Originally published at: Guest Post: The Day the Safety Died
Richard McSpadden’s legacy calls for a renewed commitment to safety in aviation maintenance.
Safety never dies. However, it takes a real personal commitment to keep it alive.
One should never ever take the soft option. Just because a pilot gets away on one occasion with scud running does not make that an argument that it is a safe practice, per se! Think, “Get Home Itis”
Good safety requires unwavering discipline in accepting professional/industry standards and not something that is expedient at the time.
BJS
Safety is a lot more complicated than we think because of the ‘human’ us. I would point anyone who has an interest in this subject to a great book by Prof Sidney Dekker ‘The Field Guide to Understanding Human Error’. It’s not expensive and it’s very readable - and opened my eyes to a very different way of looking at safety and what to do when bad things happen
I’m not going to second guess the decisions that were made. I don’t have all the evidence, but from what I understand, there weren’t many good options available at this particular airport should an engine malfunction shortly after takeoff. Sometimes even the very best decisions are unable to guarantee a safe outcome. Such is the nature of the aviation world we inhabit. If we decide to leave the ground, we must eventually return to earth and there are no risk-free alternatives even in the best of conditions and in perfectly good aircraft.
Be careful out there, be safe out there… and RIP when the worst occurs.
The Impossible Turn claims the most experienced and the most inexperienced. The only way not to end up in a smoking hole is not to attempt it, yet every month somebody will take a try it.
The long awaited release of the NTSB report on the McSpadden accident really leaves more questions open than it solves. While we can conclude there were engine performance issues, what I find more disturbing is the fact that the NTSB comes up with the conclusion that performance issues were due to ‘undetermined reasons’ . What the NTSB did focus on as contributory to the actual accident where weight and balance issues and performance issues related to density altitude / center of gravity as well as pilot performance.
Over the last five to 10 years ‘undetermined reasons’ seems to be a new mantra in NTSB investigative processes . To apparently focus blame on maintenance issues based on the information in this report seems t a little far fetched at this point . I do certainly agree that McSpadden would expand his logic of safety into the maintenance world . Unfortunately lacking specific factual evidence in any accident leads us to speculate on what specific chain of events may have been present and may have been obvious to an operator . Many accidents are going into the books as labeled ‘ambiguous’ and unfortunately it looks like this will be another one .
While Maintenance is a key safety factor so is adhering to the POH for the aircraft. I think in this case the focus of maintenance safety is misplaced and the focus on operation owithin the POH should have been stressed.
the report notes the cg was forward of the forward limit by an inch. this is not trivial.
from my reading of the NTSB report"
Lake Placid accident report quick summary
Engine sounded like not at full power. This should have been caught during run up . Sound analysis estimated 2150 rpm also indicative of low power. witness stated Longer take off than Beech.,(900 to 1300 feet. vs 900 feet book values) should have been an indicator. LKP runway 4200 feet. Brief white cannot be fully explained though the carbon fouling on the plugs may be indicative of the shutdown and start up depending on how this was performed. .
Aircraft post mortem noted discrepancies w fuel drain control and lifters neither were determined to be significant to aircraft operation. carbon fouling should have been noted on runup.
NOTE however CG was calculated w pilot information and fuel load to be 1 inch FORWARD of CG limit.Loading With Abandon - Aviation Consumer an article on weights and CG of popular aircraft.
The CG limit is determined to help facilitate safe flight. While safe flight is not guaranteed while flying within weight and cg limits once you are out of these you are in effect flying illegally, flying an unsafe aircraft, and basically a test pilot. The article glossed over these facts to hang on a perceived but unproven performance limitation caused by a yet unproven maintenance issue. The real safety issue seems to be the operation of the aircraft outside it POH and design limitations. Never a good idea.
from the above unless i missed something, outside the carbon fouling which should have been noted on runup w low rpm and or a larger than normal drop in rpm w magcheck there is no real reason to focus on the maintenance of this aircraft as the cause of the accident as much as the forward cg and the pilot not noting power issue on takeoff.
The conclusion that maintenance is at fault here seems dubious at best. I’m not seeing anything other than a vaguely worded statement about “engine power loss for undetermined reasons”. My limited understanding of this accident has caused me to conclude that the pilot attempted an impossible turn and came up short of the runway. It would seem that in the not too distant past, the same maneuver was performed with a successful outcome.
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