Maybe someone can learn something from this:

[GlennAB1]

NTSB Identification: ATL85MA177
The docket is stored on NTSB microfiche number 31193.
Nonscheduled 14 CFR operation of GENERAL AVIATION, INC.
Accident occurred Friday, May 31, 1985 in NASHVILLE, TN
Aircraft: GULFSTREAM G-159, registration: N181TG
Injuries: 2 Fatal.
NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.
THE ACFT WAS BEING OPERATED AS GENERAL AVIATION FLT 115 & WAS DEPTG ON A ROUTINE NIGHT FLT. DRG TAKEOFF/INITIAL CLIMB, THE LEFT ENG LOST PWR. THE FLT CREW ATTEMPTED TO CONT THE CLIMB-OUT, BUT FOLLOWING THE APPLICATION OF WATER-METHANOL, THE PLT LOST DRCTNL CONTROL. SUBSEQUENTLY, THE ACFT BANKED TO THE LEFT, ENTERED A DSCNT & IMPACTED BETWEEN THE PARALLEL RWYS. AN INVESTIGATION DISCLOSED THAT THE LEFT PROPELLER'S BLADE ANGLE WAS 21 DEGS. NO PREIMPACT SYS MALFUNCTION OR FAILURE WAS FOUND. THE COCKPIT VOICE RECORDING INDICATED THAT THE FLT CREW DID NOT COMPLETE ALL OF THE ITEMS ON THE BEFORE TAXI/TAKEOFF CHECKLIST. ONE OF THE ITEMS (PRESUMABLY NOT COMPLETED) WAS A CHECK OF THE H.P. COCK LEVERS. THE CHECKLIST REQUIRED THAT THE H.P. COCK LEVERS BE IN 'CRUISE LOCKOUT' FOR TAKEOFF. THE LEFT H.P. COCK LEVER WAS FOUND BETWEEN THE 'FUEL OFF' & 'FEATHER' POSITIONS. MOVEMENT TO THIS POSITION WOULD HAVE DEACTIVATED THE AUTO-FEATHER SYS & SHUT DOWN THE LEFT ENG.


The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

• EMERGENCY PROCEDURE..IMPROPER..PILOT IN COMMAND
  
• PROPELLER FEATHERING..NOT PERFORMED..PILOT IN COMMAND
  
• PREFLIGHT PLANNING/PREPARATION..INADEQUATE..PILOT IN COMMAND
  
• CHECKLIST..NOT FOLLOWED
  
• REMEDIAL ACTION..NOT ATTAINED..COPILOT/SECOND PILOT
  
• AIRSPEED(VMC)..NOT MAINTAINED..PILOT IN COMMAND
  
• POWERPLANT CONTROLS..IMPROPER USE OF..PILOT IN COMMAND
  
• FLUID,FUEL..STARVATION

Contributing Factors:

• LIGHT CONDITION..NIGHT

 

[Zeldman]

That is pretty tuff to listen to.

 

[GlennAB1]

Yeah, especially if you knew them ;( Sorry about that, there's a warning with it on utube, I thought it would be with the link. Maybe some good can come from it.

 

[luvflyin]

I learned something from it. To remind myself that while in the air you sometimes don't have time to go through the checklist step by step, there is never an excuse for not doing it pre-takeoff.

Aviate, navigate, communicate. Things happened very fast. We'll never know, but just maybe if he hadn't taken a few seconds to tell the tower they had a problem, he may have thought of the solution to the problem in time. I don't know that airplane and haven't flown a twin since getting the rating, but at that point it seems to me the solution is pull power to the good engine and give yourself a chance to at least crash straight ahead, upright.

 

[Ted]

Thanks for sharing. That is definitely rough to listen to. They flew the plane the whole way, obviously didn't give up or curl up into a ball, even though in the last few seconds it seems obvious they knew they weren't getting out of this one.

It looks as though the pilot didn't recognize that he was losing ability to control the airplane until after it was obvious (from the video) that he was banking. So adding the extra power only made things worse.

Back when Wayne used to post on here, he used to talk about the fastest way to kill students in the King Air sim. It was to fail the autofeather on them. They assumed it would work, and when it didn't they had effectively the same result as this ill-fated Gulfstream. A few years ago, I went to SimCom to their 421 sim focusing on the proverbial "V1 cut", basically the same as happened in this report. After we broke the 421 sim (which was easy to do), they put us in the 425 sim. My sim partner and I turned off the autofeather, which the instructor got very angry about. He said "You're just wasting your time, it's impossible to fly out of an engine failure in this sim without the autofeather." I responded "Well I'm pretty sure we'll walk away if we crash, so we'll try it anyway."

My sim parter flew out of every single engine failure without any trouble, simply because we flew piston twins and expected there to be no autofeather. The takeaway I got from that is that you should still be prepared to "identify verify feather" in a turboprop in case the autofeather fails on you. Maybe this doesn't apply in a situation such as this, but it's something I keep in mind when I do fly smaller turboprops.

And, of course, checklist...

These discussions are good so that we can learn something from those who died.

 

[mscard88]

My sim parter flew out of every single engine failure without any trouble, simply because we flew piston twins and expected there to be no autofeather.

The difference is you knew what was coming. When it happens it's quick and at low altitude such as right after liftoff it can get ugly quickly. I'm not challenging your ability or skill at all. You should have had the instructor surprise you w/ an engine failure (and auto-feather fail) and then see what would have happened. That would be a little more realistic.

 

[GlennAB1]

You'd have to know the G-1, and the full story to really comprehend the mistakes made. Langley was Captain, Mahler was FO for the company. The news quoted the marshaller: "the guy that was normally the pilot was in the right seat and copilot was in the left. Predeparture checklist wasn't followed. That was the first biggie. Arming the water methanol at high power was the second which everyone should have known, is a no-no, and you can hear Mahler say turn it off. A question still remains, what happened to the left engine HP cock? I think a key factor is: It was dark.

 

[Ted]

The difference is you knew what was coming. When it happens it's quick and at low altitude such as right after liftoff it can get ugly quickly. I'm not challenging your ability or skill at all. You should have had the instructor surprise you w/ an engine failure (and auto-feather fail) and then see what would have happened. That would be a little more realistic.

Agreed fully, it wasn't an entirely realistic failure. We were treating it not as a 425 sim but for the reasons we were there for Twin Cessna purposes. My point was that we were able to fly out of what the instructor said was an "unflyable" situation by using a piston skillset and expecting the plane to be broken.

 

[Cpt_Kirk]

You can always learn from something like this. Sad situation.

 

[Ted]

A question still remains, what happened to the left engine HP cock? I think a key factor is: It was dark.

I love night flying and know nothing about the G-1, but I'd agree.

I did one night leg in the 414 thus far, but am generally sticking to day flights for the moment. I don't have the instinctive knowledge of the location of every switch, knob, lever, etc. like I did on the 310.

 

[Jimmy cooper]

Or more recently when the Gulf Stream pilots missed the gust lock on preflight and killed everyone. Both were highly qualified, lots of hours and well respected.

 

[GlennAB1]

The G-1 gust lock automatically disengaged with the advancement of both throttles.

 

[GlennAB1]

The difference is you knew what was coming. When it happens it's quick and at low altitude such as right after liftoff it can get ugly quickly. I'm not challenging your ability or skill at all. You should have had the instructor surprise you w/ an engine failure (and auto-feather fail) and then see what would have happened. That would be a little more realistic.

That is essentially what happened in this accident. The follow-up action for auto feather on the G-1 is to manual feather. That's probably why the HP cock was found between OFF and Feather, they were attempting to manually feather but just ran out of time. They realized they had a problem just after Vr. I can hear one engine spooling down. They probably assumed it auto feathered. It was dark, and they possibly didn't realize the HP cock was in OFF, deactivating auto feather. So, on one side you have an 11.5' diameter 4 blade paddle at fine pitch, 0 degree, (the Gulfstraem manual states fine pitch was found nearly as efficient as prop reverse) and on the other side you arm water methanol and you can hear the engine's reaction. No wonder he said he couldn't hold it.

 

[Ted]

I just realized that the airplane in this report is the one in your avatar. I gathered you knew the pilots and the story - did you fly this plane?

 

[GlennAB1]

Yeah, I knew them. I was maintenance in IND waiting for them. The Avatar is from a picture I took, a tribute. I just stumbled upon the accident recreation video, before I posted it.

 

[unsafervguy]

thats a tough one to listen to. as I have said in other threads, I am not making judgements of them, but they made a mistake and paid the ultimate price for it. hopefully the aftermath teaches at least one person something and saves a life down the road.

bob

 

[GlennAB1]

That is the reason for posting it.

 

[whereisrandall]

I love night flying and know nothing about the G-1, but I'd agree.

I did one night leg in the 414 thus far, but am generally sticking to day flights for the moment. I don't have the instinctive knowledge of the location of every switch, knob, lever, etc. like I did on the 310.

And HOW many thousand hours do you have logged? Thanks, Ted - that's great perspective on personal minimums.

 

[denverpilot]

Curiosity: What's the relationship of "Litigation Sciences" to the accident? I assume someone hired them to make the video during a lawsuit afterward?

 

[Ted]

Yeah, I knew them. I was maintenance in IND waiting for them. The Avatar is from a picture I took, a tribute. I just stumbled upon the accident recreation video, before I posted it.

Sorry for your loss. The sting from those lost in plane crashes never seems to go away.

And HOW many thousand hours do you have logged? Thanks, Ted - that's great perspective on personal minimums.

2,500ish, with over 2,000 in piston twins. By this time next week I'll have close to 40 hours in the 414, but I'm still getting used to the switch locations. Part of that is because for the most part, switches are just on or off for the flight, so I really have not been doing a lot of switch flipping since my legs are typically 2-4 hours. Also, the 414 has all the switches located along the side, whereas the 310 had them all on the panel. So it's not even the same general location.

One thing I am going to do to help is get a set of switch covers, like these:

http://www.aircraftspruce.com/catalog/elpages/toggleswitchcvr.php?clickkey=3008779

Those help a lot in low vis conditions. You can group switches by color, which is what I did. That helps make it easy, since a lot of times you want switches on (or off) in groups. For example de-ice, lights, etc. Or you can more easily recognize the switch location by its color and surrounding colors, rather than having to try to read. You have several rows of switches rather than the 310, which had just a line.

Human factors matter.

 

[luvflyin]

I'm multi rated but haven't flown one since the check ride many moons ago. I read this and what I think is that when it gets to the point where you can't stop the roll, the solution is pull the throttle on the good engine. In the scenarios run in the sims for these types of airplane's, does that ever come up? Nothing is working, you're rolling over, just pull the good engine and give yourself a chance to survive it?

 

[Ted]

I'm multi rated but haven't flown one since the check ride many moons ago. I read this and what I think is that when it gets to the point where you can't stop the roll, the solution is pull the throttle on the good engine. In the scenarios run in the sims for these types of airplane's, does that ever come up? Nothing is working, you're rolling over, just pull the good engine and give yourself a chance to survive it?

That is correct. I think a lot of times these sorts of basic things get forgotten in more sophisticated turboprop/jet aircraft that have "guaranteed" performance. At some point, you're still better off just landing straight ahead.

 

[Zeldman]

a

I'm multi rated but haven't flown one since the check ride many moons ago. I read this and what I think is that when it gets to the point where you can't stop the roll, the solution is pull the throttle on the good engine. In the scenarios run in the sims for these types of airplane's, does that ever come up? Nothing is working, you're rolling over, just pull the good engine and give yourself a chance to survive it?

Too many times on take off it isn't a slow roll, but a quick snap roll. This scenario apparently was a slow roll.

That is one of my self briefings every time I take off. Engine failure or anomaly before rotation, close throttles and stop on runway, after rotation, gear down, and runway remaining then close throttles and land. After rotation and no runway remaining, gear up, clean up, pitch for blue line, fly the plane, if enough time then feather and secure, then return to land. And one option is if everything is going wrong, close both throttles, put the plane down in a wings level attitude.

We will never know what really happened in the cockpit on this flight, or the pilots thought process.

 

[GlennAB1]

Sorry for your loss. The sting from those lost in plane crashes never seems to go away.

Thanks, kinda reliving it all over again after stumbling upon the video. I had months of nightly dreams of being in the jumpseat. Having simulator time and been run and taxi qualified, the same scenario kept playing over and over in my mind... sucked.

 

[Ted]

Thanks, kinda reliving it all over again after stumbling upon the video. I had months of nightly dreams of being in the jumpseat. Having simulator time and been run and taxi qualified, the same scenario kept playing over and over in my mind... sucked.

I have dreams of crashing. Despite not having any connection, they tend to be similar in nature (night, etc.) although flying a Twin Cessna (since that's what I fly).

The mind does strange things to us in aviation.

 

[dscottford]

That is essentially what happened in this accident. The follow-up action for auto feather on the G-1 is to manual feather. That's probably why the HP cock was found between OFF and Feather, they were attempting to manually feather but just ran out of time. They realized they had a problem just after Vr. I can hear one engine spooling down. They probably assumed it auto feathered. It was dark, and they possibly didn't realize the HP cock was in OFF, deactivating auto feather. So, on one side you have an 11.5' diameter 4 blade paddle at fine pitch, 0 degree, (the Gulfstraem manual states fine pitch was found nearly as efficient as prop reverse) and on the other side you arm water methanol and you can hear the engine's reaction. No wonder he said he couldn't hold it.

I was a friend of Dave Langley and had the unfortunate experience to watch this whole thing happen. I worked for 10+ years at BNA for an FBO there and got to know Dave well. I also got lots of experience with G1's from a ground perspective. I remember when they taxied out the engines didn't sound right. The G1 whines very loudly. They also have autosync so the props are always in sync as lone as the throttles are close to each other. I have always believed that the mixture lever(s) were not locked and as they rolled out on take-off the left lever worked its way into the shutdown position, effectively disarming the autofeather.
Sadly, not an event I enjoy remembering.

 

[benyflyguy]

That’s pretty haunting to listen to. While plane is way out of my league and don’t understand the why and whats. The take home concept is that we have checklists for reasons.

 

[Huckster79]

I’ve added the first line on my checklists: do this like checklist knowing people love you. It stops some of the automatic lifelessness of a procedure it often becomes.