Here's the actual epilogue from DFS: Report | CT114161 Tutor - Epilogue
“Following the take-off, a loud, impact-like sound was heard by both occupants and the aircraft then experienced a loss of thrust.”
Other common symptoms of a compressor stall: rumbling noise and rise in Exhaust Gas Temperature. "Impact-like sound" must be engineerese for what we called a "bang".
“The pilot initiated a climb straight ahead”
Standard emergency response drill was “Zoom” (trading airspeed for altitude, as was done) - “Idle” (move the throttle in the left hand fully aft) - “Air Start” (starter button on the throttle). One should be gently turning towards a safe ejection area, if possible.
No mention was made in the Epilogue that a relight was attempted.
I have heard that, for a reason that I cannot remember, the “Idle” movement was removed from the checklist some time ago.
“and then elected to carry out a left-hand turn back towards the airport.”
This is what really baffled me, right from the beginning. It’s never a good idea, at low altitude and low airspeed. It was stressed to us that we should always make the decision to eject prior to even getting into the aircraft. Ejecting is a last-ditch measure, and nobody wants to leave the comfort of one’s cockpit (especially mid-Saskatchewan-winter prior to the climate returning to normal as we have been experiencing of late), and there may be no time (like in this case) to think things through. There are no medals given for saving a crippled aircraft.
One’s decision-making skills plummet in such stressful times, though, and, for whatever reason, he thought that he could make it back for a safe landing and, while he made a wrong decision, I cannot, in all fairness, fault him for what he tried to do given the max-crappy hand that he was dealt.
“The manoeuvre resulted in an aerodynamic stall halfway through the turn before the pilot gave the order to abandon the aircraft. Both occupants subsequently ejected”
I was impressed that Jenn ejected almost simultaneously. She’d obviously paid attention to her training, and likely was expecting, or had been warned to expect, an ejection order. Such a loss.
A second or two earlier, a couple of degrees less bank, and…
“and the aircraft was destroyed upon impact in a residential area.
A simple turn to avoid the built-up area would have been better for all. There was lots of wilderness/grazing land available.
“Evidence gathered during the investigation revealed that both occupants’ ejection sequences were outside of the ejection envelope.”
Which was obvious from the initial video postings.
“DNA evidence collected from the engine’s internal components confirmed the ingestion”
NOT “sucked in” as the press keeps saying.
“of a bird as witnessed from video evidence; however, the damage it caused was insufficient to cause a catastrophic failure.”
There was/is a history of occasional compressor stalls with the Tutor, generally with no known cause and easily cleared, but I cannot remember the details thirty-nine years after I last flew it. It wouldn’t necessarily take much to disturb the airflow to the compressor.
“Rather, it resulted in a compressor stall that was never cleared.”
I would have preferred a little clarity regarding “never cleared” - no attempt made, or a
unsuccessful attempt(s) made?
“The investigation recommends a directive be published which outlines the aircrew’s priority where an emergency during the take-off or landing phase occurs and has the potential to result in an ejection near or over a populated area.
“The investigation also recommends further training on engine-related emergencies be practiced in the takeoff/low-level environment.”
This, also, baffles me, as it should have been hammered home during previous training and also during his conversion to the Tutor. Perhaps there were unreasonable expectations made, as the Snowbirds are all experienced Pilots. Training shortcoming? Maybe. In the good, old pre-computer days, and in the absence of all of the CYA DLN courses etcetera, we would all sit around the aircrew lounge and read Flight Safety magazines and discuss the incidents and accidents therein, and sometimes our own, between flights or until the Mess bar opened on the bad-weather days.
There was also more general awareness of hazards back then, as we had many more aircraft, flew many more hours, and operated in more risky environments so accidents were a little more common. We lost eighteen guys in various crashes in 1982 (the worst year in my time in), seemingly every other couple of weeks.
“It is also recommended that the practice of storing items between the ejection seat and the airframe wall cease immediately.”
There are only two, tiny, external baggage compartments on the Tutor. People would put their empty bags in, then stuff all of their items in on top to gain every possible cubic fraction-of-an-inch (the doors would occasionally not get latched properly, leaving trails of underwear and toothbrushes across Saskatchewan and elsewhere), but there is NO NO NO excuse for jamming stuff around one’s final means of survival.
Or cases of beer in the nose gun bay of a CF5 (beer strike in Alberta, quick trip to Moose Jaw, no consideration of air pressure reduction while climbing to cruise altitude, “pop-pop-pop-pop”, very unhappy ground crew and “customers”).
“Finally, further research is recommended into the potential options that would stabilize the CT114 ejection seat from any tendency to pitch, roll or yaw immediately following its departure from the ejection seat rails.”
I was under the impression that a drogue parachute had been added since I flew the Tutor. No mention of considering a seat replacement, though.