[Kharon]

Ops Manual dexterity.

The two events featured above, IMO – highlight a notable trend in the ATSB's background 'reporting' after the investigation. The 'need' for changes and amendments to the 'Operations Manual'.

This has featured in nearly all of the latest rounds of investigations to become almost a trend', alongside of some fairly 'basic' handling errors.

“A superior pilot uses his superior judgment to avoid situations which require the use of his superior skill.” (Borman).

A fair enough comment on the properly trained and disciplined pilot, but the 'training and discipline' element seems to be missing in some reported events. If the 'superior judgement' was not gained through superior training (include 'on-line) ; events like the G8 one above are almost inevitable. The part about 'avoiding' situations has very real implications; yet there is stark evidence that the ability to 'define and correct' is often 'lacking'. The G8 event a classic example; multiple opportunities to correct the approach path not taken; why? ATSB probably lack the time , resources and interest to take a long rearward look at the lead up to this event. That however is not the fault of the investigators. The 'radical' cause of this event can probably be backtracked to pre first solo, through to 'checked to line' with the public in the back.

We've probably all done it at one time or another – hot and high – albeit sometimes unavoidable; BUT, the first time, back in the beginning of training should begin to be the last time in routine operations. A briefing on where the 'mistake' began should be detailed, on the white board. Beginning with the selected 'top-of-descent' point, ending with the 'ways and means' available to correct the approach, circuit and landing. The 'ability' to modify the final stages of a flight (hot/high – low/slow etc.) is an essential part of the pilot's tool kit. So much for the 'formative years'.

Once junior has outgrown short pants and is signed on to do a 'grown-ups' job; there is a further 'training' regimen to close off. This begins with the 'Ops Manual' a.k.a. 'the Bible'. The modern version is full of stuff which will not affect the pilot as much as the operator. (I digress again). Part of 'the manual' is the Pilot Operating Manual' (POH) AND the company operating policy and techniques. These are 'important' elements, operationally and legally binding; should 'push come to shove': as it occasionally does. In short this 'stuff' must be beaten into the wooden head of the bright eyed junior warrior; (should they wish to become older warriors).

They say one cannot put an old head on young shoulders; one can (with persistence) teach 'em how to 'see' the impending stuff up; and,what to do if you have stuffed it all up. A junior commercial pilot, on a fine day, in a serviceable aircraft, in the country,  getting 'out of shape' should never have had any reason to 'do' other than put a bit of power on, extend to circuit and return in good order to a routine approach and landing. This did not happen; ATSB reports the what, but to me, I'd want to know why. That could have gone horribly wrong; Murphy taking a day off is little excuse.

Whilst laudable amending 'the manuals', should not be necessary; if there were 'flaws' within then those should have been flagged early; the check to line should have identified any shortcoming in operating technique and corrected long before turning the pilot loose on the public. None of this is rocket science; been that way since Pontius went solo. The notion of 'blame' is redundant here; the name of the game is stopping those holes in those famous cheese slices to align. Ops Manual dexterity allowing.............

Right, I'll go back to my knitting now and sit quietly in a corner.

Toot – toot....

[Kharon]

FWIW -

The ATSB report on the "Kabulture" or "Caboolture" mid-air event is out:-
Short version below.



Toot - toot..

[Kharon]

No matter how much you shake and dance.

“Mr Wright has indicated he will plead not guilty and has strenuously denied any wrongdoing.”[url=https://www.skynews.com.au/australia-news/crime/celebrity-croc-wrangler-matt-wrights-lawyers-seeking-mother-of-pilots-phone-records-from-after-helicopter-crash/news-story/bb9309b8aa8c3e92757babcb52397b0f][/url]

“Justice Blow set a tentative date of July 28 for a trial that is expected to run for up to five weeks.”

“Nothing is ever settled until it is settled right.” We can point our finger and make up excuses, we can invent arguments and do anything else we want, but the key to the skeleton jingles in our pocket until we settle matters right.” (JRK)..

Pleas note the R44 chopper.  The video below is worth watching: ignore the 'drama' and yes, it is a risky way to earn some much needed dollars. The math is simple enough; $300 an hour to run the chopper:: $20 per egg :: harvest 250 eggs = $5000 - $1000 expenses; that's about a $4000 payday. Insurance, maintenance etc will need to come out of that pot. But, take a look at the chopper; it is almost immaculate, fully serviceable and obviously well maintained. Money well spent. Despite the typical NT 'just bush boys' larrikin antics; this was supremely 'professional' and as safe as possible; sensible risk 'analysis: not too shabby, all things considered.

Now, Justice Blow has set five weeks aside to hear the 'Wright' case; there will be expert counsel on the pitch, both sides with an argument to sell on. But in the background carefully coiffed and manicured will be the 'unseen' never questioned CASA operatives who failed, dismally, to properly oversight the operations of this cowboy outfit. On paper, the operation 'stacked up' so a certificate to operate was granted; lovely manuals and boxes ticked. Signed, sealed and duly forgotten. The event which led to the tragedy could have been prevented, the warning signs were all there, clear and unequivocal. The 'doings' in Broome and the 'connections' should have at least raised some doubts, enough to warrant at least an operational audit; maintenance, serviceability, fuel loads, flight and duty etc. The only thing that occurred was the CASA Board arriving for lunch and a joy flight. The two Muppets charged with oversight and 'surveillance' never deigned to leave their air conditioned luxury to pay the operation any mind. Talk about mind over what matters.

The ATSB report speaks to some unsettling practices and a cavalier approach to 'operational' standards and 'good' practice. We shall watch this case with some interest; as the prophet says; - the last few drops fall down your pants.

Toot – toot...

[P7_TOM]

ATSB - Chopper break up - final report released.

[Peetwo]

ATSB pays compliment to GA pilot?? -

Via Popinjay media minions...

Effective decision-making contributed to successful forced landing on highway after engine failure and fire



The pilot of a Cirrus SR22 conducted a forced landing on the Mitchell Highway in central NSW after the light aircraft experienced an engine failure and in-flight fire, an ATSB investigation report details.

On 24 January 2025, a pilot and a passenger were flying from the Gold Coast to Mildura.

About three hours into the flight, while approximately 150 km north-west of Dubbo and cruising at about 8,000 ft, the aircraft’s engine oil pressure decreased below normal operating limits.

In response the pilot began to divert for a landing at Nyngan. But as they were making a PAN PAN radio call announcing their intentions, they heard the engine begin to ‘rev up’, followed by a ‘bang’.

The pilot then made a MAYDAY broadcast to ATC, advising that the engine had experienced a mechanical failure and they would be making an emergency landing on the Mitchell Highway, east of Nyngan.

As ATC acknowledged the broadcast, the pilot observed flames ‘pouring’ from the top of the cowl.

The report notes the pilot elected not to deploy the aircraft’s ballistic recovery parachute due to concerns that the fire was fuel related, and that a parachute-assisted landing may result in injuries to the passenger, who was pregnant.
Instead, the pilot began an emergency descent, putting the aircraft into a ‘dive’ in an attempt to put out the fire. The fire self-extinguished, but smoke began to enter the cockpit.

Despite the subsequent reduced visibility, the pilot proceeded to navigate the aircraft to land on the highway, while avoiding road traffic, for a successful forced landing with no injuries.

“The pilot’s timely and effective decision-making, likely supported by their experience on the aircraft type and knowledge of its performance capabilities, mitigated the risk of injury and further damage to the aircraft,” ATSB Director Transport Safety Dr Stuart Godley said.

Dr Godley noted in-flight engine failures in single-engine aircraft often result in the pilot experiencing high workload and time pressure, making preparedness critical.

“This incident demonstrates how the ‘aviate, navigate, communicate’ framework establishes a clear hierarchy of priorities, particularly during emergencies,” he continued.

“Acting in the appropriate order of priority improves situational awareness and supports coordinated responses in a dynamic environment.”

After the landing, the pilot inspected the engine and found the crankcase had ruptured adjacent to cylinder 6, below the induction duct assembly. A connecting rod had separated from the crankshaft and the air filter was visibly damaged by fire.

A disassembly and inspection of the engine had yet to be conducted at the time of publication of the ATSB’s investigation report. As a result, the ATSB was unable to determine the root cause for the loss of oil pressure or the mechanical failure of the engine.

“Although engine failures are relatively rare, they do happen,” Dr Godley concluded. “Given the potential severity of the consequences of an engine failure or power loss in a single‑engine aircraft, such occurrences therefore need to be planned for and managed appropriately.”

Read the final report: Engine failure involving Cirrus SR22, VH-DCB, 28 km east of Nyngan, New South Wales, on 24 January 2025

Publication Date
15/08/2025

MTF...P2

[Kharon]

Where a Highway is Heaven..

This report from the ATSB - HERE - kicked off a casual, but interesting far ranging discussion. I thought I'd mention it here only because IMO it is worthy of consideration.

“The pilot’s timely and effective decision-making, likely supported by their experience on the aircraft type and knowledge of its performance capabilities, mitigated the risk of injury and further damage to the aircraft,” ATSB Director Transport Safety Dr Stuart Godley said.

There is some common platitude in that statement; but, in essence it is accurate. Now, engine failure is a rare occurrence; well down the statistical list, but they do happen. The rareness of the event and the lack of actual experience in managing the event tends toward it being a 'Tick & Flick' item in the expensive training regime. Not due to 'slack' training, but due to the rarity of failure, the reliability of the modern engines and the maintenance standards imposed. 

Godley - “Although engine failures are relatively rare, they do happen,” Dr Godley concluded. “Given the potential severity of the consequences of an engine failure or power loss in a single‑engine aircraft, such occurrences therefore need to be planned for and managed appropriately.”

What Godley writes is true enough; but it takes you nowhere near a failure and the ground coming at you between 110 - 150 kph. Particularly over rough country; the 'startle factor' plus Adrenalin plus drills plus trying to rectify if possible plus subconscious 'worry' etc.. It is a big job make no mistake; and that smooth paddock may be a lot less appetising up close and committed. 

Godley - “This incident demonstrates how the ‘aviate, navigate, communicate’ framework establishes a clear hierarchy of priorities, particularly during emergencies,” he continued. “Acting in the appropriate order of priority improves situational awareness and supports coordinated responses in a dynamic environment.”

Again, as a general statement, this is an acceptable mantra; however, it does not translate to either training or a skill/ confidence builder; not in the real world. Some of the best 'handling' pilots I've seen all had a common thread within their log books - Glider training; and ,or, an instructor like mine who had to teach a powered approach, after every landing being without it for a good while. A glide approach; been a useful tool that one, on occasion. A couple of good things gliding teaches is the 'out landing' : run out of energy, find a paddock, but, it is rare. In a glider you must always be aware and conscious of the air you are working and the terrain below and the need for 'speed' and position and the capability of the air-frame. This awareness, 'feel' and the notion that not to run out of height to trade for distance is an essential. Every landing is, essentially, a forced landing, practiced until it becomes routine, second nature. It all produces a pilot with skills attuned to managing without engine assistance.

So, given the reliability of modern engines are these skills essential? Well, that depends don't it. Statistically, probably not; nowhere near a need to mandate it; so it comes down to the 'training' received and practice for the remote possibility. Personally, I was 'lucky' my instructor mixed power off and powered landings before first solo; and, thereafter on Nav's would ask the question 'What if?" A wrong answer or selection of options produced simulated failure and I'd execute the drill until my error was realised; "not going to make it". Power on and something like "watch the wind next time" would be the gentle admonishment, always with a grin and a wink. Valuable - Oh! bet on it, many times now have I nodded a silent thank you, to that man and those who came after him.

Sorry, this became a ramble; but we still loose few in weather and forced landing; situational awareness is skill which needs to be kept and practiced. That is down to the individual, not CASA or the ATSB. Platitudes will not help when the whatsit hit the fan. There, a fool's rambling two bob's worth - all done.

Toot - toot.

[Kharon]

Those magical Six minute markers.

Historically, there have been many (many) events which involve VFR flights ending up in IMC; also, the number of 'engine' problems, leading to forced landings is worth noting. Of the 'statistics'/ percentages etc, I have no research to define 'trends' or circumstances or even 'causal factors'. The 'numbers' mean little to those involved in an 'event' - the warnings and advice and training continue to be ignored on a regular basis. This was, essentially, the fact that started an interesting discussion last evening, casual enough but IMO - worth a scribble. Short ramble follows:-

Now, this is a really 'old school' notion, coming from the days when a mid air with a Pterodactyl was on the cards. I have always kept in my flight bag an ancient, ragged, plastic covered WAC chart; the first one I ever owned; a good luck charm against Murphy; it still carries the marks of my first adventures out of the training area. Back in those days, a Chino-graph pencil, a Douglas protractor, an E6B 'computer' and a 'clip-board' were 'tools of trade'. Prosaic enough kit; but it all served me well. Back then, a visit to the 'Met' office gave the usual stuff, wind, temperature and 'weather'. The wind was cribbed onto the E6B and a 'heading' and ground speed' could be roughed out for each leg. The 'Met' data could be used to 'plan' the flight; often this led to 'alternate' routes being plotted on the map to 'step around' forecast marginal' conditions. Each leg was plotted onto the chart, with 'diversion' points, where considered necessary, and 15^ splay either side of the track laid in. Forecast ground speed was then plotted in six minute marks along the route.

It was task enjoyed, considered, and it did take some time to do 'properly'.  But, worth every minute and valuable beyond ESP. Plotting the 'diversion' points was a very effective method of stimulating 'situational awareness' 12 minutes were gifted before 'decision' time; time to 'look' ahead, asses and 'call it'. This 'system' had an added advantage; an almost 'sub-conscious' picture of the terrain and the chances of finding a suitable 'paddock' should the Donkey hand in its notice.

The first Garmin 100 I ever used, blew me away; WOW!! Under the IFR it was god sent; priceless at night and it backed up ADF/VOR/ DME readings which was fantastic in the middle of the night. The modern gear is a fabulous tool and nearly, very very nearly, all that the average Joe needs for VFR or even IFR. But, I wonder, can that technology fully replace for the VFR pilot the sense of 'connection' with the operating environment a map, a plan and those magical six minute marks which brought the 'situation' fully into focus.

Those 'markers' - on a chart - almost forced the right questions to be asked; should I divert; if so to where, how is the weather that way - can I step around  it; if so, what is the terrain like for a forced landing? And etc - The magical electronics cannot make those decisions; nor can it see what is ahead or options to the side; or even nearest suitable paddock - should the need arise.

I don't know; I love the new equipment (most of it) and it is a marvel and a wonderful tool - no if's or buts about it. Then, I look again at my humble WAC charts and remember the 'lessons' they shared with me; a scrap of paper, some lines and a boat load of 'situational awareness' for the cost of a pencil, half an hour to consider and plot my course, present 'sound' options and keep those options firmly in my mind every six minutes, earning my keep and getting me to the Pub in one piece.

Here the Ramble endeth; my two Bob spent as pleased me best, in provoking discussion to assist in preventing another UCFIT from VFR into IMC. Just saying......Best I get another round in before P7 bellows for "Ale; you young scalawag Ale". ...

Toot - toot..