[Peetwo]

Questions for the Coroner?? - Part I

Via Search 4 IP: 

Probity - As you like it – Or; perhaps not....

This ramble, based on collective opinion was prompted by the 'passing strange' published investigation report, into a seriously 'non-event' sponsored and fronted by Godley, big cheese in the ATSB Goon squad, under the command of the Wee Bearded Popinjay. A pointless report, hardly worthy of media cover, not if taken at face value. So, a pilot's power lever wandered from the desired position – the pilot returned said power lever to correct position, reset the throttle friction and continued on; probably thinking 'must remember that'. It has happened to hundreds of B200 pilots – at least once. So why is ATSB, Godley and crew wasting resources promoting a 'something nothing' event we wonder. In defence of the Essendon DFO build perhaps, timing is all?

There's not too much to 'like' about the investigation of the Essendon DFO event. IMO it has been a shambles from the get go. But, just for the moment lets put the dubious parentage and approval for the DFO monstrosity out of the frame and focus on the crash event. Bear with the ramble while we examine some elements which could, perhaps, be of some interest to the Coroner, those left behind wondering, et al.

In general, most pilots pretty much follow a well beaten track pre departure; check the weather forecast, rearrange flight plan as required, check the weight and balance, order fuel if needs be, erc. Then amble out to do the pre flight checks and prepare the aircraft (more or less). The B200 manual provides a 'Before Engine Start' check list (41 items in my book). Many of which may be checked before loading passengers and baggage; this for practical purposes – a fault in any system is best detected prior to loading. This check list (my book) does not mention 'trim tabs' at this stage, but it does focus on 'cockpit' system. Most pilots would, at this stage at least note the position of both the roll and rudder trim wheels; almost automatic to reset to Zero at this stage.– Bear in mind that the 'after landing checks' (and SOP) call for the trim tabs to be reset to 'zero', after landing – a habit forming ritual. Even then, most pilots would check, as a matter of routine, the 'tech log' first; engineering often tinker, and may not have 're-set' before exiting the cockpit. However, had maintenance been carried out, it would be noted and the tech-log is usually checked first by the crew.

Either way, to any pilot experienced on type any serious out of trim zero setting would, on balance, be spotted while doing the pre-flight. It is probably worth mentioning here that during the pre flight 'walk around' (external checks); checking the physical position of all trim tabs, against witness marks is a written requirement, this to check the veracity of external position indication against the cockpit indicators.. Even so – in my B200 book, the Before Take Off check list also focuses the pilots attention on 'flight controls' and Trim. The elevator control wheel is a large round item, next to the pilots right knee; the rudder trim is directly within the sight line, below and just slightly to the right – can't miss it. But even then, the check list goes on to itemise 'Trim Tabs'. Even to the lay mind, it must by now becoming obvious that any pilot would have a hard time 'missing' a gross miss set of an essential, potentially lethal mandatory check list item.

ATSB report categorically states that there was a gross rudder trim setting error and cite this as the fundamental cause of the event....

For a moment consider the percentage chances of that statement actually being correct. The questions which demand answer have not been examined. The big one is “Why'. With 'how' running a close second. While you consider this, please remember back to flying lesson number one; from that point onwards; for any aircraft flown, the setting of 'trim' and throttle friction has been an essential element; drummed in hard and often. It becomes a deeply ingrained habit, a good one, most essential to not only efficient, safe, comfortable operations, but an imperative during any 'emergency/ abnormal' procedure. Almost a reflex action to any disciplined pilot who has progressed beyond first solo. While on the subject, put your hand up if you have ever forgotten to reset after landing and taken off again shortly thereafter – think back to the speed you where doing on the runway, when the Penny dropped – well below rotate speed perhaps? Anyone with more than a handful of hours in the B200 would pick up a gross rudder out of trim condition at about  40 knots and have it corrected before 50 knots, half a turn is all it needs – remember the rudder of the B200 is a powerful force – it needs to be for OEI operation.

So, this all comes back to the pilot on the day. Was he distracted – did the phone ring; or was there an urgent call from nature during the pre flight interrupting the check list half way through checking the set of the trims? Has ATSB defined why multiple opportunities to note an out of trim condition were not taken; interruption/distraction as a possibility, or was it something else? Like perhaps the trim was set correctly pre flight and impact forces drove the indicator to 'full' deflection. That is a higher percentage chance than an cognisant pilot 'missing' the check. Was the pilot actually 'fit for duty' that day? We still don't know in detail. There is a wide range of 'medical' possibilities, both physical and psychological existing within the ambit of reasonable, reasoned consideration. Should these elements have been exhaustively eliminated as part of the ATSB investigation and presented to the Coroner?

Only my opinion; but one shared by many, those that believe the ATSB investigation into this event needs to be re-examined in detail. It ain't 'wrong' but it seems 'off' somehow. There are several items which raise elements of reasonable doubt to the the interested, experienced reader. The eye-brow raising begins with the mad dash to the crash site by the the then director Hood, he arrived before the smoke and dust cleared – unusual to say the least – the risk of scene contamination just for a start.  Then the adamant pronouncement that the rudder bias set full left was 'the' sole cause; wrong? – No – but way 'off' for a lay down misere. This followed by the bizarre pronouncement that the DFO building was indeed a safety item, of benefit to the travelling public even. For (according to Hood) had the aircraft hit the freeway then the carnage would have been greater – WTD !? Had the event occurred just a little later in the day and hit the building 20 feet lower the carnage would have been horrendous. Definitely 'Off' – a safe bet there.. The whole investigation seems to have been 'cack-handed' particularly when compared to the British and American examinations of 'similar' events. Then there is all the fuss about the timing of the report, the delays, the obfuscation about the DFO approvals and endless 'legal' speculation on runway width safety zone impingement. When you listen to Senator's questions in Estimates, one of the glaring sleight of hand answers confounds the Questioner; but not industry experts. The questions surrounded the mandatory 'safety zones' required each side of operational instrument runways. The 'Splay'. The glib, answers easily brought the Senators to a point where, for lack of wider knowledge, they were fobbed off with take off and landing vertical 'margins' – i.e straight ahead, but the requirements for mandated 'width' of 'safety zones' was neatly avoided. There is a case to answer right there, make no mistake about it..

Nearly there; last, but by no means least we must consider the pilot. There are three items of note which seem to have been 'eliminated' from the ATSB investigation. Both Coroner and legal Eagles would be well served by requesting and requiring some 'medical' opinion; even if just to eliminate these elements 'from our enquiry' - so to speak.

At least two independent physiological and psychiatric opinions must be provided for consideration. (If it was my call, I'd have the autopsy revisited to boot). I make this remark after conferring with over twenty experienced Check pilots, Chief pilots and highly experience flight crew. I have also canvassed to subject with two highly qualified medical men and one very astute medical lady. All considered it important (given the events on the day) that a full history across the medical disciplines would be beneficial to inquiry; beginning at least two years prior to the incident at Mt Hotham. For it was that day which should have rang a lot of large bells, very loudly.

Revisit the Mt Hotham event. In the beginning was the proposed charter operation to Mt. Hotham; quite complex involving several aircraft arriving within a given time frame at a non controlled aerodrome, within a given set of arrival times. Routine, just another day in a charter pilot's life. The events at Hotham were, to say the least, very concerning from an operational standpoint. It is reasonable to say that most Chief pilots would have grounded the pilot immediately after landing. While the list of 'errors' is troublesome; the reasons for persisting with the flight path flown that day are alarming. Disoriented and quite probably 'lost' with traffic overhead and below, in cloud, over mountainous terrain; 99.9% of professional pilots would have climbed to a lowest safe height, gone a distance away (clear air), let the holding aircraft land, take time to compose both heart and mind and returned to execute the approach as specified. Quartermain persisted in what I consider a very dangerous exercise, endangering not only his own command, but other aircraft and the passengers within. That, stand alone demands serious attention and considered expert opinion on residual mind state at the time of the DFO event. Then there is the physical condition of the pilot to consider – medication, reason for same, side effects, fitness to fly, etc.

Then consider the Essendon take off and subsequent collision with a building that should never have been placed where it is. Was the building 'complicit' or at least a contributing factor to the deaths? Perhaps there was a fighting chance for the pilot to recover the aircraft, given a little more clear air within the boundaries of the runway as they were before 'manipulation' shifted to odds.

Lets look at the aircraft track from zero to collision and consider the actions of the pilot from the 'cleared for take off' – to the full stop on the roof of the DFO. Consider the time line. Start the clock:-

“Cleared for take off etc..

Ok – here we go, hand on BOTH power levers – power increasing – all good 40 knots and “bugger me” we are off the centre line; now count ::100, two hundred; three hundred – most pilots would have by the end of that count, checked the whole flight system; engines reading correctly; trims set (Uh-Oh) lots of right leg required (50 Kts) rudder trim out (reset) 60 Kts back on centreline – no bells and whistles – V1, Vr and off we go to Golf.

So why was one of three reasonable options not actioned? 1 – Abort – power off, brakes on, exit runway return to base. 2 – Engine not performing; abort. Repeat the above. 3- Left rudder trim hard over – reset and continue perhaps. But no; just an increasing loss of control and multiple Mayday calls from airborne, right until the bang at the end of the short journey.

Did all the holes in that famous slice of cheese line up? Technically, they did. But to me, it seems the 'official' knitting became unravelled long before the final stanza was played. Humans are fragile creatures, was this pilot subject to things beyond his control or knowledge; did a flash back to Hotham freeze his reasoning faculties? Did he have a 'brain bleed' '? Was his medication (if any) in some way connected; could he have recovered if not for the DFO obstacle?. We just don't know; but one thing is absolutely damned certain. There has been a hanger full more money, time and effort spent in an attempt to deny that the DFO was, in any way, shape or form, parked in the wrong spot than poor old Quartermain has had lavished on defining exactly what went wrong that day and why. A lesson denied? A report as left hand biased as the alleged rudder trim was? Some folks died that day; it could have been worse, a whole world worse and yet the DFO still stands, all legal and correct they say; I wonder....

Ayup...Add it all together and ask was there a clearly defined pathway to the inevitable future incident or accident. I just don't know; but had I been his Chief pilot it would be a long, long while after Hotham before I turned him loose, unaccompanied. Even then, before that he'd have to get through the Devil's own check ride after medical evaluation (mind and body). It is a wonder CASA let it all slide away as easily as it did; just another small wonder of the many.

Now the Brits lost a B200 at Blackebush; the flight path, time frame and result equal to our homegrown version. The Brits nailed it; tick, correct answer. Australia's ATSB grabbed the first straw on offer indicating 'pilot error' and neatly, but elegantly shot themselves in the nether regions (their arse for the unlettered).

My venerable, ancient Pelican (Grumble to us) came up with a ripper suggestion;  verbatim I do quote it.  “What if Old mate shoved on the coals and then spotted the misaligned rudder trim; took his paw off the taps to adjust that and the throttle drifted back – brain fade – Hotham flash back – brain crash - May day – no valid escape route or remedial action due to lack of cognitive action”. Not too bad a notion is it. Then there's P7's question - “was the rudder trim hard over setting created by the impact forces, it is only a mechanical link system, a good wallop in the right place could have forced mechanical linkages in that direction”. We just don't know; but the Brits report made 'good sense' – the American reports are credible – the ATSB version; not so much. Perhaps the ever increasing lack of operational credibility (see Pel Air, MH 370 and Angel Flight) has influenced that notion; perhaps; but whatever is influencing ATSB reporting on fatal accident needs to be gone; tout de suite – and the tooter the sweeter, in our most humble opinion.

End of opinion piece – I shall now return my thumbnail to the tar pot. But I say ATSB has become a thoroughly dysfunctional outfit. No longer fit for any purpose bar providing top cover and credible deniability for those very, very few who need it. Like those who know the DFO needs to be demolished but dare not acknowledge it – lest the rice bowls are taken away.

That's it.

Toot – toot.

Okay then, to the dots-n-dashes...  

To begin it is hard not to draw the conclusion, that the former Hooded Canary led ATSB, had drawn a conclusion/hypothesis that strongly supported the degraded performance of the pilot and his possible normalised deviance of not adhering to B200 preflight and pre-takeoff checklist procedure: ref - https://theconversation.com/lessons-lear...sts-103834 & Mr Hood said the pilot had five opportunities to pick up the error that led to the crash. 

 

However let us rewind to the day after the tragic DFO accident, with reference to this Age article:
https://www.theage.com.au/national/victo...uif2a.html

"With any accident, particularly aviation accidents, we find that initially there are several factors that leap out at you," Mr Hood told reporters on Wednesday.

"The investigators are trained not to put any bias on what is the obvious.

"So whilst in the initial walk-through [on Tuesday], the initial examination of records, we have discovered some interesting facets, we really need to gather all the evidence and conduct the analysis before we can say what caused the accident..

..Fairfax Media revealed Mr Quartermain was the subject of a long-delayed ATSB investigation over a safety incident while flying a similar model of plane in 2015.

Mr Hood said he was unaware of the pilot's previous history, and refused to answer questions about why the investigation has not yet been completed, nor whether Mr Quartermain, 63, was safe to fly."

Now ffwd 17 months to the release of the final report (which for such a high profile, complex systemic investigation must be close to an ATSB record for completion?), where the Essendon Fields airport operator put out this statement (my bold):

ESSENDON FIELDS STATEMENT – FINAL ATSB REPORT

SEPTEMBER 24, 2018|IN AIRPORT|BY ESSENDON FIELDS

Essendon Fields Airport today welcomed the release of the final ATSB report into the tragic events on 21 February 2017 which resulted in the deaths of five people.

The release of this final ATSB report is important to help ensure some closure for the widows of the victims both in the United States and Australia and the thoughts and best wishes of everyone at Essendon Fields are always with those families.

The ATSB investigation has confirmed in great detail the circumstances relevant to the events of that day. The report’s finding outlines clear contributing factors to this accident and additional factors that increased the risk of what happened in February 2017. The report provides several strong safety messages relevant for the entire aviation industry.

The significant public interest into the circumstances of this tragedy will ensure the learnings from this report will strengthen the already impressive safety record for the entire aviation industry in Australia. Safety remains the first priority at Essendon Fields at all times.

The final ATSB report makes it clear the operation or conditions at Essendon Fields Airport played no role in this terrible crash.

The report confirms that the presence of the DFO building struck by the aircraft did not increase the severity or the consequences of this accident. This building is not subject to further investigation.

The ATSB is conducting a separate investigation into the approval process of two other buildings at Essendon Fields DFO. We note those buildings were approved by CASA prior to construction. Those two buildings did not contribute to this accident.

Essendon Fields Airport looks forward to the release of the report into the building approval process and will continue to work co-operatively with the ATSB on this investigation. Until then it is not appropriate to comment further on this matter.

Chris Cowan, CEO

   
  
Hmm...so did they get the conclusion that they (desperately) wanted ie pilot error?? - 

Now ffwd again (with the DFO approval process investigation then in it's 3rd year) to this Oz article:

Pilot’s ‘tendency to confuse instruments’ to be raised in inquest

FRANCES VINALL

6:57PM MAY 28, 2021

A pilot who crashed a light aircraft into a shopping complex may have had a tendency to get instruments confused and “an overall lack of situational awareness when operating aircraft”, a court has heard.

A Coroners Court of Victoria inquest will investigate the circumstances that led to a plane crashing into DFO Essendon in 2017, bursting into flames and killing all five people on board.

A pre-inquest hearing on Friday heard pilot Max Quartermain may have either failed to notice a key problem with the plane’s rudder trim position or accidentally set the position wrong himself.

Counsel assisting the court Liam Magowan said of Mr Quartermain: “There is some suggestion in the evidence that Mr Quartermain did not always undertake the mandatory flight checks and that appropriate systems may not have been in place”.

“There is some suggestion in the evidence that Mr Quartermain had demonstrated a tendency to confuse instruments,” he added.

“By this I mean, an intention to operate one instrument, but mistakenly operating another.”

The B200 Super King aircraft was supposed to fly that morning from Essendon Airport to King Island, off the coast of Tasmania.

On board were American tourists Greg De Haven, Glenn Garland, Russell Munsch and John Washburn.

On February 21, 2017, the plane prepared for takeoff just before 9am with instructions to turn to the right.

Instead, “witnesses familiar with the aircraft type noticed a noticeable yaw to the left”, Mr Magowan said.

It reached 160 feet while tracking an arc to the left and was only in the air for 10 seconds before it began to descend.

The pilot frantically transmitted seven “mayday” signals over the Essendon Tower radio frequency.

Two seconds later, it collided with the roof of the shopping centre building and crashed into a loading area, bursting into flames.

The Australian Transport Safety Bureau found: “The primary physical cause of the accident was that the aircraft’s rudder trim was likely in full nose left position at the commencement of the takeoff”.

“How the rudder came to be in that position is likely to be, broadly, the issue of this inquest,” Mr Magowan said.

“There may be issues as to Mr Quartermain’s practice in relation to compliance with civil aviation regulations.”

The inquest may also examine if it was a good idea to have a retail outlet centre so close to Essendon Airport.

“The retail outlet centre is located, in effect, at the end of (a) runway,” he said.

The inquest is slated to run in September.

Finally to add some dots on the "K" post (quoted above), here is the photo depiction of the rudder trim: 


It can be seen that from full left to full right it is approximately a 160 degree turn and to neutral approximately a 80 degree turn. From experience, for an averagely skilled pilot, it is a relative basic action to reset to neutral within 3-5 seconds. and with a pilot familiar with B200 it is a natural action when conducting OEI asymmetrics and indeed through the phases of normal flight ie T/O, climb, cruise, descent and landing.

Next the loose power lever friction nut, this is what was said in AO-2017-024 FR:

Power lever roll back (creep)

Throughout the investigation, the ATSB spoke with numerous B200 pilots who highlighted the importance of ensuring power lever frictions were adequately tightened prior to take-off. In their experience, if inadequate power lever friction was set, the power levers could ‘creep’ back from the full-power position when the pilot removed their hand from the levers after take-off.

If power lever movement is not noticed, the aircraft may not climb and accelerate normally, and rudder force may be required to keep the aircraft straight. In addition, the auto-feather system will be disarmed if either power lever moves back past the ‘90% engine’ speed position (refer to section titled Autofeather system below).

Now refer back to the very similar UK AAIB B200 fatal accident - HERE

TBC...P2