[thorn bird]

In one word Sandy,

YES!

[P7_TOM]

I reckon there’s a big point being missed here. An airport, like Bankstown, handles in any given day a wide variety of aircraft, with a fairly extensive ‘list’ of potential ‘events’. From student pilots on first solo to sophisticated jet transport aircraft, through to helicopters etc. While the ‘risk’ of accident or incident is minimized there is always the possibility that Murphy’s law will apply – if it can go wrong – etc.

Can you imagine the unholy dust up when it really, truly and really goes wrong and; say, for example, a student on minimal fuel, doing a first ‘solo’ has an engine failure – or; a corporate jet has a major failure or; a chopper is obliged to ‘auto-rotate’ - all very real possibilities. That’s why we have so many rules, regulations and ‘safety’ requirements – to keep those on the ground safe. That is why there are clear of obstruction areas promulgated about airports (for safety's sake) – yet: shit happens. if  you never drive on a freeway, the chances of blowing a tyre – at speed – are reduced. The speed and weight of the family Holden is significant when F=Ma is applied; the same formula can be used to determine the forces involved at almost double the best (standard) Holden speed. A student pilot, landing the first aircraft flown is landing well above the legal speed limit 0f 110 Kph – the most humble of ‘real’ aircraft land at around 110 to 160 Kph. The kinetic energy of bigger aircraft at about 180 Kph + the fuel load (keep the Holden running for a week) is a serious force to be reckoned with; should it ‘arrive’ – unexpected like – in your front parlour.

Statistics confirm there are more accidents during the take off and landing phase of flight than any other. Yet silly bugger developers, who don’t live in harms way, seem to think that the possibility of an unwanted guest in the front parlour is unthinkable and unquantifiable.

It ain’t – the event at Bankstown was ‘rare’ occurrence – and there, but for the grace of the gods of fate, no one got hurt. There are good reasons for making aerodromes with lots of room – mostly related to Sir Isaac Newton’s laws of physics, with a nod to Murphy’s immutable law.

Wiki - Murphy's law is a popular adage that states that "things will go wrong in any given situation, if you give them a chance," or more commonly, "whatever can go wrong, will go wrong." A number of variants on the rule have been formulated, as have several corollaries.

[Peetwo]

VH-ZEW C172 fatal - ATSB Final Report released.

Via the ATSB website: https://www.atsb.gov.au/publications/inv...Ag.twitter

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What happened

At about 1410 Eastern Standard Time on 8 September 2015, the pilot of a Cessna Aircraft Company 172S, registered VH-ZEW, departed Point Cook Airfield, Victoria, on a solo navigational training flight via waypoints that included Ballarat Airport, Victoria. GPS data showed that the aircraft was on the third leg of the planned journey, cruising at about 3,000 ft above mean sea level when it started to descend rapidly. The aircraft impacted rising terrain at about 2,200 ft and was destroyed. The pilot who was the sole occupant, was fatally injured.

What the ATSB found

The site and wreckage inspection identified that the aircraft impacted terrain in a level, slight right‑wing low attitude. That indicated that the pilot likely stopped the aircraft’s descent and started to initiate a manoeuvre to avoid the terrain. It is likely that the pilot manually manipulated the controls while the autopilot was on and engaged in a vertical mode. As a consequence, the autopilot re-trimmed the aircraft against pilot inputs, inducing a nose-down mistrim situation, which led to a rapid descent. The aircraft’s low operating height above the ground, due to the extent and base of the cloud, along with rising terrain in front of the aircraft, gave the pilot limited time to diagnose, react, and recover before the ground impact.

There was no advice, limitation, or warning in the aircraft pilot operating handbook or avionics manual to indicate that if a force is applied to control column while the autopilot is engaged, that the aircraft’s autopilot system will trim against the control column force, and possibly lead to a significant out of trim situation. Training requirements for autopilot systems was rudimentary at the recreational pilot licence (RPL) level due to stipulated operational limitations for its use. At the time of the accident there was no regulatory requirement for pilots to demonstrate autopilot competency at the RPL level.

What's been done as a result

The ATSB issued safety recommendations to the aircraft and autopilot manufacturers about the provision of limitations, cautions and warnings for autopilot systems and audible pitch trim movement.

The flight training organisation updated their operations manual, as a result of flight testing they conducted, to include warnings about the operation and function of the autopilot system absent in the manufacturer’s documentation. The hazard of manual manipulation of the flight controls with the autopilot engaged was also emphasised to students.

Safety message

Technologically advanced avionics and autopilot systems are now often fitted to general aviation aircraft used for flight training, private and charter operations. It is essential for all pilots to develop a thorough understanding and operation of all systems fitted to the aircraft they are flying. It is also important that student pilots consolidate manual flight and navigation skills before using the advanced auto flight modes or extensively using autopilot systems. Avionics and aircraft manufacturers should increase pilot awareness of automated systems by providing written warnings surrounding known issues and including visual and aural alerts in auto flight systems to increase pilot awareness of non-standard inputs. Fundamentally, pilots should be aware that if the automation is not performing as expected, then the safest option under most circumstances is to disengage the system and manually fly the aircraft.


VH-ZEW main wreckage. Source: ATSB



Source: ATSB

---

And surprise, surprise this ATSB AAI actually included the very rare promulgation of 2 safety recommendations... :

---

---

Safety issue description

The lack of manufacturer written advice, limitations, cautions, or warnings (written or aural) about autopilot response to manual pilot control inputs meant that pilots may be unaware that their actions can lead to significant out of trim situations, and associated aircraft control issues.

Response to the safety issue by Cessna Aircraft Company

The functionality described is true of virtually every autopilot [fitted to FAR 23 certified aircraft]. The type of autopilot behavior being discussed is covered in chapter 4 of the Federal Aviation Administration’s Advanced Avionics Handbook (FAA-H-8083-6, attached). The first page of the chapter discusses autopilot concepts and in the “How to use an autopilot function,” says, “Allow the FD/autopilot to accomplish the modes selected and programmed without interference, or disengage the unit.  Do not attempt to “help” the autopilot perform a task. In some instances, this has caused the autopilot to falsely sense adverse conditions and trim to the limit to accomplish its tasking.  In more than a few events, this has resulted in a total loss of control and a crash.”

ATSB comment/action in response

Knowledge is imparted in a number of ways, which include reading operating manuals, conducting training, communicating with experienced pilots and learning from one’s own experiences.

Advanced avionics and autopilot systems are now fitted to a significant number of primary training aircraft, such as the Cessna 172S (VH-ZEW). The level of knowledge that individual pilots have in this environment starts at a low base level and builds over time. The ATSB contends that student pilots are not likely to be aware of issues surrounding manual manipulation of the flight controls with the autopilot on. It is therefore important to implement methods that enhance pilots’ awareness of the issue, including aircraft and avionics systems operating manuals having the requisite limitations, cautions and warnings in place.

It is clear from the content of the FAA handbook that they believe a warning about the issue is required. Although the handbook provides very good educational material, it does not take the place of aircraft operating manuals as a reference guide.

The G1000 avionics and GFC700 autopilot systems are fitted to numerous aircraft types. Some flight manuals include limitations, cautions and warnings and some do not.

Additionally, there were no audible warnings provided for mistrim to enhance pilot awareness in the G1000 avionics system with the GFC 700 autopilot fitted, despite that being a feature of the superseded autopilot system.

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

Recommendation
Action organisation: Cessna Aircraft Company (Textron)
Action number: AO-2015-105-SR-004
Date: 17 April 2018
Action status: Released

ATSB safety recommendation Cessna Aircraft Company (Textron)

The ATSB recommends that Cessna Aircraft Company, in conjunction with Garmin, implement changes to their operations manuals so that all aircraft types fitted with their autopilots have the limitations, cautions and warnings applied consistently.
 
 
Current issue status: Safety action pending
 


Last update 17 April 2018 

---

Safety issue description

The lack of manufacturer written advice, limitations, cautions, or warnings (written or aural) about autopilot response to manual pilot control inputs meant that pilots may be unaware that their actions can lead to significant out of trim situations, and associated aircraft control issues.

Response to safety issue by Garmin

The avionics manufacturer indicated that since all autopilots work the same way, it was common knowledge for pilots not to manually manipulate the flight controls with the autopilot on. Therefore, any advice, limitations, or warnings about the issue would not be required. They also indicated that the presence of a limitation, warning, or caution is generally left up to the certifier of the equipment in the airplane [in this case Cessna].

ATSB comment/action in response

Advanced avionics systems and autopilots are now fitted to many aircraft used by relatively inexperienced pilots. Therefore it is important that every opportunity is taken to inform them of the potential danger posed by manual manipulation of the flight controls with the autopilot on.

Recommendation

Action organisation: Garmin
Action number: AO-2015-105-SR-006
Date: 17 April 2018
Action status: Released

ATSB safety recommendation Garmin

The ATSB recommends that Garmin, in conjunction with aircraft manufacturers, takes action to ensure that all aircraft types fitted with their autopilots have the limitations, cautions and warnings documented in the aircraft’s operating manuals. Further, the ATSB recommends that Garmin consider the use of audible warnings to enhance pilots’ awareness of mistrim situations brought on by the autopilot system.
 
 
Current issue status: Safety action pending
 


Last update 17 April 2018 

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---

There was also a MR accompanying the release of this AAI Final Report: 17 Apr 2018 [News Item] Know how your aircraft’s avionics and autopilot will react.

Finally here is the other Aunty's take on this report:

Autopilot incompetence may have played role in RMIT student's fatal Cessna crash: ATSB
ABC Ballarat
By Charlotte King
Tue 17 Apr 2018, 4:39pm



Photo: The crash site in Millbrook near Ballarat in September 2015. (Supplied: Air Transport Safety Bureau)

Aviation authorities have found a student pilot who lost control on her first solo navigation flight was not formally assessed on the autopilot function.

The 19-year-old RMIT student, who has never been publicly named, died in September 2015 when the Cessna she was flying in crashed into a Millbrook paddock, near Ballarat.

More the two years on, the Australian Transport Safety Bureau (ATSB) has released its report into the accident, finding the aviation student's efforts to manually control the aircraft while it was in autopilot mode are likely to have led her to lose control and nose-dive into the rural property.

The ATSB's executive director, Nat Nagy, said the crash raised serious concerns.

"It is now common for general aviation aircraft to be equipped with autopilot systems," Mr Nagy said.

"And while these systems can be very useful, it is vitally important that pilots understand how the systems will react in different circumstances.

"If automation is not performing as expected, then the safest option under most circumstances is for them to disengage the system."

The ATSB revealed it was not a requirement for trainee pilots to demonstrate knowledge of the autopilot and its limitations.

"The pilot's underpinning knowledge of the autopilot system could not be ascertained due to the absence of formal assessment," the report said.

In July 2017 the Civil Aviation Safety Authority introduced an element into the Flight Examiners Handbook, which requires pilots to demonstrate knowledge of the autopilot system when they are assessed for a Recreational Pilot Licence.

The ATSB also expressed concerns over the absence of warnings in the manufacturer's manual for the Cessna 172 — commonly used as a primary training aircraft.

"It was likely that the inexperienced pilot was not aware of how the autopilot would react to manual control inputs," the report stated.

"The inclusion of limitations, cautions and warnings in the aircraft documentation … would likely enhance pilot awareness of such situations."

Autopilot warnings now included in manual

The flight training organisation involved in the young pilot's aviation course with RMIT has updated its operations manual to include warnings about the operation of the autopilot system — warnings that are absent in the manufacturer's documentation.

The avionics manufacturer, Garmin, told the ATSB that it was "common knowledge" for pilots not to manipulate the flight controls with the autopilot on.

RMIT has meanwhile amended its standard operating procedures to include a warning to pilots that loss of control is possible if a pilot tries to manually override autopilot.

The university said its community was "devastated" by the accident, and said "the ATSB report confirms that RMIT followed procedures and was operating within regulations, [but] out of respect for the family, we won't be commenting on the report any further".

MTF...P2

[Cap'n Wannabe]

...and an article from Australian Flying..

Autopilot Response a Factor in Cessna Crash: ATSB

A misunderstanding of how an autopilot would respond to manual input may have a contributed to the fatal crash of a Cessna in 2015, according to an ATSB investigation report released today.
The pilot of Cessna 172 VH-ZEW was on a training flight from RMIT Flight Training at Point Cook on 8 September 2015 when it crashed into high ground east of Ballarat, Victoria. The pilot was on her first navigation exercise and did not survive the impact.

"The site and wreckage inspection identified that the aircraft impacted terrain in a level, slight right-wing low attitude," the report states. "That indicated that the pilot likely stopped the aircraft’s descent and started to initiate a manoeuvre to avoid the terrain. It is likely that the pilot manually manipulated the controls while the autopilot was on and engaged in a vertical mode.

"As a consequence, the autopilot re-trimmed the aircraft against pilot inputs, inducing a nose-down mistrim situation, which led to a rapid descent."

The aircraft was approaching the 2200-foot summit of Black Mount at the time, which reduced the time the pilot had to switch off the autopilot and recover from the nose-down pitch.

Data recovered from the G1000 systems fitted to the aircraft showed that the pilot had engaged several modes during the accident flight, and that the autopilot mode had been changed six times in the last 30 seconds of recorded data. It also showed that at one stage the pitch angle of the aircraft was higher than the pitch command given to the autopilot.

The ATSB also found that there was nothing in the aircraft manuals that specifically warned that the trim would operate against any manual inputs.

"There was no advice, limitation, or warning in the aircraft pilot operating handbook or avionics manual to indicate that if a force is applied to control column while the autopilot is engaged, that the aircraft’s autopilot system will trim against the control column force, and possibly lead to a significant out of trim situation," the ATSB report states.

"Training requirements for autopilot systems was rudimentary at the recreational pilot licence (RPL) level due to stipulated operational limitations for its use. At the time of the accident there was no regulatory requirement for pilots to demonstrate autopilot competency at the RPL level."

Garmin responded to the ATSB by saying it didn't consider a warning necessary because it was "common knowledge" that pilots shouldn't try to apply manual control inputs whilst the autopilot is on. Regardless, the ATSB has recommended that all cautions and warnings should be documented because of the inexperience of pilots being confronted with autopilots.

The full report is on the ATSB website.

[Kharon]

From the ABC – fatal helicopter accident in WA.

Couple if interesting parallels between this one and the last one on the Barrier reef pontoon: event occurred during second approach and the automatic floatation failed top deploy.
 
I note both ABC and ATSB prefer to feature the lack of current ‘escape practice’ while ignoring two buggered up approaches, the second ending up a CFIT event, problems with an emergency door release and the failure of the floatation devices. Just saying…..
 
MTF.

[Peetwo]

From the ABC – fatal helicopter accident in WA.

Couple if interesting parallels between this one and the last one on the Barrier reef pontoon: event occurred during second approach and the automatic floatation failed top deploy.
 
I note both ABC and ATSB prefer to feature the lack of current ‘escape practice’ while ignoring two buggered up approaches, the second ending up a CFIT event, problems with an emergency door release and the failure of the floatation devices. Just saying…..
 
MTF.

Via the ATCB:

The occurrence

On 14 March 2018, at about 2330 Western Standard Time,[1] an Eurocopter Deutschland GMBH EC135 P2+ helicopter, registered VH-ZGA and operated by Heli-Aust Whitsundays Pty Limited,[2] departed Port Hedland Heliport,[3] Western Australia to collect a marine pilot from a departing bulk carrier and transfer that person back to Port Hedland.

The flight was being conducted in the charter category, at night under the Visual Flight Rules (VFR). A pilot recently employed by the operator was flying the helicopter, under the supervision of a company training and checking pilot.

At about 2348, while the helicopter was being operated in the vicinity of the bulk carrier, it descended and collided with the water. The training and checking pilot escaped from the helicopter and was rescued a short time later. The location of the other pilot was unknown and a search continued throughout the night and into the following day. On 17 March 2018, the helicopter wreckage was located on the seabed and the missing pilot was found inside.

This update provides an initial summary of the occurrence circumstances and initial investigation activities.

Background and sequence of events

The operator of the helicopter was contracted by the port operator to transfer marine pilots to and from ships that were berthing and departing Port Hedland. The marine pilots were responsible for the safe navigation of those vessels to and from the port.

Although the helicopters were usually operated on a single-pilot basis, the two pilots had been rostered to fly together on a series of flights during the late afternoon on 14 March 2018, and continuing their duty into that night and the following morning. These flights were the recently employed pilot’s (pilot under check) first night-time marine pilot transfer flights at Port Hedland. The training and checking pilot was the pilot in command and was sitting in the left (copilot) seat of the cockpit. He was supervising the pilot under check, who as the handling pilot for the flights, was seated in the right (pilot) seat of the cockpit. Both seating positions were fitted with fully-functioning flight controls.

Marine pilots were normally delivered by helicopter to arriving vessels at the boarding ground for the anchorage. When departing, marine pilots were usually collected from vessels in vicinity of the Charlie One (C1) and Charlie Two (C2) channel markers, about 20 NM north-west of Port Hedland.

During the earlier part of evening, the helicopter crew had completed three flights transferring marine pilots. Two of those flights were at night, one to the anchorage boarding ground to an inbound bulk carrier and the later one to a departing bulk carrier at C1/C2. Soon after that flight arrived back at the heliport and the marine pilot had disembarked, the helicopter pilots departed to collect another marine pilot from C1/C2, on what was to be the accident flight.

Figure 1 depicts Port Hedland, the shipping channel and the location of the channel marker at C2.

Figure 1: Map showing Port Hedland, the shipping channel and Charlie 2 
Source: Pilbara Ports Authority, annotated/modified by ATSB.

The surviving pilot, who was the training and checking pilot, reported that the flights had proceeded normally and that the first two night flights had been without incident. During night operations, it was standard procedure to use the helicopter’s autopilot during climb, cruise and descent and it would remain engaged until the helicopter was stabilised on final approach, with the landing vessel in sight.

The training and checking pilot recalled that the outbound vessel was sighted and was well-lit with floodlighting of the deck and accommodation quarters. The weather conditions were fine, with no cloud, rain or obstructions to visibility. The wind, relative to the deck of the ship was reported to be ‘red 090, 15 kt’, meaning the environmental wind when combined with the forward motion of the ship, was 15 kt from a relative direction, 90 degrees left of the ship’s bow. That wind direction necessitated an approach to the vessel from its right side, with the helicopter flying a right-direction circuit to land. A circuit was flown around the bulk carrier and the pre-landing checklist was completed, including the arming of the helicopter’s emergency flotation system.

The training and checking pilot reported that the approach continued such that the helicopter was aligned on the final approach. The autopilot ‘upper’ modes were decoupled[4] and the helicopter passed through the ‘entry gate’[5] with an airspeed of 50‑60 kt at 500 ft. Soon after, that approach was discontinued when both pilots agreed that the approach path had become too steep to continue.
The marine pilot awaiting the transfer had sighted the helicopter approaching the vessel. He recalled that there was not a lot of wind, there was no moon but there were stars visible in the sky. The navigation of the shipping channel had been completed and control had been handed back to the ship’s crew. After observing the helicopter circle the vessel, he saw the helicopter again fly past the left side of the vessel, consistent with joining the circuit to land on the deck and he started to make his way down the internal stairwell to the ship’s deck.

After the first approach, the training and checking pilot reported a standard missed approach was flown, the autopilot upper modes were recoupled and the helicopter was set-up to make another approach. The training and checking pilot recalled that on the second approach, the helicopter was turned inbound on the final approach, the autopilot upper modes were decoupled, they again passed through the entry gate and the deck of the ship was in sight. He recalled that the pilot under check had reduced the power to commence the descent, and again soon after. The training and checking pilot pointed out the descent rate and requested an increase in power, and was satisfied that the necessary correction was being made.

By the time the marine pilot had reached the deck of the ship, he could see the helicopter’s anti-collision strobe lights, along with the green navigation light on the right side of the helicopter. He did not recall seeing the red navigation light on the left side of the helicopter, nor the steerable searchlight used by the crew of the helicopter to illuminate the deck of the ship for landing. The marine pilot became concerned about the helicopter’s approach path and assessed that the helicopter was descending low on the horizon compared to previous flights.

The training and checking pilot next recalled hearing the radio altimeter annunciating ‘check altitude, check altitude’. The radio altimeter was programmed to make this annunciation when the radio altitude reduced below the preselected altitude. It was the operator’s standard procedure to set a radio altitude of 300 ft prior to take-off. He stated that he immediately called that he was taking over control of the helicopter and was making a missed approach.

He did not recall any alarms or other alerts from the helicopter’s warning systems. Soon after, the helicopter collided with the water surface and the cabin immediately flooded and submerged.

The marine pilot had continued to watch the helicopter as it descended towards the water. He recalled seeing a splash of water, that was lit by a flash from the helicopter’s strobe light and immediately returned to the bridge to commence alerting action with the port authority.

The recorded ground track of the helicopter outbound from the heliport and to the accident site is shown at Figure 2 and the final ground track in vicinity of the vessel can be seen in Figure 3.

Figure 2: Ground track of the helicopter to collect the marine pilot
[img=463x0]https://www.atsb.gov.au/media/5774267/ao2018022_figure-2.jpeg?width=463&height=463&mode=max&sharpen=2[/img]
The helicopter was fitted with Automatic Dependent Surveillance Broadcast (ADSB equipment). That equipment enabled air traffic services and other pilots to track aircraft without using conventional ground-based radar installations. The signals transmitted by the ADSB equipment can also be received and recorded by other specialised ground-based receivers, such as those operated by flight tracking websites. Those receivers are situated at numerous locations around the world and feed data to centralised computer servers and accessed using internet browsers and other utilities. The image displays the server-recorded ADSB ground track for the helicopter as it travelled to collect the marine pilot. Source: Background image GoogleEarth, overlaid with FlightRadar24 ADSB track data, annotated by ATSB.

Figure 3: Ground track of the helicopter in vicinity of the departing bulk carrier
[img=463x0]https://www.atsb.gov.au/media/5774268/ao2018022_figure-3.jpeg?width=463&height=463&mode=max&sharpen=2[/img]
The image displays the helicopter’s ADSB ground track and pressure altitude (to the nearest 100 ft) while operating in vicinity of the departing bulk carrier. The positions of the distress signal from the PLB and the helicopter wreckage are also depicted. Note that the ADSB data points are not at regular fixed-time intervals. The vessel location was broadcast by its automatic information system (AIS). Source: Background image GoogleEarth, overlaid with FlightRadar24 ADSB data, AIS data from Pilbara Ports Authority and annotated by ATSB.

The training and checking pilot recalled that he did not have time to take a breath before the cockpit flooded with water. He was submerged in the helicopter and still strapped into his seat. He tried to operate the emergency door jettison, but had difficulty remembering the action and did not believe that the door had released. He felt around in front of him and to the left identified an alternative exit pathway and used his left hand to keep hold of that pathway. Using his right hand, he attempted to unplug his helmet communications cord.

The cord did not easily disconnect, so using the same hand, he released the helmet chinstrap and removed the helmet. He also used his right hand to release his harness, then placed that hand on the opposite side of the exit pathway and using both hands, pulled himself through that opening to escape the cockpit. After vacating the cockpit and still underwater, he felt for the inflation toggle on his personal flotation device (PFD) and activated one chamber. The chamber inflated normally and took him to the surface.

After reaching the surface, the training and checking pilot saw the helicopter was still afloat but inverted, so he clung onto the helicopter’s left landing skid. He did not see the other pilot and was unsure of his location. The helicopter emergency flotation system had not automatically activated during the initial collision with water and inversion of the fuselage. After a short time, he recalled that the helicopter’s life rafts could be deployed using manual deployment handles mounted on the underside of the helicopter’s rear skid cross-tubes. He activated one of these handles and two life rafts deployed. The life raft that deployed from the left helicopter skid was trapped under the skid. The life raft from the right helicopter skid deployed normally and he boarded that raft. The training and checking pilot recalled that the helicopter floated for a period of time before sinking.

The training and checking pilot also remembered that his PFD was equipped with a personal locator beacon (PLB) and he activated it. The PFD was also equipped with distress flares and he used these to visually signal his position.

Nearby vessels responded during the initial stages and as did vessels from the port. The initial response was focussed on the distress position indicated by the PLB and the sighting of the flares. The training and checking pilot was recovered from his life raft about 1 hour after the ditching. He had sustained minor injuries.

A surface search for the missing pilot and wreckage was initiated and continued during the night and the next two days. A seabed sonar search of the area also commenced with a hydrographic survey vessel. The helicopter wreckage was identified on the seabed on 17 March 2018 (see Figure 4 and Figure 5). It was substantially intact and resting on its right side in about 20 m of water.

Figure 4: Sonar image of helicopter resting on the seabed, on its right side
[img=463x0]https://www.atsb.gov.au/media/5774261/ao2018022_figure-4.jpg?width=463&height=463&mode=max&sharpen=2[/img]
Source: Pilbara Ports Authority and contractors working on their behalf.

Figure 5: Sonar image of helicopter resting on the seabed, on its right side

Source: Pilbara Ports Authority and contractors working on their behalf.

Divers from the Western Australia Police Force located the missing pilot in the cockpit of the helicopter. At the time of recovery, he was not wearing his helmet, his harness was unfastened and his PFD had not been deployed.
Video taken by the police divers during their initial dives on the wreckage indicated that the emergency jettison for the left copilot’s door had been activated, but with the door still remaining with the fuselage. The front left cockpit Perspex windshield was broken.

Wreckage recovery

The Pilbara Ports Authority and their contractors commenced action to recover the helicopter, with the assistance of the police divers. The ATSB placed a Protection Order on the helicopter wreckage and provided the necessary permissions to recover the helicopter and transfer into secure storage.

The helicopter wreckage was recovered from the seabed during 18 and 19 March 2018 (Figure 6). The wreckage was moved into the secure storage area where it was examined by the ATSB.

Figure 6: Helicopter wreckage being lifted onto the dock

Source: ATSB.

Pilot information

Training and checking pilot

The training and checking pilot held a Civil Aviation Safety Authority (CASA)-issued Part 61 Air Transport Pilot Licence – Helicopter (ATPL(H)) and an Air Transport Pilot Licence - Aeroplane. Relevant checks recorded in his company recency record indicated for helicopters:

• an instrument proficiency check on 7 June 2017
  
  
• a low-level flight review on 14 October 2016
  
  
• an instructor rating on 24 May 2016
  
  
• a flight examiner rating on 8 June 2017
  
  
• a multi-engine helicopter flight review and EC135 biennial flight review on 27 October 2016
  
  
• a base check on an EC135 on 17 March 2017
  
  
• simulator training H135 on 17 March 2017
  
  
• CAO 20.11 training on EC135 on 17 July 2017
  
  
• a line check on 5 April 2017
  
  
• a night VFR review on 24 May 2016
  
  
• Class 1 pilot medical, valid to 2 October 2018.
  

The training and checking pilot had last completed helicopter underwater escape training (HUET) on 9 September 2015.

Records indicated that the training and checking pilot had flown to Port Hedland on 5 March 2018 and had been rostered to fly through to 15 March 2018, before flying out from Port Hedland on 16 March 2018. The training and checking pilot had been completing flight reviews and checks on a number of the company pilots in Port Hedland, in addition to a number of days flying with the pilot under check during the accident flight.

Pilot under check

The pilot under check held a CASA-issued Part 61 ATPL(H). Relevant checks recorded in his company recency record indicated:

• a low-level flight review on 16 August 2016
  
  
• a base check on an EC135 on 12 March 2018
  
  
• CAO 20.11 training on EC135 on 5 March 2018
  
  
• a night VFR review on 4 August 2016
  
  
• Class 1 pilot medical, valid to 18 April 2018.
  

The pilot under check had last completed HUET on 9 February 2009.
Records indicated that the pilot under check had completed company induction in Mackay the week prior to the accident and had flown to Port Hedland on 9 March 2018. Those records indicated he was continuing training in Port Hedland until 18 March 2018 and due to commence line operations at Port Hedland from 20 March 2018.

Meteorological information

Meteorological and hydrographic information in vicinity of the accident site was routinely recorded by the Pilbara Ports Authority ‘Metocean’ equipment. That information comprised data on the sea state, tidal movements, wind velocity and atmospheric pressure.

During the late evening, light seas and a gentle ebbing tide (less than 1 kt) was being recorded in vicinity of the C2 beacon, the closest recording site to the accident location.

At 2350, the wind was about 11 kt from 253 degrees, with gusts to 13 kt. The atmospheric pressure was 1008.5 hPa.

Last light on 14 March 2018 at Port Hedland was 1845. The moon was a waning crescent with 9 per cent of the visible disk illuminated. The moon had set at Port Hedland at 1619 and was due to rise again at 0356 on 15 March 2018. Consequently, there was no visible moon at the time of the accident.

Helicopter information

The helicopter was powered by two Pratt & Whitney PW 206 B2 engines, both with digital engine control (FADEC) systems. The power from the engines was transferred to the main rotor blades by the main transmission, a two-stage flat design gearbox.

The helicopter was equipped with a four-bladed, hydraulically-controlled rigid main rotor. Antitorque was provided by a Fenestron-type system.
The helicopter cabin had two hinged doors for the pilot and copilot seating positions and two sliding doors on either side of cabin. Each of the hinged doors had the ability to jettison the door via pins securing the door hinges to the fuselage. Each of the rear sliding doors had a pop-out emergency exit.

The helicopter was equipped with a three-axis autopilot and a stability augmentation system. Instrumentation fitted to the helicopter cockpit included an integrated primary flight display, a navigation display and a cockpit warning panel. There was also a central panel display system, that comprised the vehicle and engine multifunction and; cautions and advisories displays.
The helicopter was equipped with an emergency flotation system[6] that comprised skid-mounted inflatable floats. The floats could be manually or automatically activated. Manual activation was using a mechanical handle on the pilot’s cyclic control. Automatic activation was via operation of a water immersion switch. Electrical power was required to initiate inflation of the automatic inflation mechanism. The helicopter was also equipped with two life rafts that could be manually deployed using a cockpit handle or external handles fitted to the cross-tubes of the helicopter’s landing skids.

Wreckage examination

The helicopter was substantially intact, although the hub of the main rotor and the main transmission had separated from the airframe during the recovery.
Several of the main rotor blades had sustained significant damage near their blade roots during water impact and one of the blades of the main rotor had struck the helicopter tail boom. The flexible coupling of the main gearbox drive output shaft had sheared. The tail rotor blades of the Fenestron antitorque system exhibited evidence of rotational damage.

Figure 7: Main rotor blades and main transmission, showing damage in vicinity of the blade roots

Source: ATSB.

The compressors and compressor housings for both engines showed evidence of engine rotation at impact. To the extent possible due to the nature of the accident damage, continuity of the flight controls was established.

The right cockpit door (pilot under check) was still attached to the airframe and the lock wire for the emergency door jettison was still intact. The emergency jettison for that door was functionally tested and was found to operate normally. The left cockpit door (training and checking pilot) did not remain attached to the airframe during recovery. The lock wire to the emergency jettison handle had been broken and the handle was in the forward (release) position.

The helicopter’s emergency flotation system had not been deployed.
Examination of the panel-mounted cockpit arming switch was consistent with the switch being in the armed position. The immersion switch for the automatic inflation system was functionally tested and found to be operating normally.

Electrical continuity was demonstrated between the circuit breaker panel, the immersion switch and the servo actuator. Examination of the actuator indicated that neither an automatic or manual inflation had been initiated.

The ATSB recovered various electronic components from the helicopter engines and airframe to assess the non-volatile memory contents. Those units included the:

• electronic engine control for each engine
  
  
• data collection unit for each engine
  
  
• cockpit warning panel
  
  
• cautions and advisories display
  
  
• vehicle and engine multifunction display.
  

The ATSB also recovered the linear actuator for the helicopter’s emergency flotation system and the flotation arm switch.

Helicopter underwater escape training

Helicopter underwater escape training (HUET) has been in use in one form or another around the world since the 1940s and is considered best practice in the overwater helicopter operating industry. HUET is designed to improve survivability after a helicopter has ditched or impacted into water. Research of accidents into water has shown that occupants who survive the initial impact will likely have to make an in-water or underwater escape, as helicopters usually rapidly roll inverted post-impact. The research has also shown that drowning is the primary cause of death following a helicopter accident into water.

Fear, anxiety, panic and inaction are the common behavioural responses experienced by occupants during a helicopter accident. In addition to the initial impact, in-rushing water, disorientation, entanglement with debris, unfamiliarity with harness release mechanisms and an inability to reach or open exits have all been cited as problems experienced when attempting to escape from a helicopter following an in-water accident.[7]

HUET involves a module (replicate of a helicopter cabin and fuselage) being lowered into a swimming pool to simulate the sinking of a helicopter. The module can rotate upside down and focuses students on bracing for impact, identifying primary and secondary exit points, egressing the wreckage and surfacing. HUET is normally part of a program of graduated training that builds in complexity, with occupants utilising different seating locations and exits. This training is conducted in a controlled environment with safety divers in the water.
HUET is considered to provide individuals with familiarity with the crash environment and confidence in their ability to cope with the emergency situation.[8] Interviews with survivors from helicopter accidents requiring underwater escape frequently mention they considered that HUET had been very important in their survival. Training provided reflex conditioning, a behaviour pattern to follow, reduced confusion, and reduced panic.[9]
Like other highly procedural and complex skills, if underwater escape is infrequently practiced, skill decays rapidly.[10] In a UK Civil Aviation Authority (2014) safety review of offshore public transport in helicopters for the oil and gas industries, it was noted that although the frequency of refresher HUET is presently every four years in the UK, this is widely regarded by experts as being inadequate.[11]

In Australia, Civil Aviation Order 95.7.3 required all helicopter flight crew engaged in marine pilot transfers to have completed a HUET course. The order has no requirement for undertaking periodic refresher training.

Operator HUET requirements

The operator’s operations manual required all pilots engaged in overwater (offshore) operations to have completed a HUET course with an approved provider during the previous 3-year period. The manual indicated the chief pilot could extend that period for an individual pilot if circumstances arise which preclude that training being done within the 3-year period. In that situation, the period of extension was to be specified at the appropriate time and would normally not exceed 6 months. The training was to be rescheduled as soon as practicable.

Part 3 of the company operations manual in relation to Port Hedland required all pilots and marine pilots to have completed a HUET course before conducting night transfers.

As indicated above (see section Pilot information), the last HUET completed by the pilot under check (who had recently joined the operator) was in 2009 and was outside the operator’s 3-year recurrent training period. On 6 March 2018, the operator’s chief pilot had booked a HUET course for the pilot under check. The training was scheduled for 24 April 2018, a full-day course with a Brisbane-based training provider. The training and checking pilot had completed HUET within the last 3 years.

The operator provided the ATSB with records of HUET course information for 24 other company pilots. One of those pilots was marginally outside the company stipulated 3-year period. The 23 other pilots had completed their HUET training within the required period.

Proposed regulations

The proposed Civil Aviation Safety Regulation Part 133 will apply to Australian air transport operations involving rotorcraft (helicopters, gyroplanes or powered-lift aircraft) that undertake charter passenger or cargo operations under subregulation 206 (1) (b) of the Civil Aviation Regulations 1988. A consultation draft of those regulations were made available in June 2012 and the period for receipt of comment closed in August 2012.

The consultation draft issued in June 2012 included the proposal, for all flights where life rafts were required to be carried, that flight crew members had successfully completed training in ditching procedures, underwater escape procedures, and use of life rafts within the previous 3 years.

The CASA website indicated that the draft regulation was being updated prior to a subsequent public consultation, which is planned for mid-2018.

Safety advisory notice

Action number: AO-2018-022-SAN-001
The Australian Transport Safety Bureau advises helicopter operators involved in overwater operations of the importance of undertaking regular HUET (helicopter underwater escape training) for all crew and regular passengers to increase their survivability in the event of an in-water accident or ditching.

Ongoing investigation

The ATSB investigation is continuing and will include the following:

• Factors associated with the survivability of the accident.
  
  
• Various factors associated with the operation of the helicopter during dark night conditions under the VFR.
  
  
• Pilot qualifications, training, experience, recency and medical information.
  
  
• Operator policies and procedures for training and checking, including normal and emergency procedures.
  
  
• Helicopter underwater escape training requirements.
  
  
• Analysis of contents of the non-volatile memory from the recovered electronic components.
  
  
• Testing of components from the helicopter’s emergency flotation system.
  
  
• Helicopter maintenance history.
  
  
• Operator policies and procedures for management of fatigue and duty time.
  

The ATSB will continue to consult with the engine and airframe type-certificate holders. In accordance with the provisions of ICAO Annex 13, the Transportation Safety Board of Canada have been provided status as accredited representative to the ATSB investigation as State of Design and Manufacture of the helicopter’s engines. The German Federal Bureau of Aircraft Accident Investigation have been provided status as accredited representative to the ATSB investigation as State of Design and Manufacture of the helicopter type.

Acknowledgements
The ATSB would like to acknowledge the significant assistance provided during the initial investigation response by the Pilbara Ports Authority, their contractors and volunteer agencies and the Western Australia Police Force.

MTF...P2 

[Kharon]

From the ATSB –– a few words about the dead stick Conquest landing on a highway in WA.

Mention is made of ‘water’ in the fuel tanks. It would interesting to know exactly how much water there was (estimated) present, how long it had been there and an analysis of the fuel upload v fuel burns against noted residual fuel for the preceding months.

That both engines quit almost at the same time speaks well for the engineers and the engine set up.

I wonder, did the passengers fly out once the aircraft was refueled? ATSB don't mention it. But it is nice that Lady Luck took a hand – that could have been a very different result; all things considered.

[Kharon]

From the ABC - a fatal at Moorabbin. - HERE.

[P7_TOM]

Tears, snot and shouting.


Hot Air Fun.

ATSB – “He took a photo (Figure 2), which he sent to the other two pilots and, following receipt of this, they each elected to launch the three balloons from Peppers Creek.”

Take a close look to the ENE; take another look at the forecast and note the Dew point and Temperature,

ATSB - “The observation at 0700 for Cessnock aerodrome was nil wind, temperature and dew point 15 °C and for Maitland was nil wind, overcast at 400 ft AGL and temperature and dew point 19 °C.”



Then lets take a quick squint at ‘the rules’

ATSB – “Between 500 and 1,500 ft above ground or water, 5,000 m flight visibility is required and the balloon is to remain clear of cloud. However, no vertical clearance from cloud below the balloon is required, provided that the top of the cloud is at or below 500 ft above ground or water, and the balloon is at least 10 NM from an aerodrome with an approved instrument approach procedure.”

ATSB – “At or below the higher of 3,000 ft AMSL or 1,000 ft AGL, flight visibility of 5,000 m is required, and the balloon must remain clear of cloud and in sight of ground or water.”

Back to the pictures.






ATSB - Landing position and injuries.

The basket landed upright, with all occupants facing forwards. The pilot had demonstrated the landing position (Figure 8) prior to departure and most passengers reported adopting that position for landing. In one of the four compartments, a passenger reported that they stood in front of their partner. Some passengers seated themselves on the floor of the basket prior to the impact with the ground

ATSB will investigate, among other items of interest:-

• weather conditions and go/no-go decision making.

• survivability including assessment of injuries and basket position/loading.

No comment except one – “Folks, the weather is not great for flying right now and the dense ground fog will spoil the amazing views”. “ We will monitor the weather, which is forecast to improve a little later and expect to get underway about 0900 – please have a coffee and a muffin, relax for an hour or so and we’ll be underway as soon as safely possible".

I should, probably, add WTD; but I’ll settle for a bottle in front of me; not a frontal lobotomy…..

[Peetwo]

Mountains out of molehills - A how to?

I have read and observed with interest the media 'beat up' and then 'letdown' by the Qantas  PR machine of the QF 94 wake turbulence incident...

Via the Oz:

Qantas A380 jet in sudden dive

MATTHEW DENHOLM
Eddie McGuire describes 10-second nosedive that terrified passengers after Qantas flight struck wake turbulence.

---

Wake turbulence suspected in Qantas jet’s sudden dive

A “terrifying” mid-air incident ­involving two Qantas A380 jets this week forced one of the aircraft into a 10-second “nosedive”, in which passengers held hands ­believing they were about to die.

The plunge above the Pacific Ocean, about two hours into QF94 from Los Angeles to Melbourne, was believed to have been caused by the vortex, or “wake turbulence”, generated by another A380, QF12, which was flying from Los Angeles to Sydney and took off two minutes before QF94.

Qantas did not report the incident to the Australian Transport Safety Bureau, but after questions from The Australian, the safety watchdog last night sought an ­explanation from the airline and promised to review the response.

Among the passengers was Channel 9 star Eddie McGuire, who spoke this morning of the on-board scare.

“Somebody described it as the feeling of going over the top of a rollercoaster, slightly, not the fall — just a little, ‘what’s going on there?’. There was a little bit of turning of the plane as well and a little bit of downward,” he said on his Triple M radio show.

“It was one of those ones that got your attention. Then it levelled off.”

Fellow QF94 passenger Janelle Wilson said the “three-quarters-full” plane, with a seat capacity of 484, suddenly entered a “free fall nosedive … a direct decline towards the ocean” for about 10 seconds.

“It was between 1½ and two hours after we left LA and all of a sudden the plane went through a violent turbulence and then completely up-ended and we were nose­diving,” Ms Wilson told The Australian yesterday.

“We were all lifted from our seats immediately and we were in a free fall. It was that feeling like when you are at the top of a rollercoaster and you’ve just gone over the edge of the peak and you start heading down.

“It was an absolute sense of losing your stomach and that we were nosediving. The lady sitting next to me and I screamed and held hands and just waited but thought with absolute certainty that we were going to crash. It was terrifying.”

Flight track details show QF12 took off from Los Angeles at 11.27pm Sunday night (US time), 57 minutes behind schedule. QF94, which departed at 11.29pm, 49 minutes late, landed safely but 30 minutes late in Melbourne at 8am on Tuesday.

While Qantas said no one was injured and no damage sustained, the incident traumatised some passengers. It is the latest in a string of mid-air scares potentially linked to the wake turbulence of the giant A380s.

Aviation consultant and experienced pilot Byron Bailey last night called for a review of standards that are meant to safely separate A380s from other aircraft. “It’s a serious problem — they are going to have to really think about this,” Captain Bailey said.

An ATSB spokesman said: “Following our correspondence, the ATSB has made inquiries with the operator (Qantas) and they are voluntarily submitting a notification. Once received, we will ­review the information to determine whether any further action is required.”

Qantas suggested there had been no breach of separation standards, as the two A380 aircraft were understood to be apart by 20 nautical miles and 1000 feet in ­altitude.

“We understand that any sudden turbulence can be a jolt for passengers but aircraft are ­designed to handle it safely,” said Qantas fleet safety captain Debbie Slade. “As the captain explained to passengers at the time, this A380 experienced a short burst of wake turbulence from another A380 flying ahead and above it.”

Ms Wilson said Qantas staff on the flight described it as the worst incident they had experienced on an aircraft.

“Everyone was pulled up from their seats by the ferocity of it; it happened so quickly with no ­notice and just shocked everyone,” she said. “There were glasses, plates, bottles that were all smashed at the back of the plane.”

Ms Wilson said that, once the plane was stabilised, the captain addressed the passengers.

“He said we had been caught in a vortex due to the A380 Qantas flight on its way to Sydney ahead of us and that they were contacting air traffic control to request an ­alternative route,” she said.

“There were three flights we knew of that were leaving from LA to Sydney, Melbourne and Brisbane (within close proximity) and we were delayed by just under an hour, so I don’t know whether that played a part in it.

“We thought ‘how do two Qantas flights get so close?’ There was a lot of anger and curiosity after we all recovered from what was ­clearly a terrifying incident.”

Ms Wilson said it was fortunate dinner had just finished, with most passengers still wearing seatbelts.

Last year, Germany’s Federal Bureau of Aircraft Accident Investigation called for an urgent review of aircraft separation standards after a near disaster when a ­private jet was hit by wake turbulence from a Sydney-bound ­Emirates A380 above the Arabian Sea.

Wake turbulence was also ­blamed for the near-stall of a Qantas 747 flight from Melbourne, about 110km from Hong Kong, in April last year. ATSB’s investigation into that incident, in which 15 passengers were injured, was “nearing ­completion”.

Captain Bailey said that, from the witness descriptions, it ­appeared as though QF94 lost autopilot control after being hit by the wake turbulence and was momentarily uncontrolled. “It’s possible that the autopilot exceeded the breakout threshold and has disconnected,” he said.

Captain Bailey said Qantas might need to adopt a different ­approach to separating A380s on the busy Los Angeles route. “It might be a smart move to stay with the airway but to have each aircraft flying staggered, two to three miles off the centre line,” he said.

And the letdown:

Qantas hails safety after drama

ANDREW BURRELL
Qantas has rejected claims that an A380 jet ‘nosedived’ during a mid-air ­scare that passengers described as a 10-second free fall.

---

Qantas hails safety in A380 jet wake turbulence drama

Qantas has strongly rejected suggestions that one of its A380 jets nosedived during a mid-air ­incident this week despite terrified passengers reporting they experienced a 10-second free-fall that felt like being on a rollercoaster.

The Australian revealed yesterday that the scare above the ­Pacific Ocean, about two hours into a QF94 flight from Los Angeles to Melbourne, is believed to have been caused by “wake turbulence” generated by another A380.

The second jet, QF12, was ­flying from Los Angeles to Sydney and took off two minutes before QF94

It is the latest in a string of mid-air scares potentially linked to the wake turbulence of the giant A380s.

Qantas said yesterday that QF94 was about 37km behind and 1000 feet below QF12 when it encountered disturbed air.

“It may have felt bumpy for the passengers, but the data shows the total up-and-down aircraft nose movement was three degrees,” chief pilot Richard Tobiano said.

“The reports of a nosedive or a plunge are wrong.”

Former commercial airline pilot Byron Bailey questioned why the pilot of QF94 was only 1000 feet below the other A380 and called for better aircraft separation standards.

“One thousand feet is asking for trouble,” he said yesterday.

But Qantas said the 1000-foot limitation reflected a global air traffic control standard for aircraft flying in the same direction and in the same corridor.

“It’s not a decision made by (Qantas),” a spokesman said. “These are the rules that air traffic controllers manage to and apply to all airlines.”

The spokesman said the two aircraft were significantly in ­excess of the required standard because they were also 37km apart.

The editor-in-chief of the Airline Ratings website, Geoffrey Thomas, described it as a “freak event” that was likely caused by “very still air”.

Among the passengers on QF94 was Nine Network presenter Eddie McGuire, who said yesterday the drop seemed to last about 10 ­seconds.

“For about 10 seconds there was a drop, it did have that feel of, you know, when you just go over the top of the rollercoaster, you just get a little bit of that feeling,” McGuire told the Today show.

“It just had that uneasy feeling as it pitched forward and to the side,” he said. “The most reassuring part about the whole thing was the Qantas pilot came on immediately and said we’ve gone up the back of the turbulence of the ­Sydney plane that had been ahead of us.”

Fellow QF94 passenger Janelle Wilson said the plane entered a “free-fall nosedive … a direct ­decline towards the ocean” for about 10 seconds.

“We were all lifted from our seats immediately and we were in a free-fall. It was an absolute sense of losing your stomach,’’ she said.

The Australian Transport Safety Bureau said Qantas had reported the occurrence.

“The operator submitted a notification this morning, which is within the required 72-hour time frame for routinely reportable matters,” it said.

“The information contained in the notification has been reviewed and the ATSB has determined that it will not be investigating.”

---

Plus:

Turbulence nothing to fear
RICHARD TOBIANO, QANTAS CHIEF PILOT
Recent reports on QF94 show that turbulence is probably one of the most misunderstood elements of flying.

---

Turbulence nothing to fear if passengers wear their seatbelts

Recent reports on QF94 show that turbulence is probably one of the most misunderstood elements of flying. For pilots, it’s an everyday part of our job and nothing to fear. Aircraft are engineered to deal with levels of turbulence well beyond anything they would realistically encounter. But we’re conscious that turbulence can put passengers on edge — especially if it’s a sudden jolt.

And because it is misunderstood, those jolts can be wrongly perceived as a “plunge” or “massive drop”. It helps to understand why turbulence happens.

Some causes are sudden changes in wind direction and speed, particularly as aircraft climb to their cruising altitude; turbulence associated with large, dense clouds; and wake turbulence, which QF94 experienced this week over the Pacific Ocean. Large jet aircraft (like the A380 or 747) disturb the air behind them, similar to the wash from a boat. It’s uncommon but that disturbed air can cause bumps for nearby aircraft, even if they are a significant distance away.

QF94 was about 37km behind and 1000 feet below the other Qantas A380 when it encountered some disturbed air. The two aircraft were well aware of each other, but wake turbulence can be hard to predict and often arrives as a sudden jolt when you’re flying smoothly. The turbulence lasted for about 10 seconds and caused the nose of the aircraft to pitch up slightly. The “plunge” that a few passengers have described was actually the A380 immediately returning itself to a steady state. Aircraft are designed to fly level and if turbulence disturbs that, the aircraft will adjust — including going back to the right altitude.

QF94 performed exactly as it was supposed to in this scenario and so did its highly trained crew. The total movement in pitch was about three degrees. The captain knew how this would have felt to passengers, so made an announcement to explain what happened and why it wasn’t cause for concern. The rest of the flight was uneventful.

Serious aviation incidents need to be reported to the Australian Transport Safety Bureau within 24 hours. Non-serious events like QF94 need to be reported within 72 hours and Qantas did that — one of hundreds of reports we and other airlines make each year that help make our aviation sector one of the world’s safest.

A lot of effort goes into avoiding turbulence. Detailed weather reports, state-of-the-art weather radars, talking to other pilots flying along the same corridors and spacing between aircraft all help to smooth things out. Turbulence can be unexpected and uncomfortable, but provided you have your seatbelt on whenever you’re seated, it’s not something to fear.

Qantas chief pilot Captain Richard Tobiano regularly flies the A380. 

Speaking of 'nose dives', one wonders how much of this heightened public/media beat ups were partly due to the recently revived interest in the 7 October 2008, QF 72 occurrence - stirred up by the not long released National Geographic Air Crash Investigation episode on QF 72?

See here (Ps Not the best copy version available -   ):    

Just saying...



MTF...P2 

[Gobbledock]

Another media beat up. There was adequate separation, some wake turbulence occurred, auto throttle disconnected, minor nose down drop in altitude and attitude, Captain/F.O recovered her. Fun is over, back to sleep for the passengers......

[thorn bird]

"Another media beat up."

Yup Gobbles,
Chatting with a guy who just completed a mission up to Darwin.
He complained the headwinds were so strong at one point he considered
getting his FO out of his seat to push, and the turbulence was so bad
he had white caps on his coffee!!

[Gobbledock]

Another one bites the dust.....

Rossair placed into administration after year-long struggle. S’pose it’s never a good thing when a CAsA Inspector is killed on a flight piloted by the CP.

http://mobile.abc.net.au/news/2018-07-04...fmredir=sm

R.I.P

[Kharon]

FWIW – The ATSB initial report on the Moorabbin accident. HERE.
 
There are a couple of ‘areas of interest’ which need some math done – glide distance/ time and the intriguing ‘descending left turn’ – need a detailed map, some performance data and a chat with a couple of mates to sort this one out. Have to wait;;;; 

Preliminary report published: 18 July 2018

On 8 June 2018, a Cessna Aircraft Company C172S, registered VH-EWE (EWE), was being operated on a private flight from, and intending to return to, Moorabbin Airport, Victoria. The flight was the first one after scheduled maintenance. The pilot, an employee of the maintenance organisation, was the sole occupant.

The aircraft departed Moorabbin Airport at about 1600 Eastern Standard Time.[1] Recorded Air Traffic Control (ATC) data showed that the aircraft climbed to an altitude of 3,000 ft above mean sea level and tracked towards Tyabb, Victoria.

At 1707, the pilot reported to Moorabbin ATC that EWE was at reporting point GMH at 1,500 ft, inbound to Moorabbin. ATC instructed the pilot to join base for runway 35 Right ®. At 1710, ATC requested EWE change runways to 35 Left (L), due to the number of aircraft tracking for 35R. The pilot accepted the runway change and at 1712, EWE was cleared to land on runway 35L. At 1713, the pilot of EWE broadcast a MAYDAY[2] radio call and stated “we’ve got engine failure”. Shortly after, the aircraft was observed in a descending left turn.

The aircraft initially contacted a power line and fence before coming to rest on a residential street against a parked car (Figure 1). The pilot was fatally injured and a post-impact fuel-fed fire destroyed the aircraft. There was also damage to a residential property and the parked car.

Figure 1: Accident site


Figure 1: Accident site of Cessna Aircraft C172S, registered VH-EWE, near Moorabbin Airport, Victoria  Source: ATSB

Aircraft information

The Cessna 172S aircraft was manufactured in 2006. It had 6,348 hours in service prior to the accident flight and was predominantly used for flight training. The aircraft was fitted with a Lycoming IO-360-L2A fuel injected engine and McCauley two-blade, fixed pitch propeller.

The maintenance carried out on EWE before the accident flight included a periodic inspection and scheduled engine change. A valid maintenance release had been issued just prior to the accident flight.

The installed engine had recently undergone a scheduled inspection and overhaul at another maintenance facility. As part of that process, the engine had been run on a test bed at the overhaul facility for about 2 hours. Post installation into EWE, it was reported that the engine was twice operated on the ground for a total of about 30 minutes.

Wreckage examination

On-site examination of the wreckage and surrounding ground markings indicated that the aircraft collided with terrain in a nose‑down attitude. The tail of the aircraft twisted clockwise as a result of the impact with the fence and was inverted. Evidence of the fire extended down the street, and was indicative of fuel being released with the rupturing of the fuel tanks.

The degree of propeller damage observed on-site was consistent with the engine not producing power at the time of impact. The engine, propeller and several other components were retained for further examination.

The aircraft was not equipped with a flight data recorder or cockpit voice recorder, nor was it required to be.

Engine and propeller examination

The engine and propeller were subsequently examined at an independent engine overhaul facility, under ATSB supervision. Representatives from the Civil Aviation Safety Authority, the aircraft maintenance organisation, the engine overhaul facility, and the aircraft insurer were present at the engine disassembly.

This examination did not identify evidence of a mechanical failure of the engine. Some additional components, including those associated with the fuel system, were retained for further examination.

Ongoing investigation

The investigation is continuing and will include consideration of the:

   examination of retained aircraft and engine components
   maintenance documentation
   pilot’s experience
   aircraft fuel records
   audio analysis of engine sound (from ATC radio recordings)
   available electronic data.

__________
The information contained in this preliminary report 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 preliminary report. As such, no analysis or findings are included in this report.

[Kharon]

Gas, Spark and Air.

This incident got a fair bit of consideration from a few of us – (darts practice). Not the full on kind, more of the ruminative, speculative sort of thing. Pointless try to nut it out without a full report on the outstanding items the ATSB has retained for further examination. However, whilst this type of discussion always ends up with more questions than answers, some of those questions can be and should be answered in the initial report. For example – the weather conditions that day have not been mentioned; they were not good. Low freezing level, rain, turbulence etc. Not an ideal day for flying – if you didn’t have to, certainly not for fun or very far from the circuit. When turbulence and moisture combine with a low freezing level the possibility of some kind of icing is always on the cards. Carburettor ice would have been a potential hazard; but, this C172 engine was fuel injected. Fuel does not seem to have been in short supply, the early engineering report leaves you with impression that ‘spark’ was not an issue, which leaves with only ‘air’ to wonder about.  This leads us to the engine air intake. Is there an alternate air source? Seems not:-

"4. Watch for signs of engine icing related icing conditions. An unexplained loss of engine speed could be caused by ice blocking the air intake filter. Adjust the throttle position to obtain maximum RPM, this may require advancing or retarding of the throttle depending on where the ice has accumulated. Adjust mixture, as required for maximum RPM."

Furry muff – but throttled back for approach, changing runway, watching for traffic, with wind and turbulence to divert the attention – the advice above is fatuous to say the least. The small adjustments required to maintain profile at a low power setting almost precludes any indication of inlet air icing being noted, let alone dealt with.

One of the more intriguing aspects is the left turn made toward the end of the flight – strange until you drag out the satellite photographs – then it all becomes clear. There is a large, tempting football field in a handy position – which, it could be argued, the pilot saw as a viable alternate to landing on some house. Hobsons choice but with speed and height – in all probability do-able. We don’t know the configuration of the aircraft – ATSB fail to mention this important element. Given the wind on the day and a glide ratio published as approximately 9:1 (at ::68 KIAS) with flap out, the aircraft was battling the odds – retracting the flap may have bought a precious few feet of airspace.

The altitude needed to make a successful glide approach is compromised by the approach procedures in place. 9000 feet travelled for each 1000 ft of height is pretty close in. Call it (for sake of a number) a 1.5 nm final; or, a requirement to be at 2000 ft at 3 nm. This does not fit the airspace model. When an area is as extensively built up as the approach to 35 at Moorabbin, a dead stick landing should be a consideration in the design of airspace. Indeed, it is a rare event, very rare, as is a King Air smacking into a DFO – but accidents on take off and landing rate where on the grand scale of occurrence?

We shall have wait and see what the ATSB eventually come up with – but for my money, this pilot was only a few feet short of walking away and telling the tale over a beer. Which leaves you to wonder about fate and ‘if only’. Take care out there – Murphy flies with everyone; for a Reason.....

Toot – toot.

Just a final thought – when I learnt almost every landing was a ‘forced landing’ with the odd engine clearing throttle up – glide approach, every time, making allowance for wind and other considerations. I wonder if the long powered approaches we see today and the extended circuits are helpful to the single engine ‘thinking’. Fair enough for multi-engine training – but,,,,

[ventus45]

Since inlet icing seems possible / probable, the BoM should do a very detailed post-cast analysis for that day, and publish it.

[P7_TOM]

Herewith – the perils of idle speculation. It seems there is another ‘hot favourite’ for the intriguing ‘left turn’. ATSB wording can be misleading, they call it as

"Shortly after, the aircraft was observed in a descending left turn."

They may however be forgiven this time: it is a safe, accurate description of the aircraft’s manoeuvring. There is a video – HERE – which, if carefully watched (a few times) shows the aircraft in what could be an incipient spin. Not proof positive but it leads to the notion that the aircraft may have overshot the runway centre line, at a low power setting, probably with a couple of stages of flap out and was in a tight turn to return to track when power was lost. The rest as they say is history now.

This notion also fits with the ATSB report – amongst others. I guess we could spend a whole evening speculating, but it would save time and energy if the ATSB would publish the Met data – 35 knots of breeze that day – the final flight path – and any video they have. It would be much better if they published a comprehensive report with clear messages. Like with this accident, like Essendon and many others, it has some safety messages to deliver. Speedily closing loops and swiftly delivering lessons to prevent a re-occurrence should be a priority.

I expect the debate will continue now – but, I shall abstain. Content to sit by the fire, quietly enjoying the Ale and ambience….

[Kharon]

Crawford defends CASA Position on GA
Acting Director of Aviation Safety defends CASA's position on general aviation.

If the ‘CASA position’ is anything like the one depicted – it will be impossible to defend.



More than almost any other CASA self promotion picture, the one above clearly demonstrates the amateurish, uneducated, unthinking, dangerous approach CASA have toward aviation safety. What CASA is promoting in that picture is both wrong and dangerous; let’s hear the Scots Git defend that. Bloody amateur’s…….

How can anyone defend the ‘position’ of the clown in the Hi-Viz vest in the picture above? Standing directly in front of a high compression engine. Two hands on a three bladed propeller, muscles tensed obviously going to ‘pull the prop through’. Of all the dumb things to do, when he bends forwards as he must - his fool head will directly in the path of the next blade through. If that engine kicks over (and they can) it will be some other poor sods left to clean up the CASA mess, once again. Hell CASA will probably prosecute the maintenance organization for faulty magneto’s or some such.

With a relatively modern, high compression aircraft engine, like the one shown, ‘swinging the prop’, or even pulling it through a compression stroke is a whole world away from the ‘Tiger Moth’ days and those happy times of ‘round (proper) engines. Horses for courses - the right way, with an engine and propeller 'user friendly' and even then, not without risk.

Spot the subtle, but important differences.

[Gobbledock]

And where are old mates earmuffs, I can’t see any hearing protection that meets the Australian standards? And he is wearing a short sleeve shirt, wouldn’t a safety conscious Regulator insist on its staff wearing hearing protection and long sleeve shirts due to the harsh Australian sun, not to mention stringent WHS requirements?

Muppets, bloody muppets

[Kharon]

What you make of - THIS -  depends on your point of view. It terrifies me………..
 
The ATSB highlight one way of ‘thinking’ i.e. there’s nothing in the rules about it, but there should be.
 
Another way of looking at it is that this industry is so totally dependent on doing what the rules say and nothing else, that it can no longer think for itself.
 
Either way – not a good look is it? Would you ever imagine that a safety agency would need to publish - THIS. 

Seriously, think about it and what it is saying about the Australian mind-set (brainwashing) through excess legislation – “It’s not in the rules so we don’t have to do it”. DS – anybody home? Hello?
 
Toot – weary – toot.