[Peetwo]

Hooded Canary catching up on AAI backlog? 

The ATCB has recently released two interesting final reports, one of which took 2.5 years to complete. Both reports were accompanied with Hooded Canary pressers -  :    

Maximum take-off weight exceeded following cargo loading irregularity


An Airbus A330 departed Sydney with the aircraft’s maximum take-off weight exceeded by 494 kg following a loading irregularity, an ATSB investigation details.

On 17 December 2017, a Qantas A330-300 was being loaded with freight in preparation for an international passenger flight from Sydney to Beijing, China. After landing in Beijing, the airline’s freight agent identified that the aircraft had been loaded incorrectly. As a result, the aircraft had departed Sydney 875 kg above the weight listed in the revised load sheet, and 494 kg above the aircraft's maximum take-off weight.

The ATSB found that an operational requirement for additional holding fuel resulted in the operating flight crew issuing a revised load instruction to carry less cargo. However, this instruction was not actioned and led to a 2,005 kg pallet of freight remaining on board the aircraft, instead of being replaced with a lighter unit weighing 1,130 kg.

The required cargo variation was not actioned by the load supervisor, as electronic messages associated with the revised loading instruction were acknowledged without being correctly interpreted. That action was probably influenced by the supervisor’s experience that load changes were accompanied by verbal advice, which did not occur on this occasion.

The ATSB’s investigation into the incident highlights the importance of communication between all parties responsible for aircraft loading. Planning and loading of freight in the high-capacity passenger sector is often conducted under significant time pressure, where delays can lead to scheduling issues.

Effective communication between all parties responsible for aircraft loading can assist in reducing errors, the investigation notes.

As a result of this, and other freight loading occurrences, Qantas have introduced handheld scanning devices that automate much of the freight confirmation and mobile communication process using printed barcode and scanning technology. The scanners were implemented at most domestic and international Qantas ports by June 2019.

Read the investigation report AO-2018-003: Aircraft loading-related occurrence involving Airbus A330-303, VH-QPD, Sydney Airport, NSW, on 17 December 2017

Hmm...not exactly sure why the HC mob continued with this investigation, although a relatively significant load weight exceedance and an obvious causal chain of events/actions (or non-actions) that led to this exceedance, surely this occurrence didn't warrant the carriage of full blown ATCB investigation?      

Warbird accident highlights the inherent risks of low-level aerobatics in high-performance aircraft


The pilot of a Yakovlev YAK 9 warbird which entered a low altitude spin before impacting the ground had not previously conducted aerobatics in the aircraft and so was unlikely to be aware of its unique handling characteristics, an ATSB investigation into the accident has found.

The investigation report details that the pilot, prior to undertaking a planned instructional flight with an instructor in the YAK 9* later that afternoon, took off from Latrobe Regional Airport, Victoria shortly after 2:20pm on 7 September 2018 for a local private flight.

Data from the nearby East Sale RAAF Base air traffic control radar showed the aircraft tracked first to the south-west, maintaining runway heading, before turning north-west. North of the town of Moe, at an altitude of about 2,800 feet above sea level, the pilot began to conduct what witnesses on the ground described as aerobatic manoeuvers.

The pilot was endorsed for aerobatic manoeuvres completed by 3,000 feet above ground level but had not previously conducted aerobatics in the YAK 9.

With limited experience and recency in flying the YAK 9, the pilot was likely unaware of the aircraft’s unique handling characteristics during aerobatic manoeuvres or spin recovery.

One witness described observing the aircraft perform what appeared to be a roll followed by a loop. The aircraft came out of the bottom of the loop and made an abrupt left turn before spiralling towards the ground. Video taken by another witness showed the aircraft in a spinning, steep nose‑down attitude prior to disappearing from view.

The aircraft was found to have impacted the ground in a paddock about 3 km north of Moe, in a flat, slightly right‑wing and nose-low attitude consistent with an aircraft established in, or recovering from, a spin. The pilot was fatally injured and the aircraft destroyed.

ATSB Transport Safety Director Stuart Macleod said the accident highlights the risks inherent with performing low-level aerobatics in high performance aircraft.

“High‑performance aircraft like the YAK 9 transition into a fully developed spin quicker and more forcefully than a typical light training aircraft. It is essential to have sufficient altitude to effectively recover from a spin,” he said.

“Experienced YAK 9 pilots stated that, depending on pilot experience, 5,000 to 7,000 feet is required to safely recover the aircraft from a developed spin.

The report notes, unlike in most other warbird aircraft, as the airspeed increases during a high-speed dive recovery, in the YAK 9 the effort required to pull back on the control stick reduces.
 
“This investigation reinforces to pilots performing low-level aerobatics the importance of observing minimum approved operating heights, commensurate with their ability and qualifications, and to engage in regular flight reviews and instruction.”
 
The investigation report notes the pilot had conducted aerobatics in a number of warbird aircraft but only had between five and six hours of flying experience in the YAK 9, and that the accident flight was the pilot’s first in the aircraft in three months.

“With limited experience and recency in flying the YAK 9, the pilot was likely unaware of the aircraft’s unique handling characteristics during aerobatic manoeuvres or spin recovery,” Mr Macleod said.  

The ATSB investigation also identified a number of safety issues that while they did not directly contribute to the accident flight, increased risk.

For example, the aircraft’s canopy had been opened intentionally in flight the previous day, resulting in the loss of documentation from the aircraft including the aircraft checklist, flight manual and maintenance release.

“Pilots need to ensure that careful preparation and planning is undertaken prior to each flight and that all documentation, checklists and required manuals are appropriately stored and accessible within the aircraft,” Mr Macleod said.

In addition, post-accident examination of the aircraft identified incomplete maintenance practices, including inadequate airframe anti‑corrosion measures and insecure primary flight controls and seat fasteners.

* The YAK-9 was a Russian-designed single-seat fighter aircraft used during the Second World War, similar in performance to the Spitfire and P-51 Mustang. The accident aircraft, a YAK-9 UM, was a replica of the original design, built in the 1990s and fitted with two seats and an American-built, rather than Russian, engine.


Read the investigation report AO-2018-061: Loss of control and collision with terrain involving YAK-9UM, VH-YIX, 19 km west-north-west of Latrobe Regional Airport, Victoria, on 7 September 2018

A few disconnections and points of interest in this investigation report, for example:

"..The instructor and the pilot discussed the absence of the checklist and other required documents. The instructor reported that they agreed that the aircraft should not be flown, but taxiing would be acceptable...The aircraft was taxied along to the run-up bay. The witnesses observed that the rear canopy of the aircraft was open and that the pilot appeared to conduct routine engine checks. A short time later, the aircraft entered runway 21, the pilot applied power and commenced to take-off.

The instructor, who was walking across the tarmac from the aero club, recalled observing the take-off roll of the YAK 9 and noted that the aircraft used more than double the normal length of runway before it lifted off. The instructor then noticed that the rear canopy was not secure.

He attempted to contact the pilot from within the aero club by radio to advise him that the rear canopy was not secure. The instructor made several broadcasts but did not receive a response from the pilot..."

Then this from this week's Hooded Canary 'Transport Safety Director' Stuart Macleod...

ATSB Transport Safety Director Stuart Macleod said the accident highlights the risks inherent with performing low-level aerobatics in high performance aircraft.


“High‑performance aircraft like the YAK 9 transition into a fully developed spin quicker and more forcefully than a typical light training aircraft. It is essential to have sufficient altitude to effectively recover from a spin,” he said.

“Experienced YAK 9 pilots stated that, depending on pilot experience, 5,000 to 7,000 feet is required to safely recover the aircraft from a developed spin.

The report notes, unlike in most other warbird aircraft, as the airspeed increases during a high-speed dive recovery, in the YAK 9 the effort required to pull back on the control stick reduces.
 
“This investigation reinforces to pilots performing low-level aerobatics the importance of observing minimum approved operating heights, commensurate with their ability and qualifications, and to engage in regular flight reviews and instruction.” 
 
The investigation report notes the pilot had conducted aerobatics in a number of warbird aircraft but only had between five and six hours of flying experience in the YAK 9, and that the accident flight was the pilot’s first in the aircraft in three months.

“With limited experience and recency in flying the YAK 9, the pilot was likely unaware of the aircraft’s unique handling characteristics during aerobatic manoeuvres or spin recovery,” Mr Macleod said. 

Earth to Macleod, do you really think it appropriate to use this particular unfortunate pilot's more than likely intended last flight accident to highlight obvious operational deficiencies and intentional illegalities as safety risk issues? 

I also find it passing strange that this week's Transport Safety Director Macleod makes this obs:

“This investigation reinforces to pilots performing low-level aerobatics the importance of observing minimum approved operating heights, commensurate with their ability and qualifications, and to engage in regular flight reviews and instruction.”

Yet in the ATSB RossAir presser for Executive Director Transport Safety Nat Nagy a similar observation wasn't made..

“Conducting the engine failure exercise after the actual take-off meant that there was insufficient height to recover from the loss of control before the aircraft impacted the ground,” said Mr Nagy. 

..despite the fact that the CASA approved simulated OEI was conducted at approximately 4,600 ft below the Cessna AFM and 2600 feet below the company OPs Manual recommended topdeck levels for that kind of operation.

MTF...P2