Ben Longden Posted January 30, 2008 Posted January 30, 2008 A bloody good friend of mine was involved in an uncontrolled collision with terrain during takeoff in his VH registered six seater on the weekend. The AC had just been fully serviced, and he usually has the takeoff trim set. Unfortunately the servicing mechanic had twiddled with it, and reset it. The mark read -3 instead of +3. As a result, the AC became unwilling to fly on rotation, and as a result the left wing, nose, prop and cowls are all 'dented.' Moral of the story is to ensure the preflight checks include setting trim to takeoff, before the takeoff roll. Ben
Guest J430 Posted January 30, 2008 Posted January 30, 2008 If its the same one I have seen the Pic's off its propably a write off. A lot of damage. Having flown a Bonanza (V tail and A36) you do not use a trim of 3 at all, maybe a bit of up trim depending on the CofG, at a reasonable aft CofG I found a fraction of down trim was good. Up 1 & Down 0.5 Must have been a handfull. He must have let go of the colum though to do that.:black_eye: J
Guest Flyer40 Posted January 31, 2008 Posted January 31, 2008 As Jim Reason once said, one of the best ways to cause an aircraft to crash is to perform maintenance on it. An unfair generalisation for sure, but his area is risk management and unfortunately he was only half joking. He went on to write a book about it called Maintenance Error. No disrespect to maintainers, just a reminder that post-maintenance flights carry a higher risk because maintainers are humans and Murphy is never far away. Dick Collins recently wrote that after servicing he flies orbits over the airfield for the best part of an hour before he considers that aircraft safe to travel or carry pax. But then his plane was a complex pressurised 210. However the concept of a post-maintenance shake down with special attention to the added risk is a good idea for all. How about an "after servicing" checklist?
facthunter Posted January 31, 2008 Posted January 31, 2008 Post- maintenance Woes. Good advice flyer 40. The more that's done the more the chances of a problem. Specified ground running, retract testing and flight testing used to be a requirement. ALL controls should be fully checked for correct sense and full and free travel. You make your own luck. Nev....
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Yenn Posted January 31, 2008 Posted January 31, 2008 Unless the pilot was going immediately into IFR flight he should have been able to see his attitude, also a change of six degrees nose down would have needed a firm push on the elevator, if the trim had been set for take off. If going straight onto instruments, the pilot should have been expecting a pitch down command due to the acceleration affect on take off. It was a failure to set a gyro instrument correctly that recently caused the crash of an airliner, I forget where it was but only in the last couple of days the papers had a report that the pilot, who was about the only survivor was going to use a defence that the passengers knew flying was dangerous to reduce his culpability in his trial. We can all make mistakes, but hopefully we can learn from others.
Ben Longden Posted January 31, 2008 Author Posted January 31, 2008 Sadly, THAT is the AC I was referring to. A lovely ship.. And yes, a post maintenance check list is a bloody good idea. Ben
Guest RogerRammedJet Posted January 31, 2008 Posted January 31, 2008 "Unless the pilot was going immediately into IFR flight ....." Which they wouldn't have been - given that the SE IFR take-off minima is 300' and 2 km! "And yes, a post maintenance check list is a bloody good idea. " but the diligent application of a Pre-Take Off checklist is an even better idea! Rog
Guest airsick Posted January 31, 2008 Posted January 31, 2008 but the diligent application of a Pre-Take Off checklist is an even better idea! I will second that.
markendee Posted January 31, 2008 Posted January 31, 2008 As I was reading Ben's first post I thought exactly the same as Roger. Only been flying five minutes but have served an apprenticeship in the A/C trade. If a load falls off a truck it is the driver's responsibility regardless who loaded it. Hope all concerned are OK. Mark
Mazda Posted January 31, 2008 Posted January 31, 2008 What a shame. I agree that we must be extra careful after maintenance. It comes back to that old air traffic controller joke. "If the pilot stuffs-up, the pilot dies. If the air traffic controller stuffs-up, the pilot dies." Well, thankfully its not that serious this time, and it applies to maintenance people, but the philosophy that it is not their lives on the line still applies. I'm not going to "blame" the pilot because he'll already want the ground to open up and swallow him. He's bent his aircraft. That's a horrible feeling both in terms of breaking such a lovely machine and wondering how much it will cost. I feel for him. I hope he is OK, that his confidence isn't too shaken and his aircraft can return to the beautiful thing that it was. I don't buy the light elevator theory. I find Arrows heavy so I'm sure the Bonanza would be quite a handful. Let it be a lesson to all of us. We can ALL make mistakes. Bad pilots and good pilots. Checklist or no checklist. It's happened enough to experienced multi-pilot airline crews to think that it can't happen to us. I guess we just need to be as careful as possible, look all around the cockpit at all instruments, fuel, trim, flaps, lights etc (and actually register what they are indicating). An instructor of mine would have a go at me if I ever said an instrument was "good" or similar, I had to say it was "in the green", "set to QNH", etc.
Guest RogerRammedJet Posted February 1, 2008 Posted February 1, 2008 The suggestion that seems to be coming through here that the LAME was at fault for altering the trim setting is grossly unfair. I generally do Pre-TO Checks on the roll - except when the aeroplane is coming out of maintenance. In that instance I taxi to the run-up bay and sit there carefully working my way through the run-up and I do the Pre-TO checks TWICE. I once flew a C210 for 2 hours with fuel leaking from under the engine bay adjacent to the exhaust. The leak was not detected in a thorough pre-flight but was apparent when the aeroplane was stopped for re-fuelling. The culprit was a finger tight only fuel line post-maintenance. I am happy to lay the blame for that squarely at the feet of the LAME involved. In this instance, if the accident resulted from an incorrectly positioned trim, the fault lies fairly and squarely at the feet of the PIC who failed to carry out effective pre-TO checks. To continue with veiled suggestions that the LAME somehow contributed to this accident is just plain WRONG! Rog
Guest airsick Posted February 1, 2008 Posted February 1, 2008 In this instance, if the accident resulted from an incorrectly positioned trim, the fault lies fairly and squarely at the feet of the PIC who failed to carry out effective pre-TO checks. I had two mates that had an argument similar to this. One guy borrowed the other guys car and then left it parked in gear. When the owner got back in he turned the key and the car jumped into his garage door (luckily not too much damage was done). He then proceeded to blame the borrower of the car for leaving it in gear because he never does. So whose fault was it? I certainly couldn't blame the guy who left it in gear and subsequently wouldn't blame the LAME either. What if the pilot who did the previous landing didn't put the trim back into TO? Would it then be his fault? What if that pilot was you? Did you make the mistake when landing or on take-off? I agree with Rog. The pilot has no one to blame but himself. This of course assumes that the trim was the problem and nothing else influenced the incident.
Guest Redair Posted February 1, 2008 Posted February 1, 2008 Greetings each... OK so I know nothing, but.... I rather like the idea of placing a finger, on each item as it is checked, so as to physically make a conection with that item and focus full attention on it. I know that checks, whether pre-TO, start-up, downwind or whatever, do have a habbit of becoming exactly that; a habbit. And while we can all religiously run through a checklist, it is very difficult to miss a switch or lever that is not in the correct position, if you actually touch it as you call it out from your checklist. Downwind check for example, try to miss that the brakes are on, if you call out "Brakes off" and touch the lever as you do it, with the lever in the wrong position. Just my thoughts, not trying to blame anyone, as we all make mistakes, and always will. Redair.
Guest Flyer40 Posted February 1, 2008 Posted February 1, 2008 Great point redair. Got a story of my own about checklists becoming routine. I always do my pre-takeoff checks using the checklist rather than relying on my poor memory. Despite that I still managed to screw it up. One day after flying the Citabria I was shocked to find one of the mag switches was already off as I shut down (there are two separate mag switches on the overhead panel rather than a key switch). I distinctly remembered checking both mags during the run up and couldn't figure it out. Didn't I check the switches during my pre-aero HASELL check and again during my downwind check? I did but I didn't, so apparently not. The next time I flew I discovered my error, but only after repeating it. During the run up I switched off the L mag, watched the rpm drop and switched it back on. Then did the same for R mag, all very routine right up to the point where I didn't switch it back on. I can't explain why, other than to say my brain must have jumped ahead to the next item on the checklist before fully completing the mag check. Adding to my embarrassment was completing the entire flight on one mag and not noticing. But I'll blame that on the abundance of power in a 160 horse Citabria. It was a good lesson tho, my checks are a lot more rigorous now. Think I should say 10 Hail Mary's or something now.
Guest Baphomet Posted February 1, 2008 Posted February 1, 2008 Even when you do a pre-takeoff check you're not out of the woods. On a recent flight I did all checks at the holding point prior to take off including "set trim for take-off" Sometime between commencing the take off roll and rotating, unseen by me, the pax jammed the plastic coke bottle he had been drinking from between the seats, pushing the trim lever to full "up". On becoming airborne, I found I needed a LOT of forward pressure to control the attitude, and my first thought was that I was dealing with a control system problem. Trim was the first thing I checked, and the problem was quickly identified and resolved. I hold myself responsible for this, I should have been more thorough in my briefing, but some things are so patently obvious you just don't think about it. Common sense I've found is not as common as it should be.
motzartmerv Posted February 1, 2008 Posted February 1, 2008 yea..i was gunna say that, with trim right forward or back the first thing that would probably leap to my mind would be some sort of control failure and the kittens would appear quite promply.. perhaps thats what happend to the guy in the original post.. its obvious to us armchair flying that the trim would be the first thing to check, but after rotating and the plane wanting to nose up or nose down violently would put the mickey up most pilots and strees them out, and we all know as stress goes up performance goes down so things could get ugly quite quickly..
Guest ozzie Posted February 2, 2008 Posted February 2, 2008 about 15 yrs ago i lost a couple of military friends at jaspers brush when the army porter they were jumping from went in on take off. survivors said that as it stalled and went in sideways the pilot was madly winding on the trim handle. he had forgot to reset it. when our DZ obtained one of the ex army porters i placed a wittness mark on the fuse and tailplane, after loading and shutting the door i would always check to see if the trim was set to take off. twice i had to indicate to the pilot to reset trim. To true with post maintenance, i always used to worry if i had overlooked anything. even more so when an arrow owner mailed my spark plug socket back after i left it under the cowl. fortunatly no action was taken as the owner did not report it as required. i changed my routine and never allowed myself to be rushed or interupted when working. but sometimes it just don't work out that way. in the eighties a cessna twin rolled inverted and crashed on take off at the airport i was working from at the time. they had found that during the major the ailerons had been reversed. this aircraft had been dual inspected and the prefighted and it was not picked up due to the haste to get the aircraft back on line. some operators would get a bit upset if anyone poked their nose into their work and commented on it. our little shop would welcome it. we worked hard with long hours so knew just how easy it is to miss something. everyone checked everyone's work. if something was not quite right it was dealt with, without attitude. to much is at stake. ozzie
motzartmerv Posted February 2, 2008 Posted February 2, 2008 Ive heard of that a few times where the controls (ailerons) are reversed by accident.. i guess thats why the pre t/off check says, full free and CORRECT.. push towards the left the left aileron should go up.. its killed even hardened test pilots..
Mazda Posted February 2, 2008 Posted February 2, 2008 Excellent points Ozzie. In regards to checking the work of others, some time ago in the RAF a disgruntled engineer deliberately didn't connect the secondary charge lanyard on the ejector seat. (The seat had two small charges instead of one big one to lessen the bang, and once the first one had gone off and the seat started to rise, the lanyard would tighten and set off the second charge). With the second charge disconnected, this meant that if a pilot had tried to eject, he would have been killed. It is not in sight so the pilot can't check it during preflight. Fortunately this man's work was checked by another engineer and the missing lanyard attachment pin was noticed. Apparently the disgruntled engineer did it deliberately hoping he'd be thrown out of the RAF, but he was thrown in gaol for 2 years instead for deliberately endangering life.
Guest ozzie Posted February 2, 2008 Posted February 2, 2008 I also got into the habit of writing everything down that i did, how i did it and when ect ect in my diary. I was dragged into court by the then CAA who had a thing against a former employer ,they had been trying to bring him undone for a number of years. they had him up on 15 various charges. some where trumped up. when they had finished throwing all sorts of tricky questions i pulled out 4 years of diaries and pointed out a lot of discrepencies in what the CAA investigator said. of the 15 charges 11 were thrown out and the magistrate called the CAA investgator into his chambers. the other four were simple things like maitenance release not being in the aircraft. it pays to keep your own records seperate to what is required. i was working for this guy when the dept raided his office and emptied it. things like employees scedules of experience, photos of completed jobs, ratings ect seemed to have become lost during the removal and the year long investigation. without those private diaries it would have gone the other way. even tho "we" won, i never recieved my SOE's back and course results back. several other things where denied. then the CAA convieniently changed names to CASA with no obligtions for the past CAA. I have since learnt that the people involved where on several personal witch hunts around the country against several operators. scarey ain't it. and it is not limited to just GA and the dept. if you get my drift
facthunter Posted February 3, 2008 Posted February 3, 2008 Check lists etc. It's the PILOT's job to check control freedom & function. Just because the trim is INDICATING in a certain position, does it mean that the tab/control is there also? No! especially after maintenance. Your first flight is essentially a TEST flight, and after control surface changes, undercarriage rigging, engine changes etc, exactly that was done. It wasn't unusual to come back with one engine feathered, or other malfunctions. MISTAKES will continue to be made, but we have to operate in a manner that eliminates the serious consequences of most (if not practically all) of them. This requires a culture of safety, an ability to learn from your own failings, and those of others, and an acceptance that every individual must accept his/her responsibility and role in this. There is a tendency to accept mistakes and errors as inevitable. Whilst this is true as a simple statement, it somehow doesn't fit right with flying. Carefull people survive best in aviation, and therefore are the best pilots by definition. If you're not sure, check it again or don't do it at all. The effectiveness of a checklist is determined by HOW you apply it. If you're distracted or just reciting it to yourself, with your mind far away, who are you kidding? In a real emergency could you reduce it it to the minumum essential items which might be needed to save your (and your passengers) life(s) A bit of a hard ask perhaps but that's what being the PIC. (pilot in command ) means after all.. Nev..
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