How A Single Loose Screw Almost Crashed This Jet | N680KH
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- เผยแพร่เมื่อ 23 ม.ค. 2021
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This is the story of N680KH, N680KH was a private cessna citation CJ1 and it was owned by a 73 year old man. He had more than 4400 hours of flying experience of which 3200 hours were logged on the CJ1. On the 13th of april 2019 the pilot and three of his friends were flying from Bournemouth international airport in england to rotterdam in the netherlands, the pilot was in the left hand seat and his friend occupied the right hand seat.
At 4:17 pm the plane lifted off from runway 08 and the plane started to climb to 3000 feet. As the plane flew a heading of 075 degrees ATC instructed the plane to climb to 10,000 feet. ATC added quote “Resume own navigation direct goodwood”. But a reply did not come. To carry out ATC’s instructions the plane needed to turn right but it didn't, the plane started to turn left.
In the cockpit the pilot felt a slight vibration and a warning light named ATLAS illuminated. At 3000 feet and 6 nm from the airport the plane started to bank left. Soon the plane was in a left bank and descending. As the plane went through 45 degrees of left bank the autopilot disconnected. In an attempt to save his plane the pilot commanded full right rudder and full right aileron but the plane was still stuck in the left hand turn. The pilot moved the throttles to idle. He continued to wrestle with his plane attempting to pull it out of its left bank.
As the plane breached 60 degrees of bank a bank angle warning sounded. 19 seconds after the mysterious left roll began the plane was pitched down by 9 degrees , the plane was in a 75 degree left bank and they were descending at 4500 feet per min. The pilot reset the ATLAS system but no luck at 4:19 pm the pilot reported a problem to ATC. ATC tried to enquire about the nature of the problem but the pilot sounded breathless and strained, they couldn't make out what the pilot was saying. Assuming that the citation was in trouble ATC advised the pilot to join the left downwind approach for runway 08 and they set the emergency protocol into action. The Controller said on the intercom “Right he sounds really panicked we don’t know what the problem is, he’s coming back in..” The controller radioed “N680KH roger join downwind left hand visually for runway 08 I have traffic on final approach at err 5 miles I can break him off...:” But the pilots responses were broken, he sounded like he was exerting himself a lot.
The pilot with all his might raised the nose of the plane and got the plane into a 30 degree left bank. He coaxed the plane upto 3200 feet. The plane now had to line up with the runway and land. He was still applying full right aileron to keep the plane in the air. The only way for him to line the plane up with the runway was to vary the amount of right rudder. He essentially flew the plane by varying the pressure exerted by his right foot.The plane lined up with the runway 1 nm from the runway. The turn onto final was so tight that the controllers thought that the plane was flying on its side, he now had to vary the right rudder in precise amounts to get the plane lined up with runway 08.
The citation flew the final approach in this state of limbo, at 4:23 PM the plane touched back down at bournemouth. All 4 onboard were shaken and exhausted but they were safe.
To understand the events of april 13th 2019 we have to look at this CJ1 in more detail because this wasnt any old CJ1 it had been modified. The CJ1 had atlas or active technology load alleviation technology. The ATLAS system is used to improve the aerodynamic efficiency of the plane. To install the ATLAS system you had to remove the original wingtips and then you had to add extensions to the wing to make it longer and at the end a winglet was added. The extensions on the wing housed what are known as TACS or Tamarack Active camber surfaces, im gonna call them TACS for short. The TACS is positioned at the trailing edge of the wing and it - วิทยาศาสตร์และเทคโนโลยี
75° bank... It's scary to even imagine. The pilot showed some prime airmanship - he didn't preocupy himself with communication more than it was necessary and the fact that he managed to avoid a wingstrike on landing is nothing short of a miracle.
The priorities in an emergency are
1: Aviate
2: Navigate
3: Communicate
He clearly put all his attention into the first item, and rightly so. With an aircraft with that much roll on it, it would have been so easy to slip up and auger in.
if you watch the whole video, it actually shows that the guy really got super lucky, because he didn't know enough about his aircraft, panicked, and didn't apply the correct action to stabilize the plane.
Sitting on a mike doesn't' do squat!.
@@PassiveSmoking I don't pilot planes, but I know those three rules since my coworker is learning to become a pilot for the Cessna 152/172 aircraft. I would have been scared for my life, and probably would have seized up and talked a lot, since I am a talkative guy, especially when I am nervous. But hey, ground below and sky above are important stuff. Kinda a shame that the ATLAS circuit boards were not covered by ceramic insulator or something like that.
I love how you also cover smaller air incidents, ones with smaller planes or where no one was killed. Keep up the great work!
I HAVE WENT BACK AND LISTEN TO SHOWS SEVERAL TIMES.
I LOVE THESE AT NIGHT YOU DONT NEED VIDEO. JUST THE NARRATIVE.
Good point. As passengers we have no idea how many times we have come close to disaster. If you fly frequently, u have most likely have been close to death numerous times
Gosh I hate it when passenger planes crash, its my nightmare. This channel has a lot of positive stories though, so it's somewhat conforting
@@ronniewall1481 100000
@@ronniewall1481 I also like these at night. Being virtual really puts a strain on your eyes cause of all the technology used (even with blue light glasses). I love that I don't have to strain even more to read it and can just relax my eyes and listen
This all took from the beginning of the problem to touch down 4-5 minutes. I can imagine that indeed the pilot didn’t get much time to assess the situation and by not heaving trained for this or at least not being informed for this I think he actually did a very good job. He could have spiraled out of control immediately.
I think ATC did an amazing job by regoncizing the problem and offering the perfect resolution. Not to distract from the pilots airmanship - but that was quick thinking from ATC and that took load of the pilot and secured other planes by essentially declaring an emergency on behalf of a non-responding pilot.
The jump in quality is amazing! The display of the actual incident in a flight simulator is significantly better than the footage of random planes you've shown before.
Great!
Agreed with the comment 💯, however one or two pics and vids of the actual aircraft type involved, along with a majority of simulated depiction videos, would be nice. But this video with all the figures was excellent
I could see my house on Poole Quay :-)
@@alphalunamare That’s incredible!!
@@Syclone0044 No, thats MSFS2020 xD
An example of fantastic airmanship. My hat's off to the pilot.
A perfect illustration of the danger of having a screw loose.
Good piloting to get himself safely out of that mess.
Can’t imagine the mental and physical stress he went through.
He also had 2 of his friends with him, adding more stress when there are other lifes at stake. Can't imagine how overwhelming the moment was when he realized it's over and they made it. The moment when all that adrenaline left that kept him composed and focused while fighting fo their lifes....
Exactly, it's one thing to say "oh use rudder trim & reduce speed" but he did not have the supplement in the POH, did not have the altitude and did not have the time. He did very well to keep the bird in the air and controllable enough to land. Any landing you walk away from is a good landing...
@@manyshnooks He had the supplements. He either didn’t read them, didn’t understand them or ignored them. Had the supplements not been in the AFM he would then be flying an unairworthy plane. Crap happens for sure. But it really boils down to familiarity and overall knowledge in type...in this case, with a complex modification to the airframe. His basic skills and general knowledge of the Citation likely saved his hid as well as his friends. Not a simple job considering the bizarre behavior of this aircraft because of this malfunction.
@@peterandersen6515 I can't imagine any kind of major stc on a bizjet to improve manoeuvrability and handling would be worth the additional risk involved in modifying the airframe and heck, the leading edge of all places - in such a way.
It's a bizjet. Fly it like a bus. Meh, I'd rather buy a Meridian anyway and save the cash I'd have spent on fuel for a gourmet hamburger (do people with bizjets have the expensive hamburger run 🍔? Or is that just a piston engine Saturday/Sunday thing)
The real award goes to the ATC.
No coms from the plane, so he vectored them back to a runway.
They are in trouble, they have not got time to talk.
‘You have runway A, heading X, cleared to land.”
I think the pilot deserves _some_ recognition here.
The accident report indicates that in the case of uncommanded roll by the ATLAS system, the priority is to reduce speed. Yet the regulators concede that the instinctive response of a pilot in such a situation is to apply opposite aileron, and it appears that full opposite aileron is not necessarily sufficient, and this pilot had to apply some rudder input as well. Even a pilot aware of the ATLAS system may be so occupied with trying to control the aircraft as to have no time left to notice the ATLAS warning light and consider what it meant.
To my mind, a system that can do this is unsafe, and should not have been certificated. At the very least, the system should be designed so that it is incapable of requiring full opposite aileron at any speed.
And just think: this all could have been avoided if the manufacturer had used a drop of Loctite on those screws.
@@HeaanLasai yeah, am aircraft mechanic & can confirm loctite is an essential sauce! We use it a lot.
On the power electronics stuff I work on, we use thread rolling screws into the aluminium heatsinks, they do not back out.
A retaining adhesive is also a good idea for a fastener which must not back out yes, not sure how that got past approval with fasteners that could back out.
@@Uncle-Duncan-Shack I wonder if a nylon screw could have been used in this case?
Then the chance of it causing a short circuit drops to zero
@@Syclone0044 It's an idea, seen that done in the power electronics stuff to hold the pc boards, good point.
Now we know why commercial airliners have so much design effort.
The pilot got the aircraft down safely. I bet he was exhausted. Important lessons here. Thanks. Great video.
Oh 100% he was mentally and physically exhausted from this incident.
Vibration is an amazing force. It keeps working until it loosens what ever can be loosen.
This is what Loctite is for.
Props on the virtual incident replay, this is very much an improvement over random aircraft footage. TACS system is apparently there in order to reduce the additional bending forces on the wing from retrofit winglet installations, the servo-controlled control surfaces basically direct air to cancel out the lifting forces on a loaded wing in lift in order to reduce the structural requirements of the wing when retrofitted with winglets.... so this failure is doubly dangerous bc the wings could exceed design considerations for lift produced when a system malfunctions!
Wow, the pilot was 73? Thank goodness they made it back to the airport safe & sound. I hadn't heard about this incident, thanks for posting it. ☺
The transition from plane footage to more relevant visual info is just amazing and shows the growth of this channel.👍🏻👍🏻👍🏻
A screw has nearly brought down a few planes, usually someone's feet get caught in the joy stick in the cockpit. It good that all four on board were shaken but not stirred.
🤔
I would never have guessed a plane could crash just because of a loose screw
Loose screws can be dangerous in a number of different ways. In this case, a loose screw in electronics can create short circuits, and those can have hard to predict wide-reaching consequences.
It's the little things that go unnoticed. Not quite the same but I had a motorcycle engine completely lock up on me after an eight mil nut sheared into two parts.
Usually if the pilot has one, it can.
I nearly lost a friend in a small plane crash. Just had a new engine installed. 10 hours of flight, at night, the engine quit and they crashed into a neighborhood. Hurt but alive. Turns out the shop that installed the engine did everything fine but a simple small internal lock nut on the fuel controller was left off by Lycoming during assembly and it backed off causing the engine to quit. A nut that can't even been seen or inspected once the fuel controller is put together.
Every day on my one hour commute to and from work I see a lot of loose screws. Just another reason I'm in hurry to see flying cars anytime soon.
When I saw the title I was like "wow, my ex almost crashed the jet"
Who built this disaster? Have they never heard of threadlocker??? Unbelievable.
You're not recommended to use threadlock on fixings within electronic assemblies if the fixing is to provide ground connections. Need to use mechanical types of locking.
@@e30mark Well, not necessarily true. However, evidently no locking devices found, either!
The manufacturer could have, and should have, potted the entire circuit board assembly to ensure all the electronics were electrically isolated. That one additional manufacturing process would have guaranteed that this never happened. I'm amazed at how stuff like this is let to slide. Not only would it have protected against short circuits, but potting also protects against moisture and corrosion. Then the use of screws compared to push pin mounting is abhorrent. The circuit board could have been designed to be mounted with plastic push pins, and the case actually molded to press against the board to ensure in stays in place, and for vibration damping.
That nobody looked at that screw, used in that situation,- and thought "this might be a problem" is - as you say - astonishing. Screws Coming Loose is as old as the invention of the things and is therefore predictable and preventable.
@@philhughes3882 Seriously, even a bit of Locktite probably would've prevented this. Shit like this really makes me wonder about some companies how could an engineer ignore the effects of vibration on a part you plan to put in a fucking plane?
MrMattumbo - Yeah, - if screws/ bolts didn't come loose, nobody would have invented loctite. Never liked flying for maintenance reasons but this is ridiculous.
So we have, as alternatives, mounting screws from the outside of the case, abf the case holding the board in place, potting the board for electrical isolation, locktite, and finally lockwire.. but nothing was done.
Kevin Payne - Also, nothing happened when the circuit was shorted out, no breakers in evidence on this TACS thing?
It's easy to say, "He should have just Trimmed"..... But there is always a reticence to start adjusting systems that are giving trouble when you have gained a modicum of control. Because in the back of your mind is the suspicion that your messing with a faulty system may degrade whatever control you have managed to attain. There's a saying that goes... "If it ain't broke, don't fix it". Which also translates, "If it isn't completely broke, don't mess with it". The pilot did what he needed to do and got back on the ground. That's a success in my book.
Another great story well told. Thank you!
Thank you for producing this (and other) episodes of Mini Air Crash Investigation!
That pilot was determined to keep that plane in the air and to land safely.
Duh
No shit
The fs animations were amazing !
Another great video from a great channel !
Keep up the good work my friend!
The fact these jets are so technologically advanced, yet one little screw can almost cause a crash, is scary to me.
I love these replay shots! really gives context to the unfolding situation as you describe it
Why manufacturer of this TCU didn't use conformal coating? It sure would help in this situation and will add protection from dust and moist as well.
It is difficult to tell from the photograph if the boards were conformal coated or not. In this case it probably would not have helped an awful lot. It wouldn't take long for a loose screw rattling over the surface to wear through the coating. Why they didn't use a drop of loctite is a mystery. It's cheap and very effective at stopping fasteners from vibrating loose.
I agree. We are always use conformal coating on avionics boards, to prevent corrosion. It also protect from short circuit by small metal objects like screws, but we always use screws with washers and other locking devices, to prevent what happened here...
From my long experience as an electronics and software engineer, I know that double or triple redundency not always protect against failure, and there is always a chance for a single point of failure. We just need to do our best to prevent it during the design.
@@Oferb553 "..I know that double or triple redundency not always protect against failure.." Very true, but unfortunately it seems nowdays many manufacturers don't aim even that high. Being content on not having even the first redundency..
Generaly speaking that is, not avionics. Good thing there strict rules in place for aviation in most of the world.
Even if they potted the board, which isn't likely, there's no reason why they couldn't have lock-wired the bolts.
@@kevinpayne3804 Lock wire is no good around electronics, just another thing that could break loose to short things out. The real fail here is the state of a very important device apparently relying on the state of a single pin. In the stuff I design, I generally put in two mechanisms that both must be activated to activate a device that I really want to make sure only gets activated when it should be. A safety critical design would go a step further with a way to self check that a mechanism has not silently failed on.
Great job my dude. These videos are great quality, some of the best original content I've seen about plane crashes. Great work!
Good job for covering these accidents or incidents that are rarely reported
Kudos to ATC. They read the cockpit situation and declared emergency.
I worked at Smiths Aircraft Instruments in the 1960s, all screws were treated with Loctite. This was a special version which contained a UV marker dye. The instruments were checked with UV light during inspection, to see that all threads lit up and had not been missed.
Amazing piloting to recover from something like this.
This summer, two small planes collided over lake Coeur d Alene Idaho. one of them was a tour plane with a family aboard. 8 dead I think. Not much information has been released about it.
Hey MACI! Thanks for keeping up the good work! Definitely can see the improvements since you started!
Crazy how I had this plane in our hanger at my work for a few months. More weird stuff happened regarding a pilot who flew it.
Okay, so it's not just me! I saw the callsign and thought to myself, "I swear I've seen a video on an ATC transcript channel about this plane".
Excellent presentation-an eye-opening event sequence culminating in an astonishing close call!
Happy to watch a video about an incident where no one died :)
It's amazing the number of systems in aircraft that are out to get you! Now we gotta add screws to the list! Their name even implies what they want to do to you! Great video, love your channel!
What a fine example of airmanship
great video
loved the detail and the graphics... awesome to hear you explain & see the diagrams explaining what happened too!
New subscriber here. I fall asleep to youtube videos every night, and I appreciate your narration.
You're my new favorite!
I'll end up watching the videos while I'm awake, too.
Good job on the simulation.
It's absurd a screw on an ac can come loose in such a manner.
One of your best episodes! Thank you I really enjoy these 👍
Happy Australia Day 🐨🇦🇺
Hey man! Just discovered this gem of a channel. Great work. Keep it up!
Another excellent presentation! Please keep up your great work.
I enjoy all of your content. Keep it coming!
Wow, that was a close call. I’d rate the pilot’s actions as outstanding- perfect landing on two counts:
1. They walked away, always good.
2. The aeroplane was able to be “reused”. Even better!
I really enjoy your attention of detail and these type of videos as opposed to some other you tubers, who just like to rehash the fight 191 etc. We like the new hat. Cheers.
You can say that it's almost "screwed" *confused smile*
Thank you very much For sharing this very important information. You explained it perfectly.
I love it when no one dies
A perfect example of "for want of a nail" problem. Other than forgetting to use the trim to ease his problem, the pilot did an exemplary job of returning a reusable aeroplane. ("great landing, &c.") In such a short incident with such small margins, I can understand him being totally focused on handling the machine. It's not a scenario that would likely be trained, so there would be no unconscious reactions.
I find it really interesting how small things can escalate into even catastrophic failures/disaster - something major.
Pikothad his hands full of airplane. It's amazing he made it down safe.
Love your channel!!
Great video. Keep up the good work!
Good pilot skills in a potentially catastrophic situation. I enjoy your videos
Have you ever thought about uploading the Audio to Spotify?
I was looking for some Podcast that would compare to your Content but didn't find something I really liked.
Good idea
The fact that he didn't originally have simulator video taught him to write good narrative -- vivid and complete.
I'd've been willing to be a British narrator for the Bournemouth controller.
GREAT SHOW.
KEEP THEM UP YOUNG MAN
This is your best one yet
When a baby like the citation does this, something is really wrong. I’ve had wonderful times on the citation( 4 years, on a middle weight robot now). No doubt the Cessna proved her golden worth by letting the pilots fly. Nice study, wasn’t aware of it.
Edit: most forgiving aircraft. Citation is the very best
Edit 2: TACS sounds similar to load alleviation function on the airbus. I spoke to a dear friend of mine flying the citation now and he told me most people don’t even know such a mod exists on the citation. once again, great study!
I believe it was from the autobiography of Chuck Yeager, wherein he recounts an incident he investigated as a test pilot, about the cause of several recent crashes of the new North American Aviation F-86 _Sabrejet._
Once inverted, the ailerons on his _Sabre_ immediately jammed and became immovably locked. Once level and upright, aileron control was regained. Upon later inspection, it was determined that a crucial bolt had been installed head-side-up (upside-down as designed) by an old, experienced North American Aviation factory line employee, because _obviously_ such things were not to be done differently in the same assembly as all the other NAA planes he had helped make. That would have been unsafe!
He was later corrected, but never told of the deaths resulting from his action.
This is a case in point demonstrating that a screw (or bolt) doesn´t _even_ have to loosen, fail, or come undone, to be potentially lethal. This is why it is said that federal aviation regulations are “written in blood“ and procedures only work when you know and follow them.
_Subscribed!_
Great video. Keep up the great work
I love these videos. Bite-sized air crash investigations, what's not to love?
Absolutely Brilliant, keep it up
Getting better with visuals good job. This would help visual people a lot.
Great work Sir !
Danm, that's some good piloting!
That was a great thank you for doing it.
Well explained. Rather surprised that no trimming was done as this was always a reflex action for me.
I was rather surprised they even made it to the ground safely, and with no damage to the plane or passengers. It was covered in the video that not all pilots would have the bandwidth to key in trim. We're all human.
Great video. I’m not sure why anyone would modify a solid steady plane
Great quality vids now, i like the match up of audio/dialogue story telling versus whats on the screen now too, new flight sim too huh? Decent.
This was an excellent one. Very interesting.
Very well done. Excellent.
Great work!
Its s Andy from down under ,that was a fantastic video , your so good at this
I commend the Atlas manufacturer. They didn’t try to cover up..FOD is normally attributed to systems outside of “brain boxes”. Lock tight might not be the remedy in this situation but it does indicate that loose screws in the cockpit and elsewhere can cause bad things to happen..
This channel is easy to listen to and includes obscure incidents that we can learn from. Will you do Singapore Airlines 117 please? But I'm not sure if hijack is something that you'd cover. Thanks!
Really interesting and current (AAIB report was only out in December 2020). Thank you.
Aviate - Navigate - Communicate. In that order. Good job by the pilot.
Aviate!
Navigate!
Communicate!
What to do when an inflight incident occurs, in the order of importance.
Being task saturated by trying to maintain flight control and to keep from crashing whilst attempting to identify and rectify one's problem is likely to make communicating with ATC problematic!
Passenger jet airliners have been flown into the ground by flight crew that got so distracted by a little problem that they failed to moniter the flight of their aircraft and ignored all of the audible alarms and warnings and all of the visual warning lights and captions!
That happened with a flight deck crew of 3 supposed professionals, so although it may appear strange that Pilots need to be reminded to actually fly the aircraft and to navigate it safely, the fact is that task saturation can very quickly let a situation become unrecoverable.
This Pilot did a truly outstanding job of flying the aircraft and getting it safely back on the runway!
Doubtless his maturity, training and flying experience (particularly on the incident aircraft) helped him in remaining calm and focussed during that horrific experience.
I would be proud to be one of his passengers, he is an excellent aviator.
Any item or component that presents a risk to the flight safety of an aircraft should be designed, manufactured and constructed so that something like an incorrectly installed fastener cannot compromise the control of the aircraft and endanger it!
There may always be the risk of incorrectly installed fasteners, but eliminating the possibility that such an error could be catastrophic to an aircraft would seem to be of critical importance!
"Think of TACS as an extra aileron" ... yup, there it is
?
EXCELLENT CHAP.....................WELL DONE
Great video
Loose screws, or any metal object in any enclosure containing electronics is a recipe for disaster. A friend of mine had a close call with a loose screw shorting out the charge controller for his Li-ion battery pack, luckily only causing a small fire.
It’s crazy to see this!! My friend bought this, he lives in Long Beach.
Like the new graphics!!
Aviate, navigate, communicate. Well done the pilot landing OK. Thanks for the video.
That aircraft must have attracted a fair amount of attention whilst at Bournemouth/Hurn airport as it's very far from common to see US N-registration aircraft this far south in the UK...
Ah, Tamarack. A controversial system in the US as it has been linked with a number of control incidents on aircraft so fitted, and the loss of airframes with deaths. In an aircraft that was lost along with those on board, another pilot familiar with the aircraft has stated that, with the amount of force the pilot would be having to put into the controls to try and stabilise the aircraft, there is absolutely no way a single pilot would be able to remove a hand from the controls to alter the trim of the aircraft. That, professional, pilot did, however, have the presence of mind to communicate exactly the issue they were having to ATC before they crashed...
These people were more than lucky in this instance. It is down to the incredible feat of airmanship by the pilot that they got back on the ground safely and with minimal damage to the aircraft. The area around Bournemouth/Hurn airport is heavily populated, so had the pilot not been able to stabilise and control it, there almost certainly would have been deaths and injuries on the ground as well...
Excellent!
Nice looking jet
Nice animations with msfs2020! Btw, small hint: you can change plane registration from ATC settings, and if you'd like to cover more animations with msfs2020, you should try the livery megapack
Can't believe how good the detail is of Bournemouth airport. What platform is this?
Great pilot.
Yo man I love your work it's remarkable, can you please make a video of the Airblue flight 202.
Amazing ATC.
Nuff respect to the old boy! Unaware to the update he muscled it down safely anyway.