Spatial Disorientation, Not Vacuum Pump, Most Likely Cause Of
Crash
By ANN Correspondent Juan Jimenez
For some time now I have
been following the events of the crash that killed Missouri Gov. Mel Carnahan, his
son Randy, and another passenger in their Cessna aircraft on
October 16, 2000. It was certainly a sad day;
three good people died, and it was a tragedy for their families and
loved ones, for the state of Missouri and for the nation.
However, it is clear that what has developed into a legal case
is nothing but a blatant attempt by attorneys to get their hands on
money they simply do not deserve, based on a sham of an
argument.
The
NTSB report for this accident clearly shows that a
great deal of effort was expended to determine a probable cause. A
complete analysis of the conditions of the vacuum pumps, the vacuum
system failure indicators and the attitude indicators was
performed. Radio contact with the pilot clearly indicated that he
was having problems with the primary attitude indicator. The NTSB
report states:
"The pilot indicated to ATC several times that he was having
problems with the airplane's primary attitude indicator. He also
told ATC that he was trying to use the right-side attitude
indicator, which indicates that the airplane did not experience a
total vacuum system failure. Examination of the wreckage revealed
rotational marks in the left and right engine vacuum pumps, which
indicates that they were most likely functioning at the time of
impact. Further, one of the vacuum gage system failure indicator
buttons exhibited evidence of having been in almost the fully
retracted position (the other indicator button was found in the
partially retracted position), which indicates that adequate vacuum
existed for the airplane's instruments to operate."
It doesn't get any clearer than this. The vacuum pumps were most
likely working just fine before the crash, so the reason had to lie
somewhere else. We're left with two explanations, the ones that the
NTSB concluded were the most likely probable causes for the
crash:
"The National Transportation Safety Board determines that the
probable cause of this accident was the pilot's failure to control
the airplane while maneuvering because of spatial disorientation.
Contributing to the accident were the failure of the airplane's
primary attitude indicator and the adverse weather conditions,
including turbulence."
The investigation of the accident included a complete analysis
of the left-side attitude indicator, and the determination was made
that it was most likely not spinning at full speed at the time of
the crash. This was based on a number of observations, not the
least of which was the finding that the gyro had scoring marks in
the direction of rotation. In addition, the face of the instrument
was inverted at the time of the crash, opposite to the attitude of
the aircraft when it impacted trees.
Even if one of the vacuum pumps had failed, the system on the
Cessna 335 incorporates a check valve into the design that serves
to isolate the malfunctioning pump from the rest of the system.
Either one of the pumps would have sufficient capacity to drive the
entire system - that is why the system was designed to be
redundant. A search of the NTSB records and the FAA Service
Difficult Report (SDR) database revealed no record of problems with
the check valve.
The NTSB analysis of the vacuum indicator revealed that there
were no problems with the vacuum failure indicators, and they
determined that there was no evidence of a failure indication of
either pump at the time of the crash.
The records of radio contact with the aircraft show that he
pilot reported that he was using the right-side attitude indicator,
which led the NTSB to conclude that indicator was working just
fine. Clearly, the vacuum system was working.
The problem with this
situation, however, is that in a 335 the right side indicator sits
several feet to the right of the pilot. That means that to
reference it, he would have had to repeatedly move his head to look
at that indicator, then back to reference his own instrument
cluster. Combine that with IMC, turbulence and the obvious stress
the situation was causing, and add to that the possibility that the
pilot was not current for flight in IMC, and you have pretty much
all the ingredients for spatial disorientation, not vacuum pump
failure.
I hear a bell ringing. Anyone who's read the analysis of another
high profile crash involving a politician's son up there where
Martha used to grow grapes ought to hear it as well.
We are then left with the task of trying to understand why the
Carnahan family is suing Parker-Hannafin, the manufacturers of the
vacuum pumps, when there is no evidence that their products
contributed in any way to this accident.
For one possible answer to that, we need to go back to the NTSB
report to see what other parties might be involved in this issue
from a legal standpoint. The attitude indicator/flight director was
provided by Sigma-Tek as an overhauled unit in 1996. It had been
repaired eleven months prior to the crash and reinstalled on the
aircraft. Chances of a good payday from that angle would be
nil.
They could have blamed the mechanics who worked on the aircraft
in the months prior to the crash, but that has even less of a
chance of jackpot award. Besides, there is no evidence that
anything the mechanics did had anything to do with the crash -
other than the fact that one of them replaced the left engine
vacuum pump some two weeks before the crash. The system was tested
after that, and it was working properly.
Where do we go from here? Parker-Hannafin, a Cleveland, Ohio
company with nearly $6 billion in revenues in 2001, some 46,000
employees as of that year and, of course, deep pockets. Clearly,
that was the juicy target, so an argument had to be concocted that
the companies products were prone to failure and that over 20 years
the company has allegedly known that their products fail.
This "Duh Moment" has been brought to you courtesy of our
country's fine tort system, the judges that run it to the benefit
of their own, and the politicians who have yet to grow the organs
necessary to take on the overdue task of its total overhaul and
reform.