SAFO 18014 25 Oct 2018

Started by Live2Learn, November 13, 2018, 09:38:31 PM

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Live2Learn

https://content.govdelivery.com/attachments/USAFAA/2018/11/13/file_attachments/1106306/SAFO18014.pdf

The preamble to the SAFO is below.  The SAFO discusses several fatal accidents where pilots failed to promptly and effectively address auto pilot malfunctions. 

It's a good read:

Subject: Identification and Manipulation of Circuit Breakers During Abnormal or Emergency Situations.

Purpose: This SAFO serves to provide guidance to flightcrews on the effective identification and manipulation of circuit breakers during abnormal and emergency situations. This SAFO is being published in response to National Transportation Safety Board (NTSB) Safety Recommendation A-09-120.

Background: There have been several fatal accidents in which the pilot was unable to identify and pull a circuit breaker (typically the autopilot) during an abnormal or emergency situation.

Briank

I've suffered a few autopilot malfunctions during my short time as a pilot.  Fortunately they were all ones I was able to override with increased manual effort.  In one case I tried to pull the breaker, but it wasn't the type you can pull.  Flush with no collar.  I'm now at the point where I just don't even use autopilots anymore, just one more unnecessary item there to kill you.

Live2Learn

Quote from: Briank on November 13, 2018, 10:26:02 PM
I've suffered a few autopilot malfunctions during my short time as a pilot.  Fortunately they were all ones I was able to override with increased manual effort.  In one case I tried to pull the breaker, but it wasn't the type you can pull.  Flush with no collar.  I'm now at the point where I just don't even use autopilots anymore, just one more unnecessary item there to kill you.

True, though if they work as advertised they can save your bacon.  Dunno if it's policy to have ALL oowered CAP aircraft equipped with pull able breakers.  If any are not I'd treat 'em like aircraft with no shoulder harnesses:  Viewed from outside, but never flown.

PHall

Well, there is one thing you can do for an autopilot malfunction and there are no circuit breakers that you can pull.
Turn Off the AVIONICS MASTER SWITCH for a minute.
This should kill the power to the Autopilot and disengage the clutches.
Turn the Avionics Master back ON you should be good to go.

TheSkyHornet

Quote
Well, there is one thing you can do for an autopilot malfunction and there are no circuit breakers that you can pull.
Turn Off the AVIONICS MASTER SWITCH for a minute.
This should kill the power to the Autopilot and disengage the clutches.
Turn the Avionics Master back ON you should be good to go.

The POH/AFM should have that in there.

What seems to have happened with N7FG is that the pilot didn't know what to do, being unfamiliar with the aircraft.

If you fly an aircraft that you're unfamiliar with, it's imperative to review the abnormal/emergency procedures to know memory actions. That said, GA is plagued by a lack of memory actions since you're operating an aircraft based on category and class rather than type certificate. Jumping from aircraft to aircraft can contribute to a lot of issues (which is why, in the 121 world, even though you have multiple type certificates, you're generally restricted to your group/type, albeit differences).

If you 'kill' the avionics in a moment of distress---and let's be clear, that may be an improper action to take if you haven't reviewed the AS/ES procedures---do not reset them without first reviewing the AS/ES steps. Let the radios stay off, and maintain level flight. Troubleshoot using procedures and see if the avionics should be turned back on. Depending on the aircraft system, it's possible that when you reactivate the avionics, it could re-engage the autopilot; and you don't want that.


All in all, this is a really good SAFO for aircraft owners/operators to re-familiarize themselves with their AFM and review their cockpit to compare systems in the AFM and what's actually installed. If you have procedures that require you to pull a circuit breaker, and you can't physically pull the button, then you need to look into whether or not you should replace the buttons---the intent of the SAFO.

Live2Learn

#5
Quote from: TheSkyHornet on November 14, 2018, 03:14:12 PM
Quote

The POH/AFM should have that in there.

...

If you fly an aircraft that you're unfamiliar with, it's imperative to review the abnormal/emergency procedures to know memory actions. That said, GA is plagued by a lack of memory actions since you're operating an aircraft based on category and class rather than type certificate. Jumping from aircraft to aircraft can contribute to a lot of issues....


The Lion Air crash and the alleged absence of mention of the new stall prevention system in either transition training for aircrews or the AFM is another illustration of problems arising from unfamiliar equipment.  In GA, with the multiplicity of STCs that affect performance and handling we're actually a lot more likely to encounter a "why'd it do THAT?" situation than pilots flying part 121.  The poster child for this was the Galloping Ghost at Reno 2015.  True, the proximal cause was an old fastener on the remaining elevator trim tab.  But, given the stresses of remarkably higher airspeeds who knows what else might have failed on the next (or any curcuit after that) pass during a high G turn while pointed directly at the grand stands?  That was why the RARA agreed to actually flight test mods BEFORE max performance races.  Imagine that!

TheSkyHornet

Quote from: Live2Learn on November 14, 2018, 09:35:19 PM
Quote from: TheSkyHornet on November 14, 2018, 03:14:12 PM
The POH/AFM should have that in there.

...

If you fly an aircraft that you're unfamiliar with, it's imperative to review the abnormal/emergency procedures to know memory actions. That said, GA is plagued by a lack of memory actions since you're operating an aircraft based on category and class rather than type certificate. Jumping from aircraft to aircraft can contribute to a lot of issues....


The Lion Air crash and the alleged absence of mention of the new stall prevention system in either transition training for aircrews or the AFM is another illustration of problems arising from unfamiliar equipment.  In GA, with the multiplicity of STCs that affect performance and handling we're actually a lot more likely to encounter a "why'd it do THAT?" situation than pilots flying part 121.  The poster child for this was the Galloping Ghost at Reno 2015.  True, the proximal cause was an old fastener on the remaining elevator trim tab.  But, given the stresses of remarkably higher airspeeds who knows what else might have failed on the next (or any curcuit after that) pass during a high G turn while pointed directly at the grand stands?  That was why the RARA agreed to actually flight test mods BEFORE max performance races.  Imagine that!

*Reno 2011

This was a prime case study for aviation accidents in grad school.

Spam

Relevant to my work right now.

We're reviewing proposals for a new USAF aircraft system for which we have a clear requirement for a system OFF switch (in the event of subsystem malfunction). I'm amazed at how poorly some respondents have addressed the requirement.

We clearly said we wanted a switch "to power off without exercising circuit breakers in the event of an error"!!!  Argh!

V/r
Spam


PHall

Quote from: Spam on November 15, 2018, 12:08:38 AM
Relevant to my work right now.

We're reviewing proposals for a new USAF aircraft system for which we have a clear requirement for a system OFF switch (in the event of subsystem malfunction). I'm amazed at how poorly some respondents have addressed the requirement.

We clearly said we wanted a switch "to power off without exercising circuit breakers in the event of an error"!!!  Argh!

V/r
Spam


You actually want them to actually work?   You're a mean one... >:D

Live2Learn

#9
Quote from: TheSkyHornet on November 14, 2018, 10:39:58 PM
Quote from: Live2Learn on November 14, 2018, 09:35:19 PM

The poster child for this was the Galloping Ghost at Reno 2015.

*Reno 2011

This was a prime case study for aviation accidents in grad school.

This is why we practice 'CRM'...  I should NEVER proof read my own text.   Mucho gusto, mi amigo.  :)

TheSkyHornet

Quote from: Live2Learn on November 15, 2018, 03:50:30 PM
Quote from: TheSkyHornet on November 14, 2018, 10:39:58 PM
Quote from: Live2Learn on November 14, 2018, 09:35:19 PM

The poster child for this was the Galloping Ghost at Reno 2015.

*Reno 2011

This was a prime case study for aviation accidents in grad school.

This is why we practice 'CRM'...  I should NEVER proof read my own text.   Mucho gusto, mi amigo.  :)

Haha. No worries.