Air Safety

I organised it all beforehand with the chief engineer who was also the proprietor. Yes, he told me, if I could have the Cessna there when they started work at 8am in the morning, they’d make sure it was finished in time for me to get home again before last light. It was summer so the days were long and it looked like a good arrangement – there was some business I needed to do in the town at the bank and the stock and station agents anyway, so I’d be able to kill two birds with the one stone.

The day didn’t even start well. My wife, who was seeing to the milking that morning (we weren’t a dairy farm in that part of the country of course, but we ran a few cows), found that one of the animals had got herself bogged in the mud round a dam where the water level was low, and I had to set to and get her out before I could go. By the time I’d done this and cleaned myself up, I was a good hour and a half behind schedule. So I didn’t get my Cessna to the workshop until getting on towards 10 o’clock.

The chief engineer (who I will call Ben, though that wasn’t his name) wasn’t impressed. Because I hadn’t kept my part of the bargain, they’d already started work in their little hangar on a Pawnee which as a working aircraft was also in for a quick 100 hourly.

“You’re making it hard,” Ben grumbled at me as he straight away took a screwdriver to my engine cowls and set about draining the oil (this with the Cessna still out on the apron). By the time the sump had drained, Ben’s two offsiders, Jim and Alex (not their real names either) had cleared a space for the Cessna inside and they soon had it pushed in out of the wind.

Jim and Alex now got on with doing the oil filter and the spark plugs, dividing their time between my Cessna and the Pawnee, while Ben took out his torch, opened the panels in the wings, and began his inspection of the Cessna’s airframe. It was obvious that despite the reception I’d got, they 60 Australian Aviation September 1995 were still going to do their best to get my aeroplane finished in time for me to get home that day.

At this stage I thought it would be diplomatic to make myself scarce, so I got a ride into town with the aerodrome groundsman and got on with my business there.

By about 4 o’clock I’d finished all I had to do and took a taxi back to the aerodrome. When I got to the hangar, it seemed that they’d all but finished. The ignition harness was all reconnected, the oil filter had been lock-wired and Alex was poking around the engine trying to fix a couple of minor oil leaks I’d mentioned.

After a while, when he reckoned it was ready for a test run, I helped him push the aircraft out of the hangar. But when he started the engine, it immediately began to run like a chaff cutter. I don’t know what they’d done to it, but Alex shut down straight away and we pushed it back inside. “Hey Jim,” Alex called to his mate, “You did the plugs – you’d better come and take a squiz at this.”

I got out of the way again and in a few minutes, the two boys pushed the aeroplane out for a second run. This time Jim got into the left hand seat, while Alex walked back inside to his Pawnee. I went over to the Cessna and got in beside Jim while he started the engine. This time all was smoothness, and after he’d checked the running to his satisfaction on both magnetos, he pulled the mixture into idle cutoff and turned off the fuel selector.

“She should be ready to go as soon as we get the cowls on,” he told me. With that he went and brought them from the hangar and proceeded to cowl the aeroplane on the apron.

I went in to see Ben and found him in his office, writing out my new Maintenance Release. I think he was still a bit peeved by my late arrival. “Well, you can’t say we don’t keep our promises,” he said a little smugly. “But next time, try and come early.”

I told him I would and thanked him for pushing the job through. It was after 5 o’clock now, and although I still had plenty of daylight for the flight home, I was keen to be on my way. The cloud had been building up during the afternoon and it looked as though we could have a storm. The forecast in fact was for isolated thunderstorms.

At least this was one time when I didn’t have to worry about a preflight inspection, I thought, as I clambered aboard, started up, and began to taxi out. I’d only gone a few metres when the engine died. To my embarrassment I realised I hadn’t turned on the fuel – at the club where I learned to fly it was the practice not to turn the fuel off on their Cessnas so as to keep the seals wet, and I’d got into the habit of following this procedure myself. I’d forgotten that Jim had turned the fuel selector off when he finished his runup.

Hoping no one had noticed, I started up again, continued to taxi out to the threshold of the duty runway, ran up the engine again quickly, and took off.

At 500 feet, because the takeoff heading almost coincided with my track home, I trimmed the Cessna into an 80 knot (148km/h) cruise-climb and settled back to enjoy the trip. But as the altimeter needle passed through 800 feet, the engine suddenly began to run rough. Worse was to come – in what seemed moments it began to make an expensive noise, lost more power, then to my abject horror, abruptly seized!

I’d never done a forced landing for real, but this was it! I’d had it drummed into me when training of course, that it can be fatal to turn back after engine failure on takeoff. But here I was at 800 feet and the terrain in front of me certainly wouldn’t do the aircraft any good.

For better or worse, with the propeller stationary and useless in front of my eyes, I set up a 70 knot (130km/h) glide and made a shallow 180 degree turn back towards the aerodrome. I got round all right, but the wide turn had put me in an awkward position for a downwind approach and there was no way I could get back to the runway from which I had just taken off. In fact it was quickly obvious that, from the angle at which I was approaching, I wouldn’t be able to reach any of the three runways. To be sure of reaching the airfield at all, I found I had to line up between the windsock and a nearby equipment shed.

There wasn’t a lot of room and for a moment or two it looked as though it was going to be a near thing. But somehow I made it, the aircraft finally thumping down hard in the long dry grass between the strips.

Conscious of a rush of adrenalin, I opened the door and slid out to see the worst. To my relief, the only visible damage to my precious Cessna seemed to be a bruised fibreglass nosewheel spat.

Ben, who had apparently been watching me depart, was out to the aircraft in his utility before I had finished looking. A man of few words, he went straight to the inspection panel on top of the engine cowling and pulled out the dipstick. There was not a drop of oil in the sump!

When he pulled the engine down next day, he found that two pistons, two big-end bearings and the camshaft, had all seized for lack of oil.

It was an experience from which we all learned something. In fact the whole episode seemed a classic illustration of what air safety literature is always telling us – that an accident is seldom the result of a single isolated event, but a chain of seemingly unimportant omissions and unhappy combinations of circumstances.

In this instance, the first was Ben’s attempt to save time by starting the inspection without waiting to issue the usual 100 hourly Inspection Schedule. This provides a check list of the items to be done, Item No 3 requiring certification that the engine oil has been replenished after draining!

Then there was the fact that three engineers were dividing their time between the two aircraft in the hangar, with no one of them fully aware of just which items had been completed.

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62 Australian Aviation September 1995

Next, when the inspection was almost finished and the engine was started for a test run, Alex’s attention was diverted before he had a chance to check for oil pressure because the ignition system wasn’t right. And when this had been fixed and Jim started the engine for the second time, his interest was in ensuring the ignition system was now satisfactory.

Then when I took over the aircraft, having been handed a new Maintenance Release with the assurance that the aeroplane was in excellent condition, I saw no need for any preflight inspection.

In a hurry to be on my way and, I did not check the fuel selector before starting the engine. And so it stopped soon after I began to taxi. This probably disguised any symptoms there might have been to indicate something wasn’t right. Apparently still in too much of a hurry, even to check that oil pressure was registering after the engine starts, I then made the worst mistake of all – failing to notice there was no oil pressure during my runup.

So the stage was finally set. I took off, the engine seized, and a serious accident was only just averted!

What did we learn from these expensive oversights?

Ben thinks it all arose because he did not follow proper workshop procedures. As well as making sure he does not put himself in that situation again, he now attaches warning notices to the controls of every aircraft from which the engine oil has been drained.

As far as I’m concerned, I now see the wisdom in always checking for myself that an aircraft is fully serviceable – at startup, during taxiing, and of course when carrying out the pre-takeoff runup.

I think Alex and Jim, having also learned a lesson they are not likely to forget, would say the same.

But how many pilots continue to rely on someone else’s say-so that their aeroplane is fully airworthy? And are content with only the most cursory of preflight checks?