[Peetwo]

Final Report AO-2024-046 - 

Attributed to Popinjay, via his media minions...
 

ATSB finalises Cairns hotel helicopter accident investigation

The ATSB has finalised its investigation into an accident involving a Robinson R44 helicopter which struck the roof of a Cairns hotel early in the morning of 12 August 2024.

“The investigation found that the pilot conducted an unauthorised and unnecessary flight at night, while affected by alcohol,” said ATSB Chief Commissioner Angus Mitchell.

“The pilot did not hold the appropriate endorsements to fly at night, did not have any experience flying the R44 at night, and they conducted the flight well below the 1,000 ft minimum height for flight over built up areas.” 

The ATSB finalised the investigation after determining it unlikely that broader safety issues or lessons would be uncovered.

“The ATSB primarily investigates to identify industry systemic safety issues, and to then influence the adoption of targeted actions to reduce future risk,” said Mr Mitchell.

“Our final report published today provides assurance to the Cairns community and the aviation industry that after gathering and analysing the available evidence, there are unlikely to be broader transport safety issues that require addressing to reduce future risk arising from this tragic accident.”

The report details that the pilot was an employee of the helicopter operator, and had gained access to their premises after entering a code into a security door keypad, and then to the hangar and the helicopter. The pilot held valid New Zealand and Australian commercial helicopter pilot licences, and had previously flown R44 helicopters. However, they were employed by the operator as a ground handler, and were not approved to, nor employed to fly the operator’s helicopters.

“Using a combination of CCTV footage, witness accounts, GPS data from the helicopter and air traffic control surveillance radar data, the ATSB was able to develop a detailed sequence of events of the accident flight,” Mr Mitchell said.

Prior to the flight, the pilot had been socialising with friends at various venues in Cairns, where they had been consuming alcohol, the report details. They had returned to their apartment around 11 pm, with CCTV footage showing them driving away from the apartment complex at 1:09 am. CCTV footage from the operator’s hangar showed the pilot moving the helicopter outside onto a helipad just after 1:30 am.

“We know from GPS and air traffic control radar data that the helicopter departed Cairns Airport shortly before 1:47 am, while CCTV footage showed that the helicopter’s strobe lights were turned off by the pilot,” Mr Mitchell said.

After taking off, the helicopter headed south towards the Cairns city centre, flying over the pilot’s apartment building and then tracking to the northern end of the Cairns wharf complex, where it completed an orbit before heading north towards the marina and continuing along the coastline.

After crossing the coastline and flying over the pilot’s apartment a second time, the helicopter circled back towards the foreshore, following it for about 1 km. 

Throughout the flight the helicopter’s altitude did not exceed 500 ft.

“Two security cameras recorded very brief portions of the final part of the flight and showed the helicopter pitching up, then almost immediately descending steeply before colliding into the roof of the hotel at about 1:51 am,” Mr Mitchell said.

“Wreckage distribution and impact marks indicate that the helicopter was inverted at impact.” 

Most of the helicopter came to rest on the hotel roof and was destroyed by impact forces and a fuel-fed post-impact fire. The pilot was fatally injured. 

Parts of the main rotor blade were found in the hotel rooms below the accident site, while the helicopter’s instrument panel, main rotor head and most of the main rotor blades were found within the hotel grounds. A portion of the same main rotor blade that struck the hotel windows was found in parkland across the road.

Fortunately there were no injuries to hotel guests and staff, nor passersby.

“From the available evidence there were no airworthiness factors with the helicopter that likely contributed to the accident,” Mr Mitchell said.

“The flight was a purposeful act, but there was no evidence available to explain the pilot’s intentions.”

Mr Mitchell concluded: “I would like to acknowledge that the nature of this accident is deeply distressing to the pilot’s family, and they have asked that I share with you their request for privacy at this time.”

Read the report: Collision with building involving Robinson R44 II, VH-ERH, at Cairns, Queensland, on 12 August 2024

Publication Date: 10/10/2024

MTF...P2 

[Peetwo]

Final Report AO-2024-046 - Part II 

Attributed to Popinjay, via his media minions...
 

ATSB finalises Cairns hotel helicopter accident investigation

The ATSB has finalised its investigation into an accident involving a Robinson R44 helicopter which struck the roof of a Cairns hotel early in the morning of 12 August 2024.

“The investigation found that the pilot conducted an unauthorised and unnecessary flight at night, while affected by alcohol,” said ATSB Chief Commissioner Angus Mitchell.

“The pilot did not hold the appropriate endorsements to fly at night, did not have any experience flying the R44 at night, and they conducted the flight well below the 1,000 ft minimum height for flight over built up areas.” 

The ATSB finalised the investigation after determining it unlikely that broader safety issues or lessons would be uncovered.

“The ATSB primarily investigates to identify industry systemic safety issues, and to then influence the adoption of targeted actions to reduce future risk,” said Mr Mitchell.

“Our final report published today provides assurance to the Cairns community and the aviation industry that after gathering and analysing the available evidence, there are unlikely to be broader transport safety issues that require addressing to reduce future risk arising from this tragic accident.”

The report details that the pilot was an employee of the helicopter operator, and had gained access to their premises after entering a code into a security door keypad, and then to the hangar and the helicopter. The pilot held valid New Zealand and Australian commercial helicopter pilot licences, and had previously flown R44 helicopters. However, they were employed by the operator as a ground handler, and were not approved to, nor employed to fly the operator’s helicopters.

“Using a combination of CCTV footage, witness accounts, GPS data from the helicopter and air traffic control surveillance radar data, the ATSB was able to develop a detailed sequence of events of the accident flight,” Mr Mitchell said.

Prior to the flight, the pilot had been socialising with friends at various venues in Cairns, where they had been consuming alcohol, the report details. They had returned to their apartment around 11 pm, with CCTV footage showing them driving away from the apartment complex at 1:09 am. CCTV footage from the operator’s hangar showed the pilot moving the helicopter outside onto a helipad just after 1:30 am.

“We know from GPS and air traffic control radar data that the helicopter departed Cairns Airport shortly before 1:47 am, while CCTV footage showed that the helicopter’s strobe lights were turned off by the pilot,” Mr Mitchell said.

After taking off, the helicopter headed south towards the Cairns city centre, flying over the pilot’s apartment building and then tracking to the northern end of the Cairns wharf complex, where it completed an orbit before heading north towards the marina and continuing along the coastline.

After crossing the coastline and flying over the pilot’s apartment a second time, the helicopter circled back towards the foreshore, following it for about 1 km. 

Throughout the flight the helicopter’s altitude did not exceed 500 ft.

“Two security cameras recorded very brief portions of the final part of the flight and showed the helicopter pitching up, then almost immediately descending steeply before colliding into the roof of the hotel at about 1:51 am,” Mr Mitchell said.

“Wreckage distribution and impact marks indicate that the helicopter was inverted at impact.” 

Most of the helicopter came to rest on the hotel roof and was destroyed by impact forces and a fuel-fed post-impact fire. The pilot was fatally injured. 

Parts of the main rotor blade were found in the hotel rooms below the accident site, while the helicopter’s instrument panel, main rotor head and most of the main rotor blades were found within the hotel grounds. A portion of the same main rotor blade that struck the hotel windows was found in parkland across the road.

Fortunately there were no injuries to hotel guests and staff, nor passersby.

“From the available evidence there were no airworthiness factors with the helicopter that likely contributed to the accident,” Mr Mitchell said.

“The flight was a purposeful act, but there was no evidence available to explain the pilot’s intentions.”

Mr Mitchell concluded: “I would like to acknowledge that the nature of this accident is deeply distressing to the pilot’s family, and they have asked that I share with you their request for privacy at this time.”

Read the report: Collision with building involving Robinson R44 II, VH-ERH, at Cairns, Queensland, on 12 August 2024

Publication Date: 10/10/2024

Courtesy the Oz:

Cairns chopper crash pilot affected by alcohol, ATSB report finds

An investigation into a Cairns helicopter crash that killed pilot Blake Wilson, has found he was drunk at the time he “purposefully” undertook the unauthorised flight.

The 23-year-old was working as a ground handler for Nautilus Aviation in Cairns, when he took the Robinson R44 and crashed it into the rooftop of the DoubleTree by Hilton hotel, early in the morning of August 12.

An Australian Transport Safety Bureau investigation revealed toxicology tests showed he had a “significant” blood alcohol content at the time, but was drug free.

Prior to the fateful flight, Mr Wilson had been out with friends to celebrate a new posting with Nautilus Aviation to Horn Island.

CCTV footage showed him drinking at various venues in Cairns, before returning to his apartment about 11pm.

Two hours later, for reasons no-one can fathom, Mr Wilson then got into his car and drove to Cairns Airport, where security cameras showed him moving a helicopter to a helipad.

He turned off the helicopter’s strobe lights before taking off at 1.47am, in an apparent attempt to conceal his departure from air traffic control and Cairns Airport staff.

The collision with the hotel roof occurred just four minutes later, at 1.51am.

ATSB chief commissioner Angus Mitchell said security cameras recorded brief portions of the final part of the flight, showing the helicopter pitching up, then almost immediately descending steeply before colliding into the roof of the hotel.

“Wreckage distribution and impact marks indicate that the helicopter was inverted at impact.” said Mr Mitchell.

Most of the helicopter came to rest on the hotel roof and was destroyed by the impact and a fuel-fed fire.

Although Mr Wilson held a helicopter pilot licence, he did not hold a night rating and there were no records of him flying a helicopter in Australia.

Mr Mitchell said the entire flight was conducted below an altitude of 500ft (152m) well below the 1000ft minimum height for flying over built up areas.

Parts of the main rotor blade were found in the hotel rooms below the crash site, while the helicopter’s instrument panel, main rotor head and most of the main rotor blades were scattered in the hotel grounds.

A portion of the same main rotor blade that struck the hotel windows was found in parkland across the road.

Mr Mitchell said it was fortunate there were no injuries to hotel guests and staff, nor passers-by.

“From the available evidence, there were no airworthiness factors with the helicopter that likely contributed to the accident,” Mr Mitchell said.

“The flight was a purposeful act, but there was no evidence available to explain the pilot’s intentions.”

He said Mr Wilson’s family were deeply distressed by the incident, and had requested privacy.

Plus, attributed to DTS Stewie Macleod today...

Bankstown forced landing likely after fuel starvation due to low quantity, unbalanced flight



A Cessna 210 was force landed on a Bankstown Airport taxiway, likely after a low amount of fuel combined with unbalanced flight to starve the engine, an Australian Transport Safety Bureau investigation has concluded.

On 26 May 2024, a Cessna T210M single piston-engine aeroplane was being ferried from Maitland to Bankstown, New South Wales, where it was to undergo maintenance. There was a pilot and a passenger on board.

During the approach to Bankstown, the engine stopped.

“The pilot identified a taxiway on the airport as a suitable place for a forced landing and elected to leave the flap retracted and the gear up in order to reduce drag and maximise glide range,” ATSB Director Transport Safety Stuart Macleod said.

Once the aircraft was over the airport, the gear was lowered, but it did not successfully lock in place due to the limited time available.

“The aircraft landed wheels-up, resulting in minor damage, but fortunately both occupants were uninjured,” Mr Macleod outlined.

An ATSB investigation determined the aircraft departed Maitland with sufficient fuel to complete the intended flight, but it was likely the amount of fuel reduced to a level that, in combination with unbalanced flight approaching Bankstown, resulted in the engine being starved of fuel.

“Fuel starvation occurrences can often be prevented by conducting thorough pre-flight fuel quantity checks combined with in-flight fuel management,” Mr Macleod explained.

“Pilots are reminded to check fuel quantities prior to departure using a known calibrated instrument such as a dipstick.”

“In addition, comparing the expected fuel burn with actual fuel remaining after a flight, will give a validated fuel burn for the aircraft and ensure the measuring equipment is accurate.”

The ATSB’s final report directs pilots to familiarise themselves with CASA’s Advisory Circular Guidelines for aircraft fuel requirements, which provides further guidance for in‑flight fuel management.

While it did not contribute to the occurrence, the ATSB also concluded the pilot’s decision to carry non-essential crew on a ferry flight for maintenance placed that additional occupant at unnecessary risk of injury.

“While the passenger was reportedly present to assist with navigation and radio communication, the ferry flight was conducted under a CASA special flight permit, requiring only essential operating crew be carried,” Mr Macleod said.

“These conditions are in place to minimise the consequences if an incident occurs during such a flight.”

Finally, the report notes, the pilot failed to complete the engine failure during flight checklist which, if followed, would have increased the likelihood of the engine being restarted in flight.

“Practising forced landings from different altitudes under safe conditions can help pilots prepare for an emergency situation,” Mr Macleod explained.

“Being familiar with emergency checklists and your aircraft’s systems will assist in an emergency when identifying and managing an engine failure.”

Read the report: Fuel starvation involving Cessna T210M, VH-MYW, 4 km north-west of Bankstown Airport, New South Wales, on 26 May 2024

Publication Date: 11/10/2024

MTF...P2 

[Peetwo]

Yet another fatal midair collision?? -

Via SkyNews Oz:

Three men confirmed dead after mid-air collision between two light planes in Sydney's south-west
Police have confirmed three men have died after a mid-air crash between two planes in Sydney's south-west.

Adriana Mageros and Bryant Hevesi
October 26, 2024 - 4:04PM

Three men have been confirmed dead after a mid-air crash between two light aircraft in Sydney’s south-west.

The horror crash occurred in the vicinity of Belimbla Park, near Oakdale, about 11.50am on Saturday.

Just before 3.30pm, police confirmed three men had been found deceased following the incident which involved a Jabiru aircraft and a Cessna 182.

Two crime scenes have been established in the area, which is located in the Macarthur region of New South Wales.


Emergency services have raced to the scene of a fatal mid-air crash between two aircraft in Sydney’s south-west. Picture: 7NEWS

Aerial footage captured by 7NEWS showed smoke rising from thick mountainous terrain in the Belimbla Park area.

Multiple emergency crews, including police, ambulance and firefighters, could be seen on the ground on Saturday afternoon.

Members of the public have been urged to avoid the area as investigations continue.

The Oaks Rural Fire Brigade confirmed numerous crews have been deployed to the scene of the aircraft collision.


Smoke seen billowing from thick terrain after the crash. Picture: 7NEWS

"Multiple crews are currently converging to Wanawong Rd Belimbla Park for a reported aircraft incident," it wrote on Facebook.

"Please stay clear of the area and use caution around emergency vehicles."

The cause of the crash is set to be probed by the Australian Transport Safety Bureau (ATSB).

"A team of transport safety investigators from the ATSB's Canberra office, with experience in aircraft operations and maintenance, is preparing to deploy to the accident sites of both aircraft to begin evidence-collecting activities," an ATSB statement said.

"Over coming days, investigators will undertake site mapping, examine the wreckage of both aircraft, and recover any relevant components for further examination at the ATSB’s technical facilities in Canberra.

"Investigators will also seek to interview any witnesses and involved parties, and collect relevant recorded information including any air traffic control and flight tracking data, as well as pilot and aircraft maintenance records, and weather information."

Plus the ATSB media link: https://www.atsb.gov.au/media/2024/mid-a...est-sydney

MTF...P2

[Peetwo]

Popinjay and Iron Bar to the rescue!! -

Via the ABC:

And from the PJ minions..

Engine failure or malfunction involving Boeing 737, VH-VYH, at Sydney Airport, New South Wales, on 8 November 2024

Summary

The ATSB is investigating an engine failure or malfunction involving a Boeing 737, VH-VYH, at Sydney Airport, New South Wales, on 8 November 2024. The aircraft was operating as Qantas flight QF520, scheduled from Sydney to Brisbane, Queensland. 

During take-off from runway 34R at Sydney Airport at about 1240, the aircraft's right engine sustained a failure or malfunction. The flight crew declared an emergency to air traffic control and returned to Sydney, landing on runway 34L. After being visually inspected and cleared by the Aviation Rescue Fire Fighting Service (ARFFS), the aircraft was taxied back to the gate and the passengers and crew disembarked normally. It was reported that some engine debris had exited the engine through the tailpipe and started a grass fire which was extinguished by the ARFFS. No other aircraft damage was evident. 

As part of the evidence collection phase of the investigation, ATSB investigators will obtain and examine maintenance records, recorded data such as flight data and radio recordings, and interview the flight crew. The engine and components will be examined at an appropriate facility. 

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.

Hmm...note how quickly Popinjay and the Commissioners can generate an AO (aviation occurrence) number, when motivated by a high profile investigation involving the Red Rat (only listed as a 'Short' ATM)...

Next, the Coulson 737 air tanker accident final report is released, via PJ's media minions (again attributed to Popinjay  ):

737 air tanker accident highlights importance of standardised operating procedures, including minimum drop heights


Minimum safe drop heights are in development for large firefighting aircraft in Australia, to address safety issues identified by an ATSB investigation into a 737 air tanker accident in south-west WA.

‘Bomber 139’, a Boeing 737 aircraft converted as a large air tanker, impacted a ridgeline after completing a drop while extending a fire retardant containment line during a bushfire-fighting task in the Fitzgerald River National Park on 6 February 2023.

After striking the ridgeline, the aircraft cleared a small line of foliage before impacting the ground a second time and then sliding to rest. The two pilots on board were able to evacuate through a cockpit window before the aircraft was consumed by a post-impact fire.

“The ATSB’s investigation found that the aircraft was conducting a drop at a low height and airspeed over descending terrain, which required the use of the idle thrust engine power setting and a high rate of descent,” ATSB Chief Commissioner Angus Mitchell said. 

“Towards the end of the drop, the aircraft’s height and airspeed decayed as it approached rising terrain that had not been detected, and was not expected, by the aircraft captain.”

While the aircraft’s thrust levers had been advanced mid-way through the drop, there was insufficient time for engine power to increase to allow the aircraft to climb away and safely clear the ridgeline crossing the aircraft’s exit path.

The report notes the ridgeline had likely not been detected as the captain, who was the pilot flying, had declined a ‘Show Me’ run from the Birddog aircraft, had conducted right hand circuits (restricting their visibility of the target area as they were seated in the left seat on the flightdeck), likely had no visibility of the ridgeline during the go-around from the first drop, and was led by the Birddog to the target through smoke on the second drop.

“Not detecting the rising terrain likely contributed to the captain allowing the aircraft to enter a low energy state during the drop.”

Further, the co-pilot did not identify nor announce any deviations during the retardant drop, which could have alerted the aircraft captain to the low-energy state of the aircraft.

“Notably, the operator and tasking agency had not published a minimum drop height for large air tankers,” Mr Mitchell said.

“This resulted in the co-pilot, who did not believe there was a minimum drop height, not making any announcements about the aircraft’s low energy state prior to the collision.”

The accident occurred when the aircraft was conducting a second drop after releasing three-quarters of its retardant load on the prior run.

“The operator’s practice of the pilots recalculating, and lowering, their target drop speed after a partial load drop also contributed to the aircraft’s low energy state.” 

The investigation found that neither the operator nor the relevant Western Australian Government Departments had published a drop height for large air tankers (whereas the US Forest Service has a minimum large air tanker drop height of 150 ft). 

This meant that aircraft captains could exercise their own judgement for drop heights to improve accuracy.
Bomber 139 was operating in Australia under a contract with the National Aerial Firefighting Centre, which did not impose a minimum drop height, but required the operator to comply with the standard operating procedures (SOPs) of the member state for the aircraft’s nominated operational base, in this case Western Australia.

In turn the Western Australia large air tanker SOPs did not impose a minimum drop height limit. 
 
Since the accident Coulson Aviation implemented a minimum drop height of 200 ft for its airtankers, while the Western Australian Department of Fire and Emergency Services and the Department of Biodiversity, Conservation and Attractions are amending procedures to incorporate drop heights, including a large airtanker drop height of 200 ft.

Meanwhile, at a national level, the Australasian Fire and Emergency Services Authorities Council, the parent organisation for the National Aerial Firefighting Centre, has undertaken to develop national large air tanker SOPs.
Separately, the ATSB has issued a safety recommendation to Coulson Aviation to address crew resource management procedures for retardant drops to reduce the risk of the aircraft entering an unrecoverable state before the pilot monitoring alerts the pilot flying.

“This accident highlights that standard operating procedures and crew resource management should be implemented with the intent to prevent an unsafe situation from developing,” said Mr Mitchell.

“Safety standards should not be solely dependent on the performance of the pilot flying and recovery call-outs.”

Read the report: Controlled flight into terrain involving Boeing 737-3H4 Fireliner, N619SW, Fitzgerald River National Park, Western Australia on 6 February 2023

Publication Date:
06/11/2024

 

MTF...P2

PS: See - HERE - the UP thread for the discussion on the B737 airtanker FR.

[Peetwo]

AO-2024-008 (Short) & AO-2023-020 (Defined) Final Reports completed?? - 

Courtesy of PJ's media minions and attributed to DTS Stewie Macleod:

Fuel management, unsecured cap risk highlighted in Aero Commander forced landing



[b]The pilot of an Aero Commander had to land the aircraft in a field after fuel siphoned overboard due to an incorrectly installed fuel cap, an ATSB investigation has concluded.[/b]

On 8 March 2024, the twin-engine Aero Commander 500-S was conducting a return freight flight from Bankstown to Parkes, with multiple stops each way.

Upon landing after the first sector of the day, the pilot found the aircraft’s fuel cap was off and secured only by a retention chain.

The pilot re-secured the cap, but found the cap off again after the second sector, after landing in Parkes.“For the two sectors from Bankstown to Parkes, the fuel cap had been incorrectly installed with the retention chain lodged in the fuel tank’s anti-siphon valve, resulting in the cap dislodging in flight, and fuel being siphoned overboard,” ATSB Director Transport Safety Stuart Macleod explained.

An inspection and rectification conducted at Parkes by a maintenance engineer fixed the issue.

“However, the pilot identified an unexplained discrepancy between expected fuel remaining and gauge quantity indication, but did not refuel to a known quantity, or amend the flight log,” Mr Macleod noted.

“This meant the aircraft left Parkes without enough fuel to complete the remaining sectors on its return trip back to Bankstown.

”After departing Parkes, the pilot likely did not monitor the fuel gauge, continued fuel calculations based on an incorrect fuel quantity, and did not refuel the aircraft to a known quantity when they landed at their final interim location, Bathurst.

Subsequently, shortly after take-off for the final sector to Bankstown, both engines lost power due to fuel exhaustion, and the pilot conducted a forced landing in a field. Fortunately, the aircraft was undamaged, and the pilot uninjured.

“A missing or unsecured fuel cap should be treated as an emergency, and if detected pilots should immediately divert to the nearest suitable aerodrome,” Mr Macleod said.

Since the incident, the operator, GAM Air, published a notice to pilots reinforcing fuel management procedures. It also commenced periodic auditing of pilot fuel calculations.

Additionally, in response to an ATSB finding that its Quick Turn Around – Pre-Start checklist did not include a fuel quantity check before start, the operator has announced the intention to discontinue using this specific checklist.

“Pre-flight fuel quantity checks should use at least two different verification methods to determine the amount of fuel on board,” Mr Macleod said.

“When using computed fuel on board and comparing against gauge readings, it is important that calculations are accurate. If any discrepancy is detected between the two methods, another method such as filling to a known quantity is required.”

Read the final report: Fuel exhaustion involving Aero Commander 500-S, VH-MEH, 6 km east of Bathurst Airport, New South Wales, on 8 March 2024 

Publication Date: 19/11/2024

Plus attributed to DTS Dr Godlike:

Saab 340 fire and smoke event highlights importance of aircraft configuration knowledge



An in-flight fire and smoke incident involving a Saab 340 freight aircraft over New South Wales last year highlights the importance of operators ensuring flight crews are aware of differences in aircraft configurations.

On 23 April 2023, the Saab 340A was being used for a non-revenue positioning flight from Wagga Wagga, New South Wales, to Charleville, Queensland with a captain and first officer on board. The aircraft was owned by Pel-Air and was being operated by flight crew from Pel-Air's sister company Regional Express (Rex).

While in cruise, the flight crew received a cargo smoke indication on the central warning panel, and fitted their oxygen masks and smoke goggles as a precaution.

A short time later, the cockpit filled with smoke.

“Commencing a diversion to Cobar, the first officer made a PAN-PAN call, and thick smoke filled the flight deck, preventing the crew from effectively seeing external visual references, or the aircraft’s flight instruments,” ATSB Director Transport Safety Dr Stuart Godley said.

While the crew was completing emergency checklists, there were warnings for avionics smoke, the cabin depressurised, and there was a right engine fire detection fail indication.

Fortunately, the crew was able to land at Cobar and evacuate the aircraft on the runway, uninjured.

Fire and Rescue personnel located a heat source at the air conditioning pack, and doused the area with water. An internal inspection later found fire damage in the area around the right recirculating fan.

An investigation by the ATSB determined the in-flight fire likely stemmed from the failure of the recirculating fan’s electronic box sub-assembly.

The investigation’s final report notes the aircraft had been operated by Rex as a passenger aircraft, before being modified to cargo configuration in 2009, for operation by Pel-Air.

“The Rex pilots usually operated passenger aircraft and were not familiar with the cargo-configuration of this aircraft, and Rex did not ensure its flight crews received training in the differences between passenger and freight-configured Saab 340 aircraft,” Dr Godley explained.

Further, it was identified both Pel-Air and Rex’s flight crew operating manuals did not include reference to the location and operation of the cross-valve handle, and the pilots were unable to locate it during the emergency checklist procedures, due to smoke.

Closing of the cross-valve was part of the checklist to address a cargo compartment smoke event, and the pilots were therefore unable to properly action this checklist, despite searching for more than a minute for the cross-valve handle.

The investigation also found the smoke curtain (to isolate the cargo area) was not in place for the flight, as is required for the cargo configuration of the Saab 340, and Saab’s pre-flight documentation for the cargo-configured 340 did not require crews to confirm that a smoke curtain was fitted.

The absence of a curtain, and the flight deck door being open, allowed smoke from the fire to enter the flight deck.
“The depressurisation occurred when the fire weakened the fuselage structure,” Dr Godley explained. 

“Fortunately, this depressurisation aided in the removal of enough smoke from the flight deck, to allow an unhindered approach into Cobar.”

Since the occurrence, Rex has amended its flight crew operating manual to require flight crews to verify the position of the cross-valve handle during pre-flight checks.

The operator has also updated training information delivered in their ground school to cover the cross-valve system for cargo-configured Saab 340 aircraft.

Pel-Air has also revised its flight crew operating manual, with a caution that the smoke barrier curtain must be installed whenever combustible material is carried.

Finally, Saab has revised its preparatory and walk-around pre-flight checklists to include the fitting of the smoke barrier curtain when carrying cargo in cargo-configured 340s.

“As this occurrence demonstrates, it is essential operators ensure flight crews are conversant with differences in aircraft configurations when required,” Dr Godley summarised.“Similarly, flight crew operating manuals must be relevant for the aircraft configuration, and manufacturer pre-flight checklists must cover the modifications fitted, so operators can write the appropriate documentation for flight crews.”

Read the final report: In-flight fire and cabin smoke involving Saab 340A, VH-KDK, 114 km east-north-east of Cobar, New South Wales, on 23 April 2023

Publication Date:
20/11/2024

MTF...P2

[Peetwo]

AO-2025-001 - Collision with water involving Cessna 208, VH-WTY, near Rottnest Island, Western Australia, on 7 January 2025

Via ATSB:

Rottnest Island Cessna 208 accident

Date: 08/01/2025

Media Contact: media@atsb.gov.au

The Australian Transport Safety Bureau (ATSB) has commenced a transport safety investigation into a collision with water accident involving a Cessna 208 floatplane during take-off near Rottnest Island, off Perth, on Tuesday afternoon.

As reported to the ATSB, during take-off the floatplane collided with the water, before coming to rest partially submerged.

The ATSB will deploy a team of transport safety investigators from its Perth, Brisbane and Canberra offices, specialising in human performance, and aircraft operations and maintenance.

Investigators will conduct a range of evidence-gathering activities, including site and wreckage examination, and recovery of any aircraft components for further examination at the ATSB’s technical facilities in Canberra.

Investigators will also seek to interview those on board, and any other witnesses and involved parties, and collect relevant recorded information including available flight tracking data, as well as pilot and aircraft maintenance records, and weather information.

The ATSB asks anyone who may have witnessed or has photos or video footage of the aircraft at any phase of the flight, or in the immediate aftermath of the accident, to make contact via the witness form on our website at their earliest opportunity.

---

Summary

The ATSB is investigating a collision with water involving a Cessna 208 Caravan Amphibian, registered VH-WTY, near Rottnest Island, Western Australia, on 7 January 2025. On board was one pilot, and 6 passengers.

During the water take-off, the aircraft was observed to become airborne then impact the water. The pilot and 2 passengers were fatally injured, and 3 passengers sustained serious injuries.

The ATSB deployed a team of transport safety investigators to the accident site with experience in aircraft operations, maintenance, and human factors. As part of the on-site and evidence collection phase of the investigation, ATSB investigators will examine the aircraft wreckage and other information from the accident site. They will also examine recovered components, interview witnesses and any involved parties, examine maintenance records and operator procedures, retrieve and review recorded data, and collect other relevant information.

The ATSB calls for any witnesses who may have seen the accident, or any pilots operating in the area who may have heard radio calls from the accident aircraft, to make contact with us via the witness form on our website.

The ATSB will release a preliminary report detailing factual information established in the investigation’s evidence-gathering phase in about two months. A final report will be released at the conclusion of the investigation and will detail analysis and findings.

However, if at any time during the investigation we discover a critical safety issue, the ATSB will work closely with the relevant stakeholders so action can be taken to address that issue.

Finally Popinjay to the rescue...

MTF...P2 

[Kharon]

Rottenest Seaplane.

Preliminary ATSB report – HERE – pretty much confirming most of what was observed/ known.  Being completely unfamiliar with the C 208 and even less familiar with 'water' operations; I read through ATSB report – and the UP commentary, more for a general knowledge increase rather than an a commentary standpoint. However, (always one) two item puzzled me and any light cast would be much appreciated; to wit:-

Wreckage examination (from Fig.8) onward.

- Dot point - “The flap selector was in the ‘full’ position and the flap position indicator was showing an intermediate position of about 15°. The wing flaps were in the retracted position.”

Take any help I can get on that??? Can the Pilot 'see' if the flap selected is actually in that position? How much flap is routinely used for a 'choppy' water take off?  Puzzled.

- Dot point - The instrument panel and combing appeared undamaged. All circuit breakers were pushed in except those corresponding to the strobe light and stall warning.

Again; is it routine to isolate the stall warning? I can see where it may become a 'nuisance' when the aircraft is 'bouncing about'?

Just asking, the curiosity curse lives....

Toot – toot.

[Peetwo]

Rottnest Seaplane.

Preliminary ATSB report – HERE – pretty much confirming most of what was observed/ known.  Being completely unfamiliar with the C 208 and even less familiar with 'water' operations; I read through ATSB report – and the UP commentary, more for a general knowledge increase rather than an a commentary standpoint. However, (always one) two item puzzled me and any light cast would be much appreciated; to wit:-

Wreckage examination (from Fig.8) onward.

- Dot point - “The flap selector was in the ‘full’ position and the flap position indicator was showing an intermediate position of about 15°. The wing flaps were in the retracted position.”

Take any help I can get on that??? Can the Pilot 'see' if the flap selected is actually in that position? How much flap is routinely used for a 'choppy' water take off?  Puzzled.

- Dot point - The instrument panel and combing appeared undamaged. All circuit breakers were pushed in except those corresponding to the strobe light and stall warning.

Again; is it routine to isolate the stall warning? I can see where it may become a 'nuisance' when the aircraft is 'bouncing about'?

Just asking, the curiosity curse lives....

Toot – toot.


P2 Addendum: 'Popinjay to the rescue!!'

Pilot assessment of sea and weather conditions, operator risk controls, and assessment and approval for floatplane operations are among a range of factors the ATSB will consider as it continues its investigation of a fatal floatplane accident off Rottnest Island, Western Australia. 

The ATSB’s preliminary report from its ongoing investigation details that on the morning of 7 January 2025, the Cessna Caravan with a pilot and 10 passengers on board operated on a passenger flight from South Perth to Rottnest Island, landing on the water at Thomson Bay.

Later that day, the pilot and six of the passengers returned to the aircraft for the return flight to South Perth. 

The take-off commenced at about 4pm, on an easterly track towards Phillip Rock, a rocky outcrop at the southern end of Thomson Bay. About 32 seconds later and 600 m from the start of the take-off run, the aircraft became airborne with a high nose attitude, before it rolled rapidly to the left and impacted the water.

Immediately after the collision, the aircraft remained partially afloat, and four surviving passengers moved into a small pocket of air in the rear of the cabin. One passenger opened the top part of the rear right door, through which they and one other passenger escaped. 

Another passenger was rescued by a witness, who broke the rear left cabin window and pulled the passenger out of the aircraft, while the fourth passenger also escaped through the window. 

The pilot and remaining two passengers were fatally injured.

“This preliminary report has been released to provide timely factual information as to the nature of the accident and updates on where the investigation is likely to focus,” ATSB Chief Commissioner Angus Mitchell emphasised.

“As the investigation continues investigators will continue to gather, review and examine evidence, in order to develop our analysis to identify those factors that contributed to the accident, as well as any factors that increased safety risk.” 

The preliminary report describes events on Rottnest Island prior to the accident flight, including that the pilot exchanged texts with the chief pilot of the operator, Swan River Seaplanes, about sea and wind conditions.

“This included a forecast noting strong and gusting winds, and consideration of an early return to South Perth,” Mr Mitchell noted.

“The pilot then boarded a small boat to assess conditions in Thomson Bay, and subsequently elected for a take-off in a different direction to take-offs conducted on prior trips.”

The ATSB’s subsequent examination of the aircraft wreckage did not identify any damage consistent with the aircraft having struck an underwater landmass or object, while a specialist borescope examination of the engine did not identify evidence of pre-accident damage. 

“The engine will be subject to a tear down by the manufacturer Pratt & Whitney Canada, the results of which will be provided to the investigation, and we will also continue our analysis of the aircraft’s recorded flight data” Mr Mitchell said.

“The investigation will include analysis of flight data from previous flights, and will seek to understand the handling of the aircraft, particularly in the context of the conditions in Thomson Bay on the afternoon of the accident.”

Bureau of Meteorology data, as well as video captured by witnesses and others, showed that conditions on the afternoon were windy with some waves in Thomson Bay. 

“The investigation will consider the information the pilot had access to for assessing these conditions, and the procedures and other risk controls used by the operator for assessing and planning take-offs from Thomson Bay,” Mr Mitchell said.

“We will also consider the system used by the operator to identify and analyse the risks associated with operating from this location, and the approvals for floatplane operations”.

The investigation will also give further consideration to recent maintenance history of the aircraft, which had entered service with the operator on 2 January (having been in storage since March 2024), and to the assessment and approval processes for floatplane operations at Rottnest Island.

“The investigation will seek to uncover and identify systemic safety risk factors. Should any critical risks be identified, we will immediately notify relevant parties so they can take safety action,” Mr Mitchell concluded.

Read the preliminary report: Collision with water involving Cessna 208 Caravan, VH-WTY, Thomson Bay, Rottnest Island, Western Australia, on 7 January 2025

Publication Date
27/02/2025

PS: This prelim was actually 21 days overdue according to the ICAO Annex 13 requirement for a prelim report to be published within 30 days of the accident occurring

[Kharon]

One day; it will all make sense.

Or, at least be something I can understand. Not being the brightest bulb on the Christmas tree don't help with the head scratching- however, I wish I could be shed of this nagging irritation about the Rottenest C 208 water operation event: I really do. The 'answer' is certainly simple enough; but it eludes and puzzles me; although I don't know why it should. However, that said – homework time.

It seems that there have been some 'mods' and 'tweeks' made over time to the 208 Flap operation 'system'. Nothing major – basic system – wise and certainly nothing that could (in normal, routine operations) create any sort of 'problem'. Seems simple enough. Your 'Basic' may be found – HERE – at Section 7:24. One page, self explanatory read. Changes and 'tweeks' may be found – HERE-; albeit not an 'official' guide it serves it's purpose. Non of this explains the curious statement from the ATSB related to the Flap system – Nada, zip, nuttin.

Wreckage examination (from Fig.8) onward. ATSB - Dot point - “The flap selector was in the ‘full’ position and the flap position indicator was showing an intermediate position of about 15°. The wing flaps were in the retracted position.”

Being ignorant of float operations; I assume that 'flap' would be used for take off; makes sense. Fine; would the routine (first 'slot' position) 10° be used; or, would the selector be moved to the intermediate 15° (not slotted) position? No idea if it actually matters or is even relevant. Well not until you read the next line from the ATSB.

ATSB - “The wing flaps were in the retracted position.”

This is direct contrast to – ATSB “The wing flaps were selected etc...” This discovery – after retrieval of the air-frame. It was also noted – ATSB - “ The flap selector was in the ‘full’ position.

This aircraft 'collided, at speed with water. This aircraft was 'probably' (guess) configured with flap @ 10 or even 15° of flap for the take-off. The cockpit indicator reflects that selection; Flap selector on retrieval shows a 'Full' down selection (last 'slotted' position) but the Flaps themselves were found 'retracted'.

Please explain – someone. I cannot deduce any sensible reason from the systems notes which can even begin to explain this curiosity. Nor do I have the operational knowledge to dive any deeper. BUT there is no-way known that this is not a factor  in this drama. ATSB seem to have skipped around this data. However; this is an electrical system; what the pointer shows is what you selected. Somewhere between zero flap afterwards and flap 15° (Assumed) set for the take off – how is it that on recovery Flap was 'retracted'?

P2: "This prelim was actually 21 days overdue according to the ICAO Annex 13 requirement for a prelim report to be published within 30 days of the accident occurring."

Aye; it beats me – perhaps this is why ATSB dragged their collective 'Learning's (Grrr) out for 50 odd days; do they not know why either? T'is no matter; as stated – not within my area of expertise; but it surely does fall square into the 'curiosity' area – big time.  - Handing over::-::

Toot – toot.

[Peetwo]

Popinjay to the rescue??

Via PJ and his minions...  

Flapping cowling door likely distracted pilot prior to Jandakot Chipmunk accident


The pilot of a Chipmunk light aeroplane was likely distracted by an unsecured engine cowling before an aerodynamic stall and collision with terrain shortly after take-off from Jandakot Airport, in Perth’s south.

On 26 April 2024 a DHC-1 MK 22 Chipmunk single piston-engine aircraft took off from Jandakot Airport.

Shortly after take-off, the aircraft conducted a left turn, likely an attempt to return to land. The pilot declared a MAYDAY, and as the angle of bank increased, the aircraft descended and collided with terrain.

The pilot, who was the sole occupant of the aircraft, was transported to hospital, but later succumbed to their injuries.

An Australian Transport Safety Bureau investigation found the pilot did not detect the engine cowl latches on the left side were left unfastened prior to flight.

“Footage showed and witness reports indicate the cowling began to flap open and closed after take-off,” ATSB Chief Commissioner Angus Mitchell said.

A review of past occurrences involving other Chipmunk aircraft did not indicate a flapping cowling would necessarily result in controllability issues.
“Rather, the flapping of the cowling likely distracted the pilot, resulting in a high cognitive workload,” Mr Mitchell explained, “at which point the aircraft commenced a low level, high angle of bank turn, and aerodynamically stalled.”

Mr Mitchell said the accident illustrated the importance of pre-flight preparation to reduce the likelihood of an abnormal occurrence.

“It should also remind pilots of the hazards that can lead to loss of control events, such as high angles of bank, particularly at low height,” he added.
During its investigation, the ATSB also identified that all 12 rivets attaching the upper structure between the front and rear cockpits sheared during the accident sequence.

Metallurgical analysis showed all 12 of the rivets were of a non-conforming type, and half of them were about one-third of the specification strength.

While this compromised the crashworthiness of the aircraft, its impact on survivability in this accident could not be determined.

Nonetheless, the ATSB issued a Safety Advisory Notice on 11 September 2024, advising Chipmunk maintainers and owners of the importance of ensuring modifications are carried out to the required specification.

“The use of non-conforming rivets significantly compromised the accident aircraft’s crashworthiness,” Mr Mitchell summarised.

“Maintainers and owners of all aircraft are reminded that when modifications are made, they must conform to the required specifications, or be returned to these specifications during maintenance.”

Read the final report: Collision with terrain involving Oficinas Gerais de Material Aeronautico DHC-1 MK 22 Chipmunk, VH-POR, at Jandakot Airport, Western Australia, on 26 April 2024

Publication Date - 25/03/2025

  
MTF...P2 

[Kharon]

Oh! Look Mum; - “there's an aircraft in my ashtray.”

Not really; but close enough on a few occasions – it happens {mostly) Outside Controlled Airspace (OCTA). The factors are well known.  Aircraft are difficult to spot, even when you know where to 'look' – remembering the closing 'speed' equation. 120 Knots = 224 Kph.  150 Knots = 277.8 Kph. 180 Knots= 333.36 Kph. The climb and descent speeds of the two aircraft at Mangalore Beechcraft (Travelair) (AEM) and the PA 44 (Seminole) (JQF) provide a rough idea of the 'closure rate' between the pair (no wind data) [irrelevant} the rate of closure in a time scale matters here. Lets say JQF was climbing at about 100 Knots ~185 Kph. Lets say AEM was descending at 160 Knots ~296 Kph. = +/- 480 Kph. Ten nautical miles is about 18.5 Kilometers. Closing speed 259 knots. Ten miles at 259 knots = 2.3 minutes.  Time not really a factor – not with prior knowledge, a plan, or a sighting; provided you know there's an aircraft climbing on your descent path.

ATSB claim (quite rightly) that there were two experienced pilots on board; fair enough – however. One was conducting a check flight the other a training flight. Lets consider that for a moment. Technically and operationally two of the most 'critical' parts of operating under the IFR are the approach and landing phase and the take – off departure phase. When training or examining a candidate pilot; where do you imagine the attention of 'training/check pilot' will be mostly focused? Lots to do, much to watch, it is a 'busy' period where the potential for a serious error 'can' occur. Focus on task is not only demanded; but absolutely essential. 

ATSB - “As such, the ATSB concluded that the pilots either failed to identify that a collision risk existed or identified the potential risk but incorrectly assessed that the aircraft were sufficiently separated. In either case, the primary defence of established self separation required in non controlled airspace was absent.”

I beg to differ M'Lud. Start  - HERE – with a good analysis by 'Blackburn' over on the UP. It is worthy of consideration – even if just for the questions it raises.
 
For example – Was the CTAF frequency 'busy'? Normally, on approach, comms are tuned to the CTAF and the area frequency (ATC). On approach/descent a 'silent' cockpit is the general rule; particularly during training to avoid distraction; unless something is turning Pear shaped. But here we have one taxi for departure coming South; one for approach heading North; one to climb, one to descend. It is a reasonable assumption that at least one of the instructing pilots would be waiting and listening for a radio call to 'sort out' the potential conflict.  It was, for a long while only a 'potential' conflict. Simple enough - “we'll maintain 5000' until over the aid” the response from the opposition Roger; will maintain 4000' until clear. CTAF busy – OK: call Center and sort it out there. But 'Sort it' the tooter the sweeter. So much for the crew efforts. Blackburn raises the specter of 'No Known Traffic' – twice. At 1120:28 the inbound pilot acknowledges the Center Controller advice of 'traffic'.

UP post - “The report also says that traffic was provided, however when AEM came on the local controller’s frequency, the crew of AEM were told on two occasions, 2 minutes apart (11.17.42 and 11.19.35) that there was NO IFR TRAFFIC. Up till then (2 minutes prior to the collision) JQF had not been provided any traffic info on the opposite direction descending traffic.

Can you spot the holes in the cheese? This report begs more questions than it answers; but, its hard to gainsay the ATSB summary:-

“Analysis conducted for the ATSB by an air traffic services subject matter expert identified a number of potential reasons why updated traffic information would not have been provided. Specifically, the controller: could reasonably expect the occupants of the aircraft were talking to each other and taking action to avoid each other may over-transmit the pilots while they are trying to talk to each other not being fully aware of any coordination between the occupants of the two aircraft, could give advice that created a hazardous situation.

Flatulent, slightly fluffy reasoning; ATC 'could' have made sure that the conflict message was delivered; and received confirmation earlier (much) from both crew. This is a part of this event which will always raise conjecture. Yet sometimes – rarely the planets align and events happen. This should have been preventable; one radio call from any party involved could have avoided it all. IFR particularly in IMC, especially in a known 'high volume' traffic area when the weather, cloud, traffic, comms and terrain is 'suspect'. The area is particularly busy; until there is dedicated ATC service (one consul) the risk remains high; more service or less aircraft seems to be the only 'bullet proof' solution; but even then, at the end of the shift there's only one fellah responsible for the flight. That's why they are paid  'the big bucks'..........

Toot toot..

[Kharon]

Mangalore (final)..

Over it; however - Somehow, the event at MNG keeps creeping into thoughts; stray notions pop up when the thinking gear is at idle (or playing Darts). The event has officially been put aside with the 'bases' neatly covered and the cracks papered over; but, something keeps nagging away. I try putting myself in each pilot seat; (even tried the ATCO stool).

“I have often tried to imagine how I might have acted differently. Always I end up in the same place.”

That place being in the right hand seat of the inbound aircraft.

Blackburn - “A review conducted by Airservices following the accident concluded that both aircraft were provided with, and acknowledged receipt of, mutual traffic that contained all relevant information.”

If we put that aside; we are left with a 13 second 'transmission' from the ATCO:-

“Between 1120:15 1120:28 Controller again called the pilots of AEM. Pilot responded and traffic information about JQF shortly to depart Mangalore was passed and acknowledged.”

So, lets start the clock about 11:22:19. 

“Between 11:22:19 1123:00 JQF Departure report to controller. Information was provided that the aircraft was passing 2,700 ft on climb to 7,000 ft and tracking to LACEY.”

“Controller advised the pilots that AEM was inbound to Mangalore in JQF's 12 o’clock position, for air-work, passing 5,000 ft on descent to not above 4,000 ft. AEM was apparently 10-11 NM from YMNG”.

By about this time, both fellah's in the right seats should have been paying a lot of attention. 10 miles ≈ 2.3 minutes (±) - a potential 'conflict' to deal with. Just a 'bread and butter' event operating OCTA. How many times during a day do IFR flights 'self separate? 'Lots of' is the ball park answer. So how long would you allow the flying pilot to establish contact with the opposite direction traffic and arrange separation? Not too long I should say.  Q - “Got that traffic mate”  A – “Yes advised them that we will maintain 5000 until clear”. Choc frog answer #1.

In the opposition aircraft; a similar scenario should be developing: “Comms established maintaining 4000' until clear”. Choc frog answer #2.

In the right hand seat, all should be quiet and content with this information provided. If it was not; then its time for the grown ups to step in and settle the quarrel;; the doomsday clock was ticking and -  Murphy was lurking.

The gods alone know what the ATSB 'simulation' of cockpit 'vision' cost; it is totally irrelevant to IFR operations (may be useful to junior VFR maybe) but IFR is a mental picture game- in IMC, OCTA all you have is the 'mind-map' of where you are and where the opposition is; this is a dynamic, fast moving, fluid situation. Communication is paramount in this routine, almost everyday occurrence, when the weather is liquid and lousy.

Oh! I don't know; but I feel the ATSB could have done a better job on this one. It reaches deep into fundamental operating practice across the spectrum; ATC, training, pilot attitudes, communication systems etc, etc. I particularity dislike this push toward more dependence on ADSB separation becoming the norm. Sure it is a great tool; but no more than that; it cannot replace an active, plugged in, situation aware mind on the flight deck. When it matters; really matters, it is that mind, not a machine which will save the day. One may only require that facility once or twice in a lifetime of flying – but when needed, it must be fully operational, when the clock is ticking.

Sorry to bang on; but the more I think about the Mangalore event; the more aligned 'holes' in the Reason cheese I find. But; as the prophets say:-

“Once is happenstance. Twice is coincidence. Three times is enemy action.

Toot – (and - back in my box) – toot.......

[P7_TOM]

Gold Coast Chopper collision.

Two 'links' below; avoid the Popinjay media bluster – really.

Link 1.

Link 2. ATSB

[P7_TOM]

Gold Coast Chopper collision.

Two 'links' below; avoid the Popinjay media bluster  – really.

Link 1.

Link 2. ATSB

[Peetwo]

Gold Coast Chopper collision.

Two 'links' below; avoid the Popinjay media bluster  – really.

Link 1.

Link 2. ATSB

Addendum: Popinjay to the rescue - Season 3

ATSB calls for research and testing for fitment of constant wear lifejackets with multipoint seatbelts



The ATSB is calling for research into the correct fitment of lifejackets while wearing aircraft multipoint seatbelts after finding that the passengers on board both helicopters involved in the 2 January 2023 midair collision at the Gold Coast were incorrectly restrained.

“The ATSB was unable to establish the level of contribution the incorrect fitment of restraints contributed to individual passenger injuries in this tragic accident,” ATSB Chief Commission Angus Mitchell said.

“However, in the event of an accident we do know that the correct fitment of seatbelts improves occupant survivability outcomes.”

Mr Mitchell said the ATSB investigation highlighted that the wearing of lifejackets potentially interfered with the correct fitment of the helicopters’ multipoint seatbelts.

“Occupants in helicopter tourism operations worldwide are at risk of increased injury in an accident due to inadvertent incorrect use of seatbelts,” he said.

“There is no readily available guidance, either from lifejacket manufacturers or regulatory authorities, regarding the correct fitment and use of constant wear lifejackets when occupants are using multipoint seatbelts.” 

For scenic flight helicopter operations over water, such as in the midair accident flight, regulators require that passengers wear a lifejacket in addition to their seatbelt. This is to ensure that passengers can access their lifejacket in a timely manner in the event of an emergency ditching or collision with water. 

“However, an occupant must survive the impact before the use of the lifejacket will be required and therefore correct fitment of their seatbelt is vital to ensure the restraints and energy attenuating features of seats work as designed.”

Most operators provide their passengers with pouch‑style constant wear lifejackets. While the lifejacket and multipoint seatbelts are commonly used together, there is no available guidance about how to integrate them while maintaining their functionality.

Manufacturer instructions for the fitment of all pouch-style constant wear lifejackets requires them to be worn around the waist and positioned at the middle of the body. However, doing so interferes with the correct fitment of a multipoint seatbelt. 

“The correct fitment of any seatbelt requires the lap portion to be worn low and tight across the hips,” Mr Mitchell stressed. 

“In this accident the operator’s ground and flight crew were not aware of how to integrate the constant wear lifejacket with seatbelts without affecting correct fitment of the seatbelt. 

“This led to the inadvertent incorrect fitment of passenger seatbelts.”

Mr Mitchell said the ATSB has issued a safety advisory notice calling for research and testing to develop guidance on integration of constant wear lifejackets with multipoint restraints so that operators and passengers can use these two pieces of equipment together without increased risk of harm. 

“The outcomes of this research and testing would contribute to a solution for the widespread problem of inconsistent and frequently incorrect wearing of seatbelts,” he said. 

“Development of guidance and procedures for aircraft operators to correctly integrate constant wear lifejackets with a multipoint seatbelt will benefit passengers across helicopter tourism operations worldwide.”

Read the safety advisory notice: Fitment of constant wear lifejackets with multipoint seatbelts

Publication Date
09/04/2025

Link: Safety issues and actions

Hmm...

Focus of the SMS

Safety issue description

Sea World Helicopters' implementation of their SMS did not effectively manage aviation safety risk in the context of the operator's primary business. Additionally, their objectives were non-specific, and the focus of safety management was primarily ground handling and WHS issues. This limited the operator's ability to ensure that aviation safety risk was as low as reasonably practicable.

Issue number: AO-2023-001-SI-07
Issue owner: Sea World Helicopters Pty Ltd
Transport function: Aviation: General aviation
Current issue status: Open – Safety action pending
Issue status justification: To be advised

Response by Sea World Helicopters

The operator disagreed with this safety issue. It stated:

Prior to Dec 2018, the PHS [professional helicopter services] management team gave a presentation to the then current staff of SWH where we stressed the importance… of Safety. It was part of our Vision and our Ethos, and we were bringing that to SWH.

It detailed our Vision to be recognized as Australia’s safest and most enjoyable helicopter tourism company and our Ethos – Safety is the foundation of what we do. Experience and enjoyment are the outcomes. These were our objectives, they are clear, concise and were published.

From the outset changes were made, in consultation with both the Chief Pilot and Safety Manager, this included changing flight paths and the building of the facility to improve safety, not only on the ground but for the movement of aircraft in all phases of flight.

Improving safety was the primary reason for making these changes.

Sea World Helicopters also stated that the ATSB had:

…continuously ignored the effects of COVID-19 and its effects throughout the world and the health issues that had to be dealt with in the SWH business. Comparing flight incident report numbers from year to year but ignoring the numbers of flights as a contributing factor. Total flights in 2019 were 20,054 and the total flights for 2020/2021 were 7195 (an average of 9 per day). In 2020 and 2021 the company operated mostly with just one pilot, that pilot was the HOFO/HAAMC.

Passenger numbers and staffing numbers decreased along with risks to report. At one point the office closed for three months. When flights did occur the passenger demographic was totally different to pre-COVID. The passengers prior to Jan 2020 were 80% Chinese Mainland groups, nearly all of whom, did not speak English. These tourist groups are yet to return to Australia.

And:

…we find the last 7 months prior to the accident, the safety management in this period is ignored as a subject by the ATSB. The amount of incident reports increased, there were more safety meetings and briefings about safety meetings in a period of time than we can find recorded for the period before Dec 2018.

In response to this finding the operator also states:

When at work the SWH team were encouraged to work as only a small team can, there was a safety suggestion box put in the team’s breakout room for them to provide any type of safety feedback, including anonymously. Minor items were done on the spot where possible. Items relating to flight safety whilst sought did not arrive as for these two years there was between one and two pilots only.

In addition to the Safety Manager, we employed a Quality, Safety & Compliance Officer, who although part-time, attended all weekly management meetings. Assistance was still provided by the PHS Safety Manager in matters of compliance and documentation.

SWH thoroughly believes it manages risk and the safety of its staff and customers very well.

ATSB comment

The operator’s response to the finding does not address effective engagement with aviation safety risk. The aspirational vision of the company did not translate into defined objectives of the safety management system. As discussed in the report in Safety policy and objectives, the objectives of an SMS are intended to be practical achievable goals.

The effect of COVID-19 was discussed in the report in the Disruption due to global pandemicsection. Following draft review, the operator provided flight numbers which have been used to normalise reporting by flight hours to account for the lower activity during COVID-19. Flight operation reports were shown to reduce after the change of ownership while WHS reporting did not, and did not recover after the pandemic.

The 7 months of SMS prior to the accident were covered in detail in various places within the Safety management section. The report related the success of the operator’s SMS in that period in managing ground handling and WHS matters. While WHS is a very important and legislated element, as stated in CASA guidelines, an aircraft operator’s SMS should concentrate on aviation safety risk.

The operator’s primary business was high frequency low duration helicopter flights from 2 nearby helipad facilities. The report agrees that the changes made were intended to improve safety, but as the SMS was not focused on aviation safety risk, processes which could have contained unintended consequences of those changes were not used.

The operator has not so far provided evidence of defining safety objectives and support for ongoing engagement with aviation safety risk, and is therefore still at risk of being limited in its ability to ensure that risk in its organisation is and will remain as low as reasonably practicable.


Safety recommendation to Sea World Helicopters Pty Ltd

The ATSB makes a formal safety recommendation, either during or at the end of an investigation, based on the level of risk associated with a safety issue and the extent of corrective action already undertaken. Rather than being prescriptive about the form of corrective action to be taken, the recommendation focuses on the safety issue of concern. It is a matter for the responsible organisation to assess the costs and benefits of any particular method of addressing a safety issue.

Recommendation number: AO-2023-001-SR-38
Responsible organisation: Sea World Helicopters Pty Ltd
Recommendation status: Released

The Australian Transport Safety Bureau recommends that Sea World Helicopters Pty Ltd develops appropriate policy and actionable objectives within its safety management system to bring the focus of the safety management system to the management of aviation safety risk.

Hmm...I can understand the pushback from the company in terms of total liability cost, reputation etc..etc. The Coroner's inquest will be interesting??

MTF...P2 

[Kharon]

Five basic rules.

Remember - "Up, Down, Left, Right – and don't hit nuffin" ; sage advice offered pre first solo; then a wink, a smile and the door closed. Gulp..Aye, happy daze..

Is the 'Left' element in that advice the more 'important' one? There is a good argument to support it being so. The 'left' seat is the 'traditional' one for the 'command' pilot; and acknowledged in design (mostly). A circuit to landing is flown using left turns; collision avoidance (conflict resolution) reflects that philosophy. Why, well that's easy enough to understand – it allows the pilot to 'see' the runway and, turning right to avoid a conflict ensures that the pilot can 'see' the other fellah (mostly). The whole thing can trouble a new FO on a bigger, two man ship; flying the aircraft with the right hand and the left manipulating power levers etc always feels a bit strange in the beginning. In any 'Left -hand' turning procedure; the right seat is, to all intents and practical purpose 'blind'.

"Sure the fight was fixed. I fixed it with a right hand. "

No matter 'how' a potential conflict is manifested; the avoidance turn is always made to the right (no watch); the PIC can (mostly) see the opposition and ensure separation is maintained. The chap in the right seat is, again mostly out of luck.

(Aside) This self separation game is deuced tricky one. The Brits have (or used to) have an ATPL examination paper called 'Lights'. Tough exam, (100% right pass mark) but being able to resolve or discard a potential conflict, armed with this learned knowledge was invaluable. But now I digress.

Reading through the ATSB report produced some first thoughts; and, begged some interesting questions, so I asked some of the BRB for a second opinion. Making a large allowance for first impressions, all noted (unprompted) the same 'initial thoughts' as my own. In a three seat wide cockpit, and flying from the 'right hand' seat all one can really see is ahead and whatever is on the right hand side. It made sense to reverse the 'pattern' the guys were flying; left circuits from the right seat – awkward to say the least. Left hand pattern;  high density traffic, boats, fast turn around, wide cockpit with passengers to look through? Probably not the 'safest' plan ever developed.

But, it is early days and the ATSB report requires further examination; however, first impression – what were they thinking? Did anyone, mention or consider changing the flight pattern?  Corrections as needed after a full read and discussions. Happy to stand corrected......

Toot – toot.

[P7_TOM]

Whimsy – down memory lane.

There was four of us sat at the table; probably close on 80,000 + collective command flight hours (the rest of 'em excluded; a wide range of experience and disciplines, and who could even begin to count the 'tales'. I got the round in, and asked 'the' question – forced landing training – anyone remember it? And, so it began. The Middle Beach fatal being the 'trigger' for further discussion (a lot of it). CASA and ATSB 'featured;' although not in good way.

However; as I was actually there at the time, my own 'experience' and 'training' was reflected and reinforced by the crew; and so, in summary I shall sketch that (in brief) as a point of disgust with the way the Middle Beach event was handled in court. Mark you, half the problem is that the bloody lawyers have even less clue than the unfortunate jurors or even the Judge. Scary when you think about it.

I was blessed with a fine instructor; the older I got the more I appreciated the work he put into my training. Sent me solo he did, and took on the thankless task of beating navigation and route flying into my wooden head. Back in those days, track and time keeping were a mandatory requirement; ETA's withing two minutes, position reports, written flight log etc. Busy enough for anyone; but Nav 1 about twenty minutes clear of departure; he asked me a question. “What if that engine fails about now?”. Man, I was working with the Whizz wheel, trying to sort out the log, trying to maintain a semblance of height, heading and find the illusive navigation landmarks - “What?” I asked. “Engine failure right now"  says he; where will you go?. Well, he had me beat hollow and speechless.  Then a big smile - “I'll fly the next leg; I want you to pick out the paddocks which suit you best and we can discuss them. There, began a habit of a lifetime; it became more difficult and demanding as time wore on and as more 'Nav's were done, it became a game. He would call “Now” - I make the decision and as we cruised along for the next 20 minutes; we would wrangle over the pluses and minuses of the selected return to Terra Firma. It took a while for me to understand the immense value of those 'discussions'; I was not taught 'forced landings' I was taught to always have a 'Plan B' at any tick of the clock; saved my aging rump on several occasions has that peerless training.

Which bring me to the point, as it were. In any emergency; the sub conscious is working overtime trying to present 'the data' gathered through experience to the operating mind; somewhere, behind the procedures and checklists and attempted remedies; the lessons and thinking process (experience if you will) are present. Inescapable really. Which brings me to the Middle Beach fatal; given the many hundreds of 'beach landings' the pilot had successfully and uneventfully conducted – has had (probably), at the time, on balance of probability and past experience, made the 'best' decision possible – given the time, place and circumstances. The engine failure was not in any way 'his' fault; in fact it was faulty. The appeal is justified; his stance is right and, given the circumstances; the 'best' outcome possible was arguably, a fair call. Kick the appeal tin at AOPA – if you can - you know you want to......Ale: large one! – fast type...

[Peetwo]

Final Report: Pilot ENDANGERS Crowd at Race

Here's another one for the list, where CASA has gone with the 'nothing to see here - move along'

..or 'nothing to do with us' approach?

(From 06:40 minutes)

Also from this week's DTS Stewie Macleod:

Aerobatic aircraft damaged at Bathurst racetrack operated in no-fly areas



An Extra 300 aerobatic aircraft that was damaged when it struck a barrier while taxiing at the Mount Panorama Circuit then took off and flew through a no‑fly area, an ATSB report details.

The aircraft was being used to deliver the trophy for the annual Bathurst 1000 motor race on 13 October 2024, with a single pilot on board.

The aircraft had taken off from Bathurst Airport, about 10 km to the west, before landing on the Mountain Straight section of Mount Panorama Circuit for the trophy handover.

After landing, the pilot conducted a reversal turn, during which the aircraft struck a barrier, resulting in damage to the tailplane.

“The pilot reported not feeling the impact, but a media helicopter pilot immediately alerted them to the issue, and recommended checking the aircraft’s tail before taking off,” ATSB Director Transport Safety Stuart Macleod said.

After taxiing to deliver the trophy, the pilot conducted a full control check and a visual check of the tail from their cockpit seated position.
With no control problems or damage identified, the pilot taxied the aircraft back uphill along Mountain Straight, before turning around again and taking off in the opposite direction from which they had landed.

“Both the landing and take‑off tracks took the aircraft into a designated ‘no‑fly area’ occupied by spectators, which did not comply with the Civil Aviation Safety Authority’s required spectator safety heights and distances for an air display,” Mr Macleod said.

“Moreover, the pilot did not conduct an external inspection after striking the barrier, and the take off and return flight to Bathurst Airport were conducted with the damaged tailplane.”

The ATSB’s report details previous application processes undertaken by the pilot for air displays at other motor races, where the pilot was regularly advised by CASA staff of the regulations restricting operating over or near spectators, and at times changed plans accordingly.

“However, the pilot’s application for the Bathurst 1000 did not describe how the landing or take off on Mountain Straight would occur,” Mr Macleod noted.

“Due to obstacles at the southern end, the take‑off and landing could only have been conducted from the north, over the no‑fly area, which was clearly marked in the pilot’s submitted diagram, but this was not specified in the application process.”

The ATSB found that CASA approved the pilot’s application despite the limited information provided.

Mr Macleod noted CASA’s advisory circular for air displays acknowledges the level of risk for air displays may be elevated for those onboard the aircraft, such displays must not increase risk for spectators and others on the ground.

“All air display personnel, including the organiser, air and ground coordinators, and pilots, must ensure displays are planned in compliance to the requirements, and conducted within these approved arrangements,” Mr Macleod concluded.

Read the report: Collision with terrain involving Extra EA 300-LT, VH-XKW, about 10 km west-south-west of Bathurst Airport, New South Wales, on 13 October 2024

Publication Date:10/04/2025

"...On 5 September, CASA acknowledged receipt of the pilot’s application by email, and provided the pilot with the contact details of the FOI assigned to assess the request. The FOI reported to the ATSB that on review of the application, they assumed the pilot would comply with the NO FLY AREAs on the display diagram and that they were unaware of the topography of Mountain Straight.

The FOI did not review any of the pilot’s previous applications and therefore was not aware of the requests to conduct landings and take-offs at the Barbagallo and Sandown racetracks. On 6 September, the FOI issued the display approval without any requests for information or clarification from the pilot and without completing the required OPS.25 worksheet..."

Reference "K" - 14/03/2017:  

Without prejudice; (or even a dog in the fight).

P2 – “Interesting that Comardy is sitting in the position of the decision maker?

It is to hoped that the position ‘decision maker’ (Hoods old job) is vacant; if so, it will one of the very best decisions Carmody ever made; if not ‘the’ best.

P2 – “Will this now be SOP for all 'show cause' enforcement actions or has Carmody sacked anyone else who can make such decisions?”

Dunno mate; but for Carmody’s sake, lets hope he is not basing his decisions on the ‘Enforcement manual’; unless of course he has signed it and now owns it as his very own. I wonder how a serious legal challenge would fare against any ‘action’ taken against a person based on that dreadful ‘McConvict’ drafted section. I reckon that would be ‘interesting’.

Seventeen days after the crash, CASA acting chief executive Shane Carmody wrote to Mr Rhoades to say his air operator’s certificate was suspended immediately because, as chief pilot and business owner, he had allowed flying that “contributes to or results in a serious and imminent risk to air safety”.

All a bit too ‘subjective’ for my taste. I’d expect most reading here have operated in ‘turbulent’ conditions, most have probably operated passenger flights in aircraft without a cockpit door; done ‘joy flights’ and ‘scenic flights’ or even back in the day, ‘commuter’ flights. How would you like a beer in the fridge for every time you’d heard a passenger ‘scream’ or similar when you hit the bumpy bits; or when you level off and come back to cruise power, or ‘crank it over a bit’ so folk can see what they came to see? It is, IMO perfectly understandable that folk are ‘nervous’ when confronted with a tiny, one engine aircraft, a stranger for a pilot and all ‘crammed’ into the small area allotted. The noises (engine and airflow) all perfectly acceptable to the ‘pilot’ heighten sensitivity, and any ‘abrupt’ change of ‘state’ increases the tension level. It is a fair bet that at least one of three passengers in a C172 just did not want to be there anyway. In defence of this pilot, it would be reasonable to argue that unless one of the passengers was an accredited pilot, capable of ‘judging’ the manner in which the flight was handled; then hearsay evidence from passengers is not only worthless, but prejudicial. If this fellah has been ‘acting the goat’; then by all means, string him up, after proof beyond reasonable is accepted by the court.  

"The flight, including the wail of the stall warning horn, is recorded in a video taken by a passenger and recovered by police."

These Qld CASA chaps do seem to like their ‘video’ evidence; the Quadrio matter is not forgotten and there may be a line of defence in those ‘images’ and recordings of ‘passengers squealing’.

Mr Carmody wrote that the video showed Mr Woodall flying at 150-200 feet; risky, because if something went wrong such as engine failure, “he would have only minimal altitude, and therefore (minimal) time, to safely manage the upset”.

Precautionary search? Seems like a very ‘safe’ precaution to landing ‘on the beach’. I would say that not to do so was certainly a risk. The procedure should be cast in stone in the company operations manual; that would be mandatory. Accepted or ‘approved’ by CASA is academic as CASA approve the Air Operators Certificate and by extension – the operations as writ. Had this fellah not done a PS and had an event on the ‘strip’ then crucifixion would be in order. Again the intent to be unsafe can be discredited, a saving of an additional five or perhaps six minutes operating costs could be avoided by ‘skipping’ the PS. So it comes back to just what is ‘unsafe’ and who is making the judgement.

Mr Carmody criticised what he called “aerobatic manoeuvres”, saying the recording “includes an audible ‘squeal’ from a passenger at the beginning of the abrupt pitch inputs”. The CASA chief said Mr Woodall should have kept up his airspeed after the engine failed, not risked a stall by banking hard, and landed on water if necessary. He alleged the plane’s fuel supply might have been contaminated by debris.

Try to define ‘aerobatic’ in this context. Provided the aircraft was not operated outside of the specified envelope, then a steep turn, or whatever is quite legal. A badly executed ‘manoeuvre’ may demonstrate a lack of skill and/or judgement; but can it be considered ‘dangerous’ without the benefit of a 'G' meter record? It is all very well to say Mr Woodall ‘should’ have done this or that after the event, indeed most pilots who have been involved in any sort of ‘event’ can recount exactly what they ‘should’ have done; and would do, if it ever happens again. I wonder if CASA ever mandated a training requirement, specific to that beach area, dedicated to establishing ‘best practice’ in the event of an engine failure, at low level on the go-around after the precautionary search? If not why not, surely that would be ‘proper’ oversight of the safety of the operations approved by CASA.

Perhaps this was a cowboy operation; perhaps not. But consider all the evidence, before pronouncing a sentence.

When we teach someone to fly – what is the noise heard during the flare and touch down? What is the purpose of that noise? Is it absolutely safe to slow the aircraft down to stall warning speed? What does the pilot have at his ready disposal to maintain the speed at which the warning occurs?

Nope, no quarrel with CASA shutting down a rogue, non at all; provided they have got all the ducks lined up and back ‘em up with proof, beyond reasonable doubt; and, perhaps adjust their thinking toward ‘prevention’ rather than prosecution.

My two bob for its worth.

Toot toot.

Plus from the ATSB FR:

..The ATSB recently noted limitations with CASA’s surveillance processes of charter operators during the period up to 2009 in its AO-2009-072 (reopened) investigation report (released in November 2017). It concluded there was a safety issue at that time with the procedures and guidance for conducting surveillance events not formally including the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards. With the introduction of the CASA Surveillance Manual in 2012, there appeared to be no additional guidance procedures or guidance that addressed this issue. A review of the available evidence associated with the surveillance of Wyndham Aviation suggests that this safety issue still existed in practice during the period up to 2017...

MTF...P2 

[Kharon]

Probability, Probity, Prosecution, Prevention and Cure.

Back to the 'Middle Beach' event; not my choice, the BRB decided to have a 'chat' about the 'back-room' blow - those surrounding the event and the ruthless prosecution of the pilot.

..”The ATSB recently noted limitations with CASA’s surveillance processes of charter operators during the period up to 2009 in its AO-2009-072 (reopened) investigation report (released in November 2017).

That comment almost gives the game away; “noted limitations with”. Etc”. It depends on who and how that is being read and translated; but – it begs the question – is CASA only interested in the 'legal' arguments which could come back at them?. In short, what did they miss or not understand related to 'operational matters'. If one has no 'experience' of a specific type of operation, then the chances are that 'something' which could cause 'trouble' has been missed – by the alleged 'expert' CASA crew.

ATSB - “It concluded there was a safety issue at that time with the procedures and guidance for conducting surveillance events not formally including the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards”.  (Amen to that)....

The underpinning logic in that adroitly framed nonsense is, like dog's balls, easy to spot from the rear view. However, it does reinforce the notion that those doing the 'surveillance' failed to identify the inherent risks associated.

ATSB - “With the introduction of the CASA Surveillance Manual in 2012, there appeared to be no additional guidance procedures or guidance that addressed this issue. A review of the available evidence associated with the surveillance of Wyndham Aviation suggests that this safety issue still existed in practice during the period up to 2017”...

No surprises there -  to amend 'procedure' opens a crack for a smart defence, any admission of CASA 'missing' a 'safety element' sends shivers through the prosecution. That element, stand alone, goes part way to explaining the ferocious, unrelenting  prosecution of the pilot conducting the 'operation' at Middle Beach, which claimed a life.

Original comments - HERE-. 

But, what of 'risk' ? There are literally mountains of analysis, pro and con, written on the subject and the satellites of safety matrix and its diaspora of prophets; all 'expert' – all trying to win a hand against 'fate' – or Murphy. Take our seemingly simple aviation operation at Middle Beach – a 'joy – flight' – an adventure flight – a 'Thrill flight' – call it what you will; but, at the end of the shift, it is nothing more than a routine operation, as conducted across the globe by countless pilots almost on a daily basis (or week-ends). The 'risk' matrix can be broken down into a few very basic areas of 'high' risk. It is within the identification of those risks and the strategies in place to minimise both the obvious and more 'subtle' risks that the 'problems' reside. The essential elements are 'who' evaluates that risk and the risk to 'them' for making that evaluation; the level of actual risk involved in the proposed operation; and the attitude of those conducting that operation toward the 'allowed' level of risk.

If we set aside the 'legal' risks involved in the conduct of 'beach landing joy flights' for a moment, for they are well and truly understood and carved in stone as part of 'operational approval'; we are left with the innocent public signing up for the 'experience'. For them, it is all a bit like a visit to the Disney Land rides; or the Big Dipper etc. There is a certain 'thrill' to be had; the option for screaming is almost mandatory and no permission is required to throw up. It is all part and parcel of a 'thrill' ride. Yet, folk do get hurt, there has been the odd death recorded, but have  'operators' been prosecuted; unless there is a gross breach of the stated 'safety parameters'. Investigated, thoroughly no doubt, which is a correct thing to do with injury of death. Yet folks still queue up all the same for the 'ride of a lifetime'. It is pretty much the same for the 'thrill flight' punters; would an 'ordinary' joy flight attract the same numbers – once around the island and home for tea? So do we have 'risk aware' punters or, is there a need to point out that the flight has perils? If so, then we need to quantify the risk matrix: percentage chance of a high risk (life threatening) event occurring: the percentage chance of a real emergency (Mayday call); same for a partial problem (Pan call) and the percentage chance of a re-portable occurrence.

Easily done – Single engine hours operated : engine failures. Say 2000:1 just for a number, same-same for accident on landing with commercial pilots – what, say 1500:1; crash on beach landings with experienced crew after conducting strip inspection; what, call it about 100,000 :1. Then quantify the risk of engine failure  at low level on a go around after a beach inspection with little in the way of time or wriggle room available – the odds against are astronomical. Ignore my 'made up' numbers, but consider the chances of the combination at Middle Beach occurring. Pretty long odds for a betting man offered on the chance of a repeat.

But I will stand behind this bit: if you were not there then how can you possibly  expound what could/ should have been done. To investigate is righteous; but to prosecute (criminal) on the 'evidence' available is, IMO, a step too far and a stretch to the giddy limits of innocent until proven guilty. Has CASA drafted a rule set or tailor made prescription as part of the Company operational approval, detailing a procedure and training regime for engine failure at/ or below 200' - on go around - with little to no options for a landing area? Then what right do they have for prosecuting the Mutt caught in that situation?

Right I'll shut up now; bloody rain is keeping me indoors when I need to be out and doing. Makes me cranky and bored; not a good combination.

Toot – toot.