Arion Lightning EFATO at Shepparton Airport 6/2/22

[Thexder]

2 minutes ago, turboplanner said:

you didn't think trying to take off downwind might be significant?

It possibly was a significant factor in this case, if he took off prematurely, but generally taking off with a 5 knot tailwind on a 1,298m runway should not be a significant contributing factor.

 

As a general rule I would just increase my rotation speed by the tailwind component, lift off gently, keep the nose lower to get more air over the wings and generate more lift.

 

This really shouldn't have been a major factor, but probably was given his apparent slow airspeed and abrupt pulling back of the elevators....another one of those chain of events rather than any single one factor. 

[Flightrite]

It always comes back to poor training. The plane driver said he was losing directional control, a well disciplined trained plane driver would have aborted the take off instead of yanking it off the ground, poor training. Stalling and not understanding what constitutes a stall and how to get out of it, poor training! 

There will always be plane drivers who think they know better, but with rigorous check flights when due (other than more box ticking during a Flight review) would show them up most times! 
 

[Thexder]

18 minutes ago, Flightrite said:

It always comes back to poor training. The plane driver said he was losing directional control, a well disciplined trained plane driver would have aborted the take off instead of yanking it off the ground, poor training. Stalling and not understanding what constitutes a stall and how to get out of it, poor training! 

There will always be plane drivers who think they know better, but with rigorous check flights when due (other than more box ticking during a Flight review) would show them up most times! 
 

I'm sorry, but poor decision making is not poor training. A pilot choosing the wrong runway or choosing not to abort a take-off is not poor training, it is poor decision making. 

 

The pilot would likely have known how to recover a stall, this is basic 101 training, but in the moment he may have panicked and make a poor decision. This is not poor training. 

[onetrack]

If you make a number of wrong decisions when in control of an aircraft, resulting in a crash, then one has to consider whether the pilot has adequate competency, and needs more training.

You have already listed around three "poor decisions", or "mistakes" on the pilots behalf, in your clear and precise description of the crash sequence.

I may be considered a little harsh in my summation here, but IMO, the Arion pilot lacks adequate competency.

The fact that he kept pulling back on the stick when he was almost stalled, is a classic error that has killed many people, and shows panic, or a lack of understanding, assuming a superior position over competent aircraft control.

[Thexder]

37 minutes ago, onetrack said:

If you make a number of wrong decisions when in control of an aircraft, resulting in a crash, then one has to consider whether the pilot has adequate competency, and needs more training.

You have already listed around three "poor decisions", or "mistakes" on the pilots behalf, in your clear and precise description of the crash sequence.

I may be considered a little harsh in my summation here, but IMO, the Arion pilot lacks adequate competency.

The fact that he kept pulling back on the stick when he was almost stalled, is a classic error that has killed many people, and shows panic, or a lack of understanding, assuming a superior position over competent aircraft control.

He could have had poor training, maybe he wasn't even compliant with his Biannual Flight Review (BFR) who knows, but simply blaming poor training is not correct. One could have had perfect training, but became complacent or even totally negligent due to poor attitude, but that isn't poor training. 

 

It seems he only purchased the plane ~7 months before the crash and in that time it looks like it was re-painted with other internal works done, so you may be correct in that he lacked adequate competency for the aircraft type. That is not poor training necessarily, as he may not have had a single lesson in the aircraft. That is poor attitude and decision making, not poor training.

 

Many pilots stall aircraft, for a variety of reasons, but poor training is very very rarely ever a causal factor. Stress is usually the most common fact and I would suggest this may also be the case in this accident. New aircraft, yawing to the left on take-off roll, stressed he pulled back too far on the stick and stalled.....On the internet 2 days later, it's an easy fix. Push the nose down and gather airspeed. In the reality of the moment, they guy made an obvious mistake and luckily he didn't pay the ultimate price.

[RossK]

Thanks Thexder for the update, it's very rare that we actually get eye witness accounts.

I had wondered how he got where he was, from the photos and google maps it looks like he was off the east side of the strip only half way down, ie there was plenty of runway left to land on.

Good news is the pilot is OK, actually that's great news.

We've all made mistakes and this is one of those swiss chees ones, where if you make enough mistakes, they line up and bite you in the end.

I've got a nice bit of video footage of a take off I did in the Sportstar with a 45 deg 25kt cross wind from the left. The plane just wanted to turn left despite full right rudder, it was a poor choice of runway in hindsight as I could have chosen the other cross runway with 45 deg crosswind from the right.

But I managed to make some good decisions during the take off roll and got us airborne - but a better decision would have been to abort and have another think about it.

There are alwys things we can learn from and do better next time.

Hopefully this pilot learns from this and does better next time.

[turboplanner]

Anyone know what the duty runway was at the time and who was in charge of the airport?

 

[Thexder]

Just now, turboplanner said:

Anyone know what the duty runway was at the time and who was in charge of the airport?

 

Again, I was there at the time, I am a member of the club that runs out of this council owned airport.

 

This is not a controlled airport, so that means pilots use their discretion as to any decision they make. No one was in charge of the airport, that's not how it works.

 

Earlier planes were using runway 18 to land as the wind was light and variable, but technically it was favouring 36. I would say this pilot just followed what other people did earlier and decided to use 18 (I'm speculating here).

 

The ERSA actually says that 18 is preferred in nil wind and this is because there are few safe places to land in the event of an engine out when taking off on 36 due to housing developments.

 

Once again this is one of those crashes where no single one factor caused it, it was a combination of many individual decisions and actions (the Swiss cheese analogy)

[Yenn]

Taking off downwind is always a poor decision. I regularly do it and uphill at the same time, because there is nowhere much to go with an engine failure in the other direction, but I know I can either accelerate and fly or abort before I run out if strip.

In this case it appears to me that upwind should have been used as it is flat country and there is enough length to allow you to get speed up and then climb away.

Was it hot? Was the wind increasing or gusting? Taking off downwind puts you in the wrong position in relation to wind shear as the downwind increases as you climb. Poor decision making and not flying the plane were in my opinion the cause of this accident. Did the pilot consult his ASI as he took off and keep the nose down to increase speed.

I once took off from Agnes Waters in a NW direction as there was nil wind at the windsock and there is high ground to the SE. The prevailing wind there is SE.

I had to keep pushing the nose of the C172 down to increase speed and was quite low when I left the runway behind. There was about 15 kts SE above the trees.

[Thexder]

30 minutes ago, Yenn said:

Taking off downwind is always a poor decision. 

I'll meet you at Mt Beauty airport and watch you take off with a 5kt headilwind on runway 14....into steep climbing terrain. 

 

No thanks, 5kt tailwind and taking rwy 32 is the correct decision. 

 

So tailwind is not always a poor decision. 

[MattP]

If you look at the eyewitness account we're not talking 15 or 20 kt gust or crosswind a 5kt quartering tailwind will have 2.5 kt of tail and 2.5kt of cross component. If he ran out of authority in essentially nil wind conditions, something is amiss in the system either the aircraft or fleshy bit between the seat and controls or both. 

 

I do notice a lot of (or what seems like a lot) runway loc incidents in the raa mag, this looks by the account to be that with the decision to try and fly out of trouble instead of stop.  I wonder if there was a pre take-off brief done? 

 

Either way glad it ended as well as it could have.

[Thexder]

To be honest, the pilot taking rwy 18 at Shepparton with a 5kt quartering tailwind was not a terrible decision. 

 

Shepparton's runway 36 has virtually no safe landing zone in the event of an emergency/engine out. 

 

Rwy 18 has plenty of safe landing options. 

 

5kt tail wind toward open paddocks instead of 5kt headwind into a housing estate is not a terrible decision... Unless you stall due to lack of airspeed...but 5kt is not a deal breaker.

 

[djpacro]

2 hours ago, Thexder said:

I've seen guys take-off 20kg over weight because "I've got a big engine and she'll lift anything" when they haven't considered the forces on the plane during turbulence, or guys think the yellow arc on the ASI is the turbulence penetration speed. 

I always consider the forces on the airplane ..... https://www.avweb.com/flight-safety/technique/turbulence-v-speeds/  Do the sums on gust loads.

 

Manoeuvring loads and structural fatigue are adversely affected by overweight operation. So is performance but, as you say, a big engine is good. 20 kg .... 3% maybe .... almost trivial compared to those aeroplanes found to have incorrect empty weights a while back along with a gross error in crew moment arms so their CG was way further aft. Fixed by adding mass on the engine - a much bigger % increase - what effect does that have on the engine mount and forward fuselage structure?

[MattP]

7 minutes ago, Thexder said:

I'll meet you at Mt Beauty airport and watch you take off with a 5kt headilwind on runway 14....into steep climbing terrain. 

 

No thanks, 5kt tailwind and taking rwy 32 is the correct decision. 

 

So tailwind is not always a poor decision. 

Yep, it's judgement, sometimes you can't have it perfect so you choose the least bad option.  Slope, terrain, runway length.  This was all covered at ppl  with da consideration, w&b in theory and then practically.  Is this still taught or part of a syllabus?

[Thexder]

2 minutes ago, MattP said:

Yep, it's judgement, sometimes you can't have it perfect so you choose the least bad option.  Slope, terrain, runway length.  This was all covered at ppl  with da consideration, w&b in theory and then practically.  Is this still taught or part of a syllabus?

Yes it is still taught on PPL (not sure about RAaus). 

 

I've taken off plenty of times with a tailwind... Downhill runway, rising terrain, more usable runway, no trees or powerlines etc etc. 

[Ando]

2 hours ago, RossK said:

Thanks Thexder for the update, it's very rare that we actually get eye witness accounts.

I had wondered how he got where he was, from the photos and google maps it looks like he was off the east side of the strip only half way down, ie there was plenty of runway left to land on.

Good news is the pilot is OK, actually that's great news.

We've all made mistakes and this is one of those swiss chees ones, where if you make enough mistakes, they line up and bite you in the end.

I've got a nice bit of video footage of a take off I did in the Sportstar with a 45 deg 25kt cross wind from the left. The plane just wanted to turn left despite full right rudder, it was a poor choice of runway in hindsight as I could have chosen the other cross runway with 45 deg crosswind from the right.

But I managed to make some good decisions during the take off roll and got us airborne - but a better decision would have been to abort and have another think about it.

There are alwys things we can learn from and do better next time.

Hopefully this pilot learns from this and does better next time.

I wonder Ross if you could post that video. Would like to see that being a low wing aircraft. Cheers Andy

[RossK]

Opening myself up for flaming but here goes.

What I did was hold the stick slightly forward until it wanted to fly (60kts IAS), at which point you can see the nose rotate left, I let it track left to avoid stressing the undercarriage and eased the stick back and up we went. (note; the Sportstar has a steerable nose wheel - I suspect this would not have worked with a castering nose wheel)

BUT, in hindsight I should have aborted as soon as I realised I had minimal rudder authority - 8 seconds into the video

As I said, we all make mistakes and the key is to learn from them.

In this instance,  I had 2 runways to choose from, 08/26 or 17/35, wind was from 045 @ 20-25knots. Runway choice was not a 50:50 decision as I thought. I opted for 08 but 35 would have been a much better option, crosswind component would have helped keep straight.

 

 

[Ando]

Thanks Ross always good to view this content. The main thing I take from this is to worry about the shape of it airborne given all the other factors are in place before hand.

[kgwilson]

A 5 knot tailwind should not be an issue in most aircraft with a competent pilot. The lightning has a 38 knot stall speed and there was 1300 metres of good sealed runway. I don't know the specs for takeoff roll but I reckon it should reach rotate speed at 300 metres in nil wind.

 

My Sierra has the same engine, shorter wingspan by 4 feet and is 40kgs lighter empty. I do not use flap for takeoff except at short or soft fields. Takeoff roll 1 up with no flap is about 180 metres.

 

I think the combination of inexperience and factors surrounding the decision to use the runway got most of the swiss cheese holes lined up & then rotating too early and pulling back induced by the unknown and onset of panic lined them up perfectly.

 

I takeoff down wind a lot. When there is an Easterly blowing I have to taxi the full 1000 metres to takeoff on 08. I line up on 26 straight off the taxi way & go. Plenty of flat paddocks ahead if I have an EFATO. I don't takeoff down wind on 08 as there are trees and houses in front of me. There are sports grounds for an emergency but it is just dumb to taxi in to the wind for 1000 metres to make a downwind takeoff. That would take a complete brain explosion.

 

I rotate at the same airspeed but my groundspeed is enhanced by at least the component of the down wind. I don't think I have ever used more than 1/2 of the runway.

 

If there is a quartering tailwind & I begin to veer one way then it is a combination of rudder and differential brake and keeping the stick forward to stay on the centreline. Once off the ground stay in ground effect for several seconds to build airspeed, then climb away as normal. If there is a stiff crosswind the same applies. Hold the aircraft on the ground till above normal rotate speed & then rotate. I have had some pretty spectacular weather cock takeoffs (well they felt spectacular anyway) but at liftoff the same rules apply. Gain airspeed before climbing away.

[Garfly]

27 minutes ago, kgwilson said:

I rotate at the same airspeed but my groundspeed is enhanced by at least the component of the down wind. I don't think I have ever used more than 1/2 of the runway.

 

6 hours ago, Thexder said:

As a general rule I would just increase my rotation speed by the tailwind component, lift off gently, keep the nose lower to get more air over the wings and generate more lift.

Thexder, I was interested in your thinking behind adding the tailwind component to your normal rotation airspeed.  I guess the ASI (in the normal course of things) is 'feeling' the wind just the same as the wings are. But maybe there are other reasons for doing that.

[Flightrite]

It’s not std practice to add any T/W component to T/Off speed. Ground roll will increase and possibly a noticeable decrease in climb perf (depending on other factors) in low powered machines. V1 in transport Cat A/C is higher though.

Edited February 8, 2022 by Flightrite

[turboplanner]

 

6 hours ago, Thexder said:

Again, I was there at the time, I am a member of the club that runs out of this council owned airport.

 

This is not a controlled airport, so that means pilots use their discretion as to any decision they make. No one was in charge of the airport, that's not how it works.

 

Earlier planes were using runway 18 to land as the wind was light and variable, but technically it was favouring 36. I would say this pilot just followed what other people did earlier and decided to use 18 (I'm speculating here).

 

The ERSA actually says that 18 is preferred in nil wind and this is because there are few safe places to land in the event of an engine out when taking off on 36 due to housing developments.

 

Once again this is one of those crashes where no single one factor caused it, it was a combination of many individual decisions and actions (the Swiss cheese analogy)

With the information available so far, I wouldn't be ready to heap all the blame on the pilot.

We don't have an official wind direction at the time he took off; as you say other aircraft were landing downwind earlier, and if there was a pattern to the circuit formatted on the downwind runway, the pilot could have been pressured into not upsetting the apple cart and calling for a circit change or a takeoff on 36.

 

I would say the decision to take off downwind was significant because there was a reasonably forseeable risk in doing so.

 

If he was coerced into making that decision, then the people involved in that may share some of the blame.

 

If no one was in charge of the airport, that's a concern too given  more than one aircraft was taking off downwind.

 

This accident is similar in some ways to the Ferris wheel accident in NSW where a judge decided who was at fault

 

Briefly

A pilot landed on a downwind runway, attempted a go round but couldn’t achieve altitude and crashed into a Ferris Wheel which had been erected in the Runway splay.

 

The Plaintiff sued to Council and Pilot.

The Pilot sued the Council

 

The Judge awarded $1.5 million to the Plaintiff, deciding that the Pilot’s share was 35%

The Pilot’s claim against the Council was unsuccessful.

 

The Court held that the harm suffered was the materialisation of an obvious risk of a dangerous recreational activity as found in Section 5L of the Civil Liability Act (a NSW Act).

 

Law Firm Chamberlains write a summary of the case:

In this link take particular note that there was a reasonably foreseeable risk, and who had the Duty of Care to eliminate that risk.

https://chamberlains.com.au/local-council-sued-following-aircraft-collision-with-ferris-wheel/

 

This case is not likely to attract similar claims since no one was hurt, but it does show that Club Members and Council are at risk if things go wrong.

 

 

[Flightrite]

I better amend my above comment re V1 ( before the precious in here get upset😂) V1 decision speed is reduced with a T/C component.

[Garfly]

43 minutes ago, turboplanner said:

 

With the information available so far, I wouldn't be ready to heap all the blame on the pilot.

We don't have an official wind direction at the time he took off; as you say other aircraft were landing downwind earlier, and if there was a pattern to the circuit formatted on the downwind runway, the pilot could have been pressured into not upsetting the apple cart and calling for a circit change or a takeoff on 36.

 

I would say the decision to take off downwind was significant because there was a reasonably forseeable risk in doing so.

 

If he was coerced into making that decision, then the people involved in that may share some of the blame.

 

If no one was in charge of the airport, that's a concern too given  more than one aircraft was taking off downwind.

 

This accident is similar in some ways to the Ferris wheel accident in NSW where a judge decided who was at fault

 

Briefly

A pilot landed on a downwind runway, attempted a go round but couldn’t achieve altitude and crashed into a Ferris Wheel which had been erected in the Runway splay.

 

The Plaintiff sued to Council and Pilot.

The Pilot sued the Council

 

The Judge awarded $1.5 million to the Plaintiff, deciding that the Pilot’s share was 35%

The Pilot’s claim against the Council was unsuccessful.

 

The Court held that the harm suffered was the materialisation of an obvious risk of a dangerous recreational activity as found in Section 5L of the Civil Liability Act (a NSW Act).

 

Law Firm Chamberlains write a summary of the case:

In this link take particular note that there was a reasonably foreseeable risk, and who had the Duty of Care to eliminate that risk.

https://chamberlains.com.au/local-council-sued-following-aircraft-collision-with-ferris-wheel/

 

This case is not likely to attract similar claims since no one was hurt, but it does show that Club Members and Council are at risk if things go wrong.

 

 

I don't see that there's a connection with the Old Bar accident and normal ops at an uncontrolled field.

If there was no fair and no ferris wheel but an accident in the same place happened would the same kind of judgement be applied?  That is, would the council be liable for simply having an airstrip? (Otherwise approved for those kind of ops) How does that make sense - even legal sense? 

 

Edited February 8, 2022 by Garfly

[Thruster88]

Shepperton is a CTAF and each pilot is free to make their own decisions as to which runway they use for takeoff or landing.