Cessna 404 Titan Pilot's Operating Handbook

Tests and research 1.16.1 Flight tests 1.16.2 Airworthiness Flight Test Report 1.16.3 Survey of engines returned from service 1.16.4 Changes in seat and structural requirements 1.16.5 Simulation of impact dynamics 333333 34 35 35 37 1.17 Organisational and management information 1.17.1 The operating company. 38 38 1.18 Additional information 1.18.1 Performance Category. 1.18.2 Emergency Procedures 1.18.3 Safety actions. 39 39 39 39 1.19 Useful or effective investigation techniques 39 2 Analysis 39 2.1 Overview 2.1.1 Flight reconstruction 2.1.2 Wreckage analysis (vii) 39 39 40 2.1.3 The initiating event 41 2.2 Other factors 41 2.2.1 Aircraft loading 41 2.2.2 Pre take-off events 41 2.2.3 Flap position. 42 2.3 Event timing 43 2.4 Before the initiating event. 2.4.1 The take-off 2.4.2 The initial climb 43 43 45 2.5 The initiating event .45 2.5.1 2.5.2 The position of the aircraft when the bang was heard The source of the bang 45 2.5.3 The aircraft height when the initiating event occurred. 46 44 44 45 2.6 Practical engine failure identification 47 2.6.1 The commander's RT transmission 47 2.7 Events between the initiating event and the right turn Deviation to the left 47 2.7.1 2.7.2 The yaw to the left 48 2.7.3 Control of bank angle. 48 2.7.4 Misfiring noises 48 2.7.5 Climb performance 49 2.7.6 The relevance of propeller condition to climb performance 49 7 4 4 4 9 ↑ 47 2.8 Condition of the engines in flight 49 49 2.8.1 The left engine. 49 2.8.2 The right engine 50 2.8.3 Operating the wrong propeller RPM lever 51 2.8.4 Spluttering noises 51 (viii) 2.8.5 2.8.6 The commander's reaction to the spluttering Engine instrument indications. 51 2.8.7 The time of feathering the right propeller 52 53 2.9 Events during the turn 53 53 2.9.1 Total power loss 2.9.2 Loss of control 2.9.3 Explanation of the right propeller blade angle at impact SSS 53 54 54 2.10 The loss of power from the left engine 55 2.10.1 Summary of left engine damage 57 2.11 Progressive power loss in the left engine 2.12 Training and testing for pilots of light piston engine aircraft 58 59 2.12.1 The forced landing option 59 2.12.2 The commander's decision to return 60 2.12.3 2.12.4 Engine failure training and testing in light twin-engine aircraft Simulator training 60 61 2.13 The implications of Performance Category C 2.14 Survivability 3 3(a) 3(b) 4. 2.14.1 Aircraft seating Conclusions Findings. Casual Factors Recommendations (ix) 61 62 62 64 64 67 67 Appendices Appendix A: Glasgow Airport Chart and most probable flight path. Appendix B: Photographs of damaged accessory Gears, Crankshaft Gear, and Torsional viscous Damper from left engine. Appendix C: Detailed examination of the left engine accessory gears. Appendix D: Analysis of the rupture of the idler pin support. Appendix E: Investigations into torsional viscous dampers and accessory gears. (x) GLOSSARY OF ABBREVIATIONS USED IN THIS REPORT AAD AAIB Additional Airworthiness Directive nm Air Accidents Investigation Branch QAR agl above ground level QNH nautical miles(s) Quick Access Recorder corrected mean sea level pressure amsl above mean sea level RAF - Royal Air Force AFS Airfield Fire Serice RPM Revolutions per minute AOP Air Operator's Certificate RT radiotelephony APS Aircraft prepared for service SFB Strathclyde Fire Brigade ARCC Air Rescue Co-ordination Centre TCM ATC Air Traffic Control Temp AVGAS Aviation gasoline ΤΟ Teledyne Continental Motors Temperature Take-off BCAR British Civil Airworthiness Requirement UK United Kingdom USA United States of America CAA Civil Aviation Authority UTC Co-ordinated Universal Time CAP Civil Aviation publication CSB Continental Service Bulletin CICL CSB - Deg Cranfield Impact Centre Limited Critical Service Bulletin Degrees DERA - Defence Evaluation and Research Agency FAA - Federal Aviation Administration FAR Federal Aviation Regulations g hrs JAA JAR - IFR KIAS Lb gravity at standard sea level hours Joint Aviation Authorities Joint Aviation Requirement Instrument Flight Rules Knots indicated airspeed pounds Lg kilograms kt knot(s) MAUW - Maximum all-up weight Mb MTOW Millibar Maximum take-off weight (xi) Air Accidents Investigation Branch Aircraft Accident Report Registered Owner Operator Aircraft Type Nationality Registration Place of Accident Date and Time No: 2/2001 (EW/C99/9/01) Fraggle Leasing Limited Edinburgh Air Charter Limited Cessna Model 404 Titan Ambassador III British G-ILGW Blackstoun Farm approximately 1nm west of Glasgow Airport, Paisley, Strathclyde Latitude: 55° 51' North Longitude: 004° 29' West Altitude: 25 feet amsl 3 September 1999 at 1136 hrs All times in this report are UTC unless otherwise stated Synopsis The accident was notified to the Air Accidents Investigation Branch (AAIB) at 1250 hrs on 3rd September 1999 and an investigation began the same day. The investigation was conducted by Mr R StJ Whidborne (Investigator-in-Charge), Mr J J Barnett (Operations), Mr R D G Carter (Engineering), Mr C I Coghill (Engineering), Mr P Hannant (Operations) and Mr D S Miller (Operations). The aircraft had been chartered to transport an airline crew of nine persons from Glasgow to Aberdeen. The aircraft was crewed by two pilots and, so far as could be determined, its take-off weight was between 8,320 and 8,600 lb. The maximum permitted take-off weight was 8,400 lb. ATC clearance for an IFR departure was obtained before the aircraft taxied from the business aviation apron for take-off from Runway 23, with a take-off run available of 2,658 metres. According to survivors, the take-off proceeded normally until shortly after the aircraft became airborne when they heard a thud or bang. The aircraft was then seen by external witnesses at low height, to the left of the extended runway centreline, in a wings level attitude that later developed into a right bank and a gentle descent. Witnesses reported hearing an engine 1 spluttering and saw at least one propeller rotating slowly. There was a brief ‘emergency' radio transmission from the commander and the aircraft was seen entering a steep right turn. It then entered a dive. A witness saw the wings levelled just before the aircraft struck the ground on a northerly track. Three survivors were helped from the wreckage by a nearby farm worker before flames from a severe post-impact fire engulfed the cabin. The investigation identified the following causal factors: The left engine suffered a catastrophic failure of its accessory gear train leading to a progressive but complete loss of power from that engine. The propeller of the failed engine was not feathered and therefore the aircraft was incapable of climbing on the power of one engine alone. A total loss of thrust occurred once the left engine had failed and the right propeller had been feathered. The commander attempted to return to the departure airfield but lost control of the aircraft during a turn to the right. Three safety recommendations were made during the course of the investigation. 2 1 Factual Information 1.1 1.1.1 1.1.2 History of Flight Background The commander had been off duty for four days and not flown commercially for the operator since Sunday 29 August 1999. On that day he underwent a non- revenue proficiency check flight in G-ILGW with an authorised type-rating examiner. Later that Sunday he operated return revenue flights to and from Newcastle in the same aircraft. The commander was working at home on the day before the accident. That evening, on the instructions of the deputy chief pilot who had been instructed by the commander, G-ILGW was refuelled with 190 litres (292 lb.) of aviation gasoline resulting in a total fuel weight of 900 lb. The aircraft remained in the open air on the business aviation ramp at Glasgow where it was normally parked. Although the aircraft was certified for single-pilot operation, the airline charter contracts required the operator to crew the aircraft with two pilots. The commander operated a significant proportion of these flights himself and the same co-pilot often accompanied him. This person was qualified to fly the generic group of aircraft to which G-ILGW belonged but he was not qualified to operate revenue flights in a Cessna 404 as single pilot because he had not undergone the requisite type-specific checks and tests. His duties were chiefly to assist the commander with radio telephony and administration; consequently, a more appropriate description for his role was 'second pilot'. Early morning activity Some time after 0500 hrs UTC (0600 hrs local time) on the day of the accident the commander left his home to drive to the airstrip nearby where a company Cessna 402 aircraft had been parked for two days. He departed the private airstrip and flew to Glasgow Airport where he landed at 0632 hrs UTC. He then transferred to one of the company's Cessna 310 aircraft to operate a traffic survey flight. That flight took off from Glasgow Airport at 0710 hrs and returned at 0800 hrs. Shortly afterwards the commander drove from Glasgow Airport to the operator's headquarters at Edinburgh Airport. He left the company offices at about 0935 hrs to drive back to the business aviation centre at Glasgow Airport. He had arrived there by 1035 hrs and subsequently he met the second pilot who had driven from Edinburgh where he was based. 3 1.1.3 1.1.4 1.1.5 Accident flight preparations The two pilots briefed for the flight in the business aviation centre and walked to their aircraft. They were content to prepare it for flight without assistance and no one paid much attention to the aircraft or the pre-flight activities of the crew. The passengers were collected in a minibus from their offices near the airport's main terminal and were driven to the aircraft where they met the crew and handed over their bags. The crew loaded the bags into the nose lockers and the passengers boarded the aircraft. The commander was the last person to board; he gave a safety briefing to the passengers before taking his seat. With 11 persons on board the aircraft's take-off weight was usually close to the maximum permitted. In recent weeks the commander had initiated a programme of determining each passenger's weight, principally because he considered the alternative method of using the nominal weights prescribed by regulation was inaccurate and operationally restrictive. A weighing device was carried on the aircraft but none of the survivors recalled anyone being weighed or asked to give their weight to the handling agent or the crew before the flight. The crew did not leave a copy of the weight and balance sheet with the handling agents. Ground manoeuvres At 1126 hrs the second pilot requested ATC clearance to start engines for the flight to Aberdeen. Clearance was granted, the engines were started, and clearance to taxi was sought at 1128 hrs. None of the three surviving passengers recalled any engine starting difficulties. The aircraft was cleared to taxi and to hold before reaching the main taxiway. Whilst it was moving, but before the aircraft entered the taxiway, a witness near the aircraft heard the speed of the engines increase and decrease accompanied by what he considered misfiring sounds from the engines as their speed changed. However, the witness saw nothing untoward and none of the survivors recalled hearing any engine misfiring whilst the aircraft was taxiing. An aviation enthusiast near the holding point for Runway 23 took a colour photograph of G-ILGW just before it reached the Runway. The photograph showed the right side of the aircraft. The wing flaps were retracted and there were no visible signs of any abnormality. The take-off The aircraft was cleared to line-up on the runway behind a departing light aircraft and it taxied into position abeam Hold A near the runway threshold (see Appendix A) where it stopped. Clearance to take-off was given and the second pilot acknowledged the clearance at 11:33:43 hrs. According to a survivor the commander was handling the controls and he increased engine power before 4