[Peetwo]

Mangalore inquest and Vic Coroner Aviation inquests? - 

Via this week's SBG and the UP:  "..Accident investigation descended into little more than a PR exercise, all to promote Popinjay from his level of incompetence to new heights.."

ER_BN

Advance,

Thank you! If you posted a link (underlined), I could not access it. May be my ongoing and increasing dementia.

However the coroner’s office has been very helpful and I believe there is a weblink available for people not able to attend in person. One can watch it just like Senate Estimates, not that I’ll be using it and it does raise some issues…

I’ve been assured the inquest is open to the general public, not that I have a “seat” at the table, it will be a case of quiet observation whilst there and reflection after each day.

Just like Global Warming, I am not optimistic about this inquest but I still have hope, if only for the relatives of the four pilots and also for the air traffic controller. My analysis would indicate those desires are not mutually exclusive…

I expect that hope to be extinguished after the inquest. I expect it to be another VH-TNP / Benalla.

The ATSB report in my opinion is full of omissions and misinformation. I am not suggesting a conspiracy, merely (like a lot of things in Australia) severely flawed by a combination of seeming incompetence, mediocrity and self interest. I cannot see any other reason for the strange content and simplistic conclusions.

The only good news is that the inquest has been given the varsity i.e. Justice John Cain, the Chief Coroner of Victoria.

However, if the right witnesses aren’t called and the right questions aren’t asked coupled with accurate physical evidence; it doesn’t matter how good the intentions are “…the road to hell is paved….” etc.

As far as I’m concerned were FS still in place the accident would not have happened. That in itself is a sad indictment of the “advancement” of policy in regard to aviation safety specifically to airspace in Australia below 10,000 ft since the early 1990s. Technology and surveillance are not always “an advancement” especially in the transition from humans to automation.

I am not sure having a front row seat was a good idea and was in fact really just a “poisoned” chalice.

Sigh!

With a quick search across the Vic Coroner website, I was able to find the following for next week's scheduled inquest hearings: https://coronerscourt.vic.gov.au/inquest...t-hearings

Name Mangalore Aircraft Accident

10:00am
Location Southbank Court 1
65 Kavanagh Street, Southbank VIC 3006
Ph : 1300 309 519
Fax : 1300 546 989
Court reference number COR 2020 0950, COR 2020 0971, COR 2020 0951 & COR 2020 0976
Coroner State Coroner Judge John Cain
Case Type Inquest

(Listed for Monday 25th through to Thursday 28th)

While trolling the Vic Coroner website, I came across the Coroner's inquest findings for other Aviation accidents, including one, that took me completely by surprise, listed as the 'Essendon Plane Accident'??

Ref: https://coronerscourt.vic.gov.au/sites/d...cident.pdf

This report was apparently delivered on the 30 September 2022. Whether or not it was publicly available from that date - who knows? I certainly can't recall there being any MSM press coverage in regards the findings?

One thing that is obvious from reading the report, is that the splintering off of the bollocks Essendon DFO Approval Process investigation, with the final report being published 30 June 2023, was a Hood masterstroke as there was not one reference to the DFO building as being a factor causal to the accident. JOB DONE - the PILOT DONE IT! 

For further proof of the pilot being completely stitched up, with CASA being a perfect model litigant and a responsible (but not liable) Federal government safety regulator see - HERE - for the legal WWC (Weasel worded confection) in reply to the CASA addressed Coroner recommendations..    

There is also an interesting (same theme -   ) CASA LSD reply for the recommendations that came from the 'Barwon Heads Accident': https://coronerscourt.vic.gov.au/sites/d...LINN_1.pdf

Dear Registrar,

Investigation into the deaths of Donald Hateley, Ian Chamberlain, Dianne Bradley and
Daniel Flinn - Barwon Heads Aircraft Crash

We refer to Coroner Jamieson’s findings dated 11 February 2020 and the two
recommendations directed to the attention of the Civil Aviation Safety Authority (CASA).

At the outset, CASA sincerely apologises for the delay in responding to the recommendations
which occurred due to an administrative oversight.

In respect of the two recommendations, the following responses are provided:

Recommendation 1 – that CASA mandate the use of SARTIME for all Visual Flight Rules
flights over water

1. Upon reviewing the Coroner’s findings, we note that CASA already has requirements
in place for the nomination of a search and rescue time (SARTIME) for visual flight
rules (VFR) flights over water.

2. As noted in the findings (see [123] – [126] of the Background Circumstances and [7]
of the Comments), pilots conducting VFR flights over water are already required to
submit a SARTIME flight notification to Airservices Australia or leave a flight note with
a responsible person. This is by force of regulations 240 and 241 of the Civil Aviation
Regulations 1988 (CAR) and paragraph 1.10 of the Aeronautical Information
Publication (AIP) En Route Supplement Australia.

3. If the focus and intent of the recommendation is that CASA require the use of
SARTIME only and not allow the leaving of a flight note for VFR flights over water,
then CASA confirms that the recommendation will be taken into consideration as part
of the ongoing regulatory development activities referred to further below.

4. Of particular relevance to this recommendation is that, following extensive
development and community consultation over a number of years, new regulations
contained in Part 91 of the Civil Aviation Safety Regulations 1998 (CASR) for the
conduct of flight operations will come into force on 2 December 2021. These
regulations will cover VFR flights over water and flight monitoring rules including
SARTIME requirements. In particular, Division 91.D.3 provides for flight notifications
as follows: (read for the CASR references etc)

Recommendation 2 – that CASA increase IFR training and recency requirements for
PPL candidates and holders, for the purpose of, but not necessarily limited to, further
education for candidates on the fatal dangers of inadvertent entry into IMC

8. At the outset, we draw to attention concerns as to references to instrument flight rules
(IFR) training in relation to private pilot licence (PPL) holders. IFR training is not
mandatory for PPL holders and references of this kind have the potential to confuse.

9. Candidates for and holders of PPLs who operate in Visual Meteorological Conditions
(VMC), being the majority of PPL holders, are not required to complete IFR training
and there is no recency requirement. However, these pilots are required to
demonstrate basic instrument flying competency as a candidate for and ongoing
holder of that licence. The assessable standards are consistent with the international
licensing standards and have been in place for many years.

10. CASA is generally satisfied that the aeronautical knowledge standards and the basic
training for instrument flying, as opposed to specific training for IFR operations, are
currently appropriate. Assessment of basic instrument flying competency is also
included as part of the mandatory biennial flight review standards for PPL holders.

11. Candidates for a PPL are also taught of the serious risks of inadvertent entry into
instrument meteorological conditions (IMC) as part of the aeronautical knowledge
standards and practical flight competencies which they must be able to demonstrate
(including via theoretical and practical examination) prior to the issue of a PPL. These
standards and competencies are set out in the Manual of Standards issued to support
Part 61 of the CASR.

12. In addition, CASA provides many safety education products including seminars and
materials such as the magazine, Flight Safety Australia, which regularly deal with the
topic of inadvertent entry into IMC. For example, a recent article in Flight Safety
Australia titled “Weather to fly” dealt with these issues. This article can be accessed at
Weather to fly . Examples of the kinds of relevant material routinely addressed at
aviation safety seminars can be accessed as “Enhancing pilot skills – expect the
unexpected“.

13. To the extent that the recommendation is targeted at CASA increasing IFR training
and recency requirements, CASA notes that IFR training, by its nature, is designed to
teach the skills necessary for pilots to safely fly by reference to instruments only. It
does not form part of the general PPL syllabus of training as it is an additional skill
and separate rating for flying operations conducted under the IFR. CASA considers
that the training presently provided to PPL pilots around the need to ensure they stay
in VFR conditions is adequate and that more specific IFR training is only necessary
for pilots who wish to operate under the IFR.

14. CASA considers that training for inadvertent entry into IMC is more appropriate for
pilots rated only for VFR conditions. Without appropriate prior training and an aircraft
designed for IFR operations, such pilots are more likely to become spatially
disoriented or unable to safely operate the aircraft in IMC.

15. Therefore, while it does not propose to take any action in relation to this
recommendation at this stage, CASA is proposing a review of the competency
standards and the two-yearly review of proficiency rules (known as a flight review) for
private pilots in the next 18 months. A review of the basic instrument flying standards
and the related non-technical skills and human factors required of PPL holders will be
included in that review.

Please contact the writer should you require further information or should you have any
further enquiries concerning this matter.

Yours sincerely,


Anthony Carter
Special Counsel
Litigation, Investigations
and Enforcement Branch

Ph: (02) 6217 1151
Fax: (02) 6217 1607

Email: anthony.carter@casa.gov.au

Also of interest from the Coroner Findings for Aviation was a response from the Department of Infrastructure, Regional Development and Cities and the Australian Transport Safety Bureau in reply to recommendations issued to the ATSB in the context of a 13 March 2016 double fatal microlight trike accident at Yarrawonga (Note the signatories -  )





(For the combined Vic Coroner Aviation accident reviews and inquest findings listed see - HERE)

MTF...P2