IAC 265 report?

Klunk001

Here's the prelim report with initial findings made by the AAIU. The question is, If it was found that a mechanical fault was the cause of the accident would the report Not have been released by now ?

http://www.aaiu.ie/upload/general/12004-2009021_PRELIMINARY_AIR_CORPS_265-0.PDF

BantryRebel

Klunk001 wrote: »

Here's the prelim report with initial findings made by the AAIU. The question is, If it was found that a mechanical fault was the cause of the accident would the report Not have been released by now ?

http://www.aaiu.ie/upload/general/12004-2009021_PRELIMINARY_AIR_CORPS_265-0.PDF

There doesn't seem to be anything in that to confirm what xflyer is saying, is there another prelim?

texas12

The finding of the PC 9 report when released could have potential to mirror those of the other reports into Air Corp crashs in relation to systemic failures etc etc . In my opinion this delay is more than likely an exercise by certain parties to reduced or re write finding that would have reflected very badly on those involved.

pclancy

Just a reminder please folks that families, collegues and friends of the crew frequent this forum so keep that in mind when you post. Thank you for the respect shown so far.

Stovepipe

Hi all,
A few corrections required: one Marchetti was lost when the aircraft was spun during aeros, despite having fuel in the tip tanks, when there was a ban on doing so (Air Corps conclusion); another was lost when the pilot carried out a loop at low level and struck a tree, which took the tail off; another was lost when it overturned on landing on the runway; the one at Corkagh park was being flown by an experienced pilot being rerated, not a cadet, the fuel selector being blamed (Air Corps conclusion).
there were many, many accidents and incidents that did not make the papers now were they published in public reports.

regards
Stovepipe

xflyer

BantryRebel wrote: »

Just wondering how you know this, is there an interim report that sates that and is it available online?

Straight from the preliminary report:

The accident site, which is locally known as Maum Dearg, is located in Crumlin East on the northern slopes of Crumlin Valley at an altitude of approximately 800 ft. It is less than one nautical mile north of the intended navigational track. The valley is enclosed on three sides by high ground (circa 1,500 ft), has an east/west orientation and is open to the east. At the time of impact, the aircraft was travelling in a northwesterly direction. It was destroyed on impact on the crest of the second and lowest of a series of three ridges. The debris trail was distributed along a 300 foot down slope and was characteristic of a high-speed impact.

I've bolded the pertinent line. One nautical mile at the PC9's cruising speed is a mere few seconds. Check out a chart or Google Earth for the area and you can see that the accident location valley is aligned similarly to the intended track to Maam. In poor visibility the dead end valley might look very similar causing an early right turn with fatal results. It would be very surprising if they deliberately flew up that valley.

So it isn't difficult to conclude that it was CFIT, in that they were not were they thought they were and hit unexpected high ground.

Now all that is easy to surmise but there will be other factors which undoubtedly be dealt with in the report. There may indeed be systemic issue. Maybe the flight should not have been attempting the prevailing conditions or maybe it should be have been aborted earlier. All accidents are the result of a chain of events. It's not as simple as saying the cadet made an early right turn and hit a hill.

We'll see when the report is finally released.

NewSigGuy

Stovepipe wrote: »

Hi all,
A few corrections required: one Marchetti was lost when the aircraft was spun during aeros, despite having fuel in the tip tanks, when there was a ban on doing so (Air Corps conclusion); another was lost when the pilot carried out a loop at low level and struck a tree, which took the tail off; another was lost when it overturned on landing on the runway; the one at Corkagh park was being flown by an experienced pilot being rerated, not a cadet, the fuel selector being blamed (Air Corps conclusion).
there were many, many accidents and incidents that did not make the papers now were they published in public reports.

regards
Stovepipe

The one in Corkagh Park was a Cadet and an experienced instructor, I never heard the fuel selector was blamed, I heard the rumor alright but I dont think any finding was ever published and I am not sure either of the pilots were ever told.

NewSigGuy

xflyer wrote: »

I have to fault your definition of CFIT, the first word is 'controlled'. Essentially the pilot is unaware there's a problem until it's too late. The classic scenario is exactly what happened to 265. Most often it means an aircraft hitting unexpected high ground. Another variation is to hit the ground during a low visibility approach. The crash that killed the Polish President was exactly that.

The others mentioned were loss of control. The pilots concerned lost control and crashed. That's not CFIT. They would have been very aware of what was happening to them for the final few seconds.

Maybe I am wrong but my understanding of CFIT is.."an accident in which an airworthy aircraft, under pilot control, is unintentionally flown into the ground, a mountain, water, or an obstacle"

I have never heard any mention of loss of control in any of the fatal crashes, certainly pilots entered maneuvers from too low an altitude or over estimated there abilities etc, however in any case a perfectly serviceable aircraft was flown into the ground.

Your own definition proves that "They would have been very aware of what was happening to them for the final few seconds" thats still CFIT and "Essentially the pilot is unaware there's a problem until it's too late" again its CFIT, in the classic CFIT situation where an Aircraft in cloud flies into a mountain the flight crew may never have known what was about to happen, and very often no avoidance action is taken. The definition of control is also open to interpretation, in the above situation where the crew were never aware of the impending impact with the mountain, Were they actually in control?

Likewise on many occasions where a maneuver is started at the wrong altitude, such as a loop that ends up in the ground, the Pilot may be making a final desperate attempt to pull the aircraft out of the situation, all these are still classed as CFIT as far as I understand.

The point I am trying to make is about the number of serviceable aircraft that have crashed, or come very close, and that seams to point to a more endemic organizational issue

Stovepipe

@newsigguy,
I knew both pilots and I assure you that neither was a cadet. The "student" was being rerated on type. They knew perfectly well that the finding of the inquiry board was that the fuel selector was worn and the selector valve did not fit exactly into the detent. I know this because I was one of the people involved in the examination of the engine and fuel system afterwards and we told them directly, as well as them being informed by the Board that the fuel selector was suspect.

regards
Stovepipe

xflyer

NewSigGuy wrote: »

The one in Corkagh Park was a Cadet and an experienced instructor, I never heard the fuel selector was blamed, I heard the rumor alright but I dont think any finding was ever published and I am not sure either of the pilots were ever told.

That's what I heard, I stand to be corrected but I was told the SOP for a simulated EFATO in the Marchetti was to change tanks. It was suggested that the fuel selector wasn't fully selected to the right or left but some intermediate position where sufficient fuel got through to keep the engine running at idle but once full power was required it all went terribly quiet. I can't prove anything but this info came via an Air Corps officer very close to the situation.

As for CFIT, this isn't just my interpretation, it's the industry definition, low level aerobatics, unauthorised aerobatics and plain showing off does not fall into CFIT. The pilots in those situations, knows exactly where they are, where the ground is but apparently not their own limitations or those of the aircraft.

But I do take your point about the number of accidents. Several can be attributable to pilot error and if you look at a number of the most recent incidents and accidents a common factor is young pilots or cadets doing something they shouldn't. Not really unique to the Air Corps or even aviation considering the carnage amongst young men in cars.

NewSigGuy

Hi Stove,

I assume the Corkagh Park accident we are talking about was in 1993, both guys are friends of mine and it was a Cadet and an Instructor it would have been the 14th regular air corps cadet class I believe.

I was told by them that they believed some kind of fuel selector issue was at the core of the problem but it was never actually established as far as I know and have been told by them, the engine didn't stop though so you can draw your own conclusion.

With regard to CFIT maybe this further definition might help, "Even highly experienced professionals may commit CFIT due to fatigue, loss of situational awareness, or disorientation. CFIT is considered a form of spatial disorientation, where the pilot(s) do not correctly perceive their position and orientation with respect to the Earth's surface".

Not really similar in any to the carnage on the roads, these are Professional pilots working for a Professional modern military organization...

Dochealth

xflyer wrote: »

BantryRebel wrote: »

Just wondering how you know this, is there an interim report that sates that and is it available online?

Straight from the preliminary report:

The accident site, which is locally known as Maum Dearg, is located in Crumlin East on the northern slopes of Crumlin Valley at an altitude of approximately 800 ft. It is less than one nautical mile north of the intended navigational track. The valley is enclosed on three sides by high ground (circa 1,500 ft), has an east/west orientation and is open to the east. At the time of impact, the aircraft was travelling in a northwesterly direction. It was destroyed on impact on the crest of the second and lowest of a series of three ridges. The debris trail was distributed along a 300 foot down slope and was characteristic of a high-speed impact.

I've bolded the pertinent line. One nautical mile at the PC9's cruising speed is a mere few seconds. Check out a chart or Google Earth for the area and you can see that the accident location valley is aligned similarly to the intended track to Maam. In poor visibility the dead end valley might look very similar causing an early right turn with fatal results. It would be very surprising if they deliberately flew up that valley.

So it isn't difficult to conclude that it was CFIT, in that they were not were they thought they were and hit unexpected high ground.

Now all that is easy to surmise but there will be other factors which undoubtedly be dealt with in the report. There may indeed be systemic issue. Maybe the flight should not have been attempting the prevailing conditions or maybe it should be have been aborted earlier. All accidents are the result of a chain of events. It's not as simple as saying the cadet made an early right turn and hit a hill.

We'll see when the report is finally released.

I disagree with respect on the orientation of flight path. Eyewitness accounts describe a/c flying in a southerly direction before turning into crimlin valley. If PF had maintained this course he would have crossed clifden to galway road just east of maam cross. This would have avoided some of the highest terrain on either side of maam valley.

Questions: why turn into blind valley?
What was configuration of a/c prior to impact?

BantryRebel

Dochealth wrote: »

I disagree with respect on the orientation of flight path. Eyewitness accounts describe a/c flying in a southerly direction before turning into crimlin valley. If PF had maintained this course he would have crossed clifden to galway road just east of maam cross. This would have avoided some of the highest terrain on either side of maam valley.

Questions: why turn into blind valley?
What was configuration of a/c prior to impact?

PF means?

Stovepipe

Hi there
PF is Pilot Flying,(the actual handling pilot) the other is PNF, Pilot Not Flying, regardless of who is actual Captain or Commander of the aircraft. The aircraft's configuration was for straight and level flight, ie, gear up, flaps up, appropriate pitch and power selected and so on. The Flight data recorder or equivalent would have recorded all of this. If the aircraft had a datalink, it might even have been sending that info back to a server somewhere in real time.

regards
Stovepipe

Dochealth

Stovepipe wrote: »

Hi there
PF is Pilot Flying,(the actual handling pilot) the other is PNF, Pilot Not Flying, regardless of who is actual Captain or Commander of the aircraft. The aircraft's configuration was for straight and level flight, ie, gear up, flaps up, appropriate pitch and power selected and so on. The Flight data recorder or equivalent would have recorded all of this. If the aircraft had a datalink, it might even have been sending that info back to a server somewhere in real time.

regards
Stovepipe

Thanks Stove

If a/c was flying inverted are there any circs where this could be considered a normal part of a training flight?

DH

xflyer

Strange question, Dochealth. Why would you think they were inverted? Also you seem to imply that they deliberately flew up the 'wrong' valley? Do you know something we don't?

In terms of flying South that fits perfectly with the information in the preliminary report, finding their way blocked by weather on the proposed track, they come South via the Lough. If you get yourself a chart you can see there are two valleys parallelling each other around upper Lough Corrib, one fairly wide that leads to Maum and the other where the accident happened, 1NM to the North which ends in high ground 3NM from the mouth. It's easy to imagine that the PF saw the open valley mouth and mistook it for the correct one. In less than a minute they would have reached the high ground.

It's hard to imagine they would have deliberately flew up that valley in the prevailing conditions.

Dochealth

xflyer wrote: »

Strange question, Dochealth. Why would you think they were inverted? Also you seem to imply that they deliberately flew up the 'wrong' valley? Do you know something we don't?

In terms of flying South that fits perfectly with the information in the preliminary report, finding their way blocked by weather on the proposed track, they come South via the Lough. If you get yourself a chart you can see there are two valleys parallelling each other around upper Lough Corrib, one fairly wide that leads to Maum and the other where the accident happened, 1NM to the North which ends in high ground 3NM from the mouth. It's easy to imagine that the PF saw the open valley mouth and mistook it for the correct one. In less than a minute they would have reached the high ground.

It's hard to imagine they would have deliberately flew up that valley in the prevailing conditions.

I am absolutely NOT implying they deliberately flew into Crimlin.

My info comes from eye witness accounts...

I would like fellow posters to know there are 2 maams in this area. One is Maam Bridge - a viilage mid way along the maam valley. The other is maam cross which is on flat ground away from the valley and south east of maam bridge- the village in the steep sided valley.

Does anyone know if this regular AC training run uses maam bridge or maam cross as its waypoint?

Thanks

DH

roundymac

Reading this thread reminds me of the AAflt 965 that flew up the wrong valley when on approach to Cali from Miami. This was caused by the radar at Cali being out of action and the pilots missing a way point when reconfiguring the on board computer. While none of this applies to the flying of the PC9, it's just the flying up the wrong valley, very sad indeed.

xflyer

Yes they were flying to Maum or Maum Bridge, not the cross which is just a crossroads. It is in a steep sided valley but quite wide. I know the area.

Did a witness describe the aircraft being inverted?

Dochealth

xflyer wrote: »

Yes they were flying to Maum or Maum Bridge, not the cross which is just a crossroads. It is in a steep sided valley but quite wide. I know the area.

Did a witness describe the aircraft being inverted?

With respect xflyer i am constrained from answering your question.

We might be on safer ground if someone familiar with AC ops could tell us if flying inverted is known to be a part of a training run such as this?

xflyer

Well Ok, but I doubt you'll get that answer.

It is fair to say that military aircraft with bubble canopies have been known to roll inverted on a navex. It gives a clearer view of the ground below without the any part of the aircraft getting in the way. Can't speak for the Air Corps though.

Dochealth

Fair enough, thanks.

Hopefully the publication of the final report will answer all of our unanswered questions...

Nforce

xflyer wrote: »

Well Ok, but I doubt you'll get that answer.

It is fair to say that military aircraft with bubble canopies have been known to roll inverted on a navex. It gives a clearer view of the ground below without the any part of the aircraft getting in the way. Can't speak for the Air Corps though.

Yep...not just bubble canopies either. Have a look at images of RAF Jetstreams and Hercules pulling high angles of bank when traversing hilly,mountainous terrain at low level (eg. The Mach Loop).
I'm not sure if the Air Corps practice NOE (Nap of Earth)training where the aircraft will fly low level and,when crossing ridges, will roll inverted and the pilot pulls back on the stick to keep closer to the terrain, before rolling upright again when on the backside of the ridge? More than likely not.

BEASTERLY

Was just going to start a thread about an article on the front page of the Wexford People newspaper today but saw this one then. I used to live close enough to the Jevens family but never knew them personally. I can't find a link so ill just quote o few pieces from the article

Article by Conor Cullen
Headline:

PLEA BY PARENTS OF CADET KILLED IN AIR TRAGEDY


'Realese report of crash... for David's honour'

A WEXFORD family are calling for the report into the air accident that claimed the life of Cadet David Jevens to be published immediately so they can 'defend his honour'

Donal Jevens has confirmed that it was not his family that requested a review of the report that claimed the life of his son and his flight instructor Captain Derek Furniss

And another quote from Mr.Jevens in the article:

'Were asking for it to be released immediately. We know the truth, but we can't defend David to anyone

The review has been ordered by Transport Minister Leo Varadkar under a statutory instrument which has never been used before in relation to an air accident here and allows for a re-examination if a report's findings 'appear to reflect adversely on the person's reputation of any person, living or dead'

xflyer

It must be frustrating for them but they needn't worry to much about his honour. He wasn't pilot in command whether he was PF or not.

While the review is undoubtedly well meaning on the part of someone close to crew. It won't change the facts.

BEASTERLY

Here's a link to article:
http://www.wexfordpeople.ie/news/family-seeking-release-of-report-into-davids-death-2964139.html

It says more on the front page but that's not online.

Dochealth

Thanks for link.
It just shows why its best to let facts speak for themselves.
Hopefully common sense will prevail without more delay.
DH

loose chippings

Hi

Could anyone let me know if there are different ways of training to be a pilot. I have passed the assessment run by the Pilot Training College but don't have the 90K for the course!

Thanks

dechand

Well if youve passed the assesment by PTC , then you should have no problem gettin into the Aer corps, just apply to them tell them what youve done and just wait to be called for a place when they are takin the next batch of recruit pilots in . keep your money and get the country to fund your training, simple , dont know why everyone doesnt do it that way.

xflyer

Dechand stop being a bold and loose tripping this is hardly the appropriate thread for this kind of question.

APM

has anyone got an update on when this report is likely to be published?

cml387

Report published here

pclancy

Before this thread continues I just want to remind everyone that friends, family, collegues and other interested parties may well frequent this forum and I want all discussion to be with empathy for their feelings and with complete respect to those involved in the incident. This is a busy forum with hundreds of visitors each day and your words may end up causing distress if its not in good taste.

Anything not following the above sentiments will be deleted and you will be permabanned from Aviation and Aircraft.

Cheers folks..i'm sure the majority of you understand.

cml387

I have a question about the precise nature of the relationship between PF and PNF in this training flight.Is the PF the one to make a decision,or the instructor?

The phrase "We have to get to Maum somehow" seems to take responsibility for the decision to continue the flight,as planned, away from the PF cadet.

I notice that the cadet had more instrument hours in the previous year than the instructor.

It's a sad read, how things can suddenly go so wrong.

xflyer

The lack of currency stood out for me too. Not just in instrument flying. But as it's a visual flight, it wasn't a factor as such. The comment that it takes 35 seconds to transition from visual flight to instruments is something notable too. 35 seconds is a long time and disorientation in that period could easily happen.

It seems in this case the PF wanted to abort, just as the other cadets did which their Instructors agreed to. In 265s case the Instructor said 'Let's continue'. In theory the Cadet could have said no as PF. But he isn't P1 and naturally he would defer to his Instructor, and senior Officer and CFI.

It is a grim read and 'somatogravic effects' is a new one for me.

Charlie Xray

A very well written report into this tragic accident and contains a lot of good gen on the effects of losing situational awareness and becoming spatially disoriented.

tippilot

In this and every other scenario the PF is the handling pilot.

The Pilot in Command is the Instructor.

Klunk001

It makes very sobering reading particularly the CVR transcript. We now know the end result and what led up to this very sad accident. The bigger picture in all this is that it shows systemic failings within the IAC. Lessons that should have been learned after Tramore were not. Self regulation and auditing is evidently not the way to go.
Yet again It's time for the IAC to take a good and long hard look at themselves and that external agencies should provide an auditing service as suggested in this report.
Being the military they could say "no thanks," they should then stick to military ops.

Nforce

Sobering reading indeed.

Lustrum

From my CATS Atpl theory book...

"Somatogravic illusions are due to changes in linear acceleration or gravity that stimulate the otolith organs"

While tragic for both families, it's good for the aviation community that the report has been released, it serves good lessons for all pilots as to how easy it is to lose your spatial orientation, and hopefully we won't see any more fatal crashes as a result of similar conditions

texas12

A very well written report .
CVR transcript is a harrowing read. I really hope the recommendations are acted upon as the majority of them were also highlighted after the Tramore accident.

My thoughts are with the families of all involved.

AlekSmart

+1 On the Report and the eventual publication of it.

From my own perspective,the report contains elenents relevant to every individual who performs similar functions,such as Bus,Train or even Car drivers.

For example,I would like to see a similar investigational and reporting procedure put in place for major Road Traffic Incidents in order to dispel the illusion that these events "just happen".

It's been far to easy in the past for Authorities to simply erect an "Accident Black-Spot" sign before walking away.

In this particular avation case,even though the report may be truly harrowing for the relatives to read,the decision to proceed with it's publication and dissemenation has to be seen as a positive one for the far wider aviation community ?

A sad read nonetheless.

Dochealth

What a superb analysis and report.
It certainly answers all the questions I had...

RIP

NewSigGuy

Very Sad reading the report, I had trouble sleeping mulling over the same old problems throughout the Corps. I am astonished that FTS had gone the way of every other flying unit in Bal, that is with postholders that are either double or tripple jobbing and/or, who are not even type rated on the units aircraft. This problem has been a major issue throughout the organization for many years.
Most squadrons were like ghost towns with the Pilots only being present to sign out the aircraft for a mission and spending the rest of there time in there “real” job somewhere else on the base. Remember you are an officer first and a pilot second! In my experience this meant that squadrons operated at the lower end of the aircrafts capabilities and the functioning of the squadron as an operational/training environment for young pilots was very much reduced compared to how it should be. That is with pilots spending time planning missions, passing on experience’s, developing operational ideas and refining SOP’s plus the hundreds of intangibles that are present in a fully functioning squadron with a full compliment of Pilots.
When I went through BFTS the OC was the Boss he was present every day he wrote the flying detail and he did the 50Hr and Final Handling checks, as a result for the instructors at least, the unit operated like a proper squadron.

It is shocking given the higher risk profile of operating high performance single engine aircraft in a training environment that AC management did not deem it important to have a full time OC but had let the role become diluted.

I have nothing but the height of respect for the deceased instructor and immense sadness for the cadet, I also greatly respect the individual who was the postholder, who I am sure, was fully employed on the Lear.

I lay the blame fully at the door of AC management who for years have, half run the Corps and have never fully engaged with the realities of running a modern aviation organization, this malaise is fully manifested in the Too many accidents and incidents and the lack of any development of the Air Corps roles or capabilities. Its current difficult position in which it lacks focus or indeed any meaningful role means its future is actually in doubt.

Klunk001

NewSigGuy wrote: »

Very Sad reading the report, I had trouble sleeping mulling over the same old problems throughout the Corps. I am astonished that FTS had gone the way of every other flying unit in Bal, that is with postholders that are either double or tripple jobbing and/or, who are not even type rated on the units aircraft. This problem has been a major issue throughout the organization for many years.
Most squadrons were like ghost towns with the Pilots only being present to sign out the aircraft for a mission and spending the rest of there time in there “real” job somewhere else on the base. Remember you are an officer first and a pilot second! In my experience this meant that squadrons operated at the lower end of the aircrafts capabilities and the functioning of the squadron as an operational/training environment for young pilots was very much reduced compared to how it should be. That is with pilots spending time planning missions, passing on experience’s, developing operational ideas and refining SOP’s plus the hundreds of intangibles that are present in a fully functioning
squadron with a full compliment of Pilots.
When I went through BFTS the OC was the Boss he was present every day he wrote the flying detail and he did the 50Hr and Final Handling checks, as a result for the instructors at least, the unit operated like a proper squadron.

It is shocking given the higher risk profile of operating high performance single engine aircraft in a training environment that AC management did not deem it important to have a full time OC but had let the role become diluted.

I have nothing but the height of respect for the deceased instructor and immense sadness for the cadet, I also greatly respect the individual who was the postholder, who I am sure, was fully employed on the Lear

I lay the blame fully at the door of AC management who for years have, half run the Corps and have never fully engaged with the realities of running a modern aviation organization, this malaise is fully manifested in the Too many accidents and incidents and the lack of any development of the Air Corps roles or capabilities. Its current difficult position in which it lacks focus or indeed any meaningful role means its future is actually in doubt.

A very good post with the various nails hit on the head.

alpha320

As requested by the moderator and to save generating a duplicate thread for this incident ,
I am just trying to ascertain the reason for the recent article in FLYING IN IRELAND re the request to reopen the investigation into the Aircorps crash some years ago now.
From what I can see this is over the Military investigation into the crash, does anyone know if this military report is available to the public ?
Also from reading between the lines this report seems to differ from the AAIU report , the Coroners inquest , and according to from what was stated by Dep Higgins TD appears to be a contradiction of both these non military bodies investigations.