X-Virus-Scanned: clean according to Sophos on Logan.com Return-Path: Sender: To: lml@lancaironline.net Date: Wed, 11 May 2005 12:04:24 -0400 Message-ID: X-Original-Return-Path: Received: from wind.imbris.com ([216.18.130.7] verified) by logan.com (CommuniGate Pro SMTP 4.3c5) with ESMTPS id 939785 for lml@lancaironline.net; Wed, 11 May 2005 10:45:36 -0400 Received-SPF: none receiver=logan.com; client-ip=216.18.130.7; envelope-from=brent@regandesigns.com Received: from [192.168.1.100] (vsat-148-63-101-227.c002.t7.mrt.starband.net [148.63.101.227]) (authenticated bits=0) by wind.imbris.com (8.12.11/8.12.11.S) with ESMTP id j4BEigiY072233 for ; Wed, 11 May 2005 07:44:46 -0700 (PDT) (envelope-from brent@regandesigns.com) X-Original-Message-ID: <42821A4F.8030500@regandesigns.com> Disposition-Notification-To: Brent Regan X-Original-Date: Wed, 11 May 2005 07:44:31 -0700 From: Brent Regan User-Agent: Mozilla/5.0 (Windows; U; Windows NT 5.1; en-US; rv:1.7.2) Gecko/20040804 Netscape/7.2 (ax) X-Accept-Language: en-us, en MIME-Version: 1.0 X-Original-To: Lancair Subject: Re: Shannon's Accident Summarized Content-Type: multipart/alternative; boundary="------------070508070805010304030308" This is a multi-part message in MIME format. --------------070508070805010304030308 Content-Type: text/plain; charset=us-ascii; format=flowed Content-Transfer-Encoding: 7bit Shannon's "Accident" was no accident, it was the inevitable outcome of a long chain of bad decisions. Tragic? Absolutely! Avoidable? Completely! This was not a case where something suddenly and unexpectedly failed resulting in an element of surprise normally associated with an "accident". The engine, over the course of hours, was methodically reducing itself to scrap. In the process it was displaying multiple symptoms of its reversion to bauxite. High temperatures, high oil consumption and low oil pressures, none of these are good signs. Adding three quarts of oil after a short demo flight and then attempting to fly home, using a high power / RPM setting, with an obviously sick engine is the wrong course of action at many levels. This reminds me of a time at a Lancair fly-in where I was approached by a pilot asking me if I thought 35 PSI of oil pressure for a Lycoming was OK. I told him that it absolutely was NOT and that I knew for a fact that his engine would fail if it was run at that pressure for long. I advised him to ground the plane until he isolated the problem, even if it was the pressure sensor. I offered to assist. He told me that the engine had been running that way since it was rebuilt 35 hours ago and that he would fly it home to Southern California and then take it to the shop for them to investigate. The engine failed on the trip home with the #4 con rod crank bearing seizing and then attempting to leave the engine compartment. In this case the "accident" was the fact that this happened on downwind at the home airport and that the pilot was able to land safely. I say accident because successfully landing a IV with a five cylinder engine and a fist sized hole in the engine case is an unexpected event. These scenarios are common because they are NOT the result of poor training but rather, poor judgment and poor judgment does not get trained out of someone if the training focuses on skills and procedures. Shannon's death was brought about by the actions and decisions of three people; the Builder, the Mechanic and the Pilot. The Builder did not fully understand the implications of the performance modifications he installed. The Mechanic did not ground an obviously sick engine. The Pilot decided to fly a sick engine, ignored multiple warning signs and decided not to make any (of several) precautionary landings. Any one of these people could of, should of grounded the airplane and prevented the last flight. Why not? Because they were all Shannon and Shannon shares a common trait with all of us. A simple fact that has caused many, many "accidents". People at far more cavalier with their own safety that the safety of others. This intrinsic human behavior has caused the death of many. Some equally simple rules to follow to counteract your natural tendency to kill yourself: Rule #1) All anomalous events REQUIRE investigation. Rule #2) Uttering the phrase "Whatever that was, I am sure it is not a problem" is NOT a repair. Rule #3) Before a flight, ask yourself if you would let your wife / child / parent fly that plane without you on board. Rule #4) The urge to ask for a second opinion is confirmation that there is an actual problem. See rule #1. Just because you are capable of building, maintaining and flying an airplane does NOT mean you are an expert in failure assessment, failure prediction or failure analysis and, what you don't know can likely kill you. Be afraid, be a coward, be overly conservative and live to learn. Regards Brent Regan --------------070508070805010304030308 Content-Type: text/html; charset=us-ascii Content-Transfer-Encoding: 7bit Shannon's "Accident" was no accident, it was the inevitable outcome of a long chain of bad decisions. Tragic? Absolutely! Avoidable? Completely! This was not a case where something suddenly and unexpectedly failed resulting in an element of surprise normally associated with an "accident".  The engine, over the course of hours, was methodically reducing itself to scrap. In the process it was displaying multiple symptoms of its reversion to bauxite.  High temperatures, high oil consumption and low oil pressures,  none of these are good signs. Adding three quarts of oil after a short demo flight and then attempting to fly home, using a high power / RPM setting, with an obviously sick engine is the wrong course of action at many levels.

This reminds me of a time at a Lancair fly-in where I was approached by a pilot asking me if I thought 35 PSI of oil pressure for a Lycoming was OK. I told him that it absolutely was NOT and that I knew for a fact that his engine would fail if it was run at that pressure for long. I advised him to ground the plane until he isolated the problem, even if it was the pressure sensor. I offered to assist. He told me that the engine had been running that way since it was rebuilt  35 hours ago and that he would fly it home to Southern California and then take it to the shop for them to investigate.  The engine failed on the trip home with the #4 con rod crank bearing seizing and then attempting to leave the engine compartment. In this case the "accident" was the fact that this happened on downwind at the home airport and that the pilot was able to land safely. I say accident because successfully landing a IV with a five cylinder engine and a fist sized hole in the engine case is an unexpected event.

These scenarios are common because they are NOT the result of poor training but rather, poor judgment and poor judgment does not get trained out of someone if the training focuses on skills and procedures.

Shannon's death was brought about by the actions and decisions of three people; the Builder, the Mechanic and the Pilot. The Builder did not fully understand the implications of the performance modifications he installed. The Mechanic did not ground an obviously sick engine. The Pilot decided to fly a sick engine, ignored multiple warning signs and decided not to make any (of several) precautionary landings. Any one of these people could of, should of grounded the airplane and prevented the last flight. Why not? Because they were all Shannon and Shannon shares a common trait with all of us. A simple fact that has caused many, many "accidents".

People at far more cavalier with their own safety that the safety of others.

This intrinsic human behavior has caused the death of many.

Some equally simple rules to follow to counteract your natural tendency to kill yourself:

Rule #1) All anomalous events REQUIRE investigation.
Rule #2) Uttering the phrase "Whatever that was, I am sure it is not a problem" is NOT a repair.
Rule #3) Before a flight, ask yourself if you would let your wife / child / parent fly that plane without you on board.
Rule #4) The urge to ask for a second opinion is confirmation that there is an actual problem. See rule #1.

Just because you are capable of building, maintaining  and flying an airplane does NOT mean you are an expert in failure assessment,  failure prediction or failure analysis and, what you don't know can likely kill you. Be afraid, be a coward, be overly conservative and live to learn.

Regards
Brent Regan
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