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left propeller. Flight data recorder (FDR) data revealed that about two seconds after rotation, the left propeller rpm decreased to 60% and the left engine torque increased off scale (beyond 5,000 ft-lbs), consistent with the left propeller traveling to the feathered position and torque increasing in an at- tempt to maintain propeller rpm. About 30 seconds later the crew shut down the left engine and attempted to return to the departure airport. Post-accident examina- tion revealed that the rudder trim was at its full-right limit, which would have occurred to counteract the left engine drag before its shutdown. The crew did not readjust trim when the drag was alleviated which resulted in the airplane being operated in a cross-controlled attitude for about 50 sec- onds, with a left bank and full-right rudder trim. Although the airplane should have been able to climb about 500 feet per minute on one engine, it slowed and descended from 300 feet in the cross-controlled at- titude until it stalled and impacted terrain. The NTSB probable cause:
The left engine propeller’s uncommand- ed travel to the feathered position during takeoff for reasons that could not be deter- mined due to impact damage. Contributing was the flight crew’s failure to establish a coordinated climb once the left engine was shut down and the left propeller was in the feathered position.
I’m going to give the two ATPs the benefit of the doubt and assume they had enough multiengine and simulator experience to know to trim the airplane after feathering a propeller and to estab- lish zero-sideslip f light for single-engine climb. Further along the compliance spectrum, stressed noncompliance is a condition when the pilot(s) may know what to do and how to do it, but under the pressure of the moment, fail to fol- low the procedure. Stressed noncompli- ance is the result of two things: lack of recent training on normal, abnormal and emergency procedures, and denial that an actual problem exists.
In training pilots are pessimists – we expect and look for things to go wrong, and actively check and crosscheck the
equipment and ourselves for anomalies and errors. Once the “dual received” log- book ink is dry, however, pilots are opti- mists – we expect things to go according to plan, and tend to think about the results of a flight (getting to destination, giving the passengers a smooth ride, etc.) and not about where we are, and what we are doing. The fix for stressed noncompliance is to train on normal, abnormal and emergency procedures regularly, review them frequently and fly the way you train – being as active a pessimist on routine flights as you are during training.
Complacent Noncompliance
From the NTSB:
A Gulfstream G-IV overran the runway during a rejected takeoff. The airplane rolled through the overrun area and across a grassy area, collided with approach lights and a localizer antenna, passed through the airport’s perimeter fence, and came to a stop in a ravine. The two pilots, a flight attendant, and four passengers died. The airplane was destroyed by impact and fire. The NTSB probable cause: the crew’s failure to perform the flight control check before takeoff, their attempt to take off with the gust lock system engaged, and their delayed execution of a rejected takeoff after they became aware that the controls were locked. Contributing were the crew’s habitual noncompliance with checklists, Gulfstream Aerospace Corporation’s failure to ensure that the G-IV gust lock/throttle lever interlock system would prevent an attempted takeoff with the gust lock en- gaged, and the FAA’s failure to detect this inadequacy during the G-IV’s certification.
This crash has become the “poster child” for complacent noncompli- ance, failure to follow procedures out of a feeling that nothing can go wrong and reinforced by “getting away with it.” The NTSB’s review of FDR data discov- ered that the specific flight crew had neglected to complete “controls free and correct” checks before takeoff “on 98 percent of the previous 175 takeoffs” in that airplane.
It’s easy to think that checklist steps and procedures aren’t important if you don’t think there are consequences for failing to perform them. The reality is that checklists tend to get longer, not shorter, as accidents occur. The answer to reversing complacent noncompliance is to use checklists and follow proce- dures religiously because they were written for a reason, even if that reason has not happened to you. Benefit from the disastrous experiences of others by never skipping checklist steps, even (or especially) when you’re in a hurry and more likely to miss something.
Intentional Noncompliance
One more from the NTSB:
A Pilatus PC-12/45 was diverting when it crashed about 2100 feet west of the run- way. The pilot and all 13 airplane pas- sengers were fatally injured. Visual meteo- rological conditions prevailed. The NTSB probable cause: (1) the pilot’s failure to ensure a fuel system icing inhibitor was added before flight; (2) his failure to take appropriate remedial actions after a low fuel pressure state (resulting from icing within the fuel system) and a lateral fuel imbalance developed, including diverting to a suitable airport before the fuel imbal- ance became extreme; and (3) a loss of control while the pilot was maneuvering the left wing-heavy airplane near the ap- proach end of the runway.
You might argue that this was a case of ignorant noncompliance if the pilot was not aware of the need for fuel sys- tem icing inhibitor. You could say it was a matter of complacent noncompliance, not adding the icing inhibitor or think- ing maintaining fuel balance would not be critical to inflight controllability. I submit, however, that the pilot knowing- ly departed with an overloaded airplane that was also in a probable aft center of gravity condition that reduces control authority and stall protection at slow airspeeds – that he was intentionally noncompliant. The Pilatus, which had seats for 10 including the pilots, had 14 people on board (including several children) and was reportedly 600 pounds
Compliance Spectrum
Emergency Noncompliance
Training/Ignorant Noncompliance
Stressed Noncompliance
Complacent Noncompliance
Intentional Noncompliance
26 • TWIN & TURBINE / February 2020 Jet Journal