BASI Report Dissected
Surely, the BASI report loses its integrity when it contradicts itself in such a significant way. But what is worse is that there was no further mention anywhere in the report of any scientific investigation or tests to understand the likely effect that an improperly feathered propeller would have on the performance and ability of the aircraft to continue flight in this configuration.
Incredibly, an entire page of the report section titled, Wreckage and impact information starting at 184.108.40.206 concentrated on the left propeller malfunctioning and the cause of it doing so. Examination of the propeller revealed 8 considerations listed down the page mentioning excessive torque being required to move one of the blades, a dislodged protective sleeve to prevent water ingress, corrosion and pitting as a result, a jammed cam assembly, and no maintenance certification to indicate having de-sludged the propeller as required every 500 hours of operation.
A specialist examination concluded that the propeller had not been able to operate to the full-feather position for some time. A video taken of the aircraft on the bottom of Botany Bay before recover operations commenced showed clearly that the propeller was not in the feathered position.
And that, my friends, is where the BASI report left it!
Addressing Some BASI Reported Items
|Page No||BASI Comment||My response|
|1||“The inability of the handling pilot (co‑-pilot) to obtain optimum asymmetric performance from the aircraft was the culminating factor in a combination of local and organisational factors that led to this accident. Contributing factors included the overweight condition of the aircraft, an engine overhaul or maintenance error, non‑-adherence to operating procedures and lack of skill of the handling pilot.”||This conflates issues over which I, as pilot in command, had no connection to what lay outside my duties. My obligation was to receive a signed and current Maintenance Document authorising flight that day (known as a Maintenance Release), a passenger manifest and a load sheet. My separate obligations (which I concluded without comment) were to review the weather for the intended flight. This had been done. I had in my immediate possession all relevant maps charts and Notams. The ‘EDC Co‑-pilot managed the flying and flew the aircraft correctly up to the time I took control. The aircraft was not mishandled during the emergency. The company Operations Manual procedures, both normal and emergency, were adhered to throughout the entire flight. The load sheet for this flight, compiled by me did not exceed the Maximum Take‑-Off Weight (MTOW) permitted for the aircraft. Without my knowledge an additional passenger and additional cargo were placed in the aircraft by the ‘EDC Co‑-pilot who did so immediately prior to the flight and did not inform me of the change. At the completion of the BASI report, two of the interim recommendations in relation to the ‘EDC Co‑-pilot training suggested: “… have attained a recognised proficiency level to conduct take‑-off and landings, including practice engine failure and handling prior to them flying aircraft on passenger carrying operations.”“… including at least one take‑-off, with a practice engine failure, at 90% of maximum take‑-off weight…” As stated above, the ‘EDC Co‑-pilot had successfully passed his First Class Multi Engine Instrument Rating Renewal three months prior to the ditching. This test had included a simulated engine failure on take‑-off. The load factor when testing an applicant was never a requirement prior to the ditching. The training the ‘EDC Co‑-pilot had received was to the required standard at that time. Ironically, deeper review into this matter would have revealed that despite the ‘EDC Co‑-Pilot’s manipulative skill, he in fact did not hold a pilot licence at all. The CAA had failed to notice that the basis of the ‘EDC Co‑-pilot’s licence was false and he had never held a valid licence at all.|
|2||“The co‑-pilot and the supernumerary pilot subsequently reported that almost full right aileron had been used to control the aircraft.” “When he first became aware of the engine malfunction, the pilot in command assessed that, although a landing back on the runway may have been possible, the aircraft was climbing safely on one engine.”||This statement is incorrect. The Supernumerary pilot did not have access to the controls as he was in the rear pilot seat. During the time the ‘EDC Co‑-pilot had operation of the controls no such event occurred. I did not use a control movement as extreme as this statement alleges as management of the aircraft did not require it. The CAA document, disagreed with BASI on this point, noting as follows:. “Control wheel movement for full aileron is 180 deg: thus 90 deg is half aileron deflection. The misunderstanding of important technical detail such as this within the time‑-frame of the investigation highlights the lack of knowledge, experience and operational recency of BASI investigators.” The critical moment for decision to land and abort a take‑-off safely is the velocity of the aircraft known as ‘V1’. Above that speed the aircraft should continue to climb out. The aircraft had long passed that speed. Operations Manual procedures were to commit to flight and deal with the matter whilst in flight. With the aircraft loaded with fuel, undercarriage not confirmed as retracted and large rocks in place at the end of the runway, this claimed option simply could not occur. I did not say that “a landing back on the runway may have been possible”. I did not say that the “aircraft was climbing safely on one engine”. These two statements were out of the question. As I could see runway ahead of me, the thought of attempting to land crossed my mind but the risks made me immediately turn to other options. In particular, at this moment, the right engine appeared to be operating properly and I expected the left‑-hand propeller to feather. By the time these issues arose there was no question at all.|
|5||“Co‑-Pilot”: “He had been granted a commercial pilot’s certificate in the USA on 16 January 1992. On 13 August 1992, he was issued with an Australian Civil Aviation Authority certificate of validation for the purpose of acting as flight crew of an Australian registered aircraft at ‘unrestricted pilot standard’ for day‑-VFR operations. This was valid until 13 November 1992. The co‑-pilot had advised the Civil Aviation Authority that he had completed DC‑-3 command endorsement training in the USA on 5 April 1992, and on the basis of this advice, his certificate of validation was annotated with a DC‑-3 type rating. He was issued with a special pilot licence in January 1993 and an Australian commercial pilot licence on 20 September 1993. The co‑-pilot’s most recent formal check was for the renewal of his command instrument rating on 9 January 1994.”||The ‘EDC Co‑-pilot produced his pilot licence to me and it appeared regular in form. There was no reason to go behind that documentation which was regular on its face.|
|6||“Weight and balance”||The officer in charge of loading was the ‘EDC Co‑-pilot who was also an owner of the aircraft operating company. No change was made by him. See comment concerning material placed into the aircraft by the ‘EDC Co‑-pilot. The previous evening I was informed by the company which organised the charter that one passenger had cancelled their flight on the aircraft, thereby providing me with an even greater margin below MTOW. The flight attendant in the cabin, as noted previously, permitted an additional passenger to board which was not brought to my attention.|
|7||“Passenger weight (as reported by the passengers) 1,634” [kgs] “Baggage (as weighed by passengers after the accident) 483” [kgs] “Fuel (456gal (imp) ,,, (estimated)) 1446kgs||For weight purposes one of two options could be taken. The first would have been to weigh each passenger (not practical and not procedural). The alternative, as per the Civil Aviation Advisory Publication 235, is to allocate a standard weight to each passenger on the basis that the standard weight will effectively average to allow an adequately close establishment of weight of passengers. This quite properly was selected as the alternative as it lies within the parameters of correct procedures. I used this publication to correctly ascertain my passenger weights as 1,413kgs. BASI believed their weights were 1,634kgs — some 221kgs in excess of the approved weight calculations. BASI staff were seen weighing the baggage wet, after recovery from the aircraft, on a set of bathroom scales. It was later said that these calculations would be “Factored” (an imprecise and undefined phrase). The absolute value of these numbers demonstrates the variability which is acceptable even in the adverse circumstances of this crash. 483kgs of baggage for mostly teenage students with their relatively light weight musical instruments and away for only two nights equated to an unrealistic 23kgs per passenger. Fuel — 1363kgs (430gal (imp)) consisting of full main tanks (168gal (imp) each) and 94gal (imp) in the left hand auxiliary tank. BASI admit that my fuel weight calculation was correct using the specific gravity method. BASI, by their own admission, added another 26gal (imp) inflating their calculated take off weight by 83kgs.|
|9||“The engine malfunction occurred when VH‑-EDC was still in the take off configuration, with the landing gear retracting, the wing flaps retracted, and full power on both engines.” “The supernumerary pilot … was aware that the aileron control was held at about 90° from the neutral position.” “Age and condition of airframe The asymmetric performance figures referred to in 1.6.3 are based on the results of test flights conducted by professional test pilots under controlled conditions, being pre‑-planned exercises specifically flown to determine single‑-engine performance. Under such conditions the test pilot is readily able to set up and maintain the aircraft in the required configuration for the duration of the test. The tests would have been flown using aircraft in excellent condition. The result achieved would have reflected the optimum performance for the aircraft with the objective being simply to demonstrate that the aircraft met the required level of performance. In service, the airframe condition can deteriorate and factors such as dents, chipped and flaked paint, misfitting doors, hatches and cowls and modifications incorporating additions to the external airframe will tend to reduce the aircraft performance. This particular aircraft had flown about 40,000 hours.”||The piloting procedure, prior to the engine failure, was for all power to be required of the engines and the control levers were positioned to deliver full power. As noted elsewhere, the pilot must rely on the position of the control levers and the indications of the instruments on the instrument panel all of which were at the maximum required power position. The statement on page 2 (in relation to 180°) is in contradiction of this statement. I reiterate my comments made regarding this. Though this paragraph is correct when taken out of context, the true context has now been demonstrated by the flight simulator data. This data takes into account all of the performance degradation factors. The simulator data reinforces the fact of the hidden deficiency in the right‑-hand engine which has now been demonstrated: also the deficiency of the BASI process of interfering with the engine (spark plugs etc) before testing. It is relevant to note the engine manufacturer’s caution which has not been taken up in this comment by the BASI. The manufacturer, Pratt and Whitney state: Pratt & Whitney Aircraft Manual of Engine Operation, page A10, sums it up by saying “it is difficult to see any tangible value in running the engine up to take‑-off rpm and manifold pressure as a routine pre‑-flight check. While it may give great satisfaction to the pilot to see these quantities registered on the instruments, a little analysis will show that this achievement is no guarantee that the expected power is being produced and delivered to the propeller.” I firmly believe that neither of ‘EDC’s engines had been tested by a recognised method to ascertain whether they were delivering full power prior to the accident and there is absolutely no way a pilot sitting in the cockpit can measure power output, he can only set the levers to provide the nominated instrument indications in MAP and RPM that are supposed to provide it.|
|11||“Flight controls. It was determined that the wing flaps were extended approximately 20‑-22°.”||In fact, this confirms that upon contacting the water the aircraft was configured for the ultimate glide (the best lift/drag ratio is achieved with flaps at 18°).|
|Page 14||“Right engine With the exception of the propeller governor, no pre‑-existing abnormalities were found.”||This statement is clearly in error and contradicted by the BASI’S own document dated 5th May 1995 states “25 spark plugs were recovered from the right engine were similarly cleaned gapped (spark electric gap) and tested. Of these 11 were considered to unserviceable, either failing to fire or from electrical breakdown when being tested.” Each engine has 28 spark plugs. The 1995 BASI document then further goes on to say: “Considering that this aircraft had been certified as completing a 100 hourly periodic inspection for maintenance release issue 4‑-6 hours prior to this accident the visual condition of the spark plugs suggests that little attention had been given to the inspection and setting of the spark plug gaps, or the worn condition of the electrodes.”|
|20||“The seats of the pilot in command and the co‑-pilot were each fitted with shoulder restraints incorporating an inertia reel. However, neither pilot was wearing a shoulder restraint. The pilots reported that the operation of the inertia reels interfered with their ability to carry out their duties.”||Whilst wearing a shoulder harness (even inertia reel) it is virtually impossible to reach down to the cockpit floor to manipulate the landing gear locking lever. Take‑-off is a time critical phase of flight giving no time to be adjusting your body with a shoulder harness in place.|
|23||“Figure 8 Use of emergency exits during evacuation from a ditched aircraft.”||The diagram is incorrect. It suggests that there is a forward door open which was not the case. It also incorrectly shows the over‑-wing exits open. The only exit provided was the rear doors and the cockpit overhead hatch where the ’EDC Co‑-pilot exited the aircraft.|
|26||“Performance charts”||The BASI report is incorrect concerning its statements regarding performance charts. The insinuations that these charts were not approved is incorrect. The aircraft operations manual, itself a document approved by the CAA authorised the charts that I was using.|
|27||“The crew had not received any formal CRM training, nor was such training required by the Civil Aviation Authority.”||At the time of this event, procedures which have now been formalised and documented by formal CRM training and procedures, were not in place. Notwithstanding this fact, the genesis of CRM lay in the corporate procedures of QANTAS, the RAAF and IPEC. These were the procedures which I followed. These procedures have subsequently become the formal steps of approved CRM. I had been trained and checked in CRM by the RAAF, TAA, QANTAS and IPEC. The RAAF Deputy Director of Flying Safety, who was present at my formal BASI interview, congratulated me on my safety procedures and attention to Crew Resource Management (CRM) saying it was the best example of CRM in operation that he had experienced.|
|28||“Aircraft operations manual Groupair was subsequently advised in a letter from Civil Aviation Authority Moorabbin that ‘The Groupair Operations Manual Part B and Part C have now been approved by the Civil Aviation Authority’. This was a clerical error, as CAA current practice was that the manual was not approved but assessed as acceptable.”||The Operations Manuals, on which I was required to rely as Captain, with ultimate responsibility for complying with them, were approved in writing by the CAA. If that were done in “error” and there were any operational difficulties, the responsibility would be to the account of the CAA.|
|29||“The pilot in command subsequently completed performance planning for the flight, aware that the Take Off performance chart he was using was not approved.”||This statement is untrue. The charts which I was required to follow were those with which I had been provided. The so called “clerical error” had no relevance to the correctness of me operating with charts which had been specifically approved. Three senior BASI officers at their Canberra office, subsequently agreed, that the charts I used were correct for me to have available.|
|30||“The pilot in command took control of the aircraft when it became apparent to him that, despite the right engine being selected to, and indicating, full power, the aircraft performance had deteriorated and the co‑-pilot was unable to fly the aircraft safely.”||There was no question, that I as pilot in command and Captain, with extensive experience should perform a ditching. I took over control in the appropriate manner when ditching became the only safe option to accomplish. Further, the BASI was aware that I had been trained in the RAAF during my time as an Orion Captain, conducting sea search and rescue, that ditchings were trained and re‑-trained by the crew.|
|36||“Consequently, he did not initially respond to the incorrect aircraft handling by the co‑-pilot. The deterioration in aircraft performance was such that when he did take control, there was little option other than to ditch the aircraft.”||The ‘EDC Co‑-pilot did not mishandle the aircraft at any time during this flight. He was under my direct observation and control. The decision to ditch the aircraft was a deliberate one taken by me due to lack of aircraft performance.|
|37||“Aircraft overloading” “The pilot in command did not ensure that the aircraft weight did not exceed the Maximum Take Off Weight. Consequently, he was not aware of the degree to which the aircraft was overloaded.”||As Captain and pilot in command I was entitled to rely on the load sheets. Those load sheets demonstrated a significant and acceptable margin below the aircraft’s maximum take‑-off weight. The covert actions of the ‘EDC Co‑-pilot in loading additional material and not informing me came to my attention after the conclusion of the flight. The flight attendant’s failure to inform me of the addition of the late‑-coming passenger was, for weight purposes irrelevant, particularly having regard to the fact that one expected female passenger had cancelled.|
|43||“The investigation team was unable to determine why SPA had not complied with EROPS requirements nor attempted to clarify the intent of the applicable CAO and AD.”||These statements are completely untrue, therefore defamatory and slanderous. ‘EDC was required to, and did comply, with Civil Aviation Order 20.7.1 which applies to aeroplanes with a MTOW in excess of 5700kg of a type first registered in Australia prior to 1 June 1963. There are no EROPS requirements in that order. A different CAO (20.7.1B) is not applicable to this aircraft as the DC‑-3 type was first registered in 1937. AD/General/69 Amendment 1 — likewise this Airworthiness Directive is not applicable either to aeroplanes first registered prior to 1st June 1963. This AD had not been issued to pilots and in fact one CAA staff member stated “I was not aware of AD/General/69 until after the accident”.|
|47||“The adoption by the pilot in command of the operations manual procedure which permitted the co‑-pilot to continue as the handling pilot following an engine failure during take‑-off, was not sound. The pilot in command was significantly more experienced than the co–pilot, and the right control position was not equipped with flight attitude instruments. The alternative procedure ensured the best use of available crew resources and was therefore more appropriate to the circumstances of the take‑-off on the accident flight.”||This assessment is not right — it is not even wrong. It is confused and jumbled. The ’EDC Co‑-pilot was competent in operating the aircraft in day visual flight conditions which were those existing up to the time of me taking control. At all relevant points of the flight the discharge of his flying task was both normal and conventional in the aviation industry. Since DC‑-3’s first came into service in 1937 in Australia, Co‑-pilots have been carrying out take‑-offs and landings from the right‑-hand seat. My decision to take control for the ditching occurred after I had concluded assessment of any other option and when it was evident that my experience and practice in water landings was immediately required. The first sentence should note the ambiguity of the BASI. On the one hand it attempts to claim that the documentation I was using was other than correct, whilst it then proceeds to demand compliance with those procedures.|
Technically the Dutch report focussed on hard demonstrated facts – again, streets ahead! For example:
“1.16.4 Propeller Drag
On request of the AIIB, Hamilton Standard produced the negative thrust (drag) figures for a propeller of the type used on the accident aircraft. The drag figures covered the blade pitch range between 4° and 80°, with a rotating propeller, and between 0° and 90° with the propeller stationary.
220.127.116.11 Reconstruction of Flight Parameters
Based on aerodynamic data and AOM (Aircraft Operating Manual)information, NLR (Netherlands Aerospace Laboratory) generated a (non-linear, 6 degrees of freedom) DC-3 computer simulation program. Into this program the drag figures, pertaining to locked propeller drag, as supplied by Hamilton Standard, were incorporated. The computer model was used to support the analyses and conclusions regarding performance and flight characteristics of the accident aircraft
3.1.8 With the calculated actual weight and a feathered propeller the PH-DDA could have maintained altitude and speed and a diversion to NAS De Kooy would have been possible.”
The key finding here is that the improperly feathered propeller removed that option. That of course assumes that the right engine was capable of delivering its rated power!
“2.4 Flight Crew Performance / Human Factors
During the return flight from Texel to Schiphol Airport, the pilots were confronted with a multiple mechanical failure ie. a combination of an engine failure and a propeller failure Due to the unpredictable variety of combinations, these emergencies cannot be and therefore are not foreseen in the training syllabi. The crew was therefore not prepared to deal with this type of emergency. Furthermore the ECL (Emergency Check List) did not provide any guidance. However, the emergency by itself was insufficient reason for the loss of control.
This part of the analysis will try to answer the question why control of the aircraft was lost and a landing on water, which was the only alternative given the circumstances, was not carried out.”
The Dutch report was an example in so many areas of how my BASI accident report should have been presented! The technical investigative analyses were deep and thorough and content tabulated with graphical representation of engine power versus propeller drag at varying blade angles was illuminating. Information provided by such authoritative sources as the propeller manufacturer (Hamilton Standard) and the Netherlands Aerospace Laboratory as well as demonstration flights made with a DC-3 of Air Atlantique at Coventry Airport in the UK, coupled with analysis by the AAIB in Farnborough, indicate how professionally the Netherlands Aviation Safety Board conducted themselves compared with our own CAA/BASI counterparts. No such technical analysis was offered by the BASI – it used unsubstantiated opinion offering nothing more than the “negligible drag increase” of the improperly feathered stationary propeller and attributed poor technique of the ‘EDC Co-pilot to be the culminating factor leading to the accident
It is pertinent here to draw attention to Appendix 4 (excerpts of the inquiry into CASA’s actions relating to reports of deficiencies in certain engines by Professor Dennis Pearce’s 36-page report) for associated documentation from independent sources which supports my conclusions on maintenance issues, particularly in regard to the engines. This is a report regarding California Airmotive, the company which had the task of maintaining the engines on the crash aircraft.
It is well worth taking a long close look at the extract below reporting the findings of a different incident to mine, to understand the consequences of incomplete or misleading investigative processes. I am well aware of them and conduct myself accordingly. Can the offenders in this other case say the same thing?