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16 September 1995 - Tamair

The flight was the second Metro III type-conversion training flight for the co-pilot. Earlier that night, he had completed a 48-minute flight. During the briefing prior to the second flight, the check-and-training pilot indicated that he would give the co-pilot a V1 cut during the takeoff. The co-pilot questioned the legality of conducting the procedure at night. The check-and-training pilot indicated that it was not illegal because the company operations manual had been amended to permit the procedure. The crew then proceeded to brief the instrument approach which was to be flown following the V1 cut.

There was no detailed discussion concerning the technique for flying a V1 cut.
The co-pilot conducted the takeoff. Four seconds after the aircraft became airborne, the check-and-training pilot retarded the left engine power lever to flight-idle. The landing gear was selected up 11 seconds later. After a further 20 seconds, the aircraft struck the crown of a tree and then the ground about 350 m beyond the upwind end of the runway and 210 m left of the extended centreline. It caught fire and was destroyed.

The co-pilot and another trainee on board the aircraft were killed while the check-and-training pilot received serious injuries.

The investigation found that the performance of the aircraft was adversely affected by: 1) the control inputs of the co-pilot; and 2) the period the landing gear remained extended after the simulated engine failure. The check-and-training pilot had flown night V1 cut procedures in a Metro III flight simulator, but had not flown the procedure in the aircraft at night. He did not terminate the exercise, despite indications that the aircraft was not maintaining V2 and that it was descending. There were few external visual cues available to the crew in the prevailing dark-night conditions. This affected their ability to maintain awareness of the aircraft's position and performance as the flight progressed. A number of organisational factors were identified which influenced the aviation environment in which the flight operated. These included, on the part of the operating company: 1) an inadequate Metro III endorsement training syllabus in the company operations manual; 2) inadequate assessment of the risks involved in night V1 cuts; and 3) assigning the check-and-training pilot a task for which he did not possess adequate experience, knowledge, or skills. Organisational factors involving the regulator included: 1) a lack of enabling legislation prohibiting low-level night asymmetric operations; 2) deficient requirements for co-pilot conversion training; 3) inadequate advice given to the operator concerning night asymmetric operations and the carriage of additional trainees on training flights; 4) deficient training and approval process for check-and-training pilots; and 5) insufficient quality control of the company operations manual.

The investigation also determined that there was incomplete understanding within the company, the regulating authority, and some sections of the aviation industry of the possible effects of engine flight-idle torque on aircraft performance. Inadequate information on the matter in the aircraft flight manual contributed to this.


Transcript of the Cockpit Voice Recorder (CVR)

Legenda C&T = Check and training pilot
CP = Co-pilot
TWR = Tamworth Aerodrome Controller
NEJ = VH-NEJ

TIME (EST) FROM TO TEXT
1942.45 The pilot in command informed the co-pilot that they were going to conduct a V 1 cut.
1942.49 - 1943.04     The co-pilot objected and questioned the legality of night V 1 cuts. The pilot in command replied that such a procedure was legal. The operations manual has been amended and there was no impediment to conducting the procedure. The co-pilot made a further objection.
1943.10- 1945.02     The pilot in command then indicated that they would be taking off on runway 12 and would continue for a runway three zero right VOR/DME approach. The crew then briefed for that approach.
1945.04- 1945.17     The co-pilot asked if they would be flying the approach on two engines. The pilot in command responded that after the V 1 cut, when the aircraft had climbed through 1,000 ft above ground level, he would probably return the aircraft to normal two engine operation.
1945.18- 1945.30     The co-pilot, assisted by the pilot in command, then revised the procedure for the VOR/DME approach.
1945.41- 1951.30     Because of other traffic, the runway 30 VOR/DME approach was not available. The crew was then given a clearance for the runway 12 VOR/DME approach and briefed for that approach. They then completed the after start checks and the taxi checks.
1951.32- 1952.45     The pilot in command then asked the co-pilot for a crew briefing. The co-pilot could not remember the complete briefing and was assisted by the pilot in command. The pilot in command repreated that they were going to conduct a V 1 cut procedure, adding that it was for the purpose of demonstration so the co-pilot would know what to expect.
1952.56- 1953.35     The co-pilot then revised the procedure for the V 1 cut - that he would call for maximum power, that the pilot in command would call positive rate of climb, and then the co-pilot would call for the landing gear to be selected up. The co-pilot continued that he would identify the failed engine and that the pilot in command would confirm the identification. He queried whether zero thrust would be set. This was confirmed by the pilot in command. The co-pilot continued that at V 2 plus five kts, flaps would be selected up and the climb speed after that would be Vyse to the acceleration altitude of nineteen hundred feet. This was corrected by the pilot in command to four hundred feet above ground level, that is, eighteen hundred feet.
1953.40- 1956.38     The crew completed the line-up checks. The co-pilot asked the pilot in command which engine he was going to fail. The pilot in command responded that he might not simulate the failure of an engine. He then indicated that they would use eighty-eight percent engine torque and one hundred knots for V 1 .
1956.49- 1956.57     The crew then requested and was issued a takeoff clearance.
1957.00 C&T CP OK we're right to go
1957.03 CP C&T What ah what call do I say here. I have to say set takeoff torque
1957.05 C&T CP Yeah you wait for all my calls and then you say set takeoff torque. OK
1957.13 C&T the annunciators clear
1957.15 C&T CP Ah you have sort of don't fight me on the levers yeah . Everything rise torques and temps
1957.18 CP C&T ah set take
1957.19 C&T CP both airspeeds are alive
1957.20 CP C&T set takeoff torque thanks
1957.22 CP C&T should I be pushing up cause I'm not doing much with those power levers there
1957.25 C&T CP that's right. I should be doing it for you or helping you
1957.29 C&T CP torque set
1957.30 C&T CP vee one. rotate
1957.33 C&T CP just ten degrees edward. yeah
1957.38 C&T CP I think we've got an engine failure
1957.39 CP C&T yep
1957.41 C&T CP set max power eh
1957.41 CP C&T are you gonna
1957.42 CP C&T set oh sorry set max power
1957.43 C&T CP yep you got it
1957.44 CP C&T positive rrr
1957.45 C&T CP yeah positive rate yeah
1957.46 CP C&T gear up thanks
1957.47 C&T CP yeah//sound of gear warning horn starts//
1957.50 CP C&T it's the ah left engine
1957.51 C&T CP vee two thanks
1957.53 CP C&T left engine
1957.54 C&T CP just don't lower the nose too much. don't fight it
1957.55 C&T CP that's it. yair left engine we've got no egt and low fuel flow there
1958.00 CP C&T (arthen) we'll ah feather the left then thanks
1958.02 C&T CP ok vee two thanks hold vee two
1958.05 C&T CP we're descending. feather the left one. ok it's feathered
1958.06 // sound of gear warning horn stops //
1958.07 // non pertinent words // // sounds of impact//
1958.09 Recording ends

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