Engine Failure while Holding

[FN FAL]

You don't have much jet time do you?

'Sled

What are you saying, that a manufacturer of jets incurs no liability for not producing a POH or checklist for their aircraft?

 

[Lead Sled]

What are you saying, that a manufacturer of jets incurs no liability for not producing a POH or checklist for their aircraft?

That's not what I'm saying at all. They are produced because of certification requirements and the FARs require that they be used. The liability issue arises if they are not provided or used.

'Sled

 

[FN FAL]

That's not what I'm saying at all. They are produced because of certification requirements and the FARs require that they be used.

So you're saying the FAA bears the liability for a faulty manufacturer's checklist that they certified and required by the FARS? And that because the FAA certified and required the checklist, that the aircraft manufacturer is let out of the liability to produce an accurate publication?

The liability issue arises if they are not provided or used.
'Sled

REALLY? So if the manufacturer of the aircraft provides pilots with a faulty checklist, the liability issue only arises if they are not provided the checklist or if the pilots don't use the faulty checklist?

 

[MauleSkinner]

Since this report was submitted for this discussion, I'll mention one of the conclusions (made with the clarity of hindsight, naturally) regarding this accident that might have some relevance to this discussion...I was told that when the airplane depressurized, the pilot made an emergency descent down to 10,000 feet, at which time he started getting vectors to the airport. The configuration of the failed engine didn't allow the airplane to maintain altitude. Had he stopped his emergency descent at 15,000 (still a breathable altitude), he would have had enough altitude to get to the airport, and could possibly have landed safely. I believe I was told that the weather at the target airport was good enough that an approach would not have been required.

When we have an emergency, we can follow immediate-action procedures, and declare an emergency to enlist ATC's help. There are situations, such as an uncontrolled fire, where we need to get on the ground immediately. On the other hand, we need to make sure that when we declare the emergency and high-tail it out of our altitude or leave the holding pattern that we don't eliminate options further down the line.

Remember...impulsivity is considered one of the 5 hazardous attitudes in aviation. Immediate action may be required, but it needs to be a measured response that helps the situation rather than one that eliminates options.

I mean no disrespect to the pilot of the MU-2...he did a fantastic job with the conditions at hand, and almost made it. I don't know that I would have done any better, but hopefully I can use the information gleaned from hindsight to shape my actions should a situation arise.

Fly safe!

David

NTSB Identification: DCA93GA042 .
The docket is stored on NTSB microfiche number 50003.

14 CFR Public Use

Accident occurred Monday, April 19, 1993 in ZWINGLE, IA

Probable Cause Approval Date: 5/10/1994

Aircraft: MITSUBISHI MU-2B-60, registration: N86SD

Injuries: 8 Fatal.

WHILE CRUISING AT FL 240, A PROPELLER (PROP HUB ARM ON THE LEFT PROP FAILED, RELEASING THE PROP BLADE, WHICH STRUCK A 2ND BLADE, BREAKING OFF ITS TIP. THIS RESULTED IN A SEVERE ENGINE VIBRATION & SHUTDOWN OF THE LEFT ENGINE.

THE LEFT ENGINE WAS FORCED DOWNWARD & INBOARD ON ITS MOUNTS. THE CABIN DEPRESSURIZED, POSSIBLY FROM BLADE CONTACT.

THE FLIGHT CREW MADE AN EMERGENCY DESCENT & RECEIVED A VECTOR TO DIVERT FOR AN ILS APPROACH TO DUBUQUE. THE AIRPLANE WAS INCAPABLE OF MAINTAINING ALTITUDE & DESCENDED IN INSTRUMENT CONDITIONS.

SUBSEQUENTLY, IT COLLIDED WITH A SILO & CRASHED ABOUT 8 MILES SOUTH OF DUBUQUE. AN INVESTIGATION REVEALED THE LEFT PROP HUB FAILED FROM FATIGUE THAT INITIATED FROM MULTIPLE INITIATION SITES ON THE INSIDE DIAMETER SURFACE OF THE HOLE FOR THE PILOT TUBE.

THERE WAS EVIDENCE THAT THE FATIGUE PROPERTIES OF THE HUB WERE REDUCED BY A COMBINATION OF FACTORS, INCLUDING MACHINING MARKS OR SCRATCHES, MIXED MICRO- STRUCTURE, CORROSION, DECARBURIZATION, AND RESIDUAL STRESSES. (FOR FURTHER INFO, SEE BLUE COVER RPRT: NTSB/ARR-93/08.)

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

THE FATIGUE CRACKING AND FRACTURE OF THE PROPELLER HUB ARM. THE RESULTANT SEPARATION OF THE HUB ARM AND THE PROPELLER BLADE DAMAGED THE ENGINE, NACELLE, WING, AND FUSELAGE, THEREBY CAUSING SIGNIFICANT DEGRADATION TO AIRCRAFT PERFORMANCE AND CONTROL THAT MADE A SUCCESSFUL LANDING PROBLEMATIC.

THE CAUSE OF THE PROPELLER HUB ARM FRACTURE WAS A REDUCTION IN THE FATIGUE STRENGTH OF THE MATERIAL BECAUSE OF MANUFACTURING AND TIME-RELATED FACTORS(DECARBURIZATION, RESIDUAL STRESS, CORROSION, MIXED MICROSTRUCTURE, AND MACHINING/SCORING MARKS) THAT REDUCED THE FATIGUE RESISTANCE OF THE MATERIAL, PROBABLY COMBINED WITH EXPOSURE TO HIGHER-THAN NORMAL CYCLIC LOADS DURING OPERATION OF THE PROPELLER AT A CRITICAL VIBRATION FREQUENCY(REACTIONLESS MODE), WHICH WAS NOT APPROPRIATELY CONSIDERED DURING THE AIRPLANE/PROPELLER CERTIFICATION PROCESS.

 

[FN FAL]

[FONT=BNDEJI+TimesNewRoman]
[FONT=BNDEJI+TimesNewRoman]No such thing as faulty checklists? 4% of commercial accidents from 1990-2000 had faulty documentation as factors in the crashes...

[FONT=BNDEJI+TimesNewRoman]http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/03-11.pdf[/FONT]

[FONT=BNDEJI+TimesNewRoman]

Table 5. Degree of injury sustained from 60 commercial aviation accidents with organizational cause factors, 1990-2000. [/FONT]

[FONT=BNDEJI+TimesNewRoman]Assessing the assigned findings for the accident sequence of events led to a more comprehensive analysis of the organizational factors. Specifically, the 60 accidents were associated with 70 organizational factors as identified by the NTSB during the original investigation. Based on both the descriptors provided by the NTSB and a review of the narratives associated with each factors, we were able to cluster these organizational factors cluster around 10 broad categories:[/FONT]




[FONT=BNDEJI+TimesNewRoman]8. Faulty documentation (4%)[/FONT]

[FONT=BNDEJI+TimesNewRoman]Ex: Inaccurate checklists, signoffs, record keeping [/FONT]



​

[FONT=BNDEJI+TimesNewRoman]NYC94FA123 [/FONT]
[FONT=BNDEJI+TimesNewRoman]Accident occurred 7/13/1994 [/FONT]
[FONT=BNDEJI+TimesNewRoman]Atlantic City[/FONT][FONT=BNDEJI+TimesNewRoman], NJ[/FONT]
[FONT=BNDEJI+TimesNewRoman]EGQA [/FONT]
[FONT=BNDEJI+TimesNewRoman]Lear LR-35 [/FONT]
[FONT=BNDEJI+TimesNewRoman]Non-scheduled, Part 135[/FONT]


[FONT=BNDEJI+TimesNewRoman]The takeoff was aborted because the pilot could not maintain directional control. The plane did not stop on the remaining runway. Improper maintenance, [/FONT][FONT=BNDEMJ+TimesNewRoman,Bold]incorrect checklist provided to aircrew (“reversed thrusters armed” missing on the checklist), and lack of pilot experience were factors in this accident. [/FONT]


[FONT=BNDEJI+TimesNewRoman]MIA96FA059 [/FONT]
[FONT=BNDEJI+TimesNewRoman]Accident occurred 1/7/1996 [/FONT]
[FONT=BNDEJI+TimesNewRoman]Nashville[/FONT][FONT=BNDEJI+TimesNewRoman], TN[/FONT]
[FONT=BNDEJI+TimesNewRoman]Airtran Airlines, Inc – VJ6A [/FONT]
[FONT=BNDEJI+TimesNewRoman]Doug DC-9-32 [/FONT]
[FONT=BNDEJI+TimesNewRoman]Scheduled, Part 121[/FONT]


[FONT=BNDEJI+TimesNewRoman]The flight crew’s improper procedures and actions in response to an in-flight abnormality resulted in the inadvertent in-flight activation of the ground spoilers during the approach to landing and the airplane’s excessively hard impact in the runway approach light area. [/FONT][FONT=BNDEMJ+TimesNewRoman,Bold]The incomplete procedural guidance contained in airline quick reference handbook and checklist, [/FONT][FONT=BNDEJI+TimesNewRoman]crews’ inadequate knowledge and understanding of aircraft systems and airline’s failure to incorporate cold weather nosegear servicing procedures in it operations and maintenance manuals were major causes of the accident. [/FONT]



[FONT=BNDEJI+TimesNewRoman]NYC96FA174 [/FONT]
[FONT=BNDEJI+TimesNewRoman]Accident occurred 8/25/1996 [/FONT]
[FONT=BNDEJI+TimesNewRoman]Jamaica[/FONT][FONT=BNDEJI+TimesNewRoman], NY [/FONT]
[FONT=BNDEJI+TimesNewRoman]TWA [/FONT]
[FONT=BNDEJI+TimesNewRoman]LKHEED L-1011 [/FONT]
[FONT=BNDEJI+TimesNewRoman]Scheduled, Part 121[/FONT]


[FONT=BNDEJI+TimesNewRoman]The flight crew failed to complete the published checklist and to adequately crosscheck each other, resulting in their failure to detect that the leading edge slats had not extended. This caused the tail to contact the runway during the computer-driven, auto-land flare for landing. Inadequate inspection procedures for the slat drive system, and the [/FONT][FONT=BNDEMJ+TimesNewRoman,Bold]operator's inadequate checklist, which did not include having the Flight Engineer monitor the double needle slat gauge were causes of the accident.[/FONT]

[/FONT][/FONT]

 

[Tarzan]

I'll play along here. For the EMB, on a dual engine failure, QRH makes no mention of sustaining a best glide (260 kts for the restart ain't it either) until prepared to attempt the relight. Thats alot of altitude ecspecial up at cruise that your going scrub off for no reason when that added time may allow you to make a field instead of how the Pinnacle boys ended up. I've heard only one instructor make mention of this and I'd doubt the 9E guys thought about it either because chances are it wasn't presented to them as an option. I don't know about the Pinnacle checklists.

How about aileron runaway. Chance are by the time you get a hand up there to disable your hydraulics, your inverted. Hmmmm, flying without hydraulics is hard as hell just in level flight making small banks. How in the heck are you going to roll wings level without it when your inverted? Memort item just says Control the airplane (yeah right),aileron system 1 and 2 OFF. Bad memory item there huh.

Checklists are not the end all. I think it's an easy place for the NTSH and FAA hang the blame along with operator error as a cause of a crash. Half those egotists have never had to see what it looks like when your going down with nothing creating any thrust. I have and it hard to make your brain work, it's more a reaction than a thought out plan of action.

 

[MauleSkinner]

Half those egotists have never had to see what it looks like when your going down with nothing creating any thrust. I have and it hard to make your brain work, it's more a reaction than a thought out plan of action.

A veteran Naval aviator had to eject for the first time on takeoff because the ship's catapault malfunctioned, and he didn't have enough thrust and speed to fly when he went off the front of the ship. Certainly not much time for thought.

Someone asked him "When did you decide to eject?" His response..."About 20 years ago."

This is why we train. This is why we have what appears to be a morbid interest in accident reports. This is why we ask questions on flightinfo.com...so that when the situation arises, the decision is already made; and our reactions, while immediate and reflexive, are carefully thought out in advance.

Fly safe!

David

 

[avbug]

I'll say it for you again. Checklists and POH's sole purpose is limit liabilty of the manufacturer. Your not following them, places the liability on you...the negligent pilot.

Thanks for clarifying that. It's what I thought you said.

What an utterly stupid thing to say.

 

[FN FAL]

Thanks for clarifying that. It's what I thought you said.

What an utterly stupid thing to say.

REEEEAAAAALY?

So what you're saying, is that the FAR required information in the POH is intended to EXPAND product liability on behalf of the manufacturer?

Ok, I get it now.

 

[ackattacker]

Once again a seemingly innocent thread goes into a tailspin. Maybe there should be a two-page limit on all threads.

Why would you continue to hold? Out of courtesy to the other people who do not have an emergency? Or just to give you something to do until the second engine went fubar?

.........

How long are you going to fly around with this "simple" engine failure, devoting all this time and effort trying to get the engine relit? What if you get it re-lit and the insides come unglued, placing you in a position where the prop can't be feathered, the engine comes out of the engine mounts or exhaust gasses cut your wingspar?

Why this antagonism? Nobody was advocating holding for any length of time. It's just that if you are in the middle of a procedure you need to be prepared to continue it and not just give up on navigation. You continue the procedure so that a) you maintain awareness of your position b) you don't have a midair c) you don't fly into the terrain

Once the immediate stuff is taken care of, by all means declare an emergency and get priority vectors to an landing as soon as practical.

Use the checklist unless you well and truly don't have time. It very well might save your life, particularly in a more complex airplane. Many emergencies, particularly system failures, can be tricky and the proper response not always obvious or easily remembered. Some dangerous advice is being dispensed on this board.

Checklists and POH's sole purpose is limit liabilty of the manufacturer. Your not following them, places the liability on you...the negligent pilot.

This statement seems open many interpretations, but at first glance is clearly wrong. There is no "sole purpose" of a checklist and POH. The most obvious purpose is to provide guidance on how to operate the aircraft safely in both normal and emegency situations, and therefore hopefully keep you from killing yourself and your passengers. Are there liability issues associated with checklist's and POH's? Sure. Can checklists and POH's be faulty? Sure. Do you think that, in the heat of an emergency, you are smarter than the guys who wrote the checklist? Foolish.

Whether it was your intent or not, you give the impression that you are advocating two thing:

1) in the event of an emergency, immediately disregard IFR procedures and put the aircraft on the ground immediately by any means possible.

2) Don't bother with the checklist, since it was only put there by the lawyers and is probably faulty anyway.

If this is not what you're saying, by all means clarify.

 

[Stifler's Mom]

Hey guys,

Let's say you have been cleared to enter a hold, and just as you enter it (i.e. as you cross the beacon/VOR/etc), you experience an engine failure in a twin.

Is it best to continue in the turn and try to manage the a/c, or, is it better to level out and go through the procedures? What about if the engine fails prior to crossing the fix while you are already in the hold?

My only concern about levelling off would be that you could risk getting outside of your protected airspace; however, trying to secure an engine failure while you are turning would not be very easy either.

What's the best option?

Thanks in advance!

You'll have to enter the hold and stay there until your EFC Time.

 

[avbug]

REEEEAAAAALY?

So what you're saying, is that the FAR required information in the POH is intended to EXPAND product liability on behalf of the manufacturer?

Ok, I get it now.

You do not get it, and I said nothing of product liability. It was you that introduced that topic, entirely unrelated to the thread, and irrelevant to the issue.

Checklists are NOT liability issues...they are proper and appropriate and important items in the cockpit. Forget liability...they are there to serve as a tool to aid in the safe operation of the aircraft.

Only a bloody idiot would suggest that a checklist has no purpose except the mitigation of liability. But, perhaps you're right. The military, every airline, every corporation, every manufacturer, every flight department, each government agency, every flight school...they all disagree with you...but apparently you know best.

You are an amazing fellow.

 

[mar]

Actually EFC time is only for lost comm.

You'll have to enter the hold and stay there until your EFC Time.

The Happy Middle Ground re: Checklists.

Checklists do have a purpose in the cockpit and we're all familiar with that. But I'd submit that they are in fact *edited* with specific word choice to limit the manufacturer's liability. But that's not their *sole* purpose.

These are litigious (and touchy) times.

 

[FN FAL]

I wasn't antagonizing nothing. I was just asking how long do you plan on sitting there dinking around with a checklist in your hand before you let the other engine run out of gas too? Engine outages are predominantly pilot caused...maybe reading how to fly the plane in flight while in IFR is the best place to get some extra dual. After all, the angel of death won't take six months to a year to figure out the causal factors as to why you're dead...you're just dead.

Whether it was your intent or not, you give the impression that you are advocating two thing:

1) in the event of an emergency, immediately disregard IFR procedures and put the aircraft on the ground immediately by any means possible.[VMC rollover at your leisure, just don't take me out of the stack when you do]

2) Don't bother with the checklist, since it was only put there by the lawyers and is probably faulty anyway. [You're stretching my words...and if you don't think that manufacturers write their manuals from cover to cover with product liability in mind, then you are simple. Reference the PDF file further on erronious company checklist that Value Jet used...the pilots were still cited for not knowing the factory Boeing manual and their lack of systems knowledge.]

If this is not what you're saying, by all means clarify.

 

[avbug]

I hear that a lot...engine failures caused by the pilot. It happens. But in every single case of engine failure I've experienced over the years, and there have been a LOT, I have never experienced one that was the result of pilot error or pilot input (save for intentional training or precautionary shutdowns).

I've never worked anywhere that used a manufacturer checklist. We always use a company developed and approved checklist. Yes, sometimes little things could be added, and often as not I'll pick up a checklist and find someone has pencilled something in there. Perhaps they forgot a bleed switch here, or forgot something there, and made a note in the checklist.

The checklist is not the be-all and end-all of getting things done. But it's there for a reason, and that reason is not to throw the weight of the world on your shoulders and alleviate the manufacturer of liability. That liability won't go away, and the manufacturer makes a much juicier target for litigation than you. Always will. Conversely, failure to adhere to the checklist can not only hurt or kill you, but can place you in a lot of legal hot water, too. That's not the manufacturer doing, that's your doing, and something over which you have complete control.