Accidents - Domestic - Printable Version

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RE: Accidents - Domestic - Peetwo - 06-16-2022

Drone taxi crash report - "Where's the kill switch?"  


Via Popinjay central: 

Quote:
RPA taxiing loss of control incident highlights the importance of fatigue management and controller design



An Australian Transport Safety Bureau investigation into a 19 June 2020 loss of control incident involving a remotely piloted aircraft (RPA) while it was taxiing following a maintenance flight highlights to RPA operators the importance of fatigue management and controller design.

After landing at Bruhl Airfield, Queensland after completing a successful autonomous test flight, the pilot of the RF Designs Mephisto RPA - a high-performance autonomous testbed which has a 2.6 m wing span and a 35 kg max take-off weight - toggled the controller’s automatic mode switch to disengage the aircraft’s automatic mode for taxi back to the hangar, the investigation report details.

The pilot then increased the throttle to provide the RPA with sufficient momentum to taxi. As the RPA turned towards the pilot, the pilot determined that it was not responding to commands to reduce the engine thrust. The pilot considered attempting to arrest the RPA by hand but determined it was moving too quickly and instead toggled the automatic mode switch to regain control and turn it away from bystanders.

The pilot then directed the RPA across the airfield and it came to rest against the perimeter fence, resulting in minor damage to the aircraft’s skin.

“The ATSB’s investigation into the incident determined that the pilot did not correctly disengage the RPA’s automatic mode,” said ATSB Director Transport Safety Stuart Macleod.

“Subsequently, when they increased the throttle to provide the aircraft with momentum to taxi back to the hangar the ‘abort landing’ function activated, increasing the throttle to maximum and overriding the pilot’s commands to decrease throttle.”

Mr Macleod noted this incident has 3 key learnings for RPA operators.

“RPA operators should be mindful of the risk of fatigue, particularly in high tempo commercial operations,” he said.
“Even when fatigue management is not mandated, operators should ensure that their fatigue management processes are robust and effective.”

The incident also highlights the importance of controllers being as simple and reliable as possible.

“If a control leaves room for human error, then it will increase the risk of this error occurring even if procedural controls are in place. Consideration should also be given to a system that allows the remote pilot to shut down the aircraft immediately in the event of an unexpected state or failure.

“Lastly, operators should be prepared for the RPA to do something unexpected and know and frequently practice emergency procedures.”

Read the report AO-2020-035 Loss of control during taxi, involving RF Designs Mephisto, remotely piloted aircraft Bruhl Airfield, 2 km south-west of Tara, Queensland on 19 June 2020

Hmmm...did Popinjay really need to waste resources on this non-event? 

MTF...P2 

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RE: Accidents - Domestic - Kharon - 06-19-2022

OK: and - then what????

Popinjay - ""Consideration should also be given to a system that allows the remote pilot to shut down the aircraft immediately in the event of an unexpected state or failure."

What a bloody good idea - a 'Kill-switch" - pearls of wisdom drop from the ATSB boss; although from which end of the boss they dibble we ain't sure.

1.852 converts Knots to KpS. 1 nm/sec = 1.852 KpS. 30 knots = 0.5 nm/ minute: so do the maths -  35 Kg @ 30 Knots = 0.926 Kilometres distance travelled - after the 'kill switch is toggled. F= MA provides the impact force of a 35 Kg thing with a 2.6 meter wingspan hitting something. All very esoteric - but if you ever want to experience F=MA in the real world, try this. Place your thumb on the workbench and allow a 0.5 Kg hammer to drop from eye height onto it. Quite a wallop ain't it; sore for a week at least, for a month's worth of pain - swing that hammer with some force (malice aforethought) - you'll get the message fast enough.  Sure, it is not a regular occurrence, but it happens and there are no 'fail safe' measures to prevent it (bar common sense). My hammer weighs in at 24 ounces (0.68 Kg) the fail safe is me. The 'drone' under consideration has no built in 'fail safe' - loose control of it, at speed and altitude and the operator who hits the 'kill' switch has no further control (non whatsoever) from that moment over 35 Kg @ 10 knots = 18.5 kilometres per hour/ 60 = 0.3 K per minute. Allow what; say a 1.5 minute descent after the 'kill' that's 2/3 kilometre (ish) travelled before it reaches the deck - out of positive control. Kill switch - yeah, OK but what about 'control' after the event - the 'impact' maths get complicated from here - but it is quite a whack. Every aircraft has an alternate means of control after say an engine failure- Aye; 'tis limited but it at least it has a fighting chance of not hitting Bunning's out of all control on a Sunday morning.. Bring on the Drones if you must - but lets have some 'fail safe' control built in with a little more imagination than just a stellar example of ATSB safety thinking like - "hit the kill switch" (and then what?)..........A well trimmed man-hole cover on descent....

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RE: Accidents - Domestic - Peetwo - 06-23-2022

Popinjay perpetuates Mangalore midair cover-up?? 

Previous thread reference:

(04-02-2022, 06:26 AM)Kharon Wrote:  First and last comment.

"At 1122:44 the controller provided the pilots in JQF with the following traffic information:

"6 [nautical] miles in your 12 o’clock is alpha echo mike, a King Air. They are inbound to Mangalore for airwork. Passing 5,000 [ft] on descent to not above 4,000 [ft]"

"At 1122:49, five seconds after the controller passed this traffic information to the pilots of JQF, an aural and visual short-term conflict alert (STCA)[6] was provided to the controller."

"By this time, JQF was climbing through 3,250 ft, had a ground speed of 81 kt and had commenced a turn to intercept their planned outbound track from Mangalore Airport to LACEY (Figure 2). At the same time AEM had a ground speed of 187 kt and was descending through 4,918 ft on a track of 354⁰. At this point, there was 5.4 NM horizontally and about 1,675 ft vertically between the aircraft."

First thoughts: from a practical POV.
Head to head - six miles separation.
One climbing, one descending.
Closing speed = 81 + 187 :: 268 Knots. (496 Kph). = 4.46 a minute. = 1.34 minutes to meeting.
Climb and descent rates (estimated) say a mean of 500 fpm each (call it a combined 1000 fpm).  AEM descending through 4918' - JQF climbing through 3250'. that's 1668' vertical separation/1000 fpm = 1.6 minutes . Ballpark..

Lets call it 90 seconds to 'the conflict' zone. Options still wide open.

To quote the 'time warp' song "and then a step to the right" - a'la TCAS, a mere 15 second right turn each would have provided enough wriggle room.

Was there time to arrange a 'you maintain 4000 - we hold at 3500 until clear? Probably; but not the optimum - busy frequency - etc, etc.

Could the ATCO have stepped in and ordered an altitude hold - in time - legally? This I cannot answer. But it brings back the ghosts from the Benalla fatal. Personally, I'd like the ATCO to have that latitude; in a 'critical' situation, even as an advisory - but the ASA people concerned will have a much better idea of what is best practice than I have. Perhaps it is a question which someone who understands the system can answer.

Self separation - see and be seen - in anything other than the perfect situation is a loaded gun, with the safety off, once clear of the circuit, particularly when operating to IFR tolerances under training. Given the conditions and circumstances, at the time, could either aircraft have spotted the other? It is a reasonable question. Perhaps being the right answer; there was only a heartbeat or two between having a story to tell over an Ale and a tragic loss.

Who's to bless and who's to blame don't enter this argument; bur IMO, we need to come up with a resolution to the obvious 'hole' in that famous cheese to ensure that this event is never repeated - ever.

My two Bob's worth; going to sit with TOM and stay right out of it.

Toot - toot.

Then yesterday this disturbing video with the accompanying Popinjay bollocks -   

Quote:

Key points

• The ATSB undertook an aircraft performance and visibility study to support its investigation into the February 2020 mid-air collision of two training aircraft near Mangalore, Victoria;
  
• The study helped investigators determine when each aircraft would have been visible to the pilots of the other aircraft;
  
• Study’s animations clearly illustrates the limitations of visual acquisition and the significant additional alerting time ADS-B IN displays would have provided.
  

A cockpit display or electronic flight bag app showing traffic information from ADS-B IN data would have alerted the pilots of two training aircraft involved in a fatal mid-air collision near Mangalore, Victoria to the position of the other aircraft much earlier compared to visual acquisition, an Australian Transport Safety Bureau study concludes.

In March, the ATSB released its final report from its investigation into the accident which found that, following receipt of verbal traffic information provided to both aircraft by air traffic control, the pilots of both aircraft did not successfully manoeuvre or establish direct radio communications to maintain separation, probably due to not recognising the risk of collision.

The accident was the first mid-air collision between two civil registered aircraft operating under the instrument flight rules (IFR) in Australia. As the collision occurred outside of controlled airspace, air traffic control (ATC) was required to provide traffic information on other IFR aircraft, but was not responsible for ensuring separation. This meant that the pilots were self-separating using radio communications and, where possible, the ’see and avoid’ principle.

‘See and avoid’ has known limitations, and central to the investigation was determining the likelihood that the pilots of each aircraft could detect the other visually in sufficient time to take avoiding action.

“To support the investigation, the ATSB initiated an aircraft performance and cockpit visibility study to determine when each aircraft may have been visible to the pilots of the other aircraft,” said ATSB Chief Commissioner Angus Mitchell.

“In addition, the study was undertaken to determine what effect an ADS-B IN system would have had on the pilots’ ability to detect traffic as they converged.” 

Aircraft fitted with ADS-B OUT transmit positional and speed information derived from GPS to receivers including those used for air traffic control. Aircraft fitted with ADS-B IN equipment can receive this information on nearby aircraft, aiding pilot situational awareness.

Mr Mitchell said the investigation found that the pilots had insufficient time to visually acquire the opposing aircraft as cloud likely obscured the aircraft up until the collision, and added the study found that even in clearer conditions the aircraft were unlikely to have had sufficient time to visually acquire one another in time to avoid a collision.

“Analysis indicated that even in clearer conditions than experienced on the day of the accident, closing speeds and shielding by the aircraft structures would have limited the pilots’ opportunities to acquire the other aircraft, with two of the four pilots involved likely having the opposing aircraft shielded from their view at key moments prior to the collision,” he said.

As part of the study the ATSB developed scale three-dimensional models of the internal and external structures of representative aircraft using laser scanning technology, and determined the pilots’ approximate eye position within each model.

Investigators then developed animations using ADS-B position and aircraft performance data showing the cockpit view for both pilots in each aircraft overlaid with simulated cockpit traffic displays and alerts. This was supplemented by recorded air traffic control data.

These animations help illustrate the limitations of visual acquisition. Moreover, they demonstrate the significant additional alerting time that would be provided by an ADS-B IN display with an aural alert.

“The study has clearly shown that had the aircraft been equipped with ADS-B IN, the pilots would have been assisted in locating the other aircraft and alerted to its position much earlier than by visual acquisition,” Mr Mitchell said.

“The ATSB continues to strongly encourage the fitment and use of ADS-B transmitting, receiving and display devices in all general and recreational aviation aircraft, as these devices can significantly assist pilots with the identification and avoidance of conflicting traffic, and are available at relatively low-cost.”

While both aircraft involved in the mid-air collision were equipped with ADS-B OUT, neither aircraft were equipped with ADS-B IN systems, and nor were they required to be.

“Both a cockpit display of traffic information with an ADS-B traffic alerting system or an electronic conspicuity device connected to an electronic flight bag application could have provided this advance warning of a potential collision to the pilots of both aircraft,” Mr Mitchell said.

“While effective radio communication remains the primary means of self-separation in non-controlled airspace, the targeted and accurate information provided by ADS-B IN can provide pilots with significant assistance.”

Read the aircraft performance and cockpit visibility study: AS-2022-001 – Aircraft performance and cockpit visibility study supporting investigation into mid air collision of VH-AEM and VH-JQF near Mangalore Airport Vic. on 19 February 2020
Read the final report: AO-2020-012 – Mid-air collision involving Piper PA-44-180 Seminole, VH-JQF, and Beech D95A Travel Air, VH-AEM, 8 km south of Mangalore Airport, Victoria, on 19 February 2020

More information about ADS-B and the benefits of using the technology: Automatic Dependent Surveillance Broadcast - Airservices

 
Hmm...



MTF...P2 

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RE: Accidents - Domestic - Peetwo - 07-07-2022

Su_Spence helps perpetuate Mangalore midair cover-up??

Via this month's Su_Spence bollocks briefing - 

Quote:ATSB's Mangalore video shows value of ADSB In
A video released by the Australian Transport Safety Bureau shows how the use of Automatic Dependent Surveillance Broadcast In (ADS-B In) would have alerted pilots of two training aircraft that they were on course for a  fatal mid-air collision over Mangalore, Victoria.

The sophisticated video accompanies a visibility study into the 2020 collision and shows that a cockpit display or electronic flight bag app would have alerted the pilots of the two aircraft long before they saw each other.

The accident was the first mid-air collision involving two aircraft operating under instrument flight rules in Australia and occurred outside controlled airspace.

Both aircraft had ADS-B Out but neither had ADS-B In.

The pilots were acting on information provided by air traffic control, as well as self-separation using radio and the ‘see and avoid’ principle.

The ATSB’s investigation found the pilots had insufficient time to physically see the opposing aircraft and avoid a collision.

However, ADS-B (in) connected to a cockpit system or an electronic flight bag would have assisted each pilot with locating the other aircraft and alerting them to its position much earlier.

‘While effective radio communication remains the primary means of self-separation in non-controlled airspace, the targeted and accurate information provided by ADS-B in can provide pilots with significant assistance,’ ATSB Chief Commissioner Angus Mitchell says.

MTF...P2 

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RE: Accidents - Domestic - Peetwo - 07-21-2022

FAA (rest of the world) bemused by Popinjay SR - 

Via the JDA Journal blog:

Quote:Australia Issues A Recommendation On An FAA Certificated Aircraft

An Australian Cessna Centurion had a catastrophic failure in 2019
ATSB investigated, issued probable cause and FAA issued ADs
Recent ATSB recommendation added concern- not noted in most recent AD

In an interesting intergovernmental action, the Australian government has issued a “warning” about a defect in a US certificated aircraft.

This is actually a step in an ongoing review of a Cessna P-210. In response to the original accident, the FAA issued Docket No. FAA-2020-0156,AD 2020-03-16, requiring:

“…visual and eddy current inspections of the carry-thru spar lower cap, corrective action if necessary, application of a protective coating and corrosion inhibiting compound (CIC), and reporting the inspection results to the FAA.”



The FAA on May 11, 2021, issued a subsequent AD and requested comments on the new proposed safety requirement. The docket includes 123 comments, including a submission by EASA, but nothing from the ATSB.  Some of the comments requested withdrawal of the proposed AD.



On November 23,2021 Australia Transport Safety Board issued this report—

Quote:In 2019 a Cessna P-210, a Cessna Aircraft Company T210M, registered VH-SUX and operated by Thomson Aviation, departed Mount Isa Airport for an aerial geophysical survey flight with a pilot and observer on board.

One hour and 40 minutes later, as the aircraft was flown west along a survey line about 25 km north‑east of Mount Isa Airport, the right wing separated from the aircraft. The structural failure led to a rapid loss of control and a collision with terrain. Both crewmembers were fatally injured, and the aircraft was destroyed.

The ATSB found that a pre-existing fatigue crack in the aircraft’s wing spar carry-through structure propagated to a critical size resulting in an overstress fracture of the structure and separation of the right wing.

Detailed examination of the structure found that relatively minor corrosion near a highly stressed location on the lower surface of the wing spar carry-through progressed into the aluminium alloy structure. This increased stress concentration in this area and led to initiation and growth of a fatigue crack, significantly reducing the strength of the structure.

In 1992, the aircraft manufacturer introduced a recommended continued airworthiness program, including a flight hour‑based repetitive eddy current inspection for cracking of the carry-through structure. This program included more stringent requirements for aircraft being used for low-level survey flights. However, following an assessment of historical data in 2011, the manufacturer replaced this inspection with a three-yearly visual corrosion inspection for all operation types, which was mandatory in Australia. This inspection variation significantly limited the opportunity to identify fatigue cracking within the carry-through structure of low-level survey aircraft prior to failure.

The ATSB also found that the cyclic loads induced by the low-level survey flight profile were significantly greater than those associated with the higher-level flight profile originally intended for the aircraft type. This probably increased the risk of a fatigue related structural failure.

As described in the below extensive article, the ATSB now recommends that Textron take further action.

Two observations make this ATSB pronouncement unusual: (i) curious why the Board did not submit this note to  AD 2020-03-16 so that the FAA might incorporate the Australian perspective and (ii) what caused the ATSB to issue this recommendation. The release does not mention any new facts or assessments which stimulated this additional action.

MTF...P2 

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RE: Accidents - Domestic - Peetwo - 07-22-2022

QFA933 low fuel MAYDAY - 

Via airlive.net:

Quote:INCIDENT Qantas #QFA933 declared an emergency after running low on fuel on approach to Perth



The pilots of a Qantas passenger jet were forced to declare a “mayday” after running low on fuel as they were put in a midair queue with other planes near Perth.

Qantas Flight 933 made the emergency call several hundred kilometres east of Perth on Monday July 18th, which has since sparked an investigation by air safety authorities. The pilots’ decision to issue the mayday happened as inbound planes to Perth were put into holding patterns due to delays at the West Australian capital’s airport.

The Qantas Boeing 737 aircraft had arrived within Perth airspace with an extra 20 minutes’ worth of fuel when air traffic controllers told the pilots that an expected holding period had extended to 16 minutes.

The pilots were told that they would have to declare a mayday to get priority to land before four other planes circling Perth.

The Qantas Boeing 737-838 aircraft, which had departed Brisbane more than five hours earlier, eventually landed safely at Perth Airport in what air-safety investigators describe as a “fuel mayday on descent”. A “fuel mayday” call by pilots is rare.


The pilots were in danger of landing without legally required reserves of fuel onboard if they had not declared the mayday.

In response to questions, the Australian Transport Safety Bureau confirmed that it was investigating a “low fuel event” involving the Qantas 737 aircraft, which occurred above Wave Rock in Western Australia on Monday.

“During descent, the crew declared an emergency due to the amount of fuel on board and proceeded to land at Perth. The aircraft landed with reserves intact,” it said.

The air-safety bureau said a final report would be released once its investigation was completed. However, it will recommend safety measures earlier if a “critical safety issue” is identified during the investigation.

Qantas chief pilot Dick Tobiano said air traffic controllers had requested the aircraft remain in a holding pattern for longer than the QF933 pilots had previously been advised, and that to be given priority to land they needed to make a fuel mayday call.

“The aircraft landed with 40 minutes of fuel in the tank, which is well above the minimum requirements. Our pilots followed the correct procedures and there was no safety issue with the flight,” he said in a statement.

MTF...P2 

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RE: Accidents - Domestic - Peetwo - 08-11-2022

Popinjay's in a spin on VH-CYO fatal; and subsequently issues SAN?? - 

Via Popinjay central:

Quote:Spin recovery accident investigation highlights limitation of Mueller/Beggs spin recovery technique for some aircraft types



Key points:

• Instructor and student were conducting an aerobatic training flight in a Cessna A150 Aerobat to introduce and practice spin entry and recovery;
  
• Instructor likely intended to practice two spin recovery techniques, one of which has been shown to not recover a Cessna A150 Aerobat established in a spin to the left;
  
• While experienced in other aerobatic aircraft, the instructor likely had no experience conducting spinning and/or spin instruction in the accident aircraft type or similar variants;
  
• ATSB has issued a Safety Advisory Notice alerting aerobatic pilots and instructors of the limitations of the Meuller/Beggs spin recovery method for some aircraft types.
  

[b]The Australian Transport Safety Bureau is advising aerobatic pilots and instructors of the limitations of the Meuller/Beggs spin recovery method for some aircraft types, after an investigation into an aerobatics training flight accident on Queensland’s Sunshine Coast.[/b]


During the accident flight on 23 June 2021, an instructor and student were likely intending to practice two methods of spin recovery. One of those techniques, broadly known as the Meuller/Beggs method, has been shown to not recover a Cessna A150 Aerobat established in a spin to the left.

Both occupants were fatally injured when the aircraft collided with bushland near Peachester.

Air traffic control radar data showed that about 20 minutes after take-off the aircraft entered a spin to the left 5,800 ft above ground level, and then impacted the ground 55 seconds later.

The ATSB’s analysis of the accident site established that the aircraft’s forward movement and low angle of entry indicated it was most likely in the process of recovering from the spin when it impacted with terrain.

The aerobatics instructor was experienced in conducting spins, primarily in the Pitts Special aircraft type, for which the Mueller/Beggs method is effective. However, it was likely that they had no experience in spinning a Cessna A150 Aerobat or any similar variant.

“The instructor likely intended to practice two spin recovery techniques, including the Mueller/Beggs recovery method, which has been shown to not recover a Cessna A150 Aerobat established in a spin to the left,” ATSB Director Transport Safety Dr Michael Walker said.

The other method planned to be demonstrated, the generic PARE method typical of most small single-engine aeroplane types, aligned closely with the aircraft’s pilot’s operating handbook (POH) and, if utilised, would recover the aircraft from a spin.

“A second student, who was also to fly the same training flight with the instructor in the Aerobat aircraft later that day, told the ATSB they believed they would be conducting both methods of spin recovery,” Dr Walker said.

“The ATSB therefore concluded it was likely the instructor was either not aware, or did not recall, that the Aerobat would not recover using this method in a spin to the left.”

Dr Walker noted that, based on the available evidence, the ATSB was unable to ascertain which recovery technique or techniques were being utilised at the various stages of the spin recovery preceding the accident. For this reason, the ATSB could not conclude if the use of an inappropriate recovery technique contributed to the accident.

“Nevertheless, this investigation presents a timely reminder that pilots should review the POH of the aircraft type that they intend to operate, and obtain instruction and/or advice in spins and recovery techniques from an instructor who is fully qualified and current in spinning that model,” Dr Walker said.

To highlight this message, the ATSB has issued a Safety Advisory Notice to aerobatic pilots and instructors, flying training organisations and aerobatic aircraft owners to raise awareness of the limitations of the Mueller/Beggs spin recovery method.

“Prior to intentionally spinning an aircraft, pilots should obtain instruction and/or advice in spins and recovery techniques from an instructor who is fully qualified and current in spinning that model,” Dr Walker said.

“All aircraft types do not spin and recover in the same way. Know your aircraft type, what recovery techniques will work and what recovery techniques will not work.”

Read the report: AO-2021-025: Collision with terrain involving Cessna A150M, VH-CYO 5 km west-south-west of Peachester, Queensland, on 23 June 2021

And the SAN: https://www.atsb.gov.au/publications/investigation_reports/2021/aair/ao-2021-025/

Quote:

Safety advisory notice

AO-2021-025-SAN-001: The ATSB strongly encourages all aerobatic pilots and aerobatic flight instructors to be aware:

• the Mueller/Beggs method of spin recovery does not recover all aircraft types from a spin
  
• the Mueller/Beggs spin recovery method limitations should be emphasised during spin theory training
  
• the Mueller/Beggs method of spin recovery will not recover a Cessna A150 Aerobat or similar variants from a spin in some circumstances
  
• they should review the pilot’s operating handbook of the aircraft type that they intend to operate for the recommended spin recovery technique
  
• prior to doing spins in any model aircraft, pilots should obtain instruction and or advice in spins from an instructor who is fully qualified and current in spinning that model.
  

Read more about this ATSB investigation: Investigation: AO-2021-025 - Collision with terrain involving Cessna A150M, VH-CYO 5 km west-south-west of Peachester, Queensland, on 23 June 2021 (atsb.gov.au)

Plus the LMH summary: http://www.australianflying.com.au/latest/spin-recovery-singled-out-in-aerobat-crash


MTF...P2 

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RE: Accidents - Domestic - Peetwo - 08-19-2022

Prelim report AO-2022-032: 

Ref: https://www.atsb.gov.au/publications/investigation_reports/2022/aair/ao-2022-032/

Quote:This preliminary report details factual information established in the investigation’s early evidence collection phase and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

Director of Transport Safety (for this week), the 'Ghost Who Walks' spin and bollocks AO-2022-032 incident...

Quote:Preliminary report details A350 passenger aircraft’s pitot probe covers were not removed until just prior to pushback



An Australian Transport Safety Bureau investigation preliminary report has detailed that an Airbus A350 passenger aircraft was about to be pushed back for departure from Brisbane Airport before it was observed that covers were still in place on its pitot probes.

Aircraft are fitted with pitot probe covers when parked at Brisbane Airport to prevent mud wasps building nests within and blocking their pitot probes, which are used to measure air pressure to calculate airspeed.

The preliminary report on the 27 May 2022 occurrence, released to provide timely information to industry to highlight the importance of pitot probe covers being removed, notes that an aircraft refueller on an adjacent bay observed the pitot probe covers were still in place when the aircraft appeared ready for pushback.

“A known hazard at Brisbane Airport, mud wasps can rapidly build nests in aircraft pitot probes,” noted ATSB Director Transport Safety Dr Michael Walker.

“An aircraft being cleared to commence taxiing and then commence take-off with all pitot probe covers still fitted is a serious event.”

Two maintenance contractor ground crew engineers – a licensed aircraft maintenance engineer (LAME) supervising an inexperienced aircraft maintenance engineer (AME) – had been assigned to conduct scheduled receipt, dispatch, certification, and maintenance duties for the Singapore Airlines A350 aircraft during a two-hour turnaround at Brisbane.

As pushback approached, the covers remained in place until an aircraft refueller, working at an adjacent bay, observed them and alerted the supervising LAME.

The pitot covers were then removed two minutes before expected departure, and pushback occurred shortly afterwards.
As part of its investigation, to date the ATSB has interviewed the LAME, AME and the refueller, and reviewed airport security video, which did not show that the required final walk-around of the aircraft was conducted by either the LAME or the AME prior to dispatch.

“From here, the investigation will include examination of flight crew pre-flight inspection procedures, engineering final walk-around procedures, and induction training procedures,” Dr Walker said.

“It will also examine the engineers’ training records, policies and procedures around fatigue and change management, and more security video recordings.”

The ATSB has previously highlighted the risks of pitot probe covers not being removed prior to departure with its investigation into a March 2018 incident where an Airbus A330 took off from Brisbane with covers still in place, meaning the flight crew were faced with unreliable airspeed indications.

That ATSB investigation (AO-2018-053) identified safety factors across a range of subjects including flight deck and ground operations, aircraft warning systems, air traffic control, aerodrome charts, and risk and change management.

“The loss of airspeed data due to mud wasp ingress can occur even after brief periods, and the use of pitot probe covers for aircraft turnarounds at Brisbane is largely an effective defence,” Dr Walker said.

“However, as that earlier ATSB investigation identified, their use introduces another risk, which is the potential for aircraft to commence a take-off with pitot probe covers still fitted.”

Read the preliminary report: Flight preparation event involving Airbus A350-941, 9V-SHH, Brisbane Airport, Queensland, on 27 May 2022
Read the AO-2018-053 final report:Airspeed indication failure on take-off involving Airbus A330, 9M-MTK Brisbane Airport, Queensland, 18 July 2018

MTF...P2 

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RE: Accidents - Domestic - Peetwo - 09-04-2022

Popinjay (no-)blames RFS in C130 firebomber accident investigation final report?? - 

Via Popinjay HQ:

Quote:C-130 large air tanker accident investigation highlights the importance of risk mitigation

Quote:Key points

• Aircraft likely stalled following a retardant drop when flying in hazardous conditions that included windshear and an increasing tailwind;
  
• Crew very likely did not know that other smaller firefighting aircraft had ceased flying in the area, and the assigned birddog aircraft had turned down the tasking, due to the hazardous conditions;
  
• Aerial firefighting operations necessarily take place in a high-risk environment, which requires a continued focus on risk mitigation, a responsibility that is shared between the tasking agency and the aircraft operator.
  

A Lockheed C-130 large air tanker that impacted the ground following an aerial firefighting retardant drop likely aerodynamically stalled when flying in hazardous conditions that included windshear and an increasing tailwind, an Australian Transport Safety Bureau investigation has found.

All three crew on board were fatally injured when the aircraft impacted slightly rising terrain while conducting a climbing left turn away from the drop site at the Good Good fire-ground near Peak View, north of Cooma, in the NSW Snowy Mountains region, on 23 January 2020.

Strong gusting winds and mountain wave activity, producing turbulence, were both forecast and present at the drop site. The fire and local terrain at the fire-ground likely exacerbated these hazardous conditions, the investigation report notes.
“The ATSB recognises the critical importance of aerial firefighting, where aircraft are flown at low altitudes and low airspeeds, often in challenging conditions, in the management and suppression of bushfires in Australia,” said ATSB Chief Commissioner Angus Mitchell.

“These operations necessarily take place in a high-risk environment, which requires a continued focus on risk mitigation, a responsibility that, in the Australian operating context, is shared between the tasking agency and the aircraft operator.

“As part of this investigation we have sought to understand the risk mitigations in place at the time of the accident, and have identified a number of safety issues that if resolved through actions will further mitigate risks for large air tanker aerial firefighting in the future.”

The investigation details that the C-130 was being operated by Coulson Aviation under contract to the New South Wales Rural Fire Service (RFS).

On the morning of the accident, the RFS State Operations Centre had tasked two large air tankers operating from RAAF Base Richmond, a Boeing 737 and the C-130, to conduct retardant drops at Adaminaby. The 737 departed first, and after conducting a drop at Adaminaby its crew reported that conditions precluded them from returning to the fire-ground.

The investigation notes that the RFS continued the C-130’s tasking to Adaminaby despite an awareness of the extreme environmental conditions and that all other fire‑control aircraft were not operating in the area at the time. (All smaller fire-control aircraft had ceased flying, a ‘birddog’ lead aircraft initially assigned to support the 737 and C-130 had declined the tasking, and the 737 was returning to Richmond, having declined further tasking to Adaminaby.)

This information was not communicated by the RFS to the C-130’s crew.

Instead, the ATSB notes that the RFS relied on the pilot in command to assess the appropriateness of the tasking to Adaminaby without providing them all the available information to make an informed decision on flight safety.

When the C-130 arrived overhead Adaminaby, the crew assessed the conditions were unsuitable and instead accepted an alternate tasking to the Good Good fire at Peak View, about 58 km to the east, which was subject to the same conditions.
Shortly after conducting a partial drop at Peak View, the aircraft commenced a climbing left turn. Following this, climb performance degraded and while at a low height and airspeed, it was likely the aircraft aerodynamically stalled, resulting in the collision with the ground.

The investigation notes that acceptance of the taskings was consistent with the operator’s practices to depart and assess the conditions to find a workable solution rather than rely solely on a weather forecast, which may not necessarily reflect the actual conditions at the fire-ground.

“The investigation found that Coulson Aviation's safety risk management processes did not adequately manage the risks associated with large air tanker operations, in that there were no operational risk assessments conducted or a risk register maintained,” Mr Mitchell said.

“In addition, the operator did not provide a pre-flight risk assessment tool for their firefighting large air tanker crews. This would provide predefined criteria to ensure consistent and objective decision-making with accepting or rejecting tasks, and would take into account elements such as crew status, the operating environment, aircraft condition, and external pressures and factors.”

Separately, the RFS had limited large air tanker policies and procedures for aerial supervision requirements and no procedures for deployment without aerial supervision, the investigation found.

The RFS also did not have a policy or procedures in place to manage task rejections, nor to communicate this information internally or to other pilots working in the same area of operation.

“The responsibility for the safety of aerial firefighting operations has to be shared between the tasking agency and the aircraft operator,” Mr Mitchell said.

“This accident highlights the importance of having effective risk management processes, supported by robust operating procedures and training to support that shared responsibility.”

Mr Mitchell noted Coulson Aviation has taken proactive safety actions in response to the accident, including the introduction of a pre-flight risk assessment tool, a new three-tiered risk management approach, and windshear procedures and training.
Separately, the RFS has committed to undertake a comprehensive review of RFS aviation doctrine and undertake detailed research to identify best practice (nationally and internationally) relating to task rejection and aerial supervision policies and procedures as well as initial attack training and certification.

Mr Mitchell welcomed that commitment but noted the ATSB has issued three safety recommendations to the RFS to take further action to reduce the risk associated with three safety issues identified in the investigation. These concern managing and communicating task rejections, aerial supervision requirements, and initial attack certification.

The ATSB has also issued two safety recommendations to Coulson Aviation. These are to further consider the fitment of a windshear detection system to their C-130 aircraft, and to incorporate foreseeable external factors into their pre-flight assessment tool.

Read the report AO-2020-007: Collision with terrain involving Lockheed Martin EC130Q, N134CG, 50 km north-east of Cooma-Snowy Mountains Airport (near Peak View), New South Wales, on 23 January 2020

Plus via Nine news:

Quote:#9News #BreakingNews #NineNewsAustralia
NSW Rural Fire Service slammed over fatal 2020 plane crash | 9 News Australia
2,889 views  Aug 29, 2022  A scathing safety report has been handed down into the 2020 tanker plane crash, which killed three American firefighters battling summer blazes in the New South Wales Snowy Mountains region.

And the other Aunty:

Quote:#ABCNews #ABCNewsAustralia
Investigation finds NSW RFS failed to fully communicate dangers before Cooma crash | ABC News
1,417 views  Aug 29, 2022  An investigation has found the NSW Rural Fire Service failed to pass on crucial information to the crew of a Large Air Tanker before it crashed near Cooma during the Black Summer bushfires.

MTF...P2 

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RE: Accidents - Domestic - Cap'n Wannabe - 09-04-2022

Quote:Outpouring of grief over loss of father, son and pilot in plane crash west of Brisbane

There’s been a huge outpouring of grief over the tragic deaths of a father and son and their pilot in a light plane crash west of Brisbane late Monday.

Agribusiness leader Tom Strachan, 49, his son Noah, 20 and pilot Garry Liehm were returning to Brisbane from Lighthouse Station at Roma, when the Cessna R182 is believed to have encountered bad weather.

After stopping at Dalby to refuel, the aircraft failed to arrive at Archerfield airport as expected, an alarm was raised and an aerial search undertaken.

Wreckage was found in bushland near Wivenhoe Dam, about 60km from Brisbane. Paramedics were winched down to the site but there were no survivors.

Mr Strachan was the executive director of Packhorse, an agricultural investment and land management company focused on regenerative farming.

Eldest son Noah was learning the ropes of the business alongside his father, who split his time between his cattle station at Roma and Brisbane home.

On Tuesday, Packhorse chairman Tim Samway said everyone was deeply saddened by the loss of their “dear friend and colleague Tom, his son Noah and their pilot Gary”.

“Tom was an inspiring entrepreneur. He was exceedingly generous and charismatic and he had an absolute passion for regenerative agriculture,” Mr Samway said.

“He was a great mate to all of us. He brought people altogether, he was one of Queensland’s great leaders. I’d have to say he had more energy than most and he’d have to be one of the most positive people you could meet.”

Mr Samway said his sudden, tragic death was a huge loss to his family who were all in shock.

“I thought Tom was indestructible,” he said.

“We’d known each other such a long time. He was one of my best mates but I’m sure there will be thousands of others who will say the same. He was one of those people.”



The Packhorse team was providing support for Tom’s widow Anna, and their three other children, two of whom were school age.

“To lose Tom and Noah, is a true tragedy. It’s a huge loss to his family who we treat as part of our family,” said Mr Samway.

The flight from Roma to Brisbane with a fuel stop at Dalby, was one Mr Strachan had made countless times, many of those with Mr Liehm who was considered “part of Packhorse”, said Mr Samway.

“For Tom it was just a commuter flight. He was regularly travelling between Roma and Brisbane. He was comfortable working in Brisbane and out on his property, which he loved,” he said.

The company for which Mr Liehm worked, Gold Coast-based Executive Helicopters was co-operating with police and investigators from the Australian Transport Safety Bureau.

An Executive Helicopters’ spokesman expressed their “deep sympathy” for family and friends of Mr Liehm and Tom and Noah Strachan.

“Words cannot express how we feel for both families. Tom has been a regular passenger with Garry and the two had developed a strong friendship,” said the spokesman.

“Garry had a 40-year and 30,000-hour unblemished safety record in flying fixed wing aeroplanes and helicopters. He was a highly respected member of the aviation community and his level of focus on aircraft and passenger safety was exemplary.”

He stressed the maintenance of the Cessna was all up to date.

“The machine logbooks have been quarantined for the investigation being carried out by the ATSB and Queensland Police.”

He said Executive Helicopters had an unblemished safety record in its 14-years of operation.

The ATSB had launched a “short” investigation into the crash, with a report expected in months rather than years.

Numerous friends of Mr Strachan posted tribute on his Facebook page, expressing their shock and disbelief.

His former preschool teacher Wendy McTaggart Lloyd said she still had many warm memories of his gentle kind nature.

“He was a much loved son and brother. So much to give. A sad loss indeed,” wrote Ms McTaggart Lloyd.

Friend Gary Lambert said “hard work and hard play” were Tom’s hallmark.

“It seems this was rubbing off on Noah as well. My thoughts are with Anna, family and friends at this most tragic of times,” said Mr Lambert.

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RE: Accidents - Domestic - P7_TOM - 09-05-2022

Solid Gold from Megan over on the UP.....

1. Keep always thine RPMs, for without them the gates of heaven shall close to thee, and though shalt pass directly to Brick City.

2. Guard thy tail rotor as thy loins; it is a sacred thing and its loss maketh the earth spin, and rise up and smite thee.

3. Pickest thou up and sittest thou down with great care lest thy machine roll in the mud like the swine and makest thou an impoverished pedestrian.

4. Loadeth not thy machine unevenly or excessively, lest thou wander and stumble like the braying ass.

5. Run not thy fuel or oil dry, for surely it is easier for the camel to pass through the eye of the needle than for a fool to autorotate into the wilderness.

6. Linger not in the curve of the deadman, for it tempteth fate, and shall bring thee back pain.

7. Swoop not low without good reason, for many are the snares of Edison and Bell; their wires yieldeth not, and maketh thee a yo-yo.

8. Loseth not sight of the earth if thou are not a master of the black art of “hard IFR”, else thy machine shall seek the earth without thy counsel, and thy friends shall mourn the passing of a fool.

9. Loseth not thy Gs for the sake of a pushover or other folly, lest thy blades shall smite thee, and journey on without thee.

10. Descendeth not without airspeed, for the air beneath thee is wrathful, and wouldst conspire with the granite to swallow thee up, far from the seeing eye of SAR.

Choc Frog the Post -  Tim Tam the writer.....

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RE: Accidents - Domestic - Kharon - 09-17-2022

A curiosity twiddle.

Having a chat with a mate recently who mentioned a 'fatal' accident of an RA Oz aircraft and the lack of any details of the accident being available. “Early days perhaps” I opined: after a short grumble about RA 'accident' reporting from old mate, the topic changed and I almost forgot the conversation; almost. Curiosity remains a curse.

The link _ HERE__ takes you to a RA page which defines the system and process of an investigation by the RA team of 'investigators' a.ka. 'Accident Consultants'.

“Accident Consultants (ACs) are typically RAAus employees who are requested to assist at accident sites by the Head of Flight Operations (HFO). The HFO is responsible for the coordination of responses by RAAus in the event of a fatal or serious accident.”

So far so good; but if you read on, the ;language' used is decidedly 'slippery' – on a quick read through the impression left is one of sound practice, but a careful read through – Process and Procedures – defines a nebulous, home spun system which seems to do the job but (IMO) lacks the 'essentials'. It also seems to remove ATSB obligations related to any fatal event. Then there is a question left hanging about the 'qualifications' needed to become an 'accident consultant'. The NTSB version is probably the gold standard - _ HERE _. ATSB do not appear to publish their requirements – HERE. Worth taking a quick scamper through the RMIT version and a decade old ICAO Agenda item. (Dull stuff but pertinent). But, I digress.

The item which sparked a twiddle was the lack of data related to fatal accident being published by RAA.

AOPA - “RAAus, according to a communication from CASA, have refused the regulator permission to publish any of its accident investigation reports, denying manufactures of RAAus registerable aircraft access”. [/color]

AOPA "Accident Reports for aircraft registered with RA-Aus are not published for the public nor are they supplied to the manufacturers.  These reports are sealed by the RAAus under strict confidentiality never to be seen by their members, and in many cases, their own Board of Directors, with the industry denied the opportunity to learn from past mistakes.
AOPA - Approached for a copy of the RAAus accident report for the Bristell accident at Clyde in Victoria, CASA has indicated that consent is required from RA-Aus to access the report and that consent has been denied by the RA-Aus.  This stunning refusal now raises the question as to who is regulating whom? And, just how committed CASA and RAAus are to their so-called ‘Safety Month’ or ‘Safe Skies for All’ slogans.

Now, we all know AOPA has a drum to bang; but, remove the by-play and boil the rhetoric down and the remains are not really palatable are they? When insurance company lawyers, interested party lawyers, relatives lawyers and  the Coroner meet, the details of any fatal accident must be examined; the 'blame game' is a battlefield and the expenses off the clock. Not to mention a glaring holes in the overall 'safety culture' and pilot training/ testing regime, aircraft limitations and suitability for task at hand.

I reckon its the veil of secrecy which troubles most. Accidents happen, the target should be prevention of repeat performance. To do this all the 'facts' must be available to the industry. Sealed investigation results which require a team of lawyers to pry open is counterproductive to the overall 'health and safety' of not only aircrew, but to those unfortunate enough to be potentially victim to similar circumstances.

There; ramble over, but to the safety oriented mind, the question WTD are RAA playing at begs a detailed answer to what is, IMO an unjustifiable stance of accident reporting. These reports need to be made fully and freely available to the aviation community – just like the NTSB or the ATSB are obliged to do.

Toot – toot.

P2 OBS??    - Via AOPA Oz FB 12 August

Quote:Aircraft Owners and Pilots Association Australia

RAAUS ADVOCATES FOR FATAL RECREATIONAL ACCIDENTS TO BE INVESTIGATED BY ATSB, AFFIRMING AOPA AUSTRALIA POLICY

The Aircraft Owners and Pilots Association of Australia (AOPA Australia) extends it's full support and endorsement with respect to a call from the Recreational Aviation Australia Limited (RAAus) for all fatal recreational aircraft accidents to be investigated by the Australian Transport Safety Bureau (ATSB).

"During the past three years, AOPA Australia has actively campaigned for fatal recreational aircraft accidents to be independently investigated by the ATSB, citing a range of genuine concerns for both the industry and the RAAus organisation itself", Benjamin Morgan, CEO AOPA Australia.

"Our efforts have included multiple written submissions to the Minister and Government, written submissions to the CASA Board of Directors and in-person testimony presented before Senate RRAT hearings." he said.

In a communication to RAAus members this week, Chairman Michael Monck and Chief Executive Matthew Bouttell confirm that they have appealed to the new Minister for the ATSB to be resourced adequately to enable them to perform investigations into fatal accidents within the Sport Aviation sector. 

"We firmly believe that the Government has a role to play in understanding why an accident that led to the loss of an Australian life, irrespective of the registration letters or numbers on the aircraft, so safety improvements can be made." they said.

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RE: Accidents - Domestic - P7_TOM - 09-17-2022

Ah ha!!

From 'Processes and Procedure' -

"If the ATSB conducts an investigation, the TSI Act provides the ATSB with legal responsibility for the investigation, which while conducted with cooperation of local police, results in the ATSB publishing a report on their website. The ATSB is protected under the TSI Act from any civil or legal action by anyone associated with the fatality."

"RAAus however, is not protected from legal or civil action at all by the TSI Act, resulting in RAAus only being able to provide a report for the police and Coroner and only providing relevant and general safety information to members."

So..... who's bright idea was it and to what end??

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RE: Accidents - Domestic - Kharon - 09-28-2022

Murphy, rocks and hard places.

There is a difference when caught between a rock and a hard place; luck and timing play a big part.

ATSB have provided two reports into similar but separate incidents; both succinct and worth consideration and some thought. There is also a 'Safety Advice' notification which makes good sense. Not a bad job by ATSB, but the SAN was issued in 2022 after the Kununurra event; which occurred after the Gove event in 2014; which occurred after Beechcraft issued their advice in 2008.


“The ATSB encourages Baron operators to review the Electrical Wire Chafing Protection section in Model Communiqué 116 (See attachment A) put out by Beechcraft in June of 2008, which is applicable to all Beechcraft models.”

The latest event (Kununurra) serves to make a couple of very valid points – it shows just how quickly things can turn to worms; and how very quickly 'options' can vanish when Murphy holds the trump card. There's our pilot, nicely lined up for a straight in, final checks – Gear down selected – gear warning, followed by silence from the gear motor, no speed reduction. During that half minute – I reckon most would be thinking about a gear malfunction; going around and cranking the gear down manually. That would be the sensible option; but following closely on the heels of this 'minor' problem – burning smell and smoke – now the options are 'limited' – belly landing and rapid evacuation seems the lesser of the two evils; but even a happy outcome from that choice is denied; smoke obscured both instrument and forward visibility. Our pilot did a great job, electrical power off; extinguisher used; cool head in tough spot, but even opening the storm port was to no avail. A classic example of just how quickly one problem can lead to another; how rapidly options can be reduced and just how fast, when least expected, without warning, a routine operation can become a bridge too far. Well done that young man; well done indeed.

Compare this event to the 2014 event approaching  Gove; these boys got the 'smoke' warning early; isolated the electrics and used the one shot extinguisher to deal with the fire. I don't know (not being there) that I would have turned the Master on again, not even for a few seconds after having used the extinguisher and I doubt I would have used the electrical system to lower the landing gear. Fuel, air and spark in a closed environment would give pause for thought. However I digress. The point is two different outcomes; from similar problems, the difference purely a matter of time and circumstance.

Anyway – just an idle twiddle in the hope it produces some food for thought and discussion over an Ale (or two).

Toot - toot..

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RE: Accidents - Domestic - Peetwo - 10-07-2022

Popinjay presents prelim report for AO-2022-034 AAI?? - WTD!   

Via Popinjay HQ:

Quote:Bird carcass located near LongRanger helicopter accident site



A wedge-tailed eagle bird carcass was located near the accident site of Bell LongRanger helicopter which experienced an in-flight break-up near Maroota, New South Wales on 9 July 2022, according to an Australian Transport Safety Bureau preliminary report.

The report details factual information from the early evidence collection phase of the investigation into the accident, and does not contain analysis or findings, which will be detailed in the investigation’s final report.

The Bell 206L1 LongRanger, registered VH-ZMF, had departed a private helipad in Cattai. The helicopter then climbed to about 700 ft above mean sea level and tracked north towards the planned destination in St Albans.

A witness to the south of Dargle Ridge recalled seeing a helicopter moments before the accident, flying straight and level towards the north, and that weather conditions were good, with clear skies and light winds.

“Several witnesses described then seeing the helicopter enter a rapid banking turn to the right while pitching up,” ATSB Chief Commissioner Angus Mitchell said.

“They heard several rotor beats change tone before a final louder noise.”
Witnesses then recalled the helicopter pitching and rolling while descending, with one witness describing separation of the main rotor blades from the helicopter.

Smoke was then observed rising from the area where the helicopter descended. The helicopter was subsequently found to have been destroyed by a post-impact fire, with the pilot sustaining fatal injuries.

“Site and wreckage examination undertaken by the ATSB determined that the vertical stabiliser, aft section of the tail boom, tail rotor and tail rotor gearbox were severed in flight and found separate to the main wreckage,” Mr Mitchell explained.

“No pre-accident defects were identified with flight controls, aircraft structure or the engine.”

A bird carcass was found to the south-west of the main wreckage site, near a section of rotor tip.

The carcass, the main rotor blade tip and a section of impacted tail boom were recovered from the site for further analysis.

“Testing on the bird carcass and biological residue found on external helicopter surfaces at the main wreckage site identified both as Aquila audax – commonly known as a wedge-tailed eagle,” Mr Mitchell said.

The ATSB’s investigation into the accident is continuing.

“With this evidence indicating a bird strike occurred prior to an in-flight break-up, the investigation moving forward will aim to determine the full sequence of events, and potential safety learnings from this accident,” Mr Mitchell said.

A final report, which will include analysis and findings, will be released at the conclusion of the investigation.

“However, should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken,” Mr Mitchell said.

Read the preliminary report: AO-2022-034 - In-flight break-up involving a Bell 206L-1 LongRanger, registered VH-ZMF, near Maroota, NSW, on 9 July 2022

MTF...P2 

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RE: Accidents - Domestic - Peetwo - 11-10-2022

Darwin Awards Nominee perhaps??

Via Popinjay central:

Quote:In-flight break-up accident highlights dangers of VFR pilots encountering IMC

Quote:Key points


Pilot likely entered instrument meteorological conditions before becoming spatially disorientated, resulting in loss of aircraft control;

Aircraft broke-up in-flight after airspeed limitations were exceeded;

During the 11 years from January 2011 to December 2021, the ATSB investigated 14 fatal accidents involving VFR into IMC.

A Van’s RV-7A light aircraft broke up in-flight after entering instrument meteorological conditions and its pilot became spatially disorientated, resulting in the loss of control of the aircraft, an ATSB investigation report details.

The amateur-built RV-7A two-seater, with the pilot the sole occupant and owner of the aircraft, was conducting a private flight under the visual flight rules (VFR) from Winton to Bowen, Queensland, on 23 April 2021. The pilot had been on a multi-day tour in company with three other pilots, each operating their own aircraft.

About 100 km into the flight, overhead Catumnal Station, the pilot most likely entered instrument meteorological conditions (IMC) and lost control of the aircraft several times, recovering control within 50 ft of the ground, before turning back towards Winton, recorded data shows.

However, about 11 km into the return leg, the pilot then resumed tracking to Bowen, climbing to above 10,000 ft and then operating at multiple altitudes between 10,000 ft and 500 ft above the ground, most likely to avoid weather along the track.

At about 90 km south of Charters Towers, the pilot again likely entered instrument weather conditions before becoming spatially disorientated, resulting in a loss of control of the aircraft. This led to exceeding the aircraft’s airspeed limitations, leading to the catastrophic failure of the airframe and the in-flight break-up.

“The ATSB found that the pilot departed Winton with a high risk of encountering adverse weather conditions along the planned route,” said ATSB Director Transport Safety Dr Mike Walker.

“There were no operational reasons for the pilot to continue the flight to Bowen, and the pilot probably had a self-imposed motivation or pressure to continue the flight.”

For a non-instrument rated pilot, even with basic attitude instrument flying proficiency, maintaining control of an aircraft in IMC by reference to the primary flight instruments alone entails a very high workload that can result in a narrowing of attention and the loss of situational awareness.

“The ATSB urges VFR pilots to avoid flying into deteriorating weather by conducting thorough pre-flight planning to ensure you have alternate plans in case of an unexpected deterioration in the weather, and to pro-actively decide to turn back, divert or hold in areas of good weather.”

Entering poor weather without the training and experience to do so can rapidly lead to spatial disorientation when the pilot cannot see the horizon.

“The brain receives conflicting or ambiguous information from the sensory systems, resulting in a state of confusion that can rapidly lead to incorrect control inputs and a resultant loss of control of the aircraft,” Dr Walker said.

Weather often does not act as the forecast predicts. Pilots must have alternatives available and be prepared to use them—even if it means returning to the departure point.

“Developing a ‘personal minimums’ checklist is an effective defence against what pilots often term as ‘push-on-itis’ or ‘get-home-itis’,” Dr Walker noted.

“A personal minimums checklist aids identifying and managing flight risks such as marginal weather conditions. It is an individual pilot’s own set of rules and criteria for deciding if and under what conditions to fly or to continue flying based on your knowledge, skills and experience.”

The ATSB’s Avoidable Accidents publication Accidents involving Visual Flight Rules pilots in Instrument Meteorological Conditions discusses a range of VFR into IMC accidents and details advice to pilots regarding how to the risk of being involved in such accidents.

Additionally, the Civil Aviation Safety Authority (CASA) has produced a number of educational resources including Weather to fly, an education program which focused on topics such as the importance of pre-flight preparation, making decisions early, and talking to ATC, and ‘178 seconds to live’, a campaign on highlighting the dangers of VFR flight into IMC.

Read the report: AO-2021-017 VFR into IMC and in-flight break-up involving Van's Aircraft RV-7A, VH-XWI 90 km south of Charters Towers, Queensland, on 23 April 2021

Publication Date
09/11/2022

This bit...

"..About 100 km into the flight, overhead Catumnal Station, the pilot most likely entered instrument meteorological conditions (IMC) and lost control of the aircraft several times, recovering control within 50 ft of the ground, before turning back towards Winton, recorded data shows.."

..an accident waiting to happen perhaps?? 

MTF...P2 

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RE: Accidents - Domestic - Kharon - 11-11-2022

Just like that:

The witness statements are of interest – and a little conflicted..

ABC news - "We saw two aircraft spiralling out of the cloud to the ground.”

ABC news - "John and Lyndal Kenman heard a loud bang and saw the two aircraft fall to the ground.”

Seems (unconfirmed) the collision was between the RA tug aircraft and the glider; unusual in itself. Released tugs head for the ground like well trimmed man-hole covers – gliders need to gain height and head in the opposite direction like homesick angels, as a general rule; routine, and a demonstrated 'safe practice' for decades. 

I wonder if the 'key' is within in the witness statements - “spiralling out of cloud” v 'between the clouds'. Two separate notions there; (through or by) then there is the questions of whether the release was 'clean' – and did that happen in or out of cloud? Was it a deliberate cloud penetration by a RA aircraft?  Questions for the Qld police to answer.

The Qld police have a very good record investigating aviation accidents, if anyone can sort out a 'most probable' they will, fairly, without brooking interference from interested parties. A thankless job, but they have been very effective, as we have seen in the past: they manage it all very well. Thanks fellah's.

Toot – toot...

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RE: Accidents - Domestic - Cap'n Wannabe - 11-11-2022

From Oz Aviation

Quote:ATSB WON’T PROBE MID-AIR CRASH AS IT MUST ‘PRIORITISE RESOURCES’



The ATSB has said it won’t investigate the fatal mid-air collision this week near the Sunshine Coast because it has to prioritise its resources towards larger aircraft.

The organisation told The Australian it understood the next of kin “wanted answers” but had to allocate its resources towards cases that would generate the “greatest public safety benefit”.

On Wednesday, a recreation aircraft and glider crashed into each other, killing the sole pilots, an 80-year-old, Christopher Turner and a 77-year-old as yet unidentified Glenwood man.

The ATSB’s chief commissioner, Angus Mitchell, said, “We understand that next of kin and the flying community that these two gentlemen were involved in do want answers, but as it stands at the moment, we do prioritise our resources to those investigations that will see the greatest public safety benefit.

“That means large passenger carrying aircraft are at the top of our priority list and then smaller passenger carrying and commercial work, then aerial work and flying training.”

Mitchell said the ATSB would help both the Recreational Aviation Australia (RAAus) and the Gliders Federation of Australia to launch their own probe.

However, the RAAus chair Michael Monck said it was itself “feeling the pinch like every other organisation” and received “very little funding”.

The Gliders Federation of Australia VP Lindsay Mitchell said the ATSB had “done it before”.

“They say you fellows can take care of that. You do the investigation,” said Mitchell.

Australian Aviation reported earlier this week how one witness told 7News he was sitting on his veranda when he heard a “big bang”.

“We thought that didn’t sound like a gunshot, and we looked up and saw white bits of plane falling out of the sky.”

Before the crash, the glider and its tug aircraft took off from Gympie Aerodrome at Kybong, the home of Sunshine Coast Gliding.

It has been confirmed the second aircraft involved in the incident was not the tow plane.

Inspector Brad Inskip said, “The glider left from the gliding club. At this stage, we’re not sure where the ultralight came from, whether it came from here … it’s too early to know.

“The investigation will involve mapping those scenes, examining the aircraft and going from there, and obviously witness statements and interviews.

“This is a tragic incident and quite a graphic scene left there for all the emergency services and for the witnesses … terrible for the family and for those involved.

“This is a little local airport where many people in the community are here together — the gliding club is obviously very close.

“It’s a small little regional gliding club. They all know each other. This is going to hit the community very hard.”

Queensland’s Forensic Crash Unit is investigating the circumstances of the incident, and a report will be prepared for the coroner.

Mid-air crashes are rare, with the last in Australia taking place in February 2020.

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RE: Accidents - Domestic - P7_TOM - 11-11-2022

Good news and Common sense...

The Oz - “Queensland’s Forensic Crash Unit is investigating the circumstances of the incident, and a report will be prepared for the coroner.

That is good news; ATSB and RA Oz have declined to invest in the investigation; maybe the common sense and no nonsense FCU , funded by Qld tax payers will prepare a solid briefing for the Coroner and even some 'safety' input: been in short supply of late. Two men dead and the WB Popinjay deems it of little publicity value, no 'selfies' or dress up kits, so two deaths just get the flick. Great ain't it?

The Oz - “It has been confirmed the second aircraft involved in the incident was not the tow plane.”

Great; that rules out one question;

The Oz - “Inspector Brad Inskip said, “The glider left from the gliding club. At this stage, we’re not sure where the ultralight came from, whether it came from here … it’s too early to know.

Just the facts; no spin, no feathers, fluff or self aggrandising; just standard, diligent investigation to find the facts, to correctly inform the Coroner. Exactly the right approach.

Well done Qld...

Cheers CWB - thanks.

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RE: Accidents - Domestic - Peetwo - 11-11-2022

Addendum:

(11-11-2022, 12:38 PM)Cap'n Wannabe Wrote:  From Oz Aviation

Quote:ATSB WON’T PROBE MID-AIR CRASH AS IT MUST ‘PRIORITISE RESOURCES’



The ATSB has said it won’t investigate the fatal mid-air collision this week near the Sunshine Coast because it has to prioritise its resources towards larger aircraft.

The organisation told The Australian it understood the next of kin “wanted answers” but had to allocate its resources towards cases that would generate the “greatest public safety benefit”.

On Wednesday, a recreation aircraft and glider crashed into each other, killing the sole pilots, an 80-year-old, Christopher Turner and a 77-year-old as yet unidentified Glenwood man.

The ATSB’s chief commissioner, Angus Mitchell, said, “We understand that next of kin and the flying community that these two gentlemen were involved in do want answers, but as it stands at the moment, we do prioritise our resources to those investigations that will see the greatest public safety benefit.

“That means large passenger carrying aircraft are at the top of our priority list and then smaller passenger carrying and commercial work, then aerial work and flying training.”

Mitchell said the ATSB would help both the Recreational Aviation Australia (RAAus) and the Gliders Federation of Australia to launch their own probe.

However, the RAAus chair Michael Monck said it was itself “feeling the pinch like every other organisation” and received “very little funding”.

The Gliders Federation of Australia VP Lindsay Mitchell said the ATSB had “done it before”.

“They say you fellows can take care of that. You do the investigation,” said Mitchell.

Australian Aviation reported earlier this week how one witness told 7News he was sitting on his veranda when he heard a “big bang”.

“We thought that didn’t sound like a gunshot, and we looked up and saw white bits of plane falling out of the sky.”

Before the crash, the glider and its tug aircraft took off from Gympie Aerodrome at Kybong, the home of Sunshine Coast Gliding.

It has been confirmed the second aircraft involved in the incident was not the tow plane.

Inspector Brad Inskip said, “The glider left from the gliding club. At this stage, we’re not sure where the ultralight came from, whether it came from here … it’s too early to know.

“The investigation will involve mapping those scenes, examining the aircraft and going from there, and obviously witness statements and interviews.

“This is a tragic incident and quite a graphic scene left there for all the emergency services and for the witnesses … terrible for the family and for those involved.

“This is a little local airport where many people in the community are here together — the gliding club is obviously very close.

“It’s a small little regional gliding club. They all know each other. This is going to hit the community very hard.”

Queensland’s Forensic Crash Unit is investigating the circumstances of the incident, and a report will be prepared for the coroner.

Mid-air crashes are rare, with the last in Australia taking place in February 2020.

(11-11-2022, 04:29 PM)P7_TOM Wrote:  Good news and Common sense...

The Oz - “Queensland’s Forensic Crash Unit is investigating the circumstances of the incident, and a report will be prepared for the coroner.

That is good news; ATSB and RA Oz have declined to invest in the investigation; maybe the common sense and no nonsense FCU , funded by Qld tax payers will prepare a solid briefing for the Coroner and even some 'safety' input: been in short supply of late. Two men dead and the WB Popinjay deems it of little publicity value, no 'selfies' or dress up kits, so two deaths just get the flick. Great ain't it?

The Oz - “It has been confirmed the second aircraft involved in the incident was not the tow plane.”

Great; that rules out one question;

The Oz - “Inspector Brad Inskip said, “The glider left from the gliding club. At this stage, we’re not sure where the ultralight came from, whether it came from here … it’s too early to know.

Just the facts; no spin, no feathers, fluff or self aggrandising; just standard, diligent investigation to find the facts, to correctly inform the Coroner. Exactly the right approach.

Well done Qld...

Cheers CWB - thanks.

Via the Oz:

Quote:ATSB will not investigate the crash that killed two pilots ay Kybong


Police at the scene of the crash between a glider and ultralight. Picture: Lachie Millard

ROBYN IRONSIDE
AVIATION WRITER
@ironsider

4:24PM NOVEMBER 10, 2022
7 COMMENTS
The families of two men killed in a mid-air crash at Kybong north of Brisbane on Wednesday may never know how the collision occurred.

On Thursday, the Australian Transport Safety Bureau announced it would not investigate the fatal crash because of the type of aircraft involved.

A non-powered glider and a recreational ultralight plane crashed into a paddock on Wednesday after colliding mid-air in relatively clear conditions.

The glider pilot was 80-year-old Christopher “Bob” Turner of Caboolture, and the ultralight pilot was a 77-year-old man from Glenwood.

ATSB chief commissioner Angus Mitchell said the bureau did not investigate accidents and incidents involving most recreational, ultralight and sports aviation aircraft including non-powered gliders, gyrocopters, hang gliders, paragliders and private hot air balloons.

“We understand that next of kin and the flying community that these two gentlemen were involved in do want answers, but as it stands at the moment we do prioritise our resources to those investigations that will see the greatest public safety benefit,” said Commissioner Mitchell.

“That means large passenger carrying aircraft are at the top of our priority list and then smaller passenger carrying and commercial work, then aerial work and flying training.”

He said the ATSB would stand by to assist the self administering organisations to which the two crash aircraft belonged to — Recreational Aviation Australia (RAAus) and the Gliders Federation of Australia.

Investigators at the scene of plane wreckage at Kybong. Picture: Lachie Millard

However RAAus chair Michael Monck said they were not in a position to investigate either unless the government was willing to commit funding.

“We would be more than happy to look into it and generate some safety outcomes that would benefit the wider public if the government was willing to help out,” Mr Monck said.

“We’re feeling the pinch like every other organisation. We’re a private organisation and we receive very little funding from the public purse.”

He said his heart went out to the families who may never get answers about the crash that claimed the lives of their loved ones.

“At the end of the day when our government isn’t committing resources those families go unserved,” said Mr Monck.

Gliding Australia vice president Lindsay Mitchell said they were staffed by volunteers and not capable of conducting such an investigation.

“I’m not surprised the ATSB is not investigating. They’ve done it before. They say you fellows can take care of that, you do the investigation,” said Mr Mitchell.

The ATSB’s decision not to investigate, came as the bureau sent investigators to Canberra Airport where a Link Airways aircraft suffered serious damage from a wayward propeller strap.

Plus...OOPS!!  :

Quote:Forgotten propeller strap leaves three people injured


A passenger of Virgin Australia partner airline Link Airways has been taken to hospital after a bizarre accident at Canberra Airport.

ROBYN IRONSIDE
AVIATION WRITER
@ironsider

3:23PM NOVEMBER 10, 2022
20 COMMENTS

A passenger on a flight operated by Virgin Australia partner Link Airways has described the mayhem that erupted when a forgotten propeller strap penetrated the fuselage of their aircraft as it took off from Canberra.

Ashleigh Atkinson was in row six of the flight to Sydney and said just as the Saab 340 was about to take off, a woman screamed, and the front row was showered with debris.

“It was a massive explosion and my husband could see there was a hole in the plane,” Ms Atkinson said.

“The flight attendant was trying to calm the woman down and saying ‘we need to wait until we’re at 1000 feet to tell the pilot’.”


A passenger on board a Link Airways flight from Canberra on Thursday took pictures of the incident, which resulted in a ratchet strap penetrating the cabin fuselage.

The Australian Transport Safety Bureau said when the propellers started turning, the strap struck the fuselage of the aircraft.

ATSB chief commissioner Angus Mitchell said they considered the incident to be serious.

“It is concerning that a passenger carrying aircraft did depart with what we understand at this stage to be the ratchet strap not removed from one of the propellers and that has subsequently come off in flight and made a penetration to some degree into the fuselage,” Commissioner Mitchell said.

“That is of particular concern to us, and something we will seek to understand what were the contributing factors, why wasn’t it picked up.”



The Link Airways’ aircraft returned to Canberra Airport after a ratchet strap penetrated the fuselage, showering passengers with debris.


Flight radar images showed the aircraft in question registered VH-VEQ taking off from Canberra, then returning within 14-minutes to the airport.

The three people injured were assessed for minor injuries at the scene, attended by the Australian Federal Police.

An AFP spokeswoman said the matter was referred to the ATSB to investigate.

Canberra Airport chief executive Stephen Byron said they had spoken to one of the injured passengers to check on her wellbeing.

“We are aware of an incident this morning involving a Link Airways aircraft,” Mr Byron said.


Flightradar image of the Link Airways flight in question. Picture: Flightradar24

“All of the appropriate aviation agencies have been contacted and Link Airways are co-operating with the investigation.”

Virgin Australia denied anyone was injured and said “all passengers had disembarked safely”.

“Virgin Australia can confirm that flight VA633 operated by Link Airways on behalf of Virgin Australia from Canberra to Sydney on Thursday, November 10 was involved in an incident near Canberra airport,” said a Virgin Australia spokeswoman.

“After becoming aware of the incident, the crew took steps in accordance with standard operating procedures to prioritise the safety of all guests and crew on board and conducted an air return in line with safety protocols.”

The ATSB investigation would also gather evidence from flight crew and passengers, with a final report to be published in due course.

Link Airways teamed up with Virgin Australia late last year, flying up to nine Canberra-Sydney services a day for the larger airline.

Under the deal, Link passengers are also eligible for Velocity frequent flyer points and in some cases can use Virgin Australia’s lounge facilities in Sydney.

Saab 340s seat 34 passengers in a 1-2 configuration and have long been used on regional routes in Australia with very few issues.

MTF...P2

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