Ed Helicopter Crashes into Glasgow Pub

Medical incapacity is a possible explanation. It is conceivable that epilepsy was the cause.

I have developed it in the last three years. It does not necessarily start with a mammoth fit. In my case, and with the benefit of hindsight, it started with a couple of “time outs”. In one case I was driving along a route I had travelled maybe a couple of hundred times before: I suddenly realised that I had overshot a turning. The second time I was walking along a road, again one I had walked along many times before, and realised that I wasn't where I should be. Each incident lasted a few seconds, but the first could have led to a serious accident – fortunately it didn't. In neither case was there any prior suggestion that it might happen.

It's difficult to describe the the feeling. It's not the “deep in thought” one, where you know where you have been but haven't been paying attention. It's a complete blank – how did I get here? It's “I shouldn't have got here". Anyone who has been there will recognise it immediately: it won't make sense to anyone who hasn't.


Yes, that makes some sense. And it's certainly at least a possibility. Thanks for the suggestion (and sorry to hear about your condition).

Would there be anyway in which onset epilepsy could be determined in an autopsy, through either brain dissection or blood/lymphatic/endocrine analysis?
 
These are all relevant, reasonable questions. It's hard to find reasonable answers to them at the moment, without at least considering the almost-unthinkable. But that's a very long way indeed from saying that the ONLY explanation is deliberate pilot action/inaction - and it's even further away from seeking to condemn or vilify the pilot.

What do you mean by 'deliberate'? Do you mean he intended the helicopter to crash, or merely that he meant to set the switches the way they were, but was mistaken in the consequences of doing so?
 
What do you mean by 'deliberate'? Do you mean he intended the helicopter to crash, or merely that he meant to set the switches the way they were, but was mistaken in the consequences of doing so?


I suppose I mean either one of those possibilities. What I'm essentially trying to say is that it is incredibly difficult, in the light of the seemingly-reliable evidence set we now have, to understand the pilot's actions from the point of view of simple pilot error/incompetence/panic.

What we have, according to the evidence, is a situation where low fuel alarms started - and increased - several minutes before the ultimate crash. And what we have, according to the evidence, is the pilot manifestly failing to correct the problem, and seemingly taking very few steps even to address it. He cannot have followed the checklist for "low fuel in supply tanks", since one of the very first steps in that checklist would have been to check the position of the fuel supply pumps. He cannot have used simple common sense to glance up and look at the switches, as the alarms lit up his instrument panel and sounded in his earphones. He cannot have followed the standard procedure - given that he self-evidently failed to solve the problem - of setting the aircraft down safely while there was still enough fuel in the supply tanks to power the engines. He did not make any radio messages.

And all of this took place over at least several minutes, as the alarms got more serious and the supply tanks used up the last of their fuel. And all the while, it appears that the pilot simply decided to head back in the direction of base - taking him right over a densely populated area of a major city.

And then, when the fuel in the supply tanks finally ran out, and the engines flamed out and stopped, the pilot failed to even attempt to execute one of the basic manoeuvres taught to helicopter pilots: a controlled autorotation hard landing (and he was a highly-experienced pilot who without a shadow of a doubt would have executed dozens of exactly this procedure in training and refresher training). And again, no radio call to inform his base that he was in big trouble and going down.

To me, the only two explanations for all of this that currently make any reasonable sense are: 1) the medical incapacitation theory (and I'd agree that some sort of minor epilepsy episode is a potential candidate) - although it would have to be a very specific type of incapacitation that enabled the pilot to keep flying the aircraft straight and level while losing the ability to think rationally/clearly; 2) some sort of deliberate act on the pilot's behalf.

Is there another possible explanation? Perhaps there is. I hope there is. Personally, I just cannot find it reasonable that a fully-functioning pilot who was intent on keeping his aircraft and its occupants (and people on the ground) safe would have followed the course of actions - and inactions - that the evidence clearly indicates. From the moment when the first "low fuel" alarm went off to the moment the aircraft hit the ground, there was a chain of pilot actions/inactions that I simply don't think can be explained in the context of a fully-fit pilot intent on correcting the situation and putting safety as his top priority.
 
Would there be anyway in which onset epilepsy could be determined in an autopsy, through either brain dissection or blood/lymphatic/endocrine analysis?
Almost certainly not, although raised levels of some types of hormones might be an indicator.
This reminds me of the Moorgate Crash There was no mechanical failure, the brakes hadn't been applied, so driver error was the only conclusion. The autopsy of the driver revealed no medical problems and he wasn't suicidal. Witnesses saw him sitting at the controls and staring straight ahead, showing no sign that he was aware that his train was hurtling at speed into the tunnel's end.
That sounds very much like an episode of "absence" epilepsy.
 
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One of the problems after Moorgate was the difficulty of recovering the bodies, and the driver's body was seriously decomposed after about four days in that very hot tunnel before they got it out.

This wasn't so bad but even so there was a delay. And quite honestly even with a very fresh body there's effectively nothing you can do to get meaningful measurements of hormones or anything like that. Once a body dies, that information is effectively lost.

Rolfe.
 
I suppose I mean either one of those possibilities. What I'm essentially trying to say is that it is incredibly difficult, in the light of the seemingly-reliable evidence set we now have, to understand the pilot's actions from the point of view of simple pilot error/incompetence/panic.

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I dont find it difficult at all. I notice from your explanation of experience you have not worked for airlines or military? If you had you would likely have received extensive training regarding case studies of prior accidents.
If all this does boil down to a series of misjudgments, miscalculations and incompetence then it will not be an anomaly as far as crashes go.
Aviation history is replete with examples or a similar nature.

One thing you seem to avoid adding to the mix is....complacency coupled with ego.
I have seen it time and time again with my very own eyes....including fatal crashes.

I see zero evidence of an intentional act here.
 
I dont find it difficult at all. I notice from your explanation of experience you have not worked for airlines or military? If you had you would likely have received extensive training regarding case studies of prior accidents.
If all this does boil down to a series of misjudgments, miscalculations and incompetence then it will not be an anomaly as far as crashes go.
Aviation history is replete with examples or a similar nature.

One thing you seem to avoid adding to the mix is....complacency coupled with ego.
I have seen it time and time again with my very own eyes....including fatal crashes.

I see zero evidence of an intentional act here.


I understand what you're saying. And I know full well how the human factors you mention - complacency and ego - can indeed be significant (and sometimes even primary) causal factors in aviation accidents.

But I still find it difficult to ascribe to complacency or ego the totality of the pilot's actions and inactions from the moment of the first "low fuel" alarm to the moment - several minutes later - when the helicopter fell out of the sky.

For a start, how and why could the pilot have either a) ignored the low fuel warnings (that were growing in number and becoming more urgent), or b) tried and failed to address the low fuel issue? Is it realistic to suppose that, for example, the pilot thought something along the lines of: "Oh yeah, I hear and see those alarms, but I'm going to ignore them because I'll easily get back to base before I run out of fuel"?

How does one explain this seeming situation where the pilot either ignored the low-fuel warnings, or somehow failed to address and correct the problem? And if it was the latter, why wouldn't the pilot have made the decision to set down somewhere safe immediately? Again, is it realistic to suppose that the the pilot thought something along the lines of: "Damn, I can't fix this problem - but no matter, I'll just keep heading home to base, over a densely populated urban area, and I'm bound to get there before we run out of fuel in the supply tanks"?

These are the sort of things that I am struggling to explain. Personally, I cannot see how even complacency, ego, hubris, pride etc can explain those sorts of decisions.

And then, when the flameouts finally occurred, how does one explain the seeming failure by the pilot to even attempt a proper autorotation controlled descent and hard landing? It's beyond doubt that the pilot would have known exactly how to perform such a manoeuvre, so why didn't he do so (or even attempt to do so)? And why didn't he radio that he was going down hard? Can we realistically ascribe those sorts of actions/inactions to complacency/ego/hubris/pride/etc?

And no, I may not have served in the military or commercial aviation - although, as I said, my father was a career military fast jet pilot who had multiple experiences heading up boards of inquiry into military aviation accidents, and I know some people in the AAIB (including, perhaps-interestingly, the man who applied human factors to the British Airways BAC 111 accident to figure out how the windscreen came to be refitted using the wrong sized bolts, causing it to blow out in flight and suck the captain out of the cockpit). So I do have at least an inkling of knowledge into the subject.

And I hope that you are correct that this was nothing more than a case of cumulative pilot error (I think that the known evidence now points to the inexorable conclusion that pilot error did indeed play a major causal role in this accident). It's just that I personally happen to believe that the evidence simply has to imply that something more was involved in regard to the behaviour of the pilot. I think that one eminently possible explanation is that the pilot suffered some form of mental incapacitation that caused him to become (for want of a better term) a "zombie" at the controls. And please don't get me wrong: I am absolutely not making accusations against the pilot, and nor am I even suggesting that the "deliberate action" scenario is the most likely explanation.

I am doing nothing more than suggesting that - in my view - the known evidence cannot reasonably explained in terms of simple pilot error. I realise that you disagree. But how, for example, would you address the questions that I posed in the third, fourth and sixth paragraphs of this post? If you can show how the evidence points to the sorts of human factors that you suggests being in play, then that would be interesting to hear.
 
At the moment, I am looking at a fuel flow mess due to the latest bulletin some of the EC135 operators have put out. It has to do with an indication problem, but it is important to note that "warning" system and "indication" system are separate circuits. Even if fuel was not what he thought it was, the warning lights should have gone off if the fuel hit x minutes left.

Even so, with the way the EC 135 tanks work, one should have flamed out first, and a few minutes later, the other. (Now, if one was already off, and the other quit sooner than he expected ... and he didn't call the tower ... then you get surprise engine dying, with a low inertia rotor head, and you could droop fast due to surprise factor. )
If you are interested, there is an extended discussion about autorotations in that thread over at PPRuNe, and in a thread devoted to that topic alone.

The aero experts and a few test pilots have pointed out that if rotor rpm decays below some percent -- I guess it is model depedent, but something like below 70% -- then not only are the engines stopped, but the blades are stalled and won't unstall. The criticality of keeping Nr in the flyable range is where some are looking for answers.
One poster said NASA and the US Army, back in the 60's, did a test and found that to be true. (Glad I wasn't on THAT test flight ...)
I feel this post, from our authority on chopper flying, seems relevant.
I don't know how long the time was between the two flameouts, but the possibility of a stall may explain the failure to autorotate.
 
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From what I remember of some discussion elsewhere....the transfer pumps are shut off during certain flight parameters under certain conditions because they will be unable to transfer fuel in the main tank under low fuel conditions. IIRC in a hover some amount of fuel (close to the 76kg) becomes unusable. At this point the transfer pumps are called out to be switched off as not to overheat. Once fwd flight is attained, which changes aircraft attitude, the pumps can be turned on again and the unusable fuel again becomes usable.
I've also read elsewhere that the "prime" pumps are not usually left on for flight(only for starting). I wonder if he simply wasn't paying attention and turned on the wrong pumps.
 
...To me, the only two explanations for all of this that currently make any reasonable sense are: 1) the medical incapacitation theory (and I'd agree that some sort of minor epilepsy episode is a potential candidate) - although it would have to be a very specific type of incapacitation that enabled the pilot to keep flying the aircraft straight and level while losing the ability to think rationally/clearly; 2) some sort of deliberate act on the pilot's behalf.

I find #2 surpassingly difficult to believe. If you're going to commit suicide in a helicopter, just point the damn thing into the ground and step on the gas. Why wait until fuel tanks and switches are involved?
 
I've also read elsewhere that the "prime" pumps are not usually left on for flight(only for starting). I wonder if he simply wasn't paying attention and turned on the wrong pumps.


Yes, you're absolutely correct. The prime pumps are only meant to be used to prime the engines with fuel for starting - once the engines are in operation, they draw fuel in from the supply tanks of their own accord.

So the apparent fact that the prime pump switches were on, while the transfer pump switches were off, does raise the distinct possibility that the pilot switched on the wrong set of pumps in error, once the low fuel alarms started.

But if that's the case, he should still have easily been able to see that even though he thought he had applied the correct remedy, the reality was that the fuel levels in the supply tanks was getting lower and lower, and the alarms were getting more and more urgent. It is therefore difficult to see why he wouldn't at some point (well before the tanks finally emptied) have thought something like: "Hmmm, the fix that I thought I had carried out obviously hasn't worked for some reason. Perhaps I had better have another look and check whether I did the right thing". Or, if not something like that, then perhaps something like: "What? The fix I applied is not working. I am rapidly running out of available fuel. I had better get this aircraft onto the ground safely before the fuel totally runs out."
 
I find #2 surpassingly difficult to believe. If you're going to commit suicide in a helicopter, just point the damn thing into the ground and step on the gas. Why wait until fuel tanks and switches are involved?


Because an unequivocal case of suicide might have different implications (insurance, death in service benefits, reputation) than something that was crafted to leave open the possibility of accidental incompetence and/or dreadful bad luck?

It's why a couple of commercial airline pilots who almost-certainly committed suicide by flying their planes into the ground made sure they had switched off the feeds to the CVR and FDR (the black boxes) before they initiated their descents. In those cases, the airlines were far from populated areas and at high altitude - and therefore there was little chance of people on the ground being able to offer any evidence. They clearly turned off the black box feeds so that there would be no evidence of their instrument inputs or the sounds in the cockpit, and the only reason for doing that would be to muddy the waters of any subsequent crash investigation.

And additionally, the airline pilots knew that they could use high aerodynamic forces to essentially prevent anyone else - crew or passengers - from regaining the controls. That would not be possible in a helicopter: if the pilot suddenly pointed the helicopter at the ground from a reasonable altitude, there was a not-insignificant chance of one of the other passengers being able to wrest back the controls. In the case of the Glasgow crash, there were two other passengers, both of whom were police officers, and both of whom would have been in close proximity to the pilot and the controls. One of the other hallmarks of the commercial airline pilot suicide/murders was that the pilot in question always found a ruse for getting all the other flight crew out of the cockpit before initiating the crash. That option simply is never available in a small helicopter.

Please note that I am only seeking to answer the specific question that was posed. I am not suggesting that this is necessarily what did happen in the Glasgow helicopter incident. In my view, my answer is a fairly adequate explanation as to why, in theory at least, a pilot who was planning to end his life while flying a helicopter with other capable passengers in close proximity might choose to engineer an equipment failure rather than simply pushing forward the cyclic and aiming at the ground.
 
The absence of any report of a problem suggests to me that the pilot either was unaware he had one, or (more likely) thought he did not- ie for reasons which seemed good to him, he was ignoring the various alarms, having concluded they were false.
I know nothing of significance about helicopter systems ( though I've flown in many as a passenger), but I do know that once a man finds a convincing reason to believe an alarm is itself faulty, he may continue to ignore, override, or switch off that alarm right up to the second reality bites his throat out.

This was the end of a ninety minute flight. It was late at night, perhaps the last flight of the shift? I think he dismissed the fuel warnings, perhaps because he was confident he had plenty fuel. I suspect he had switched the pumps off for the last hover and had failed to restart them. When the first engine shut down, he probably started a hasty reassessment of the situation, but in the middle of that the second engine died and the rotor stalled with insufficient forward speed or rotor speed to recover.
That's all bad in that it adds up to pilot error , but there's no need to suppose any self destructive impulse or onset of illness. (Having seen the effects of stroke, the idea of a pilot suffering one on approach is just flatly terrifying, but I think everything that happened is explicable by normal human nature).


ETA- If the above turns out to be probable, perhaps a redesign of the fuel system might ensure that if one engine did die for lack of fuel, the second would not do so for at least five minutes? (Not much help if you are 40 miles west of Shetland, but it would have made all the difference here).
 
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The absence of any report of a problem suggests to me that the pilot either was unaware he had one, or (more likely) thought he did not- ie for reasons which seemed good to him, he was ignoring the various alarms, having concluded they were false.
I know nothing of significance about helicopter systems ( though I've flown in many as a passenger), but I do know that once a man finds a convincing reason to believe an alarm is itself faulty, he may continue to ignore, override, or switch off that alarm right up to the second reality bites his throat out.

This was the end of a ninety minute flight. It was late at night, perhaps the last flight of the shift? I think he dismissed the fuel warnings, perhaps because he was confident he had plenty fuel. I suspect he had switched the pumps off for the last hover and had failed to restart them. When the first engine shut down, he probably started a hasty reassessment of the situation, but in the middle of that the second engine died and the rotor stalled with insufficient forward speed or rotor speed to recover.
That's all bad in that it adds up to pilot error , but there's no need to suppose any self destructive impulse or onset of illness. (Having seen the effects of stroke, the idea of a pilot suffering one on approach is just flatly terrifying, but I think everything that happened is explicable by normal human nature).


ETA- If the above turns out to be probable, perhaps a redesign of the fuel system might ensure that if one engine did die for lack of fuel, the second would not do so for at least five minutes? (Not much help if you are 40 miles west of Shetland, but it would have made all the difference here).


But the EC135 has a graphical illustration of fuel levels sitting right in front of the pilot's eyes. It's circled in red in this photo:




That blue graphic area is a three-part "bar chart" showing the fuel levels in the two transfer tanks (on either side) and the main tank (in the middle). The height of the bar indicates the fuel quantity, and the actual quantity is also listed above each respective bar.

So even if, for some reason, the pilot thought the multiple alarms were all faults, he also had additional graphical and textual evidence in front of his eyes as to the actual levels of fuel in the supply tanks. Is it realistic to suggest that the pilot somehow decided that not only were all the alarms false, but that also the fuel indicator instruments were displaying false readings?

The only scenario in which I can see this being a realistic possibility is if there had been previous documented problems around incorrect fuel load sensor readouts (most relevantly if there was such a history on this particular aircraft, but also perhaps if another similar aircraft had experienced such a sensor reading fault).

Otherwise, I would suggest that it's difficult to see how the pilot could have unilaterally decided (and without radioing the ground either for technical advice, remember) that all the information he was receiving regarding the fuel status - the multiple "low fuel" alarms, and the graphical/textual indication of the fuel running out in the two supply tanks while the main tank remained adequately full - was all incorrect and misleading, and that in reality (in his mind) he actually had ample fuel in his supply tanks.
 
Thanks LondonJohn.

One problem with epilepsy is that the neurologists who diagnose and treat it don't seem to have experienced it themselves. I dealt, in my professional career as a psychologist, with a number of epileptic clients. If I knew then what I know now from personal experience my approach would have been radically different.

The one thing which it appears is that epilepsy takes a wide range of forms. What I have experienced could well have been the cause of the Moorgate disaster – it certainly fits. It is also likely that if it was this the other people aboard would not have realised what was happening and have had time to react.
 
Because an unequivocal case of suicide might have different implications (insurance, death in service benefits, reputation) than something that was crafted to leave open the possibility of accidental incompetence and/or dreadful bad luck?

Perhaps, but now you're in danger of piling speculation on top of speculation, something with which I'm not entirely comfortable. And in any case, I would imagine that a pilot intent on making a suicide look like an accident could do so in a way that would be utterly convincing -- simply shouting "I'm having a seizure!" into the radio mic just before steering the craft into the nearest building would do quite nicely. I see no reason to flirt with the potentially volatile and defamatory notion of pilot suicide, not when it really doesn't make any sense (at least not yet, short of a major new revelation about the pilot's personal life) and the facts appear explainable via other, more ordinary possibilities.
 
Perhaps, but now you're in danger of piling speculation on top of speculation, something with which I'm not entirely comfortable. And in any case, I would imagine that a pilot intent on making a suicide look like an accident could do so in a way that would be utterly convincing -- simply shouting "I'm having a seizure!" into the radio mic just before steering the craft into the nearest building would do quite nicely. I see no reason to flirt with the potentially volatile and defamatory notion of pilot suicide, not when it really doesn't make any sense (at least not yet, short of a major new revelation about the pilot's personal life) and the facts appear explainable via other, more ordinary possibilities.


Yes, you may well be totally correct in these observations. I would agree that it takes speculation-upon-speculation to arrive at a scenario where the pilot decides to engineer the crash via a contorted and complex method (although I still think that there are - in theory at least - valid reasons why a pilot who had given this issue a fair amount of thought might choose to choreograph just such a long-winded build-up to a deliberate accident).

But that still leaves the overarching issue of how and why this accident actually DID happen. Since we now appear to know (via the latest AAIB report) that the primary cause of the accident was the incorrect positioning of the fuel pump switches in the cockpit, we have to conclude that pilot error was the underlying cause. And then there was apparently a secondary case of pilot error in that he either ignored the alarms altogether or failed in his attempt to fix the problem. And then there was apparently a third case of pilot error in that he neglected to put down the aircraft safely while there was still enough fuel in the supply tanks - as per the standard procedure for this emergency if there's no immediate fix. And then there was a fourth case of pilot error in the failure to execute an autorotation controlled descent and landing once the engines had flames out - again as per standard procedure, and a manoeuvre that would have been deeply ingrained in a pilot of his ability and experience.

So just how and why were so many errors made? That's the important question. Could they just have been a cumulative series of genuine errors of judgement, and/or failures of training, and/or personal shortcomings (freezing, panicking etc)? My personal view is that there were too many errors, and too many simple opportunities to remedy the situation safely, for this to be a reasonable explanation.

I might be wrong in my assessment above. But if not, then what else could have been the underlying factor? To me, some sort of incapacitating brain event does seem to be a possible candidate. As, regrettably, does some sort of deliberate planned action on the pilot's behalf. But what else?

Look - perhaps I am totally overanalysing this, and this was nothing more than a case of an overconfident, hubristic, egotistical pilot thinking that he knew better than the instruments and alarms, and refusing to admit to his own shortcomings (although this still would not appear to explain the failure to conduct a proper autorotation landing after flameout). Or perhaps something will turn up totally out of left field that totally alters the perception of the evidence - just as a (slightly facile) example, it might transpire that the polarity on the fuel pump switches had been accidentally reversed in a maintenance error just before that evening's flight, or that there was for some reason a total (and temporary) electrical and hydraulic failure at some point. Although I would suggest that the chances of this sort of "game changing" evidence turning up at this point in the investigation would be very small.
 
Well, I agree 100% that whatever did happen appears to be a puzzler at this point. I'm a huge fan of those "Air Emergency" television shows (perhaps a morbid admission on my part) because it's fascinating to see how the investigators painstakingly piece together the story from often seemingly inconsequential bits of data. So I fully understand -- and share -- the interest in figuring out what occurred. The answers are often instructive, and can make for safer air transport in the future.
 
I would suggest that it's difficult to see how the pilot could have unilaterally decided (and without radioing the ground either for technical advice, remember) that all the information he was receiving regarding the fuel status - the multiple "low fuel" alarms, and the graphical/textual indication of the fuel running out in the two supply tanks while the main tank remained adequately full - was all incorrect and misleading, and that in reality (in his mind) he actually had ample fuel in his supply tanks.

I truly don't know. I have seen people ignore multiple alarms ( even turning them off) before now. (Not in aircraft though). Sheer pig headed stupidity can adequately explain a lot.

In truth, we are speculating beyond the data, but I think the investigators must be looking at physical and psychological conditions now the purely technical explanation appears inadequate.
 
This may indeed help to explain how the fuel transfer pump switches found themselves in the "off" position at some point during the flight.



But surely, once the "low fuel" alarms started sounding, the instinctive response by the pilot (not to mention the standard written procedure) would have been to follow a train of thought along the following lines: "Hmm, the supply tanks are low on fuel. Now, these tanks are supplied by the main tank. So how much fuel do I have in the main tank? More than enough. OK. So, how come there's plenty of fuel in the main tank but very little in the supply tanks? Why is the fuel not getting from the main tank into the supply tanks? Ah wait, it's the fuel transfer pumps that move the fuel in this way. I'd better look up and check whether those pumps are on or off. Oh Jeez, they're off. I'll turn them on again. Ah, that's better, the supply tanks are now replenishing fine from the main tank. Crisis over."



So even if the fuel transfer pumps had previously been switched off for a legitimate reason, why on earth wouldn't the pilot have checked the switches once the "low fuel" warnings started (and kept going and going and going)? And then, once the alarms had been going for some minutes, why didn't the pilot declare himself baffled (assuming that he didn't look up and check the switches) and make an emergency landing in any case?



I simply find it very hard to understand how and why the pilot would have kept flying - seemingly en route to base - with those alarms going off, his supply tank gauges running to zero, and with him self-evidently having been unable to identify or fix the cause of the growing emergency. And all that without even making a radio call to inform the tower/control of his situation.


I've been instructing for a while, and you'd be amazed at what perverse actions people take under stress. I know of a student who, when faced with the simulated loss of the right engine just after takeoff in an Aztec, reached up and turned off the magnetos on the left engine. My friend, who was the instructor on that flight, told me it was the best 30 seconds' of flying he'd ever done while flying around trees trying to get the plane to climb.

The student, an experienced multi-engine pilot, never could explain why he did what he did.
 

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