Navajo lands on the street in yyc

[pelmet]

Some chief pilot or consultant wrote a SOP into the Ops Manual that omitted switching to the inner tanks from the descent checklist - as specified in the manufacturer flight manual.

The Transport Canada folks in charge of approving Ops Manuals didn't notice.

Unfortunately the pilots followed the faulty SOP and were short of time to troubleshoot.

The SOP was an accident waiting to happen.

I have come across a few accident reports over the years where information in the official manuals published by the manufacturers did not make it into the general SOP that pilots use every day. It is a good idea to read through some of the more obscure stuff at some point. You may be surprised about some of the interesting information that is in there which is frequently mixed in with a large amount of info that is not necessarily pertinent.

[C.W.E.]

+1.

Operate the aircraft in accordance with the flight manual, it (and any supplements) were developed by the design approval holder, and approved by the certification authorities.

It is as simple as that.

They were very fortunate they did not hurt or kill anyone.

Furthermore that is hardly a difficult airplane to operate it is equivalent to being the Cessna 172 of light twin engine airplanes and have been in use for many decades.

[trey kule]

It has been some years now since I flew a 31, but I do have a fair amount of time on them...

So....lets clear this up.

The POHs are quite clear on when to switch to inboards.
The Capt, or other pilots should have seen the error in the SOPs and brought that to the attention of management...A perfect example of using SMS.

All the pilots, if they were properly trained would immediately have seen that omission.

So who wrote the SOPs, and said they were “training” SOPs. The sense I get is they were written by someone who really had no idea of what SOPs are and no familiarity with the Navajo. Which reflects very badly on management. And who trained both the Captain and the FO?
In any event that does not resolve the Captain for fuel mismanagement. They should have shown at least enough initative to read the POH...
It is not a difficult aircraft to manage the fuel.

In my career I have seen so many pilots flying these delightful little planes that have no clue how the systems work or what to do when something goes wrong. In this case what should have been a rather benign oopsie, and a simple switching to the inboards when an engine started surging,

[Tailwheelup]

I've just read the report - and this report appears to be "redacted"
that is, essential information appears to have been removed from the report.

When I've seen similar "redacted" reports, it could be seen as the politicization of an accident report
to assist the operator with its insurance premiums.

First, the report fails to state what the Captain and First Officer stated regarding the fuel selection at the end of the cruise.

There is NOTHING in this report that indicates that either pilot actually followed the check list and changed the fuel from outboard
to inboard.

Second, the report fails to state what the fuel selection was when the aircraft was examined.

The report "alludes" they followed the check list but, conveniently omits the essential facts.

The question everyone wants to know is, did this aircraft run out of fuel because the fuel selectors
were left on the outboard tanks?

The answer appears to be yes, because there is no apparent other possible cause.

Some SOP's are figments of imagination by those with delusions of grandeur. Instead of the POH, the "company"
decided in a certain person's wisdom that a QRH could be "written", as an "introduction" and "learning tool".

Well its turned out that the QRH was riddled with problems that might be related to being partially plagiarized from a Jetstream.

The same sort of long winded nonsense goes on with their Cessna 172 that unnecessarily complicates what is simply laid out in the Cessna (POH) /Airplane Flight Manual.

You would think that the penny might drop to use the AFM's of the manufacturer but no, someone, thinks they know better than the manufacturer
and removed the descent check list "fuel on mains" and put it on the "pre-landing"

There was also nothing in this report about prior maintenance such as "changing fuel pumps" due to fuel flow problems
that just might have been attempting to fly on empty outboards.

[co-joe]

...The captain held a valid airline transport pilot licence – aeroplane, Class 1 aeroplane instructor rating, a Group 1 instrument rating, a glider pilot licence...

Looks like a glider license may have been a key element to the success of "the miracle on 36th street".

[C.W.E.]

So what happened to the crew, are they still flying there?

[co-joe]

So what happened to the crew, are they still flying there?

Probably at Air Canada by now.

[trey kule]

I know, I know, what can we possibly learn from an accident that happened more than 60 days ago...,

In any event, can anyone with actual knowledge tell us what happened to the crew and where they are today? No speculation or cleverisims please.

No names either please. Just looking for some information for a course. The consequences of certain accidents.

[iflyforpie]

They were charged and suspended from flying.

They were put on a secret blacklist that only chief pilots and HR ladies know about to ensure they could never fly commercially again.

For seven times seven years they will have to do their annual walk of shame through the airport terminal to atone for their sins.

Their shame and disgrace will extend to seven generations so even their children’s children’s children’s children’s children’s children will never be able to be professional pilots.

But seriously, who cares? Some pilots would hang up he headset like the Keystone Kid. Some pick the the pieces and persevere, gaining employment through the unwary or someone willing to give them a second chance.

[C.W.E.]

Some pick the the pieces and persevere, gaining employment through the unwary or someone willing to give them a second chance.

If they worked for me and they had good hands and feet skills I would give them another chance.

One thing for sure they won't run out of fuel again, assuming they did in fact run out of fuel.

[CanadianBird]

It has been some years now since I flew a 31, but I do have a fair amount of time on them...

So....lets clear this up.

The POHs are quite clear on when to switch to inboards.
The Capt, or other pilots should have seen the error in the SOPs and brought that to the attention of management...A perfect example of using SMS.

All the pilots, if they were properly trained would immediately have seen that omission.

So who wrote the SOPs, and said they were “training” SOPs. The sense I get is they were written by someone who really had no idea of what SOPs are and no familiarity with the Navajo. Which reflects very badly on management. And who trained both the Captain and the FO?
In any event that does not resolve the Captain for fuel mismanagement. They should have shown at least enough initative to read the POH...
It is not a difficult aircraft to manage the fuel.

In my career I have seen so many pilots flying these delightful little planes that have no clue how the systems work or what to do when something goes wrong. In this case what should have been a rather benign oopsie, and a simple switching to the inboards when an engine started surging,

I fly a Mooney, with retractable gear. First thing we did in circuits is go through GUMPS. G is for GAS or Fuel... as in, make sure you have it set to the proper/correct tank, which is the fuller one. Can't believe this was missed on a SOP. I still call pilot complacency / error.

[pelmet]

One thing for sure they won't run out of fuel again, assuming they did in fact run out of fuel.

Running out of fuel is called fuel exhaustion. Ie no more fuel on board. This was a case of fuel mismanagement ie. plentyof fuel but none of it going to the engines. I guess it wasssumed by the pilots when the engines quit(or at least the first one) that it was a failure due to a fault with the engine and handled that way.

[goingnowherefast]

Yeah, they're not making that mistake again. I've blown a tank in a Navajo too, but I was well aware that the tank was near empty, and wasn't surprised by it. I also resolved the issue by switching to a tank with lots of gas in it.

[trey kule]

Thank you ifly for your articulate and well reasoned answer.

Despite your so what attitude, I had a reason for asking. I wasnt looking for names.
As part of a training course, it is sometimes good to have examples of consequences for actions of pilots that have found themselves in these circumstances. It also may be an example to be used for proper training, cockpit resource management, and a couple other things. I believe there are a lot of lessons to take away from this accident/incident.

New pilots tend to treat these instances as learning lessons, and believe there are no consequences. Management of companies never seem to relate to what appears to be serious management failures here. Maybe there were no consequences to the crew or company .

Unfortunately, I cannot talk to the crew and get their perspective post crash. Might have given some great insight for others.

But the answers to the question help fill a database as best as can be done without input from the crew.

Again thank you for your post. Now if any of the grown ups here can answer the question, it would be appreciated. Feel free to PM.

[iflyforpie]

New pilots tend to treat these instances as learning lessons, and believe there are no consequences. Management of companies never seem to relate to what appears to be serious management failures here. Maybe there were no consequences to the crew or company .

Yeah... I think my response was appropriate for that level of thinking. And considering most of your posts have a sardonic tone as well... I’ll let it stand.

[trey kule]

Sardonic. How unfair a characterization....though I will give it to you that it is a pretty impressive word for a 14 year old to use

Just in case you missed the , That was intended to be humorous.

Us old sardonics do have sense of humour.