Photo: Airlink 8911 Wreckage, from SACAA Report, Cover page.

Eddie Sez:

The captain did not have a track record of having problems dealing with engine failures during training but this incident was his second where he appeared unable to cope when it happened in an airplane. The first officer appeared to be doing a competent job of flying the airplane during the engine failure but completely disengaged once the captain took over. This engine failure could have been survived had the captain applied proper stick and rudder inputs and simply left the failed engine alone. Why do some pilots with adequate simulator training records do so poorly in aircraft? I think it may be a form of panic.

A transport category airplane certified under 14 CFR 25 is designed to fly with the critical engine out, so if anything kills you, it is probably you. The two most likely ways for that to happen is when you (a) apply the wrong rudder, or (b) shut down the wrong engine. Too many pilots think of an engine failure as a macho test of speed to see who can get the rudder in so fast that other pilots don't even notice the yaw. If the airplane doesn't have time to yaw, you aren't doing it right. Now all of my engine failure experience has been in two or four-engine jets. You should practice this in a simulator, but this has always worked for me:

  1. Allow the yaw to develop, this gives you time to think and will provide a needed clue as to what is going on.

  2. Level the wings with ailerons, and unless climb performance is critical, do not rush in with rudder.

  3. Note which hand is slow (if you have a yoke) or which way the hand is pointed (if you have a stick). This is where your foot will need to be to correct the yaw. "Step on the low hand" as well as "step on the ball" of your slip indicator. Do not stomp on the rudder, you could lose the tail. Your application should take at least a second, two would be better.

  4. Wait until you are at least 1,500' before shutting down engines.

  5. Make an engine shutdown a CRM process that includes a "wait and see" step:
    1. Put your hand on the throttle you intend to pull and ask the other pilot to confirm, "I suspect number one is failed, I have my hand on the number one throttle. Confirm?"

    2. Pull the throttle to idle and wait. Verify the situation didn't get worse.

    3. Announce the throttle pull reaction and your intention to shut down the engine, get validation. "I've pulled number one to idle, the yaw hasn't changed and we are still climbing. I am about to shut down number one. Confirm?

What follows are quotes from the relevant regulatory documents, listed below, as well as my comments in blue.


Accident Report


Narratives

[SACAA Report, ¶1.11.4]


Analysis

[SACAA Report, ¶2]


Probable Cause

[SACAA Report, ¶3.2]


See Also

Pilot Psychology / Panic

Procedures & Techniques / Crew Resource Management


References

South African Civil Aviation Authority (SACAA) Accident Investigation Report CA18/2/3/8690, Jetstream Aircraft 4100 ZS-NRM: Loss of control after engine failure and misidentified engine shutdown after take-off from Durban Airport, South Africa on 24 September 2009