Before we go any further, please note – we DO NOT as yet have all the facts related to this incident. Before an impartial assessment there are some questions to which answers must be found.
The three headed dog, aka Cerberus is, once again, in the headlights; they have a part in each and every act in this tale. The CASA in the lead up to the incident, the ASA for their part and the ATSB, who, with their usual cunning have diluted the entire event to an ‘unstable approach’ which is a Bollocks for starters.
First the questions of the pilot:-
Did the GPS test OK before departure?
Was there a RAIM test conducted prior to committing to the Hotham approach?
Did the GPS ‘do it’s job’ and get the aircraft safely to the initial approach fix for Hotham?
At any stage of flight, particularly before committing to or starting an approach in ‘for real’ weather, what is the accepted norm for any ‘abnormal’ indication after cross check? ; correct CW, get some clear air, height and let folks know what you are doing. BUT one of the minor problems of having but one GPS unit and no ground aid to cross check against, is, how in the seven hells are you to know there’s anything wrong? until the CFIT. In both the Lockhart and Bennella fatal accidents, this question was never satisfactorily answered. We are blessed this time; a radar trace and no one hurt (nod to the gods). So much for the GPS, the MR* will tell part of the story. The pilot should have written volumes after such an event.
MR* in very broad terms; a flight deck document, on which the Pilot records, amongst other data, any item that has failed, not tested correctly or is not functioning as it should. Any ‘endorsement’ requires an engineering sign off before a return to service.
The next item which is of some interest is the communications log, the exchange with Air Traffic. It can be a little challenging when there are multiple aircraft arriving at a destination where the weather is a factor. Routinely, the pilot advises the area controller of a transfer to the ‘common’ frequency, this allows contact with all other aircraft within the defined area, normally, the pilot will listen to the ‘area’ but communicate with any other ‘local’ traffic on ‘common’. This is important, as most will understand, without TCAS it is impossible to ‘see’ through cloud and sight traffic which may, or may not be conflicting. This is done quite easily through accurate reporting of height, distance and bearing from a known position. For example you are ten miles North of Hotham at 14, 000 feet, expecting to commence the instrument approach – on the hour. Another aircraft is five miles North of Hotham, leaving 9000 feet, outbound on the approach: the crew can quite easily ensure safe margins through height and speed management. Now then; the first aircraft fails to become visual; no problem, the missed approach procedure is executed and the aircraft follows a prescribed path to safe height and normally is able to track back to the start of the approach, the other traffic is advised and it becomes, just another day at the office. But if any one of those ‘guarantees’ fail the risks increase.
I only labour the point (and bore those who understand) because in this incident almost all safeguards were lost; particularly if the pilot had NFI the GPS was leading him astray. Had the reliance been on basics; time, speed, rate of descent, heading and wind allowance, using the GPS to support the ‘mind map’ then, perhaps, the ‘all’s not well’ penny would have dropped sooner and a rapid exit, stage left, could have been accomplished with a minimum of fuss.
But it’s all speculation; I wish ATC could have chimed in – with a WTF you playing at; but I’d like to know if they had some communications, even just for Search and Rescue (SAR) watch expiry time; odds on bet they had an update, it’s quite normal during bad weather for a scheduled ‘operations normal’ time to be given and, ATC may not be alarmed at an aircraft ‘wandering about’ looking for a cloud break to descend through; so criticism of the ATC is ‘unfair’. The system is dreadful, not the coal face kids on the consuls.
Anyway, more questions than answers – as usual – . Let’s hope that if (IF) the pilot made a mess of the approach and failed to ‘sort it’ that the system is robust enough to allow a honest mistake, flexible enough to allow for a retraining period and any subsequent testing is honest and impartial. Did not happen to Dom James and a couple of others, one mistake, career blown away. Makes it hard to own up and seek redemption through rehabilitation.
Cerberus bites; not only the hand which feeds it.
Apologies to those who have worked it out, my sympathies to the pilot and nothing for a system which can and does create these untenable situations.
Toot – toot.
