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From: "George Lendich" <lendich@aanet.com.au>
To: "Rotary motors in aircraft" <flyrotary@lancaironline.net>
References: <list-3734503@logan.com>
Subject: Re: [FlyRotary] Re: AeroElectric-List: Complex aircraft NTSB report
Date: Mon, 29 Jun 2009 17:15:05 +1000
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 Phil,
What is a Vision look-a-like.
George (down under)

> Maybe a summary could be that sloppiness, and mistakes are more fatal in 
> flying than in other, less demanding pastimes.  Some are lucky when the 
> mistake bites them ....... most are not.  Of course, the type of mistakes 
> vary with the pastime (for instance, cheating on your wife is more fatal 
> to politicians than to pilots :))
>
> The only, real bit of information I am interested in is if this accident 
> was caused by some design problem that I need to correct in my own 
> project.
> The rest is superfluous, accept to say that the fewer mistakes I make, the 
> better chance I have of not becoming a statistic like this guy.  At least 
> the tragedy of including his loved ones (those who would naively trust 
> this person) in this accident was avoided.
>
> Know your limits, and have a plan.
> phil stitzer,  Vision look-a-like w/rotary
>
> Dave wrote:
>>
>>
>> Al..
>>
>> This is probably the first time I've had to say:
>>
>> I disagree with you.
>>
>> All of the minutiae you are saying is superflous is actually germane in 
>> my opinion.
>>
>> While the EFIS wasn't calibrated, and in theory, wasn't required to even 
>> be there, it was most likely (i.e. educated guess) situated in the 
>> primary flight display's position of front and center. By not being set 
>> up properly it was giving bad data (even the pitot static was 
>> uncalibrated).. so airspeed was unreliable. Altitude was unreliable. 
>> Unessential in theory to Day VFR flight but lets be honest here, the 
>> device was giving bad info, alarming constantly and was a distraction.
>>
>> The manually controllable propeller also has bearing here. EVERY SINGLE 
>> TIME he made a throttle adjustment he had to make a prop adjustment, and 
>> he had yet to sort out if he was using prop or engine RPM. This is a big 
>> addition to the workload compared to a fixed pitch prop.
>>
>> This guy was using a handheld GPS, plugging his headset into the panel to 
>> make radio calls, and unplugging it afterwards, because the panel was 
>> tied into the EFIS, which was having its own party sending alarm after 
>> alarm, from not being set up properly.
>>
>> The above 3 items result in a tremendous distraction and workload 
>> increase. He was flying something faster, more powerful than anything 
>> he'd been in before. At 200 hrs, I was already past complex, high power 
>> and actual-IFR training. His logbook is unavailable but its inferred his 
>> experience is in low powered Cherokee airframes. It doesn't say if he did 
>> his checkride at 40 hrs or 100. The difference between those two makes a 
>> difference. At 70 hrs I started flying Grumman Tigers. Slick plane and I 
>> had to plan ahead much further than I ever had before in 152's and 172's. 
>> I went around more times in that airframe until I managed to get my speed 
>> control on target. And this was fixed gear, fixed prop, and a working 
>> instrument panel. Getting into a Mooney 20-E a couple hours later put me 
>> right behind all over again, even though I was by now used to gear and 
>> prop. And I originally was a 45 hr private pilot who had to transit Class 
>> B airspace to get to my checkride, and who had self studied for every 
>> written I had ever taken (and used commercial and instrument texts while 
>> prepping for Private)
>>
>> Back to the report: The rudder trim was attached with duct tape. At that 
>> particular moment it was attached. You are right. Duct tape is not a safe 
>> method of attaching mission critical hardware. Combine this with the 
>> stripped/damaged pushrod and what you see here is a ticking timebomb 
>> waiting to bite you. Its germane. It tells you that there was at least 
>> ONE ticking time bomb that they DID find. I have doubts it was the only 
>> one.
>>
>> The fact that clecoes were used in flight shows an approach to flight 
>> safety that is unsatisfactory. Did they fail? No. Could they have? Very 
>> likely.
>>
>> We dont know if unterminated wires were a factor or not. They could have 
>> caused a short. There wasn't much mention of circuit breakers. The cable 
>> not being in its terminal IS pertinent, as is the manner of (not) 
>> crimping it, given that his engine is dependent on electrical power for 
>> continued operation. This one issue above all others is VERY germane to 
>> the the event.
>>
>> Its perhaps more appropriate to look at this event in the context not of 
>> an accident CHAIN but an accident WEB. Think outside the box. Every 
>> little nitpick here comes together in a synergistic manner to result in a 
>> plane that was most likely never airworthy, and an accident waiting to 
>> happen.
>>
>> The factual report is showing time after time after time of suboptimal 
>> decisionmaking. That is VERY germane to the situation as it is this 
>> habitual poor decisionmaking that is the most likely cause of the 
>> accident. The actual component or issue that caused the actual crash, the 
>> actual departure from controlled flight, may never be found or known, but 
>> the factual report as I read it will point towards "the nut behind the 
>> wheel/stick" as most proximate cause to the event.
>>
>> And.. again.. this is a factual report.. the facts of the situation, the 
>> airframe and the pilot. The "probable cause" statement comes later. The 
>> investigator was obviously concerned with a thorough investigation of all 
>> RELATED and GERMANE factors that could possibly bear on the accident. And 
>> I must readily admit, this factual report was much more detailed than 
>> what I have become accustomed to reading with regards to experimental 
>> amateur built aircraft accidents over the years.
>>
>> Dave
>>
>> Al Gietzen wrote:
>>> Thank you Ernest for that detailed review.  I had somewhat the same
>>> impression. I kept reading, and reading, expecting to find at some point
>>> what caused the accident - but never did.  Only thing that seemed clear 
>>> was
>>> that the pilot was not a thorough and rigorous person, which was likely 
>>> a
>>> contributing factor.
>>>
>>> Al G
>>>
>>>
>>>>   I've had several private links to this posting.
>>>>   Very sad. It's an unfortunate fact of the human
>>>>   condition that rational thought processes and
>>>>   understanding of simple-ideas can be so terribly
>>>>   diminished by hazardous behaviors.
>>>>
>>>>
>>> Let's not let simple ideas get lost in our sympathy for the pilot in 
>>> this accident.  Most of this report is superfluous fluff with little 
>>> bearing on what could have caused the accident.  In fact, there is no 
>>> statement of what caused the accident that could be blamed on the lack 
>>> of a rational thought processes on the part of the builder.
>>>
>>> Most of the report was dedicated to pointing out how the high-end EFIS 
>>> was not calibrated.  At no point was the lack of calibration cited as a 
>>> contributing factor to the accident.  The man was flying day VFR.  The 
>>> instrument was superfluous for the mission.  The fact that the pilot was 
>>> not familiar with the instrument's operation was superfluous to the 
>>> report.  The fact that the instrument was in the plane at all was 
>>> superfluous to the report.  How could anything displayed on an 
>>> uncalibrated EFIS translate into a plane taking a 35 to 60 degree 
>>> nosedive during a day VFR flight?
>>>
>>> Most of the remainder of the report was equally superfluous.  The first 
>>> flight occurred on July 12.  The accident occurred on November 2.  The 
>>> fact that clecoes held the cowling on for the first flight was 
>>> superfluous to the accident report.  It might have been germane if an 
>>> accident had occurred with the clecoes still in use, but that was not 
>>> the case.
>>> The fact that the propeller was under manual control vs some sort of 
>>> electronics is superfluous.  Are there not many examples of airplanes 
>>> flying just fine with manual control?  And I hear that there are a few 
>>> flying with no pitch control at all.  There is some information that the 
>>> pilot was having issues with coordinating the engine power with the 
>>> propeller pitch controls.  But that does not translate to taking a 35 to 
>>> 60 degree nose dive into terra firma.  I can't even translate it to a 
>>> situation where the pilot would not be able to maintain altitude.  It 
>>> might translate to an inability to maintain smooth level flight, but 
>>> there is a wide gulf between smooth level flight and a dirt bath.
>>>
>>> The report pointed out that the rudder trim was attached with duct tape. 
>>> The key word is "attached".  How did a *rudder* trim that was *attached* 
>>> contribute to a 60 degree nosedive?  How does an *attached* rudder trim 
>>> even make it difficult to maintain altitude?  An aileron trim tab rod 
>>> had been broken and poorly repaired.  Was the weak attachment cause of 
>>> an accident, or more superfluous data?
>>>
>>> The report makes hay of the pilots lack of high performance training. 
>>> He was flying the plane for nearly 4 months before the accident.  I 
>>> would imagine that high performance training would cover issues like 
>>> severe P factors and overspeeding the airplane.  Is "maintaining 
>>> altitude" taught exclusively in high performance trainging now?  If not, 
>>> why is the lack of such training an issue?  The report details the 
>>> pilots rush to get to Oshkosh, and the pilots willingness to falsify 
>>> records in order to meet legal requirements.  How did any of that 
>>> contribute to an accident that occurred months later?
>>>
>>> There were some wires not connected.  So?  Did any of them contribute to 
>>> the inability to maintain altitude?  I have several wires in my project 
>>> that are slated for future upgrades.  It's much easier to run them now 
>>> than when everything is closed up.  They are not connected to anything. 
>>> If something really bad happens to me, those wires will have nothing to 
>>> do with it, but will "unconnected cables" be cited in the report anyway?
>>>
>>> I suggest reading the report again...but cross out all the superfluous 
>>> lines that obviously have nothing at all to do with the accident.  Cross 
>>> out the parts that point out "He didn't follow the rules.  He was a 
>>> BAAAAD man."  It'll be a much shorter report.  The pilot of N289DT may 
>>> very well be a prime candidate for a Darwin Award, but we can't know 
>>> that from reading this report.  All I can tell is that the investigator 
>>> was much more concerned with pointing out how the pilot was not 
>>> following procedure than about what occurred.
>>>
>>>
>>
>>
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>
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