Tecnam crash Calgary

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pelmet
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Tecnam crash Calgary

Post by pelmet »

Sorry AvCanada moderators....saving lives is more important than not hurting feelings. Two experienced pilots died in a Tecnam P2006 last year and we need to be discussing how to prevent it from happening again. If someone has posted something not within the guidelines, then eliminate the post and the poster, not the thread.

According to the accident report.....
"Although steps had been taken to ensure that instructors and students were aware of the handling characteristics of the Tecnam P2006T, a non-standard training practice had been developed by some of the flight instructors at Mount Royal University. Although, at times, that practice resulted in manoeuvres (i.e., aerobatic movements and spins) that exceeded aircraft limitations, the practice continued."

The question is, why are people continuing to put themselves in a dangerous position. Word of mouth instead of example might be a preferred way to pass on the information. I was checked out on an aircraft a few years ago which had some nasty stall characteristics. While that standard stall had reasonable behaviour, I was told to do a turn to final type of maneuver where the final approach course is overshot and therefore inside rudder is applied. All of a sudden, the aircraft is completely out of control in a near aerobatic maneuver. While it is a good demonstration with much to learn from if done successfully, when I checked other people out, I didn't demonstrate this aircraft characteristic, I just mentioned about it as I really didn't feel like being the PIC responsible for having to recover the aircraft or ensure that the recovery was done properly by someone else.

The pilot who checked me out had an aerobatic background, but I do not. And when you are suddenly in an unusual attitude, a non-aerobatic guy is more likely than not to make an incorrect input no matter how much has been read previously about such scenarios in the past. So I avoided this maneuver and am here to pontificate.

Why demonstrate a nasty scenario when the scenario is one that you want to avoid.

http://www.tsb.gc.ca/eng/rapports-repor ... 7w0024.pdf

Please don't delete this post and keep it here in the name of aviation safety.
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Last edited by pelmet on Sun Feb 25, 2018 5:13 pm, edited 2 times in total.
Boney
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Re: Tecnam crash Calgary

Post by Boney »

Years ago, during my flight training, I did a manoeuvre, not unlike the above post, and didn’t like the way the aircraft felt. I overshot and returned, landed and went immediately to my instructor and explained my experience.

He smiled, and both of us went up to the training area at 3000 ft to recreate the senerio. To my surprise, we flipped. Good thing I stopped what I was doing at 300 ft.

At that time, spins and unusual attitude was part of the training for your cpl. I believe it’s no longer trained.

Hmmmmm
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MrWings
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Re: Tecnam crash Calgary

Post by MrWings »

pelmet wrote: Sun Feb 25, 2018 11:20 am Sorry AvCanada moderators....saving lives is more important than not hurting feelings. Two experienced pilots died in a Tecnam P2006 last year and we need to be discussing how to prevent it from happening again. If someone has posted something not within the guidelines, then eliminate the post and the poster, not the thread.
Completely agree. If we sweep this under the rug, we learn nothing from this.

The culture demonstrated in this scenario is no different than operators who continually fly over gross, don’t carry enough reserves or bust minimums.
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Tertle
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Re: Tecnam crash Calgary

Post by Tertle »

Boney wrote: Sun Feb 25, 2018 11:58 am Years ago, during my flight training, I did a manoeuvre, not unlike the above post, and didn’t like the way the aircraft felt. I overshot and returned, landed and went immediately to my instructor and explained my experience.

He smiled, and both of us went up to the training area at 3000 ft to recreate the senerio. To my surprise, we flipped. Good thing I stopped what I was doing at 300 ft.

At that time, spins and unusual attitude was part of the training for your cpl. I believe it’s no longer trained.

Hmmmmm
Fortunately, both of those are still taught and are part of the CPL flight test.
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rookiepilot
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Re: Tecnam crash Calgary

Post by rookiepilot »

Agree with above. I'll keep it short and sweet.

Any 700 operators willfully and repeatedly busting approved TC and manufacturer procedures can be at risk of having their OC revoked.

The same standard should be even more stringently applied to flight schools. To be a teacher -- should be one held to the very highest standards.

And in this case, like most, it is completely the responsibility of management, to wisely manage.
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Zaibatsu
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Re: Tecnam crash Calgary

Post by Zaibatsu »

It absolutely floors me that what’s supposed to be a professional university with professional and experienced flight instructors not only would deviate from recommended practices, and not tell anyone of the severe consequences of those practices they barely escaped from before, but continued to do them in spite of what must have been the well-known danger involved.

I’ve flown lots of light twins. A few of them quite oddly configured and unforgiving of sloppiness at the edge of the envelope. Not once during stall practice and recovery have I ever experienced anything close to the extreme attitudes and altitude losses that MRC figured was business as usual until the crash. I haven’t even experienced it in the simulator.
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mbav8r
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Re: Tecnam crash Calgary

Post by mbav8r »

Zaibatsu wrote: Sun Feb 25, 2018 3:00 pm It absolutely floors me that what’s supposed to be a professional university with professional and experienced flight instructors not only would deviate from recommended practices, and not tell anyone of the severe consequences of those practices they barely escaped from before, but continued to do them in spite of what must have been the well-known danger involved.

I’ve flown lots of light twins. A few of them quite oddly configured and unforgiving of sloppiness at the edge of the envelope. Not once during stall practice and recovery have I ever experienced anything close to the extreme attitudes and altitude losses that MRC figured was business as usual until the crash. I haven’t even experienced it in the simulator.
As for the why the original thread was removed, you could probably point the finger at a few bad eggs who didn’t want to learn, just glance at the report and come on here to make insulting comments about a couple of pilots who died, one of which I knew fairly well and can categorically state he would not do this for thrill.
It’s called normalized deviation, it’s very easy to fall into that trap, I believe the report on the challenger mentions this as a factor. It’s pretty easy to sit there and say it wouldn’t happen to you, imagine a colleague tells you about something that happened during a training event that you need to watch out for and then it someone says maybe we need to show students to watch out for it, etc..
My understanding is that this isn’t the first time this particular type has done this but I’m not positive.
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rookiepilot
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Re: Tecnam crash Calgary

Post by rookiepilot »

mbav8r wrote: Sun Feb 25, 2018 4:31 pm It’s called normalized deviation, it’s very easy to fall into that trap, I believe the report on the challenger mentions this as a factor. It’s pretty easy to sit there and say it wouldn’t happen to you, imagine a colleague tells you about something that happened during a training event that you need to watch out for and then it someone says maybe we need to show students to watch out for it, etc..
My understanding is that this isn’t the first time this particular type has done this but I’m not positive.
Respectfully-- in this admittedly outsiders view, that is absolutely insane way to run a training program. Instructors are not allowed to create their own syllabus, any more than line pilots create their own SOP's, that deviate from the manufacturer's recommended operating procedures.

Want to add something? Take it up with the manufacturer. Have an experienced test pilot, test it, if approved. Do it professionally, and document it.

I don't get this at all. Totally bizzare.
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MrWings
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Re: Tecnam crash Calgary

Post by MrWings »

Exactly. SOPs are there for a reason. If you work outside of them, however good the intentions, don't be surprised if the pilots or the organization gets scrutinized.
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RatherBeFlying
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Re: Tecnam crash Calgary

Post by RatherBeFlying »

Twins can be and are certified without determining flight behavior when stalled with yaw. I don't know if there's any quantified tolerance for yaw when stalling a twin.

Likely some twins bite harder than others in this condition. But there's no certification requirement for flight testing spins as there is with singles, even those where spins are prohibited. So there's really no way for pilots to know - except by word of mouth.

The SD cards retrieved from the remaining MRU Tecnams showed one flight with a similar excursion as the accident. Had this excursion been shared with safety management and the manufacturer, perhaps the instructors would have been properly cautioned about the dangers of allowing yaw during a stall demonstration.

According to the report MRU has switched to Senecas, but we should note that a Seneca operated by another flight school recently crashed taking off from Springbank.
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pelmet
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Re: Tecnam crash Calgary

Post by pelmet »

RatherBeFlying wrote: Sun Feb 25, 2018 5:44 pm Twins can be and are certified without determining flight behavior when stalled with yaw. I don't know if there's any quantified tolerance for yaw when stalling a twin.

Likely some twins bite harder than others in this condition. But there's no certification requirement for flight testing spins as there is with singles, even those where spins are prohibited. So there's really no way for pilots to know - except by word of mouth.

The SD cards retrieved from the remaining MRU Tecnams showed one flight with a similar excursion as the accident. Had this excursion been shared with safety management and the manufacturer, perhaps the instructors would have been properly cautioned about the dangers of allowing yaw during a stall demonstration.

According to the report MRU has switched to Senecas, but we should note that a Seneca operated by another flight school recently crashed taking off from Springbank.
I wonder what happened to the Tecnam's. I would like to fly one.
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JL
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Re: Tecnam crash Calgary

Post by JL »

The report was also making a point that if if an aircraft has not been assessed at all for spins why would you perform a full stall? Recoveries should be initiated at the first sign (buffet, light, horn) as you would in real life.
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mbav8r
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Re: Tecnam crash Calgary

Post by mbav8r »

rookiepilot wrote: Sun Feb 25, 2018 4:42 pm
mbav8r wrote: Sun Feb 25, 2018 4:31 pm It’s called normalized deviation, it’s very easy to fall into that trap, I believe the report on the challenger mentions this as a factor. It’s pretty easy to sit there and say it wouldn’t happen to you, imagine a colleague tells you about something that happened during a training event that you need to watch out for and then it someone says maybe we need to show students to watch out for it, etc..
My understanding is that this isn’t the first time this particular type has done this but I’m not positive.
Respectfully-- in this admittedly outsiders view, that is absolutely insane way to run a training program. Instructors are not allowed to create their own syllabus, any more than line pilots create their own SOP's, that deviate from the manufacturer's recommended operating procedures.

Want to add something? Take it up with the manufacturer. Have an experienced test pilot, test it, if approved. Do it professionally, and document it.

I don't get this at all. Totally bizzare.
When we deviate from a know practice on purpose because we think our way is better or whatever our reasons are, not allowed really has nothing to do with it
http://lmcontheline.blogspot.com/2013/0 ... t-can.html
“It is called the normalization of deviance, and it is deadly. The normalization of deviance is defined as: “The gradual process through which unacceptable practice or standards become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2821100/
“Many serious medical errors result from violations of recognized standards of practice. Over time, even egregious violations of standards of practice may become “normalized” in healthcare delivery systems. This article describes what leads to this normalization and explains why flagrant practice deviations can persist for years, despite the importance of the standards at issue”
http://code7700.com/deviance.htm
“The Academic Definition of the normalization of deviance comes from a book written by Professor Diane Vaughn following the 1986 explosion of Space Shuttle Challenger. The book is tedious reading but makes a very good case that even an organization as highly esteemed as the National Aeronautics and Space Administration (NASA) can be corrupted by the normalization of deviance”
“It is a sad commentary on our profession that we have had to adopt the phrase "Normalization of Deviance" as our own.

It refers to when pilots deviate from Standard Operating Procedures so often that their SOP-less practice becomes the new norm. It seems that with each couple of passing years we have a new poster child in the case history books and right now that prime example belongs to Gulfstream IV N121JM, which crashed attempting to take off from Hanscom Field, Bedford, Massachusetts with its gust lock engaged.”
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Re: Tecnam crash Calgary

Post by 5x5 »

Excellent post, mbav8r.

One of the reasons why people who feel that “No one should ever do that” need to relax a bit. Also examples of where looking at accidents with the intent of assigning absolute individual blame is often contrary to actual learning, which can limit the identification of the real issue that needs to be rectified.

Certainly we don’t want “normalization of deviance” to become a catch phrase to absolve pilots of their own responsibilities, but awareness of it may help someone be to a bit more willing to question a practice that they aren’t comfortable with. I think we’ve all heard the phrase “That’s the way we’ve always done it”. It’s a bit tricky when there are a lot of procedures in aviation where there is more than one way to accomplish the same goal, but awareness of the possibility is valuable.
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Re: Tecnam crash Calgary

Post by Boney »

Tertle wrote: Sun Feb 25, 2018 12:25 pm
Boney wrote: Sun Feb 25, 2018 11:58 am Years ago, during my flight training, I did a manoeuvre, not unlike the above post, and didn’t like the way the aircraft felt. I overshot and returned, landed and went immediately to my instructor and explained my experience.

He smiled, and both of us went up to the training area at 3000 ft to recreate the senerio. To my surprise, we flipped. Good thing I stopped what I was doing at 300 ft.

At that time, spins and unusual attitude was part of the training for your cpl. I believe it’s no longer trained.

Hmmmmm
Fortunately, both of those are still taught and are part of the CPL flight test.
Right on. Good to know. Cheers.
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bobcaygeon
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Re: Tecnam crash Calgary

Post by bobcaygeon »

Sorry but I flew and trained (initial course 705) with the retired airline pilot.
He was very professional, knowledgeable and almost painfully boring to fly with because he followed the rules ie no small chat below 10K, etc. (Some of the most anal pilots I've ever worked with don't even follow that rule)
Cowboy was the last word I'd use.
There's more to the story that we'll never know.
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lownslow
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Re: Tecnam crash Calgary

Post by lownslow »

bobcaygeon wrote: Tue Feb 27, 2018 8:10 amCowboy was the last word I'd use.
That's probably true, but that's the insidious nature of normalization of deviance or SOP creep or whatever you want to call it; it's slow and chips away over a very long period. No professional wakes up and says, "I'm going to do something dangerous today," yet dangerous actions still happen and in a lot of cases they're done with good intentions.
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