Of ancient Traps, Book learning and 'Automatics'.
The ATSB did not have a great deal to work with in this event – HERE-. Tough job; and the report, while factual (and acceptable) has, for me at least, triggered some deep thinking. From here I intend to 'ramble on' a little, FWIW in hope of making an effort to prevent another, similar event: be it CFIT or weather related or both. I believe there is a small element missing in 'essential' thinking in these modern days. Been wrong before, but it is my Two Bob's worth.
Way back in time I was gifted certain things by Grandfathers, Uncles and my own Papa. Instant love affairs; a Collie puppy from working stock; a Pony from brilliant blood stock; a fishing rod. hand made in split cane and a reel turned by an Uncle; a set of old chisels and a battered wooden hand plane and the big one a BSA Batam powered by a Villiers 98 cc monster. These 'gifts' were never just 'given'. The training of the pup was overseen by a man who loved and understood the breed. The pony came from a 'Master of Hunt' - unbroken, together we learned how to behave. The fishing rod and reel needed to be mastered and the tools demanded hours of training. The motor bike opened up new worlds and, strangely, the rules of 'learning' applied. There's more, but I hope you see the common thread. Each, in their own way, demanded an 'understanding' insight and knowledge. Non of the 'learning' was tick, flick and forget. It showed a way to 'see', to think and 'understand' what it was; of itself, in escence.
Enter the aircraft; Uncle Sam, a Viscount (among other beasts) Captain. Many journeys between boarding school and wherever 'home' was were spent with Sam, even the rough ones; full explanations and running commentary always, even after journey's end. Thus; the die was cast. To me, ground school, flight training and every lesson offered was soaked up like a drunk on a pub crawl. These things mattered and it seemed to me 'important' that I understood as much as possible; as per preconditioning. My first pup won a sheep dog trial; Grandpa smiled and said “ain't you glad you did it properly.” So it is with 'flight'.
Do 'professionals' take risks? No, they do not – BUT (a great big one) ignorance and 'ego' are not in the equation. Often, a decision must be made; to make 'that' decision invokes many conscious and sub-conscious 'lessons'. Experience matters, but 'hours' in the log book don't always reflect the 'deep' lessons, those not learned (or taught). It is a complex process. That said, supporting any 'decision' is 'education' lessons learned and taken into practical application. This is important stuff. It forms a solid base for any future decision made; but now sharpened with actual 'experience' makes for the professional mind of honest personal 'operating' limitations.
End of Ramble: now the latest accident report. -HERE -. Read it and weep. Not too much for the dead; but for those left behind from a completely preventable event which claimed another four lives from the growing pile of 'flight into unsuitable conditions' and the failure to recognise trouble, long before it gains the upper hand. Take look at the picture below; a trap: well set and flawlessly operational. The ATSB did a good job on this one, as best they could, considering all. I have but one question, why? Why continue to climb into icing? One look at the pretty clouds, the temperature, the forecast and the limitations of the aircraft ; Why is a bloody fair question. Let us think now on what the ATSB could not say.
ATSB - “According to the aircraft owner, when either the altitude hold or vertical speed modes were selected, the autopilot would not disengage automatically. Also, when in these modes and the flight controls were manually manipulated, the system would apply trim in the opposite direction to maintain the selected altitude or vertical speed.”
Let's just disregard 'real' autopilots and leave them in out of this equation for a moment. I have no doubt that this model is an excellent tool for cruise legs or even climb and descent in 'fair' weather. But, given the limitations noted, would it not be prudent to hand fly the 'climb' into suspect, icing conditions weather? Cloud like that and the 'mixing' and the hills affecting the wind flow – this is not the time for coffee and letting the AP do the work; it ain't as efficient as a pair of eyes and hands working together, 'feeling' the conditions and those effects to get the maximum out of the air-frame.
ATSB. “The POH indicated that, any failure or malfunction of the electric trim or autopilot could be overridden by manually manipulating the control yoke. Further, if a trim runaway occurred, the pilot was to de-energise the circuit by pulling the circuit breaker (PITCH TRIM, ROLL TRIM, or AUTOPILOT) and land as soon as the conditions permitted.
BUT! Where is the 'alarm? - “Hoi, wooden head, I can't do this”...Nope, not there, not required and should not be needed, a pilot should 'know' when the aircraft is “struggling” and needs guidance and assistance to a 'softer passage'.
ATSB “ a freezing level of 4,000 ft in the south and 7,000 ft in the north [Canberra was centrally located within the south region”.
P7 - The perfect trap shown below.
![[Image: AO-2023-045-Figure%20%288%29.png?itok=HHiyOTxP]](https://www.atsb.gov.au/sites/default/files/styles/wide/public/2025-10/AO-2023-045-Figure%20%288%29.png?itok=HHiyOTxP)
ATSB - “The estimated freezing level of 7,000 ft at Canberra and forecast broken cumulus/stratocumulus from 5,000 ft to 10,00 ft indicated the forecast depth of the icing layer overhead Canberra had increased to 3,000 ft. Figure 6 depicts the NSW-E GAF, current at the time of the pilot’s last NAIPS area briefing request. Information relevant to the flight is labeled and highlighted. This forecast included a freezing level of 9,000 ft for the area containing Scone (area B) and a freezing level of above 10,000 ft for the area containing the destination of Armidale (area A).”
I will leave it there for generalities. Had the pilot actually taken note of the Met lessons (mixing) and the effect of Ice accretion on air-frame performance, and 'understood' the forecast then perhaps, just maybe, remembering the old old rule of icing layers and their 'mixing' perhaps could have opted for a slightly longer, less risky track, burned off an extra $100 in costs and lived to pay the bill. Perhaps understanding the limitations of engine performance with altitude; ice accretion on air frame performance and 'weight' increases then inherent risks associated with buggering about with limited options, low performance aircraft and dynamic weather, they may all be having an Ale and talking about how an 'educated' pilot saw the all safely home; through knowledge, skill and judgment. Or, just by taking a humble, less limiting route for the aircraft.
No apology offered; too many funerals; far too many. Learn what is necessary to survive, not what is required to pass the exam. It matters.
Selah.
The ATSB did not have a great deal to work with in this event – HERE-. Tough job; and the report, while factual (and acceptable) has, for me at least, triggered some deep thinking. From here I intend to 'ramble on' a little, FWIW in hope of making an effort to prevent another, similar event: be it CFIT or weather related or both. I believe there is a small element missing in 'essential' thinking in these modern days. Been wrong before, but it is my Two Bob's worth.
Way back in time I was gifted certain things by Grandfathers, Uncles and my own Papa. Instant love affairs; a Collie puppy from working stock; a Pony from brilliant blood stock; a fishing rod. hand made in split cane and a reel turned by an Uncle; a set of old chisels and a battered wooden hand plane and the big one a BSA Batam powered by a Villiers 98 cc monster. These 'gifts' were never just 'given'. The training of the pup was overseen by a man who loved and understood the breed. The pony came from a 'Master of Hunt' - unbroken, together we learned how to behave. The fishing rod and reel needed to be mastered and the tools demanded hours of training. The motor bike opened up new worlds and, strangely, the rules of 'learning' applied. There's more, but I hope you see the common thread. Each, in their own way, demanded an 'understanding' insight and knowledge. Non of the 'learning' was tick, flick and forget. It showed a way to 'see', to think and 'understand' what it was; of itself, in escence.
Enter the aircraft; Uncle Sam, a Viscount (among other beasts) Captain. Many journeys between boarding school and wherever 'home' was were spent with Sam, even the rough ones; full explanations and running commentary always, even after journey's end. Thus; the die was cast. To me, ground school, flight training and every lesson offered was soaked up like a drunk on a pub crawl. These things mattered and it seemed to me 'important' that I understood as much as possible; as per preconditioning. My first pup won a sheep dog trial; Grandpa smiled and said “ain't you glad you did it properly.” So it is with 'flight'.
Do 'professionals' take risks? No, they do not – BUT (a great big one) ignorance and 'ego' are not in the equation. Often, a decision must be made; to make 'that' decision invokes many conscious and sub-conscious 'lessons'. Experience matters, but 'hours' in the log book don't always reflect the 'deep' lessons, those not learned (or taught). It is a complex process. That said, supporting any 'decision' is 'education' lessons learned and taken into practical application. This is important stuff. It forms a solid base for any future decision made; but now sharpened with actual 'experience' makes for the professional mind of honest personal 'operating' limitations.
End of Ramble: now the latest accident report. -HERE -. Read it and weep. Not too much for the dead; but for those left behind from a completely preventable event which claimed another four lives from the growing pile of 'flight into unsuitable conditions' and the failure to recognise trouble, long before it gains the upper hand. Take look at the picture below; a trap: well set and flawlessly operational. The ATSB did a good job on this one, as best they could, considering all. I have but one question, why? Why continue to climb into icing? One look at the pretty clouds, the temperature, the forecast and the limitations of the aircraft ; Why is a bloody fair question. Let us think now on what the ATSB could not say.
ATSB - “According to the aircraft owner, when either the altitude hold or vertical speed modes were selected, the autopilot would not disengage automatically. Also, when in these modes and the flight controls were manually manipulated, the system would apply trim in the opposite direction to maintain the selected altitude or vertical speed.”
Let's just disregard 'real' autopilots and leave them in out of this equation for a moment. I have no doubt that this model is an excellent tool for cruise legs or even climb and descent in 'fair' weather. But, given the limitations noted, would it not be prudent to hand fly the 'climb' into suspect, icing conditions weather? Cloud like that and the 'mixing' and the hills affecting the wind flow – this is not the time for coffee and letting the AP do the work; it ain't as efficient as a pair of eyes and hands working together, 'feeling' the conditions and those effects to get the maximum out of the air-frame.
ATSB. “The POH indicated that, any failure or malfunction of the electric trim or autopilot could be overridden by manually manipulating the control yoke. Further, if a trim runaway occurred, the pilot was to de-energise the circuit by pulling the circuit breaker (PITCH TRIM, ROLL TRIM, or AUTOPILOT) and land as soon as the conditions permitted.
BUT! Where is the 'alarm? - “Hoi, wooden head, I can't do this”...Nope, not there, not required and should not be needed, a pilot should 'know' when the aircraft is “struggling” and needs guidance and assistance to a 'softer passage'.
ATSB “ a freezing level of 4,000 ft in the south and 7,000 ft in the north [Canberra was centrally located within the south region”.
P7 - The perfect trap shown below.
ATSB - “The estimated freezing level of 7,000 ft at Canberra and forecast broken cumulus/stratocumulus from 5,000 ft to 10,00 ft indicated the forecast depth of the icing layer overhead Canberra had increased to 3,000 ft. Figure 6 depicts the NSW-E GAF, current at the time of the pilot’s last NAIPS area briefing request. Information relevant to the flight is labeled and highlighted. This forecast included a freezing level of 9,000 ft for the area containing Scone (area B) and a freezing level of above 10,000 ft for the area containing the destination of Armidale (area A).”
I will leave it there for generalities. Had the pilot actually taken note of the Met lessons (mixing) and the effect of Ice accretion on air-frame performance, and 'understood' the forecast then perhaps, just maybe, remembering the old old rule of icing layers and their 'mixing' perhaps could have opted for a slightly longer, less risky track, burned off an extra $100 in costs and lived to pay the bill. Perhaps understanding the limitations of engine performance with altitude; ice accretion on air frame performance and 'weight' increases then inherent risks associated with buggering about with limited options, low performance aircraft and dynamic weather, they may all be having an Ale and talking about how an 'educated' pilot saw the all safely home; through knowledge, skill and judgment. Or, just by taking a humble, less limiting route for the aircraft.
No apology offered; too many funerals; far too many. Learn what is necessary to survive, not what is required to pass the exam. It matters.
Selah.