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philperry9
Joined: 23 Nov 2011
Posts: 381
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 Posted: Thu Apr 09, 2015 8:53 pm Post subject: NTSB - Probable Cause |
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Some of you might have seen this already, but Doug Nebert's probable cause was published today. This was the accident in Oregon last May. (2 Fatal - 1 Serious)
In case the links do not work, the case ID is WPR14FA218 so you can look it up yourself.
I will give you the nutshell, but you need to go read the documents. RTV was used to seal NPT fittings on a (recently installed) fuel flow transducer. A ~0.25" chuckof RTV came loose and flowed downstream into the metered nozzle of the transducer. The metered hole was ~0.115" in diameter and the RTV plugged the hole and starved the engine of fuel. To make matters worse, a stall (and likely the start of a spin) occurred during the forced landing.
This is worth a read. There were other indications of an aircraft with questionable maintenance, but the event that brought down this airplane was 100% preventable. The real disappointing part is that the issue was pointed out by a friend but ignored.
Even if we don't have RTV on our fuel lines (I hope we don't - Same thing for Teflon Tape), there is a lesson in here for all of us. It doesn't do us any good to share information and concerns with each other if we aren't going to take a moment to stop in our tracks and seriously listen to them. Ears open, mouth closed, stop, and think. I'm as guilty as the next person, but this is a case where we can all reset ourselves and improve our fleets record.
Phil
[quote][b]
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flying-nut(at)cfl.rr.com
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| Posted: Fri Apr 10, 2015 4:11 am Post subject: NTSB - Probable Cause |
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This whole story really saddens me. In the 34 years I've been around experimentals I've seen a lot of 'stupid builder tricks' done by intelligent, knowledgeable builders. I rank them up with running out of fuel and VFR pilots flying into IFR conditions. How does it happen? What thought process took them down the path to the ultimate failure???
I've seen experimentals I wouldn't even sit in, much less fly in. Glaring construction practices ..... not hidden like this case ..... where a lot of 'counseling' was ignored, resulting in a fatal accident. Many were personal friends.
In this case the builder was informed of a prior, improper use of RTV, but it didn't matter. It's sad, but our hobby is shot through with 'experts' that also think 'their way is a better way', and the newbie builder is cannon fodder for their misguided information.
I'm guilty of failing to 'just build it' ..... I don't like the way some things are done ..... but the mods are done with all the information found in AC 43-13. I really feel that no builder should be given an airworthiness certificate unless he/she produces their own copy. It would have saved a fair amount of lives.
Over the years I've tried to learn what went wrong in an accident scenario, not just the cause, but where/how the failure came to be. This one was obvious, many others are sinister and lie it wait for years. Phil is spot on .... we are our brothers keeper ......
As a point of perspective, we read/hear/know of an accident where a highly skilled (famous, prolific builder, pilot, etc.) is no longer with us because of an aviation accident ..... if they go west prematurely, what chance do I have to grow old and die of natural causes??? All I can do is try to learn from their demise and become more knowledgeable, and hopefully make the proper decisions down the road.
If you deviate from the norm (it's that mod thingy again) please get as many opinions and sets of eyes as you can, just in case there's a flaw in your thought process. What you learn may not be entirely correct, but the discussion adds immeasurably to your analysis.
I now relinquish the soapbox.
Linn
On 4/10/2015 12:50 AM, Phillip Perry wrote:
[quote] Some of you might have seen this already, but Doug Nebert's probable cause was published today. This was the accident in Oregon last May. (2 Fatal - 1 Serious)
In case the links do not work, the case ID is WPR14FA218 so you can look it up yourself.
I will give you the nutshell, but you need to go read the documents. RTV was used to seal NPT fittings on a (recently installed) fuel flow transducer. A ~0.25" chuckof RTV came loose and flowed downstream into the metered nozzle of the transducer. The metered hole was ~0.115" in diameter and the RTV plugged the hole and starved the engine of fuel. To make matters worse, a stall (and likely the start of a spin) occurred during the forced landing.
This is worth a read. There were other indications of an aircraft with questionable maintenance, but the event that brought down this airplane was 100% preventable. The real disappointing part is that the issue was pointed out by a friend but ignored.
Even if we don't have RTV on our fuel lines (I hope we don't - Same thing for Teflon Tape), there is a lesson in here for all of us. It doesn't do us any good to share information and concerns with each other if we aren't going to take a moment to stop in our tracks and seriously listen to them. Ears open, mouth closed, stop, and think. I'm as guilty as the next person, but this is a case where we can all reset ourselves and improve our fleets record.
Phil
No virus found in this message.
Checked by AVG - www.avg.com
04/09/15 [b]
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Tim Olson
Joined: 25 Jan 2007
Posts: 2879
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| Posted: Fri Apr 10, 2015 7:22 am Post subject: NTSB - Probable Cause |
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Phil,
Thanks for posting. That's just sickening to read. Regarding Linn's
post, I truly think that the people who most often do the very
questionable things are also the ones that will never listen
to the advice, so it's a hopeless plea, sadly. I think back
to how many times I had to get on Dan Lloyd and he never
listened once. This particular accident/pilot was far less
lax than Dan was, but still, there are just far too many things
in the report to allow me to just think "well, at least he
knew what he was doing". It was a shocking read, and horrifying
when you consider the discussion about the crash and the child,
and see the numerous pictures of the plane. There isn't anything
left of the front end, and you can't blame the angle of impact
on anything but poor piloting, even if you excuse the RTV
use. This accident didn't have to end this way.
Some things I noted...
The fuel handle was installed reverse indicating. Why? Why
can't a pilot understand that things like that are critical,
and you need to install them so that ANYONE can understand
them?
Of course, the RTV on the NPT threads... So how many times
do we have to discuss this? No teflon tape, no RTV. Fuel
lube I guess is the common one, which is good. If you use
a paste of any type, or even in the case of anti-seize on
spark plugs, you don't put it on the first couple threads.
These are just common knowledge practices. You don't want
to contaminate the inside, nor give opportunity for the
compound to come off inside.
Here's one I'm not familiar with. The electric fuel pump
was a "Facet Automotive". Someone else help me out here
as I'm not familiar with the carbureted RV-10 fuel system.
Is that a normal pump, or something hacked in? I know
Facet pumps are used often, but is that the proper pump?
Fuel systems aren't something to screw with, so hopefully
that was the right one.
The fuel selector position, and key position it's hard
to interpret. Not good for trying a restart, but
the fuel valve off for the crash is a good thing. Not
sure what to think about the key position though.
There seem to be numerous issues with the plane. I hate it
when I hear of people flying continually and regularly without
addressing an issue. I mean, he was frustrated with
the "constant hassle" of having to reset the alternator
in flight. REALLY!?!? I think if mine blows ONCE I need
to look at it. Twice and it's an issue for sure. But
constantly in flight? WTF are you doing carrying passengers
if this is the case?!?! That blows my mind.
Then there's the 125psi fuel pressure. Again, you have
an indication like that and you just fly it?!?!?! I met
a guy once who never calibrated his engine sensors.
You have to add proper scale factors and offsets for
them to even read accurately. He adjusted his oil pressure
on the engine to match his NON-setup instrument. Then
found out how to set the instrument up from me.
WTF is that about!?! You didn't have time to do that
before you first flew? Far better than killing yourself!
My only comment to people like that is "THINK!!!!"
Then there's the comments from people that they tried
to start the engine and the "stater wasn't connected" which
it sounds like is actually that the starter was falling
off the engine and not making contact. He had heard
it making noise on previous flights and now it wouldn't
start. Again, REALLY? You hear something odd and
don't investigate it?
Another one... the Prop only made 2450 RPM, but that's the
way it's always been so it wasn't fixed. REALLY!?!?!?
So something as important as your engine making the
power it needs to isn't important to you? Truly I say,
here is someone who just didn't give a crap about
doing things "right". There are too many indicators.
Didn't put the fuel transducer in earlier because it needed
a certain amount of space and had to bend tubing to do it.
Gosh, so that's a reason to just not install it then?
Then finally DID put it in, but used RTV and didn't connect
any wiring to it. This should have been done PRIOR
to the first flight.
And I don't care if you're Sean Tucker, if you're flying
a carbureted airplane you shouldn't consider yourself
"not a big proponent of carb heat" if you're going to
fly IFR (or even VFR). Carb heat provides a very
specific function. If you want to ignore it on your
landing prep, that's one thing, but if you dang well
better know when is a good time to think about using it.
And finally, a plea from me, to you. If you're not someone
who's going to thoughtfully approach your build, and try
to do things right, please try to refrain from using my
name in your internet postings. I know, I know, his
Andair fuel valve install wasn't involved in the crash
cause at all, other than maybe the fact that he put the
handle on reversed, but I wasn't thrilled about seeing
that he referred to me in his forum post. If you like
what you see, copy it, but if you're doing all sorts
of other stupid things, just leave my name out of it.
It's like not calling it a "Van's RV-10" if you're
going to significantly modify the airframe. I don't
need to be tied to your improper methods of build or
maintenance. Better yet, just try to do everything to
certified aircraft standards and procedures and you
won't have to worry about what your NTSB report reads
like (or at least cut your chance).
Sorry, that may have been part analysis, part rant, but
it drives me nuts to see some of the things that bring down
planes, especially RV-10's. So far there's been only a
very tiny fraction of accidents that were not directly
attributable to something stupid that someone did.
Let's try to eliminate those sorts of things because
we'd have a *near* spotless safety record on our make and
model if you eliminated the things that were pure
ignorance and idiocy.
Tim
On 4/9/2015 11:50 PM, Phillip Perry wrote:
| Quote: | Some of you might have seen this already, but Doug Nebert's probable
cause was published today. This was the accident in Oregon last May.
(2 Fatal - 1 Serious)
* The probable cause document
<http://www.ntsb.gov/_layouts/ntsb.aviation/GeneratePDF.aspx?id=WPR14FA218&rpt=fi>
is a humbling read...
* Every document in the entire docket
<http://dms.ntsb.gov/pubdms/search/hitlist.cfm?docketID=57129&CFID=524058&CFTOKEN=34830451>
is worth the read...
* Specifically the photos in this document
<http://dms.ntsb.gov/public%2F57000-57499%2F57129%2F570028.pdf> are
full of emotion. Anger, Sadness, Disbelief, Confusion.
In case the links do not work, the case ID is WPR14FA218 so you can look
it up yourself.
I will give you the nutshell, but you need to go read the documents.
RTV was used to seal NPT fittings on a (recently installed) fuel flow
transducer. A ~0.25" chuckof RTV came loose and flowed downstream into
the metered nozzle of the transducer. The metered hole was ~0.115" in
diameter and the RTV plugged the hole and starved the engine of fuel.
To make matters worse, a stall (and likely the start of a spin) occurred
during the forced landing.
This is worth a read. There were other indications of an aircraft with
questionable maintenance, but the event that brought down this airplane
was 100% preventable. The real disappointing part is that the issue was
pointed out by a friend but ignored.
Even if we don't have RTV on our fuel lines (I hope we don't - Same
thing for Teflon Tape), there is a lesson in here for all of us. It
doesn't do us any good to share information and concerns with each other
if we aren't going to take a moment to stop in our tracks and seriously
listen to them. Ears open, mouth closed, stop, and think. I'm as
guilty as the next person, but this is a case where we can all reset
ourselves and improve our fleets record.
Phil
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jdriggs49(at)msn.com
Guest
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| Posted: Fri Apr 10, 2015 8:28 am Post subject: NTSB - Probable Cause |
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Tim,
I seem to remember an RV-10 that crashed about seven years ago and it was reported to still have clecos holding the cowl on. That's not what caused the wreck and death but was symptomatic of the whole thing. As I remember it was ruled a stall-spin, as usual!😜
| Quote: | Date: Fri, 10 Apr 2015 10:19:52 -0500
From: Tim@MyRV10.com
To: rv10-list@matronics.com
Subject: Re: RV10-List: NTSB - Probable Cause
--> RV10-List message posted by: Tim Olson <Tim@myrv10.com>
Phil,
Thanks for posting. That's just sickening to read. Regarding Linn's
post, I truly think that the people who most often do the very
questionable things are also the ones that will never listen
to the advice, so it's a hopeless plea, sadly. I think back
to how many times I had to get on Dan Lloyd and he never
listened once. This particular accident/pilot was far less
lax than Dan was, but still, there are just far too many things
in the report to allow me to just think "well, at least he
knew what he was doing". It was a shocking read, and horrifying
when you consider the discussion about the crash and the child,
and see the numerous pictures of the plane. There isn't anything
left of the front end, and you can't blame the angle of impact
on anything but poor piloting, even if you excuse the RTV
use. This accident didn't have to end this way.
Some things I noted...
The fuel handle was installed reverse indicating. Why? Why
can't a pilot understand that things like that are critical,
and you need to install them so that ANYONE can understand
them?
Of course, the RTV on the NPT threads... So how many times
do we have to discuss this? No teflon tape, no RTV. Fuel
lube I guess is the common one, which is good. If you use
a paste of any type, or even in the case of anti-seize on
spark plugs, you don't put it on the first couple threads.
These are just common knowledge practices. You don't want
to contaminate the inside, nor give opportunity for the
compound to come off inside.
Here's one I'm not familiar with. The electric fuel pump
was a "Facet Automotive". Someone else help me out here
as I'm not familiar with the carbureted RV-10 fuel system.
Is that a normal pump, or something hacked in? I know
Facet pumps are used often, but is that the proper pump?
Fuel systems aren't something to screw with, so hopefully
that was the right one.
The fuel selector position, and key position it's hard
to interpret. Not good for trying a restart, but
the fuel valve off for the crash is a good thing. Not
sure what to think about the key position though.
There seem to be numerous issues with the plane. I hate it
when I hear of people flying continually and regularly without
addressing an issue. I mean, he was frustrated with
the "constant hassle" of having to reset the alternator
in flight. REALLY!?!? I think if mine blows ONCE I need
to look at it. Twice and it's an issue for sure. But
constantly in flight? WTF are you doing carrying passengers
if this is the case?!?! That blows my mind.
Then there's the 125psi fuel pressure. Again, you have
an indication like that and you just fly it?!?!?! I met
a guy once who never calibrated his engine sensors.
You have to add proper scale factors and offsets for
them to even read accurately. He adjusted his oil pressure
on the engine to match his NON-setup instrument. Then
found out how to set the instrument up from me.
WTF is that about!?! You didn't have time to do that
before you first flew? Far better than killing yourself!
My only comment to people like that is "THINK!!!!"
Then there's the comments from people that they tried
to start the engine and the "stater wasn't connected" which
it sounds like is actually that the starter was falling
off the engine and not making contact. He had heard
it making noise on previous flights and now it wouldn't
start. Again, REALLY? You hear something odd and
don't investigate it?
Another one... the Prop only made 2450 RPM, but that's the
way it's always been so it wasn't fixed. REALLY!?!?!?
So something as important as your engine making the
power it needs to isn't important to you? Truly I say,
here is someone who just didn't give a crap about
doing things "right". There are too many indicators.
Didn't put the fuel transducer in earlier because it needed
a certain amount of space and had to bend tubing to do it.
Gosh, so that's a reason to just not install it then?
Then finally DID put it in, but used RTV and didn't connect
any wiring to it. This should have been done PRIOR
to the first flight.
And I don't care if you're Sean Tucker, if you're flying
a carbureted airplane you shouldn't consider yourself
"not a big proponent of carb heat" if you're going to
fly IFR (or even VFR). Carb heat provides a very
specific function. If you want to ignore it on your
landing prep, that's one thing, but if you dang well
better know when is a good time to think about using it.
And finally, a plea from me, to you. If you're not someone
who's going to thoughtfully approach your build, and try
to do things right, please try to refrain from using my
name in your internet postings. I know, I know, his
Andair fuel valve install wasn't involved in the crash
cause at all, other than maybe the fact that he put the
handle on reversed, but I wasn't thrilled about seeing
that he referred to me in his forum post. If you like
what you see, copy it, but if you're doing all sorts
of other stupid things, just leave my name out of it.
It's like not calling it a "Van's RV-10" if you're
going to significantly modify the airframe. I don't
need to be tied to your improper methods of build or
maintenance. Better yet, just try to do everything to
certified aircraft standards and procedures and you
won't have to worry about what your NTSB report reads
like (or at least cut your chance).
Sorry, that may have been part analysis, part rant, but
it drives me nuts to see some of the things that bring down
planes, especially RV-10's. So far there's been only a
very tiny fraction of accidents that were not directly
attributable to something stupid that someone did.
Let's try to eliminate those sorts of things because
we'd have a *near* spotless safety record on our make and
model if you eliminated the things that were pure
ignorance and idiocy.
Tim
On 4/9/2015 11:50 PM, Phillip Perry wrote:
> Some of you might have seen this already, but Doug Nebert's probable
> cause was published today. This was the accident in Oregon last May.
> (2 Fatal - 1 Serious)
>
> * The probable cause document
> <http://www.ntsb.gov/_layouts/ntsb.aviation/GeneratePDF.aspx?id=WPR14FA218&rpt=fi>
> is a humbling read...
> * Every document in the entire docket
> <http://dms.ntsb.gov/pubdms/search/hitlist.cfm?docketID=57129&CFID=524058&CFTOKEN=34830451>
> is worth the read...
> * Specifically the photos in this document
> <http://dms.ntsb.gov/public%2F57000-57499%2F57129%2F570028.pdf> are
> full of emotion. Anger, Sadness, Disbelief, Confusion.
>
> In case the links do not work, the case ID is WPR14FA218 so you can look
> it up yourself.
>
> I will give you the nutshell, but you need to go read the documents.
> RTV was used to seal NPT fittings on a (recently installed) fuel flow
> transducer. A ~0.25" chuckof RTV came loose and flowed downstream into
> the metered nozzle of the transducer. The metered hole was ~0.115" in
> diameter and the RTV plugged the hole and starved the engine of fuel.
> To make matters worse, a stall (and likely the start of a spin) occurred
> during the forced landing.
>
> This is worth a read. There were other indications of an aircraft with
> questionable maintenance, but the event that brought down this airplane
> was 100% preventable. The real disappointing part is that the issue was
> pointed out by a friend but ignored.
>
> Even if we don't have RTV on our fuel lines (I hope we don't - Same
> thing for Teflon Tape), there is a lesson in here for all of us. It
> doesn't do us any good to share information and concerns with each other
> if we aren't going to take a moment to stop in our tracks and seriously
> listen to them. Ears open, mouth closed, stop, and think. I'm as
> guilty as the next person, but this is a case where we can all reset
> ourselves and improve our fleets record.
>
> Phil
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Dick Sipp
Joined: 11 Jan 2006
Posts: 215
Location: Hope, MI
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| Posted: Fri Apr 10, 2015 8:36 am Post subject: NTSB - Probable Cause |
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Tim,
This needed to be said and you did it well. We all need to be reminded
periodically that this is serious business.
We should be taking pride in learning how to build and fly our planes to the
best of our ability rather than looking for shortcuts.
I remember well trying to find a way to console Dan's wife at his funeral.
Not fun.
Dick Sipp
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rv10flyer(at)live.com
Guest
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| Posted: Fri Apr 10, 2015 8:41 am Post subject: NTSB - Probable Cause |
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Tim;
Your rant is merited. As you know I and I'm sure many others respect you and
your integrity with building. Dan served as a sad but great motivator to me
to assure I NEVER fly anyone in my plane until I know it is perfectly (or as
perfect as I can expect). Your feedback on that accident served as large
part of my CAP presentation many years ago. When I went through "you’re the
inspector" and showed the events many thought I made up the whole story up
it was so far fetched that anyone would do this. I agree that 4 years later
we find that another person followed the same road. when I was given my
Airworthiness, but the same person who was my Technical Counselor, who
insisted in seeing the various phases of my build before signing off the
final pink slip, he would not allow me to pass without showing him the panel
and the steps I took to assure it met the "initial airspeed and gauge
ranges". The fact was simple in his mind.. The first flight is when
something may show up.. in my case way high oil pressure, that is no time to
determine you have an issue. For someone to go so many hours without an
issue is amazing in itself, but to be so naïve to fly another person in such
a poorly managed airplane is another Dan episode.
I have been told, more than once, that what I am doing isnt necessary, but
anyone who knows me knows that I take hours researching GAMI folks, EAA
speakers and Lycoming and come up with my own theory on engine temps and if
"its normal". point here is not one person but a few comments that I
consider. I usually take the experienced folks I know, one being in a
airpark in Texas and listen carefully for what, when needed I should change.
This forum is full of ideas, most are excellent some overkill, but I still
take your feedback very seriously Tim, and when you play such a huge part in
a forum, writing articles for magazines and being a -10 (soon to be -14)
guru, your name will come up.
There is that 1% of builders who will make the rest of us look bad, but from
what I have seen and the folks I have met, there is 99% solid folks who
really are concerned about doing a proper annual and certifying they
actually did everything. I am constantly looking at other demises, some are
just bad luck and planning, some plain "Darwin award candidates" but some
are something I have found myself being in at one point, the decision of a
NTSB report was recalled and I made a decision based on "lessons learned",
in that case in Texas, we landed, all it was was a rain shower (with huge
clouds exploding up) but I was tempted to go on, Im here and the decision
may have been overkill, but at least can see that the plane is safely
sitting in the hangar for the next flight today.
Yes, this event is a sad one, hopefully none of us will learn anything,
other than don’t cut corners and use the wrong product for the job, but it
may be a reminder for something we have done that may cause us to consider
changing how we did it. (use a torque wrench on a fitting versus it "being
tight enough", etc)
Our first day of Officer basic in Fort Rucker we had an officer walk across
the grass, versus walking on the walkway. The Commander at the time told us
all that "if we cut corners on something as simple as following the walkway,
we would find ourselves cutting corners in the way we lived our lives and in
the aircraft"
Be safe and enjoy the flight!
Pascal
--
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rv10flyer(at)live.com
Guest
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| Posted: Fri Apr 10, 2015 8:43 am Post subject: NTSB - Probable Cause |
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that’s the Dan story Tim was alluding to- http://rvnewsletter.blogspot.com/2009/06/dan-lloyd-crash.html
From: Danny Riggs (jdriggs49(at)msn.com)
Sent: Friday, April 10, 2015 9:24 AM
To: rv10-list(at)matronics.com (rv10-list(at)matronics.com)
Subject: RE: NTSB - Probable Cause
Tim,
I seem to remember an RV-10 that crashed about seven years ago and it was reported to still have clecos holding the cowl on. That's not what caused the wreck and death but was symptomatic of the whole thing. As I remember it was ruled a stall-spin, as usual!😜
| Quote: | Date: Fri, 10 Apr 2015 10:19:52 -0500
From: Tim(at)MyRV10.com
To: rv10-list(at)matronics.com
Subject: Re: NTSB - Probable Cause
--> RV10-List message posted by: Tim Olson <Tim(at)myrv10.com>
Phil,
Thanks for posting. That's just sickening to read. Regarding Linn's
post, I truly think that the people who most often do the very
questionable things are also the ones that will never listen
to the advice, so it's a hopeless plea, sadly. I think back
to how many times I had to get on Dan Lloyd and he never
listened once. This particular accident/pilot was far less
lax than Dan was, but still, there are just far too many things
in the report to allow me to just think "well, at least he
knew what he was doing". It was a shocking read, and horrifying
when you consider the discussion about the crash and the child,
and see the numerous pictures of the plane. There isn't anything
left of the front end, and you can't blame the angle of impact
on anything but poor piloting, even if you excuse the RTV
use. This accident didn't have to end this way.
Some things I noted...
The fuel handle was installed reverse indicating. Why? Why
can't a pilot understand that things like that are critical,
and you need to install them so that ANYONE can understand
them?
Of course, the RTV on the NPT threads... So how many times
do we have to discuss this? No teflon tape, no RTV. Fuel
lube I guess is the common one, which is good. If you use
a paste of any type, or even in the case of anti-seize on
spark plugs, you don't put it on the first couple threads.
These are just common knowledge practices. You don't want
to contaminate the inside, nor give opportunity for the
compound to come off inside.
Here's one I'm not familiar with. The electric fuel pump
was a "Facet Automotive". Someone else help me out here
as I'm not familiar with the carbureted RV-10 fuel system.
Is that a normal pump, or something hacked in? I know
Facet pumps are used often, but is that the proper pump?
Fuel systems aren't something to screw with, so hopefully
that was the right one.
The fuel selector position, and key position it's hard
to interpret. Not good for trying a restart, but
the fuel valve off for the crash is a good thing. Not
sure what to think about the key position though.
There seem to be numerous issues with the plane. I hate it
when I hear of people flying continually and regularly without
addressing an issue. I mean, he was frustrated with
the "constant hassle" of having to reset the alternator
in flight. REALLY!?!? I think if mine blows ONCE I need
to look at it. Twice and it's an issue for sure. But
constantly in flight? WTF are you doing carrying passengers
if this is the case?!?! That blows my mind.
Then there's the 125psi fuel pressure. Again, you have
an indication like that and you just fly it?!?!?! I met
a guy once who never calibrated his engine sensors.
You have to add proper scale factors and offsets for
them to even read accurately. He adjusted his oil pressure
on the engine to match his NON-setup instrument. Then
found out how to set the instrument up from me.
WTF is that about!?! You didn't have time to do that
before you first flew? Far better than killing yourself!
My only comment to people like that is "THINK!!!!"
Then there's the comments from people that they tried
to start the engine and the "stater wasn't connected" which
it sounds like is actually that the starter was falling
off the engine and not making contact. He had heard
it making noise on previous flights and now it wouldn't
start. Again, REALLY? You hear something odd and
don't investigate it?
Another one... the Prop only made 2450 RPM, but that's the
way it's always been so it wasn't fixed. REALLY!?!?!?
So something as important as your engine making the
power it needs to isn't important to you? Truly I say,
here is someone who just didn't give a crap about
doing things "right". There are too many indicators.
Didn't put the fuel transducer in earlier because it needed
a certain amount of space and had to bend tubing to do it.
Gosh, so that's a reason to just not install it then?
Then finally DID put it in, but used RTV and didn't connect
any wiring to it. This should have been done PRIOR
to the first flight.
And I don't care if you're Sean Tucker, if you're flying
a carbureted airplane you shouldn't consider yourself
"not a big proponent of carb heat" if you're going to
fly IFR (or even VFR). Carb heat provides a very
specific function. If you want to ignore it on your
landing prep, that's one thing, but if you dang well
better know when is a good time to think about using it.
And finally, a plea from me, to you. If you're not someone
who's going to thoughtfully approach your build, and try
to do things right, please try to refrain from using my
name in your internet postings. I know, I know, his
Andair fuel valve install wasn't involved in the crash
cause at all, other than maybe the fact that he put the
handle on reversed, but I wasn't thrilled about seeing
that he referred to me in his forum post. If you like
what you see, copy it, but if you're doing all sorts
of other stupid things, just leave my name out of it.
It's like not calling it a "Van's RV-10" if you're
going to significantly modify the airframe. I don't
need to be tied to your improper methods of build or
maintenance. Better yet, just try to do everything to
certified aircraft standards and procedures and you
won't have to worry about what your NTSB report reads
like (or at least cut your chance).
Sorry, that may have been part analysis, part rant, but
it drives me nuts to see some of the things that bring down
planes, especially RV-10's. So far there's been only a
very tiny fraction of accidents that were not directly
attributable to something stupid that someone did.
Let's try to eliminate those sorts of things because
we'd have a *near* spotless safety record on our make and
model if you eliminated the things that were pure
ignorance and idiocy.
Tim
On 4/9/2015 11:50 PM, Phillip Perry wrote:
> Some of you might have seen this already, but Doug Nebert's probable
> cause was published today. This was the accident in Oregon last May.
> (2 Fatal - 1 Serious)
>
> * The probable cause document
> <http://www.ntsb.gov/_layouts/ntsb.aviation/GeneratePDF.aspx?id=WPR14FA218&rpt=fi>
> is a humbling read...
> * Every document in the entire docket
> <http://dms.ntsb.gov/pubdms/search/hitlist.cfm?docketID=57129&CFID=524058&CFTOKEN=34830451>
> is worth the read...
> * Specifically the photos in this document
> <http://dms.ntsb.gov/public%2F57000-57499%2F57129%2F570028.pdf> are
> full of emotion. Anger, Sadness, Disbelief, Confusion.
>
> In case the links do not work, the case ID is WPR14FA218 so you can look
> it up yourself.
>
> I will give you the nutshell, but you need to go read the documents.
> RTV was used to seal NPT fittings on a (recently installed) fuel flow
> transducer. A ~0.25" chuckof RTV came loose and flowed downstream into
> the metered nozzle of the transducer. The metered hole was ~0.115" in
> diameter and the RTV plugged the hole and starved the engine of fuel.
> To make matters worse, a stall (and likely the start of a spin) occurred
> during the forced landing.
>
> This is worth a read. There were other indications of an aircraft with
> questionable maintenance, but the event that brought down this airplane
> was 100% preventable. The real disappointing part is that the issue was
> pointed out by a friend but ignored.
>
> Even if we don't have RTV on our fuel lines (I hope we don't - Same
> thing for Teflon Tape), there is a lesson in here for all of us. It
> doesn't do us any good to share information and concerns with each other
> if we aren't going to take a moment to stop in our tracks and seriously
> listen to them. Ears open, mouth closed, stop, and think. I'm as
> guilty as the next person, but this is a case where we can all reset
> ourselves and improve our fleets record.
>
> Phil
Navigator to Un/Subscription,
via the Web http://forums.matronics.com
http://www.matronics.com/contribution
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jdriggs49(at)msn.com
Guest
|
| Posted: Fri Apr 10, 2015 8:49 am Post subject: NTSB - Probable Cause |
|
|
I think it's somewhat of an ego thing to a certain degree. It's hard on our egos when somebody calls out something we have done wrong on our "babies"!
Flying is very unforgiving when our egos get in the way. Unfortunately the family usually pays the ultimate long term price
| Quote: | From: rsipp@earthlink.net
To: rv10-list@matronics.com
Subject: Re: RV10-List: NTSB - Probable Cause
Date: Fri, 10 Apr 2015 12:34:08 -0400
--> RV10-List message posted by: <rsipp@earthlink.net>
Tim,
This needed to be said and you did it well. We all need to be reminded
periodically that this is serious business.
We should be taking pride in learning how to build and fly our planes to the
best of our ability rather than looking for shortcuts.
I remember well trying to find a way to console Dan's wife at his funeral.
Not fun.
Dick Sipp
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jdriggs49(at)msn.com
Guest
|
| Posted: Fri Apr 10, 2015 8:57 am Post subject: NTSB - Probable Cause |
|
|
Ahhh! It's been so long that I'd forgotten who it was. I still remember some of the lessons of that crash however!
From: rv10flyer(at)live.com
To: rv10-list(at)matronics.com
Subject: Re: RV10-List: NTSB - Probable Cause
Date: Fri, 10 Apr 2015 09:40:08 -0700
that’s the Dan story Tim was alluding to- http://rvnewsletter.blogspot.com/2009/06/dan-lloyd-crash.html
From: Danny Riggs
Sent: Friday, April 10, 2015 9:24 AM
To: rv10-list(at)matronics.com
Subject: RE: RV10-List: NTSB - Probable Cause
Tim,
I seem to remember an RV-10 that crashed about seven years
ago and it was reported to still have clecos holding the cowl on. That's not
what caused the wreck and death but was symptomatic of the whole thing. As I
remember it was ruled a stall-spin, as usual!😜
| Quote: | Date: Fri, 10 Apr
2015 10:19:52 -0500
|
| Quote: | Subject: Re: RV10-List: NTSB - Probable
Cause
|
| Quote: |
<Tim(at)myrv10.com>
|
| Quote: |
Phil,
Thanks for posting. That's
just sickening to read. Regarding Linn's
|
| Quote: | post, I truly think that the
people who most often do the very
|
| Quote: | questionable things are also the ones
that will never listen
|
| Quote: | to the advice, so it's a hopeless plea, sadly. I
think back
|
| Quote: | to how many times I had to get on Dan Lloyd and he
never
|
| Quote: | listened once. This particular accident/pilot was far less
lax than Dan was, but still, there are just far too many things
|
| Quote: | in the
report to allow me to just think "well, at least he
|
| Quote: | knew what he was
doing". It was a shocking read, and horrifying
|
| Quote: | when you consider the
discussion about the crash and the child,
|
| Quote: | and see the numerous pictures
of the plane. There isn't anything
|
| Quote: | left of the front end, and you can't
blame the angle of impact
|
| Quote: | on anything but poor piloting, even if you
excuse the RTV
|
| Quote: | use. This accident didn't have to end this way.
|
| Quote: | Some things I noted...
The fuel handle was installed
reverse indicating. Why? Why
|
| Quote: | can't a pilot understand that things like
that are critical,
|
| Quote: | and you need to install them so that ANYONE can
understand
|
| Quote: | them?
Of course, the RTV on the NPT
threads... So how many times
|
| Quote: | do we have to discuss this? No teflon tape,
no RTV. Fuel
|
| Quote: | lube I guess is the common one, which is good. If you
use
|
| Quote: | a paste of any type, or even in the case of anti-seize on
spark plugs, you don't put it on the first couple threads.
|
| Quote: | These are
just common knowledge practices. You don't want
|
| Quote: | to contaminate the
inside, nor give opportunity for the
|
| Quote: | compound to come off
inside.
|
| Quote: |
Here's one I'm not familiar with. The electric fuel
pump
|
| Quote: | was a "Facet Automotive". Someone else help me out here
as
I'm not familiar with the carbureted RV-10 fuel system.
|
| Quote: | Is that a normal
pump, or something hacked in? I know
|
| Quote: | Facet pumps are used often, but is
that the proper pump?
|
| Quote: | Fuel systems aren't something to screw with, so
hopefully
|
| Quote: | that was the right one.
The fuel selector
position, and key position it's hard
|
| Quote: | to interpret. Not good for trying a
restart, but
|
| Quote: | the fuel valve off for the crash is a good thing.
Not
|
| Quote: | sure what to think about the key position though.
There seem to be numerous issues with the plane. I hate it
|
| Quote: | when I hear
of people flying continually and regularly without
|
| Quote: | addressing an issue.
I mean, he was frustrated with
|
| Quote: | the "constant hassle" of having to reset
the alternator
|
| Quote: | in flight. REALLY!?!? I think if mine blows ONCE I
need
|
| Quote: | to look at it. Twice and it's an issue for sure. But
constantly in flight? WTF are you doing carrying passengers
|
| Quote: | if this is
the case?!?! That blows my mind.
|
| Quote: |
Then there's the 125psi fuel
pressure. Again, you have
|
| Quote: | an indication like that and you just fly
it?!?!?! I met
|
| Quote: | a guy once who never calibrated his engine
sensors.
|
| Quote: | You have to add proper scale factors and offsets for
them to even read accurately. He adjusted his oil pressure
|
| Quote: | on the engine
to match his NON-setup instrument. Then
|
| Quote: | found out how to set the
instrument up from me.
|
| Quote: | WTF is that about!?! You didn't have time to do
that
|
| Quote: | before you first flew? Far better than killing yourself!
My
only comment to people like that is "THINK!!!!"
|
| Quote: |
Then there's
the comments from people that they tried
|
| Quote: | to start the engine and the
"stater wasn't connected" which
|
| Quote: | it sounds like is actually that the
starter was falling
|
| Quote: | off the engine and not making contact. He had
heard
|
| Quote: | it making noise on previous flights and now it wouldn't
start. Again, REALLY? You hear something odd and
|
| Quote: | don't investigate
it?
|
| Quote: |
Another one... the Prop only made 2450 RPM, but that's
the
|
| Quote: | way it's always been so it wasn't fixed. REALLY!?!?!?
So
something as important as your engine making the
|
| Quote: | power it needs to isn't
important to you? Truly I say,
|
| Quote: | here is someone who just didn't give a
crap about
|
| Quote: | doing things "right". There are too many indicators.
|
| Quote: | Didn't put the fuel transducer in earlier because it needed
a
certain amount of space and had to bend tubing to do it.
|
| Quote: | Gosh, so that's
a reason to just not install it then?
|
| Quote: | Then finally DID put it in, but
used RTV and didn't connect
|
| Quote: | any wiring to it. This should have been done
PRIOR
|
| Quote: | to the first flight.
And I don't care if you're
Sean Tucker, if you're flying
|
| Quote: | a carbureted airplane you shouldn't
consider yourself
|
| Quote: | "not a big proponent of carb heat" if you're going
to
|
| Quote: | fly IFR (or even VFR). Carb heat provides a very
specific
function. If you want to ignore it on your
|
| Quote: | landing prep, that's one
thing, but if you dang well
|
| Quote: | better know when is a good time to think
about using it.
|
| Quote: |
And finally, a plea from me, to you. If you're
not someone
|
| Quote: | who's going to thoughtfully approach your build, and
try
|
| Quote: | to do things right, please try to refrain from using my
name
in your internet postings. I know, I know, his
|
| Quote: | Andair fuel valve install
wasn't involved in the crash
|
| Quote: | cause at all, other than maybe the fact
that he put the
|
| Quote: | handle on reversed, but I wasn't thrilled about
seeing
|
| Quote: | that he referred to me in his forum post. If you like
what you see, copy it, but if you're doing all sorts
|
| Quote: | of other stupid
things, just leave my name out of it.
|
| Quote: | It's like not calling it a "Van's
RV-10" if you're
|
| Quote: | going to significantly modify the airframe. I
don't
|
| Quote: | need to be tied to your improper methods of build or
maintenance. Better yet, just try to do everything to
|
| Quote: | certified aircraft
standards and procedures and you
|
| Quote: | won't have to worry about what your
NTSB report reads
|
| Quote: | like (or at least cut your chance).
Sorry, that may have been part analysis, part rant, but
|
| Quote: | it drives me
nuts to see some of the things that bring down
|
| Quote: | planes, especially
RV-10's. So far there's been only a
|
| Quote: | very tiny fraction of accidents that
were not directly
|
| Quote: | attributable to something stupid that someone
did.
|
| Quote: | Let's try to eliminate those sorts of things because
we'd
have a *near* spotless safety record on our make and
|
| Quote: | model if you
eliminated the things that were pure
|
| Quote: | ignorance and idiocy.
|
| Quote: | Tim
On
4/9/2015 11:50 PM, Phillip Perry wrote:
|
| Quote: | > Some of you might have seen
this already, but Doug Nebert's probable
|
| Quote: | > cause was published today.
This was the accident in Oregon last May.
|
| Quote: | > (2 Fatal - 1
Serious)
|
| Quote: | >
> * The probable cause document
>
<http://www.ntsb.gov/_layouts/ntsb.aviation/GeneratePDF.aspx?id=WPR14FA218&rpt=fi>
|
| Quote: |
is a humbling read...
> * Every document in the entire
docket
|
| Quote: | >
<http://dms.ntsb.gov/pubdms/search/hitlist.cfm?docketID=57129&CFID=524058&CFTOKEN=34830451>
|
| Quote: |
is worth the read...
> * Specifically the photos in this
document
|
| Quote: | >
<http://dms.ntsb.gov/public%2F57000-57499%2F57129%2F570028.pdf>
|
are
| Quote: | > full of emotion. Anger, Sadness, Disbelief, Confusion.
> In case the links do not work, the case ID is WPR14FA218 so
you can look
|
| Quote: | > it up yourself.
>
> I will give
you the nutshell, but you need to go read the documents.
|
| Quote: | > RTV was
used to seal NPT fittings on a (recently installed) fuel flow
|
| Quote: | >
transducer. A ~0.25" chuckof RTV came loose and flowed downstream into
|
| Quote: |
the metered nozzle of the transducer. The metered hole was ~0.115"
in
|
| Quote: | > diameter and the RTV plugged the hole and starved the engine of
fuel.
|
| Quote: | > To make matters worse, a stall (and likely the start of a
spin) occurred
|
| Quote: | > during the forced landing.
>
>
This is worth a read. There were other indications of an aircraft with
|
| Quote: |
questionable maintenance, but the event that brought down this
airplane
|
| Quote: | > was 100% preventable. The real disappointing part is that
the issue was
|
| Quote: | > pointed out by a friend but ignored.
> Even if we don't have RTV on our fuel lines (I hope we don't -
Same
|
| Quote: | > thing for Teflon Tape), there is a lesson in here for all of
us. It
|
| Quote: | > doesn't do us any good to share information and concerns
with each other
|
| Quote: | > if we aren't going to take a moment to stop in our
tracks and seriously
|
| Quote: | > listen to them. Ears open, mouth closed, stop,
and think. I'm as
|
| Quote: | > guilty as the next person, but this is a case
where we can all reset
|
| Quote: | > ourselves and improve our fleets
record.
|
| Quote: | >
> Phil
Navigator to
|
Un/Subscription,
http://forums.matronics.com
| | - The Matronics RV10-List Email Forum - | | | Use the List Feature Navigator to browse the many List utilities available such as the Email Subscriptions page, Archive Search & Download, 7-Day Browse, Chat, FAQ, Photoshare, and much more:
http://www.matronics.com/Navigator?RV10-List |
|
|
|
| Back to top |
|
|
Tim Olson
Joined: 25 Jan 2007
Posts: 2879
|
| Posted: Fri Apr 10, 2015 11:34 am Post subject: NTSB - Probable Cause |
|
|
Yeah, that crash was the first, and it had a big impact on a
lot of us. I guess if you're going to have a crash at a
particular time, that had so many warning signs, that may
have been as "good" a time as any. It got a lot of people
to stop and reflect on what they have in their garage, before
they went out to fly. I also hate to be so "down" on this
pilot in this crash that we're talking about today too...it's
not my intention to just criticize the pilot, but it does
put the blame where it lies, and as usual, he didn't just
take his own life with him. So it serves as a good
attitude check for us all. It's sad that we even need
that sometimes.
Overall, I think it's easy to see that the RV-10 has proven
to basically have an unscathed safety record when it comes
to the airframe. In thinking through the fatal and non-fatal
crashes we have on the list, pretty much every one of them
was caused by someone doing something they shouldn't have.
This should be comforting to us all in that it does show
that the onus is on US for the ability to safely take
our passengers from ground to sky to ground again without
incident. I not only do not want to dodge responsibility
for my flights, but I want to accept it happily. I am
personally glad that the NTSB does not pull punches and
lays the blame on the pilot almost every single time.
It really is up to US to make sure that we aren't the
next statistic. NOTHING that we are doing is ground breaking
and new. There have been hundreds and thousands of people
who went before us and paid in blood for all of the rules
and regulations and designs that keep us safe today.
If we fly our best and use our best judgement, we really
should not have need to worry much about the successful
outcome of any flight. (with few rare exceptions)
Certainly we enjoy a far better safety record than many
other models of airplanes, and that we should be
humbly proud of.
Tim
On 4/10/2015 11:55 AM, Danny Riggs wrote:
| Quote: | Ahhh! It's been so long that I'd forgotten who it was. I still remember
some of the lessons of that crash however!
|
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| Back to top |
|
|
Bob Turner
Joined: 03 Jan 2009
Posts: 885
Location: Castro Valley, CA
|
| Posted: Fri Apr 10, 2015 1:01 pm Post subject: Re: NTSB - Probable Cause |
|
|
"We have met the enemy, and he is us" - Pogo
The other sad thing about both Dan and Doug is that, when faced with the ultimate high-stress test, they both failed as pilots. And they're not alone. No matter how often it's drilled that you never let the plane stall, that you fly it into the trees or until it won't fly anymore, both allowed it to stall while still a fatal distance above the ground. I suspect that we all think we have 'the right stuff', that we wouldn't do that. Yet some of us do. Clearly biennially doing a few stalls at 4000' isn't good enough. And stall training very low is too risky. Is there any way to do realistic training outside of a million dollar simulator? How can we get the "save the plane" mentality out of our thinking? Do we do too much "simulated emergency" training where there's always an airport right below us? What's the right training mix of benefit vs risk? I sure wish I knew the answers to these questions.
| | - The Matronics RV10-List Email Forum - | | | Use the List Feature Navigator to browse the many List utilities available such as the Email Subscriptions page, Archive Search & Download, 7-Day Browse, Chat, FAQ, Photoshare, and much more:
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_________________
Bob Turner
RV-10 QB |
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flying-nut(at)cfl.rr.com
Guest
|
| Posted: Fri Apr 10, 2015 1:41 pm Post subject: NTSB - Probable Cause |
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On 4/10/2015 5:01 PM, Bob Turner wrote:
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"We have met the enemy, and he is us" - Pogo
I miss Pogo! And he was spot on with that one.
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| Quote: | The other sad thing about both Dan and Doug is that, when faced with the ultimate high-stress test, they both failed as pilots. And they're not alone. No matter how often it's drilled that you never let the plane stall, that you fly it into the trees or until it won't fly anymore, both allowed it to stall while still a fatal distance above the ground. I suspect that we all think we have 'the right stuff', that we wouldn't do that. Yet some of us do. Clearly biennially doing a few stalls at 4000' isn't good enough. And stall training very low is too risky. Is there any way to do realistic training outside of a million dollar simulator? How can we get the "save the plane" mentality out of our thinking? Do we do too much "simulated emergency" training where there's always an airport right below us? What's the right training mix of benefit vs risk? I sure wish I knew the answers to these questions.
I've had three off-field emergency landings and one on-airport emergency
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landing, and with the help of all those angels on my shoulders, they
were non-events .... no further damage to the airframe, pilot,
people/property on the ground .... or the ground. 
I firmly believe that we really have no clue how we will react when the
s..t hits the fan ..... until it does. All we can do to prepare for
emergencies is to think .... 'how would I handle that ?????' when we
read of an accident or incident. I do that all the time. I learn from
survivors how they handled their 'oh s..t' moments. The problem with
emergency training is that there are far too many ways for disaster to
occur than we have the time/knowledge to prepare for them. We just try
and cope the best we can. Sometimes we win, and sometimes we lose. I
think it was Bob Hoover who said 'Fly the airplane as far into the crash
as you can.' Sage advice. Trying to stretch the approach to the impact
point with insufficient energy will most likely turn a flying airplane
into a lawn dart. It is, as you said, the 'save the plane' mentality,
and I've lost friends because of it. My airplanes owe me nothing ....
I've had so much pleasure with their use that if I lose one .... I hope
to be around another day to fly again. Yes, it will be painful, and I'd
be happy to survive and mourn.
Linn
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philperry9
Joined: 23 Nov 2011
Posts: 381
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| Posted: Fri Apr 10, 2015 2:21 pm Post subject: NTSB - Probable Cause |
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| Quote: | " All we can do to prepare for emergencies is to think .... 'how would I handle that ?????' when we read of an accident or incident. I do that all the time. I learn from survivors how they handled their 'oh s..t' moments. "
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Comment above:
I have a wife who has a PhD is this sort of stuff. (Really)
She was telling me about a study conducted by an I/O Psychologist who was in the Bay Area during the World Series Earthquake. After the quake occurred, he observed there were two different types of people. There were those people that immediately jumped into action securing themselves and rescuing people. Then there were others who folded up and basically sat on the street curb crying. It gave him an idea to conduct a study and try to determine why a catastrophic event of this size polarized the people into two separate groups.
After conducting the study, he found that the group of people took action overwhelmingly played through what-if scenarios in their head. If this happens, how would I react. What would I do. Where would I go? What would my plan be? What would get me in trouble? I call them the Walter Mitty crowd and I tend to identify with them. 
The other group were those who just blindly lived their lives day to day. Never realizing they were a moment away from catastrophe. No clue that their version of day-to-day life should be expected.
Phil
Do Not Archive
[quote][b]
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gengrumpy
Joined: 07 May 2013
Posts: 131
Location: Tullahoma, TN
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| Posted: Fri Apr 10, 2015 5:25 pm Post subject: NTSB - Probable Cause |
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Amen!
Well said, Tim!
grumpy
| Quote: | On Apr 10, 2015, at 10:19 AM, Tim Olson <Tim(at)MyRV10.com> wrote:
Phil,
Thanks for posting. That's just sickening to read. Regarding Linn's
post, I truly think that the people who most often do the very
questionable things are also the ones that will never listen
to the advice, so it's a hopeless plea, sadly. I think back
to how many times I had to get on Dan Lloyd and he never
listened once. This particular accident/pilot was far less
lax than Dan was, but still, there are just far too many things
in the report to allow me to just think "well, at least he
knew what he was doing". It was a shocking read, and horrifying
when you consider the discussion about the crash and the child,
and see the numerous pictures of the plane. There isn't anything
left of the front end, and you can't blame the angle of impact
on anything but poor piloting, even if you excuse the RTV
use. This accident didn't have to end this way.
Some things I noted...
The fuel handle was installed reverse indicating. Why? Why
can't a pilot understand that things like that are critical,
and you need to install them so that ANYONE can understand
them?
Of course, the RTV on the NPT threads... So how many times
do we have to discuss this? No teflon tape, no RTV. Fuel
lube I guess is the common one, which is good. If you use
a paste of any type, or even in the case of anti-seize on
spark plugs, you don't put it on the first couple threads.
These are just common knowledge practices. You don't want
to contaminate the inside, nor give opportunity for the
compound to come off inside.
Here's one I'm not familiar with. The electric fuel pump
was a "Facet Automotive". Someone else help me out here
as I'm not familiar with the carbureted RV-10 fuel system.
Is that a normal pump, or something hacked in? I know
Facet pumps are used often, but is that the proper pump?
Fuel systems aren't something to screw with, so hopefully
that was the right one.
The fuel selector position, and key position it's hard
to interpret. Not good for trying a restart, but
the fuel valve off for the crash is a good thing. Not
sure what to think about the key position though.
There seem to be numerous issues with the plane. I hate it
when I hear of people flying continually and regularly without
addressing an issue. I mean, he was frustrated with
the "constant hassle" of having to reset the alternator
in flight. REALLY!?!? I think if mine blows ONCE I need
to look at it. Twice and it's an issue for sure. But
constantly in flight? WTF are you doing carrying passengers
if this is the case?!?! That blows my mind.
Then there's the 125psi fuel pressure. Again, you have
an indication like that and you just fly it?!?!?! I met
a guy once who never calibrated his engine sensors.
You have to add proper scale factors and offsets for
them to even read accurately. He adjusted his oil pressure
on the engine to match his NON-setup instrument. Then
found out how to set the instrument up from me.
WTF is that about!?! You didn't have time to do that
before you first flew? Far better than killing yourself!
My only comment to people like that is "THINK!!!!"
Then there's the comments from people that they tried
to start the engine and the "stater wasn't connected" which
it sounds like is actually that the starter was falling
off the engine and not making contact. He had heard
it making noise on previous flights and now it wouldn't
start. Again, REALLY? You hear something odd and
don't investigate it?
Another one... the Prop only made 2450 RPM, but that's the
way it's always been so it wasn't fixed. REALLY!?!?!?
So something as important as your engine making the
power it needs to isn't important to you? Truly I say,
here is someone who just didn't give a crap about
doing things "right". There are too many indicators.
Didn't put the fuel transducer in earlier because it needed
a certain amount of space and had to bend tubing to do it.
Gosh, so that's a reason to just not install it then?
Then finally DID put it in, but used RTV and didn't connect
any wiring to it. This should have been done PRIOR
to the first flight.
And I don't care if you're Sean Tucker, if you're flying
a carbureted airplane you shouldn't consider yourself
"not a big proponent of carb heat" if you're going to
fly IFR (or even VFR). Carb heat provides a very
specific function. If you want to ignore it on your
landing prep, that's one thing, but if you dang well
better know when is a good time to think about using it.
And finally, a plea from me, to you. If you're not someone
who's going to thoughtfully approach your build, and try
to do things right, please try to refrain from using my
name in your internet postings. I know, I know, his
Andair fuel valve install wasn't involved in the crash
cause at all, other than maybe the fact that he put the
handle on reversed, but I wasn't thrilled about seeing
that he referred to me in his forum post. If you like
what you see, copy it, but if you're doing all sorts
of other stupid things, just leave my name out of it.
It's like not calling it a "Van's RV-10" if you're
going to significantly modify the airframe. I don't
need to be tied to your improper methods of build or
maintenance. Better yet, just try to do everything to
certified aircraft standards and procedures and you
won't have to worry about what your NTSB report reads
like (or at least cut your chance).
Sorry, that may have been part analysis, part rant, but
it drives me nuts to see some of the things that bring down
planes, especially RV-10's. So far there's been only a
very tiny fraction of accidents that were not directly
attributable to something stupid that someone did.
Let's try to eliminate those sorts of things because
we'd have a *near* spotless safety record on our make and
model if you eliminated the things that were pure
ignorance and idiocy.
Tim
On 4/9/2015 11:50 PM, Phillip Perry wrote:
> Some of you might have seen this already, but Doug Nebert's probable
> cause was published today. This was the accident in Oregon last May.
> (2 Fatal - 1 Serious)
>
> * The probable cause document
> <http://www.ntsb.gov/_layouts/ntsb.aviation/GeneratePDF.aspx?id=WPR14FA218&rpt=fi>
> is a humbling read...
> * Every document in the entire docket
> <http://dms.ntsb.gov/pubdms/search/hitlist.cfm?docketID=57129&CFID=524058&CFTOKEN=34830451>
> is worth the read...
> * Specifically the photos in this document
> <http://dms.ntsb.gov/public%2F57000-57499%2F57129%2F570028.pdf> are
> full of emotion. Anger, Sadness, Disbelief, Confusion.
>
> In case the links do not work, the case ID is WPR14FA218 so you can look
> it up yourself.
>
> I will give you the nutshell, but you need to go read the documents.
> RTV was used to seal NPT fittings on a (recently installed) fuel flow
> transducer. A ~0.25" chuckof RTV came loose and flowed downstream into
> the metered nozzle of the transducer. The metered hole was ~0.115" in
> diameter and the RTV plugged the hole and starved the engine of fuel.
> To make matters worse, a stall (and likely the start of a spin) occurred
> during the forced landing.
>
> This is worth a read. There were other indications of an aircraft with
> questionable maintenance, but the event that brought down this airplane
> was 100% preventable. The real disappointing part is that the issue was
> pointed out by a friend but ignored.
>
> Even if we don't have RTV on our fuel lines (I hope we don't - Same
> thing for Teflon Tape), there is a lesson in here for all of us. It
> doesn't do us any good to share information and concerns with each other
> if we aren't going to take a moment to stop in our tracks and seriously
> listen to them. Ears open, mouth closed, stop, and think. I'm as
> guilty as the next person, but this is a case where we can all reset
> ourselves and improve our fleets record.
>
> Phil
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