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Accidents after a distraction

In the spirit of our new ILAFFT forum, I think here is an interesting accident report that clearly demonstrates something that I’ve always thought to be true.

I’ve always thought, from my readings of various accidents, that a lot of accidents arise following a minor distraction. The distraction upsets the follow, and as a result you can end up making a stupid mistake.

Here is the accident report itself. It isn’t very long, as there isn’t a lot to be said. But there is a big lesson for all of us.
Click here

In essence the pilot was ready to departure, and then had to shut down due to an accident on the runway. They waited three hours before the runway was reopened, and when it was reopened, they redid their checks. But their flow was now changed, and presumably they were anxious to get going, and I’m sure were thinking “Of course everything is fine. I checked it three hours ago and haven’t left the aircraft since.” But they missed the fact that they had unlatched the canopy for some air, and it wasn’t properly secured now for take off.

So the initial accident proved to be a distraction, and the pilot’s flow was altered, and they made a mistake. Thankfully this was a minor mistake.

But this mistake proved to be a second distraction, and the pilot needed to return to the field after take off. In the accident report, it says “He reported that control difficulties due to the canopy being open prevented him from achieving a normal flare”. Maybe that is true, but I can’t help but think that it might have been a situation that the pilot was very distracted by the open canopy rather than a control difficulty.

In any case, the subsequent landing the pilot appears to have landed short of the runway clipping some crops and well…has a less than perfect landing.
You can see the incident here. If you don’t want the background, you can skip to 1:50 for the action.


I think we can all learn a little from this in that, if something goes wrong, or something unusual happens, this is precisely the time that we should follow our procedures / check-list to the letter, as this is when we are most likely to be distracted. In such times it can be really tempting to ignore check lists and normal procedures and deal with the issue, but we should fight that temptation.

Apart from the two distractions I think there is one more interesting point in this.
The last sentence of the report says:

He considered that he had not taken enough time to ensure the pre-takeoff checks were properly carried out and that, given the break, the checks should have be started again from the beginning, despite any time pressure.

Note the last two words. The pilot felt under time pressure. It’s not clear what the source of the time pressure was, but I can well imagine that after the runway was closed for 3 hours, that they didn’t want to delay anyone else’s take off by taking longer than necessary for checks. But if you listen to the video, you’ll hear the pilot of the aircraft behind him in the queue (the one with the camera) state (as the eventful aircraft is on final) that they need to wait for the engine to reach 50 degrees. So they were never actually holding anyone up, and the time pressure may have been imaginary.

Maybe nothing spectacular in this report, but it’s nice to be able to see how a chain of events leads to the final accident, and to be able to see a video of the accident as well as the report.

dp

EIWT Weston

Yeah, it’s happened to me.

I was preflighting and was distracted by something (I don’t remember what, it’s over 10 years ago – maybe a phone call – but it’s not really important). At the point where I was interrupted I had opened the cowling and was checking the oil level.

I flew to an airfield 45 minutes away and landed, and when I got out was surprised to see what looked like the Exxon Valdez oilspill on the side and belly of the aircraft. It looked like I had a catastrophic oil leak. I opened the cowling… and found the dipstick sitting on top of the engine, where I had left it after being distracted while checking the oil level.

I think about 2 quarts had come out of the oil filler but it looked like gallons. It took hours to get it all off.

Andreas IOM

That happened to someone here in a piston twin too

Administrator
Shoreham EGKA, United Kingdom

dublinpilot wrote:

“He reported that control difficulties due to the canopy being open prevented him from achieving a normal flare”. Maybe that is true, but I can’t help but think that it might have been a situation that the pilot was very distracted by the open canopy rather than a control difficulty.

It’s really strange how the canopy was that wide open. Almost like something was wedging it in. I’d expect the added resistance to be minimal. On the DA40 / DA42, the POH mentions that (as expected) flying characteristics are unchanged.

alioth wrote:

I was preflighting and was distracted by something (I don’t remember what, it’s over 10 years ago – maybe a phone call – but it’s not really important). At the point where I was interrupted I had opened the cowling and was checking the oil level.

I flew to an airfield 45 minutes away and landed, and when I got out was surprised to see what looked like the Exxon Valdez oilspill on the side and belly of the aircraft. It looked like I had a catastrophic oil leak. I opened the cowling… and found the dipstick sitting on top of the engine, where I had left it after being distracted while checking the oil level.

I think about 2 quarts had come out of the oil filler but it looked like gallons. It took hours to get it all off.

This is one of my real fears with baggage compartments, cowlings, doors, dip sticks etc. I handle it by never closing anything without screwing it in, or latching it shut.

EGTK Oxford

I am aware of a couple of incidents related to canopies like this. As I understand it, depending the pressure distribution, the canopy might not be closed (i.e. it could be open a few inches). This means that there could be an opening at the front where air can blast in. A reliable source (with a Lancair Legacy) tells me that if the canopy isn’t securely latched and pops open late in the take-off run, the 100 mph+ wind will blow your headset off, disturb all of the paper in the cockpit, and provide extreme difficulty seeing at all.

My source tells me they managed to abort the take-off after being a couple feet in the air. Damage occurred, but no injuries and all was repairable. They thought that it would have been really bad if they were flying.

Sometime later I read a similar accident report, as I recall it was a Lancair 320 or Legacy departing Oshkosh, with the canopy open. I think the conclusion was loss of control whilst trying to close the canopy in the climb out, but given the first hand recount above, it might have been difficult just to fly the airplane.

Hard to say in relation to the video above, but they seem to be lucky they got it back down in one piece.

My Cherokee on the other hand could fly all day with the door open.

Sans aircraft at the moment :-(, United Kingdom

I had done my start-up checks, and was doing my pre-take off checks, touching things as I did so. No other traffic, and airfield surrounded by Class G. (Wick)
ATC in a friendly voice, asked if I could accept a FIS instead of ATC for training purposes.
I said " G-WF Affirm". I didn’t see what difference it would make.
An angry voice shouted “That needs a read back”. As I read back that I would accept a FIS, I turned off the fuel, which I had been touching. Fortunately I had a long runway, and closed the throttle immediately I noticed a change in engine note, while noting that the fuel pump was on, and mags on both. Fuel on was the third thing I looked at.
I had just flown my 2000th solo hour on the inbound flight.

Maoraigh
EGPE, United Kingdom

Similar happened to me. Departing from Kemble, there were quite a few aircraft arriving (UL meet) and also quite a few wanting to depart. Due to the inbound traffic faffing around (planes missing the taxiways, going the wrong way etc), I had already been significantly held up and was running close to being late for my arrival slot at Duxford., I was at the run up area and asked by the controller whether I was ready for an immediate departure otherwise he would send out the Canberra first, giving me another 5 minute delay.

I had nearly completed my before departure checklist and said ‘ready for immediate departure’, rolled onto the runway and missed the very last check on the list. Door closed (this was in a Warrior). Rotated and as I was climbing, the door popped open. My dad then made the mistake of trying to release the catch to close it again. The noise from that door opening was incredible. I could hardly hear anything, even though I had an active headset on. I flew the circuit, calling my intentions, only to arrive on Final and see the Canberra lined up on the runway. At that point, I finally received a transmission asking me to use the grass runway. Fortunately I’d used it before and hence it was no problem but it drilled into me the importance of checking each item on the list.

@Canuck: As long as it only pops open slightly, I agree. But here it was a good couple of inches open and the air noise was just deafening. What I didn’t know then is that there is a procedure to close the door – by reducing airspeed and opening the storm window on the pilot side ;-)

A TB10 pilot got killed due to the distraction of a luggage door coming open, at Shoreham I believe.

Administrator
Shoreham EGKA, United Kingdom

What I didn’t know then is that there is a procedure to close the door – by reducing airspeed and opening the storm window on the pilot side ;-)

That may be the case in your aircraft, but if someone told you that rather than reading it in the POH yourself, then I’d read the POH.

The proceedure in the PA28 that I fly is quite different, and involves closing off all air vents into the cabin. I’ve the door pop open a few times due to a dodgy catch that took a while to get repaired, and I can testity that it’s nearly impossible to close (even with two people) if you use the incorrect proceedure, but using the correct proceedure it’s an non event, even if solo.

EIWT Weston
12 Posts
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