[Kharon]

Clean up run.

On sober reflection, I have no quarrel with ‘compliance’ per-se.  Indeed, I wonder how many rules one complies with in any given day.  From the moment you open the front door there are thousands of rules which govern your life.  Add ‘em up, the number will surprise you, consider walking down the street, from home to the car, driving to the airport.  You are covered from every angle; from dropping a tissue on the footpath to parking the car.  Then there are thousands of ‘small’ rules even within your car insurance policy.

Mostly the rules are based on common sense, litter for example is an expensive, undesirable commodity; the rules don’t stop people bringing cartloads of ‘stuff’ to parks and such, then leaving the remains behind for some other poor sod to clean up.  

But simple rules are easiest to ‘comply’ with, particularly when the spirit and intent of the rule is clear.  No one wants to run out of fuel and a sensible margin is prudent, particularly at sea or airborne.  So clear regulation is required to define the bare minimum required; fair enough.  From this a payload can be determined, the numbers are crunched and, verily when the paperwork equals the TOW the flight may be despatched, all legal, neat and tidy.  No problem with this except – the extra ton – ‘for Mum and the kids’ is an unwritten by-law, drafted in blood based on experience.  This is the one that can land you in strife; even if it saves the day, keeps the numbers legal and the company name intact.

Now a PIC may, without question order extra fuel and many do. There is no legal requirement to explain or apologise for this, even if it means a reduced payload or a tech stop.  This is a legal prerogative and it should be beyond question; but is it, truly.  It’s the point where law and ‘common’ sense meets both company and peer pressure; the rule of strict compliance used to override the inherent caution of a seasoned crew.  To give in to pressure and go with strictly minimum fuel uplift is all the law requires.  So the fifth column goes to work, planning begins to add ‘buffers’ to bring the minimum up to an artificial minimum, this may be further modified by creative arithmetic until the point is reached where a balance is struck.  This is all counterproductive, a steady bleeding of profit which could be taken by using, with confidence, the minimum allocated and allowing for the odd day where an intuitive ton was loaded inboard, without askance of the PIC.

I’m not using this as a fuel planning exercise, but more to point out that enforced strict compliance, to the last Kg of fuel from both sides can and does create additional expense, pressure, suspicion and risk.  The fuel law is clear enough – in a complicated way – it is how the spirit and intent of that law is ‘applied’ which creates the unseen consequences.  We have a lot of this ‘risk’ written into our aviation laws, the fact that this can, when pleases, be exploited to suit the regulator on a mission is well established.  Clear cut, easily complied with regulation will reduce much of the above and below the line ‘impression’ of compliance, rather than promote it.  

We wrote that which is done. We do that which is written; ergo, compliance without subjective, personal interpretation, on a whim.    

Sorry ‘V’ just felt a need to explain ‘compliance’ as a variable, malleable commodity rather than a fixed asset.  

I know, I know; back to my knitting? Right.

[P7_TOM]

Proof positive from a good ATSB report that the ‘old enemies’ are still with us.  In each generation of pilots they still claim a share of the kill.

Mudgee fatal - from ATSB - HERE.

[Kharon]

A Sunday ramble.

The old enemies meet at Mudgee.

Safety message – “Although amateur-built aeroplanes operated in the Experimental category are not required to be fitted with a stall warning device, owner-pilots should consider the benefits of such devices as a last line of defence against the inadvertent approach to, or entry into an aerodynamic stall.”

The statement above just qualifies as a message.  It could be loosely described as a ‘safety message’ and would probably be palatable to the general public and acceptable to politicians. But does it go far enough, down to the equation radicals?  It also begs the question is there a need for ATSB to get down to root causes and examination of same?

I think it does not; and believe that ATSB should, with a standard accident of this type, be providing ‘in-depth’ analysis, reporting the result, making recommendations and providing education.

We have now a situation where two, perhaps three ‘generations’ of newly fledged pilots have not been taught the ‘basics’, thoroughly, by those who were not taught the basics.  The situation is clearly evidenced by the ludicrous exemption required, by junior instructors before they can demonstrate and teach the ‘low and slow’ envelope – HERE -.

I don’t know which is worse; a pilot who, whether through ignorance or intent deliberately placed an aircraft in an untenable situation; or, a pilot who did not recognise that the aircraft was in a ‘bad place’ and failed to correct the ‘error’.  Dead either way: confounded by two ancient enemies.  Manoeuvred by fate into a hellish position; low, slow, overbanked and no engine to rely on, as a last resort, to execute the time honoured ‘going around’.  There was I believe enough time and space to effect an engine out landing, bank off and land straight ahead, rather than persist with runway alignment; but that is only an opinion and speculative. Without an engine and almost stalled, the only solution was to get some wind over the wings and make the best of a forced landing.  Hobson's choice? absolutely.  

The ‘figure of eight’ (fig 5 - p6) interested the ATSB, me too.  If I’m reading the diagram correctly, the northerly position (97 KIAS @ 1394 AGL) looks to be ‘good’ for a circuit join 04 on crosswind leg – to downwind – etc. bog standard.   The following track indicates a descent to the South (104 KIAS @917 AGL) followed by a turn North and a crosswind circuit join.  I note the closest windsock is located on the main taxiway, toward the runways intersection.  I wonder, was the initial intent to land 34?  Quick overfly to check the windsock, left hand down and pedal the crate along ‘downwind’ to final 34.  97/1394 < 104/917 < 84/937 – lined up 34. Perfect for a glide approach engine out.  Up until the position marked by the arrow (Fig 8 like orbit) you could be forgiven thinking the intent was to land straight ahead. Perhaps this is where the engine problem became apparent; too high with 937 to loose and not far to run. From the Fig 8 arrow, you could speculate on a ‘stretched’ glide, overhead to a tight base and join on a short-ish final.  

I digress; it is impossible to know what was happening in the pilot’s mind and the ATSB have carefully avoided, as they should, idle speculation such as my ramblings. The main items of danger have been elucidated, clearly and succinctly; carby ice is a known killer, stretching a glide is as lethal now as it ever was; accelerated stall a deadly companion to low and slow. Killers all, for generations past.

Solution – probably (IMO) a retrospective to the days when a student was not sent ‘first solo’ without those dangers being firmly implanted in the thickest of heads.  It is rare (or used to be) that a qualified pilot would get an aircraft anywhere near a ‘stall’, but the potential for these types of accident during ‘training’, particularly early in the piece, is high.  Maybe the need for a ‘special’ qualification to teach how to avoid these known killers is redundant; perhaps all should know and fully understand the basics as a matter of course.

Aye well, just a speculative Sunday twiddle, by way of paying my respects for those who died and those that mourn their loss.

Toot toot.

[Peetwo]

Tiger tragedies - AO-2013-226

Just released is the Final Report for 16 December 2013 tragic Tiger in-flight break-up near South Stradbroke Is: 

Download Final report

[PDF: 3.98MB] 
 
What happened

On 16 December 2013, at about 1215 Eastern Standard Time, a de Havilland DH82A (Tiger Moth) aircraft, registered VH-TSG, took off from the operator’s airstrip at Pimpama, Queensland with a pilot and passenger on board. The purpose of the flight was to conduct a commercial joy flight in the Gold Coast area. At about 1224, 1 minute after the pilot commenced aerobatics, the left wings failed and the aircraft descended steeply; impacting the water about 300 m from the eastern shoreline of South Stradbroke Island. The aircraft was destroyed and the two occupants were fatally injured.

What the ATSB found

The ATSB found that both of the aircraft’s fuselage lateral tie rods, which assist in transferring flight loads through the fuselage, had fractured. The location of the fracture coincided with areas of pre-existing fatigue cracking in the threaded sections of the rods, near the join with the left wing. The tie rods fractured during an aerobatic manoeuvre, resulting in the left lower wing separating from the aircraft and subsequent in-flight break-up. The ATSB also found that the tie rods were aftermarket parts manufactured under an Australian Parts Manufacturer Approval (APMA). In this respect, safety issues were identified in areas of the tie rods’ design and manufacture, as well as in the supporting regulatory approval processes. Safety issues were also identified in the maintenance and operation of the aircraft.

What's been done as a result

The ATSB consulted with the Type Design Organisation, regulators and investigation authorities from Australia, New Zealand and the United Kingdom about the failure of the APMA tie rods, which occurred well before the published retirement life for Tiger Moth tie rods. In response, the United Kingdom Civil Aviation Authority issued an airworthiness directive on 21 March 2014 that mandated the removal from service of all tie rods produced by the same Australian manufacturer. The airworthiness directive was subsequently also mandated by the Australian Civil Aviation Safety Authority and the New Zealand Civil Aviation Authority. Significant additional safety action is proposed by the Type Design Organisation to further enhance the safety of all Tiger Moth operations. In addition, the ATSB has issued a safety recommendation to the Civil Aviation Safety Authority to take action to provide assurance that over 1,000 other parts approved for APMA at about the same time as the tie rods were appropriately considered before approval.

Safety message

This accident emphasises the need for the full consideration of a part’s service history when redesigning and manufacturing parts critical to the structural integrity of the aircraft. It also shows the important role of the regulator in ensuring that parts approved under an APMA have been fully considered and shown to comply with the design requirements. Further, in the context of maintenance, it shows the importance of utilising genuine or approved substitute aircraft parts that are suitable for purpose, especially in sections of the aircraft that are critical to flight.

In addition, the ATSB cautions commercial vintage aircraft operators about the risks associated with aircraft age and the importance of understanding the originally-intended use of the design before commencing their operations.

 VH-TSG

Source: David Welch, Air-Britain Photographic Images Collection

It is reassuring to see that the ATSB have addressed an important Safety Recommendation to CASA:

Civil Aviation Safety Authority Australian Parts Manufacturer Approval implementation approvals


Safety Issue
Over 1,000 parts were approved by the Civil Aviation Safety Authority for Australian Parts Manufacturer Approval using a policy that accepted existing design approvals without the authority confirming that important service factors, such as service history and life‑limits, were appropriately considered.

Safety Recommendation AO-2013-226-SR-044

The ATSB recommends that the Civil Aviation Safety Authority takes action to provide assurance that all of the replacement parts that were approved for Australian Parts Manufacturer Approval by the Regulatory Reform Program Implementation team in 2003 have appropriately considered important service factors, such as service history and life‑limits.

 
Hmm...not a good look when you consider the possibility of more holes in the cheese that maybe attributed to CASA dragging their feet with the RRP & past obfuscation of ATSB safety recommendations...

[/url]
Pilot's role in fatal Tiger Moth crash
Courier Mail
 - ‎2 hours ago‎

The Civil Aviation Safety Authority has now ordered the removal of all rods made by the same Australian manufacturer and the ATSB has recommended CASA also check approvals for another 1000 parts.

MTF..P2

[Kharon]

Below, from the UP is my pick for QoM.  It’s certainly Tim Tam quality; and, serves very well to highlight one of  the true culprits, identified by the ATSB Safety Recommendation.  This was a preventable accident that happened.   I have no doubt the reasons justifying the lack of CASA oversight are valid and that no blame can be sheeted home to the ‘safety system’.  But who’s safety stands, once again, as ‘the’ question.  

The integrity of 1000 part numbers now in question; even if there are only 10 of each part in stock, that is 10,000 individual items under suspicion. No problem, the Strictly No Liability policy covers all.

Penny Washers on the UP - HERE.

IFEZ is quite right – we all depend upon our maintenance outfits to an extent which we seldom appreciate, possibly because the safety record is generally very good.

But our maintenance outfits depend upon their parts suppliers (if parts are available at all.)
And the parts suppliers depend upon the manufacturers of the parts, who need meaningful design documentation to work from.
And the manufacturers depend upon their raw material suppliers who have to supply metals to the required specifications.
And on their heat treatment people.
And on the electroplaters and the NDT specialists.
And so on. They all have to operate proper inspection processes and certify the results.

That is before you start altering the basic design by bringing in substitute materials with different tensile strengths, notch sensitivities, fatigue characteristics and maybe different manufacturing techniques.

So CASA should have been monitoring all this to make sure it was being done properly, but instead seem to have abandoned their supervisory role for reasons which were no doubt good ones so far as they were concerned.

This does not just apply to old aircraft with a long (and probably very safe) history. The ATSB Report mentions over 1000 other parts made by this same company for other aircraft, some of them in the Commercial Air Transport category.

Are we going to see a general recall of all these parts for inspection?

Who wants to fly in a VH reg. Embraer EMB 120 or a Fokker F28 right now?

[Peetwo]

Below, from the UP is my pick for QoM.  It’s certainly Tim Tam quality; and, serves very well to highlight one of  the true culprits, identified by the ATSB Safety Recommendation.  This was a preventable accident that happened.   I have no doubt the reasons justifying the lack of CASA oversight are valid and that no blame can be sheeted home to the ‘safety system’.  But who’s safety stands, once again, as ‘the’ question.  

The integrity of 1000 part numbers now in question; even if there are only 10 of each part in stock, that is 10,000 individual items under suspicion. No problem, the Strictly No Liability policy covers all.

Penny Washers on the UP - HERE.

IFEZ is quite right – we all depend upon our maintenance outfits to an extent which we seldom appreciate, possibly because the safety record is generally very good.

But our maintenance outfits depend upon their parts suppliers (if parts are available at all.)
And the parts suppliers depend upon the manufacturers of the parts, who need meaningful design documentation to work from.
And the manufacturers depend upon their raw material suppliers who have to supply metals to the required specifications.
And on their heat treatment people.
And on the electroplaters and the NDT specialists.
And so on. They all have to operate proper inspection processes and certify the results.

That is before you start altering the basic design by bringing in substitute materials with different tensile strengths, notch sensitivities, fatigue characteristics and maybe different manufacturing techniques.

So CASA should have been monitoring all this to make sure it was being done properly, but instead seem to have abandoned their supervisory role for reasons which were no doubt good ones so far as they were concerned.

This does not just apply to old aircraft with a long (and probably very safe) history. The ATSB Report mentions over 1000 other parts made by this same company for other aircraft, some of them in the Commercial Air Transport category.

Are we going to see a general recall of all these parts for inspection?

Who wants to fly in a VH reg. Embraer EMB 120 or a Fokker F28 right now?

Yesterday courtesy of Safety Culture more dissemination of the full implications of the ATSB findings:

ATSB investigation found tie rod fracture resulted to Tiger Moth crash

Reported by Haydee | 01:43pm, Monday 25 January, 2016


Photo: mmisof, Pixabay

The Australian Transport Safety Bureau released a final report into the Tiger Moth crash at the Gold Coast in December 2013, which resulted to the death of a 26-year-old pilot and his passenger, a French tourist.

The crash happened shortly after the aircraft took off from the operator’s airstrip at Pimpama, Queensland.

A minute after the pilot commenced aerobatics, the left wing failed and the aircraft descended steeply into the water near South Stradbroke Island.

ATSB’s investigation found that both of the fuselage lateral tie rods, which help transfer flight loads through the fuselage has been fractured. The tie rods fractured during an aerobatic manoeuvre resulting in the left lower wing separating from the aircraft and subsequent in-flight break-up.

“The ATSB found that the tie rods were aftermarket parts manufactured under an Australian Parts Manufacturer Approval (APMA). In this respect, safety issues were identified in areas of the tie rods’ design and manufacture, as well as in the supporting regulatory approval processes.”

There were also safety issues identified in the maintenance and operation of the aircraft.

“The ATSB consulted with the Type Design Organisation, regulators and investigation authorities from Australia, New Zealand and the United Kingdom about the failure of the APMA tie rods, which occurred well before the published retirement life for Tiger Moth tie rods,” ATSB said in a statement.

“In response, the United Kingdom Civil Aviation Authority issued an airworthiness directive on 21 March 2014 that mandated the removal of all APMA-manufactured tie rods from service. The airworthiness directive was subsequently also mandated by the Australian Civil Aviation Safety Authority and the New Zealand Civil Aviation Authority.
Significant additional safety action is proposed by the Type Design Organisation to further enhance the safety of all Tiger Moth operations.

“In addition, the ATSB has issued a safety recommendation to the Civil Aviation Safety Authority to take action to provide assurance that over 1000 other parts approved for APMA at about the same time as the tie rods were appropriately considered before approval.

“This accident emphasises the need for the full consideration of a part’s service history when redesigning and manufacturing parts critical to the structural integrity of the aircraft. It also shows that important role of the regulator in ensuring that parts approved under an APMA have been fully considered and shown to comply with the design requirement. Further, in the context of maintenance, it shows the importance of utilising genuine or approved substitute aircraft parts that are suitable for purpose, especially in sections of the aircraft that are critical to flight.

“In addition, the ATSB cautions commercial vintage aircraft operators about the risks associated with aircraft age and the importance of understanding the originally-intended use of the design before commencing their operations.”

 The penny is slowly dropping on the implications of the SR as being evidence that even within CASA, severely delayed, overburdened, & punitive regulations leads to a tick & flick culture, & consequently poor oversight of a vital sector of the industry.

 As we know the ATSB (beyond reason) are normally extremely adverse to issuing SRs, especially to the regulator, so let's look into the guts of the SR to see what triggered it from the ATSB point of view & what has occurred in terms of response so far:

Civil Aviation Safety Authority Australian Parts Manufacturer Approval implementation approvals


Issue number: AO-2013-226-SI-07

Who it affects:

Operators of aircraft fitted with parts manufactured under those Australian Parts Manufacturer Approvals

Issue owner: Civil Aviation Safety Authority

Operation affected:

Aviation: Airspace management

Background:
Investigation Report AO-2013-226

Date:
21 January 2016

Safety issue description

Over 1,000 parts were approved by the Civil Aviation Safety Authority for Australian Parts Manufacturer Approval using a policy that accepted existing design approvals without the authority confirming that important service factors, such as service history and life‑limits, were appropriately considered.

Action organisation:
Civil Aviation Safety Authority
Date:
21 January 2016
Action status:

The ATSB provided the Civil Aviation Safety Authority (CASA) with written information about this safety issue and then followed up with a meeting on 11 February 2015 to discuss the issue. In correspondence following that meeting, CASA advised of the following safety action:

CASA has reviewed its processes and procedures applicable at the time for the appointment of CAR 35 authorised persons and concluded that although CAR 35 regulation referred to design standards and not airworthiness requirements, one of the usual limitations on all CAR 35 instruments was to consider relevant/applicable ADs and therefore the issue of AD consideration was covered in this way. Nevertheless, it appears, on the basis of the ATSB investigation, that, at least in one case, a CAR 35 design approval was given without considering applicable ADs.

In order to assess the potential scope and establish direction of any future actions, if any, CASA has made a decision to conduct a review of the approach of all former CAR 35 authorised persons, before 2003, with regards to the assessment of ADs in their approvals made under CAR 35 regulation. The data for this review will be collected during the scheduled surveillance events, for currently active design authorised persons, and via communication in writing with inactive and retired (former) CAR 35 authorised persons that were active before 2003. Once the results are received, an assessment will be conducted and further action decided. If in the course of collecting data, any adverse trends are noticed, an appropriate interim action will be initiated.

Subsequently, following their review of the draft report, CASA advised that they would not be carrying out any further safety action in respect of this safety issue. 

ATSB response:

The ATSB acknowledges CASA’s initial action to address this safety issue. However, the ATSB is concerned that this action does not specifically examine the over 1,000 Australian Parts Manufacturer Approvals undertaken by the Regulatory Reform Program Implementation (RRPI) team in 2003. The effect of the policy direction given to the RRPI team, and lack of CASA files containing records of CASA’s engineering assessments of those parts, means there is no assurance that the tie rod manufacturer’s other RPPI-approved APMA parts were not similarly affected by the issues identified with the tie rod replacement parts approval. In support of this, the ATSB has become aware that at least one other part listed on the tie rod manufacturer’s APMA approved by the RRPI, for the DHC-1 Chipmunk aircraft, is the subject of an airworthiness directive that places a life limitation on the part. Like the APMA for the tie rods, there is no mention of the airworthiness directive, or life limitation, on the associated APMA documents.

As a result, the ATSB has issued the following safety recommendation.

Recommendation

Action organisation:
Civil Aviation Safety Authority

Action number:
AO-2013-226-SR-044

Date:
21 January 2016

Action status:

Released

The ATSB recommends that the Civil Aviation Safety Authority takes action to provide assurance that all of the replacement parts that were approved for Australian Parts Manufacturer Approval by the Regulatory Reform Program Implementation team in 2003 have appropriately considered important service factors, such as service history and life‑limits.  
 
Current issue status:
Safety action pending
 



Last update 21 January 2016

 
Oh how this sounds oh so familiar..  

Nearly a year ago CASA get advised of an ATSB identified 'safety issue', to which they respond with some standard long winded preamble designed to totally obfuscate & belittle the ATSB safety concern.

Next the ATSB again draw attention to the 'safety issue' in the DIPs DRAFT report process. To which, with a standard response, CASA simply say - "up yours, nothing to see here, go away!"  

However to the ATSB credit they have formalised and got on the record a SR, which proves to me that there is still hope for the once proud State AAI (BASI/ATSB). I do wonder if perhaps the white hats at the bureau have got away with this while Dolan (CASA's go to man) is somewhat distracted by his continued obfuscation campaign (on behalf of the Malaysians) of the MH370 SIO search. 

One thing that should be noted is that all the above actions/inactions instigated by CASA in response to this 'significant safety issue' was conducted/ignored/obfuscated while under Skidmore's watch...


MTF...P2   
 

[Kharon]

Collision with water involving Piper Aircraft Corp PA-28-235, VH-PXD, 33 km SSE of Avalon Airport, Victoria on 29 January 2016.

ATSB to investigate a fatal - HERE -  Not too many 'facts' just yet and little in the way of sensible comment.  
Sad day for all, condolences to those left behind. 

[Kharon]

If you do nothing else today read -THIS – Grab a coffee and a comfy chair, prepare to enjoy a demonstration of the stark differences between that ‘then’ and this 'now'.  

The link takes you to the ATSB report on an accident involving the beloved Chipmunk. Nah! - Skip the poorly written ATSB twaddle, that is just the usual milk and water pap ATSB seem to produce these days.  Go to the appendices ‘A’ and read a real report from the old days, back when the ‘department’ had pilots who knew their trade and writers who could get the safety message delivered.  

Food for thought, a banquet; not solely for the lessons taught, but a reminder of a trade and craft almost lost; the art of flying.

One loop closed.  RIP Aviation Safety Digest.

Toot toot.

[Kharon]

FWIW, courtesy of ‘The Age’ a little more background into the fatal accident off Point Lonsdale Vic.  General information only and another ‘expert’ being quoted.

[Peetwo]

FWIW, courtesy of ‘The Age’ a little more background into the fatal accident off Point Lonsdale Vic.  General information only and another ‘expert’ being quoted.

Update to this tragedy yesterday courtesy Bayside News:

Divers search for body after plane crash

February 10, 2016 Stephen Taylor

POLICE divers were yesterday still searching for the body of 55-year-old Mordialloc man Daniel Flinn, who died when the plane in which he was flying with three friends crashed into Bass Strait, off Barwon Heads, late last month.

The fuselage of the Piper Cherokee carrying the bodies of Donald Hately, 68, of Noble Park, Di Bradley, 63, of Black Rock, and her 65-year-old husband Ian Chamberlain, was recovered soon after the accident but Mr Flinn’s body has yet to be found.

The friends had left Moorabbin airport on Friday 29 January intending to spend the weekend at the races at King Island. It is usually a 90 minute trip.

Their 1967 dual-control plane was heading into “really heavy weather; terrible sky and lots of driving rain” – and flying as low as 100 metres over the ocean – according to a Queenscliff fisherman who saw the lead-up to the crash.

Although it has not yet been made public who was piloting the aircraft, all on board were regarded as experienced aviators. There was no distress call.

Aviation experts say pilot error is the major cause of air crashes – especially disorientation in cloud.

Late Sunday afternoon the plane’s engine block, propeller and part of the fuselage were found on the seabed, at a depth of 33 metres, about four kilometres offshore between Point Lonsdale and Barwon Heads.

The wreckage was found using a remote operated vehicle which determined its location and guided police divers to the site. The wreckage was then loaded onto a barge and towed into Williamstown where it was to be inspected by investigators this week.

The Civil Aviation Safety Authority said yesterday it was “not in a position to comment [on the accident] as there is an investigation under way by the Australian Transport Safety Bureau.  We will study the findings carefully when they are available.”

The bureau, as part of its investigation, will examine weather conditions at the time; pilot training and experience, and aircraft maintenance records.

Their preliminary report is expected to be released in early March. They ask that any witnesses call 1800 020 616.

Police are preparing a report for the coroner.

 Here is the page link - Investigation number: AO-2016-006 - for those people interested in monitoring the progress of the ATSB investigation.


MTF...P2

[Peetwo]

FINAL REPORT - In-flight breakup involving PZL Mielec M18A Dromader aircraft, VH-TZJ, 37 km west of Ulladulla, NSW on 24 October 2013

What happened


On 24 October 2013, the pilot of a modified PZL Mielec M18A Dromader, registered VH-TZJ, was conducting a firebombing mission about 37 km west of Ulladulla, New South Wales. On approach to the target point, the left wing separated. The aircraft immediately rolled left and descended, impacting terrain. The aircraft was destroyed and the pilot was fatally injured.

What the ATSB found

The ATSB found that the left wing separated because it had been weakened by a fatigue crack in the left wing lower attachment fitting. The fatigue crack originated at small corrosion pits in the attachment fitting. These pits formed stress concentrations that accelerated the initiation of fatigue cracks.

The ATSB also found that, although required to be removed by the aircraft manufacturer’s instructions, the corrosion pits were not completely removed during previous maintenance. During that maintenance, the wing fittings were inspected using an eddy current inspection method. This inspection method was not approved for that particular inspection and may not have been effective at detecting the crack.

Data from a series of previous flights indicated that the manner in which the aircraft was flown during its life probably accelerated the initiation and growth of the fatigue crack.
Finally, the ATSB also found a number of other factors which, although they did not contribute to the accident, had potential to reduce the safety of operation of PZL M18 and other aircraft. These included the incorrect calculation of the flight time of M18 aircraft and a lack of robust procedures for the approval of non-destructive inspection procedures.

What's been done as a result

The Civil Aviation Safety Authority (CASA) revised the airworthiness directive for inspection of the wing attachment fittings to ensure that they were inspected using the magnetic particle inspection method. CASA also made, or plans to make, a number of changes to their systems and procedures to address issues identified in this report.
Separately, the ATSB reminded operators of M18 aircraft of the importance of the correct application of service life factors when operating at weights above the original maximum take-off weight. In addition, PZL Mielec plans to release additional maintenance documentation clarifying the need for removal of the wings for proper inspection of the wing attachment fittings. Finally, at the request of the owner, the supplemental type certificate for operation of the modified M18 Dromader at take-off weights up to 6,600 kg has been suspended by CASA.

Safety message

This accident shows that even when flying within operational limits, the ‘harder’ and faster an aircraft is flown the more rapidly the structure will fatigue.

To help ensure that maintenance objectives are consistently met, the ATSB reminds aircraft maintenance personnel of the importance of only using properly-approved maintenance instructions. This accident confirms the importance of referring directly to those maintenance instructions when conducting maintenance.

Safety Issues:

Removal of wings to complete service bulletin actions


Although wing removal was necessary to provide adequate access for effective visual and magnetic particle inspections of M18 wing attachment fittings, the aircraft manufacturer’s service bulletin E/02.170/2000 allowed the wings to remain attached during these inspections.

Issue number:

AO-2013-187-SI-02

Who it affects:

Maintainers of M18 aircraft completing CASA AD/PZL/5 and PZL Mielec service bulletin E/02.170/2000

Status:

Safety action pending

---

 

M18 Dromader airframe life factoring

Operators of some Australian M18 Dromaders, particularly those fitted with turbine engines and enlarged hoppers and those operating under Australian supplemental type certificate (STC) SVA521, have probably conducted flights at weights for which airframe life factoring was required but not applied. The result is that some of these aircraft could be close to or have exceeded their prescribed airframe life, increasing the risk of an in-flight failure of the aircraft’s structure.

Issue number:

AO-2013-187-SI-01

Who it affects:

Operators of PZL M18 aircraft

Status:

Adequately addressed

---

 

Spectrum of flight loads

Operation of M18 aircraft with a more severe flight load spectrum results in greater fatigue damage than anticipated by the manufacturer when determining the service life of the M18. If not properly accounted for, the existing service life limit, and particular inspection intervals, may not provide the intended level of safety.

Issue number:

AO-2013-187-SI-04

Who it affects:

All operators of M18 aircraft

Status:

Adequately addressed

---

 

Use of eddy current inspection for airworthiness directive AD/PZL/5

The eddy current inspection used on VH-TZJ, and other M18 aircraft, had not been approved by the Civil Aviation Safety Authority as an alternate means of compliance to airworthiness directive AD/PZL/5. This exposed those aircraft to an inspection method that was potentially ineffective at detecting cracks in the wing attachment fittings.

Issue number:

AO-2013-187-SI-03

Who it affects:

All operators of M18 aircraft that have had their M18s inspected using the eddy current procedure QP.00.36 (EC)

Status:

Adequately addressed

---

 

Adequacy of the eddy current inspection procedure

The documented procedure for eddy current inspection of M18 wing attachment fittings did not assure repeatable, reliable inspections.

Issue number:

AO-2013-187-SI-06

Who it affects:

All operators of M18 aircraft that have had their M18s inspected using eddy current procedure QP.00.36 (EC)

Status:

Adequately addressed

---

 

Civil Aviation Safety Authority records

Important information relating to Civil Aviation Safety Authority (CASA) airworthiness directive AD/PZL/5 was not contained in CASA’s airworthiness directive file, but on other CASA files with no cross-referencing between those files. This impacted CASA’s future ability to reliably discover that information and make appropriately‑informed decisions regarding the airworthiness directive.

Issue number:

AO-2013-187-SI-07

Who it affects:

All aircraft operators in Australia

Status:

Adequately addressed

---

 

Assessment of NDT procedures

The Civil Aviation Safety Authority did not have a defined process for a robust, systematic approach to the assessment and approval of alternative non-destructive inspection procedures to ensure that the proposed method provided an equivalent, or better, level of safety than the original procedure.

Issue number:

AO-2013-187-SI-08

Who it affects:

All aircraft operators in Australia

Status:

Safety action pending

---

 

Australian supplemental type certificate SVA521

The engineering justification supporting Australian supplemental type certificate SVA521 did not contain consideration of the effect an increase in the average operating speed could have on the rate of fatigue damage accumulation.

Issue number:

AO-2013-187-SI-09

Who it affects:

All aircraft operators of the M18 aircraft in Australia operating under STC SVA521

Status:

Adequately addressed

MTF..P2

[Peetwo]

FINAL REPORT - In-flight breakup involving PZL Mielec M18A Dromader aircraft, VH-TZJ, 37 km west of Ulladulla, NSW on 24 October 2013

Safety Issues:

Removal of wings to complete service bulletin actions

Although wing removal was necessary to provide adequate access for effective visual and magnetic particle inspections of M18 wing attachment fittings, the aircraft manufacturer’s service bulletin E/02.170/2000 allowed the wings to remain attached during these inspections.

Issue number:

AO-2013-187-SI-02

Who it affects:

Maintainers of M18 aircraft completing CASA AD/PZL/5 and PZL Mielec service bulletin E/02.170/2000

Status:

Safety action pending

---

 
M18 Dromader airframe life factoring

Operators of some Australian M18 Dromaders, particularly those fitted with turbine engines and enlarged hoppers and those operating under Australian supplemental type certificate (STC) SVA521, have probably conducted flights at weights for which airframe life factoring was required but not applied. The result is that some of these aircraft could be close to or have exceeded their prescribed airframe life, increasing the risk of an in-flight failure of the aircraft’s structure.

Issue number:

AO-2013-187-SI-01

Who it affects:

Operators of PZL M18 aircraft

Status:

Adequately addressed

---

 
Spectrum of flight loads

Operation of M18 aircraft with a more severe flight load spectrum results in greater fatigue damage than anticipated by the manufacturer when determining the service life of the M18. If not properly accounted for, the existing service life limit, and particular inspection intervals, may not provide the intended level of safety.

Issue number:

AO-2013-187-SI-04

Who it affects:

All operators of M18 aircraft

Status:

Adequately addressed

---

 
Use of eddy current inspection for airworthiness directive AD/PZL/5

The eddy current inspection used on VH-TZJ, and other M18 aircraft, had not been approved by the Civil Aviation Safety Authority as an alternate means of compliance to airworthiness directive AD/PZL/5. This exposed those aircraft to an inspection method that was potentially ineffective at detecting cracks in the wing attachment fittings.

Issue number:

AO-2013-187-SI-03

Who it affects:

All operators of M18 aircraft that have had their M18s inspected using the eddy current procedure QP.00.36 (EC)

Status:

Adequately addressed

---

 

Adequacy of the eddy current inspection procedure

The documented procedure for eddy current inspection of M18 wing attachment fittings did not assure repeatable, reliable inspections.

Issue number:

AO-2013-187-SI-06

Who it affects:

All operators of M18 aircraft that have had their M18s inspected using eddy current procedure QP.00.36 (EC)

Status:

Adequately addressed

---

 

Civil Aviation Safety Authority records

Important information relating to Civil Aviation Safety Authority (CASA) airworthiness directive AD/PZL/5 was not contained in CASA’s airworthiness directive file, but on other CASA files with no cross-referencing between those files. This impacted CASA’s future ability to reliably discover that information and make appropriately‑informed decisions regarding the airworthiness directive.

Issue number:

AO-2013-187-SI-07

Who it affects:

All aircraft operators in Australia

Status:

Adequately addressed

---

 

Assessment of NDT procedures

The Civil Aviation Safety Authority did not have a defined process for a robust, systematic approach to the assessment and approval of alternative non-destructive inspection procedures to ensure that the proposed method provided an equivalent, or better, level of safety than the original procedure.

Issue number:

AO-2013-187-SI-08

Who it affects:

All aircraft operators in Australia

Status:

Safety action pending

---

 

Australian supplemental type certificate SVA521

The engineering justification supporting Australian supplemental type certificate SVA521 did not contain consideration of the effect an increase in the average operating speed could have on the rate of fatigue damage accumulation.

Issue number:

AO-2013-187-SI-09

Who it affects:

All aircraft operators of the M18 aircraft in Australia operating under STC SVA521

Status:

Adequately addressed

Media coverage

First from Oz Flying:

The Dromader crash site south of Nowra. (ATSB)


Dromader Investigation points to Fatigue Cracks
16 Feb 2016

Fatigue cracks in wing mounting lugs caused the crash of an M18A Dromader firebomber in 2013, according to the ATSB report released yesterday.

Dromader VH-TZJ was in operation as a single-engine aerial tanker (SEAT) over a bushfire near Ulladulla, NSW, on 24 October 2013, when the port wing separated in flight. The pilot died in the accident.

" ... the left wing separated because it had been weakened by a fatigue crack in the left wing lower attachment fitting," the ATSB report states.

"The fatigue crack originated at small corrosion pits in the attachment fitting. These pits formed stress concentrations that accelerated the initiation of fatigue cracks.

The ATSB discovered during the investigation that manufacturer–PZL Mielec–issued instructions to remove the pits, but the pits were not completely removed during previous maintenance. Also, the components were tested for cracks using an eddy current inspection, which was not approved for that particular inspection and may not have detected the crack.

The ATSB report also stated that the way VH-TZJ had been flown prior to the accident could have accelerated the crack growth rate.

"The aircraft had been operated at higher speeds and subjected to a more severe flight load spectrum than assumed by the manufacturer when it determined the aircraft's service life limitation. This likely increased the rate of fatigue damage, increasing the rate of formation and growth of the micro-cracks in the left outboard wing lower attachment fittings."

CASA has since revised the Airworthiness Directive for inspecting the wing attachments to specify magnetic particle inspection.

The full investigation report is on the ATSB website.

Passing strange??- Yesterday the Bloomberg Business article on MH370 - see HERE - quoted the MH370 Super Sleuth Muppet as saying he is consumed by MH370:

Back in Canberra, the ATSB is investigating about 130 incidents in total -- ranging from a freight train derailment in Queensland to a seaplane crash off northeast Australia.

Yet Dolan says he’s consumed by MH370. He speaks mostly in a soft, low tone, pausing often as he chooses his words. At a table in his office, he refers to a map of the search zone in front of him as he outlines the analysis of the plane’s final moments:

Yet in the following ABC article he features as the ATSB spokesperson on the Dromader Final Report:

Undetected stress fatigue crack caused wing to break off in water bombing plane crash that killed pilot David Black


ABC Illawarra
By Nick McLaren
Posted Tue at 9:21amTue 16 Feb 2016, 9:21am


Photo: A Dromader water bomber pictured in flight. (Supplied: Hustvedt)

An investigation report into a fatal plane crash on the New South Wales south coast has found the left wing separated from the plane mid-flight due to an undetected fatigue crack.

The M18 Dromader was carrying out water bombing operations for the Rural Fire Service when it crashed near Ulladulla in October 2013.

The crash resulted in the death of experienced pilot David Black, 43, from Trangie in central-west NSW.

The final report from the Australian Transport Safety Bureau (ATSB) found the wing separated from the plane due to a fatigue crack in the lower attachment fitting, which originated in small corrosion pits.

The corrosion pits were not successfully removed during maintenance, and the unapproved inspection method may not have been effective in detecting the crack.

"The result of weathering, interaction with the metal and so on could lead to corrosion of the metal and that leads to pitting of the metal, and the way of dealing with that is to strip back the metal and remove the pitting," ATSB chief commissioner Martin Dolan said.

"And that wasn't done fully effectively in this case."

The report also noted the harder and faster an aircraft was flown, the more rapidly the structure would fatigue.

Mr Dolan said despite approval to carry heavier loads, the stresses to the plane could have been more accurately calculated.

"There was a range of tests and approvals that were done to allow it to fly with a heavier load," he said.

"But looking back over the various calculations done about that, we think that the risk of parts of the aircraft being subject to stress and fatigue risk was probably under calculated."

Since the accident, Commissioner Dolan said procedures for inspections and recommendations for carrying additional weight were close to being fully implemented.

"They have actually been implemented or are in the process of being implemented, and we'll just keep an eye on them until the work has been complete," he said.

"But we are satisfied with the action that has been taken or the action that's proposed."

The M18 Dromaders are no longer approved for water bombing operations.

Maybe the usual spokesperson was off crook; or due to budgetary constraints has had his/her hours cut back? Probably a good thing because it would seem that the CC (on top of being a MH370 Super Sleuth; & deep sea salvage & search expert) is something of an airframe fatigue & aircraft (NDI) engineering expert...  


MTF...P2


 

[Gobbledock]

A pondering Beaker?

A reflective Beaker;

"Yet Dolan says he’s consumed by MH370. He speaks mostly in a soft, low tone, pausing often as he chooses his words. At a table in his office, he refers to a map of the search zone in front of him as he outlines the analysis of the plane’s final moments"

He mi mi mi's slowly because that is what happens when you are the product of a scientific experiment gone wrong! As for choosing his mi mi mi's carefully, that's because anything he says could impact on his beloved Minsicules career, hence the 'softly slowly approach', the head wobbles and the occasional masturbation of the beard. And oh yes, 'that table' where he has famously posed (beard on and beard off) for many photos, especially the almost portrait like one of him smiling behind the giant glass of water! Yes, very Beaker'esq and almost a Brett Whitely.

Not being able to solve the MH370 mystery from behind his robust desk (or balance his budget) will probably be one of the Super Sleuths greatest regrets as he mi mi mi's out the door into retirement. I'm sure we will read about it in his biography. Dougy the lapdog might write it, or perhaps we will read about his career from off the back of a public shitter door somewhere.

Ho hum, the real world continues outside of the troposphere that these Can'tberra bureaucrats live in. Does the IOS give a flying handful of pony pooh about what the bearded buffoon thinks? Nope. It's just another news article for me to wipe my ass with.

Beaker, please piss off, soon, there's a good bureaucrat. Nobody listens to your horse shit...

[Peetwo]

..He mi mi mi's slowly because that is what happens when you are the product of a scientific experiment gone wrong! As for choosing his mi mi mi's carefully, that's because anything he says could impact on his beloved Minsicules career, hence the 'softly slowly approach', the head wobbles and the occasional masturbation of the beard. And oh yes, 'that table' where he has famously posed (beard on and beard off) for many photos, especially the almost portrait like one of him smiling behind the giant glass of water! Yes, very Beaker'esq and almost a Brett Whitely.

Not being able to solve the MH370 mystery from behind his robust desk (or balance his budget) will probably be one of the Super Sleuths greatest regrets as he mi mi mi's out the door into retirement. I'm sure we will read about it in his biography. Dougy the lapdog might write it, or perhaps we will read about his career from off the back of a public shitter door somewhere...

Dear Deidre - Where art thou?

Slightly (but not really) mimimiffed because on doing my weekly sojourn to the pages (1&2) of the Great Super Sleuth's  Dear Deidre blog...

Great news - Oh goody.

Dear Deirdre, is a famous agony Aunt who writes for the UK Sun.  The mail bag is famous;  “and you've been caught in flagrante on the desk wearing some suspenders ", then the Sun's Deirdre Sanders is for you.

Now we have the Australian version – Dear Dreary.   Yes children, it’s true; back, by popular demand, the world’s greatest aviation safety analyst.  You can see why when you read through the P2 post, the brilliant, original, insightful thinking of one of the foremost doyens of the Beyond all Reason methodology. 

Is it modesty which prevents you from posting comment on the Dear Dreary boards?  You can see how a torrent of compliments and demands for more of the brilliant, dynamic insights into accident investigation would distract the mighty analyst from his sworn mission; to meet the world wide demand for his very own ‘beyond all reason’ system of accident investigation.  

There are of course those who would gainsay this.  The tendentious bloggers who will ask silly questions, make comment and decry the ‘Beyond Reason’ model.  They will cite all manner of accident and incident investigations which they falsely claim are aberrations.  The Australian Senate in Parliament committee which was critical of Dreary, the methods used and the lack of clarity were of course misinformed and led a stray by those miscreants who disagreed.  In response to those baseless, tendentious accusations and just to prove, categorically, once and for all that the ‘Dreary Beyond Reason’ method is flawless, one investigation is being revisited.  Rumour has it the great man may condescend to write the report himself; won’t that be grand children?

I shall make it my mission in life to visit  -Uriah_Heep.gov.au/Dear_Dreary  - every day; so I may be fully informed and read the great mans words.  

Minnie, fetch that bucket – I have great need of it.


Toot toot.

...I discovered that the relevant link is stuck in some kind of a vortex/time-warp loop


Hmm...maybe it is just another in a long list of strange coincidences; or maybe the great Muppet has decided to copyright his own blog for when he leaves the bureau??

Oh well time will tell I guess  - MTF..P2  

Ps Maybe it is just me?? So try and click on the Blog link below & please let me know how you get on:

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[Kharon]

It is never good news to hear of the death of an aviator, indeed it is a sadness to all.  But, as in all walks of life, accidents happen, people get hurt or die.  The tragedy is doubled when there is no benefit in the form of lessons learnt which may reduce the percentage chance of another similar event occurring and claiming more lives.  The statement below from RAAus is worth considering:-

Accident at Katoomba Airport 27 February 2016

RAAus is saddened to advise members of the death of Mr Rod Hay. Mr Hay died in an accident at Katoomba Airport on 27 February 2016 involving Jabiru 55-3692.

The damage to nearby trees in conjunction with the extensive damage to the propeller and lack of visible external damage to the engine indicates the engine appeared to be operating at impact. To fully examine the engine, RAAus is conducting a supervised engine tear down with officials from ATSB and Jabiru.

The control systems of the aircraft were all confirmed as connected to key points after impact and all damage is consistent with impact damage.

At present our preliminary assessment of the evidence appears to support a possible loss of control with the cause as yet undetermined. RAAus will continue to work with authorities on the investigation and advise members again once we have more information.

I think that this fairly timely and reasonably adequate initial report on a very sad and disturbing occurrence is a sign that RAA has recognised that Members have a genuine need for reasonable advice in the case of serious accidents. The quick response after the Moruya accident was better information than we have had out of RAA for some years and the people in RAA involved are to be thanked, I believe, for this significant improvement in communications.

It has also been a relief that this particular thread has not instantly degenerated into formula 'Jabiru' bashing posts and everybody has been respectful and reticent to assume a position on the initial report.

It is - in my belief - a good step forward that ATSB is involved, so we may get the results of trained, expert accident investigation.

RIP Rod Hay - the type of stalwart of the RAA movement.

Out of terrible news there are some commendable positives for those left behind, wondering ‘how and why’.  Perhaps this is the beginning of the desperately needed reform of accident investigation and reporting of all accidents.  It would be a tonic to see an unbiased, technically accurate report of this accident supported by positive recommendations directed toward prevention.

There is little else to say at this point except offer sincere condolences to family and friends and hope that some good will come out of the event.  I am certain that Rod Hay or any aviator would hope that an untimely death provided a legacy which helped prevent a similar event in the future.

RIP Rod Hay, Godspeed.

Selah.

[Peetwo]

FWIW, courtesy of ‘The Age’ a little more background into the fatal accident off Point Lonsdale Vic.  General information only and another ‘expert’ being quoted.

Update to this tragedy yesterday courtesy Bayside News:

Divers search for body after plane crash

Preliminary report released:

Summary

Summary
On 29 January 2016, a Piper aircraft PA-28-235, registered VH-PXD, was being operated on a private flight from Moorabbin Airport, Victoria to King Island Airport, Tasmania. There were four people on board, three of whom were private pilots. At this stage of the investigation, the pilot in command has not been established. Other aircraft from the same aero club were also flying to King Island over the course of the afternoon.

The aircraft departed Moorabbin Airport runway 13L at 1203 Eastern Daylight-saving Time[1]. Recorded air traffic control (ATC) data indicated that the aircraft climbed to 1,000 ft then turned south-west near Seaford. The aircraft then climbed to 1,400 ft tracking over Port Phillip Bay, then west towards the Bellarine Peninsula (Figure 1). The ATC data also showed that, after passing over Point Lonsdale, the pilot carried out a series of turns, before there was a final steepening and rapidly-descending turn.

A witness, who was fishing approximately 3 km off the coast near Barwon Heads, reported seeing the aircraft descend out of cloud in a steep, nose-down attitude with the right wing lower than the left. The witness recalled that a few seconds later, the aircraft impacted the water about 200 m from their positon.

Examination of the witness reports and derived ATC data indicated that the aircraft impacted the water at about 1228. A number of witnesses, including other aero club pilots in the area at about the time, reported that visibility in the area between Barwon Heads and Point Lonsdale was reduced by cloud and rain.

The four aircraft occupants were fatally injured and the aircraft was destroyed.

Figure 1: Map showing the aircraft’s departure point, its track (in yellow), Seaford and the accident site

Source: Google earth, modified by the ATSB

Wreckage examination
Wreckage examination indicated that the aircraft’s fuselage and associated components were subjected to high impact forces and subsequently failed in overload. The aircraft’s wings were not located. A number of aircraft components, including the engine and propeller, were recovered for later technical examination.

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

• pilots’ qualifications and experience
  
• engine, propeller and other recovered aircraft components
  
• maintenance documentation
  
• effect on the flight of the weather in the region.
  

[*]
 
The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.
__________

1. Eastern Daylight-saving Time (EDT) was Coordinated Universal Time (UTC) + 11 hours.

   
   
   

[*]
 
Photo
Download
 

To download an image click the download link then right-click the image and select save image as.

Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly.
 
General details

Date:
29 Jan 2016
 
Investigation status:
Active
 
Time:
12:28 ESuT
 
Investigation type:
Occurrence Investigation
 
Location   (show map):
near Point Lonsdale, Port Phillip Bay
 
State:
VIC
 
Release date:
09 Mar 2016
 
Occurrence category:
Accident
 
Report status:
Preliminary
 
Highest injury level:
Fatal
 
Expected completion:
Jan 2017 
 
Aircraft details

Aircraft manufacturer:
Piper Aircraft Corp
 
Aircraft model:
PA-28-235
 
Aircraft registration:
VH-PXD
 
Sector:
Piston
 
Damage to aircraft:
Destroyed
 
 
 
 


Last update 09 March 2016

[*]

MTF...P2

[Kharon]

PA 23 accident near Mareeba; not much more info, the ATSB are 'on the job'.

Report - HERE.

[Peetwo]

Flight Safety - "..no one can ‘out-experience’ human physiology.."

Excellent article from CASA's Flight Safety online publication: 

Be afraid of the dark

• Feature
  

Mar 21, 2016


A pitch-black sky and an empty landscape made for a deadly combination that was no respecter of daylight command hours.

How much experience does it take to safely fly out of an outback Australian campground at night with zero ambient illumination? 1000 hours? 5000 hours? 10,000? The hands at the controls of the AS355F2 Twin Squirrel near Lake Eyre on the evening of 18 August 2011 had successfully piloted for over 16,000 helicopter hours. This placed the pilot in command (PIC) among Australia’s most experienced and most respected. These same hands had skilfully guided machine and crew through the infamous weather of the 1998 Sydney to Hobart yacht race. In 2011 he had flown into the flood-ravaged Lockyer Valley where his crew were the first to broadcast the devastation of the 2011 Queensland floods. Now these seasoned hands were about to pilot a machine on a routine 30-minute flight to an overnight stop at a nearby homestead. Tragically, despite the fact the aircraft was completely serviceable, equipped in accordance with the regulations and piloted by a 16,000-hour veteran, it would never arrive.

The crew of the news helicopter had arrived at the Cooper Creek campground near Lake Eyre to film a normally barren lakebed flush with water and life. The intention was to capture footage of the revitalised lake and then interview a tour group who had set up camp. They would then fly back to the homestead for the evening. Filming and campground interviews saw darkness descend before the Squirrel departed. At about 19:00, some 40 minutes after last light and with no horizon-glow from the recently retreated sun, the Twin Squirrel began its final take-off. Climbing near-vertically from the hover, using the campfire as an initial reference point, the aircraft ascended from Cooper Creek into the pitch black of outback darkness.

Anyone who has flown dark-night operations in outback Australia will attest to the oppressive darkness enveloping the aircraft once the comforting glow of the ground is gone. A pilot who flew for the same news company in similar conditions had called this moonless darkness ‘frightening’. Without moonlight or useful ground lights, an ascent at night offers only eerie nothingness between ground and sky. Visually, no matter how experienced the pilot, it is impossible to discern any difference between down and up outside the aircraft.

As the aircraft climbed to 1500 ft above Cooper Creek inlet, the ability of the pilot’s visual system to orientate the aircraft was rendered irrelevant by the darkness. This left only the physiological ‘balance organs’ between him and serious disorientation: the easily fooled vestibular and somatosensory systems. (See this Flight Safety Australia story for a comprehensive discussion of the biological basis of spatial disorientation.) The safest thing to do at this point would have been to ‘get on the clocks’; that is, focus on the aircraft attitude indicating systems (the Squirrel had two) and let the artificial horizon be the guide. However, as the aircraft climbed further and further away from the ground into the outback darkness, the pilot focused on programming the GPS. Witnesses on the ground were surprised to see the aircraft level off, tracking in almost the opposite direction from the homestead, and then slowly turn right as the pilot pressed the GPS buttons.

Inside the cockpit, the pilot, with his eyes off the attitude indication systems and on the GPS, did not notice his aircraft had entered a slight and yet treacherous descending right-hand turn. The aircraft instruments displayed this movement perfectly, but with his eyes elsewhere, and with the balance organs of the inner ear failing to detect the insidious movements of the right turn, the aircraft’s angle of bank and rate of descent continued to increase.

During the day any set of eyes looking to the horizon would have seen the alarming descent attitude of the aircraft and quickly called attention to it. Within seconds the aircraft could have been righted and proceeded safely on its way. But in the unforgiving darkness of remote Australia, and with the aircraft’s attitude change below the detection threshold of the balance organs (about two degrees per second) there would never be such a life-saving call. With noise-cancelling headsets subduing the increasing wind-rush, the only indication of imminent catastrophe was the unnoticed aircraft instruments—the ‘clocks’—by now showing the aircraft at nearly 60 degrees angle of bank and 4000 feet per minute descent. Ten seconds after this, the aircraft hit the ground at nearly 90 degrees angle of bank with impact forces that were unsurvivable.

The simple fact is no one can ‘out-experience’ human physiology. A 16,000-hour pilot’s vestibular system, for good or for ill, will operate in the same way, with the same limitations, as that of a 100-hour pilot. On that night over Lake Eyre any pilot, no matter how experienced, and with those same conditions, would have had physiologically the same sensory experiences as the accident pilot. The only difference—the life-saving, accident preventing difference—would have been to get eyes ‘on the clocks’. These would have provided mechanically what human systems physiologically could not: accurate orientation in the intractable darkness. Flying on the clocks increases the pilot’s workload dramatically, particularly if they are not current in what Wolfgang Langewiesche called the ‘fierce and monkish art’ of instrument scan. Conceptually, workload for a helicopter pilot is no different to workload for the engine, as measured on the little torquemeter with the percentage scale: if either goes beyond 100 per cent something’s got to give. It appears a misprogrammed GPS added the deadly few per cent.

Neither the pilot nor the helicopter was equipped for true darkness. The pilot did not hold a command instrument rating, and the helicopter was not approved for IFR operations because, among other things, it had no stability augmentation system.

The Australian Transport Safety Bureau’s (ATSB) report revealed a sad truth about the pilot’s 16,000 hours. Of those, fewer than 500 were conducted at night. This equated to about two per cent of the pilot’s flying time. This meant 98 of every hundred flights (on average) were in daylight conditions; and months separated sporadic night flights. The ATSB also estimated the greater majority of these night hours were over lit areas, including the night proficiency checks. On the pilot’s last night check some months before, the check pilot wrote: ‘The check was not conducted in dark-night conditions’ and the pilot’s next check ‘should address night flight in marginal VMC to revise instrument scan skills’. The ATSB discoveries indicated a form of experience/currency dissymmetry had developed. Essentially the pilot’s type of experience and currency did not match the type of experience/currency demands of a dark-night departure. Sixteen thousand hours of day flying were ultimately rendered irrelevant by the unmet demands of a dark night instrument scan. Night VFR conditions are essentially urban—they do not exist in the vastness of outback Australia.

Among the many safety lessons from the Lake Eyre tragedy are two important lessons regarding this experience ‘dissymmetry’. Firstly, ‘experience’ alone can be a fickle safety metric especially in the helicopter world. Employment requirements in industry are generally quite clear in terms of such things as command, instrument and multi-engine hours, but the sheer diversity of rotary wing operating profiles can produce interesting mismatches of experience-to-task. For example, an operator might stipulate 100 hours on type for a multi-engine IFR helicopter operating using night vision goggles (NVG) but zero hours requirement for NVG itself. This then means the operator hires a pilot with the requisite hours on type, but the pilot with 500 hours NVG and thousands of hours total time is rejected. In another situation, a pilot has thousands of hours total and hundreds of hours instrument (from a time ten years before) but has been flying mainly in remote areas in recent years. They are then expected to act as a PIC in congested airspace and inclement weather. In these situations, as for the Lake Eyre accident, experience alone is not a replacement for targeted currency training, or for appropriate recency.

A second lesson is that rules are not necessarily built for experience dissymmetry—they are not necessarily built for a distracted, pressured or fatigued pilot having their worst night in the worst conditions. At the time of the Lake Eyre crash, the rule-set covering night VFR was comprehensive but it missed a key hazard—non-stabilised, single-pilot flight with zero external visual cues. This was located in rules relating to IMC. An amendment to Civil Aviation Order 20.18 came into effect from 1 January 2016, and specifies that if ‘surface features’ or a visible discernible horizon cannot be seen, a helicopter must have two pilots, or an autopilot, or an approved automatic stabilisation system. This amendment means any operations similar to the Lake Eyre flight nearly five years ago will only be legal if flown by two pilots or in a stabilised aircraft.

But no set of rules, no matter how thorough or admirable in intent can by itself, stop a tragedy. That requires pilots, maintainers, bosses and even passengers to understand the hazard, and the reason for the rule. As aviation author Ernest K. Gann said: ‘Rule books are paper—they will not cushion a sudden meeting of stone and metal.’

The tragedy at Lake Eyre should encourage us all to review our own experience and proficiency. We should ask if they are adequate not just for the routine, but also for the worst conditions at the worst time. It’s easy (and correct) to say ‘I would never fly in dark night conditions’, but the broader lesson is to beware of other situations where your experience and your actual proficiency don’t match up. This accident should also remind us that even the best of us can be at our worst; that is, distracted, or fatigued, or stressed, or pressured, and this should encourage us to review our own rules—whether they be from the regulator or embedded in our expositions and operations manuals—to consider whether they are proportionate and appropriate. Asking ‘do I have the experience and proficiency for the worst conditions I can reasonably expect?’ and ‘do my procedures and rules address this?’ are far safer questions than ‘how much experience do I have?

Some excellent, possibly life-saving lessons to be learnt from the 2011 Lake Eyre ABC Chopper tragedy are clearly articulated in the FSA article & ATSB Final Report. However I am afraid to say that hypocrisy & duplicity still rain supreme in the halls of Aviation House & the ATSB -

..At the time of the Lake Eyre crash, the rule-set covering night VFR was comprehensive but it missed a key hazard—non-stabilised, single-pilot flight with zero external visual cues. This was located in rules relating to IMC. An amendment to Civil Aviation Order 20.18 came into effect from 1 January 2016, and specifies that if ‘surface features’ or a visible discernible horizon cannot be seen, a helicopter must have two pilots, or an autopilot, or an approved automatic stabilisation system. This amendment means any operations similar to the Lake Eyre flight nearly five years ago will only be legal if flown by two pilots or in a stabilised aircraft...

Please refer to page 4 & 5 of PAIN report - Coronial Analysis.Fatal Accidents. 

1) CFIW: East of Cape Hillsborough, QLD, Bell 407, VH-HTD; 17 October 2003.



Report - R20050002.



Issue date 14 March 2005.



http://www.atsb.gov.au/media/24411/aair2...82_001.pdf


http://www.atsb.gov.au/publications/reco...50002.aspx


As a result of the investigation, safety recommendations were issued to the Civil Aviation Safety Authority recommending: a review of the night VFR requirements, an assessment of the benefits of additional flight equipment for helicopters operating under night VFR and a review of the operator classification and/or minimum safety standards for helicopter EMS operations.

& recommendations from the ATSB & the Coroner (in particular take note of Coroner recommendations para 15 & 18):

ATSB Safety Recommendation.



The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review it's operators classification and/or it's minimum safety standards required for helicopter Emergency Medical Services operations. This review should consider increasing; (1) the minimum pilot qualifications, experience and recency requirements, (2) operational procedures and (3) minimum equipment for conduct of such operations at night.



Coroner Hennessy.



12. That CASA consider regulating for the initial training of a helicopter pilot to include night VFR training.



13. That CASA and the industry move towards a national system of accreditation and uniform standards for provision of EMS services in Australia.



14. That CASA investigate reclassification of EMS helicopter operations into charter category, or create a separate EMS category of aviation in order to provide the benefits of increased level of regulation and CASA oversight, than that presently available under the aerial work category.



15. That CASA ensure that appropriate information be provided to pilots on an ongoing basis regarding the issue of spatial disorientation.



16. The Coroner supports CASR draft regulations part 61 and 133 becoming final.



17. That beacons, both visual and radio, be placed on prominent and appropriate high points along routes commonly utilised by aero-medical retrieval teams, including Cape Hillsborough.



18. The Coroner supports the ATSB recommendations 20030213,and promulgation of information to pilots; 20040052, assessment of safety benefits of requiring a standby altitude indicator with independent power source in single pilot night VFR; 20040053, assessment of safety benefits of requiring an autopilot or stabilisation augmentation system in single pilot VFR; and R20050002, review operator classification and minimum safety standards for helicopter EMS operations.

Do I need to comment? I don't think so - UFB!


MTF..P2  

[Kharon]

Interested in the C.172 incident off Byron I went onto the UP, just to see if any ‘facts’ had turned up and stumbled over this posted by ‘glenb’

We are from CASA and we are here to "help"
________________________________________
I'm the Chief Pilot and Business Owner of an AOC that was recently involved in an Accident. I would rate myself a very vocal critic of CASA. Not the individuals within CASA, but of the CASA created situation the Industry is now in. I retract nothing I have said or written previously.

As with every time CASA walks into the Building of any AOC holder, they could most likely create a "situation" that could make an interruption to Business imminent. That "situation" could potentially be triggered from almost any level within that Organisation, and could stick for some time if required. Especially, after an Accident of an AOC holder that can be a tad "difficult".

It was the first time I have experienced one of these "engagements" and will be working hard to make it my last!

How did it go? EXACTLY, as I would have expected it to go, when dealing with the Regulator that is "banging heads" with me.

It worked as it should. Fortunately I don't have a past experience to compare it with so I cant say if it is better or worse. I can say, I do have a higher expectation of CASA now than in the past and they met it.

CASA chose, to miss their opportunity to "nail me". I reiterate I stand 100% behind every other public comment I have made, but they say Trust is earned. For the first time in years, I actually feel it is within reach.

Some excellent CASA generated products to support Schools were released in the last couple of days. Maybe all the fertiliser that has been dumped, and a good Groundsman is actually resulting in fresh growth. Lets pray and hope for a good season.

It is an interesting post, for several reasons; not least of all being the fact that Glen can countenance the notion of trust.  One swallow does not a summer make, however I can’t help the small glimmer of hope that popped up when I read it.  Can you imagine it, an operator, pilots and CASA working together to prevent another, similar accident occurring.  Identifying all the elements, fixing up the system and then CASA reaching for the ‘breach’ book’ as a last resort, rather than the first thought.

A simple cultural change from a simple act of good faith i.e. CASA doing their job properly as a safety regulator, not a quasi police operation and execution squad.

Let’s hope this attitude is here to stay, it would be a refreshing change to find good things to say, even better if some of the old McComic school of bastardry and embuggerance had departed the fix.

“This is no flattery. These are counselors
That feelingly persuade me what I am.”
Sweet are the uses of adversity,
Which, like the toad, ugly and venomous,
Wears yet a precious jewel in his head.
And this our life, exempt from public haunt,
Finds tongues in trees, books in the running brooks,
Sermons in stones, and good in everything.

[Peetwo]

Interested in the C.172 incident off Byron I went onto the UP, just to see if any ‘facts’ had turned up and stumbled over this posted by ‘glenb’

We are from CASA and we are here to "help"
________________________________________
I'm the Chief Pilot and Business Owner of an AOC that was recently involved in an Accident. I would rate myself a very vocal critic of CASA. Not the individuals within CASA, but of the CASA created situation the Industry is now in. I retract nothing I have said or written previously.

As with every time CASA walks into the Building of any AOC holder, they could most likely create a "situation" that could make an interruption to Business imminent. That "situation" could potentially be triggered from almost any level within that Organisation, and could stick for some time if required. Especially, after an Accident of an AOC holder that can be a tad "difficult".

It was the first time I have experienced one of these "engagements" and will be working hard to make it my last!

How did it go? EXACTLY, as I would have expected it to go, when dealing with the Regulator that is "banging heads" with me.

It worked as it should. Fortunately I don't have a past experience to compare it with so I cant say if it is better or worse. I can say, I do have a higher expectation of CASA now than in the past and they met it.

CASA chose, to miss their opportunity to "nail me". I reiterate I stand 100% behind every other public comment I have made, but they say Trust is earned. For the first time in years, I actually feel it is within reach.

Some excellent CASA generated products to support Schools were released in the last couple of days. Maybe all the fertiliser that has been dumped, and a good Groundsman is actually resulting in fresh growth. Lets pray and hope for a good season.

It is an interesting post, for several reasons; not least of all being the fact that Glen can countenance the notion of trust.  One swallow does not a summer make, however I can’t help the small glimmer of hope that popped up when I read it.  Can you imagine it, an operator, pilots and CASA working together to prevent another, similar accident occurring.  Identifying all the elements, fixing up the system and then CASA reaching for the ‘breach’ book’ as a last resort, rather than the first thought.

A simple cultural change from a simple act of good faith i.e. CASA doing their job properly as a safety regulator, not a quasi police operation and execution squad.

Let’s hope this attitude is here to stay, it would be a refreshing change to find good things to say, even better if some of the old McComic school of bastardry and embuggerance had departed the fix.

“This is no flattery. These are counselors
That feelingly persuade me what I am.”
Sweet are the uses of adversity,
Which, like the toad, ugly and venomous,
Wears yet a precious jewel in his head.
And this our life, exempt from public haunt,
Finds tongues in trees, books in the running brooks,
Sermons in stones, and good in everything.

On the positivity of the 'glenb' UP post,  maybe this is truly a sign that CASA are finally embracing their 'new culture' philosophy. However call me a cynic but when you read the following from my post off the AVMED Proctology forum, quoting a Courier Mail article published today, you get the sense that perhaps there is another dimension to CASA being all touchy, touchy, feely, feely, to 'glenb' over this tragic accident:

QANTAS cleared international pilot Paul Whyte to fly one month before police believe he deliberately crashed his light aircraft into the ocean off northern NSW.

The Lennox Head man passed a mental health check in February even though he had been struggling to deal with a marriage breakdown for nearly a year.

Qantas confirmed the father-of-two had flown Boeing 747 aircraft with a capacity of 467 passengers on the Brisbane to Los Angeles route as a first officer in the weeks before his death on Monday.

The Australian and International Pilots Association has repeatedly declined to comment saying ‘we are not obligated’ to speak about the incident, despite Mr Whyte officially representing the union at Civil Aviation Safety Authority meetings in recent years.

Revelations Mr Whyte was cleared for duty have raised questions from mental health experts about the quality and frequency of checks.

Griffith University psychiatrist Harry McConnell said mental health checks could not pick up sudden changes in stability and called for pilots to more readily report warning signs of their peers to managers.

“Even if he had a mental health screening, it would only have been valid at the time,” he said.

“Even if he wasn’t suicidal a month ago, obviously there was something that happened in the interim that has changed his way of thinking and his mental state.

“These peer programs like they have in North America are good for that and lets mates to look out for mates.

“It would allow airlines to keep track of mental health on a more immediate level.”

A Qantas spokesman said all pilots had annual health checks which involved “a number of physical and psychological tests”.

The tests rely heavily on pilots themselves reporting any “significant” change in their health to obtain a medical certificate.

“Pilots who have a history of psychosis, alcoholism, drug dependence, personality disorder, mental abnormality or neurosis are disqualified from holding a Class 1 medical certificate — therefore cannot be a commercial airline pilot,” he said.

“As per CASA regulations, all Qantas pilots undergo annual medical evaluations in order to maintain their flying licence.

“This includes a number of physical and psychological tests conducted by a designated aviation medical doctor in a process overseen by CASA.

“Paul passed his annual medical check in February this year. He also passed his proficiency check in November 2015, which includes simulator testing.”

The spokesman added: “There are a number of failsafes from a safety of flight perspective, including the ‘two in the cockpit’ rule that was introduced last year.
“On most international flights there are generally four pilots on board each flight.”

Qantas Chief Pilot Captain Richard Tobiano told the Gold Coast Bulletin the tragedy was “very upsetting” for Mr Whyte’s “family, friends and colleagues”.

“It is with great sadness that I confirm that an off-duty Qantas pilot was flying a light aircraft which went missing off the northern coast of New South Wales on Monday evening,” he said.

“As you can imagine this is a very upsetting time for his family, friends and colleagues, and we’re providing them with as much support as we can.
“I ask you to respect their privacy at this time.

On Monday the father of two rented a Cessna 172 from the Northern Rivers Aero Club in Lismore, sent a final text message to his family and crashed the plane six nautical miles offshore from Byron Bay. Qantas has confirmed he was in cleared for active duty on the day he died.

MTF...P2