powered up and went around, got the gear down, and landed. The engine mounts had to be replaced, the props, governors, and because he did not have engine stoppage, the TCM bulletin suggests but does not demand magnafluxing and bearing inspection....so he didn't have it done.
Click to expand...

Evil. Besides the serious unbalance issue and everything associated with that, I'd be terrified of it throwing a blade, possibly through me. I'll slide it in on that one thankyouverymuchhaveaniceday.
 
fgcason said:
Joe, if you and I had in that plane together, we would not have been fighting over the controls due to any significant conflict of interest. Depending on conditions at the time, I would have likely taken it off the side of the runway to use the grass to help slow down. More friction is good when trying to stop. Also careful S-turns once you're slow enough could make the runway longer than it actually is.

IMHO foregoing any blatant in my face way bad threat, once the wheels are on the ground with engine problems, it stays on the ground and I'll take my lumps for my decision if need be.
Click to expand...

I don't know if sliding through the grass is going to slow you any more than asphalt unless the brakes are gone too, but I do agree that by the time you figure an overrun is immenent, a go around is a real bad idea (even with a good engine). I'd also point out that during an approach with a sick engine, one should pay close attention to airspeed and insure that you are on target altitude and speed wise over the fence. Excess speed is very easy to fix on the final, and big trouble on the ground.

Unless they've lengthened the runway at CGC since last summer, he had over 4500 feet of asphalt to work with. That ought to be sufficient to land a Tiger.
 
He who hesitates is lost.

Another NTSB accident report happened not too far from here. Solo pilot landed too fast and bounced. She tried to salvage the landing until she saw telephone poles ahead. She attempted a go around but ended up making an off field landing. The go around was botched because she delayed her decision to get back into the air (she tried to stick the landing long past the time she should have aborted the landing), she continued the go around without retracting full flaps and she had carb heat on.

What the accident Joe posted and this accident have in common appears to be that the pilot did not have a clear plan. Said another way, they were behind the plane.

How often while en route are you behind the plane but you remain blissfully unaware because nothing pushed you to that point?

(EDIT) I'm reminded of a concern the FAA expressed some years ago. It seems the typical dual instruction for engine out emergency landings was resulting in something peculiar. A number of pilots had experienced real engine out scenarios but only went through the motions--just like in their training. Some even had made their approach for an off flield landing, then, at 100 agl or so they rowed the throttle forward and pitched up--just like in training. I don't know what made me think of this or even that it is pertinent to this case but I do wonder how long the effects of the principal of primacy as it relates to the training environment.
 
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languisher said:
I don't know if sliding through the grass is going to slow you any more than asphalt unless the brakes are gone too, but I do agree that by the time you figure an overrun is immenent, a go around is a real bad idea (even with a good engine). I'd also point out that during an approach with a sick engine, one should pay close attention to airspeed and insure that you are on target altitude and speed wise over the fence. Excess speed is very easy to fix on the final, and big trouble on the ground.

Unless they've lengthened the runway at CGC since last summer, he had over 4500 feet of asphalt to work with. That ought to be sufficient to land a Tiger.
Click to expand...

I fly off a airport that has 3 turf runways. And yes both takeoff and on landing it does have an affect on distance compared to asphalt. As for being to fast on approach I would much rather have to much speed and/or altitude than not enough. Yes flying by the numbers is best but if you have to be wrong I don't want it to be on the speed or altitude side. And yes once on ground stay there. A couple of years ago I had a reduction of engine power after takeoff at Midland International. About 800 ft AGL on a 45 degree departure is when I went from full power to about 1800 RPM. I let the tower know and they cleared me to do whatever I wanted. I came around and made a crosswind landing at max crosswind comportment. Sure I could of came on around to land into the wind but that would of required me to pass a great big runway. Not me, as I would much rather run the risk a ground loop than come up short of a good runway. At touch down I slid about 15 feet off of center line prior to the tires getting a good grip. All it cost me what a new set of underwear. I would make the same choice again if faced with the same situation. That is why I carry insurance.
 
Richard said:
He who hesitates is lost.

Another NTSB accident report happened not too far from here. Solo pilot landed too fast and bounced. She tried to salvage the landing until she saw telephone poles ahead. She attempted a go around but ended up making an off field landing. The go around was botched because she delayed her decision to get back into the air (she tried to stick the landing long past the time she should have aborted the landing), she continued the go around without retracting full flaps and she had carb heat on.

What the accident Joe posted and this accident have in common appears to be that the pilot did not have a clear plan. Said another way, they were behind the plane.

How often while en route are you behind the plane but you remain blissfully unaware because nothing pushed you to that point?

(EDIT) I'm reminded of a concern the FAA expressed some years ago. It seems the typical dual instruction for engine out emergency landings was resulting in something peculiar. A number of pilots had experienced real engine out scenarios but only went through the motions--just like in their training. Some even had made their approach for an off flield landing, then, at 100 agl or so they rowed the throttle forward and pitched up--just like in training. I don't know what made me think of this or even that it is pertinent to this case but I do wonder how long the effects of the principal of primacy as it relates to the training environment.
Click to expand...

CFIs usually break it off at 500 feet unless actually landing, not 100 feet and also state " You would land off field at this point but we need to break off the simulation here...".
Your examples... ? ...denial is such sweet sorrow. Pathetic for any pilot. Who needs 'em anyway ?

Another example from martial arts "self defense" you guessed it, they pulled their punches instead of landing them on their assailants. Duh.
 
sere said:
I fly off a airport that has 3 turf runways. And yes both takeoff and on landing it does have an affect on distance compared to asphalt. As for being to fast on approach I would much rather have to much speed and/or altitude than not enough. Yes flying by the numbers is best but if you have to be wrong I don't want it to be on the speed or altitude side. And yes once on ground stay there. A couple of years ago I had a reduction of engine power after takeoff at Midland International. About 800 ft AGL on a 45 degree departure is when I went from full power to about 1800 RPM. I let the tower know and they cleared me to do whatever I wanted. I came around and made a crosswind landing at max crosswind comportment. Sure I could of came on around to land into the wind but that would of required me to pass a great big runway. Not me, as I would much rather run the risk a ground loop than come up short of a good runway. At touch down I slid about 15 feet off of center line prior to the tires getting a good grip. All it cost me what a new set of underwear. I would make the same choice again if faced with the same situation. That is why I carry insurance.
Click to expand...

I think you missed my point(s). It's certainly often true that a rollout (without heavy braking) will be shorter on turf than asphalt, but outside of something so soft that the wheels bury themselves, you should be able to decelerate more rapidly using threshold braking on asphalt than on grass, wet or dry.

As to carrying extra speed in a dead stick landing, I agree that too much is usually better than too little, but what I tried to say was that if you carry a reasonable extra pad on the approach speed, you can easily dissapate it with a slip on short final with no risk of coming up short. Any excess speed carried into the touchdown itself will be a detriment to your saftey.

As to chosing a runway not aligned with the wind vs one less readily available, I'd generally agree with your choice. With a sick engine, it's not a good bet that it will continue to provide any power for long.
 
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