• This report is to promote aviation safety and not to establish legal liability.
  • Unless stated otherwise all times are local (Bravo time)
  • The CAA’s report contains padding, repetition, poor English and incompetence. So, in the interest of clarity and readability, I have had to correct and paraphrase extensively.
If the aircraft had been cleaned up and the gear retracted it could have been safely flown back and landed.

Aircraft Registration: ZS-KFT

Date of Accident: 8 October 2012

Time of Accident: 1146Z

Type of Aircraft: Piper-34-200T

Type of Operation: Private (Part 91)

Pilot-in-command Licence Type: Commercial

Age: 20 Licence Valid: Yes

Pilot-in-command Flying Experience Total Flying Hours: 531,0 Hours on Type 66,9

Last point of departure: Runway 12 at Bethlehem Aerodrome (FABM).

Next point of intended landing: Lanseria International Airport (FALA).

Location of the accident site: Panorama residential area, Bethlehem 21’02 /20’10” at 5 561ft AMSL.

Met Info Wind: 090˚/11kt; Visibility: 10 km; Temperature: 23˚C; 1/8 Cloud cover. The density altitude was 7 573 ft

Number of people on board: 1 + 0

No. of people injured: 0

No. of people killed: 0

SYNOPSIS

After take-off from Runway 12 the aircraft climbed to approximately 250 ft AGL when the left hand engine RPM suddenly decreased from 2450 rpm to 1500 rpm. The pilot reported that he then advanced both power levers, but the left engine failed completely. He executed a left turn in order to turn back towards the runway and executed a forced landing on an open field at the western side of the aerodrome. The aircraft rolled for approximately 400 metres before it which it went through a ditch and collided with a fence and a street light pole.

The landing gear was substantially damaged during the landing, and the left hand propeller separated from the engine during the impact sequence.

The investigation revealed that both the fuel selectors were found in the cross-feed position, this configuration is prohibited in accordance with the flight manual.

The pilot did not feather the engine following engine power loss as required by PHO.

PROBABLE CAUSE

Fuel mismanagement

MASS AND BALANCE

Aircraft Basic Empty Weight: 2 823

Pilot: 185

Fuel on board: 416

Take-off weight: 3 424

The maximum take-off weight for this aircraft was 4 570 lb.

The fuel was tested and found to be free from any contamination.

During the on-site inspection of the cockpit, the propeller pitch levers were found to be full forward. This is inconsistent with the settings of a feathered propeller. It was therefore concluded that the left propeller had not been feathered. The pilot could not explain why it was so.

The left Continental TSIO-360-EB, was removed from the wreckage and transported to a maintenance facility. It was not possible to subject the engine to a bench-test procedure, due to the impact damage. An engine teardown inspection was carried out. No anomalies were found that could have prevented the engine or its accessories from operating normally.

The fuel system components were bench-tested. They were found to meet all the operating requirement limitations as contained in the manufacturer’s manual and was found operating satisfactorily.

Irrespective of the reason for the power loss, the aircraft could still have been flown safely if the pilot feathered the left-hand propellor.

The pilot was licensed and current in accordance with existing regulations and had accumulated 39,9 hours on the aircraft within 90 days. He obtained a multi-piston engine rating on the Piper Seneca on 25 February 2012 at total flying hours of 131,3. That would have been the last time that he had completed emergency drills on this aircraft.

The pilot did not comply with the emergency procedures for an engine failure during take-off as stipulated in the pilot’s handbook. However, it cannot be ignored from a human factor’s point of view that due to the aircraft’s height and the inoperative engine, the pilot’s workload had increased substantially, leaving him with no other option than to execute a forced landing.

If you lose power firewall the levers until you can identify the engine which has lost power.

FROM THE POH

The fuel selectors are on the floor between the front seats.

Each selector has three positions: ON – OFF – X FEED.

ON causes each engine to feed from the tanks on its side.

X FEED causes the engine to feed from the tanks on the opposite side.

OFF shuts off the fuel from a side. If one engine is inoperative the selector for that engine must be in the OFF position when the operative engine is selected to X FEED.

Taking-off with both selectors on “crossfeed” is prohibited.

And he didn’t brief himself on what he would do if an engine failed. Here is what he should have said – out loud. (We put far more value on instructions that we hear – even if they come from our own mouths.

  • If an engine fails – or if I have difficulty keeping straight – while there is usable runway ahead – I will throttle fully back on both engines and stop on the runway ahead.
  • If there is no usable runway I will:
  • Fly the aircraft by keeping straight with the rudder, and lower the nose if necessary to maintain at least 76 kts.
  • Take full power by moving all six power levers fully forward.
  • Retract the undercarriage. Heavy metal pilots like to do the flaps first in case the aircraft sinks on to the runway. (Light aircraft generally don’t have the inertia for this to be a problem. The undercarriage is a major drag contributor – it’s best to get rid of it asap.)
  • Retract the flaps
  • Identify – dead foot = dead engine
  • Confirm identification by throttling back the suspect engine
  • Bring the mixture on the dead engine to idle/ cutoff
  • Feather the dead engine.
  • I will then use 5 degrees of bank into the dead engine and trim as needed.
  • Finally I will replan my flight, notify ATC, tidy up – cowl flaps, mags, fuel pumps, alternators, etc.”

This may seem like a long list of things to remember at a critical stage of flight. And if you are not current and so suffer from the startle factor, it is indeed a formidable list. But think of it this way, if you can’t run through the immediate actions in less than 15 seconds, you should not be flying a twin.

The difference between just flying a light twin, and flying it safely, is largely defined by how you handle that crucial 15 seconds. When you convert to a light twin it’s not just another type in your license – it’s a massive step that separates a pilot with a professional attitude from the weekend warrior.

It’s a very big deal if you are not current. This is when most out-of-practice multi-engine pilots kill all on board. And it is a total non-event if you are current.

When I say current, I don’t mean current on twins – I mean current on EFATO actions. I have seen many accident reports where pilots who have thousands of hours in twins lose control and go inverted soon after an engine fails. You are either current and competent with an EFATO, or you are not. This is no time to scratch your head and try to remember what should do.

I advise all twin pilots to sit in the aircraft on the ground and go through those initial actions, up to feathering, time and time again. You will be surprised how quickly, smoothly and safely you can do everything once your muscle memory gets used to it.

So, to recap, this guy failed to switch the fuel on and he failed to prepare for an engine failure.

If I had been a passenger I would have climbed out before the pilot opened the throttles for take-off.

When the left engine lost power at 250 feet, the aeroplane did two things on its own – it turned left – into the dead engine and it lost height rapidly. At this stage the pilot had the presence of mind to level the wings before it ploughed into a field and ran for 400 metres before taking the gear off in a ditch and hitting a lamp post.

According to the POH a lightly loaded Seneca will easily land and stop in less than 400 meters – even at that density altitude. This aircraft was very light – 1,146 pounds below gross.

“sit in the aircraft on the ground and go through those initial actions”

The report says nothing about flaps being used for the landing, and the photographs show no signs that they were used. This is a hobby-horse of mine. If you are going to land, or crash, do so at the slowest possible speed. Even a small reduction in speed causes a massive decrease in damage. As the inertia varies with the square of the speed, using flaps can make any crash much more survivable.

We don’t know whether the undercarriage was retracted after take-off, but it was found to be extended for the landing. This is worth a bit of consideration. There are two schools of thought on when to retract the undercarriage after take-off in a light twin.

The first, suggests that you leave the undercarriage down until there is no more usable runway ahead. This seems eminently sensible – if there’s a problem and you simply throttle everything right back and land straight ahead on the runway.

The second school of thought says – if you have stacks of runway ahead it seems stupid to drag the aeroplane slowly into the sky with the gear hanging out. It’s more energy efficient to pull up the gear once you are clear of the ground and have a positive rate of climb. You can now accelerate and gain height rapidly. If there is an engine failure you have the advantage of a clean aeroplane and plenty of height and airspeed.

I use the second option – not because I have any figures on it but – because it just feels right. If an engine fails, I want it to be when the aircraft is clean, accelerating and climbing. I really don’t want it to happen when I have a bag of drag at low speed and low altitude.

Either way, this guy should have retracted the gear before he was at 250 ft. And it was certainly down when he landed – so perhaps he wasn’t entirely a passenger. But that immediate left turn – into the dead engine, and the immediate loss of height are exactly what the aeroplane will do on its own if you do nothing. Or perhaps the new young pilot was simply doing the instinctive thing that any low hour, single or multi, pilot tends to do – turn immediately back to the field.

There used to be a rule with twins that said never turn into the dead engine, but this is not strictly correct – all asymmetric turns should be gentle, and there is a strong tendency for turns into the dead engine to tighten up and cause a rapid loss of height if you are not careful.

I see that the CAA’s final comment was that the pilot’s workload had increased substantially, leaving him with no other option than to execute a forced landing. What absolute rubbish. If the aircraft was flown properly it would have had a rate of climb, at that density altitude, of 300 ft/min and a single engine ceiling of 14,000 feet.

NEWS FLASH.

I’m sitting in a coffee house in Wilderness enjoying the palm trees and a cool breeze off the sea. As I try to tidy up this article I have a Eureka moment – I have just found out why the aircraft crashed. Have a close look at these two photos of Seneca fuel selectors. The one with a hand in it is from the accident aircraft. Spot the difference? The plastic label for the ON position has been broken off. Although the pilot should have been familiar with the forward for ON position, he obviously wasn’t. He had a brain-fart, or possibly worse – a hangover – and simply didn’t have his mind on the job. The rest is history.

WHAT CAN WE LEARN?

  • A light twin is only slightly more difficult to handle than a single – until an engine fails. It then demands immediate and professional action.
  • Fuel selection in any aircraft is a life-or-death thing – it calls for more than casual attention.
  • Expect an engine failure on EVERY take-off, in any aircraft, and brief yourself for it.
  • ANC – In any emergency the rule is Aviate, Navigate, and Communicate, in that order. Aviate means fly the aeroplane no matter what. Navigate means point it in the most intelligent direction. Communicate means tell someone who can help – but only if you have plenty of time.
  • A turn into the dead engine on a twin must be planned and gentle.
  • Full flap during any landing will give you a slower touchdown and make it more survivable.
  • Moving up to a multi calls for moving up in professionalism.

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