BART: SEPTEMBER - 2019

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78 - BART: SEPTEMBER - 2019 SMASH A Citation 500 crashed into a house near Biggin Hill Airport from where it had taken off. S KYbrary provides a description of the accident as follows: “On 30 March 2008, a privately oper- ated Cessna Citation 500 which had just taken off from Biggin Hill UK for Pau, France in day VMC reported ‘engine vibration’. Whilst positioning for a return to land, the aircraft descended, and the pilots reported a major power problem just before it struck the side of a house killing all five occupants and destroying the house and adjacent property in the intense fire which followed.” The Flight Crew Pilot A was 57 years old. He held a UK Airline Transport Pilot’s License and had accumulated 18 hours on type and 8278 hours total flight time. Pilot B was the older of the two pilots. He was 63 years old and had an experience of 4533 total flying hours, of which an unknown amount in excess of 70 hours was flown on the Cessna Citation on a FAA Commercial Pilot Certificate. Both pilots had previous experience in multi-pilot operations on various aircraft types. However, both pilots had only received training and check- ing on operating the Cessna Citation in the single pilot role. Pilot A and Pilot B were thus properly licensed and qualified to operate the aircraft for single pilot operation only. The Aircraft The Cessna Citation 500 is a light twin-engine jet, thus a complex motor-powered aircraft. It is certified for single pilot private operation. For commercial operation, it must be crewed by two pilots. The aircraft had been maintained to the manufactur- er’s standards, and no maintenance deficiencies were detected by the investigation. The Flight Pilot B had arrived at the Biggin Hill Airport (UK) at 11:00 UTC and began flight preparations. Pilot A joined him 45 minutes later, and both continued to prepare for the flight jointly. At 13:00 UTC, the three passengers arrived at the terminal, and they were brought to the aircraft. The take-off from Runway 21 at 13:33 UTC was uneventful. One minute into the climb, Pilot B trans- mitted “And Victor Papa Bravo Golf Echo er we’re making an immediate turn to return to the airport immedi- ate turn to the airport.” Two minutes later, Pilot B made the following final transmission: “And er Victor Golf Echo we have a major problem a major power problem it looks as though we’re er going in we’re going in.” Shortly after that call, the aircraft crashed. As the CE500 was not equipped with a voice or flight data recorder, we only have limited knowledge of what happened in the cockpit during that flight. The BBC News reported on the out- come on the day after the accident: “Witnesses reported seeing the jet fly- ing low over homes before crashing into the house in Romsey Close. Home owner Edwin Harman was away on holiday at the time of the crash, and his wife, Pat, who had returned early, was on her way to the house after spending the night at her daughter’s. Coroner Roy Palmer said it was ‘extremely fortuitous’ that no one was in the house at the time and through ‘great good fortune’ that no one was killed on the ground.” The Technical Investigation In order to find out which factors had contributed to the fatal outcome, the investigators conducted extensive ONE PLUS ONE IS TWO. REALLY? SAFETY SENSE When two pilots qualified to operate alone are flying together, do they add up to performing as a team of two? Michael R. Grüninger and Capt. Andreas Grauer investigate BART: SEPTEMBER - 2019 - 79 WRECKAGE A detached house was completely destroyed in the fireball created as the plane crash landed. research based on the wreckage, the radar flight path records, computer simulations and witness accounts. Mark Jarvis, senior engineering inspector at the Air Accidents Investigation Branch, concluded that a damaged bearing of the plane’s air- conditioning and pressurization sys- tem most likely caused the vibration, and that a rivet head missing from the left engine’s fuel-cut-off lever could have caused the pilot to inadvertently shut the engine down when retarding the thrust lever. Further, it was found that the engine emergency restart checklist was ambiguous with regard to the dif- ference of starting one engine at a time or both engines simultaneously. The report finally concludes that technical factors probably led to the shut-down of both engines but that it would have been possible to restart the them in time and to escape the emergency, had the restart procedure been applied correctly. The Crew Coordination Question Two pilots qualified to operate alone flying together – do they add up to performing as a team of two? In the absence of flight recorders, the investigators could not determine the nature or extent of any multi-crew co- operation issues nor the role of either pilot in trying to deal with the emer- gency. Hence, we do not know which pilot was actually handling the aircraft at the different stages of the flight. We do know though that the two pilots had not been trained to interact as a team on the CE500. The benefit of multi-crew operations can only be achieved if both pilots are trained to work together, by applying the same set of procedures and hav- ing a common understanding of the operator’s operating policies. European and US regulations as well as all airlines under their legisla- tion acknowledge this by clearly out- lining multi-crew requirements, train- ing standards for commercial opera- tions and well-defined task sharing between the Pilot-in Command and the First Officer. Pilots have to under- go Multi-Crew Co-operation (MCC) and Crew Resource Management (CRM) training and they have to do line flying under supervision in their role in order to be checked out as a fully qualified multi-crew flight crew member. In corporate and private aviation things are handled differently at times although some of the operated air- craft are no less advanced nor less complex than airliners.