One of the best accident reports I've ever read

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PilotDAR
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One of the best accident reports I've ever read

Post by PilotDAR »

Here is the report of a jump Caravan crash in Ireland:

http://www.aaiu.ie/sites/default/fil...l%20Report.pdf

It is one of the most thorough and well written reports I have ever seen!
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Re: One of the best accident reports I've ever read

Post by Ki-ll »

The link in not valid. Could you please re-post.
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Re: One of the best accident reports I've ever read

Post by valleyboy »

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Re: One of the best accident reports I've ever read

Post by Schooner69A »

An excellent report...
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bodyflyer2
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Re: One of the best accident reports I've ever read

Post by bodyflyer2 »

Hmm, I guess it is a lot of detail for a lighter aircraft with just pilot and one pax on board.

They did their homework on figuring out aircraft speeds and descent rates and so on as the loss of control happened.

Still, sometimes things get so wordy that it is hard to pull out the relevant info. I think the report was a bit messy about putting forth its various ideas on how the loss of control happened, scattering information about and not even being as clear as it could have been in the final causes.

(Eg, one Finding being that one wing might have been close to the stalling angle of attack during the descending turn... but at an estimated 140 knots. Which means he'd have to be pulling like 3g's or also be very uncoordinated on the controls. Not impossible but the Finding on its own without context is a bit unhelpful.)

Basically the accident reason seems to have been the pilot was hotdogging it a bit much, yanking and banking with too much abandon. Known for doing some vertical banked high speed turns while trying to burn off extra altitude and speed when coming back from a skydive drop and getting ready to set up for landing. I didn't go back and check if the report actually stated it, but who knows if the pilot was showing off a bit more of a fun ride to the passenger, who was a kid.


And as usual, the report finds all those regulatory infractions that aren't thought about before hand. Some are easy to miss, some should have been realized. For example:

- Missing sun visor. Someone might think 'who cares'. There was no MEL list and the MMEL list only allows 10 days before fixing. So it was technically not allowed.

- Pilot's medical was out of date first couple weeks he was flying for the DZ. Operator might think, "Well, that's on him. Why should we check? His responsibility to be legal. Anyway, no harm, he got it updated later."

- Confusion over who is "The Operator "of the plane when a plane & pilot are hired, and thus who is responsible for what. Doesn't matter for those making a handshake agreement, but duh apparently the authorities do care. It is that kind of professional paperwork stuff that gets in the way of just going and flying...

- Passengers in a skydiving aircraft. Big area of contention between skydivers and authorities. While the RULES are laid out in the report, they don't get into the whole issue in general. Though even those operators worldwide who take passengers up, nowadays they typically make sure a passenger has a parachute and briefing. Wouldn't have mattered in this case anyway.

- Authorities still get their knickers in a knot about skydiving aircraft banking over 60 degrees. "But it isn't licensed for aerobatics!" Very common for turbine skydiving aircraft to do very steep diving turns when first starting to descend. In the USA there was a case where the skydiving operator actually won when charged -- the ruling was that while the bank over 60 degrees is still aerobatic, such a steep turn was part of 'normal' skydiving operations for those kinds of planes and thus exempt under the particular FAA rules. Not that I know whether that sets any precedent, and of course it doesn't for a UK plane in the EU.


At least it was nice that the authorities did a thorough investigation into a baffling case -- An apparently fine aircraft suddenly diving into the ground while setting up for landing.
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Re: One of the best accident reports I've ever read

Post by PilotDAR »

one wing might have been close to the stalling angle of attack during the descending turn... but at an estimated 140 knots. Which means he'd have to be pulling like 3g's or also be very uncoordinated on the controls. Not impossible but the Finding on its own without context is a bit unhelpful.)
Just for context, when I was flying a Transport Canada flight test on a modified Grand Caravan, which included intentional one turn spins at both full forward, and full aft C of G, recovery from a one turn spin, and the resulting dive, often got to near Vne, and 2.5G, so the numbers in the report are entirely believable for an unintentional spin entry.
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Re: One of the best accident reports I've ever read

Post by bodyflyer2 »

I think the 140 knots was while under control in a moderately descending turn, before control was lost and the plane overbanked and dove steeply. Anyway the report conclusions seem reasonable if a bit messily stated.

(@ PilotDAR: Sounds sporty, doing aft CofG Caravan spins! I've only had the pleasure of an inadvertent stall in one, while on jump run, as a skydiver in back. Got to about 75 degree bank on the recovery, the video shows, while jumpers jumped off or out.)
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Re: One of the best accident reports I've ever read

Post by pelmet »

bodyflyer2 wrote:
Sun Mar 22, 2020 10:04 am
Hmm, I guess it is a lot of detail for a lighter aircraft with just pilot and one pax on board.

They did their homework on figuring out aircraft speeds and descent rates and so on as the loss of control happened.

Still, sometimes things get so wordy that it is hard to pull out the relevant info. I think the report was a bit messy about putting forth its various ideas on how the loss of control happened, scattering information about and not even being as clear as it could have been in the final causes.

(Eg, one Finding being that one wing might have been close to the stalling angle of attack during the descending turn... but at an estimated 140 knots. Which means he'd have to be pulling like 3g's or also be very uncoordinated on the controls. Not impossible but the Finding on its own without context is a bit unhelpful.)

Basically the accident reason seems to have been the pilot was hotdogging it a bit much, yanking and banking with too much abandon. Known for doing some vertical banked high speed turns while trying to burn off extra altitude and speed when coming back from a skydive drop and getting ready to set up for landing. I didn't go back and check if the report actually stated it, but who knows if the pilot was showing off a bit more of a fun ride to the passenger, who was a kid.


And as usual, the report finds all those regulatory infractions that aren't thought about before hand. Some are easy to miss, some should have been realized. For example:

- Missing sun visor. Someone might think 'who cares'. There was no MEL list and the MMEL list only allows 10 days before fixing. So it was technically not allowed.

- Pilot's medical was out of date first couple weeks he was flying for the DZ. Operator might think, "Well, that's on him. Why should we check? His responsibility to be legal. Anyway, no harm, he got it updated later."

- Confusion over who is "The Operator "of the plane when a plane & pilot are hired, and thus who is responsible for what. Doesn't matter for those making a handshake agreement, but duh apparently the authorities do care. It is that kind of professional paperwork stuff that gets in the way of just going and flying...

- Passengers in a skydiving aircraft. Big area of contention between skydivers and authorities. While the RULES are laid out in the report, they don't get into the whole issue in general. Though even those operators worldwide who take passengers up, nowadays they typically make sure a passenger has a parachute and briefing. Wouldn't have mattered in this case anyway.

- Authorities still get their knickers in a knot about skydiving aircraft banking over 60 degrees. "But it isn't licensed for aerobatics!" Very common for turbine skydiving aircraft to do very steep diving turns when first starting to descend. In the USA there was a case where the skydiving operator actually won when charged -- the ruling was that while the bank over 60 degrees is still aerobatic, such a steep turn was part of 'normal' skydiving operations for those kinds of planes and thus exempt under the particular FAA rules. Not that I know whether that sets any precedent, and of course it doesn't for a UK plane in the EU.


At least it was nice that the authorities did a thorough investigation into a baffling case -- An apparently fine aircraft suddenly diving into the ground while setting up for landing.
Finally finished it tonight. I agree with the analysis of the report by bodyflyer2. It takes way too long to get through. I suppose it is a great report for investigators to read with good info for them to reference. For a pilot....many will just be fine to skim through an interesting area here and there and then go to the end and discover that the exact detail of how control was lost is unknown.

I would suggest that the accident investigation unit look at some of the NTSB reports where a lot of the boring technical detail is referenced in a docket which can be easily found on the website while keeping the report much smaller.

Just an opinion of course and obviously there will be those that differ based on how much detail you like.
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Re: One of the best accident reports I've ever read

Post by cncpc »

I agree with the OP with the proviso that I'd say it was one of the most thorough reports I've read.

I am an Irish citizen. I've lived there and seen how aviation worked. It was described to me by an Irish pilot as a "...cottage industry", despite the expertise at Aer Lingus and with the leasing companies, at the time mainly GPA. The one accident investigation I was involved in involved a gong show crash during an IFR ride with an Irish Aviation Authority examiner on board. At that time, these were people trying to carry out an aviation oversight function. They were not fully at the races.

This is a long way from that time (mid 90s). This was an excellent report, every possible issue was considered, the right analysis came out in the wash. Lots of people on this forum could say that it was a 50 mile hike to a place 50 yards away, and sure, you could take that view. I see progress and bedrock competence in my countrymen, and women, who did this investigation. Well done.

It is an investigation of a private crash in which there is no finger pointed at the government. It may be different when the conduct of government officials are questioned. That was the case in the lawsuit I was involved in. It is in one major investigation that is now really dragging out...the Irish Coast Guard Sikorsky collision with Blackrock, a 200 foot rock right in the middle of a 200 foot, ten mile, run-in from a letdown over the Atlantic to a fuelling spot on the mainland coast. Involved a contracted operation run by CIH, and some buck shee approach that seems to have started out as a VFR route for supply and personnel replacement between the two heliports, and ended up being adapted for ad hoc use as an IFR approach using the waypoints, but with no indication that the offshore waypoint was anything other than a GPS point in the ocean.

Tragically, it was this, and it was dark with overcast around 200 feet.

Image
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