Hiya guys, I’ve told a few of you about the fatality at East Fortune a few
weeks ago where the guy started his engine on full power, (he was a licensed
pilot) he had the base bar secured to the front strut.
Gordon at East Fortune has put this email out to all his club members, I think
it’s very good and there’s a lot of points in there that we should all
consider.
In light of Ken's recent accident, this is a timely reminder about procedures,
which you've probably been expecting.
The AAIB are currently investigating the incident and their report could take 6
months to a year to be completed. In the meantime, we cannot make any
assumptions or draw any conclusions about what happened. However, we have a
fairly good idea about the chain of events from security camera footage, and as
such, I’d like to give you a general idea of what happened, as people are
worried if the cause is unknown.
The accident itself has been mis-reported in the press as they were given very
little information by the police. It was not a landing accident. It was a
mis-handled start up on full power, which stayed on full power. The aircraft
careered off, hitting the runway sign, and unintentionally getting airborne,
possibly with the bar still strapped to the front strut. Controlled flight
would not be possible like this and the aircraft came down in the field behind
the hangars. It was not a flying handling error. It was an unfortunate chain of
events which resulted in a short piece of uncontrolled flight. Based on this,
here is our advice:
STAMPS check & human performance
We're all familiar with the engine start acronym, STAMPS. Occasionally however,
checklists are vulnerable to the way human skills work. The repeatable nature
of checklist tasks means that the brain can turn checklist tasks into an
unconscious skills task in the same way as many other tasks. The reason the
brain does this is in order to save attention, which is the opposite of the
intention. This can lead to pilots using checklists in the same way that skills
are performed; i.e. without paying attention to the items being checked. How
often have we seen ‘Harness and helmet straps secure’ and the seat belts are
still hanging out of the sides? Or the hand throttle opened up fully, thinking
it’s the choke you’ve just opened.
Speak checks out loud
One good rule of thumb is that if any doubt surfaces, pilots should recheck. A
good way to make sure you’re covering everything is to talk the checks out
loud. If you’re saying them, even to yourself, the act of verbalising them
makes them less hard to miss. I always talk through my checks, even to trial
flights.
Fingers on mags at start-up
The second, and probably most important point, is ‘M’ for Mags. When you switch
the mag switches on for start-up, keep your fingers on them, gloves off. As I
said in a previous email after a runaway trike went through the electric fence
and tipped over, if the revs pick up when you start,
1. Lift your foot off the foot throttle
2. Quickly check and snap the hand throttle closed.
3. If the revs stay high, switch the mags off immediately.
Visualise and practice
We had an interesting chat - a lot of chats actually – with the AAIB
investigators. They were saying how easy it is to go through the motions of
covering switches like this, but not be mentally rehearsed and ready to
actually switch them off if needed. This is even more likely when you haven’t
had a starting problem for a long time.
You need to have a clear mental picture of doing this. When revs run away on
full power, it is very sudden and the acceleration is extreme. It is very easy
to become a startled rabbit in the headlights and fail to switch off. It needs
to be a reflex action.
The best advice we can give is to sit quietly in the trike and try to visualise
a revs runaway like this, and practice the switch off. As instructors, we are
now going to actually practice this with students out on the runway. Start up,
instructor pulls the revs up to full, and the student must switch off. If he or
she doesn’t manage it, we just take off. You could practice this yourselves too
if the circuit is clear. Just be aware that if you don’t switch off
immediately, forget it and fly the plane. You don’t want to manage the switch
off just as the plane rotates!
Rehearse out loud ‘what would I do if…?’
Finally, this last bit of advice may be worth adopting. One of our club members
who now flies commercially and flies with a lot of experienced pilots and
instructors, told me that even the most experienced pilots will sit before an
action, either start up or take off, and talk through – not just think through
– their actions for every possible scenario such as stuck throttle, brake
failure, engine failure after take off – where will I go etc. It is the action
of speaking the words out loud which mentally prepares you if something goes
wrong. I’ve now heard of quite a few pilots who do this. It is a good way to
have your brain in gear and avoid the tunnel vision which can happen when
things do go wrong.
The micro-switch
All trikes built since around the appearance of the GT450s have a micro switch
fitted to the hand throttle which prevents the starter from being operated
unless the hand throttle is fully closed. A lot of people aren’t aware of this.
We are often told ‘my battery is totally dead, the engine won’t turn over’. Our
response is ‘did you check the hand throttle was totally closed?’ The throttle
has to be right back on the stop to be able to start. It’s a safety feature
fitted to all trikes after a runaway trike (in Yorkshire) on full power hand
throttle, went through a fence, narrowly missing some children. It hit a
portacabin, seriously injuring the pilot - hence our rule that you must always
have your plane pointing away from buildings for start up. Older trikes such as
Alphas, Blades, XLs, Quantums and early Quiks do not have this micro switch, so
it relies on you making sure the throttle is fully closed. If your trike
doesn’t have one, it might be worth retro-fitting a micro switch as an added
safety feature. Ken’s trike did not have this.
Carb throttle butterflies – DI checks
It is worth remembering that even if your plane has a micro switch, and the
hand throttle is closed, if one or both of the carb throttle butterflies are
still open – either a jammed cable or broken return spring, the engine will
start on high revs and career off. The only option then is to switch off. To
avoid this, as you’ve been shown as part of your training, during your DI
checks and before every flight, just operate the hand and foot throttles and
then check that the carb butterflies have fully closed. Speak to me or Graeme
if you’ve forgotten and are not sure what to look for – don’t worry, we all
forget stuff over time!
There are other issues which need to be discussed, but I’m going to leave them
till another time. I know that if any email is too long, you’ll just glaze over
and miss a lot of it.
Now go and fly!
Our type of flying is still one of the most inherently safe forms of aviation
and you shouldn’t let this dent your confidence. It’s certainly not easy to be
there with this incident at the front of our minds, but there is nothing here
that should make you think ‘this could have happened to me’. Just take your
time, adopt the above, and try and get up and enjoy some flying like Ken would
have wanted us all to do.
See you down there
Gordon
Sent from my iPhone cos I'm out n about
