[Peetwo]

Closing the VFR into IMC safety loop - Live killer still lurks?? 

In light of the recent spate of GA/Recreational private pilot fatal accidents CASA put out the following very sobering Youtube video:

Hitting the timewarp switch I refer you to this post from "K" in April 2020: Fraught with peril – however....

Interesting, that on this same page, this pic featured...



Which brings me to a different but related safety loop, Clinton McKenzie produced this lengthy but (IMO) essential reading post on the UP:

ADS-B IN – A different perspective on the recent hype

My attention was recently drawn to a rather curious post by the ATSB on LinkedIn, about the ASD-B rebate. The post says:

We’re joining with the Australian Maritime Safety Authority in encouraging general and recreational aircraft owners to take advantage of the government’s Automatic Dependent Surveillance Broadcast (ADS-B) rebate program before it closes on 31 May next year.

- the STCA was designed as an alert for a breakdown in separation standards

- there was no set separation standard in non-controlled airspace

- the pilots were responsible for their own separation

they decided that a safety alert or traffic avoidance advice was not required, and cleared the aural alert.

The equipment on the two IFR aircraft generated what the air navigation service system construed as “nuisance” alerts – “an alert which is correctly generated according to the defined STCA system parameters (rule set), but is considered operationally inappropriate by the controller” - discussed further in the ATSB report. Many people were – and remain – astonished and appalled at that outcome.

Many of those alerts would not be construed as “nuisances” and dismissed as such if they occurred in airspace with separation standards. But changing the airspace arrangements around places like Mangalore and Ballina and… would create “nuisances” of a different kind: The airspace regulator would have to make those changes and the air navigation service provider have to employ more controllers.

Problem: What to do to shift the focus away from inadequate air navigation services and airspace arrangements, so as not to upset that status quo, while doing something that seems to address the risk of another IFR/IFR mid-air collision?

Solution: Encourage everyone to get ADS-B IN.

That way, Airservices is under less pressure to provide better or more services, ATSB continues to get all the data to help explain, in three dimensional graphic detail, the track to the smoking hole and AMSA continues to get all the data to better “affect” - I think the correct word in the context of ATSB’s statement is “effect” - a rescue if anyone survives. Meanwhile, the aviation safety and airspace regulator – CASA keeps its lips pursed and avoids eye contact. A new cockpit gizmo, subsidised by someone else, is an excellent solution for all the agencies concerned. Pats on the back all round!

VFR pilots should make no mistake: Our biggest risk - aside from inadvertent entry into IMC or fuel exhaustion or starvation - arises from being ‘heads down’ in the cockpit rather than keeping a proper lookout. There are of course visibility limitations created by airframe structures of every aircraft and the relative locations of other aircraft in flight. But it’s certain a pilot’s not going to see anything anywhere outside the aircraft while ever the pilot’s focusing on a gizmo in the cockpit and making the assumption it’s a source of traffic truth.

Assumptions about the absence of conflicting returns on a ADS-B IN system display and silence on the radio can lead to a dangerous false sense of safety. Just as there are plenty of explanations for silence on the radio, only one of which is the absence of other aircraft in the vicinity, there are plenty of explanations for no ADS-B IN system returns, or inaccurate information, on an ADS-B IN display. (Most of the traffic based at my local aerodrome involves aircraft that have no ADS or SSR transponder - at least none that’s switched on - whose pilots are best described as ‘taciturn’.)

There are plenty of examples of VFR pilots seeing an ADS-B IN return on their EFB and using that information to see and avoid - or mutually arrange separation from - another aircraft. And there are plenty of examples of IFR aircraft seeing VFR ADS information and doing the same. And that’s a great outcome. But those pilots don’t know what traffic wasn’t displayed accurately or at all in their cockpits at the time. There is no guarantee that all traffic in the vicinity will ever be displayed by ADS-B IN systems. And as with any other aircraft system, you have to know what the specific ADS-B IN system you’re using can do, how to get it to do what it can do and how to confirm it's actually doing what you assume and hope it’s doing, and that means understanding the system’s failure modes.

For all those reasons and more, I consider this to be an overstatement by ATSB:

To support its investigation into the [Mangalore] mid-air collision, the ATSB initiated an aircraft performance and cockpit visibility study to determine when each aircraft may have been visible to the pilots of the other aircraft. The study clearly showed that had the aircraft been equipped with ADS-B IN, the pilots would have been assisted in locating the other aircraft and alerted to its position much earlier than by visual acquisition.

There are lots of “ifs” missing from that sentence and the ATSB’s categorical “would have” conclusion. Both the Otter and Beaver in the Alaska tragedy were equipped with ADS-B IN but that didn’t result in either pilot comprehending the location of the other’s aircraft into which they collided.

The ATSB went on to say:

Both a cockpit display of traffic information with an ADS-B traffic alerting system or an electronic conspicuity device connected to an electronic flight bag application could have provided this advance warning of a potential collision to the pilots of both aircraft with this tragic accident probably being avoided.

Could have. If. Probably. The Beaver in the Alaska tragedy was carrying an EFB with a traffic alerting system. It didn’t work in the case of the Otter because the Otter was, unknown to its pilot and previous pilots, not broadcasting pressure altitude information. The Otter had traffic alerting capability, too. Until it was removed.

The equipment actually fitted to the Mangalore aircraft in compliance with regulatory requirements actually ‘triggered’ Short Term Conflict Alerts in the air navigation service system. Another description of those alerts is “advance warning of a potential collision”. That’s the verypurpose of STCAs. And the pilots of the aircraft probably assumed – reasonably I would suggest, given all of the safety hype around the original ADS-B mandate – that the air navigation service system would pass on those warnings rather than being justified in unilaterally dismissing them. Perhaps the tragic accident would have also been avoided if IFR pilots had clearly understood what a dangerously invalid assumption they were making about what the new ADS-B system was going to do for them.

On the subject of cockpit gizmos, there is one which is very cheap, very reliable, very accurate and almost pilot-proof: A modern carbon monoxide detector.

I mention carbon monoxide detectors because of the NSW Coroner’s Court inquiry and findings in the wake of the tragedy in which seven lives were lost in the Beaver accident at Jerusalem Bay in Sydney in 2017. One of the useful (and disturbing) things a modern CO detector will show you is the high level of CO to which we’re often exposed while just taxiing around on the ground (or water) in ‘ordinary’, serviceable aircraft. It will also help you to work out what to do with vents and windows to reduce the levels of exposure. Many of you will be blissfully unaware of the extent of your on-ground exposure and CASA remains wilfully blind to it, relying instead on reports from LAMES about defects found during maintenance and waiting for more CO exposure-caused fatalities and injuries.

In the course of the Coronial inquiry CASA was asked, in effect, how many more fatalities it would take before CO detectors would be mandated. According the Coroner, the CASA witness “frankly acknowledged”:

To be honest I'd say it would take probably unfortunately a number of accidents, hopefully not fatal, to trigger the risk level to be in the range where regulatory action would be required.

Translation: Affordable safety. CASA has decided that the value of lives potentially saved by mandating CO detection equipment is not sufficient to justify the mandate.

The evidence given by CASA was to the effect that there are approximately 8,365 single piston engine aircraft in operation in Australia and that dash-mounted CO detectors cost about $1,200. (Let’s set aside the fact that there are much cheaper options that are just as reliable and accurate, and include aural and visual alerts, as some panel mounted versions – remember how long it took to get rid of the fixed ELT mandate and how long it took for EFBs to be accepted by the regulator?) On CASA’s figures that’s about $10,000,000 to fit the single piston engine fleet. So, that means CASA reckons it’s not worthwhile spending $10,000,000 on CO detectors until the further body count makes it worthwhile.

In contrast, to justify CASA’s regulatory response in the wake of the Angel Flight tragedies involving a total of six fatalities (one near Nhill in 2011 the other near Mt Gambier in 2017), Dr Aleck of CASA said:

Our objective here is not to specifically address what caused those two accidents; it's to address what kinds of things can cause incidents and accidents of this kind. We're being prospective. If we were to wait for sufficiently robust data to support an evidence-based decision for every individual decision we took in this space, we would have to wait for a dozen or more accidents to occur.

When asked by the Angel Flight CEO as to why CASA had chosen to by-pass the usual protocols for regulatory change, the then CEO of CASA said:

I have the power; because it’s easy.

Why was CASA “prospective” rather than waiting for more accidents in the Angel Flight case, by-passing the usual regulatory change process, but is waiting for more fatalities and injuries in the case of CO detectors? Answer: The capricious consequences of politics. Pressure was put on CASA by the federal government to be seen to do something in the case of Angel Flight and, sadly for the next victims of CO exposure, the Beaver tragedy barely raised a federal government eyebrow in the direction of CO detectors. That’s probably because of the time it took to work out that CO exposure was a factor in the tragedy.

Get ADS-B IN by all means. But don’t believe all the hype. It’s not a panacea for situational awareness or the intractable inadequacies in air navigation services and airspace arrangements.

Yours in aviation safety.

A bag of choccy frogs for that one CM...

MTF...P2