Is this finally one for the White Hats??
It may have taken nearly 3 years but today the ATSB finally released their report into the Perth Skyshow Mallard fatal (and not a Hooded Canary in sight...
):
ATSB calls for improved airshow display approval and oversight
![[Image: ao2017013_ch-cqa_2.jpg?width=670&height=...7713498625]](https://www.atsb.gov.au/media/5777035/ao2017013_ch-cqa_2.jpg?width=670&height=478.04407713498625)
[b]The ATSB is calling for the implementation of improved tools and guidance for airshow display approvals and oversight following its investigation into a high profile fatal accident at an Australia Day air display in Perth in 2017.[/b]
A pilot and passenger were fatally injured when their Grumman G-73 Mallard amphibious aircraft aerodynamically stalled over the Swan River and collided with the water during the air display, which was part of the City of Perth’s Australia Day Skyworks event.
The ATSB’s investigation into the accident established that the Mallard was to conduct two circuits over Perth Water, ‘in company’ (that is, following behind at a prescribed distance) with a Cessna Caravan aircraft. The pilot of the Caravan had previous experience operating in this location, including participating in this air display. Following the Caravan was intended as a risk mitigator against the Mallard pilot’s unfamiliarity with display flying over the Swan River.
However, after conducting two passes in company, with both aircraft departing the display area, the pilot of the Mallard subsequently requested of, and received approval from, the air display ‘ringmaster’ to conduct a third pass. The aircraft then returned to the display area without the Caravan and in a manner contrary to the standard inbound procedure, requiring turns at higher bank angles and lower altitudes within a confined area to become established on the display path.
The ATSB investigation found that the aircraft stalled at an unrecoverable height. Had the Mallard re-entered the display area using the standard procedure for the air display, the manoeuvres required to position for the third pass would have been relatively benign with a significantly reduced risk of mishandling the aircraft. Further, the pilot’s decision to carry a passenger was also contrary to the requirements of the display approval and increased the severity of the outcome.
“Air displays have inherent and unique risks that everyone involved – pilots, organisers, and regulators – have responsibilities in addressing,” ATSB Executive Director Transport Safety Nat Nagy said.
“It is important that holders of these key positions have a thorough understanding of their role and responsibilities, to ensure adequate completion of safety critical tasks. Having well-defined, transparent, and consistent processes for planning and approval of air displays assists in identifying risks and implementing effective mitigation strategies.”
Mr Nagy said the investigation also highlighted that pilots can limit their exposure to risk by only participating in displays that are within their own and their aircraft’s capabilities and limitations.
“Pilots should not undertake any impromptu manoeuvres that have not been planned or practiced,” he noted.
Since the accident, CASA had independently published a revised manual of guidance for air displays in September 2017.
“The ATSB acknowledges the improvements to CASA’s manual of guidance for air displays and the associated forms,” Mr Nagy said. “But while these changes improve existing guidance, we consider that they only partially address the safety issue surrounding air display approval and oversight.”
Consequently, the ATSB has issued a formal safety recommendation to CASA calling for further improved air display approval and oversight tools and guidance, and enhanced procedures to ensure the suitability air display organisers, coordinators and participants.
More information about the accident, the investigation, and the safety issues and actions that have emerged can be found in the report AO-2017-013: Collision with water involving Grumman American Aviation Corp G-73, VH-CQA, 10 km WW of Perth Airport, Western Australia on 26 January 2017.
This is the safety recommendation:
Hmm...I can feel a running TAB coming on for when/where/if Fort Fumble will get around to proactively addressing this SR...
MTF...P2
It may have taken nearly 3 years but today the ATSB finally released their report into the Perth Skyshow Mallard fatal (and not a Hooded Canary in sight...
):ATSB calls for improved airshow display approval and oversight
[b]The ATSB is calling for the implementation of improved tools and guidance for airshow display approvals and oversight following its investigation into a high profile fatal accident at an Australia Day air display in Perth in 2017.[/b]
A pilot and passenger were fatally injured when their Grumman G-73 Mallard amphibious aircraft aerodynamically stalled over the Swan River and collided with the water during the air display, which was part of the City of Perth’s Australia Day Skyworks event.
The ATSB’s investigation into the accident established that the Mallard was to conduct two circuits over Perth Water, ‘in company’ (that is, following behind at a prescribed distance) with a Cessna Caravan aircraft. The pilot of the Caravan had previous experience operating in this location, including participating in this air display. Following the Caravan was intended as a risk mitigator against the Mallard pilot’s unfamiliarity with display flying over the Swan River.
However, after conducting two passes in company, with both aircraft departing the display area, the pilot of the Mallard subsequently requested of, and received approval from, the air display ‘ringmaster’ to conduct a third pass. The aircraft then returned to the display area without the Caravan and in a manner contrary to the standard inbound procedure, requiring turns at higher bank angles and lower altitudes within a confined area to become established on the display path.
The ATSB investigation found that the aircraft stalled at an unrecoverable height. Had the Mallard re-entered the display area using the standard procedure for the air display, the manoeuvres required to position for the third pass would have been relatively benign with a significantly reduced risk of mishandling the aircraft. Further, the pilot’s decision to carry a passenger was also contrary to the requirements of the display approval and increased the severity of the outcome.
Having well-defined, transparent, and consistent processes for planning and approval of air displays assists in identifying risks and implementing effective mitigation strategies[i].[/i]
“Air displays have inherent and unique risks that everyone involved – pilots, organisers, and regulators – have responsibilities in addressing,” ATSB Executive Director Transport Safety Nat Nagy said.
“It is important that holders of these key positions have a thorough understanding of their role and responsibilities, to ensure adequate completion of safety critical tasks. Having well-defined, transparent, and consistent processes for planning and approval of air displays assists in identifying risks and implementing effective mitigation strategies.”
Mr Nagy said the investigation also highlighted that pilots can limit their exposure to risk by only participating in displays that are within their own and their aircraft’s capabilities and limitations.
“Pilots should not undertake any impromptu manoeuvres that have not been planned or practiced,” he noted.
Since the accident, CASA had independently published a revised manual of guidance for air displays in September 2017.
“The ATSB acknowledges the improvements to CASA’s manual of guidance for air displays and the associated forms,” Mr Nagy said. “But while these changes improve existing guidance, we consider that they only partially address the safety issue surrounding air display approval and oversight.”
Consequently, the ATSB has issued a formal safety recommendation to CASA calling for further improved air display approval and oversight tools and guidance, and enhanced procedures to ensure the suitability air display organisers, coordinators and participants.
More information about the accident, the investigation, and the safety issues and actions that have emerged can be found in the report AO-2017-013: Collision with water involving Grumman American Aviation Corp G-73, VH-CQA, 10 km WW of Perth Airport, Western Australia on 26 January 2017.
This is the safety recommendation:
Quote:Air display approval and oversight
Issue number: AO 2017-013-SI-01
Who it affects: Air displays: Organisers and participants in air displays
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Other
Background: Investigation Report AO-2017-013
Date: 19 November 2019
Safety issue description
The Civil Aviation Safety Authority (CASA) did not have an effective framework to approve and oversight air displays, predominantly due to the following factors:
While the Air Display Manual provided guidance to organisers conducting an air display, it did not inherently provide the processes and tools needed for CASA to approve and oversee one and no other documented guidance existed.
Unlike the accreditation models adopted by some other countries, CASA did not have a systematic approach for assessing the suitability of those responsible for organising, coordinating and participating in air displays.
CASA did not have a structured process to ensure that risks were both identified and adequately treated.
The combination of these factors significantly increased the likelihood that safety risks associated with the conduct of the air display were not adequately managed.
Proactive Action
Action organisation: Civil Aviation Safety Authority
Action number: AO 2017-013-NSA-01
Date: 19 November 2019
Action status: Released
At the time of the occurrence, the Civil Aviation Safety Authority (CASA) had a revised air display guidance manual in draft. This was subsequently published in September 2017 as the Air Display Administration and Procedure Manual. Version 3.0 of this manual was published in April 2018. Pro-active safety actions arising from the new publication included:
the requirement to conduct a risk assessment as part of the air display planning
the requirement for the display organiser and display coordinator to document their relevant qualifications and associated display experience, to allow CASA to assess their suitability for the role
further clarification of roles and responsibilities, and display organisational expectations
enhanced forms for display pilots and additional crew, to assist the display coordinator in their assessment of the pilot and display, and to ensure all persons on board are identified and authorised.
ATSB response:
The ATSB acknowledges the improvements to the Civil Aviation Safety Authority’s Air Display Administration and Procedure Manual, and associated forms. While these changes improve existing guidance and partially address the safety issue, The ATSB considers that further improvements can be made to provide additional assurance of the suitability of key personnel, and to provide enhanced guidance and tools around the approval and oversight of air displays. Accordingly, the ATSB issues the following recommendation.
Recommendation
Action organisation: Civil Aviation Safety Authority
Action number: AO-2017-013-SR-029
Date: 19 November 2019
Action status: Released
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority undertake further work to enhance their tools and guidance for air display approval and oversight, and procedures to ensure the suitability of those responsible for organising, coordinating and participating in air displays.
Current issue status: Safety action pending
Hmm...I can feel a running TAB coming on for when/where/if Fort Fumble will get around to proactively addressing this SR...
MTF...P2