[Peetwo]

Update: Is Mercury retrograde?

Before these occurrences fade off into the usual ATSB veil of obfuscation and top-cover investigative reporting, one final MSM coverage from Tassie's the Mercury...  :

Australian Transport Safety Bureau to investigate Virgin incident at Hobart Airport
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/article/5a03f5f00184ca3145a4067652df89b6?esi=true&t_template=s3/chronicle-tg_tlc_storyheader/index&t_product=Mercury&td_device=desktop[/img]ALEXANDRA HUMPHRIES, Mercury
December 9, 2016 12:00am

[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/article/5a03f5f00184ca3145a4067652df89b6?esi=true&t_template=s3/chronicle-tg_tlc_storymeta/index&t_product=Mercury&td_device=desktop[/img]
THE Australian Transport Safety Bureau has launched an investigation into an incident involving two Virgin Australia Boeing 737s on the tarmac at Hobart International Airport.
A Sydney-bound passenger flight was pushing back from the parking bay just after 10am on Wednesday when it hit a Melbourne-bound flight that was boarding.

According to the investigation summary, damage to both planes was still being assessed.
No one was injured in the incident.

The ATSB will interview flight and ground crews as part of its investigation, which is expected to be completed by February next year.

The incident caused delays at Hobart airport all day on Wednesday with customers angered as check-in lines snaked through the terminal.

Passengers on the stationary Melbourne flight described feeling the plane shaking and hearing a rumbling noise at the moment of impact.

Rohan Williams was travelling to the Gold Coast via Sydney, and said he heard a loud thud.

“[It was] as if you were on a drive and you drive over a pothole,” he said.

“I looked out the window and there was a bit of a crack in one of the tails.”

The Civil Aviation Safety Authority said pilots and ground-handling personnel were responsible for preventing contact when an aircraft was being pushed back from a parking position.

The authority said it was unlikely wind could have caused the problem.

Virgin Australia has confirmed that two aircraft made light contact at the boarding gates at Hobart airport.

The company has also launched an investigation into the incident.

A third Virgin Australia plane encountered minor engineering issues at Hobart airport soon afterwards, which caused additional delay to outgoing flights

And so the ATsB should investigate the wing strike. Although Virgin used its typical watered down weasel words and said there was no safety risk to passengers, that is complete bullshit. It turned out to be minor damage, but it could have been a very different outcome. Fires have started from such contact in the past with other airlines.

Excellent point you make Gobbles, these taxiing rash occurrences have the potential for far more calamity and mayhem than you will ever read about in a dodgy half-assed & pc'd ATSB report.

Take for example the following off the ATSB - 'search for IP thread': 

ATSB post Beaker: From the sublime to the ridiculous -  

Today the ATSB released a final report that took 1105 days to investigate into a pushback incident, which saw a Virgin B737 collide with the tail cone of a Jetstar A320  - UDB!

Collision during pushback between Boeing B737-8FE, VH-YID and Airbus A320-232, VH-VGR Melbourne Airport, Victoria, on 10 August 2013
 
Investigation number: AO-2013-125
Investigation status: Completed
 

• Final Report
  
• Photo
  

Final Report
Download Final Report
[ Download PDF: 1.35MB]
 
 
Listen to this PDF
Alternate: [ Download DOCX: 10.15MB]
 
What happened

On 10 August 2013, an Airbus A320-232, registered VH-VGR (VGR) and operated by Jetstar Airways Pty Ltd was holding short of gate D2 at Melbourne Airport, Victoria. At the same time, a Boeing B737-800, registered VH-YID (YID) and operated by Virgin Australia Airlines Pty Ltd. (Virgin) was approved by air traffic control for a pushback from bay E1 once VGR was on the gate at bay D2. The dispatcher for YID assessed VGR was on the gate and commenced the pushback. During the pushback, the left wingtip of YID collided with the tail cone of VGR, damaging both aircraft. There were no injuries.

What the ATSB found

The ATSB found that the dispatcher for YID could not visually confirm the position of VGR relative to gate D2 and assessed that because the aircraft hadn’t moved, it was on the gate. The pushback ground staff followed the normal practice for a pushback from bay E1. However, this practice did not allow for visual monitoring of the left side of the aircraft, such as by using a wing walker. This meant it was not possible for the dispatcher to identify the collision risk in time to prevent the collision.

What's been done as a result

Virgin advised that following this occurrence, they issued a local instruction to ground staff, mandating the use of wing walkers from certain bays at Melbourne Airport, including bay E1.

Safety message

This occurrence highlights the importance of ensuring that adequate clearance exists prior to commencing pushback. This includes using sufficient personnel to ensure visibility of each side of the aircraft at all times.
 
Photo

Download Wing tip damage to the Virgin Australia aircraft VH-YID - Source: ATSB

Download Gates D2 and E1 - Apron diagram of Melbourne Airport. Source: Apron diagram Melbourne Airport, occurrence details by ATSB

Download Figure 3: Damage to the tail cone of VGR aft of the APU, looking from left to right of the aircraft. Source: ATSB

Download Figure 4: Screenshot of YID during pushback, 5 seconds before the collision with VGR and showing the position of the tug and the dispatcher. Source: Melbourne Airport, modified by the ATSB

Download Figure 5: Pushback of the same Virgin flight from bay E1 on the next day. Source: ATSB 

General details

Date: 10 Aug 2013
 
Investigation status: Completed
 
Time: 9:33 EST
 
Investigation type: Occurrence Investigation
 
Location   (show map): Melbourne Airport
 
Occurrence type: Taxiing collision/near collision
 
State: Victoria
 
Occurrence class: Operational
 
Release date: 18 Aug 2016
 
Occurrence category: Accident
 
Report status: Final
 
Highest injury level: None
 
 
Aircraft 1 details

Aircraft manufacturer: Airbus
 
Aircraft model: A320
 
Aircraft registration: VH-VGR
 
Serial number: 4257
 
Operator: Jetstar Airways
 
Type of operation: Air Transport High Capacity
 
Damage to aircraft: Substantial
 
Departure point: Melbourne, Vic.

Aircraft 2 details

Aircraft manufacturer: The Boeing Company
 
Aircraft model: 737
 
Aircraft registration: VH-YID
 
Serial number: 38709
 
Operator: Virgin Australia
 
Type of operation: Air Transport High Capacity
 
Damage to aircraft: Substantial
 
Departure point: Melbourne, Vic.
 
 
 


Last update 18 August 2016

Planetalking has picked up on this report and more than adequately highlights the totally farcical laughing stock that the ATSB has become in the world of ICAO Annex 13 aviation accident/incident investigative authorities:

ATSB takes three years to investigate pushback bingle

Australia's safety investigator exhaustively concludes that airlines need to keep a sharp lookout while reversing their jets. Really? Yes.

Ben Sandilands

This is the Virgin violated tail cone of the Jetstar A320

In what might be an attempt to embarrass Government over lack of resources the ATSB has today published its final report into a low speed terminal area bump and grind between a Virgin 737-800 and a Jetstar A320 at Melbourne Airport three years ago on August 10.

It was a minor incident although it carried the risk of a becoming major had fuel in the wing of the Virgin flight caught fire when it ripped off the tail cone of the Jetstar plane.
After 36 months the ATSB concluded that:

This occurrence highlights the importance of ensuring that adequate clearance exists prior to commencing pushback. This includes using sufficient personnel to ensure visibility of each side of the aircraft at all times.

No shit Sherlock. This is really laying it on the line about the under funding of the transport safety investigator. No-one takes three years to investigate the aviation equivalent of a car in a shopping carpark reversing into a stationary vehicle.

The clear message, and it is a genuine safety message, is that the ATSB has been so gutted of resources that this bingle which should have taken less than a month to exhaustively investigate was left to only fitful moments of attention for three years while the safety investigator struggled to sort out more serious matters.

Not that it always succeeds in such efforts. It not only screwed up a compromised investigation into the Pel-Air medivac charter crash of 2009, but seems hopelessly lost in dealing with its past serious errors and coming up with a credible and comprehensive new final report.

It took three years to fail to address the principle safety issue which saw a Virgin and a Qantas 737 both forced to land short on fuel at a fog shrouded airport in Mildura the same year because neither needed to be fuelled under Australia rules to find an alternative to Adelaide airport when it was closed by a deterioration in the weather when neither had anywhere else they could go.

But while there are many valid grounds for criticising or despairing about the ATSB, it hasn’t been given the government support necessary to actually do its job in a timely manner.  It treatment is a reflection on successive governments who have adopted policies of cutting back on spending on public services until they break.

If the ATSB can’t deal with a pushback incident at Melbourne airport in less than three months let alone three years, it is broken.

It may be severely broken but the questions are can it be fixed; is Greg Hood the man to fix it; and/or has he been given a mandate to fix it? If the answer is no to any of those questions, then I am afraid the ATSB is doomed to irrelevance and the eventual scrap heap...

Then reflect on the Ferryman's thoughts off the blog on this incident:

Three strikes.

• Posted by admin
  
• on August 20, 2016
  
• • Accidents and Inquiry, Senate Estimates - Unplugged
  

20Aug

“The ATSB found that the dispatcher for YID could not visually confirm the position of VGR relative to gate D2 and assessed that because the aircraft hadn’t moved, it was on the gate. The pushback ground staff followed the normal practice for a pushback from bay E1. However, this practice did not allow for visual monitoring of the left side of the aircraft, such as by using a wing walker. This meant it was not possible for the dispatcher to identify the collision risk in time to prevent the collision.”

The Sandilands article – HERE – begins by describing the ground collision between two aircraft as a super market car park bingle, then, after skipping several essential omissions in the ATSB report, takes a shotgun approach to the wide range of problems ATSB have, hitting the odd one or two, while the flock escapes. Missing an opportunity for a defining snap shot of where the ATSB is utterly failing the nations travellers.

ATSB – “This occurrence highlights the importance of ensuring that adequate clearance exists prior to commencing pushback. This includes using sufficient personnel to ensure visibility of each side of the aircraft at all times.”

The ATSB statement above, properly analysed, is terrifying.  It clearly defines the utter ineffectiveness of the agency, at all levels.  It also clearly defines the willing emasculation of the ATSB under Dolan.  I shall try, in my clumsy way, to make this simple for the politicians who need to get off their collective beam ends and make sure that either (a) this report is the tool used to close down the ATSB, disband it and save a fortune; or (b) return the ATSB to its proper role as the primary, independent arbiter of ‘safety’.  ATSB  cannot be allowed to wallow along as an ineffective, toothless, captive waste of time and money.  Australia is now so far away from true ICAO compliance that, if we were honest, a token ‘investigator’ parked in an office at the rear of the CASA building would suffice and be on a par with the other ‘token’ ICAO compliance requirements we need to be ‘seen’ to meet.

A good question; but not the first from ‘Dan Dair’ – “Now I think about it, I’d have probably asked what systems of assessment the airline or ground handler has in place before pushing-back an aircraft.”

Anyone who has suffered through a crowded shopping centre car park will understand what a busy air-side parking area – Ramp – is like when it is busy.  Arriving and departing a ramp (or gate) is probably one of the most dangerous parts of the entire journey.  Think on – a vehicle, about half the size of a football pitch, without rear view mirrors needs to be reversed about 100 meters into traffic.  The typical 737 is 12+/- meters high, wing span in the 30 meter range and some 35 meters long and weighs in somewhere between 65,000 and 85,000 kg.  I’ll leave the Kinetic energy calculation and the calorific potential in the fuel tanks to you; but it’s a big number.

To get this aircraft ‘pushed-back’ onto a live taxi way requires the coordinated effort of every safety agency we have and the company ‘system’.  It is a massive effort; laws need to be in place through parliament; CASA must turn that law into a rule set which define responsibility, procedure and method. The company must transmogrify that rule into practical, workable solutions, develop a system which ensures legal and operational safety; train staff within that system and maintain the machinery which completes the act.  Flight crew need to be trained to comply with their end of the story and provide the essential link between traffic control and ground crew.  The ATCO managing the ‘ground control’ station has to coordinate traffic all over the aerodrome; from newly landed off the runway, those moving to designated parking areas and those pushing back to begin a journey.  Why is the fool rambling on about this? – well, consider the amount of links in that chain; the potential for an incident is huge.

The point I am labouring to make that somewhere, somehow a link in that safety chain failed and an incident occurred. But which link and why?  It is for this answer we must depend on an impartial ATSB.

Were the company procedures robust, did they comply?
Was the ATC sufficiently trained?
Did the CASA approval of the procedure comply with safety rules?
Did the tug driver make an error.
Were the sight lines obstructed?
Was fatigue an issue?
Was lighting a problem?
Were the push back lines clearly defined?
Who is to make the adjustments to procedure to prevent a reoccurrence?
Who is to approve those adjustments?
What new procedures have been initiated?

I could, if pushed, develop a page of questions which should have been answered.  I would bet a beer or even two, that the companies involved Safety Management Systems (SMS) asked and provided answers to those questions, and more.  I have no doubt of that; but I cannot prove it as fact.  The findings of the ‘internal’ investigations will, quite rightly, remain private.

The ATSB public findings will not assist in the prevention of a reoccurrence; why?  Well there ain’t any; well, not any that are worth a good god damn.

I have no quarrel with SMS.  What I object to is that there may have been a slackening of requirements which allow a company to legitimately reduce (for example) say the number of personnel required to effect a simple push-back; which increases the risk of a repeat.  We don’t know and no one else is telling the tale,
Perhaps it’s just my curiosity curse, I like to know what happened and what was done to prevent it happening again.  For this I rely on the ATSB; if the ATSB cannot provide those answers; then what is the purpose of them?

Long ramble over, but it seems to me there was a little more to consider than a simple ‘beg-your-pardon’ in a carpark.

“Just be careful crossing the road kids” – last words ever heard by young Jimmy as he chased the bouncing ball.

Toot – knitting? – toot.  Apologies to 737 type specialists.

 
Hmm..do I get some sort of a premonition of a common link here (read causal chain... ), nah couldn't be - or could it??

MTF...P2

[P7_TOM]

Only a ‘twiddle’ as “K” would call it; can't be buggering about with  stats to back it  – but it seems to me that ‘push-back’ and ‘ground’ incidents’ have been on the increase for a while now. There is a distinct pattern in the ‘dots’ which suggests something has changed. Before the bottom line became so much more important than common sense; there were not so many touchy-feely incidents.  So what changed, who allowed a relaxation, why; and, just who influenced that relaxation?

The statistics clearly define this 'relaxation' – why FDS has the ATSB allowed this to become the unquestioned, norm – unchallenged?  Perhaps Hoody can now earn his corn by answering these questions. I am sick, to the back teeth, of ‘financial expediency’ trumping operational good sense.

Hood has a ‘get-out-of jail’ free card from the Senate – time to earn that trust. Start with ‘why’, suddenly we have a heap of “Light Contacts”. Mate! - there ain’t no such ducking thing: not when 150 + tons of fuel loaded machinery collide @ even 10 knots (5 each for the uninformed); the Kinetic energy, as described by Newton, defies the best run “beyond all reason” model, statistically unchallenged  garbage. It never happened before because it was never allowed to happen – ya duckin' halfwit.

Get real – sort it out; or, alternatively - fuck off.

[Gobbledock]

I've dissected Tom. (I hope it didn't hurt mate?)

Toms twiddle sums up the situation perfectly. I've cherry picked just a couple of points out of it but they are points that on the surface are very basic, but if you dig deep into Tom's comments you will come to some very ugly and concerning conclusions;

Nugget 1;
"it seems to me that ‘push-back’ and ‘ground’ incidents’ have been on the increase for a while now. There is a distinct pattern in the ‘dots’ which suggests something has changed. Before the bottom line became so much more important than common sense; there were not so many touchy-feely incidents.  So what changed, who allowed a relaxation, why; and, just who influenced that relaxation?"

Absolutely. There were NEVER so many incidents in the pre-LCC days. Back then only a qualified aircraft engineer headsetted an aircraft. Most were 'long in the tooth' Gingerbeers who were accompanied by long serving ground crew in the pushback tug, again many had decades of experience under their belt. It was simply the way it was! Now? Well now you don't even have an aircraft Engineer on the headset with some of our airlines, it could be an ex school teacher or pottery maker with less than a years airside experience doing the headset. And if it is a traditional pushback procedure with a tug and driver, well some of those lads again have a mere year or two ramp experience under their belt. Cost cutting, penny pinching and a total lack of understanding or appreciation of the process and safety risks by executive bean counters has seen the bottom of the barrel well and truly reached. 'Profits before safety'.

Nugget 2;
"Hood has a ‘get-out-of jail’ free card from the Senate – time to earn that trust. Start with ‘why’, suddenly we have a heap of “Light Contacts”. Mate! - there ain’t no such ducking thing: not when 150 + tons of fuel loaded machinery collide @ even 10 knots (5 each for the uninformed)"

The assessment and understanding of this incident by Hoody and/or his investigator through the comment of 'light contact' is again extremely worrying. Firstly, there is only ever 'contact'. Nothing should ever contact an aircraft in a manner it wasn't designed to do, EVER! And to label it 'light contact' is preposterous. Define 'light' Greg? What aircraft 'contact' scale do you measure against? Show us your matrix mate? Actually don't bother Greg, you speak utter bullshit. YOU have made an assumption based on no quantifiable measuring tool, and that is a dangerous precedent for any investigative authority to promote. An investigator investigates and reports using factual evidence, quantifiable analysis, not making up his own personal language or tools, FFS. Also, in the old days just having a set of mobile stairs rubber bumper touching the aircraft would see a pilot or ground engineer rip you a new one! But now, according to Hoody's boys; when you have two passenger aircraft and a wing from one collides with a tail cone of another and damages the shit out of the two aircraft causing a huge amount of damage it is just 'light contact'. UFB. Are these muppets serious?

Nugget 3;
"Get real – sort it out; or, alternatively - fuck off".

Good to see a no holes barred statement as above. Tom sums the ATsB situation up precisely. This level of incident and the subsequent investigation report is a disgrace. Greg, mate, if you can't do the job (and it certainly looks like you are following in Beakers footsteps), please expedite your exit from the building forthwith. In other words, fuck off, NOW.

The ATsB are obviously using the below methodology to determine what is a serious or non serious situation? Enjoy;

[Sandy Reith]

Most interesting comments to one whose push back experience in a lifetime of GA has been restricted a sometimes back breaking push by hand of various GA types from 402 to 150. However I appreciate the logic and the questions that should have had logical answers. I would though question the lack ATSB funding argument. It would not take hundreds of thousands of dollars, I reckon you could farm out most of the investigations and get much better reports in a timely fashion. The posts here indicate levels of expertise that could be utilised. As for the increasing invective, please gents tone it down. Yes frustration is boiling over but politeness is essential. We must stick to the facts and present the case that anyone will read.

[P7_TOM]

Sandy; mate, comrade in arms, respected fellow aviator, esteemed counsel; brother and friend for life – be a good chap and sod off with the ‘polite’ requirement.

Only out of deference to and respect for Aunty Pru, do we use the ‘duck’ word as emphasis – however; there is no embargo on plain speaking. In a pub or even a cockpit, there would be no hesitation is using ‘robust’ direct Anglo Saxon to express or emphasise a point of view; so why not here, when warranted?  You would not let anyone insult or demean your family name; kick your dog, slag your abilities or insult your intelligence; not without an impolite fight.

I, for one, am tired of the happy horse shit dealt out to the aviation community, the insults to intelligence, the lip service, the weasel words, all the clap trap these arseholes pronounce and expect ‘us’ to believe.  Well, duck that for a game of soldiers. I ain’t no Christian, slap me and expect me to turn the other cheek? – in your dreams. Want a piece of me, you need to be damn hungry.  Stating and supporting that 150 tons of aircraft ‘in light contact’ is a non event is fighting talk; rude, disrespectful, insulting and degrading – I call that impolite; actually it is damnably rude; unforgivably, completely and utterly. Yet I am the one who must ‘do the polite’?  No my friend, not me, but I have seen the elephant and dragged burning folk from the result of a light contact – ‘nuff said.

It is better, I agree, overall, to be ‘polite’ when you may, to people you can respect, those who have earned your consideration. It is even, on occasion a good thing to be polite to those who have not; but when some wanker cannot be called a tosser; because it ain’t polite, well there, alas, we must differ. Can’t be rude to the minister or one of his minions – bollocks. They are bloody rude to us: insult us in every possible way, every day; yet I am the one who must ‘do the polite’? Nah mate, not me, not in a million - life is far too short; and anyway, bowing and scraping make my aged knees ache.

Big smile – Huge.

[Gobbledock]

Sandy, no offence intended mate. I still love you, but I struggle with diplomacy, not my strong suit. And I particularly struggle to accept the steaming mounds of shit that bureaucrats and their political masters have shoved down my throat (and many others) for decades. When I see the ATsB watering down an incident for no reason greater than protecting their Minister and a 'large' airline, I get pissed off. When I see Government sanctioned and approved malfeasance,bullying and mistreatment I get infuriated (Butson, Quadrio, Casey). Warts and all and full steam. It's just who I am.

However, on a more positive note, Sir Tom said;

"It is better, I agree, overall, to be ‘polite’ when you may, to people you can respect, those who have earned your consideration".

Now I couldn't agree more to that. I would challenge anybody to find a tersely worded comment from the Gobbledock in relation to Rev Forsythe, Senators Xenophon, Nash or Fawcett. Now to be certain, the last 3 are Politicians and I don't agree with all of their policies or actions at times. But the three of them seem to understand aviation, actually give a shit about people's lives and safety, and they have all worked very hard to right a hell of a lot of wrongs. They also don't tolerate or foster bullying and malfeasance that I am aware of. You can't say that about the majority of the other trough dwellers.

Enough. Time to bury the hatchet, first three rounds are on me. That tight-arse Ferryman reckons if I don't shout everyone he won't let me work on the Houseboat for the annual CAsA passenger collection service at the end of the month. I can't miss out on that!!!

[Sandy Reith]

Thank you gentlemen, you explain your point expertly as usual. Call me old fashioned I struggle with the f word in public. I should get out there more often. I agree the fight and outrage. I was writing to my MP about what was to unfold in our industry at least thirty years ago when, with a only a couple of notable exceptions, no one was very public for reform and airline pilots were sitting high on their pay packets, many of the seniors bidding for shore time and working a 300 hour year. Don't open that one I hear you say but most industry leaders seemed to be fairly comfortable with the status quo in those days prior to the dispute.

At least I think it's pretty much agreed and recognised now that political action is the first priority and skirmishes with public servants won't yield much. So the question is how? Direct political party involvement, publicity, AOPA and TAAAF support. Work to be done, meetings to attend, letters and phone calls to MPs. For one thing Liberal Party membership has waned considerably and therefore members are more valuable especially in marginal seats. We've no alternative but to keep up pressure, no one saw the Berlin Wall coming down.

[P7_TOM]

Just to close it off:-

I can both respect and understand Sandy’s approach; in the ‘old days’ we had to be scrubbed and tidy before going anywhere near a doctors surgery – a home visit from the same meant hours of cleaning.  Back then people gave and were given ‘respect’; good manners prevailed. I still can’t, to this day, sit on a bus seat when a lady is standing; or, not open a door for those behind; or, even move aside to let someone carrying ‘stuff’ to move through easily. It’s the same on the road – I was taught that you must never; ever, drive to cause someone to change speed or direction and patience – in short ‘manners’ and an appreciation of t’uther fellahs predicament were taught – situational awareness ring a bell.

These elements were, on occasion, beaten into us. But, with age comes wisdom. When you have forty odd years experience of watching a fine, profitable (ish), proud industry, based on excellence going slowly, but irrevocably down the shitter; mostly due to sheer incompetence, arrogance and a parsimonious realisation that a ‘comfy’ life could be had – provided the deck was stacked your way – then I tend to take a dim view of that lack of respect, caring and duty. In short it makes me cranky.

Past and present ministers, since Keeting rejigged the rules, have been taking the Mickey and the money; without a care in the world. A whole CYA package has been skilfully crafted to ensure that no one is accountable, to the point that the word ‘safety’ places those who should be ‘accountable’ above the law.

I agree with GD; there are those who have my respect, trust and have earned my ‘good’ manners. Then, there are those who have not; they deserve the same treatment they dish up. Hence, if anyone, no matter who or how 'politely', tell me to ‘duck off’ or show me no respect; do not be surprised if injury is added to the insult.  End of…….

[P7_TOM]

C 172 Down on Middle Island - MTF

Western Times.

ABC.

[P7_TOM]

C172 incident in Qld .  Update from the ABC now with one confirmed fatality.

[Peetwo]

Aussie aviation safety record - The luck of the Irish?

Off the latest FSA online publication we are reminded just how close we came to our worst aviation disaster ever... :

The finger of fate
Jan 16, 2017

image: © Airbus A340 cockpit | Airbus SAS

One mistyped digit almost led to what could have been the worst crash in the history of Australian aviation. Adrian Park analyses an incident that exposes some uncomfortable truths about automation, redundancy and the role of human pilots.

It was a busy Friday night at Tullamarine Airport as the crew of Emirates Flight EK407 prepped the aircraft for the 14-hour flight to Dubai. Cockpit activity was high as the crew ran checklists, confirmed clearances and computed performance calculations. With the help of an onboard laptop, known as an electronic flight bag (EFB), the first officer calculated the required take-off speed for the aircraft’s weight of 362.9 tonnes and made a dangerous mistake: instead of entering the intended 362.9 tonnes the first officer inadvertently made a typo and entered 262.9 tonnes. The design of a keyboard with the ‘2’ and the ‘3’ adjacent to each other, the preoccupation with a departure clearance, cockpit busyness and a slightly misaligned keystroke produced a lift-off speed 100 tonnes out. An unchecked case of ‘garbage-in, garbage-out’ came into play and, as pushback commenced, hidden amongst the many other inputted figures of flap configuration, altimeter setting, anti-ice selection, centre of gravity, wind speed, wind direction, outside air temperature, runway surface condition and air conditioning status, a single out-of-place digit endangered hundreds of lives.

In all likelihood by the end of today, if you haven’t done so already, you will make some sort of data entry error. It could be as you attempt to long in…er log in to your computer and inadvertently hit an adjacent key. It could be as you type vital text or numbers an (sic) auto-correct misses the fact you meant to type ‘and’. It could be when you are relating your too mistakes er… two mistakes for the day via a text message. It doesn’t matter whether you’ve been typing for decades; it is inevitable, sooner or later and probably sooner, an adjacent key will be tapped, a letter left out or numbers entered back to front.

Thankfully, the consequences to these kinds of mistakes are generally innocuous. All is well after a second read or a ‘please retype your password’ message gets our attention. All is well in cases like this because something looks unreasonable and we fix it. We look at the figures, we check them against some norm or standard and we note the deviation with a view to correcting it. This is what’s often called a ‘reasonableness’ test. For typos, no harm no foul, retype with the correct words or numbers and move on. But what happens when there’s an undetected, uncorrected typo in the take-off calculations for a passenger airline carrying hundreds of passengers weighing in at several hundred tonnes?

This was the case in the darkness of evening on 20 March 2009 for Emirates Flight EK407, an Airbus A340-541, on take-off from Melbourne. As EK407 received its clearances, lined up and accelerated down runway 16, the crew of four experienced pilots—two operating pilots and two ‘augmenting’ pilots—had missed three key opportunities to detect and correct the 100-tonne typo. The first opportunity was before pushback when the first officer handed the laptop to the captain to check the take-off performance parameters. At this point, the captain was supposed to verbally check the calculated weight from the aircraft’s flight management and guidance system with the inputted weight on the EFB laptop. Perhaps, due to the general busyness in the cockpit or perhaps due to the preoccupation with the details of a departure clearance, that verbal check was never made.

The second opportunity to detect the error was during the load sheet confirmation procedure when the first officer read aloud the take-off weight first from the flight management and guidance system, and then from the EFB laptop calculations written on the flight plan. With a slip of the tongue he incorrectly read out a figure of 326.9 tonnes from the flight plan before correcting to 362.9 tonnes. He corrected the relatively innocuous slip of the tongue, but still didn’t notice the EFB laptop calculations were out by 100 tonnes.

The third opportunity also came and went without correction to the maverick digit. In this case, the reasonableness test involved cross-checking a characteristic airspeed of the aircraft known as the ‘green dot’ speed. The check compared the EFB laptop-calculated green dot speed with the green dot speed from the flight management and guidance system. The first officer called out the green dot speed of 265 knots—some 40 knots different to the EFB laptop figure of 225 knots—and the captain confirmed the figure without question. Investigators would later surmise this was because the last digit of each respective speed ended with a five and the normal check required the two green dot speeds to be within two knots of each other—the captain had apparently mentally cued from the last digits of each number only. In any case EK407 was now rolling down runway 16 accelerating towards a dangerously low lift-off speed.

Partly because of the darkness of the evening and partly because of the lack of a clear cockpit warning for a low acceleration rate, none of the four pilots noted the aircraft’s acceleration was dangerously sluggish and that the 3.5 kilometres of runway was being consumed. At a much later point along the runway than normal, and at the spuriously calculated lift-off speed, the captain called ‘Rotate’. The first officer duly complied initiating a nose-up command to the sidestick by applying back pressure. Nothing happened. With the aircraft 100 tonnes heavier than calculated there simply wasn’t enough lift. A struggle began between aerodynamics and gravity.

The captain repeated his call: ‘Rotate!’ The first officer again, more urgently this time, applied back-stick. The nose lifted but gravity continued to prevail against aerodynamics and the aircraft remained firmly stuck to the ground—now with only 300 metres of runway remaining. The captain, recognising the danger, quickly selected ‘take-off/go-around’ on the thrust levers, but it was a further three seconds before the aircraft could generate take-off lift. In the meantime, the A340 was out of runway.

In earlier generations, pilots would sometimes be heard talking colloquially about ‘unsprightly’ take-offs as ‘dragging one’s sorry backside into the air’. That was exactly what the Airbus A340 was doing. At 265 metres from the end of the runway, with a high nose attitude and marginal aerodynamic lift, the rear end of the aircraft struck the bitumen of the runway. The ground contact, which continued along the remaining length of the runway, gouged the aluminium skin down to the supporting ribs as well as dislodging a large service panel. Still there was not enough lift to overcome gravity’s persistent pull. The A340 overran the end of the runway into the grass and dirt, its tail carving a near continuous rut before slowly inching its way into the air—so slowly in fact that it struck a ground-based strobe light (about 30 cm high), the localiser near-field monitor antenna (about 60 cm high) and finally the main localiser array (about 3 m high).

image: © Airbus A340 | Aero Icarus

By now, the maximum thrust setting the captain had selected was finally doing its job and the aircraft was able to climb away despite the damage to the tail. About five minutes after having been alerted to the tail strike by an automated message, the first officer pulled out the EFB laptop to calculate the landing performance parameters for an emergency landing. It was then he noticed the EFB laptop had a weight figure one hundred tonnes out. There was little time for self-reproach: the first officer had also noticed the cabin was not pressurising and that the cabin crew were reporting smoke in the rear cabin. The captain consulted with the augmenting crew and decided to dump fuel over Port Philip Bay and return for a landing as soon as possible, which they were able to do without further incident. The ‘smoke’ was later determined to be ingested dust from the tail strike that had deformed a pressurisation seal.

In some ways you’d be forgiven for thinking, at least in the grand scheme of things, simple typos wouldn’t occur on the flight deck of EK407. The aircraft was staffed not just by two pilots, but four experienced and relatively well-rested pilots. The flight was not experiencing delays and there were no other known external factors affecting the crew.

The ‘reasonableness’ levels in the reasonable tests on the flight deck of EK407 should have been high and the opportunity for error low. The fact that it did occur without the usual suspects of fatigue, external pressures and inexperience prompted the ATSB to conduct further research. The goal was to identify why skilled and highly trained crews were unable to detect fundamentally wrong calculations. The results, derived from a French research report as well as its own research, were sobering. In a 20-year period, 31 other significant incidents similar to EK407 were identified, and, in a survey carried out with a major airline, 50 per cent of respondents stated they’d experienced take-off performance errors.

The ATSB noted: ‘(Such errors) have multiple origins and involved a range of devices and systems. For example, crew actions could result in the wrong figure being used in a system, in data being entered incorrectly, data not being updated and data being excluded in a range of systems including performance documentation, laptop computers, FMS and aircraft communications addressing and reporting systems’.

Furthermore: ‘The occurrences reviewed indicated the systemic nature of the problem, and the fact that it manifests irrespective of location, aircraft type, operator and flight crew.’

Perhaps an ideal solution to the aviation typo would be an artificial intelligence check, but such designs are still in the future. In the meantime, the following is worth remembering: firstly, unreasonable data may sneak past because of the lack of an ‘order of magnitude’ paradigm. This is where there is no consistent average figure to which the brain can become accustomed. For example, if I write that I weigh 1000 kg we know almost immediately a mistake has been made because our brains are conditioned to the ‘normal’ weight of a person being far less than 1000 kg. The same normative mental cueing would apply to an aircraft weight if the take-off weight was relatively static, but unfortunately, as was the case for EK407, take-off weights vary widely depending on fuel and passenger loads. This means that for any wide-ranging, performance-critical figures we need to have sound cross-checks and to be especially aware of data entry mistakes—especially if such figures are obscured by the data denseness of other parameters.

Secondly, though surprisingly they did not play a major role for EK407, the ATSB’s research showed the usual suspects remain the major players for most other data issues—fatigue, stress, inexperience, distraction and miscommunication. These not only produce errors, they also undermine reasonableness checks. Who amongst us hasn’t looked at figures at 3 am or during high stress (for whatever reason) and had trouble making them compute? Knowing this means we should avoid these states wherever possible, or at least during these undesirable states, double check and even triple check flight-critical data.

What would have happened if EK407 had crashed off the end of Tullamarine at take-off speed? There had been one other A340 runway overrun—Air France flight 358 at Toronto in 2005. Everyone survived, but it was travelling about 70 knots when it overran a wet runway, nearly 100 knots slower than flight 407 at the end of its runway.

The loss of 275 lives on flight EK407 would have made it the first large-scale aviation disaster in Australia. And it all would have been because of uncorrected ‘finger trouble’.

EK407 ought to make us reconsider the reasonableness of our own reasonable checks—particularly when we are fatigued, inexperienced, stressed or distracted. Given the appalling consequences of an aviation typo, it’s the only reasonable thing to do.

 
MTF...P2

[Cap'n Wannabe]

An aircraft crashed into the Swan River, Perth..

A PLANE has crashed into the Swan River hours before the annual Australia Day Skyworks show is due to kick off.

The incident happened just after 5pm.

It is unclear whether the crash will affect the Skyworks show, which was due to start at 8pm.

More to come.

[Peetwo]

An aircraft crashed into the Swan River, Perth..

A PLANE has crashed into the Swan River hours before the annual Australia Day Skyworks show is due to kick off.

The incident happened just after 5pm.

It is unclear whether the crash will affect the Skyworks show, which was due to start at 8pm.

More to come.

Via news.com.au:

Swan River plane crash: Man, woman dead in Australia Day tragedy in Perth
January 27, 2017 7:58am

A screen grab obtained from supplied vision shows a plane that crashed into the Swan River during Australia Day festivities in Perth. Picture: AAP/Mark Annette-Stuart and Jorden Teo

TWO people are dead after a plane stalled, nosedived and crashed into Perth’s Swan River in front of thousands of horrified Australia Day revellers.

Police confirmed this morning that the pilot and only passenger were both killed when the flying boat, a Grumman G-73 “Mallard” stunt plane, crash-landed into the river just after 5pm and broke up on impact.

The crash came just hours before scheduled Australia Day fireworks, which were cancelled in the wake of the tragedy.


The plane seconds before it crashed into Perth’s Swan River. Picture: Supplied/Mark Annette-Stuart and Jorden Teo/AAPSource:AAP


Two people have been killed in a plane crash on the Swan River in Perth just hours before the city’s annual Australia Day skyworks show. Picture: Vicky ClarkeSource:Supplied

The pilot and passenger were confirmed dead a short time later. The pair are believed to be husband and wife.

The aircraft will remain in the water under guard by water police, and the scene will be reassessed later this morning after consultation with Department of Transport and the Australian Transport Safety Bureau, police say.

The tragedy was captured on video and posted to social media, along with hundreds of comments.

“It looked like it just broke in half as it hit the water. The sound as it hit … was just shocking,” one witness told ABC News.

Another who saw the crash, local resident Mark Annette-Stuart, told AAP: “The plane seemed to be banking and then it looked like it was turning too sharply and just seemed to fall into the water.”

Boats rushed to the wreckage near Heirisson Island in a desperate effort to rescue survivors but it was to no avail.


A West Australian police boat patrols the debris of a plane that crashed into the Swan River yesterday afternoon. Picture: Richard Wainwright/AAPSource:AAP

WA Police acting commissioner Stephen Brown told reporters it was fortunate the plane didn’t hit other people.

“For reasons yet unknown, it’s entered the waterway, thankfully without injuring anyone else on the ground or any other people who are here at the event,” he said.
Authorities will this morning focus on what caused the crash.

“Firstly we have a scene out here which will be subject to both coronial and a CASA (Civil Aviation Safety Authority) investigation,” Mr Brown said.


The plane will remain underwater as investigations continue into the tragedy this morning. Picture: Richard Wainwright/AAPSource:AAP

“It’s really important that we preserve that scene to make sure that we can extract everything we can to find out why this tragic event occurred.”

Perth Lord Mayor Lisa Scaffidi said the fireworks were cancelled out of respect for the dead and to “conserve the integrity of the (crash) site”.

More than 300,000 people were expected to attend the Skyworks show. However Mr Brown urged those gathered to head home.

Extra public transport services had been organised to help them on their way, he said.
It’s not known whether the plane was there as part of the planned festivities.

At the South Perth foreshore, families setting up for tonight’s Skyworks rushed to the river’s edge as the plane crashed into the water.

“I was watching the show and all I saw was the plane just nosedive into the water,” witness Natasha Eyles said.

“As it hit the water you could see the plane break into two.”

Witness Craig Newill was with his family when the plane went down. “We were so stunned and shocked,” he told News Corp. “We could see him stall.

“His wings were pointing to the sky and to the water and we thought ‘this is not good’ then we saw it break into two pieces.”


Scheduled fireworks were cancelled in the wake of the tragedy. Picture: Richard Wainwright/AAPSource:AAP

PerthNow reader Kristijana Dutkovic said: “Saw it do a couple of passes over the water & then it dropped straight into the water.

“Boats were quick to respond though — hope they (are) all right.”

The City of Perth issued a statement just after 6pm confirming the fireworks had been cancelled due to the incident.

The display, which attracts massive crowds each year, had been due to start at 8pm. It is the first time the event has been cancelled in its 33-year history.
— with staff writers

RIP..

[Peetwo]

An aircraft crashed into the Swan River, Perth..

A PLANE has crashed into the Swan River hours before the annual Australia Day Skyworks show is due to kick off.

The incident happened just after 5pm.

It is unclear whether the crash will affect the Skyworks show, which was due to start at 8pm.

More to come.

Further Update.

Again courtesy ABC online  :

Australia Day Perth plane crash: Special approval given to air show, CASA says
By Rebecca Turner

Posted 9 minutes ago Fri 27 Jan 2017, 6:36pmvideos

Video: Plane crashes into Swan River during Australia Day air show (ABC News)

As the search for answers continues over a fatal plane crash on Perth's Swan River, the Civil Aviation Safety Authority (CASA) has revealed it does not usually approve air displays over public gatherings or boats on the water.

Key points:

• Cause of fatal plane crash during Australia Day air show in Perth remains unclear
  
• CASA approved all aircraft and pilots as part of regulation of event
  
• Sea plane described as "extremely good machine" by vintage plane expert
  

But the regulatory body said it gave special approval for Thursday's Australia Day air show, during which mining executive Peter Lynch and his colleague and partner Endah Cakrawati plunged to their death in their seaplane.

Their tragic descent was witnessed by thousands of onlookers gathered on the banks of the river and on boats moored nearby.

"Under the regulations, except during take-off and landing, or where specifically approved as part of the program of events, the minimum height at which any aircraft may operate is 500 feet above ground level," a CASA spokeswoman said in a statement.

"Air displays over built-up [suburban] areas, public gatherings and vessels on the surface of a body of water are not normally approved.

"These rules ensure the safety of the public and those involved in the flying display."

Photo: It remains unclear what caused the sea plane to plunge into the water before thousands of onlookers. (Supplied: Michael Legg)

The crash has left aviation experts scratching their heads over the cause.

The show is organised by the City of Perth and regulated by CASA, which has to approve all participating aircraft and pilots.

Passengers are not allowed to be on board, although each pilot is allowed to carry an observer.

Plane an 'extremely good' machine: expert

Aero Club of WA chief executive David Currey said it was the first accident in the history of the air show — with the biggest event on the WA aviation calendar taking a year to organise and choreographed down to the last second.

"CASA put a lot of time and effort into doing their due diligence," he said.

"It was very, very unlucky."

According to vintage plane expert Rob Poynton, the model of plane flown by Mr Lynch — a 1948 Grumman G-73 Mallard — was an "extremely good" machine.
"Just because it's old and used, doesn't mean anything," he said.
"As long as it's had the required maintenance, it's fine."

Pilot spoke about work done on plane

Mr Lynch first started flying about 25 years ago.

Photo: Tributes have been paid to pilot Peter Lynch and his girlfriend Endah Cakrawati, who died in the crash. (Supplied: Halden Boyd)

As he explained to Sydney aviation journalist Phil Buckley in 2013, he bought the airplane in the US in 2011 before undertaking significant flying training and maintenance work with the aircraft.

"The aircraft was in Northern Idaho and I had it ferried to Florida via Covingtion Aircraft in Oklahoma on the way, to get both engines and props fully overhauled," he said.

"It had some work and avionics done in Florida to finish it off before it had to be ferried to Australia."

The Australian Transport and Aviation Safety Bureau (ATSB) is investigating the crash but has indicated it could take a year to complete, potentially leaving the future of the air show in limbo.

Perth Lord Mayor Lisa Scaffidi said the format of the Australia Day event would be reviewed for future years, but the Skyworks show would continue in "some form or another".

RIP..

[Peetwo]

An aircraft crashed into the Swan River, Perth..

A PLANE has crashed into the Swan River hours before the annual Australia Day Skyworks show is due to kick off.

The incident happened just after 5pm.

It is unclear whether the crash will affect the Skyworks show, which was due to start at 8pm.

More to come.

Further Update.

Again courtesy ABC online  :

Australia Day Perth plane crash: Special approval given to air show, CASA says
By Rebecca Turner

Posted 9 minutes ago Fri 27 Jan 2017, 6:36pmvideos

Video: Plane crashes into Swan River during Australia Day air show (ABC News)

As the search for answers continues over a fatal plane crash on Perth's Swan River, the Civil Aviation Safety Authority (CASA) has revealed it does not usually approve air displays over public gatherings or boats on the water.

Key points:

• Cause of fatal plane crash during Australia Day air show in Perth remains unclear
  
• CASA approved all aircraft and pilots as part of regulation of event
  
• Sea plane described as "extremely good machine" by vintage plane expert
  

But the regulatory body said it gave special approval for Thursday's Australia Day air show, during which mining executive Peter Lynch and his colleague and partner Endah Cakrawati plunged to their death in their seaplane.

Their tragic descent was witnessed by thousands of onlookers gathered on the banks of the river and on boats moored nearby.

"Under the regulations, except during take-off and landing, or where specifically approved as part of the program of events, the minimum height at which any aircraft may operate is 500 feet above ground level," a CASA spokeswoman said in a statement.

"Air displays over built-up [suburban] areas, public gatherings and vessels on the surface of a body of water are not normally approved.

"These rules ensure the safety of the public and those involved in the flying display."

Photo: It remains unclear what caused the sea plane to plunge into the water before thousands of onlookers. (Supplied: Michael Legg)

The crash has left aviation experts scratching their heads over the cause.

The show is organised by the City of Perth and regulated by CASA, which has to approve all participating aircraft and pilots.

Passengers are not allowed to be on board, although each pilot is allowed to carry an observer.

Plane an 'extremely good' machine: expert

Aero Club of WA chief executive David Currey said it was the first accident in the history of the air show — with the biggest event on the WA aviation calendar taking a year to organise and choreographed down to the last second.

"CASA put a lot of time and effort into doing their due diligence," he said.

"It was very, very unlucky."

According to vintage plane expert Rob Poynton, the model of plane flown by Mr Lynch — a 1948 Grumman G-73 Mallard — was an "extremely good" machine.
"Just because it's old and used, doesn't mean anything," he said.
"As long as it's had the required maintenance, it's fine."

Pilot spoke about work done on plane

Mr Lynch first started flying about 25 years ago.

Photo: Tributes have been paid to pilot Peter Lynch and his girlfriend Endah Cakrawati, who died in the crash. (Supplied: Halden Boyd)

As he explained to Sydney aviation journalist Phil Buckley in 2013, he bought the airplane in the US in 2011 before undertaking significant flying training and maintenance work with the aircraft.

"The aircraft was in Northern Idaho and I had it ferried to Florida via Covingtion Aircraft in Oklahoma on the way, to get both engines and props fully overhauled," he said.

"It had some work and avionics done in Florida to finish it off before it had to be ferried to Australia."

The Australian Transport and Aviation Safety Bureau (ATSB) is investigating the crash but has indicated it could take a year to complete, potentially leaving the future of the air show in limbo.

Perth Lord Mayor Lisa Scaffidi said the format of the Australia Day event would be reviewed for future years, but the Skyworks show would continue in "some form or another".

RIP..

Further Update: The Plot Thickens

Here we go -  Are we about to witness a classic case of CASA subverting safety risk mitigation in favour of (CYA) liability risk mitigation?? 

Observe the following update this evening via WA Today:

January 27 2017 - 5:54PM

Perth Skyshow plane tragedy probe a logistical nightmare

David Allan-Petale

Australia's Civil Aviation Safety Authority says the plane that crashed into the Swan River during the Perth Skyshow on Thursday was not approved to fly below 500 feet.

Pilot Peter Lynch and his passenger and partner Endah Cakrawati died when the plane crashed into the Swan River during the City of Perth's annual Australia Day event.

Two people have died after a plane crashed into Perth's Swan River in front of thousands of people gathered for the Australia Day Skyworks display. Vision courtesy Seven News.

The seaplane stalled and nose-dived into the water about 5pm, breaking up on impact, as revellers looked on in horror.

In a statement to WAtoday, CASA said Mr Lynch's aircraft was operating as part of an approved air display, which was given special permission to operate.

Mr Lynch was a keen aviation enthusiast.

Swan River plane crash at Perth Skyshow: Tributes for victims Peter Lynch, Endah Cakrawati

Acting Police Commissioner Stephen Brown paid tribute to the victims and praised emergency services.

Swan River plane crash: investigations begin, skyshow will not be rescheduled


"All aircraft operating as part of the air display sought and received approval from the Civil Aviation Safety Authority to do so," CASA said in the statement.

"Under the regulations, except during take-off and landing, or where specifically approved as part of the program of events, the minimum height at which any aircraft may operate is 500 feet above ground level.

"Air displays over built up (suburban) areas, public gatherings and vessels on the surface of a body of water are not normally approved."

Investigators are working to determine what led to the plane crashing, with two efforts running simultaneously - one spearheaded by WA police and another being coordinated by the Australian Transport Safety Bureau (ATSB).

Safety authorites will inspect the plane on Friday, which is still in the Swan River. Photo: Channel 7

Police will concentrate on determining the cause of death while the ATSB will look at air safety and technical issues, though both investigations will overlap.

ATSB investigators are currently at the crash site and will spend the next few days examining the scene, interviewing witnesses, and collecting maintenance and pilot records and air traffic control data.

The recovery operation has begun. Photo: 9 News Perth

A recovery operation is now underway - footage from 9 News Perth shows workers on a barge using a crane to secure larger parts of the wreckage, with divers in the water.

Aviation investigations manager Greg Madden said on Friday the plane, which is under guard by a police vessel, is of an aircraft type that didn't appear to have a history of faults.

"We'll be certainly looking closely at the aircraft history but at this stage, there's nothing to indicate that there's a problem with the aircraft," Mr Madden told ABC radio.

He said the model was not required to have a flight data or cockpit voice recorder, but other recording devices may be on board. A preliminary update on the investigation is expected to be uploaded to the ATSB website in about 30 days.


Endah Cakrawati, 30, and pilot Peter Lynch died after the plane crashed into the Swan River. 

The Grumman Mallard is a medium sized, twin-engined amphibious aircraft that was manufactured in the United States from 1946 to 1951.

It's still widely in use around the world, with Australia's Paspaley Group running a fleet of turbo-prop equipped Mallards, servicing the pearl farms which are at the core of its operations.

On its website, Paspaly said it has "an excellent safety record."

The bodies of Mr Lynch, 52, and his female passenger Ms Aricakrawati, 30, have been recovered from the Swan River, while the aircraft itself remains in situ in the water with investigators analysing the wreckage.

Various aviation sources say the Grumman Mallard can weigh around four tonnes, and acting Commissioner Brown said extracting the crashed aircraft from the middle of the Swan River will be a huge logistical exercise.

"There would be a lot of work to do on the remains of the plane and it could take up to six months for the results to be known," acting Commissioner Stephen Brown told Radio 6PR on Friday.

"We want it to come out as pristine as it can and we want to be able to recover all of the parts. And they might not just be in that immediate vicinity so that's going to take some time."

Acting Commissioner Brown said once the plane has been extracted from the water, comprehensive investigations could then begin at either a police or ATSB facility in Perth.

"That'll be conversations between our police forensic officers and the ATSB as to where the best place to house it is. And then we'll start that meticulous job of working through the wreckage," he said.

On its website, the Bureau lists the fatal incident as having an 'occurance type' of 'collision with terrain' with the aircraft listed as destroyed.

The ATSB is seeking to speak with witnesses and collect any video recordings that might assist its work.

Those who witnessed the crash in person requested to contact the ATSB on 1800 020 616 or email ATSBinfo@atsb.gov.au.

A final report on the incident from the ATSB is expected to be published within 12 months.

 
Hmm...no comment - YET!

MTF...P2

[Cap'n Wannabe]

Australia's Civil Aviation Safety Authority says the plane that crashed into the Swan River during the Perth Skyshow on Thursday was not approved to fly below 500 feet.

This certainly sounds like a CYA event...from what I can gather, the aircraft was turning onto final. I'm not up on seaplane ops, but one could assume that that being the case, the pilot had every reason to be below 500 feet..

[Peetwo]

Australia's Civil Aviation Safety Authority says the plane that crashed into the Swan River during the Perth Skyshow on Thursday was not approved to fly below 500 feet.

This certainly sounds like a CYA event...from what I can gather, the aircraft was turning onto final.  I'm not up on seaplane ops, but one could assume that that being the case, the pilot had every reason to be below 500 feet..

Spot on Cap'n...   But was he approved to land? If so did that approval to land not have any contingency for overshooting the designated flight display box? These and other questions will hopefully come out in due course... In the meantime here is another update, this time from the Oz that only reinforces my personal suspicions on this tragic accident:  

‘No chance’ for death pilot
12:00amPAIGE TAYLOR
Peter Lynch appeared to have been attempting to accelerate when his vintage seaplane plunged into Perth’s Swan River.

Mining executive and father of three Peter Lynch appeared to have been attempting to accelerate out of a turn that had become a steep bank when his vintage seaplane plunged into Perth’s Swan River, instantly killing him and his partner in front of an ­Australia Day crowd of 60,000.

Crash investigators and aviation experts yesterday told The Weekend Australian the 69-year-old Grumman Mallard’s low altitude meant there was no chance any pilot could have recovered the situation once the angle of the bank on the plane hit 90 degrees, causing the plane’s nose to drop.

Western Australia Police yesterday published advice for families who saw the tragedy as they ­picnicked and waited for the ­annual SkyShow fireworks display, advising parents: “Tell children the truth”.

“Thank God it went down in the water where it went down,” acting commissioner Brown said.

“Not too far away on the foreshore are thousands of people.”

Yesterday Mr Lynch’s employer, Andrew Forrest’s Fort­escue Metals Group, praised him as a great mate with “energy, enthusiasm and a great team spirit”.

“He will be missed enormously,” said FMG’s chief executive Nev Power.

Clive Palmer and Waratah Coal, where Mr Lynch, 52, worked for 10 years, said “his zest for business flowed into his personal life, where his passions for restoring cars, boating and flying, were ­infectious”.

His partner Endah Cakrawati, 30, was an investment and public relations manager originally from Indonesia who moved to Perth with Mr Lynch last year.

The plane in which they died was one of only eight worldwide that still had original twin ­engines.

Just two weeks ago Mr Lynch flew the Grumman from Queensland to Western Australia with his three children.

Yesterday Geoff Dell, an ­associate professor of accident ­forensics and investigation at Central Queensland University, said there were several important lines of inquiry.

“Listening to the engine, it sounds like he’s put the power right up — that would be the natural thing to do (in a steep bank),” Mr Dell said.

But Mr Dell said that, once the angle of the wings reaches about 70 degrees, it would be difficult to recover. Once wings are vertical, the pilot needs time and altitude to roll the wings horizontal again.

“He was probably responding to the steepness of the bank. You would ram the throttle into the firewall,” he said.

“He was commanding the roll into the turn and for some reason it rolled to ‘wings vertical’ and the investigators will be looking at why.”

  

 MTF...P2

[Kharon]

Out loud thinking.

I have now watched the video of the Mallard crash several times; you can, in a simulator recreate the scenario, with pretty much the same results. Low and slow, power down and a desperate, last gasp attempt to align with a runway. Even in the sim it is a dreadful feeling as the aircraft just slips away, controls ineffective, the crash inevitable. The last seconds of life must have been horrendous for the crew.  

“Now cracks a noble heart. Good-night, sweet prince;
And flights of angels sing thee to thy rest. ”

It makes me sad, but also angry – I want to know why this happened. I fully understand the aerodynamics and the factual stuff; in spades. But non of that explains why the aircraft was placed in an untenable situation. I can fully understand the motivation – get the job done; but I fail to understand why a competent, experienced pilot would try to ‘screw’ the aircraft through the eye of a very fine mathematical needle.

IMO, one of the important messages to be drummed into a pilot’s mind is selection of priority – staying alive being the primary, in fact the only message which matters, when trumps turn to shite.  Instinct (natural or learned) should have been screaming – ‘go around’, let's drag our collectives arses out of this aerodynamic sling. What reason could trump the organisms self preservation instinct? What could overrule the basic tenets of aerodynamic law, taught to the neophyte from day one?

In my fuzzy way, I keep coming back one reason – the ‘box’. An artificial, strictly enforced imaginary barrier which, should you stray out of its confines, carries penalties. Aerobat pilots understand these barriers, very well indeed and spend literally many, many hours perfecting the skill needed to execute ‘ragged edge’ manoeuvres within the specified dimensions; for to stray could cost them the completion. Same – same for the ‘air-show’ crews; any impingement on ‘the box’ is likely to end with ‘approval’ suspended or even revoked; so the ‘box’ matters.

A little adrenalin, a little excitement, a little distraction, a little ‘get it done’, a little anticipation of cold drinks, Australia Day BBQ and the applause of the crowd could that, possibly, influence even the most experienced, disciplined of minds?

Aye well, I don’t know the answers. But I do know that ‘bugger the box’ and damn the consequences would have been high on my priority list; following survival. Anyway, ‘tis a sad thing, particularly for those close, left behind with every Australia day a painful reminder. Let’s just hope some good comes from this tragedy and we find the right answers to prevent a repeat.

Selah

P2 - "K" just a bit more information to cogitate on, via news.com.au:

Plane crash pilot shared concerned texts with friend hours before fatal plunge
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/article/089ebbe48e43bd45508edcf2e0e4d645?esi=true&t_template=s3/chronicle-tg_tlc_storyheader/index&t_product=CourierMail&td_device=desktop[/img]Grant Taylor, Rourke Walsh and Angela Pownall, News Corp Australia Network
January 28, 2017 3:00am
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/article/089ebbe48e43bd45508edcf2e0e4d645?esi=true&t_template=s3/chronicle-tg_tlc_storymeta/index&t_product=CourierMail&td_device=desktop[/img]
THE PILOT killed in Thursday’s Skyworks plane tragedy had raised concerns about the wind and heat conditions over the city just an hour before the deadly crash that also claimed the life of his partner.

Father-of-three Peter Lynch, 52, and Endah Cakrawati, 30, both died instantly when their twin engine Grumman Mallard flying boat appeared to stall during a tight turn and then plunged nose first into the Swan River in front of tens of thousands of onlookers.

Mr Lynch had owned the plane since 2011 and had spent more than 120 hours at the controls. But as a newcomer to Perth, he had never before attempted to land it on the river.

He shared his concerns about the flight with friend Mack McCormack via a series of text messages, just 30 minutes prior to taking off from Serpentine.



Peter Lynch was concerned about the hot winds in Perth that day.

The pilot had only been given approval to fly two days prior to the Skyshow.

“My biggest concern is how hot it is today and the lack of wind,” Mr Lynch said in the message.

“Perth gets very hot compared to back east I’ve noticed.”

Mr McCormack, who runs Red Baron Seaplanes, said Mr Lynch had also been battling with the Civil Aviation Safety Authority to allow him to fly in the Australia Day air show right up until the 11th hour.

The approval was finally granted on January 24 and a delighted Mr Lynch left a voice message on Mr McCormack’s phone that day saying: “Guess what mate, I got my type rating and everything through from CASA... and I am pretty happy about that as it means I will be in the show.”

Ms Cakrawati was also nervous about the flight and had originally intended to stay on the ground, before changing her mind at the last minute.

She told friends on social media earlier in the day that she was: “Super excited yet nervous. I can do it, wish me luck.”

Police believe the recovery of the broken-up plane could take a year to fully recover from the river. Picture: Michael Wilson The West Australian

Mr McCormack said he was watching from the Barrack Street jetty as the plane went into the water and knew instantly that it was likely to prove fatal.

“When you saw what happened, as soon as the wing dropped there was no recovering from there,” he said.

“I got in our safety vessel and got over there as fast as I could but it was all over before we even got there.

“It was just inexperience unfortunately and just a tragically sad situation.”

Mr Lynch had moved to Perth from Queensland in June to take up a senior role with Fortescue Metals Group as head of business development.

His former wife Laura, who lives with their three children in Brisbane, paid tribute to him on Facebook yesterday.

Red Baron operator Mark McCormack was in communication with the pilot on the day of the crash. Picture: Michael Wilson The West Australian

“With great difficulty I am unbearably saddened to confirm that my great friend and the father of my children passed after a tragic accident on the Swan River in Perth yesterday,” she said.

FMG chief executive Nev Power said Mr Lynch had been a “great mate” to all at the company in the short time he had worked there.

“He brought energy, enthusiasm and a great team spirit to the role and he will be missed enormously,” he said.

Mr Lynch was yesterday remembered as a man of vision in both aviation and mining.
Close friend Halden Boyd said Mr Lynch also led a consortium which planned a $21m air park development at Evans Head Memorial Aerodrome in New South Wales.

“He became everybody’s mate,” Mr Boyd said.

“He was a very fastidious pilot, safety was number one.”

Mr Lynch performed at Evans Head in the Great Eastern Fly-in before flying back to WA with his children, who returned to Brisbane last week.

An investigation into the crash is now being conducted by WA Police and the Air Transport Safety Bureau.

The plane’s fuel tanks were recovered from the water early yesterday but the rest if the aircraft — which split in two on impact — remained in the water.

Acting police Commissioner Stephen Brown said the recovery operation was complex and likely to take days.

Peter Lynch’s partner Endah Cakrawati thought about missing the flight. Picture: Angelo Di-Benedetto

“We want it to come out as pristine as we can and we want to be able to recover all of the parts,” he said. That is going to take some time,” he said.

“From that, in the coming months we will have a better understanding as to what happened and why.”

Lord Mayor Lisa Scaffidi yesterday defended the decision to cancel Thursday night’s fireworks display, claiming it was in the interests of public safety given the risks of fuel in the water.

“I believe it was the right decision and we don’t hold back on the decision now despite the disappointment with some aspects within the community,” she said.

Ms Scaffidi said the Skyshow could not be rescheduled to another date because it was not “logistically feasible”.

The future of the air show would also now be reviewed.

“I don’t believe it is the end of Skyworks but it is an appropriate time to reconsider all operational aspects of such an event, particularly aerial flights,” Ms Scaffidi said.
- Additional reporting by Thomas Chamberlin

[P7_TOM]

As requested - I scanned the UP boards to see if there was anything worth mentioning related to the Mallard accident: happily, there was one post from "Step Turn" who seems to actually know of what he speaks - speculation to be sure; but worth a minute or two.

From the UP by 'Step Turn".


There's lots of talk about this accident, and turns, with varying reference to wind. I'm not a Mallard pilot, nor am I familiar with Perth, but to inform myself a little, I did some Google Earth measuring of the flying display area before commenting here. Presuming that is was the intention of the pilot to avoid flying over land (built up areas) as depicted in the flying display graphic kindly posted, let's consider dimensions:

The water area depicted on the graphic equates roughly to the runway and infield dimensions of an airport with one 8000 foot runway, and a bisecting crossing 4500 foot runway. Let alone an aircraft the size [and lesser maneuverability] of the Mallard, would it be considered normal flight operations to fly a circuit inside the infield of an airport of these dimensions? I think not - that would be unusual flying. Possible, but unusual.

Perhaps this pilot practiced the turn at a place of similar dimensions, to get used to what most anyone would consider tight maneuvering. I have no idea. I know that water flying can dramatically alter perception of space for maneuvering - it can look like there's room, but there's not that much. This is a major teaching point when I train flying boat pilots.

I train that a water landing is preceded with one or more reconnaissance passes, with consideration for dimensions, the approach, hazards, and the possible affect of wind. I wonder if this pilot had the opportunity to fly some practice or reconnaissance passes before landing.

It is certain that he, as any of us would, maneuvered so as to avoid overflight of crowds or even shore. Once it started going bad, tightening the turn was not going to fix it. He had already run out of room for maneuvering within the normal flying characteristics of that 'plane. I fly light floatplanes and flying boats, and what I see in that video would worry me for maneuvering a light seaplane, let alone the larger Mallard.

I can imagine that this pilot felt pressure to perform with his aircraft, and further would not want to disappoint his passenger. He pressed further into a maneuver than perhaps he had the practice, performance and maneuverability with which to complete it.

The facts will come out, but in the mean time, discussion of what is evident so far can benefit all pilots in reminding that when maneuvering close to the ground/landing in a non aerodrome environment, extra awareness and caution are needed to assure that the required minimum space is available, and that there is an escape plan if the maneuver is going wrong. This video will become an element of my training, with the obvious aspects discussed, even before a formal investigation report is written. Anything we do to make pilots think is good.

Thank you for a 'professional' notes and comments.  That's it "K", there ain't enough ale in the keg to make me want to plow through that lot again; just lucky there was a small saving grace.

[Gobbledock]

Peter Lynch was well loved and liked along the Queensland eastern seaboard and central Queensland. He also spent time with a couple of other good Drivers in Indonesia.

I've has a couple of thoughts about this accident but out of respect to those who have passed away I shall remain silent.
But I noticed some similarities to the  B-52 Bud Holland crash at Fairchild Airforce Base. I reiterate some similarities, not all. Namely;
- low altitude flying and sharp turn in a larger aircraft type not easily and normally put through such a manoeuvre.
- operational pressure; pressure to perform in circumstances not usually encountered or normally flown regularly by the PIC
- possible distorted judgement; a breakdown of wise judgement and sound decision making due to adrenalin and pressure to perform in front of tens of thousands of people watching your every move, within a confined area that had little room for error built in, and again in unfamiliar surroundings.

They are my only thoughts. Just a few out loud ponderings while the accident remains under investigation. Certainly I am not comparing Peter to Bud Holland as Holland was an almost certified fruitloop, narcissist and complete rogue. I am comparing the aircraft configurations and circumstances including both accidents occurring at an air-show.

R.I.P dear aviators