[Kharon]

Boys and girls – Aunt Pru rules apply to this one; no speculation on this site - not until the ATSB have finished their work. There will be enough armchair experts banging their gums, speculating and generally attempting to insert their own ideas into the why and the how of it. None of it remotely helpful. Spare a thought for those did a fine job of the SAR, took and are still taking risks to establish some facts and piecing together a complex jigsaw puzzle in extraordinarily difficult conditions.

Well done the rescue crews and all who assisted; a heartfelt thank you is warranted. Let’s hope the ATSB can eliminate the obvious quickly and get this one done in a timely manner.

Patience;

Toot – toot.

[Peetwo]

Topcover or not to topcover; that is the question?  

Just catching up on the latest Hooded Canary PC'd AAIs...

First from last week, via the Oz:

CFS crew survive scary landing

ROBYN IRONSIDE
CFS volunteers were left very shaken by a dramatic landing of a charter flight which caused significant damage to the aircraft.

---

An investigation is underway into the dramatic landing of a charter flight carrying Country Fire Service volunteers at Mount Gambier in South Australia.

According to an Australian Transport Safety Bureau investigation brief, the Beech Aircraft B200 operated by Desert-Air Safaris made a hard landing and ground strike, causing significant damage to both propellers.

The ATSB said the pilot reported difficulties landing at the airport, and was unable to stop the aircraft on the runway after a heavy landing.

“(The pilot) decided to conduct a go-around … and then conducted another approach and landing,” said the ATSB brief.

“The post-flight inspection of the aircraft revealed substantial damage to both propellers.”

Photographs of the aircraft shared on the pilots’ forum pprune.org, show the propeller tips bent at right angles, apparently as a result of hitting the runway.

None of the nine CFS volunteers on board were injured but The Australian understands they were left very shaken by the incident last Saturday, December 8.

Emergency services were called to the airport which was initially reported as a “light plane crash on tarmac with fuel leaking”.

South Australian police are also investigating.

Aircraft operator, Dick Lang’s Bush Pilots, have been contacted for comment.

As part of the ATSB investigation, “relevant persons” including the pilot will be interviewed, and engineering reports obtained.

A final report is expected in the second half of next year.

---

ATSB investigation page: https://www.atsb.gov.au/publications/inv...-2018-080/

Summary

The ATSB is investigating a hard landing and ground strike involving a Beech Aircraft Corporation B200, registered VH-ODI, operated by Desert-Air Safaris, at Mount Gambier Airport, South Australia, on 8 December 2018.
The pilot reported experiencing difficulties landing at Mount Gambier. After a heavy landing, the pilot was unable to safely stop the aircraft on the runway and decided to conduct a go-around. The pilot then conducted another approach and landing. The post-flight inspection of the aircraft revealed substantial damage to both propellers. No one was injured as a result of this occurrence.
As part of the investigation, the ATSB will interview relevant persons, including the pilot, obtain engineering reports and other additional information.
A report will be published at the conclusion of the investigation.

Next from Oz Aviation yesterday:
 

ATSB INVESTIGATING VIRGIN AUSTRALIA ATR 72 ENGINE FLAME-OUT INCIDENT
written by Australianaviation.Com.Au December 18, 2018

File image of a Virgin Australia ATR 72-600. (Seth Jaworski)

The Australian Transport Safety Bureau (ATSB) says it is investigating an incident involving a Virgin Australia ATR 72 where both engines on the regional turboprop airliner flamed out, one after the other, while flying in heavy rain.

The incident near Canberra airport involved ATR 72-600 VH-FVN while on a flight from Sydney, the ATSB said on Monday afternoon.

“While the aircraft was descending through 11,000ft in heavy rain, the right engine’s power rolled back (decreased) and the engine flamed out. The engine automatically re-started within five seconds,” the ATSB said.

“The descent continued and, while passing through 10,000ft, the left engine’s power also rolled back and that engine flamed out before automatically relighting. The crew selected manual engine ignition for the remainder of the flight and the landing.”

The aircraft landed safely without further incident, but the flight tracking website flightaware.com shows VH-FVN remained on the ground in Canberra for the following three days, before returning to service operating a flight to Sydney on Monday morning.

The track flown by VH-FVN on its December 13 flight from Sydney to Canberra. (flightaware.com)

The ATSB says it has begun the evidence collection phase of its investigation into the incident, and that it has downloaded the aircraft’s flight data recorder.[size=undefined]

[size=undefined]Investigations typically take 12 months to be completed, but the safety investigator says that: “Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate action can be taken.”[/size][size=undefined]

VH-FVN was delivered new to Skywest Airlines, for operations on behalf of Virgin Australia, in September 2012 (a month before Virgin Australia announced its intention to acquire Skywest, which was subsequently renamed Virgin Australia Regional Airlines).

The aircraft is powered by Pratt & Whitney Canada PW127M turboprops.

[/size][/size]

---

ATSB investigation page: https://www.atsb.gov.au/publications/inv...-2018-081/

Summary

The ATSB is investigating an engine-related occurrence involving ATR 72-600, VH-FVN, near Canberra Airport, Australian Capital Territory, on 13 December 2018.
While the aircraft was descending through 11,000 ft in heavy rain, the right engine’s power rolled back (decreased) and the engine flamed out. The engine automatically re-started within five seconds. The descent continued and, while passing through 10,000 ft, the left engine’s power also rolled back and that engine flamed out before automatically relighting. The crew selected manual engine ignition for the remainder of the flight and the landing.
As part of the investigation, the ATSB has downloaded the flight data recorder and will be gathering additional information.
A final report will be released at the end of the investigation.
Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate action can be taken.

Hmm...that 2nd one I would definitely like to see a weather radar depiction of the storm cell that could create a heavy enough rain shower to flame out both engines? - just saying...  


MTF...P2 

[Kharon]

Me too!. WTD.

P2 – “Hmm...that 2nd one I would definitely like to see a weather radar depiction of the storm cell that could create a heavy enough rain shower to flame out both engines? - just saying”...

I would like to know what the hell drove a crew to persist, despite ‘radar’ and terminal advice and the METAR and the TAFOR and the Area forecast to continue the approach? Large ‘Red’ lumps on the radar, Canberra’s notorious turbulence, tall rocks and tress and stuff. Brave, stupid or; conditioned by HR to ‘maintain the on-time’ bullshit?

If conditions are demonstrated to be so bad that the Auto ignition is actually used it’s a fair call that the aircraft had no bloody business being there in the first place.

“Canberra tower VARA 123, we’d like to hold in our present position to allow the weather to pass through.

ATC – Rodger VARA 123, hold North of 25 mile DME on the 030 Canberra VOR radial, two minute right hand pattern maintain FL 120; advise when ready for descent.

10 – 15 minutes later, routine ‘bad weather’ approach and landing. Time for a coffee, “Sorry for the delay folks, as you may have noticed, the weather today is not user friendly – have a nice day”.

Easiology 101. You bet.

Toot - toot.

[Peetwo]

Interim factual released:  AO-2017-118 Collision with water involving de Havilland Canada DHC-2 Mk 1 (Beaver), VH‑NOO Jerusalem Bay (Hawkesbury River), NSW, on 31 December 2017

Interim factual report released into Hawkesbury River floatplane accident

The Australian Transport Safety Bureau (ATSB) have released an interim factual report into the collision with water involving DHC-2 Beaver floatplane, VH-NOO, which occurred at Jerusalem Bay, adjacent to the Hawkesbury River, NSW, on 31 December 2017.
[img=208x0]https://www.atsb.gov.au/media/5775495/ao2017118_seaplane_newss.jpg[/img]
The interim factual report updates the known circumstances of the accident to date, including the aircraft’s flight path prior to the accident, environmental conditions, post-accident aircraft examination, maintenance history and pilot experience.
ATSB Executive Director, Transport Safety, Mr Nat Nagy, said it is important to note the ongoing nature of the investigation.
“It is important to note that the ATSB’s investigation into this tragic accident is ongoing, so we are constrained on the information we can release publicly at this time,” Mr Nagy said. “However, the interim report, which we released today, does provide a factual update on the investigation so far. The report does not include any findings or recommendations – these will be provided in a final report, which we do anticipate to be released in the first half of next year.”
After taking-off from Cottage Point, the aircraft climbed and turned right into Cowan Creek heading towards the main Hawkesbury River into the prevailing wind on a standard departure path. However, while over Little Shark Rock Point, the aircraft made a right turn, reversing its direction. The aircraft levelled out before flying on a straight path directly towards Jerusalem Bay with a tailwind. Shortly after, the aircraft entered Jerusalem Bay at an altitude below the surrounding terrain height.
As the aircraft approached Pinta Bay the aircraft was witnessed to make a steep right turn. During the turn, the aircraft’s nose suddenly dropped prior to colliding with the water in a near vertical positon.
The interim report outlines the post-accident aircraft examination and aircraft maintenance history with no evidence of any pre-existing issues found.
“With no on board data available from the aircraft itself, transport safety investigators have been able to use witness statements and images retrieved from one of the passenger’s cameras, to determine what happened in the lead up to this accident,” Mr Nagy said. “The ATSB’s investigation is continuing and will now look at a number of factors surrounding the pilot’s health and medical history.
“We have engaged an aviation medical specialist to assist with reviewing the pilot’s medical records as well as the autopsy results, which the ATSB has recently received over the past month. That review is now underway and we expect the results to appear from that over the coming months.”

MTF...P2 

[Kharon]

From the ABC.


Scary and not remotely funny, every pilot’s nightmare – fire in the cockpit. Lady luck played a hand in this game; well done all. Nice to home for Christmas and on the road to recovery.

Just one question; where was the cockpit fire extinguisher and it's condition when the ATSB found it? Surely the ATSB can tell us what caused the fire and how to prevent another; maybe even recommend 20.11 type training as part of another informative report.

"I learned about flying from that". Alas.........

Toot - toot

[P7_TOM]

Knocking on heavens door.

With it being the weekend before the great annual ‘knock-off’ there is a shortage of technical insight to the extraordinary accident mentioned above; however, here are a great many questions which, I believe, need answers – from the ATsB, CAsA and possibly the training outfit.

In an airborne fire situation, as any boy scout will tell you, an ability to contain and supress the flames; and, to isolate the heat source is essential. These are  fairly important systems to have in an aircraft engine bay; there ain’t in reality much in the way of ‘combustible’ material in there. Lots of ‘heat’ sources but not too much you could throw on a BBQ to cook the snags with.

One of the big dangers is ‘fuel’, particularly fuel under pressure – spaying – even the most humble of aircraft have a system which, in an emergency, can stop fuel entering the engine bay, behind the engine fire-wall i.e. a fuel cock (tap) located within the cockpit.  In a single engine aircraft, turning off the fuel supply will stop the engine running, leading to forced landing (with luck) but the aircraft is not burning. With proper maintenance the chances of a ‘fuel-fed’ fire in an engine bay equal those of winning the Lottery.

If you take ‘fuel’ out of the mix, you may as well exclude ‘oil’ which needs a lot of provocation to ‘burn’; which leaves us with ‘electrics’. Fuses, known as circuit breakers are built into the system to protect against ‘over-heat’ – or overload creating heat if you prefer and ‘short circuit’. To keep this as simple as possible; think of a car or even a motor bike. The battery is used to ‘start’ the engine, once the engine is running, the ‘Alternator’ becomes active and will replace the ‘charge’ taken out of the battery used during the start; then the Alternator will 'feed' the heavy current use items, and only top up the battery as and when required. It is a heat source and a potential spark producer. Should the Alternator warning flash (ring, beep or whatever) or the ‘gauge’ starts showing an overload condition – there is ‘usually’ a system provided to isolate the Alternator; even if it only a simple circuit breaker; it is essential that the system can be ‘controlled’. Removing a ‘heat source’ and potential damage to essential systems. This leaves us with the battery. Lead Acid (car battery) can produce Hydrogen, when charging. The aircraft battery is usually ahead of the engine firewall; or isolated within the airframe and ‘vented’ to prevent any chance of an explosive gas becoming a danger. So far, so good.

So, WTD happened in Tasmania? A glass fibre aircraft caught fire at altitude. Why?

I would also be interested in the procedures used to contain and control the fire. As in was the pilot able to isolate the Alternator; could he isolate the battery; why was the entire ‘heat source’ not shut down immediately the fire was determined to be ‘uncontrollable’; was the ‘circling’ necessary? 

"[and] that Inspector Hopkins circled above Hagley for a short time, looking for an area to make an emergency landing.

Was the fire extinguisher used after all methods of fire control had failed?

As stated, not enough technical ‘systems’ control data at hand – or; even situational details.

Fire – airborne is potentially lethal, fiberglass burns.

Please note: I am in no way knocking or denigrating the pilot. Senior, seasoned police officers are not known for their lack of courage, calmness or stupidity. He did remarkably well and earns a Choc frog for a job well done (and a beer if I ever get to meet him). But I am left wondering about (a) what was the root cause of the fire; (b) what systems control are available to contain ‘fire’ (heat); © why are the ATSB not investigating the accident?

That’s it, nothing else except to wish ‘Hoppy’ a speedy recovery and a merry Christmas. Curiosity is a bitch though ain’t it.

Sweetheart – these pilgrims here are thirsty – could you oblige; thank you……..

[P7_TOM]

Get on with it. (Royal command).

Aunt Pru has decided I need to follow up on this incident. I have plead ignorance of ‘all’ facts – however – needs must when the Devil drives. I have been able to establish that it was – in all probability – a fuel fed fire. Here we run into a nightmare of ‘certification’ details. It seems at first glance – please note – first glance – that there is little ‘control’ of the fuel supply system forward of the firewall through the ‘plumbing’. It is acceptable for the first 50 hours of the approval process to use pretty much whichever lawn mower or ,motor bike fuel supply lines and fittings are on special at Bunning’s.

Should those supply lines last for the initial 50 hours of ‘test flying’ then they be accepted as suitable for the next stage in the certification process. And so it goes. Until the homebuilt Tupperware is deemed suitable for a VH registration.

Not a bad system, not too bad at all, until a fuel line junction decides to quit and sprays fuel into an engine bay. Heat source, air and fuel combined, in the right proportions = FIRE.

Non of my business what folk choose to use as fuel lines or fittings – non at all – however. 

“The answer to that question M'boy (he's new) is always Yes – unless I say No – Yes, thank you – I will.

[Gobbledock]

Council workers been laying runways again with road bitumen?

From Your GayBC;

Sticky situation at Geraldton Airport strands passengers as new tarmac on runway fails to set

https://mobile.abc.net.au/news/2019-01-2...fmredir=sm

More of an incident rather than an accident. But I don’t buy the Council bullshit story. Someone ducked up the project big time. Weather is no excuse. They knew the risks prior to laying the new rubber. They could’ve cancelled the work at the last minute. Expensive exercise yes, but not as expensive as this cockup will prove to be!! Oops.

[Kharon]

From the annals of the Un-ducking-believable:-

Oggers – “The 'taxiway' is halfway down the runway. I would have thought that the operation whose pilot believes a landing half way down a 637m strip is normal, has issues with its training and supervision”....Choc Frog.

Not buying into this one – ATSB missed the point by a country mile. But I do wonder just who is training our children and how? Um – short field take off, landing and the risks associated? Anyone. Lucky that strip was dry. Yup; definitely in the UDB category.

Toot - head shake - Toot.

[Peetwo]

Tales of Robo cracking cylinders and class actions - 

Via Ironsider in the Oz...

Class action looms in chopper probe

ROBYN IRONSIDE

A mystery gremlin causing potentially dangerous cracking in helicopter engine cylinders could be the subject of a major class action once the culprit is found.

An investigation by the Australian Helicopter Industry Association with assistance from the Australian Transport Safety Bureau aims to pinpoint the cause before mustering season gets into full gear in April.

AHIA and investigation chairman Ray Cronin said the premature cracking of exhaust valves in piston engines had increased by up to 400 per cent over the past four years.

“There’s really two issues — an inlet valve issue and an exhaust valve issue,” Mr Cronin said.

“The inlet valve failures are a lot more dramatic — they have a sudden loss of power. The exhaust valve failures are less aggressive yet the power denigration is significant.

“In that situation where a pilot needs the full power available, that could easily lead to an accident and we need to prevent this.”

The helicopters most vulnerable to the problem are the Robinson R22s and the R44 Raven 1s, with an estimated 700 cylinders being replaced in the Northern Territory in the past four years.

Mr Cronin said the investigation was leaving “no stone unturned”, looking at every possible cause including climate, parts supply and fuel.

Although no crashes had been linked to the issue, Mr Cronin said aircraft had been landing prematurely.

North Australian Helicopters’ head of maintenance Steve Minear said the problems had coincided with a reduction in the lead content in the fuel supply.

“We had a presentation from Viva Energy and they’re claiming it’s not the fuel,” Mr Minear said.

“But pretty much the only thing that’s changed in the last few years is the fuel, and in the last 12 months we’ve had to replace 50 or 60 cylinders. It’s an expense to the industry.”

He said as a result of the premature cracking, North Australian Helicopters had adjusted its maintenance schedule to check the valves every 100 hours, instead of every 300 hours.

“If it is the fuel that’s caused these issues, I could see possibly a class action,” said Mr Minear.

A Viva Energy spokesman said the company was an active part of the investigation group.

“Viva Energy is a long-term manufacturer of avgas in Australia and our fuel, supplied throughout most of the country, meets all relevant fuel quality specifications with no quality or operability issues,” he said.

Lycoming, which is the primary affected engine manufacturer, is also part of the investigation group.

Mr Cronin said the investigation was continuing at an accelerated pace, and they hoped to have answers in weeks rather than months.

“We’re calling for any operator who’s had any problems associated with this to get in touch with us,” he said.

MTF...P2 

[Peetwo]

Prelim report released on Par Avion Islander crash. 

Via the ATSB AAI webpage: https://www.atsb.gov.au/publications/inv...-2018-078/

Preliminary report published 4 February 2019

What happened
On 8 December 2018, a Pilatus Britten-Norman BN-2A-20 Islander, registered VH-OBL, operated by Par Avion, was conducting a positioning leg under the visual flight rules1[/url]] from Cambridge Aerodrome to Bathurst Harbour, Tasmania. The aircraft departed the aerodrome at 0748 Eastern Daylight Time (EDT),[] and was scheduled to arrive at Bathurst Harbour about 0845 to pick up five passengers for the return flight to Cambridge Aerodrome.

At 0829, the Australian Maritime Safety Authority (AMSA) received advice that an emergency locator transmitter (ELT) allocated to VH-OBL had activated. AMSA advised the Tasmanian Police and the aircraft operator of the activation, and initiated search and rescue efforts. The rescue efforts included two helicopters and a Challenger 604 search and rescue jet aeroplane. The Challenger arrived over the beacon signal location at around 0925; however, due to cloud cover it was unable to visually identify its precise location. Multiple attempts were made throughout the day to locate the accident site, however, due to low-level cloud, the search and rescue operation was unable to confirm visual location of the aircraft until about 1900. The aircraft wreckage was located in mountainous terrain near the Western Arthur Ranges in the Southwest National Park. The search and rescue crew determined that the accident was unlikely to have been survivable. The search and rescue helicopter crew considered winching personnel to the site; however, due to a number of risks, including potential for cloud reforming, the time of day and lighting, and other hazards associated with the mountainous location, the helicopter departed the area. The aircraft wreckage was accessed the following day, when it was confirmed that the pilot, the sole occupant of the aircraft, was fatally injured.

Position and altitude information was obtained from FlightAware, which recorded a combination of ADS-B and Spidertracks[4[/url]] data. The data showed the aircraft tracking to the southwest towards Bathurst Harbour (Figure 1). At approximately 0816, the aircraft entered a valley near the West Portal in the Western Arthur Ranges, and proceeded to conduct a number of turns. The final ADS‑B data point recorded was at 0828.

Figure 1: Track of VH-OBL from Cambridge Aerodrome towards Bathurst Harbour, showing the accident location

Source: Google earth and FlightAware, modified by ATSB

Site and wreckage
ATSB investigators travelled to Hobart, Tasmania as part of this investigation. However, due to the remote location and access difficulties, and other risks associated with the mountainous location of the wreckage, the ATSB did not attend the accident site. Investigators conducted numerous interviews, gathered relevant information and worked closely with the Tasmanian Police to gain an understanding of the accident. A number of items recovered from the wreckage and detailed photographs by the Tasmania Police forensic investigators will be examined by the ATSB.

Figure 2: Accident location of VH-OBL in the Western Arthur Ranges

Source: Tasmania Police

Pilot information
The pilot held a current Commercial Pilot Licence (Aeroplane) and had completed a flight review on 25 May 2017. The pilot also held a Class 1 Aviation Medical Certificate that was valid until 26 February 2019. The available information indicated that the pilot had about 540 hours total aeronautical experience, with 82.5 hours on Islander aircraft.

Ongoing investigation
The investigation is continuing and will include examination of the following:

• recovered components and available electronic data
  
  
• aircraft maintenance documentation
  
  
• weather conditions
  
  
• pilot qualifications and experience
  
  
• operator procedures
  
  
• research and previous occurrences.
  

Acknowledgements
The ATSB acknowledges the support of Tasmania Police for their assistance during this investigation.

MTF...P2 

[Peetwo]

Prelim report released on Par Avion Islander crash. 

Via the ATSB AAI webpage: https://www.atsb.gov.au/publications/inv...-2018-078/

Preliminary report published 4 February 2019

What happened
On 8 December 2018, a Pilatus Britten-Norman BN-2A-20 Islander, registered VH-OBL, operated by Par Avion, was conducting a positioning leg under the visual flight rules1[/url]] from Cambridge Aerodrome to Bathurst Harbour, Tasmania. The aircraft departed the aerodrome at 0748 Eastern Daylight Time (EDT),[] and was scheduled to arrive at Bathurst Harbour about 0845 to pick up five passengers for the return flight to Cambridge Aerodrome.

At 0829, the Australian Maritime Safety Authority (AMSA) received advice that an emergency locator transmitter (ELT) allocated to VH-OBL had activated. AMSA advised the Tasmanian Police and the aircraft operator of the activation, and initiated search and rescue efforts. The rescue efforts included two helicopters and a Challenger 604 search and rescue jet aeroplane. The Challenger arrived over the beacon signal location at around 0925; however, due to cloud cover it was unable to visually identify its precise location. Multiple attempts were made throughout the day to locate the accident site, however, due to low-level cloud, the search and rescue operation was unable to confirm visual location of the aircraft until about 1900. The aircraft wreckage was located in mountainous terrain near the Western Arthur Ranges in the Southwest National Park. The search and rescue crew determined that the accident was unlikely to have been survivable. The search and rescue helicopter crew considered winching personnel to the site; however, due to a number of risks, including potential for cloud reforming, the time of day and lighting, and other hazards associated with the mountainous location, the helicopter departed the area. The aircraft wreckage was accessed the following day, when it was confirmed that the pilot, the sole occupant of the aircraft, was fatally injured.

Position and altitude information was obtained from FlightAware, which recorded a combination of ADS-B and Spidertracks[4[/url]] data. The data showed the aircraft tracking to the southwest towards Bathurst Harbour (Figure 1). At approximately 0816, the aircraft entered a valley near the West Portal in the Western Arthur Ranges, and proceeded to conduct a number of turns. The final ADS‑B data point recorded was at 0828.

Figure 1: Track of VH-OBL from Cambridge Aerodrome towards Bathurst Harbour, showing the accident location

Source: Google earth and FlightAware, modified by ATSB

Site and wreckage
ATSB investigators travelled to Hobart, Tasmania as part of this investigation. However, due to the remote location and access difficulties, and other risks associated with the mountainous location of the wreckage, the ATSB did not attend the accident site. Investigators conducted numerous interviews, gathered relevant information and worked closely with the Tasmanian Police to gain an understanding of the accident. A number of items recovered from the wreckage and detailed photographs by the Tasmania Police forensic investigators will be examined by the ATSB.

Figure 2: Accident location of VH-OBL in the Western Arthur Ranges

Source: Tasmania Police

Pilot information
The pilot held a current Commercial Pilot Licence (Aeroplane) and had completed a flight review on 25 May 2017. The pilot also held a Class 1 Aviation Medical Certificate that was valid until 26 February 2019. The available information indicated that the pilot had about 540 hours total aeronautical experience, with 82.5 hours on Islander aircraft.

Ongoing investigation
The investigation is continuing and will include examination of the following:

• recovered components and available electronic data
  
  
• aircraft maintenance documentation
  
  
• weather conditions
  
  
• pilot qualifications and experience
  
  
• operator procedures
  
  
• research and previous occurrences.
  

Acknowledgements
The ATSB acknowledges the support of Tasmania Police for their assistance during this investigation.

Why did pilot fly into valley?
ROBYN IRONSIDE
Nikita Walker had less than 100 flying hours on the plane that crashed into mountainous terrain in Tasmania. Her experience is now the focus of an ATSB probe.

---

ATSB releases report into light plane crash in Tasmania


The investigation into a fatal plane crash in Tasmania last December will examine the pilot’s qualifications and experience, among other factors.

A preliminary report by the Australian Transport Safety Bureau has revealed Par Avion pilot Nikita Walker had fewer than 100 flying hours on the Pilatus Britten-Norman Islander.

Walker was operating the aircraft on the morning of December 8, travelling from Cambridge Aerodrome to Bathurst Harbour to collect five passengers for the return trip.

About 40-minutes after departing Cambridge an emergency locator beacon was activated, triggered a search by the Australian Maritime Safety Authority and Tasmanian police.

Two helicopters and a Challenger 604 search and rescue jet set out to look for the site of the beacon in mountainous terrain near the Western Arthur Ranges, but were hampered by low level cloud.

The wreckage of the airport was eventually located about 7pm, but it was decided a recovery mission should not be attempted until daylight because of the terrain and weather.

The following day the wreckage was accessed, and the pilot confirmed dead.

The report said the aircraft had entered a valley and conducted a number of turns before the last position and altitude information was recorded.

ATSB investigators travelled to Tasmania in the following days but due to the remote location and mountainous terrain did not go to the crash site.

Walker, 30, started working as a commercial pilot for Par Avion in 2016, and had accumulated 82.5 hours on the Islander, out of a total 540-flying hours.

Par Avion managing director Shannon Wells said it was not appropriate to comment on the preliminary report.

After the crash Mr Wells said Walker had done all her training with Par Avion and was “well-versed in Tasmania flying conditions”.

In addition to the pilot’s experience, the ATSB investigation will examine weather conditions, aircraft maintenance, operator procedures and available electronic data.

A final report is expected by the end of the year.

On a lighter note a pilot had a lucky escape yesterday:

Plane lucky: pilot’s near-miss



ROBYN IRONSIDE

It made a heck of a noise as it smashed though a suburban back fence, but the pilot of this light plane — and the locals — had a narrow escape.

---

It made a hell of a noise: Narrow miss as light plane crashes through back yard fence


A six-seater aircraft on a flight from Maroochydore to Toowoomba has crashed into trees in a suburban area of the Sunshine Coast narrowly missing homes.

The 38-year-old pilot of the Beechcraft Bonanza escaped with minor injuries after apparently losing engine power and radioing “mayday” shortly after take-off.

Palmwoods resident John Leach said he was in the shower at about 9am when he heard a noise he thought was a speeding car that had run off the road and crashed.

“I came out of the shower and my wife said she thought a tree had come down because we could see broken branches,” Mr Leach said.

“I thought it made a hell of a noise for a tree and we couldn’t see anything out of the ordinary so we went back inside.”

A neighbour then alerted them to the near miss, Mr Leach said.

“They said ‘you won’t believe it but it’s a plane that’s crashed into the trees’,” he said.

“None of us saw it happen but it looked like the plane hit the forest area with its wing and snapped off the trees going through, and that’s spun the plane.

“It broke the fall of the plane and probably saved the pilot’s life.”

He said it was possible the pilot may have been heading towards a vacant area around a lake, or the lake itself.

“I assume if you haven’t got any power it would be hard to control a plane but I think the forest would’ve saved him, by breaking the fall,” said Mr Leach.

“One wing was sheared off halfway through.”

Ambulance officers were on the scene within minutes and transported the pilot to hospital with minor injuries.

Flight aware data shows the Beechcraft Bonanza was en route from nearby Maroochydore Airport to Toowoomba, when the incident occurred.

The aircraft is registered to Toowoomba-based company Aircraft Solutions.

The Australian Transport Safety Bureau will decide later today whether the incident warrants further investigation.

MTF...P2 

[P7_TOM]

Seasoning – not flight hours.

“A preliminary report by the Australian Transport Safety Bureau has revealed Par Avion pilot Nikita Walker had fewer than 100 flying hours on the Pilatus Britten-Norman Islander.”

“Walker, 30, started working as a commercial pilot for Par Avion in 2016, and had accumulated 82.5 hours on the Islander, out of a total 540-flying hours.”

It has been a long held tenet of mine that pilots need to be ‘seasoned’. A total of 540 hours is about eight months worth work for a busy operator. A collective of ‘seasoned’ pilots all agree; no matter what your ‘experience’ level – if you have not operated an aircraft over the route across a ‘season’ then your ‘total experience’ counts for little – except as a back stop. Personally; if I had to fly the ‘job’ - as scheduled, I’d have been down the coast in anything less than CAVOK – it would make little difference to anyone – not even an operator. But, unfamiliar with the type, unfamiliar with the ‘local’ vagaries of weather etc. I’d have opted for the line of least resistance and best chance of completion. Bear in mind I’ve never, not once, flown the route or landed at the nominated port, which IMO, despite experience levels would have placed me at an increased risk level – just through a lack of familiarity.

It is a ‘problem’ with arbitrary ‘experience’ levels. Qualified? Absolutely. Legal? Most certainly. “Safe”? Highly subjective. ‘Seasoned’? Not – no way.

Operators need to be free of the ‘compliance’ impost to concentrate on  real 'operational practicality' .

“The aircraft departed the aerodrome at 0748 Eastern Daylight Time (EDT),[] and was scheduled to arrive at Bathurst Harbour about 0845 to pick up five passengers for the return flight to Cambridge Aerodrome.”

Five passengers; nine seats – Visual Flight Rules?  On a not quite ‘gin clear’ day. Why not send a seasoned pilot along? – One who had flown the route, under the VFR many times. Not a ‘check flight - just a helping hand to provide, if nothing else, the benefit of past experience, route and weather knowledge and; the escape routes should it all go South. Too busy amending manuals or preparing for audit perhaps.

On paper ‘compliance’ is all well and good for the ‘legal’ watchdog. But for a kid, with SDA in the way of ‘seasoning’ to be turned loose without a ‘grown-up’ to hold the hand of someone who has never, in 540 hours, been boxed in; trapped, or, known early enough that it’s time for Plan B is directly related to the damn silly arbitrary ‘numbers’ set by CASA and the profligate demands of a ‘compliance’ at any cost regulator. Legal – sure as the gods made little green apples  Safe? Clearly not. Someone has a child to bury and mourn in this clearly above board, all legal tragedy.

Time for a re-think perhaps about what, exactly, is important?

Time on type – insignificant. Number of sectors to and from – Vital. Written route briefing – essential. Written en route SOP essential. Port SOP – essential. Required by CASA ? Audited by CASA? Approved by CASA?

Dream on old fool; dream on. Practical Safety? Easy question – one more; and, then a Taxi home. Fill it up Kid - I'm safe as houses - legally. Isn't that all that matters?

P2 comment - Somewhat related I note that the FAA have just published the following safety enhance brief...

https://www.faa.gov/news/safety_briefing..._17_04.pdf

[Sandy Reith]

Impossible to judge an individual accident without intimate knowledge, and this degree of knowledge is often lost in the accident itself.

Having operated my own charter and scheduled services in general aviation aircraft I know we can improve the total environment for the employment of junior or inexperienced pilots, not to mention all the other pilots.

The broad terms, for a start, the regulatory environment must change. Priority would be to change the ‘them and us’ and big stick approach. The current regulatory regime induces fear of flight and retribution from CASA, armed as it is, inappropriately, with a great raft of criminal sanctions and ease of prosecution by the strict liability provision. The fear of flight and regulator sanction is often, to some degree, instilled in the earliest training phase. This mitigates against clear and rational decision making in flight. There’s nothing wrong about a healthy respect for what is a sometimes difficult and potentially dangerous pursuit, but that respect should not be exaggerated or exacerbated into irrational fear by a wrong psychological approach.

CASA should drop it’s incessant mantra of ‘safety’ and delete that word from it’s title. Paradoxically this would be a first step in creating a safer flying environment in Australia.

P7 (rude insertion) - Amen to that Sandy; airline pilots get lots and lots of mentoring. A new start in the bush gets - ??

[Peetwo]

Final Report on fatal crash of Cessna VH-HWY.

Ref: https://www.atsb.gov.au/publications/inv...-2017-102/

What happened


On 23 October 2017, a charter flight operated by Air Frontier using a Cessna C210L aircraft, registered VH-HWY (HWY), was tasked to transport a coffin with a deceased person from Darwin Airport to Elcho Island, Northern Territory. There were two pilots on board – the supervising pilot in command in the right seat and the pilot in command under supervision on the left. After departing Darwin at 1307 CST, the left seat pilot requested air traffic control (ATC) for a 5 NM diversion left or right of track to avoid adverse weather. The aircraft was cleared to divert right of track, and to climb to 9,500 ft. After four minutes, ATC asked whether further track diversions were required; first 10 NM, then 20 NM, which were accepted.

At 1332, the aircraft entered an uncontrolled descent before it collided with terrain. The pilots were fatally injured and the aircraft destroyed.

What the ATSB found

Shortly after VH-HWY diverted to avoid adverse weather, the aircraft entered an area of strong convective activity and rapidly developing precipitating cells, which resulted in it experiencing severe turbulence and possibly reduced visibility for the pilots. While flying in these conditions, a combination of airspeed, turbulence and control inputs probably led to excessive loading on the aircraft’s wings, which separated from the fuselage in-flight before it collided with terrain.

The ATSB found that the pilots had no experience flying in the ‘build-up’ to the wet season in the Darwin area. Although pairing a supervisory pilot with a pilot new to the company was likely to reduce risk in other instances, in this case it did not adequately address the weather-related risks because neither pilot had experience flying in the region during the wet season.

Safety message

Recognising and avoiding tropical weather conditions that present significant hazards to flight can be particularly challenging for pilots without operational experience in the tropics. Knowing how to reduce the risk, including the appropriate distance to keep away from thunderstorms and cumulus clouds predominantly comes through exposure to those conditions. In many cases, deviations of 10 NM to avoid phenomena like towering cumulus clouds may not be sufficient.

Pilots are encouraged to use all available resources to avoid adverse weather, including forecasts and requesting ATC assistance. Awareness of the weather avoidance actions of other pilots in the area can also be useful. There is considerable value in ongoing education and guidance for pilots in recognising and responding to deteriorating weather conditions during flight. This can include additional (cue-based) training, guidance specific to the risks in the region, education initiatives from industry bodies, and learning from the knowledge and experience of peers.

Smaller operators employing pilots with limited exposure to local conditions, such as in the tropics, can better manage related risks by pairing new pilots with ones experienced in those conditions.

VH-HWY in Darwin VH-HWY in Darwin

Source: Air Frontier

And via the Oz today: 

Fatal crash pilots lacked Northern Territory wet season experience: ATSB

ROBYN IRONSIDE
AVIATION WRITER
@ironsider

6:52PM APRIL 9, 2019



The single engine Cessna 210 operated by Air Frontier disappeared from the radar twice before plunging at high speed from about 10,000 feet, 25-minutes into the flight.


An investigation into a light plane crash that killed both pilots on board has found neither had experience flying in the Northern Territory’s wet season.

Pilot in command under supervision Darcy McCarter, 23, and supervising pilot Daniel Burrill, 33, were transporting the body of an indigenous man from Darwin to Elcho Island for a traditional Aboriginal burial when they struck bad weather on October 23, 2017.

The single engine Cessna 210 operated by Air Frontier disappeared from the radar twice before plunging at high speed from about 10,000 feet, 25-minutes into the flight.

The Australian Transport Safety Bureau investigation found turbulence combined with the high airspeed ripped the wings from the plane as it nosedived to earth.

A final report on the crash released today, said 14 minutes after departure the pilot in command under supervision requested a diversion from the flight plan due to weather.

Further diversions were sought as the weather worsened, and eventually the aircraft was lost from Air Traffic Control radar twice within 15 seconds.

“Shortly after VH-HWY diverted to avoid adverse weather, the aircraft entered an area of strong convective activity and rapidly developing precipitating cells, which resulted in it experiencing severe turbulence and possibly reduced visibility for the pilots,” the report said.

The report went on to highlight the hazards of the Northern Territory wet season.

“Pilots in tropical areas need to recognise and respond to these conditions to avoid the hazards including turbulence, windshear and reduced visibility,” said the report.

“This is more challenging when a pilot has not experienced these conditions and therefore may not accurately assess the situation or perceive the risks.”

In the case of this flight, neither pilot had flown during a previous wet season in Darwin, the report noted.

“Although pairing a supervisory pilot with a pilot new to the company was likely to reduce risk in other instances, in this case it did not adequately address the weather-related risks because neither pilot had experience flying in the region during the wet season,” the ATSB report said.

A safety message was issued advising “smaller operators” to manage the risk of employing pilots with limited exposure to local conditions by pairing them with ones experienced in those conditions.

MTF...P2 

[Kharon]

A hat trick.

The ABC seems to be trying to whip up ‘drone’ accident in Wyndham WA into something – honestly. You can bet on two things, the solid wall of silence that comes with any ‘experimental’ military project and that whatever went sideways will get sorted. End of.

Instead of providing a vicarious ‘conspiracy’ fillip for breakfast consumption, perhaps the media could get down and dirty by getting some ‘real’ investigation done; the recent two fatal aviation accidents in Qld ain’t a headline grabber; but we do have a steady stream of fatal crashes. Almost a pattern; now, if the ‘rules’ are not preventing the accidents and the investigators take so long to come up with a report into the accident; there is genuine scope for real inquiry.

When a report into an accident eventually gets published – and we are talking in years here; any useful information which may assist in stopping a developing ‘trend’ is rendered useless; and, worse - accepted as 'normal'. Provided the flight ticked all the legal boxes, it’s fine. You can die whenever and wherever you please – you’re legal – no wukkers – case closed. You become part of a data base and forgotten – RIP.

Our much vaunted ‘safety system’ is becoming a very expensive operation which has not in the last decade provided any substantive decrease in the accident rate. Yet the media seem to quite happy to accept this, publish trite little stories which attract little interest, without getting into the underpinning foundations of this now ‘normalized deviance’. Ayup, we loose a few every year, so what…………Pathetic.

What say you P2 – VFR into IMC and NVMC accidents – facts and figures? Worth doing?

Toot – FDS – toot.

[Peetwo]

A hat trick. - Part II

The ABC seems to be trying to whip up ‘drone’ accident in Wyndham WA into something – honestly. You can bet on two things, the solid wall of silence that comes with any ‘experimental’ military project and that whatever went sideways will get sorted. End of.

Instead of providing a vicarious ‘conspiracy’ fillip for breakfast consumption, perhaps the media could get down and dirty by getting some ‘real’ investigation done; the recent two fatal aviation accidents in Qld ain’t a headline grabber; but we do have a steady stream of fatal crashes. Almost a pattern; now, if the ‘rules’ are not preventing the accidents and the investigators take so long to come up with a report into the accident; there is genuine scope for real inquiry.

When a report into an accident eventually gets published – and we are talking in years here; any useful information which may assist in stopping a developing ‘trend’ is rendered useless; and, worse - accepted as 'normal'. Provided the flight ticked all the legal boxes, it’s fine. You can die whenever and wherever you please – you’re legal – no wukkers – case closed. You become part of a data base and forgotten – RIP.

Our much vaunted ‘safety system’ is becoming a very expensive operation which has not in the last decade provided any substantive decrease in the accident rate. Yet the media seem to quite happy to accept this, publish trite little stories which attract little interest, without getting into the underpinning foundations of this now ‘normalized deviance’. Ayup, we loose a few every year, so what…………Pathetic.

What say you P2 – VFR into IMC and NVMC accidents – facts and figures? Worth doing?

Toot – FDS – toot.

 - Wilco "K" - 

How about we kick it off with this? ref: https://www.atsb.gov.au/media/4462266/ao..._final.pdf

&..from here: Joining the dots on Fort Fumble's 18 year obfuscation of ATSB identified Night VFR safety issue

Although it needs an update Appendix A is particularly relevant:

Appendix A

Accidents involving night VFR operations The ATSB reviewed its occurrence database for accidents in Australia from 1993 to 2012 that met the following criteria:
• occurred at night
• conducted under the visual flight rules (VFR)
• occurred in visual meteorological conditions (VMC) or probable VMC
• involved a pilot that had either a night VFR rating or a command instrument rating (CIR)
• involved an aircraft equipped for night VFR flight or instrument flight rules (IFR) flight
• involved either controlled flight into terrain (CFIT) or a loss of aircraft control in flight, and the loss of control did not appear to be related to any technical problem with engines, flight controls or primary flight instruments.

Table A1 lists 13 accidents that met these criteria. Another five accidents that occurred during agricultural spraying operations also met the criteria. In addition, there were other accidents that may have met the criteria but there was insufficient information available to determine the nature of the accident or whether the conditions were VMC or IMC. At least six other accidents probably involved VFR flights entering IMC at night during the same period.

Of the 13 accidents in Table A1, the following was noted:
• 11 occurred in dark night conditions
• none occurred immediately after take-off, one occurred on final approach, three occurred during flight at low level, and the remainder occurred during climb or en route
• in only one case did the pilot in command have a current CIR
• in four cases there were passengers on board but the pilot had probably not met the relevant recency requirements for carrying passengers at night
• five accidents involved helicopters, three of which were CFITs and two involved loss of control.
• 10 accidents resulted in fatalities, with the only non-fatal accidents being three helicopter accidents involving CFIT at low speed from low level or during climb. During 1993 to 2012 there were also eight accidents involving IFR flights at night that otherwise met the same criteria.

Three occurred very soon after take-off and four were CFITs during approach. All occurred in dark night conditions. The rate of IFR versus night VFR accidents could not be determined due to very limited information available on the amount of night flying under the two types of rules. However, it would be expected that significantly more flying at night is conducted under the IFR than the VFR.

Senator FAWCETT: When there is an aircraft accident and there is a fatality and the coroner becomes involved, can you describe the relationship between ATSB and the coroner?

Mr Dolan : The legislation, the Transport Safety Investigation Act, requires us to cooperate with coronial processes. Therefore, coroners have, if you like, a special relationship with us. There is a range of information and support that we are required to give to coroners that we do not give to other legal processes. We try, as far as possible, to ensure that our reports are reliable and comprehensive and therefore can be used by coroners to form their views, which are largely no blame and in parallel with what we are trying to establish.

We recognise that there are areas where coroners will investigate and we do not. We are trying to deal with that carefully. We do that mostly by making sure we are in close contact with the police who are working with the coroner so that there is clarity from the beginning as to whether we are going to be playing to any significant extent. We are always happy to explain our reports to coronial processes. In addition, we have been offering accident fundamentals training, the basics of how we approach our job, to a range of police officers across the jurisdictions who are likely to be assisting coroners in carrying out their duties.

Senator FAWCETT: Do coroners ever face the situation where they have to choose between your advice and that of another aviation expert?

Mr Dolan : Quite often. It used to be more common than I think I have noticed in the last year or two that alternative views were put to coroners—

Senator FAWCETT: Who would those other stakeholders be?

Mr Dolan : Our experience has been that counsel assisting, in trying to do a comprehensive job in support of a coroner, sought other lines of information and brought it to bear in the process. Other parties, all of whom have their own interests in a coronial process, often find it necessary to test a range of alternative hypotheses. Sometimes the weight comes down to a different place than we placed it. That is just part of the relationship. If there is a coronial finding that is inconsistent with what we found or more information comes to light in the course of an inquest that is relevant to our investigation, we will reopen the investigation and make sure that is properly weighed up in our processes.

Senator FAWCETT: I notice CASA is often another player in the coronial inquests and often you will highlight something, the coroner will accept it and basically tick off in his report on the basis that a new CASR or something is going to be implemented. Do you follow those up? I have looked through a few crash investigations, and I will just pick one: the Bell 407 that crashed in October '03. CASR part 133 was supposed to be reworked around night VFR requirements for EMS situations. I notice that still is not available now, nearly 10 years after the event. Does it cause you any concern that recommendations that were accepted by the coroner, and put out as a way of preventing a future accident, still have not actually eventuated? How do you track those? How do we, as a society, make sure we prevent the accidents occurring again?



Mr Dolan : We monitor various coronial reports and findings that are relevant to our business. We do not have any role in ensuring that coronial findings or recommendations are carried out by whichever the relevant party may be. I think that would be stepping beyond our brief.

Senator FAWCETT: Who should have that role then?

Mr Dolan : I would see that as a role for the coronial services of the various states. But to add to that, because we are aware of the sorts of findings—as you say, it is not that common that there is something that is significantly different or unexpected for us, but when there is—we will have regard to that obviously in our future investigation activities and recognise there may already be a finding out there that is relevant to one of our future investigations.

Senator FAWCETT: Would it be appropriate to have—a sunset clause is not quite the right phrase—a due date that if an action is recommended and accepted by a regulatory body, in this case CASA, the coroner should actually be putting a date on that and CASA must implement by a certain date or report back, whether it is to the minister or to the court or to the coroner, why that action has not actually occurred?

Mr Dolan : I think I will limit myself to comment that that is the way we try to do it. We have a requirement that in 90 days, if we have made a recommendation, there is a response to it. We will track a recommendation until we are satisfied it is complete or until we have concluded that there is no likelihood that the action is going to be taken.

Senator FAWCETT: Mr Mrdak, as secretary of the relevant department, how would you propose to engage with the coroners to make sure that we, as a nation, close this loophole to make our air environment safer?

Mr Mrdak : I think Mr Dolan has indicated the relationship with coroners is on a much better footing than it has been ever before. I think the work of the ATSB has led that. I think it then becomes a matter of addressing the relationship between the safety regulators and security regulators, as necessary, with the coroners. It is probably one I would take on notice and give a bit of thought to, if you do not mind.

Senator FAWCETT: You do not accept that your department and you, as secretary, have a duty of care and an oversight to make sure that two agencies who work for you do actually complement their activities for the outcome that benefits the aviation community?

Mr Mrdak : We certainly do ensure that agencies are working together. That is certainly occurring. You have asked me the more detailed question about coroners and relationships with the agencies. I will have a bit of a think about that, if that is okay.

Senator FAWCETT: Thank you.

And the follow up by Senator Fawcett in the October 2012 Supp Budget Estimates:

Senator FAWCETT: Chair, given the inquiry on Monday I do not actually have a huge number of questions, except to follow up something with Mr Mrdak. Last time we spoke about closing the loop between ATSB recommendations and CASA following through with regulation as a consequential change within a certain time frame. The view was expressed that it was not necessarily a departmental role to have that closed loop system. I challenged that at the time. I just welcome any comment you may have three or four months down the track as to whether there has been any further thought within your department as to how we make sure we have a closed loop system for recommendations that come out of the ATSB.

Mr Mrdak : It is something we are doing further work on in response to your concerns. We recognise that we do need to ensure the integrity of the investigatory response and then the regulatory response. So it is something we are looking at closely. I and the other chief executives in the portfolio will do some further work on that area.

Senator FAWCETT: Do you have a time frame on when you might be able to report back to the committee?

Mr Mrdak : Not as yet. I will come back to you on notice with some more detail.

Senator FAWCETT: If I could invite you to come back to the chair perhaps with a date for a briefing to the committee, outside of the estimates process, as to how you might implement that.

Mr Mrdak : Yes.

Senator FAWCETT: Because the work by ATSB is almost nugatory if you do not have a closed loop system that makes sure it is implemented in a timely manner.

Mr Mrdak : We will come back to you on that.

This time there was a listed QON to which M&M conveniently sidestepped by hand balling it back to Beaker and the ATSB:

Mr Mrdak: It is something we are doing further work on in response to your concerns. We recognise that we do need to ensure the integrity of the investigatory response and then the regulatory response. So it is something we are looking at closely. I and the other chief executives in the portfolio will do some further work on that area.

Senator FAWCETT: Do you have a time frame on when you might be able to report back to the committee?

Mr Mrdak: Not as yet. I will come back to you on notice with some more detail.

Answer:

One of the principal safety improvement outputs of an ATSB investigation is the identification of ‘safety issues’. Safety issues are directed to a specific organisation. They are intended to draw attention to specific areas where action should or could be taken to improve safety. This includes safety issues that indicate where action could be taken by CASA to change regulatory provisions.

The ATSB encourages relevant parties to take safety action in response to safety issues during an investigation. Those relevant parties are generally best placed to determine the most effective way to address a particular safety issue. In many cases, the action taken during the course of an investigation is sufficient to address the issue and the ATSB sets this out clearly in its final report of an investigation.

Where the ATSB is not satisfied that sufficient action has been taken or where proposed safety action is incomplete, the investigation report will record the safety issue as remaining open. In addition, if the issue is significant and action is inadequate, the ATSB will make a recommendation, to which the relevant party is required to respond within 90 days.

The ATSB monitors all safety issues (including all associated recommendations) until action is complete or it is clear that no further action is intended. At this point, the issue will be classified as closed. When safety issues are recorded as closed, the basis for this decision is also specified: whether the issue has been closed as adequately addressed, partially addressed,
not addressed, no longer relevant or withdrawn.

A safety issue remains open (like a recommendation) until such time as it is either adequately
addressed, or it is clear that the responsible organisation does not intend taking any action
(and has provided its reasons). In the event that no, or limited, safety actions are taken or
proposed, the ATSB has the option to issue a formal safety recommendation. However,
experience has been that this is rarely required.

The ATSB policies and procedures for identifying and promoting safety issues, including
through the issuance of a formal recommendation, is outlined in its submission to the Senate
References Committee Inquiry into Aviation Accident Investigations.

The ATSB’s Annual Plan and part of the ATSB’s Key Performance Indicators specifically
relate to a measurement of safety action taken in response to safety issues; in the case of
‘critical’ safety issues, the target is for safety action to be taken by stakeholders 100% of the
time, while for ‘significant’ safety issues, the target is 70%. For 2011-12, there were no
identified critical safety issues and 28 significant safety issues. In response to the significant
safety issues, adequate safety action was taken in 89% of cases and a further 4% were
assessed as partially addressed.

As previously advised to the Committee (Q59 – May 2012), CASA has a formal process for
following up on recommendations and safety issues identified by the ATSB, as provided for
in the Memorandum of Understanding between the agencies. Aviation safety agency heads
will continue to monitor the present arrangements to provide an adequate system for
addressing issues identified through ATSB investigations.

This was the answer to Q59 from the May 2012 Budget Estimates: 

Senator FAWCETT: You do not accept that your department and you, as secretary, have a
duty of care and an oversight to make sure that two agencies who work for you do actually
complement their activities for the outcome that benefits the aviation community?

Mr Mrdak: We certainly do ensure that agencies are working together. That is certainly
occurring. You have asked me the more detailed question about coroners and relationships with
the agencies. I will have a bit of a think about that, if that is okay.

Answer:

In terms of coordination between agencies there are in place a number of mechanisms that
ensure effective cross agency handling of issues in relation to safety matters having regard to
the specific legislative roles of each agency. These include the establishment of formal
Memorandum of Understanding between the Australian Transport Safety Bureau (ATSB) and
the Civil Aviation Safety Authority (CASA) and between the ATSB and Airservices Australia
(Airservices).

In relation to interaction with coroners this takes place in a number of ways. The ATSB
supports the coronial process by explaining the findings from its own investigation through the
provision of briefings to the coroner and giving evidence at inquests.

The ATSB also brings any aviation safety related issues identified in the ATSB investigation or
from the coroner’s findings to the attention of the Civil Aviation Safety Authority (CASA),
Airservices Australia and industry by publicising them on the ATSB’s website. Where
appropriate, comments are specifically sought from both CASA and Airservices, and that
information is also included on the ATSB’s website.

In relation to CASA, Airservices or the Department, all organisations participate in the coronial
process when requested. Where coroner’s findings are directed at any of these organisations,
the coroners’ recommendations are fully considered and where agreed, actions are
implemented to enhance aviation safety.

ref - pg 2 here: https://www.aph.gov.au/~/media/Estimates...ports.ashx

All that weasel worded rhetoric and supposed proactive actions, by M&M and the three Aviation Safety Stooges back then, some seven years later - amounted to what exactly, in addressing or closing the loop on significant identified safety issues (like the Night VFR accident issue)...  



MTF...P2 

[Cap'n Wannabe]

Another Jabiru catches fire...

[Kharon]

I just wonder why ATSB and the almighty CASA have not picked up on the fact that quite a LARGE (stalistically) number; % wise; of 'kit built’ aircraft have been catching fire- in flight?  All fuel related ?  Seems to me we’ve had a fair few lately – staring with that Copper in Tassy.  "Trend" perhaps?

Is it that CASA are ‘removed’ from these ‘incidents’ by clever manipulation of their remit – for “safety”?  How many more need to “catch fire” before this small, but persistent ‘anomaly” is examined with the same microscopic view as Angel Flight are getting.

Fair Dinkum – it stinks.

Toot – off to the BBQ – toot.

[P7_TOM]

“Some there be that shadow kiss; Such have but a shadow's bliss.”

It is starting to seem as though it is up to Aunt Pru to get the ball rolling on a fell, dark, deep matter of ‘safety’. Before we take a closer look at the ‘in’s and out’s’ of the subject matter there is an overview question; which, perforce must be examined. It stands alone.

Do ‘pilots’ actually need to be capable of ‘flying’ the aircraft?

It is a fair question. One simple question which, if AP pursues the matter will start war drums booming all over the world – but children; answer it we must, before we can proceed down the dark road of total dependence on flight director and magenta line. Recently I flew a visual night approach to an aerodrome well known to me. It had been great fun to play with the clever automatic systems installed in the newly discovered ‘baby’ jet. I hated the ‘disconnection’ I felt once the 'automatics’ took over – but appreciated the ‘ease and convenience’ of it all; until I got bored (at about 500 feet). No matter, ‘tis a new age and one must learn to move with the times – as stated – it was fun to learn about and play with the new toys. However – even at a home base aerodrome a night approach – even in the perfect conditions existing is not a thing to be trifled with. I was distracted and alarmed to discover a ‘magenta’ line predicting my turn onto final. I can see where such a thing may be ‘handy’. I can even see a practical use for the thing, at an unfamiliar field when things are ‘murky’ –but -to demand that I rely on it, every time, all the time, is a total bollocks. Yet there sits the SOP. Despite the fact that by following it I am actually ‘behind’ (well) the aircraft. True fact………

Elegance, situational awareness and a nicely judged turn onto final after a NDB approach was always the hallmark of ‘a good operator’. It was and remains to this day an art form – total absorption into the current situation. Yes; there have been times I remember when a little extra help would have appreciated – but ‘essential’ no; no way known to man. 0300 o’clock – a short on (required) fuel NDB approach into Tenant Creek, during a storm – no Auto pilot – complex engines, basic instruments was our bread and butter: run of the mill stuff we (old school) did it all the time. No more died than we loose today. Ever wonder Why?

This is not a tale I’ve told to many, in fact very, very few – however as we intend to open what is IMO a very unpleasant can of worms; perhaps I should use it as an introduction to where we are going to take this discussion. Big breath – (true) story follows:-

It was, by anyone’s measure a filthy night; storms, icing, turbulence the whole works; it was about 0200 – return leg – Melbourne – Sydney. Big load of freight in the back of a Be 18, sans Auto pilot. (Not that it matters, but the aircraft was deliciously nice to hand fly). Bang - #2 catches fire: Wallop – the pitot static froze over, half an inch of clear ice – everywhere  and: no kidding - the AH decided to quit. (all true): Crash – the storm we were skirting got really, really busy. Time to get out of Dodge and find a safe haven, the lightning and hail had decided we were fair game. Using the ‘tilt’ of the standby compass, a descent power setting and my watch, we timed a descent to the nearest VOR approach. Flew that approach – to minima (close as I dared) then opted out. Diverting to another paddock. Eventually, using very ‘BASIC’ instrument flying techniques i.e. ‘emergency’ style we broke visual an the minima, landed in about 25 knots across and ‘evacuated’ at a very sedate pace. RFFS were there (Bless ‘em) the old Flight Service had got ‘em moving; they blew out the last wisps of fire and tried to find the crew. Me? I was easy to spot sat on the fence having a well earned smoke – the ‘kid’ had wandered off (departed), found a bus, went home to his Mum and has never set foot in an aircraft since – his voice has never, ever, dropped the two octaves it obtained when I called for a ‘missed approach” the first – calling ‘standby’ for the second really did some damage.

Get to the point old fool they shout. OK I will. Not for the first time, and hopefully not for the last – basics, common sense, practical instrument flying combined with a decade of not relying on ‘automatics’ had solved my small problems that night, saved us (well that and Lady Luck). All of which leads me to my second question:-

Would the ‘automatics’ have resolved my problems any better?

I am not set ‘agin’ the systems we use today – however. When the going gets tough etc. When the last line of automatic defence has been breached – what is left – but man, machine and whatever the gods may throw – just for sport.

Is a ‘dependence’ on automatics eroding the essential skill required of an ‘instrument’ pilot?

Is a belief that what happens in a simulator occurs in the ‘real’?

There; five questions – Back from leave next week; so time enough for the BRB to draw up the battle lines. BUT – we are going to do this- fair warning.

“Now then, who’s round is it? Last night away – back to the compliance grind soon. Is it all worth it? Of course it is.