[Kharon]

From the bus stop.

Toddled into the kitchen early this morning – destination coffee; DT had the TV news going, no option but to hear the twaddle spewing forth as I used mental telepathy to hurry the kettle along. One positive thing has come out of the ATSB report – the media have a juicy bone to play with. “Pilot error” they shriek, hysterically, between advertorials. Gods spare me! But, the ATSB have neatly achieved their goal, the public will have forgotten this accident long before they’ve forgotten the benefits of early buying of funeral insurance, just before the cash cow comes on to distract ‘em. I do not however believe the seriously interested parties will be so easily distracted or satisfied with the ATSB advertorial. The report begs more questions than it provides answers.

One of the biggest howlers is the ATSB notion, skilfully woven into the text is that having a building within the confines of the runway is in fact a bloody good thing; as it actually assisted in reducing the carnage. It is a delightful bit of artistic whimsy, just enough hint to suggest that the DFO actually saved lives. Bravo the spin doctors. I expect we must applaud the video makers; the dramatic angles used to display the whole 12 second event are worthy of a Hollywood movie, Oscar for special effects. Aye, the big PR machine is hard at it, gods alone know the cost of the smoke and mirrors. The litigation which will inevitably follow this event for the next decade will be ‘interesting’. I’m not sure that the relatives of the deceased are even aware of Aunt Pru; but the old girl has some very sage advice them. Drag in the NTSB and the FAA for a second opinion on the ATSB report; make certain they provide an independent analysis. You are facing a well rehearsed PR machine, well versed in the dark arts of obfuscation. There are serious people, with clout and large rice bowls to protect behind the scenes.  But enough of all that – caveat emptor etc.

Once you begin to peel the fancy wrapping off this ATSB confection there are only a couple of ‘real’ facts presented. (1) Rudder trim allegedly set to maximum deflection – nose left. When you take a look at the centre consul of the Be20, just below and behind the quadrant (power controls) there are two large (palm sized) round, black handles, surrounded by graduated, easily read scales. There are clearly marked triangles, which, when aligned provide a crystal clear indication of when both the aileron and rudder trim are in the neutral position. Very hard not to see; almost impossible. Even the most cursory glance, while setting the cabin pressure controls (just behind the trim controls) a huge discrepancy would, even subconsciously, be noted. There is no tangible evidence that the aircraft was committed to take off with full left rudder. The only fact established is that examination after the event found the rudder setting hard over. The rest is pure speculation, dressed up to fit a scenario.

For example; (and apologies to the purists) there is ‘rudder boost’ system which (in lay terms) depends on bleed air pressure from the engines being ‘equal’. At a set ‘differential’ the rudder boost kicks in to assist with directional control in the event of an engine failure OR a difference in bleed air pressure; and it works very effectively. Food for the thought table right there, not even mentioned. But quick ring around of over 25,000 collective hours ‘on type’ one thing that all remember is how to ‘un-stick’ a recalcitrant BAV. (Coke bottle the favourite tool).

Early graphics suggest that the aircraft’s flight path was drifting to the left well before any rudder authority could have come into play; the more accurate representations clearly define this. The wreckage, due to the fire and the location must create a reasonable doubt on prognosis. A difficult task, with precious few ‘clues’ and certainly not enough hard evidence provided to claim, absolutely, gross pilot error; or to rule out ‘other’ factors.  

Even the claim of an overweight take – off is suspect. Speculation and estimate; not the mandatory ‘paper-work’ of manifest + weights + known fuel. I wonder why non of this has been produced. The old adage that ‘when the paper-work equals the aircraft weight, it’s legal to go’ holds very true in Australia. There must be a clearly defined paper trail left behind for any commercial operation, all the ‘i’s’ dotted and ‘t’s crossed; lest you cop a large fine. But ATSB can’t produce one scrap of hard data to support ‘overload’. Passing strange is that.

Anyway – I shall find a quiet corner and read the wretched thing through, carefully. But, first impression – Frog-pooh, cleverly disguised as pony-pooh, wrapped up in enough fancy paper to fool the idiot media and keep both the ministerial and departmental rear ends out of the spotlight. It is always so.

Toot – toot.

[Peetwo]

HVH snow-job report swallowed by MSM - 

Some media reports from the Oz that IMO suggest how HVH & co cleverly manipulate the MSM to slowly but surely reinforce 'the pilot did it' propaganda:

Pilot error caused deadly crash
ROBIN IRONSIDE
The fiery crash which killed five people when a light plane plunged into a DFO building last year has been blamed on pilot error.

---

The long-awaited report into last year’s horrific Essendon plane crash has found pilot error most probably caused the tragedy and not any sort of mechanical defect.

Five people, including pilot Max Quartermain were killed, when the Beechcraft King Air B200 crashed into the DFO Building near Essendon Airport on February 21, 2017.

The four passengers Russell Munsch, Greg De Haven, Glenn Garland and John Washburn, were American tourists heading to King Island for a day of golf.

The Australian Transport Safety Bureau report on the crash said the pilot did not detect the aircraft’s rudder trim was in the full nose-left position prior to take-off.

“The position of the rudder trim resulted in a loss of directional control and had a significant impact on the aircraft’s climb performance in the latter part of the flight,” the report said.

The aircraft was only in the air for nine seconds before the crash, when it was observed to veer sharply left and was unable to avoid the DFO building.

Another contributing factor was the fact the aircraft was 240kg above its maximum take-off weight of 5670kg.

The report went on to say the pilot and operator did not have an appropriate flight check system in place for the aircraft.

“Although this did not contribute to this accident, it increased the risk of incorrect checklists being used, incorrect application of the aircraft’s checklists and checks related to supplemental equipment not being performed,” said the report.

Why the rudder trim was in the full nose-left position was not completely apparent in the report, which noted that the ATSB “could not exclude the possibility the rudder trim had been manipulated by unknown persons prior to the flight”.

“However the aircraft had been stored in a secure hangar until the previous afternoon,” said the report.

“After this, the aircraft was parked outside the hangar within the confines of the airport.”

Former airline captain and RAAF fighter pilot Byron Bailey said the findings were devastating.

“The thing is, (the rudder trim) is never touched,” said Mr Bailey.

“For it to be wound in the full left position is very unusual.

“Normally the only time you would use the rudder trim would be in an engine failure situation. This guy wouldn’t have known what was going on.”

He said it highlighted the need for proper pre-flight checks and not taking anything for granted.

The report said a review of witness observations and air traffic control audio recordings found no evidence to suggest that the before takeoff (run-up) checks had been completed by the pilot.

A separate report is being prepared by the ATSB into the approval of the DFO building adjacent to Essendon Airport.

However the report said the “presence of the building struck by the aircraft was unlikely to have increased the severity of the outcome of this accident”.

The widows of the four passengers killed will release a statement through their Australian lawyer later today.

---

Pilot boasted no need for checks

ROBYN IRONSIDE
A pilot who boasted he did not need checklists, failed to spot an incorrectly positioned control, resulting in a crash that killed five.

A pilot who once boasted that he did not need pre-flight checklists, failed to spot an incorrectly positioned control in his aircraft, resulting in a crash that killed him and four American tourists near Essendon Airport in Melbourne.

Lawsuits seeking millions of dollars in damages will be filed in the wake of the final Australian Transport Safety Bureau report on the crash, on February 21 last year.

Max Quartermain, 67, was at the controls of the Beechcraft King Air B200 on a flight from Essendon to King Island off Tasmania’s northwest coast.

Shortly after a longer than normal takeoff roll, the aircraft was seen to veer sharply to the left as Quartermain repeatedly radioed “mayday”.

After just 10 seconds of flight, the plane crashed into the DFO shopping centre on nearby Bulla Road and burst into flames.

The ATSB report found that the rudder trim of the Beechcraft King Air B200 was in the full nose-left position prior to takeoff, ­causing a loss of directional control that affected the aircraft’s climb.

The report also found the aircraft was 240kg over the maximum takeoff weight, and a tripped “impact switch” for the cockpit voice recorder had not been reset.

ATSB chief commissioner Greg Hood said the rudder-trim position should have been picked up in any of five standard pre-flight checks for the B200.

“There were opportunities in the checklist that existed for the pilot to ensure that the rudder trim was set to neutral, prior to takeoff,” Mr Hood said.

Statements provided by people who had flown with or knew Quartermain indicated he was not always in the habit of consulting checklists during pre-flight ­inspections.

On one occasion, a passenger said he had to prompt Quartermain to close the main cabin door of the aircraft just before takeoff.

Another pilot said Quartermain had indicated he did not believe in checklists.

The report also quoted previous correspondence between the ATSB and Quartermain in which he suggested “you don’t need to use a checklist because you are doing it every day”.

In late 2015, following a near miss over Mount Hotham, the Civil Aviation Safety Authority identified Quartermain did not have an approved flight-check system for the B200.

He was also ordered to undergo an instrument-proficiency check, which he failed on the first attempt but passed three weeks later.

Yesterday, Gordon Legal partner Paul Henderson, who is representing the widows of Quartermain’s passengers, said he had recommended they make a claim under the Civil Aviation Carrier’s Liability Act and take a negligence action against the pilot’s ­estate.

Mr Henderson said claims made under the act were capped at a maximum of $725,000, but the negligence action meant there was an opportunity to gain “true compensation” for the widows of Glenn Garland, 67, Greg DeHaven, 70, Russell Munsch, 62, and John Washburn, 67.

“They’re experiencing a range of emotions from frustration to a great sense of sadness and a great sense of loss and, to some degree, anger,” he said.

Lawsuits would be filed in the next 60 days, Mr Henderson said.

A statement from Quartermain’s daughter Melissa said she and her brother were having a “very difficult time coming to terms with losing our dad”.

“We love him dearly and he is missed enormously,” she wrote.

“We will always remember him as the wonderfully loving and proud father, and adoring Papa to his three grandchildren.

“Our lives will never be the same without him.”

& a Sandy comment :

The claim that the pilot did not use check lists should be assessed against the background of common practice in flight training. We do not normally teach flying using a physical check list, it is normal to follow a ‘learnt by rote’ check list for the critical stages of flight. It might be a valid argument to say that having to pull out a written check list or handle a physical tab system which displays a sequence of written instructions is creating a distraction from the actual task of, for example, noting engine parameters or looking outside to determine the proper operation moving control surfaces. Different story in more complex aircraft with two pilots. 

In many experienced eyes the ATSB, an independent body as of 2009 by then Minister Albanese, has fallen well short in its reports and the too easy ‘blame the pilot’ mentality  undermines the the most important element, how to prevent this from happening in the future. In addition the explanation for how the rudder trim would be wound over to one side and left there (extremely unusual) might bear further investigation as would be the question why the rudder force could not be overcome. 

---

Checklists indispensable to safety
BYRON BAILEY
This incident shows how vital it is for ­pilots to take time to action checklists fully.

---

I have often thought single-pilot multi-engine charter flying is the most demanding sphere of civil aviation. The pilot can be responsible for flight planning, fuel load, passenger and baggage, often with time pressure, as well as safely flying the aircraft.

But there is no excuse for missing vital cockpit checklists that ensure the safety of the flight.

The KingAir checklists specify in the before-engine start cockpit set up, that the three control surface trims of pitch (electric switch on the control column yoke) and manual aileron and rudder trim wheels be checked through the full range and be returned to the neutral takeoff settings. The trim wheels are highly visible just behind the throttle quadrant and very obvious markings indicate the neutral position.

The taxi checklist also requires the pilot to verify the trims are set for takeoff.

On the takeoff roll, it would have been apparent quite early as aerodynamic forces increased as the speed built up that the aircraft was wanting to deviate to the left.

This would have needed increasing right rudder to keep straight — so why did the pilot not abort takeoff before the rotation point? It would have been increasingly obvious there was a problem.

Simulator training emphasises the need to stop for any problem before 80 knots. The aircraft apparently rotated after a ground roll of 700m, which still left plenty of room to stop. At this stage, the pilot would have had his hands full: full right rudder and aileron just to try to keep straight and unable to retract the landing gear. As well as missing a required pre-takeoff visual check of the rudder trim position, the pilot continued while having control difficulties when all training would demand a discontinuation.

Engine fire/failure and loss of directional control are safety ­issues that are not taken into the air before the vital speed V1, which occurs just before rotation and there is no choice but to abort the takeoff.

There is a widespread opinion among general aviation pilots that checklists are too long-winded, thus increasing the likelihood of missing an item, but this incident shows how vital it is for ­pilots to take time to action checklists fully and undergo takeoff emergencies simulator training.

Byron Bailey is a former RAAF fighter pilot and Emirates 777 captain.

Come on Bailey you should know better than to swallow that HVH bollocks...

Yet to find a dissenting media report? Which means that (at this point in time) the HVH weasel worded confection of half baked hypotheses and factually incomplete assumptions, that are  contained within yet another dodgy ATSB final report will remain unchallenged by any decent investigative journalist; or independent aviation accident investigative expert? 

This means that much like in the PelAir cover-up; the Mildura fog duck-up; the Lockhart River tragedy etc..etc; that once again the aviation safety bureaucracy have managed to Hoodwink the Minister/Govt while effectively obfuscating all responsibility and potential liability for this accident...  

However it is yet to be seen whether the ICAO, the FAA and/or the NTSB will be quite so convinced that there is nothing more to this tragic accident than an incompetent and therefore negligent pilot:

Quote from Oz Aviation article yesterday (my bold): 

ATSB raises questions about building approvals process for shopping centre

The ASTB said the building the aircraft struck did not increase the severity of the consequences of this accident.

“In the absence of that building, the aircraft’s flight path would probably have resulted in an uncontrolled collision with a busy freeway, with the potential for increased ground casualties,” the report said. P2 - Still shaking my head over that unprofessional bollocks statement...

However, the ATSB said its investigation did identify that two of the four buildings within the retail precinct “exceeded the obstacle limitation surface (OLS) for Essendon Airport”. “While those exeedances had been approved by the Civil Aviation Safety Authority, the ATSB identified several issues relating to the building approval process for the precinct,” the report said.

“It is beyond the scope of this investigation to consider in detail the issues identified with the Bulla Road Precinct building approval processes.

“These issues will be addressed in the current ATSB Safety Issues investigation ‘The approval process for the Bulla Road Precinct Retail Outlet Centre AI-2018-010’.”
The ATSB final report noted the OLS for the departure runway was not infringed and VH-ZCR did not collide with those buildings.

Essendon Airport chief executive Chris Cowan said it was clear from the final ATSB report “the operation or conditions at Essendon Fields Airport played no role in this terrible crash”.

“The report confirms that the presence of the DFO building struck by the aircraft did not increase the severity or the consequences of this accident. This building is not subject to further investigation,” Cowan said in a statement.

“The ATSB is conducting a separate investigation into the approval process of two other buildings at Essendon Fields DFO. We note those buildings were approved by CASA prior to construction. Those two buildings did not contribute to this accident.”

Committee views
Essendon Airport accident
4.44      As the investigations continue into the tragedy that occurred at Essendon Airport in February 2017, the committee observes that such a terrible event may trigger reinvigorated discussions at all levels of government on broader airport land use planning and development issues, to improve the safety for all those who engage with airports.
4.45      The recently announced ATSB investigation into the building approval process for buildings around Essendon Airport, resulting from the Essendon crash, will play an important role in progressing discussions about aviation safety in relation to urban development. As previously noted, the findings of this investigation should be carefully considered in the context of legislative changes to airport planning laws.
4.46      The committee hopes that the important work of NASAG goes some way to addressing the concerns of stakeholders about building and structures near runways, and the impact these have on safe aircraft operation.
4.47      It appears to the committee that the encroachment of developments, be they residential or commercial, on and near airport land presents significant safety concerns. It is essential that safety on and around airports is given proper consideration at all times, without being overridden by commercial pressures.
4.48      The committee is of the view that a holistic approach should be taken to airport planning, and this should be reflected in the MP process. It should be incumbent on all airport lessees, developers and planners to do more than the bare minimum to adhere to airport planning legislation and frameworks, in order to give proper consideration to broader safety considerations.

The following extract is from the now decade old 2008 ICAO audit report:

And from the ICAO 2017 audit report: http://auntypru.com/wp-content/uploads/2...t_full.pdf

AGA:
Ensure that the State has a coordinated mechanism to ensure full and effective implementation of the obstacle limitation surfaces (OLS) at aerodromes, including arrangements to prohibit any building developments which could create an obstacle to aircraft operations.

http://www.auntypru.com/forum/thread-143...ml#pid9296

P2 comment: It is worth keeping in mind, that this more than decade old ICAO identified SSI (serious safety issue), would presumably have been known by the present CASA CEO Carmody when he gave evidence as the Deputy CEO to Byron in the Senate RRAT committee inquiry into the administration of CASA. Hansard extract 2 July 2008 public hearing: 

S10926_pdf.pdf Size: 714.02 KB  Downloads: 1

Senator O’BRIEN—I understand ICAO conducted an audit of our aviation circumstances

earlier this year involving, obviously, CASA as the regulator. And I have seen a story which
suggests that deficiencies in air safety in Australia have been uncovered in that audit. Is that so?

Mr Byron—I am not aware of deficiencies in air safety. Certainly, the write-up of the audit
process is ongoing, and I might have to defer to Mr Carmody, who handles this part of the
organisation, just to give the latest update. But from my recollection of the debriefing, naturally there were some issues that we need to attend to. The only one that was of significant note that I really need to think about is the ongoing training of our largely new workforce. A lot of them come to us qualified; we need to continue our efforts to give them technical training, and we are working on a workforce capability program for that now. But my understanding is that, in terms of the key elements of the audit that related to legislation, oversight and airworthiness directives, we scored quite high in the draft stages.

Mr Carmody—Senator, I can respond in a little more detail if you wish.

Senator O’BRIEN—Yes, please.

Mr Carmody—The final report is not out yet; it is not out till the end of the year.

Senator O’BRIEN—And there is a draft between now and then as well, isn’t there?

Mr Carmody—Yes, there is a draft. In fact, we go back and forth and talk about the draft and those sorts of things with ICAO. We have reviewed our score against the critical elements in the ICAO standard and we think we have come out of it quite well—very well, in fact. There is one area we did not come out particularly well. I think we were still above the global average, but we are not as far ahead as we would like to be. In all other areas, we did quite well P2 - Why does that comment sound so familiar?? 

Senator O’BRIEN—So which area were you not satisfied with?

Mr Carmody—The area we are not satisfied with is technical personnel qualification and
training. What we needed to be able to demonstrate more clearly was a linkage between our human resources systems and the training that is undertaken in our field offices, and be able to indicate more clearly than we could to ICAO the qualifications of personnel and some of those things. That is my understanding, Senator, and I think we are working very hard on that now. We are also looking at some technical training aspects that came out of that. But, as I said, I think we were still equal to or above the global average on that score, and we were well above on the rest.

Senator O’BRIEN—Where does the global average sit? What sorts of nations are you talking about being at the average level, given that we have a fairly high standard, I would have thought?

Mr Carmody—I could find some data, but, off the cuff, for example, we are ahead of New
Zealand in a range of areas. I do not know about the United States, I am sorry. We are ahead of Canada in some areas. Our ratings were between eight and nine out of 10 on the critical elements and five out of 10 on the training personnel element. So, overall, we think we have done quite well—and the global average was low on that training personnel qualification area. That is clearly a focus for ICAO to build on as they go around the world, so they are pressing everybody on exactly the same points.

CHAIR—Does Dr Aleck have any additional information on that?

Mr Carmody—No, he does not. P2 - Hmm..that's a peculiar response -  There is a chart that I do not have with me that I would like get hold of. I might be able to get hold of it and come back with a more detailed response later, to make sure those numbers are exactly right.

Senator O’BRIEN—So were they talking about training within CASA or training generally?

Mr Carmody—Training within CASA. It lists technical training of qualified personnel and
how much technical training we are doing, and as I indicated we are not as far ahead as we would like to be.

Senator O’BRIEN—So, in the context of a major staff turnover, we now find ourselves with
a training deficiency. Is that how I should understand the circumstances?

Mr Carmody—I think that some of the things we were not able to demonstrate were, for
example, our diploma in aviation safety, which had not started—it starts this year. There are actually a range of things that we were not actually in a position to demonstrate because they were not in play, but, certainly, we did not come out as well as we would like to. I would not characterise it quite as seriously as you have, Senator, but it is important.

Senator O’BRIEN—Have these criteria been applied in the past?

Mr Carmody—I am presuming—

Senator O’BRIEN—Sorry, you were not there.

Mr Carmody—that ICAO uses the same methodology. I do not know.

 
This also means that Carmody would have been fully cognisant of this ICAO identified SSI when he gave evidence in the May 2017 Budget Estimates:

       
&..



He would also have been cognisant of the November 2017 ICAO report finding...

...Ensure that the State has a coordinated mechanism to ensure full and effective implementation of the obstacle limitation surfaces (OLS) at aerodromes, including arrangements to prohibit any building developments which could create an obstacle to aircraft operations...

  ...yet CASA did not provide any input to the following QON submitted and subsequently answered by the Dept:

Portfolio Question Number 201
Question - Senator PATRICK: Are you looking at public safety zones around Sydney Airport? 
Mr McRandle: We're looking at public safety zones generally across Australian airports as part of the National Airports Safeguarding Framework. A consultation process commenced a little over a week ago with the community around public safety zones. It will include all airports. Queensland has already incorporated the public safety zone approach to their airports. There are others around Australia that haven't adopted it. 
Senator PATRICK: That's on your website, is it? 
Mr McRandle: It is on our website. 
Ms Spence: We can send the link to the secretariat if that would help? 
Senator PATRICK: That might be helpful, and I'm happy to help advertise that.
Answer The National Airports Safeguarding Advisory Group is seeking comments on a draft new Guideline I— Managing the Risk in Public Safety Zones at the Ends of Runways. The draft guideline is available on the Department of Infrastructure, Regional Development and Cities’ website at: https://infrastructure.gov.au/aviation/environmental/airport_safeguarding/nasf/public_consultation_nasf.aspx.

Nor did Carmody and/or CASA provide any insight/input, on the identified ICAO SSI (x2), when the Senate RRAT committee were conducting their Airports Amendment Bill 2016 inquiry - https://www.aph.gov.au/Parliamentary_Bus...ndmentBill . This was despite the inquiry report being subsequently delayed by request by the then minister Chester (because of the YMEN DFO accident occurring) and the subsequent duplicate finding from the November ICAO audit (see above)...  


MTF...P2 

[Kharon]

Curiosities – rather than comments.

The first cab off the rank is an acknowledgement of the ‘tin-kickers’ good work. It must have been a hellish of a job sorting out as much data and ‘fact’ as they did. In fact, when you take a long hard look at the crash site, you have to admire all those involved, ambulance, fire, police etc. A terrible job very well done once again by our ‘services’. Thank you all.

I’m not sure the same praise can be lavished on those who polish and refine the ‘final’, sanitized version of the investigators analysis; however, it is up to us to complete our own analysis and form an opinion. Mind you, it is quite a thing, stand alone,  that ATSB reports are always treated with suspicion these days. Sad indictment. No matter. I always like to read through the entire thing anyway, note down those items which cause irritation of the curiosity bump, then pick ‘em out for further consideration. That, I regret is as far as I have gotten so far. FWIW (and it ain’t that much) the following stand out passages tug at the subconscious, needing further head scratching.

Bulla Road Precinct obstacle limitation surface exceedances.

ZCR collided with a building constructed on the south-eastern corner of Essendon Airport (Figure 8). This building was one of four, collectively known as the Bulla Road Precinct – Retail Outlet Centre (outlet centre), proposed by the airport lessee in 2003, approved by the Federal Government in 2004, and completed in 2005.

The ERSA, a component of the Aeronautical Information Publication, publishes information about an airport’s infrastructure and, in particular, runway data and airspace obstructions that may affect operations at the airport. The airport data for Essendon included seven obstacles that breached the airport’s obstacle limitation surfaces (OLS). Four of those obstacles infringed the runway 26 transitional surface component of the OLS and were associated with two buildings within the outlet centre that were not struck by the aircraft. CASA accepted the breaches in 2015 after the airport operator applied lighting and colour to the obstacles to mitigate their risk to aircraft operations.

The OLS are a series of surfaces that set the height limits of objects around an airport. The transitional surface is a component of the OLS that is immediately adjacent to the runway area. The runway area includes the runway itself and an adjacent area that is required to be graded and clear of all obstacles. The intent of the OLS is to provide airspace around an airport that is kept as free as possible from obstacles so as to permit the intended aircraft operations at the airport to be conducted safely, as well as to prevent the airport from becoming unusable as a result of growth of obstacles around it. The airport operator is responsible for establishing an applicable OLS. The surfaces of the OLS are based on a complex set of criteria that include whether the runway is used for departures and/or landings, and the types of approaches attached to that runway.

At the request of the investigation, the airport operator produced an OLS based on runway 17/35 only, and mapped the outlet centre obstacles in relation to this particular OLS. That data identified that the listed obstacles did not penetrate the OLS for runway 17/35. The airport operator also identified a further three obstacles that were not listed in the ERSA as breaching the OLS. They were not listed as they were considered minor breaches of the OLS. These obstacles related to light poles in the area of the outlet centre. The aircraft did not collide with any of the obstacles that breached the OLS.

ZCR was fitted with a Fairchild model A100S CVR in June 1996, at about the time the aircraft entered service. The fire-damaged CVR was removed from the wreckage and transported to the ATSB’s technical facilities in Canberra for examination. The CVR was successfully downloaded, however, no audio from the accident flight was recorded. The recovered audio related to a previous flight on 3 January 2017. This recording began at the expected time prior to engine start. The recording stopped, however, at about the time the aircraft landed at the arrival aerodrome.


The post-landing taxi and engine shutdowns were not recorded. It was likely that the ‘impact switch’ was activated during the landing and power was removed from the CVR.
 

P.40. - Due to fire damage to ZCR, the ATSB could not determine which checklist was in the aircraft. The aircraft manufacturer provided a copy of the checklist referenced in the operations manual, a copy of the correct checklist by serial number for ZCR, 101-590010-309F, and a copy of a POH applicable to ZCR. The manufacturer advised that the checklists were unlikely to contain checks related to modifications to the aircraft such as the CVR. The three checklist sources were compared and it was found that, in regard to the rudder trim and weight and balance items, the checklists were identical. None of the checklists contained CVR checks.

Rudder trim.

The left rudder trim cable had failed at a position towards the rear of the fuselage. Inspection of the cable fracture revealed necking-type failure of individual strands within the cable. That, and the way the cable was splayed, were indicative of an overstress fracture, likely as a result of the collision (Figure 30).

Elevator trim.
Both the left and right elevator trim actuators were found in a position that equated to a full nose-up trim position. Witnesses, CCTV and ADS-B evidence either opposed or did not support ZCR having full nose-up trim at take-off. It is possible that the elevator trim was moved to this position by the pilot in an attempt to control the aircraft’s flight path or the trim may have moved as a result of impact forces. The ATSB determined however, that it was unlikely that the elevator trim was in the full nose-up position at take-off and etc.
 

Flap system.
The left inboard and outboard flap control surfaces were destroyed by fire. The right inboard and outboard flaps had separated from the aircraft and broken into numerous sections during the impact sequence.

All four flap actuators were identified in the wreckage. The left inboard and outboard actuator outer bodies had been fire-damaged, however, their internal shafts and attachment points were present. Initial on-site examination of the aircraft wreckage indicated the flaps were extended approximately 10°. More detailed analysis of the left inboard and outboard actuators, however found they were likely in the fully retracted, UP position, when the aircraft collided with the building. An accurate assessment of the right wing flap positions was not possible due to impact and fire damage.

Yaw damper and rudder boost operation.

The ATSB was unable to determine whether the yaw damper was engaged on the accident flight or when the pilot normally engaged the yaw damper (refer to section titled Aircraft wreckage – Cockpit instruments and switches). There was no evidence found to support a rudder boost malfunction (refer to section titled Aircraft wreckage – Rudder boost system inspection). Both systems could be disconnected by the pilot and the aircraft manufacturer advised that the pilot should have easily been able to overcome forces generated by the rudder boost and yaw damper systems.

P 57. - Ground roll, flight path and aircraft attitude

Automatic Dependent Surveillance Broadcast (ADS-B) data and closed-circuit television (CCTV) footage revealed ZCR reached the required rotation speed of 94 kt when about 730 meters from the threshold of runway 17. The aircraft then remained on the ground for an additional 285 meters and rotated at 111 kt. The data also showed that, at some point between 470m and 920 m from the threshold, ZCR’s ground track began to veer left from the runway centreline. At rotation, a witness familiar with the aircraft type observed a yaw to the left followed by a relatively shallow climb. The ATSB’s analysis of ZCR’s flight path profile and the impact sequence found that, the aircraft had minimal sideslip for the initial climb followed by substantial sideslip for the later part of the flight and at impact. The analysis also found there was minimal left roll, not exceeding 10° for the duration of the flight.

That’s about it for now, I shall confer with my peers and betters to see if a better conclusion can be reached than all  ‘pilot error’. Little doubt there was some pilot error, but it is a matter of how much of the blame for the total disaster can be laid at the feet of a dead man.

One thing is for certain sure; the pilot had sweet bugger all to do with the buildings being where they are; that, standing alone, is worthy of serious investigation. That will be fun, won’t it?

Toot – toot..

[Peetwo]

ATSB YMEN DFO FR: More questions than answers - 

Not sure how Hoody ever believed that any sane, respecting professional aviator (especially aviators with some time on type) would swallow that bollocks report, is simply beyond me... 

Anyway to add to the "K" curiosities from above, the following is from Sandy off one of the AP email chains:

Just read the Essendon Kingair report. I did not see any follow up on this strange elevator trim setting. Anyone any thoughts? What would happen if there was a loss of direct elevator control?

Quote from the report:-

“Elevator trim


Both the left and right elevator trim actuators were found in a position that equated to a full nose‑up trim position. “

      
And from Grogmonster off the UP a similar (amongst other) curious OBS: https://www.pprune.org/pacific-general-a...st10261266

Hi everyone,


I want to stay clear of nasty politics and deal with facts so I have a couple of things to add / ask and I will let you guys carry on.

1. Has anyone looked at the NTSB report on the Wichita, Kansas B200 crash? Its very similar.
2. Has anyone considered that the elevator trim in this incident was found fully nose up but attributed to impact forces and yet impact forces have been discounted with regard to the rudder trim. Why???
3. From personal experience I can tell you that a loose friction nut rollback will leave approximately 600 ft lbs of torque in play hence the ," producing power condition," of the left engine.
4. Systems knowledge here. If you have a failure of the instrument bleed air valve in the "off" position on say the right engine the rudder boost system would sense a lack of reference air from the right engine therefore assuming an engine failure and it would cause the rudder boost to activate and the aircraft would want to veer into the opposite engine. In this scenario the pilot could possibly wind in a heap of rudder trim to compensate or reduce power on a good engine or a combination of both. Confused????
5. A lot of conclusions have been drawn from the state of the wreckage however a lot of change, trim or power lever movements, could have been happening in the cockpit in those short seconds before impact.

I shall leave you guys to it and I look forward to the comments.

Groggy

I also note this (like-minded OBS) post from Propsforever:

And once again from me:


If you Keep a B200 with 2 Engines running below 160ft, after 5100ft distance you are going the better of 160kts even with the gear down.
If you Keep the Speed below 110kts, wich almost no one would do ( read below), the Ship would climb at an unsane angle.

In Europe, "Norwegian Air Transport" trains to climb at V2. Everybody else i know, trys to get to Cruiseclimb as fast as possible. To build up some kinetic Energy and to pass 121KT= V2 Flaps up, to raise the flaps (( 1% mor Gradient)), wich happens usually around 50ft AGL

Unfortunatly the B200 i fly is in Maintenance/Repair, otherwise i would try the Scenario at an safe Altitude and Report.

Slighly Off Topic, but related to the Accident:
The reason i dont like to climb with V2 on an 2 Engine Departure is: You are maintaining an Pitch Attitude of give or take 20degr. @ 121KTs clean( Stall Speed 100kt ...). Now one Engine quits and you Need to decrease your pitch to 10degr. while the Aircraft is getting slower and trying to roll on its back. All the Odds are against you in this Scenario.

Every knot of Speed you carry more is just safety! If you climb out with 10degr. you do 160kts, the recommended Cruise climb.

If you loose an Engine above V2se, just maintain Pitch - Keep Directional Control, wich is easier because of reduced Torque effects - Clean up - Check Autofeather in Progress and relax!

I just dont buy the conclusion of this Accident Report. It might even happened that the Pilot has put the trim in the wrong direction while airborne. I have seen this happen with unexperienced Copilots, until it settled into them wich direction to turn. Usually they werent used ( or trained) to work the Ruddertrim and where at first annoyed to get ordered to trim "all the time".

Hmm...much like the ATR in picture above, was there any possibility that VH-ZCR was structurally compromised/damaged prior to this accident?

..At the terminal, ZCR was refueled and the pilot was observed on CCTV to walk around the aircraft, stopping at the left and right engines[4] before entering the cabin. The pilot was then observed to leave the aircraft and wait for the passengers at the terminal...

Wonder if we could get a copy of the CCTV footage of the pilot doing the walkaround? 

MUCH MTF...P2 

[Peetwo]

AAI Real World lessons?

Meanwhile in the REAL world of full, frank, no bollocks aviation accident investigation the NTSB Chair gets my vote for QOTM...  

Via Stuart David Harry‏ @discoair on Twitter: https://twitter.com/discoair/status/1046205854356295680

---

"That's what NOTAMs are, they're just a bunch of garbage that nobody pays any attention to" - @NTSB Chairman Robert Sumwalt at the Air Canada 759 hearing.  - Amen, brother!

&..

NTSB Chairman Calls Notams 'Garbage'
by Chad Trautvetter
 - September 28, 2018, 11:41 AM

NTSB chairman Robert Sumwalt called the Notam system in the U.S. “messed up” this week during a hearing on the July 7, 2017 incident at San Francisco International Airport (SFO) in which an Air Canada Airbus A320 nearly landed on a crowded taxiway. The crew mistook the taxiway as their cleared runway—28R—because Runway 28L was closed. The pilots failed to catch that note on page eight of the 27-page list the SFO Notams.

After acknowledging the “crew didn’t comprehend the Notams,” Sumwalt then read a verbose and complicated entry that limited a portion of a taxiway to aircraft with a wingspan of 214 feet or less. “Why is this even on there?” he asked. “That's what Notams are: they’re a bunch of garbage that no one pays any attention to,” adding that they’re often written in a language that only computer programmers would understand.

Sumwalt also relayed a recent experience he had flying the jumpseat into North Carolina’s Charlotte/Douglas International Airport, saying, “There were pages and pages and pages of Notams, including one for birds in the vicinity of the airport…when are there not birds in the vicinity of an airport?”

Not surprisingly, one of the NTSB’s six safety recommendations stemming from this incident is a “more effective presentation of flight operations information to optimize pilot review and retention of relevant information.”

---

Okay after that short but amusing no bullshit (REAL world Annex 13 AAI) interlude; back to HVH's ATSB 2018 book of faery tales...  - http://auntypru.com/a-curiously-intrigui...rie-story/ & http://www.auntypru.com/forum/thread-143...ml#pid9357

MTF...P2 

[Gobbledock]

P2;

Okay after that short but amusing no bullshit (REAL world Annex 13 AAI) interlude; back to HVH's ATSB 2018 book of faery tales... Dodgy

HVH is too busy even for ‘faery tales’ at the moment. The endless hours he puts in to ‘correcting the record’ and other such piffle robs him of quality investigative oversight time. Someone emailed me a photo of him today posing with Dr Brendan Nelson. 

---

 ATSB @atsbinfo
An exhibition of transport safety investigation memorabilia

A new exhibit installed at the ATSB’s Canberra offices explores the past and present of transport safety investigation in Australia.

Read more here: http://www.atsb.gov.au/newsroom/news-items/2018/exh

---

Add to that all of the hi-vis photos, a snapshot with 10D Chester, a snapshot of him holding a sign which says, can you believe this - “I’m rising to the challenge”, and well..............well you get the picture, HVH is simply too busy committing acts of folly to be  fostering due diligence, transparency, and to act with probity. 

The ATsB, its an absolute travesty. It still has the bones - some good, hard working skilled Investigators being the pillars of the organisation. But 5 years of Beaker and now 2 years of Hood at the helm, backed up by inbred Ministers who have dicks softer than a bowl full of ice-cream has destroyed the place, well the definition of a steaming turd comes to mind.

Shame shame shame

[Kharon]

Give me the simple life.

Sumwalt - “That's what Notams are: they’re a bunch of garbage that no one pays any attention to,” adding that they’re often written in a language that only computer programmers would understand.

I’d have agree; on pure ‘safety’ grounds. To stay legal you are obliged to plough through a massive amount of data; HO + Area + destination + alternate etc. There are reams of the stuff. The very real risk to a flight is that you miss an important one; the very real risk for the provider is that if an incident can be sheeted home to them; then, someone’s rice bowl will get broken.

The ‘cover your 6’ mentality Australian aviation law has produced generates this sort of arse covering overkill. NOTAMs and MET should be provided in plain English, simple, concise and relevant. The amount of ‘code’ one is obliged to translate in a weather briefing is mind boggling – same-same NOTAM’s.

With today’s computer power and systems; would it not be possible to generate a ‘package’ of Met and Notam data pertinent to the flight plan? A simple package, in plain language, with only the essentials (just the facts Ma’am). They way things are, the current system is self defeating; too much guff, not enough ‘stuff’ – so crew just collect the huge pile of paper, scan for the ‘bits’ that matter and bin the rest at the end of the day. Easy to miss an essential on page 33.

Crew - “But, but that was one line on page 149 M’Lud; in code, hidden between a 3 inch, 1000 abbreviated code words on airspace boundaries and a 4 inch, 14,000 accronyms on a military exercise, 2000 miles away”.

Judge – “Sorry chaps; strict liability, here, have a criminal record and join the queue at Centre-Link”.



Toot – toot.

[Peetwo]

ATSB: The copy & paste Annex 13 AAI?

From page 54 of the UP King Air down thread - https://www.pprune.org/pacific-general-a...on-54.html - there was a bit of a ding-dong going on between Old Akro and resident troll/CASAsexual/HVH lover FGD??

Old Akro

Which incident are you referring to here, Old Akro?

Report WPR09LA451. B200 Kingair. The main wreckage was 4420 ft from the point of lift off at about 10 deg from the runway centre line. The rudder trim was full left AND elevator trim 9 degree nose up (should have been 2-3) AND the RH propeller " one half inch forward of the feather position" AND both power levers were one inch aft of the full power setting. AND the left condition lever was in the low idle position while the right condition lever was in the high idle position. 

The report notes: "The Hawker Beechcraft investigator stated that the position of the right propeller lever “…would cause the right engine to reach a higher torque because the propeller is now on the primary governor. The result would be a yaw in a left direction.” "

So, this aircraft should have had a much larger left yaw than ZCR, yet it basically crashed on runway heading, suggesting that the pilot had directional control. 

The NTSB report did not attribute a cause of the accident to any particular one of the mis-set controls, but the pilot said: " The pilot added that he had both hands on the yoke until the airplane crashed. " which infers that it was not the rudder correction that was his main struggle. 

By comparison with the US B200 which crashed 4420 ft from lift off 10 deg of runway, ZCR crashed about 1500 ft from lift off and about 40 deg from runway heading. There is no indication in the report that the US B200 climbed above 100 ft. ZCR achieved about 650 ft before descending. 

The two incidents barely seem analogous. and I think the US incident suggests that directional control can be maintained despite full left rudder trim. It would have been good if the ATSB tested this.

---

FGD135

Old Akro,

You are consistently misrepresenting and misquoting these reports. You're definitely pushing an agenda, but we're onto you.

Report WPR09LA451. B200 Kingair.

In your first post this morning, you stated that the pilot "did maintain directional control, despite full NL rudder trim". This is a misrepresentation. If you use Google Earth to look at the runway in question, and the two buildings this aircraft collided with, you will see that the veer to the left after takeoff appears almost identical to that by ZCR. That is not what most people would consider "maintaining directional control". My Google Earth is playing up, but if you want me to take some precise measurements for comparison with ZCR, I will find a way to do so.

The rudder trim was full left AND elevator trim 9 degree nose up (should have been 2-3) AND the RH propeller " one half inch forward of the feather position" AND both power levers were one inch aft of the full power setting. AND the left condition lever was in the low idle position while the right condition lever was in the high idle position.

The condition levers had no bearing on the outcome. The RH prop lever, however, may have had some bearing, but it must be noted that this was how the lever was found in the wreckage - no analysis appears to have been conducted as to whether it was in this position during the takeoff.

The report notes: "The Hawker Beechcraft investigator stated that the position of the right propeller lever “…would cause the right engine to reach a higher torque because the propeller is now on the primary governor. The result would be a yaw in a left direction.” "

This is not true. At best, the power output of the RH engine would have matched the LH, or it may have been less. It all depends on when the lever was put in that position, relative to when the takeoff torque was set.

If BEFORE the torque was set, then the pilot most likely advanced both power levers to the target takeoff torque (2,230 ft-lbs), as normal, but if the RH prop lever was in the reported position, then the RH RPM would not have come up to 2,000 RPM. It would have got to only about 1,800 (my estimate). In this case, the RH engine is actually producing LESS power than the LH.

If the lever was positioned AFTER the torque was set, then yes, the torque of the RH prop is increased - but the RPM is reduced, with the result that the power output is about the same. So, in neither case would the reported position of the RH prop lever have caused an increase in the NL yaw moment.

The pilot added that he had both hands on the yoke until the airplane crashed. " which infers that it was not the rudder correction that was his main struggle.

I imagine the tendency to roll L would be very strong in these instances, and with the low airspeed, may well have required full R aileron.

By comparison with the US B200 which crashed 4420 ft from lift off 10 deg of runway, ZCR crashed about 1500 ft from lift off and about 40 deg from runway heading. There is no indication in the report that the US B200 climbed above 100 ft...

As I stated above, the veered path appears almost identical to ZCR. The buildings in the US case were much closer, and appear to be lower. Until I make some measurements, it appears to me that the only difference between these two accidents was that the US aircraft was about 50-60 feet lower than ZCR at the same point.

I think the US incident suggests that directional control can be maintained despite full left rudder trim.

Disagree - and all the evidence disagrees with this assertion.

And on it goes until Lead Balloon steps in and puts a cap on the FGD bollocks...

Lead Balloon

We all have an ‘agenda’, FGD.

Your ‘agenda’ is to defend a report that reaches the oh-so-convenient conclusion that the only hole in the Swiss cheese was the pilot.

Others like me (and I suspect OA) have an ‘agenda’ of testing the reasoning and findings of an oh-so-compromised ATSB.

I for one do want you to “take some precise measurements [of the details of the B200 accident with report number WPR09LA451] for comparison with ZCR”, so please “find a way to do so” on google maps. I’m surprised that more detail of the US accident were not included in the ZCR report, if the path of the aircraft in US accident was, in fact, so similar to that of ZCR.

---

FGD135

As requested, I have done some work with Google Earth to compare the flight paths of VH-ZCR and N726CB, the latter being the King Air B200 that took off from Hayward Executive airport, California on 16/9/2009, with full nose-left rudder trim.


N726CB veered left after becoming airborne and struck the roof of a 10 metre high (estimate) building. The point of impact was 15 degrees off the runway azimuth, at a distance of 670 metres - measured from the lift-off point. I have assumed a distance of 500 metres for this takeoff roll (see attached image).

For the takeoff of VH-ZCR, I have drawn a line of the same vector onto the Essendon image, to see how close the two impact points are (see image).

The two points are about 150 metres apart. ZCR has veered more, which could be explained by its 15 knot greater airspeed at lift-off (assuming that N726CB rotated at a normal speed). The greater airspeed would give a greater initial nose-left yawing moment.

Another possible explanation: the pilot of N726CB had 37 year old knees, as compared to the 76 year old knees in ZCR.

The distance from lift-off to impact for N726CB was about 670 metres. For ZCR, this distance was about 620 metres.

The biggest unknown in this exercise has been the length of the takeoff run for N726CB. I have assumed 500 metres, but if that actual takeoff had got off to a more leisurely, rolling start, then this distance could have been closer to 600 metres, which would have put the endpoints of the two vectors within about 75 metres of each other.

---

Lead Balloon

Thanks FGD.

I acknowledge the similarities. But I don’t see too much precision in stuff like:

“I have assumed a distance of”,

“could be explained by”

“Another possible explanation”

“The biggest unknown”

“could have been closer”

All of your assumptions and reasoning may be reasonable. But they may also be wrong in fact.

The difference between our approaches is that all of your assumptions and reasoning are in one direction, to make the two incidents as similar as possible and thereby to ‘prove’ the two incidents had the same cause. My (and I suspect OA’s and others’) approach is to ask: What if your assumptions, possible explanations and known unknowns turned out to show substantial differences between the two incidents? Frankly, the latter approach is the one that ATSB should take, rather than jump to a conclusion then find as much stuff to support that conclusion, even if it means making assumptions that may be invalid and positing explanations that could be wrong.

I apologise if you’ve already answered these questions, but what is your theory as to who set the trim to full NL, when and why? I realise that these questions are irrelevant for those who consider there is only one hole in the Swiss cheese in this tragedy, but they are not irrelevant to others. You’ve said you don’t believe that the pilot set the rudder trim to full NL during pre-flight checks then failed to set it correctly due to distraction. If you are correct, it inexorably follows...

However my curiosity was piqued more by the 2009 US (Hayward Executive B200 occurrence) NTSB final investigation report...  

I am currently on my 2nd run through that report and it's associated pictorial/PDF evidence archive. Besides the fact that the occurrence pilot is extremely lucky to be alive, so far I am starting to get a very uneasy feeling about the so called 'similarities' of these two accidents...  

Anyway not wanting to sway opinion AP has instructed me to provide the links for other interested IOS member's independent and considered review...    

References: https://reports.aviation-safety.net/2009...N726CB.pdf & https://dms.ntsb.gov/pubdms/search/hitli...TXTSEARCHT=

Much..much MTF - P2 

[Peetwo]

ATSB cut & paste AAI: Pictures worth a thousand words?

As an addendum to my last -  

LB said: "...What if your assumptions, possible explanations and known unknowns turned out to show substantial differences between the two incidents? Frankly, the latter approach is the one that ATSB should take, rather than jump to a conclusion then find as much stuff to support that conclusion, even if it means making assumptions that may be invalid and positing explanations that could be wrong..."

Keeping in mind the (nailed it) LB statement, let us now take the FGD pictorial offering (coupled with his/her skewed opinion/review of the similarities in the two accidents) and compare to the NTSB evidential documentation and investigation pictures...

Spot the differences?

Starting with overheads:

Link for the Wikipedia reference for Hayward Executive Airport: https://en.wikipedia.org/wiki/Hayward_Executive_Airport

Next the wreckage, the centre console control quadrant & the rudder boost switch position:

Hmm...that rudder and elevator trim IMO is pretty damn obvious - as for the rudder boost...err no comment -

Finally the following is a copy of the FAA pilot interview record:

Incoming! 


MTF...P2 

[Peetwo]

The HVH YMEN DFO faery tale grows...    


Reference P7 Accidents - Domestic post: http://www.auntypru.com/forum/thread-103...ml#pid9398 

..I note, with some amusement, that the ‘experts’ on the UP are finally catching on. Shan’t bother you all with the posts – but, to further elaborate the abysmal ATSB performance in support of only the gods know what; a quote directly from the Be20 bible.

“The engine driven fuel pump (high pressure) is mounted on the accessory case in conjunction with the fuel control unit (FCU). Failure of this pump results in an immediate flame-out.” The primary boost pump (low pressure) is also engine driven and is mounted on the drive pad on the aft accessory section of the engine. This pump operates when the gas generator (N1) is turning and provides sufficient fuel for start, take-off all flight conditions except operation with hot aviation gasoline above 20, 000 feet altitude, and operation with cross-feed.

The minister should be asking his experts to clearly define what actually happened that day, at Essendon. They could, in turn, ask the ATSB what the hell they are playing at. Better yet, he could bring in the IIC and ask him; on oath, (in camera) if he can – hand on heart – provide a little more ‘fact’ than the Hood faery story. I’d expect some folk in the USA would value anything a little better than the current Wild Ass Guess (WAG) which claims, without any convincing supporting data or proof, 100% Pilot error. 

The simple truth minister is the ATSB management have NFI; the ‘tin-kickers’ might; but there is not enough evidence here to support any claim other than supposition. The bloody aircraft hit a building and burned, killing 5; that is fact – after that – well, you pay your money and take your chances...

Not exactly sure why but the last time I looked the mods over on the UP are still mulling over whether to approve Grogmonster's NTSB report attachment...

Grogmonster:

Some frightening similarities here people. Not Rudder Trim !!!!
Attachments Pending Approval
[img=16x0]https://www.pprune.org/images/attach/pdf.gif[/img]
 
NTSB report on Wichita Crash.pdf

---

Lead Balloon: 

Pending approval, here’s some of the report:

The airline transport pilot was departing for a repositioning flight. During the initial climb, the pilot declared an emergency and stated that the airplane "lost the left engine." The airplane climbed to about 120 ft above ground level, and witnesses reported seeing it in a left turn with the landing gear extended. The airplane continued turning left and descended into a building on the airfield. A postimpact fired ensued and consumed a majority of the airplane.

Postaccident examinations of the airplane, engines, and propellers did not reveal any anomalies that would have precluded normal operation. Neither propeller was feathered before impact. Both engines exhibited multiple internal damage signatures consistent with engine operation at impact. Engine performance calculations using the preimpact propeller blade angles (derived from witness marks on the preload plates) and sound spectrum analysis revealed that the left engine was likely producing low to moderate power and that the right engine was likely producing moderate to high power when the airplane struck the building. A sudden, uncommanded engine power loss without flameout can result from a fuel control unit failure or a loose compressor discharge pressure (P3) line; thermal damage prevented a full assessment of the fuel control units and P3 lines. Although the left engine was producing some power at the time of the accident, the investigation could not rule out the possibility that a sudden left engine power loss, consistent with the pilot's report, occurred.
A sideslip thrust and rudder study determined that, during the last second of the flight, the airplane had a nose-left sideslip angle of 29°. It is likely that the pilot applied substantial left rudder input at the end of the flight. Because the airplane's rudder boost system was destroyed, the investigation could not determine if the system was on or working properly during the accident flight. Based on the available evidence, it is likely that the pilot failed to maintain lateral control of the airplane after he reported a problem with the left engine. The evidence also indicates that the pilot did not follow the emergency procedures for an engine failure during takeoff, which included retracting the landing gear and feathering the propeller.

---

Old Akro:

The ATSB report of ZCR's recent flights / maintenance is sketchy. 


FlightAware shows ZCR returning to Essendon on Feb 4 at approx 2pm with a flight time of 1:24
But the ATSB does not show it flying on that day. 
The ATSB lists ZCR as flying 6 hours on Feb 5, but flight aware has nothing on that day. ZCR has ADSB. I don't understand how a 6 hour flight could be unrecorded by FlightAware. 

The RUMOUR I heard at the time was that it spent about 3 weeks in Adelaide unscheduled after a problem on the leg to Adelaide. The flight aware record supports this. The ATSB report does not mention this. although the flight it lists of Jan 13 when landing gear malfunction was reported may fit with this. At the time the 3rd hand rumour I had was that it was having work done on the FCU and that it was a repeat issue. I'll re-iterate that the rumour I had within days of the accident was 3rd hand. I cant vouch for it. But, it did spend time in Adelaide that corresponded with the rumour. 

An FCU failure has precedent and in many ways fits the facts. But, the ATSB report doesn't acknowledge it. 

and I don't understand why the 4 February flight in FlightAware returning from Adelaide does not appear in the list of recent flights in the report.

Anyway for the benefit of those IOS and BRB members interested, here is some links for the quoted NTSB final report into the 30 October 2014 B200 fatal accident at Wichita, Kansas (Report No. - CEN15FA034): 

1. https://www.ntsb.gov/_layouts/ntsb.aviat...4112&key=1
   
2. https://aviation-safety.net/database/rec...20141030-0
   
3. http://www.kathrynsreport.com/2016/02/be...g-air.html
   

NTSB Identification: CEN15FA034
14 CFR Part 91: General Aviation
Accident occurred Thursday, October 30, 2014 in Wichita, KS
Probable Cause Approval Date: 03/01/2016
Aircraft: RAYTHEON AIRCRAFT COMPANY B200, registration: N52SZ
Injuries: 4 Fatal, 2 Serious, 4 Minor.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The airline transport pilot was departing for a repositioning flight. During the initial climb, the pilot declared an emergency and stated that the airplane "lost the left engine." The airplane climbed to about 120 ft above ground level, and witnesses reported seeing it in a left turn with the landing gear extended. The airplane continued turning left and descended into a building on the airfield. A postimpact fired ensued and consumed a majority of the airplane. 

Postaccident examinations of the airplane, engines, and propellers did not reveal any anomalies that would have precluded normal operation. Neither propeller was feathered before impact. Both engines exhibited multiple internal damage signatures consistent with engine operation at impact. Engine performance calculations using the preimpact propeller blade angles (derived from witness marks on the preload plates) and sound spectrum analysis revealed that the left engine was likely producing low to moderate power and that the right engine was likely producing moderate to high power when the airplane struck the building. A sudden, uncommanded engine power loss without flameout can result from a fuel control unit failure or a loose compressor discharge pressure (P3) line; thermal damage prevented a full assessment of the fuel control units and P3 lines. Although the left engine was producing some power at the time of the accident, the investigation could not rule out the possibility that a sudden left engine power loss, consistent with the pilot's report, occurred.

A sideslip thrust and rudder study determined that, during the last second of the flight, the airplane had a nose-left sideslip angle of 29°. It is likely that the pilot applied substantial left rudder input at the end of the flight. Because the airplane's rudder boost system was destroyed, the investigation could not determine if the system was on or working properly during the accident flight. Based on the available evidence, it is likely that the pilot failed to maintain lateral control of the airplane after he reported a problem with the left engine. The evidence also indicates that the pilot did not follow the emergency procedures for an engine failure during takeoff, which included retracting the landing gear and feathering the propeller.

Although the pilot had a history of anxiety and depression, which he was treating with medication that he had not reported to the Federal Aviation Administration, analysis of the pilot's autopsy and medical records found no evidence suggesting that either his medical conditions or the drugs he was taking to treat them contributed to his inability to safely control the airplane in an emergency situation.


The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

• The pilot's failure to maintain lateral control of the airplane after a reduction in left engine power and his application of inappropriate rudder input. Contributing to the accident was the pilot's failure to follow the emergency procedures for an engine failure during takeoff. Also contributing to the accident was the left engine power reduction for reasons that could not be determined because a postaccident examination did not reveal any anomalies that would have precluded normal operation and thermal damage precluded a complete examination.
  

 
The first and most obvious question is why was this final report not listed in the ATSB's 'related occurrences' section of the VH-ZCR final report -   

Probably because it didn't fit the HVH faery tale:

Related occurrences

A review of the ATSB’s occurrence database and the United States’ National Transportation Safety Board’s (NTSB) online database identified three potentially similar accidents that involved an aircraft taking off with the rudder trim not correctly set.

  
After reviewing the NTSB accident reports, phots and video footage, IMO there is absolutely no debating the remarkable similarities in the two accidents. What makes it worse is that I suspect that the ATSB investigation team have actually referred to the NTSB report as some of the investigatory methodology is remarkably similar.

Example: 

..The NTSB conducted a sideslip thrust and rudder study based on information from the surveillance videos. This study evaluated the relationships between the airplane's sideslip angle, thrust differential, and rudder deflection. Calculations made using multiple rudder deflection angles showed that full right rudder deflection would have resulted in a sideslip angle near 0°, a neutral rudder would have resulted in an airplane sideslip angle between 14° and 19°, and a full left rudder deflection would have resulted in an airplane sideslip angle between 28° and 35° airplane nose left. Calculation of the airplane's sideslip angle as captured in the image of the airplane during the last second of flight showed that the airplane had a 29° nose-left sideslip, which would have required the application of a substantial left rudder input...

---

https://www.atsb.gov.au/publications/inv...-2017-024/

...Following witness observations of a significant left yaw, the ATSB attempted to define the aircraft’s sideslip and roll angles at different points along the flight path using video footage from CCTV and a vehicle dashboard camera. Still images were extracted from the CCTV and dashboard camera footage, and the location of the aircraft was determined using ADS-B data at points A through G (Figure 16). ZCR’s track was determined at each point using ADS-B data...

...Analysis of the roof impact marks indicated that:

• the aircraft had a heading angle of about 86 ⁰ (T)
  
  
• the ground track was about 114 ⁰ (T)
  
  
• the aircraft was at a sideslip angle of about 28⁰ left of track
  
  
• the aircraft was slightly left-wing and nose-low with a shallow angle of descent at the initial roof impact
  
  
• after the initial impact, the aircraft rotated left on its vertical axis until the fuselage was about parallel with the rear parapet wall of the building...
  

P2 comment - I note in the case of the Wichita accident that on 26 October 2016 Flight Safety International filed a lawsuit against 12 different companies associated with the King Air crash: http://www.kathrynsreport.com/2016/10/be...g-air.html

FlightSafety files lawsuit over 2014 King Air crash 

WICHITA, Kan. FlightSafety International has filed a lawsuit, naming more than 12 companies (19 defendants total) it says contributed to the October 2014 fatal crash of a Beechcraft King Air near Wichita's Mid Continent Airport, now known as Dwight D. Eisenhower National Airport.

On Oct. 30, 2014, a Beechcraft B200 Super King Air crashed into a flight safety training center building near the airport, killing the pilot and three people inside the training center.

Among the defendants in the lawsuit are Textron Aviation, Yingling Aircraft, Beechcraft Corporation, Hartzell Propeller, Inc., Pratt and Whitney Engine Services, Inc. and the plane's previous owner.

Investigators say the pilot failed to maintain control of the King Air after a reduction in power to its left engine.

Source:  http://www.kwch.com

  
Finally on a somewhat related issue it would appear that Hoody is desperately trying to schmooze the APS review panel in the lead up to the ANAO audit of the ATSB (ref: https://www.anao.gov.au/work/performance...urrences-0 ) -  : https://uploadstorage.blob.core.windows....32d550.pdf

Thank you for providing the opportunity for the Australian Transport Safety Bureau (ATSB) to participate in the review of the Australian Public Service (APS) through this submission/case study.

As we discussed at the recent APSC-hosted forum for small agencies, I consider it important that we, as a small agency serving the Australian Government and people, provide a contemporary perspective to the review in relation to the manner in which we are evolving our business model and practices.

In facilitating this commitment, I would like to suggest that relevant panel members might wish to participate in the opportunity for an “experiential” visit to a small agency such as ours. In our case, this would be a timely venture as we are currently undergoing an efficiency audit by the Australian National Audit Office (ANAO). In preparing for this audit, we have taken the time to reflect on our past, present and future state in terms of achieving our primary function to improve transport safety with priority given to delivering the best safety outcomes for the travelling public.

As a backdrop and potentially an agenda for the visit, during the past two years, the ATSB has embarked on an “evolution” program that has resulted in fundamental changes to the way in which we operate. 

    
...“experiential” visit.. 

...Definition of experiential. - relating to, derived from, or providing experience : empirical experiential knowledge experiential lessons...

Perhaps definition should include...'greasing the wheels'...'gilding the lily'...'pulling the wool over one's eyes' etc..etc 


MTF...P2 

[Gobbledock]

Of hi-vis vests and polishing turds

The Hooded one can dress up this accident with any decorations that he likes but it won’t alleviate the following facts;
1. The ATsB report is an absolute load of embarrassing piffle.
2. The appearance of cutting and pasting and ‘massaging’ of words from the USA’s ‘similar’ accident is glaringly, and embarrassingly, obvious.
3. The PIC may or may not have been a bit of a dubious character when it came to following S.O.P’s, and he may be the cause of the accident occurring, but would the outcome have been the same if the DFO had not been built, with consent, at the end of a runway and on top of that penetrating the OLS?

The Senate, eventually, must demand answers and must demand full disclosure and the full paper trail of who at CAsA signed off on the DFO to be built as is and where it is. The paperwork exists, an approval was granted, a risk assessment/safety case was undertaken, and all of this passed approvingly through CAsA’s fingers. No amount of HVH protection of the Minister can hide these facts.

P.S P2, in regards to the fu#kwit Moderators over on UP, assuming it is the same wankers that were there 4 years ago, it wouldn’t surprise me in the least if they are deleting/obstructing posts. That shit site has always been political and unless you bow down to those dickheads with inflated egos they do as they please. Jerkoffs

TICK TOCK

[P7_TOM]

GD – what do you make of this – 'Thing'

As much as it galls me to actually be impelled to quote a post on the UP; I may have to – unless, perhaps - I can find another way to debunk it. I shall try. Let’s see. Uhmm?

OK. Once in the dim and distant past (two decades) it was my privilege and absolute pleasure to fly for a well known RPT Be20 operation. That operation flew about 250,000 (guesstimate)  hours of scheduled services using the peerless 200 . The company was ‘top notch’, the Check and Training ferocious; the SOP cast in stone, reinforced by Senior pilots and C&T. There was a roller blind checklist (fully approved) which flowed through the entire flight operation. It was much easier and much more efficient to follow the check list and SOP than anything else. I was but a ‘pup’ – (10,000 hours multi command), under the IFR and I had much to learn. I have kept a ‘record’, a diary if you will, of all the reported anomalies I; or; other pilots experienced, for no other reason than a desire to learn and understand the aircraft and the operation. That diary, to this very day has provided insight into training. There are some pretty intricate, tricky, bloody awkward, ‘unusual’ puzzles there, which clever pilots managed and good engineers nutted and sorted out.

But never, not once – not on the whole world wide web- can I find anyone who has recorded a trim wheel grub screw becoming detached, rendering the position of the rudder trim ‘knob’ as not referring to the position of the actual rudder. Not a one. The reason for this is simple; there is a ‘detent’ within the circular hole the trim wheel sits on; a flat section which (rather neatly) fits the half moon shape of the spindle. Same as the knob on the car radio – get it….

Old mate the HVH is getting desperate now. He must have some Wally on the UP actually saying ‘his’ trim wheel not only fell off – but had other crew tricked into believing the position indicted was wrong? WTD – BOLLOCKS – Prove it = paperwork + crew reports+ engineering reports + Beechcraft AD+ all the associated hoopla attending. Absolute crap, totally amatuerish, un provable, ridiculous, puerile bull-sheee-it.

The Hood hold over the government – lest he sing his sorry Pel-Air song is well past it’s use by date and now, very much on the nose. Bring back our real ATSB – or: close it down. Industry has little use for the current diorama, drama, faery tales or horse pooh. It is becoming ridiculous; not to mention embarrassing.

Aggh – Can’t be bothered to elaborate this much further. NO. I shall have another Ale and put the dribbling’s of fools out of my mind. Make of it what you will.

[Peetwo]

Search 4 IP continues on YMEN DFO prang report - 

Follow the chain, via the UP:

Lead Balloon - So apparently the PIC did neither the cockpit/cabin check nor the external walk around check, at least not in relation to the rudder trim.


Still no explanation as to how the rudder trim apparently came to be set full NL before the flight. And the performance airborne with two engines producing full power was really poor - puzzling so - even assuming the rudder was trimmed full NL. 

Incredible. Really incredible. -   

---

Squawk7700 - A little bit of context. It's a very large trim. You'd think it would be hard to miss it. I also note what may be a slight off-set of the rudder to the right, despite the controls appearing to be in a neutral position.




Sincerest apologies if I have the wrong model.

---

Old Akro

Quote:

So apparently the PIC did neither the cockpit/cabin check nor the external walk around check, at least not in relation to the rudder trim.

The report notes that the pilot is seen doing a walk around on CCTV.

---

Old Akro

Quote:

A little bit of context. It's a very large trim. You'd think it would be hard to miss it

The big unanswered question is, assuming the trim was left full left for the take-off, could the pilot counteract it?

The report has not tested this.

They put a guy in a SIM, but he did not fly the accident profile. The SIM flew up to (or slightly over) 140 knots, but the accident aircraft did not get above about 112 knots airspeed (report lists groundspeed).. If the trim condition was the cause of the accident and the SIM flew the accident profile, then the SIM should have a) not got above 112 knots and b) crashed. 

The other alternative would be to do what the ATSB did in the last trim related fatal accident at Essendon - the Partenavia. in 1978. In this instance the ATSB flew a real aeroplane in a disciplined test manner and recorded the force required to counteract the elevator trim at different trim settings and airspeed. The results table was part of the report. I would think that a diligent report would have followed the same methodology the ATSB used in the past. 

As a result of the Partenavia accident an AD was issued soon after that changed the elevator trim limits. If the out of position rudder trim is so catastrophic and there is a history of other incidents, you would think that some review of the B200 rudder trim might be warranted and mooted in the report.

And then some more bollocks from Hoodlum (I mean) FGD135:

FGD135

Quote:

If the trim condition was the cause of the accident and the SIM flew the accident profile, then the SIM should have a) not got above 112 knots and b) crashed.

Old Akro, you are making the assumption that the sim is a 100% faithful replication of the real aircraft. Myself and several other posters have already pointed out to you that no simulator, of any aircraft, is that accurate - especially when flight "outside the envelope" is involved.

I suspect that, due to the large sideslip angle, the fin would have been fully stalled - thus putting the aircraft outside the envelope.

And you're also not allowing for possible differences in the physical performance of the sim pilot vs the real pilot. This has also been pointed out to you.

Quote:

... the ATSB flew a real aeroplane in a disciplined test manner and recorded the force required to counteract the elevator trim at different trim settings and airspeed.

I suspect that ATSB policy may not permit them to take a real aircraft outside the envelope. To have done testing with less than full NL trim may not have had sufficient validity - particularly whilst the fin remained unstalled.

 To which LB & OA replied...

Lead Balloon

Quote:

Originally Posted by FGD135 
Old Akro, you are making the assumption that the sim is a 100% faithful replication of the real aircraft. Myself and several other posters have already pointed out to you that no simulator, of any aircraft, is that accurate - especially when flight "outside the envelope" is involved.

I suspect that, due to the large sideslip angle, the fin would have been fully stalled - thus putting the aircraft outside the envelope.

And you're also not allowing for possible differences in the physical performance of the sim pilot vs the real pilot. This has also been pointed out to you.

I suspect that ATSB policy may not permit them to take a real aircraft outside the envelope. To have done testing with less than full NL trim may not have had sufficient validity - particularly whilst the fin remained unstalled.

Just goes to show how much of the report is based on speculation, fuelled by confirmation bias.

---

Old Akro

Quote:

I suspect that ATSB policy may not permit them to take a real aircraft outside the envelope. To have done testing with less than full NL trim may not have had sufficient validity - particularly whilst the fin remained unstalled.

Firstly, FGD. I disagree strongly with you, but do respect that you apply intellect & logic. 

But, a) simulators are commonly used to reconstruct accident scenarios. Its clear that the ATSB didn't do this. and b) we don't know what they did because they haven't provided any details in the report (unlike for example the Partenavia report). But the SIM flying they did and the conclusions they reached are from airspeeds outside that flown by the accident aircraft and therefore, invalid. 

You don't need to fly "outside the envelope" to test a hypothesis and I think the 1978 Partenavia report demonstrates this nicely. in this instance, the ATSB took a real aeroplane that was identical to the crashed one and had a pilot experienced on type fly it. The pilot flew a predetermined flight test that consisted of flying a range of different airspeeds at each of the marked trim settings. The control forces were measured at each airspeed / trim combination. When the pilot approached the limit of comfort of control-ability of the aircraft, he stopped and didn't proceed to the next trim setting / airspeed. 

If this testing was possible and warranted for the last trim related fatality, why wouldn't it be now?

A 1 hour flight, 2 brake pedal force transducers, a motec logger and this topic would have been nailed and if it was the smoking gun would have obviated the need for the whole sideslip calculation mess. 

The ATSB has not provided any firm evidence either in terms of statements from the manufacturer, interviews with other B200 pilots or flight test data to support its assertion that the aircraft was not controllable with full left rudder trim. If full left rudder trim can be counteracted by foot application of right rudder, then there is another factor at play (which may better fit the long take-off run which the ATSB has conveniently glossed over). 

The B200 aircraft certification requires that the pilot is able to counteract full elevator trim. There is no similar requirement for rudder trim, although someone pointed to another requirement that infers this. I would question whether full rudder trim leading to loss of control of the aircraft was diligent "fail safe" deign. 

The whole premise of the report is therefore based upon speculation.

As a passing coincidence (or not -   ) I note that today HVH and his loyal minions released the ATCB annual report: https://www.atsb.gov.au/publications/201...t-2017-18/
(Warning: There is a high probability (> 30% PROB) that a spew bag will be required -   )

[img=505x0]https://www.atsb.gov.au/media/5775181/cc_review_2017-18.jpg?width=670&height=302.156862745098&sharpen=2[/img]
In my second year as Chief Commissioner, the team and I have continued to position the ATSB as a multi-modal, teams-based, world-class transport safety investigation agency. At the start of 2017–18, the Australian Government allocated the ATSB additional funding to address the resourcing challenges encountered in previous years. We have used this funding to put the ATSB on a path of transformation.

And under the aviation section of the report: 

Aviation
During the year, we completed 25 complex aviation safety investigations and 34 short investigations.

The ATSB released the findings from its second investigation into the ditching of an Israel Aircraft Industries Westwind aircraft (VH-NGA) off Norfolk Island in 2009 (AO‑2009‑072). The release of this report demonstrates the diligence of the ATSB in ensuring that it drives safety forward. Thirty-six safety factors were included in the report, with the key message for flight crew, operators and regulators being that unforecast weather can occur at any aerodrome. There is a need for robust and conservative in‑flight fuel management procedures for passenger-transport flights to remote islands and isolated aerodromes. P2 - Kind of ironic when you consider this post today on the AP: http://www.auntypru.com/forum/thread-37-...ml#pid9433

Another published report relating to weather was the investigation into a collision with terrain involving an Airbus Helicopters EC 135 T1 (VH-GKK) at Cooranbong, New South Wales in 2015 (AO-2015-131). The safety message from this investigation is that avoiding deteriorating weather conditions requires thorough pre-flight planning. Pressing on into instrument meteorological conditions without a current instrument rating carries a significant risk of encountering reduced visual cues leading to disorientation.

Two reports were published covering pilot interaction with automated technology: a collision with terrain involving a Cessna 172 (VH-ZEW) near Millbrook in Victoria in 2015 (AO-2015-105) and a near collision involving Beech Aircraft Corp B200 (VH-OWN and VH-LQR) at Mount Hotham in Victoria in 2015 (AO-2015-108). Pilots need to have a thorough understanding of all systems on board their aircraft and have the skill to provide redundancy when those systems fail or their performance is reduced.

In addition to completing some significant investigations, a number were also commenced over the year. The collision with water involving a de Havilland Canada DHC-2 Beaver aircraft (VH-NOO) on the Hawkesbury River in New South Wales on New Year’s Eve drew substantial media attention (AO-2017-118). The ATSB response demonstrated our ‘on-call’ readiness at all times. The preliminary factual report was released on 31 January 2018.

P2 comment: Note how the ongoing high profile AAI(s) like the Perth Mallard prang; or the ATR bent tail occurrence; or even the YMEN DFO accident final report; do not even raise a passing mention -  


MTF...P2 

[6317alan]

Old Acro, has the Partenavia crash details all wrong, he is just following the then Departments coverup of the Design failure of the Trim System FAR 23 requirements on trim runaway pilot strength requirements, and then completely ignored thei Departments own requirements to flight test the aeroplane type before certification in Australia If the Department had followed their own requirements the accident would not have happened! They still tried to “Blame the Pilot” and probably would have gotten away with it had we died! The pilot is aderment he did not operate the trim switch and the Coroner believed him and so do I. The only test flight that actually tested the trim system properly was not carried out until Feb 1989, 11 years later on when another PN68 with the “modified Correct” trim installed had a trim runaway at Moorabbin! It only took 15 years of legal bullshit before they settled out of court.

[Peetwo]

Ironsider sees through the HVH bollocks?

6317alan - Thank you for 'correcting the record' - perhaps someone could point this out to OA on the UP?? From experience I am pretty that OA will not take offence and would me than willing to make the appropriate corrections...  

Coming back to HVH weasel words and bollocks AR, I note the following Ironsider article in the Oz today : https://www.theaustralian.com.au/busines...542278d39d

Backlog for aviation investigators
ROBYN IRONSIDE

The Australian Transport Safety Bureau completed only 9 per cent of its major aviation investi­gations within 12 months last year, despite employing 17 more investigators.

The ATSB’s annual report showed 23 “complex” aviation investigations were finalised in 2017-18, down from 27 the previous year and 32 in 2015-16.

Of those completed, just two met the 12-month deadline, well short of the 90 per cent target adopted by the ATSB.

Another 17 rail and marine investigations were completed, with only 25 per cent of the rail investigations meeting the 12-month deadline, and 8 per cent of marine investigations.

Chief commissioner Greg Hood said a concerted effort was being made to clear a backlog of older investigations that would lead to more timely investigations in the future. “The backlog was due to resourcing issues experienced by the ATSB prior to my commencement as chief commissioner,” Mr Hood said. “The government provided additional funding in last year’s budget which has enabled us to recruit 17 new investigators, (most) of whom started in February.’’

He said the completion of the ATSB’s involvement in the MH370 search and several other high-profile investigations had also helped boost the number of investigators. “While I accept full accountability for the performance of the ATSB, delays to investigations can sometimes also be attributed to influences outside our control,” Mr Hood said.

“It is also very important to note that the quality of an investigation, and its final report, remains of critical importance to me and the ATSB. In my two years as chief commissioner, I have received little negative feedback in relation to the quality of our serious incident and accident investigation reports.”

One area in which the ATSB did exceed its performance target was a 26 per cent increase in ­social media followers, well above the 10 per cent it had targeted.

As of June 30, there were 81 ongoing complex aviation investigations and 34 ongoing short ­investigations. These included more than a dozen investigations dating back more than a year, including the probe into three deaths in a Ross Air Cessna Conquest 2 crash at Renmark in South Australia, and an Angel Flight crash at Mount Gambier last June, which took three lives.

The ATSB is yet to deliver its final report on the Perth Skyshow crash that killed a pilot and his passenger on Australia Day 2017, or the in-flight engine failure on an AirAsia X A330 in June 2017.

Hmm...no comment - 

MTF...P2 

[Gobbledock]

Wrong wrong wrong

Toga boy said;

”Chief commissioner Greg Hood said a concerted effort was being made to clear a backlog of older investigations that would lead to more timely investigations in the future. “The backlog was due to resourcing issues experienced by the ATSB prior to my commencement as chief commissioner,” Mr Hood said”

That may be true as I believe that the former chief bean counter and mi mi mi-ing Beaker Dolan did indeed release about 30 staff of which many were incredibly qualified and experienced AI’s. However, Greg, a professional executive/CEO deals with the lemon he is handed when he starts. You never come out blaming previous management of saying piffle such as ‘this occurred before my time’. That’s pony Pooh. Crunch the numbers again, approach the new Miniscule and if you don’t get the resources you need then start leaking like a sieve to the media. Either that or due to a delay in an accident report being finalised it causes another accident to occur in the meantime, such as a Kangaroo tail protruding out of a smoking hole, and then watch the bucket of money get topped up!

Tick Tock

[Peetwo]

ANAO swallows Hoody's horse pooh sandwich??

Barely 2 months into it's audit of the ATSB the ANAO have wasted no time stripping off some of the sheen from Hoody's carefully plated up pickled horse pooh sandwich. However in the process it would appear that the ANAO has inadvertently inhaled some of the Hoody spin & bulldust (sob story) sprinkling and are already hinting at reprieves on their upcoming carefully O&O'd (i.e. not politicised during an election) wet lettuce report...   

From Ironsider, via the Oz today:
  

Audit office looks into granting ATSB more time for investigations
ROBYN IRONSIDE
The Australian Transport Safety Bureau may be given more time to complete complex investigations after falling miserably short of key performance benchmarks last year.

The Australian National Audit Office is reviewing the ATSB, which finalised just two aviation investigations within the designated 12-month time period in 2017-18.

Speaking exclusively to The Australian, chief commissioner Greg Hood said comparable agencies in the US, Canada and New Zealand had “more like two years to do an investigation”.

“So the ANAO is going to be having a pretty good look at the KPI (key performance indicator) in relation to time and we’ll be looking at the data we have, to work out what is an appropriate KPI,” Mr Hood said.

“It would be crazy to keep an arbitrary KPI when your data tells you 18 months is more ­realistic.”

He acknowledged that the ­bureau was most criticised for the length of time it took to complete investigations but rarely for the quality of the work it did. P2 comment - What a load bollocks - IMO the commissioner filtered PC crap that has been coming out of the ATSB in recent years simply beggars belief...  

The bureau now has 153 open investigations on its books, 110 of which relate to aviation after an “annus horribilis” last year.

“We had 22 (aviation) accidents last year resulting in 41 ­fatalities,” Mr Hood said.

“In 2018 thus far we’ve had eight fatal ­accidents and nine ­fatalities. You tend to get unpredictability in ­accidents in the aviation sector from one year to the next.”

Mr Hood also revealed that the ATSB was partnering with a registered training organisation after letting its own RTO status lapse a few years ago because of cost.

“We’re not really a training ­organisation, we’re a doing ­organisation,” he said. “But without an RTO partner, we had no pathway to tertiary accreditation for our people, which is important from a credibility perspective ­internationally and also from the coronial perspective.”

As well as training ATSB ­investigators, the yet-to-be-named RTO partner will train others in the industry such as marine investigators and those from the airlines.

“They’ll have a structured program to put people through and that’s got to be good for the industry and for the whole Southeast Asia, where there’s a bit of a gap in terms of who trains transport safety investigators,” Mr Hood said. “We’re really hopeful the partnership will deliver good ­accredited training for us.”

ATSB investigators may even need a broader skill set in future, with the Department of Infrastructure, Regional Development and Cities examining what ­agency should look into things such as space-related crashes or autonomous vehicle incidents.

“Together with the department, we’re working towards a ­vision for 2025, and what we think the ATSB is going to look like in seven years’ time.”

Do you get the impression that HVH is trying to manipulate the running of the ANAO audit? Why is he talking out of school and almost trying to preempt the ANAO audit team's conclusions? 
Hmm...Hoody trying to influence an audits outcome reminds me of this not so long ago...  

http://www.auntypru.com/forum/thread-139...ml#pid6816

http://www.auntypru.com/forum/thread-139...ml#pid6908

Safety boost from Thor’s ICAO audit

Thor Thormodsson has spent the past eight years travelling the world undertaking safety oversight audits for the International Civil Aviation Organization (ICAO).

Excerpt from a Kathryns Report blog post  : http://www.kathrynsreport.com/2014/01/ai...-body.html

Hmm...this is it the bit that should ring alarm bells (but probably won't -  ) for the Murky Mandarin and his minions...

...“To learn from an accident, we need reports that are complete, accessible and timely.

"We also need states to fully respect the standards and processes enshrined in global agreements for participation in the investigation by all specified parties.”

Aviation safety can also be improved with proper communication between regulators and industry in order to ensure that industry experience and know-how is suitably incorporated into new regulations and standards...

  
And we all now know how that turned out i.e. once again slapped with an ICAO wet lettuce...  

ref: https://infrastructure.gov.au/aviation/i...t_full.pdf

AIG: Fully implement the ATSB’s action plan to ensure that all accident and incident investigation reports are completed within the established timelines. 

Hmm...still wonder where the so called 'corrective action plan' is?

5.1 In accordance with the MOU agreed to between Australia and ICAO, Australia replied in a letter dated 23 February 2018 that it had no comments on the draft report and also reiterated its commitment to develop its CAPs accordingly. 

MTF...P2 

[Gobbledock]

HOODY SPEAKETH PIFFLE, FOLLY AND WAFFLE

Granted, it was ridiculous when the ATsB ditched its RTO capability. It was detrimental to the workforce. It also occurred during the systemic demise and dismantling of the once reputable organisation along with mass redundancies of experienced people under the direction of idiot management and even more idiotic Ministers. Perhaps the Minister and Prime Ministers department have become bored with handing over billions of our dollars to PNG, Indonesia, the Clinton Foundation and the UN and they have a couple of leftover crumbs to feed Hoody’s desire to improve safety?

The Hooded one said;

”Mr Hood also revealed that the ATSB was partnering with a registered training organisation after letting its own RTO status lapse a few years ago because of cost.“We’re not really a training ­organisation, we’re a doing ­organisation,” he said. “But without an RTO partner, we had no pathway to tertiary accreditation for our people, which is important from a credibility perspective ­internationally and also from the coronial perspective.”As well as training ATSB investigators, the yet-to be-named RTO partner will train others in the industry such as marine investigators and those from the airlines”.

Greg, forget it. Too much expense for too little gain. Just send each Investigator or newbie to Cranfield in the UK. 6 weeks at around $35k. Some of the best training they will ever receive! Much better standard than Australia’s chickenshit standards.

Tick $$$$ Tock

P7 addendum - Amen to that - Hood is winging it - without feathers, ticker or ability. Not necessarily in that order. Verbal flatulence however, seems to be in oversupply. Tweet tweet, little Canary......................

[Peetwo]

ATSB WOFTAM investigation AO-2018-075 - WTD?  

If Hoody is seeking to find some serious cred while the ANAO wet lettuce crew are hanging around I really have my doubts whether this one will do it... 

From Ironsider via the Oz: 

Snoozing pilot misses landing
The FlightAware data that shows how the pilot of a Piper PA-31 Navajo overflew its destination by 46km, before turning back.

• ROBYN IRONSIDE
  AVIATION WRITER
  @ironsider[img=0x0]https://i1.wp.com/pixel.tcog.cp1.news.com.au/track/component/author/6e7c15929181150836944cea1b4d0979/?esi=true&t_product=the-australian&t_template=s3/austemp-article_common/broadsheet/components/article-author/widget&td_bio=false&td_location=none[/img]
  
• 1:22PM NOVEMBER 26, 2018
  

An investigation has been launched into an incident in which a pilot fell asleep during a one-hour charter flight, resulting in the aircraft overflying its destination by 46km.

The 6.21am Vortex Air flight from Devonport to King Island on November 8 ultimately landed safely despite the pilot’s mid-flight snooze.

FlightAware data shows the trip was the first of seven flown that day by the Piper PA-31 Navajo, which can carry up to nine passengers.

The Australian Transport Safety Bureau is treating the incident as a “pilot incapacitation” and a spokesman declined to provide any further details.

It is understood the ATSB made the decision to investigate after receiving more information about the flight.

As part of the investigation, the ATSB will interview the pilot and review operational procedures of Vortex Air.

The company’s managing director Colin Tucker refused to comment.

A final report on the incident is expected early next year

And from the ATSB website maze... 

The ATSB is investigating a pilot incapacitation involving a Piper PA-31, VH-TWU, operated by Vortex Air, near King Island Airport, Tasmania on 8 November 2018.

During the cruise, the pilot fell asleep resulting in the aircraft overflying King Island by 46km.

As part of the investigation, the ATSB will interview the pilot and review operational procedures.

A final report will be released at the conclusion of the investigation.
 

Hmm...maybe the HVH ATCB crew are trying to bump up their 'pilot incapacitation' stats ... 


Quote from ATSB website: https://www.atsb.gov.au/about_atsb/inves...dures/#fn1

...In addition, the ATSB has observed that many accidents involve repetition of past occurrences where the contributing factors are similar and the safety issues are well known...

The apples and oranges of AAI? 

So why is the ATSB investigating an incident, that from the outside looking in, has the simple conclusion that the pilot was tired and possibly fatigued? Shouldn't this be a straight forward case for the regulator to investigate?

Now compare that to the following disturbing article from the other Aunty yesterday...

Five bush pilot deaths within a month spur calls for improved training
ABC Broken Hill 
By Rhys Carman
Updated yesterday at 10:53am



PHOTO: The plane that crashed to the ground leaving two people seriously injured near Menindee. (Supplied: Barrier Police District)

A recent rash of fatal light aircraft crashes in far west New South Wales has led a former commercial airline pilot to call for more rigorous training for bush pilots.

Throughout October and November there have been four serious light aircraft crashes in regional New South Wales, leading to five deaths and putting two other people in hospital.

Four men died on the same day on late October, only hours apart, beginning with a gyrocopter crash in Orange killing two.

Three hours later, another light aircraft went down north of Wentworth in the state's far south-west killing 20-year-old Kayden Cullinan and 22-year-old Nicholas Walters.

On November 18, a 50-year-old man was killed when his aircraft crashed on a stretch of road on a property near Moree.

And on November 19, a plane crashed into the ground on a property near Menindee, 100 kilometres east of Broken Hill, seriously injuring a 53-year-old man and a 47-year-old woman.

They were flown to the Royal Adelaide Hospital and remain in serious but stable conditions.

Paul Martin, the general manager of livestock at large pastoral producer Webster Limited, was once an airline pilot with Virgin Australia, City Jet Air in France and QantasLink in Western Australia before settling in Outback NSW.

He said the spike in light aircraft crashes was taking its toll on the agricultural industry, when times were tough enough in the Outback with families battling the drought.

Mr Martin, who stressed that he was not commenting on the recent crashes, is calling for improved pilot training and safety.

"We've got to get really involved with the process of education and training. If we don't get this stuff sorted out, there's going to be more deaths," Mr Martin said.

"There will be more people killing themselves and tearing more small communities apart."

Mr Martin said he wants to see a program established to offer ongoing training to all people who fly light aircraft in regional Australia.

"These bi-annual flight review programs are not enough for those who are constantly engaged in low altitude operations," he said.

Mr Martin singled out gyrocopter pilots, who he said were not covered by the bi-annual flight review program that their fixed-wing compatriots must follow.

"The rotary wing pilots in the gyrocopters, they don't go through any training ever again for the rest of their lives. To me that's absolutely farcical," he said.

Civil Aviation Safety Authority spokesman Peter Gibson said he believed there was always room for more training when dealing with light aircraft.

"One of the hardest things when dealing with people in regional areas is the isolation and getting out to them to administer training where appropriate," he said.

"We are committed to keeping some of the highest standards of aircraft training in the world."



PHOTO: Gyrocopter pilots are not required to retrain throughout their career after obtaining their licence. (ABC News)

The type of work that people do in light aircraft on Outback properties is imperative to being productive on the land.

Bush pilots fly in dry, dusty conditions, and there are constant distractions and pressure to get the job done.

"Without the aircraft in the skies things would be so much harder out here, especially in these dry times," Mr Martin said.

"The water run on our property would take two days in a car. I can get it done in two hours flying around the property.

"So we have to improve our training and education. It's a must."

 
Surely the ATSB could mount a strong argument for instigating and committing resources to a systemic investigation into these spate of regional remote fatal accidents - 

Tweeting the above prompted an interesting response from Dr K from the Limerick University in Dublin, Ireland:

Five bush pilot deaths within a month spur plea for constant retraining https://www.abc.net.au/news/2018-11-24/p...e/10550174 … via @ABCNews

---

Dr K I Kourousis
@K_Kourousis 

Need to check the details around these accidents; I am not sure if they investigated by ATSB or the RAA. Don't get why RAA is given the authority to investigate any accidents though.

And my response:

...Do you mean RAAus? If so RAAus are self-regulated see here: http://www.auntypru.com/forum/thread-37-...ml#pid9553 … & part I here: http://www.auntypru.com/forum/thread-116...ml#pid9567 … therefore RAAus will investigate all accidents/incidents of a/c registered under RAAus & depending on resources ATSB will investigate VH registered accidents...

---

It would appear the crash at Wentworth near Mildura that killed 2 was a RAAus aircraft but the ATSB is providing technical assistance: https://www.atsb.gov.au/publications/inv...-2018-072/ … as for the gyrocopter fatal on the same day ATSB are again providing technical assistance: https://www.atsb.gov.au/publications/inv...-2018-073/ …

---

Dr K for a really good review on how the RAAus self-administration (CASR Part 149) system works (or not) please refer to @aopaaustralia tweet here: https://twitter.com/aopaaustralia/status...4157247488 … one day the ATSB won't investigate aviation accidents at all, they'll just provide technical assistance...

And Dr K's response:

Exactly. Why's is there a need for two regulatory regimes? Why is RAAus regulated aircraft not subject to independent reviews (rather they are investigated by RAAus)? Technical assistance by ATSB is a different story.

Finally my reply:

"Why's is there a need for two regulatory regimes?" - Short answer is there isn't, except if your the Big R-regulator trying to marginalise sectors of the GA industry through division - see Part II here:http://www.auntypru.com/forum/thread-116...ml#pid9567 … or @aopaaustralia here:  https://parlinfo.aph.gov.au/parlInfo/sea...nt=Default 

&..

As for the ATSB not investigating RAAus and/or most private pilot GA accidents/incidents, Australia have notified a difference to the ICAO Annex 13 SARPs - see here: http://www.airservicesaustralia.com/aip/...18-h44.pdf … under para 5.1.1 & 5.1.2: http://www.airservicesaustralia.com/aip/...gation.pdf …

P2 QON - So the question is why do we persevere with the funding of the obviously conflicted, non-independent, CASA lapdog the ATSB? Why don't we simply just keep the technical lab expertise of the ATSB and in the process save the taxpayer millions? 

MTF...P2 

[Peetwo]

Ironsider follow up to snoozing pilot incident - 

via the Oz today:

Pilot fell asleep at wheel
ROBYN IRONSIDE
Two investigations are under way into a freight flight that overflew its destination because the pilot was asleep

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Freight pilot’s 40 winks propels two safety investigations

Two investigations are under way into a freight flight that overflew its destination by almost 50km because the pilot was asleep.

The Civil Aviation Safety Authority is investigating the fatigu­e management practices of flight operator Vortex Air.

The Australian Transport Safety Bureau is also investigat­ing the incident, which it classified as “pilot incapacitation”.

The flight left Devonport in Tasmania at 6.20am on November 8, to make the 250km trip to King Island. It was the first flight of the day for the Piper PA-31-350 Navajo Chieftain, which can carry up to 700kg of freight.

The Australian understands the pilot reported for duty despite having had little or no sleep the prev­ious night due to a personal crisis. He was the only person on board and, according to the ATSB investigation summary, fell asleep during the cruise part of the one-hour flight.

It’s thought a radio call may have woken him after the aircraft overflew King Island Airport by 46km. The Piper landed safely just after 7.20am, then went on to do six further flights that day.

The ATSB investigation was launched in response to “addit­ion­al information” received by the bureau in the past week but a spokesman was unable to provide any further details.

As part of the investigation, the pilot would be interviewed and operational procedures reviewed, the ATSB summary said.

A CASA spokesman said its investigation would focus on the fatigue risk-management practices of Vortex Air to ensure it met Australian standards.

Vortex managing director Colin Tucker refused to comment yesterday on the incident.

Devonport Airport general manager Dave Race said Vortex Air was a reputable and safe operator that conducted regular flights, carrying freight and passengers to King Island, which boasts three golf courses.

King Island Council Mayor David Munday also described Vortex as a “professional” airline.

Research undertaken by the ATSB on pilot incapacitation incide­nts in Australia between 2010 and 2014 found they were rare in the general aviation sector.

There are only two reported cases of pilots falling asleep on the job. In one case, the pilot of a Cessna 210 Centurion awoke to find he had entered controlled airspace twice without clearance while flying from Port Macquarie on the NSW mid-north coast to Bankstown in Sydney. In the second, a passenger awoke the pilot of a Gippsland GA-8 who nodded off doing locust spotting over farmland in Ardlethan, NSW.

MTF...P2