[Peetwo]

As requested and required, a few of our 'older' associates read and considered the report from ATSB - (above) with a view toward prevention of a repeat performance. One of the more interesting elements discussed was 'Australian Ice' as opposed to it's northern hemisphere counter part.

In essence, it is the same stuff and it's affects on aircraft performance identical, no matter where you pick it up. A known killer, the world over. The difference lays in 'where' it is encountered; and in what season the operation is conducted.

Mid November in Australia is almost 'summer' while in the northern hemisphere it is late Autumn - verging on winter. So, for example a turbine engine and airframe operating in Oz can base performance expectations on ISA + 10° C at MSL; in the USA ISA -5° C is a fair expectation (ballpark). Freezing levels respectively 15 ° C apart, which places the 'alert zone' considerably lower in the northern lands; which is an advantage to performance and an earlier escape from the icing layer. Mind you, I've had ice accretion in temperatures as high as +5 and as low as -25, it all depends on what weather type you are operating in, and where. Our man in the 210 would be somewhere near enough 'max power' at F180 and was dragging some ice around with him; between 'cloud layers'. Can anyone spot the danger areas in this scenario? There are just a few large red flags waving.

Options - climb out of the icing. In theory worth a shot - provided the horsepower available will carry the aircraft through a climb with an iced airframe, already performance degraded (no de-ice boots); and, that there is guarantee of clear air above a 'layered' sky; and, that the ice accumulation does not impact on TAS which leads to a fuel/range problem. - So, having accumulated some ice on the initial climb - and 'topping' the cloud not an option, the next option is 'down' - back through the icing layers - down low enough to shake off the ice. You know there is ice down there - probably have some idea of where you began to pick it up - so why not leave the 'heat' on until you are below that level? So, you descend and arrive at a lower level with double the original ice - and a reduced TAS/range problem, at least until until the ice obligingly disappears. But will it? Here we meet Murphy - always present. 

But what of the airframe performance? Ice weighs - ice disturbs the airflow - ice costs speed and fuel - ice tends to cling in areas not visible - in short, carting ice about the place is at the high end of the risk scale.

One of the more potential serious risks in 'warm' lands is the height at which the arbitrary 'Freezing level' is found. Often toward the top end of turbine power available; but the 'freezing level' ain't the problem is it. The FL simply defines what? The problem area is the icing layers above that - the red zone - where layers merge and mix; where convective currents spread cooled water particles which are quite happy to turn into ice with a small nudge from an airframe. Ice has a habit of 'building' which affects airflow, and allows more area to be presented, degrading speed which allows even more build up - and so begins the chain of events which lead to the hole in that famous cheese reserved for those who failed to have a clear plan and focus on the insidious 'ice-man' who rides with Murphy. 

The slick answer is 'if you get into ice - get out of it' - The sensible, thinking pilot's answer should be .................? Handing over..

Addendum - Flight Safety Detectives : Episode 95 

Icing Issues General Aviation Pilots Need to Know – Episode 95

Several accidents caused by icing reveal safety information that pilots need to know. As we head into a time when icing can be common, John, Greg and Todd want to be sure everyone avoids the mistakes other pilots have made.

“Icing has greater impact on general aviation aircraft than commercial planes. It is important to be prepared for icing incidents,” Greg says.

In this episode the Flight Safety Detectives focus on one general aviation icing event and relate it to lessons learned from other accidents involving icing. The takeaways benefit all pilots. They dig beyond the stated NTSB findings to highlight how pilots need to prepare for icing and how to manage the situation.

Included is a discussion of the TKS Weeping Wing system. They cover the benefits as well as the shortcomings.

Knowledge is power, and the Flight Safety Detectives want to empower every pilot with the latest insights on how to deal with icing as well as the details of relevant safety regulations.

MTF...P2 

[Peetwo]

And the Director of Transport Safety this week is? 

Via the ATSB:

---

VFR pilot likely experienced low cloud conditions and reduced visual cues ahead of controlled flight into terrain accident




Key points

• Aircraft collided with a ridge while attempting to exit the Western Arthur Range in low-visibility conditions;
  
• The pilot was operating under the visual flight rules;
  
• Accident highlights the hazards associated with flying in mountainous terrain and the challenges of in-flight weather-related decision‑making;
  
• Investigation analysed operator’s safety management system and Civil Aviation Safety Authority regulatory oversight.
  

The pilot of a twin-engine Islander aircraft was attempting to exit south-west Tasmania’s Western Arthur Range in low visibility conditions when it collided with a ridgeline, an Australian Transport Safety Bureau investigation details.
The Airlines of Tasmania-operated aircraft was conducting a positioning flight under visual flight rules on the morning of 8 December 2018 from Hobart’s Cambridge Airport to an airstrip at Bathurst Harbour in the Southwest National Park. A single pilot was on board.

Satellite-based ADS-B transponder data from the aircraft showed that the pilot had tracked from Cambridge Airport direct to Bathurst Harbour, passing through a gap (or saddle) in the Arthur Range known as ‘the portals’, a route used in low cloud conditions.

After passing through the saddle, flight data showed the aircraft manoeuvred in a valley, consistent with the pilot assessing different options for possible routes through to Bathurst Harbour, before tracking back towards the portals, the investigation’s final report details.

While in a turn under power and pilot control, the aircraft collided with a ridge on the Western Arthur Range, at an elevation of about 885 m (2,805 ft). The aircraft was destroyed in the accident and the pilot was fatally injured.

“The ATSB’s investigation found that the pilot was using a route through the Arthur Range due to low cloud and had continued over a saddle in the range at a lower altitude than previous flights along the same route,” said ATSB Director Transport Safety Dr Stuart Godley.

“During this, the pilot likely encountered reduced visual cues, and while attempting to exit the range, the aircraft collided with a ridge that formed part of the Western Arthur range,” he said.

“For pilots, this tragic accident highlights the hazards associated with flying in mountainous terrain and the need to have an escape route. It also shows the challenges of in-flight weather-related decision‑making.”

The investigation also found that Airlines of Tasmania’s guidance to its pilots for operations to Bathurst Harbour was primarily given verbally and was not well documented.

“This resulted in the operator’s pilots having varied understandings of the expectations regarding in-flight weather-related decision-making at the Arthur Range saddle,” Dr Godley said.

The ATSB’s investigation also found that, while not a contributing factor to the accident, the operator’s safety management processes had limited opportunities to proactively identify risks in all operational activities and to assess the effectiveness of risk controls.

“For operators, this investigation highlights the importance of using multiple sources to identify the hazards potentially affecting the safety of their operations, rather than relying on one key source. These can include safety occurrence reports, inspections, audits, flight data, and expert judgment,” Dr Godley said.

“Likewise, it is equally important that operators monitor and evaluate the ongoing effectiveness of existing risk controls to ensure that they remain appropriate.”

Subsequent to the accident, in January 2020, Airlines of Tasmania introduced specific guidance for its south‑west Tasmanian operations, introducing visibility requirements for pilots using the direct route through the Arthur Range saddle.

In addition, the operator added further information and guidance to its training syllabus, and introduced changes to its safety management system.

The investigation notes the operator has also committed significant resources into installing technologies to assist with flight planning and oversight of its operations. This included the installation of a new high definition 360° webcam at the Bathurst Harbour airstrip and the installation of ADS-B ground receivers at a number of locations, including within the Southwest National Park.

Another aspect of the ATSB’s investigation was an analysis of the Civil Aviation Safety Authority (CASA)’s oversight of Airlines of Tasmania, including surveillance activities. The investigation found that, while not a contributing factor to the accident, CASA’s process for acquitting repeat safety findings was not effective. While there were ongoing communications with the operator, CASA did not conduct any formal surveillance activities specifically related to the operator's safety management system.

Finally, the investigation notes that, while ADS-B transponder data provided important information to the ATSB’s investigation, the aircraft was not fitted with an onboard recording device (nor was it required to be).

“An on-board recorder would have provided valuable information to better understand the pilot’s in-flight weather-related decision-making and identify potential safety issues,” Dr Godley said.

 “The use of lightweight recorders on smaller aircraft conducting commercial passenger operations can provide a relatively simple and cost-effective way of achieving of the benefits of traditional recorders fitted to large aircraft.”

Read the report AO-2018-078: VFR into IMC and controlled flight into terrain involving Pilatus Britten-Norman BN2A, VH-OBL, 101 km west-south-west of Hobart, Tasmania, on 8 December 2018

---

P7 - Reality fix - HERE -

P2 comment: From the man who said these weasel words under Senate RRAT questioning; (read - HANSARD)  



And then, when his new boss was busy trying to schmooze Senator McDoolittle, was strangely mute on the subject of the collective (ATSB/CASA) Angel Flight embuggerance?? 

From 22:00 minutes:

MTF...P2 

[P7_TOM]

Hmmm!

“An on-board recorder would have provided valuable information to better understand the pilot’s in-flight weather-related decision-making and identify potential safety issues,” Dr Godley said.

I say Bollocks. But, would it have prevented the 'basic' cause? I think not. The weather in Southern end of Tasmania is on frequent occasions 'difficult' to manage and has been known to be so for a very long time. IMO, for the last decade it has been an easy matter to make 'video' recordings of the 'options' available for an aerodrome like Bathurst Island; to replace the time honoured written briefings and photographs. Back in the day - in 'awkward places' a series of briefings; and, as many sessions of 'hand holding' was required before a new pilot was signed off with a company 'route and strip' approvals. There was invariably a page in the briefing notes which defined (where possible) alternate routes which provided the 'best' option for various weather patterns and seasonal events. Cheap as chips - drafted by those whose experience was hard won. A most satisfactory system.

A quick look at the weather pattern for the day of the accident; the flight path selected and the possible alternate routes suggest to me that the items mentioned above may have prevented yet another VFR into IMC fatality. The ATSB have (IMO) once again failed to address the glaringly obvious cause and elected to recommend using a system which could provide a better understanding of the blindingly obvious rather than tackle one of the biggest known killers. This accident like many other similar events was totally avoidable; in no particular order the prevention could begin at company, ATSB and CASA level. I don't care who starts thinking like airmen rather than lawyers; just so long as it happens; and soon.

[P7_TOM]

From the ATSB - HERE - a completed report on things that make you go Hmmm!

[Peetwo]

From the ATSB - HERE - a completed report on things that make you go Hmmm!

Hmmm...this is interesting??

Reasons for the discontinuation

The Civil Aviation Safety Authority have put in place regulations designed to ensure aircraft are airworthy and pilots are properly trained and qualified. When owners operate outside of the rules, they remove the built-in safety defences and undetected problems are more likely to emerge. Given that the aircraft and engine had not been maintained in accordance with the regulations for about 10 years, a more detailed investigation to find the source of the engine failure would have unlikely led to the identification of broader systemic safety issues. On that basis, the ATSB determined that there was limited safety benefit in continuing to direct resources at this investigation when compared with other priorities and elected to discontinue this investigation.

- All fixed then...

Next a completed investigation, via the Yaffa: 

ATSB Investigation finds No Cause for 182 Crash

10 February 2022

An ATSB accident investigation has failed to determine the cause of the fatal crash of a Cessna 182Q off Moreton Island in January 2022.

The final report, released today, focused on the potential for carburettor icing and the noted that the aircraft appeared to have been descended to an altitude over water that wouldn't have allowed a glide back to land.

VH-WNR was being flown on a private scenic flight from Caloundra Airport in QLD when it crashed into the sea near Flinders Reef only seconds after the pilot issued a brief Mayday call. The aircraft had been tracking north up the east coast of Moreton Island when the pilot began a descent towards the reef from 1200 feet. Inspection of the wreckage showed significant damage and neither the pilot nor the passenger have ever been found.

"ATSB examination of the underwater video identified that the aircraft was likely destroyed by collision with water at a moderately high speed," the report states. "Damage to the aircraft cabin from the collision with water indicated that it was unlikely to be survivable. There was no evidence of fire.

"All major aircraft components were accounted for, and there was no evidence of pre-impact defects or structural failure. As far as could be established, cockpit switch positions were configured as expected for normal flight."

The ATSB was unable to find any pre-existing defects with the engine or aircraft systems that could have caused the engine to fail and found evidence that the aircraft had 135 litres of fuel on board, which was sufficient.

However, the ATSB said the weather conditions at the time were conducive to carburettor icing, and although the carburettor heat control was found in the OFF position, investigators were unable to determine if the control had been applied prior to impact.

"ATSB analysis found that the engine’s power was reducing over the last part of the flight, over a period of about 100 seconds," the ATSB has said. "At the time of the accident, the weather conditions were conducive to carburettor icing. These conditions are common in the region.

"However, a conclusion regarding the possible influence of carburettor icing on the development of the accident could not be drawn with any certainty.

"The ATSB also found that the pilot had descended over water beyond the glide range of a suitable landing area twice on a previous flight, limiting the options for a forced landing in the event of an emergency.

"Although it could not be determined whether the aircraft’s descent out of glide range was intentional, pilots are reminded that the operation of single engine aircraft over water should at all times be conducted with consideration of the aircraft’s glide distance to a suitable landing area."

The full report is on the ATSB website.

And: ATSB releases Cessna 182 collision with water near Moreton Island investigation final report

MTF...P2

[Peetwo]

ATSB recent AAI reports etc.

Via the ATSB website:

Flight below minimum altitude a reminder of high workload during approach, landing



Key points:

- Pilot experienced data entry difficulties during turbulence, which combined with environmental conditions, and timing of clearance from air traffic control, led the pilot to experience high workload;

- Pilot inadvertently selected the incorrect radio frequency during approach, and the aircraft descended below minimum altitude while ATC attempted to re-establish communications;

- Incident is a reminder for pilots of high workload during approach and landing, which can be exacerbated by additional factors such as turbulence.


A pilot’s high workload, including data entry difficulties, while conducting an approach to land at Adelaide Airport in instrument meteorological conditions likely affected their situational awareness resulting in their aircraft descending below the assigned minimum altitude.

An Australian Transport Safety Bureau investigation into the incident details that on the morning of 12 August 2021, the twin-engine Aero Commander 500-S was conducting a private flight from Port Lincoln to Adelaide with a pilot and passenger on board.

After descending to 3,800 ft during the approach, the pilot was cleared by air traffic control to track direct to the GPS waypoint GULLY, the initial waypoint for the area navigation (RNAV) instrument approach into Adelaide.

However, the pilot reported having difficulties entering the RNAV approach into the aircraft’s touchscreen multi-function display due to turbulence.

“Several factors including the environmental conditions, data entry difficulties, and the timing of the clearance for the GULLY waypoint, likely led to the pilot experiencing a high workload,” ATSB Director Transport Safety Dr Stuart Godley explained.

By the time the pilot correctly input the approach into the system, the aircraft had just overflown the GULLY waypoint. This meant when the pilot then selected the ‘Direct-To’ option on the display, the autopilot commanded a sharp turn to the right, to commence an orbit to attempt to overfly the waypoint to recapture it.

The controller then began giving the pilot instructions, intending to vector the aircraft back to the waypoint, but a short time later, communications were lost.

“The ATSB found that during the approach the pilot had inadvertedly selected the incorrect radio frequency,” Dr Godley said.
For about 4 minutes before contact was re-established, the aircraft continued on its assigned heading, but began descending below its assigned altitude.

“During this time, the approach controller attempted to contact the pilot and issued three terrain safety alerts. The lowest altitude the aircraft descended to was 2,480 ft, close to the highest point within 5 NM of the aircraft’s track, which was 1,913 ft.”

Once communications were re-established, the approach controller issued the pilot a terrain safety alert and instructed the pilot to climb immediately to 5,000 ft.

The aircraft then tracked to Adelaide Airport and landed without further incident.

Dr Godley said the event highlights the heightened workload pilots experience during the approach and landing phases of flight.

“Pilots must continuously monitor aircraft and approach parameters, and the external environment, to ensure they maintain a stable approach profile and make appropriate decisions for a safe landing,” Dr Godley said.

“Distractions and unanticipated events can further increase a pilot’s workload leading to undetected errors and a loss of situational awareness.

“During high workload phases of flight, pilots should remain focused on monitoring the aircraft instruments and avoid fixating on a problem.”

Read the report: AO-2021-033: Flight below minimum altitude involving Aero Commander 500 S, VH-LTP near Adelaide Airport, South Australia, on 12 August 2021

---

ATSB releases Redcliffe scenic flight accident preliminary report



Key points:

- Investigation is on-going, preliminary report outlines factual information established during the early evidence-collection phase;
- According to witness reports the aircraft’s engine ran rough, then stopped completely, shortly after take-off;
- Pilot attempted to return to the aerodrome but ditched the aircraft 170 m from the shoreline;
- Aircraft flipped over during ditching, coming to rest inverted in about 2 m of water.

The ATSB has released a preliminary report from its on-going investigation into a fatal accident involving a Rockwell International 114 light aircraft near Redcliffe aerodrome, north of Brisbane, on 19 December 2021.

The report, which details factual information from the investigation’s early evidence collection phase, notes that the aircraft departed Redcliffe for a private scenic flight. On board were a pilot and three passengers.

“A number of witnesses located at the airport, in other aircraft, and on the water in boats, observed the accident aircraft take off and retract its landing gear,” ATSB Director Transport Safety Dr Michael Walker said.

“A short time later, witnesses reported that the engine ran rough briefly before stopping completely.”

Another pilot reported hearing the pilot of the accident aircraft broadcast on the radio that they were returning to the aerodrome, and the aircraft was observed to make two left turns, consistent with manoeuvring back to the runway, and extend its landing gear.

“As the aircraft neared the mangrove tree line to the north of the aerodrome, it was observed to descend and ditch into the water of a tidal mud flat, about 170 m from the shoreline,” Dr Walker said.

“During the ditching, the aircraft flipped over, coming to rest inverted in about 2 m of water.”

The pilot and three passengers were fatally injured in the accident and the aircraft was destroyed.

To date, ATSB investigators have recovered and examined the aircraft wreckage, conducted witness interviews,
disassembled and examined the engine, reviewed the aircraft’s maintenance history, and examined security camera footage from the aerodrome.

“As the investigation continues, the ATSB’s investigation will include a disassembly and examination of the aircraft’s propeller, testing engine components, analysis of data recorded from onboard systems, and further analysis of available footage,” Dr Walker said.

“Should a critical safety issue be identified at any time during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.”

Read the preliminary report: AO-2021-053 Collision with terrain involving a Rockwell International 114, VH WMM 1 km north of Redcliffe Aerodrome, Queensland, on 19 December 2021

---

Powerline survey aircraft stalled at a height too low for recovery



Key points:

- During low-level survey work, a Cessna 172 stalled and entered a spin at a height that was insufficient for recovery;
- Accident highlights importance of managing airspeed and bank angle to minimise risk of stall;
- Operator has made changes to training and checking, and intends to modify their aircraft with an angle of attack indicator and g-meter with recording and data download capacity.

A Cessna 172 aircraft conducting powerline inspections near Canberra stalled and entered a spin at a height too low for recovery before it collided with the ground, an Australian Transport Safety Bureau investigation details.

In the early afternoon of 13 April 2021, the Cessna R172K departed Canberra Airport to conduct powerline surveying to the north of Sutton township, NSW. On board was a crew of two comprising a pilot and an observer.

About three hours into the flight, while manoeuvring to inspect a powerline adjacent to Tallagandra Lane, nearby witnesses observed the aircraft flying low above the trees before it commenced a left turn that continued into a steep descent before colliding with the ground.

The pilot and the observer were fatally injured in the accident, and the aircraft was destroyed.

During the accident flight, according to recorded data and witness accounts, the Cessna transitioned from a level, right turn to the north-north-east into a tighter, possibly climbing, left turn.

From the ATSB’s analysis of the turns conducted by the pilot earlier in the flight, it was estimated that the final turn was likely conducted at a comparatively high angle of bank and closer to the stall speed of the aircraft.

As the manoeuvre continued, the aircraft likely exceeded the critical angle of attack for the wing, causing the wing to aerodynamically stall.

“This investigation reinforces to pilots the importance of managing airspeed and bank angle to minimise the risk of stalling,” ATSB Director Transport Safety Stuart Macleod said.

“This is particularly important when operating in close proximity to the ground, such as conducting low-level air work, as well as during take-off and landing, as recovery may not be possible.”

Mr MacLeod noted the Pilot’s Operating Handbooks for most light aircraft, including the accident Cessna R172K’s, provides stall speed guidelines to avoid a wings level stall.

However, pilots should be cognisant of the raised stall speed when operating turns.

“In a bank the vertical lift component is reduced, and so pilots must pull back on the control yoke to maintain altitude,” noted Mr Macleod.

“This increases the angle of attack of the wing, and if the angle of attack reaches a critical angle, loss of lift and increased drag occurs, and the wing will aerodynamically stall.”

Following the accident, the operator amended the training and checking section of its Operations Manual to incorporate Threat and Error Management and Situational Awareness training modules for powerline low-level survey operations. The amendments enhanced existing topics in the operator’s crew resource management training and stipulated learning outcomes and assessment criteria specific to Threat and Error Management and Situational Awareness.

“The operator also provided detail of intended additions to its low-level procedures to implement an airspeed ‘manoeuvre margin’ that will take into account the increased stall speed associated with steep turns,” Mr Macleod said.

Further, the operator plans to modify its aircraft to include an angle of attack indicator and a g-meter with recording and data download capability.

“These will not only supplement the aircraft’s stall warning device by providing additional warning of an impending stall, but will allow for a record of the maximum and minimum in-flight readings to be downloaded post flight for review,” Mr Macleod said.

Read the report AO-2021-016: Loss of control and collision with terrain involving Cessna R172K, registered VH-DLA near Sutton, New South Wales, on 13 April 2021

---

Low-level aerobatics preceded high speed water impact off South Stradbroke Island



Key points:

- Aircraft was conducting low-level aerobatics prior to colliding with water;
- ATSB encourages witnesses, particularly those in the aviation industry, to report concerns regarding unsafe behaviour through confidential reporting channels;
- Investigation found a pre-existing fatigue crack in the aircraft’s elevator bellcrank, although this did not contribute to the accident.

A Yak-52 warbird aircraft had been conducting low-level aerobatics at a height of less than 500 ft above the ground before it collided with water at high speed, fatally injuring the pilot and passenger, an Australian Transport Safety Bureau investigation report details.

The two-seat Yak-52, an ex-military trainer aircraft, departed Southport Airport, on Queensland’s Gold Coast, on the morning of 5 June 2019 for a private aerobatic flight expected to last about 30 minutes. The pilot had owned the aircraft since 2018, and held an endorsement to conduct aerobatics at no less than 3,000 ft above ground level.

When the aircraft did not return to Southport as planned, a search and rescue operation commenced, with part of the aircraft’s propeller located on South Stradbroke Island later that afternoon. The pilot and passenger, who had sustained fatal injuries, and additional wreckage, were recovered from the waters near Jumpinpin channel in the following days.

“The ATSB’s investigation established that prior to the accident the pilot had conducted a number of aerobatic manoeuvres below 500 ft above ground level,” ATSB Director Transport Safety Dr Stuart Godley said.

“While the absence of recorded data for the last phase of flight or witnesses to the accident meant we could not determine with certainty that the pilot was conducting an aerobatic manoeuvre immediately prior to the aircraft’s impact with the water, the ATSB considered it a possibility.”

Dr Godley said the ATSB was able to build a detailed understanding of much of the accident flight, including from air traffic control surveillance radar, which recorded an aircraft over South Stradbroke Island conducting operations with significant track and speed fluctuations, consistent with aerobatic manoeuvres, and witness reports.

Witnesses on South Stradbroke Island reported that they observed an aircraft consistent with the accident aircraft conduct a “loop, cut right, and dive below the tree line”.

“During the accident flight and previous flights, the pilot conducted low-level aerobatics without having completed the required training or having the appropriate endorsement to do so,” noted Dr Godley.

“This would have potentially limited the pilot’s appreciation of the inherent risks associated with low-level aerobatics.”

Dr Godley noted that research shows that pilot perceptions of risk may decrease with repeated successful outcomes, and if a pilot has a history of flights without incident, then they may perceive that they have a lower likelihood of an adverse outcome based on their prior incident-free experiences.

“This accident highlights the inherent risks associated with performing low-level aerobatics where there is a reduced safety margin for recovery,” Dr Godley said.

“Even more so, it demonstrates the importance of being suitably-trained and qualified to conduct these operations.”

The investigation noted that people with aviation experience and knowledge had witnessed the pilot undertake previous low-level aerobatic flights.

While there had been some attempts to communicate concerns about risk-taking behaviour to the pilot, the investigation did not find evidence that the pilot’s behaviour had been formally reported.

“We encourage witnesses, particularly those within the aviation industry, to report any concerns regarding unsafe behaviours through mechanisms such as confidential reporting systems, such as the ATSB’s own REPCON, or the Civil Aviation Safety Authority’s online reporting portal,” Dr Godley said.

“Confidential reporting provides a means to escalate concerns about pilot behaviour while providing protections for the source of the report.”

Dr Godley also noted that the investigation found a pre-existing fatigue crack in the aircraft’s elevator bellcrank, which had the potential to fail in-flight, leading to a loss of control.

Although this crack did not contribute to the accident flight, the finding prompted the ATSB in November 2020 to issue a safety advisory notice to Yak-52 maintainers and owners, emphasisng the importance of dye penetrant inspections to remove defective elevator bellcranks from service.

Read the report: AO-2019-027 Collision with water involving Yakovlev Aircraft Factories Yak‑52, VH-PAE near South Stradbroke Island, Queensland, on 5 June 2019

---

Expectation bias from pilot’s greater familiarity with IFR procedures likely led to runway incursion during rare VFR flight



Key points:

- Cleared for Bankstown’s runway 29R, a Beech Baron crossed the runway and entered the occupied runway 29C without clearance;
- The pilot had been conducting IFR flights with the aircraft on a regular basis for the last 18 months but had not operated a VFR flight for some considerable time and had never departed from runway 29R.

The runway incursion of a Beech Baron aircraft onto an occupied runway at Bankstown Airport highlights the potential effect of expectation bias and the importance of pilots focusing on specific instructions given by air traffic controllers, a new Australian Transport Safety Bureau investigation report says.

On the morning of 26 October 2021, the Baron aircraft, registered VH-NSK, and operated by Little Wings, was conducting a post-maintenance flight to test its stall warning system, the investigation report details. Prior to this flight the pilot had not conducted a VFR flight from the airport for some considerable time and had only departed Bankstown from runway 29C for flights over the last previous 18 months. 

Following pre-flight checks, the aircraft was cleared to taxi to holding point A8 for a departure from runway 29R. Once there, the pilot contacted air traffic control (ATC) and advised they were holding short of runway 29R for departure and were advised to hold position. Just prior to this, an Embraer 190 received clearance to enter runway 29C at holding point A2, for high-power engine runs.

Moments later ATC instructed VH-NSK to line-up and wait for runway 29R. The pilot read back their instruction and seeing VH-NSK commence taxiing the Tower controller began assisting two helicopters operating north of the airport. During this time VH-NSK crossed runway 29R and entered and lined up on runway 29C.

Turning back to VH-NSK, the Tower controller issued an instruction for take-off.  When VH-NSK was detected on runway 29C, the Tower Controller immediately called for VH-NSK to ‘hold position, hold position you are lined up on Centre, hold position’ and issued repeated instructions to stop. At the same time, the pilot of VH-NSK saw the Embraer conducting high-power engine runs on runway 29C and did not commence the take-off.

ATSB Transport Safety Director Stuart Macleod said this incident highlights the importance of pilots focusing on the specific instructions given by air traffic controllers and how expectation bias can affect how they receive and understand verbal instructions

“As the pilot of the Baron aircraft had only conducted IFR flights departing from Bankstown’s runway 29 centre for the last 18 months it is likely their focus had narrowed to the actions for the unfamiliar VFR departure and despite confirming their instructions back to ATC they reverted to what they had done previously.

“When issued instructions by air traffic control, pilots need to focus on listening and then repeat what was said in your head and then actively apply that information,” said Mr Macleod.

For more information on runway safety and avoiding errors that lead to runway incursions go to Airservices Australia’s A pilot’s guide to Runway Safety and their specific publications for Bankstown, Moorabbin, Parafield, Jandakot and Archerfield airports.

Read the report: AO-2021-046: Runway incursion involving Beech Aircraft Corp. 58, VH‑NSK, Bankstown Airport, New South Wales, on 26 October 2021

Hmm...all this mad flurry of activity from the Bearded Popinjay's ATSB but still no conclusion to the nearly 4 year investigation in to the Essendon DFO approval process: https://www.atsb.gov.au/publications/inv...-2018-010/ - 

MTF...P2 

[Peetwo]

ATSB release Mangalore mid-air collision AAI final report - 

Popinjay media release:

ATSB releases Mangalore mid-air collision investigation final report

Key points:

• Two twin-engine training aircraft collided mid-air near Mangalore Airport, Victoria fatally injuring four pilots;
  
• Both aircraft were flying in non-controlled airspace at the time of the collision;
  
• ATSB supports systemic enhancements to the overall Australian air traffic system that have been assessed by regulatory and air traffic specialists as providing a net overall safety increase;
  
• The ATSB strongly encourages the fitment and use of Automatic Dependent Surveillance Broadcast (ADS-B) avionics, with some equipment currently available within Australia at low cost and can be used without any additional regulatory approval or expense.
  

The Australian Transport Safety Bureau has released the final report from its investigation into the mid-air collision between two training aircraft near Mangalore, Victoria, on 19 February 2020, identifying contributing safety factors to the accident relating to self-separation in non-controlled airspace.

The report details that shortly before 11.00am, a twin-engine Beech Travel Air departed from Tyabb Airport for a return Instrument Flight Rules (IFR) training flight to and from Mangalore Airport – a non-controlled airport in Class G airspace – with a student pilot and an instructor onboard. At around the same time, a pilot under examination and flight examiner were at Mangalore Airport preparing for an instrument rating flight test in a twin-engine Piper Seminole.


While the Travel Air was on descent and the Seminole was on climb, the two aircraft collided at an altitude of around 4,100 feet about 8 km (4 nm) south of Mangalore Airport. Tragically, all four pilots were fatally injured and both aircraft were destroyed.



Prior to the collision, the pilots of each aircraft had been provided with traffic information about the other aircraft, in accordance with procedures, by an air traffic controller in Melbourne Centre. In addition, other pilots monitoring the common traffic advisory frequency (CTAF) radio channel for the Mangalore area reported hearing pilots from both aircraft make radio broadcasts, but had no recollection of hearing them speaking directly to each other.



The accident was the first mid-air collision in Australia between two civilian aircraft operating IFR under procedures that have been in place for many decades.



“The ATSB identified that, following receipt of verbal traffic information provided to both aircraft by air traffic control, the pilots did not successfully manoeuvre or establish direct radio communications to maintain separation, probably due to the collision risk not being recognised,” said ATSB Chief Commissioner Angus Mitchell.



“The investigation also determined that while it is probable the aircraft were in instrument meteorological conditions at the time of the collision, due to extensive cloud in the area, the known limitations of the ‘see-and-avoid’ principle meant that the pilots were unlikely to have seen each other in sufficient time to prevent the collision even in clear weather.”



In non-controlled airspace, irrespective of whether an aircraft is operated under instrument or visual flight rules, pilots are responsible for separation from other aircraft.



“As such, if made aware of traffic, either via advice from air traffic control, a received broadcast, or any other means, it is vitally important for pilots that the traffic is hazard assessed and, if necessary, a plan is established to assure separation.”

Mr Mitchell stated that self-separation using broadcast traffic advice is subject to human error, even when it involves experienced pilots.



“The ATSB notes that had the aircraft been operating in controlled airspace, they would have been positively separated by air traffic control, and therefore the collision would have been unlikely to have occurred, and while the available evidence in this investigation does not support a conclusion that the present system of self‑separation in Mangalore airspace is unsafe, there is an opportunity to reduce safety risk further.



“The ATSB supports systemic enhancements to the overall Australian air traffic system that have been assessed by regulatory and air traffic specialists, in keeping with their obligations, as providing a net overall safety increase.”



Mr Mitchell noted in this accident that while the pilots were responsible for self-separation within the Mangalore CTAF area, they did not have access to the same surveillance data radar or automatic dependent surveillance broadcast (ADS-B) information that was available to air traffic control.



“As a result, the pilots were required to make timely decisions to avoid a collision without the best available information,” he said



“Consequently, the ATSB strongly encourages 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,” Mr Mitchell said.



ADS-B is a system which transmits GPS-derived position data, aircraft identification and other aircraft performance parameters. In Australia, all aircraft operating under the IFR are required to be fitted with ADS-B broadcast (or ADS-B OUT).

Both accident aircraft were fitted with ADS-B OUT, but neither aircraft was fitted with a system to receive ADS-B information directly from other aircraft (known as ADS-B IN), and nor were they required to be.

“The continuous positional information that ADS-B provides, when used with a relevant alerting capability enabled, can assist in highlighting a developing situation many minutes before it becomes hazardous – a significant improvement on both point-in-time radio traffic advice and ‘see and avoid’.”



Mr Mitchell noted that in December 2021, the Department of Infrastructure announced a $30 million fund to provide rebates to general aviation aircraft operators to fund up to $5,000 or 50% of the cost of installing ADS-B transponder technology into their aircraft.



“When details of that fund are finalised, the ATSB looks forward to further highlighting the benefits of ADS-B, and in particular ADS-B IN, to the aviation community.”



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

Media coverage: Uncontrolled airspace left crash pilots flying blind in Victoria & Pilots didn't take Action in Mangalore Mid-air: ATSB

MTF...P2 

[P7_TOM]

In Mid air.

I am not buying into this one. Nope, not Goanna do it: no way. But. for the careful reader of ATSB confections, I suggest that close attention be paid to the 'time' lines' and the activities on both flight decks; on a practical operational basis, these are important factors. I might also suggest that some attention be paid to the almost excessive 'explanatory' pages related to the ATC 'responsibility' (or lack thereof).

Real sympathy for the ATCO and true sorrow for the aircrew prevent further analysis - lest I loose my rag completely. Nuff said.......

[Kharon]

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.

[Peetwo]

First page verdict?? - 

Some excellent (but disturbing) OBS so far "K" and Ol'Tom...  

The Kingair pick up alone provides food for thought (ie Kingair descent rate vs Travelair). However what really rang my bells was that the first time the departing a/c JQF was given any indication that they had conflicting traffic was 1min 46 seconds before the collision occurred...  

I must admit that I've only just had a chance to open up and read the final report, so it was with dismay and disbelief when I read the following under the 'what has been done as a result' (or more accurately what hasn't been done):

Airservices Australia (Airservices) have proposed a change to the Civil Aviation Safety Authority (CASA) to introduce a surveillance flight information service (SFIS) around Mangalore Airport, designed to provide enhanced traffic information services to all aircraft operating in a 20 NM radius of the airport. The proposed service would require all aircraft to broadcast on the CTAF within the broadcast area, while providing a dedicated air traffic controller operating on the CTAF to provide a flight information service utilising surveillance.

By listening on the CTAF, the controller would be able to determine whether aircraft have arranged their own separation following receipt of traffic information and provide updated traffic information if required. A similar service was introduced around Ballina Airport in August 2021.

In September 2021, the CASA Office of Airspace Regulation (OAR) announced an aeronautical study into the airspace within a 25 NM area of Mangalore Airport, up to an altitude of 8,500 ft. The scope of this study involves:

• a review of traffic type and density over the previous 5 years
  
• an evaluation of the suitability and efficiency of the airspace
  
• a review of the equitability of access to the airspace, the appropriateness of the airspace classification and the suitability of the existing services and facilities provided by Airservices Australia.
  

As of February 2022 this aeronautical study has not been published.

The proposal for the introduction of an SFIS on the Mangalore CTAF is currently on hold pending completion of the OAR review.


However, a dedicated controller is providing safety alerting on the Mangalore CTAF in the interim period. Communications on the CTAF are recorded by Airservices when the safety alerting service is operational. A further consultation has been raised by Airservices to lower the base of Class E airspace around Mangalore Airport. As of February 2022 that proposal was in review by Airservices following an industry consultation period.

Hmm...so CASA OAR were only prompted to have an interest in this matter 17 months after a fatal mid-air collision occurred in a busy block of airspace within secondary radar coverage and adjacent to Melbourne CTA. Why weren't these reviews and proposed actions implemented within weeks of the accident occurring?? 

Quote from the preliminary report, issued 2 months after the accident:   

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.

      
P2 comment: Not sure how a mid-air collision involving two flight training aircraft, flying under IFR rules in busy (radar environment) airspace, adjacent to CTA, does not automatically trigger the promulgation of a critical safety issue?? 

MTF...P2 

[Wombat]

The Mangalore report seems to me exercise in establishing an ongoing regime of plausible deniability while giving the impression of providing a safety service.

[Cap'n Wannabe]

Via Australian Aviation

ATSB CALLS EC130 CRASH AMONG WORST IN VICTORIAN HISTORY



The ATSB’s chief commissioner has called Thursday’s Eurocopter EC130 crash in north Melbourne one of the worst in the state’s history.

Angus Mitchell added his team would use software and drones to build up a 3D picture of the crash site but warned the full investigation would take “many months” to complete.

The incident, involving a Microflite charter helicopter, took place near Mount Disappointment and killed the pilot and all four passengers on board.

“We will look at what we can gather from the site, and as you can imagine, that is very challenging in a situation like this where we’ve had a collision with terrain and potentially a fire,” Mitchell said.

He told reporters his team would also go through maintenance records, investigate qualifications and examine the weather forecast for the day, which was thought to include low-lying clouds and nearby bushfire smoke.

“Our main goal here is not only to work out what occurred and what brought the helicopter down, but equally, what are some of the lessons that may be learnt so we can prevent instances like this occurring into the future.”

The ATSB’s comments come after more details of those on board were revealed.

The pilot has now been identified as 32-year-old Dean Neal, who Microflite hailed as always putting “the safety and wellbeing of his passengers in the highest of his priorities”.

“Our broken hearts go to the families and friends of those who were flying with him. Your unspeakable loss is understood by us all,” the business said.

“We know Dean would have done anything in his power to deliver his passengers safely to their destination.”

It’s also transpired one of the passengers was 73-year-old Paul Troja, the chairman of Warragul-based livestock firm, R Radford & Son.

“Paul was a very passionate individual, and as chairman, he was actively involved in the operation of our business,” Radford’s CEO, Paul Scanlon, told The Australian.

“He was a great mentor to many of us at Radford’s and in the industry, always willing to offer advice and an opinion.

“Paul was a very strong and accomplished leader. He wasn’t just active on the board, he would come down to the site, walk around and talk to the staff, he wasn’t a hands-off board member.”

The helicopter is believed to have taken off from Moorabbin Airport before picking up passengers in Batman Park, Melbourne at 7am on 31 March. It was headed to Ulupna, in northern Victoria.

The single-engine light helicopter crashed in thick bushland, making rescue efforts increasingly difficult. It took until shortly after midday for the EC130 to be located.

[P7_TOM]

East Kimberly accident report

From the ABC - HERE -.

[Kharon]

The Mt Disappointment event.

AO- 2022 - 16 is an active investigation; the ATSB report may be found - HERE -.

The last 25 short seconds of this flight clearly define the end result of a series of events which should be made into a mandatory training module at every flight school and flying group. Most IFR pilots would immediately spot the 'traps' as would experienced 'mountain' pilots - the forecast clearly defined the risks.

ATSB/ BoM - "The forecast for cloud in area C was for a broken layer from 2,000-3,000 ft and a broken layer from 3,000-8,000 ft. Area A was forecast to have few cloud from 3,000-5,000 ft.

ATSB/ BoM - "At 0758, at Kilmore Gap, the relative humidity was 95% and the wind was 17 kt from 171°. The cloud cover was few at 394 ft and broken at 3,510 ft above ground level. At 0811 the cloud had become broken at 394 ft above ground level.

All the clues are there - broken layers - unstable, humid conditions, 17 knots of Southerly breeze, operation below LSALT - between mixing layers? One aircraft got lucky, the other didn't. The passenger reports describe accurately just how fast Murphy can operate with a potential victim at low level, over high ground, between layers of cloud. 25 seconds was all it took, the slim margin between escape and sudden death.

ATSB -"The passenger in the front right seat had flown in helicopters for about 30 years. The passenger recalled that, as they crossed Mount Disappointment, heavy cloud rolled in resulting in ‘a white-out with ground visibility no longer evident’


ATSB -"The passenger looked outside and saw cloud in front and to the left, and then heard the pilot announce they were going ‘hard left’. When the passenger next looked outside, they ‘could not see anything, it was like a white‑out’.


A classic scenario - one which, IMO defines one of the only possible 'inadvertent' entries into IMC - at night on instrument approach - layers of cloud merge and all the ground lights vanish - hit the TOGO and get out of Dodge.  But in daylight, operating VFR - there is little excuse and the importance of a back door and a defined limit point when pushing your luck are essential - 25 seconds and 800 feet the difference between one escape and one tragedy. Worth a moments thought ain't it.

ATSB - "Therefore, they elected to take a more direct track to their destination, which took them over Mount Disappointment, to the east of Kilmore Gap (Figure 2). While tracking north towards Mount Disappointment, the helicopters were above a layer of scattered cloud with an estimated top of 2,500-3,000 ft and below a layer of broken cloud with an estimated base of about 4,500 ft.

Perfect setting for CFIT, the crash site and final event horrific -


ATSB - "The ATSB’s site survey established that XWD had impacted a large old growth tree (Figure 4), which broke the upper tree trunk and severely disrupted the cabin. The helicopter then descended on a southerly trajectory at an angle of about 45° to ground impact. The vegetation surrounding the accident site was comprised of 2 distinct levels of growth. A new growth canopy that had an average height of 24 m, and old growth trees that had an average height of about 70 m. The old growth tree break was about 41 m above ground level (elevation of 759 m). The elevation of the base of this tree was 718 m, which indicated that the elevation of the top of the tree was likely about 2,585 ft (788 m). Therefore, the tree impact very likely occurred between 2,490–2,585 ft (759–788 m).



No amount of regulation can prevent a repeat event; the regular fatal and serious events resulting from VFR operators being trapped in IMC demands serious consideration, from grass roots to executive level. There are options; easy access to Night VMC with basic instrument flight skills; navigation exercises with emphasis on weather navigation and escape plans (back door exits), mandatory competence on rate 1 turns under the hood. There is much that could be done, officially and unofficially. It remains a given that some folks will 'push their luck' and, sometimes you have to - can't be avoided - but how to put an old head on young shoulders is a puzzle which has baffled mankind since the cave.

Ramble over - apologies - but repetitive, mostly avoidable accidents just keep happening; perhaps a road show could help reduce the rate - education not intimidation - even a mandated standard for basic instrument flight - I don't pretend to know the answer - but, we need to find one - before the inevitable next ATSB report is released on the same subject.

Right -O back to my knitting it is.

[Wombat]

How about a new regulation prohibiting VFR flight in conditions other than CAVOK, backed up by a 50 penalty unit punishment and strict liability? That ought to do it (/sarc).

How easy (or hard) is basic IFR training, both fixed and rotary? I am familiar with the "little knowledge is a dangerous thing" argument and the cost of such training would be stratospheric in Australia. Foggles don't work very well.

[Peetwo]

Fact: The Air is the same Downunder -   

When I first read the known details about this tragic accident and now with the prelim report, I could not help but make the comparison to the Kobe Bryant ( see - Kobe Bryant NTSB Final Report released.  & C&C III: Homendy Final Media brief.)

Well it would seem that someone else has seen the similarities? Picked this up from the excellent Simple Flying blog in the US:

Five Lives Lost In Repeat Of Kobe Bryant Crash

BY MICHAEL DORAN
PUBLISHED 15 HOURS AGO

Despite all the new technologies in helicopters and airplanes, controlled flight into terrain happens far too frequently and lives are lost.



A May 12 preliminary report into a helicopter crash that killed five people in Australia looks eerily similar to the crash that killed US basketball legend Kobe Bryant and eight others in 2020. Both accidents involved a pilot flying under visual flight rules (VFR) becoming disoriented after flying into dense clouds. After losing visual contact with the ground, both pilots lost their situational awareness and flew their aircraft into the terrain.

On March 31, 2022, the Australian accident involved an Airbus EC130 helicopter carrying one pilot and four passengers. The aircraft was traversing mountainous terrain when it hit the top of a large, old-growth tree, crashed to the ground and caught fire. The Australian Transport Safety Board's (ATSB) preliminary report goes into great detail about the changing weather conditions en route. It also correlates the reducing visibility with the pilot's decision to continue the flight while operating under VFR.

What happens when you don't know which way is up?

The crash aircraft was behind another Airbus EC130 from the same company, carrying five people. A front-seat passenger in the lead aircraft, a pilot, told the ATSB that his pilot had radioed the other aircraft to discuss the approaching bad weather.

The passenger added that "a wispy cloud went past us and then a heavy white cloud came down and dumped on us,

"...and as we crossed Mt Disappointment heavy cloud rolled in, resulting in a white-out with ground visibility no longer evident."

He said the lead pilot radioed the trailing aircraft and said words to the effect, 'U-turn, U-turn, U-turn' and immediately completed a U-turn. The other pilot radioed back with words to the effect, 'aren't we going to cut through?' and the passenger saw the helicopter pass just below them.

According to the ATSB preliminary report, one aircraft took immediate evasive action and five people lived. The other aircraft carried on and five people died.

Preliminary reports are due within a prescribed period, and this one ends with all the data gathered. The ATSB now starts the difficult job of determining all the factors that contributed to the accident.



The ATSB has collected all the evidence and now has to find what contributed to the accident. Photo: Australian Transport Safety Bureau

CFIT affects both rotary and fixed-wing aircraft

Unfortunately, controlled flight into terrain (CFIT) happens far too regularly and afflicts rotary and fixed-wing aircraft. A perfectly functional aircraft is piloted into terrain because the pilot lost their sense of where they are, or as some would put it, 'which way is up.'

From 2010 to 2019, the US National Transport Safety Board (NTSB) identified 20 helicopter crashes and another 184 airplane accidents in the US stemming from spatial disorientation of pilots.

In 2019 an Airbus AS350 helicopter operated by Safari Aviation crashed in a mountainous region of Hawaii, with seven people losing their lives. In 2020 Kobe Bryant's aircraft was flying under VFR rules when it inadvertently entered heavy cloud and descended steeply into a fog-shrouded hillside, killing nine.

Also released yesterday was the final report on a helicopter crash in Canada in 2021 that killed four people. Canada's Transportation Safety Board says the crash was due to the pilot's decision to fly in poor weather at night.

It pointed to deteriorating weather and poor visibility causing the pilot to lose control and hit the ground. The report also questioned conducting night VFR flights when the regulations do not clearly define what a 'visual reference to the surface' actually means.

What needs to change - VFR regulations or pilot training in poor visibility?

MTF...P2 

[Sandy Reith]

What needs to change is a good question, or what needs to be added? It’s inexplicable that there was not a terrain warning, even your mini iPad with the usual moving map displays tracking into high ground.
Or why not a radar advisory? Why didn’t they have IFR capability? Is IFR training in the CASA strangled GA industry too difficult and expensive? I’d say yes definitely to that latter question.

[Kharon]

Idle speculation - Situation Awareness.

FWIW - been pondering the Mt Disappointment (and other) CFIT events off and on over the last few days, trying, in my muddled way, to hunt down the radicals. There are a couple of 'stand out' items which, IMHO merit some discussion. Now, I ain't saying these are the answer to a pagans prayer, but.....

Item one: examinations for licence. There has always been 'exams' to pass - head scratching book work by the bucket full. Pass them you must - but I wonder if the modern trend is learning to 'pass' rather than 'learning' the subject as part of your toolkit. For example, radio and similar stuff; I hated the subject - did as much as needed to pass (more than 70% not required) and left the rest up to those with an interest and understanding; hence my less than optimum knowledge (pig ignorant). The thing worked until the smoke escaped or it did not - end of. However, all other subjects seemed to have great relevance; and, were worthy of additional research; handy tools to have in the bag; these were not tedious subjects. My bookcase reflects this - but I digress.

One absolute favourite was 'Met' - the dynamics and the scale of weather and the effect it will have on any flight, fascinating. (patience - I'll get there) - When we had briefing office crew, a chat with the Met man was always worth the time and the dry printed forecast became a 'living' dynamic thing. I doubt I could count the number of times where some additional gas was tanked - based not on the forecast - but on the possibility of it being needed - the Mildura incident springs to mind. There was a 99% chance that fog would be a factor - there were lots of early warning signals, time and fuel for early diversion - the trap was announced, forecast and very neatly sprung. A close call - you bet. (Question - command prerogative reduced by?)...

Today's focus seems to be on the 'legal' of weather, rather than the 'dynamics' of the weather. After 0330 Z alternate required; at 2100 rain; at 0400 cavok. Which is theoretically fine and dandy - provided someone informed the actual weather that it was expected to perform within these time lines. That is if you can actually read (translate) the forecast - or rather read between the lines of the highly coded message provided. Most seem to look to 'legally' cover their arse ahead of 'operationally' assessing the potential for Murphy to get a look in.

A study course aimed at 'pass and forget' is about as much use to a working airman as chocolate spark plugs; reading a forecast which is almost undecipherable to those who are not reading them almost every day is unacceptable; but, then we look at the latest CFIT. Take a look at the forecast for that day - a real look; look at the before picture, the potential, the development, the lapse rates, humidity and breeze; and the actual. Then read the passenger notes. Much like the Mildura 'nearly' and the half dozen other CFIT, maybe a failure to understand what the weather forecast was actually telling them and a lack of understanding of the situation they were flying into tells us part of the tale. Dead, but dead legal. Somethings wrong there.

Perhaps there are two daemons which could stand eradication. Lack of faith in the forecast; lack of understanding of the forecast. Maybe we could add in the reliance on GPS as a contributing factor. Not knocking the GPS - love it to bits - but; is it a good thing early in the navigational training? Perhaps (and just saying) that early in the piece, the pilot should be checking the GPS is right, rather than the GPS doing the heavy lifting. An awareness of terrain, track and weather affecting all should be trained to be instinctive (don't know). But, seems to me that if that 'instinct' is not nurtured and instilled at an early stage, given that we all get slack after a while - can it affect basic situational awareness, that which keeps us mostly out of harms way?

Aye: All purely idle speculation on my part; a ramble to make some sense of it all. Before the heavy duty stuff comes to mind - stuff like "Oh, I've done it a thousand times and always squeezed through" except the once. Memory of flying in PNG reminds me that there are old pilots, there are bold pilots - but very few old bold pilots. CFIT related to weather consistently remains at the top of the fatal list; despite the posturing and rhetoric of 'the' so called safety agencies. Time to reduce the body count methinks (the only rock solid thought on the subject).

Toot toot.

[Wombat]

The one that scares me is that the safest course of action might not be the legal course of action and people confuse legality and safety.

For example, "Windy.com" offers an interesting forecast compared to NAIPS but I don't believe it is an authorised source of weather data.

NAIPS said I could fly today, "Windy" said I shouldn't. Windy was right.

[Kharon]

Yeah - But....

There is a great big 'but' hanging over Wombat's quandry - a perennial, global question that aircrew (of any stamp) must answer.

The answers as varied as the those who must respond; from the 'duck it - I'll go' to the 'no flying, not today' - and pretty much every variation in between. There is also a thing called command prerogative. There is also a long list of questions which must be settled in the mind of the PIC before committing aviation. Mostly, these are (or should be) settled long before pre departure preparation; mostly. But lets stick to weather flying for non commercial operations for now.

There's our mate Wombat - looking at two weather forecasts - two 'opinions' if you like; one says good to go, the other says not so good. Who's opinion is the most important? The answer is neither - the only one that really matters, legally, operationally and 'in the safety case' is the pilot's. Go or don't go that is the final question. The battle should commence long before scheduled departure - preferably the night before at the latest. Just checking the TV weather forecast every night is not a bad habit - even a daily visit to the BoM site is a good practice - it provides a picture of the weather patterns - how the weather is acting, how the prevailing winds are changing and creating this or that event, where and importantly, which way the pattern is moving and the weather it is generating; an overview if you like. The BoM site is a valuable tool - the general area and TAF forecasts a good place to start forming an opinion. Don't forget - you can always request and receive a route forecast.

Wombat's daily double indicates that perhaps today is not the best day to go flying. This also begs a list of questions - do I need to go now? The worst case is (IMO) the scenario where three of four have decided to visit - say an airshow for the weekend as an example. Fixed times, bookings etc, in short a schedule. Trying to meet this pre planned, anticipated schedule can be an important factor in decision making; it must not be allowed to become 'the' factor. The age old adage "if you've time to spare, travel by air" applies to VFR operations more than any other.

And so, on a dodgy forecast the flight departs - but only to the first pre selected gate - here a decision must be made; continue or knock off. Between gate 1 and gate 2 more decisions - do we turn Left at Albuquerque and book into a pub, turn right and avoid the weather, stop at Kickinatinalong for fuel and a burger and wait? But gate 2 slides by, the weather has held - so on we go - alas, the forecast lousy weather is ahead of us - how lousy is it? what's to hit? can I step around the worst? how much motion lotion can I spare before I scamper back to a friendly paddock? It is no bloody use at all to be making these decisions 'on the fly' - this is a battle action plan decided before the baggage was loaded. And even then, as von Moltke said -

'no plan of operations can with any certainty reach beyond the first encounter with the enemy.’

Treat every journey as a battle; consider the both the big and small things which can spoil your day; it becomes a habit after a while - a flight plan is a great starting point, but not an iron clad contract.  Sure 99.9 times in every hundred all is well; but never (not ever) forget about Murphy - every-man's copilot; and, 70% of the time, the weather don't always comply with the BoM forecast; not to the sentence and often not even to the letter. Guile, cunning and knowledge are the hand tools of the thinking pilot. 

Aye, 'tis but a thumbnail dipped in tar - a note, scribbled to mate during second coffee, but even so, a place to start thinking about the oldest enemies of flight.

Toot - toot...