Pilot Error

Never turn the plane to a dead engine








By Perseus Echeminada  

November 4, 2012

MANILA, Philippines - A combination of pilot error and a defective engine caused the crash of a Piper Seneca aircraft carrying Interior and Local Government Secretary Jesse Robredo off Masbate last Aug.18, investigators said.

Killed with Robredo in the crash were pilot Jessup Bahinting and student pilot Nepalese Khshitiz Chand. Robredo’s aide Police Senior Inspector Jun Abrasado survived the crash.

The plane was en route to Naga City from the Mactan International Airport in Cebu when it went down off Masbate.

A 14-page draft report of a five-man investigating body created by former Transportation and Communications Secretary Manuel Roxas II said the pilot lacked proficiency in handling aircraft in abnormal situations.

The report said that five minutes after take-off, the pilot sought permission from air traffic control to climb to 6,500 feet but was instructed to remain at 2,500 feet until 20 miles out.

Four minutes later the pilot reported the aircraft was at 2,300 feet. That was the last recorded communication of the plane with the Mactan air traffic control.

Data gathered by the Manila Area Control Center (MACC) showed that the Piper Seneca aircraft or flight X4431 was at 4,000 feet heading 353 degrees at 4:07 pm. After eight seconds it was still at the same altitude, moving 340 degrees.

The aircraft disappeared from the radar screen for a few seconds and reappeared at an altitude of 3,900 feet at 010 degrees.

“Twenty-four seconds later the aircraft was still at 3,900 feet altitude with a speed of 80 knots. This time the aircraft was 33.7 kilometers from Masbate and 91.1 km from Mactan. Seconds later the aircraft was monitored at 3,900 feet with speed of 70 knots and heading 345 degrees. This was the last data picked up by MACC before the aircraft disappeared from the radar display,” the report said.

At 4:25 p.m., the aircraft was reported to have crashed in the waters some 1.1 km from the Masbate airport runway 21. 

Survivor’s account
Based on Abrasado’s account, the pilot informed them of engine trouble 23 minutes after takeoff at 3:07 pm.

“Baka hindi umabot ang propeller natin sa Naga. Magbalik tayo Cebu (Our propellers might not be able to make it to Naga. Let’s go back to Cebu),” the pilot was quoted as telling his passengers.

But Abrasado said the plane appeared to be flying normally even on one engine. He texted a staff of Robredo requesting for airline booking for the secretary and himself for the next available flight to Manila.

“Later he (Abrasado ) sensed that the plane was changing direction and at the same time noticed an orange indicator on the instrument panel, initially blinking slowly, and later increasingly faster. Suddenly, he heard a noise and saw the right hand propeller stop, at the same time the orange indicator steadily lit,” the report said.

When Abrasado asked if they were returning to Cebu he was told by Bahinting that they were proceeding to Masbate. The captain reportedly told them of his three failed attempts to restart the engine.

“Suddenly, he (Abrasado) saw the plane slowly veering to the left for final approach to the runway but it seemed to him that the pilot miscalculated the runway and maneuvered the plane too late and they went past the runway,” the report said.

“Then Abrasado looked at the pilot and saw the latter turn his head to the right and glance to the rear over his right shoulder, and remembers seeing his face turn red and eyes wide open (bulging). The airplane turned right and ditched upward, followed by a swift vertical nosedive,” the report said.

Civil Aviation Authority of the Philippines investigator Cesar Lucero told The STAR that turning the plane to the right when the right engine was already dead was a fatal error of the pilot.

“The cardinal rule among pilots is never turn the plane to a dead engine,” he said. 

No pre-flight briefing
Also according to the report, no pre-flight briefing occurred at the Mactan International Airport.

The report also said the student pilot, who was not yet qualified to fly a Piper Seneca, was occupying the pilot’s seat.

Considering that the flight was for a VIP, the student pilot’s Indian flight instructor should have been on the flight and not his student.

The report also questioned the decision of the pilot to continue the flight 23 minutes after he sensed “propeller problem.”

“If the flight returned to Mactan, it would have landed safely with still two engines, as the loss of the right engine was after 38 minutes of flight after the initial propeller problem was noted,” the report stated.

The loss of the right engine was reported 33.7 km from Masbate airport and it took 17 minutes flying on a single left engine before the aircraft crashed 800 meters from the runway.

The report said witnesses testified that the landing gears of the aircraft were deployed.

“The last and fatal decision made was making a right controlled turn toward the dead engine, the aircraft manual says that if turn is made towards a dead engine the aircraft will pitch up about 15 degrees followed by a stall towards the dead engine,” the report said.

“Altitude is the insurance against stalls or spins. Without it recovery is impossible,” it said.

The other findings include: left engine idler shaft was loose, stud screwed to the crank case broken and the slotted nut missing; lock plate damaged; left magneto had evidence of burn; all piston rings stuck up; all piston heads and spark plugs had carbon deposits.
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