Student Mistakenly Ejects From Harvard II

[Bograt]

Interesting that you mention that... when the folks for Ottawa strapped into a cockpit of another Harvard they noticed that the the comms cord naturally fell on the investigators lap. He was apparently stopped from accidentally making the same mistake that the SP made. They photographed the incident then looked for signs that it could have happened in the accident. Apparently they discovered a small piece of the comm cord embedded into the ejection handle.

So in the span of 48 hours, this incident happened twice. Apparently during the first flight test of the Texan 2, the test pilot made the same mistake. Texan 2 coms cords have no slack (that is to say there isn't anything left past the connection for the Oxygen hose). In our aircraft before the accident we could have 18 inches or so of slack.

The SP had to strap in at least 6 times prior. It has been recommended that all SPs have to be supervised until CH4/IF1.

 

[Bo]

I worked with this guy during OJT. Gonna get his autograph when I get to Moose Jaw  ;D

Charlie: [to Eject] So you're the one.
Eject: Yes ma'am.

 

[Journeyman]

Many, many people have gone before this guy with out having a problem. To blame it on equipment and not improper strap in technique is a little off the mark.

Outside my lane,* but it sounds like you're suggesting people should be responsible for their behaviour. Too funny.


* The more pilots I know, the more I prefer being under a parachute  ;D

 

[I_am_John_Galt]

I worked with this guy during OJT. Gonna get his autograph when I get to Moose Jaw  ;D

Charlie: [to Eject] So you're the one.
Eject: Yes ma'am.

That was some of the best flying Run-Up Checks I've seen to date - right up to the part where you got killed Ejected.

 

[Loachman]

We've been flying Harvards for 7 years now, never has this been a concern. Many, many people have gone before this guy with out having a problem. To blame it on equipment and not improper strap in technique is a little off the mark.

This doesn't surprise me at all. One can probably come up with several examples of people getting away with something for years until it catches up to some poor sod.

Hercs had been doing Battle Breaks for almost ever until the Air Force Day flypast in Edmonton in 1985, when two out of three collided and killed ten guys.

True, that was perhaps mainly procedural rather than equipment-related, but the lack of critical upward visibility from the cockpit was a major contributing factor.

Technique can compensate for design flaws, but sooner or later the flaw is going to win. If something can go wrong, it will. Maybe not in the first seven years, but the eighth perhaps.

 

[observor 69]

You just know somebody was going to say the following:

Murphy's law is a popular adage in Western culture that broadly states that things will go wrong in any given situation, if you give them a chance. "If there's more than one possible outcome of a job or task, and one of those outcomes will result in disaster or an undesirable consequence, then somebody will do it that way." It is most often cited as "Whatever can go wrong, will go wrong" (or, alternately, "Whatever can go wrong will go wrong, and at the worst possible time," or, "Anything that can go wrong, will," or even, "If anything can go wrong, it will, and usually at the most inopportune moment"). The saying is sometimes referred to as Sod's law. Finagle's law, which can be rendered as "Anything that can go wrong, will—at the worst possible moment," is a variation.

http://en.wikipedia.org/wiki/Murphy's_law

 

[childs56]

Just because 1000 people before this student didnt have a problem with the procedures or equipment doesn't make the incident any less of safety issue.

When I was fixing the F18 I noticed more then a few situations that have been ongoing for 20 years or so with these A/C. It was deemed safe untill some one hurts themselves. All issues were brought up as were the replys that have been given after proper paperwork to fix the situation was returned.

Personalle responsibilty has to come into play at some time in scenerio. But as a student these should be minimized to the fullest. 

Flight Safety is everyones responsibilite, from the newest Private up to the CDS.

Unfortunalty this one cost about $250,000. But this really is a drop in the bucket for mistakes that are made daily fixing and operating these and the other inventory of CF A/C.

Never fool yourself. If it happened it is safety issue. If it happens again in a short time frame it is a training issue.
If the same student makes the same mistake it is a training failure. They didnt get it. They wont get it. Dismiss them and carry on. 

 

[Inch]

I figured I'd get piled on for that post.

My point of view is one that probably comes with being a cocky new AC on a 40+ year old helicopter. Our last Sea King crash was pilot error, plain and simple. Technique put that aircraft into the water, not equipment, heard that first hand from the guy who had his hands on the controls. NVG's would have probably helped, but they're not an option on the Sea King without extensive modifications that just aren't going to happen before we start converting to the CH148.

All aircraft have some flaw of some sort, that's unavoidable. Technique, training and proficiency are what keeps us from getting killed or injured every time we take an aircraft flying. It's impossible to mitigate all risk, humans are prone to error, from those designing the aircraft, the builders, the maintainers and the pilots. At some point there will be an incident, I don't know of any aircraft that went it's whole life without taking the life of some poor sod.

So my point was simply that, as an aviator, we all want to blame the equipment instead of ourselves when things go wrong. Sometimes it is the equipment, but the majority of the time the cause factors in an incident are more human related than equipment flaw related. Sometimes you just have to say, "Yep, I screwed up".

I know you've heard the saying, "there are two types of pilots, those that have and those that will."

 

[aesop081]

As a cocky newly apointed Lead AES Op, will take the ballanced position here......if i may

I agree with Inch about the tendency to blame the gear rather than blame ourselves as individuals.  I think it is a natural human reaction. Human factors is a complicate affair when it comes to aviation ( HPMA training asside) and like Inch said, most occurences are "human error".

That the oxygen hose is too long does not releive the person in the seat from ensuring that he/she properly straps on the aircraft. I can only assume that this problem is widely known in MJ.

BTW...My aircraft is only 27 years old

 

[observor 69]

Bograt said :

"So in the span of 48 hours, this incident happened twice. Apparently during the first flight test of the Texan 2, the test pilot made the same mistake. Texan 2 coms cords have no slack (that is to say there isn't anything left past the connection for the Oxygen hose). In our aircraft before the accident we could have 18 inches or so of slack."

Does this mean that there was a technical problem with cord length and that it has since been rectified?

 

[Loachman]

As a cocky 40+(++++++++++)-year-old pilot on a 10-year-old helicopter with a few hours and a few funerals behind me (none of my own, but close) I'd like to emphasize what CTD said.

In this case, it appears that, again, a recognized problem existed that went uncorrected until some poor kid exploded from his aircraft and was lucky enough to survive. This problem could, apparently, have been fixed pretty simply and for much less than $250,000.

Part of the human error in this case was not correcting the equipment in the first place and whoever didn't report the potential problem and/or whoever didn't take corrective action bear more responsibility than the student.

 

[Inch]

When you put it that way, I do agree with what you're saying.

 

[Loachman]

Thanks. If only my wife was so reasonable.

 

[ChrisG]

Coincidence.

This months aviation safety letter, (civil) has an article about the safety culture and explains (and I paraphrase because I read it and then 'filed' it) that in the past we looked for the cause of an accident and if it was found to be pilot error then we just said 'pilopt error.'  However the new safety culture must then ask, "so why did the pilot make this error?"  Assuming that we are all trying to be sensible and all trying to stay alive,  short of disastrous circumstances beyond our control (which presumably would not be pilot error)  we should look into why the pilot made the error and rectify the lack of training or the mindest or the lack of safety culture that allowed the circumstances themselves to occur.

In all the years of the harvard 11 no one has noticed the risk prone com cord,  and if they did,  how was it allowed to continue.  When pilots,  and all other operators, are compensating for  unnecessary risk factors ( and we do it all the time) we may avoid,  for a long time,  that risk but we are also putting ourselves at risk in other ways because of the increased work load.

 

[aesop081]

If this was a well-know issue with the Harvard II....was there not an AIF out on it ?

 

[Zoomie]

If this was a well-know issue with the Harvard II.

Couldn't have been too well-known.  I don't recall ever having an issue with the comms cord. 

I remember hooking up my helmet and then forgetting about it. 

The handle was always there but never really an issue - should be an interesting Flight Safety report.

 

[Bograt]

Obviously the pilot's strap in lead to the ejection. This strap in was the result of a number of possible factors including:

• nervousness- first flight jitters
• poor visibility as a result of winter kit and mask interfering with line of sight
• late walk, and subsequent rush

Contributing factors may include:

• Coms cord length

The purpose of flight safety is to not assign blame to an individual but rather identify the factors and causes of incidents that may lead or have lead to incidents- and make recommendations so that these occurrences could be minimized in the future.

There is now an AIF for SP to strap in. Also, I believe there will be a recommendation regarding eye protection on the ramp for all ground crew and aircrew (CFS sure packs a punch)- never believed to be a problem in the past, but now it has been identified as a risk factor.

The Flight Safety System is extremely important. If it was to assign blame to specific individuals, there would be much less reporting of minor events like gear overspeeds, close calls, etc... If the SP was deliberately neglectful or reckless there is the "Summary investigation" that are can lay blame and charges. Obviously that wasn't the case in this incident.

Stupid mistake from the result of inexperience and the opportunity to make the mistake (ie a long coms cord).

Cheers,