**AIA / AECMA Project Report**

**on**

**Propulsion System Malfunction**

**Plus**

**Inappropriate Crew Response**

**(PSM + ICR)**

**Volume 1**

**1 November 1998**

**G. P. Sallee D. M. Gibbons**

**AIA Co-Chair AECMA Co-Chair**

![](media/image1.emf) ![](media/image2.emf)

**Foreword**

This document reports the results of a study to assess the causes and
contributing factors in accidents and incidents where a single benign
propulsion system malfunction occurred and the pilot(s) did not
appropriately handle the situation. This study was undertaken in
response to a Federal Aviation Administration (FAA) letter of 6 March
1996 requesting the Aerospace Industries Association (AIA) to use data
from a previous AIA activity and a recent accident as a basis for
initiating development of guidelines for an engine failure indications
system. The AIA responded to the FAA on 19 June 1996 with a letter
proposing to undertake the requested activity. The AIA proposed that the
initial focus of activity would be on assembling all of the relevant
facts and data associated with historical accidents and incidents,
experience with various mitigation approaches, fixed-base and motion
based simulator capabilities and programs, and other relevant
information appropriate to a thorough study of engine failures coupled
with inappropriate crew response(s). Once the data collection process
had been accomplished, a follow-on phase would analyze and synthesize
these data in order to prepare recommended corrective actions. AIA wrote
that AIA believed that all parties would be best served by not
prematurely focusing on "a solution". Upon completion of this work a
decision gate would be taken before deciding how to proceed into
additional phases that could suggest multiple paths and increased use of
resources.

AIA requested The European Association of Aerospace Industries (AECMA)
jointly sponsor and Co-chair the project on "Propulsion System
Malfunction Plus Inappropriate Crew Response (PSM+ICR)". Representatives
from all affected organizations were invited to participate mindful that
the project would ultimately progress into the Aviation Rulemaking
Advisory Committee and Harmonization Processes. The organizations
represented included regulatory authorities, accident investigation
authorities, pilot associations, airline associations, training
companies, and simulator, airplane and engine manufacturers.

This report summarizes the facts and data collected, analytical results,
conclusions and recommendations for potential corrective action. The
report is being transmitted by AIA and AECMA to the Regulatory
Authorities for consideration and appropriate action. It has been
acknowledged that a similar situation exists in the rotorcraft industry;
however, it was agreed in the beginning of this workshop that only
Turboprop and Turbofan airplanes would be considered (14 CFR Part 23 &
25). It is recommended that a similar exercise take place for the
rotorcraft industry outside of this workshop with the aid of appropriate
industry experience.

This report is separated into two volumes. Volume 1 contains the report
results and appendices 1 through 3. Volume 2 contains the remaining
appendices 4 through 15.

**Contributing Organizations and Individuals**

  ----------------------------------------------- -----------------------
  Aero International (Regional)                   Claude Bechet

                                                  J. Andrew Bedson

  Aerospace Industries Association (AIA)          Howard Aylesworth

  Aerospatiale                                    Johann Hervault

                                                  Patrick Zaccaria

  Air Accidents Investigations Branch (AAIB)      Peter Coombs

                                                  K. Smart

  AIR BC                                          Hans Lammers

                                                  Garrett Smith

                                                  Kurt Ruhwald

  Air Canada                                      John Hart

  Air Canada Pilots Association (ACPA)            Capt. David Edward

                                                  Capt. Thomas Jerrard

  Air Transport Association (ATA-STIG --          Duane Sebens
  Northwest Airlines)                             

                                                  Gary Vechik

  Airbus Industrie                                Yves Benoist

                                                  Capt. Jim Duncan

                                                  Jean-Michel Govaere

                                                  Anne Jany

                                                  Georges Rebender

                                                  Capt. William Reichert

  Airline Pilots Association (ALPA)               Kevin Comstock

                                                  William Edmunds

                                                  Capt. Daniel Ford

                                                  Roland Liddell

                                                  Michael Shelton

                                                  Tim Hester

                                                  Howard Long

                                                  Capt. John Sciera

                                                  Capt. Roy Tucker

  Allied Signal Engines                           David Looper

                                                  William Moring

  Allison Engine Company                          Donald Risser

                                                  Barry Rohm

  Association of European Airlines                Peter Malanik

  Atlantic Coast Airlines                         Ken Latour

  Atlantic Southeast Airlines (Regional Airline   Dean Karnatz
  Association)                                    

  Bombardier Aerospace                            Jim Donnelly

                                                  David Lamb

  British Aerospace (BAe)                         Tim Allen

                                                  Mike Bayley

                                                  Paul Emmerson

                                                  Dave Gibbons

                                                  Daniel Gurney

                                                  Len Houston

                                                  Colin Irvine

                                                  Martin Maltby

                                                  Rene Nibbelke

  CAE Electronics                                 Capt. Kip Caudrey

  Canadian Airline Pilots Association             Al Murray
  ----------------------------------------------- -----------------------

**Contributing Organizations and Individuals**

  ----------------------------------------------- -----------------------
  Canadian Airlines International                 Peter Howe

                                                  Capt. Jack Tucker

  Cessna Aircraft Company                         Doug Hazelwood

                                                  Donald Mallonee

  CHIRP                                           Peter Tait

  Cranfield University                            Helen Muir

  Embry-Riddle Aeronautical University            Marco Pizer

  European Regional Airlines Association (ERA)    Roy Humphreyson

                                                  Ian Wigmore

  Federal Aviation Administration (FAA)           Kathy Abbott

                                                  Donald Armstrong

                                                  Anne Azevedo

                                                  Tom Boudreau

                                                  Martin Buckman

                                                  Tom Clinton

                                                  Ed Cook

                                                  Michael Dostert

                                                  William Emmerling

                                                  Steven Kolb

                                                  Hals Larsen

                                                  Dy Le

                                                  George Lyddane

                                                  Lee Nguyen

                                                  Lanny Pinkstaff

                                                  Robert Pursel

                                                  Thomas Toula

                                                  James Treacy

  Federal Express Corporation                     Capt. Ryan Swah

  Fokker Services B.V.                            Wim Overmars

  General Aviation Manufacturer's Association     William Schultz

  General Electric Aircraft Engines               Roland Crandall

                                                  Tony Freck

                                                  Sarah Knife

                                                  Joseph Marksteiner

  Gulfstream Aerospace Corporation                Ted Mendenhall

                                                  William Shira

  Hartzell Propeller Inc.                         Roger Stallkamp

  Independent Consultant                          Tony Wassell

  International Air Transport Association (IATA)  Tore Granaas

  International Federation of Air Line Pilots     Capt. Steve Last
  Assoc. (IFALPA)                                 

  Joint Aviation Authorities (JAA/CAA)            Robin Boning

                                                  Hazel Courtney

                                                  David Lambourne

                                                  Rex Riddington

                                                  Laurent Gruz

  KLM                                             Desiree Van Leeuwen

  KLM - IFALPA                                    Wynand Moonan

  Lockheed Martin Aero and Naval Systems          Richard Trusis

  NASA Langley Research Center                    Paul Schutte

                                                  Anna Trujillo
  ----------------------------------------------- -----------------------

**Contributing Organizations and Individuals**

  ----------------------------------------------- -----------------------
  NASA Lewis Research Center                      Sanjay Garg

                                                  Carol Russo

                                                  Donald Simon

  National Transportation Safety Board (NTSB)     Kenneth Egge

                                                  Jerome Frechette

                                                  Douglas Weigmann

  Pratt & Whitney Canada                          Mark Feeney

  Pratt and Whitney                               Dick Parker

                                                  Al Weaver

  Raytheon Aircraft/Beech/Hawker                  Eric Griffin

                                                  Conrad Jackson

  Reflectone Inc.                                 Capt. Bruce Anderson

  Regional Airline Association                    David Lotterer

  Rolls Royce plc                                 John Chambers

                                                  Michael Cooper

                                                  David Gibbons

  Securite' de Vols -- Aviation Safety            Pierre Mouton

  Smiths Industries Aerospace                     Alison Starr

  SNECMA-Villaroche                               Gerard Clergeot

                                                  Yves Halin

  The Boeing Company                              David Carbaugh

                                                  James Johnson

                                                  Pam Rosnik

                                                  G. Philip Sallee

                                                  William Shontz

                                                  Jerry Swain

                                                  Dennis Tilzey

                                                  Van Winters

  The Boeing Company -- Douglas Products Division Steven Lund

                                                  Alan Macias

                                                  Paul Oldale

  Tompson Training and Simulation                 Michael Brookes

                                                  Mark Dransfield

  Transport Canada                                Andrew Chan

                                                  Len Cormier

  Transport Canada                                Michel Gaudreau

                                                  Larry Green

                                                  Merlin Preuss

  Transportation Safety Board of Canada           Nick Stoss

  UK Flight Safety Committee                      Peter Richards

  U.S. Air Force                                  Ken Burke

                                                  Major Jeff Thomas

  U.S. Army                                       Lawrence Katz

                                                  Robert Wildzunas

  United Airlines                                 Steve Ferro

                                                  Chuck Ferrari

                                                  Capt. Bill Yantiss
  ----------------------------------------------- -----------------------

> **VOLume 1 -- Table of Contents**

[Page No.]{.underline}

Foreword ii

Contributing Organizations and Individuals iii

Volume 1 -- Table of Contents vi

1.0 Executive Summary 1

2.0 Introduction 4

3.0 Definitions and Acronyms 8

4.0 Data Collection, Analysis Process and Results 12

5.0 Propulsion System Instrumentation and Failure Warning Systems 36

6.0 Simulator Capabilities and Realism with respect to Propulsion

System Malfunction 41

7.0 Flight Crew Training 44

8.0 Human Factors 50

9.0 Regulatory Requirements 63

10.0 Conclusions 66

11.0 Recommendations 69

Appendices List 72

Appendix 1 NTSB Final Recommendations for Jetstream 31 Accident, 13 Dec
94 73

Appendix 2 Letter from FAA to AIA 77

Appendix 3 Letter from AIA to FAA 80

**1.0 Executive Summary**

The task report presented herewith was undertaken by AIA/AECMA at the
request of the FAA in response to an NTSB recommendation arising from
the 13 December 1994 turboprop accident at Raleigh-Durham, which
resulted in fatal injuries to 15 passengers and 2 crew. The NTSB
findings in this event strongly suggested that a warning light intended
to indicate the activation of a recovery function was falsely
interpreted as engine failure and led to inappropriate crew action. The
FAA recognized that there were additional data suggesting that this
accident was one of a number of similar accidents, and that a study
would be appropriate to look into all commercial transport accident
histories where an inappropriate crew action may have been taken in
response to what should have been a benign propulsion system
malfunction.

The rate of occurrence per airplane departure for PSM+ICR accidents has
remained essentially constant for many years. These accidents are still
occurring despite the significant improvement in propulsion system
reliability over the past 20 years, suggesting an increase in rate of
inappropriate crew response to propulsion system malfunction.

At this point in time, the number of worldwide accidents for this
propulsion system malfunction with inappropriate crew response "cause"
is about 3 per year in revenue service, with an additional 2 per year
associated with flight crew training of simulated engine-out conditions.

A Project Group was formed, encompassing experts from authorities,
accident investigation agencies, airframe, engine, and simulator
manufacturers, and airline, pilot, and training organizations. The group
also included human factors experts from various organizations. The
Project Group gathered extensive data from all available sources where
propulsion system malfunction coupled with inappropriate crew response
led to an airplane accident/incident. These data were analyzed, and
conclusions and recommendations were developed based upon them.

The major conclusions from this project are:

a.  Although the vast majority of propulsion system malfunctions are
    recognized and handled appropriately, there is sufficient evidence
    to suggest that many pilots have difficulty identifying certain
    propulsion system malfunctions and reacting appropriately.

b.  Particularly in the turboprop arena, pilots are failing to properly
    control the airplane after a propulsion system malfunction which
    should have been within their capabilities to handle.

c.  While a review of instrumentation and warning systems was conducted,
    there is no clear evidence to link standards of engine
    failure/malfunction indications with the probability of
    inappropriate crew response. In addition, there are no human factors
    methodologies or human factors studies which provide clear evidence
    of the effects of a propulsion system failure indication on the
    probability of crew error. However, continued research and human
    factors activity in this area is strongly recommended, along with a
    review of the propulsion system instrumentation requirements.

d.  The group was unable to find any adequate training materials (books,
    videos, etc.) on the subject of modern propulsion system malfunction
    recognition.

e.  There are no existing regulatory requirements to train pilots on
    propulsion system malfunction recognition (stall/surge, severe
    engine failure, etc.)

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f.  The training requirements related to "Recognition and correction of
    in-flight malfunctions" are found in Appendix C of 14 CFR Part 63
    for **[Flight Engineers]{.underline}**. The disposition of the
    flight engineer's recognition training requirements to pilots of
    airplanes where no "Flight Engineer" position exists is not
    apparent. However, the expectation does exist that the pilots will
    perform the duties of the flight engineer.

g.  The simulator propulsion system malfunction models in many cases are
    inaccurate and/or do not have key cues of vibration and/or noise.
    There is also no robust process that ensures the quality and realism
    of simulator propulsion system malfunction models or that the
    malfunctions which are used in the training process are those most
    frequently encountered in service or those most commonly leading to
    inappropriate crew response. This shortfall leads, in some cases, to
    negative training.

h.  While current training programs concentrate appropriately on pilot
    handling of engine failure (single engine loss of thrust and
    resulting thrust asymmetry) at the most critical point in flight,
    they do not address the malfunction characteristics (auditory and
    vibratory cues) most likely to result in inappropriate response.

i.  The changing pilot population, coupled with reduced exposure to
    in-service events from increased propulsion system reliability, is
    resulting in large numbers of flight crews who have little or no
    prior experience with actual propulsion system failures.

j.  Data suggest that various opportunities exist for negative transfer
    of trained pilot behavior and experience when transitioning between
    different airplane types.

The major recommendations from this study are as follows:

a.  The requirements of 14 CFR Parts 61 and 121 / JAR-OPS / JAR-FCL need
    to be enhanced for pilot training in powerplant failure recognition,
    the effect of powerplant failure on airplane performance and
    controllability, and the subsequent control of the airplane.

b.  The regulatory authorities should establish and implement a rigorous
    "process" to ensure that the following occurs during the development
    of a pilot training program:

-   Identification of powerplant failure conditions that need to be
    trained;

-   Preparation of training aids (Tools & Methods);

-   Establishment of the appropriate means to conduct the training;

-   Assurance that each pilot receives the appropriate training for both
    malfunction recognition and proper response to it; and

-   Validation of training effectiveness, along with a feedback loop to
    improve / update training.

c.  The mandatory pilot training program associated with simulated V~1~
    engine failures in an airplane has caused a number of hull
    loss/fatal accidents. The value of performing this training in the
    airplane should be reviewed. It is the Project Group's belief that
    this specific training could be better effected in simulators. Where
    suitable simulators are not available, the airplane handling task
    could then be adequately and much more safely trained at altitude
    where recovery can be safely accomplished.

d.  The use of flight idle on turboprop airplanes for simulated engine
    failures or in the event of a malfunction should be reviewed by
    industry because of the potential association with loss of control
    events if the engine is not shut down.

e.  The aviation industry should undertake as a matter of high priority
    the development of basic generic text and video training material on
    turboprop and turbofan propulsion system malfunctions, recognition,
    procedures, and airplane effects.

f.  The regulatory authorities should establish a means to ensure that
    the simulators used to support pilot training are equipped with the
    appropriate realistic propulsion system malfunctions for the purpose
    of "recognition and appropriate response training". To this end, the
    industry should develop specifications and standards for the
    simulation of propulsion system malfunctions.

g.  A review of propulsion system instrumentation requirements should be
    completed to determine if improved engine displays or methods can be
    found to present engine information in a manner which would better
    help the pilot recognize propulsion system malfunctions.

h.  It is recommended that the aviation industry sponsor activity to
    develop appropriate human factors methodologies to study both
    annunciation and training effectiveness for turboprop and turbofan
    propulsion system failures.

i.  Circumstances of negative transfer from previous training or
    operations should be identified and their lessons learned should be
    communicated as widely as possible within the industry.

Supporting details for the above major conclusions and recommendations
are included in sections 10 and 11 along with others drawn from the
facts and data reviewed in this project.

**2.0 Introduction**

On 13 December 1994 a Jetstream 31 turboprop crashed at Raleigh Durham,
resulting in fatal injuries to 15 passengers and two crew. Three
passengers survived the crash. The accident was investigated by the
National Transportation Safety Board (NTSB), which concluded that the
pilot had mistakenly assumed that an engine had failed and subsequently
failed to respond appropriately. The NTSB considered recommending that
the regulations for future transport and commuter airplanes be modified
to require "clear and unambiguous indication of engine failure", however
this recommendation was not included in the final report. The final NTSB
recommendations (A-95-98) are provided as Volume 1, Appendix 1. The
Federal Aviation Administration (FAA), partly in reaction to the NTSB
investigation, requested that the Aviation Industries Association (AIA)
undertake a project to identify the issues related to the accident and
define any corrective actions required, see Volume 1, Appendix 2. In
response to the FAA, the AIA noted that a substantial number of serious
incidents and accidents had occurred with similar links in the causal
chain (based on the historical record of propulsion system related
accidents presented in the AIA PC-342 committee report of May 1993). At
this point in time, the number of worldwide accidents for this
propulsion system malfunction with inappropriate crew response "cause"
is about 3 per year in revenue flights, with an additional 2 per year
associated with flight crew training of simulated engine-out conditions.

The FAA request to AIA included undertaking a project to:

a.  Review relevant events and determine what factors influence crew
    errors following an engine failure.

b.  Define safety-significant engine malfunctions.

c.  Develop the guidelines for an engine failure indication system.

d.  Define the process and guidelines for an engine failure simulation.

e.  Define guidelines for engine failure recognition training.

f.  Identify the process for validating the effectiveness of these
    guidelines.

The FAA encouraged the AIA to invite broad participation with the
expectation that the project would eventually move into an Aviation
Regulatory Advisory Committee (ARAC) activity and progress into an
FAA/JAA/TC Harmonization Project, if required.

The AIA responded that it would undertake the requested project and
would examine the need for corrective action; see Volume 1, Appendix 3.
The initial focus of the project activity would be to assemble all:

-   relevant facts and data including associated historical accidents
    and incidents;

-   experience with various mitigation approaches;

-   fixed- and motion-based simulator capabilities and programs;

-   recommend potential improvement opportunities, and

-   other relevant information appropriate to a thorough study of the
    issue.

The AIA response further stated that the AIA believed all parties would
best be served by not prematurely focusing on \"a solution.\" An
AIA-Transport Committee (AIA-TC) "Project" was established and a
chairperson selected to initiate the project. The Project chairperson
chose the workshop approach for the meetings of the Project Group as the
most appropriate format for sharing relevant data, information, and
views. Additionally, the AIA-TC chairperson requested that The European
Association of Aerospace Industries (AECMA) co-sponsor and co-chair the
activity, and assist with the collection and analysis of turboprop
transport airplane event data. AECMA agreed to co-chair the Project, and
to help the data collection and analysis tasks related to turboprop
transport airplanes.

The conduct of this Project required contributions from various parties
with expertise in propulsion, flight crew training, airplane operations,
flight deck design, simulator design, and human factors. The effort
involved assembling and analyzing the available data (incidents and
accidents from commercial airplane operations), and understanding the
contributing factors to the events of interest, as well as the relevant
technologies. The military services (U.S. Air Force. and U.S. Army)
participated and shared relevant information and experience, including
potential solutions and research on mitigating technologies. Additional
information to promote a comprehensive viewpoint included operational
and training flight crew experience with turboprop/turbojet/turbofan
airplane propulsion system failures, the variation in propulsion system
failure indicating systems currently installed, and the appropriateness
of current training and simulation capabilities. Aviation human factors
experts were provided by Boeing, Airbus, British Aerospace, NTSB, NASA,
and the U.S. Army. Regulatory and accident investigation specialists
participated. The simulator manufacturers and flight crew training
specialists also made valuable contributions to the group's
understanding of simulation and training issues.

The Project Group created a number of Task Groups addressing specific
areas of interest. The Task Groups covered the following:

-   Turbofan data acquisition and analysis

-   Turboprop data acquisition and analysis

-   Simulation

-   Cockpit Instrumentation

-   Human Factors

-   Procedures and Training

-   Regulations and Advisory Materials

There are several places in the FAR's and JAR's related to transport
category airplanes that address loss of thrust from powerplants such as
FAR/JAR 25.107, 25.109, 25.145, etc. In summary, current regulations
require airplanes to be designed to have the capability of continued
safe flight after the failure of the most critical engine at the most
critical point in the flight. The achievement of this outcome is
obviously contingent on the flight crew's recognition that the
propulsion system has malfunctioned in order to take the appropriate
action.

During the last twenty years, there has been significant improvement in
propulsion system reliability as shown in Figure 2.1. Despite the
significant reduction in propulsion system malfunctions, the overall
PSM+ICR accident/incident rate has remained essentially constant,
suggesting that the likelihood of inappropriate crew response to the
propulsion system malfunction has increased. Uncontained engine failures
had previously been the dominant contributor to propulsion related
turbofan and turboprop airplane accidents, but with the steady effort of
the industry, uncontainments have been reduced. PSM+ICR is now the
dominant contributor (25% of hull loss and fatal accidents over the past
5 years) to propulsion related turbofan and turboprop airplane
accidents.

![](media/image3.emf){width="6.247222222222222in"
height="3.303472222222222in"}

**Figure 2.1** Summary of total Inflight Shutdown (IFSD) rates for
turbojets and turbofan

engines since 1958 shows a clear trend toward lower IFSD rates

The Project Group analyzed accident/incident information for both
turboprop and turbofan airplanes to try to establish why the improvement
in propulsion system reliability has not been reflected in the
accident/incident statistics. The work included examination of existing
propulsion system instrumentation, pilot training programs, and
simulator standards, as well as an assessment of possible changes to
regulatory requirements related to these fields.

Events considered as part of this study are those which were initiated
by a propulsion system malfunction on a single engine combined with an
inappropriate crew response to that malfunction which then resulted in
an accident or serious incident. In the process of data collection, a
significant number of training accidents where crews responded
inappropriately to simulated propulsion system malfunctions (e.g., V~1~
engine failure) have been identified. The Project Group management
decided it would be appropriate to offer some views in relation to these
training type of accidents.

It is clear from examination of the data that some areas of difficulty
encountered by flight crews are different in the turboprop and turbofan
worlds. The Project Group recognizes that transition of crews between
the airplane types will continue to occur; therefore, common solutions
must be found wherever possible, while highlighting any differences.

The Project Group acknowledges the contributions from all the major
airframe and engine manufacturers, simulator manufacturers, regulatory
authorities, training organizations, pilot groups, accident
investigation authorities, and participating operators, as shown in the
acknowledgment section.

1.  **DEFINITIONS AND ACRONYMS**

AECMA The European Association of Aerospace Industries

AEA Association of European Airlines

AIA Aerospace Industries Association

ARAC Aviation Rulemaking Advisory Committee

CAA Civil Aviation Authority

CFR Code of Federal Regulations

DC&ATG Data Collection & Analysis Task Group

DGAC-F Direction Generale de l'Aviation Civile (France)

EPDB Engine parameter display behavior

FAA Federal Aviation Administration

FAR Federal Aviation Regulations

HFEC Human Factors Error Classification

ICR Inappropriate Crew Response

JAA Joint Aviation Authorities

JAR Joint Aviation Regulations

NTSB National Transportation Safety Board

PSM Propulsion system malfunction

TC Transport Canada

PHASE of FLIGHTS:

Taxi On ground operation of the airplane prior to initiating takeoff run
and following the landing roll out from the active runway.

Rejected Takeoff A takeoff that is discontinued after takeoff thrust is
set and the takeoff roll has begun.

Takeoff The operational phase from application of takeoff power at the
start of roll until the airplane is 1,500 feet above the takeoff
surface, or at which the transition from takeoff to the enroute speed
(first power reduction) is completed.

Initial Climb The operational phase from 1,500 feet above ground level
or at which the transition from takeoff to enroute speed (first power
reduction) is completed lift off to flaps up retraction altitude.

Climb The operational phase from the end of initial climb until cruising
altitude is achieved.

Cruise The operational phase from the transition from climb to assigned
cruise flight altitude until the transition from cruise to descent.

Descent The operational phase from the end of cruise until the beginning
of approach at the initial navigation fix for the approach phase.

Approach The operational phase from the end of descent at the navigation
fix to wheels touchdown. The phase from the end of descent to the outer
marker, or 5 miles to the airport, is often referred to as Initial
Approach; Final Approach is then the phase from the end of Initial
Approach or outer marker to flare for touch down of the wheels.

Landing The operational phase from flare and touchdown of the wheels
until the end of roll out and turn off of the active runway.

Go-around An aborted approach/landing situation where the airplane is
commanded to a takeoff/climb pitch attitude and requires the application
of power to provide necessary airplane performance to abort the landing.

**Compressor stall/surge --** The terms "surge" and "stall" are used
interchangeably within this report to describe the breakdown of engine
airflow within the engine. Compressor stall/surge occurs when the
stability limit of a compressor is violated. A single surge event may
occur, or several may occur which are typically spaced less than one
second apart. A high-power surge is accompanied by an audible report
from the engine, which may be accompanied by tangible structure-borne
vibration and/or flames from the inlet and/or exhaust. Within the
engine, airflow reverses, leading to vibratory thrust pulsation and loud
acoustic noises, along with "flames" out the inlet and/or exhaust. The
symptoms associated with compressor surge are dependent on the level of
thrust or power at which the engine is being operated. At high power
levels, the thrust oscillations will be large and the noise will be
extremely loud akin to a cannon or a shotgun blast at 10 feet. At low
power, the thrust oscillation may not be noticed and the sound will be
muted; the only cues may be the effect on engine displays. Compressor
stall/surge may or may not be the result of a mechanical malfunction and
may or may not be recoverable.

**Symptom --** Symptom is defined in this report as a cue perceived by
the pilot. Symptoms may be auditory, visual, tactile or olfactory; i.e.
loud noise, the smell of smoke, a yawing motion or onset of vibration. A
symptom is what the pilot perceives as sensory input, which may suggest,
based on training, that something is different or wrong.

**Error Classification --** The following error type classification
definitions were identified and used in the assessment of the PSM+ICR
events:

**Skill-based behavior** is when the pilot executes a very familiar task
without consciously thinking about how it is executed, almost automatic.

Two types of **skill-based errors** can be identified:

-   slips; doing the right thing incorrectly - i.e., if the outcome of
    the action is different from intended.

-   lapses; intending to do something, but, because of distraction or
    memory failure, not completing the action.

**Rule-based behavior** is when the pilot performs a sequence of
familiar sub-routines that is consciously controlled by a rule or
procedure stored in long-term memory or a checklist. The rules can be in
the form of *if (state) then (diagnosis)* or *if (state) then (remedial
action)*. Rules can be gained through experience or communicated from
other persons' know-how as an instruction.

**Rule-based errors** are typically associated with the
misclassification of situations leading to the application of the wrong
rule or the incorrect recall of procedures.

Two types of rule-based errors can be identified:

-   errors of omission; not doing something you should do.

-   errors of commission; doing the wrong thing - also called mistakes.

**Knowledge-based behavior** comes into play when a pilot is faced with
novel, unfamiliar situations, for which no procedures are available. The
problem solving required in these unfamiliar situations is goal-driven.
Goals are formulated based on an analysis of the environment and the
overall aims of the person.

**Knowledge-based errors** arise from any or all of the following;
selecting the wrong goal, incomplete or inaccurate knowledge (of the
systems and the environment), and human limitations in terms of
information processing and memory required for complex problem solving.

The same two types of knowledge-based errors can also apply to
knowledge-based errors:

-   errors of omission; not doing something you should do.

-   errors of commission; doing the wrong thing-also called mistakes.

Reason (1990)[^1] describes that, with increasing expertise, the primary
focus of control moves from the knowledge based to the skill based
level; but all three levels can co-exist at any one time. For example;

-   diagnosis may be [knowledge based]{.underline} (unfamiliar
    situation),

-   once a diagnosis is made, a procedure is selected using rule-based
    behavior; and the procedure is performed in an automatic,
    highly-practiced manner (skill-based behavior).

**Propulsion System Malfunction + Inappropriate Crew Response
(PSM+ICR)** - An event where the pilot(s) did not appropriately handle a
single benign engine or propulsion system malfunction. Inappropriate
response includes incorrect response, lack of response, or unexpected or
unanticipated response.

**Negative Training** - Training effects which result in behavior that
is not appropriate in real operational flight situations (e.g. display
cues in engine failure training using engine fuel cuts are different
from the cues experienced during real engine failure in flight).

**Negative Transfer** (of training on different airplane) - Negative
transfer is when previous training or experience on another airplane
type is inappropriate, or even counter productive, in the current
airplane type. Negative transfer is most likely to occur during
stressful, high workload situations when pilots revert to 'old habits'.

**4.0 Data Collection, Analysis Process and Results**

The objective of the data collection and analysis task groups was to
examine the historical record of airplane accidents and incidents
related to propulsion system malfunction plus inappropriate flight crew
response (PSM+ICR) to identify potential improvement opportunities.
Experts from the airframe and engine manufacturers, flight crew
training, and regulatory agencies conducted the analysis.

Collection of relevant data for this activity focused on western-built
commercial transport airplanes. Each airframe and engine manufacturer
provided the best available factual information for the events involving
its respective products. It should be noted that the depth of
information available for accidents/incidents varies widely, and that a
great deal of difficulty was encountered getting substantive data on the
smaller turboprop airplane types. It is hoped that, in the future, more
emphasis will be placed on recording factual findings of such events
because of their importance to activities of the type undertaken here.

The data analysis teams focused on identifying the "key factors"
involved in the sequence of events, including flight deck symptoms,
cues, contextual variables, and classification of error types. Key
factors are those specific "links" in the chain or attributes of an
event sequence for each accident or incident that had a significant
impact on the outcome. In addition, an assessment to identify
opportunities to further minimize the probability of inappropriate crew
response to propulsion system malfunctions was conducted. PSM+ICR
accident and incident rates with respect to time were developed to
identify any trends. Accident and incident rates by worldwide regions
were assessed to determine any regional differences.

The data analysis process concentrated on a small number of "data-rich"
events. Care was taken to test that the conclusions drawn from these
events remained appropriate for those other events where data were
sparse.

The process for identifying improvement opportunities was carried out in
the following manner:

-   Each event was judged independently and improvement opportunities
    identified.

-   The opportunities identified from the data-rich events were assessed
    in relation to those with sparse results to ensure

a.  All potential solutions had been identified; and

b.  Identified solutions remained appropriate in all cases.

The analysis process was not intended to focus on the root cause of the
initial propulsion system malfunction, but rather on the malfunction
symptom(s) experienced by the flight crew and their response to that
malfunction symptom(s).

**4.1 Turbofan Data Analysis**

This section contains the results of the data and analysis for turbofan
accident/incident events from 1959 through 1996 for western built
commercial transport airplanes that are heavier than 60,000 pounds
maximum gross weight. There were a total of 79 events analyzed, 34 of
which were accidents. A summary of each event is contained in Volume 2,
Appendix 4.

This section also includes a qualitative judgment of improvement
opportunities. A summary of the conclusions reached by the group is also
included.

**4.1.1 Turbofan Propulsion System Malfunction Symptoms**

The propulsion system malfunctions symptoms present in turbofan
accidents and incidents are presented below.

[Symptom (Accident and Incidents) Percent of Total]{.underline}

Compressor stall/surge 63

Power loss 14

Stuck throttle (throttle remains fixed) 6

Fire warning 5

No response to commanded power 3

EGT warning light 1

Low oil quantity 1

Severe vibrations & perceived power loss 1

Suspected power loss due to airplane deceleration 1

Temporary power loss due standing rwy water ingestion 1

Thrust reverser "Unlock" light on 1

Thrust reverser did not transition to "Rev Thrust" 1

Thrust reverser to "Unlock" position, no power increase 1

[Symptom (Accidents Only) Percent of Total]{.underline}

Compressor stall/surge 53

Power loss 16

Stuck throttle (throttle remains fixed) 6

Fire warning 6

Suspected power loss due to airplane deceleration 6

EGT warning light 3

Low oil quantity 3

Temporary power loss - standing runway water ingestion 3

Thrust reverser did not transition to "Rev Thrust" 3

**4.1.2 Turbofan Event Categories**

The data analysis identified four major categories for the turbofan
PSM+ICR events. These categories are: Rejected Takeoffs, Loss of
Control, Shutdown/Throttled Good Engine, and Other.

-   Rejected Takeoffs

> at/above V~1~ following compressor stall/surge, severe vibration, or
> warning lights

-   Loss of Control resulting from:

> \- Undetected thrust asymmetry due to slow, quiet engine or throttle
> malfunction
>
> \- Aerodynamic cues masked by auto-throttle/auto-pilot until situation
> develops
>
> wherein airplane recovery becomes difficult

-   Shutdown/Throttled Good Engine

> Inappropriate crew response to an engine malfunction (surge, severe
> vibration) leading to shutdown or power reduction of the wrong engine
> either by:
>
> \- incorrect diagnosis
>
> \- incorrect action following correct diagnosis

-   Other

\- Difficulty isolating which engine is malfunctioning,

\- Failure to recognize the need to take action or follow established
procedures (i.e.,

continuously surging engines)

**4.1.2.1 Turbofan Rejected Takeoffs**

> Accidents (\*)

[SYMPTOM]{.underline} [No. Events]{.underline} [Fatal]{.underline}
[Hull]{.underline} [Subst Dmg]{.underline}

-   Rejected takeoffs at or above V~1~ resulting in runway overrun

Compressor stall/surge 16 1 2 5

Power loss 4 0 1 1

Fire warning 2 0 1 1

EGT warning light 1 0 0 1

Severe vibration / perceived power loss 1 0 0 0

Perceived power loss 1 0 0 1

Thrust reverser "Unlock" light - no overrun 1 0 0 0

-   RTO attempted after V~1~,

Compressor stall/surge 1 0 0 0

-   Rejected takeoff below V~1~ resulting in runway overrun

Compressor stall/surge 2 0 1 1

-   Rejected takeoff below V~1~ with no overrun

Mis-identified eng malfunction as tire failure [1 0 0 0]{.underline}

> **Totals** 30 1 5 10

Note (\*): The accidents are classified as Fatal, Fatal-Hull Loss, Hull
Loss or Substantial Damage per the National Transportation Safety Board
(NTSB) definitions.

Engine bird strikes played a role in 8/28 (29%) of the RTO events.

Another 8/28 (29%) of RTO's involved wet or contaminated runways.

**4.1.2.2 Turbofan Loss of Control**

Accidents

[SYMPTOM]{.underline} [No. Events]{.underline} [Fatal-H]{.underline}
[Hull]{.underline} [Subst Dmg]{.underline}

-   Loss of Control - In flight

Power loss 4 3 0 1

Stuck throttle (throttle remains fixed) 2 2 0 0

Loud bang, power loss 1 1 0 0

Training flight (V~1~ cut plus power loss) 1 0 1 0

Power loss & loss control returning to land 1 1 0 0

-   Loss of Control - On ground

Asymmetric thrust during landing 2 0 1 0

Uncoordinated approach and landing 3 0 2 0

resulting in offside landing - with

single engine power loss

14 7 4 1

No horizon or ground reference was present in 4/9 of the loss of control
accidents in-flight.

**4.1.2.3 Turbofan Shutdown / Throttle Good Engine**

> Accidents

[SYMPTOM]{.underline} [No. Events]{.underline} [Fatal-H]{.underline}
[Hull]{.underline} [Subst Dmg]{.underline}

-   Shutdown Good Engine (23)

Compressor stall/surge 6 0 0 0

Compressor stall/surge & power loss 4 0 0 0

Stuck throttle (throttle remains fixed) 3 0 0 0

Loud noise (growling sound), EGT rise 2 0 0 0

Fire warning 2 0 0 0

Power loss 2 0 0 0

Power loss, perceived both engines failed 1 0 0 0

Noise, vibration, compressor stall/surge 1 0 0 0

Vibration, smell, compressor stall/surge 1 1 0 0

Power loss, no throttle response 1 0 0 0

-   Throttled Good Engine (4)

Compressor stall/surge 3 0 0 0

Loud bang, power loss [1 0 1 0]{.underline}

Totals 27 1 1 0

**4.1.2.4 Turbofan - Others**

Accidents

N[o. Events]{.underline} [Fatal-H]{.underline} [Hull]{.underline} [Subst
Dmg]{.underline}

Failure to complete procedures 3 1 1 0

engine shutdown checklist

ATC communication error resulting 1 0 0 0

in shutdown of a good engine

Failure to detect asymmetric thrust 1 0 0 0

(stuck throttle)

Excessive pitch attitude with single 1 0 0 0

engine power loss

Continuous surging of multiple engines [2 1 1 0]{.underline}

8 2 2 0

**4.1.3 Turbofan Error Type Classifications**

Error classifications as defined in section 3 have been used in
analyzing the events. An in-depth discussion of the analytical results
for error type classification is provided in section 8.0, Human Factors,
which provides a description of the types of events corresponding to
these errors.

The following summarizes the results of the error classification. In
many of the events, multiple errors were assessed.

**Accident & Incidents Accidents Only**

[Error classification]{.underline} [% Total]{.underline} [Error
classification]{.underline} [% Total]{.underline}

Skill 29 Knowledge & Rule 29

Knowledge & Rule 26 Knowledge & Skill 19

Rule 21 Knowledge 14

Knowledge 10 Rule 14

Knowledge & Skill 7 Skill 14

Rule & Skill 7 Rule & Skill 9

**4.1.4 Turbofan - Potential Areas for Improvement**

A process was undertaken in an attempt to identify improvement
opportunities, based on data analysis. This process proceeded event by
event, using the following techniques. The conclusions offered here
should not be taken literally, but rather should be used to identify a
hierarchy (relative ranking) of the opportunities for improvement. Each
event was judged independently and evaluated qualitatively by the
analysis team of subject-matter experts.

The following definitions of areas where improvement opportunities could
be found were used.

**Design**

Annunciation - Design and implementation of an engine or system
malfunction indicating system.

System - Corrective design and implementation action on the cause(s) of
propulsion system malfunction.

Simulation - Design and implementation of representative propulsion
system failure symptomology (auditory, visual, & tactile cues) in
simulators.

**Training**

Initial - Flight crew training on the identification and proper response
to failure condition symptomology/annunciation/indication.

Recurrent - Exposure, training, and check ride testing on the
identification and proper response to failure condition
symptomology/annunciation/indication and current operating anomalies and
problems.

Academic/System - Audio and visual training (AVT) and computer-based
training (CBT) for recognition and training in system functions and
malfunction/failure characteristics.

**Simulation**

Fixed Base - Capability enhancement of failure/malfunction
representation for recognition and proper response training.

Full Flight - Capability enhancement of failure/malfunction
representation for recognition and proper response training.

**Procedures**

New - Development of new procedures related to failure/malfunction
condition; recommended action.

Modified - Enhancement of current procedure(s).

**Communication**

Manuals - Add material addressing the propulsion system malfunction into
Operating Manuals as appropriate.

Awareness - Special awareness/training publications including videotape
awareness information, operating bulletins, airline publications,
special briefings, and/or safety symposia.

**Crew Resource Management**

Crew Coordination - Additional training, etc., with emphasis on crew
coordination.

**Culture**

Cross-Culture Adaptation - Refers to those learning groups (such as
pilots, mechanics, et al) who have English as a second language and a
non-European language as their primary language. This refers especially
to cultures which use pictographs, Cyrillic symbols and/or reverse
reading direction (other than left to right and/or up to down). This
culture adaptation need is most evident in English-labeled flight decks.

**4.1.4.1 Summary of Results for Potential Areas for Improvement**

The data analysis team considered each event in the database and
determined by consensus what were the potential areas for improvement
based on each event. These potentials were then tabulated and are
presented as percentages in the table below.

![](media/image4.emf)

**Figure 4.1.4.1** Potential Improvement Opportunities

The areas with greatest potential improvement opportunities were those
of "awareness" and "systems design". Providing "awareness" information
to flight crews on these types of events and the symptoms that the crew
faced was judged by the team to be beneficial in all cases. Further, the
team realized that reduction in the frequency of the initiating
propulsion system malfunction/failures would also be effective (reduce
the rate directly). However, the data team noted that such improvements
(reducing the initiating propulsion system malfunction/failure rate)
would be difficult to achieve, at least in the near term.

Training (initial, recurrent and academic/systems) was judged to
represent good potential for improvement particularly if the training
was part of basic airmanship training. Training for malfunction
recognition could be integrated into current training programs with
negligible cost. Enhanced text and video material could be developed at
reasonably low cost. Training in malfunction recognition was seen as an
integral part of flight crew procedures training to ensure appropriate
response to malfunctions.

The design areas of annunciation and simulation symptomologies were also
considered to have high potential to provide improvement. Both
annunciation system and simulation symptomology design action should be
evaluated critically using the appropriate validity assessment
techniques.

It is clear there is no single solution. The data indicate that it will
take a combination of enhanced awareness, training and simulation of a
relatively few failure types to achieve an order of magnitude reduction
in the accident rate for PSM+ICR. The enhancement of full-flight
simulators with a few appropriately-designed engine malfunction
simulations, in conjunction with better training, was identified as
having a high potential for success.

**4.1.5 Turbofan - Phase of Flight for Events**

The figure 4.1.5 below depicts the percentage of turbofan events as a
function of flight phase. The majority of events, over 70% occur during
the takeoff and climb phase of flight.

![](media/image5.emf)

**Figure 4.1.5** Phase of flight distribution summary

**4.1.6 Turbofan Accident & Incident Rates**

The figure 4.1.6 below depicts the PSM+ICR annual accident rate per 10
million departures for the turbofan events. This rate was calculated
using the number of hull loss and substantial damage type accidents per
year divided by the total yearly commercial fleet airplane departures.
The annual accident rate for PSM+ICR appears to be constant.

![](media/image6.emf)

**Figure 4.1.6** Annual accident rate trend with time - Hull loss and
substantial damage

The figure below depicts the PSM+ICR annual Hull Loss-only accident rate
per 10 million departures for the turbofan events. This rate was
calculated using the total number of hull loss accidents per year
divided by total yearly commercial fleet airplane departures. The annual
accident rate for PSM+ICR appears to be basically constant.

![](media/image7.emf)

**Figure 4.1.6** Annual accident rate trend with time - Hull loss only

**4.1.7 Turbofan Regional data**

Differences appear to exist between the airplane accident rates in
different geographical and geopolitical regions. These differences have
been attributed to a number of factors such as cultural differences,
resource limitations, equipment used, underlying engine reliability
rates, training approaches, etc. The validation of cause and effect is
not clearly demonstrated by anything other than the rate difference.
Volume 2, Appendix 15 contains the charts developed to assess the
statistical differences by airline regional and airplane generation
aspects.

The differences in the accident rates for PSM+ICR were examined using a
number of statistical significance tests. The confidence intervals
suggest that some differences exist, but the statistically small number
of events, the existence of multiple potential underlying causes, and
the lack of detailed circumstantial information make it impossible to
definitively establish the reasons for the differences.

Several factors may play important roles in the rate differences. These
include the training program used and the cumulative experience levels
of the flight crews. When the group considers future trends such as more
pilots paying for their qualification training, improved powerplant
reliability with decreased exposure to on-the-job training, lack of
regulatory requirements for training beyond the V~1~ cut, and the
general decrease in cumulative flight deck experience, it is unclear
that the above-average historical experience in the US and Canada
community will continue into the future. There is a strong possibility
that differences perceived to be due to the training and experience in
less-developed regions will become the future for the developed
countries due to neglect of this type of training and the retirement of
crews who had the experience to recognize such failure conditions and
react properly. There is no reason to believe that any region is immune
to these types of accidents; therefore, early action would seem to be
indicated.

It would be preferable to be proactive than to wait for what is
perceived to be an increased exposure to these types of accidents in the
future years. There is nothing in the data to suggest either that the
U.S. and Canada are immune from these events, or that their rates will
continue to be better than the worldwide average.

**4.1.8 Turbofan Training Accidents**

A review of the historical accident record for western-built turbofan
airplanes involving training accidents where either single or multiple
engines were reduced to minimum thrust setting (simulated engine-out
conditions) was conducted to examine relative frequency, phase of
flight, and geographical location of the events. The following chart
depicts the number of simulated engine-out training related accidents
(Substantial Damage, Hull Loss, and Fatal) in comparison to the PSM+ICR
accidents since the beginning of commercial jet transport service.

![](media/image8.emf)**Figure 4.1.8** Comparison of PSM+ICR revenue
service events versus simulated engine-out crew training events

Volume 2, Appendix 5 provides a summary of the substantial damage, hull
loss and fatal type accidents for the turbofan training related events.
The following tables summarize the 30 simulated engine-out training
accidents history by phase of flight and the airline geographical
location. Analysis results of the simulated engine-out training related
events are only included in the section of the report.

**DATA PERIOD: 1959-1998**

[Flight Phase Events]{.underline} [Geographical Region
Events]{.underline}

Takeoff 11 USA 13

Go-around 1 Asia 5

Climb 5 S. America 4

Cruise/Inflight 2 Europe 3

Final Approach 4 Oceania 2

Landing 7 Canada 1

Africa 1

Middle East 1

> **DATA PERIOD: 1988-1998**

[Flight Phase Events]{.underline} [Geographical Region
Events]{.underline}

Takeoff 4 USA 2

Inflight 1 Asia 2

Landing 1 Oceania 1

S. America 1

**4.1.9 Turbofan - Summary of Findings**

-   Calendar frequency of accidents is 1 per year in revenue service and
    1 per year in training

-   Loud bangs [(compressor stall/surges)]{.underline} and/or
    vibration-related malfunctions are influencing factors and appear to
    be outside most crews' experience (training and service events).
    This class of symptoms is a major contributor to inappropriate crew
    response.

-   In all cases of accidents after RTO's above V~1~, the airplane would
    have flown satisfactorily.

-   Quiet malfunctions which are slow and have unobserved onset cues
    (masked by automatic controls) are a major contributor to
    inappropriate crew response.

-   Many flight crew members will never experience an in-service
    propulsion system malfunction (power loss, high power surge, no
    response to commanded power) in their careers (estimate 0.7 to 0.9
    events/career).

-   Crews appear to have sometimes reacted inappropriately to
    annunciation lights (Engine Fail, EGT exceedance, Fire Warning,
    Thrust Reverser Unlock) during takeoff phase at or above V~1~.

-   Crews sometimes had difficulty identifying which engine was
    malfunctioning. Modern surge recovery systems tend to eliminate an
    EGT exceedance as a visible cue of engine malfunction, thus making
    the identification of the affected engine more difficult.

-   Negative transfer due to basic ADI display philosophy differences
    may have been a factor in two "loss of control" accidents involving
    asymmetric thrust related events.

-   Regional similarities across groups exist with PSM+ICR event
    occurrence rates. However, there is nothing in the data to suggest
    that any regions are immune from these events. Airplane generation
    rate data breakdown indicates that no significant differences exist
    between airplane generation types.

In addition to the main study, a more detailed study which addressed all
engine malfunction-related RTO's above V~1~ in the GE/CFMI commercial
fleet, was completed. The results of this specific analysis supported
the conclusions of the main study given above, and produced certain
additional detailed conclusions as given below:

-   The number of RTO's above V~1~ per calendar year is increasing in
    line with the increasing number of airplane departures. The rate of
    inappropriate crew response to an alarming engine malfunction
    symptom in the high-speed portion of the takeoff roll is remaining
    constant per opportunity or engine malfunction.

-   The probability of inappropriate crew response is not affected by
    the number of engines on the airplane (i.e., having more instruments
    to watch does not increase confusion).

-   Engine compressor stall/surge, flight deck warnings, vibration and
    yaw are relatively likely to result in a pilot decision to reject a
    takeoff above V~1~.

-   There is considerable variation between operators in the incidence
    of RTO's above V~1~. Most geographical regions include operators
    with a significant incidence of these events.

-   Crew experience alone does not appear to affect the likelihood of
    the event.

The very limited data available indicate that an engine stall/surge
accompanied by a flight deck warning may have a higher probability of an
RTO above V~1~ than an engine stall/surge without a flight deck warning.
The detail charts of this study are provided in Volume 2, Appendix 6.

**4.1.10 Turbofan - Potential Corrective Action Opportunities**

The following are suggested as potential corrective action
opportunities:

**A.** To provide assistance to crews in identifying that an engine has
malfunctioned:

-   Develop a flight crew "Awareness Package" to provide information to
    line-flying pilots to provide the following:

    1\. Examples of appropriate and inappropriate crew responses
    (lessons learned)

    2\. Types of engine malfunctions, characteristics and flight deck
    effects

    3\. Frequency of malfunctions

    4\. Impact of technology features on crew recognition and the need
    for no action

    (e.g., surge detection and recovery)

-   Enhance the crew training curriculum (expand engine events beyond
    V~1~ throttle chops), malfunction simulation representation, and
    training for both recognition and proper response for propulsion
    system malfunctions.

-   Train crews for engine surge malfunction recognition and proper
    response.

-   Provide a means to assist crews in identifying which propulsion
    system is malfunctioning in-flight (may not be feasible for legacy
    hardware).

B.  Communicate the meaning of V1 and its related performance aspects to
    line-flying

pilots.

**4.2 Turboprop Data Analysis**

Regrettably, only a few turboprop airplanes have flight data recorders;
therefore the data available from turboprop accidents is
disproportionately small. Although the data enabled identification of
Loss of Control as the major category to PSM+ICR accidents, insufficient
data were available from the accident information to allow a meaningful
analysis of the reasons for the loss of control. In an effort to
understand the underlying factors in the Loss of Control events,
advantage was taken of the engineering and operational expertise of the
manufacturers, airline, and pilot representatives participating in the
data analysis task group. The participants' experience of actual
incidents which involved potential loss of control situations both in
operation and simulations was used as a basis for recommending potential
improvement opportunities. Data in this report were obtained from formal
accident reports and manufacturer databases. The incident experience
drawn upon by the experts may be not included in these data. It has been
determined that all data included in this report are in the public
domain and, therefore the relevant data set is provided in full in
Volume 2, Appendix 7 for the PSM+ICR turboprop events. Volume 2,
Appendix 8 provides a summary of the turboprop training-related
accidents.

Of the initial 114 events that were collated, only 75 met the objectives
of this report. During the initial review phase, additional searches for
data relating to known events were not successful. Of the final 75
events only a few had sufficient data to elaborate on the accident
cause; these were classified as data-rich events.

A significant number of events were rejected as failing to meet the task
criteria. In some of these events, it was the Inappropriate Crew
Response that preceded the Propulsion System Malfunction; i.e., the crew
actions caused the engines to fail, which subsequently led to an
accident. Many of these Inappropriate Crew Responses were associated
with flight in icing conditions and crew actions in fuel system
management. Although not part of this report, the crew actions (human
factors), in these events should be investigated further, as they may
give insight to human errors that lead to propulsion system malfunction.

Accidents involving flight training where the engine failure was
simulated have been retained in the database and have been used in this
analysis.

The analysis considered the following categories:

-   Distribution over time.

-   Phase of flight and event category.

-   Error type.

-   Type of malfunction, type of flight.

-   Effect of autofeather.

-   Geographical location.

Detailed analysis concentrated on data-rich accidents.

The analysis was reviewed with operators and manufacturers who
participated in the study, and whose opinion were sought to confirm the
conclusions. Issues relating to training and airplane instrument
displays were also discussed with operators, often resulting in
wide-ranging differences of opinion.

Human factors analysis of the data did not show any root causes for the
accidents due to insufficient data. However, several human-centered
factors were identified by the operators who participated in the study
which would appear to center on training and operating problems.

Subdivision of airplane accidents involving non-14 CFR 121 operations,
or those involving airplanes with 19 or less seats failed to show any
patterns that differed from the general conclusions.

Specific airplane flight deck and instrument arrangements were reviewed.
Again, the lack of data prevented quantitative analysis, and many
conclusions in these areas are also subjective.

**4.2.1 Distribution over time**

The annual numbers of turboprop PSM+ICR events since 1985 are shown in
Figure 4.2.1 below. It will be seen that there is no recognizable upward
or downward trend in the annual numbers. However, it does show that
these events continue to occur at a rate of 6 3 events per year,
indicating that action is required if this rate is to be reduced. The
data for 1997 are only partially complete.

![](media/image9.emf)

**Figure 4.2.1** Chronological Distribution of Turboprop PSM+ICR Events
since 1985

**4.2.2 Phase of Flight**

The number of propulsion system malfunction events which occurred during
a particular phase of flight is shown in Fig 4.2.2. The phases of flight
are defined in Section 3.0 of this report. The dominant phase of flight
for all turboprop propulsion system malfunctions is Takeoff - this
accounts for half of the accidents. The next highest flight phase in the
rankings was Approach, where there were 12 events (16% of the total).

![](media/image10.emf)

**Figure 4.2.2** All events, by phase of flight

All of the take-off events occurred once the airplane were airborne.
There was one rejected takeoff (RTO) event recorded for turboprop
airplanes. This is a significant difference from turbofan events. The
reason for this difference is that most turboprop operations are not
conducted from runways where the accelerate-stop distance is limiting.
Even at the "spoke" airfields of the typical US "hub and spoke"
operations, runways are 7000 - 8000 feet long and are more likely to be
obstacle clearance limited. This forces the turboprops to reduce
take-off weights, which further improves their stopping capabilities.
High speed aborts on turboprops seldom result in overruns.

There were no data-rich events in the takeoff phase of flight.

**4.2.3 Event Category**

The accidents were categorized and the results are plotted on Figure
4.2.3 below. The dominant event category is Loss of Control, accounting
for 63% of all events.

![](media/image11.emf)

**Figure 4.2.3** All events, by category

4.  **Flight Phase and Event Category**

Figures 4.2.2 and 4.2.3 show clearly that Takeoff and Loss of Control
individually dominate their respective analyses. Figure 4.2.4 shows that
these two classifications strongly coincide. A correlation of the data
by flight phase and event category shows that 70% of the "powerplant
malfunction during takeoff" events led to loss of control, either
immediately (22 events) or on the subsequent approach to re-land (4
events). Or, put another way, 55% of the "loss of control" events
occurred during the takeoff phase of flight.

It is concluded that the overwhelming majority of turboprop accidents
resulting from powerplant malfunctions occur during the takeoff phase of
flight and are due to the loss of control of the airplane.

![](media/image12.emf)

**Figure 4.2.4** All events, by category and phase of flight

5.  **Error Type**

Each accident was evaluated to determine the specific error type
associated with the inappropriate crew response. However, the assessment
was based on the opinions of the experts involved. The error types are
those defined in Section 3.0 of this report. Figure 4.2.5 below shows
the distribution of error types.

![](media/image13.emf)

**Figure 4.2.5** All events, by type of error

For a given (certificated) airplane type, rule-based errors are
generally addressed by training**.** Discussion of this data with
operators supported these findings and again identified problems, in
human factors, training, and regulation, which are discussed later.

6.  **Type of Flight**

The percentage of accidents for a given type of flight is shown at Fig
4.2.6. Revenue flights accounted for 80% of the events. As discussed
previously, the data does not support a detailed breakdown between 14
CFR Part 121 and other operations.

A disproportionately large number of events (17%) occurred during
training or test flights.

![](media/image14.emf)

**Figure 4.2.6** All events, by type of flight

7.  **Type of Powerplant Malfunction**

The types of powerplant malfunction identified as the initiating event
are shown in Figure 4.2.7. Propulsion system failures resulting in an
uncommanded total power loss was the dominant category. Turboprop
engines seldom experience compressor stall/surge. This is significantly
different from the situation on turbofans. Discussion with engine
manufacturers concluded that one reason for this difference is that most
turboprop engines (and some small turbofan engines) have a centrifugal
stage in the compressor and hence are more tolerant to instability.

"Shut down by crew" events are those where either a malfunction of the
engine occurred (partial power loss/torque fluctuations etc.) and the
crew then shut down that engine, or where one engine malfunctioned and
the other (wrong) engine was then shut down. The distinction between
"shut down by crew" and "failed" is that in the "failed" events the
engine suffered a total power loss prior to any crew intervention.

There were 6 of the 13 "shut down by crew" events where the pilot shut
down the wrong engine - three of which were on training flights where
the instructor had deliberately throttled one engine and the student
then shut down the wrong engine. Accidents where the engine was not shut
down, but maintained at flight idle, identified a category where there
could have been a serious misunderstanding and lack of knowledge of
turboprop operations. When an engine is at idle the unfeathered
propeller can give negative thrust, which, particularly at low airspeed,
can result in a thrust asymmetry beyond that for which the airplane was
certificated. Events in this category included training and deliberate
"idle" selection by the crew. Each of these categories will be discussed
later.

![](media/image15.emf)

**Figure 4.2.7** All events, by type of powerplant malfunction

8.  **Failure Cues**

There is little data to show which sensory cues, other than system
alerts and annunciators, that the crew used or failed to use in
identifying the propulsion system malfunction. Also, it is unknown
whether, in fact, the crews recognized that they had a powerplant
malfunction, or which powerplant was malfunctioning. Unfortunately, in
the turboprop accidents, few of the crew survived.

9.  **Effect of Autofeather**

The influence of autofeather systems on the outcome of the events was
examined. The "loss of control during takeoff" events were specifically
addressed since this is the type of problem and flight phase for which
autofeather systems are designed to aid the pilot. In 15 of the events,
autofeather was fitted and armed (and is therefore assumed to have
operated). In 5 of the events, an autofeather system was not fitted and
of the remaining 6, the autofeather status is not known. Therefore, in
at least 15 out of 26 events, the presence of autofeather failed to
prevent the loss of control. This suggests that whereas autofeather is
undoubtedly a benefit, control of the airplane is being lost for reasons
other than excessive propeller drag.

**4.2.10 Geographical location**

The analysis of the data with respect to geographical location was
inconclusive. The largest number of accidents took place in North
America, but this is roughly in proportion to the number of turboprop
airplane operating in the geographic regions. Additionally, the Western
Hemisphere produced more consistent data.

**4.2.11 Operations and Personnel**

The following statements were derived from discussions between the
turboprop task group members, based on personnel experience, and were
assembled to provide some perspective on the potential differences
between turboprop and turbofan powered airplane operations. In the quest
to understand why pilots were losing control of the airplane, the
following potential contributing factors were identified. There has been
no statistical analysis performed to substantiate the following issues.
Although the data enabled identification of Loss of Control as the major
category to PSM+ICR accidents, insufficient data were available from the
accident information to allow a meaningful analysis of the reasons for
the loss of control. In an effort to understand the underlying factors
in the Loss of Control events, advantage was taken of the engineering
and operational expertise of the manufacturers, airline, and pilot
representatives participating in the data analysis task group. The
participants' experience of actual incidents which involved potential
loss of control situations both in operation and simulations were used
as a basis for recommending potential improvement opportunities.

Some turboprop operations are frequently characterized as having
lower-cost operations, lesser experienced crews, and airplanes which may
be demanding in flight path/speed control following engine failure. The
pilot associations and airline members report a decrease in the
availability of experienced pilots. Training groups report that pilot
candidates having less motivation or natural ability are allowed to
progress through basic training. Regional airlines report a high
turn-over rate of pilots in the turboprop sector, particularly by
advancement to jet airplanes, that further reduces the turboprop
operator\'s experience level, resulting in early promotion of
lower-experienced first officers. Some operators reported that some
captains did not trust junior first officers due to the first officers'
low experience level and training.

Thus, in most in-flight emergencies, those captains not only flew the
airplane and commanded the drills to be taken, but also actively
participated in the drills, which detracted from the primary task of
flying.

Older turboprop airplanes had a reputation as being demanding in skill
and workload. A crewmember would expect to serve an apprenticeship as a
first officer to acquire skills and experience of situation and
diagnostic technique. More recent airplanes utilize designs and
equipment, which are more error tolerant. However, as the overall crew
qualifications and skill levels can easily be eroded by the high turn
over rates and expectation of early promotion, those pilots now flying
older airplanes are disproportionately less experienced. There should be
a review of the balance of requirements between airplane certification
and crew qualification, particularly for inexperienced crews flying
older airplanes. It was also reported that instructors and authorized
maintenance test pilots can be appointed to those positions as staff
jobs, without the necessary experience or abilities. There are no
requirements for specific training that must be completed before
assuming an instructor's or authorized maintenance test pilot's
position.

The connection between the certification basis of the airplane (the
assumptions made about crew capability to recognize and handle) and
pilot training is unclear to the participants of the task group. This
forms the basis for the recommendation for the development of a process
to ensure that all parties have a clear understanding of the
philosophies and assumptions on which the designs are based. Also, there
should be formal training and qualification for instructors and
maintenance test pilots.

12. **Human Factors**

The following major issues have been identified during the analysis of
the turboprop data:

Examples of negative training have been identified where the symptoms
and modeling of propulsion system malfunctions can be inconsistent with
the real operational event. In addition, with the preponderance of
on-aircraft training, the only training exposure pilots see is the
throttle cut to idle at V~1~; again, this is inconsistent with the kinds
of events most likely to be seen in service operational environment.

Negative transfer has also been seen to occur since initial or ab initio
training is normally carried out in aircraft without autofeather
systems. Major attention is placed on the need for rapid feathering of
the propeller(s) in the event of engine failure. On most modern
turboprop commercial transport airplanes, which are fitted with
autofeather systems, this training can lead to over-concentration on the
propeller condition at the expense of the more important task of flying
the airplane.

Both negative training and transfer are most likely to occur at times of
high stress, fear and surprise, such as may occur in the event of a
propulsion system malfunction at or near the ground.

Loss of control may be due to lack of piloting skills or it may be that
preceding inappropriate actions had rendered the airplane uncontrollable
regardless of skill. It is very difficult, with just the database, to
sort these two situations out. The recommended solutions (even within
training) would be quite different for these two general circumstances.
In the first instance, it is a matter of instilling through practice the
implementation of appropriate actions without even having to think about
what to do in terms of control actions. In the second instance, there is
serious need for procedural practice. Physical and mental workload can
be very high during an engine failure event. The physical aspects are
determined by the certification requirements. However, many turboprop
airplanes have higher control forces than turbofan airplanes, and thus
may be physically more demanding. It is suggested that the certification
requirements related to control forces be reconsidered in light of the
above assessment.

**5.0 Propulsion System Instrumentation and Failure Warning**

**Systems**

**5.1 Turbofans**

The indication task group was composed of members from each of the major
airplane and engine manufacturers, the FAA, the NTSB, and airline flight
crews. The group heard presentations from several parties detailing
potential problems with existing designs, proposed new methods for
presenting information to the flight crew, and discussed real-life
experiences which had resulted in accidents.

A primary area of concern is during takeoff roll approaching and above
V~1~ where warning messages have influenced flight crews to abort even
when the takeoff should have been continued; e.g., above V~1~. (It is
noted that there has been much discussion and confusion concerning the
flight crew decisions and actions that have to be completed at or before
V~1~ when aborting a takeoff. Actions have been taken by the various
manufacturers and certification authorities which are designed to
address this issue.)

Crews have aborted takeoffs based on lack of indications following a
loud noise or heavy vibration. In at least one case, a severe engine
stall or surge was thought to be a bomb, and the captain elected to
abort the takeoff after V~1~. It is possible to indicate the source of
some surges and engine noises. Several engine manufacturers have stated
that their FADEC-equipped engines could detect a compressor stall/surge
and send a message in a timely manner to the cockpit. Tire failures,
which sound like an engine surge on some airplanes, are already
annunciated throughout the length of the takeoff roll (no V~1~ inhibit)
on at least one airplane. It would also be possible to annunciate severe
engine out-of-balance conditions to the flight crew. However, the data
also indicate that flight crews have inappropriately aborted takeoffs at
high speed based purely on cockpit indications. Some pilots have
indicated that a timely, reliable and \"trained to\" indication of the
source of a noise or vibration could provide the necessary information
for the crew to decide that an airplane is airworthy, when in the past
they would have been convinced otherwise.

A further area of concern was power asymmetry resulting from a slow
power loss, stuck throttle, or no response to throttle coupled with
automatic controls. Flying aids, such as the auto-pilot and
auto-throttle, can mask significant power asymmetry until a control
limit is reached. At this point, the flight crew has to intervene,
understand the malfunction, and assume control of an airplane which may
be in an upset condition. Better indications and/or annunciations of
power asymmetry could warn crews in advance and allow them time to
identify the problem and apply the appropriate procedures.

A separate issue of cockpit indications inducing crew error relates to
the design layout of those indications in at least one event. Although
the existing regulation in FAR/JAR 25.1321(c)(1) is explicit, the
evaluation of a particular layout is subjective. The layout factors
should not be ignored, and the suitability of new displays for use by
airline pilots should be further evaluated. Consideration of the
development of additional guidance material for FAR/JAR 25.1321 is
recommended.

The task group discussed the issue of whether presentation of all
parameters required by the FAR/JAR regulations helps or hinders in
diagnosing engine malfunctions. These parameters may help in trend
monitoring, but their varying relationships at different power and
atmospheric conditions make them difficult for crews to use when
analyzing a problem.

Improvements in cockpit indications alone may not significantly reduce
crew error in handling propulsion system malfunctions. In takeoff abort
situations, digital flight data recorder (DFDR) information shows that
the flight crew\'s decision is often made and executed within 2 seconds
of the event. In a number of instances, crews testified that the actual
propulsion system malfunction they experienced was unlike anything they
had ever heard or seen. They incorrectly concluded that the airplane was
not airworthy.

A topic that merits further consideration is that of the use of
automation to warn the crew when they may have taken an inappropriate
action in response to a malfunction; e.g., a challenge regarding the
selection of an engine to be shut down.

Volume 2, Appendix 9 contains the results of a fleet survey of engine
failure indications for turbofan powered airplanes.

**5.2 Turboprops**

1.  **Instrumentation and Displays**

The role of engine and flight instruments displays in accidents was
considered during the analysis and Volume 2, Appendix 10 contains a
fleet survey of turboprop airplane engine failure indications. However,
the wide variation, differing applications, and lack of specific data
relating to displays precludes a statistical analysis.

2.  **Engine Instruments**

There were no accidents where instruments or engine displays could be
clearly identified as the root cause. There were accidents where
displays may have contributed to the outcome, but, even in these
instances, there were extenuating circumstances of poor maintenance or
flight training. It is observed that as airplane designs have evolved,
the size of the turboprop engine instruments has been reduced. While, in
the past, classic, direct-drive propeller airplanes had three large ATI
propeller gauges, modern turboprop displays may be as small as one inch
in diameter. Additionally, parameters have been grouped within a single
display and occasionally use concentric pointers.

3.  **Propeller Instruments**

On turboprop airplanes malfunctions of the propeller subsystem may be as
or more critical than engine malfunctions. Although not directly
supported by the accident analysis there exists a body of
incident/accident data which suggests that more-comprehensive propeller
condition instrumentation may be beneficial for turboprop airplanes,
particularly those with free-turbine installations. It is therefore
recommended that and appropriate group within the FAA/JAA harmonization
process consider additional propeller instrumentation.

**5.2.4 Airplane Instruments Potentially Relevant to Loss of Control**

Turboprop airplane flight instruments have improved in recent years. The
three small ATI attitude and compass displays have been replaced with
five large ATI instruments or more, recently, EFIS. With the advent of
integrated displays and redundant airplane electrical designs, turn rate
instruments are no longer fitted to modern airplanes. However, many
pilots undertook their basic twin engine flying training in airplanes
using a 'turn co-ordinator' instrument, where rate of turn is depicted
in a similar manner to roll attitude. Recently, some major flight
training establishments have banned the use of this instrument, as it
can be misunderstood as bank angle. The more traditional turn needle and
slip ball are now used. Human factors investigation has shown that
well-learned responses from basic training may have a significant effect
in later years. Thus, the use of the 'turn co-ordinator' in basic
training could result in incorrect concentration on roll control at the
expense of controlling lateral acceleration in the event of an engine
failure. **Industry should investigate the suitability of turn
co-ordinator instruments in training airplanes where commercial
airplanes do not use these displays.**

5.  **Lateral Acceleration**

In recent years, lateral acceleration displays have decreased in size,
particularly when integrated with Electro-mechanical ADIs or EFIS.
However, the requirement to control slip is still a vital parameter in
controlling turboprop-powered airplanes in asymmetric flight. In
turbofan-powered airplanes slip is now not so important, as the control
systems and engine locations have changed with time. Turboprop airplanes
often use displays and formats developed for large jet transports, but
the turbofan transport EFIS symbol size and format may be totally
inappropriate for turboprop airplanes. Some of the turbofan airplanes
have automatic rudder compensation or little requirement for the control
of lateral acceleration in the event of an engine failure, particularly
on rear-engined airplanes. These airplanes have smaller slip displays,
which may be inadequate for turboprop airplanes. Thus, some turboprop
airplanes have less than optimum instrument displays for lateral
acceleration. **The requirements for the clear display of lateral
acceleration should be reviewed.**

6.  **Flight Directors**

Modern airplane flight instrument displays have flight-directed (FD)
guidance systems. Few of these have been optimized for use following
engine failure. Most control laws used in take-off modes are based on
heading/roll and pitch attitude. If this type of FD is used when an
engine fails the resulting airplane yaw will result in a flight-directed
roll command to restore the heading or a wings-level attitude. The
pilot's natural instinct and trained response is to follow the FD; the
command is conceptually similar to a turn co-ordinator instrument. The
emphasis on the control of lateral acceleration by immediate use of
rudder is lost, as there are no flight directed rudders. The pitch FD
command during takeoff, and in some systems go-around, is to maintain
constant attitude, but the original value is almost certainly
inappropriate for a climb with an engine failed. The requirement is to
control speed, particularly respecting the V~mca~ and stall margins.
Few, if any, turboprop airplanes have a takeoff/go-around FD mode with a
speed command control law**. A Flight Director display should not be
used during takeoff or go-around unless it has been specifically
approved for engine failure operations.**

7.  **Low Speed Awareness**

EFIS displays with low speed awareness symbols may provide enhanced cues
of low speed following an engine failure. If the airplane is
inappropriately configured or the propeller has not been feathered, the
crew does not have a display of the increased minimum control speed
(V~mca~). The adjustment of the low-speed symbol to match the V~mca~ for
the actual airplane configuration should be considered in future
designs. EFIS strip speed displays, with high values at the top,
conflict with the convention of speed an attitude control, 'pulling up'
to the high numbers results in loss of speed. Similarly, with these
displays, fast slow indications cannot be used due to conflicting
direction of error information. The exposure time of airplanes with
these displays is still relatively low in comparison to the time-scale
of the database, and there was no conclusive evidence from the data to
suggest that instrument displays caused any accidents.

**5.3 SUMMARY**

1.  For turbofan engines, an "engine surge" indication could be
    beneficial. Such an indication would be useful within one second of
    the event during the takeoff and go-around phases of flight, and
    should be engine-position specific.

2.  An asymmetric thrust indication displayed to the flight crew when
    the thrust asymmetry exceeds a pre-determined value could be
    beneficial.

3.  An engine failure indication, e.g., \"ENG #\_ Fail\", displayed to
    the flight crew when the engine rolls-back or runs down to a
    sub-idle condition, could be beneficial.

4.  A review of propeller condition instrumentation is recommended to
    establish if additional instrumentation could be beneficial.

5.  Manufacturers' representatives indicated that retrospective
    embodiment of additional engine failure/malfunction indications,
    particularly on non-FADEC engines, would be extremely difficult, if
    not impossible.

6.  A tire failure indication provided to the flight crew within one
    second of the tire failure during both the takeoff and landing
    phases of operation could be beneficial.

7.  A review of propulsion system parameters is recommended to determine
    if improved engine displays or methods can be found to present
    engine information in a manner that would help the flight crew
    recognition and handle engine malfunctions.

8.  Standardization among the airplane manufacturers regarding engine
    caution and warning messages and inhibit strategies during different
    flight phases (reference ARP 450D) is recommended.

9.  The locations of Warnings, Indicators, and Controls should not lead
    to a mistaken association with a particular engine.

10. It is evident that, where practical, all of the messages associated
    with systems that are affected by an engine failure be made
    secondary to a primary \"engine failure (sub-idle)\" indication.

11. Consideration should be given to the use of automated systems to
    provide warning that a crew action may be inappropriate.

**6.0 Simulator Capabilities and REALISM with Respect to Propulsion
System Failures**

**6.1 Overview**

The FAA and the ATA both conducted reviews of powerplant malfunction
simulation characteristics in modern simulators during the course of
this project. These reviews disclosed variability (lack of
standardization) and, in some cases, the lack of realism of the sound
and motion for specific simulated propulsion system malfunctions. The
lack of realism had previously not been considered significant, as
flight simulators were primarily intended to be used for training
performance and controllability issues and were not expected to be used
for propulsion system malfunction recognition training. There are no
standards or specifications for the design and presentation of many
propulsion system malfunctions in flight simulators. The reason for the
observed variability and lack of realism is due to the prior lack of
industry recognition of the need for propulsion system malfunction
recognition pilot training. No criticism is intended or implied by the
above preceding statement.

**6.2 General**

Volume 2, Appendix 11 contains the results of a simulator survey
conducted worldwide. There is a significantly lower number of simulators
for turboprop than for turbofans. Simulators are evaluated and
classified by various regulatory standards; e.g. FAA AC 120-40B or
JAR-STD. These standards address all instruments, equipment, panels,
systems, and controls as installed in the simulator, including the
assemblage of equipment and computer software programs necessary to
represent the airplane in ground and flight operations, through the
range of normal operations and a number of abnormal and/or emergency
situations; a visual system that provides an out-of-the-cockpit view; a
motion system; a sound system for providing appropriate sounds and
noises throughout the operating range of the airplane; and a control
loading system to provide the pilot with proper control feel and
feedback.

Throughout the development of airplane flight simulators, there has been
a concerted effort to measure all performance and handling qualities of
the simulator against the same parameter as measured on the airplane. It
was for this reason that the criterion adopted for the basis of this
measurement has been that "...only (the aircraft) manufacturer's flight
test data (is) accepted for initial qualification" and that
"...exceptions to this policy must be submitted to appropriate
regulatory authorities for review and consideration" before being
accepted.

A majority of the airplane flight simulators in service at this time
represent turbofan-powered transport category airplanes. However, there
are a growing number of smaller business jet or commuter jet simulators
coming on line. An even smaller number of simulators represent
turbo-propeller-powered airplanes. In fact, of the complete simulator
inventory, only approximately 15% simulate turboprop airplanes. This
disparity is primarily due to the relative cost of the airplane and its
respective simulator. It may also be in part due to the current
regulatory requirement to use airplanes to accomplish all of the
required training and testing for all pilots, initially and recurrently
-- and a mere "authorization" to use simulation, if desired, to meet
those same requirements. The cost of operating a turboprop airplane may
well be essentially equal to what it may cost to lease time in a
qualified simulator for the specific airplane type, not to mention the
cost of transporting pilots from their home base to the simulator's
location and the per diem necessary during their stay. However, the use
of simulators for training in place of the airplane even for turboprop
types is increasing. In fact, in Canada, the use of a simulator is
mandated for airplanes above 19 seats, and the U.S. is in the process of
mandating the use of a simulator for all Part 121 operations; i.e., 10
seats and above. Certain relief is expected for limited applications and
the change will allow the use of airplanes for the completion of
training, testing, and/or checking activities that cannot be supported
in Level A or Level B simulators.

**6.3 Overall Realism**

In today's simulators, for all airplane types, the synergistic operation
of the aerodynamic programming, the visual system, the motion system
(including the control loading system), and the sound system provides an
excellent level of realism when compared to the operation of an
airplane. The objective is that pilot behaviors that are demonstrated
and reinforced in the simulator, as well as skills that are learned and
polished in the simulator, are behaviors and skills that should not have
to be adjusted or adapted when they are required to be used and depended
upon in the airplane. Such facility provides for more complete training
and more complete evaluation of pilots; and that yields a more
competent, and thereby, a safer pilot.

Currently there is an active Sound Requirements Working Group that has
the objective of describing both static and dynamic cases where sounds
as heard in the airplane cockpit will be developed for use in the
simulator. This situation is applicable only to Level D simulators, but
all simulation device levels will undoubtedly benefit from having this
type of objective data available.

**6.4 Realism with Respect to Engine Malfunctions or Failures**

Among the current regulatory requirements for pilot training, testing,
and checking is one that requires that pilots be trained for and
demonstrate competence in being able to handle the airplane should they
experience an "engine failure" (usually a "failure" of the most critical
engine or the propeller on the most critical engine) at the most
critical point of flight, typically V1. When these tasks were
accomplished solely in the airplane, this engine/propeller "failure" was
simulated by a rapid throttle reduction to an idle thrust position.

When training, testing, and checking of pilots was moved largely from
the airplane into simulators, the requirement for training and
competency demonstration during "engine/propeller failures" remained
unchanged. The typical malfunction represented in the simulator for
training remained the rapid loss of thrust rather than more
representative failures likely to be seen in operation. Where attempts
were made to include more representative malfunctions, these were often
programmed, modified, and "tuned" to a series of subjective descriptions
related by the relatively few pilots who experienced them, rather than
based on data from real events.

There is a growing quantity of information that indicates the
simulations provided in pilot training, testing, and/or checking are not
sufficiently realistic. Perhaps the most notable malfunction that fits
this description is that of a low airspeed, high engine-RPM compressor
stall/surge on a high bypass, turbofan engine. Pilots who have
experienced such occurrences describe moderate to severe airframe
buffeting or vibrations, a "shotgun blast" noise that startles everyone
in the airplane cockpit, and if at night, flames streaking forward of
the engine inlet, accompanied by the airplane response to the rapidly
varying thrust. Pilots who have flown simulators with malfunctions or
failures programmed to simulate certain circumstances often report that
buffeting or vibrations and the accompanying noise of a compressor
stall/surge at high engine RPM is unrealistically low in most, if not
all, simulators.

The group opinion is that, while the aerodynamic/visual/control
feel/motion cueing of current advanced simulators is good, the motion
system buffeting and sound system contributions do not well represent
many propulsion system malfunctions, particularly high power compressor
stall/surge of the turbofan engine. There is currently no basis for
standardization of the propulsion system malfunction cues.

**6.5 Probable Areas of Focus -- Simulator Motion and Sound Systems**

The simulator manufacturers have confirmed that it would be possible to
modify both motion and sound systems of simulators to improve the
realism of propulsion system malfunction representation. The engine and
airframe manufacturers also confirm that data can be made available to
produce more realistic malfunction simulations. Care is needed to ensure
the increased levels of vibration and noise do not degrade the system
capability.

As part of the Project Group's activity, a survey was initiated to
establish the extent of data available from the airframe, engine and
propeller manufacturers, which could assist in ensuring more realistic
malfunction simulations. This work is on going and not yet completed.
However, Volume 2, Appendix 12 contains a proposed list of propulsion
system malfunction descriptions which need to be considered for
incorporation into simulators for malfunction recognition training.

**7.0 Flight Crew Training**

**7.1 General**

In the days of reciprocating engines and the early generations of jet
and turboprop airplanes flight engineers were assigned the duties of
recognizing and handling propulsion system anomalies. Specific training
was given to flight engineers on these duties under the requirements of
CFR Part 63 - Certification: Flight Crew Members Other than Pilots, see
Volume 2, Appendix 13. To become a pilot, an individual progressed from
flight engineer through co-pilot to pilot and all pilots by this
practice received powerplant malfunction recognition training. In those
times, the majority of pilots were likely to see several engine failures
during their careers, and failures were sufficiently common to be a
primary topic for discussion in the pilot fraternity. Today, it is not
clear how pilots learn to recognize and cope with propulsion system
malfunctions.

With the huge improvement in reliability of turbofan and turboprop
engines in the last 20 years, many pilots will never experience a
genuine engine failure in service. In addition, the pilot profile is
changing rapidly, with a large reduction in the number of ex-military
pilots in commercial service and a significantly shorter time to achieve
the position of captain (approximately 3 to 6 years recently as compared
to 15 to 20 years historically in the major carriers). Both the training
and the flying regime in the military provides much greater exposure to
propulsion system malfunctions and the need to properly diagnose and
deal with them.

At present, pilot training and checking associated with propulsion
system malfunction concentrates on emergency checklist items which are
normally limited, on most airplanes, to engine fire, in-flight shutdown
and re-light, and, probably, low oil pressure. In addition, the training
and checking will cover the handling task following engine failure at or
close to V~1~. In order to maximize the handling task in the latter
case, the most rapid loss of thrust, a fuel cut or engine seizure is
usually most appropriately used. Pilots generally are not exposed in
their training to the wide range of propulsion system malfunctions that
can occur.

No evidence was found of pilot training material (books, videos, etc.)
on the subject of propulsion system malfunction recognition on modern
engines. Nor, apart from 14 CFR 63, Flight Engineer Training, was there
any requirement to provide such training.

The range of propulsion system malfunctions that can occur, and the
symptoms associated with those malfunctions, is wide. If the pilot
community is, in general, only exposed to a very limited portion of that
envelope, it is almost inevitable that the malfunctions that occur in
service will be outside the experience of the pilots (flight crew). It
was the view of the group that, during basic pilot training and type
conversion, a grounding in propulsion system malfunction recognition is
necessary. This should be reinforced, during recurrent training with
exposure to the extremes of propulsion system malfunction; e.g., the
loudest, most rapid, most subtle, etc. This, at least, should ensure
that the malfunction is not outside the pilot's experience, as is often
the case today.

Powerplant malfunctions communicate to the flight crew in multiple ways.
Loud noise, onset of vibration, display behavior, and smells of smoke
are some of the cues, of a malfunction. Lacking training and exposure to
these cues, and with the increased reliability of modern engines and
propellers, there is little chance for a pilot to gain experience as a
co-pilot before being called upon to provide an appropriate response as
the pilot in command. The accident and incident event data examined in
this project suggest that pilots have difficulty in determining the
appropriate action when confronted with a situation never before
experienced.

It is beyond the charter of this project to suggest how pilot training
should be conducted on propulsion system malfunctions recognition. The
design of modern commercial transport airplanes requires that an
airplane be designed to provide the capability for continued safe flight
and landing after the failure of the most critical engine at the most
critical point in the flight. The realization of continued safe flight
is critically dependent on the pilot recognizing and appropriately
responding to powerplant malfunctions. The lack of training on the
recognition aspect is seen as a significant oversight. In the future, it
is suggested that designers should make note of the malfunctions that
pilots are expected to recognize and handle. In addition, a process
should be developed to collect this information and pass it forward to
the pilot-training community to address. If designers must assume that
pilots will recognize a malfunction and take appropriate action to
minimize the chance of a hazardous or catastrophic effect, there should
be a process that ensures all pilots receive the appropriate training.

The industry trend is for some ab initio pilots to be required to pay
for their initial training. This emerging practice puts pressure on
training companies to provide training at a cost that individuals can
afford. Without a regulatory requirement for propulsion system
malfunction recognition training to be provided or taken, only a minimal
level of training will be provided. It is recommended that a qualified
group of training experts review the supporting data and material
enclosed, and be tasked with defining an appropriate minimum
recognition-training standard. It is recommended that an attempt be made
to recapture some of the training course material for flight engineers;
that material should then be used as a baseline.

The lack of text books, videos, etc., on the subject presents a
challenge.

Volume 2, Appendix 12 contains a proposed list of simulator malfunctions
that need to be considered for propulsion system malfunction recognition
training.

Crews need to train to build the confidence that they can safely
continue a takeoff with an engine failure past V~1~. The high number of
runway departures following high-speed rejected takeoffs (RTO's) beyond
V~1~ with turbofan airplanes clearly indicates that a number of factors
may unduly influence captains at 250+ feet per second ground speed to
make the wrong decision in not continuing the takeoff.

Although it is important to quickly identify and diagnose certain
emergencies, the industry needs to effect cockpit/aircrew changes to
decrease the likelihood of a too-eager crew member in shutting down the
wrong engine. Many pilots today obtained their early multi-engine time
and ATPs in a reciprocating twin. The standard mentality is to train to
achieve lightning reflexes and decision-making in the event of an engine
failure during or after takeoff. With the acknowledgment that certain
engine/propeller malfunctions require immediate action due to high-drag
conditions, it is seldom required to identify, diagnose, and secure jet
and turbofan powerplants in a radically short elapsed time period. Yet
that is conventional thinking. Many pilots today flying jet equipment
have considerable flight time on reciprocating/turboprop airplanes. The
think-quick/secure-quick mentality is still there in the jet cockpit
when the flight crews move up from the prop to the jet ("first learned,
most retained" {Law of Primacy}). However, there are very few turbofan
powerplant failure scenarios that require such immediate action. Except
for four-engine airplanes, there are no "critical" engines on a jet as
with a prop airplane. Emphasis during training for jet crews should be
placed on deliberate, considered actions during an engine failure. Habit
patterns are hard to break.

**7.1.1 Summary**

Accident and incident events from history have similar characteristics.
These characteristics suggest that the flight crew did not recognize the
propulsion system malfunction occurrence from the symptoms, cues, and/or
indications. The symptoms and cues were, on occasion, misdiagnosed
resulting in inappropriate action. In many of the events with
inappropriate action, the symptoms and cues were totally outside of the
pilot's experience base (operational and training). The symptoms and
cues, common to the majority of turbofan transport events, were very
loud noise (similar to a shotgun blast at 10 feet) and/or the onset of
extreme vibration. The levels of these symptoms and the airplane's
reaction to them, had not been previously encountered by the flight
crew. Loud noises and vibration cues were occasionally misidentified
(e.g. tire failure) as powerplant failures, and also have led to
inappropriate response.

Any assumption that engine failure recognition training will occur in
service is not currently valid with modern engine reliability. The onset
of aural and tactile cues in powerplant failure in modern simulators is
still inadequate and misleading relative to the accident and incident
cases assessed. To recognize powerplant failures, the entry condition
symptoms and cues need to be presented during flight crew training as
realistically as possible. When these symptoms and cues cannot be
presented accurately, training via some other means should be
considered. Care should be exercised to avoid the chance of negative
training. The need to accomplish failure recognition emerges from
analysis of accidents and incidents that initiated with single
powerplant failures which should have been, but were not, recognized and
responded to in an appropriate manner.

Flight departments, from ab initio upward to the largest flight training
departments, need to develop unique and innovative methodologies to
better educate and train aircrews in the basics of powerplant operations
and aerodynamics. All pilots need solid understanding of the performance
factors that drive V~x~, V~y~, V~2~, and other important airspeed
requirements. Special attention should be devoted to pilots who are
transitioning from a high-time background in another airplane, for habit
patterns will be deeply ingrained. Transition and even upgrade pilots
should be afforded some amount of free play time during simulator
sessions to experiment with engine-out flying qualities, the special
combination of indications and warning/advisory lights, and as many
perturbations of engine/system anomalies as possible.

**7.2 Turboprop Training**

**7.2.1 Training Engine Failure Recognition**

Training for engine failure or malfunction recognition is varied. It is
feasible that a pilot throughout training will never have had to
identify a failed engine. Engines are shut down to practice re-start
drills. During these demonstrations, the pilot does not have to evaluate
the condition of the gas generator or propeller system by reference to
the instruments; \"the fuel is off so, it must have stopped\". This is
indicative of a reaction to a single piece of data (one instrument or a
single engine parameter), as opposed to assessing several data sources
to gain information about the total propulsion system.

During in-flight engine failed training (for the purpose of practicing
airplanes handling), the engine is only simulated failed. Again, the
pilot gains no experience of actual engine failure recognition. The
propulsion system instruments show a normal, healthy engine but at low
power. The dominant datum is the instructor retarding the power lever.
An additional negative aspect of simulated in-flight training is that
during a go-around, only the live engine power lever is advanced. For
those accidents where one engine was at idle as a precaution, the crew
is not pre-disposed to using the idling engine.

Operators reported that there is little or no training given on how to
identify a propulsion system failure or malfunction. Often, audio
identification predominates due to the awareness of propeller pitch
change, but this is only a single data source which could represent
either a propulsion system failure or a minor engine control system
malfunction. A cross-check of propulsion system parameters between
engines is taught as a quick reference to identify which engine has a
problem. However, this technique does not always give sufficient
information about a particular engine or necessarily the correct answer.
Industry should provide training guidelines of how to recognize and
diagnose the engine problem by using all available data in order to
provide the complete information state of the propulsion system.

**7.2.2 Operational Training**

Generally, flight or simulator training is procedure based. Many
operators only train to the minimum standard; i.e., to pass the takeoff
V~1~ cut check ride and, where applicable fly a single engine go-around.

There are few specific requirements for propulsion system failure
recognition or malfunction diagnosis.

Airplane flight handling policy is often decided at operator level,
either by the management and training staff or local authority
inspectors. Surprisingly, operators reported varying opinions on whether
to control the yaw before roll or vice versa as the correct immediate
action for an engine failure. The airframe manufacturer normally gives
this advice, but where it is not explicit, or there is no textbook to
refer to, folklore and partially understood aerodynamic theories are
used to justify procedures.

Basic and recurrent training should include a consistent and in-depth
explanation of asymmetric thrust flight and the flight control
techniques to be used. Industry should consider the provision of
training aid material to support the identification of propulsion system
failure or malfunction and to standardize training for asymmetric
flight. For example, many training schools and operators teach the
necessity to trim the airplane in yaw at V2 to reduce the high foot
loads due to asymmetric thrust. However, they may also fail to teach or
demonstrate that, as the airplane subsequently accelerates, the
requirement for rudder decreases. From the new trimmed state, the rudder
force and position lessen as airspeed increases; these can appear to the
pilot to be in the opposite sense to that required to control the
initial failure. This potential confusion, together with the stress of
the situation, may adversely affect the crew's performance. Some
manufacturers recommend that, following a propulsion system failure, yaw
trim should not be used or applied fully until the airplane has reached
the final take off speed.

**7.2.3 Stall recovery training**

The recommended procedure for stall recovery training should be reviewed
by industry as it is believed to be a source of negative transfer
between turboprops and turbofans. Maintaining adequate speed is
essential to controlling of the airplane. The small performance margins
in turboprop airplanes result in low climb rates during single engine
operations; thus, the crew may be reluctant to lower the pitch attitude
in order to accelerate. Furthermore the basic stall warning recovery
training could compound this situation. If training teaches to hold a
constant attitude, apply power and achieve minimum height loss, there is
little or no applicability of this technique to the problems of
low-speed flight following engine failure. Classic stall recovery
training concentrates on the low power and approach and landing
scenarios, where power can be applied to restore speed without attitude
change. Stalls with an engine failed during takeoff or go-around are not
taught due to the problems of V~mca~. With an engine failed, speed can
only be controlled by adjusting attitude, as power is already at the
maximum. This technique is in conflict with the basic stall recovery
training and may therefore cause confusion during low speed flight with
an engine failure.

**7.2.4 Use of Flight Idle**

It is concluded from review of the accidents occurring during training,
where one engine was deliberately set to flight idle, that either the
check pilot did not understand the flight mechanics of turboprop
airplanes at flight idle power or failed to maintain the conditions
simulating an engine failure. At flight idle, the unfeathered propeller
will give negative thrust at low airspeed. For zero thrust a particular
value of torque must be set and maintained with changing airspeed.
During training or a check flight it is possible that, since the
instructor has to act as both the non-flying pilot as well as the check
and safety pilot, the attention to power resetting can be overlooked.

The use of flight idle in training has two further negative aspects.
Firstly, retarding an engine to idle is of little value for the
recognition of a true engine failure by reference to instruments. In
some cases (free turbine engines), the core engine is running normally
and the propeller speed or torque is artificially set to a false value.
The propeller torque is adjusted, or should be set, to give zero thrust.
This is similar to day-to-day conditions during a descent and thus gives
the crew a feeling of normality. Secondly, once a crew has been given
training with an engine at flight idle they then could be predisposed to
use the technique as a precaution for a partially diagnosed or minor
powerplant malfunction. The use of flight idle for training during
simulated engine failures and as a precautionary action in the event of
a propulsion system malfunction should be reviewed by industry.

**7.2.5 Negative Thrust**

When given a choice between shutting an engine down or selecting idle,
the crew often opts for idle. This is due to a situation where it may be
better to maintain an engine at idle with the propeller feathered for
electrical or hydraulic services as a precaution against a further
problem rather than shutting the engine down. This debate applies for
free-turbine installations only, as in the case of single shaft engines,
the engine must be shutdown to feather the propeller. This issue is
another potential source of negative transfer. If, with an engine at
idle, with an unfeathered propeller, the crew fails to recognize the
problem of negative thrust at low airspeed, or, conversely, fails to
appreciate the higher effective V~mca~ (which the manufacturer does not
have to publish), loss of control is most probable. Although most
manufacturers advise the correct propulsion system setting for zero
thrust, there is no mandated training for this operation, nor for any
demonstration of the increased V~mca~.

Abnormal flight operations with the engine at idle (zero thrust)
resulted in an accident recorded by one of the data-rich events. The
airplane deviated from the flight path during the approach due to
negative thrust, and, during the subsequent go-around the handling pilot
lost control of the airplane. This type of behavior occurs in other
events, particularly during go-arounds where the crew does not use the
precautionary engine for power, and the handling pilot fails to
recognize the negative thrust and then loses control. Modern airplane
certification standards are such that an airplane can be flown safely
with an engine shut down and that a failure of the remaining engine is
very much less likely than the requirement to fly a go-around. Most
manufacturers recommend that for an engine malfunction the engine should
be shut down with the propeller feathered. However, where there is
choice, pilots appear to have developed closely held assumptions
regarding the need for additional redundancy. This issue should be
reviewed by industry but training should clearly indicate the
manufacturer's recommendations, and the logic behind them.

**8.0** **HUMAN FACTORS**

1.  **Background**

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1.  **Human Factors Role in the Workshop**

Human Factors Specialists participating in the AIA Workshop on PSM+ICR
had three important functions to perform:

-   Provide real-time inputs on the human factors perspective to issues
    under discussion by the various task groups during workshop
    sessions.

-   Develop and implement a process to validate the recommendations made
    by the workshop task groups using error data derived from human
    factors analyses of the accident/incident databases of the Data
    Collection & Analysis Task Groups - Turbofan & Turboprop.

-   Develop human factors-based recommendations related to methods for
    validating the effectiveness of proposed corrective actions when
    implemented.**\
    **

The human factors (HF) specialists involved in the workshop process and
HF Task Group came from Airbus, Boeing, British Aerospace, FAA, NASA,
NTSB, and the U.S. Army. The human factors specialists, knowledgeable in
commercial air transport issues, are a limited resource. The Project
Group wishes to express their thanks for the help provided.

2.  **Databases**

There are three databases involved in the development and validation of
the recommendations produced by the workshop. These are:

-   The Data Collection & Analysis Task Group (DC&ATG) - Turbofan
    summary database (Volume 2, Appendix 4) and results for turbofan
    events described in Section 3.1 of this report.

-   A human factors error classification database derived from the
    summary event data of the Turbofan - DC&ATG database (Volume 2,
    Appendix 14).

-   The Data Collection & Analysis Task Group - Turboprop database
    (Volume 2, Appendix 7) and results for turboprop events described in
    Section 4.2 of this report.

The first two of these three databases served as the primary sources for
recommendations and for the development of the validation process to
support those recommendations. The related research to be described
below served as secondary sources for the validation process.

3.  **Related Research**

Human Factors research related to the efforts of the workshop is of two
types: that dealing with the classification of errors and inappropriate
responses of aircrews in the presence of system malfunctions, and basic
applied research on flight crew/system interface design.

A review of research on flight deck design, especially as related to
propulsion systems and as conducted at NASA Langley Research Center
(LaRC) was presented at the initial AIA/AECMA Workshop on PSM+ICR held
in Seattle, WA, in January of 1997[^2]. This material contains
recommendations on both top-level conceptual issues as well as specific
research results. Additional relevant research references were also made
available as an addendum to the presentation. This material will be
particularly useful in support of efforts to validate any proposed
design solutions that may be derived from workshop recommendations.

The work of several authors on the classification of errors in aviation
accidents was also reviewed. Research directly relevant to workshop
issues as well as relevant error classification work is discussed in
more detail in Section 8.4.2.7. The relationship of the results of this
related work to the results of the Human Factors Error Classification
(HFEC) model and the error classification database generated in support
of the workshop activities is discussed as well.

2.  **Database Development and Analysis**

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1.  **Turbofan Database**

A description of the development of the PSM+ICR database and analysis of
the data for turbofan events is discussed in Section 4.1 of this report.
A member of the Human Factors Task Group participated in an initial
detailed analysis of the events in the summary version of this database.
Conclusions and recommendations resulting from the activities of the
DC&ATG-Turbofan are to be found in the above-mentioned section. The
summary data on which the results and recommendations from the
DC&ATG-Turbofan are based were used in developing the Human Factors
Error Classification (HFEC) database. The validity of the workshop
recommendations will be addressed using this latter database.

**8.2.2 Turboprop Database**

For various reasons, the Turboprop Database has such a paucity of
context data that no validation of the turboprop recommendations based
on human factors error classification data could be included in the
workshop final report. However, a large number of human factors issues
are dealt with and recommendations made based on the data available.
These are summarized in Section 4.2 TURBOPROPS and other sections of the
report related to the analysis of turboprop accident/incident data.

**8.3 Overview of Human Factors Analysis**

A detailed summary of the results of and rationale for applying the
Human Factors Error Classification (HFEC) model to the DC&ATG - Summary
Turbofan Database can be found in Volume 2, Appendix 14. Also included
in this appendix are the complete HFEC database and the error
classification model used in deriving the database. Table 8.3 below
provides an overview of the data summarized in Appendix 14 and permits
comparison of the results with other studies of flight crew error to be
discussed in Section 8.4.2.7. A total of 218 cognitive errors were
identified within the 79 events of the Summary Turbofan Database. The
average number of errors per event was 2.8, with a range of errors per
event of 1 - 9. There were only two events in which there was only one
cognitive error identified. This finding of multiple cognitive errors
per events precluded an attempt to achieve a simple mapping of
recommendations to event and thus dictated the approach taken in
relating the Human Factors recommendations to the overall workshop
recommendations.

The error classification data are organized by error category, number of
events in which the error occurred, and percent of error total. Within
some of the categories, a further breakdown is shown with headings that
help to relate the data to other research efforts to be discussed later.
The percentage values shown for these generic subcategories represent
percentages within the category.

**Table 8.3 Summary of Error Data by Error Categories**

**[Category]{.underline}** **[\# of Errors]{.underline}** **[Percent of
Total]{.underline}**

**Detect** **18** **8%**

**Interpretation** **81** **37%**

Processing 55 68%

Knowledge 26 32%

**Strategy/Procedure** **47** **22%**

**Execute** **72** **33%**

Slips/Lapses 18 25%

Other skill-based errors 54 75%

(execution, coordination,

piloting skills, timing, etc.)

> **Totals** **218** **100%**

The **bolded** numbers under the "# of Errors" column represent the
total number of times errors in each category occurred in the database.
It is interesting to note that when the number of events in which a
major category of error occurred are counted, the pattern of frequency
across error categories is the same. That is, **detection** errors
occurred in 18 events, **interpretation** errors occurred in 58 events,
**strategy/procedure** errors occurred in 44 events, and **execution**
errors occurred in 47 events. As can be seen, multiple interpretation
and execution type errors within an event were more likely than
detection or strategy/procedure errors. The former two categories of
error had the greatest number of sub-categories and thus provide greater
opportunity to develop more detailed bases for the recommendations. This
greater potential is reflected in the level of detail that could be
provided for the workshop recommendations related to errors of
interpretation and execution.

**8.4 Validating Recommendations**

**8.4.1 General**

The term "validation" as used here refers to the process of determining:

a.  that there is a direct and documented link between the human
    behavior in PSM+ICR events and the workshop recommendations;

b.  that the human factors analyses of the types of errors observed or
    inferred in the PSM+ICR events not only substantiate the
    recommendations but also provide sufficient guidance for specific
    actions which may be taken to implement the recommendations; and

c.  that there are at least generic, if not specific, guidelines for
    human performance testing to assess the effectiveness of implemented
    recommendations in both training and design.

Accomplishing this validation process was the major task confronting the
Human Factors Task Group (HFTG). Toward this end, an error model was
developed and applied to the turbofan summary database (see Volume 2,
Appendix 14). The error classification database developed from this
application goes beyond the error classification work already done by
the DC&ATG. The purpose of obtaining this additional detail in error
classification was to provide needed insight into the cognitive aspects
of PSM+ICR as a basis for detailed recommendations in training and
design. Application of the error classification database to the
recommendations of the project group is presented below.

**8.4.2 Support for Workshop Recommendations**

Taken together, the error classification data illustrated in Table 8.3
above and summarized in Volume 2, Appendix 14 show strong support from
several perspectives for the workshop recommendations which relate to
crew training and design. A detailed discussion follows of the error
data as they can be applied to specific aspects of flight crew training.
No specific recommendations are made at this time regarding flight deck
design. However, the generic recommendations for how flight deck design
issues should be addressed (e.g., the need to validate the effectiveness
of current and future system malfunction annunciations) are included
later, as are generic recommendations on the validation of training
solutions which may grow out of workshop recommendations. A detailed
mapping of error category data to the workshop recommendations follows.
Also included here is a discussion of related applied research and error
classification efforts. This related research tends to verify the
appropriateness of the workshop error classification work in that the
pattern of results obtained here fits quite well in general with
patterns obtained with other error models and pilot populations.

**8.4.2.1 Detect**

Most of the errors identified across events within this category were
monitoring errors; that is, failure to monitor ("note") control position
(e.g., throttles, switches, levers) or engine instrument behavior,
either as noting deviations from normal in a detect sense or failure to
monitor these deviations over time. Recommendations here can focus on
both training and design. Because of the differences in the details in
type of engine parameter display behavior (EPDB) to be noted and
differences in the root cause producing the non-normal EPDB, emphasis on
detection and interpretation should be addressed in training. Throttle
position, or, more generally, thrust asymmetry, can perhaps best be
addressed with alerts. This design recommendation recognizes the role of
very high workload, very low workload, and distractions as major
contributing factors to this type of error.

**8.4.2.2 Interpret**

Errors in integrating and interpreting the data produced by propulsion
system malfunctions were the most prevalent and varied in substance of
all error types across events. This might be expected given the task
pilots have in propulsion system malfunction (PSM) events of having to
integrate[^3] and interpret [data]{.underline} both between or among
engines and over time in order to arrive at the
[information]{.underline} that determines what is happening and where
(i.e., to which component). The error data clearly indicate that
additional training, both event specific and on system interactions, is
required. This training theme is to be found throughout the conclusions
of the DC&ATG-Turbofan and overall recommendations of the workshop.

In twenty-two (22) events alone, crews reacted inappropriately on the
basis of one or two very salient cues (e.g., loud "bangs", yaw,
vibration), thus failing to integrate all the data relevant to
understanding what was happening and where. It should be possible to
modify this behavior through training, given improved representation of
PSM's in simulators during initial training, recurrent training, and
proficiency checks. This same **failure to integrate relevant data**
resulted in seven (7) instances where action was taken on the wrong
engine. These failures to integrate data occurred both when EPDB was
changing quickly (and thus more saliently), as well as when it was
changing more slowly over time. Training in turbofan airplanes needs to
continually emphasize the necessity of taking the time to integrate
[all]{.underline} data relevant to a PSM in order to interpret the
situation correctly and enhance the likelihood that appropriate action
will be taken. There is anecdotal evidence to suggest that some
operators may consciously or unconsciously establish training
environments that tend promote too-rapid response to PSM's. There is
also potential for negative transfer of training and experience from
turboprop to turbofan airplanes (e.g., in certain turboprop airplane
engine malfunctions, immediate action is required in order not to lose
control of the airplane). Negative transfer issues such as this should
be considered in detail in the development of training programs.

A second subcategory of errors related to interpretation involved
**erroneous assumptions** about the relationship between or among
airplane systems and/or the misidentification of specific cues during
the integration/interpretation process. Errors related to erroneous
assumptions should be amenable to reduction, if not elimination, through
the types of training recommended by the workshop. Errors due to
misidentification of cues need to be evaluated carefully for the
potential for design solutions.

A third (and major) subcategory of errors leading to inappropriate crew
responses under "interpret" was that of **misinterpretation of the
pattern of data** (cues) available to the crew for understanding what
was happening and where in order to take appropriate action. Errors of
this type may be directly linked to failures to properly integrate cue
data because of incomplete or inaccurate mental models at the system and
airplane levels, as well as misidentification of cues. A number of the
events included in this subcategory involved misinterpretation of the
pattern of cues because of the similarity of cue patterns between
malfunctions with very different root causes; in some cases, the root
cause was not even in the propulsion system (e.g., blown tire
interpreted as surge, or vice versa). This type of error behavior should
be particularly amenable to modification through training of the types
recommended by the project group.

A fourth subcategory here pertains to errors involving **failure to
obtain relevant data from crew members**. Errors classified under this
category might also be classified as being of the "partially or poorly
integrated data" type. However, the separate callout of failing to
integrate input from crew members into the pattern of cues is considered
important for developing recommendations regarding crew coordination. It
also highlights the fact that inputs to the process of developing a
complete picture of relevant cues for understanding what is happening
and where can and often must come from other crew members as well as
from an individual's cue-seeking activity. Understanding the crew
coordination aspects of this fact should lead to specific impact on
training programs when dealing with how to handle PSM's. These errors
are different from "not attending to inputs from crew members", which
would be classified as detection errors.

A fifth subcategory entitled "**knowledge of system operation under
non-normal conditions lacking or incomplete**" was included apart from
the "misinterpretation" subcategory because the evidence from the events
in the DC&ATG-Turbofan summary database clearly supported the analysis,
indicating that these errors were based on erroneous or incomplete
mental models of system performance under non-normal conditions. The
inappropriate crew responses were based on errors produced by faulty
mental models at either the system or airplane level. Reduction in
errors of this type can be achieved through more complete training on
system operation and systems interaction during PSM's.

**8.4.2.3 Strategy/Procedure**[^4]

The rationale for using both the "strategy" and "procedure" terms is
illustrated in Figure 8.4 and Figure 1 Volume 2, Appendix 14. The term
"procedure" is used to refer to those situations where a formal, written
procedure or widely accepted "best practice" exists, or should exist,
for dealing with a PSM which has been appropriately identified. The term
"strategy" is used to infer the plan of action selected by a crew when
no formal procedure or best practice existed or, at least, was known to
the crew. Implementation of an inappropriate strategy would be
classified as a knowledge-based error, whereas selecting the wrong
procedure to use with a particular PSM would be a rule-based error. For
the purpose of supporting Workshop recommendations, the error
classification model breaks down the types of errors leading to
inappropriate crew response in the Strategy/Procedure category well
beyond the rule-based/knowledge-based error classification. By doing so,
the relationship between the error classification data and the
recommendations of the Workshop are much clearer.

![](media/image16.emf)

**Figure 8.4** Classification of Errors in the Presence of Propulsion
System Malfunctions

Which Lead to Inappropriate Crew Responses[^5]

By far, the greatest number of errors, in terms of number of events
involved, were attributed to the selection of an **improper
strategy/procedure** given the conditions under which the event
occurred. There were a total of forty-three (43) events in which an
improper procedure or strategy was chosen given the conditions. This
category was divided into three subcategories that can be used to
support different aspects of the workshop recommendations. These
subcategories were:

Choosing to execute a RTO above V~1~ speed (21 events);

Choosing to reduce power on one or both engines below safe operating
altitude (5

events); and

Selecting other strategies which deviate from "best practice" (17
events).

The number and nature of the errors in the first subcategory definitely
validate the need for Recommendation 5 and 7 of the overall workshop
recommendations (see section 11.0), as well as several points made by
the DC&ATG-Turbofan in their list of "potential corrective action
opportunities". Those events in the second subcategory support the need
for Recommendations 5 and 7 as well. The events containing errors
relevant to Strategy/Procedure that have been placed in the third
subcategory are so diverse in nature they represent something of an
"other" category. This diversity defied efforts to aggregate the data in
a way that would focus on particular recommendations. One might consider
the errors represented as pertaining to poor "airmanship" if this could
be considered as referring to the use of poor judgment over very diverse
circumstances while flying airplanes.

Other subcategories under Strategy/Procedure contained too few events to
warrant an interpretation of their relevance to the recommendations of
the workshop.

**8.4.2.4 Execute**

The errors classified under this general heading produced inappropriate
crew responses (ICR's) that were inappropriate because of errors in
execution as opposed to ICR's which resulted from errors made in the
processing and/or interpretation of data or those made in the selection
of action to be taken. As such, the subcategories are quite diverse, and
are therefore dealt with independently for the most part with respect to
recommendations.

The first two subcategories represent the **classic "slip" and "lapse"
errors,** as defined by Reason (1990). These are "carry out unintended
action" and "failure to complete action". There were eighteen (18)
events in which errors of these types occurred. They represent instances
in which switches or throttles affecting normally-operating engines were
inadvertently thrown, closed, activated, etc, or, situations in which
steps in a procedure were omitted with very serious consequences. Errors
of these types do not lend themselves to elimination through training.
They must be addressed through error-tolerant design or designs that
preclude the slip from happening, or, through the use of designs that
support the execution of procedures which preclude the inadvertent
omission of procedure steps. These skill-based errors, according to
Reason (1990), are the most frequent in occurrence but are also the most
likely to be caught and recovered. This relationship also held in the
HFEC database.

Errors that involved **poor execution of action** are much more amenable
to training as a corrective action. There were thirteen (13) events
containing errors of this type. They represent errors in technique
rather than omission. For the most part, they represent the need to
concentrate on the development and maintenance of the ability to
properly execute non-normal procedures.

Events in which there was **poor/no crew coordination in carrying out
action** were included here. There was some ambivalence as to whether
this was an error type or contributing factor. A "poor/no crew
coordination" category was also included under Contributing Factors. The
event lists do overlap to some extent, but the distinction is between
poor/no crew coordination in executing a particular action (execute
error) versus lack of crew coordination in general (contributing
factor). A total of twenty-one (21) events were classified as having
errors involving lack of crew coordination in the action taken. These
errors indicate the need for increased focus on the training of crews to
coordinate their actions during PSM events. This recommendation is much
more narrowly focused than one dealing with CRM in general.

A subcategory of **poor piloting skills** was also included to classify
skill-based errors of this sort that were related to PSM events. A
problem when including an error category of this nature is that of
defining the error itself. This problem can best be understood by
reviewing the items in this category as found in Volume 2, Appendix 14.
If PSM events are represented more realistically and become a regular
part of training and testing of pilots, perhaps potential for this type
of error will be dealt with both specifically and more systematically.

A final subcategory under Execution was **failure to initiate action in
a timely manner**. This category was included in an attempt to capture
the timing aspect of errors. Nine (9) events were identified as
containing this type of error. Timing errors have a tendency to
exacerbate other errors that are occurring during a PSM event. The issue
of timing needs to be addressed as a part of training to deal with all
PSM events. It is more complex than simple admonishments to take one's
time in dealing with non-normal events. Crews need at least initial
guidance on effective timing of actions and the variations in such
timing as a function of specific PSM events.

> **8.4.2.5 Violations**

Violations as errors are very different from the types of error
described thus far. The difference is in intent. The types of
inappropriate crew responses classified as violations during the error
classification process involved specific violations of company policy or
procedures. Needless to say this was very rare; at least evidence of it
was very scarce in the DC&ATG-Turbofan Summary Database. Dealing with
violations of this sort requires a) the very clear, concise statement of
company policies and procedures; b) their dissemination to all flight
crews; and c) an evaluation of the process which insures that flight
crews have access to, understand, and abide by these policies and
procedures.

**8.4.2.6 Contributing Factors**

These aspects of the events were identified and categorized for the
purpose of providing "context" for the events. Relating contributing
factors to the error data offers the possibility of understanding at
least some of the conditions which have relevance to or seriously impact
human performance, and may provide a framework for better understanding
the "why" of human error; [particularly,]{.underline} the cognitive
errors. Unfortunately, the resources were not available to develop the
relational database that would be necessary to exploit the potential
contribution of these data to our understanding of the "whys" of at
least some of the errors contained in the database. Such a relational
structure should be a critical component of any further efforts with the
error classification database.

**8.4.2.7 Relationship of Data to Related Research**

There are several research efforts (Shontz, 1997; Wiegmann & Shappell,
1997[^6]; Shappell & Wiegmann, 1997[^7]; Wildzunas, R.M., 1997[^8];
O'Hare, [et al]{.underline}, 1994[^9]) in which the results relate to
the error classification work done for the workshop. The patterns of
error classification across these studies are remarkably similar even
though the pilot populations are very different; i.e., Army helicopter
pilots, general aviation pilots, military pilots (Navy), transport
pilots, and instructor pilots (transport). The differences in patterns
may be explained largely in terms of differences in definitions for
similar categories of errors, as well as differences in the criteria
investigators used in assigning errors to categories.

Wildzunas (1997) investigated wrong-engine shutdowns in Army helicopters
using both a survey and simulator study. The pattern of errors by
cognitive function was very similar to the PSM+ICR error data. The
functions contributing the greatest number of errors were diagnostic
(here, "interpretation") and action (here, "execute") as they were in
the Human Factors Error Classification (HFEC) database. The largest
difference was in the major contribution of strategy/procedure errors in
the HFEC database, whereas there were very few goal, strategy, and
procedure errors in Wildzunas' simulator study. His survey data showed
that pilots felt that improper diagnosis and lack of training were major
factors affecting their actions on the wrong engine. This supports the
recommendations of the workshop with regards to the need for enhanced
training to improve crew performance in determining what is happening
and where.

Wiegmann and Shappell (1997) compared several models of human error,
including that of Rasmussen (1982) to parse error data from mishaps
involving Navy and Marine pilots. Their database included 3293 mishaps
attributed at least in part to human causes. The pattern of errors
classified using the Rasmussen model was very similar to those shown in
Table 8.3 for the HFEC database. When allowances are made for model
differences and definitions, the patterns of error classification using
the other models (including Reason's) were also similar to those of the
HFEC database.

O'Hare, [et al]{.underline}, (1994) also used the Rasmussen model (1982)
for error classification in one of the two studies reported. The pattern
of errors by cognitive function was again similar to that obtained in
the HFEC database. The exception was the very high proportion of serious
accidents associated with errors in goal setting in their data. The HFEC
database had no errors in this classification because there were no data
on which to base inferences about goal setting in the DC&ATG-Turbofan
Summary Database. Further comparisons between the O'Hare, [et
al,]{.underline} data and the HFEC database with regards to the
relationship between error category and seriousness of the accident was
not possible with the limited resources available to support the
workshop effort, however, this might be of interest if there is support
for further analyses in the future.

Shappell and Wiegmann (1997) have proposed yet another approach to human
error analysis in airplane accident investigations which includes many
categories of data not included in the models discussed above. The
"contributing factors" of the HFEC database overlap somewhat with the
Shappell and Wiegmann set of "unsafe conditions of the operator" and
less with their "unsafe supervision" set. However, there is complete
overlap of the HFEC database and their set called "unsafe acts of the
operator".

Shontz (1997) conducted a study of pilot reactions to high-power
compressor stall/surges under conditions where the pilots were not
expecting the event. (The pilots assumed they were only participating in
a CFIT procedure validation process.) No inappropriate actions were
taken on wrong engines during the event, but the interpretations of what
was happening varied widely across pilots, as did the procedures called
for and executed. Thus, the errors and inappropriate response categories
for this study matched those of the HFEC database with the exception of
execution errors.

This review of related research indicates that the HFEC model and
analysis has produced results which are similar to those of both
research studies (Wildzunas, 1997; Shontz, 1997) and error
classification efforts (Wiegmann and Shappell, 1997; O'Hare, [et
al]{.underline}, 1994) with regards to the cognitive function categories
used and the pattern of errors within these categories. The HFEC
analysis and classification results can be improved with additional
reliability and validity checks but the basic findings appear to be on
target and the workshop recommendations appear to be relevant.

5.  **Generic Human Factors Recommendations for Validating Recommended
    Training and Design Solutions**

**8.5.1 Recommendations for Training**

-   Eventually, current training scenarios should be analyzed to avoid
    redundancy in the initiating propulsion system malfunction (PSM)
    events used (especially V~1~ cuts) so that recommendations for
    realistic PSM event recognition and recovery training can be
    implemented without increasing overall training time. Some
    preliminary efforts in this area are a part of the process of
    developing recommendations (see, for example, Volume 2, appendix
    12).

-   Cooperation of a selected set of airlines should be sought for the
    purpose of evaluating the effectiveness of training recommendations.
    Proficiency checks and LOFT scenarios for individual pilots should
    contain PSM's which vary in both type and regularity of appearance
    within and across test sessions; i.e., pilots should not be able to
    anticipate getting the same PSM's each time they receive proficiency
    checks - or even getting a PSM with every proficiency check. The PSM
    event simulation should be consistent for all pilots in the test
    group. Pilot behavior in the presence of unexpected PSM events
    should be recorded in detail and summarized across all pilots within
    PSM event in order to gauge effectiveness of the simulation and
    training. This would require de-identification of all performance
    behavior in terms of both individuals and airlines.

-   Both the quality and extent of reporting of pilot behavior in
    response to PSM events that occur during revenue flights should be
    upgraded in order to develop the database necessary to evaluate
    training effectiveness. This should be a long-term effort involving
    as many airlines as possible. The objective would be to determine
    if, following training and/or dissemination of an "awareness
    package", the rate of RTO's and wrong-engine actions in the presence
    of surges actually decreases. The process established should be kept
    in place long enough to determine if the "boomerang effect"[^10]
    occurs; this is a common occurrence following efforts to enhance
    pilot awareness of appropriate responses to unsafe conditions
    through dissemination of awareness material or with one-shot
    training exercises.

**8.5.2 Recommendations for Design**

The validation of design recommendations per se may be more difficult in
that it presumes that a design solution is more efficacious (at least in
the long run) than a training solution. The evidence to support
validation of a design recommendation typically must be stronger and
more persuasive than that necessary to validate a training solution
because the former have much greater economic implications than the
latter and the evidence for greater safety impact is seldom any
stronger. The exception to this is when design solutions are actually
tested by gathering human performance data under carefully-controlled
conditions. Training solutions are typically assumed to be effective.

The validation of design recommendations should include evidence to
support the contention that a design solution is in the best interests
of all concerned. Generic requirements for this process are:

-   Current design should have clear shortcomings in terms of
    information transfer capabilities that cannot readily or reliably be
    overcome with reasonable training and continuous testing via
    proficiency checks and LOFT scenarios.

-   Target airplane models can be identified for the design
    recommendation, and potential value in terms of error reduction with
    the implementation of the design recommendation can be estimated.

-   Credible design solutions can be generated from the
    recommendation(s).

-   Credible testing procedures, metrics, and equipment (especially
    simulator capabilities) are available to evaluate design solutions.

With respect to the last requirement, it is recommended that combined
government and industry support be provided to develop test methodology
(procedures, metrics, and equipment) that produces results which are
clearly and unequivocally valid for the civil aviation operational
environment. Techniques from the research lab do not always meet this
requirements. The group also needs metrics which represent system
performance in terms that are meaningful for, and directly applicable
to, the operational environment. Any number of efforts have attempted to
achieve these objectives in venues other than the civil transport flight
deck; these can provide both conceptual and technical guidance for
achieving the methodological breakthroughs required. But, the requisite
methodology does not yet exist - it must be developed, and should be, in
a timely manner.

**9.0 Regulatory Requirements**

Commercial Transport airplanes designed and certified under Parts 23 or
25 of the FAR's and JAR's are required to be capable of continued safe
flight following the failure of the most critical powerplant at the most
critical point of the flight. From the analysis carried out by the group
it has been identified that a primary cause of the powerplant-related
accidents and incidents has been the fundamental inability of the flight
crew to correctly identify and/or respond to the initial powerplant
malfunction. Review of the regulatory requirements has shown that the
requirements to train flight crews for abnormal propulsion system
behavior are assigned to flight engineers under 14 CFR Part 63. Also,
although training on handling thrust loss is assigned to pilots under 14
CFR Part 61 there are no references to 14 CFR Part 63 in Part 61. The
industry adoption of two-man flight crews as a standard has left the
issue of propulsion system malfunction recognition training essentially
not addressed. A similar situation exists in both Transport Canada (TC)
and Joint Airworthiness Authority (JAA) Regulations, based on
preliminary reviews.

The task group considers that regulatory action may be appropriate in a
number of areas to address this issue. The areas of consideration for
regulatory review are threefold: first, a need to include both generic
and type-specific engine malfunction recognition training at appropriate
points in the training and checking curricula; second, the inclusion of
specific requirements for realistic training simulator modeling of
engine malfunction, including audio and tactile modeling; and third,
possible changes to the powerplant instrument requirements contained in
the airplane design codes.

**9.1 Propulsion System Malfunction Recognition Training**

With the significant increase in engine reliability, it is likely that
many pilots will go through their entire careers without experiencing a
serious propulsion system malfunction. The existing 14 CFR Part 61
training requirements concentrate on ensuring the pilot can handle the
airplane in the event of an engine failure (thrust loss). This training
is normally accomplished, either in a simulator or on the airplane, with
a power cut and rapid loss of thrust at the critical point of flight
(V~1~). This is not representative of the most probable failures
actually seen in operation such as high-power stall/surge or
unidentified loss of thrust from a low-power situation.

The Task Group therefore proposes that ARAC be tasked to consider
amending the training requirements to include engine failure recognition
training at appropriate points in the syllabus. The following FAR's are
recommended for review to include engine failure recognition training:

14 CFR Part 61 Certification: Pilots and flight instructors

Subpart E Paras 125 and 127

Subpart E Paras 153, 155 and 157

Appendix A, Appendix B

14 CFR Part 121 Operating requirements: Domestic, flag, and supplemental
operations

> Subpart N Paras 403(a) (3), 419(a) (1) and (2), 439(b) (2)

Subpart O

Appendix E, Appendix F

Appropriate changes to equivalent sections of 14CFR Part 135 Operating
requirements: Commuter and on-demand operations, are also recommended.

Where training is carried out in the airplane rather than a training
device, it is recommended that specific engine failure recognition
ground training should be mandated. This is particularly relevant to 14
CFR Part 135 operations.

Equivalent changes to JAR-FCL 1, Subparts D, E and F, to require
inclusion of engine failure recognition training as both generic and
type-specific training are also recommended. Again, revision to JAR-OPS
1, Subpart N, Appendix 1 through 1.965, should be reviewed for inclusion
of specific engine failure recognition ground training where use of the
airplane, rather than a training device, is permitted.

**9.2 Simulator Modeling**

It has been established that engine failure models incorporated in
training simulators, which in some cases cover a wide range of failures,
are often of questionable realism. Only the rapid thrust loss after a
fuel cut used for V~1~ engine failure handling training was found to be
generally accurate. This lack of accuracy may not only lead to a lack of
awareness of actual engine failures, but may actually provide negative
training that could lead flight crews to misinterpret symptoms of
genuine engine failures.

It is recommended that the following regulations be reviewed with the
intention of incorporating requirements that ensure engine failure
modeling is properly representative of the failures likely to occur in
service, particularly for the audio and tactile (vibration) aspects of
such failures/malfunctions.

14 CFR Part121 Operating requirements: Domestic, flag, and supplemental
operations

> Subpart N Paras 407, 424, 425 and 441(c)

Appendix H

AC 120-40 (as amended) and AC 120-45 (as amended) will require review to
include the need for accurate simulation of engine failures.

It is also recommended that Appendix H include a requirement that the
simulator model be based on data provided by the engine manufacturer. A
method should be found to ensure that the models of propulsion system
malfunctions provided by the simulator manufacturers are based on data
for the most-probable malfunctions, as provided by the airframe and
engine manufacturers.

Equivalent changes to JAR-STD and other affected regulations are also
recommended.

**9.3 Powerplant Instrumentation**

A wide range of powerplant instrumentation is provided on multi-engine
commercial airplanes. Some evidence is available regarding the
effectiveness of the different ways in which powerplant information is
presented to flight crews. It is proposed that ARAC be tasked with
reviewing the requirements of FAR/JAR 23 and 25, paras 1305, 1321, 1337
and 1585, in order to produce an updated standard for powerplant
instrumentation based on the information available. At this time, it is
not expected, that retrospective application of a revised standard of
instrumentation will be justified.

**10.0 Conclusions**

1.  The purpose of flight training programs is aimed primarily at
    ensuring the pilot can exhibit the flying skills necessary to
    control the airplane satisfactorily at all times, including in the
    event of an engine failure. The pilot's ability to handle engine
    failures is dependent on the sum of his or her training and service
    experience. With the significant increase in powerplant reliability,
    a pilot's general exposure to in-service powerplant malfunctions can
    no longer be assumed to always be sufficient to ensure that the
    malfunction is properly identified and appropriately handled.

2.  The information developed in this activity indicates there is a
    shortfall in some pilots' abilities to recognize and/or handle
    propulsion system malfunctions. The shortfall from initial
    expectation is due to improved modern engine reliability, changing
    propulsion system failure characteristics (symptoms), changes in
    flight crews' experience levels, and related shortcomings in flight
    crew training practices and training equipment.

3.  Industry has not provided adequate pilot training processes or
    material to ensure pilots are provided with training for powerplant
    malfunction recognition. This shortfall needs urgent action to
    develop suitable text and video training material which can be used
    during training and checking of all pilots for both turboprop- and
    turbofan-powered airplanes.

4.  The training requirements related to "Recognition and correction of
    in-flight malfunctions" are found in Appendix C of 14 CFR Part 63
    for **[Flight Engineers]{.underline}**. The disposition of the
    flight engineer's recognition training requirements to pilots of
    airplanes where no "Flight Engineer" position exists is not
    apparent. However, the expectation does exist that the pilots will
    perform the duties of the flight engineer.

5.  Concerns were also identified with the published propulsion system
    malfunction procedures, and the methods used for the validation of
    their correctness.

6.  A substantial number of the turbofan accidents reviewed are related
    to propulsion system malfunctions resulting in high-speed aborts,
    including above V~1~ and V~r~. Accordingly, current pilot training
    may be deficient in addressing the symptoms of the malfunctions,
    particularly loud noises and the importance of V~1~ and V~r~ speeds.
    There was only one RTO-related accident identified on turboprop
    airplane in the database.

7.  A significant number of turboprop and turbofan accidents have been
    identified where training of propulsion system malfunctions on or
    near the runway was taking place.

8.  The dominant cause of turboprop propulsion system malfunction and
    inappropriate crew response accidents is loss of control. The
    largest number of events occur during the take off phase of flight.
    There was only one turboprop rejected take off accident; this is a
    significant difference from the turbofan airplane accident data.

9.  The review of simulator capabilities shows that the technology
    exists to better produce realistic propulsion system malfunction
    scenarios. However, at the moment, realistic scenarios are often not
    properly defined nor based on airframe or powerplant manufacturers'
    data. Rather, the scenarios are often based on the customers'
    perceptions of the failure scenario. There is generally no airframe
    or powerplant manufacturers' input into realistic engine
    failure/malfunction scenarios as represented in simulators.
    Furthermore, the engine failures currently addressed in most
    training do not cover loud noises and the onset of heavy vibration.
    Complete and rapid loss of thrust is currently being trained and is
    probably the most critical from an airplane handling perspective;
    however, this failure is not necessarily representative of the
    malfunctions most likely to be encountered in service. There is also
    evidence that this lack of realism in current simulations of
    turbofan propulsion system malfunctions can lead to negative
    training, increasing the likelihood of inappropriate crew response.
    Review of current simulators indicates that the tactile and auditory
    representation of airplane response to engine compressor stall/surge
    is very misleading.

10. Considerable effort was undertaken to review existing engine failure
    indication systems and their differences and similarities between
    airplane manufacturers. All airframe manufacturers of later
    turbofan-powered airplanes inhibit alerts as a function of phase of
    flight, but at somewhat different phases of flight. The group
    believes that standardization of the flight-phase inhibit points is
    desirable. In general, the propulsion system malfunction alerts are
    not inhibited on turboprop-powered airplanes. The group also
    believes that a review of powerplant instrumentation requirements
    could be beneficial. In particular, engine surge, asymmetric thrust,
    engine failure, and tire failure annunciations were thought to be
    worthy of consideration to assist the crew in determining what
    malfunction had occurred. However, there is currently no clear
    indication substantiated by review of service experience or human
    factors testing that establishes whether the propulsion system
    malfunction warning systems installed on current airplanes are
    either beneficial, neutral, or detrimental. Research on the issue is
    desirable.

11. Adequate data could not be found to link standards of engine
    failure/malfunction indications with the probability of
    inappropriate crew response. Design evaluation suggests that
    retrospective embodiment of engine failure/malfunction indications,
    particularly on non-FADEC engines, would be extremely difficult, if
    not impossible. There have been no human factors studies performed
    to determine if a link exists between engine failure/malfunction
    warning and a reduced level of engine plus crew error
    accidents/incidents. There are arguments that real or false warnings
    may exacerbate the problem in certain circumstances, particularly
    during the takeoff phase of flight. Clearly, training would still be
    required.

12. The group agreed that, unless propulsion system malfunction
    recognition training was an actual requirement, such training would
    likely not take place consistently across the industry. The group
    further agreed that requirements for better realism of simulator
    reproductions of powerplant malfunction/failure scenarios should
    also be mandated. The affected sections of the JAR's and FAR's which
    are recommended for review are identified in Section 9. This
    regulatory activity should be conducted under the ARAC umbrella and
    should be included in the harmonization work program. The review of
    the requirements should cover the following points:

-   identification of propulsion system malfunctions to be trained;

-   the design and use of flight crew training equipment;

-   the inclusion of propulsion system malfunction recognition training
    in both

-   training and checking programs; and

-   powerplant instrumentation requirements.

13. Data suggest that various opportunities exist for negative transfer
    of trained pilot behavior and experience when transitioning between
    different airplane types.

14. Since the turboprop database is not data rich, many of the following
    specific conclusions are based on limited incident information
    received from manufacturers and operators represented in the group.
    The participants' experience of actual incidents in both operation
    and simulations was used as a basis for reaching these conclusions.

-   Current constant attitude airplane stall recovery training may be
    detrimental to the pilot's low air speed control during engine
    failure operations. The assessment of error types indicates that
    training and regulation could reduce skill- and rule-based errors by
    pilots.

-   The assessments of error types suggest that skill- and rule-based
    errors predominate.

-   Flight-idle and zero thrust are generally not the same. The use of
    flight-idle power settings in simulated engine-out training or as a
    precautionary power setting may result in negative thrust (increased
    drag) with an unfeathered propeller and expose the crew to an
    increased hazard.

-   The use of throttle chops to flight idle to simulate real engine
    failures has little training value in relation to training the
    pilots to identify real propulsion system malfunctions or failures.
    This practice is of benefit to train airplane handling.

-   During one engine inoperative operations priority should be placed
    on airspeed control. With an engine failed, speed can only be
    controlled by adjusting attitude, as power is already at the
    maximum. This technique may be in conflict with the basic stall
    recovery training, and may therefore cause confusion during
    low-speed flight with an engine failure.

-   Turboprop flight instrument displays are evolving. There appears to
    be weaknesses in the display of lateral acceleration slip. Flight
    director systems that are not specifically designed for takeoff and
    go-around could give inappropriate commands following propulsion
    system malfunction or failure.

**11.0 Recommendations**

1.  The requirements need to be enhanced to recognize the need for pilot
    training in powerplant failure recognition. It is recommended that
    14 CFR Parts 61 and 121 / JAR-OPS / JAR-FCL be amended to require
    inclusion of engine failure/malfunction recognition in pilot
    training syllabi.

2.  Regulatory authorities should review the requirements and content of
    pilot training for propulsion system malfunction or failure and the
    control of the airplane immediately after takeoff.

3.  The regulatory authorities should establish and implement a rigorous
    process to ensure that the following occurs during the development
    of a training program:

-   Identification of powerplant failure conditions that need to be
    trained;

-   Preparation of the training aids (Tools & Methods);

-   Establishment of the appropriate means to conduct the training;

-   Assurance that each flight crew member receives the appropriate
    training for both malfunction recognition and proper response to it,
    and

-   Validation of effectiveness, along with a feedback loop to
    improve/update training.

4.  The performance of V~1~ thrust cut training in the airplane has
    caused a number of hull loss/fatal accidents. The value of this
    training in the airplane should be scrutinized and only conducted
    with extreme care. It is the Project Group's belief that this
    specific training could be better effected in simulators. Where
    suitable simulators are not available, the airplane handling task
    can be adequately and much more safely trained at altitude where
    recovery from extreme upset conditions can be accomplished.

5.  The aviation industry should undertake the development of basic
    generic text and video training material on turboprop and turbofan
    propulsion system malfunctions, recognition, procedures, and
    airplane effects.

6.  The regulatory authorities should establish a means to ensure that
    the simulators used to support flight crew training are equipped
    with the appropriate realistic propulsion system malfunctions for
    the purpose of "recognition and appropriate response training", and
    that the simulated malfunctions are consistent with the propulsion
    system malfunctions identified as needing to be trained. As a
    minimum, the airframe and engine manufacturers should be involved in
    the development of the simulation of propulsion system malfunctions.
    The scenarios that need to be included in training programs should
    focus on the accident/incident data produced by this group. The
    industry needs to ensure that propulsion system malfunctions
    reproduced in simulators do not produce negative training.

7.  The requirements for propulsion system instrumentation should be
    reviewed, and requirements and advisory material related to
    powerplant and propellers should be established:

-   A review of propulsion system parameters should be completed to
    determine if improved engine and propeller displays or methods can
    be found to present information in a manner which would help the
    flight crew diagnose malfunctions.

-   Failure and malfunction annunciation and warnings to provide
    improved means for crews to identify propulsion system malfunctions.
    The areas for consideration include, the types of annunciation and
    warnings (visual, aural, tactile, etc.), introduction of
    annunciations for engine surge, asymmetric thrust, engine failure,
    tire failure; and standardization of warning and annunciation
    inhibits.

-   Standardization among the airplane manufacturers regarding engine
    caution and warning messages and inhibit strategies during different
    flight phases (reference ARP 450D) is recommended.

8.  The retroactive embodiment of additional engine failure warning on
    existing airplanes would be both difficult and costly. Therefore,
    research and development are required prior to any possible
    recommendation for retroactive installation of such equipment.
    Methodologies are not yet available that would allow evaluation of
    the benefits or detriments of the introduction of additional
    annunciations of propulsion system malfunctions to existing airplane
    types. These must also be developed. (See item 10 below.)

9.  Flight training departments should enhance training methodologies to
    educate and train pilots in propulsion system malfunction effects on
    airplane performance. This relates to both the frequency and quality
    of training given in this area. All pilots need solid understanding
    of the performance factors that drive V~1~, V~r~, V~2~, and other
    important performance and handling requirements. It is essential
    that the specialized training materials developed in areas such
    propulsion system malfunction are properly communicated to the
    line-flying pilots.

-   Industry should provide training guidelines of how to recognize and
    diagnose the engine problem by using all available data in order to
    form the best possible information about the state of the propulsion
    system.

-   Circumstances of negative transfer from previous training or
    operations should be identified and their lessons learned should be
    communicated as widely as possible within the industry.

10. It is recommended that the aviation industry sponsor activity to
    develop appropriate human factors methodologies to address both
    annunciation and training effectiveness for turboprop and turbofan
    propulsion system failures.

11. The following recommendations are specific to turboprop airplanes:

-   The use of flight idle on turboprop airplanes for simulated engine
    failures or in the event of a malfunction should be reviewed by
    industry because of the potential association with loss of control
    events if the engine is not shut down.

-   Stall recovery training should be reviewed by industry and
    regulatory authorities for possible negative training effects in one
    engine inoperative situations.

-   Industry should investigate the suitability of turn co-ordinator
    instruments in training airplane where commercial airplanes do not
    use these displays.

-   There should be formal training and qualification requirements for
    instructors and maintenance test pilots.

-   In terms of loss of control in turboprop airplanes, the
    certification requirements for the clear display of lateral
    acceleration should be reviewed.

-   The use of a Flight Director display should not be allowed during
    takeoff or go-around unless it has been specifically approved for
    one engine inoperative takeoffs and landings because of possible
    incorrect pitch guidance.

**TABLE OF CONTENTS -- APPENDICES**

**Volume 1 Appendices Page**

Appendix 1 NTSB Final Recommendations for

> Jetstream 31 Accident, 13 Dec. 1994 75

Appendix 2 Letter from FAA to AIA 79

Appendix 3 Letter from AIA to FAA 82

**Volume 2 Appendices** *(not contained in Vol. 1 -- see Vol. 2)*

Appendix 4 Summary of Turbofan data 2

Appendix 5 Turbofan Training Accident Summaries 38

Appendix 6 Summary of GE/CFMI Commercial Fleet RTO Study 45

Appendix 7 Summary of Turboprop data 48

Appendix 8 Summary of Turboprop Training events 116

Appendix 9 Fleet survey of engine failure indications - turbofans 125

Appendix 10 Fleet survey of engine failure indications - turboprops 133

Appendix 11 Survey of Simulators 137

Appendix 12 Simulator Malfunction List for Turbofans - Proposed 140

Appendix 13 Appendix C to CFR Part 63, Flight Engineer Training

> Course Requirements 146

Appendix 14 Human Factors 154

Appendix 15 Turbofan Statistical Difference Assessment 178

**APPENDIX 1**

**NTSB Final Recommendations for Jetstream 31 Accident, 13 DEC 94**

**APPENDIX 1 - NTSB Final Recommendations for Jetstream 31 Accident, 13
DEC 94**

Findings:

1\. The flightcrew was properly certificated in accordance with Federal
Aviation Regulations and company procedures.

2\. The airplane was certificated and maintained in accordance with
existing regulations, except for the improper installation of the FPA-80
as a substitute for a GPWS.

3\. Air traffic control services were properly performed.

4\. Weather was not a factor in the accident.

5\. The captain associated the illumination of the left engine IGN light
with an engine failure.

6\. The left engine IGN light illuminated as a result of a momentary
negative torque condition when the propeller speed levers were advanced
to 100 percent and the power levers were at flight idle.

7\. There was no evidence of an engine failure. The CVR sound spectrum
analysis revealed that both propellers operated at approximately 100
percent RPM until impact, and examination of both engine revealed that
they were operating under power at impact.

8\. The captain failed to follow established procedures for engine
failure identification, single engine approach, single go-around, and
stall recovery.

9\. The flightcrew failed to manage resources adequately; specifically,
the captain did not designate a pilot to ensure aircraft control, did
not invite discussion of the situation, and did not brief his intended
actions; and the first officer did not assert himself in a timely and
effective manner and did not correct the captain\'s erroneous statement
about engine failure.

10\. Although the first officer did perform a supportive role to the
captain, his delayed assertiveness precluded an opportunity to avoid the
accident.

11\. Flight 3379 did not encounter any wake turbulence during the
approach to runway 5L, or during the departure from controlled flight.

12\. AMR Eagle training did not adequately address the recognition of
engine failure at low power, the aerodynamic effects of asymmetric
thrust from a \"windmilling\" propeller, and high thrust on the other
engine.

**APPENDIX 1 - NTSB Final Recommendations for Jetstream 31 Accident, 13
DEC 94**

13\. AMR Eagle provided \"negative simulator training\" to pilots by
associating the IGN light with engine failure and by not instructing
pilots to advance both power levers during single engine go-arounds as
required by the operation manual.

14\. AMR Eagle and Flagship Airlines crew training records do not
provide sufficient detail for management to track performance.

15\. Flagship Airlines management was deficient in its knowledge of the
types of crew records available, and in the content and use of such
records.

16\. Flagship Airlines did not obtain any training records on the
accident captain from Comair. Further, Comair\'s standard response for
employment history would not, had it been obtained, have included
meaningful information on training and flight proficiency, despite the
availability of such data.

17\. The FAA did not provide adequate guidance for, or ensure proper
installation of, the FPA-80 as a substitute for a GPWS on Flagship\'s
fleet.

18\. The structure of the FAA\'s oversight of AMR Eagle did not provide
for adequate interaction between POIs and AMR Eagle management personnel
who initiated changes in flight operations by the individual Eagle
carriers.

Probable Cause:

The National Transportation Safety Board determines that the probable
causes of this accident were: 1) the captain\'s improper assumption that
an engine had failed, and 2) the captain\'s subsequent failure to follow
approved procedures for engine failure, single-engine approach and
go-around, and stall recovery. Contributing to the cause of the accident
was the failure of AMR Eagle/Flagship management to identify, document,
monitor, and remedy deficiencies in pilot performance and training.

Recommendations:

As a result of the investigation of this accident, the National
Transportation Safety Board makes the following recommendations:

\--to the Federal Aviation Administration:

Publish advisory material that encourages air carriers to train flight
crews in the identification of and proper response to engine failures
that occur in reduced power conditions, and in other situations that are
similarly less clear that the traditional engine failure at takeoff
decision speed. (Class II, Priority Action) (A-95-98)

**APPENDIX 1 - NTSB Final Recommendations for Jetstream 31 Accident, 13
DEC 94**

Review the organizational structure of the FAA surveillance of AMR Eagle
and its carriers with particular emphasis on the positions and
responsibilities of the Focal Point Coordinator and principal
inspectors, as they relate to the respective carriers. (Class II,
Priority Action) (A-95-99)

Ensure that all airplanes (other than the AMR Eagle J3201 fleet) that
currently use a Collins FPA-80 in lieu of GPWS, under the provisions of
14 CFR 135.153, have installations that comply with Federal regulations.
(Class II, Priority Action) (A-95-100)

Require all airlines operating under 14 CFR Parts 121 and 135 and
independent facilities that train pilots for the airlines to maintain
pertinent standardized information on the quality of pilot performance
in activities that assess skills, abilities, knowledge, and judgement
during training, check flights, initial operating experience, and line
checks and to use this information in quality assurance of individual
performance and of the training program. (Class II, Priority Action )
(A-95-116)

Require all airlines operating under 14 CFR Parts 121 and 135 and
independent facilities that train pilots for the airlines to provide the
FAA, for incorporation into a storage and retrieval system, pertinent
standardized information on the quality of pilot performance in
activities that assess skills, abilities, knowledge, and judgment during
training, check flights, initial operating experience, and line checks.
(Class II, Priority Action ) (A-95-117)

Maintain a storage and retrieval system that contains pertinent
standardized information on the quality of 14 CFR Parts 121 and 135
airlines pilot performance during training in activities that assess
skills, abilities, knowledge, and judgement during training, check
flights, initial operating experience, and line checks. (Class II,
Priority Action) (A-95-118)

Require all airlines operating under 14 CFR Parts 121 and 135 to obtain
information, from the FAA\'s storage and retrieval system that contains
pertinent standardized pilot training and performance information, for
the purpose of evaluating applicants for pilot positions during the
pilot selection and hiring process. The system should have appropriate
privacy protections, should require the permission of the applicant
before release of the information, and should provide for sufficient
assess to the records by an applicant to ensure accuracy of the records.

# (Class II, Priority Action) A-95-119) 

**APPENDIX 2**

**Letter from FAA to AIA**

# APPENDIX 2 - Letter from FAA to AIA

![](media/image17.emf)

  ------------------------------------------------- ---------------------
  U.S. Department                                   **Transport Airplane
                                                    Directorate**

  of Transportation                                 **Aircraft
                                                    Certification
                                                    Service**

                                                    

  **Federal Aviation**                              1601 Lind Avenue,
                                                    S.W.

  **Administration**                                Renton, Washington
                                                    98055-4056
  ------------------------------------------------- ---------------------

06 March 1996

Mr. Howard Aylesworth, Jr.

Director, Airworthiness and Regulations

Aerospace Industries Association of America, Inc.

1250 Eye St. N. W.

Washington, D.C. 20005-3922

Dear Mr. Aylesworth:

The purpose of this letter is to encourage the Aerospace Industries
Association of America (AIA) to utilize data from previous AIA activity
and a recent accident as a basis for initiating development of
guidelines for an engine failure indication system.

On December 13, 1994, an American Eagle Jetstream Super 31 crashed near
Morrisville, North Carolina. The National Transportation Safety Board
investigation indicates that contributing causes of the accident were:

a\. The captain\'s improper assumption that an engine had failed.

b\. The captain\'s subsequent failure to follow approved procedures for
engine failure, single engine approach and go-around, and stall
recovery.

Studies conducted by the AIA under the Continued Airworthiness
Assessment Methodology, PC 345 Committee, previously identified that
inappropriate flightcrew response to an engine malfunction is a leading
cause of propulsion system related accidents. The data showed that crew
error related accidents following an engine failure on airplanes with
three engines (which incorporate cockpit indication of engine failure)
are roughly 1 accident in 7500 engine failure/shutdowns. Data for two
engine airplanes that do not incorporate an engine failure indication
show 1 accident in roughly 700 engine failure/shutdowns. Discussion of
this data with members of the AIA indicates that further review of the
accident history should be undertaken to better understand the factors
that result in flightcrew error following an engine failure. The review
would include identification of any deficiencies in current simulations
available for flight crew training. This review may result in a
recommendation that 14 CFR parts 25 and 23 should be amended to require
new airplane designs to provide pilots with an unambiguous indication of
engine failure.

# APPENDIX 2 - Letter from FAA to AIA

The FAA believes that there may be a number of contributing factors
involved in these historical events that should be investigated, such
as:

a\. Heightened crew concern following an engine failure on a two-engine
airplane.

b\. Reduced flightcrew response times needed to maintain directional
control on airplanes with two wing-mounted engines, which necessitate
rapid response to an engine out event.

c\. Lack of guidance that establishes standards for engine manufacturers
to provide a clear indication of \"engine failure.\"

d\. Reduced experience level of flightcrew operating airplane types
involved in these accidents.

e.  The absence of engine failure recognition training.

f\. The absence of realistic engine failure or malfunction simulations
for training.

The FAA encourage that the AIA undertake a project to:

a\. Review relevant events and determine what factors influence crew
error following an engine failure.

b\. Define safety significant engine malfunctions.

c\. Develop the guidelines for an appropriate engine failure indication
system.

d\. Define the process and guidelines for engine failure simulation.

e\. Define guidelines for engine failure recognition training, and.

f\. Identify the process for validating the effectiveness of these
guidelines.

If the AIA study resulted in a finding that development of new
regulatory requirements and/or guidance, these new requirements/guidance
would apply to all new and possibly re-engined multi-engine FAR part 25
and part 23 (commuter category) aircraft, and embrace all types of
propulsion systems. It is envisioned that this project would be started
as an industry project that would be transferred to the appropriate
Aviation Rulemaking Advisory Committee working group and involve
harmonization with the other civil aviation authorities.. To ease the
transition of the recommendations into the regulatory processes, we
encourage broad participation by all

elements of the aerospace industry, including human factors specialists,
engine manufacturers, airplane manufacturers, and flightcrew training
specialists.

Sincerely,

*ORIGINAL SIGNED BY*

*DARRELL M. PEDERSON*

Ronald T. Wojnar

Manager, Transport Airplane Directorate

Aircraft Certification Service

file: MDostert\\memo\\aiaerror.doc

File: 8042 -25

**APPENDIX 3**

**Letter from AIA to FAA**

# APPENDIX 3 - Letter from AIA to FAA

![](media/image18.emf){width="3.417361111111111in"
height="0.9763888888888889in"}

> March 7, 1997

Mr. Ronald T. Wojnar

Manager

Transport Airplane Directorate

Federal Aviation Administration

1601 Lind Avenue S.W.

Renton WA 98055-4056

Dear Mr. Wojnar:

My letter of June 19, 1996 indicated that the AIA would undertake the
activity you requested in your letter of March 6, 1996. The AIA planned
to review accident and incident data associated with engine failures,
coupled with inappropriate crew response, and examine the potential need
for corrective action. The initial focus of the activity would be to
assemble all relevant facts and data associated with historical
accidents and incidents, experience with various mitigation approaches,
fixed base and motion based simulator capabilities and programs, and
other relevant information appropriate to a thorough study of engine
failures coupled with inappropriate crew response. Once this had been
accomplished, a follow-on phase would analyze and synthesize these data
in order to draw appropriate conclusion.

Last June AIA had anticipated this project would be initiated before
mid-September, and would be completed by August of 1997. The phase
identifying causal factors and engine malfunctions would begin in
January 1997, and be completed by October of 1997. It was recommended
that G. P. Sallee of Boeing chair this activity. Your concurrence was
requested before initiating the project as outlined.

Lacking a formal FAA response to my June 1996 letter, yet with
encouragement from the FAA staff, AIA launched the TC Project with a
Workshop on "Propulsion System Malfunction Plus Inappropriate Crew
Response" on January 14-16, 1997 at the SeaTac Red Lion Hotel in
Seattle. A copy of the attendance roster is included herewith and shows
participation from the FAA, JAA, NTSB, US Air Force, NASA-Langley, ALPA,
and US, Canadian, and European Manufacturers.

# APPENDIX 3 - Letter from AIA to FAA

Letter to R. Wojnar

March 7, 1997

Page 2

The success of the workshop and the depth of material presented will
minimize any schedule slippage due to a late start. The AIA TC Project
chairman has requested that AIA ask AECMA to jointly sponsor, co-chair,
and provide the focal point with respect to data collection and analysis
of turboprop aircraft related events. This request is under active AIA
review and I anticipate it will be positively received.

Based on the overall reaction to the workshop, AIA presumes that the TC
Project plan meets the FAA's need and has your approval. AIA will
continue to report periodically on project status.

Sincerely,

*ORIGINAL SIGNED BY*

*HOWARD AYLESWORTH, JR.*

Howard Aylesworth, Jr.

Director, Airworthiness and Regulations

HA:mps

**PSM+ICR REPORT**

**APPENDICES**

**02 SEPT 98 - Draft**

Appendix 1 NTSB Final Recommendations for Jetstream 31 Accident, 13 Dec.
1994 (book 1)

Appendix 2 Letter from FAA to AIA (book 1)

Appendix 3 Letter from AIA to FAA (book 1)

Appendix 4 Summary of Turbofan data

Appendix 5 Turbofan Training Accident Summaries

Appendix 6 Summary of GE/CFMI Commercial Fleet RTO Study

Appendix 7 Summary of Turboprop data

Appendix 8 Summary of Turboprop Training events

Appendix 9 Fleet survey of engine failure indications - turbofans

Appendix 10 Fleet survey of engine failure indications - turboprops

Appendix 11 Survey of Simulators

Appendix 12 Simulator Malfunction List for Turbofan

Appendix 13 Appendix C to Part 63, Flight Engineer Training Course
Requirements

Appendix 14 Human Factors

**APPENDIX 4 - Summary of Turbofan PSM+ICR Events**

**APPENDIX 4 - Summary of Turbofan PSM+ICR Events**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

10 73/1ST/2/HF LOSS OF CONTROL FAPP/G-A POWERLOSS

**Summary of Event:**

POWERLOSS, GO-AROUND EXECUTED + LOSS OF CONTROL (STALL)

**Summary of Narrative:**

THE AIRCRAFT WAS ON FINAL APPROACH AND CLEARED TO LAND BY THE TOWER.
WHEN IT REACHED 90

METERS (300 FEET) HIGH, IT INITIATED A GO-AROUND WITH FULL POWER. THE
AIRCRAFT PITCHED-UP IN

EXCESS, STALLED BANKING TO THE RIGHT AND HIT THE GROUND ABOUT 2500 FEET
TO THE RIGHT OF

THE RUNWAY. NO.1 ENGINE HIT THE GROUND WITH NO POWER. NUMBER 2 ENGINE
HIT THE GROUND

WITH FULL POWER. PROBABLE CAUSE: PILOT FACTOR\--FAILURE TO MAINTAIN
FLYING SPEED.

CONTRIBUTING FACTOR\--POWERPLANT FAILURE/LOSS OF THRUST FROM ONE ENGINE.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

39 \*85/EWB/4/S LOSS OF CONTROL CRUISE POWERLOSS (NO.4)

**Summary of Event:**

POWERLOSS + FAILURE TO CORRECT FOR THRUST LOSS RESULTING IN AIRPLANE
STALL

**Summary of Narrative:**

DURING CRUISE AT FL410 THE AIRPLANE EXPERIENCED A HORIZONTAL WINDSHEAR
CONDITION CAUSING

A GRADUAL INCREASE IN AIRSPEED AND A RESPONSE BY THE AUTOTHROTTLE SYSTEM
WHICH WAS IN

THE MACH MODE AND THE AUTOPILOT WAS IN THE ALTITUDE HOLD MODE. THE
AUTOTHROTTLE SYSTEM

RETARDED THE POWER LEVERS GRADUALLY TO IDLE (50 SECONDS ELAPSED TIME).
AS AIRSPEED

DECREASED POWER LEVERS ADVANCED SLOWLY TO MCT (40 SECONDS ELAPSED TIME)
AND ENGINE NO.4

WENT INTO A SUBIDLE CONDITION DURING THE ACEL. AS THE AIRPLANE BEGAN TO
ROLLOFF DUE TO

THRUST ASYMMETRY WITH THE AUTOPILOT MAINTAINING HEADING HOLD. THE PILOT
THEN

DISENGAGED THE AUTOPILOT AND THE AIRPLANE IMMEDIATELY ROLLED TO THE
RIGHT & ENTERED A

NEAR VERICAL DIVE INTO THE CLOUDS. THE CREW RECOVERED CONTROL BELOW
FL110 AFTER EXITING

THE CLOUDS AND REGAINED A VISUAL HORIZON. RECOVERY WAS COMPLETED AT
FL095. THE AIRPLANE

EXPERIENCED NEGATIVE LOAD FACTOR AND IN EXCESS OF 5.0 G\'s POSITIVE LOAD
FACTOR. THE CREW

MANAGED TO RELIGHT THE NO.4 ENGINE AND DIVERTED TO SFO WHERE THEY LANDED
UNEVENTFULLY

AT 1330 LOCAL TIME. THE RECOMMENDED PROCEDURE FOLLOWING A POWERLOSS IS
TO DIS-CONNECT

AND/OR RE-TRIM WITH A/P ENGAGED INSPECTION OF THE AIRPLANE REVEALED
SUBSTANTIAL DAMAGE.

NTSB PROBABLE CAUSE: THE CAPTAINS PREOCCUPATION WITH AN INFLIGHT
MALFUNCTION AND HIS

FAILURE TO MONITOR PROPERLY THE AIRPLANE\'S FLIGHT INSTRUMENTS WHICH
RESULTED IN HIS

LOSING CONTROL OF THE AIRPLANE.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

77 95/2ND/2/HF LOSS OF CONTROL GOAROUND VIBRATION & BANG (LOW

POWER SURGE), THRUST

LOSS

**Summary of Event:**

SINGLE ENGINE POWERLOSS (FAN BLADE FRACTURE) + GOAROUND & LOSS OF
CONTROL

**Summary of Narrative:**

THE AIRPLANE WAS CLEARED FOR THE APPROACH TO RWY30 AT APPROXIMATELY 200
FEET ABOVE

GROUND LEVEL WHEN THE CREW INITIATED A GO-AROUND (REPORTED TO THE TOWER
AS SOME KIND OF

A PROBLEM) AND SUBSEQUENTLY LOSS CONTROL OF THE AIRPLANE. THE
INVESTIGATION REVEALED

ENGINE SUFFERED A FAN BLADE FRACTURE WHICH ULTIMATELY RESULTED IN A
POWERLOSS.

WITNESSES AND ATC INDICATE THE AIRPLANE INTIATED A GO-AROUND BUT NEVER
GAINED ALTITUDE

AND ROLLED OVER AND IMPACTED THE GROUND. THE ACCIDENT INVESTIGATION
REPORT FOUND THE

PROBABLE CAUSE OF THE ACCIDENT AS FOLLOWS: THE PROBABLE CAUSE OF THE
ACCIDENT IS LOSS OF

CONTROL OF THE AIRPLANE OVER THE COURSE OF ATTEMPTING AT RESTARTING FUEL
(INITIATING

GO-AROUND THRUST) DURING LANDING WITH LOW POWER. CONTRIBUTING CAUSES TO
THIS SITUATION;

(1.) THE STRUCTURAL FAILURE OF THE FIRST STAGE COMPRESSOR BLADE FROM
ENGINE ONE, WHICH

LED TO A LOSS OF POWER AND A DEVIATION FROM THE LANDING TRAJECTORY. (2.)
THE SLOW OR LATE

EXECUTION OF THE FUEL RESTARTING (GO-AROUND) PROCEDURE WHILE OPERATING
ON A SINGLE

ENGINE, UNKNOWN TO THE CREW, WHICH LED TO AN IRREVERSIBLE LOSS OF SPEED.
THE COMMISSION

HOLDS THAT THE CREW INTIATED A FUEL RESTARTING (GO-AROUND) PROCEDURE TO
LATE, THINKING

THAT IT ALWAYS HAD AVAILABLE POWER TO ITS TWO ENGINES.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

37 83/1ST/4/HF LOSS OF CONTROL - ASYM TAKEOFF POWERLOSS SUSPECTED

THRST

**Summary of Event:**

POWERLOSS + LOSS OF CONTROL

**Summary of Narrative:**

AIRPLANE ABORTED TAKEOFF AND RETURNED TO HANGER FOR ENGINE MAINTENANCE.
NO.4 ENGINE

WAS PRODUCING POPING SOUNDS AT POWER LEVEL ABOVE 1.7 EPR. CARGO WAS
UNLOADED PRIOR TO

AN ATTEMPTED FLIGHT TO MIAMI. IT WAS REPORTED THAT OPERATING NORMALLY
AND ONE ENGINE

WAS SET AT REDUCED THRUST. JUST AFTER TAKEOFF THE AIRPLANE VEERED TO THE
RIGHT AND

IMPACTED IN AN INDUSTRIAL NEIGHBORHOOD. THREE CREW MEMBERS WERE FATALLY
INJURED AS

WELL AS ELEVEN PERSONS ON THE GROUND.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

50 88/EWB/3/I LOSS OF CONTROL - ON LANDING THRUST REVERSER TO

GROUND UNLOCK POSITION

**Summary of Event:**

ASYMMETRIC THRUST DURING LANDING DUE TO FWD THRUST + FAIL TO RECOGNIZE -
OFFSIDE RWY

**Summary of Narrative:**

AS THE CAPTAIN WAS DEPLOYING REVERSERS DURING LANDING, #2 & #3 REVERSERS
UNLOCKED &

DEPLOYED (GREEN LIGHT CONDITION), BUT #1 REVERSER WAS BINDING & ONLY
MOVED TO THE UNLOCK

POSITION (AMBER LIGHT CONDITION). CAPTAIN WAS NOT WARNED OF THIS
CONDITION, THOUGH 2ND

OFFICER SHOULD HAVE MONITORED LIGHTS. CAPTAIN SAID HE REACHED TO CHECK
#1 LEVER, AT ABOUT

THAT TIME, AIRCRAFT YAWED RIGHT. DESPITE IMMEDIATE ACTION BY THE
CAPTAIN, DIRECTIONAL

CONTROL OF THE AIRCRAFT WAS LOST DUE TO YAWING CAUSED BY INOP THRUST
REVERSER.

AIRCRAFT CONTINUED OFF RUNWAY, CROSSED 2 TAXIWAYS AND NOSE GEAR
COLLAPSED.

INVESTIGATION REVEALED THAT AFTER TOUCHDOWN NO.1 ENGINE ACCELERATED WITH
FWD THRUST

AS #2 AND #3 ENGINE PROVIDED REVERSER THRUST. AT ABOUT THE SAME TIME,
THE AIRCRAFTS NOSE

LIFTED OFF THE RWY TO A 4 DEG ATTITUDE & THE AIRCRAFT WENT OFF THE
RUNWAY. AN EXAM OF THE

THROTTLE QUADRANT REVEALED THE S1-847 SW WAS CURLED / TWISTED & 2
SUPPORT SHAFTS

(HOLDING THE SWS) WERE BENT CAUSING INTERMITTENT OPEN OF THE NO.1 THRUST
REVERSER.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

44 85/EWB/4/H LOSS OF CONTROL - ON LANDING THRUST REVERSER (NO.1) DID

GROUND-ASYMMETRIC NOT TRANSITION TO \"REV

REVERSE THRUST;THRTL THRUST\", YAW RIGHT,

CABLE FAILED THRUST INCREASE TO FULL

**Summary of Event:**

ASYMMETRIC THRUST+ FAILURE TO RECOGNIZE - OFFSIDE LANDING

**Summary of Narrative:**

DURING LANDING ROLLOUT THE AIRPLANE VEERED OFF RIGHT SIDE OF RUNWAY.
AIRPLANE PASSED

THROUGH A DRAINAGE DITCH, WENT OVER A GRASSY AREA, THEN ONTO A CONCRETE
RAMP WHERE

THE LEFT OUTBOARD WING STRUCK AN ILLUMINATION STANDARD. THIS CAUSED THE
AIRPLANE TO SPIN

AROUND COMING TO A STOP ON A 360 DEGREE HEADING 250 METERS TO THE RIGHT
OF RUNWAY 14

CENTERLINE. WEATHER WAS NOT CONSIDERED A FACTOR IN THE ACCIDENT. ALL
LANDING GEAR

FOLDED AFT. THE BODY GEAR ARE IMBEDDED IN THE FUSELAGE TO STATION 1660,
NOSE GEAR IN E/E

COMPARTMENT, LH WING GEAR SEPARATED AND 100 METERS AWAY. ALL NACELLES
RESTING ON

GROUND. BOTH INBOARD STRUTS BUCKLED UPWARD. THE FUSELAGE IS BADLY
BUCKLED AND BENT

JUST AFT OF THE WING BETWEEN DOORS 3 AND 4. LOWER BODY IS SIGNIFICANTLY
DAMAGED. WING

LEADING EDGES ARE DAMAGED AS ARE WING TRAILING EDGES WHICH WERE STRUCK
BY GEAR. IT HAS

BEEN CONCLUDED THAT BEFORE THE ENGINES WERE PLACED IN REVERSE, THE #1
ENGINE THRUST

CONTROL CABLE SEPARATED. IF THE CABLE PARTED BEFORE THE REVERSE THRUST
LEVER SIGNALED

\"OPEN\" TO THE SOLENOID CONTROLING THE AIR VALVE, THE ENTIRE MECHANICAL
PART OF THE CABLE,

QUADRANT, DIRECTIONAL VALVE, PUSH PULL CABLE AND FUEL CONTROL, WOULD BE
DRIVEN TOWARD

FULL FORWARD THRUST BY THE TENSION IN THE CAMPANION T1A CABLE. THE PILOT
HAD NO IMMEDIATE

MEANS TO CONTROL THE #1 ENGINE THRUST, EXCEPT TO CUTOFF FUEL AND THE
AIRPLANE DEPARTED

THE RUNWAY BEFORE IT COULD BE STOPPED. THE FAA ISSUED AN AIRWORTHINESS
DIRECTIVE FOR

REPETITIVE INSPECTIONS UNTIL THE BRACKET IS REPLACED PER THE SERVICE
BULLETIN. THE AIRPLANE

IS CONSIDERED UNECONOMICAL TO REPAIR IS DECLARED A HULL LOSS.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

34 83/1ST/2/HF LOSS OF CONTROL - CLIMB POWERLOSS

RETURN TO LANDING (UNRECOVERABLE)

**Summary of Event:**

POWERLOSS + RETURNING TO LANDING & LOSS CONTROL - CRASH

**Summary of Narrative:**

SHORTLY AFTER TAKEOFF ENGINE NO.1 FAILED, AND THE AIRPLANE TURNED BACK
TO THE AIRPORT.

WHILE BANKING TO THE FINAL APPROACH, A WING TIP CONTACTED THE GROUND
INSIDE AIRPORT

BOUNDARIES. THE FUSELAGE FRACTURED INTO THREE SECTIONS. ADDITIONAL DATA:
FLIGHT WAS

NORMAL UNTIL TRANSITION FROM TAKEOFF TO CLIMB AT WHICH TIME THE NO.1
ENGINE FAILED. THE

CREW HAD NOT COMPLETED EMERGENCY PROCEDURES TRAINING. THE CREW DID NOT
APPLY

PROCEDURES ADEQUATE TO THE EMERGENCY PRESENTED, THEY SELECTED RUNWAY 3
(DOWNWIND)

GIVEN THAT THEY SHOULD HAVE RETURNED TO RUNWAY 21 OR CONTINUED AHEAD.
THE FINAL

APPROACH CONFIGURATION WHICH WAS ACCOMPLISHED SIMULTANEOUSLY (GEAR &
FLAPS DOWN)

CAUSED A REDUCTION IN AIRSPEED, DID NOT IMMEDIATELY SELECT TAKEOFF
POWER, TRIED TO LAND

DOWNWIND ON RWY 3 INSTEAD OF CLIMBING OUT IN THE BEST CONFIGURATION,
THEN MAKING A

LANDING APPROACH TO RUNWAY 21 AS ADVISED BY TOWER.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

61 \*92/MNB/2/H LOSS OF CONTROL / STUCK DESCENT STUCK THROTTLE

THROTTLE

**Summary of Event:**

ASYMMETRIC THRUST (STUCK THROTTLE) + FAIL TO RECOGNIZE- CONTROL LOSS

**Summary of Narrative:**

THE AIRPLANE IMPACTED A MOUNTAIN 630 METERS HIGH 32 KILOMETERS FROM THE
AIRPORT DURING

DESCENT. DFDR DATA INDICATE WITH THE AUTOTHROTTLE AND AUTOPILOT ENGAGED,
THE RH THRUST

LEVER WAS RESPONDING INTERMITTENTLY TO AUTOTHROTTLE COMMANDES. ON LEVEL
OFF AT 7200

FEET THE LEFT THRUST LEVER RESPONDED NORMALLY BUT THE RIGHT DID NOT
RESPOND AND

REMAINED AT IDLE. THE AUTOPILOT ATTEMPTED TO COMPENSATE FOR
ASSYMMETRICAL THRUST BY

COMMANDING LEFT AILERON. THE HEADING STARTED TO DRIFT RIGHT AND AS THE
LEFT ENGINE

APPROACHED 80% THRUST, THE AIRPLANE BEGAN TO BANK TO THE RIGHT. HEADING
SELECT WAS

ACTIVATED ON THE MODE CONTROL PANEL FOR 14 SECONDS AND THEN DESELECTED.
THE AIRPLANE

WAS NOW PASSING 50 DEGREES BANK. CONTROL WHEEL STEERING WAS ACTIVATED
WITH A RIGHT WING

DOWN INPUT OPPOSITE TO THAT WHICH THE AUTOPILOT WAS HOLDING. THE RIGHT
THRUST LEVER

WAS NOW ADVANCED AND THE RIGHT BANK AND NOSE PITCH ANGLE RAPIDLY WENT TO
78 DEGREES

NOSE LOW. THE AIRSPEED INCREASED THROUGHT 300 KNOTS WITH THE ENGINE
THRUST NOW NEARLY

SYMMETRICAL AT 88%. LAST BANK ANGLE WAS APPROX 155 DEGS RIGHT ROLL,
PITCH 78 DEGS NOSE LOW,

AIRSPEED 413 KNOTS.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

74 \*95/EWB/2/H LOSS OF CONTROL / STUCK CLIMB NO RESPONSE TO

THROTTLE COMMANDED POWER

**Summary of Event:**

ASYMMETRIC THRUST (STUCK THROTTLE) + CREW FAILED TO RECOGNIZE - CONTROL
LOSS

**Summary of Narrative:**

THE FIRST OFFICER WAS MANUALLY FLYING THE AIRPLANE, THE AUTOTHROTTLE AND
FLIGHT

DIRECTORS WERE ENGAGED, AND PROFILE MODE WAS USED. SOON AFTER TAKEOFF,
THE FIRST

OFFICER STARTED A LEFT TURN TO GO DIRECT TO THE SECOND WAYPOINT WHICH
WAS NORTHWEST OF

THE AIRPORT. AFTER PASSING THRUST REDUCTION ALTITUDE (AT 1500 FEET AGL),
THE FLAPS WERE

RETRACTED TO POSITION 15/0 (THE SLATS WERE STILL EXTENDED). AT THIS
POINT, THE CAS WAS

ABOUT 190 KTS AND THE BANK ANGLE WAS INITIALLY STABILIZED NEAR 20
DEGREES LEFT. ABOUT 30

SECONDS LATER, THE BANK ANGLE INCREASED, THE AIRCRAFT WENT INVERTED, THE
PITCH

DECREASED TO 80 DEGREES NOSE DOWN, AND THE AIRCRAFT CRASHED WITH A CAS
IN EXCESS OF 300

KTS. NO ONE SURVIVED THE IMPACT, 49 PASSENGERS AND 11 CREW MEMBERS WERE
ON BOARD. THE

PRELIMINARY INVESTIGATION SHOWS THAT THE AIRCRAFT TOOK OFF WITH A GROSS
WEIGHT OF 105

METRIC TONS WITH A THRUST SETTING THAT WAS EQUAL TO MAXIMUM TAKEOFF
THRUST. SOON AFTER

TAKEOFF, THE AIRCRAFT WAS CLEARED TO PROCEED TO THE SECOND WAYPOINT AND
THE F/O

STARTED A LEFT TURN. AFTER PASSING THRUST REDUCTION ALTITUDE, THE
AUTOTHRUST SYSTEM

TRANSITIONED TO CLIMB MODE. HOWEVER, THE RIGHT THROTTLE LEVER DID NOT
RETARD NORMALLY.

IT REMAINED ABOVE CLIMB POWER FOR ABOUT 55 SECONDS. THIS CAUSED THE LEFT
THROTTLE LEVER

TO MOVE (OVER 42 SECONDS) TO THE IDLE POSITION. THE MOST PROBABLE CAUSE
FOR THIS

MALFUNCTION WAS EXCESSIVE FRICTION (BINDING) IN THE RIGHT THROTTLE. THIS
AIRPLANE, LIKE MOST

MODERN COVENTIONAL AIRPLANES, USES A SINGLE SERVO MOTOR TO MOVE THE
THROTTLE LEVERS

DURING AUTOTHROTTLE OPERATIONS. IN THESE SYSTEMS, THE AUTOTHRUST SYSTEM
SENDS A

SIGNAL TO THE SERVO MOTOR TO ATTEMPT TO MOVE BOTH THROTTLES UNTIL THE
EPR/N1 OF THE

ENGINE WHICH IS PRODUCING THE HIGHEST POWER REACHES THE NEW LIMIT.

IN AN APPARENT ATTEMPT TO COUNTERACT THE OVERBANKING TENDENCY, WHICH WAS
DUE TO THE

THRUST ASYMMETRY, THE F/O MADE A RIGHT ROLL INPUT TO THE CONTROL WHEEL
TO STABILIZE THE

BANK ANGLE NEAR 20 DEGREES. HOWEVER, ABOUT 28 SECONDS LATER AND FOR
UNEXPLAINED

REASONS, THE F/O BRIEFLY MADE A LARGE LEFT ROLL INPUT TO THE CONTROL
WHEEL (AN INPUT INTO

THE TURN AND TOWARD THE ENGINE THAT WAS AT IDLE). THIS INPUT APPARENTLY
CAUSED THE BANK

ANGLE TO INCREASE FROM ABOUT 30 DEGREES TO 45 DEGREES. AT THIS POINT,
THE F/O ASKED THE

CAPTAIN TO ENGAGE AP1. THE A/P ENGAGED FOR ABOUT ONE SECOND. IT THEN
DISENGAGED DUE TO

THE PILOT APPLYING A PITCH INPUT FORCE GREATER THAN 33 POUNDS TO THE
CONTROL WHEEL. IT IS

SIGNIFICANT TO NOTE THAT, PRIOR TO LOSING CONTROL OF THE FLIGHT PATH,
THE ROLL INPUTS TO THE

CONTROL WHEEL NEVER EXCEEDED 50 PERCENT OF THE DEFLECTION THAT WAS
AVAILABLE. ALSO,

THERE IS NO EVIDENCE OF ANY INPUT TO THE RUDDER PEDALS THROUGHOUT THIS
EVENT.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

43 \*85/2ND/2/H LOSS OF CLIMB COMPRESSOR SURGE, AND

CONTROL-INCORRECT POWERLOSS

RUDDER

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE (POWERLOSS) + INCORRECT FLIGHT CONTROL
INPUT- CONTROL LOSS

**Summary of Narrative:**

WITNESS REPORTED THAT SOON AFTER TAKEOFF SMOKE AND FIRE WAS COMING FROM
THE RIGHT

ENGINE. THE AIRCRAFT CLIMBED TO 700 FEET AGL, (167KTS) THEN ROLLED INTO
A STEEP RIGHT BANK

AND CRASHED ON AIRPORT PROPERTY ONE FOURTH OF A MILE FROM THE RUNWAY IN
A NOSE-DOWN

ATTITUDE. INVESTIGATION SHOWED THAT A RIGHT ENGINE COMPRESSOR BLADES AND
SPACER EXITED

THROUGH A 4 INCH BY 4 INCH HOLE IN THE ENGINE CASING AT THE 11 O\'CLOCK
POSITION. ANALYSIS OF

THE VOICE AND CRASH RECORDER SHOWED THAT THE AIRPLANE YAWED RIGHT, WAS
PULLED UP TO 2

G\'s AND STALLED BEFORE ROLLING RIGHT, POSSIBLE INVERTED AND CRASHING.
NTSB PROBABLE

CAUSE\-\-\-\--THE FLIGHTCREW\'S IMPROPER USE OF FLIGHT CONTROLS IN
RESPONSE TO THE

CATASTROPHIC FAILURE OF THE RIGHT ENGINE DURING A CRITICAL PHASE OF
FLIGHT, WHICH LED TO

AND ACCELERATED STALL AND LOSS OF CONTROL OF THE AIRPLANE. CONTRIBUTING
TO THE LOSS OF

CONTROL WAS THE LACK OF CREW COORDINATION IN RESPONSE TO THE EMERGENCY.
THE RIGHT

ENGINE FAILED FROM THE RUPTURE OF THE 9TH TO 10TH STAGE REMOVABLE SLEEVE
SPACER IN THE

HIGH PRESSURE COMPRESSOR BECAUSE OF THE SPACER\'S VULNERABILITY TO
CRACKS. THE CREW

APPLIED INCORRECT RUDDER 4-5 SECONDS AFTER THE ENGINE MALFUNCTION,
INITIALLY THE RUDDER

WAS DEFLECTED IN THE CORRECT DIRECTION. BOTH CREW MEMBERS WERE RELATIVE
INEXPERIENCED

IN THE AIRPLANE.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

6 71/1ST/4/H LOSS OF TAKEOFF POWERLOSS

CONTROL-TRAINING

**Summary of Event:**

TRAINING FLIGHT-SIMULATED ENG-OUT + POWERLOSS (SE), CONTINUED TAKEOFF -
LOSS OF CONTROL -

IMPACTED GROUND

**Summary of Narrative:**

AIRCRAFT WAS ACCOMPLISHING A SIMULATED HEAVY WEIGHT TAKEOFF. AFTER BRAKE
RELEASE

ACCELERATION WAS SATISFACTORY AT 80 KTS AND AT V1 (115KTS). AFTER V1
NO.4 ENGINE WAS

THROTTLED BACK TO IDLE AND AT ABOUT THIS POINT THE ENGINEER NOTICED
POWER LOSS ON NO.3

ENGINE. THE AIRCRAFT STARTED TO VEER TO THE RIGHT AND THE PILOT ROTATED
IN AN ATTEMPT TO

COMPLETE THE TAKEOFF. AS THE AIRCRAFT TOOK A HIGH NOSE-UP POSITION, THE
VENTRAL FIN

CONTACTED THE RUNWAY AND THE AIRCRAFT DEPARTED THE RUNWAY AT A 30 DEGREE
ANGLE.

AIRCRAFT TRAVELED ABOUT 4000 FEET IN A STRAIGHT LINE ACROSS ROUGH
TERRAIN, SHEDDING

ENGINES AND LANDING GEAR. THE TAIL SECTION OF THE FUSELAGE SEPARATED
JUST BEFORE THE

AIRCRAFT CAME TO A STOP. FIRE SPREAD RAPIDLY AND CONSUMED THE AIRCRAFT.
THE FORWARD

MAIN DOOR WAS FOUND TO BE JAMMED SHUT SO THE CREW OF 5 EVACUATED THROUGH
THE COCKPIT

SLIDING WINDOWS. PROBABLE CAUSE ESTABLISHED FROM ARB SUMMARY (ICAO):
PILOT FACTOR- LOSS

OF CONTROL DUE TO FAILURE TO FOLLOW CORRECT PROCEDURES.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

68 94/2ND/3/I OTHER - ATC TAKEOFF COMPRESSOR SURGE

COMMUNICATION ERROR

RESULTING IN SHUTDOWN

GOOD ENGINE

**Summary of Event:**

VIBRATION, POWERLOSS + RTO AND SHUTDOWN GOOD ENG (TOWER INCORRECTLY
IDENTIFIED)

**Summary of Narrative:**

SOON AFTER BEGINNING TAKEOFF ROLL. TOWER CALLED AND TOLD CAPTAIN THEY
SAW FLAMES OUT

WHAT THEY THOUGHT WAS THE NO.1 ENGINE. AT THE SAME TIME, A/C BEGAN TO
VIBRATE AND NO.1

ENGINE WAS SHUTDOWN. TAKEOFF WAS ABORTED AND DURING TAXI VIBRATION
CONTINUED UNIT THE

NO.2 ENGINE SHUT ITSELF DOWN. ON C1 BLADE WAS FOUND TO BE COMPLETELY
LIBERATED FROM THE

HUB AND MISSING. HEAVY DAMAGE TO BELLMOUTH; INLET CASE STRUTS BROKEN
FROM OUTER CASING

AND TWISTED. NO.1 FAN BLADE EVENT WAS CONTAINED. DAMAGE TO NO.1 ENGINE
WAS PREVIOUS FOD

WHICH WAS FOUND DURING BORESCOPE REQUIRED PRIOR TO FERRY FLIGHT. A/C
FERRIED TO SFO AND

ENGINE REMOVED ON 3/15. ONE BLADE FRACTURED 3.5 INCHES ABOVE PLATFORM.
NO CASE

PENETRATION. FOUR IGV\'S BROKEN FREE AT OUTSIDE DIAMETER OF CASE. LAB
ANALYSIS OF BLADE

WILL BE REPORTED WHEN AVAILABLE. IN THIS EVENT IT DOES SHOW DIFFICULTY
IN IDENTIFYING WHICH ENGINE IS MALFUNCTING.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

35 83/1ST/2/H OTHER - FAILURE TO TAKEOFF COMPRESSOR SURGE

COMPLETE SHUTDOWN

PROCEDURES

**Summary of Event:**

LOUD BANG, DISINTEGRATION + FAILURE TO COMPLETE SHUTDOWN PROCEDURES - ON
RWY

**Summary of Narrative:**

THE AIRCRAFT SUSTAINED AN UNCONTAINED FAILURE OF THE NO.2 ENGINE DURING
TAKEOFF ROLL. THE

AIRCRAFT WAS STOPPED ON THE RUNWAY AND THE PAX AND CREW EVACUATED VIA
THE EMERGENCY

SLIDES. SUBSEQUENT FIRE SERIOUSLY DAMAGED (HULL LOSS) THE AFT PORTION OF
THE AIRPLANE

BEFORE AIRPORT EMERGENCY CREWS WERE ABLE TO BRING IT UNDER CONTROL. IT
WAS REPORTED

THAT THE CREW NEGLECTED TO ACTIVATE THE FIRE EXTINGUISHING SYSTEM.
PROBABLE CAUSE:

IMPROPER SHUTDOWN PROCEDURE FOLLOWING AND UNCONTAINED ENGINE FAILURE.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

81 96/1ST/4/HF OTHER - FORCED LANDING TAKEOFF COMPRESSOR SURGE -

POWERLOSS

**Summary of Event:**

COMPRESSOR SURGE BEFORE V1+ SHUTDOWN (FIRE WARNING) OF ANOTHER ENGINE
RESULTING IN

FORCED LANDING

**Summary of Narrative:**

INITIAL REPORT; AFTER TAKEOFF AT NIGHT THE AIRPLANE FAILED TO GAIN
ALTITUDE AND REPORTEDLY

HIT A CHURCH BELL TOWER 5 MILES FROM THE RUNWAY AND CRASHED INTO
NEIGHBORHOOD HOUSES.

REPORTEDLY, THERE WERE THREE CREW MEMBERS AND ABOUT 27 LOCAL PEOPLE
FATALLY INJURED.

THE AIRPLANE REPORTEDLY CONTAINED CARGO. THE AIRCRAFT WAS DESTROYED BY
IMPACT AND

POST IMPACT FIRE WHEN IT CRASHED AMONGST BUILDINGS SHORTLY AFTER
TAKEOFF. THE ACCIDENT

HAPPENED IN DARKNESS (2245L) BUT IN CLEAR WEATHER WITH UNLIMITED
VISIBILITY AND A FULL MOON.

THE AIRCRAFT HAD TAKEN OFF FROM RUNWAY 23 BUT THEN APPARENTLY FAILED TO
CLIMB. IT

SUBSEQENTLY STRUCK A RADIO MAST ON RISING GROUND ABOUT 4.5 MILES BEYOND
THE END OF THE

RUNWAY. THE POIINT OF INITIAL IMPACT WAS SOME 125 FEET ABOVE THE
AIRFIELD ELEVATION (255FT).

AT TAKEOFF THE AIRCRAFTS WEIGHT WAS UNDERSTOOD TO BE 305,183 LBS. (MTW
322,200LB). IT IS

REPORTED THAT THE AIRCRAFTS NO.2 ENGINE EXPERIENCED A SURGING CONDITION
DURING THE

TAKEOFF ROLL BEFORE V1. IT IS BELIEVED THE CREW REDUCED POWER ON NO. 2
DURING THE SURGING

CONDITION AND CONTINUED THE TAKEOFF. ADDITIONALLY IT IS UNDERSTOOD THAT
THE CREW

SHUTDOWN NO.3 ENGINE SHORTLY AFTER LIFT OFF DUE TO A FIRE WARNING AND
THE SIDE COWL FROM

THE NO.3 ENGINE WAS FOUND ON THE RUNWAY. LIMITED INFORMATION.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

57 91/2ND/3/I OTHER - MIS-IDENTIFIED TAKEOFF HEAVY NOISE AND VIBRATION,

MALFUNCTION COMPRESSOR SURGE

**Summary of Event:**

HEAVY NOISE & SHAKING, COMPRESSOR SURGE+ RTO, CREW MIS-IDENTIFY AS TIRE
FAILURE

**Summary of Narrative:**

DURING TAKEOFF ROLL AT APPROXIMATELY 70 KNOTS HEAVY NOISE AND SHAKING
WAS EXPERIENCED.

THE AIRCRAFT BEGAN TO VEER TOWARD THE RIGHT SIDE OF THE RUNWAY. BECAUSE
THE ENGINE

READINGS WERE NORMAL THE CREW SUSPECTED A RIGHT MAIN WHEEL PUNCTURE. THE
TAKEOFF WAS

ABORTED. THE AIRPLANE TURNED OFF THE RUNWAY AND STOPPED FOR INSPECTION.
THE NOSE DOME

ON THE RH ENGINE HAD DEPARTED ITS MOUNTINGS AND FALLEN DOWN INTO THE
INLET. THE NOSE

DOME, ACCESSORY DRIVE HOUSING AND A FAN BLADE WERE DAMAGED. THE CAUSE OF
THE NOSE DOME

COMING LOOSE IS STRONGLY SUSPECTED TO BE OVER-TORQUING OF THE NOSE DOME.

NOTE: need to move to RTO stack.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

59 92/MWB/2/I OTHER-ASYMMETRIC CRUISE NO REPSONE TO COMMANDED

THRUST, STUCK THROTTLE POWER

**Summary of Event:**

ASYMMETRIC THRUST (STUCK THROTTLE) + FAILED TO DETECT ASYMMETRY -
AIRPLANE ROLLED,

RECOVERED

**Summary of Narrative:**

AFTER LEVELOFF AT A CRUISING ALTITUED OF FL390, ITS AIRSPEED SLIGHTLY
EXCEEDED THE DESIRED

VALUE, AND THE AUTOTHROTTLES REDUCED THE POWER TO BRING THE AIRSPEED
BACK TO THE

PROPER SETTING. HOWEVER, WHEN POWER WAS AUTOMATICALLY REAPPLIED, THE
LEFT ENGINE DID

NOT RESPOND BUT REMAINED AT 0.98 EPR, THIS CAUSED THE RIGHT ENGINE TO
REACH A MAXIMUM

CRUISE THRUST OF 1.54 EPR AS THE AUTOMATIC SYSTEM ATTEMPTED TO HOLD
AIRSPEED. THE FLIGHT

CREW FAILED TO DETECT THE THRUST LOSS ON THE LEFT ENGINE, AND THE
AIRSPEED BLED FROM 250

KTS TO 180 KTS DURING A PERIOD OF SEVEN MINUTES. THE AUTOPILOT CONTINUED
TO HOLD ALTITUDE

AND GROUND TRACK DURING THIS TIME, ALTHOUGH AN INCREASING AMOUNT OF
AILERON DEFLECTION

WAS REQUIRED TO DO SO. THE AIRCRAFT ROLLED 15 DEGREES TO THE LEFT WHEN
THE AUTOPILOT

WAS NO LONGER ABLE TO MAINTAIN CONTROL WITH THE ASYMMETRIC THRUST
CONDITION. THE CREW

DISCONNECTED THE AUTOPILOT AND TOOK RECOVERY ACTION. THE MALFUNCTIONING
LEFT ENGINE

WAS SHUTDOWN AND A SINGLE-ENGINE LANDING WAS ACCOMPLISHED WITHOUT
FURTHER INCIDENT AT

AN ALTERNATE AIRPORT.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

32 82/EWB/4/I OTHER-BEARING FAILURE + CLIMB EXCESSIVE AVM WARNING

CREW FAILED TO SECURE LIGHT, VIBRATION,

ENG COMPRESSOR SURGE

**Summary of Event:**

AVM EXCEEDANCE + FAILURE TO SECURE ENGINE RESULTED IN DISINTEGRATION

**Summary of Narrative:**

FROM RR THE \"RED TOP\" ON THIS INCIDENT ONLY REFERS TO SHUTDOWN OF
ENGINE NO.2 DUE TO AN LP

LOCATION BEARING FAILURE AT 6400 FT ON CLIMB OUT OF JEDDAH. THE AIRCRAFT
DID AN ATB AND

LANDED WITH 3 ENGINES OPERATING. ENGINE NO.1 WAS SHUTDOWN IN ERROR AND
RESTARTED FOR

LANDING AND WAS ALSO FODED DUE TO INGESTION OF DEBRIS FROM THE LPT OF
THE NO.2 ENGINE.

SOME DAMAGE TO THE LEADING EDGE OF THE WING AND THE TOP OF THE WING
INBOARD OF THE NO.2

ENGINE. RR BELIEVES THE EVENT TO BE A RELATED MULTIPLE DUE TO
ENGINE+CREW-\"DAVE

ALLARD\"-RR. AN AVM EXCEEDANCE AND VIBRATION ALERT OCCURRED ON NO.2
ENGINE APPROXIMATELY

10 SECONDS AFTER LIFT OFF. THE THROTTLE WAS CLOSED AND THEN POWER WAS
RESTORED OVER A

PERIOD OF 2 MINUTES. IT REMAINED AT POWER UNTIL THE ENGINE FAILED SOME 5
MINUTES AND 38

SECONDS AFTER THE INTIAL WARNING. (EMERGENCY PROCEEDURES REQUIRE
THROTTLE CLOSURE &

START LEVER TO CUT-OFF IN RESPONSE TO HIGH ENGINE VIBRATION). AFTER
ENGINE FAIILURE THE

CAPTAIN ORDERED SHUTDOWN OF THE NO.2 ENGINE BUT THE FLIGHT ENGINEER
PULLED THE NO.1

ENGINE FIRE HANDLE. ON SEEING THE NO.1 ENGINE FUEL VALVE LIGHT INDICATE
CLOSED, HE THEN

PULLED THE NO.2 ENGINE SHUTDOWN TEE HANDLE. THE NO.1 ENGINE WAS
RESTARTED AND A THREE

ENGINE LANDING ACCOMPLISHED. THE NUMBER 2 ENGINE FAILURE STARTED FROM A
LP LOCATION

BEARING FAILURE, FOLLOWED BY FAN SHAFT FAILURE, LP TURBINE OVERSPEED AND
MAJOR ENGINE

DAMAGE.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

62 \*93/MNB/2/I OTHER-COMPRESSOR G-AROUND COMPRESSOR SURGE

SURGE;UNABLE TO ISOLATE

WHICH ENGINE WAS

AFFECTED

**Summary of Event:**

LOUD BANGS, COMPRESSOR SURGE + DIFFICULTY ISOLATING WHICH ENGINE

**Summary of Narrative:**

THE CREW INITIATED A LOW APPROACH AND GO-AROUND AT APPROXIMATELY 100
FEET AGL WITH

AUTOTHROTTLES AND AUTOPILOT ENGAGED AND FLAP WHERE RETRACTED TO 1 DEG.
GO-AROUND

AIRPLANE PERFORMANCE WAS NORMALY (ENGINE THRUST, CLIMB PERFORMANCE-OK).
THE AIRPLANE

ACCELERATED TO 180 KTS AND SEVERAL HARD ENGINES SURGES WERE FELT.
THOUGH, WHICH ENGINE

WAS SURGING WAS NOT READILY APPARENT. AT 3500 FEET THE AUTOTHROTTLES
WHERE TRIPPED OFF

AND BOTH ENGINE THROTTLES WERE RETARED TO 1.03 TO 1.05 EPR WITH
CONTINOUS SURGES STILL

OCCURRING. APPROXIMATELY 3 MINUTES LATER, VISUAL AND AUDIBLE SURGES WERE
IDENTIFIED AS

THE RIGHT HAND ENGINE, AND IT WAS REDUCED TO IDLE. THE SURGING STOPPED
AT IDLE. AN

UNEVENTFUL ONE ENGINE INOPERATIVE LANDING WAS ACCOMPLISHED WITH FLAPS 20
AND THE RH

ENGINE AT IDLE. NO FURTHER SURGES OCCURRED. THE HPC DAMAGE WAS SEEN FROM
ABOUT THE

EIGHT STAGE REARWARD. CREW INTERVIEWS STATED THAT AFTER THE ENGINE
SURGES BEGAN THE

INSTRUMENTS APPEARED TO HAVE EPR, N1, AND EGT HAD OSCILATIONS BUT ON
BOTH ENGINES. IT WAS

NOT READILY APPARENT WHICH ENGINE WAS IN SURGE. IT KINDA LOOK LIKE THE
OSCILATIONS WERE

GREATER ON THE RH THAN LH ENGINE. THE NATURE OF THE SURGE WAS SOUNDING
LIKE,

BOOM-BOOM,,,, BOOM-BOOM,,,,BOOM-BOOM, A DOUBLE QUAILTY TO THE SOUND. AS
THE CREW WAS

UNABLE TO DETERMINE POSISTIVELY WHICH ENGINE WAS SURGING, THE FLIGHT
ANALYST ENGINEER

WENT TO THE BACK TO START LOOKING IN THE LOWER HOLD, AND HE HEARD THE
BLEED UNLOADING ON

THE RH ENGINE AND SAW THE RH ENGINE OSCILATING (MOVING AROUND RELATIVE
TO THE WING). HE

THEN INFORMED THE FLIGHTCREW AND THEY RETARDED THE THROTTLE ON THE RH
ENGINE AND

SURGINE STOPED. 5 MINUTES AFTER THE START OF SURGINE THE CREW LANDED
UNEVENTFULLY.

NOTE: Not included in event calculations, but included because of
difficulty in identifying which engine.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

51 88/2ND/2/HF OTHER-DUAL ENG TAKEOFF COMPRESSOR SURGES

POWERLOSS;CONTINUOUS

SURGING ENG\'S

**Summary of Event:**

LOUD BANGS, COMPRESSOR SURGE, POWER REDUCTION + ADVANCED THROTTLES
RESULTING IN TOTAL

POWERLOSS RESULTING IN FORCED LANDING

**Summary of Narrative:**

SHORTLY AFTER LIFTOFF A LARGE GROUP OF PIGEONS WAS ENCOUNTERED RESULTING
IN A REDUCTION

OF EPR INDICATION AND SURGING ON BOTH ENGINES. CAPTAIN MOVED THE THRUST
LEVERS TO FULLY

FORWARD AS THE AIRPLANE APPEARED NOT TO BE CLIMBING AT 300 FEET ABOVE
THE RUNWAY

ELEVATION. RWY ALT 6,020 FT. BOTH ENGINES CONTINUED SURGING AND THE
AIRCRAFT WAS NOW ABLE

TO CLIMB TO 1400 FEET AGL WHERE THE CREW EXECUTED AN AIR TURNBACK TURNED
DOWNWIND TO

SET UP A LANDING APPROACH. AS THE CAPTAIN TURNED TO THE BASE LEG BOTH
ENGINES QUIT

RUNNING AND A GEAR UP LANDING WAS MADE IN A SMALL CLEARING. THE LEFT
ENGINE AND THE 41

SECTION SEPARATED FROM THE OTHERWISE INTACT AIRPLANE. AN INTENSE FIRE
QUICKLY DEVELOPED

FROM RELEASED FUEL. MANY PASSENGERS WERE UNABLE TO EVACUATE BEFORE BEING
OVERCOME BY

SMOKE AND FIRE. IT WAS ESTIMATED FROM THE ENGINE DAMAGE THAT THE LEFT
ENGINE HAD

INGESTED 15 BIRDS, THE RIGHT ENGINE 11. OPERATING THE ENGINES IN
CONTINUOUS SURGE CAUSED

THE FINAL STAGE COMPRESSOR BLADES TO SEPARATE, SUBSEQUENTLY MELTING THE
TURBINE

BLADES. ANALYSIS OF THE ENGINES INDICATED THAT SURGE FREE OPERATION WAS
POSSIBLE BY

RETARDING THE THROTTLE TO CLEAR THE SURGE CONDITION EVEN WITH THE
ASSOCIATED ENGINE

DAMAGE.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

58 91/MNB/2/H OTHER-DUAL ENG CLIMB CONTINUOUS COMPRESSOR

POWERLOSS;CONTINUOUS SURGES (BOTH ENGINES

SURGING ENG\'S SEQUENTIAL)

**Summary of Event:**

LOW HUMMING NOISE, COMPRESSOR SURGES + THROTTLE SLIGHTLY RETARDED
WITHOUT CEASING

SURGES - FORCED LANDING

**Summary of Narrative:**

AIRPLANE CRASH LANDED IN AN OPEN FIELD 4:05 MINUTES AFTER TAKEOFF. POWER
WAS LOST ON BOTH

ENGINES DUE TO WINGS SHEDING ICE DURING ROTATION. THE AIRPLANE BROKE
INTO 3 SECTIONS. NO

AIRFRAME FIRE. NO.1 ENGINE HAD A FIRE WARNING 1:31 MINUTES AFTER
TAKEOFF. A PILOT AND 3 PAX

SAW ICE COMING OFF THE WING ON THE RH SIDE WING AND SUSPECT THE SAME FOR
THE LH SIDE. THE

ACCIDENT INVESTIGATION REPORT IS SUMMARIZED AS FOLLOWS: PRIOR TO TAKEOFF
THE AIRCRAFT

WAS DEICED. THE CAPTAIN MADE A ROLLING TAKEOFF WHICH WAS NORMAL UP TO
THE ROTATION. IN

CONNECTION WITH LIFTOFF THE CAPTAIN HEARD AN ABNORMAL NOISE WHICH HE
COULD NOT IDENTIFY.

THE NOISE WAS RECORDED BY THE AIRCRAFTS CVR AS A LOW HUMMING NOISE.
AFTER APPROX 25

SECONDS FLIGHT THE RIGHT ENGINE STARTED TO SURGE. THE CAPTAIN THROTTLED
BACK ON THAT

ENGINE SOMEWHAT, BUT WITHOUT THE SURGING CEASING. THE SURGES CONTINUED
UNTIL THE

ENGINE STOPPED DELIVERING THRUST 51 SECONDS AFTER THE SURGES HAD
STARTED. WHEN THE

FLIGHT HAD LASTED 65 SECONDS THE LEFT ENGINE ALSO STARTED TO SURGE,
WHICH THE PILOTS DID

NOT NOTICE BEFORE THIS ENGINE ALSO LOST THRUST. THIS HAPPENED TWO
SECONDS AFTER THE

RIGHT ENGINE HAD FAILED. WHEN THE ENGINES HAD FAILED THE CREW PREPARED
FOR AN EMERGENCY

LANDING. WHEN THE AIRCRAFT WAS ENTIRELY OUT OF THE CLOUD AT A HEIGHT OF
300 TO 250 METERS

THE CAPTAIN ELECTED TO TRY AND LAND IN A FIELD IN ROUGHLY THE DIRECTION
OF FLIGHT.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

47 88/EWB/4/I OTHER-EXCESSIVE PITCH TAKEOFF COMPRESSOR SURGE

ATTITUDE 22DEG

W/POWERLOSS

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE + PITCH ATTITUDE EXCEEDED TARGET BY 11
DEGREES - RECOVERED

**Summary of Narrative:**

DURING TAKEOFF IN CONDITIONS OF SQUALLY CROSSWINDS, AS THE MAIN WHEELS
OF THE AIRCRAFT

LEFT THE RUNWAY THE COMPRESSOR OF THE NO.4 ENGINE SURGED, RESULTING IN A
THRUST LOSS

FROM THAT ENGINE. THE AIRCRAFT BANKED TO THE RIGHT AND PITCHED UP TO AN
ATTITUDE OF 22

DEG, WHICH WAS SOME 11 DEGREES GREATER THAN THAT RECOMMENDED AFTER AN
ENGINE FAILURE.

WITH THE STICK SHAKER OPERATING, THE AIRCRAFT DESCENDED TOWARDS THE HIGH
GROUND THAT

LIES DUE WEST OF THE AIRPORT UNTIL THE COMMANDER, USING MAX THRUST FROM
THE THREE

REMAINING ENGINES, WAS ABLE TO ESTABLISH A CLIMB PROFILE AND THE
AIRCRAFT THEN ACHIEVED A

SAFE HEIGHT. THE REPORT CONCLUDES THAT THE INCIDENT WAS CAUSED BY THE
FOLLOWING: \-\--A

SURGE INDUCED LOSS OF THRUST FROM THE NO.4 ENGINE JUST AFTER ROTATION.
THE COMMANDER

DELAYING INPUT OF DOWN ELEVATOR UNTIL THE PITCH HAD REACHED 22 DEGREES
WHICH WAS WELL

ABOVE THAT RECOMMENDED AND CONSEQUENTLY THE SCHEDULED THREE ENGINE CLIMB

PERFORMANCE NOT BEING ACHIEVED.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

27 81/1ST/4/I OTHER-POWERLOSS,ATB,U CLIMB COMPRESSOR SURGE

NCORD APPR &

LANDING/OFFSIDE -

PILOTING SKILL

**Summary of Event:**

LOUD BANG, POWERLOSS + UNCOORDINATED APPROACH & LANDING / VEERED OFFSIDE
AT 80 KTS

**Summary of Narrative:**

DURING CLIMB, AIRCRAFT EXPERIENCED NO.3 ENGINE COMPRESSOR SURGE (LOUD
BANG) AND

POWERLOSS AND FIRE WARNING. FIRE WAS EXTINGUISHED AIRBORNE AND AIRCRAFT
MADE AIR

TURNBACK, LANDING 25,000 KG OVERWEIGHT AND 25 KTS FAST ONTO A WET RUNWAY
WITH A 7.5 KTS

TAILWIND. UNABLE TO STOP, AT 80 KTS THE PILOT ELECTED TO VEER OFF RUNWAY
ONTO SOFT GROUND.

ALL ENGINES WERE FOD\'D AND THERE WAS SOME DAMAGE TO THE MLG TRUCK
BEAMS. THE AIRCRAFT

WAS NEVER REPAIRED SINCE IT WAS AT THE END OF IT\'S ECONOMIC LIFE.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

1 68/1ST/4/HF OTHER-PYLON S/O VALVE CLIMB COMPRESSOR SURGE

NOT

SECURED,UNCONTROLED

FIRE

**Summary of Event:**

DISINTEGRATION + CREW FAILED TO SECURE ENG AND TURN OFF BOOST PUMPS
RESULTING IN

UNCONTROLLED FIRE AND ENGINE SEPEPARATION

**Summary of Narrative:**

ONE MINUTE AFTER TAKEOFF, NO.2 ENGINE FAILED. THE COMPRESSOR DISK CUT
THE FUEL LINE

RESULTING IN A FUEL FIRE AND THE CREW FAILED TO CLOSE SHUTOFF VALVE IN
THE PYLON AND ALSO

FAILED TO SHUTOFF BOOST PUMPS WHICH CONTINUED TO PUMP FUEL ONTO THE RAMP
FOR 20 MINUTES.

MADE AN IMMEDIATE RETURNED LANDING, ON APPROACH THE NO.3 ENGINE FELL
OFF. EVACUATION

STARTED AS SOON AS THE AIRPLANE STOPPED BUT FIVE WERE OVERCOME BY HEAT
AND SMOKE AND

DID NOT ESCAPE.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

30 81/1ST/4/H OTHER-RETURN TO LANDING LOW OIL QUANTITY

LANDING; UNCOORD

APPR&LNDG-LOC-ASYM REV

THRUST- BELOW Vmcg

**Summary of Event:**

SINGLE ENGINE SHUTDOWN DUE OIL LOSS + UNCOORDINATED APPROACH & LANDING -
CONTROL LOSS /

OFFSIDE

**Summary of Narrative:**

AIRCRAFT RETURNED WITH NO.3 ENGINE SHUTDOWN DUE TO OIL LOSS. LANDED IN
TYPHOON

CONDITIONS\--GUSTY WINDS, TAILWIND, AND CROSSWIND. LANDED TOO FAR DOWN
RUNWAY AND

INITIALLY REVERSED ENGINE 1 & 4 WHEN IT LOOKED LIKE HE MIGHT OVERRUN,
PILOT BROUGHT UP NO.2

ENGINE IN REVERSE. AIRPLANE DEPARTED LEFT SIDE OF RWY, CROSSED GRASS,
BROKE OFF NLG, AND

ENDED UP ON HIGH SPEED TURNOFF. A/C SCRAPPED.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

3 69/1ST/4/S RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE + RTO AT V1 RESULTING IN OVERRUN

**Summary of Narrative:**

DURING TAKEOFF ROLL , THE AIRCRAFT HIT A FLOCK OF BIRDS (SEA GULLS).
NO.2 ENGINE SURGED AND

THE CREW ELECTED TO ABORT AT 138 KTS. V1=138, VR=145, V2=162. AIRCRAFT
OVERRAN END OF THE

RUNWAY BY 560 FEET INTO A MUD SWAMP. NO FIRE AND NO INJURIES. NO.1,2 AND
3 SHOWED SIGNS OF

BIRD INGESTION WITH NO POWERLOSS. LEFT MAIN AND NOSE LANDING GEARS
COLLAPSED, LOWER

SURFACE OF FUSELAGE DAMAGED. FLAPS DAMAGED, NO.2 PYLON BUCKLED OUTWARD.
FUSELAGE

BROKEN CIRCUMFERENTIALLY FROM WINDOW LINE TO WINDOW LINE WITH 3 INCH
SEPARATION AT BODY

STATION 550. ALL ENGINES DEVELOPED REVERSE THRUST DURING RTO 110%. THE
CREW ACTIONS IN

THE ABONDONED TAKEOFF PROCEDURES WERE TIMELY IN RESPECT OF THROTTLE
CLOSURE,

APPLICATION OF REVERSE THRUST AND ACTUATION OF SPEED BRAKES BUT THE
EVIDENCE INDICATES

THAT THERE MAY HAVE BEEN A DELAY IN APPLICATION OF WHEEL BRAKES BEYOND
THAT DELAY

ASSUMED IN THE ACCELERATE/STOP CERTIFICATION PERFORMANCE CALCULATIONS.
THE CAPTAIN WAS

SCANNING THE ENGINE INSTRUMENTS DURING THE TAKEOFF (PNF) AT THE TIME THE
AIRCRAFT STRUCK

THE BIRDS AND LOSS OF POWER FROM NO.2 ENGINE OCCURRED. HE SAW THE NO.2
EPR DROP FROM ITS

SETTING OF 1.85 TO 1.55 AND THIS INITIATED HIS DECISION TO ABANDON THE
TAKEOFF. THE FLIGHT

ENGINEER ALSO SAW THE EPR DROP TO 1.55 AND CALLED THAT THERE WAS A POWER
LOSS.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

4 70/2ND/2/H RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE + RTO ABOVE Vr RESULTING IN OVERRUN

**Summary of Narrative:**

THE AIRCRAFT, ON A SCHEDULED PASSENGER FLIGHT, WAS BEING OPERATED BY THE
CO-PILOT.

IMMEDIATELY AFTER ROTATION FOR TAKEOFF A LOUD EXPLOSION WAS HEARD AND
THE CO-PILOT

DETECTED A LOSS OF THRUST FROM THE NO.1 ENGINE, AND APPLIED RUDDER TO
HOLD THE HEADING.

THE CO-PILOT APPARENTLY OVERCORRECTED, CAUSING THE AIRCRAFT TO YAW TO
THE RIGHT. THE

CAPTAIN ASSOCIATED THE LOUD NOISE AND YAW TO THE RIGHT WITH A NO.2
ENGINE FAILURE (AND HE

SAID HE SAW THE RIGHT ENGINE INSTRUMENTS SPOOL DOWN) AND SO ATTEMPTED TO
APPLY LEFT

RUDDER. DURING A BRIEF PERIOD OF UNCERTAINTY AT 50 TO 100 FEET THE PILOT
ELECTED TO ABORT

AND REGAIN THE RUNWAY. THE AIRLINE DECIDED TO NOT REPAIR THE AIRPLANE.
PROBABLE

CAUSE-DECISION AND ACTION TO TERMINATE THE TAKEOFF WERE BASED ON
ERRONEOUS JUDGEMENT

THAT BOTH ENGINES HAD FAILED. FACTORS: NO.1 ENGINE FAILED AS A RESULT OF
A FIRST STAGE (N2)

TURBINE BLADE FAILURE. FLIGHT CREW DID NOT UTILIZE THE ENGINE AND
AIRCRAFT INSTRUMENTS TO

DETERMINE THE CONDITION OF THE ENGINES, ALTITUDE, AND AIRSPEED. THE
COMPANY PROCEDURES

AND APPLICABLE FLIGHT MANUALS DICTATE THAT THE FLIGHT CREW SHOULD HAVE
CONTINUED WITH

ONE ENGINE INOPERATIVE. THE CAPTAIN ERRONEOUSLY DECIDED POWER TO BOTH
ENGINES HAD BEEN

LOST. THE AIRCRAFT WAS AIRBORNE AND ABOVE V2 SPEED AT THE TIME OF THE
ENGINE FAILURE.

FACTORS LEADING TO INAPPROPRIATE RESPONSE: THE FIRST OFFICER WAS AT THE
CONTROLS AT THE

TIME OF THE EMERGENCY DEVELOPED AND STAYED ON THE CONTROLS WITH THE
CAPTAIN

THROUGHOUT THE ABORT. THE CAPTAIN ORALLY TOOK OVER COMMAND OF THE
AIRCRAFT CONTROLS

THREE SECONDS AFTER THE BANG NOISE. THE AIRCRAFT MADE A YAW TO THE RIGHT
JUST AFTER THE

BANG SOUND (F/O RUDDER INPUT-OVERCORRECTED). THE CAPTAIN STATE HE SAW
THE RIGHT ENGINE

INSTRUMENT INDICATING A MALFUNCTION.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

8 72/2ND/2/S RTO TAKEOFF TEMPORARY POWERLOSS

DUE TO STANDING WATER

INGESTION DURING T/O

**Summary of Event:**

POWERLOSS (TEMPORARY) DUE RUNWAY WATER INGESTION + RTO ABOVE V1, OVERRUN

**Summary of Narrative:**

DURING THE TAKEOFF ROLL IN RAIN, THE LEFT ENGINE APPEARED TO LOOSE POWER
AT ABOUT 126 KTS.

V1=128KTS , DECISION TO ABORT = 132 KTS, ABORT SPEED = 135 KTS. THE
PILOT ELECTED TO ABORT BUT

WAS UNABLE TO STOP ON THE RUNWAY. GROUND SPEED WAS ABOUT 10 MPH WHEN
AIRPLANE

OVERRUN END OF RUNWAY AND DOWN AN INCLINE INTO A SHALLOW SALT WATER
SWAMP. ONLY THE

GEAR AND LOWER FUSELAGE ENTERED THE WATER. FIVE DAYS TO REMOVE AIRCRAFT.
THERE WAS NO

FIRE. PILOT FACTOR - IMPROPER HANDLING OF AN ABORTED TAKEOFF. ENGINE
RELATED DUE TO

APPARENT POWERLOSS. CAA REPORT: TAKEOFF SPEED CALCULATED AS V1=135,
Vr=136, AND V2=143.

THE DRY V1 WAS CORRECTLY AMENDED TO THE WET RUNWAY VALUE OF 128KTS.
HAVING BEEN

ADVISED BY ATC OF STANDING WATER AT ABOUT THE MID POINT OF THE RUNWAY,
TAKEOFF WAS

PERFORMED WITH WATER INJECTION IN USE AND ENGINE IGNITORS ON. AT ABOUT
126KTS THE AIRCRAFT

RAN INTO ONE OR BOTH POOLS OF STANDING WATER, WHICH WERE ASTRIDE THE
CENTERLINE AND

ABOUT 4 METERS DIAMETER AND 2 CM DEEP. ENTRY INTO THE STANDING WATER
RESULTED IN

DIRECTIONAL CONTROL PROBLEMS, A HESITATION IN THE AIRCRAFT RATE OF
ACCELERATION, AND A

TEMPORARY LOSS OF THRUST PROBABLY FROM NO.1 ENGINE. THERE WAS AN
INTERVAL OF ABOUT 5

SECONDS BETWEEN RUNNING THROUGH THE WATER AT 126KTS AND THE INITIATION
OF ACTION TO

ABORT THE TAKEOFF. BY THIS TIME THE ENGINE MALFUNCTION HAD CEASED AND IT
WAS PROBABLY

ACCELERATING AGAIN TOWARDS FULL THRUST. THE AIRCRAFT WAS ALSO
ACCELERATING AGAIN AND

ATTAINED A MAXIMUM SPEED OF 135KTS ABOUT 2 SECONDS AFTER THE ACTION TO
ABORT THE TAKEOFF

WAS TAKEN (ABOUT 132KTS). DECELERATION FROM THE PEAK SPEED OF 135 WAS
CONSISTENT WITH

BOTH ENGINES OPERATING CORRECTLY IN REVERSE THRUST AND WHEEL BRAKES
FUNCTIONING

PROPERLY AND BEING CORRECTLY USED.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

12 75/2ND/3/S RTO TAKEOFF SUPECTED POWER LOSS DUE

TO AIRCRAFT DECELERATION

**Summary of Event:**

PERCEIVED POWERLOSS (STANDING RUNWAY WATER) + RTO ABOVE V1 - OVERRUN

**Summary of Narrative:**

AT A LATE STAGE IN THE TAKEOFF FROM RUNWAY 28 (WHICH WAS VERY WET AS A
RESULT OF RECENT

RAIN), THE AIRCRAFT ENCOUNTERED AN AREA OF STANDING WATER AT V1. THIS
RESULTED IN A

PERCEIVED \"MARKED DECELERATON\" AND LEAD THE CAPTAIN TO ABORT THE
TAKEOFF. IT COULD NOT

BE STOPPED ON THE RUNWAY AND THE PILOT STEERED IT OFF TO ONE SIDE ON TO
GRASS. THE

PROBABLE CAUSE WAS DETERMINED AS THE PILOTS DECISION TO ABORT THE
TAKEOFF ON A WET

RUNWAY AT V1. CONTRIBUTORY FACTORS WERE THE LOW EFFECTIVE BRAKING
COEFICIENT OF

FRICTION AND THE FAILURE OF THE CAPTIAN TO ASCERTAIN THE EXTENT AND
DEPTH OF WATER

PRESENT ON THE RUNWAY PRIOR TO TAKEOFF. FDR DATA INDICATED: THE HIGHEST
AIRSPEED WAS

127.1 KTS AT 1045 METERS FROM START OF ROLL. THE WET V1 CALCULATION WAS
117 KTS. ESTIMATED

THE THROTTLES WERE CLOSED AT 122 KTS. NO.1 & 2 ENGINES SUFFERED
POST-ACCIDENT INGESTION;

ALL THREE ENGINES PERFORMED UP TO SPECIFICATION ON BENCH TEST. THERE WAS
NO EVIDENCE OF

PRE-CRASH MALFUNCTION. THE CAPTAINS DECISION TO ABANDON TAKEOFF WAS AN
INSTANTANEOUS

REACTION TO THE SENSATION HE EXPEREICNED - THAT OF A MARKED DECELERATION
\"COMPATIBLE

WITH A LOSS OF ENGINE POWER\". HOWEVER, THIS SENSATION WAS NOT SUPPORTED
BY THE ENGINE

GAUGES AND THE FDR INDICATES THAT HAD THE TAKEOFF NOT BEEN ABANDONED,
THE AIRCRAFT

WOULD HAVE BECOME AIRBORNE NORMALLY. THERE WAS NO EVIDENCE OF PRE-MISHAP
TECHNICAL

FAILURE.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

14 76/EWB/3/I RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE + RTO ABOVE Vr - OVERRUN

**Summary of Narrative:**

PILOT ABORTED TAKEOFF WHEN NO.2 ENGINE SURGED. AIRCRAFT WAS ROTATING
WITH THE NOSE

LANDING GEAR OFF THE RUNWAY WHEN THE DECISION TO ABORT WAS MADE. THE
AIRCRAFT WENT OFF

THE END OF THE RUNWAY ABOUT 200 FEET WITH THE MAIN LANDING GEAR
REMAINING ON HARD

GROUND AND THE NOSE GEAR IN MUD UP TO THE STEERING CYLINDERS. PASSENGERS
WERE REMOVED

FROM THE AIRCRAFT WITH MOBLE STANDS. WEATHER WAS BAD WITH RAIN, SLEET,
SNOW, AND WIND.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

16 \*77/EWB/3/I RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD NOISE, FLASH OF LIGHT, COMPRESSOR SURGE + RTO ABOVE V1, (WET RWY) -
OVERRUN

**Summary of Narrative:**

DURING TAKEOFF ON RWY 28 AT 155KTS (V1=144) THE \"ENGINE FAILURE\"
WARNING LAMP CAME ON AND

THERE WAS A LOUD NOISE. THE CREW ABORTED THE TAKEOFF, ACTIONED THE
BRAKES AND REVERSED

ALL ENGINES. THE AIRCRAFT OVERRAN ABOUT 200 FEET, LAST PART OF RUNWAY
SILTED OVER.

TAKEOFF SPEEDS WERE V1=144KTS, VR=152, V2=165KTS. THE STALL WAS DUE TO A
TEMPERATURE

SENSOR COLD SHIFT.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

17 77/2ND/3/I RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE + RTO AT Vr - OVERRUN

**Summary of Narrative:**

DURING TAKEOFF ROLL CAPTAIN HEARD LOUD BANG AT ROTATION. \"ENGINE
FAILURE\" LIGHTS AND PACK

TRIP LIGHTS CAME ON AND CAPTAIN ABORTED TAKEOFF. AIRPLANE CONTINUED
ROLLING STRAIGHT

AHEAD STOPPING PARTIALLY OFF END OF RUNWAY. LEFT MLG REMAINED ON RUNWAY.
RIGHT MLG

STOPPED APPROXIMATELY TWO FEET OFF END OF RUNWAY AND NLG APPROXIMATELY
60 FEET OFF END.

THERE WAS NO REPORTED AIRPLANE DAMAGE OR PERSONNEL INJURY. ENGINE WAS
RUNUP TO

TAKEOFF POWER TO SIMULATE FULL TIME RUN TO ROTATION. NO.2 ENGINE HAD
SEVERE COMPRESSOR

STALLS AT 25 SECONDS INTO RUNUP AT WHICH TIME IT SHOOK THE WHOLE
AIRPLANE. ALL OTHER

ENGINES OPERATED NORMALLY AND THE \"ENGINE FAIL\" LIGHTS CAME ON AT THE
TIME OF RUNUP

STALLS. AIRPLANE WAS FERRIED FOR UNSCHEDULED NO.2 ENGINE CHANGE.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

19 78/2ND/2/H RTO TOUCH&GO POWERLOSS

**Summary of Event:**

POWERLOSS + RTO ABOVE V1 - OVERRUN

**Summary of Narrative:**

THE AIRCRAFT WAS ON A FLIGHT CREW TRAINING WITH A STUDENT PILOT. A TOUCH
AND GO LANDING

WAS MADE ON RUNWAY 25. WHEN AT ABOUT THE MIDPOINT ON THE 8300 FT RUNWAY,
THE AIRCRAFT

STRUCK A FLOCK OF PIGEONS. THE INSTRUCTOR PILOT TOOK OVER CONTROLS AND
ATTEMPTED TO

MAKE A GO-AROUND BUT HIS EFFORTS WERE INHIBITED BY THE STUDENT PILOT
APPLYING THE BRAKES.

ALTHOUGH THRUST DECAY WAS NOTED ON THE NO.1 ENGINE THE AIRCRAFT SPEED
WAS INITIALLY

ADEQUATE FOR A GO-AROUND. THE AIRPLANE OVER RAN THE END OF THE RUNWAY BY
940 FEET. THE

RIGHT MLG COLLAPSED AND THE RIGHT ENGINE SEPARATED. AN INTENSE FIRE
DESTROYED THE RIGHT

WING AND MOST OF THE FUSELAGE. NO INJURIES. PROBABLE CAUSE: CO-PILOT WAS
APPLYING BRAKING

ACTION RESULTED IN AN ABORT OF AN ATTEMPTED TOUCH & GO.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

21 \*78/EWB/4/S RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD NOISE, COMPRESSOR SURGE + RTO AT V1 - OVRRUN

**Summary of Narrative:**

TAKEOFF WAS DELAYED 15 MINUTES TO ALLOW BRAKES TO COOL. DURING TAKEOFF
RUN AT 145 KTS THE

NO.3 ENGINE SURGED. V1=145. ABORTED INITIATED AND REVERSE THRUST WAS
OBTAINED ON #1 AND

#2 ENGINE. THE AIRCRAFT CAME TO A STOP ABOUT 200 FEET PAST END OF RUNWAY
WITH THE LEFT

MAIN GEAR COLLAPSED AND SEPARATED. INVESTIGATION SHOWED THAT TIRE PIECES
STARTING AT

6000 FEET FROM THE START OF ROLL AND THE N0.3 ENGINE SHOWED DAMAGE DUE
TO INGESTION OF

THE TIRE. PROBABLE CAUSE: PILOT FACTOR DELAY IN APPLYING BRAKES AND
REVERSE THRUST AFTER

DECISION TO ABORT. TAKEOFF WEIGHT WAS 764,302 LBS. MAX IAS WAS 160KTS.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

22 78/EWB/3/I-2 RTO TAKEOFF POWERLOSS

**Summary of Event:**

POWERLOSS + RTO AT V1- OVERRUN (ICY RWY)

**Summary of Narrative:**

DURING TAKEOFF ON RUNWAY 22 AN \"ENGINE FAIL LIGHT\" ILLUMINATED AT V1.
THE TAKEOFF WAS

ABORTED AND THE AIRPLANE OVERRAN THE RUNWAY COMING TO REST ABOUT 100
FEET BEYOND THE

RUNWAY END AND JUST TO THE RIGHT OF CENTERLINE. ALTHOUGH BOTH AFT SLIDES
WERE DEPLOYED,

59 PAX AND THE CREW DEPLANED NORMALLY THROUGH THE VENTRAL STAIRS.
OBSERVATIONS OF THE

LAST 200 TO 300 FEET OF RUNWAY SHOWED THAT IT WAS SNOW PACKED OVER
PATCHES OF ICE. THERE

WERE NO REPORTED INJURIES AND THE ONLY AIRPLANE DAMAGE WAS A BLOWN NO.4
TIRE DUE TO A

SEVERE FLAT SPOTTING. THE AIRPLANE HAD BEEN STEERED TO THE RIGHT TO
AVOID THE APPROACH

LIGHTS ALTHOUGH ONE LIGHT WAS STRUCK BY THE NOSE WHEEL. THE NO.2 ENGINE
HAD INTERNAL

DISTRESS AS EVIDENCED BY METAL IN THE TAILPIPE. WEATHER: WIND 220 AT IS
TO 20KTS; TEMP 10 DEG

F; CEILING 1200 OVERCAST; VISIBILITY - BLOWING SNOW WITH VIS AT 2.5
MILES ; DAYLIGHT AT 16:00 LOCAL

TIME. NO INJURIES WITH MINOR DAMAGE TO AIRCRAFT.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

28 \*81/2ND/3/S RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, POWERLOSS + RTO ABOVE Vr - OVERRUN

**Summary of Narrative:**

AT 1610 EDT A SCHEDULED PAX FLIGHT OVERRAN RUNWAY 9L WHEN THE CAPTAIN AT
THE CONTROLS

ABORTED THE TAKEOFF. THE ABORT ACTION WAS INITIATED WHEN THE FLIGHT CREW
HEARD AN

EXPLOSION AND OBSERVED A PARTIAL LOSS OF POWER ON THE NO.2 ENGINE
IMMEDIATELY AFTER Vr

CALLOUT AND AFTER NOSE GEAR LIFTOFF. V1=129 KTS, V2=144KTS. THE AIRCRAFT
CAME TO REST 421

FEET BEYOND THE END OF THE RUNWAY SURFACE, 215 FEET TO THE LEFT OF THE
RUNWAY

CENTERLINE IN SOFT RAIN SOAKED GROUND WITH THE AIRCRAFT STRADDLING A
SHALLOW DRAINAGE

DITCH. THE PAX WERE EVACUATED VIA USE OF THE LEFT SIDE EMERGENCY CHUTES.
SIX OF THE PAX

SUSTAINED MINOR INJURIES DURING THE EVACUATION OF THE AIRCRAFT. THE
AIRCRAFT SUSTAINED

SUBSTANTIAL DAMAGE OT ITS RIGHT MAIN LANDING GEAR. THERE WAS NO EVIDENCE
OF FIRE. THIRTY

GROUND WITNESSES WERE INTERVIEW AND MOST OF THEM DESCRIBED A SERIES OF
LOUD BOOMING

SOUNDS EARLY IN THE TAKEOFF ROLL. ABOUT 1/3 OF THE WITNESSES SAID THAT
THE LOUDEST

EXPLOSION OCCURRED AT OR NEAR THE TIME THAT THE AIRCRAFT WAS ROTATED.
TOGW=151,000 LBS.

WEATHER AT THE TIME: 700 SCATTERED, ESTIMATED 4,000 BROKEN, 20,000
OVERCAST, VISIBILITY 5 MILES

IN LIGHT RAIN, TEMP 79 DEG F, DEW POINT 70 DEG F, WIND 190 AT 15 KTS.
ALTIMETER 29.69 INCHES HG.

NO.2 ENGINE EXAMINATION: AIR INTAKE DUCT HOUSING INTERIOR DID NOT REVEAL
ANY SIGNS OF

CORROSION OR FAILED FASTNERS AND ALL VORTEX GENERATORS WERE IN PLACE AND
INTACT. NO

DAMAGE TO LPC AND FREE TO ROTATE. VISIBLE EXAMINATION OF TURBINE DID NOT
REVEAL AND

DAMAGE OR OPERATING DISTRESS AND ALSO FREE TO ROTATE. INTERNAL BORESCOPE
DID NOT

REVEAL ANY INTERNAL OPERATING DISTRESS OR DISCREPANCIES.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

36 \*83/EWB/4/S RTO TAKEOFF EGT WARNING (AMBER AND

RED)

**Summary of Event:**

EGT WARNING LIGHT + RTO ABOVE V1 - OVERRUN

**Summary of Narrative:**

AIRCRAFT WAS DEPARTING RWY 13 AT A GROSS WEIGHT OF 820,000 LBS. DURING
THE TAKEOFF

ACCELERATION, THE CREW GRADUALLY REDUCED THRUST ON #2 ENGINE BECAUSE OF
HIGH EGT, THE

AMBER WARNING LIGHT HAVING COME ON AT APPROX. 80 KTS, AND THE RED
WARNING ON AT 120KTS.

STOPPING ACTION WAS INITITATED AT ABOUT 163 KTS AND THE AIRPLANE
EVENTUALLY ACCELERATED

TO 166 KTS. NEAR THE END OF THE RUNWAY, THE AIRPLANE DEPARTED THE
LEFTSIDE OF THE RUNWAY,

BREAKING OFF ALL LANDING GEAR IN SOFT GROUND. ALL FOUR ENGINES CONTACTED
THE GROUND, THE

RESULTING UPWARD FORCES DAMAGING THE ENGINE STRUTS. THERE WAS NO FIRE
AND ONLY MINOR

FUEL LEAK THROUGH A PULLED CENTER FUEL TANK FASTNER. FAILURE OF THE
ENGINE WAS

DETERMINED TO BE SEPARATION OF THE FIRST STAGE TURBINE BLADE RETAINER.
WEIGHTS: TO GW

372,700 KG, FUEL 106,000 KG, CARGO 112,820 KG, FLAPS 20 DEG, 20.1% CG,
STAB TRIM AT 6 3/4 UNITS

NOSE-UP, MIDE GREEN BAND, VI=157 KTS, VR=168.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

38 85/EWB/4/I-1 RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE + RTO ABOVE V1 - OVERRUN

**Summary of Narrative:**

PILOT ABORTED TAKEOFF DUE TO APPARENT BIRD INGESTION ON NO.2 ENGINE. THE
AIRPLANE

CONTINUED OFF THE END OF THE RUNWAY 11 FOR 140 METERS WITH ALL WHEELS
BURIED TO THE RIMS

IN THE GRASS OVERRUN. TIRES 1,3,5,9,11,AND 15 DELFATED. NO.4 THRUST
REVERSER WAS INOPERATIVE

AND THRUST REVERSERS 2 AND 3 WERE USED FOR THE STOP. THE DFDR FIRST
INDICATION OF

STOPPING CAME AT A SPEED OF 174 KTS IAS 54 SECONDS FROM START OF ROLL
AND SIX SECONDS

BEYOND V1=155. GROSS WEIGHT UNKNOWN. NO.2 FAN DUCT HAD EVIDENCE OF
FEATHERS BUT THE FAN

BLADES SHOWED NO EVIDENCE OF DAMAGE. WEATHER: LOCAL AREA HAD HEAVEY RAIN
SHOWERS

PRIOR TO EVENT, BUT WAS NOT RAINING AT THE TIME OF EVENT. DFDR ANALYSIS:
DATA INDICATED

THAT THE V1 SPEED OF 155 KTS IAS OCCURRED AT A GMT OF 19:52:48 WHICH WAS
48 SECONDS FROM

START OF TAKEOFF ROLL. THE FIRST ACTION TO ABORT THE TAKEOFF OCCURRED AT
GMT 19:52:54 WHEN

THE BRAKES WERE APPLIED, WHICH WAS 54 SECONDS FROM START OF TAKEOFF ROLL
AND 6 SECONDS

BEYOND THE V1 SPEED.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

40 85/1ST/4/H RTO TAKEOFF FIRE WARNING

**Summary of Event:**

FIRE WARNING + RTO - OVERRUN

**Summary of Narrative:**

DURING THE TAKEOFF ROLL FOR THE START OF A FERRY FLIGHT, THE CREW
RECIEVED A NO.1 ENGINE

FIRE WARNING. THE CREW INTIATED AN ABORTED TAKEOFF AND THE AIRCRAFT
OVERRAN RUNWAY END

AND WAS DESTROYED BY FIRE. CREW REPORTEDLY ESCAPED INJURY. NO ADDITIONAL
DETAILS

AVAILABLE.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

45 86/2ND/2/I RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE + RTO AT Vr - OVERRUN

**Summary of Narrative:**

IN HEAVY RAIN NEAR V1 (AFTER INITIATION OF ROTATION ACCORDING TO ONE
PAX) A FLOCK OF SEAGULLS

WAS ENCOUNTERED. THE NO.1 ENGINE INGESTED AT LEAST ONE BIRD AND
STALLED/FLAMED-OUT. THE

TAKEOFF WAS ABORTED AND THE AIRPLANE DEPARTED THE RUNWAY AT A POINT 84
FEET PROIR TO

REACHING 6000 FOOT RUNWAY END. THE AIRPLANE CAME TO REST IN A MARSHY
TERRAIN ABOUT 160

FEET PAST DEPARTURE END OF THE RUNWAY AND 96 FEET OFF OF THE RIGHT SIDE.
LIGHT SKID MARKS

BEGAN 50 FEET PRIOR TO THE POINT OF RUNWAY DEPARTURE.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

46 \*86/EWB/2/H RTO TAKEOFF COMPRESSOR SURGE

(POWERLOSS)

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE + RTO ABOVE Vr (AFTER LIFTOFF) - OVERRUN

**Summary of Narrative:**

DURING TAKEOFF ROLL, JUST AFTER ROTATION, LOUD BANG WAS HEARD ON THE
RIGHT HAND ENGINE.

AIRCRAFT WAS INITIATING IT\'S TAKEOFF WHEN CREW DECIDED TO ABORT. HEAVY
LATERAL VIBRATIONS

WERE FELT AND HEARD. INSTRUMENTS COULD NOT BE READ BY THE CREW. THE
CAPTAIN ASSUMED

CONTROL AND BROUGH THE NOSE BACK DOWN. THE AIRCRAFT WAS AIRBORN FOR
ABOUT 4 SECONDS.

THE CAPTAIN PULLED BACK THE THROTTLES AND SELECTED REVERSE THRUST.
AIRCRAFT OVERRAN

THE END OF THE RUNWAY. AIRCRAFT HIT HIGH INTNSITY LIGHT AND OTHER
OBSTACLES. ALL LANDING

GEAR SEPARATED AND AIRCRAFT CAME TO REST ON BOTH ENGINES AND UNDER
CARRIAGE. ALL PAX

EXITED USING SLIDES WITH EIGHT MINOR INJURIES. THE FLIGHT CREW REPORTED
BIRDS ON THE

RUNWAY DURING THE TAKEOFF ROLL AND BIRD DEBRIS WAS FOUND IN THE KISS
SEAL AREA OF THE

PRE-COOLER FAN AIR DUCT ON RH ENG. THE TAKEOFF WAS ABORTED AFTER
ROTATION. THE RH

ENGINE HAD INGESTED A BLACK KITE BIRD. TWO FAN BLADES SUSTAINED
TRANSVERSE FRACTRURES

DUE TO INGESTION OF THIS 2.2 LB BIRD.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

48 88/2ND/2/I RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE-I + RTO ABOVE V1 - OVERRUN

**Summary of Narrative:**

AT ABOUT 100 KTS, A FLOCK OF BIRDS SEEN TO BE OCCUPYING THE CENTER OF
THE RUNWAY. AS THE

AIRPLANE PASSED THRU THE BIRDS A RAPID DECREASE IN P7 WAS NOTED AND THE
CAPTAIN CALLED

STOP. CO-PILOT APPLIED REVERSE THRUST AND BRAKES. THE AIRCRAFT OVERRUN
THE END OF THE

RUNWAY BY 161 FEET (49 METERS) INTO A CLEARWAY. DECISION TO ABORT
DETERMINED TO BE 147 KTS.

CREW FORGOT TO USE \"LIFT DUMPERS\".

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

49 \*88/EWB/4/S RTO TAKEOFF FIRE WARNING

**Summary of Event:**

FIRE WARNING + RTO ABOVE V1 - OVERRUN

**Summary of Narrative:**

FIRST OFFICER ABORTED TAKEOFF AT 170 KTS FOLLOWING #4 ENGINE FIRE
WARNING, V1=156KTS. THE

FIRST OFFICER REMOVED HIS HANDS FROM THE THROTTLES ABOUT V1. ABOUT 2
SECONDS LATER, NO.4

ENGINE FIRE WARNING ACTIVATED. THE CAPTAIN REACHED IN THE DIRECTION OF
THE THROTTLES, A

MOVE THE FIRST OFFICER INTERPRETED A SIGN TO ABORT. THE FIRST OFFICER
VERY RAPIDLY TOOK

HOLD OF THE THROTTLES, PULLING THEM BACK TO THE STOPS, APPLIED BRAKES
AND PLACED ALL

ENGINES IN REVERSE. GW 778,000 LBS. OVERRAN END OF RUNWAY ABOUT 300
METERS. SEPARATED ALL

GEAR. DAMAGE TO AIRCRAFT - SEPARATED ALL ENGINES, NLG FOLDED INTO REAR
OF WHEEL WELL.

FUEL TANKS 2,3 AND ? PUNCTURED. NO FIRE. UNDERSIDE OF FUSELAGE AND ALL
T/E FLAPS DAMAGED.

TWO TIRES FAILED DUT TO STRIKING RUNWAY LIGHTS, OTHER TIRES SEEM OK.
BRAKES LOOK OK. #4

ENGINE HAS TURBINE CASE CRACK NEAR AFT FLANGE WELD. CRACK EXTENDS 9
THROUGH 12 TO 3

O\'CLOCK. V1=156, Vr=172, V2=180 KIAS. RUNWAY 28 IS 12,500FT LONG AND
HAS A PAVED 1000FT OVERRUN.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

52 \*88/MNB/2/S RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANGS, COMPRESSOR SURGE + RTO ABOVE Vr

**Summary of Narrative:**

DURING TAKEOFF IN DAY VMC, AFTER Vr, THE CREW FELT SOMETHING THEY
INTERPRETED TO BE LEFT

HAND MAIN LANDING GEAR TIRE FAILURE. SUBSEQUENT INVESTIGATION SHOWED THE
LH ENGINE HAD A

HPT BLADE FAILURE (CONTAINED). THE CAPTAIN ELECTED TO ABORT , REGAINED
THE CONTROLS, AND

PUSHED THE THE NOSE OVER. THE NLG COLLAPSED AFT AND THE AIRCRAFT WAS
STOPPED ON THE

RUNWAY WITH ALL MLG TIRES DEFLATED. ALL CREW AND PASSENGERS EVACUATED
THE A/P WITHOUT

ANY REPORTED INJURIES. THE FUSELAGE WAS FRACTURED FORWARD OF THE WING.
HIGHLIGHTS OF

INTERVIEW WITH CAPTAIN AND F/O\-\-\--DEPARTURE AND ENGINE OUT
PROCEEDURES WHERE NOT

BRIEFED PRIOR TO THE ATTEMPTED TAKEOFF PER EAL FLIGHT OPERATIONS MANUAL.
FIRST OFFICER

PERFORMED THE TAKEOFF, V1=128,Vr=133,V2=140. TAKEOFF PERFORMED USING THE
AUTOTHROTTLE,

TAKEOFF WAS NORMAL UP TO V1, THE AIRCRAFT CAMEOFF \"VERY SMOOTHLY\" A
SMOOTH SLOW

ROTATION. RUNWAY LENGTH WAS NOT CRITICAL. AS THE NOSE CAME OFF THE
RUNWAY THERE WERE

TWO MUFFLED SHOTGUN NOISES. AT THE MOMENT OF THE ABNORMAL SOUNDS, THE
F/O SCANNED THE

ENGINE INDICATIONS AND EICAS. THE SCREENS INDICATED NORMAL ENGINE
OPERATION. THERE WAS A

SLIGHT AIRCRAFT MOVEMENT TO THE LEFT, NOT A MAJOR MOVEMENT. HE HAD BOTH
HANDS ON THE

YOKE. THE CAPTAIN SUDDENLY TOOK CONTROL OF THE AIRCRAFT BY CLOSING THE
THROTTLES. F/O

WAS NOT SURE IF THERE WAS VERBAL COMMUNICATION BETWEEN HIMSELF AND THE
CAPTAIN

REGARDING THE CHANGE IN FLYING RESPONSIBILITIES. F/O ASSISTED THE
CAPTAIN IN THE BRAKING.

DURING DECELERATION THE AIRCRAFT WENT FROM A NOSE LEVEL ATTITUDE TO A
FIERCE NOSE DOWN

POSITION. SPOILERS & REVERSE THRUST OPERATED NORMALLY DURING THE ABORT.
THE CAPTAIN

SAID HE THOUGHT HE HAD PLENTY OF ROOM TO STOP THE AIRCRAFT. IT WAS THE
CAPTAINS FIRST

ABORTED TAKEOFF IN AN AIRPLANE, ALTHOUGH HE HAD RECEIVED SUCH RTO
TRAINING IN A FLIGHT

SIMULATOR INCLUDING TRAINING ON THE USE OF MAXIMUM BRAKING.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

54 90/1ST/4/H RTO TAKEOFF COMPRESSOR SURGE +

VISUAL SIGHTING OF BIRDS,

SURGES ON NO.2&3 ENGINES

**Summary of Event:**

COMPRESSOR SURGE + RTO BELOW V1 - OVERRUN

**Summary of Narrative:**

DURING THE INITIAL PORTIONS OF THE TAKEOFF ROLL THE CREW SPOTTED SOME
BIRDS ON THE

RUNWAY AHEAD AND ALONG THEIR FLIGHT PATH. THINKING THAT THE AIRCRAFT
COULD NOT BE

STOPPED IF ABORTED, THE PIC CONTINUED THE TAKEOFF. HOWEVER, AS THE
AIRCRAFT CONTINUED

THE TAKEOFF ROLL, THE BIRDS STARTED TO FLY OFF THE RUNWAY. SOME OF THE
BIRDS COLLIDED WITH

THE AIRCRAFT AND CAUSED A MOMENTARY SURGE ON NO.2 & 3 ENGINES. ALARMED
BY THE SURGE THE

PILOT MADE A HIGH SPEED REJECTED TAKEOFF. THE ABORT WAS UNSUCCESSFUL.
THE AIRCRAFT

OVERRUN THE END OF THE RUNWAY AND FELL HEAVILY ON TO THE LOWER GROUND
AND BROKE-UP.

THE CO-PILOT WAS INJURIED SERIOUSLY. ABORT INITIATE AT 118 KTS AND
V1=131KTS.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

55 91/EWB/2/I RTO TAKEOFF SEVERE VIBRATIONS &

PERCEIVED POWERLOSS

**Summary of Event:**

TIRE TREAD INGESTION, SEVERE VIBRATION & PECEIVED POWERLOSS, + RTO ABOVE
V1

**Summary of Narrative:**

DURING TAKEOFF ROLL THE PILOT REPORTED SEVERE VIBRATION FROM THE NO.1
ENGINE AND A

PERCEIVED POWERLOSS HE THEN ELECTED TO ABORT. THE DFDR INDICATED THAT
THE CALIBRATED

AIRSPEED REACHED 172 KTS BEFORE THE TAKEOFF WAS ABORTED. THE AIRCRAFT
OVERRAN THE

RUNWAY END AND WAS BROUGHT TO A REST APPROXIMATELY 200 METERS BEYOND THE
END OF THE

RUNWAY AND 60 METERS TO THE LEFT OF RUNWAY CENTERLINE. THE PILOT USED
NOSEWHEEL

STEERING TO AVOID OBSTACLES BEYOND THE RUNWAY END LINE. THERE WAS NO
FIRE REPORTED

PRIOR TO, DURING, OR AFTER THIS EVENT AND THERE WAS NO EVIDENCE OF FIRE
VISIBLE ON THE

ENGINE OR AIRCRAFT. THERE WAS NO NON-CONTAINMENT ASSCIATED WITH THIS
EVENT. DUE TO THE

TIRE TREAD INGESTION, ALL ENGINE RELATED DAMAGE WAS CONTAINED WITHIN THE
ENGINE CASING

AND NACELLE. HOWEVER, IT WAS REPORTED THAT THE PILOT EXPERIENCED SEVERE
VIBRATIONS FROM

THE NO.1 ENGINE AND A PERCEIVED POWER LOSS. HE ABORTED THE TAKEOFF BASED
ON THE

PERCEIVED POWER LOSS.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

56 91/MNB/2/I RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANGS, COMPRESSOR SURGE + RTO AT Vr

**Summary of Narrative:**

THE AIRCRAFT WAS PRESENTLY BEING FERRIED. CREW PERFORMED A TAKEOFF ABORT
WHICH WAS

INITIATED AT Vr WHEN THE RIGHT ENGINE SURGED THREE TIMES AND THE
AIRCRAFT YAWED. AIRCRAFT

EXITED OFF RUNWAY 27L AT TURN OFF T2. THIS LOCATION IS APPROXIMATELY
7500 FT FROM THE

RUNWAY START. TOTAL LENGTH OF RUNWAY IS 13002 FEET. BORESCOPE INSPECTION
OF ENGINE NO.2

REVEALED COMPRESSOR STAGE 2 LINER DISTRESS AND BENT STAGE 2 BLADES.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

60 92/EWB/4/I RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE + RTO ABOVE V1 - OVERRUN

**Summary of Narrative:**

DURING TAKEOFF ROLL AT 165 KNOTS, ENGINE NO. 1 SURGED WITH A LOUD BANG
AND OVERTEMP. A

REJECTED TAKEOFF WAS PERFORMED AT 167 KNOTS (ABOVE V1). THE COMPRESSOR
SURGE WAS

CAUSE BY A BIRDSTRIKE TO THE ENGINE. THE AIRCRAFT CAME TO STOP WITH THE
NOSE LANDING GEAR

OFF THE RUNWAY ON THE GRASS. ALL OF THE MAIN LANDING GEAR TIRE FUSES
RELEASED. AN

EMERGENCY EVACUATION, MINOR INJURIES REPORTED TO 10 PEOPLE. MAINTENANCE
CREW FOUND

EVIDENCE OF BIRD REMAINS AT THE 3.0 BLEED VALVE AND PRECOOLER. NO FAN
BLADES DAMAGED.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

64 93/EWB/4/I-2 RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE + RTO ABOVE V1 - OVERRUN

**Summary of Narrative:**

DURING TAKEOFF A BIRD WAS INGESTED INTO THE ENGINE DURING TAKEOFF ROLL
AT 182 KNOTS. AN

REJECTED TAKEOFF WAS INITIATED AND THE AIRCRAFT OVERRUN THE END OF THE
RUNWAY BY

APPOXIMATELY 400 METERS. THERE WERE NO INJURIES OR FATALITIES. THE EVENT
INVOLVED TWO

LARGE COMMON BUZARDS BEING INGESTED INTO THE THE NO.2 ENGINE WITH THE
LOSS OF MAJOR FAN

BLADE PEICES. THE DECISION TO REJECT THE TAKEOFF OCCURRED SEVERAL
SECONDS AFTER THE

BIRDSTRIKE AT AN AIRPLANE SPEED WELL ABOVE THE TARGET V1 DECISION SPEED
OF 163 KNOTS. THE

AIRPLANE OVERRAN THE END OF THE RUNWAY BY APPROXIMATELY 420 METERS AND
DAMAGED A

NUMBER OF LIGHT FIXTURES LOCATED JUST BEYOND THE END OF THE RUNWAY.
BIRDS WERE SEEN ON

THE RUNWAY PRIOR TO INGESTION.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

65 93/MWB/3/I RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE + CREW THROTTLED GOOD (ALL) ENGINES,
CORRECTED AND CONTINUED

TAKEOFF

**Summary of Narrative:**

DURING TAKEOFF ROLL, AT, NEAR, OR ABOVE V1 ONE OF THE ENGINES SURGED AND
THE FIRST OFFICER

(PILOT FLYING) INITIATED AN ABORT BY THROTTLING ALL ENGINES, THE CAPTAIN
THEN TOOK CONTROL

AND RE-ADVANCE THROTTLES AND CONTINUED THE TAKEOFF. THE INVESTIGATION
SHOWED THE NO.3

ENG SURGING, THEN NO.1 AND NO.2 ENGINES BEING COMMANDED TO REDUCED
POWER, THEN BEING

RETURNED TO TAKEOFF POWER. IT COULD BE THAT THE POWER REDUCTION WAS THE
NORMAL POWER

RETARDED TO CLIMB POWER. THEN THE THROTTLES FOR NO.1 AND NO.2 APPEAR TO
BE READVANCED

TO TAKEOFF POWER. THE NO.3 THROTTLE MUST ALSO HAVE BEEN ADVANCED BECAUSE
EGT EXCEEDED

LIMITS FOR LONG DURATION.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

75 95/MWB/2/I-1 RTO TAKEOFF THRUST REVERSER \"REV

UNLK\" LIGHT ON

**Summary of Event:**

RTO AT V1, T/R \"REV UNLK\" LIGHT ON, ABORT ON RUNWAY

**Summary of Narrative:**

TAKEOFF ABORTED AT 150 KTS DUE TO ENGINE NO.1 THRUST REVERSER TRANSIT
LIGHT CAME ON.

WHEELS DEFLATED. DECISION TO ABORT T/O WAS AT V1. ACTUAL ABORT OCCURRED
AFTER V1 DUE TO

REACTION TIME.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

76 \*95/EWB/3/S RTO TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, SHUDDER, VIBRATIONS, COMPRESSOR SURGE + RTO ABOVE V1 -
OVERRUN

**Summary of Narrative:**

THE AIRCRAFT WAS ON A SCHEDULED FLIGHT, DURING THE TAKEOFF RUN, JUST
AFTER THE AIRCRAFT

ACCELERATED THROUGH 167 KNOTS, THE CREW HEARD A LOUD BANG, FELT
CONSIDERABLE VIBRATION

AND AIRFRAME SHUDDER, AND REJECTED THE TAKEOFF. THE AIRCRAFT COULD NOT
BE STOPPED ON

THE RUNWAY, AND THE NOSE GEAR COLLAPSED AS THE AIRCRAFT ROLLED THROUGH
THE SOFT

GROUND OFF THE END OF THE RUNWAY 26. THE BOARD DETERMINED THAT THE
ENGINE ON THE LEFT

WING LOST POWER AT A CRITICAL POINT IN THE TAKEOFF RUN AND THAT THE
REJECTED TAKEOFF WAS

INITIATED AT A POINT AND SPEED (ABOVE V1) WHERE THERE WAS INSUFFICIENT
RUNWAY REMAINING TO

STOP THE AIRCRAFT ON THE RUNWAY. CONTRIBUTING TO THIS OCCURENCE WERE THE

MISIDENTIFICATION OF THE CAUSE OF THE LOUD BAND AND LACK OF KNOWLEDGE
REGARDING THE

CHARACTERISTICS OF ENGINE COMPRESSOR STALLS. THE COMPRESSOR STALL AND
LOSS OF POWER, IN

THE LEFT ENGINE, WERE THE RESULT OF THE FAILURE OF COMPRESSOR BLADES IN
THE HIGH

PRESSURE COMPRESSOR SECTION OF THE LEFT ENGINE.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

78 \*96/EWB/3/H RTO TAKEOFF LOUD BANG (COMPRESSOR

SURGE) & POWERLOSS

**Summary of Event:**

LOUD BANG, VIBRATIONS (COMPRESSOR SURGE) POWERLOSS + RTO ABOVE Vr

**Summary of Narrative:**

AFTER THE AIRPLANE COMMENCED THE TAKEOFF ROLL, SHORTLY AFTER IT PITCHED
UP SOME 11

DEGREES AND LIFTED OFF AT A SPEED OF 171 KNOTS, A LOUD BANG WAS HEARD
WITH AN ACCOMPAINED

POWERLOSS FROM THE NO.3 ENGINE. THE FLIGHT CREW INITIATED AN ABORTED
TAKEOFF ABOVE Vr.

BASED ON THE DISASSEMBLY INSPECTION OF THE ENGINE, THE DAMAGE WAS
DETERMINED TO BE A

FRACTURE OF A HPT STAGE 1 BLADE. THE VREF SPEEDS FOR THE FLIGHT WERE
CALCULATED AS

FOLLOWS: V1 149, Vr 157, V2 171. THE AIRPLANE RE-CONCTACTED THE RUNWAY
AND DEPARTED THE END

OF THE RUNWAY. THE AIRPLANE CAME TO REST AND CAUGHT FIRE AND WAS
DESTROYED. AIRPLANE

INFORMATION: 211,300 kg with CG at 18.9% MAC (MTW = 251,744 KGS WITH A
CG RANGE 10.6% TO 28.4%.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

80 96/MWB/4/I RTO Takeoff POWERLOSS + DECEL

STALL/SURGE

**Summary of Event:**

POWERLOSS + RTO ABOVE V1

**Summary of Narrative:**

CREW REJECTED TAKEOFF AT 159 KNOTS DUE TO NO.4 ENGINE POWERLOSS
ACCOMPAINED BY A DECEL

SURGE. THE POWERLOSS WAS CAUSED BY A LEAKING/OPEN ENGINE CONTROL SENSE
LINE. THE

AIRPLANE WAS STOPPED ON THE TAXIWAY. THE TOWER INFORMED THE CREW THERE
WAS SMOKE

COMING FROM THE UNDERSIDE OF THE AIRPLANE. SLIDES R1, 2, and 4,
L1,2,4,5, AND UPPER DECK WERE

DEPLOYED. ALL PAX AND CREW DEPARTED WITH 2 PAX RECEIVING SERIOUS
INJURIES. THERE WAS NO

HULL DAMAGE AND 10 OF THE 16 MAIN GEAR TIRES DEFLATED DUE TO FUSE PLUGS
BLOWING.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

29 \*81/EWB/4/S RTO - STOP PROCEDURE TAKEOFF COMPRESSOR SURGE,

AIRPLANE SHUDDER, FLASH

OF LIGHT

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE, EGT LIGHT + RTO 5 KTS BELOW V1 - OVERRUN

**Summary of Narrative:**

DURING TAKEOFF ROLL, THE PILOT IN COMMAND REJECTED THE TAKEOFF AFTER THE
FLIGHT ENGINEER

CALLED OUT \"ENGINE FIRE\". THE AIRCRAFT OVERSHOT AND STOPPED ABOUT 20
METERS FROM THE

END OF THE RUNWAY. DURING THE TAKEOFF ROLL APPROXIMATELY 20 SECONDS
AFTER THE FIRST

OFFICER CALLED OUT 80 KNOTS, THE PILOT IN COMMAND HEARD A BANG SOUND
COMING FROM THE

OUTSIDE IMMEDIATELY FOLLOWED BY A MOMENTARY SHUDDERING OF THE AIRCRAFT.
THE PILOT IN

COMMAND ASKED \"WHAT\'S THE MATTER\" ? A SECOND LATER, THE FLIGHT
ENGINEER REPORTED

\"ENGINE FIRE\" AND THE COMMANDER INITIATED THE REJECTED TAKEOFF. THE
FLIGHT ENGINEER BASED

HIS CALLOUT ON THE ILLUMINATION OF NO.4 EGT LIMIT LIGHT FOLLOWING THE
\"BANG SOUND WHICH HE

ALSO HEARD AND ON THE ACCOMPANYING FLASH OF LIGHT HE NOTED FROM THE
STARBOARD SIDE OF

THE AIRCRAFT. THERE WERE NO VISUAL, OR AURAL ENGINE FIRE WARNING. IN THE
PRE-COCKPIT VOICE

RECORDER (CVR) PLAYBACK INTERVIEW, ALL THREE FLIGHT DECK CREW TESTIFIED
THAT THE FIRST

OFFICER CALLED OUT V1, BUT THIS CALLOUT DOES NOT APPEAR ON THE CVR
PLAYBACK. THE DFDR

READOUT SHOWED THAT WHEN THE ABORT DECISION WAS MADE, THE AIRCRAFT
AIRSPEED WAS 147

KNOTS, 5 KNOTS BELOW V1. THE AIRCRAFT WAS WITHIN ALLOWABLE GROSS TAKEOFF
WEIGHT.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

5 70/EWB/4/I SHUTDOWN GOOD ENGINE CLIMB FIRE WARNING

**Summary of Event:**

FIRE WARNING + SHUTDOWN GOOD ENG, RESTARTED ENGINE

**Summary of Narrative:**

FIRE WARNING ILLUMINATED ON NO.2 ENGINE SHORTLY AFTER TAKEOFF. CREW
INADVERTENTLY

CLOSED FUEL CUTOFF LEVER FOR NO.1 ENGINE WHICH THEN HAD HIGH EGT.
RETURNED NO.1 FUEL

CUTOFF TO ON AND ENGINE RETURNED TO NORMAL. ATB JFK WITH NO.2 SHUTDOWN.
FOUND 15TH

STAGE BLEED DUCT WAS RUPTURED AT THE PRECOOLER.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

7 72/EWB/4/I-1 SHUTDOWN GOOD ENGINE CLIMB FIRE WARNING

**Summary of Event:**

FIRE WARNING + SHUTDOWN GOOD ENGINE, RESTARTED

**Summary of Narrative:**

DURING PREVIOUS MAINTENANCE, A FUEL FLOW XMITTER ON THE NO.3 ENGINE HAD
BEEN REMOVED.

WHEN IT WAS REINSTALLED, ITS O-RINGS WERE CUT IN TWO PLACES. THIS
ALLOWED A FUEL LEAK.

DURING THE CLIMB OUT, THE LEAKING FUEL CAUGHT FIRE. SUBSEQUENTLY THE
NO.3 ENGINE WAS

SHUTDOWN. HOWEVER, DURING THE SHUTDOWN PROCESS, THE FE INADVERTENTLY
CLOSED THE LP

FUEL VALVE FOR THE NO.2 ENGINE WHICH THEN RAN DOWN. THE CAPTAIN DECLARED
AN EMERGENCY,

DUMPED FUEL, AND RETURNED TO NAIROBI. ENROUTE THE NO.2 ENGINE WAS
RESTARTED AND A 3

ENGINE LANDING ACCOMPLISHED.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

9 72/EWB/4/I-2 SHUTDOWN GOOD ENGINE CRUISE COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, POWERLOSS + SHUTDOWN GOOD ENGINE, RESTARTED

**Summary of Narrative:**

INITIAL REPORTS ARE THAT NO.1 ENGINE SURGE WITH POWERLOSS DUE TO FAILURE
OF A FIRST STAGE

TURBINE BLADE. NO.2 ENGINE WAS APPARENTLY SHUTDOWN FOR RISING EGT FROM
APPARENT SURGE

CONCURRENT WITH NO.1 SURGE AND AIRCRAFT YAW PRODUCED BY SHUTTING DOWN
NO.1 ENGINE. IT IS

ESTIMATED THAT THE SHUTDOWN OF NO.2 ENGINE WAS INADVERTENT AND/OR NOT
NECCESSARY.

NO.2 ENGINE RESTARTED.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

11 75/EWB/4/I-1 SHUTDOWN GOOD ENGINE CRUISE COMPRESSOR SURGE

**Summary of Event:**

SOUND HEARD, POWERLOSS + SHUTDOWN GOOD ENGINE, RESTARTED BOTH ENGINES

**Summary of Narrative:**

AT FL370 A SOUND WAS HEARD AND NO.3 ENGINE N1 OBSERVED TO BE DECREASING.
WHILE NO.3 ENGINE

WAS BEING SHUTDOWN, NO.4 EGT WAS REPORTED AS RISING AND NO.4 SHUTDOWN.
AIRPLANE

DESCENDED, NO.3 RESTARTED AT FL250, NO.4 RESTARTED AT FL230 AND FLIGHT
CONTINUED TO SIN.

NOTHING FOUND WRONG. SUSPECT COMPRESSOR DETERIORATION AND CREW
INADVERTENTLY

SHUTDOWN NO.3-WRONG ENGINE.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

13 75/EWB/4/I-2 SHUTDOWN GOOD ENGINE CRUISE HI STAGE BLEED LIGHT,

COMPRESSOR SURGE

**Summary of Event:**

LOUD NOISE, RAPID RISE IN EGT + SHUTDOWN GOOD ENGINE, RESTARTED BOTH
ENGINES

**Summary of Narrative:**

SEVERAL SECONDS AFTER BEGINNING CRUISE AT FL390, THE HIGH STAGE BLEED
BLUE LIGHT

ILLUMINATED ON NO.3 ENGINE. IMMEDIATELY FOLLOWING THERE WAS A STRONG
STALL. EPR FELL WITH A

RAPID RISE IN EGT. ONE OR TWO SECONDS LATER ALL PARAMETERS FELL ON NO.4
ENGINE. RESTART

OF BOTH ENGINES WAS ACCOMPLISHED AT FL280. TIME ON TWO ENGINES WAS 3
MINUTES. ENGINES

CHECKED OK. NO CAUSE FOUND. SUSPECT CREW ERROR - INADVERTENTLY SHUTDOWN
OF NO.4 ENGINE

WHEN TRYING TO SHUTDOWN NO.3 OR FUEL MANAGEMENT ERROR (OUT OF SEQUENCE).

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

15 77/EWB/4/I SHUTDOWN GOOD ENGINE CLIMB COMPRESSOR SURGE

**Summary of Event:**

LOUD NOISE, COMPRESSOR SURGE, POWERLOSS + SHUTDOWN GOOD ENGINE,
UNSUCCESSFUL RESTART -

TWO-ENGINE LANDING

**Summary of Narrative:**

DURING CLIMB AT FL280, ENGINES NO.1 AND 2 STALLED AND QUIT RUNNING. BOTH
ENGINES SHUTDOWN.

ATTEMPTS TO RELIGHT WERE UNSUCCESSFUL. RETURNED TO HND AND OVERWEIGHT
LANDING MADE.

METAL IN CHIP DETECTOR OF NO.2 ENGINE. NO.1 NOTHING FOUND WRONG. SUSPECT
NO.1 ENGINE

SHUTDOWN INADVERTENTLY.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

18 78/2ND/3/I-1 SHUTDOWN GOOD ENGINE CLIMB POWERLOSS

**Summary of Event:**

POWERLOSS + SHUTDOWN GOOD ENGINE, RESTARTED

**Summary of Narrative:**

DURING CLIMB NO.3 ENGINE FLAMEDOUT. SUSPECT GEAR ACCESSORY SHAFT
FAILURE. ESSENTIAL

POWER SELECTED TO NO.1 ENGINE, BUT UNABLE TO SELECT, SO SWITCHED TO NO.2
ENGINE. NO.1

ENGINE THEN OBSERVED TO SPOOL DOWN AND STOP. APPROXIMATELY 2000 FEET
LOST. RESTARTED

NO.1 ENGINE AND AIR TURNBACK. NO OTHER INFORMATION. SUSPECT CREW ERROR
ASSOCIATED WITH

DIFFICULTIES OF NO.3 FLAMEOUT.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

20 78/EWB/4/I SHUTDOWN GOOD ENGINE CRUISE COMPRESSOR SURGE

**Summary of Event:**

NOISE, POWERLOSS + SHUTDOWN GOOD ENGINE, RESTARTED

**Summary of Narrative:**

AFTER 4:55 HOURS OF FLIGHT NO.4 ENGINE SURGED AND OVERTEMP DUE TO 7TH
STAGE HUB BROKE.

NO.3 ENGINE INADVERTENTLY SHUTDOWN DURING THE RESTART ATTEMPT ON NO.4
ENGINE. TWO

ENGINE TIME 4-7MINUTES. NO.3 RESTARTED AND NO.4 REMAINED SHUTDOWN DURING
THE DIVERSION.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

23 79/EWB/4/I-1 SHUTDOWN GOOD ENGINE CRUISE COMPRESSOR SURGE AND

OVERTEMP

**Summary of Event:**

NOISE, COMPRESSOR SURGE, OVERTEMP + S/D GOOD ENGINE, RESTARTED BOTH
ENGINES

**Summary of Narrative:**

DURING FLIGHT THE NO.2 ENGINE EXPERIENCED SURGE AND OVERTEMP.
APPROXIMATELY 40 SECONDS

LATER NO.3 ENGINE SPOOLED DOWN AND FLAMED OUT. APPROX 8-10 MINUTES SINCE
LAST FUEL HEAT

AND FUEL TANK TEMP AT -20 DEG C. BOTH ENGINES RESTARTED AT FL280. SINCE
NO CAUSE FOUND FOR

NO.3 ENGINE, ASSUME NO.2 ENGINE HAD STEADY STATE SURGE DUE TO
DETERIORATION AND NO.3 WAS

AN INADVERTENT SHUTDOWN.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

24 79/2ND/2/S SHUTDOWN GOOD ENGINE CRUISE COMPRESSOR SURGE

**Summary of Event:**

LOUD EXPLOSION, POWERLOSS, DECOMPRESSION + SHUTDOWN GOOD ENGINE,
RESTARTED ENGINE

**Summary of Narrative:**

ENROUTE IN CRUISE AT FL200, THE PILOT REPORTED A LOUD EXPLOSION FROM THE
REAR OF THE

AIRCRAFT. THE CABIN IMMEDIATELY DEPRESSURIZED AND OXYGEN MASKS DEPLOYED.
CAUSE OF

EXPLOSION WAS A FAILURE OF THE RH ENGINE 7TH AND 8TH STAGE DISK SPACER.
SECTIONS OF THE

SPACER PENETRATED THE ENGINE COWLING, ENTERING THE CABIN NEAR THE RH
LAVATORY AND

EXITING THROUGH THE TOP OF THE FUSELAGE. IT WAS REPORTED THAT THE PILOT
SHUT DOWN BOTH

ENGINES, STARTED APU, THEN RESTARTED THE LH ENGINE AT FL050 FEET, AND
MADE AN UNEVENTFUL

EMERGENCY LANDING. GROUND INSPECTION REVEALED THE 7TH TO 8TH STAGE DISK
SPACER HAD

FAILED LEAVING A 5\"X7\" HOLE IN THE ENGINE CASE AT 0900 POSITION.
SPACER HARDWARE WENT

THROUGH THE APRON JUST BEHIND THE FORWARD ENGINE MOUNT AND THE TOP OF
THE PYLON,

ENTERED FUSELAGE APPROXIMATELY ONE FOOT ABOVE THE PYLON AT STATION 965,
WENT THRU THE

LAV, AND EXITED AT THE TOP OF THE FUSELAGE JUST FORWARD OF STATION 965.
JUST ABOVE THE RH

LAV, A WIRE BUNDLE WAS HIT SEVERING AND DAMAGING MANY WIRES. THIS BUNDLE
CARRIES ALL

INSTRUMENT WIRING TO BOTH ENGINES, WITH THE EXCEPTION OF EGT, AND PASSES
THROUGH THE

UPPER RH CORNER OF THE PRESSURE BULKHEAD. ENGINE IGNITION IS IN ANOTHER
BUNDLE WHICH

GOES THROUGH THE PRESSURE BULKHEAD IN THE SAME AREA. THE EGT WIRING
PASSES THROUGH

THE BULKHEAD IN THE LOWER RH CORNER.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

25 80/EWB/3/I SHUTDOWN GOOD ENGINE DESCENT NO RESPONSE TO THROTTLE

**Summary of Event:**

NO THROTTLE RESPONSE, POWERLOSS + SHUTDOWN GOOD ENGINE, RESTARTED ENGINE

**Summary of Narrative:**

ON DESCENT NO.3 ENGINE WOULD NOT RESPOND TO POWER LEVER. ENGINE WAS
SHUTDOWN AND

RESTARTED BUT STILL NO RESPONSE, SO ENGINE WAS SHUTDOWN AGAIN. AS NO.3
ENGINE RAN DOWN

A MASTER CAUTION LITE AND ELECTRICAL CUE LIGHT CAME ON FOR NO.2 ENGINE.
AUTOPILOT

DISENGAGED. CREW NOTED NO.2 HAD FLAMED-OUT. ENGINE RESTARTED AFTER 20 TO
30 SECONDS. A

THREE ENGINE LANDING ACCOMPLISHED WITHOUT FURTHER PROBLEM. MECHANICAL
PROBLEM

DISCUSSED ABOVE FOUND ON NO.3 BUT NO CAUSE FOUND FOR NO.2 ENGINE
FLAMEOUT. NO.2 ENGINE

INADVERTENTLY SHUTDOWN AS PART OF NO.3 ENGINE PROBLEMS.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

26 81/2ND/2/I SHUTDOWN GOOD ENGINE TAKEOFF POWERLOSS

**Summary of Event:**

PERCEIVED BOTH ENGINES FAILED, POWERLOSS (SE) + SHUTDOWN GOOD ENG - RTO

**Summary of Narrative:**

ABORTED TAKEOFF DUE TO CREW REPORTED BOTH ENGINES FAILED. MAINTENANCE
FOUND THE LH

ENGINE HAD A FAILED FUEL PUMP SHAFT SHEARED. RH ENGINE SHOWED NO
DISCREPIENCIES SUSPECT

INADVERTENT SHUTDOWN BY GRABBING TOO MANY HANDLES.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

31 81/EWB/4/I SHUTDOWN GOOD ENGINE CRUISE POWERLOSS

**Summary of Event:**

POWERLOSS + SHUTDOWN GOOD ENGINE, RESTARTED

**Summary of Narrative:**

LOST POWER ON NO.1 ENGINE AND SHUTDOWN NO.2 ENGINE BY MISTAKE. RELIGHT
NO.2 ENGINE AND

CONTINUED ON FOR A THREE ENGINE LANDING.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

33 82/EWB/4/I SHUTDOWN GOOD ENGINE CLIMB COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE (POWERLOSS) + SHUTDOWN GOOD ENGINE,
RESTARTED

**Summary of Narrative:**

THIS INCIDENT REFERS TO SHUTDOWN OF ENGINE NO.2 DUE TO AN LP LOCATION
BEARING FAILURE AT

6400 FT ON CLIMBOUT. THE AIRCRAFT DID AN ATB AND LANDED WITH 3 ENGINES
OPERATING. ENGINE

NO.1 WAS SHUTDOWN IN ERROR AND RESTARTED FOR LANDING. SOME DAMAGE TO THE
LEADING EDGE

OF THE WING AND THE TOP OF THE WING INBOARD OF THE NO.2 ENGINE. AFTER
ENGINE FAIILURE THE

CAPTAIN ORDERED SHUTDOWN OF THE NO.2 ENGINE BUT THE FLIGHT ENGINEER
PULLED THE NO.1

ENGINE FIRE HANDLE. ON SEEING THE NO.1 ENGINE FUEL VALVE LIGHT INDICATE
CLOSED, HE THEN

PULLED THE NO.2 ENGINE SHUTDOWN TEE HANDLE. THE NO.1 ENGINE WAS
RESTARTED AND A THREE

ENGINE LANDING ACCOMPLISHED. THE NUMBER 2 ENGINE FAILURE STARTED FROM A
LP LOCATION

BEARING FAILURE.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

42 85/MWB/2/I SHUTDOWN GOOD ENGINE CRUISE COMPRESSOR SURGE

**Summary of Event:**

NOISE (SHUDDER), VIBRATION, COMPRESSOR SURGE + SHUTDOWN GOOD ENGINE,
RESTARTED

**Summary of Narrative:**

DURING CRUISE AT FL390 AIRFRAME BEGAN TO SHUDDER. LEFT THROTTLE WAS
RETARDED TO IDLE BUT

BUFFET (SUSPECT COMPRESSOR STALL) CONTINUED. LEFT ENGINE WAS SHUTDOWN
BUT BUFFET

CONTINUED. MADE A PRECAUTIONARY LANDING. STARTED APU AT FL350. BUFFET
STOPPED AS

DECENDING THROUGH FL290. STARTED LEFT ENGINE ON DRIFT DOWN. BORESCOPE #1
ENGINE AND

NOTHING FOUND WRONG. #2 ENGINE BORESCOPED AND FOUND HPC DAMAGE. CREW
SHUTDOWN THE

WRONG ENGINE.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

53 \*89/MNB/2/H SHUTDOWN GOOD ENGINE CLIMB COMPRESSOR SURGE,

MODERATE TO SEVERE

VIBRATION, BURNING SMELL,

AND SOME VISIBLE SMOKE IN

**Summary of Event:**

VIBRATION, SMELL, COMPRESSOR SURGE + SHUTDOWN GOOD ENGINE -TOTAL
POWERLOSS - FORCED

LANDING

**Summary of Narrative:**

APPROACHING FL290 IN THE CLIMB, THE CREW EXPERIENCED SYMPTOMS OF SURGE,
MODERATE TO

SEVERE VIBRATION, A BURNING SMELL, AND SMOKE DUE TO LEFT ENGINE FAN
BLADE FRACTURE. IT IS

REPORTED THAT THE CREW BELIEVED THAT SMOKE AND VIBRATION WAS FROM THE
RIGHT ENGINE, AND

THE RIGHT THROTTLE WAS RETARDED 20 SECONDS AFTER THE ONSET OF THE
VIBRATION. THE

CAPTAIN STATED THAT AFTER RETARDING THE RIGHT THROTTLE, THE SMELL AND
SIGNS OF SMOKE

WERE REDUCED, AND HE REMEMBERED NO CONTINUATION OF THE VIBRATION. AN
EMERGENCY WAS

DECLARED, AND THE RIGHT ENGINE WAS SHUTDOWN ABOUT 40 SECONDS AFTER THE
VIBRATION

BEGAN. THE LEFT ENGINE POWER WAS SUCCESSFULLY REDUCED, AND CONTINUED TO
OPERATED AT

\"COMPARATIVELY LOW POWER\" BUT WITH HIGHER THAN NORMAL VIBRATION IN THE
DESCENT. AFTER

POWER HAD BEEN INCREASED ON THE LEFT ENGINE FOR THE APPROACH TO RUNWAY
27, AT 900 FT AGL

AND 2.4 NMILES FROM TOUCHDOWN, WITH GEAR DOWN AND FLAPS 15 DEGREES, THE
LEFT ENGINE LOST

POWER, ACCOMPAINED BY HIGH VIBRATION LEVELS. A LEFT ENGINE FIRE WARNING
OCCURRED 17

SECONDS AFTER THE POWER LOSS. ATTEMPTS TO START AND OBTAIN THRUST FORM
THE RIGHT

ENGINE BEFORE GROUND CONTACT WERE NOT SUCCESSFUL. INITITAL CONTACT WAS
ON LEVEL

GROUND BUT THE AIRPLANE THEN PITCHED OVER AND IMPACTED A MAJOR HIGHWAY
AND ITS

EMBANKMENT COMING TO REST ABOUT 900 METERS FROM THE THRESHOLD OF RUNWAY
27.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

63 93/EWB/4/I-1 SHUTDOWN GOOD ENGINE TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE + SHUTDOWN GOOD ENGINE - TWO ENGINE LANDING

**Summary of Narrative:**

IT WAS REPORTED FROM THE FLIGHT CREW THAT DURING TAKEOFF AT FL004 THE
NO.2 ENGINE SURGED

WITH A PEAK EGT OF 870 DEGREES C. AT APPROXIMATELY FL006 THE NO.1 ENGINE
SURGED WITH A PEAK

EGT OF 889 DEGREES C. BOTH ENGINES WERE SHUTDOWN SOMETIME AFTER 1000
FEET ABOVE GROUND

LEVEL (AGL) APPARENTLY (FLT CRW RPRT) DUE TO EGT LIMIT EXCEEDANCE. EGT
RED LINE LIMIT IS 670

DEGREES C. THE AIRCRAFT CONTINUED THE TAKEOFF AND DUMPED FUEL (66,000
LBS) OVER THE WATER

AND RETURNED FOR AN UNEVENTFUL TWO-ENGINE LANDING. FAILURE OF THE INLET
SPINNER

RESULTED IN 3 UNCONTAINED LOCATIONS (2,6,10 O\'CLOCK) ON ENG NO.2 WERE
EVIDENT IN THE INLET

FORWARD OF THE \"A\" FLANGE. 1 LOCATION OF AIRCRAFT FOD WAS NOTED ON THE
LH AIRCONDITIONING

BODY FAIRING UNDER THE LH WING.

ENGINE MANUFACTURE INVESTIGATIOIN EXECUTIVE SUMMARY STATES: PROBABLE
CAUSE OF THE NO.2

ENGINE SURGE IS ATTRIBUTED TO THE LIBERATION OF THE INLET CONE ASSEMBLY.
THERE IS

INSUFFICIENT PHYSICAL DAMAGE TO THE NO.1 ENGINE TO EXPLAIN THE SURGE
(MAYBE A DECEL SURGE,

FROM A THROTTLE CHOP) AND IFSD. NO.2 ENGINE. BORESCOPE INSPECTION CHECK
OK, THE ENG WAS

FLOWN BACK TO MAIN BASE WHERE THE NO.1 ENGINE WAS CHANGED DUE TO EGT
OVERTEMPERATURE.

A ENGINE OVERHAUL HOT SECTION WAS PERFORMED WITH NEGATIVE FINDING AND
THE ENGINE WAS

RE-ASSEMBLED AND RE-INSTALL AND HAS BEEN FLYING PROBLEM FREE SINCE.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

66 \*93/MNB/2/I SHUTDOWN GOOD ENGINE APPROACH STUCK THROTTLE

**Summary of Event:**

ASYMMETRIC THRUST (STUCK THROTTLE + SHUTDOWN GOOD ENGINE (BELIEVED IT
FLAMED OUT)

**Summary of Narrative:**

EXPERIENCE AN INFLIGHT ENGINE SHUTDOWN NO.2 ENGINE DURING THE FINAL
PHASE OF APPROACH AT

696 FEET. INITIAL CREW REPORTS INDICATED THAT ENGINE NO.2 HAD APPARENTLY
FLAMED OUT.

HOWEVER, THE CREW HAD APPARENTLY MISTAKEN THE RETARDING OF ENGINE NO.2
THRUST LEVER BY

THE AUTOTHROTTLE TO BE THE ENGINE WINDING DOWN AND SO SHUTDOWN THE
ENGINE. A SINGLE

ENGINE LANDING WAS ACCOMPLISHED WITHOUT FURTHER INCIDENT.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

71 \*94/MWB/4/I SHUTDOWN GOOD ENGINE CLIMB COMPRESSOR SURGE

**Summary of Event:**

LOUD BANGS, COMPRESSOR SURGE + SHUTDOWN GOOD ENGINE; THREE ENGINE
LANDING

**Summary of Narrative:**

FLIGHT CREW REPORTED THAT 1 MINUTE AND 50 SECONDS AFTER TAKEOFF THEY
HEARD A LOUD BANG

AND FELT THE AIRCRAFT SHUDDER. THIS WAS FOLLOWED BY THREE LOUD BANGS.
ENGINE NUMBER 2

WAS SHUTDOWN AND THE AIRCRAFT RETURNED TO LANDING. ENGINE NO.2 WAS
BORESCOPED AND NO

PROBLEMS FOUND. FOLLOWING FURTHER REVIEW OF ONBOARD CMC MESSAGES, GROUND
CREW

DETERMINED ENGINE POSITION THREE (3) S/N 724441 (TT/TC 6998/1392 HAD
EXPERIENCED SURGE. FROM

DFDR DATA: NO.3 ENGINE SURGED DURING POWER REDUCTION FROM T/O PWR TO CLM
PWR SETTING

(AUTOTHROTTLE), \~1,800 FT AGL, NO.3 SURGED 3 TIMES THEN RECOVERED, 4
SECONDS AFTER THE

THIRD SURGE ON NO.3 THE NO.2 THROTTLE WAS PULLED TO IDLE. 6 SECONDS
AFTER NO.3 SURGE THE

NO.2 ENGINE HAD A SURGE DETECT FLAG, IE.. ACCEL OR DECEL SURGE
CONDITION.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

73 \*95/MWB/2/I- SHUTDOWN GOOD ENGINE CLIMB STUCK THROTTLE

**Summary of Event:**

ASYMMETRIC THRUST (STUCK THROTTLE) + SHUTDOWN GOOD ENGINE

**Summary of Narrative:**

CREW REPORT: AFTER THE TOP OF CLIMB POWER REDUCTION. ENGINE NO.1 HAD N2
VIBRATION OF 3.0

UNITS WITH ASSOCIATED THROTTLE VIBRATION. AFTER CONFIRMATION, ENGINE
NO.1 WAS SHUTDOWN.

ON RETURN TO \_\_\_, ENGINE NO.2 REMAINED JAMMED AT 94% N1. ENGINE NO.1
WAS RELIT AND ALLOWED

TO STABILIZE. ENGINE NO.2 WAS THEN SHUTDOWN AND AIRCRAFT RETURNED
UNEVENTFULLY.

SEQUENCE OF EVENTS: OPERATION OF THE FLIGHT WAS NORMAL UNTIL TOP OF
CLIMB. WHILE LEVELING

OFF AT 12,000 FEET ON A SHORT SECTOR OF 20 MINUTES DURATION, THE CAPTAIN
NOTICED THAT THE

TRPEZOID IN HIS PRIMARY DISPLAY WAS DISPLACED, THE AIRCRAFT WAS YAWING
AND SEEMED TO BE

OUT OF TRIM. HE DREW THE F/O\'S ATTENTION TO THIS AND THE F/O NOTICED
THAT THE AILERON TRIM

WAS 5 UNITS OUT AND THE CONTROL WHEEL ACCORDINGLY DISPLACED. ALMOST
SIMULTANEOUSLY,

THE CAPTAIN NOTICED THAT THE NO.1 THROTTLE LEVER WAS VIBRATING. THE
CAPTAIN LOOKED AT THE

ENGINE PARAMETERS AND SAW THEM DECREASING, HE ASK FOR THE ENGINE PAGE ON
THE ECAM AND

WHEN SELECTED BY THE F/O, BOTH NOTICED A N2 VIBRATION OF 3 UNITS, WITH
WHAT THEY BOTH

THOUGHT WAS AN INCREASING TREND. THE CAPTAIN FELT VIBRATION ON THE NO.1
THROTTLE WHICH

WAS CONFIRMED BY THE F/O. AT THIS POINT THE CAPTAIN CONCLUDED THAT THE
NO.1 ENGINE MIGHT

HAVE FAILED. THE CAPTAIN DECIDED THAT NO.1 ENGINE WAS IN DISTRESS,
POSSIBLY BECAUSE OF A

BIRD STRIKE, AND WARRANTED A PRECAUTIONARY SHUTDOWN TO AVOID FURTHER
DAMAGE. NO.1

THROTTLE WAS NOT MOVED OUT OF ITS STOP AT ANY TIME DURING THE PROCESS
FOR THE SAME

REASON. THE DECISION TO TURN BACK WAS MADE, AND THE ENGINE FAIL CHECK
LIST FOR THE NO.1

ENGINE WAS FOLLOWED AND THE NO.1 ENGINE WAS SHUTDOWN WITH THE FIRE
HANDLE. UPON INTIATIN

DESCENT, THE CAPTAIN SELECTED LEVEL CHANGE ON THE FLGIHT CONTROL UNIT
BUT IT WOULD NOT

ENGAGE. HE THEN REALIZED THAT NO.2 THROTTLE WOULD NOT MOVE, AND
CONCLUDED THAT IT WAS

JAMMED. THE F/O WAS VERY SUPRISED AT THIS AND ASKED IF HE COULD EXERCISE
THE NO.2

THROTTLE. THERE WAS FURTHER DISCUSSION AND BOTH AGREED THAT NO.1
THROTTLE MAY HAVE

RETARDED TO FLIGHT IDLE STOP SO THAT THE AUTO FLIGHT SYS COULD ACHIEVE
THE SPEED

SELECTED. A MUTUAL DECISION WAS NOW MADE TO START NO.1 ENGINE. THE
ENGINE START INFLIGHT

CHECK LIST WAS FOLLOWED AND THE NO.1 ENGINE WAS STARTED. HOWEVER, IT
ONLY RAN FOR A

SHORT PERIOD 1 MIN & 3 SEC BEFORE STOPPING AGAIN. THE CAPT. ASK THE F/O
TO CHECK ALL CIRCUIT

BREAKERS, WHICH HE DID BY GETTING OUT OF HIS SEAT AND EXAMINING THE CB
PANEL. WHILE THE F/O

WAS OUT OF HIS SEAT, THE CAPTAIN NOTICED THE DISAGREEMENT RED LIGHT ON
IN THE NO.1 FUEL

LEVER, AND BOTH THEN THOUGHT THAT THE ATTEMPT TO RELIGHT THE ENGINE
SHOULD BE

ACCOMPLISHED.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

79 96/MNB/2/I SHUTDOWN GOOD ENGINE APPROACH STUCK THROTTLE

**Summary of Event:**

ASYMMETRIC THRUST (THROTTLE STUCK AT IDLE) + SHUTDOWN GOOD ENGINE

**Summary of Narrative:**

PRELIMIARY REPORTS INDICATE ARE THE AT FL230 THROTTLE STUCK AT IDLE
DURING DESCENT

OPERATIONS. AGAIN DURING THE APPROACH PHASE TBD ALT. DURING AN
AUTOTHROTTLE COMMAND

TO INCREASE POWER, THE RH ENGINE ACCELERATAING NORMALLY WHILE THE LH
ENGINE REMAINED AT

FLIGHT IDLE. THE ASYMETRIC THRUST CONDITION CAUSED THE AIRCRAFT TO BANK
AND YAW. THE

CREW SUBSEQUENTLY INTERPRETED THIS AS AN ENGINE FLAME OUT AND CLOSED THE
ENGINE FUEL

SHUTOFF LEVER. THE ENGINE WAS THEN SUCCESSFULLY RE-LIT USING STARTER
ASSIST. THE ENGINE

BEHAVED NORMALLY UNTIL THE APPROACH WHEN AGAIN THE THRUST LEVER FAILED
TO SPOOL UP THE

ENGINE. THE AUTOPILOT WAS DISENGAGED AND A NORMAL APPROACH AND LANDING
WAS CARRIED

OUT. THE AUTOTHROTTLE WAS MADE INOPERATIVE PENDING INVESTIGATION. THE
RESULTS OF THE

FDR PRINT OUT INDICATED THAT THE ENGINE HAD NOT IN FACT FLAMED-OUT. AN
AUTOTHROTTLE

COMMAND TO INCREASE POWER RESULTED IN NO.2 ENGINE ACCELERATING NORMALLY
WHILST THE NO.1

REMAINED AT FLIGHT IDLE. THIS ASYMETRIC THRUST CONDITION CAUSED THE
AIRCRAFT TO BANK AND

YAW. THE CREW SUBSEQUENTLY INTERPRETED THIS AN ENGINE FLAME OUT AND
CLOSED THE ENGINE

FUEL SHUTOFF LEVER. THE ENGINE BEHAVED NORMALLY UNTIL THE APPROACH WHEN
AGAIN THE

THRUST LEVER FAILED TO SPOOL UP THE ENGINE. THE AUTOPILOT WAS DISENGAGED
AND A NORMAL

APPROACH AND LANDING CARRIED OUT. A/T MADE INOPERATIVE.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

41 85/EWB/4/I-2 SHUTDOWN GOOD CLIMB COMPRESSOR SURGE

ENGINE-TWO-ENG OUT

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE + SHUTDOWN GOOD ENGINE - TWO-ENGINE LANDING

**Summary of Narrative:**

NO.3 ENGINE STALLED AT FL001 FEET WITH METAL IN THE TAILPIPE. INITIATED
ENGINE SHUTDOWN AND

AIR TURNBACK TO ALT. THEN THE FUEL FLOW TO NO.4 ENGINE DROPPED BY 2205
PPH. CREW THEN

SHUTDOWN NO.4 ENGINE AND DECLARED AN EMERGENCY. THE SECOND ENGINE
SHUTDOWN

APPARENTLY OCCURRED BECUASE OF A LACK OF CREW COORDINATION AND
MISUNDERSTANDING AS

THE ENGINE PARAMETERS DROPPED BECAUSE THE POWER LEVER HAD BEEN RETARDED.
NOTHING

WAS FOUND WRONG WITH THE ENGINE UPON INSPECTION.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

67 \*93/EWB/2/I THROTTLED GOOD ENGINE TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE + CREW THROTTLED GOOD ENGINE, CORRECTED

**Summary of Narrative:**

DURING TAKEOFF AT 100 FEET ABOVE GROUND LEVEL (AGL), NO.1 ENGINE
COMPRESSOR SURGED.

FLIGHT CREW RETARDED NO.2 THROTTLE. CREW CORRECTED NO.2 THROTTLE
(RESTORED),

CONTINUED TAKEOFF, COMPLETED AN UNEVENTFUL AIR TURNBACK TO THE FIELD.
DFDR DATA

INDICATES THE FOLLOWING: NO.1 EPR DROPPED FROM TARGET EPR OF 1.48 TO
1.05 DURING THE SURGE

FOR A PERIOD OF 2 SECONDS. NO.2 EPR WAS REDUCED BY THE CREW FROM A
TARGET EPR OF 1.48 TO

1.28 ERP THEN RESTORED TO 1.46 DURING A 10 SECOND PERIOD. IT APPEARS
THAT NO.2 POWER LEVER

ANGLE (PLA) WAS RETARED 13 DEGREES FOR A PERIOD OF 6 SECONDS.

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

69 \*93/MWB/2/I- THROTTLED GOOD ENGINE TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE+THROTTLED (ALL) GOOD ENGINES-CORRECTED

**Summary of Narrative:**

DURING TAKEOFF AT 500 FEET ABOVE GROUND LEVEL, THE NO.2 ENGINE
COMPRESSOR SURGED. THE

CREW THROTTLED BOTH ENGINES, THEN RE-ADVANCED THROTTLES. NO.2 ENGINE
SURGED AGAIN AND

POWER WAS REDUCED ON NO.2 ENGINE. TAKEOFF WAS CONTINUED AND RESULTED IN
AN UNEVENTFUL

AIR TURNBACK. DFDR ANALYSIS INDICATES THE FOLLOWING: 1.5 SECONDS AFTER
THE NO.2

COMPRESSOR SURGED, THE NO.1 & NO.2 THROTTLES WERE REDUCED FROM 80
DEGREES TO 50

DEGREES, THEN RETURNED TO 75 DEGREES OVER A PRIOD OF 4 SECONDS. THEN
NO.2 ENGINE

COMPRESSOR SURGED AGAIN, THEN NO.2 THROTTLE RETARDED TO LESS THAN 40
DEGREES TLA. N1

ROTOR SPEED ON NO.2 ENGINE DROPPED FROM APPROX 100% TO 62% IN ABOUT 1
SECOND. NO.1 ENGINE

ROTOR SPEED WAS COMMANDED FROM 100% TO 84% FOR A PERIOD OF 4 SECONDS.
EGT DID NOT

EXCEED LIMIT.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

70 94/MWB/2/I-2 THROTTLED GOOD ENGINE TAKEOFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANG, COMPRESSOR SURGE + CREW THROTTLED GOOD ENGINE, CORRECTED

**Summary of Narrative:**

AT ROTATION, CREW REPORTED NO.1 ENGINE STALLED. DFDR DATA INDICATES THE
RH ENGINE POWER

REDUCED FROM APPROX 1.5 TO 1.3 EPR DURING THE TAKEOFF NEAR ROTATION.
ANALYSIS OF THE

CYCLE DECK SHOWS AT +20 ISA THE RH ENGINE LOST 30% OF COMMANDED THRUST
FOR THOSE

CONDITIONS (12,621 LBS).

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

72 94/MWB/2/I-1 THROTTLED GOOD ENGINE TAKOEFF COMPRESSOR SURGE

**Summary of Event:**

LOUD BANGS, COMPRESSOR SURGE + CREW THROTTLED GOOD ENGINE

**Summary of Narrative:**

THE AIRPLANE EXPERIENCED A LEFT ENGINE SURGE JUST AFTER TAKEOFF AT 290
FEET ALT. AFTER THE

SURGE, THE CREW RETARDED THE THROTTLE. THE CREW THEN ADVANCED THE
THROTTLE, NO

FURTHER SURGES AND ALL PARAMETERS WERE NORMAL. WHAT\'S NOT STATED IN THE
REPORT IS THE

FACT THAT THE DFDR DATA INDICATION THE RH ENGINE WAS ALSO RETARDED FROM
EPR=1.55 TO

EPR=1.21 (48% OF COMMANDED THRUST LOSS) DELTA Fn=21,852 POUNDS. THE
SURGED ENGINE EPR

REDUCED TO 1.03 THEN RECOVERED. THE CREW ELECTED TO CONTINUE THE FLIGHT.
AN EGT

EXECEEDANCE WAS RECORDED ON LH ENGINE WITH THE MAX TEMP = 670. EGT
EXCEEDANCE.

**Propulsion System Malfunction + Inappropriate Crew Response**

**Summary of Turbofan Data**

**Event #: ID Number: PSM+ICR Category: Phase of Flight: Engine
Symptom:**

2 69/2ND/2/H THROTTLED GOOD ENGINE - TAKEOFF COMPRESSOR SURGE

FORCED LANDING

**Summary of Event:**

POWERLOSS (SE)+THROTTLED GOOD ENGIINE TO IDLE RESLTING IN FORCED LANDING

**Summary of Narrative:**

IMMEDIATELY AFTER TAKEOFF THE AIRCRAFT DEVELOPED PERFORMANCE PROBLEMS.
AS THE

AIRCRAFT ROTATED (117KTS) INTO A CLIMB ATTITUDE A DULL BANG WAS HEARD
(IMMEDIATELY

ASSOCIATED BY THE CREW WITH THE ENGINES) AND AFTER LOOKING AT THE EGT
GAGES, AND

OBSERVING THAT NO.1 ENGINE WAS INDICATING A TEMP 20 DEG C HIGHER THAN
NO.2 ENGINE, THE

PILOT-IN-COMMAND (JUMP SEAT) SAID \"I THINK IT\'S NUMBER 1\" AND AFTER A
BRIEF PAUSE SAID

\"THROTTLE IT\" AND THE PILOT ELECTED TO THROTTLE BACK THE NO.1 ENGINE.
AFTER CLOSING NO.1

THROTTLE HE REDUCED CLIMB ANGLE TO 6 DEG FROM 12 DEG. AT THE SAME TIME,
THE COPILOT WHO

HAD REACHED FOR THE CHECKLIST AND WAS LOOKING FOR THE PAGE RELATING TO
AN ENGINE

EMERGENCY, BECAME AWARE OF THE SHARP REDUCTION IN ACCELERATION; NOTICED
THE LANDING

GEAR WAS STILL DOWN AND HE RETRACT IT IMMEDIATELY. THE AIRCRAFT REACHED
A MAX HEIGHT OF

250 FEET AND THEN BEGAN LOSING SPEED. AS GROUND CONTACT BECAME
INEVITABLE AND IMMENT,

THE PILOT MADE A CONTROLLED GEAR UP LANDING 8200 FEET FROM THE RUNWAY
THRESHOLD AND

SLID ON THE SNOW COVERED GROUND FOR 1400 FEET. INVESTIGATION REVEALED
INADVERTANT

DISPLACEMENT OF NO.2 THROTTLE AND COMPLETE THROTTLE CUT ON NO.1 ENGINE.
ENGINE

TEARDOWN OF NO.2 REVEALED A SEGMENT OF HP TURBINE SEAL CAUSED THE HP
COMPRESSOR SURGE

WHICH WAS INITIALLY THOUGHT TO BE NO.1 ENGINE.

**APPENDIX 5 - Turbofan Training Accidents**

**APPENDIX 5 - Turbofan Training Accidents**

**1959 707 Cruise Region: USA Substantial Damage**

While practicing two-engine-out minimum control speed condition, at
119-120 knots (10k below threshold speed), aircraft entered a spin to
the right. successful recovery from spin resulted in loss of no. 4
engine and strut from wing. Aircraft landed successfully with no further
incidents. recovery was accomplished at 5000 feet altitude after a loss
of 3000 feet.

**1959 707 Final Approach Region: USA Hull Loss**

During a training flight, the crew made a no flaps wave-off and
continued around the traffic pattern with the gear extended. The crew
then simulated a failure of nor 3 and 4 engines and on final approach,
the aircraft entered a severe yaw, and crashed into the ground.

**1960 CV880 Climb Region: USA Hull Loss**

During takeoff, daylight training flight, #4 engine throttled back prior
to takeoff. Airplane nosed up rapidly, stalled. Left wing dropped
briefly then rolled to right vertical bank & crashed.

**1965 CV880 Climb Region: USA Hull Loss**

On takeoff for training #4 throttle pulled to idle as trainee rotated,
corrective rudder applied. lift off ok. Captain then adjusted power on
#1&2 slightly, right wing dropped and could not correct stalled.
Airplane crashed with no injuries.

**1966 DC8 Climb Region: Oceania Hull Loss**

Routine training takeoff simulated #4 engine failure shortly after
rotation right wing dropped. Airplane failed to accelerate and slipped
inward to ground, cartwheeled & disintegrated.

**1966 CV880 Takeoff Region: Asia Hull Loss**

During takeoff for a daylight, VFR training flight, #1 engine was
throttled back to simulate engine failure. Pilot trainee lost control
and allowed left wing and #1 engine to contact ground in nose-high
attitude. airplane then pitched over abruptly, separating landing gear
and all engines. An immediate fuel fire prevented escape.

**Turbofan Training Accidents**

**1966 707 Landing Region: Europe Substantial Damage**

Approach for 1st touch & go made on ILS. #1 engine throttled back,
trainee under the hood, screen removed at 200\' and slightly left of
centerline. Alignment correction & touched down hard and bounced on nose
wheel. Found fuselage buckled.

**1967 DC8 Final Approach Region: USA Hull Loss**

Crashed during simulated 2 engine out landing approach. Killed 13 on
ground as well as all aboard.

**1967 DC8 Final Approach Region: Canada Hull Loss**

Two engines out (throttle to idle) on 1 side approach being practiced.
Right wing dropped sharply before impact. Hit inverted.

**1968 DC8 Landing Region: USA Hull Loss**

Training flight simulating 2 engines out, allowed airspeed to drop below
VMC. 200 ft after touchdown, swerved off runway 3500 feet across grass &
ditch. All gear & engines separated. Fire consumed. all escaped.

**1969 CV880 Climb Region: Asia Hull Loss**

While on a training flight, the flight instructor reduced power on No. 4
engine on downwind side just after liftoff. The airplane rose to 125 ft
and the right wing dropped, hitting the runway. the airplane slid 3000
ft across open terrain stopping on taxiway and burst into flames. The
pilot had not input sufficient rudder to maintain directional control
with asymmetric thrust.

**1969 707 Go Around Region: USA Hull Loss**

During a training flight, the airplane was making a three engine
approach with No. 4 engine in idle. The instructor called for a missed
approach at decision height and the go-around was started. At this time
a senior captain observer announced the loss of hydraulic system. in
accordance with procedures, all hydraulic pumps were turned \'\'off\'\'.
Without hydraulic rudder control, directional control could not be
maintained with assymetrtic thrust. The aircraft rolled to the right,
lost altitude, and impacted the ground, right wing low.

**1970 707 Landing Region: USA Substantial Damage**

Training flight simulated one engine out full stop landing. Inboards
engines reversed ok - came out of reverse at 80 kt. decel with brakes
only appeared marginal so again reversed. Crew could not slow for
turnoff and overran at 30mph across ditches. Nose & right MLG & No.3
engine separated.

**Turbofan Training Accidents**

**1971 707 Takeoff Region: Asia Hull Loss**

Doing simulated heavy weight takeoff. After V1, engine No.4 was
throttled to idle. At the same time, No.3 engine lost power. The
airplane started to veer right. Pilot rotated and ventral fin hit
runway. The airplane departed the runway at 30 degree angle, and went
4000 ft across rough ground shedding parts. Fire destroyed the airplane
but no injuries were reported.

**1973 720 Final Approach Region: USA Substantial Damage**

During type-rating flight check the airplane stayed in traffic pattern
for another landing. Power on No. 1 & No.2 engines retarded for 2 engine
landing. Airplane hit hard and both LH and RH main bounced and airplane
bounced, nose gear collapsed. No fire.

**1975 DC9 Landing Region: Europe Substantial Damage**

A trainee was being checked for captain rating. During a landing rollout
in which single engine reversing was being demonstrated, directional
control was lost, the airplane ran off the side of the runway, coming to
rest 400 meters off the runway in a ditch. The runway was reported to
have been wet.

**1975 737 Takeoff Region: S. America Substantial Damage**

The aircraft was engaged in a training flight to checkout 3 new first
officers. A department of civil aviation check pilot occupied the RH
seat. a company pilot was in the observers seat. The pilot in the LH
seat was to expect an engine cut at takeoff. During the takeoff roll the
check pilot cut No.1 engine at V1. The pilot in the LH seat rotated the
aircraft to the desired attitude (14 degrees) and the gear was raised.
The pilot in the center seat noticed the aircraft nose drop to about 6
degrees and advised the pilot in the LH seat to raise the nose. At about
this time the check pilot in the RH seat took over the controls as the
airplane settled on to the runway with the gear up. the airplane came to
rest about 70 meters short of the far end of the runway. Time from V1 to
contact with the runway was about 11 seconds. The airplane slid parallel
to the runway centerline on the left engine for 1300 feet. At this point
the forward fuselage contacted the runway and slid another 1100 feet and
at this point the right engine contacted the runway. At this point the
airplane veered to the left and came to rest after another 250 ft slide.
Late in the veer the LH engine separated and rolled under the wing. A
small fire occurred in the left engine but was quickly extinguished.

**1977 707 Takeoff Region: Europe Hull Loss**

During a training flight, a crosswind takeoff, No. 1 engine was retarded
by the instructor pilot in the left seat to simulate engine failure just
as the airplane became airborne. A large yaw and left roll developed and
the instructor pilot took control but was unable to recover. The
airplane hit the ground and all engines and landing gear were torn off.
Fire destroyed the aircraft, but all aboard evacuated, with one captain
trainee suffering a broken heel.

**Turbofan Training Accidents**

**1979 DC9 Takeoff Region: USA Hull Loss**

Crashed just after airborne while practicing a takeoff with total loss
of the airplane while a student pilot in the LH seat lost control and
stalled during a simulated left engine out after V1.

**1979 727 Landing Region: Africa Substantial Damage**

Airplane on a re-position flight, with apparently some crew training.
During approach to land, the airplane was configured with #1 engine
intentionally shut down, \'\'A\'\' system hydraulics isolated, & all 3
generators off. Touched down on runway 19 about 3600 ft beyond threshold
and rolled off right side of runway into soft dirt, rolled parallel to
runway, across intersecting runway 11, & made slow pivot to left,
skidding across runway 19. Left main landing gear and nose gear
collapsed into their wheel wells. Flaps, lower wing surface and lower
fuselage were damaged severely.

**1979 707 Takeoff Region: Middle East Hull Loss**

On a training flight to upgrade first officers to captain, there was a
training captain, a flight engineer, and 4 trainee captains. On takeoff
after the third touch and go landing, the airplane rotated normally but
then yawed back and forth in a nose high attitude and stalled. The right
wing struck the ground and the airplane turned upside down and slid to a
stop, on fire. the cockpit voice recorder indicates a possible simulated
engine out on takeoff with some error by the trainee pilot and confusion
during relinquishing of control.

**1979 747 Landing Region: USA Substantial Damage**

On landing, all engines went into reverse normally. No.4 EGT went to 820
degrees and throttle lever kicked back and could not be moved. No fire
warning, but first officer saw fire on #4 engine. Engine shut down, fuel
shutoff valve in wing closed and both fire bottles discharged. Airplane
rolled to stop clear of runway on a taxiway, and fire extinguished by
ground equipment. No evacuation was conducted. Pylon forward (firewall)
bulkhead of No. 4 engine had separated allowing the forward end of the
engine to drop, rupturing the main fuel line in the pylon, resulting in
fuel fire.

**1980 CV880 Takeoff Region: S. America Hull Loss**

On a training flight with 3 crew and one instructor, lost engine power
on takeoff and crashed.

**Turbofan Training Accidents**

**1983 737 Climb Region: S. America Hull Loss**

A cargo flight with a crew of 2 was making a takeoff when the airplane
failed to gain any significant altitude, and crashed. The crash site was
approximately 300 meters beyond the end of the runway about 300-400
meters to the left of the runway centerline, and about 100 feet below
runway elevation. ground marks indicated that the airplane impacted in
an inverted attitude and approximately 50 degrees nose down. the voice
recorder transcript does not reveal any problem during the takeoff roll,
however, just before the call \'\'rotate\'\' there was a distinct sound
of engine deceleration and directly after the call \'\'gear up\'\' the
landing gear warning horn began sounding. Approximately 1.5 seconds
after the warning horn sound, there was a comment, \'\'it is
sinking\'\'. about 5 seconds later the warning horn stopped. the first
officer was in the left seat making the takeoff and was training for
being up graded to captain. Unconfirmed indications are that this was an
engine cut on takeoff exercise.

**1988 737 Takeoff Region: Asia Substantial Damage**

During the takeoff, on a daylight training flight on runway 17, the
instructor pilot reduced the left engine power to idle at V1 to simulate
engine failure. The takeoff was continued but the aircraft yawed and
rolled to the left, dragging the left wing tip and fracturing the left
wing spars at aileron mid-span. One of the pilots advanced the left
engine power but the aircraft veered off the runway. The left engine
contacted the ground and the landing gear was damaged. The wind was
reported as 70 degrees left crosswind, 20 kts, gusting to 27 kts. No
injuries were reported.

**1991 707 Inflight Region: Oceania Hull Loss**

At 5000 ft on a training flight, while demonstrating a two-engine out
Vmca maneuver, control was lost and the airplane did a three turn
spin/spiral into the sea. According to Boeing analysis of the flight
data and voice recorders, the maneuver was entered with power reduced on
the No. 1 and 2 engines, rudder boost off, and at about 150 knots. The
recommended speed for this maneuver is about 200 knots. The rudder
effectiveness was significantly reduced with the boost off, and in
combination with the low airspeed and thrust asymmetry, control was
lost.

**1993 DC9 Landing Region: USA Substantial Damage**

Apparent confusion during a training flight touch and go. One engine may
have been in reverse. Directional control was lost and airplane departed
off the runway side. Nosewheel well structure was damaged and left wing
top surface skin wrinkled.

**1994 737 Takeoff Region: Asia Hull Loss**

During local training following the fourth or fifth touch-and-go on
liftoff the airplane turned to the left and impacted the ground near the
international terminal. Debris from the 737 impacted an Aeoroflot IL-86
parked at the terminal. both airplanes were destroyed by impact and post
impact fire. Operator reports simulated engine failures (simulated by
low thrust) were being practiced during the touch-and-go's. Four
fatalities were from the 737 and the rest from the IL-86 or ground
personnel.

**Turbofan Training Accidents**

**1996 DC8 Takeoff Region: S. America Hull Loss**

Airplane crashed one minute after takeoff. Captain was conducting F/O
training and pulled No. 1 engine back during the takeoff roll. He then
pulled No. 2 back after rotation. F/O allowed the airplane nose to get
too high and the airplane stalled and went into a flat spin.

**1998 RJ-145 Takeoff Region: USA Substantial Damage**

Control lost during takeoff at Jefferson county regional airport,
Beaumont, Texas, during simulated engine failure on rotation during a
crew training flight. The port wing hit the runway, aircraft impacted
grass alongside the runway and undercarriage collapsed, damaging both
port and starboard wings, the fuselage and fan sections of both engines,
which ingested large quantities of mud. Of the four on board, one was
seriously injured, two others sustained minor injuries and the fourth
escaped unharmed.

**APPENDIX 6 - Summary of GE/CFMI Commercial Fleet RTO Study**

**APPENDIX 6 - Summary of GE/CFMI Commercial Fleet RTO Study**

![](media/image19.wmf)

![](media/image20.wmf)

**APPENDIX 7 - Summary of Turboprop PSM+ICR Events**

**APPENDIX 7 - Summary of Turboprop PSM+ICR Events**

**PSM-ICR Turboprop Data, Jan 1985 - present**

1

*01-Sep-98*

**Event No: Geographical Region of Europe**

**Date: 4-Dec-85 Location: Palma de Mallorca, Spain**

**Airplane Aero Commander 680T Event H**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Overrun**

**Summary of Event: Overran after power loss on takeoff run**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Runway**

**Initiating Event Altitude 0**

**Vmc infringed N**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller TPE331-43A**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller Low power**

**Propulsion System**

**Crew Aborted takeoff but failed to prevent overrun**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S, R**

**Autopilot engaged (Y/N) N**

**Narrative :** Pilot reported low power on one or both engines on TO.
Hit small concrete wall after running off runway. Collapsed nose gear &
one main gear. Prop strike on both engines & one prop went thru
fuselage. 5 on board.

**PSM-ICR Turboprop Data, Jan 1985 - present**

2

*01-Sep-98*

**Event No: Geographical Region of N America**

**Date: 15-Apr-88 Location: Seattle, WA**

**Airplane Dash 8 Event H**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of directional control**

**Summary of Event: Engine fire on takeoff. Went around. Didn\'t shut
down engine. Lost hydraulics & departed runway on landing.**

**Type of Airline Operation (FAR 121**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude**

**Vmc infringed N**

**Pilot Flying (C/FO):**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller PW120**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller Power loss, then fire**

**Propulsion System Gross fuel leakage from improperly fitted HP fuel
filter cover**

**Crew Failed to shut off fuel supply to engine in accordance with fire
drill**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N) N**

**Narrative :** Shortly after takeoff crew noted RH eng power loss.
Decided to return for landing. Large fire seen in RH nacelle when gear
lowered. After landing, directional control & all braking lost. Aircraft
left LH side of runway when power lever set to Flight Idle. Aircraft
rolled onto ramp - struck ground equipment & jetways. Destroyed by fire.
Cause found to be fuel leak from improperly installed HP fuel filter
during overhaul, not discovered following engine installation.

**PSM-ICR Turboprop Data, Jan 1985 - present**

3

*01-Sep-98*

**Event No: Geographical Region of Europe**

**Date: 21-Jan-89 Location: Dragoer, Denmark**

**Airplane Metro II Event H**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Crashed on approach following engine shutdown. Prop
did not feather.**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Cruise**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed Y**

**Pilot Flying (C/FO):**

**Weather Day/Icing**

**Runway**

**Engine/ Propeller TPE331-3U**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller Low oil pressure & torque. Severe vibration**

**Propulsion System**

**Crew Lost control during single engine approach**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N)**

**Narrative :** One eng began to lose oil pressure & torque. Aircraft
was in icing so elected to keep eng running. Finally shut down eng after
severe vibration encountered. Prop did not feather. Crashed on approach
short of runway in weather.

**PSM-ICR Turboprop Data, Jan 1985 - present**

4

*01-Sep-98*

**Event No: Geographical Region of Asia**

**Date: 18-Apr-97 Location: Tanjungpandan,**

**Airplane ATP Event HF**

**Airplane Second Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Engine failure on descent. Failed prop not
feathered. Control lost when good engine power increased to**

**Type of Airline Operation (FAR**

**Engine Training Flight N**

**Phase of Flight: Descent**

**Flight Phase Detail:**

**Initiating Event Altitude 4000**

**Vmc infringed Y**

**Pilot Flying (C/FO): C**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller PW126A**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed N**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System None found. Fire damage precluded complete
investigation of engine accessories**

**Crew Failed to recognise engine failure and to follow engine shutdown
drill to feather prop.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** During descent at 4000ft, pilot retarded both power
levers to Flight Idle. The LH eng flamed out. RH eng continued to
operate normally. LH eng Np continued at 80% due to windmilling. 40 secs
later, LH low oil pressure warning light illuminated. Prop still not
feathered. Descent continued at 160kIAS. At 800ft, gear & flap selected.
Airspeed started to fall. At 140kIAS, LH Np started to droop below 80%,
indicating prop blades on FI stop. IAS continued to fall to 100kts. RH
power lever then fully advanced & max power applied on RH eng. Likely
that control lost at this point & aircraft fell rapidly to ground.

**PSM-ICR Turboprop Data, Jan 1985 - present**

5

*01-Sep-98*

**Event No: 003 Geographical Region of N America**

**Date: 31-May-85 Location: Nashville, TN**

**Airplane Gulfstream G-159 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Loss of control after engine failure on takeoff
climb**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude 100**

**Vmc infringed Y**

**Pilot Flying (C/FO): C**

**Weather Night/VMC**

**Runway**

**Engine/ Propeller Dart 529**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed N**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System No 1 engine failed because HP cock lever was in
wrong position**

**Crew Failed to feather prop before applying max power to remaining
engine.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N) N**

**Narrative :** During initial TO climb LH eng lost power. Crew
attempted to continue climbout but after applying water meth pilot lost
directional control. A/C banked left, entered descent & impacted between
parallel runways. No pre- impact system malfunction found. CVR indicated
pre-takeoff checks not properly completed. LH HP cock lever found
between Fuel Off & Feather. This shut down engine and disarmed
autofeather system.

**PSM-ICR Turboprop Data, Jan 1985 - present**

6

*01-Sep-98*

**Event No: 004 Geographical Region of S America**

**Date: 23-Jun-85 Location: Juara, Brazil**

**Airplane Embraer 110 Event HF**

**Airplane Second Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Stalled during single engine approach**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Approach**

**Flight Phase Detail: Finals**

**Initiating Event Altitude 200**

**Vmc infringed N**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller PT6A-34**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted N**

**Autofeather/ autocoarsen armed N**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller Crew saw fuel leak from engine**

**Propulsion System Faulty fuel nozzle damaged turbine hardware, leading
to fuel line rupture**

**Crew Crew shut down engine on approach but stalled short of runway**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S, R**

**Autopilot engaged (Y/N) N**

**Narrative :** Faulty fuel nozzle on LH engine generated blowtorch
effect damaging turbine hardware. Rotor imbalance ruptured fuel return
line. On seeing fuel leak crew shut down LH eng and attempted landing on
nearby runway. A/C stalled & crashed short of runway.

**PSM-ICR Turboprop Data, Jan 1985 - present**

7

*01-Sep-98*

**Event No: 006 Geographical Region of S America**

**Date: 4-Aug-85 Location: Mocoa, Brazil**

**Airplane Embraer 110 Event H**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Loss of control after engine failure on takeoff
climb**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude 100**

**Vmc infringed Y**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller PT6A-34**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted N**

**Autofeather/ autocoarsen armed N**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller**

**Propulsion System Engine exploded**

**Crew**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N) N**

**Narrative :** On takeoff at V2 LH eng exploded. A/C continued in
uncontrolled flight & collided with trees 1600m from runway.

**PSM-ICR Turboprop Data, Jan 1985 - present**

8

*01-Sep-98*

**Event No: 007 Geographical Region of N America**

**Date: 25-Aug-85 Location: Auburn, MN**

**Airplane Beech 99 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Crashed after engine failure on approach**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Approach**

**Flight Phase Detail: Finals**

**Initiating Event Altitude 150**

**Vmc infringed N**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller PT6A-27**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted N**

**Autofeather/ autocoarsen armed N**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller**

**Propulsion System Engine failed**

**Crew**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S, R**

**Autopilot engaged (Y/N) N**

**Narrative :** Engine failure on finals, aircraft crashed, post crash
fire. All 8 on board killed.

**PSM-ICR Turboprop Data, Jan 1985 - present**

9

*01-Sep-98*

**Event No: 010 Geographical Region of USSR**

**Date: 2-Mar-86 Location: Bugulma, Russia**

**Airplane An 24 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Stalled during single engine approach**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Approach**

**Flight Phase Detail: 5 miles out**

**Initiating Event Altitude 1500**

**Vmc infringed N**

**Pilot Flying (C/FO):**

**Weather IMC**

**Runway**

**Engine/ Propeller AL24A**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System Electrical fault caused prop to feather & eng to
stop.**

**Crew Failed to apply control inputs to counter thrust asymmetry
following engine failure.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N) N**

**Narrative :** During IMC approach, 1 second after flap extension, No 1
eng stopped & the prop feathered. Crew did not counter asymmetric
thrust. Airspeed decreased & A/C stalled & crashed 8 km from runway.

Failure of autofeather sensor C/B caused prop to feather & eng to stop.

**PSM-ICR Turboprop Data, Jan 1985 - present**

10

*01-Sep-98*

**Event No: 011 Geographical Region of Asia**

**Date: 30-Mar-86 Location: Pemba, India**

**Airplane An 26 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Loss of control after engine failure on takeoff
climb**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Climb**

**Initiating Event Altitude 1000**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller AL24A**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller Problems**

**Propulsion System**

**Crew**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S, R**

**Autopilot engaged (Y/N) N**

**Narrative :** A/C crashed & burned shortly after TO from Pemba. Crash
occurred seconds after crew reported engine problems & that emergency
landing would be attempted.

**PSM-ICR Turboprop Data, Jan 1985 - present**

11

*01-Sep-98*

**Event No: 013 Geographical Region of Asia**

**Date: 15-Dec-86 Location: Lanzhou, China**

**Airplane An 24 Event HF**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Crashed on approach after engine failure during
climb**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Climb**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather Severe icing**

**Runway**

**Engine/ Propeller AL24A**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller**

**Propulsion System Failed**

**Crew Lost control during single engine approach**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N)**

**Narrative :** Severe icing occurred during climb. RH eng failed & prop
was feathered.A/C returned for landing but crashed during approach.

**PSM-ICR Turboprop Data, Jan 1985 - present**

12

*01-Sep-98*

**Event No: 016 Geographical Region of N America**

**Date: 18-Feb-87 Location: Quincy, IL**

**Airplane Westwind E18S Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Stalled and crashed during return to airport shortly
after TO.**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude 400**

**Vmc infringed Y**

**Pilot Flying (C/FO): FO**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller PT6A-20**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System**

**Crew**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S, R**

**Autopilot engaged (Y/N)**

**Narrative :** A/C on initial climb after TO near to gross weight.
Witness said engs sounded normal. At 400\' A/C seen to pitch up 10 deg
then level off & enter LH turn. A/C made another LH turn & pilot
reported he was returning to field. Did not state problem. Witness said
A/C was in 30 deg LH bank turning toward airport when A/C stalled &
descended to ground in vertical nose down attitude. LH prop found
feathered. No eng problem found. Previous LH eng problem on 28/1/87 -
NFF.

**PSM-ICR Turboprop Data, Jan 1985 - present**

13

*01-Sep-98*

**Event No: 019 Geographical Region of N America**

**Date: 23-Apr-87 Location: Wilmington, NC**

**Airplane SA226TC Event HF**

**Airplane Second Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Loss of control after uncontained eng failure on
TO**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude 150**

**Vmc infringed**

**Pilot Flying (C/FO): FO**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller TPE331-3**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller**

**Propulsion System Uncontained 3rd stage turbine failure**

**Crew Failed to maintain control following eng failure on takeoff**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S, R**

**Autopilot engaged (Y/N) N**

**Narrative :** During TO co-pilot said they had lost RH eng. Witnesses
heard loud noise & saw flame shoot from RH eng. Saw A/C nose high cross
end of runway at 150ft before hitting trees. RH eng had uncontained 3rd
stage turbine failure. Some loss of electrical power resulted from eng
failure. Pilot should have been able to land back on runway after eng
failure.

**PSM-ICR Turboprop Data, Jan 1985 - present**

14

*01-Sep-98*

**Event No: 020 Geographical Region of Europe**

**Date: 26-Apr-87 Location: Blackbushe, UK**

**Airplane Cessna 441 Event HF**

**Airplane Second Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Crashed on go-around from short finals. Engine
failure suspected.**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Go-around**

**Flight Phase Detail:**

**Initiating Event Altitude 200**

**Vmc infringed Y**

**Pilot Flying (C/FO): C**

**Weather**

**Runway**

**Engine/ Propeller TPE331-8**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System**

**Crew Lost control after aborting go-around in favour of immediate
landing**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N)**

**Narrative :** A/C cleared to land. On short finals reported that he
had problem & was going around. Pilot\'s next call was that he was
\"going in\". Controller saw A/C veer to left & crash. Invest\'n found
go-around initiated due to unsafe MLG indication. Curved flight path of
A/C from go-around to impact & progressive increase in bank angle
suggests asymmetric thrust most probable cause.

**PSM-ICR Turboprop Data, Jan 1985 - present**

15

*01-Sep-98*

**Event No: 023 Geographical Region of Europe**

**Date: 12-Sep-87 Location: Southend, UK**

**Airplane Beech 200 Event HF**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Loss of control after engine failure during climb**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Climb**

**Flight Phase Detail: 2 miles out**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO): C**

**Weather Night/IMC**

**Runway**

**Engine/ Propeller PT6A-41**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted N**

**Autofeather/ autocoarsen armed N**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System Ruptured diaphragm in LP compressor bleed valve,
causing engine instability**

**Crew Failed to maintain control following engine shutdown after
takeoff**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N) N**

**Narrative :** A/C much lower than usual during initial climb.
Witnesses reported uneven engine sounds & loud bang. In- flight fire
seen. LH prop found feathered, RH prop rotating at high rpm at fine
pitch. LH shutoff valve found closed. Likely that LH eng was shut down.
No pre-impact damage to LH eng rotating assy found. Only damage was
ruptured diaphragm in the LP compressor bleed valve. Previous similar
failures of valve (on other A/C) caused dramatic flux of TQ & ITT
requiring eng shutdown.

**PSM-ICR Turboprop Data, Jan 1985 - present**

16

*01-Sep-98*

**Event No: 029 Geographical Region of N America**

**Date: 29-Dec-87 Location: Telluride, Col**

**Airplane SA226 Event S**

**Airplane Second Hazard Level: 2**

**PSM+ICR Category: Loss of directional control**

**Summary of Event: Applied asymmetric reverse thrust on landing,
departed runway**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Landing**

**Flight Phase Detail: Landing roll**

**Initiating Event Altitude 0**

**Vmc infringed N**

**Pilot Flying (C/FO):**

**Weather Crosswind**

**Runway Icy**

**Engine/ Propeller TPE331-10**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller No beta light on landing**

**Propulsion System**

**Crew Applied reverse thrust despite having evidence of prop control
malfunction**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N) N**

**Narrative :** During approach pilot felt downdraughts & crosswind.
After touchdown pilot said he did not get RH beta light. Said he applied
reverse power on both engs. A/C drifted left, pilot corrected with
brakes & nosewheel steering, then applied TO power. A/C veered right,
ran off RH side of runway. Witness said A/C landed fast & long. No eng
or prop malfunction found. Reverse not recommended on icy runway or when
beta light not lit on one eng.

**PSM-ICR Turboprop Data, Jan 1985 - present**

17

*01-Sep-98*

**Event No: 032 Geographical Region of Europe**

**Date: 25-Jan-88 Location: E Midlands, UK**

**Airplane Beech King Air Event HF**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Stalled following engine failure on go-around**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Go-around**

**Flight Phase Detail:**

**Initiating Event Altitude 100**

**Vmc infringed Y**

**Pilot Flying (C/FO): C**

**Weather IMC**

**Runway**

**Engine/ Propeller PT6A-28**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted N**

**Autofeather/ autocoarsen armed N**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller**

**Propulsion System Split in RH eng compressor bleed valve diaphragm**

**Crew Failed to maintain control during go-around following engine
failure**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N)**

**Narrative :** A/C on short finals in low visibility ILS approach.
Pilot called for go-around. A/C crashed 600m beyond threshold & caught
fire killing sole occupant. Checks on engs found small split in RH eng
compressor bleed valve diaphragm. Would have caused 300ft.lb torque loss
at go-around. Pilot failure to control this condition, plus possible
disorientation in poor visibility, caused A/C to stall.

**PSM-ICR Turboprop Data, Jan 1985 - present**

18

*01-Sep-98*

**Event No: 035 Geographical Region of N America**

**Date: 25-Mar-88 Location: Decatur, TX**

**Airplane Jetstream 31 Event H**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of height**

**Summary of Event: After precautionary shutdown, aircraft could not
maintain altitude & made forced landing**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Descent**

**Flight Phase Detail: 4000ft**

**Initiating Event Altitude 4000**

**Vmc infringed N**

**Pilot Flying (C/FO): C**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller TPE331-10**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted N**

**Autofeather/ autocoarsen armed N**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller Torque fluctuations of up to 30%**

**Propulsion System No actual malfunction found**

**Crew Failed to verify that torque flux was real (rather than
indication fault). Applied wrong shutdown drill.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N) N**

**Narrative :** LH torque flux seen during descent, but no yaw noticed.
Elected to shut down eng. LH prop did not feather & drag increased until
a/c could not maintain altitude. Eng restarted & descent rate increased
(even with full power on RH eng). Shut down LH eng again. Descent
continued and forced landing made in a field. No eng defects found. LH
prop found on start locks. Likely cause was inadvertent use of ground
shutdown drill, putting prop on start locks, resulting in high drag.

**PSM-ICR Turboprop Data, Jan 1985 - present**

19

*01-Sep-98*

**Event No: 036 Geographical Region of N America**

**Date: 24-May-88 Location: Lawton, OK**

**Airplane Embraer 110 Event H**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Loss of control after engine failure on takeoff
climb**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude 100**

**Vmc infringed Y**

**Pilot Flying (C/FO): C**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller PT6A-34**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System Turbine blade separation**

**Crew**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N)**

**Narrative :** LH eng failed during takeoff. A/C yawed sharply left &
climbed to 100ft before losing height. Struck ground & ran several
hundred feet before coming to rest. Examination of LH eng showed turbine
blade separation. Prop had autofeathered.

**PSM-ICR Turboprop Data, Jan 1985 - present**

20

*01-Sep-98*

**Event No: 038 Geographical Region of S America**

**Date: 6-Jul-88 Location: Barranquilla, Colombia**

**Airplane CL 44 Event HF**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Crashed after uncontained engine failure on
takeoff**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Rotation**

**Initiating Event Altitude 25**

**Vmc infringed Y**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller Tyne**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted ?**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 4**

**Engine Position:**

**Engine/ Propeller**

**Propulsion System Uncontained failure**

**Crew Lost control after losing engines #3 & #4.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N) N**

**Narrative :** Immediately after rotation #4 eng had uncontained
failure. Flew circuit & approach but lost control & crashed short of
runway. Reported that #3 eng also had to be shut down & RH wing on fire
prior to crash.

**PSM-ICR Turboprop Data, Jan 1985 - present**

21

*01-Sep-98*

**Event No: 043 Geographical Region of N America**

**Date: 20-Jan-89 Location: Buena Vista, CO**

**Airplane Convair 580 Event S**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of thrust**

**Summary of Event: One engine was shut down. Crashed after remaining
engine failed when pilot inadvertently shut off fuel**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Cruise**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed N**

**Pilot Flying (C/FO):**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller Allison 501D13H**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted ?**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller Low oil pressure**

**Propulsion System Not confirmed**

**Crew Shut down good engine during clean-up drills following first
engine shutdown. Used wrong restart procedure**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S, R**

**Autopilot engaged (Y/N)**

**Narrative :** During flight, crew shut down RH eng for low oil
pressure. Shortly after, LH eng lost power (tank shutoff valve switch
was near crossfeed switch). Attempts to restart LH eng failed. With no
AC power, pilot could not unfeather RH prop for restart. Emergency
landing made on uneven ground. Check of RH eng did not show malfunction.
Exam\'n of LH eng showed severe turbine heat damage. Pilot set power
lever ahead of Flt Idle during LH restart, against Flt Manual caution to
set AT Flt Idle.

**PSM-ICR Turboprop Data, Jan 1985 - present**

22

*01-Sep-98*

**Event No: 044 Geographical Region of N America**

**Date: 8-Apr-89 Location: Tampa, FL**

**Airplane Beech C45H Event S**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of thrust**

**Summary of Event: Loss of thrust resulting in forced landing
immediately after becoming airborne**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude 100**

**Vmc infringed**

**Pilot Flying (C/FO): C**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller PT6A-20**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted ?**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System Fuel contamination**

**Crew Failed to continue takeoff after engine failure**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** LH eng failed after take-off due to fuel contamination.
Pilot made forced landing off departure end of runway with RH eng still
developing power, as seen from prop strike marks on ground. Post
accident fuel analysis showed sand & fibre contamination. Pilot had just
refuelled but source of contamination was not determined.

**PSM-ICR Turboprop Data, Jan 1985 - present**

23

*01-Sep-98*

**Event No: 048 Geographical Region of N America**

**Date: 5-Nov-89 Location: Dallas, TX**

**Airplane Jetstream 31 Event S**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Heavy landing**

**Summary of Event: Heavy landing due to mis-selection of flaps
following engine failure en-route.**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Climb**

**Flight Phase Detail: En-route**

**Initiating Event Altitude**

**Vmc infringed N**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller TPE331-10**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller Low oil pressure**

**Propulsion System Damaged seal on prop piston allowing oil leakage
into bleed air**

**Crew Selected wrong flap setting for single engine landing at
diversion airfield**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** At 6000ft, smoke entered cabin & pax panicked. Shortly
after, RH oil pressure fell & RH eng was shut down. During diversion,
mis-selection of flaps resulted in hard landing with tailcone hitting
ground. Veered off runway.

Prop had recent maintenance on dome O-ring. Extensive oil contam in
cowl. Piston seal found damaged. Oil entered ECS causing smoke.

**PSM-ICR Turboprop Data, Jan 1985 - present**

24

*01-Sep-98*

**Event No: 050 Geographical Region of N America**

**Date: 9-Jan-90 Location: Jacksonville, FL**

**Airplane Mu 2B Event S**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of thrust**

**Summary of Event: Forced landing. Engine shut down, unable to apply
full power on remaining engine.**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Cruise**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed N**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller TPE331-10**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller Fluctuating torque**

**Propulsion System None found**

**Crew Failed to confirm engine malfunction before shutting down**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S, R**

**Autopilot engaged (Y/N)**

**Narrative :** In cruise, shut down an eng for fluctuating torque.
Unable to get more than 40% torque from remaining eng. Landed in marsh.
Investig\'n did not find any eng malfunction

**PSM-ICR Turboprop Data, Jan 1985 - present**

25

*01-Sep-98*

**Event No: 051 Geographical Region of N America**

**Date: 19-Jan-90 Location: Broomfield, CO**

**Airplane Mu 2B Event S**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Engine malfunction on takeoff roll. Lost control &
departed runway.**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Takeoff roll**

**Initiating Event Altitude 0**

**Vmc infringed Y**

**Pilot Flying (C/FO): C**

**Weather Day/IMC, heavy snow showers**

**Runway Snow covered**

**Engine/ Propeller TPE331-10**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller Lost RPM**

**Propulsion System**

**Crew Failed to maintain direction control on runway**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N) N**

**Narrative :** Pilot said during takeoff roll, LH eng lost RPM. Lost
directional control & plane departed LH side of runway. Struck runway
sign & 2 lights. Skidded sideways for 3000ft, crossed runway & stopped
in ditch. Heavy snow falling & runway covered in snow.

**PSM-ICR Turboprop Data, Jan 1985 - present**

26

*01-Sep-98*

**Event No: 052 Geographical Region of N America**

**Date: 9-Feb-90 Location: Rapid City, SD**

**Airplane Mu 2B Event HF**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Loss of control after engine failure on takeoff**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude 100**

**Vmc infringed Y**

**Pilot Flying (C/FO):**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller TPE331-10**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System Coupling shaft failed in fatigue**

**Crew Failed to maintain control following eng failure on takeoff**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N) N**

**Narrative :** Shortly after lift-off, aircraft entered steep nose-up
attitude at low IAS. Pilot witness said a/c reached height of approx.
100ft, slowed & entered Vmca roll & crashed inverted, nose down, left of
runway.

Invest\'n showed coupling shaft in LH eng failed thru\' fatigue. LH prop
had feathered.

**PSM-ICR Turboprop Data, Jan 1985 - present**

27

*01-Sep-98*

**Event No: 054 Geographical Region of Asia**

**Date: 3-Apr-90 Location: Libuhanraio, Indonesia**

**Airplane DHC 6 Event H**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of height**

**Summary of Event: Engine oversped during takeoff, aircraft lost height
& hit hill**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude**

**Vmc infringed N**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller PT6A-27**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller Engine oversped**

**Propulsion System**

**Crew Failed to maintain climb performance following eng failure on
takeoff**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N) N**

**Narrative :** Soon after takeoff, LH eng oversped, aircraft lost
height & struck crest of hill, crashing into trees.

**PSM-ICR Turboprop Data, Jan 1985 - present**

28

*01-Sep-98*

**Event No: 055 Geographical Region of S America**

**Date: 18-Apr-90 Location: Contadora Is., Panama**

**Airplane DHC 6 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Loss of control after engine failure on takeoff**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude**

**Vmc infringed Y**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller PT6A-27**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller**

**Propulsion System**

**Crew Failed to maintain control following eng failure on takeoff**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N) N**

**Narrative :** Shortly after takeoff, RH eng failed & aircraft entered
descending right turn which continued until impact with the sea

**PSM-ICR Turboprop Data, Jan 1985 - present**

29

*01-Sep-98*

**Event No: 056 Geographical Region of S America**

**Date: 10-May-90 Location: Tuxla Gutierrez, Mexico**

**Airplane F27 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of height**

**Summary of Event: Crashed after engine failure on approach**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Approach**

**Flight Phase Detail: 4.5km out**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller Dart 522**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller**

**Propulsion System**

**Crew Failed to maintain approach flight path after engine failure**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N)**

**Narrative :** RH eng failed on approach. Aircraft struck trees and
crashed 4.5km from airport

**PSM-ICR Turboprop Data, Jan 1985 - present**

30

*01-Sep-98*

**Event No: 057 Geographical Region of Asia**

**Date: 18-May-90 Location: Manila, Philippines**

**Airplane Beech 1900 Event HF**

**Airplane Second Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Loss of control after engine failure on takeoff**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Climb**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller PT6A-65**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller**

**Propulsion System**

**Crew Failed to maintain control following eng failure on takeoff**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N)**

**Narrative :** Crashed & burned in residential area shortly after
takeoff, reportedly following an engine failure

**PSM-ICR Turboprop Data, Jan 1985 - present**

31

*01-Sep-98*

**Event No: 058 Geographical Region of N America**

**Date: 23-Aug-90 Location: Houston, TX**

**Airplane Gulfstream G-159 Event HF**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Loss of control after engine failure on takeoff**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude**

**Vmc infringed Y**

**Pilot Flying (C/FO):**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller Dart 529**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System Partial power loss due to faulty fuel pump**

**Crew Failed to maintain control following eng failure on takeoff**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S, R**

**Autopilot engaged (Y/N)**

**Narrative :** Pax & witnesses said that during takeoff, aircraft yawed
both left & right after lift-off. Then veered left & contacted ground LH
wing low. Invest\'n showed LH eng had partial power loss due to faulty
fuel pump. Power loss not enough to trip autofeather. Manual feathering
had been started, but blades had not reached full feather before impact.

**PSM-ICR Turboprop Data, Jan 1985 - present**

32

*01-Sep-98*

**Event No: 059 Geographical Region of N America**

**Date: 24-Aug-90 Location: Mattapan, MA**

**Airplane PA31 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of height**

**Summary of Event: Crashed on approach following engine shutdown**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Go-around**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO): C**

**Weather Day/IMC**

**Runway**

**Engine/ Propeller PT6A-28**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted ?**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller Overtorque indication**

**Propulsion System Fuel pump drive shaft failure**

**Crew Failed to maintain approach flight path after engine failure**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N)**

**Narrative :** Pilot noted LH eng overtorque as aircraft was on ILS
approach. Made go-around & started another approach with eng shut down.
Unable to maintain height & descended. Crashed into 2 houses 6 miles
from airport. Exam of LH eng showed fuel pump drive shaft sheared at
plastic coupling. Driveshaft bearings also failed, allowing shaft to
move & cause overtorque.

**PSM-ICR Turboprop Data, Jan 1985 - present**

33

*01-Sep-98*

**Event No: 060 Geographical Region of N America**

**Date: 6-Sep-90 Location: Nashville, TN**

**Airplane Mu 2B Event HF**

**Airplane Second Hazard Level: 5**

**PSM+ICR Category: Loss of height**

**Summary of Event: Took off with known low power defect on one engine.
Failed to climb. Crashed.**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude**

**Vmc infringed Y**

**Pilot Flying (C/FO): C**

**Weather Day/VMC 95 deg F**

**Runway**

**Engine/ Propeller TPE331-10**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller Low power**

**Propulsion System None found**

**Crew Took off with known engine defect.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** On previous flight, low power noted in RH eng. RH fuel
flow 5 Gal/hr less than left & RH ITT 50 deg less. Decided to ferry
aircraft. Aircraft remained low after takeoff, then rolled right &
dropped sharply. Impacted RH wing low 2 miles from end of runway. No
pre-impact failure found. Both engs had evidence of rotation at impact.
Maintenance not informed of engine problem before flight.

**PSM-ICR Turboprop Data, Jan 1985 - present**

34

*01-Sep-98*

**Event No: 062 Geographical Region of N America**

**Date: 29-Nov-90 Location: Des Moines, IA**

**Airplane PA31 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Loss of control after engine failure on approach**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Approach**

**Flight Phase Detail: Finals**

**Initiating Event Altitude**

**Vmc infringed Y**

**Pilot Flying (C/FO): C**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller PT6A-35**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted ?**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System None found**

**Crew Failed to feather prop after engine failure**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** On final approach, pilot told controller he might have
to shut down an eng. Did not declare emergency. On short finals,
aircraft rolled left & descended into terrain. Exam showed LH eng was
not developing power, although LH prop was not feathered. Evidence that
RH was producing high power at impact. No mechanical defect in LH eng or
prop found.

**PSM-ICR Turboprop Data, Jan 1985 - present**

35

*01-Sep-98*

**Event No: 063 Geographical Region of N America**

**Date: 17-Dec-90 Location: Chattanooga, TN**

**Airplane Jetstream 31 Event S**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of directional control**

**Summary of Event: Landed with one engine stuck at full power. Departed
runway**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Climb**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO): C**

**Weather Night/VMC**

**Runway Dry**

**Engine/ Propeller TPE331-10**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller Engine stuck at full power**

**Propulsion System Power lever disconnect**

**Crew Failed to shut down engine prior to landing**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** Power lever disconnected after takeoff, leaving eng
stuck at full power. Pilot elected not to shut down eng until after
touchdown, upon which directional control was lost. Aircraft left runway
& was damaged in outfield.

**PSM-ICR Turboprop Data, Jan 1985 - present**

36

*01-Sep-98*

**Event No: 064 Geographical Region of N America**

**Date: 22-Feb-91 Location: Tulsa, OK**

**Airplane Mu 2B Event HF**

**Airplane Second Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Loss of control after engine failure on takeoff**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude 500**

**Vmc infringed Y**

**Pilot Flying (C/FO): C**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller TPE331-10**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller**

**Propulsion System None found**

**Crew Failed to apply rudder trim after engine failure**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S, R**

**Autopilot engaged (Y/N) N**

**Narrative :** Aircraft doing test flight after replacement of both
engs. Witnesses said takeoff roll & initial climb appeared normal, but
at 500ft aircraft entered right bank until wings were vertical. Nose
fell thru\' & aircraft hit ground inverted in steep nose down attitude.
Exam showed RH eng shut down & feathered. No evidence of pre- impact
failure of either eng or airframe systems. Gear was up & LH spoiler
deployed. Rudder trim should have been used to prevent spoiler
deployment. Rudder trim found in neutral position. Pilot was not regular
line pilot.

**PSM-ICR Turboprop Data, Jan 1985 - present**

37

*01-Sep-98*

**Event No: 065 Geographical Region of S Pacific**

**Date: 18-Apr-91 Location: Tahiti**

**Airplane Do 228 Event HF**

**Airplane Second Hazard Level: 5**

**PSM+ICR Category: Loss of thrust**

**Summary of Event: One engine failed, crew shut down the other**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Cruise**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller TPE331-5**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller**

**Propulsion System**

**Crew Did not correctly identify failed engine. Shut down remaining
good engine.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** During flight one eng failed & crew shut down remaining
eng by mistake. Made emergency landing with no motive power.

**PSM-ICR Turboprop Data, Jan 1985 - present**

38

*01-Sep-98*

**Event No: 067 Geographical Region of Africa**

**Date: 10-Jun-91 Location: Luanda, Angola**

**Airplane Hercules L100 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Loss of control after engine failure on takeoff**

**Type of Airline Operation (FAR**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller Allison 501**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted N**

**Autofeather/ autocoarsen armed N**

**No of Engines: 4**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System**

**Crew**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N) N**

**Narrative :** LH eng reportedly failed shortly after takeoff. Control
lost. Aircraft exploded on impact

**PSM-ICR Turboprop Data, Jan 1985 - present**

39

*01-Sep-98*

**Event No: 068 Geographical Region of S America**

**Date: 7-Oct-91 Location: Moron, Argentina**

**Airplane IAI 101 Event S**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of directional control**

**Summary of Event: No reverse on one engine during landing. Attempted
to take off again. Crashed.**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Landing**

**Flight Phase Detail: Landing roll**

**Initiating Event Altitude 0**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller PT6A-36**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted ?**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller Prop did not apply reverse thrust**

**Propulsion System**

**Crew Failed to cancel reverse thrust when asymmetry experienced on
runway. Wrongly decided to take off again**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N)**

**Narrative :** Aircraft was making touch & go landings & had landed for
final touchdown. When reverse thrust applied eng

accelerated but prop did not go into reverse. RH eng responded normally.
Lost directional control. To avoid veering off runway, aircraft was
lifted off but fell violently to ground. Bounced & deviated 1000m from
centreline, struck 2 cement posts & hit wire fence.

**PSM-ICR Turboprop Data, Jan 1985 - present**

40

*01-Sep-98*

**Event No: 070 Geographical Region of CIS**

**Date: 9-Feb-92 Location: Guryev, Kazakhstan**

**Airplane An 24 Event S**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of airspeed**

**Summary of Event: Attempted single-engine approach after go-around.
Landed (very) short of runway**

**Type of Airline Operation (FAR**

**Engine Training Flight N**

**Phase of Flight: Descent**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather IMC**

**Runway**

**Engine/ Propeller AL24A**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted ?**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System**

**Crew Failed to maintain airspeed after engine failure**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N)**

**Narrative :** Go-around flown with LH eng failed. On second approach
aircraft lost speed & landed 6km short of runway. Attributed to
combination of eng failure, approach in conditions below minima & lack
of radar control on final approach.

**PSM-ICR Turboprop Data, Jan 1985 - present**

41

*01-Sep-98*

**Event No: 072 Geographical Region of N America**

**Date: 22-Apr-92 Location: Perris Valley, CA**

**Airplane DHC 6 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of thrust**

**Summary of Event: Engine failure on takeoff. May have shut down wrong
engine**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller PT6A-20**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller**

**Propulsion System Gross fuel contamination**

**Crew May have shut down remaining good engine**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** Ground loader fuelled aircraft from fuel truck. Said
flight crew did not sump tanks after fuelling. Immediately after takeoff
RH eng lost power, RH wing lowered to 90 deg & aircraft hit ground
beside runway. Forward fuel tank, which feeds RH eng, found to contain 8
gals mixture of water, emulsifier & bacteria. LH prop control found
siezed in feather position. LH prop blades near feather.

**PSM-ICR Turboprop Data, Jan 1985 - present**

42

*01-Sep-98*

**Event No: 073 Geographical Region of N America**

**Date: 16-Jun-92 Location: New Castle, DE**

**Airplane Beech 200 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Engine failure on final approach. Attempted
go-around. Lost control.**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Go-around**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed Y**

**Pilot Flying (C/FO):**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller PT6A-41**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted N**

**Autofeather/ autocoarsen armed N**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System Turbine blade failure**

**Crew Failed to maintain control during go-around following engine
failure**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** Witnesses saw aircraft on normal final approach, then
saw it drop low and slow, retract the gear & roll to the left into
trees. Exam of LH eng showed failure of turbine blade. RH eng OK. Radar
confirmed drop in airspeed before hitting trees.

**PSM-ICR Turboprop Data, Jan 1985 - present**

43

*01-Sep-98*

**Event No: 075 Geographical Region of N America**

**Date: 10-Aug-92 Location: Gainesville, GA**

**Airplane Cessna 441 Event S**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Partial loss of thrust**

**Summary of Event: Birdstrike after takeoff. Lost power on one engine.
Forced landing**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude 50**

**Vmc infringed N**

**Pilot Flying (C/FO): C**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller TPE331-8**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller Partial power loss**

**Propulsion System Birdstrike damage to turbine section**

**Crew Failed to establish single-engine climb configuration (raise
gear)**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** Pilot said that after takeoff he hit a flock of birds.
Said RH eng immediately had a partial loss of power. Did not try to
raise gear or flaps, & aircraft would not maintain altitude. Exam of
engs showed rotational scoring of RH turbine housing only.

**PSM-ICR Turboprop Data, Jan 1985 - present**

44

*01-Sep-98*

**Event No: 076 Geographical Region of N America**

**Date: 25-Aug-92 Location: Hot Springs, AK**

**Airplane SA227 Event HF**

**Airplane Second Hazard Level: 5**

**PSM+ICR Category: Partial loss of thrust**

**Summary of Event: Lost power & crashed shortly after takeoff**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller TPE331-10**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller**

**Propulsion System**

**Crew**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge**

**Autopilot engaged (Y/N)**

**Narrative :** Aircraft reportedly lost power & crashed shortly after
taking off on test flight following maintenance

**PSM-ICR Turboprop Data, Jan 1985 - present**

45

*01-Sep-98*

**Event No: 079 Geographical Region of N America**

**Date: 30-Aug-92 Location: Greenwood, MS**

**Airplane Cessna 425 Event S**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Engine shutdown in cruise. Stalled and crashed on
approach**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Cruise**

**Flight Phase Detail:**

**Initiating Event Altitude 20000**

**Vmc infringed**

**Pilot Flying (C/FO): C**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller PT6A-112**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted ?**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller Fluctuating oil pressure**

**Propulsion System Oil leakage due to broken chip detector**

**Crew Mis-set power on approach and lost height**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N)**

**Narrative :** In cruise at 20000ft pilot shut down LH eng & feathered
prop due to fluctuating oil pressure. Declared emergency & was executing
single-eng approach when he noted his sink rate was high so he retracted
the gear & flaps. Aircraft crashed short of runway. Chip detector on LH
eng found broken due to brittle condition from manufacture.

**PSM-ICR Turboprop Data, Jan 1985 - present**

46

*01-Sep-98*

**Event No: 081 Geographical Region of CIS**

**Date: 19-Oct-92 Location: Ust\'nem, Russian**

**Airplane An 28 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Aircraft crashed following engine failure on
takeoff**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller TVD-10S**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted ?**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller**

**Propulsion System**

**Crew**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge**

**Autopilot engaged (Y/N)**

**Narrative :** Aircraft crashed following engine failure on takeoff

**PSM-ICR Turboprop Data, Jan 1985 - present**

47

*01-Sep-98*

**Event No: 082 Geographical Region of S America**

**Date: 21-Oct-92 Location: L Caballocha, Peru**

**Airplane DHC 6 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of height**

**Summary of Event: Engine failure en route. Made forced landing on lake
and sank**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Cruise**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller PT6A-27**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller**

**Propulsion System**

**Crew**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge**

**Autopilot engaged (Y/N)**

**Narrative :** Whilst en route pilot reported an eng had failed.
Aircraft subsequently crashed into lake & sank during attempted forced
landing.

**PSM-ICR Turboprop Data, Jan 1985 - present**

48

*01-Sep-98*

**Event No: 083 Geographical Region of Asia**

**Date: 9-Jan-93 Location: Surabaya, Indonesia**

**Airplane HS 748 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Crashed during attempted return following engine
failure after takeoff**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller Dart 552**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller**

**Propulsion System**

**Crew**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N)**

**Narrative :** Shortly after takeoff RH engine believed to have failed.
Pilot attempted to return to airport but aircraft crashed into swamp,
overturned, broke in two & caught fire.

**PSM-ICR Turboprop Data, Jan 1985 - present**

49

*01-Sep-98*

**Event No: 084 Geographical Region of CIS**

**Date: 16-Jan-93 Location: Kustanay, Kazakhstan**

**Airplane An 24 Event H**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Crashed short following engine failure on approach**

**Type of Airline Operation (FAR**

**Engine Training Flight N**

**Phase of Flight: Approach**

**Flight Phase Detail:**

**Initiating Event Altitude 1300**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted ?**

**Autofeather/ autocoarsen armed ?**

**No of Engines:**

**Engine Position:**

**Engine/ Propeller**

**Propulsion System**

**Crew**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge**

**Autopilot engaged (Y/N)**

**Narrative :** On approach at 1300ft agl, 7.5miles from airfield, LH
eng suddenly shut down & prop feathered. Crew did not report problem to
ATC & continued approach. On finals at 200ft, began to veer to left. ATC
told crew to go around. Captain increased power on RH eng & retracted
gear. Aircraft continued to lose height & struck ground in left bank
200yds short & 500yds left of runway. Slid into ramp & hit another
aircraft. Visibility was 3000yds, cloud base 1000ft.

**PSM-ICR Turboprop Data, Jan 1985 - present**

50

*01-Sep-98*

**Event No: 090 Geographical Region of S America**

**Date: 12-May-93 Location: Rio de Janeiro, Brazil**

**Airplane Embraer 120 Event S**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Landed hot with one engine stuck at full power.
Overran.**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Approach**

**Flight Phase Detail: Finals**

**Initiating Event Altitude 300**

**Vmc infringed N**

**Pilot Flying (C/FO):**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller PW118**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed N**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller Sudden uncommanded power increase on RH engine.**

**Propulsion System**

**Crew Failed to establish suitable engine power condition for landing.
Should have elected to go around.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** During final visual approach, at 300ft power suddenly
increased on RH eng. Crew tried to reduce power on both engs. LH
responded normally, but RH stayed at high power. Pilot continued
approach & touched down 1000ft along runway 30kts higher than normal.
Aircraft overran & collided with rocks just beyond end of runway.

**PSM-ICR Turboprop Data, Jan 1985 - present**

51

*01-Sep-98*

**Event No: 091 Geographical Region of CIS**

**Date: 5-Jul-93 Location: Ramenskoye, Russia**

**Airplane IL 114 Event HF**

**Airplane Second Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Lost power & stalled shortly after takeoff**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Takeoff roll**

**Initiating Event Altitude 0**

**Vmc infringed Y**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller TV 7-117**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted ?**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller Loss of thrust**

**Propulsion System**

**Crew Continued takeoff with evident loss of thrust on one engine**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** During takeoff run, RH eng failed to produce enough
thrust & there was also an electrical system fault warning. Takeoff
continued but as soon as aircraft became airborne it was seen to roll
then pitch up steeply. Stalled and crashed.

**PSM-ICR Turboprop Data, Jan 1985 - present**

52

*01-Sep-98*

**Event No: 092 Geographical Region of Europe**

**Date: 28-Dec-93 Location: Ampuria, Spain**

**Airplane Shorts Skyvan Event HF**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Aircraft struck trees & crashed during attempted
go-around**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Approach**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO): C**

**Weather**

**Runway**

**Engine/ Propeller TPE331-2**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller**

**Propulsion System Fuel starvation**

**Crew Failed to maintain control during go-around following engine
failure**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** Aircraft struck trees & crashed during attempted
go-around. At impact, one eng not developing power & was believed to
have been shut down earlier in approach. Suspect that eng failed due to
lack of fuel.

**PSM-ICR Turboprop Data, Jan 1985 - present**

53

*01-Sep-98*

**Event No: 094 Geographical Region of Europe**

**Date: 25-Feb-94 Location: Uttoxeter, UK**

**Airplane Viscount Event HF**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of height**

**Summary of Event: Forced landing after multiple engine failures and
ice acretion**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Descent**

**Flight Phase Detail:**

**Initiating Event Altitude 15000**

**Vmc infringed N**

**Pilot Flying (C/FO): C**

**Weather Night/ Severe icing**

**Runway**

**Engine/ Propeller Dart 530**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 4**

**Engine Position:**

**Engine/ Propeller Flameout**

**Propulsion System Multiple flameouts due to ice ingestion**

**Crew Failed to avoid extreme icing conditions. Failed to follow
checklists to relight failed engines.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** On descent at 15000ft, #2 eng failed & prop
autofeathered. One minute later, #3 eng started to run down. Attempts to
restart both were initially unsuccessful, but eventually #2 restarted.
At this point #4 eng failed.

Despite further attempts, #3 & 4 never restarted. Aircraft unable to
maintain height & latterly yaw control was lost. Aircraft struck ground
& broke up. Cause found to be multiple eng failures due to extreme ice
encounter.

These were compounded by poor crew actions in completing emergency
drills, preventing successful recovery of available engine power.

**PSM-ICR Turboprop Data, Jan 1985 - present**

54

*01-Sep-98*

**Event No: 095 Geographical Region of Europe**

**Date: 4-Apr-94 Location: Amsterdam, Holland**

**Airplane Saab 340B Event HF**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Made approach and go-around with one engine at
Flight Idle. Lost control due to asymmetry.**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Climb**

**Flight Phase Detail:**

**Initiating Event Altitude 16500**

**Vmc infringed Y**

**Pilot Flying (C/FO): C**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller CT7-9B**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed N**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller Low oil pressure warning light**

**Propulsion System No engine defect. Oil pressure switch was faulty,
giving erroneous warning.**

**Crew Failed to follow checklist regarding oil pressure warning. Failed
to apply rudder to counter asymmetric thrust during**

go-around

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S, R**

**Autopilot engaged (Y/N) Y**

**Narrative :** During climb thru 16500ft crew saw RH low oil pressure
warning light. Elected to return to departure airport on ILS approach
with RH eng at Flight Idle. During approach captain applied little or no
rudder & aircraft drifted to right of runway. Go-around was executed but
during climb no rudder was applied to counter high asymmetric thrust &
aircraft rolled to right. Pitch increased, IAS fell & bank angle
increased. Captain lost control & aircraft hit ground in 80 deg bank.
Cause found to be inadequate use of flight controls during asymmetric
go-around, resulting in loss of control. Crew criticized for being
unaware of consequences of making an approach with one eng in Flight
Idle

**PSM-ICR Turboprop Data, Jan 1985 - present**

55

*01-Sep-98*

**Event No: 096 Geographical Region of N America**

**Date: 18-Jun-94 Location: Fort Frances, Ontario**

**Airplane Cessna 441 Event H**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Birdstrike after takeoff. Lost power on one engine.
Lost control & crashed**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Rotation**

**Initiating Event Altitude 0**

**Vmc infringed Y**

**Pilot Flying (C/FO): C**

**Weather**

**Runway**

**Engine/ Propeller TPE331-8**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System**

**Crew Failed to maintain control following eng failure on takeoff**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S, R**

**Autopilot engaged (Y/N) N**

**Narrative :** On takeoff just after rotation, bird struck LH eng. LH
eng lost power but pilot continued takeoff. Aircraft veered to left, LH
wing tip struck ground & aircraft crashed.

**PSM-ICR Turboprop Data, Jan 1985 - present**

56

*01-Sep-98*

**Event No: 097 Geographical Region of Asia**

**Date: 5-Jul-94 Location: Dera Ismail Khan,**

**Airplane F27 Event H**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of height**

**Summary of Event: Power loss on approach. Go-around attempted but lost
height & made forced landing**

**Type of Airline Operation (FAR**

**Engine Training Flight N**

**Phase of Flight: Approach**

**Flight Phase Detail: Finals**

**Initiating Event Altitude**

**Vmc infringed N**

**Pilot Flying (C/FO):**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller Dart 522**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller Lost power**

**Propulsion System**

**Crew Failed to properly configure aircraft for single-engine
go-around**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** During finals on visual approach, LH eng began to lose
power. At 200ft, elected to go-around. Applied full power to RH eng &
retracted flaps & gear. Aircraft continued to lose height & pilot made
successful forced landing in paddy field.

**PSM-ICR Turboprop Data, Jan 1985 - present**

57

*01-Sep-98*

**Event No: 098 Geographical Region of Europe**

**Date: 17-Jul-94 Location: Ajaccio, Corsica**

**Airplane Beech 90 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Lost control on approach with one engine feathered**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Approach**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller PT6A-20**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted ?**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System Loss of fuel pump drive**

**Crew Lost control during single engine approach**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S**

**Autopilot engaged (Y/N)**

**Narrative :** Aircraft was on approach with LH eng feathered due to
loss of fuel pump drive. Lost control 200m short of runway & crashed on
beach.

**PSM-ICR Turboprop Data, Jan 1985 - present**

58

*01-Sep-98*

**Event No: 099 Geographical Region of N America**

**Date: 4-Aug-94 Location: Williamstown, MA**

**Airplane Beech A100 Event HF**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Lost control after engine failure on takeoff climb**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO): C**

**Weather Day/VMC**

**Runway Dry**

**Engine/ Propeller PT6A-28**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted ?**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller**

**Propulsion System None found**

**Crew Failed to maintain control following eng failure on takeoff**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S, R**

**Autopilot engaged (Y/N)**

**Narrative :** Aircraft had had maintenance for slow acceleration on RH
eng. LH & RH fuel controls swapped over. On subsequent takeoff,
witnesses reported aircraft was slow and low. LH prop blades seen nearly
stopped. Aircraft turned left & LH wing tip hit ground. Complete
disassembly of both engines revealed no defects. LH prop blades found at
feather at impact.

**PSM-ICR Turboprop Data, Jan 1985 - present**

59

*01-Sep-98*

**Event No: 100 Geographical Region of S America**

**Date: 2-Sep-94 Location: Fortaleza, Brazil**

**Airplane Embraer 110 Event S**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Stalled onto runway during go-around with one engine
at idle power**

**Type of Airline Operation (FAR**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller PT6A-27**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller LH engine power dropped to idle**

**Propulsion System Engine control linkage to fuel control
disconnected**

**Crew Failed to feather prop of failed engine**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** After takeoff, LH eng power dropped to idle. Turned
back. During final approach with gear/flaps down, LH eng at idle, pilot
lost runway alignment & attempted go-around. Gear selected up & full
power applied to RH eng. Aircraft did not react & stalled. Found ball
end fitting of fuel control linkage disconnected. Nut & washer found in
cowling. Cotter pin not found.

**PSM-ICR Turboprop Data, Jan 1985 - present**

60

*01-Sep-98*

**Event No: 101 Geographical Region of N America**

**Date: 13-Dec-94 Location: Raleigh-Durham, NC**

**Airplane Jetstream 32 Event HF**

**Airplane Second Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Stalled during attempted go-around with one engine
at Flight Idle**

**Type of Airline Operation (FAR 135**

**Engine Training Flight N**

**Phase of Flight: Approach**

**Flight Phase Detail:**

**Initiating Event Altitude 2100**

**Vmc infringed N**

**Pilot Flying (C/FO): C**

**Weather Night/IMC**

**Runway**

**Engine/ Propeller TPE331-12**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller Ignition light illuminated**

**Propulsion System None. Engine was functioning properly at all times
up to impact.**

**Crew Failed to follow drills for engine failure identification,
go-around & stall recovery.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** Aircraft was on ILS approach. At 2100ft captain noticed
an ignition light had come on. Concluded that LH eng had flamed out, but
did not follow emergency procedures for eng failure. Elected to carry
out missed approach. Called for max power on RH eng. Aircraft turned to
left. LH eng was at Flight Idle. IAS dropped & stall warning horns
sounded. FO told captain to lower nose. Soon after, descent rate
increased dramatically. Captain lost control & aircraft crashed 4 miles
southwest of runway. Probable causes were captain\'s improper assumption
that an engine had failed, and captain\'s subsequent failure to follow
approved procedures for engine failure, single-engine approach &
go-around, & stall recovery

**PSM-ICR Turboprop Data, Jan 1985 - present**

61

*01-Sep-98*

**Event No: 102 Geographical Region of CIS**

**Date: 20-Jan-95 Location: Krasnoyask, Russia**

**Airplane Let L-410 Event HF**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Lost control after engine failure on takeoff climb**

**Type of Airline Operation (FAR**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather Night/VMC**

**Runway**

**Engine/ Propeller M 601**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted ?**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller**

**Propulsion System Fuel contamination ?**

**Crew Failed to maintain control following eng failure on takeoff**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** Shortly after takeoff in darkness but normal weather,
aircraft began to veer to right. Control not regained & aircraft struck
trees 1000m beyond end of runway & 450m to right. On impact, RH eng was
not developing power & RH prop was feathered. Aircraft believed to be
440 lb above MTOW. Possibility of fuel contamination.

**PSM-ICR Turboprop Data, Jan 1985 - present**

62

*01-Sep-98*

**Event No: 105 Geographical Region of N America**

**Date: 13-May-95 Location: Boise, ID**

**Airplane Hercules C130 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Crashed after takeoff following reported #2 engine
fire**

**Type of Airline Operation (FAR**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller T56**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted N**

**Autofeather/ autocoarsen armed N**

**No of Engines: 4**

**Engine Position: 2**

**Engine/ Propeller**

**Propulsion System Engine fire**

**Crew Failed to maintain control following eng fire on takeoff**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** Shortly after takeoff pilot declared emergency &
reported fire in #2 eng. Shortly after, contact lost. Witnesses reported
seeing aircraft go out of control & \"nose over\".

**PSM-ICR Turboprop Data, Jan 1985 - present**

63

*01-Sep-98*

**Event No: 107 Geographical Region of Asia**

**Date: 3-Oct-95 Location: Bakangan-Tapak Tuan,**

**Airplane CASA 212-100 Event HF**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of height**

**Summary of Event: Unable to maintain height after engine failure
en-route. Crashed into trees.**

**Type of Airline Operation (FAR**

**Engine Training Flight N**

**Phase of Flight: Cruise**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller TPE331-5**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller Loss of oil pressure**

**Propulsion System**

**Crew**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** About 30 min after takeoff crew reported they had shut
down LH eng due to loss of oil pressure & were unable to maintain
height. Continued to make calls until 500ft agl. Just before impact with
tree tops pilot shut down RH eng. Aircraft was close to max weight

**PSM-ICR Turboprop Data, Jan 1985 - present**

64

*01-Sep-98*

**Event No: 111 Geographical Region of N America**

**Date: 19-Jan-96 Location: West Columbia, SC**

**Airplane Mu 2B Event H**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Lost control on approach after engine shutdown
during flight**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Cruise**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller TPE331-10**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller Would not restart. No fuel or ignition**

**Propulsion System Fuel shutoff valve found closed**

**Crew Failed to use proper engine restart drill.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** On maintenance test flight pilot performed NTS check on
LH eng. Two attempts to restart LH eng unsuccessful. Each time prop came
out of feather & started to windmill but there was no fuel or ignition.
Aircraft returned to land. On short finals witness saw aircraft pitch up
then down, then heard sound of power increase. Aircraft rolled to left,
pitched nose down & impacted ground. Exam of LH eng found no sign of
pre- impact failure or malfunction. LH eng fuel shutoff valve found in
closed position.

**PSM-ICR Turboprop Data, Jan 1985 - present**

65

*01-Sep-98*

**Event No: 112 Geographical Region of N America**

**Date: 16-May-96 Location: Houston, TX**

**Airplane Mu 2B Event S**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Shut down engine after takeoff. Configured aircraft
wrongly for climbout. Returned. Selected gear late. Crash**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO): C**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller TPE331-10**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller Fluctuating torque**

**Propulsion System**

**Crew Failed to follow single engine flying procedures**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** Pilot reported that after takeoff aircraft yawed to left
& LH indicated torque was fluctuating. Shut down & feathered LH eng &
returned to airport. At 115kts, 20 deg flap, pilot claimed he could not
climb. Required configuration is 140kts, 5 deg flap. Approached runway
at 90 degrees then made 90 deg turn to align. Delayed gear extension to
reach runway. Landed before gear fully down. Gear collapsed & slid off
runway.

**PSM-ICR Turboprop Data, Jan 1985 - present**

66

*01-Sep-98*

**Event No: 113 Geographical Region of N America**

**Date: 20-Jul-96 Location: Scottsdale, AZ**

**Airplane Mu 2B Event H**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of height**

**Summary of Event: Uncontained engine failure on takeoff. Unable to
climb. Forced landing.**

**Type of Airline Operation (FAR 91**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Rotation**

**Initiating Event Altitude 50**

**Vmc infringed N**

**Pilot Flying (C/FO): C**

**Weather Day/VMC**

**Runway Dry**

**Engine/ Propeller TPE331-10**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller**

**Propulsion System Uncontained rotor failure**

**Crew Failed to follow single engine flying procedures**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** Just after lift-off, RH eng had uncontainted failure as
gear was retracting. Aircraft would not climb & pilot elected for forced
landing. Aircraft destroyed by fire.

**PSM-ICR Turboprop Data, Jan 1985 - present**

67

*01-Sep-98*

**Event No: 114 Geographical Region of Asia**

**Date: 7-Dec-96 Location: Banjarmasin, Indonesia**

**Airplane CASA 212 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Engine fire shortly after takeoff. Lost control and
crashed.**

**Type of Airline Operation (FAR**

**Engine Training Flight N**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller TPE331-5**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller Engine fire**

**Propulsion System**

**Crew Failed to follow fire drill and fly the aircraft**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** Crew reported engine fire shortly after takeoff.
Witnesses on ground saw fire while aircraft was still airborne. Aircraft
crashed into factory.

**APPENDIX 8 - Summary of Turboprop Training Events**

**APPENDIX 8 - Summary of Turboprop Training Events**

**PSM-ICR Turboprop Training Event Data, Jan 1985 - present**

1

*01-Sep-98*

**Event No: Geographical Region of Middle East**

**Date: 1-Apr-87 Location: Oman**

**Airplane Do-228 Event H**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of thrust**

**Summary of Event: Crashed after instructor failed one engine and
student shut down the other on training flight**

**Type of Airline Operation (FAR 91**

**Engine Training Flight Y**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude**

**Vmc infringed N**

**Pilot Flying (C/FO): FO**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller TPE331-5**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller**

**Propulsion System**

**Crew Did not correctly identify failed engine. Shut down remaining
good engine.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** Training instructor failed an engine at low altitude.
Student shut down good engine.

**PSM-ICR Turboprop Training Event Data, Jan 1985 - present**

2

*01-Sep-98*

**Event No: 018 Geographical Region of N America**

**Date: 8-Apr-87 Location: Travis AFB, CA**

**Airplane Hercules L100 Event HF**

**Airplane First Hazard Level: 5**

**PSM+ICR Category: Loss of control**

**Summary of Event: Loss of control after 2 engs failed to respond
during go-around.**

**Type of Airline Operation (FAR**

**Engine Training Flight Y**

**Phase of Flight: Go-around**

**Flight Phase Detail:**

**Initiating Event Altitude**

**Vmc infringed Y**

**Pilot Flying (C/FO): C**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller Allison 501-D22A**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted N**

**Autofeather/ autocoarsen armed N**

**No of Engines: 4**

**Engine Position:**

**Engine/ Propeller Engs failed to respond when throttles advanced**

**Propulsion System Bleed valves contaminated with oil/tar**

**Crew Failed to maintain control following eng failures on go-around**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N) N**

**Narrative :** A/C crashed during go-around after baulked landing. Nos.
1 & 2 engs failed to respond when throttles advanced. Both engs
decelerated & airspeed decreased during go-around. Flaps were retracted
causing reduction in hydraulic pressure. Instructor could not maintain
Vmc & lost control. A/C destroyed by fire. Heavy oil & tar residues
found on bleed valves & No. 1 & 2 compressors, limiting eng response to
throttle movement. Recent oil leak marks found.

**PSM-ICR Turboprop Training Event Data, Jan 1985 - present**

3

*01-Sep-98*

**Event No: 024 Geographical Region of N America**

**Date: 24-Sep-87 Location: Twin Falls, ID**

**Airplane SA227AC Event H**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Simulated V1 cut, unable to gain height. Flaps
mis-set.**

**Type of Airline Operation (FAR 135**

**Engine Training Flight Y**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Initial climb**

**Initiating Event Altitude 25**

**Vmc infringed Y**

**Pilot Flying (C/FO): FO**

**Weather Night/VMC**

**Runway**

**Engine/ Propeller TPE331-11**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted N**

**Autofeather/ autocoarsen armed N**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller**

**Propulsion System Simulated engine cut by check pilot.**

**Crew Failed to maintain control following (simulated) eng failure on
TO, compounded by mis-set flaps.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S, R**

**Autopilot engaged (Y/N) N**

**Narrative :** Check pilot conducting captain proficiency on another
company pilot under night conds. Pilot in command started TO, check
pilot simulated eng cut after TO. PIC unable to accel to V2, climb or
maintain directional control. A/C levelled off, lost IAS & drifted
right. Check pilot failed to take control or terminate eng cut
simulation. A/C hit ILS tower, lost RH wing tip & lost control. Hit
ground & slid to stop. Flaps & flap handle found at 1/2 pos\'n instead
of 1/4.

**PSM-ICR Turboprop Training Event Data, Jan 1985 - present**

4

*01-Sep-98*

**Event No: 034 Geographical Region of N America**

**Date: 9-Feb-88 Location: Springfield, Ohio**

**Airplane Jetstream 31 Event HF**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Aircraft pitched up, rolled & crashed on go-around**

**Type of Airline Operation (FAR 135**

**Engine Training Flight Y**

**Phase of Flight: Go-around**

**Flight Phase Detail:**

**Initiating Event Altitude 150**

**Vmc infringed Y**

**Pilot Flying (C/FO): FO**

**Weather**

**Runway**

**Engine/ Propeller TPE331-10**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted N**

**Autofeather/ autocoarsen armed N**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller**

**Propulsion System Simulated engine cut by check pilot.**

**Crew Failed to maintain control following (simulated) eng failure on
go-around, compounded by mis-set flaps.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge S, R**

**Autopilot engaged (Y/N) N**

**Narrative :** Training flight. A/C on finals, but started to climb &
began to oscillate in yaw & roll. Pitched up, rolled right & entered
vertical descent. Rolled thru\' 270 deg & hit ground steep nose down. RH
eng found operating at reduced power. LH at full power. Flaps found
retracted contrary to AFM. No evidence of system malfunction. Training
pilot known to be harsh towards students, esp. during one-eng
go-arounds.

**PSM-ICR Turboprop Training Event Data, Jan 1985 - present**

5

*01-Sep-98*

**Event No: 046 Geographical Region of S America**

**Date: 3-Jul-89 Location: Manaus, Brazil**

**Airplane Embraer 110 Event H**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of thrust**

**Summary of Event: Forced landing after instructor failed one engine
and student shut down the other on training flight**

**Type of Airline Operation (FAR 91**

**Engine Training Flight Y**

**Phase of Flight: Go-around**

**Flight Phase Detail: Climb**

**Initiating Event Altitude 1500**

**Vmc infringed N**

**Pilot Flying (C/FO): FO**

**Weather Day/VMC**

**Runway**

**Engine/ Propeller PT6A-34**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller Second engine flamed out after first engine was
failed**

**Propulsion System**

**Crew Did not correctly identify failed engine. Shut down remaining
good engine.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** After missed approach, instructor cut LH eng at 1500ft.
Few seconds later RH eng flamed out. Attempts to restore power
unsuccessful, & pilot made forced landing with gear up on a road 1 mile
from threshold. Aircraft caught fire. Wrong engine secured?

**PSM-ICR Turboprop Training Event Data, Jan 1985 - present**

6

*01-Sep-98*

**Event No: 080 Geographical Region of Europe**

**Date: 6-Oct-92 Location: Prestwick, Scotland**

**Airplane Jetstream 32 Event HF**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of control**

**Summary of Event: Aircraft rolled & crashed following simulated V1
cut**

**Type of Airline Operation (FAR 91**

**Engine Training Flight Y**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Rotation**

**Initiating Event Altitude 0**

**Vmc infringed Y**

**Pilot Flying (C/FO): FO**

**Weather Day/VMC**

**Runway Dry**

**Engine/ Propeller TPE331-12**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 2**

**Engine/ Propeller Retarded to Flight Idle**

**Propulsion System None**

**Crew Focussed on engine identification, failed to raise gear &
maintain attitude**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** During takeoff run captain simulated an eng failure by
retarding RH power lever to Flight Idle once control had been passed to
first officer. Aircraft rotated & climbed slightly steeper than usual
with gear still down.

Approx 10 secs after rotation FO reminded to raise gear. Captain made Up
selection on FO\'s command 2 secs later. Gear warning & stall warning
horns sounded simultaneously. Two secs later captain took controls &
restored power to retarded eng but aircraft continued to roll right &
struck ground inverted. No evidence of aircraft malfunction or medical
factors.

**PSM-ICR Turboprop Training Event Data, Jan 1985 - present**

7

*01-Sep-98*

**Event No: 087 Geographical Region of N America**

**Date: 19-Apr-93 Location: Merced, CA**

**Airplane Jetstream 31 Event H**

**Airplane Second Hazard Level: 4**

**PSM+ICR Category: Loss of height**

**Summary of Event: Crashed following simulated engine failure after
takeoff**

**Type of Airline Operation (FAR 135**

**Engine Training Flight Y**

**Phase of Flight: Takeoff**

**Flight Phase Detail: Rotation**

**Initiating Event Altitude 0**

**Vmc infringed**

**Pilot Flying (C/FO): FO**

**Weather Night/VMC**

**Runway Dry**

**Engine/ Propeller TPE331-10**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted Y**

**Autofeather/ autocoarsen armed Y**

**No of Engines: 2**

**Engine Position: 1**

**Engine/ Propeller Retarded power lever to near Flight Idle**

**Propulsion System None**

**Crew Failed to maintain climb performance following eng failure on
takeoff**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** Shortly after becoming airborne, check pilot retarded LH
power lever approx to Flight Idle to simulate engine failure. Aircraft
heading drifted left by 70 degrees. Pilot then returned aircraft to
correct heading. VSI showed climb rate of 500fpm. Shortly after,
aircraft levelled then began to descend at 500fpm. IAS increased from
120 to 130kts. Aircraft struck ground 1/4 mile from runway. Both engines
later found to be operating at point of impact.

**PSM-ICR Turboprop Training Event Data, Jan 1985 - present**

8

*01-Sep-98*

**Event No: 108 Geographical Region of CIS**

**Date: 1-Nov-95 Location: Chimkent, Kazakhstan**

**Airplane An 24 Event S**

**Airplane First Hazard Level: 4**

**PSM+ICR Category: Loss of thrust**

**Summary of Event: Forced landing after instructor failed one engine
and student shut down the other on training flight**

**Type of Airline Operation (FAR**

**Engine Training Flight Y**

**Phase of Flight: Approach**

**Flight Phase Detail: Finals**

**Initiating Event Altitude**

**Vmc infringed**

**Pilot Flying (C/FO):**

**Weather**

**Runway**

**Engine/ Propeller AL24**

**Engine Shut Down (SD), Throttled (T), Failed (F) or Other (O) ?:**

**Autofeather/ autocoarsen fitted ?**

**Autofeather/ autocoarsen armed ?**

**No of Engines: 2**

**Engine Position:**

**Engine/ Propeller Shut down**

**Propulsion System**

**Crew Did not correctly identify failed engine. Shut down remaining
good engine.**

**Crew Error Class\'n - Skill (S), Rule (R) or Knowledge R**

**Autopilot engaged (Y/N)**

**Narrative :** During crew training, on final approach instructor shut
down LH eng to simulate eng failure. IAS decreased & instructor called
for power to be increased on RH eng. Student attempted to increase power
on LH eng & shut down remaining eng. Aircraft touched down hard 1100m
short of runway.

**APPENDIX 9 - Fleet Survey of Engine Failure Indications - Turbofans**

![](media/image21.png){width="8.59375in" height="6.445138888888889in"}

**ENGINE FAILURE INDICATIONS FOR AIRBUS FLEET**

(3 = Master Warning, 2 = Master Caution, 1 = No Master Caution, No =
Nothing)

**WARNING CAUTIONS**

**MESSAGE / INHIBITS A300 / A310 A319 / A320 / A321 A340 A330**

SUB IDLE 2 2 2 2

None None None

Sub Idle Sub Idle High Power

SURGE-BANG No 2 2 2

3,4,5,7,8 3,4,5,7,8 Except GE Engine

ENGINE FAIL No No No No

Red Display (Red Display) (Red Display)

RPM OVER RED LINE 2 2 3 3

4,8 4,8 4,8

Red Display (Red Display) (Red Display)

EGT OVER RED LINE 2 2 2 2

4,8 4,8 4,8

EVM HI I 1 1 1

ENGINE THRUST No No No No

N~1~ Lim Validation only N~1~ Lim validation only

Reverse Thrust

2 2 2

Reverse Unlock (uncommanded) (uncommanded) (uncommanded)

4,8 4,5,8,9 4,5,8,9

Reverse Armed 2 2

1,8,9,10 1,8,9,10

Tire Fail

![](media/image22.wmf)

+---------+---+--------+--------+-----------+--------+-------+----+----+
| Wa      |   | B7     | B777   | B747      | B7     | B737  | B7 | B7 |
| rning/C |   | 47-400 |        |           | 67/757 |       | 07 | 27 |
| autions |   |        |        |           |        |       |    |    |
| M       |   |        |        |           |        |       |    |    |
| essages |   |        |        |           |        |       |    |    |
+---------+---+--------+--------+-----------+--------+-------+----+----+
| Sub     |   | ENG X  | ENG    | no        | 767    | 6/    | no | no |
| Idle    |   | FAIL   | FAIL   |           |        | 7/800 |    |    |
|         |   | C      | L/R    |           | L/R    |       |    |    |
|         |   | aution |        |           | ENG    | ENG   |    |    |
|         |   | m      | C      |           | FAIL   | FAIL  |    |    |
|         |   | essage | aution |           |        |       |    |    |
|         |   |        | m      |           | Op     | (Eng  |    |    |
|         |   | a-\>e, | essage |           | tional | Dis   |    |    |
|         |   | k-\>l  |        |           |        | play) |    |    |
|         |   |        |        |           | C      |       |    |    |
|         |   |        |        |           | aution | 1     |    |    |
|         |   |        |        |           | m      | /2/3/ |    |    |
|         |   |        |        |           | essage | 4/500 |    |    |
|         |   |        |        |           |        |       |    |    |
|         |   |        |        |           | a-\>e, | no    |    |    |
|         |   |        |        |           | k-\>l  | me    |    |    |
|         |   |        |        |           |        | ssage |    |    |
|         |   |        |        |           | 757 no |       |    |    |
|         |   |        |        |           | m      |       |    |    |
|         |   |        |        |           | essage |       |    |    |
+---------+---+--------+--------+-----------+--------+-------+----+----+
| Surge   |   | no     | no     | no        | no     | no    | no | no |
+---------+---+--------+--------+-----------+--------+-------+----+----+
| Engine  |   | no     | Time   | no        | no     | no    | no | -  |
| Fail    |   |        | Cr     |           |        |       |    | 10 |
|         |   |        | itical |           |        |       |    | 0~ |
| *engine |   |        |        |           |        |       |    | 1~ |
| is      |   |        | ENG    |           |        |       |    |    |
| pr      |   |        | FAIL   |           |        |       |    | -  |
| oducing |   |        | (PFD)  |           |        |       |    | 20 |
| less    |   |        |        |           |        |       |    | 0~ |
| the     |   |        | a,b,   |           |        |       |    | 2~ |
| co      |   |        | e-\>l  |           |        |       |    |    |
| mmanded |   |        |        |           |        |       |    |    |
| thrust* |   |        | Thrust |           |        |       |    |    |
|         |   |        | Sho    |           |        |       |    |    |
|         |   |        | rtfall |           |        |       |    |    |
|         |   |        |        |           |        |       |    |    |
|         |   |        | ENG    |           |        |       |    |    |
|         |   |        | Thrust |           |        |       |    |    |
|         |   |        | C      |           |        |       |    |    |
|         |   |        | aution |           |        |       |    |    |
|         |   |        | m      |           |        |       |    |    |
|         |   |        | essage |           |        |       |    |    |
|         |   |        |        |           |        |       |    |    |
|         |   |        | a-\>   |           |        |       |    |    |
|         |   |        | d,     |           |        |       |    |    |
|         |   |        | k-\>l  |           |        |       |    |    |
+---------+---+--------+--------+-----------+--------+-------+----+----+
| RPM     | L |        | L      | (N1 TACH) | L      | 3     | n  | n  |
| over    | i |        | imited | round     | imited | /4/5/ | o~ | o~ |
| red     | m |        | by     | dial:     | by     | 6/7/8 | 3~ | 3~ |
| line    | i |        | ove    | i         | ove    |       |    |    |
|         | t |        | rspeed | ndicators | rspeed | Li    |    |    |
| *Engine | e |        | gov    | have a    | gov    | mited |    |    |
| RPM     | d |        | ernor. | "max      | ernor. | by    |    |    |
| limited | b |        |        | ind       |        | over  |    |    |
| by EEC  | y |        | ENG    | ications" | For    | speed |    |    |
| red     | o |        | RPM    | pointer.  | 767,   | gov   |    |    |
| lines.* | v |        | L      |           | L/R    | ernor |    |    |
|         | e |        | IMITED | Vertical  | ENG    |       |    |    |
|         | r |        | L/R    | scale:    | RPM    | If    |    |    |
|         | s |        | Ad     | il        | LIM    | re    |    |    |
|         | p |        | visory | luminates |        | dline |    |    |
|         | e |        | M      | amber     | Ad     | exce  |    |    |
|         | e |        | essage | light on  | visory | eded, |    |    |
|         | d |        |        | the       | M      | red   |    |    |
|         | g |        | If     | i         | essage | gage  |    |    |
|         | o |        | r      | ndicator. |        | on    |    |    |
|         | v |        | edline |           | If     | di    |    |    |
|         | e |        | exc    |           | r      | splay |    |    |
|         | r |        | eeded, |           | edline |       |    |    |
|         | n |        | red    |           | exc    | 6/    |    |    |
|         | o |        | gage   |           | eeded, | 7/800 |    |    |
|         | r |        | on     |           | red    |       |    |    |
|         | . |        | d      |           | gage   | b     |    |    |
|         |   |        | isplay |           | on     | -\>g, |    |    |
|         | E |        |        |           | d      | h+,   |    |    |
|         | N |        | b-\>g, |           | isplay | i-\>l |    |    |
|         | G |        | h+,    |           |        |       |    |    |
|         | X |        | i-\>l  |           | b-\>g, | 1/200 |    |    |
|         | R |        |        |           | h+,    |       |    |    |
|         | P |        |        |           | i-\>l  | no    |    |    |
|         | M |        |        |           |        | over  |    |    |
|         | L |        |        |           |        | speed |    |    |
|         | I |        |        |           |        | gov   |    |    |
|         | M |        |        |           |        | ernor |    |    |
|         | I |        |        |           |        |       |    |    |
|         | T |        |        |           |        |       |    |    |
|         | . |        |        |           |        |       |    |    |
|         |   |        |        |           |        |       |    |    |
|         | A |        |        |           |        |       |    |    |
|         | d |        |        |           |        |       |    |    |
|         | v |        |        |           |        |       |    |    |
|         | i |        |        |           |        |       |    |    |
|         | s |        |        |           |        |       |    |    |
|         | o |        |        |           |        |       |    |    |
|         | r |        |        |           |        |       |    |    |
|         | y |        |        |           |        |       |    |    |
|         | M |        |        |           |        |       |    |    |
|         | e |        |        |           |        |       |    |    |
|         | s |        |        |           |        |       |    |    |
|         | s |        |        |           |        |       |    |    |
|         | a |        |        |           |        |       |    |    |
|         | g |        |        |           |        |       |    |    |
|         | e |        |        |           |        |       |    |    |
|         |   |        |        |           |        |       |    |    |
|         | I |        |        |           |        |       |    |    |
|         | f |        |        |           |        |       |    |    |
|         | r |        |        |           |        |       |    |    |
|         | e |        |        |           |        |       |    |    |
|         | d |        |        |           |        |       |    |    |
|         | l |        |        |           |        |       |    |    |
|         | i |        |        |           |        |       |    |    |
|         | n |        |        |           |        |       |    |    |
|         | e |        |        |           |        |       |    |    |
|         | e |        |        |           |        |       |    |    |
|         | x |        |        |           |        |       |    |    |
|         | c |        |        |           |        |       |    |    |
|         | e |        |        |           |        |       |    |    |
|         | e |        |        |           |        |       |    |    |
|         | d |        |        |           |        |       |    |    |
|         | e |        |        |           |        |       |    |    |
|         | d |        |        |           |        |       |    |    |
|         | , |        |        |           |        |       |    |    |
|         | r |        |        |           |        |       |    |    |
|         | e |        |        |           |        |       |    |    |
|         | d |        |        |           |        |       |    |    |
|         | g |        |        |           |        |       |    |    |
|         | a |        |        |           |        |       |    |    |
|         | g |        |        |           |        |       |    |    |
|         | e |        |        |           |        |       |    |    |
|         | o |        |        |           |        |       |    |    |
|         | n |        |        |           |        |       |    |    |
|         | d |        |        |           |        |       |    |    |
|         | i |        |        |           |        |       |    |    |
|         | s |        |        |           |        |       |    |    |
|         | p |        |        |           |        |       |    |    |
|         | l |        |        |           |        |       |    |    |
|         | a |        |        |           |        |       |    |    |
|         | y |        |        |           |        |       |    |    |
|         |   |        |        |           |        |       |    |    |
|         | b |        |        |           |        |       |    |    |
|         | - |        |        |           |        |       |    |    |
|         | \ |        |        |           |        |       |    |    |
|         | > |        |        |           |        |       |    |    |
|         | g |        |        |           |        |       |    |    |
|         | , |        |        |           |        |       |    |    |
|         | h |        |        |           |        |       |    |    |
|         | + |        |        |           |        |       |    |    |
|         | , |        |        |           |        |       |    |    |
|         | i |        |        |           |        |       |    |    |
|         | - |        |        |           |        |       |    |    |
|         | \ |        |        |           |        |       |    |    |
|         | > |        |        |           |        |       |    |    |
|         | l |        |        |           |        |       |    |    |
+---------+---+--------+--------+-----------+--------+-------+----+----+
| EGT     |   | Red    | Red    | Round     | Red    | 6/    | n  | n  |
| over    |   | Gage   | Gage   | dial EGT: | Gage   | 7/800 | o~ | o~ |
| red     |   | on     | on     | i         | on     |       | 3~ | 5~ |
| line    |   | D      | D      | ndicators | D      | Red   |    |    |
|         |   | isplay | isplay | display   | isplay | Gage  |    |    |
|         |   |        |        | an amber  |        | on    |    |    |
|         |   | b-\>g, | b-\>g, | light.    | b-\>g, | Di    |    |    |
|         |   | h+,    | h+,    |           | h+,    | splay |    |    |
|         |   | i-\>l  | i-\>l  | Vertical  | i-\>l  |       |    |    |
|         |   |        |        | Scale     |        | b     |    |    |
|         |   |        |        | i         |        | -\>g, |    |    |
|         |   |        |        | ndicators |        | h+,   |    |    |
|         |   |        |        | have      |        | i-\>l |    |    |
|         |   |        |        | amber and |        |       |    |    |
|         |   |        |        | red, 2    |        | 3/    |    |    |
|         |   |        |        | mode of   |        | 4/500 |    |    |
|         |   |        |        | over      |        |       |    |    |
|         |   |        |        | tem       |        | Red   |    |    |
|         |   |        |        | perature. |        | light |    |    |
+---------+---+--------+--------+-----------+--------+-------+----+----+

+---------+--------+--------+-----------+--------+-------+----+----+
| FADEC   | ENG X  | ENG    | n/a       | 767    | 6/    | n  | n  |
| fault   | C      | C      |           | L/R    | 7/800 | /a | /a |
|         | ONTROL | ONTROL |           | ENG    |       |    |    |
| *FADEC  |        |        |           | C      | ENG   |    |    |
| no      | Ad     | Ad     |           | ONTROL | CO    |    |    |
| d       | visory | visory |           |        | NTROL |    |    |
| ispatch | M      | M      |           | Ad     |       |    |    |
| faults* | essage | essage |           | visory | (L    |    |    |
|         |        | L/R    |           | M      | ight) |    |    |
|         | d-\>k+ |        |           | essage |       |    |    |
|         |        | d-\>k+ |           |        | d     |    |    |
|         |        |        |           | d-\>k+ | -\>k+ |    |    |
|         |        |        |           |        |       |    |    |
|         |        |        |           | 757    | 1     |    |    |
|         |        |        |           |        | /2/3/ |    |    |
|         |        |        |           | PW:    | 4/500 |    |    |
|         |        |        |           |        |       |    |    |
|         |        |        |           | ENG    | N/A   |    |    |
|         |        |        |           | C      |       |    |    |
|         |        |        |           | ONTROL |       |    |    |
|         |        |        |           |        |       |    |    |
|         |        |        |           | Ad     |       |    |    |
|         |        |        |           | visory |       |    |    |
|         |        |        |           | M      |       |    |    |
|         |        |        |           | essage |       |    |    |
|         |        |        |           |        |       |    |    |
|         |        |        |           | RR N/A |       |    |    |
+---------+--------+--------+-----------+--------+-------+----+----+
| EVM Hi  | r      | r      | no~6~     | amber  | 6/    | n  | n  |
|         | everse | everse |           | /white | 7/800 | o~ | o~ |
|         | video  | video  | RR        | video  | over/ | 6~ | 6~ |
|         | at 2.5 | at 4   | RB211-524 | at 2.5 | under |    |    |
|         | scalar | scalar | has vib   | scalar | re    |    |    |
|         | units  | units  | monitor.  | uni    | verse |    |    |
|         |        |        |           | ts(RR) | video |    |    |
|         | pop-up | pop-up |           |        | at    |    |    |
|         |        |        |           | pop-up | 2.5   |    |    |
|         | d-\>f  | d-\>f  |           |        | s     |    |    |
|         |        |        |           |        | calar |    |    |
|         |        |        |           |        | units |    |    |
|         |        |        |           |        |       |    |    |
|         |        |        |           |        | p     |    |    |
|         |        |        |           |        | op-up |    |    |
|         |        |        |           |        |       |    |    |
|         |        |        |           |        | d-\>f |    |    |
+---------+--------+--------+-----------+--------+-------+----+----+
| Engine  | no     | see    | no        | no     | no    | no | no |
| Thrust  |        | above  |           |        |       |    |    |
+---------+--------+--------+-----------+--------+-------+----+----+
| Reverse | Green  | Green  | Green REV | Green  | Green | no | no |
| Thrust  | REV on | REV on | on Eng    | REV on | REV   |    |    |
|         | Eng    | Eng    | Display.  | Eng    | on    |    |    |
|         | D      | D      | Option    | D      | Eng   |    |    |
|         | isplay | isplay | ~7,8,9~   | isplay | Di    |    |    |
|         |        |        |           |        | splay |    |    |
+---------+--------+--------+-----------+--------+-------+----+----+
| Reverse | Amber  | Amber  | Amber REV | Amber  | 6/    | a  | a  |
| U       | REV on | REV on | on Eng    | REV on | 7/800 | mb | mb |
| nlocked | Eng    | Eng    | Display.  | Eng    |       | er | er |
|         | D      | D      | Option    | D      | Amber | l  | l  |
|         | isplay | isplay | ~7,8,9~   | isplay | REV   | ig | ig |
|         |        |        |           |        | on    | ht | ht |
|         |        |        |           |        | Eng   |    |    |
|         |        |        |           |        | Di    |    |    |
|         |        |        |           |        | splay |    |    |
|         |        |        |           |        |       |    |    |
|         |        |        |           |        | 1     |    |    |
|         |        |        |           |        | /2/3/ |    |    |
|         |        |        |           |        | 4/500 |    |    |
|         |        |        |           |        |       |    |    |
|         |        |        |           |        | N/A   |    |    |
+---------+--------+--------+-----------+--------+-------+----+----+
| Reverse | no     | no     | no        | no     | no    | no | no |
| Armed   |        |        |           |        |       |    |    |
+---------+--------+--------+-----------+--------+-------+----+----+
| Tire    | Tire   | Tire   | no        | Tire   | no    | no | no |
| Fail    | Pr     | Press  |           | Pr     |       |    |    |
|         | essure |        |           | essure |       |    |    |
|         |        | Ad     |           |        |       |    |    |
|         | C      | visory |           | Op     |       |    |    |
|         | aution | M      |           | tional |       |    |    |
|         | M      | essage |           |        |       |    |    |
|         | essage |        |           | Ad     |       |    |    |
|         |        |        |           | visory |       |    |    |
|         | f-\>k  |        |           | M      |       |    |    |
|         |        |        |           | essage |       |    |    |
+---------+--------+--------+-----------+--------+-------+----+----+

NOTES: 1.No indication. 2.Engine FAIL illuminates, Bleed air \<105 psi.
3.Red line indication only. 4.Red line indication only, no over speed
governor to limit RPM. 5.Some 727\'s and 737-100/-200 have EGT
indicators with internal amber over temp light. 6.Option only. Also
called AVM (Airborne Vibration Monitor). Monitored at the Flight
Engineer (FE) panel, indication only. FE has a test switch to verify the
operational integrity of the engine vibration system. 7. Amber light for
REV operating, blue for reverser in transit. 8. Amber light for reverser
unlock, blue for reverser in transit. 9. Amber light only - steady for
stowed and full reverse position, flashing while in transit.

![](media/image23.png){width="8.933333333333334in"
height="5.9319444444444445in"}

**ENGINE FAILURE INDICATIONS FOR DAC AIRCRAFT**

**Warning / Caution Message MD-11 DC-10 MD-95 MD-90 MD-80 DC-9**

**(Inhibited)**

Sub Idle 2 No 2 2 No No

(a-\>e; h-\>j) (TBD) (a-\>e, i)

1

Surge-bang (Option) No 1 2 No No

(a-\>e; h-\>j) (TBD) (a-\>e, h, i)

Engine Fail N1 Diff N1 Diff No No No No

(e-\>j) (Flt Rev Thrust)

RPM over red line 2 No 2 2 No No

(d, e, i) (TBD) (d, e, i)

EGT over red line 2 Small light 2 2 No No

(d, e, i) on gage (TBD) (d, e, i)

1

EVM HI (Option) 1 TBD 1 No No

(a-\>f, h, i) (Option) (TBD) (a-\>f, h, i)

ReverseThrust Eng Display Eng Display Eng Display Eng Display Eng
Display Eng Display

(none) (TBD) (none)

Reverse Unlock Eng Display Eng Display Eng Display Eng Display Eng
Display Eng Display

(none) (TBD) (none)

GE only

Reverse Armed 1 Some GE 2 2 No No

d, e, h, i (TBD) (d, e, h, i)

Tire Fail 2 Aural No TBD No No No

(no inhib)

**APPENDIX 10 - Fleet Survey of Engine Failure Indications - Turboprop**

**APPENDIX 10**

**Fleet Survey of Engine Failure Indications - Turboprop**

<table style="width:100%;">
<colgroup>
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 9%" />
<col style="width: 0%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 16%" />
<col style="width: 0%" />
<col style="width: 17%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td><p><strong>A/C</strong></p>
<p><strong>Manufacturer</strong></p></td>
<td colspan="2"><strong>Aircraft Model</strong></td>
<td colspan="2"><strong>Engine Model</strong></td>
<td colspan="2"><strong>Passengers</strong></td>
<td colspan="2"><strong>Engine Failure Indication</strong></td>
<td colspan="2"><strong>Triggering Mechanism</strong></td>
<td colspan="2"><strong>Simulator</strong></td>
<td colspan="2"><strong>Autofeather System With Uptrim</strong></td>
<td colspan="2"><strong>Auto Relight or Auto Ignition</strong></td>
<td colspan="2"><strong>Low Pitch / Beta Light</strong></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">AI(R)</td>
<td colspan="2">ATR 42-300</td>
<td colspan="2">2 X P&amp;WC PW120</td>
<td colspan="2">50</td>
<td colspan="2">No dedicated "Engine out" light or look-up panel light.
Decaying parameters, A/C system alerts, &amp; A/C yaw.</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">No</td>
<td>Yes</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2">ATR 42-320</td>
<td colspan="2">2 X P&amp;WC PW121</td>
<td colspan="2">50</td>
<td colspan="2">Same as above</td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td colspan="2">No, except for mod kit</td>
<td>Yes</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2">ATR 42-500</td>
<td colspan="2">2 X P&amp;WC PW127E</td>
<td colspan="2">50</td>
<td colspan="2">Same as above</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td>Yes</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2">ATR 72</td>
<td colspan="2">2 X P&amp;WC PW124B</td>
<td colspan="2">70</td>
<td colspan="2">Same as above</td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td>Yes</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2">ATR 72-200</td>
<td colspan="2">2 X P&amp;WC PW127</td>
<td colspan="2">74</td>
<td colspan="2">Same as above</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td>Yes</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2">ATR 72-210</td>
<td colspan="2">2 X P&amp;WC PW127F</td>
<td colspan="2">74</td>
<td colspan="2">Same as above</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td>Yes</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2">Jetstream Super 31</td>
<td colspan="2">2 X Garrett TPE331-12UAR</td>
<td colspan="2">19+2</td>
<td colspan="2">No dedicated "Engine out" light. Decaying parameters,
negative torque, A/C system alerts, &amp; A/C yaw.</td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">NTS with uptrim</td>
<td colspan="2">No, yes for -32</td>
<td>Yes</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2">Jetstream 41</td>
<td colspan="2">2 X Garrett TPE331-14GR/HR</td>
<td colspan="2">29+3</td>
<td colspan="2">Same as above</td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td>Yes</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2">Jetstream 61</td>
<td colspan="2">2 X P&amp;WC PW127D</td>
<td colspan="2">70+4</td>
<td colspan="2">No dedicated "Engine out" light. Decaying parameters,
A/C systems alert &amp; A/C yaw.</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td>Yes</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2">ATP</td>
<td colspan="2">2 X P&amp;WC PW126A</td>
<td colspan="2">72+2</td>
<td colspan="2">Same as above</td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td>Yes</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Bombardier</td>
<td colspan="2">de Havilland DHC-6 Twin Otter</td>
<td colspan="2">2 X P&amp;WC PT6A-20/27</td>
<td colspan="2">19</td>
<td colspan="2">No engine light or look-up panel light. Decaying
parameters &amp; A/C yaw.</td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">Yes, but no uptrim</td>
<td colspan="2"></td>
<td>Yes</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2">de Havilland Dash 7-150</td>
<td colspan="2">4 X P&amp;WC PT6A-50</td>
<td colspan="2">50</td>
<td colspan="2">Glare panel amber "Engine Fail" light</td>
<td colspan="2">Torque pressure falls below 30 psi.</td>
<td colspan="2">Yes</td>
<td colspan="2">Yes, but no uptrim</td>
<td colspan="2"></td>
<td>Yes</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2">de Havilland Dash 8-100</td>
<td colspan="2">2 X P&amp;WC PW120A</td>
<td colspan="2">39</td>
<td colspan="2">No dedicated "Engine out" indication. Decaying
parameters, A/C systems alert, &amp; A/C yaw.</td>
<td colspan="2">Low oil pressure triggers when less than 52 psi</td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td colspan="2">No</td>
<td>Yes</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2">de Havilland Dash 8-200</td>
<td colspan="2">2 X P&amp;WC PW123C</td>
<td colspan="2">39</td>
<td colspan="2">Same as above</td>
<td colspan="2">Same as above</td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td colspan="2">No</td>
<td>Yes</td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 9%" />
<col style="width: 6%" />
<col style="width: 16%" />
<col style="width: 17%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td><p><strong>A/C</strong></p>
<p><strong>Manufacturer</strong></p></td>
<td><strong>Aircraft Model</strong></td>
<td><strong>Engine Model</strong></td>
<td><strong>Passengers</strong></td>
<td><strong>Engine Failure Indication</strong></td>
<td><strong>Triggering Mechanism</strong></td>
<td><strong>Simulator</strong></td>
<td><strong>Autofeather System With Uptrim</strong></td>
<td><strong>Auto Relight or Auto Ignition</strong></td>
<td><strong>Low Pitch / Beta Light</strong></td>
</tr>
<tr class="even">
<td></td>
<td>de Havilland Dash 8-300</td>
<td>2 X P&amp;WC PW123B</td>
<td>60</td>
<td>Same as above</td>
<td>Same as above</td>
<td>Yes</td>
<td>Yes</td>
<td>No</td>
<td>Yes</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>CASA</td>
<td>C212-300 Aviocar</td>
<td>2 X Garrett TPE331-10R</td>
<td>26</td>
<td>No dedicated "Engine out" light. Decaying parameters, system alerts
&amp; A/C yaw.</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>CASA/IPTN</td>
<td>CN-235-100</td>
<td>2 X GE CT7-9C</td>
<td>44/45</td>
<td>Same as above</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Convair</td>
<td>580</td>
<td>2 X Allison 501-D13</td>
<td></td>
<td>No dedicated "Engine out" light</td>
<td></td>
<td></td>
<td>No, light in CLA handle</td>
<td>No</td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td>640</td>
<td>2 X RR Dart</td>
<td></td>
<td>"Low torque light"</td>
<td></td>
<td></td>
<td>No, light in CLA handle</td>
<td>No</td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Fairchild Dornier (Sweringen)</td>
<td>228-212</td>
<td>2 X Garrett TPE331-5A-252D</td>
<td>19</td>
<td>No dedicated "Engine out" light. A/C yaw, torque, and EGT are prime
indications. LOP and gen.</td>
<td>Torque goes negative, low EGT, oil pressure below 40 psi, generator
drops off at 62% Ng.</td>
<td></td>
<td>NTS, no uptrim</td>
<td>Yes</td>
<td>Yes</td>
</tr>
<tr class="even">
<td></td>
<td>328</td>
<td>2 X P&amp;WC PW119B</td>
<td>30</td>
<td>No dedicated "Engine out' light. Decaying parameters, system alerts,
&amp; A/C yaw.</td>
<td></td>
<td>Yes</td>
<td>Yes (B &amp; C models, no uptrim)</td>
<td>Yes</td>
<td>Yes</td>
</tr>
<tr class="odd">
<td></td>
<td>Metro 23-12/III</td>
<td>2 X Garrett TPE331-12UAR</td>
<td>19</td>
<td>Aircraft yaw followed by amber SRL light, low oil pressure,
hydraulic pressure and generator off-line</td>
<td>Single Red Line (SRL) triggers when engine is below 80% RPM, low oil
pressure below 40 psi, low hydraulic pressure below 1250 psi.</td>
<td>Yes</td>
<td>NTS, no uptrim</td>
<td>Yes</td>
<td>Yes</td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Embraer</td>
<td>EMB-110P1-41 Bandeirante</td>
<td>2 X P&amp;WC PT6A-34</td>
<td>19</td>
<td>No dedicated "Engine out" light. Decaying parameters, A/C systems
alerts, &amp; A/C yaw.</td>
<td></td>
<td></td>
<td>No</td>
<td>No</td>
<td>Yes</td>
</tr>
<tr class="even">
<td></td>
<td>EMB 120 Brasilia</td>
<td>2 X P&amp;WC PW118</td>
<td>30</td>
<td>Same as above</td>
<td></td>
<td>Yes</td>
<td>Yes</td>
<td>No</td>
<td>Yes</td>
</tr>
<tr class="odd">
<td></td>
<td>EMB 120ER Advanced Brasilia</td>
<td>2 X P&amp;WC PW118A</td>
<td>30+3</td>
<td>Same as above</td>
<td></td>
<td></td>
<td>Yes</td>
<td>No</td>
<td>Yes</td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Fokker Aircraft</td>
<td>Fokker 50</td>
<td>2 X P&amp;WC PW125B</td>
<td>58</td>
<td>"L ENG OUT" or "R ENG OUT" lights on the central annunciator panel
along with Master Caution</td>
<td>Nh less than 60% sends a signal to the Integrated Alert System and
Auto-ignition.</td>
<td></td>
<td>Yes</td>
<td>Yes</td>
<td>Yes</td>
</tr>
</tbody>
</table>

<table style="width:100%;">
<colgroup>
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 9%" />
<col style="width: 0%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 16%" />
<col style="width: 0%" />
<col style="width: 17%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td><p><strong>A/C</strong></p>
<p><strong>Manufacturer</strong></p></td>
<td colspan="2"><strong>Aircraft Model</strong></td>
<td colspan="2"><strong>Engine Model</strong></td>
<td colspan="2"><strong>Passengers</strong></td>
<td colspan="2"><strong>Engine Failure Indication</strong></td>
<td colspan="2"><strong>Triggering Mechanism</strong></td>
<td colspan="2"><strong>Simulator</strong></td>
<td colspan="2"><strong>Autofeather System With Uptrim</strong></td>
<td colspan="2"><strong>Auto Relight or Auto Ignition</strong></td>
<td colspan="2"><strong>Low Pitch / Beta Light</strong></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2">Fokker 50</td>
<td colspan="2">2 X P&amp;WC PW127B</td>
<td colspan="2">58</td>
<td colspan="2">"L ENG OUT" or "R ENG OUT" lights on the central
annunciator panel along with Master Caution</td>
<td colspan="2">Nh less than 60% sends a signal to the integrated Alert
System and Auto-ignition.</td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td>Yes</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2">Fokker F27</td>
<td colspan="2">2 X RR Dart 6/7</td>
<td colspan="2">48</td>
<td colspan="2">"Low Torque Light"</td>
<td colspan="2">Torque less than 50 Psi</td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td colspan="2">No</td>
<td>Yes</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">HAMC</td>
<td colspan="2">Y-12-11</td>
<td colspan="2">2 X P&amp;WC PT6A-27</td>
<td colspan="2">17+2</td>
<td colspan="2">Cockpit gages are the only indication. No special
lights.</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2">No</td>
<td colspan="2">No</td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Lockheed</td>
<td colspan="2">Electra</td>
<td colspan="2">4 X Allison 501-D13</td>
<td colspan="2"></td>
<td colspan="2">No dedicated "Engine out" light</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2">No</td>
<td colspan="2">No</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2">L100</td>
<td colspan="2">4 X Allison 501-D22A</td>
<td colspan="2"></td>
<td colspan="2">No dedicated "Engine out" light.</td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">No</td>
<td colspan="2">No</td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Raytheon Aircraft</td>
<td colspan="2">Beech 1900C</td>
<td colspan="2">2 X P&amp;WC PT6A-65B</td>
<td colspan="2">19+2</td>
<td colspan="2">No dedicated "Engine out" light. Decaying parameters and
A/C yaw.</td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">Yes, but no uptrim</td>
<td colspan="2">Yes</td>
<td>No</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2">Beech 1900D</td>
<td colspan="2">2 X P&amp;WC PT6A-67D</td>
<td colspan="2">19+1/2</td>
<td colspan="2">Same as above</td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">Yes, but no uptrim</td>
<td colspan="2">Yes</td>
<td>No</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">SAAB</td>
<td colspan="2">340B</td>
<td colspan="2">2 X GE CT7-9B</td>
<td colspan="2">37</td>
<td colspan="2">No dedicated "Engine out" light. Decaying parameters,
system alerts &amp; A/C yaw.</td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">Auto corsen</td>
<td colspan="2">Yes</td>
<td>Yes</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2">2000</td>
<td colspan="2">2 X Allison AE2100A</td>
<td colspan="2">50(58)</td>
<td colspan="2">Red EICAS "ENG OUT" message and Master Warning
Light</td>
<td colspan="2">Gas generator speed decreases below 56% triggers the
FADEC to check appropriate signals.</td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td>Yes</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">Shorts Brothers</td>
<td colspan="2">330</td>
<td colspan="2">2 X P&amp;WC PT6A-45R</td>
<td colspan="2">30</td>
<td colspan="2">No dedicated "Engine out" light. Decaying parameters,
system alerts &amp; A/C yaw.</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2">360</td>
<td colspan="2">2 X P&amp;WC PT6A-67R</td>
<td colspan="2">39</td>
<td colspan="2">Same as above</td>
<td colspan="2"></td>
<td colspan="2">Yes</td>
<td colspan="2">Yes</td>
<td colspan="2"></td>
<td></td>
</tr>
</tbody>
</table>

**APPENDIX - 11 Survey of Simulators**

**APPENDIX - 11 Survey of Simulators**

**Turbofan Aircraft Simulator Worldwide Census**

+-----------------------+-----------------------+----------------------+
| **AIRPLANE**          | **Number of           | **FAA Certified      |
|                       | Simulators\***        | Simulators**         |
| **MODEL**             |                       |                      |
+=======================+=======================+======================+
| A300                  | 21                    | 5                    |
+-----------------------+-----------------------+----------------------+
| A300-600              | 14                    | 2                    |
+-----------------------+-----------------------+----------------------+
| A310                  | 17                    | 7                    |
+-----------------------+-----------------------+----------------------+
| A320                  | 35                    | 14                   |
+-----------------------+-----------------------+----------------------+
| A330                  | 9                     | 1                    |
+-----------------------+-----------------------+----------------------+
| A340                  | 12                    | 3                    |
+-----------------------+-----------------------+----------------------+
| Astra                 | 1                     | \--                  |
+-----------------------+-----------------------+----------------------+
| Avro RJ (all)         | 11                    | \--                  |
+-----------------------+-----------------------+----------------------+
| B707                  | 15                    | 2                    |
+-----------------------+-----------------------+----------------------+
| B727                  | 70                    | 45                   |
+-----------------------+-----------------------+----------------------+
| B737                  | 117                   | 50                   |
+-----------------------+-----------------------+----------------------+
| B747                  | 91                    | 19                   |
+-----------------------+-----------------------+----------------------+
| B757                  | 31                    | 23                   |
+-----------------------+-----------------------+----------------------+
| B767                  | 39                    | 17                   |
+-----------------------+-----------------------+----------------------+
| B777                  | 13                    | 7                    |
+-----------------------+-----------------------+----------------------+
| BAC 1-11              | 6                     | 1                    |
+-----------------------+-----------------------+----------------------+
| BAe 146               | 5                     | 3                    |
+-----------------------+-----------------------+----------------------+
| Beechjet (BE-400)     | 4                     | 1                    |
+-----------------------+-----------------------+----------------------+
| Caravelle             | 1                     | \--                  |
+-----------------------+-----------------------+----------------------+
| Challenger (all)      | 13                    | 13                   |
+-----------------------+-----------------------+----------------------+
| Citation (all)        | 28                    | 24                   |
+-----------------------+-----------------------+----------------------+
| Concorde              | 2                     | \--                  |
+-----------------------+-----------------------+----------------------+
| DC-8                  | 14                    | 9                    |
+-----------------------+-----------------------+----------------------+
| DC-9                  | 32                    | 29                   |
+-----------------------+-----------------------+----------------------+
| DC-10                 | 23                    | 11                   |
+-----------------------+-----------------------+----------------------+
| F28                   | 8                     | 8                    |
+-----------------------+-----------------------+----------------------+
| F70/100               | 10                    | \--                  |
+-----------------------+-----------------------+----------------------+
| Falcon (all)          | 16                    | 16                   |
+-----------------------+-----------------------+----------------------+
| Gulfstream (all)      | 16                    | 10                   |
+-----------------------+-----------------------+----------------------+
| Il-86/96              | 2                     | \--                  |
+-----------------------+-----------------------+----------------------+
| Jetstar               | 1                     | 1                    |
+-----------------------+-----------------------+----------------------+
| L-1011                | 15                    | 6                    |
+-----------------------+-----------------------+----------------------+
| Learjet               | 18                    | 17                   |
+-----------------------+-----------------------+----------------------+
| MD-11                 | 14                    | 11                   |
+-----------------------+-----------------------+----------------------+
| MD-80+                | 39                    | 8                    |
+-----------------------+-----------------------+----------------------+
| MD-90                 | 4                     | 4                    |
+-----------------------+-----------------------+----------------------+
| MU-2/300              | 2                     | 1                    |
+-----------------------+-----------------------+----------------------+
| NA-265                | 3                     | 3                    |
+-----------------------+-----------------------+----------------------+
| Premier 1             | 1                     | \--                  |
+-----------------------+-----------------------+----------------------+
| Sabreliner            | 3                     | \--                  |
+-----------------------+-----------------------+----------------------+
| Tu-204                | 2                     | \--                  |
+-----------------------+-----------------------+----------------------+
| Westwind I/II         | 3                     | 2                    |
+-----------------------+-----------------------+----------------------+
| **TOTAL TURBOFAN      | **781**               | **373**              |
| SIMULATORS**          |                       |                      |
+-----------------------+-----------------------+----------------------+

**Turboprop Aircraft Simulator Worldwide Census**

+-----------------------+----------------------+-----------------------+
| **AIRPLANE**          | **Number of          | **FAA Certified       |
|                       | Simulators\***       | Simulators**          |
| **MODEL**             |                      |                       |
+=======================+======================+=======================+
| ATR42/72              | 9                    | 7                     |
+-----------------------+----------------------+-----------------------+
| BAe ATP               | 1                    | 1                     |
+-----------------------+----------------------+-----------------------+
| BAe 125               | 7                    | 7                     |
+-----------------------+----------------------+-----------------------+
| BAe HS 748            | 1                    | \--                   |
+-----------------------+----------------------+-----------------------+
| Beech 1900A/B/C/D     | 6                    | 4                     |
+-----------------------+----------------------+-----------------------+
| Beech Bonanza         | 6                    | 6                     |
+-----------------------+----------------------+-----------------------+
| Beech Baron           | 5                    | 2                     |
+-----------------------+----------------------+-----------------------+
| Cessna 172/182        | 1                    | \--                   |
+-----------------------+----------------------+-----------------------+
| Cessna 300/400        | 4                    | 4                     |
+-----------------------+----------------------+-----------------------+
| Cessna Caravan        | 2                    | \--                   |
+-----------------------+----------------------+-----------------------+
| Cessna Centurion      | 1                    | \--                   |
+-----------------------+----------------------+-----------------------+
| Cessna Conquest       | 3                    | \--                   |
+-----------------------+----------------------+-----------------------+
| Commander             | 1                    | \--                   |
+-----------------------+----------------------+-----------------------+
| Convair 440           | 1                    | \--                   |
+-----------------------+----------------------+-----------------------+
| CN325 (Casa)          | 2                    | \--                   |
+-----------------------+----------------------+-----------------------+
| Dash 6                | 1                    | 1                     |
+-----------------------+----------------------+-----------------------+
| Dash 7                | 1                    | 1                     |
+-----------------------+----------------------+-----------------------+
| Dash 8                | 8                    | 8                     |
+-----------------------+----------------------+-----------------------+
| Do-228/328            | 3                    | 2                     |
+-----------------------+----------------------+-----------------------+
| EMB-110/120           | 10                   | 6                     |
+-----------------------+----------------------+-----------------------+
| F27                   | 2                    | \--                   |
+-----------------------+----------------------+-----------------------+
| F50                   | 3                    | \--                   |
+-----------------------+----------------------+-----------------------+
| G-159                 | 2                    | 2                     |
+-----------------------+----------------------+-----------------------+
| Hawker 700/800        | 1                    | \--                   |
+-----------------------+----------------------+-----------------------+
| Jetstream (all)       | 9                    | 9                     |
+-----------------------+----------------------+-----------------------+
| King Air (incl. C12,  | 28                   | \--                   |
| U-21)                 |                      |                       |
+-----------------------+----------------------+-----------------------+
| L-382                 | 1                    | 1                     |
+-----------------------+----------------------+-----------------------+
| Metro (all)           | 7                    | 1                     |
+-----------------------+----------------------+-----------------------+
| Mooney (252)          | 1                    | \--                   |
+-----------------------+----------------------+-----------------------+
| Pilatus PC-12         | 1                    | \--                   |
+-----------------------+----------------------+-----------------------+
| Piper Cheyenne (all)  | 18                   | \--                   |
+-----------------------+----------------------+-----------------------+
| Piper Malibu          | 1                    | \--                   |
+-----------------------+----------------------+-----------------------+
| Piper Navajo          | 2                    | \--                   |
| Chieftain             |                      |                       |
+-----------------------+----------------------+-----------------------+
| Piper Seneca          | 1                    | \--                   |
+-----------------------+----------------------+-----------------------+
| SA-226/227            | 6                    | 6                     |
+-----------------------+----------------------+-----------------------+
| Saab 340 (all)        | 12                   | 12                    |
+-----------------------+----------------------+-----------------------+
| Saab 2000             | 2                    | 1                     |
+-----------------------+----------------------+-----------------------+
| Shorts 360            | 1                    | 1                     |
+-----------------------+----------------------+-----------------------+
| Viscount              | 2                    | \--                   |
+-----------------------+----------------------+-----------------------+
| Xian Y7-100           | 1                    | \--                   |
+-----------------------+----------------------+-----------------------+
| **TOTAL TURBOPROP     | **174**              | **86**                |
| SIMULATORS**          |                      |                       |
+-----------------------+----------------------+-----------------------+

**Rotorcraft Simulator Worldwide Census**

+-----------------------+----------------------+-----------------------+
| **AIRPLANE**          | **Number of          | **FAA Certified       |
|                       | Simulators\***       | Simulators**          |
| **MODEL**             |                      |                       |
+=======================+======================+=======================+
| AS332/SA330           | 2                    | \--                   |
+-----------------------+----------------------+-----------------------+
| Bell 200 series (all) | 1                    | 2                     |
+-----------------------+----------------------+-----------------------+
| Bell 400 series (all) | 2                    | 1                     |
+-----------------------+----------------------+-----------------------+
| Cheyenne (all)        | 18                   | \--                   |
+-----------------------+----------------------+-----------------------+
| Chinook               | 1                    | \--                   |
+-----------------------+----------------------+-----------------------+
| L3-DGAC               | 1                    | \--                   |
+-----------------------+----------------------+-----------------------+
| S-61N                 | 2                    | \--                   |
+-----------------------+----------------------+-----------------------+
| S-76                  | 3                    | 1                     |
+-----------------------+----------------------+-----------------------+
| **TOTAL ROTORCRAFT    | **30**               | **4**                 |
| SIMULATORS**          |                      |                       |
+-----------------------+----------------------+-----------------------+

**APPENDIX - 12 Simulator Malfunctions For Turbofan**

**APPENDIX - 12 Simulator Malfunctions For Turbofan**

**[TURBOFAN /TURBOFAN POWERED AIRCRAFT]{.underline}**

**MALFUNCTION AND FAILURE CONDITIONS THAT FLIGHT CREWS NEED TO**
**CONSIDER (BE KNOWLEDGEABLE ABOUT)**

**[SAFETY SIGNIFICANT MODES]{.underline}**

**Single Engine Flameout** - Single engine flameout will result in
overall airplane thrust loss, thrust asymmetry and resulting aircraft
yaw proportional to the thrust difference and moment arm (engine
installation position relative to airplane centerline). It will cause
loss of engine provided services from the flamed-out engine, i.e.,
generator trip to 'off'. The failure condition may not produce a change
of noise cue but may result in an lessening of the overall engine noise
level. Fuel flow will drop to the minimum level (not zero) and the rotor
speeds will drop to levels lower than idle while EGT will also drop. The
aircraft yaw, indications of electrical power loss, and low and
decreasing levels of rotor speed, pressure ratio, exhaust gas
temperature, and fuel flow are key cues which should lead to
recognition. (Frequency of Single engine flameout is between 1 per
10,000 and 1 per 100,000 airplane flights.)

**Multiple Engine Flameouts** - Multiple (two or more) engine flameouts
will result in a relatively larger overall thrust loss and may or may
not produce thrust asymmetry and resulting airplane yaw. The flameouts
of all engines will produce loss of engine-provided services, i.e.,
electrical power. The loss of engine noise, decreasing engine
parameters\*, generator trips to off, and loss of pressurization are all
cues. Loss of aircraft speed, in all modes but descent, will also be a
cue requiring the airplane to be pitched over to retain speed. All of
the engine parameters will be decreasing. The majority of total power
loss events will be as the result of fuel management error or encounter
with environmental factors like severe rain, hail, volcanic ash, or
icing. While the order of flameout may appear random, they are
essentially simultaneous. (Frequency of multiple engine power loss will
depend on the number of engines installed, but will range from 1 per
100,000 to 1 per million aircraft flights). The cues should lead flight
crews to confirm that fuel is flowing to all engines and to immediately
attempt to inflight re-start the engines. Sequential engine flameouts,
those not due to a common cause, are much less likely to occur (less
than 1 per 100 million aircraft flights and slightly more likely on four
and three engine aircraft than on twin engine aircraft).

**Engine Seizure** - Inflight engine rotor seizure is a rare event and
requires that significant internal damage has occurred. (Engine rotor
seizure events reported as found on the ground, after flight, are not
proof that the rotor stopped turning while inflight.) Seizure is sudden
stoppage of the rotation of any of the engine rotors. The failure will
occur very quickly and the affected rotor RPM will drop to zero,
significant airplane/engine vibration and EGT will rise above limits (at
least initially). Thrust loss and resulting yaw will be immediate cues.

If the Fan rotor seizes (likelihood between 1 per 10 million and 1 per
100 million aircraft flights), there will be mild buffet and some
incrementally increased drag over the drag level that occurs for a
windmilling engine (about 25% increase of normal windmilling engine
drag). The aircraft drag for a locked fan rotor will vary with flight
speed, and the required rudder deflection will be slightly increased but
there will be no difficulty in controlling the airplane (based on
service experience). There will be a slight decrease, less than 5%, in
airplane range performance. The high pressure rotor will continue to
rotate but at a reduced speed from normal windmilling.

If the high pressure rotor seizes, immediate thrust loss will occur, the
high rotor speed will drop to zero, and no services will be provided for
the locked up engine. EGT will rise initially above redline. Windmilling
drag, however, will not be noticeably affected.

**Engine Stall / Surge** - Engine surge at high power settings will
cause a loud noise (equivalent to cannon fire at a distance or shotgun
blasts at 10 feet from your ear) which will have one or more bangs or
reports. There will be yaw-coupled aircraft vibration. EGT may increase
towards redline but is no longer a key cue since surge recovery logic in
modern controls may have restabilized the engine airflow. Engine spool
speeds will fluctuate while the engine is surging and will stabilize
upon recovery. The key cue is "loud noise" and yaw vibration coupling.
Which engine has surged may not be detectable from the flight deck
parameter displays. Severe engine failures will usually be announced by
an engine surge and be immediately followed by a permanent thrust loss
and rising EGT. Surge by itself, breakdown in engine airflow, will
usually self-recover so that the pilot is left with the loud noise along
with yaw-coupled vibration followed by "situation normal". Over reaction
to the loud noise and yaw-coupled vibration should be avoided. Look for
other cues including continuing thrust oscillations or permanent thrust
loss or rising EGT prior to taking action. (An engine surging will be
experienced between 1 per 10,000 and 1 per 100,000 airplane flights.)

**Engine Thrust Runaway** **(fuel control failure mode)** - Engine fuel
control failure modes that cause engine thrust runaway will cause engine
thrust to increase with fuel flow going to the maximum level. All
related engine parameters will be increasing, and some may exceed
limits. Asymmetric thrust and the resulting yaw may be experienced with
the level of yaw dependent on flight speed and degree of thrust
difference between engines on the airplane. The normal response of
reducing thrust through power lever reduction may not be occur. The crew
may need to shut the engine down with the fuel cut off switch/lever or
fire handle. (This engine fuel control system failure condition occurs
about 1 per 10 million aircraft flights.)

**Engine Thrust Failed Fixed (fuel control failure mode) -** Engine
thrust will not respond to movement of the throttle or may respond in
one direction only. (This engine fuel control system failure condition
occurs about 1 per 10 million aircraft flights).

**Engine Separation** - When an engine separation occurs, thrust loss,
yaw and coupled roll (for wing mounted engines) will result, reflecting
the loss of powerplant weight as well as thrust. Engine parameter flight
deck indications will indicate loss of signal (wires will have
separated) and electrical, hydraulic and pneumatic system performance
will reflect loss of supply. Engine separations can occur on aft body
mounted engine airplanes (i.e.727) without significant audio or tactile
cues that they have separated. Separation of engines while running
normally is likely to cause severe consequences while separation at low
(flight idle or below) forward thrust are more likely to be benign.
(Frequency of occurrence between 1 in 10 million and 1 in 100 million
aircraft flights) .

**Severe Damage -** Severe engine damage events will result in loss of
thrust, yaw due to thrust asymmetry, vibration, loud noise, engine
parameters of rotor speed and pressure ratio fall to windmilling levels
or near zero, EGT rises to redline, fuel flow decreases. EGT may then
fall indicating flameout. A fire warning may occur on some but not all
events. Severe engine damage events come in several types**:**

1.  **Engine Severe Damage - 1:** N1 and N2 fall rapidly to below idle
    levels, fuel flow and EGT rise into red zone with no response to
    throttle, and vibration may continue due to out of balance loads.

```{=html}
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```
2.  **Engine Severe Damage -2:** Loud noise**,** N1 and N2 fall rapidly
    to below idle levels, fuel flow drops, EGT rise into red zone with
    no response to throttle, and fire warning goes off - no effect for
    initial fire bottle discharge.

(Severe engine failures will occur at a rate between 1 and 5 per million
aircraft flights.)

**Onset of Severe Engine Vibration -** The onset of engine vibration
will be detected by tactile cues or by annunciations, and indicates an
internal engine failure**.** A core engine blade failure will be
accompanied by engine surge with rotor speed disagreements with other
engines and an EGT increase may occur. Thrust loss may also occur and
may vary from non-detectable to significant yaw. A fan blade failure
will be accompanied with an engine surge (loud noise), vibration and
perhaps odor in the cabin. The vibration may continue after engine
shutdown. (Engine vibration associated with failures will occur between
5 and 10 per million aircraft flights.)

**Engine Thrust Reverser Deployment** (Inadvertent) - Inadvertent thrust
reverser deployment on older aircraft types (non high bypass ratio
engine powered) have demonstrated that the aircraft can be controlled
with thrust reverser deployed at low engine power. "Rev " annunciation
display with immediate reduction of power to idle coupled with severe
yaw (depending on engine installation and distance from airplane
centerline) will serve as cues. (Frequency of occurrence is between 1
per million and 1 per 10 million aircraft flights.) Inadvertent thrust
reverser deployment on some high bypass ratio engine powered airplanes
is considered to be a hazardous or worse failure condition.
Retrospective design changes and new designs have been made to preclude
the occurrence of inadvertent thrust reverser deployment in flight. (No
training is required or should be required for an extremely improbable
and uncontrollable failure condition.)

**Power Lever Failure** (mechanical systems) - Power lever failure comes
in several varieties as follows:

a.  Power lever can not be moved - engine operating normally;

b.  Power lever movers but no engine response, and

c.  Power lever mechanism fails causing engine to accelerate or
    decelerate and also not respond to power lever motion.

Crew may need to use the fuel shutoff switch/lever or fire handle to
shut engine down.

(Power lever failures occur at a 1 per 10 million to 1 per 100 million
aircraft flights.)

**Engine Idle Disagree - Not a safety significant failure mode.**

**Fire and Overheat Warning -** Fire and Overheats are annunciated and
warned as appropriate. Fire may or may not be a part of severe engine
failures. (Inflight fires occur about 1 per million aircraft flights.)

**Fuel Leakage / Loss of Fuel Quantity** - Fracture of a fuel pipe or
component after the fuel flow measuring device on the engine will result
in a high fuel flow being indicated without equivalent or appropriate
response of the engine. The fuel flow will be high and fuel quantity in
the tank may confirm the differences. Cues are higher than normal fuel
flow for other engine parameter indications (N1, N2, EGT, EPR), fuel
flow higher than other engines, and/or sudden decreases in and loss of
fuel quantity. (Rate of fuel leakage/ loss of fuel quantity events are
about 1 per million aircraft flights.)

**Inflight Restarting -** Inflight restarting is a response to multiple
engine flameout or shutdown and is accomplished using windmill
restarting, quick restarting or power assisted restarting procedures
(either engine or APU). If a total power loss occurs, the flight crew
should attempt to restart engines in accordance with published inflight
restarting procedures. However, since the engine response will be
**SLOWER** than on the ground, pilots may be confused about the
successfulness of the restart. The engine will spool up very slowly, and
crew awareness of how engines will normally behave during an altitude
inflight restart is recommended. (Inflight engine restarting occurs at
the rate of 1 per 100,000 to 1 per 1 million aircraft flights based on
service history.)

**Engine Oil Indications:**

> **Oil Filter Delta Pressure -** annunciated cue may be due to blockage
> or instrumentation failure.
>
> **Loss of Oil Quantity -** annunciated cue may be due to leakage or
> high oil consumption.
>
> **High Oil Temperature -** annunciated cue may be due to leakage,
> trapped/blocked flow, or cooler failure.
>
> **Engine Low Oil Pressure -** annunciation cue of low oil pressure.

Engine Oil Indications should be ignored during the takeoff until safety
altitude is reached. Oil pressure loss can occur for a variety of
reasons: from leakage, seal failure or pump failure. The loss of oil
quantity or increase in oil temperature should be used to confirm oil
systems malfunctioning. Engine Low Oil in combination with increasing
vibration and fluctuating or dropping rotor speed is a much more
substantive "situation" an may indicate a the progression of a bearing
failure. (Engine oil indication will occur between 1 per 10,000 and 1
per 100,000 airplane flights. Precautionary shutdown may be indicated to
minimize engine repair cost.) Ignoring engine oil malfunction
indications for more than a few minutes may lead to severe engine
failure or seizure with the cues defined above.

**Engine Starting Malfunctions**. Engine starting malfunctions on the
ground will occur at a rate of about 5 to 10 per 10,000 airplane
flights.

> **Hot Start.** - Hot start is indicated by rapidly rising EGT at a
> faster rate than normal and is usually accompanied with a slower than
> normal rate of rotor speed increase).
>
> **Hung Start** - Rotor speed acceleration rate is very slow and may
> not continue to rise after starter cut out speed is achieved.
>
> **Inflight Restarting** ( See above.)

**APPENDIX 13 - Appendix C to Part 63 Flight Engineer Training Course
Requirements**

**APPENDIX 13 - Appendix C to Part 63 Flight Engineer Training Course
Requirements**

\(a\) Training course outline\--(1) Format. The ground course outline
and the

flight course outline are independent. Each must be contained in a
looseleaf

binder to include a table of contents. If an applicant desires approval
of

both a ground school course and a flight school course, they must be
combined

in one looseleaf binder that includes a separate table of contents for
each

course. Separate course outlines are required for each type of airplane.

\(2\) Ground course outline. (i) It is not mandatory that the subject

headings be arranged exactly as listed in this paragraph. Any
arrangement of

subjects is satisfactory if all the subject material listed here is
included

and at least the minimum programmed hours are assigned to each subject.
Each

general subject mt be broken down into detail showing the items to be

covered.

\(ii\) If any course operator desires to include additional subjects in
the

ground course curriculum, such as international law, flight hygiene, or

others that are not required, the hours allotted these additional
subjects

may not be included in the minimum programmed classroom hours.

\(iii\) The following subjects and classroom hours are the minimum
programmed

coverage for the initial approval of a ground training coue for flight

engineers. Subsequent to initial approval of a ground training course an

applicant may apply to the Administrator for a reduction in the
programmed

hours. Approval of a reduction in the approved programmed hours is based
on

improved training effectiveness due to improvements in methods, training

aids, quality of instruction, or any combination thereof.

Classroom

Subject hours

Federal Aviation Regulations 10

*To include the regulations of this chapter that apply to flight*

*engineers*

Theory of Flight and Aerodynamics 10

Airplane Familiarization 90

To include as appropriate:

Specifications.

Construction features.

Flight controls.

Hydraulic systems.

Pneumatic systems.

Electrical systems.

Anti-icing and de-icing systems.

Pressurization and air-conditioning systems.

Vacuum systems.

Pilot static systems.

Instrument systems.

Fuel and oil systems.

Emergency equipment.

Engine Familiarization 45

To include as appropriate:

Specifications.

Construction features.

Lubrication.

Ignition.

Carburetor and induction, supercharging and fuel control systems

Accessories.

Propellers.

Instrumentation.

Emergency equipment.

Normal Operations (Ground and Flight) 50

To include as appropriate:

Servicing methods and procedures.

Operation of all the airplane systems.

Operation of all the engine systems.

Loading and center of gravity computations.

Cruise control (normal, long range, maximum endurance)

Power and fuel computation.

Meteorology as applicable to engine operation

Emergency Operations 80

To include as appropriate:

Landing gear, brakes, flaps, speed brakes, and leading edge

devices

Pressurization and air-conditioning.

Portable fire extinguishers.

Fuselage fire and smoke control.

Loss of electrical power.

Engine fire control.

Engine shut-down and restart.

Oxygen.

Total (exclusive of final tests) 235

The above subjects, except Theory of Flight and Aerodynamics, and

Regulations must apply to the same type of airplane in which the student

flight engineer is to receive flight training.

\(3\) Flight Course Outline. (i) The flight training curriculum must
include

at least 10 hours of flight instruction in an airplane specified in Sec.

63.37(a). The flight time required for the practical test may not be
credited

as part of the required flight instruction.

\(ii\) All of the flight training must be given in the same type
airplane.

\(iii\) As appropriate to the airplane type, the following subjects must
be

taught in the flight training course:

Subject

NORMAL DUTIES, PROCEDURES AND OPERATIONS

*To include as appropriate:*

Airplane preflight.

Engine starting, power checks, pretakeoff, postlanding and shut-down

procedures.

Power control.

Temperature control.

Engine operation analysis.

Operation of all systems.

Fuel management.

Logbook entries.

Pressurization and air conditioning.

RECOGNITION AND CORRECTION OF IN-FLIGHT MALFUNCTIONS

*To include:*

Analysis of abnormal engine operation.

Analysis of abnormal operation of all systems.

Corrective action.

EMERGENCY OPERATIONS IN FLIGHT

*To include as appropriate:*

Engine fire control.

Fuselage fire control.

Smoke control.

Loss of power or pressure in each system.

Engine overspeed.

Fuel dumping.

Landing gear, spoilers, speed brakes, and flap extension and retraction.

Engine shut-down and restart.

Use of oxygen.

\(iv\) If the Administrator finds a simulator or flight engineer
training

device to accurately reproduce the design, function, and control

characteristics, as pertaining to the duties and responsibilities of a
flight

engineer on the type of airplane to be flown, the flight training time
may be

reduced by a ratio of 1 hour of flight time to 2 hours of airplane
simulator

time, or 3 hours of flight engineer training device time, as the case
may be,

subject to the following limitations:

\(a\) Except as provided in subdivision (b) of this paragraph, the
required

flight instruction time in an airplane may not be less than 5 hours.

\(b\) As to a flight engineer student holding at least a commercial
pilot

certificate with an instrument rating, airplane simulator or a
combination of

airplane simulator and flight engineer training device time may be
submitted

for up to all 10 hours of the required flight instruction time in an

airplane. However, not more than 15 hours of flight engineer training
device

time may be substituted for flight instruction time.

\(v\) To obtain credit for flight training time, airplane simulator
time, or

flight engineer training device time, the student must occupy the flight

engineer station and operate the controls.

\(b\) Classroom equipment. Classroom equipment should consist of systems
and

procedural training devices, satisfactory to the Administrator, that

duplicate the operation of the systems of the airplane in which the
student

is to receive his flight training.

\(c\) Contracts or agreements. (1) An approved flight engineer course

operator may contract with other persons to obtain suitable airplanes,

airplane simulators, or other training devices or equipment.

\(2\) An operator who is approved to conduct both the flight engineer
ground

course and the flight engineer flight course may contract with others to

conduct one course or the other in its entirety but may not contract
with

others to conduct both courses for the same airplane type.

\(3\) An operator who has approval to conduct a flight engineer ground
course

or flight course for a type of airplane, but not both courses, may not

contract with another person to conduct that course in whole or in part.

\(4\) An operator who contracts with another to conduct a flight
engineer

course may not authorize or permit the course to be conducted in whole
or in

part by a third person.

\(5\) In all cases, the course operator who is approved to operate the
course

is responsible for the nature and quality of the instruction given.

\(6\) A copy of each contract authorized under this paragraph must be

attached to each of the 3 copies of the course outline submitted for

approval.

\(d\) Instructors. (1) Only certificated flight engineers may give the
flight

instruction required by this Appendix in an airplane, simulator, or
flight

engineer training device.

\(2\) There must be a sufficient number of qualified instructors
available to

prevent an excess ratio of students to instructors.

\(e\) Revisions. (1) Requests for revisions of the course outlines,

facilities or equipment must follow the procedures for original approval
of

the course. Revisions must be submitted in such form that an entire page
or

pages of the approved outline can be removed and replaced by the
revisions.

\(2\) The list of instructors may be revised at any time without request
for

approval, if the requirements of paragraph (d) of this Appendix are

maintained.

\(f\) Ground school credits. (1) Credit may be granted a student in the

ground school course by the course operator for comparable previous
training

or experience that the student can show by written evidence: however,
the

course operator must still meet the quality of instruction as described
in

paragraph (h) of this Appendix.

\(2\) Before credit for previous training or experience may be given,
the

student must pass a test given by the course operator on the subject for

which the credit is to be given. The course operator shall incorporate

results of the test, the basis for credit allowance, and the hours
credited

as part of the student\'s records.

\(g\) Records and reports. (1) The course operator must maintain, for at

least two years after a student graduates, fails, or drops from a
course, a

record of the student\'s training, including a chronological log of the

subject course, attendance examinations, and grades.

\(2\) Except as provided in paragraph (3) of this section, the course

operator must submit to the Administrator, not later than January 31 of
each

year, a report for the previous calendar year\'s training, to include:

\(i\) Name, enrollment and graduation date of each student;

\(ii\) Ground school hours and grades of each student;

\(iii\) Flight, airplane simulator, flight engineer training device
hours,

and grades of each student; and

\(iv\) Names of students failed or dropped, together with their school
grades

and reasons for dropping.

\(3\) Upon request, the Administrator may waive the reporting
requirements of

paragraph (2) of this section for an approved flight engineer course
that is

part of an approved training course under Subpart N of Part 121 of this

chapter.

\(h\) Quality of instruction. (1) Approval of a ground course is
discontinued

whenever less than 80 percent of the students pass the FAA written test
on

the first attempt.

\(2\) Approval of a flight course is discontinued whenever less than 80

percent of the students pass the FAA practical test on the first
attempt.

\(3\) Notwithstanding paragraphs (1) and (2) of this section, approval
of a

ground or flight course may be continued when the Administrator finds\--

\(i\) That the failure rate was based on less than a representative
number of

students; or

\(ii\) That the course operator has taken satisfactory means to improve
the

effectiveness of the training.

\(i\) Time limitation. Each student must apply for the written test and
the

flight test within 90 days after completing the ground school course.

\(j\) Statement of course completion. (1) The course operator shall give
to

each student who successfully completes an approved flight engineer
ground

school training course, and passes the FAA written test, a statement of

successful completion of the course that indicates the date of training,
the

type of airplane on which the ground course training was based, and the

number of hours received in the ground school course.

\(2\) The course operator shall give each student who successfully
completes

an approved flight engineer flight course, and passed the FAA practical
test,

a statement of successful completion of the flight course that indicates
the

dates of the training, the type of airplane used in the flight course,
and

the number of hours received in the flight course.

\(3\) A course operator who is approved to conduct both the ground
course and

the flight course may include both courses in a single statement of
course

completion if the provisions of paragraphs (1) and (2) of this section
are

included.

\(4\) The requirements of this paragraph do not apply to an air carrier
or

commercial operator with an approved training course under Part 121 of
this

chapter providing the student receives a flight engineer certificate
upon

completion of that course.

\(k\) Inspections. Each course operator shall allow the Administrator at
any

time or place, to make any inspection necessary to ensure that the
quality

and effectiveness of the instruction are maintained at the required

standards.

\(l\) Change of ownership, name, or location. (1) Approval of a flight

engineer ground course or flight course is discontinued if the ownership
of

the course changes. The new owner must obtain a new approval by
following the

procedure prescribed for original approval.

\(2\) Approval of a flight engineer ground course or flight course does
not

terminate upon a change in the name of the course that is reported to
the

Administrator within 30 days. The Administrator issues a new letter of

approval, using the new name, upon receipt of notice within that time.

\(3\) Approval of a flight engineer ground course or flight course does
not

terminate upon a change in location of the course that is reported to
the

Administrator within 30 days. The Administrator issues a new letter of

approval, showing the new location, upon receipt of notice within that
time,

if he finds the new facilities to be adequate.

\(m\) Cancellation of approval. (1) Failure to meet or maintain any of
the

requirements of this Appendix for the approval of a flight engineer
ground

course or flight course is reason for cancellation of the approval.

\(2\) If a course operator desires to voluntarily terminate the course,
he

should notify the Administrator in writing and return the last letter of

approval.

\(n\) Duration. Except for a course operated as part of an approved
training

course under Subpart N of Part 121 of this chapter, the approval to
operate a

flight engineer ground course or flight course terminates 24 months
after the

last day of the month of issue.

\(o\) Renewal. (1) Renewal of approval to operate a flight engineer
ground

course or flight course is conditioned upon the course operator\'s
meeting the

requirements of this Appendix.

\(2\) Application for renewal may be made to the Administrator at any
time

after 60 days before the termination date.

\(p\) Course operator approvals. An applicant for approval of a flight

engineer ground course, or flight course, or both, must meet all of the

requirements of this Appendix concerning application, approval, and

continuing approval of that course or courses.

\(q\) Practical test eligibility. An applicant for a flight engineer

certificate and class rating under the provisions of Sec. 63.37(b)(6) is
not

eligible to take the practical test unless he has successfully completed
an

approved flight engineer ground school course in the same type of
airplane

for which he has completed an approved flight engineer flight course.

\[Amdt. 63-3, 30 FR 14560, Nov. 23, 1965, as amended by Amdt. 63-15, 37
FR

9758, May 17, 1972\]

14 CFR 63 \* Amendment 63-30 \* Dec. 28, 1995

**APPENDIX 14 - Human Factors**

**APPENDIX 14 - Human Factors**

**HUMAN FACTORS ERROR CLASSIFICATION SUMMARY AND DATABASE**

**SUMMARY**

**Error Classification Model Development Based on Turbofan Data**

**Error Classification Model**

Before discussing the error classification scheme, it is important to
make a distinction between what happens in human error and why it
happens. The inappropriate crew response (ICR) term which is a prominent
part of the workshop title refers to "what" happened in terms of human
behavior. An ICR can be intentional or unintentional. As was discussed
in Human Factors Section 7.0, we are most concerned about the
intentional ICR's based on faulty cognitive processes because the
inappropriateness of these responses is much more difficult for the
flight crew to detect and correct. Errors in cognitive processes are the
primary concern here because understanding the "why" of these errors
will lead to properly focused solutions in terms of training or design.
The ICR's of the accidents and incidents analyzed here can be found in
the Turbofan Summary Database. The cognitive errors inferred from that
database are to be found in the Human Factors Error Classification
database in this appendix. It is the combined analysis of cognitive
errors plus contributing factors which ultimately enable us to
understand the "why" of airplane accidents and incidents which have been
attributed to "pilot error".

An error classification scheme for modeling cognitive errors in
conjunction with propulsion system malfunctions was developed as part of
the human factors function for the PSM+ICR Workshop series. The
objective was to provide a vehicle whereby the error data derived from
the event databases could be mapped onto the recommendations developed
through the Workshop; thus providing a direct link to the event data.
The model developed is an adaptation of Rasmussen's (1982)[^11] and
Reason's (1990)[^12] taxonomies for classifying information processing
failures and interpreted within the framework of Shontz's (1997)[^13]
concept of the data transformation process. It represents a cognitive
approach to human error analysis with the emphasis on understanding the
"why" of human error as well as the "what". The extremely limited data
available in the

Turbofan-DC&ATG Summary Database on which to base inferences about why
cognitive errors occurred in a particular event mean that the attempt to
understand "why" can have only limited success. Nevertheless, the
attempt provides a much richer database for developing and supporting
recommendations and allows the development of more detailed
recommendations for addressing the issues of PSM+ICR.

The model developed is illustrated below in Figure 1. The primary error
categories are represented by the terms located around an "inverted
U-shaped function". The higher-level classifications of skill-, rule-,
and knowledge-based errors are shown in approximate relationship to the
primary categories. The mapping of these relationships, however, is only
approximate as can be seen by reviewing the detailed classification of
errors as shown in the second major section of this appendix.
Sub-categories within each of the primary error categories were also
developed to provide for a finer-grained analysis which could support
more detailed recommendations. The Turbofan-DC&ATG Summary Database
contains accident/incident events which occurred between 1968 and 1996.
References to time frame (early, middle, late) are made within this
range without fixed boundaries. However, the time frames the terms refer
to are roughly "early" (late '60s and '70s), "middle" ('80s), and "late"
('90s).

![](media/image24.wmf)

Figure 1. Classification of Errors in the Presence of Propulsion System
Malfunctions

Which Lead to Inappropriate Crew Responses[^14]

The number of sub-categories under each of the primary categories
varies. The objective was to develop meaningful breakdowns in the data
which could be used to support recommendations. Most of the
sub-categories contain at least two additional groupings of the error
data. Since the model is a work in progress, a few sub-categories were
retained which have no event-driven error data as yet.

In addition to the categories shown above and their attendant
sub-categories, "contributing factors" were identified when possible
that may have influenced crew behavior during the event. Mapping
contributing factors to the errors identified or inferred in the events
can strengthen the inferences that must be made when attempting to
analyze the cognitive behavior in a PSM event. Clearly, developing a
relational database and instantiating it with the descriptions of error
behavior would provide the ideal vehicle for the analysis.
Unfortunately, the resources required for such an activity were not
available to support this workshop activity. However, a similar but more
qualitative and limited activity was accomplished using a spreadsheet
format containing the ICR and contributing factor data.

**Summary of Error Classification Data**

At this point, a caveat regarding the error classification database
found in this appendix should be noted. While continuing members of the
Human Factors Task Group (HFTG) have reviewed the database, they have
not verified the individual error/event assignments by a detailed review
of the turbofan event summary database. The error model and assignment
of error behaviors to categories was accomplished by a single member of
the HFTG. Constraints placed on distribution of the database by its
contributors precluded sending detailed copies of the turbofan event
summary database to individual HFTG members. Other members of the task
group were not available to come to Boeing-Seattle where the turbofan
database is kept in order to accomplish the verification task. However,
members of the HFTG have reviewed the error classification data as shown
in this appendix, and concur with the classifications based on the data
presented. While the HFTG does not consider this situation to invalidate
the error classification database, the support provided for the
recommendations must be tempered with this knowledge.

Summary statements regarding the error classification database are
presented below by primary category and sub-category.

**Detect**

Errors classified under this general category relate to the initial
process of gathering data needed to ascertain "what is happening and
where" during a non-normal event. Errors committed here can affect the
entire process of transforming data into information as the basis for
decisions and actions.

> [Data not attended to]{.underline} (cues, annunciations, context, wx
> information, etc.)

These errors relate to a failure to [obtain]{.underline} the data
necessary to ascertain system state. It was generally difficult, if not
impossible, to determine "why" data were not obtained given the level of
detail available in the Turbofan-DC&ATG Summary Database. However, the
fact that the necessary data was not used in determining action taken
was usually quite obvious. The answer to the "why" question of crew
behavior often lies in integrating relevant information about
Contributing Factors from the event report. While events have been
assigned to the Contributing Factor categories where the determination
could be made from direct report in the summary database or through
inference based on the same source, resources were not available to set
up a relational database with the error classification and contributing
factor data. Therefore, inferences as to the "why" of crew errors are
not a part of this analysis but could be if resources became available
in the future. This statement applies to all the categories of the error
classification analysis.

> There are two additional sub-categories within this category.

*Failure to monitor throttle position and/or engine parameter display
behavior (EPDB).*

There were seven (7) instances of this type of error spread across the
database from the latest to the earliest entries and across three
generations of airplanes. Crews failed to monitor either throttle
position or engine parameter displays for up to several minutes until
upset occurred or the crew took wrong engine action. Workload conditions
on the flight deck preceding the event varied across events from very
high (initial climb) to very low (cruise). Thus while the context varied
considerably across these events, the results where the same - lack of
systems awareness.

*Failure to monitor EPDB over time between/across engines.*

There were also seven (7) instances of this type of error occurring
across the time frame of the database and airplane types. The time
available to monitor EPDB also varied widely but this error was recorded
when it was clear that the engine performance data was available but not
used in determining what action to take. It should be emphasized that
what was available was [data]{.underline} dispersed over the engine
displays not [information]{.underline} about what was happening and
where.

[Data attended to then forgotten]{.underline}

These memory lapse errors are difficult to identify or infer unless
there is a direct report of their occurrence by the crew. It was not
possible to make this determination on any of the events from the
summary database. Nevertheless, it is a possible explanation for
behavior, particularly decision making behavior, in many of the events.
Therefore the sub-category is retained in the error classification
database for possible use in the future.

[Data misperceived]{.underline}

This category is meant to cover those instances where the crew misread,
mishear data/cues in the process of trying to ascertain "what is
happening and where". This is also very difficult to infer and
differentiate from "not attending to" and "partially or poorly
integrated" error classifications. Examples are:

> \- Look at one parameter and encode it mentally as another; e.g.,
> observe eng. #1 parameters decreasing but label them eng. #2 for
> further action; or
>
> \- Misperceive callout of "eng. #2 fail" as "eng. #1 fail".

There were four(4) instances of this type of error occurring. The
evidence for the occurrence of the type of error was very direct
including self report data. It is the type of error against which there
is little defense other than crew coordination and cross-checking.

**Interpretation**

This category contains more errors than any of the others. The
integration and interpretation functions of the data transformation
process are most sensitive to rule and knowledge base errors. These
errors are cognitive errors and as such very difficult to verify as to
their exact nature because their classification depends so heavily on
inference. The strength of the inferences varies across events as a
function of the availability of the human factors related data that is
typically included in accident, incident, and occurrence reports.

[Data partially or poorly integrated]{.underline} (key relationships not
noted)

These errors represent failure to properly and adequately complete the
integration function in transforming data (as individual cues) into
information (as the answer to the questions "what's happening and where
is it happening; i.e., system or component affected). The
accident/incident/occurrence event typically occurs because of a
combination of system malfunction plus crew error in terms of incorrect
interpretations of system state (based on incomplete data) coupled with
actions taken on the basis of these incorrect interpretations. It is
extremely difficult to differentiate between "not attended to" and
"partially or poorly integrated" cognitive behavior - given the
database. Thus, classification of this inferred behavior may, in some
cases, be arbitrary or even redundant between these two types of error.
Proper completion of the integration function is critical to accurate
interpretation. Failures may be the result of lack of knowledge, time
constraint, or perceptual inadequacies (e.g., can't read instruments due
to vibration).

*Action taken on the basis of one or two cues (e.g., loud bang, bang +
yaw, bang + vibration, yaw + vibration, etc.)*

This was one of the largest categories of error in the error
classification database with twenty two (22) events containing errors
associated with this type of inappropriate crew response (ICR). Most,
but not all, of the events in which this ICR occurred were RTO overrun
events. The ICR occurred throughout the time frame of the database and
with glass cockpit as well as earlier generations of airplanes. Dealing
with this type of ICR is one of the central concerns addressed by
recommendations from the AIA Workshop.

*Action taken on wrong engine based on interpretation of incomplete or
poorly*

*integrated pattern of cues.*

The six (6) ICR's are identified here as a sub group because they all
relate to taking action of some sort on the wrong or unaffected engine
during an event. The ICR's occurred across the middle and late time
frame of the database and across all three generations of airplanes.

*Failure to integrate EPDB and other cues over time (difficult to
differentiate from*

*"data not attended to" errors)*

The errors associated with the four (4) events assigned to this category
represent failures in crew monitoring behavior which occurred over time
and clearly indicated a failure to integrate data over time. In most of
the events, monitoring over time was required in order to ascertain what
was happening and where. In one instance, integrating environmental
conditions (runway) with EPDB was required for arriving at the
appropriate decision/action.

[Assumptions about data relationships incorrect]{.underline}

These errors are due to either a) limited or inaccurate mental model at
the system level and possibly the airplane level (i.e., relationship
between propulsion and other systems), or b) misidentification of
individual cues leading to misinterpretation of the nature of the event
and selection of inappropriate action.

*Erroneous assumption(s) about system or cue relationships*

Assignment of the errors to this category was based on direct crew
reports. This error was found in two events

*Misidentification/interpretation of cues*

Assignment of the errors to this category was also based on direct crew
reports. This error was also found in two events.

[Data pattern misinterpreted]{.underline}

Errors of this type may be directly linked to failures to properly
integrate cue data because of incomplete or inaccurate mental models at
the system and airplane levels as well as misidentification of cues.
Time constraints and workload are also contributing factors in this type
of error. There are useful distinctions to be made between the former
and latter causes of the errors but it was difficult, if not impossible,
to distinguish between or among causes based on the data available in
the database. Initial attempts to make this distinction were abandoned.

Twenty three (23) errors involving misinterpretation of the pattern of
cues available to the crew during an event were assigned to this
category. The assignment was clearly warranted based on inappropriate
action taken and/or direct crew report. Designation of error to this
level can be used to support more detailed recommendations than error
data based on less substantial evidence.

[Failure to obtain relevant data/information from crew
members]{.underline}

Errors classified under this category might also be classified as being
of the "partially or poorly integrated data" type. However, the separate
callout of failing to integrate input from crew members into the pattern
of cues is considered important for developing recommendations. These
errors are different from "not attending to inputs from crew members"
which would be classified as detection errors. These errors could be
lumped under a poor crew coordination category but again specificity
would be lost. Errors assigned to the "poor crew coordination" category
are more complex and usually refer to crew activity throughout the
event.

Errors in this category can be further sub-divided into failures of
captains to obtain specific, relevant inputs from the crew or for crew
members failing to inform the captain of data crucial to understanding
what is happening and where. In either case, important data does not get
integrated into the overall pattern of cues surrounding or generated by
the event. Nine (9) of these errors were identified from the database.

[Failure to interpret condition (event + context) as
non-normal]{.underline}

This error classification is used when crews failed to realize that the
airplane was in an

unsafe or non-normal condition.

Two instances of this type of error were identified.

[Nature of relationships among cues/annunciations not
understood]{.underline}

The behavior that would dictate a classification difference between this
category and "data pattern misinterpreted" were impossible to come by
from the database as it exists. The "bewilderment" aspect of behavior
during an event would support this error classification. While
identification of this type of error would be particularly useful in
developing specific recommendations for training, it was not possible to
break the classification down to this level. The category is retained
here as a place holder for errors of this type when they can be
identified.

[Knowledge of system operation under non-normal conditions lacking or
incomplete]{.underline}

These errors are based on erroneous or incomplete mental models of
system performance under non-normal conditions. There is some apparent
overlap with the third Interpretation category, but the link to faulty
mental model is clearer in the behavior representing errors in this
category.

This category contained ICR's based on faulty mental models at the
system level (propulsion) or the airplane level (relationships among
airplane systems). There were eleven (11) instances of knowledge-based
errors of this type in the database.

**Establish Goal**

Errors classified under this general category are knowledge-based
errors. The turbofan summary database was too limited to permit useful
inferences about these types of errors. The categories are included here
to illustrate this aspect of the error classification scheme.

[Established an inappropriate goal]{.underline}

RTO events would be listed here only if there were no airline published
policy or procedure and the crew was never exposed to the Boeing Takeoff
Safety Training Aid. Otherwise the RTO events are rule-based errors.

[Failure to properly prioritize goals]{.underline} (Selection of a goal
for first action blocks achievement of other important goals)

[Failure to recognize conflicting goals]{.underline}

**Strategy/Procedure**

The terms strategy and procedure are used here to indicate two different
types of errors. When the term "procedure" is used, the inference is
that a written procedure or widely recognized "best practice" is
available for implementation when proper interpretation of a cue pattern
occurs. Errors where this is the case are rule-based errors. When the
term "strategy" is used it refers to the case where no procedure exists
so the crew must devise a strategy for action when they encounter the
event. Employing an inappropriate strategy is a knowledge-based error if
the situation has no precedent for the crew to follow in terms of either
written procedure or best practice. The recommendations will be
different for these two different types of errors.

[Improper strategy/procedure chosen]{.underline}

These are rule-based errors where the crew chose to execute an
inappropriate procedure

for the conditions or a strategy which deviated from "best practices".
Aborting a takeoff

above V1 is an example of the former; reducing power on engines below
safe altitude is

an example of the latter.

Of the 43 instances of strategy and procedural error, 49% involved
aborting takeoffs above V1, 12% involved power reductions below safe
operating altitudes, and 29% were other strategies involving deviation
from best practices. Combined, these represent the largest sub-category
of errors leading to ICR's in the database.

[Strategy/procedure could not be achieved due to lack of appropriate
skill/knowledge]{.underline}

These errors are knowledge-based. The goal selected may have been
appropriate but the crew did not have the knowledge or skill to
implement an appropriate strategy.

Two events in the database involved errors of this type.

[Choosing not to implement appropriate procedure]{.underline}

These are rule-based errors where correct procedures or strategies were
clearly available

but disregarded. They are often the flip side of choosing an improper
procedure/strategy.

Two events in the database involved errors of this type.

**Execute**

The number of errors in the general area of execution of actions taken
in the presence of propulsion system malfunctions rivaled that of the
general area of Interpretation. There were seven sub-categories of
errors in this general area.

[Carry out unintended action]{.underline}

These are the classic "slip" errors as defined by Reason (1990).

Most of the fifteen (15) ICR's classified under this heading involved
moving the wrong throttle or fuel valve then following through with the
engine shutdown steps. Indications were that the action began with a
slip and then continued without verification of correctness of the
initial act.

[Failure to complete action]{.underline}

These errors are typical "lapse" errors or errors of omission (Reason,
1990) where all steps in a procedure are not carried out; usually
because of workload or interruptions.

There were three (3) of these errors identified across the events in the
database involving fire handles, fire extinguishers, or fuel shutoff
valves.

[Poor execution of action]{.underline}

These are errors of technique rather than omission. The action taken was
poorly

executed.

This sub-category contains thirteen (13) instances of ICR's representing
a wide variety of poorly executed actions. Assignment of some of the
errors to this category versus one on "poor piloting skills" can be
argued depending on the breadth or narrowness of one's definition of
piloting skills. These errors tend to be in the way a procedure or
step(s) in the procedure are executed as opposed to airplane handling
skills. The latter errors are classified as poor piloting skills here.

[Failure to initiate action]{.underline}

These errors may be caused by inattention or a failure to recognize a
cue pattern as

indicating a non-normal condition. They are the action side of failure
to recognize.

One event contained an error that could clearly be categorized as being
of this type.

[Poor/no crew coordination in carrying out action]{.underline}

There is some ambivalence as to whether this is an error type or
contributing factor at

this point. There is also a "poor/no crew coordination" category under
Contributing

Factors. The event lists do overlap to some extent, but the distinction
is between

poor/no crew coordination in executing a particular action (here) vs.
lack of crew

coordination in general (contributing factor). It is further
distinguished from an earlier discussed error category which focused on
failures to communicate specific cue data between Captain and crew.

This was another large sub-category of errors which spanned the time
frame of the database as well as airplane generation. In other words, it
continues to be a contributor to PSM+ICR events. There were twenty-one
(21) errors in this category.

[Poor piloting skills]{.underline} (closed-loop control skills)

These errors are specifically related to controlling the flight path of
the airplane.

There were ten (10) errors of this type in the database events with the
majority occurring in events which happened during in middle years of
the database time frame .

[Failure to initiate action in a timely manner]{.underline}

This is an attempt to capture the timing aspect of errors.

The nine (9) errors identified in this section represent instances where
the timing error played a major role in the poor performance in dealing
with the event. Timing may also have played a part in other errors
identified elsewhere.

**Violations**

Reason (1990) defines two levels of violations. His terms are used here
but the

definitions are specific to this application. Crew actions in these
events were assigned to the following categories when specific evidence
of a violation was documented in the database. Needless to say, this was
very rare. Inferred violations were not recorded.

[Routine]{.underline}

These are the more "minor" violations of company policy or procedures
but which can have a major impact on the course of an event.

Two violations of the sort could be positively identified from the
turbofan summary database.

[Exceptional]{.underline}

This category was used when the violation was of a more serious nature
and made a direct contribution to the event.

Two violations of the sort could be positively identified from the
turbofan summary database

**Factors That Contribute to Errors**

These aspects of the events were identified and categorized for the
purpose of providing "context" for the events. Relating contributing
factors to the error data offers the possibility of understanding at
least some of the conditions which have relevance to or seriously impact
human performance and may provide a framework for better understanding
the "why" of human error.

Seventeen different "contributing factors" were identified as being
present and having played a part in enhancing the potential for errors.
These were:

> *Data not present or unreadable* - present in four (4) events
>
> *Workload due to: weather or ATC and Dispatch communication
> requirements* - One event
>
> *Lack of training on condition (event + context)* - Twenty one (21)
> events; all but one inferred from time frame and/or availability of
> training aids.
>
> *Little or no experience with condition(s)* - Thirteen (13) events;
> inferred from actions or time in position data.
>
> *Fatigue* - Two events
>
> *Weather* - Twelve (12) events; this factor was generally reported for
> all events.
>
> *Runway conditions* - Nine (9) events; this factor was also reported
> if other than bare and dry.
>
> *Loss of situation awareness* - Three events; strong evidence
> available to support inference. May have been present at some level in
> most, if not all, events.
>
> *Poor/no crew coordination* - Twenty four (24) events. The
> classification of poor crew coordination as a contributing factor is
> based on evidence and inference of its poor quality or absence based
> on overall crew performance.
>
> *System(s) fail to operate because of MEL action* - One event.
>
> *Bird strike or assumed bird strike* - Nine (9) events. Usually the
> assumption made was that more than one engine had been affected by
> bird strike.
>
> *Conditions not as calculated ( weight, wind speed/direction, etc.)* -
> one event
>
> *Night* - One event. There may have been a number of events which
> occurred at night but in only one was it considered a contributing
> factor to the event itself.
>
> *Equipment failure* - Ten (10) events; where the equipment failure
> contributed to the severity of the event. All events began with some
> type of propulsion system malfunction.
>
> *Maintenance error(s)* - One event
>
> *Design* - four events; all involving lack of alert for thrust
> asymmetry
>
> *Negative transfer* - Three events; all inferred from previous pilot
> experience (sometimes extensive) with "outside in" ADI where pilots
> were flying "inside out" ADI at the time of the event.
>
> *Inadequate/inappropriate procedures in place for the conditions* -
> two events

*Procedure not available (no formal procedure exists)* - database detail
too limited support identification of this condition as a contributing
factor at this time.

**HUMAN FACTORS ERROR CLASSIFICATION DATABASE**

**BACKGROUND**

The attached material is an attempt to classify cognitive errors based
on analysis of the Turbofan Summary Database in such a way as to support
the development of detailed recommendations on solutions for addressing
PSM+ICR issues. The "model" used as adapted from Rasmussen (1982) is
shown in Figure 1. It illustrates the now ubiquitous error
classification levels of skill-based, rule-based, and knowledge-based
errors as well as Rasmussen's inverted U components. The error
categories identified within this context include only the basic
cognitive functions. The transitions between functions are illustrated
with arrows. Application of the model to accident/incident data has
resulted in the identification of varying numbers of specific error
types (sub-categories) within the basic categories. Additional error
types may be defined and refinement of existing definition wording can
be expected also with any future work on the model.

The primary weakness in the error classification process is the
variability in the amount of human performance data in the
accident/incident reports upon which to base error classification
interpretations. In some cases, the classifications are highly
inferential while in others the conclusions are well supported by the
data available. The rationale for assigning the cognitive errors in a
particular event (accident/incident/occurrence) to a particular error
classification category are illustrated by general descriptive material
plus behavioral statements or statements of conditions. These statements
are labeled with an alpha-numeric ID which matches the event ID on the
Turbofan-DC&ATG Summary Database. Thus, the error judgments are tied
directly to the database. Most of the error categories have examples of
crew behavior or assumptions about crew behavior (i.e., inappropriate
crew responses) that support the assignment of a particular error
category to a particular event.

The items that are listed at the end under "Factors That Contribute to
Errors" are a partial listing of the "ecological" variables that must be
considered in solving human-machine interface problems. As Vicente
(1997)[^15] proposes, we must take an ecological as well as cognitive
approach to developing the interface. This applies whether the solutions
proposed are training, procedural, or design.

**TYPES OF ERRORS** (With Explanations and Examples)

**Detect (D)**

Errors classified under this general category relate to the initial
process of gathering data needed to ascertain "what is happening and
where" during a non-normal event. Errors committed here can affect the
entire process of transforming data into information as the basis for
decisions and actions.

> [1. Data not attended to]{.underline} (cues, annunciations, context,
> wx info, etc.)

These errors relate to a failure to [obtain]{.underline} the data
necessary to ascertain system state. It is generally difficult, if not
impossible, to determine "why" data were not obtained. However, the fact
that the necessary data was not used in determining action taken is
usually quite obvious. The answer to the "why" question often lies in
integrating relevant information about Contributing Factors from the
event report. There are two additional sub-categories within this
category.

a.  Failure to monitor throttle position and engine parameter display
    behavior (EPDB).

> 96/MNB/2/I - Engine indications showing #1 eng. at flight idle not
> flamed out as assumed by crew; #1 eng. throttle at idle position.
>
> 95/EWB/2/HF - Engine indications showing #1 eng. thrust settings lower
> than #2 and decreasing; #1 eng. throttle retarding toward idle while
> #2 throttle remains at high thrust level.
>
> 95/MWB/2/I-2 - #2 eng. throttle jammed at 94% while #1 eng. throttle
> slowly reducing power under A/T command. Failed to notice #2 eng.
> throttle position when diagnosing problem in #1 eng.
>
> \` 92/MNB/2/HF - #2 eng. throttle stuck at idle during level off while
> #1 throttle advanced with A/T engaged; A/P holding left aileron;
> airplane began to bank right
>
> 92/MWB/2/I - #1 eng. went subidle during level off at cruise and was
> not detected for over seven minutes; throttle split, airspeed bleed
> off, finally 15 degree bank when A/P could not compensate for
> asymmetric thrust.
>
> 85/EWB/4/S - Crew failed to note that #4 eng. had gone sub idle while
> engines controlled by A/T.
>
> 69/2ND/2/H - None of the three pilots on flight deck noticed that #2
> throttle had inadvertently been displaced below full power.

b.  Failure to monitor EPDB over time between/across engines.

> 89/MNB/2/HF - Vibration indication on #1 eng. ignored; Engine
> Parameter Display Behavior (EPDB) of [both]{.underline} engines not
> monitored closely due to numerous radio communication interruptions
> and initiations. Missed erratic behavior of N1 on #1 eng.
>
> 88/MNB/2/S - Capt. as PNF apparently not monitoring engine instruments
>
> 88/EWB/3/I - F/E not monitoring reverser unlock lights
>
> 86/2ND/2/I - Engine operating status not determined following bird
> strike
>
> 85/EWB/4/I-1 - Failed to acquire relevant EPDB before abort decision
>
> 75/2ND/3/S - Capt. failed to obtain input on status of propulsion
> system prior to abort decision.
>
> 70/2ND/2/H - Capt. as PNF failed to carefully scan engine instruments
> before acting

[2. Data attended to then forgotten]{.underline}

> These memory lapse errors are difficult to identify or infer unless
> there is a direct report of their occurrence by the crew.

[3. Data misperceived]{.underline}

This category is meant to cover those instances where the crew misread,
mishear data/cues in the process of trying to ascertain "what is
happening and where". This is also very difficult to infer and
differentiate from "not attending to" and "partially or poorly
integrated" error classifications. Examples are:

> \- Look at one parameter and encode it mentally as another; e.g.,
> observe eng. #1 parameters decreasing but label them eng. #2 for
> further action; or
>
> \- Misperceive callout of "eng. #2 fail" as "eng. #1 fail".

81/EWB/4/I - Apparent misperception of Engine Parameter Display Behavior
(EPDB) cues

81/2ND/2/I - Both engines perceived as failed, only #1 eng. had in fact
failed

70/2ND/2/H - Capt. misinterpreted F/O rudder over-correction to right as
#2 eng. fail and incorrectly "perceived" #2 eng. instruments spooling
down.

94/2ND/3/I - Tower personnel misperceived affected engine and gave
incorrect identification of affected engine to the crew.

**Interpretation (I)**

This category contains more errors than any of the others. The
integration and interpretation functions of the data transformation
process are most sensitive to rule and knowledge base errors. These
errors are cognitive errors and as such very difficult to verify as to
their exact nature because their classification depends so heavily on
inference. The strength of the inferences varies across events as a
function of the paucity of the human factors related data that is
typically included in accident, incident, and occurrence reports.

1.  [Data partially or poorly integrated]{.underline} (key relationships
    not noted)

These errors represent failure to properly and adequately complete the
integration function in transforming data (as individual cues) into
information (as the answer to the questions "what's happening and where
is it happening; i.e., system or component affected). The
accident/incident/occurrence event often occurs because of a combination
of system malfunction plus pilot error in terms of incorrect
interpretations of system state

(based on incomplete data) coupled with actions taken on the basis of
these incorrect interpretations. It is extremely difficult to
differentiate between "not attended to" and "partially or poorly
integrated" cognitive behavior - given the database. Thus,
classification of this inferred behavior may, in some cases, be
arbitrary or even redundant between these two types of error. Proper
completion of the integration function is critical to accurate
interpretation. Failures may be knowledge-driven, the result of time
constraint, or perceptual (e.g., can't read instruments due to
vibration).

a.  Action taken on the basis of one or two cues (e.g., loud bang,
    bang + yaw, bang + vibration, yaw + vibration, etc.)

> 96/MWB/4/I - Action taken in reaction to one or two ambiguous cues;
> yaw, noise
>
> 94/MWB/2/I-1 - Crew could not readily determine which eng. was
> affected. Action taken in reaction to one or two ambiguous cues; yaw,
> noise.
>
> 94/MWB/4/I - Action taken in reaction to one or two ambiguous cues;
> noise
>
> 93/MWB/2/I-3 - Retarding of both throttles at low altitude (500 ft)
> indicates pilot not sure which engine is surging.
>
> 93MWB/3/I - Speed of reaction to noise and yaw cues precluded analysis
> of what actually was happening.
>
> 93/MNB/2/I - Failed the correlate throttle position/movement, A/T
> engaged, and EPDB to properly identify the problem. Action taken in
> reaction to one or two ambiguous cues; eng. parameters winding down
>
> 93/MWB/3/I - Action taken in reaction to one or two ambiguous cues;
> yaw, noise
>
> 88/MNB/2/S - Quick scan by F/O as PF missed any Engine Parameter
> Display Behavior (EPDB) to indicate what was happening where. Action
> taken in reaction to one or two ambiguous cues; two loud bangs and
> slight yaw to left
>
> 88/EWB/4/S - Action taken in reaction to one or two ambiguous cues;
> action taken based on Capt. hand movement toward throttles.
>
> 86/EWB/2/H - Action taken in reaction to one or two ambiguous cues;
> loud noise, heavy vibrations.
>
> 85/2ND/2/HF - Malfunctioning engine not properly identified by both
> crew members. Action taken in reaction to one or two ambiguous cues;
> yaw and noise.
>
> 85/MWB/2/I - Buffet cue was difficult to isolate to an engine. Other
> cues not properly integrated to identify affected engine. Action taken
> on vibration alone.
>
> 85/EWB/4/I-1 - Failed to integrate and interpret Engine Parameter
> Display Behavior (EPDB) reflecting engine performance before
> initiating RTO procedures. Action taken in reaction to one or two
> ambiguous cues; birds present, loud bang.
>
> 81/EWB/4/S - F/E based response to Capt. query re what was happening
> on EGT limit light only. Called "Engine Fire".
>
> 81/2ND/3/S - EPDB data not integrated over time. Action taken in
> reaction to one or two ambiguous cues; loud Bang(s) partial power loss
> on affected engine.
>
> 78/EWB/4/S - Capt. apparently was not certain whether #3 or #4 eng.
> was affected. Failed to deploy thrust reversers on #3 and #4 eng.
> Action taken in reaction to one or two ambiguous cues; loud Bang.
>
> 76/EWB/3/I - EPDB not integrated for accurate assessment of propulsion
> system status. Action taken on loud bang only.
>
> 75/2ND/3/S - No additional data other than perceived "marked
> deceleration" cue used in making abort decision.
>
> 75/EWB/4/I-1 - Interpretation of #3 eng. failure based only on "N1
> decreasing"
>
> 72/2ND/2/S - Time between hitting pools of standing water and decision
> to abort was adequate to evaluate engine performance; power recovery
> under way. Action taken in reaction to one or two ambiguous cues;
> momentary reduction in rate of acceleration plus some directional
> control difficulties from hitting pools of standing water.
>
> 70/2ND/2/H - Capt. reacted to Bang and F/O induced yaw to the right
> without reference to EPDB.
>
> 69/2ND/2/H - Pilot-in-command (PIC) did not integrate all aspects of
> EPDB on both engines before calling "throttle it" command (or
> suggestion) based only on perceived 20 degree C discrepancy in EGT
> between #1 and #2 engines.

b.  Action taken on wrong engine based on interpretation of incomplete
    or poorly

integrated pattern of cues.

> 94/MWB/2/I-2 - Discrepancy between eng. crew reported surged and eng.
> throttled
>
> 94/2ND/3/I - Failed to verify incorrect identification of affected
> engine by tower.
>
> 89/MNB/2/HF - EPDB not monitored closely so pattern of parameter
> behaviors not observed. Failed to include vibration and erratic N1
> behavior indications over time in decision to shut down an engine.
>
> 85/EWB/4/I-2 - All Engine Parameter Display Behavior (EPDB) on #4 eng.
> not considered in shutdown decision. Drop in fuel flow not related to
> thrust reduction for ATB.
>
> 81/EWB/4/I - Apparent failure to integrate EPDB cues to correctly
> identify affected engine.
>
> 81/2ND/2/I - EPDB on #2 eng. not integrated over time

c.  Failure to integrate EPDB and other cues over time (subtle but
    important difference between this subcategory and "data not attended
    to" errors)

> 96/MNB/2/I - Cues indicating difference between flight idle and flame
> out not properly interpreted.
>
> 95/MWB/2/I-2 - Failed to note #2 jammed at 94% while parameters on #1
> falling (due to A/T action) while #1 throttle moving to idle.
>
> 78/EWB/3/I-2 - Data in runway conditions not integrated with engines'
> status for Go decision.
>
> 72/EWB/4/I-2 - EPDB of #2 eng. not evaluated over time for true
> picture of its operating condition resulting in wrong engine shutdown.

[2. Assumptions about data relationships incorrect]{.underline}

These errors are due to either a) limited or inaccurate mental model at
the system level and possible the airplane level (i.e., relationship
between propulsion and other systems, or b) misidentification of
individual cues leading to misinterpretation of the nature of the event
and selection of inappropriate action.

a\. Erroneous assumption(s) about system or cue relationships

> 89/MNB/2/HF - Assumed air-conditioning to cockpit provided by #2 eng.
> so thought smoke and smell coming from #2 eng.
>
> 75/2ND/3/S - Association of marked deceleration cue with engine
> failure incorrect under the conditions (substantial standing water on
> runway).
>
> b\. Misidentification/interpretation of cues
>
> 88/MNB/2/S - Capt. decision to abort made on assumption that loud bang
> was a blown tire when stall/surge occurred due to turbine blade
> failure.
>
> 81/2ND/3/S - Capt. decision to abort made on assumption of uncontained
> engine failure.

[3. Data pattern misinterpreted]{.underline}

Errors of this type may be directly linked to failures to properly
integrate cue data because of incomplete or inaccurate mental models at
the system and airplane levels as well as misidentification of cues.
Time constraints and workload are also contributing factors in this type
of error. There are useful distinctions to be made between the former
and latter causes of the errors but it is difficult, if not impossible,
to distinguish between or among causes based on the data available in
the database. Initial attempts to make this distinction were abandoned.

> 96/MNB/2/I - Interpreted failure of engine to spool up from flight
> idle as engine flameout. A/T engaged, #2 eng. throttle advanced while
> #1 eng. throttle at idle; #1 eng. EPDB indicating flight idle not
> flameout/failure.
>
> 95/EWB/2/HF - At one point, large left roll input made into eng. with
> low thrust while bank angle in that direction was already at least 30
> degrees.

95/MWB/2/I-2 - #1 eng. Engine Parameter Data Behavior (EPDB) interpreted
as eng. fail rather than as the result of A/T inputs.

94/MWB/4/I - #3 eng. surged, #2 eng. shutdown; commanded thrust rollback
on #2 interpreted as result of surges.

> 93/EWB/2/I - Misidentified affected eng. and retarded good eng.
> throttle at very low altitude (100 ft)
>
> 93/MNB/2/I - A/T actions in retarding throttle to maintain approach
> speeds interpreted as eng. failure
>
> 92/MNB/2/HF - Large aileron input in the wrong direction during
> attempt to recover created an unusual attitude condition possibly due
> to misinterpretation of ADI. Attempt to engage Heading Select to
> correct drift. Large aileron input toward the low wing (opposite of
> what A/P was holding). ADI may have been misread due to negative
> transfer
>
> 91/2ND/3/I - Cues misinterpreted as tire problem when actually an
> engine turbomachinery damage problem

89/MNB/2/HF - Comparison of engines' N1 done intermittently at just the
wrong time when both values were fairly close together. Thus
misinterpreting relative N1 behavior of the two engines. Misinterpreted
EPDB as indicating #2 eng. malfunctioning when #1 eng. was bad.
Vibration and erratic N1 behavior of #1 eng. nor considered.

88/MNB/2/S - Two Bangs and yaw were a surge misinterpreted as blown
tire(s). RTO initiated because Capt. thought airplane had blown tire(s).
Absence of Engine Parameter Display Behavior (EPDB) indicating engine
failure.

85/2ND/2/HF - Affected engine misidentified by at least one crew member
(based on first correct then incorrect rudder inputs). Yaw plus EPDB
cues would establish what was happening and where.

85/MWB/2/I - Deliberate shut down of wrong engine assumed to be based on
misinterpretation of EPDB observed. Lower EGT on #1 eng. interpreted as
indicating affected engine where as higher EGT on #2 eng. actually
indicated affected engine. Buffet continued after #1 eng. shut down.

85/EWB/4/I-2 - Drop in fuel flow on #4 eng. attributed to engine failure
instead of thrust reduction.

81/EWB/4/I - EPDB may have been misinterpreted

81/EWB/4/S - EGT limit light misinterpreted to indicate engine fire by
F/E

81/2ND/3/S - Loud bang of engine surge interpreted as a (possible)
uncontained engine failure with extensive collateral damage

81/2ND/2/I - EPDB data on #2 eng. misinterpreted by crew as engine
failure.

75/2ND/3/S - Perceived "marked deceleration" caused by standing water on
the runway misinterpreted as engine failure

75/EWB/4/I-1 - Misinterpreted decreasing N1 as engine failure (also I-1
error)

72/EWB/4/I-2 - Quick action to shut down #2 eng. based on
misinterpretation of poorly integrated data.

72/2ND/2/S - Loss of acceleration and directional control problems
misinterpreted as loss of thrust to degree takeoff was no longer
feasible and RTO initiated.

70/2ND/2/H - Capt. misinterpreted F/O rudder over-correction to right as
#2 eng. fail and incorrectly "perceived" #2 eng. instruments spooling
down.

69/2ND/2/H - PIC misinterpreted EPDB and erroneously identified #1 eng.
and the affected engine.

4.  [Failure to obtain relevant data/information from crew
    members]{.underline}

(D-1). Errors classified under this category might also be classified as
being of the "partially or poorly integrated data" type. However, the
separate callout of failing to integrate input from crew members into
the pattern of cues is considered important for developing
recommendations. These errors are different from "not attending to
inputs from crew members" which would be classified as detection errors

a.  Failure of Captain to obtain all relevant inputs from crew

> 91/MNB/2/H - Crew unaware of clear ice on wings (input from ground
> crew)
>
> 89/MNB/2/HF - Failed to ask cabin crew for help in identifying
> affected engine
>
> 85/EWB/4/I-2 - Failed to check among flight crew members for actions
> that would account for fuel flow reduction in #4 eng.
>
> 85/EWB/4/I-1 - Capt. failed to obtain EPDB interpretation from F/E
>
> 75/2ND/3/S - Capt. failed to obtain status of propulsion system from
> F/E

70/2ND/2/H - Capt. failed to obtain input from F/O who was PF as to what
he thought was happening.

b\. Failure of crew members to provide relevant data or failure to
cross-check erroneous data

> 88/EWB/3/I - F/E failed to report status of reverser unlock lights
>
> 81/EWB/4/S - Capt. based abort decision on incorrect diagnosis of
> engine fault made by F/E
>
> 69/2ND/2/H - Failure to verify the PIC's identification of the
> affected engine

[5. Failure to interpret condition (event + context) as
non-normal]{.underline}

> This error classification is used when crews failed to realize that
> the airplane was in an
>
> unsafe or non-normal condition.
>
> 95/EWB/2/HF - Airplane in a climbing left turn as required for
> departure being flown; fail to recognize that combination of stuck
> throttle and A/T system behavior was producing desired flight path and
> not pilot inputs.
>
> 85/EWB/4/S - Crew failed to note sub-idle condition of #4 eng.

6.  [Nature of relationships among cues/annunciations not
    understood]{.underline}

The behavior that would dictate a classification difference between this
category and "data pattern misinterpreted" will be hard to come by from
the database as it exists. The "bewilderment" aspect of the behavior
would support this error classification. It may simply not be meaningful
to break the classification down to this level.

7\. [Knowledge of system operation under non-normal conditions lacking
or]{.underline}

[incomplete]{.underline}

These errors are based on erroneous or incomplete mental models of
system performance under non-normal conditions. There is some apparent
overlap with the I-3 category, but the link to faulty mental model is
clearer.

> a\. Faulty mental model at the system level
>
> 88/2ND/2/HF - Simultaneous or alternate (as appropriate) reduction of
> power on the engines may extend their operating life somewhat under
> these circumstances
>
> 86/EWB/2/H - PF not aware of (or did not believe) information about
> engine capabilities following bird strike.
>
> 86/2ND/2/I - PF not aware of (or did not believe) information about
> engine capabilities following bird strike.
>
> 85/EWB/4/I-1 - PF not aware of (or did not believe) information about
> engine capabilities following bird strike.

72/2ND/2/S - Decision to reject takeoff based on incorrect assessment of
thrust producing capability of the engines.

b\. Faulty mental model at the airplane level

> 89/MNB/2/HF - Major factor in shutting down of #2 eng. was erroneous
> assumption as to source of smoke and smell.
>
> 83/EWB/4/S - F/E apparently not aware of effect of gradually reducing
> throttle on V1 speed/distance relationship.
>
> 83/1ST/2/HF - Lowered Gear & flaps simultaneously causing loss of
> airspeed at critical time.
>
> 78/EWB/3/I-2 - Abort decision triggered by onset of "Engine Fail
> Light" when crew had a flyable airplane.
>
> 77/2ND/3/I - "Engine Fail" light interpreted as not having flyable
> airplane
>
> 77/EWB/3/I - "Engine Fail" light interpreted as not having flyable
> airplane

**Establish Goal (EG)**

Errors classified under this general heading are knowledge-based errors.

[1. Established an inappropriate goal]{.underline}

RTO events would be listed here only if there were no airline published
policy or procedure and pilots were never exposed to the Boeing Takeoff
Safety Training Aid. Otherwise the RTO events are rule-based errors.

[2. Failure to properly prioritize goals]{.underline} (Selection of a
goal for first action blocks achievement of other important goals)

[3. Failure to recognize conflicting goals]{.underline}

**Strategy/Procedure (S/P)**

[1. Improper strategy/procedure chosen]{.underline}

> These are rule-based errors where the crew chose to execute an
> inappropriate procedure
>
> for the conditions or a strategy which deviated from "best practices".
> Aborting a takeoff
>
> above V1 is an example of the former; reducing power on engines below
> safe altitude is
>
> an example of the latter.

a.  Execute RTO procedure when airplane has achieved V1 speed or higher

> 96/MWB/4/I - Chose to abort TO above V1 for surge
>
> 93/MWB/3/I - F/O chose to abort takeoff for surge at or above V1;
> Capt. intervened and continued takeoff.
>
> 93/EWB/4/I-2 - F/O chose to abort takeoff for surge at or above V1 and
> assumed FOD had occurred
>
> 92/EWB/4/I - Chose to execute an RTO for surge at a speed above V1
>
> 91/MNB/2/I - Chose to execute RTO for surge at Vr (with plenty of
> runway)
>
> 91/EWB/2/I - Chose to execute RTO for vibration and perceived power
> loss well above V1.
>
> 88/MNB/2/S - Attempted RTO above V1. Takeoff should not have been
> aborted for either surge or blown tire.
>
> 88/EWB/4/S - F/O initiated RTO well above V1 on own initiative
> following engine fire warning
>
> 88/2ND/2/I - Chose to initiate RTO well above V1 when potential for
> bird strikes was obvious well before V1
>
> 86/EWB/2/H - Chose to initiate RTO at Vr following bird strike
>
> 86/2ND/2/I - Chose to initiate RTO at Vr following bird strike

85/EWB/4/I-1 - Chose to initiate RTO 19 kts above V1 on wet runway
following a \` bird strike with two reversers inoperative.

> 81/2ND/3/S - Chose to initiate RTO at Vr + with nose gear off the
> ground.
>
> 78/EWB/3/I-2 - Given runway conditions and two good engines, an RTO
> initiated at V1 would not have been the correct procedure to chose.
> Although RTO purported to have been initiated at V1, snow pack over
> ice at stopping end of runway reduced braking efficiency. Airplane
> could not be stopped on the runway under these conditions.
>
> 78/EWB/4/S - Chose to initiate RTO well above V1
>
> 77/2ND/3/I - Chose to initiate RTO at VR with flyable airplane.
> Airplane could not be stopped on the runway under these conditions
>
> 77/EWB/3/I - Chose to initiate RTO at VR + with flyable airplane.
> Airplane could not be stopped on the runway under these conditions.
>
> 76/EWB/3/I - Chose to initiate RTO above Vr with flyable airplane on
> contaminated runway. Airplane could not be stopped on the runway under
> these conditions
>
> 75/2ND/3/S - Chose to initiate RTO near Vr with flyable airplane on
> wet runway. Airplane could not be stopped on the runway under these
> conditions.
>
> 72/2ND/2/S - Chose to initiate RTO above V1 with flyable airplane on a
> wet runway. Airplane could not be stopped on the runway under these
> conditions.
>
> 70/2ND/2/H - Capt. chose to assume control of airplane and initiate a
> RTO 50-100 ft off the ground and above V2. Airplane could not be
> stopped on the runway under these conditions.

b.  Power reduction below safe operating altitude

> 94/MWB/2/I-1 - Chose to reduce thrust on both engines at very low
> altitude (290 ft) following surge in left eng.
>
> 94/MWB/2/I-2 - Chose to reduce thrust on one eng. near Vr to clear
> surge
>
> 93/MWB/2/I-3 - Chose to reduce thrust on both engines at low altitude
> (500 ft) during takeoff
>
> 93/EWB/2/I - Chose to retard throttle below 400 ft.
>
> 69/2ND/2/H - Pilot-in-charge rapidly closed identified throttle below
> 200 ft.
>
> c\. Other strategies which deviate from "best practice"
>
> 96/1ST/4/HF - Continued TO after losing one, possibly two engines,
> before V1
>
> 96/MNB/2/I - Chose to close fuel shutoff lever when engine at flight
> idle because of malfunctioning A/T.
>
> 95/EWB/2/HF - Tried to engage A/P while in 45 degree bank as a
> recovery strategy.
>
> 93/MNB/2/I - Chose to shut down good eng.
>
> 91/MNB/2/H - Crew chose to take off with clear ice on wings. During
> takeoff, the ice came loose and was ingested into both engines causing
> FOD and unrecoverable surging.
>
> 92/MNB/2/HF - Actions taken created an unusual attitude at night.
>
> 89/MNB/2/HF - Chose to shut down good engine and leave it shut down on
> final approach, thus relying on power from severely damaged engine.
>
> 88/2ND/2/HF - Applying continuous max power with heavy FOD is not
> conducive to sustained engine operation.
>
> 85/1ST/4/H - RTO initiated at high speed with insufficient runway
> remaining.
>
> 85/MWB/2/I - Strategy to reduce vibration and save engine not achieved
> because of wrong engine shutdown.
>
> 83/1ST/2/HF - Chose to execute downwind landing. Gear & flaps down
> simultaneously caused reduced airspeed. Did not immediately select
> takeoff power.
>
> 83/EWB/4/S - F/E attempted to control EGT by gradually reducing
> throttle on affected engine instead of calling for an abort fairly
> early in the takeoff run (80 kts). No V1 call.
>
> 82/EWB/4/I - Capt. reduced then restored power to malfunctioning
> engine till engine failed. Procedure is to shut it down for high
> vibration
>
> 81/1ST/4/I - ATB procedure executed inappropriate for the conditions.
> Attempted landing overweight, 25 kts fast onto wet runway, with
> tailwind.
>
> 81/1ST/4/H - PF Created thrust imbalance at low speed by bringing in
> #2 eng. reverser with #3 eng. shut down.
>
> 81/EWB/4/S - F/E's failure to set full takeoff power prior to 80 kts
> moved V1 distance point further down the runway making a successful
> RTO more difficult if not impossible. Takeoff roll started 150 meters
> down the runway also moving calculated V1 point. (Overrun was 20
> meters)
>
> 79/2ND/2/S - Capt. shut down both engines and descended 15,000 ft
> before restarting good engine.

[2. Strategy/procedure could not be achieved due to lack of appropriate
skill/knowledge]{.underline}

These errors are knowledge-based. The goal selected may have been
appropriate but the crew did not have the knowledge or skill to
implement an appropriate strategy.

> 88/2ND/2/HF - ATB would not be successful without careful management
> of thrust applications
>
> 83/1ST/2/HF - Crew committed several piloting errors in addition to
> loss of control.

[3. Choosing not to implement appropriate procedure]{.underline}

> These are rule-based errors where correct procedures or strategies
> were clearly available
>
> but disregarded. They are often the flip side of choosing an improper
> procedure/strategy.
>
> 96/1ST/4/HF- Did not execute RTO with engine fail below V1
>
> 83/EWB/4/S - F/E chose to reduce power on affected engine rather than
> call "engine fail".

[4. Failure to reconcile conflicting strategies/procedures]{.underline}

No errors recorded so far that could serve to operationally define this
type of error.

**Execute (E)**

[1. Carry out unintended action]{.underline}

> These are the classic "slip" errors as defined by Reason (1990).
>
> 94/MWB/2/I-1 - #2 eng. throttle reduced inadvertently when #1 throttle
> pulled back in response to surge.
>
> 94/MWB/4/I - Intention aspect inferred; reached for #3 and shutdown #2
> (or see E-1).
>
> 94/MWB/2/I-2 - #1 eng. reported as having surged, #2 eng. throttle
> reduced 30% at rotation.
>
> 85/2ND/2/HF - Assume wrong rudder inputs not intentional
>
> 82/EWB/4/I - F/E pulled fire handle on #1 eng. instead of #2 eng. as
> ordered.
>
> 81/EWB/4/I - Engine shutdown could have been a slip
>
> 80/EWB/3/I - Possible inadvertent shutdown of #2 eng. during shutdown
> of #3 eng. Nobody admitting it.
>
> 79/EWB/4/I-1 - Possible inadvertent shutdown of #3 eng. while
> executing shutdown procedure on #2 eng.
>
> 78/EWB/4/I - #3 eng. inadvertently shut down in process of shutting
> down #4 eng
>
> 78/2ND/3/I-1 - #1 eng. shut down inadvertently while trying to shift
> essential power source to #2 eng. after first trying to select #1 eng.
>
> 77/EWB/4/I - Possible inadvertent shutdown of #1 eng. when #2 eng.
> failed. Inability to restart #1 makes this questionable.
>
> 75/EWB/4/I-2 - inadvertent cutoff of fuel to #4 eng. (fire handle or
> fuel shutoff valve) while shutting down #3 eng. following compressor
> surge.
>
> 72/EWB/4/I-1 - Fuel valve for #2 eng. inadvertently closed during
> shutdown procedure being executed for #3 eng.
>
> 70/EWB/4/I - Fuel cutoff valve on #1 eng. inadvertently closed when
> engine fire warning occurred in #2 eng.
>
> 69/2ND/2/H - In process of reducing #1 throttle to idle, #2 throttle
> partially closed

2.  [Failure to complete action]{.underline}

These errors are typical "lapse" errors or errors of omission where all
steps in a procedure are not carried out; usually because of workload or
interruptions.

> 95/MWB/2/I-2 - #1 eng. shutdown with fire handle. Fire handle not
> returned to OFF position before attempting to restart #1.
>
> 83/1ST/2/H - Crew failed to discharge fire extinguishers as part of
> shutdown procedure.
>
> 68/1ST/4/HF - Failed to close fuel shutoff valve in pylon; failed to
> shut off booster pumps.

[3. Poor execution of action]{.underline}

> These are errors of technique rather than omission. The action taken
> was poorly
>
> executed.
>
> 90/1ST/4/H - Failed to execute RTO procedure adequately; poor braking
> technique
>
> 88/MNB/2/S - Slammed nose gear back on runway while both pilots
> applied maximum braking causing nose gear to collapse.
>
> 88/2ND/2/I - Failed to deploy spoilers as part of RTO procedure
>
> 88/EWB/4/I - Allowed airplane to over-rotate by 11 degrees and right
> wing drop when surge in #4 eng. occurred at rotation.
>
> 85/2ND/2/HF - Control inputs resulted in high speed stall and rudder
> into the dead engine.
>
> 83/1ST/2/HF - Did not select takeoff power immediately. Gear & flaps
> lowered simultaneously.
>
> 81/1ST/4/H - Unstable approach; landed long
>
> 81/EWB/4/S - F/E did not bring engines up to full takeoff power before
> 80 kts. Capt. did not apply maximum continuous braking during RTO. No
> indication of reversers being used.
>
> 78/EWB/4/S - PF delay in applying brakes; reversers on #3 and #4 eng.
> not deployed
>
> 78/EWB/4/I - Engine shutdown procedure not properly executed (fire
> handle or fuel switch for #3 eng. inadvertently moved during shutdown
> of #4 eng.)
>
> 69/1ST/4/S - Delay in applying brakes on top of overload, rolling
> takeoff, and a reduction in reported head wind led to overrun.
>
> 69/2ND/2/H - Poor execution of engine shutdown procedures resulted in
> fire and fatalities
>
> 68/1ST/4/HF - Poor execution of engine shutdown procedures resulted in
> fire and fatalities

[4. Failure to initiate action]{.underline}

> These errors may be caused by inattention or a failure to recognize a
> cue pattern as
>
> indicating a non-normal condition. They are the action side of failure
> to recognize.
>
> 95/EWB/2HF - Stuck throttle condition existed for 42 seconds with no
> action taken to correct problem; no rudder input throughout entire
> event.

[5. Poor/no crew coordination in carrying out action]{.underline}

There is some ambivalence as to whether this is an error type or
contributing factor at

> this point. There is also a "poor/no crew coordination" category under
> Contributing
>
> Factors. The event lists do overlap to some extent, but the
> distinction is between
>
> poor/no crew coordination in executing a particular action (here) vs.
> lack of crew
>
> coordination in general (contributing factor).
>
> 93/MWB/3/I - No evidence of formal transfer of control from F/O to
> Capt.

89/MNB/2/HF - Failed to coordinate with cabin crew; Capt. and F/O
working independently, Capt. did not cross-check and verify F/O
identification of affected engine.

88/MNB/2/S - Capt. took control of airplane during RTO without verbal
call for control resulting briefly in conflicting control inputs

88/EWB/3/I - F/E failed to advise Capt. immediately of status of
reverser unlock lights

88/EWB/4/S - Capt. did not call for RTO, F/O assumed Capt. hand movement
toward throttles a signal to abort takeoff.

88/2ND/2/I - No cross-check to assure proper execution of procedure

85/2ND/2/HF - Assume two pilots making control inputs or giving
directions for control inputs which are not correlated with required
control inputs for the situation.

85/EWB/4/I-2 - Coordination among crew on thrust reduction and apparent
failure of #4 eng. did not occur.

83/EWB/4/S - F/E/ did not advise Capt. of actions/intentions. No V1\`
call out made. No V1 speed bug used.

83/1ST/2/H - No cross-check by crew on proper and complete execution of
shutdown procedure.

81/EWB/4/I - Poor coordination between Capt. and F/E in accomplishing
engine shutdown.

81/EWB/4/S - Crew failed to coordinate actions for optimum RTO
execution.

81/2ND/3/S - F/E failed to advised Capt. that engine had not failed
completely.

81/2ND/2/I - Crew failed to coordinate interpretation of Engine
Parameter Display Behavior (EPDB) for correct analysis of event.

78/2ND/2/H - Instructor pilot attempting Go-Around while student pilot
was applying brakes.

78/2ND/3/I-1 - Assume action on procedure shared among crew members.

72/EWB/4/I-2 - Malfunction diagnostic process not well coordinated among
crew

71/1ST/4/H - Total lack of crew coordination during loss of control
event.

70/2ND/2/H - Capt. as PNF did not perform his duties of scanning engine
instruments to determine what was happening where; F/O stayed on the
controls after Capt. assumed control and called for control verbally.

69/2ND/2/H - PIC should not have intruded into flying the airplane and
dealing with the engine malfunction

68/1ST/4/HF - Poor crew coordination in dealing with malfunction

[6. Poor piloting skills]{.underline} (closed-loop control skills)

> These errors are specifically related to controlling the flight path
> of the airplane.
>
> 92/MNB/2/HF - Poor systems monitoring
>
> 90/1ST/4/H - Poor execution of braking action
>
> 88/EWB/4/I - Poor airplane control during surge at rotation
>
> 85/2ND/2/HF - Elevator and rudder inputs where exactly the opposite of
> what they should have been.
>
> 83/1ST/4/HF - Poor airplane control on lift off with #4 eng. set at
> reduced power for ferry flight
>
> 83/1ST/2/HF - Lost control during final approach, wing tip caught the
> ground.
>
> 81/1ST/4/H - Lost control when created imbalance by bringing in #2
> reverser with #3 eng. shut down
>
> 81/1ST/4/I - Unstable approach
>
> 73/1ST/2/HF - loss of control during Go-Around. Strange, would have
> expected plane to go in to the left.
>
> 71/1ST/4/H - Loss of control during simulated heavy wt. takeoff

[7. Failure to initiate action in a timely manner]{.underline}

> This is an attempt to capture the timing aspect of errors.
>
> 92/MNB/2/HF - Failed to advance #2 throttle manually at level off;
> failure to assume manual control during thrust asymmetry recovery
>
> 92/MWB/2/I - Failed to address rollback to subidle when it occurred
> (action delayed for over 7 minutes.
>
> 88/EWB/3/I - Failed to immediately reduce power on all engines
>
> 88/2ND/2/I - Failed to immediately deploy "lift dumpers" (spoilers)
>
> 88/EWB/4/I - Failed to correct properly for surge in #4 eng. at
> rotation
>
> 85/EWB/4/S - failure to recover from unusual attitude before losing
> 32,000 ft.
>
> 83/EWB/4/S - F/E failed to advise Capt. of engine failure in a timely
> manner.
>
> 78/EWB/4/S - Delay in initiating RTO at or very near V1 when surge
> occurred
>
> 68/1ST/4/HF - Failure to turn off booster pumps resulted fuel being
> pumped onto the ramp for 20 minutes

**Violations (V)**

Reason (1990) defines two levels of violations. His terms are used here
but the

definitions are specific to this application. Crew actions in these
events were assigned to the following categories when specific evidence
of a violation was documented in the database. Needless to say, this was
very rare. Inferred violations were not recorded.

[1. Routine]{.underline}

These are the more "minor" violations of company policy or procedures
but which can have a major impact on the course of an event.

> 88/MNB/2/S - RTO procedures not briefed before takeoff
>
> 83/EWB/4/S - F/E Reduced throttle instead of calling "engine fail". No
> V1 call

[2. Exceptional]{.underline}

> This category was used when the violation was of a more serious nature
> and had a direct
>
> contribution to the event.
>
> 70/2ND/2/H - Company procedures and applicable flight manuals dictate
> that crew should have continued takeoff with one engine inoperative.
>
> 69/2ND/2/H - Pilot-in-charge took action on the throttles below 700 ft
> in direct violation of company policy (training manual)

**FACTORS THAT CONTRIBUTE TO ERRORS**

These aspects of the events were identified and categorized for the
purpose of providing "context" for the events. Relating contributing
factors to the error data offers the possibility of understanding at
least some of the conditions which have relevance to or seriously impact
human performance and may provide a framework for better understanding
the "why" of human error; [particularly]{.underline} the cognitive
errors.

[1. Data not present or unreadable]{.underline}

> 91/EWB/2/I - Pilot reported vibration so bad couldn't read instruments
> (however, also reported perceived loss of power.)
>
> 86/EWB/2/H - Crew reported lateral vibrations so heavy could not read
> instruments
>
> 85/2ND/2/HF - Outside horizon not visible from this airplane during
> this phase of flight.
>
> 78/EWB/3/I-2 - Condition of runway at stopping end may not have been
> available to the crew although should have been expected given the
> location and time of year.

[2. Workload due to: wx, ATC and Dispatch interface
requirements]{.underline}

> 89/MNB/2/HF - F/O and Capt. talking to ATC and Dispatch several times
> during the event. These communications interrupted crew's attempt to
> coordinate on several occasions. F/O trying unsuccessfully to
> reprogram FMC in decent and initial approach.

[3. Lack training on condition (event + context)]{.underline}

> 96/MWB/4/I - Inferred from general lack of training across airlines on
> surges
>
> 96/MNB/2/I - Inferred from general lack of training across airlines on
> subtle A/T failures

95/EWB/2/HF - Inferred from general lack of training on event across
airlines; F/O as PF was low time

92/MNB/2/HF - No unusual attitude recovery training available to crew

92/EWB/4/I - Takeoff Safety Training Aid not available

91/MNB/2/H - Conditions outside crew training experience

89/MNB/2/HF - Conditions outside crew training experience

88/2ND/2/HF - Crew lacked training on procedures with multiple engine
FOD

88/EWB/4/I - PF lacked training for surge at this point in takeoff under
adverse wind conditions.

86/EWB/2/H - Crew lacked training on RTO decision criteria; Takeoff
Safety Training Aid not published yet.

85/2ND/2/HF - Extensive review of crew training by NTSB documented this

85/EWB/4/I-1 - Inferred from general lack of training on event across
airlines

83/1ST/4/HF - Conditions outside crew training experience

83/1ST/2/HF - Crew had not completed emergency procedures training

81/EWB/4/S - F/E lacked training and/or skill on engine malfunction
identification.

81/2ND/3/S - Capt. lacked takeoff safety training to counter earlier
experience.

78/2ND/2/H - Student pilot not trained on engine loss procedure for
takeoff or Go-Around

77/2ND/3/I - Crew lacked training on criteria for RTO's (assumed based
on time frame)

77/EWB/3/I - Crew lacked training on criteria for RTO's (assumed based
on time frame)

76/EWB/3/I - Crew lacked training on criteria for RTO's (assumed based
on time frame)

73/1ST/2/HF - Conditions outside crew training experience

[4. Little or no experience with condition(s)]{.underline}

96/1ST/4/HF - Inferred from action taken

96/MWB/4/I - Inferred from event occurrence frequency

> 95/EWB/2/HF - Inferred from action or lack of action taken. Low time
> F/O as PF. Same event occurred on same airplane on the previous
> flight.
>
> 92/MNB/2/HF - Lack of experience with condition inferred from actions
>
> 89/MNB/2/HF - Low time crew members in both positions
>
> 88/MNB/2/S - First RTO for either pilot
>
> 88/2ND/2/HF - Inferred from action taken
>
> 86/EWB/2/H - Inferred from action taken
>
> 85/2ND/2/HF - Both pilots low time in type
>
> 85/EWB/4/I-1 - Inferred from action taken
>
> 83/1ST/4/HF - Inferred from actions taken
>
> 83/1ST/2/HF - Inferred from series of inappropriate actions taken.
>
> 78/2ND/2/H - Student pilot's lack of experience caused startle
> reaction and inappropriate response (applying brakes during go-around)

[5. Fatigue]{.underline}

> 96/1ST/4/HF - Inferred from night TO
>
> 69/2ND/2/H - fatigue cited as possible factor in poor judgment
> displayed by PIC's

[6. Weather]{.underline}

> 95/EWB/2/HF - Departure in snow storm
>
> 91/MNB/2/H - Clear ice on wings
>
> 88/EWB/4/I - Squally crosswinds on takeoff
>
> 86/2ND/2/I - Heavy rain
>
> 85/EWB/4/I-1 - Heavy rain showers before event
>
> 81/1ST/4/H - Typhoon conditions for landing, gusty tail and crosswinds
>
> 81/1ST/4/I - unstable ?
>
> 78/EWB/3/I-2 - Blowing snow
>
> 76/EWB/3/I - Rain, sleet, snow, wind
>
> 75/2ND/3/S - Recent rain
>
> 72/2ND/2/S - Raining
>
> 69/1ST/4/S - Shifting winds

[7. Runway conditions]{.underline}

86/2ND/2/I - Very wet runway (standing water?)

85/EWB/4/I-1 - wet runway

81/1ST/4/H - wet runway

81/1ST/4/I - 7.5 kt tailwind

78/EWB/3/I-2 - Snow pack over ice at stopping end of runway

77/EWB/3/I - Wet runway

76/EWB/3/I - Runway contaminated (sleet, rain, snow)

75/2ND/3/S - Wet runway with extensive area of standing water

72/2ND/2/S - Wet runway with pools of standing water

[8. Loss of situation awareness]{.underline}

> 95/EWB/2/HF - Neither member of the crew was aware of why airplane was
> flying the way it was.
>
> 92/MNB/2/HF - Crew not aware of A/T and A/P inputs in response to
> thrust asymmetry produced by malfunctioning throttle system
>
> 85/EWB/4/S - Capt. lost situational awareness while dealing with
> inflight malfunction

[9. Poor/no crew coordination]{.underline}

> 96/1ST/4/HF - Inferred

95/EWB/2/HF - No cross-check by PNF of PF actions or inaction

93/MWB/3/I - Inadequate RTO criteria briefing before takeoff (Inferred
from actions)

92/MNB/2/HF - No cross-check of airplane system conditions by
[both]{.underline} pilots

89/MNB/2/HF - Lack of crew coordination from onset of event to crash

88/MNB/2/S - Capt. as PNF not doing engine instrument scan during
takeoff roll; no positive call out indicating Capt. was taking control
to execute a RTO.

88/EWB/4/S - No clear understanding of criteria or signal for RTO
briefed before takeoff. On taxi out, F/O had asserted emphatically that
[if]{.underline} an RTO were required, HE would execute the procedure.

88/2ND/2/I - No cross-check of procedure items by crew to assure proper
completion

85/EWB/4/I-2 - Poor coordination and cross-checking by crew on true
status of engines and who was doing what to which engine.

85/EWB/4/S - Crew failed to monitor and cross-check engine and flight
instruments.

83/EWB/4/S - F/E failed to keep Capt. advised of his actions/intentions.
No V1 callout.

83/1ST/2/HF - Crew failed to carry out basic airmanship tasks.

82/EWB/4/I - Procedural errors and slips by Capt. and F/E. Lack of crew
coordination.

81/EWB/4/I - Poor coordination of engine shutdown procedure between
Capt. and F/E.

81/EWB/4/S - Poor coordination of RTO procedures

81/2ND/3/S - Capt. not advised by F/E on affected engine EPDB status.

81/1ST/4/I - Crew did not plan effective ATB strategy.

78/2ND/2/H - Student pilot not briefed for this event

78/2ND/3/I-1 - Non-normal procedure execution not coordinated

76/EWB/3/I - Crew failed to coordinate info exchange on propulsion
system status

75/2ND/3/S - Crew failed to coordinate info exchange on propulsion
system status

72/2ND/2/S - - Crew failed to coordinate info exchange on propulsion
system status

70/2ND/2/H - Both pilots were on the control during the RTO; no
verification of airplane status between crew members.

69/2ND/2/H - Affected engine identified by senior pilot in jump seat
whose real purpose was to supervise co-pilot. Senior status of PIC gave
too much weight to his "suggestion". Decisions and flying the airplane
should have been done by the pilot-in-charge.

[10. System(s) fail to operate because of MEL action]{.underline}

> 85/EWB/4/I-1 - Two outboard thrust reversers could not be used - one
> inop.

[11. Bird strike or assumed bird strike]{.underline}

> 93/EWB/4/I-2 - Two large common buzzards in #2 eng.
>
> 92/EWB/4/I - Bird strike initiated surge; no fan blade damage
>
> 88/2ND/2/HF - Multiple bird strikes in both engines
>
> 88/2ND/2/I - Assumed multiple bird strikes from flock of birds on
> runway
>
> 86/EWB/2/H - Ingested black kite bird in #2 eng.
>
> 86/2ND/2/I - Bird strike in #1 eng., at least one seagull
>
> 85/EWB/4/I-1 - Feathers present but no fan blade damage
>
> 78/2ND/2/H - Bird strike on #1 eng. during Go-Around
>
> 69/1ST/4/S - Bird strikes in three of four engines, one with FOD

[12. Conditions not as calculated]{.underline} (weight, wind
speed/direction, etc.)

69/1ST/4/S - Fuel overload due to faulty hydrometer

[13. Night]{.underline}

92/MNB/2/HF

[14. Equipment failure]{.underline}

> 95/EWB/2/HF - #2 throttle stuck at high power setting with A/T
> engaged.
>
> 93/MNB/2/I - Defective torque switch in A/T system suspected;
> Turbomachinery damage
>
> 93/EWB/4/I-1 - Turbomachinery damage and collateral damage to second
> engine
>
> 92/MNB/2/HF - #2 eng. throttle failed to respond to A/T inputs
>
> 92/MWB/2/I - #1 eng. went to subidle at level off to cruise
>
> 91/EWB/2/I - Tire tread ingested into #1 eng., FOD and heavy vibration
>
> 89/MNB/2/HF -Turbomachinery damage on #1 eng.
>
> 88/MNB/2/S - Turbomachinery damage on #1 eng.
>
> 85/EWB/4/H - Throttle cable parted at just the wrong time resulting in
> full forward thrust just as other three engines went into reverse on
> landing.
>
> 85/2ND/2/HF - Uncontained engine failure

[15. Maintenance error(s)]{.underline}

> 72/EWB/4/I-1 - Maintenance error produced leaking O-rings; fuel
> ignited and caused engine fire #3 eng.

[16. Design]{.underline}

96/MNB/2/I - No alert for thrust asymmetry

95/EWB/2/HF - No alert for thrust asymmetry

92/MNB/2/HF - No alert for thrust asymmetry

92/MWB/2/I - No alert for thrust asymmetry

[17. Negative Transfer]{.underline}

92/MNB/2/HF - Previous planes flown by pilots were Russian with ADI
horizon indication the opposite of airplane being flown.

85/EWB/4/S - Failure to recover from unusual attitude before so much
altitude was lost may be due to negative transfer from Russian to USA
ADI's.

95/EWB/2/HF - Low time F/O as PF. Possible Eastern Block ADI experience
involved.

[18. Inadequate/inappropriate procedures in place for
conditions]{.underline}

91/MNB/2/H - Company policy and procedures for dealing with clear ice
removal were inadequate.

72/2ND/2/S - No policy or procedures in operators manual to provide
guidance for pilots with regards to isolated pools of standing water on
the runway.

19. [Procedure not available(no formal procedure exists)]{.underline}

[^1]: Reason, J. (1990), Human Error, Cambridge University Press.

[^2]: Trujillo, Anna C. (1997). Propulsion System Malfunction Plus
    Inappropriate Crew Response. Presentation made at AIA/AECMA Workshop
    on Propulsion System Malfunction + Inappropriate Crew Response,
    Ramada Inn, Seattle, WA., January 14-16.

[^3]: In this context, "integrate" is taken to mean the process of
    gathering data which are relevant to the problem at hand in order to
    develop an accurate "picture" (individual data points plus the
    relationships among them) of the PSM.

[^4]: No errors pertaining to the **Establish Goals** category could be
    inferred because of the very limited nature of the data in the
    Turbofan - DC&ATG Summary Database necessary to appropriately make
    such inferences.

[^5]: Adapted from Rasmussen's (1983) and Reason's (1990) taxonomies for
    classifying information processing failures and interpreted within
    the framework of Shontz's (1997) concept of the data transformation
    process.

[^6]: Wiegmann, D.A. and Shappell, S.A. (1997). Human factors analysis
    of post-accident data: Applying theoretical taxonomies. *The
    International Journal of Aviation Psychology*, [7]{.underline},
    67-81.

[^7]: Shappell, S.A. and Wiegmann, D.A. (1997) A human error approach to
    accident investigation: The taxonomy of unsafe operations. *The
    International Journal of Aviation Psychology*, [7]{.underline}(4),
    269-291.

[^8]: Wildzunas, R.M. (1997). Error analysis of UH-60 single-engine
    emergency procedures. Presented at AIA Workshop III on Propulsion
    System Malfunction + Inappropriate Crew Response, in Atlanta, GA,
    October 7-9, 1997.

[^9]: O'Hare, D., Wiggins, M., Batt, R., Morrison, D. (1994). Cognitive
    failure analysis for aircraft accident investigation. *Ergonomics*,
    [37]{.underline}(11), 1855-1869.

[^10]: Accidents and incidents related to a particular unsafe condition
    appear to be reduced for a period of time following dissemination of
    "awareness" material but eventually return to or near the
    pre-dissemination rate of occurrence.

[^11]: Rasmussen, J. (1982). Human errors: a taxonomy for describing
    human malfunctions in industrial installations. *Journal of
    Occupational Accidents*, [4]{.underline}, 311-333.

[^12]: Reason, J. (1990). *Human Error*, Cambridge: Cambridge University
    Press.

[^13]: Shontz, W.D. (1997) Crew information requirements analysis
    (CIRA). Boeing Document D6-82110.

[^14]: Adapted from Rasmussen's (1983) and Reason's (1990) taxonomies
    for classifying information processing failures and interpreted
    within the framework of Shontz's (1997) concept of the data
    transformation process.

[^15]: Vicente, K. (1997). Should an interface always match the
    operator's mental model? CSERIAC Gateway, Vol. VIII, 1, 1-5.