G-LAMI PA-46 Rejected Take-off

172driver wrote:

The pilot flying the aircraft was not qualified to do so and prob90 not on the insurance

For a long time my insurance had “any pilot with owner’s permission with >1000 hours” (paraphrased). Last year we were named pilots only but only because the previous policy went up so much.

Having read all comments posted on the case here, I realise we all more or less agree on the mistakes made, and the chain of events.

Being of same age, albeit with 10K less hours than the commander, my take-away is trying to understand what happened in his thinking, or rather lack off. Demo effect, over confidence, misjudgment, assumptions, sales and time pressure, certainly not a good combination. Any I missed?

An interesting thought is that the commander, by delegating the take-off, or at least throttle management, to a non qualified “PF”, might have indirectly prevented a disaster…

PS
Not sure it’s been yet mentioned, but the CAA is intending to publish an article in its ‘Clued Up’ magazine about takeoff decision making and RTO considerations in general aviation

What a ridiculous accident

If the AAIB report was one liner, I would pick this as an accurate description

Quote
might have indirectly prevented a disaster…

Then the 1.5 hours on type…

If the power increased into a red, where a warning lamp ignites, and knowing that some odds are against me (full cabin, short runway) I do not understand why the takeoff roll wasn’t aborted earlier.

I don’t know nothing about engine management of the 350, but take it that @Sebastian_G does. So if the warning light is not usually coming up at full throttle then takeoff should have been aborted at the very moment the red light came up.

@UdoR am guessing a combination of 1. Turbo lag it would take a couple of seconds on reaching full throttle to result in over-boost and 2. Startle and lack of ‘multi crew’ coordination, with unclear PIC decision making role.

If there even had been a take off brief, not clear from the report, it wouldn’t be surprising if the potentially (usually) momentary master red over-boost was not treated as an emergency requiring a rejection of the take off, and then if it remained on, a startle effect resulting in further delay.

Improvised multi crew without proper briefing on a marginal performance take off in an unfamiliar aircraft is a lot of swiss cheese holes lining up quickly.

It’s very possible to overboost the PA46-350P if you just yank the lever forward, that’s why SOP is to increase power to 35” on the brakes, release then gradually push power to max – it’s then very rare to get an overboost if the controller is properly set.

It’s very possible to overboost the PA46-350P if you just yank the lever forward

We did always treat it as a mini turbine. Spool the engine up and down gently. On a car this engine would be unusable due to amazing turbo lag. Now I think about it we never did even try what would happen if the throttle was pushed from idle to full power very fast.

UdoR wrote:

So if the warning light is not usually coming up at full throttle then takeoff should have been aborted at the very moment the red light came up.

Actually this might be an incident caused by modern avionics. Our Mirage had the old analogue instrument. It did not happen as we spooled it up gently but a short overboost would not have been very visible. In a glass cockpit there are two issues. First a red very visible warning might come up and the pilot might be afraid to log any exceedance data in the computer so the tendency to pull back power much faster than in analogue times.

Unfortunately many new planes show way too often red warnings on transient engine data so pilots might get used to live with this. Our Meridian will also do a very short red blink on the prop rpm because the controller will overshoot the 2000rpm by maybe 20 or so rpm. In analogue times nobody did care and modern avionics should focus more on real issues than tiny numeric differences.

Graham wrote:

The flight was private and not an instructional flight, and the PA46 is a single-crew aircraft.

Therefore the commander was the only crew member

No. Part-OPS / NCO is very clear. Is crew anybody that (definition 29 in Annex I of Part-OPS):

• is assigned duties on board the aircraft

Under Part-NCO (see GM1.NCO.OP.180), "any person can be designated as crew member provided that:

• the role, according to the reasonable expectation (…), will enhance the safety of the flight or achieve an operational objective of the flight;
• the person, according to the reasonable expectation (…), is capable of fulfilling the role;
• the person has been briefed on the role as a crew member and informed that they are crew, not a passenger;
• the person agrees to the role as a crew member."

Furthermore,

• Crew members are not considered to be passengers
• Crew members may be required, by specific provisions of this Regulation and other Implementing Rules, to hold licences, ratings or other personnel certificates to fulfil certain roles such as instructor, examiner or flight engineer in certain circumstances

In this definition, when your children are passengers, the nanny can be designated as crew, in charge of taking care of them while you fly the plane. Anyone tasked with helping you “see and avoid” other planes can be designated as crew. In the case at hand, the person in the right front seat was flying the plane under supervision of the PIC. If that’s not a flight crew position…

With respect to “single-crew aircraft”, this does not mean it is forbidden to fly it with more than one crew, it means that one crew is the legal minimum. Not maximum.

RobertL18C wrote:

I never figured out how the PC12 operators (including some under multi crew SOPs) use Denham as the ASDR probably exceeds ASDA.

They are not flying under an commercial OPS, but under Part-NCO (which you can do with employed professional pilots in a syndicate structure)? Under Part-NCO TODR must exceed TODA, there is nothing about ASDR and ASDA, and nothing about a 1.3 or 1.5 safety factor to be added on top.