Navajo lands on the street in yyc

[cncpc]

Oy, what about the light on the fuel pump switch thing?

[C.W.E.]

by goingnowherefast » Mon May 28, 2018 12:58 pm

Still waiting for CWE to reply to my post. He seems more interested in petty bickering than backing up his opinions.

O.K. here is a reply.

goingnowherefast wrote: ↑Mon May 28, 2018 5:20 am
The TSB investigates more than just the immediate facts. They ask why, and then ask why again and again and again.

They do?

Give us some examples.

They look at why they didn't take enough gas. Well they thought they had enough. Well why did they think that? The pilot before them said there was lots remaining. Well why did they trust him? Because thats how its been for years, and the gauges looked about right.

That information would be available in the first interview.

Why did the gauges lie and why is company culture so lax about fuel? Gauges lied because a float was half sunk. Company culture was like this because that's what the old boss taught everybody. Well now we have one finding as to cause, not following the company fuel policy. Now why was the float half sunk? There was a pin hole in the top. Why was there a hole in the float? Better go through all the tech logs and find out that the sender was replaced 12 months ago. Did the hole develop recently or manufacturing defect?

And who is responsible to fix such company culture?

We've gone from "pilots ran out of gas, they're liable for millions, pull their license" to a part defect and possibly an AD for a certain brand of fuel sender. This is just demonstrating the why path that lead to the results, there's also the why's that don't lead anywhere.

Sure, there are so few Navajo's flying and they are such new aircraft that we just have not had time to get to know them yet.

Every time you ask why it takes time to investigate. You don't go through a year of maintenance paperwork in 3 hours. Did the fuel gauge lie because the gauge sucked, resistance problem in old wires, which sender was it? Takes time to rip the plane apart and investigate every component.

Am I to believe that there are that many pilots flying for these companies that no one wrote up a report that there was one or more faulty fuel gauges they just guess at how much fuel they have before flying?

Or why did that fuel leak develop.

A fuel leak will be visible as soon as they look at the airplane.

Or why did automotive diesel get into the tanks.

That also will be evident on the first inspection.

Could ask why a million times for every senario.

Don't give them more ideas.

[C.W.E.]

You are also at the end of your career/retired, so you don't have to be afraid of evil ops managers or chief pilots or other powers that be to try and sabotage your career because they disagree with something you posted on AvCanada.

So if you work for Aircanada for instance you can be penalised for posting on Avcanada?

[North Shore]

goingnowhere, CWE, Rockie, and telex.... enough with the bickering, please. On topic, or hold your tongues.

[goingnowherefast]

Oy, what about the light on the fuel pump switch thing?

If it's the light I'm thinking of, it will illuminate when the fuel pressure on the outlet side of the primary electric fuel pumps drops below a certain threshold. There are really only 4 things that will set it off. No fuel, vapour lock, pump failure or the pump turned off. It is actually the first pump in a series of 3 separate pumps per side, so no other combination of fuel pumps will cause the light to extinguish.

[JL]

TSB report

http://www.bst-tsb.gc.ca/eng/rapports-r ... 8w0054.asp

[pelmet]

The TSB?

They take forever to release any findings but maybe eventually they will share it with the public.

Looks like they are getting quicker. That being said, an analysis and Probable Cause(which the NTSB is mandated by law to provide) would be nice.

[telex]

So ran the outboards dry and didn’t switch to mains?

[anofly]

no new causes of aircraft crashes this year... someone else said that once...

https://www.ntsb.gov/_layouts/ntsb.avia ... 289&akey=1

i think this (and every other navajo accident in the ntsb database) should be requred reading for every navajo driver....

" Red fuel boost pump warning lights, mounted in the annunciator panel, provided a visual indication of an inoperative fuel boost pump"

would a navajo driver please tell me what makes the red light come on? low pressure? low flow? or electrical failure?
The light comes on when fuel boost pressure is less than 3 psi, so a failure of supply or pump failure will get the light on. There have now been two Navajo crashes in a few short years where folks failed to realize draining the aux tanks “caused” the fuel boost pump failure lamp to come on, and did not attempt to restore fuel flow by switching to an onboard tank that had fuel in it,,,,

from a navajo ground school

During initial checks fuel is turned off so at to check cross feed. Once fuel is turn off a few moments later the FUEL BOOST INOP annunciator will illuminate indicating no flow to the pump. Once fuel is restored the annunciator will extinguish. 
This annunciator will illuminate when a tank is run dry. Quickly switch to full tank and activate emergency boost pump to prevent engine surging. (3-5 seconds after lamp before engine is starved for fuel at cruise power)

[trey kule]

So ran the outboards dry and didn’t switch to mains?

Yep. Simple as that.



I am gobsmacked that this became such an SMS issue, with corrective action.
Fire the Capt....9500 hrs and can’t manage the fuel in a ho...!

Then when they hire anew one actually look for qualified not cheap.
And do some proper training. Odd that The TSB did not look into that, or at least did not mention it...I guess the paperwork must all have been in order.

[C.W.E.]

When I first read about this accident I thought that they had ran out of fuel due to departing with insufficient fuel for the flight.

Seems I was wrong.

[RatherBeFlying]

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.

[C.W.E.]

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.

So that relieves the pilots from the responsibility of knowing how to properly operate the airplane?

[PilotDAR]

So that relieves the pilots from the responsibility of knowing how to properly operate the airplane?

+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.

[J31]

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.

Surely you jest!

One of the cornerstone drills that one is taught in primary flight training is to check the fuel with an engine failure. Especially when you have more than one fuel tank to feed from.

[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".