[Peetwo]

Coroner Inquest report: Nikita Jo Walker

Via Search 4 IP:

It is an old drum; but a good one.

It's worth taking a moment to read 'Cloudee's' post on the UP _HERE_.

"A coroner examining the 2018 death of a young pilot says he cannot find anyone at fault following her fatal crash at a mountain range in remote southern Tasmania — but slammed Australia's air safety investigator for its "worthless" investigation of the tragedy."

I wonder; now this could just be a one-off bark by a Coroner having a bad case of flatulence on the day. On the other hand, it could, just, maybe, be the opening stanza of something much more valuable. There is long, long line up of Coroner remarks and open dissatisfaction related to aviation deaths. Victoria has had it's fair share lately and will keep the Coroners enclave busy for a while yet.

We all do it, in the pub after work; during a break or at the end of a shift; discuss the latest item of interest and voice our opinion. I imagine that within the realms of the Coroner, with certain restrictions, there may be a similar amount of general 'discussion' - perhaps not related to specifics - but to 'general' common features. Items like the ATSB reports for example. I know I get fed up reading the ATSB reports, when they finally emerge from the sheltered workshop. Trying to convert those reports into something of value toward prevention of a repeat is essentially a waste of time and effort. It must be frustrating for the Coroners; there is long history of their recommendations and input being dismissed or denigrated by the aviation authorities (and that is a historical fact).

Take the Essendon DFO event for a classic, ranked up there with Lockhart River, or even as far back as the Seaview event. How is the Coroner to make a decision without 'all' the facts being presented in the report. How does a Coroner deal with that which is not mentioned, particularly when much is swept under the carpet. The Coroner can only deal with that which is presented or can be determined; but what of the background 'noise'; that which is not investigated and yet may have some relevance.

Questions - for instance; why was Hood, not a qualified investigator on the Essendon scene in record time; did he contaminate the 'scene'? Was his first encounter with burned bodies traumatic to the extent that his judgement was impaired? How extensive was the examination of the pilots medical history and general background post event? Does the Coroner realise that at ingrained habit of all multi engine pilots in the King Air class of aircraft is keep a hand on the power levers throughout the take off; apart from the five or six second it takes to retract the undercarriage? Or even why an experienced pilot would not spot an out of trim condition before the speed indicator was off the peg? To me it seems that these and other items (like the Mayday call-outs) are relevant to the Coroner's thinking. Not mentioned. - But I digress.

The case in point is the event in Tasmania; yet another CFIT. This type of accident is way up on this list of 'repeat' events; nearly all fatal. ATSB are now waving the ADSB flag as a 'cure-all'. Of course this is 100% proof snake oil; ADSB would be of no value to either the Essendon or the Tasmanian pilots; non whatsoever. (MTF on this).

Aye well; this Coroner may just have has indigestion - the mini rant soon forgotten and glossed over; his report about as much use as the ATSB's in preventing a repeat performance where low cloud and high terrain meet the unfortunate. How many has this killed in the last few years and what has ATSB done to reduce the toll?

"Similarly, the Coroner cannot determine civil liability, although the Coroner’s finding may be relied upon in subsequent civil proceedings and/or insurance claims."

Toot - toot...;

Via the other Aunty:

Coroner finds 2018 death of pilot Nikita Walker in Tasmania 'an accident', ATSB report slammed



The coroner's inquest into the death of a "talented and conscientious" pilot has failed to establish why her aircraft crashed into a mountain in remote southern Tasmania but has heavily criticised Australia's air safety investigator over its "worthless" report on the tragedy.

Nikita Walker, 30, was in control of a Pilatus Britten-Norman BN2A-20 Islander and had departed Cambridge, near Hobart on 8 December 2018 around 7:48am.

She was scheduled to arrive at Bathurst Harbour about 45 minutes later to pick up five passengers for the return flight.

Around 8:29am, the Australian Maritime Safety Authority was informed the emergency locator transmitter on the aircraft had activated and advised Tasmania Police.

In its report on the crash, the Australian Transport and Safety Bureau (ATSB) said when search and rescue aircraft arrived at the scene, they were "unable to visually identify the precise location" of the plane.

Key points:

• The coroner cleared Tasmanian airline Par Avion of any "systemic issues" in relation to pilot Nikita Walker's death
  
  
• He said Ms Walker was "attempting to avoid crashing by trying to find a break in the weather" before impact
  
  
• The coroner said the ATSB report "lacks much by way of reasoning, is largely speculative and … is of little forensic value"
  
  

The ATSB report noted the pilot of a rescue helicopter "reported observing cloud covering the eastern side of the Western Arthur Range, and described a wall of cloud with its base sitting on the bottom of the Western Portal" while at the scene.

In findings handed down on Thursday, coroner Simon Cooper said the evidence identified "no particular factor as especially causative or contributory" to Ms Walker's fatal crash.

"The evidence, viewed as a whole, does not point to any particular factor as especially causative or contributory to Ms Walker's fatal crash, Mr Cooper said."

"The aircraft was serviceable. Ms Walker was sufficiently experienced and appropriately qualified. She was well-rested and unaffected by either drugs or alcohol."

"Why she flew into the Western Portal is not something the evidence enables me to determine with any real certainty.

"I consider the clear evidence relating to her flight path immediately before the crash makes it obvious Ms Walker was attempting to avoid crashing by trying to find a break in the weather."

"It follows that I am satisfied that her death was due to misadventure, that is, an accident."



ATSB report into crash 'worthless'

Mr Cooper said: "In my view, in a general sense, the [ATSB] report lacks much by way of reasoning, is largely speculative and is, from my perspective at least, of little forensic value."

“One other obvious problem with the report … is that there is no indication of the author or author’s qualification to express the opinions and conclusions contained in it. In fact, there is even no indication as to the identity of the author or authors."

Mr Cooper said: "Perhaps most surprisingly, despite the fact that it was investigating an aircraft crash, the ATSB report does not appear to attempt to establish, at all, the reason for the crash."

"In short, the ATSB report was of so little use as to be, from my perspective, in the performance of my obligations under the Coroner's Act 1995, worthless. I have no regard to it, other than in a general sense, and specifically disregard the findings it contains."



Ms Walker had moved from Queensland to Tasmania to pursue her career as a commercial pilot with Tasmanian airline Par Avion in 2016.

She had been flying for two years at the time of her death in December 2018.

In his report, Mr Cooper noted her housemate said he and Ms Walker "had a cup of tea" the night before, with her going to bed "around 8:30 to 9pm" and getting up about 6:30am to make her way to work.

Mr Cooper cited Par Avion's submission that Ms Walker was "flying visually and under control" immediately before impact.

"In my view, the evidence enables a conclusion that until the very last moment of the flight, immediately before colliding with the Western Portal, Ms Walker remained in complete control of her aircraft," he found.

"What happened in the immediate moment before colliding … can only be speculation."

Mr Cooper said the evidence related to the crash also "does not reveal any systemic issue" in relation to the airline, Par Avion, or the weather forecasting by the Bureau of Meteorology.

Mr Cooper described Ms Walker as a "talented and conscientious pilot, popular with her colleagues and trusted by her employer".

He expressed his sincere condolences to all who knew and loved Ms Walker for their loss.

The ATSB and Par Avion have been contacted for comment.

(P2 - Cheers Wannabe well captured and copied mate... )

Plus via the Coroner report: https://auntypru.com/wp-content/uploads/...8.2022.pdf







Perhaps now might be a good time to reflect on how things have changed (NOT - ) since the publication of the PAIN_Net 2015 'Coronial Analysis' document: https://auntypru.com/wp-content/uploads/...alysis.pdf

---

Coronial Analysis. Fatal accidents.

Released – Senate Inquiry/RRAT_Folio. -1-

To whom it may concern.

One of the twenty five categories in a research project being undertaken by a small,
privately funded group of qualified, experienced aviation professionals focuses on
Coronial inquiries made in response to fatal accidents involving aircraft.

The purpose was, without bias, prejudice, fear, agenda or other motive to achieve a
clearly defined goal. The improvement of safety for the travelling public and the
people who work within the aviation industry.

The approach to the construct has been simple, and asked only two questions.

a) Was the accident preventable ?.
b) What steps have been taken to prevent repetition in similar circumstances ?.

Research was conducted over a wide area including:-

a) Extensive operational background analysis, private anecdotal and publicly
available data; and, considered expert opinion.

The intent was to present alternative or revised assessment of accidents where, in
the opinion of the group, the most probable and ranked contributing causes related
to the incidents were not clearly defined or presented for Coronial considerations.

It became apparent over some two hundred man hours of research into some thirty
investigations that 3 powerful elements were effectively preventing a satisfactory
conclusion to clearly defining the contributing causes and pro active prevention of a
similar repetition of the event.

We noted the following items:-

1) The frustration expressed by various Coroners, through transcripts, where
trying to establish a clear picture through the lack of deep technical knowledge
and sound advice.
2) The frustration expressed by the Australian Transport Safety Bureau (ATSB) in
almost every report published, where sound advice and research has been belittled
or waved aside as insubstantial.
3) The seemingly deeply entrenched culture of constant antagonism and
abrogation of responsibility existing between the Civil Aviation Safety Authority
(CASA) and the ATSB.

These issues appear to often place the Coroner in the invidious position of having to
make a choice between 2 'expert' opinions.

The following incident reports are from a wide range available for consideration;
they, we believe encompass the issues noted.

We believe that non of the promised legislation, against which many Coroners
based their recommendations, is available for practical use.

We believe none of the Coroners recommendations have been adopted to produce,
in any practical, meaningful way improved safety outcomes.

We believe that, in real terms, there has been no pro active approach to reduce
the self evident risks or casual factors related to the provided reports.

We firmly believe that all the presented incidents still have the potential to be
repeated.

The report editors.

---

MTF...P2