It had been loaded with five containers of
de-icing fluid, contrary to the approved training organisation’s prohibition on the carriage of
cargo and dangerous goods. One container, loaded in the front right footwell close to the
flying controls, limited the control stick’s available forward movement.
The aircraft was near its maximum permitted takeoff weight and aft centre of gravity limit
when it departed. This, together with the limited control authority available, caused the
accident.
I am puzzled about the comment on dangerous goods prohibition, does the ATO operate under NCO? does their manual state that one can’t carry de-ice fluids in the cockpit?
Ibra wrote:
does their manual state that one can’t carry de-ice fluids in the cockpit?
Apparently!
I do hope this young pilot has made a recovery to full health. This is a large organisation, and it is surprising the underlying commercial pressure in the background. Relatively very young and inexperienced instructor, but a Deputy CFI, trying to get the job done. The DA-40 has benign stall characteristics, so the outcome is probably better than in other types.
No mention of the typical safety management systems apparatus that you would find in a typical multi location integrated school: risk assessment tools integrated into operational dispatch procedures, health and safety oversight over dangerous goods onsite, flight recording and flight data monitoring (which could aid in the accident investigation), etc
Funny they emphasize DGR labeling ;)
Too much regulator addiction for paper flying, manuals and important heads/chiefs who take their jobs so seriously they order loading of huge canisters into a DA40. Fancy marketing. More and more of it required to hide the rotten core?
Dries apparently had the idea for composite aircraft watching Formula 1 races and seeing drivers emerge from brutal crashes unscathed. He reckoned the energies involved are similar for light aircraft and designed the planes around a safety cage. Seems like this guy benefited from it as have many others.
Snoopy wrote:
Sounds like safety is a big paper exercise, nothing more
Not in most ATOs, even in smaller ATOs I have worked with we had two days of professional CRM annually, very visible safety officers with good leadership skills, and safety monitoring systems. I fear this was the case of a remote base that had developed a weak safety culture.
It is puzzling how much emphasis they put on the content of the containers, while the problem was that he put something in the front seat that (partly) blocked the controls.
If the de-icing fluid was replaced by packages potatoes the crash could also have happened if loaded the same.
The lesson learned should be more about be careful when loading something in the front seat (as it could shift). Instead of an incorrect labeled de-icing fluid.
It is all too normal that in these reports, the focus is put is on some bureaucratic/regulatory side aspect (because bureaucrats are good at that), whilst the point is much easier and as you say: never load any cargo in the footwell or on the frontseat of an an aircraft with stick controls. That belongs into basic pilot training (and also is common sense) and has nothing to do with “safety management systems”.
Bingo!
@RickB couldn’t agree more. The content of the containers was totally irrelevant to the outcome of the flight. But hey, that’s British Health & Safety madness run wild.
What surprises me a bit in this sad saga is that the pilot apparently did a ‘free and correct’ check and didn’t notice anything amiss.
