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OPERaTiN& CONOrTrOti

NC 17 EPIs-BC4TO~ IS JUN! 94,

We would like to express our appreciation at this time FACTS are :

to Mr . W . H . Stuart of Vancouver, B .C ., for providing us with the
Stronger than Argument
above photograph which appeared in an earlier issue of "Crash
Comment" .
More Impressive than Reasoning

More Dependable than Opinion

What Has This To Do With You?

Just this -- whether youarean aircrew officer, technical

officer or tradesman the time will come when you will be required
to 1}articil,ate, either as a member or witness, in a board of inquiry .

What Will The Board Expect From 'You?

The answer is easily given in one word -- FACTS!

i`,1`,'
1Is~ltil
The more FACTS you can uncover during an investigation
into a flying accident, the more certain you can be that the resultant
action will reduce the number of similar accidents in the future .

0 40

(_)
  , `~ `. ., , . . ,. . , \,
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\,
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morrow, so make sure you have enough length for a
glassy water take-off .

Last year we had a few cases of damaged hulls due,

possibly, to too much haste . Sometimes it takes as much
19 as an hour to beach an aircraft . Sometimes it is wiser
~t..t .I uL .~ .,t..y .u.. .t.u 1 Y .1L *IL to sail in rather than to use po-over . When in doubt net
the old lead-line out and put the wheels down . Always
\ . . . . . .. . . . . . .. . . . .. .. .. . . .\, . ..~,o . ., ., .\, ... . . . .. . ., :`., . \\_ . .,, ,~ \~
. .\. . ~.,. . . . . . . ~. .a\\
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use a crewman in the bow .
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., \ ~ ~, . , It's all very well for us to sit here and theorize, but we
know enough about operating conditions to understand
that, regardless of the care which you take, landing in
KNOW YOUR AIRCRAFT strange places has hazards which even you may not be
able to anticipate . We ask you to use extreme caution .
A survey of the Canso accidents since January 1948 to
December 1951 reveals that 60% have occurred while operating from Of course, there's the one where the crew struck a dock,
a water base (take-off', landing or taxiing), 35% while operating from we don't remember the specific details, but it could have
a land base and 5°o during flight . The fact that 60% of the accidents been a combination of wave, tide, wind or current . Then
occurred while operating from water, would indicate that more there's the bouyancy aspect of salt water as compared to
emphasis should be placed on water training . The following article freshwater . Don't depend on the "Waterline method" of
which a1;peared in an earlier issue of "Crash Comment" is repro- loading . Sea operations are different . You get off soqner .
duced hereunder ; You draw less water . These variables exist in different
proportions during every operation of a flying boat . They
"STILL VJATERS RUN DEEP? require vour undivided attention ."

The Eskimo will tell you that dark water is O .K . but don't
take this as a general rule, particularly when you are
flying Canso aircraft . During orey days most water, par-
As the seasonfor water operations is nearly upon us, the
ticularly north of the Circle, appears dark . Conversely,
"points to note" in this aspect of Canso flyin~ are published :
during sunny days, it has that clear, transparent appear-
ance which makes you think that every sandbar is just
under the surface . What is more, our geological friends Know your pilot's operating instructions, especially
those applicable to water flying .
tell us that ice will move rock shoals and that the channels
at river mouths are altered annually . So if you landed
in that spot last year don't assume that careful examin- Know the aircraft - it will pay dividends when operating
from _remote bases .
ation is not necessary this year .

If you ask any of the experienced pilots .vhat to do about Know the basic weight of your airc raft and the maximum
landing in strange waters they will give you this sort of E~ermissible all-up weights as laid down in Pilot's
briefing, but will end up by saying that they won't guar- Operating Instructions .
antee anYthino, . They all suggest, however, that you take
Know how to load your aircraft in accordance with C of
your time . Look the situation over carefully . Select your
landing path, your probable take-off runs, your beach, G limits .
rrarkthem by prominent features, then go in and or
fi ._-? N-ourself another landin,7, area . R emember that the Know your engine handling procedures .

1 .
 Know the technique to use when making off-shore land-
ings and take-offs - the effect of swells, current, tide,
wind, etc .

Know your emergency landing procedures .

Know the proper procedures for beaching, mooring,

0
anchoring and docking - and the factors that decide
which facility should be employed for an intended stop-
over .

Know when and how to use your drogues and/or under- Although the Harvard (including Texan) accident rate has
carriage when manoeuvring on water . dropped considerably when compared with the previous quarter, as
usual the majority of accidents are still occurring during landings .
Know your emergency drills i .e ., - undercarriage low-
ering and raising, float operations, dinghy and abandon-
ing drills .
I [t will be noted that the number of taxiing accidents has increased
by 50% .

The following is a breakdown of the combined Harvard

Know how to operate your APU and keep it serviceable . and Texan accidents for the quarter :

Know your crew individually, their capabilities and Take-off . . . . . . . . . . . . . . . . . . . . . , . . . . . . L

limitations .
In Flight, . . . . . . . . . . . . . . . . . . . . . . , . . . .5
Ensure you have a working knowledge of the other crew
positions - it rnay help in an emergency . Taxiing, . . . is
Ensure that your crewmen know how to handle ropes - Landing . . . .32
tying the proper knot at the proher time and in the proper
1 lace may save you many a headache when beaching,,
mooring, or tying up to a dock . Total . . . . . . . . . . . . , . . . . . . . . . . . . . . - .54

Ensure you have a knowledge of tides if operating in

tidal waters .

Ensure that your bilge pump is serviceable and remains

so - it may save your life .

The importance of thinking before acting in flying boat

operations cannot be over-emphasized, therefore :

" = ~ `'' -~' `` Estimate the situation.

. . .., :> , ,
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Ma k e yrour decision .
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( (v)
 .:
3?\\::~

tl-~T VNIMM

_ ., . . . B RD
' OA
.. . .
. ~ . . ~ .
s Not including in the findings (where applicable) par -
ticulars and estimated cost of any damage involved,
or not stating reason for non-inclusion .

The president or investigating officer omitting to

initial alterations and insertions .
Not stating in full the rank, name, decorations and
appointments of the convening authority . i The h resident or investi g atin g officer omittin g to
.
416111;,1̀~1 initial each page of evidence .
Not stating correctly the numbers, ranks, names,
appointments, units and stations of the president and Not complying with KR(Air) Art . Z1 :Z1 respecting
members, or of the investigating officer . civilian claims .

Not stating the correct terms of reference as quoted Failing to record compliance with KR(Air) Art . Z1 :06
in the assembly order . when applicable, i .e ., when character or reputation
of officer or airman is affected .
Notnumbering the pages of the proceedings consec-
utively commencing with the front page as "1" Failing to make recommendations when called for
by terms of reference .
Not prefacing the evidence of witnesses with thear
full particulars and the requisite preamble . Failure by the president and all members, or by the
investigating officer, to sign the findings and re-
Not obtaining signature of witness on each and every commendation, and date the proceedings .
page on which his evidence appears .
Recording the evidence of more than one witness on
Recording irrelevant evidence which has no bearing the same page .
on the matter under investigation .
Failing to reserve sufficient space on final page for
Commencing numbering of questions put to each wit- insertion of remarks of A .O .C . and appropriate auth-
ness at "1" instead of continuing the numbering con- ority at A .F .H .Q ., where applicable .
secutively throughout in one single series .
Failure of court or investigating officer, where app-
Not designating exhibits by letters, e .g ., "Exhibit A, licable, to express opinion as to whether the injured
B, C, etc .," and not marking them as part of the pro- party was on duty and whether to blame .
ceedings of the particular investigation .
Failing toattach form R .C .A .F . R .78A in the case of
I Not making mention of the exhibits in the body of the
j)~ investigations into a personal injury or death .
proceedings .
Failing to comply with specific orders prescribed
for investigations into flying accidents .

(vi) (vii)
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0 N0 . 1 -- FLAP

After an overshoot, the pilot made another attempt to land

and noted that it took an abnormally long time for the flaps to lower .
As another overshoot was impossible due to lnw fuel load . the excessive
he i~Yht was dived off and the aircraft crossea the button at 130 knots .
The pilot applied full brake immediately upon touching down and the
aircraft came to a stop 3/4 down the runway . Due to harsh braking
action the starboard tire blew out and left the aircraft before a full
V stop was attained .

Technical investigation revealed that there was a lag of

5 seconds only in the flap operation,

The accident was assessed as pilot error - the pilot was

reproved .

0 NO . 2 -- UP AGAIN DOWN AGAIN

This pilot checked his undercarriage down and locked upon

receivingfinal landing clearance from the tower but selected under-
carriageuhagain in preparation for an overshoot when he noticed an
Expeditor taxiing back up the "live" runway . The Expeditor cleared
the runway in use, however, and the pilot continued his landing app-
roachwith undercarriage in the "up" position . In the final stages of
his approach he was notified by the tower that his undercarriage was
\
\' up . Power was applied but not in time to prevent the aircraft coming
1\\. in contact with the runway and a wheels-up landing was made with
\\\ '.
\. minor damage to the aircraft .

\
., : : .
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; ,
" NO . 3 -- FLAME OUT

While flying as Number 4 during formation practice at

30,000 feet, the pilot throttled back to change position . While carry-
ing out this manoeuvre he fell slightly behind the remainder of the
formation and upon opening the throttle to regain his position, noticed
there was no response . The throttle was closed and opened again with
no effect and the pilot broke formation and carried out a forced landing,
damaging the aircraft extensively .

Although this case has not been finalized, a strip inspect- i 0 N0 . 5 -- A WHEELS-UU LANDIhr1
ion of the engine has revealed no mechanical failure . This could have
been rough use of throttle at height .
i

. , .

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0 i~,0 . 4 -- II~~EX1~ERIENCE
The pilot reports he made a normal selection for lowering
After completion of a simulated landing at altitude the the undercarriage and did not know that the wheels had failed to go
throttle was ol;ened for an overshoot . Being inexperienced on type, ;'o,un . The tower warned the pilot of the position of his urdercarriage
the pilot allowed the airspeed to build up beyond the "maximum 1jer- teo late to avoid a wheels-up landing . Retraction tests c<~~ rI(-I1 01-1t on
rr,issible for undercarriage down" before selecting "wheels-up" . the aircraft showed that although the undercarriage warning horn was
This resulted in damage to the nose wheel door and retractin" link- unserviceable, the undercarriage warning lights operated normally .
age on the forward bulkhead .
This accident is still under review .
The cause of this accident - inexperience on type .

We wonder if the pilot was adequately brief ed on this point .

0 NO . 6 -- OIL ON WINDSCREEN \
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The aircraft returned from a training trip with a film of

oil on the windscreen and the pilot attempted a formation landing .
On "rounding out" his aircraft hit the slipstream of the preceding
aircraft and the starboard wing struck the runway .
" 0
Corrective action was taken and a successful overshoot
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and landing were carried out . \

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Under the circumstances we would hardly consider a 0 NO . 9 -- DOWN'~VIND

formation landing appropriate .
This pilot, upon completion of a night instrument flight,
The accident was attributed to pilot error . made visual contact over his destination at 3,000 feet . Landing ins-
tructions were received from the tower, the runway in use being 03 .
" NO . 7 -- NO OIL The pilot made a rapid descent and commenced his approach on run-
way 21 . No check was made by the pilot during the approach to as-
While taking part in a formation exercise the pilot noticed certain his magnetic heading . The aircraft landed 1 / 3 dovn the run-
that his oil pressure had dropped off to zero . He immediately set way and as the braking action was poor, ran off the end, causing
course for base, and despite the fact that the engine cut-out complete- damage to the port engine nacelle .
ly a few miles short of the aerodrome, made a successful "wheels
down" landing on the runway . Although the pilot claims that the "lead in" lights .vere
lit on runway 21, no evidence has appeared, as yet, to substantiate
Upon examination it was found that the oil tank was empty his claim .
and the engine had seized .
This case is still under investigation .
& NO . 8 -- ANOXIA?

Thepilotflightplanned VFR direct while on a ferry flight

l
and indicated his intentions of flying at 3,000 feet . During the trip
he ran into thunder storin activity and notified airways that he was
climbing to 18,000 feet to avoid icing conditions . Thirteen minutes
later, the aircraft crashed and burned, killing the pilot . Although the
exact cause of this accident may never be known, the following facts
were brought to light : ,.,
\ XX~~~ `. \~
\)~ ( ' total flying time on tyf;e - 6 hrs . 15 mins .
Pilots
\ :\
\ \\ .\, -
\
~ ,\ \.., .
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~(b) ~ Total instrument flying time
for past six months - 50 mins .

Total link trainer time for

past six months - Nil

Pilot was not equipped to take oxygen although

he notified airways that he was climbin;; to
18,0100 feet to avoid icin,,~ .
 ,... \ ,. \ 0 NO . 11 -- POOR AIR MANSHIP?
~
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This aircraft had a flat tire on the starboard side which

required inflating before the aircraft was able to take off on a nav-
igation exercise . Upon approaching to land after completion of his
exercise, the pilot decided to touch-down on his port wheel first as
J he was doubtful if the starboard tire was serviceable . This caused
the aircraft to start a ground loop, the pilot used harsh brakes to
correct the swing and the aircraft nosed up . The result is depicted
on the front cover .

This accident is still under investigation but we consider

the pilot should not have accepted the aircraft if he was doubtful of
its serviceability .
~

0 NO . 12 -- CARELESSNESS

While taxiing close to a snow bank, the pilot executed a

0 NO . 10 -- FATAL short radius turn . The tail fin was damaged when it came in contact
with a large lump of frozen snow which had rolled down off the bank .

Although this accident was attributed primarily to an error

This aircraft departed on an IFR flight plan with a ''met"
in judgement and the secondary cause as carelessness, we would like
ceiling of 1100 feet and the visibility one mile in rain and fog . After
to know how long the lump of frozen show had been allowed to lie in
take-off, the pilot reported the ceiling as 400 feet, Two or three
a position where it was a potential hazard to taxiing aircraft .
minutes later the pilot requested a "course to steer" from the VHF
"Homer" . Two courses were passed but the last course not acknow-
The pilot was awarded an administrative deduction .
ledged by the aircraft . After being airborne foi approximately five
minutes the aircraft crashed into a hill at the 525 foot level and killed
six of the occupants and seriously injuring the sole survivor . It would
appear that the pilot was carrying out a wide circuit of the aerodrome .

This accident has been assessed provisionally as "cause

obscure" but the investigation has not been finalized .

f_1%
'A7 ~rom
rIN

A Good Safety Record Reflects Ability .

~.J
 \ AA EM,ON
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* NO . 14 -- COCKPIT CHECKS

The pilot att~--mpted a nidhtlanding with his undercarriage

not fully down . Upon throttling back, the warning horn sounded and
the l:ilot took overshoot action but not in time to prevent damage to
0 NO . 13 -- the propeller when it struck the ground . The aircraft completed an-
other circuit and landed successfully .

The incident was assessed as pilot error and the I;ilot

awarded an administrative deduction,

This aircraft was proceeding to a water base for the pur- * NO . 15 -- TOO MUCH BRAKE
pose of changing from floats to wheels . Shortly after touching down
~ while carrying out a "glassy water" landing) the aircraft struck a The aircraft swung after landing . Corrective action was
sand bar and turned over on its back . taken to stop the swing but the excessive use of brakes with no power
caused theaircraftto nose up and the Fropeller to strike the runway .
Result - a "B" category crash. Fire broke out and damaged the engine .

During the board of inquiry the following factors were The cause of this accident was assessed as pilot error .
made known ;

on floats .
inexperlenc ed
The pilot was .
. at this base-
had not p
revious 1 y landed
14
The 1 ,ilot
interlan d
DireCto r y of H ' able at
.
n to GAP 454 were avall
Accordig radio fac ilities board to
Aerod r omes), nczln the .
there -s no evlde e contact
th is base bbut ,
attemht \ ed to ma k ~ApA~V,i1`1`,I,,,, s
"
p1lo t
show that the or
e that either the pilot
to indicat GAP 454 .
No evidence
e --c Consulted
.-~fti c .~r _
the f~ rieti~~
0
The pr :-11 :ary cause of this accident has been assessed as
,ilot error with lack of proper briefing as a secondary cause .

Due to the pilot being inexperienced no disciplinary action

was taken in this case,
 . . :. .

We wonder if this hilot read the article "Your Harvard

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' a n earlier edition of ''Crash Comm-
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0 NO . 17 -- BIG FEET?

The student was carrying out a night landing when his

left flying boot jammed between the brake pedal and inside rudder
bar causing left brake to be al;plied . The instructor immediately app-
lied right rudder to correct the swing but his action increased the
pressure of the student's left foot on the brake pedal . The right
brake was then applied and the aircraft went forward on its nose
damaging the propeller and engine .

0 NO . 18 -- VARIATION EAST, MAGNETIC LEAST

This pilot was designated as leader of a formation of three

aircraft that were to be ferried under VFR conditions . A short dis-
tance from their destination they broke formation when adverse
weather was encountered . The pilot wa's brought over his destination
by means of VHF "Homer" but as the weather was below limits he
was diverted to another aerodrome . A "course to steer" was passed
to the pilot by the control tower . A short time later (while flying in
a snow shower) the aircraft crashed into the side of a mountain at
the 7,000 foot level . The route flown by the pilot shows that he was
approximately 45o off course .

0 NO . 16 -- COi"?TRAR`i' TO RE"]ULATIONS The pilot died later of injuries .

The pilot was autnorized to carry out a dual dive bombing This accident is at present under investigation by a board
exercise and was designated as leader of a three-plane formation. of inquiry but we wonder if the magnetic variation of 22o E had been
While waiting for permission from the bombing range to commence added to the true course rather than subtracted .
the exercise, the leader of the formation began "tail chasing" his
Number 2 . After making several attacks, the pilot did a sharp climb- 0 NO . 19 -- MAINTENANCE - MATERIEL?
ing "wingover" to the right and passed under his Number 2 in a diving
vertical bank . Thepilot did not recover from this manoeuvre and the Following a normal run-up and take-off, the power was
aircraft crashed, killing both occupants . His last attackhadbeen reduced from 32" to 28" when a loud bang was heard and all power
carried out at 2,000 feet . was temporarily lost . The engine was found to run intermittently at
32" and the pilot made an attempt to do a partial circuit and land .
The verdict - loss of control while carrying out unauthor- Height could not be maintained, however, and the pilot carried out a
ized manoeuvres contrary to regulations contained in CAP 100, para successful forced landing .
97(2) (b) & (c), CAP 100, para 99(1) & (3) and AFRO, para 310 dated
25May51 . u Technical examination revealed that the loss
was due to rocker box failure .
of power

A heavily loaded Harvard will not take rough handling

either aerodynamically or structv.rally . This reminds us to remind you - is EO l0A-lOBB-5 2
being complied with at your unit?

-10- -11 -
0 NO . 20 -- WHO HAS CONTROL? A.~.RriaFc 1
The instructor and student missed both visual and R i T
instructions regarding a change of runway and taxied up the runway ,i" I -

I
ou recelvinn
inuse as an aircraft was approaching to land . The approaching air-
craft commenced an overshoot at the same time as the taxiing air-
craft cleared the runway . In an attempt to keep clear of the over-
shooting aircraft, the instructor o1~ened his throttle at the same time
as the student applied brakes . This resulted in the aircraft nosing up ®
and damaging the propeller .

Ur
WW.

90
l Y-~ . .1-bwV.Y~YwW.-Y ..d " 1Yr

~')M W.

The instructor apparently opened the throttle without first " +w~Y.Ww.-~wr

advising the student that he was taking over control of the aircraft . law: . .
. . _ .. _ . . , . .. .,~ _..

The cause was attributed to pilot error on the part of the

instructor .

0 NO . 21 -- MULES ARE MIGHTY TOUGH

A senior student was taxiing his aircraft prior to a solo

flight and failed to notice a "shop mule" which had stalled at the edge
of the taxiing strip . Although the pilot's view was unobstructed and
braking action considered good, no brake was ahl,lied and the air-
craft received considerable darnage when it carne in contact with the
mule .

This accident was assessed as carelessness and the pilot

awarded an administrative deduction .

- 12 -
 DFS LIBRARY
LIBRARY COPY -this
pub must be returned .