Closing the safety loop - Coroners, ATSB & CASA
#39

(12-05-2016, 09:34 PM)Peetwo Wrote:  The Ghosts of Canley Vale revisited -  Angel
(08-15-2015, 02:37 PM)Peetwo Wrote:  
(08-15-2015, 11:29 AM)crankybastards Wrote:  Channel 9 News, which ran the story in Sydney last night may be interested in a follow up if they had documents to the effect above.

Every time a fatal accident happens CASA must be implicated either in neglect of oversight, incompetence or maintaining a mischief. It's not good enough to let The "Department of Funny Handshakes" gain traction for the impetus of their "New World Order". A new World where aviation is non existent except for the Illuminati.

CASA must suffer the harangue of thousands shouting "I TOLD YOU SO", I TOLD YOU SO.

cranky for your benefit, & others interested, here is a further "K" comment from a post off "Overdue & Obfuscated" relevant to the Canley Vale tragedy and the subsequent ATSB/CASA cover-up after the fact: O&O #post1

Quote:K" -comment - The words Canley Vale, Andy Wilson, Cathy Sheppard or VH-PGW will mean little to many outside Australia.   Norfolk Island and VH-NGA may mean something as that was a widely carried story.  The focus of interest lays in the fact that neither of these accidents seem to have been reported to ICAO as per the book.
 

I find the similarities and parallels between the two 'missing' report intriguing.  We know that the ATSB system for reporting is spot on, the TSBC tell us so.  Whoever is ultimately responsible for the despatch of those reports clearly has a bullet proof system and clearly uses it, as every other report transmission has been made in a timely, proper manner; which begs the question.  How did these two heavily criticised, highly suspect reports slip through the robust ATSB system net.  It's probably just a coincidence that the same crew managed and edited both final reports, funny how things like that just happen.  Must be one of them there 'aberrations'.   

No doubt the word weasels are hard at, developing 'credible' excuses, I expect some wretched clerical type will get moved, an apology issued and all will be bright and rosy, once again in the DoIT garden.  Terrific.

Also for the benefit of readers here is a link for a PAIN supplementary submission to the Senate PelAir cover-up inquiry - PGW Canley Vale pdf.

It is also worth noting that the ATSB also white-washed, subverted, obfuscated the records that they presented as all investigative material to the Canadian Transport Safety Board - Independent review of the Australian Transport Safety Bureau's investigation methodologies and processes.

I note off the UP that the tragedy & travesty of the unresolved, definitely obfuscated VH-PGW fatal accident at Canley Vale has once again resurfaced... Undecided

For the record Confused :
Quote:Lumps

Turbocharger failure and the incorrect engine shut down? Wouldn't be the first mishandled turbocharger failure in PA31s, and would explain a few things...

How come the ATSB were forced to revisit their wonky Whyalla report yet PGWs report is still in its original ignorant and incurious form?

Old Akro

The ATSB report was a crock. One of my favourite failings of the report was that they changed the radio transcript between the draft and final report. Another is that they used groundspeed (from radar returns) plus the forecast wind to estimate airspeed. But, they used made the same adjustment both flying away from Bankstown and returning to Bankstown. I forget the wind direction, but they (for example) gave it a headwind in both directions. Then they used this flawed arithmetic to criticise the pilots airspeed control!!

Its not at all clear that the pilot shut down the wrong engine. The engine he left operating was still operating, but failed to allow the aircraft to maintain altitude. It was never investigated whether the operating engine was capable of producing full power.

A factor that was never highlighted in the report is that the pilot complied with ATC descent requests. These descent requests were the standard profile that ATC use for its own convenience to descent IFR aircraft below the Sydney steps. So, the pilot did not find out that the aircraft would not maintain altitude until it was too late and his fate was sealed. For me a massive lesson is that ATC are not necessarily going to have your best interests at heart in an emergency. If the pilot had refused to comply with the ATC descent requests and maintained altitude, there would have been a happier outcome.


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Lead Balloon

I'm appalled to note that I'm unsurprised to note another ATSB 'report' that is a mixture of fiction and inept bungling.

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Lumps

Originally Posted by LeiYingLo 
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Quote:Which is what any competent twin pilot knows to do and would've done in the first place
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Simplistic answer that doesn't help.

Akro et al, Furious agreement gents, but I didn't mean to revive this thread for repetition.

Even with the ATC descents it should have maintained height at 2500ft on one... unless the one that was going was only putting out a bit over 200hp in its naturally aspirated form

- in the tests following the accident was the scenario and performance of one engine shut down and one operating without turbocharger evaluated?

- with this in mind was the turbocharging system on the 'good' or operating engine really closely examined? Or was it assumed that the bad engine was the one that the pilot shut down, and this was the one that got most attention? (perhaps the ATSB investigators are time poor and are under some form of pressure to get results under time constraints, leading to unconscious bias or assumptions that suit their own situation, so to speak)

- maybe it all was done by ATSB, but in reports of yesteryear a hypothesis would be proposed and the proven or disproven with the available evidence (or insufficient evidence, which no doubt is what happened here, but at least mention that in its relation to the hypothesis!)

- for those of us that want to know, I'd argue all of us that have lives invested in aviation, what is the avenue to get reports re-examined?

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Old Akro

Quote:
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Quote:Which is what any competent twin pilot knows to do and would've done in the first place.
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The pilot was young. He was under great stress. He received what was essentially was an instruction from ATC. He needed to descend anyway. I don't condemn him for complying or blindly trusting that the instruction was in his best interests rather than traffic management expediency.

The issue is that the ATSB have a massive blind spot about this and other issues which firstly, denies the ability to understand the truth of the situation and secondly to learn from the experience.

It was a scandalously shabby report.
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Adamastor

The first transmission from ATC to the pilot was maintain 5000’ which the pilot accepted but then either chose not, or was unable, to do. They descended below that assigned level and were then issued further descent.

ATC then specifically asked the pilot whether they were capable of maintaining altitude and advised that if they were unable, that YSRI aerodrome was 2nm away. They got another non-committal response, the aircraft overflew YSRI, and the rest is tragic history.

Your assertion that a controller would deliberately put an IFER (in-flight emergency response) aircraft in increased danger because it suited their airspace layout or traffic management is disgusting.

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thorn bird

Adamaster,
is your assertion the pilot should have landed at YSRI? I passed over RIC shortly after the event. The runway was obscured by Fog.

There is nothing in the ATSB report about organisational, operational and bullying issues with the operators chief pilot, reported to CASA but ignored.

I have experienced an engine failure in the type aircraft and had no problem maintaining height for a considerable distance, over 60 NM.

Listen to the voice of the young pilot on the tapes, he is cool, calm, in control and endeavouring to find solutions to his problem, he flew his aircraft under control to the very end.

I knew this young man very well, he was well trained and very well aware of the limitations of the aircraft he was flying.

You arm chair experts are quick with your condemnation, but you were not there on the day, nor is there anyway to establish what actually occurred.

Suffice it to say, any SAFETY issues that may have been learnt went out the window to protect a vindictive incompetent regulator.

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Adamastor

Thorn_bird, I can see that this was a difficult accident to deal with for both of us.

Quote:
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Quote:Is your assertion the pilot should have landed at YSRI?
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No, it is not.

Quote:
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Quote:There is nothing in the ATSB report about organisational, operational and bullying issues with the operators chief pilot, reported to CASA but ignored.
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Agreed.

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Quote:I knew this young man very well, he was well trained…
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I knew him too. It was a tragic loss, and yes, it is still raw.

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Quote:You arm chair experts are quick with your condemnation…
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The only person I was attempting to ‘condemn’ was Old Akro for stating that the ATC deliberately placed a stricken aircraft in further harm’s way for something as trivial as airspace layout or ‘traffic management expediency’. Attempting to lay blame after a tragedy is a natural response, but that was uncalled for and simply not true.

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Quote:Suffice it to say, any SAFETY issues that may have been learnt went out the window to protect a vindictive incompetent regulator.
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I learnt plenty from this one (and would gladly give it all back in a heartbeat), but I agree that other valuable lessons were lost in the haze. Safe flying.[/url][/url][/url][/url][/url]
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Messages In This Thread
Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 08-14-2015, 07:49 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Kharon - 08-15-2015, 05:59 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by crankybastards - 08-15-2015, 11:29 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 08-15-2015, 02:37 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Kharon - 08-16-2015, 06:31 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Gobbledock - 08-16-2015, 07:51 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 08-25-2015, 09:32 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Sandy Reith - 08-26-2015, 03:53 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 08-27-2015, 02:42 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Kharon - 08-28-2015, 06:30 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 09-01-2015, 05:45 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 12-01-2015, 02:55 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 12-04-2015, 11:32 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 12-04-2015, 06:04 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Gobbledock - 12-04-2015, 02:40 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Kharon - 01-26-2016, 12:36 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 01-27-2016, 07:21 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Kharon - 02-05-2016, 06:34 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 02-15-2016, 06:34 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by P1_aka_P1 - 02-16-2016, 05:27 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Kharon - 02-22-2016, 05:27 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Ziggy - 02-24-2016, 12:04 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by P7_TOM - 02-22-2016, 02:16 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Choppagirl - 02-12-2019, 04:04 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Kharon - 02-27-2016, 04:24 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Gobbledock - 03-14-2016, 08:17 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 03-28-2016, 09:26 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Gobbledock - 03-28-2016, 10:51 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 04-06-2016, 08:46 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by P7_TOM - 04-13-2016, 07:07 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 07-27-2016, 08:36 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 08-05-2016, 11:31 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by ventus45 - 08-05-2016, 12:04 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Gobbledock - 08-05-2016, 08:09 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 08-16-2016, 08:46 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 09-02-2016, 09:05 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 11-02-2016, 07:06 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Gobbledock - 11-02-2016, 07:16 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 12-05-2016, 09:34 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 12-20-2016, 07:17 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 03-18-2017, 08:17 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 01-20-2018, 08:00 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 06-23-2018, 09:05 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 07-04-2018, 10:51 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 07-06-2018, 09:10 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 10-04-2018, 08:55 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Kharon - 04-17-2019, 08:09 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 05-10-2019, 11:31 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 06-20-2019, 10:23 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 07-22-2021, 10:09 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 09-22-2021, 11:49 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Cap'n Wannabe - 09-22-2021, 06:34 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by thorn bird - 09-25-2021, 08:44 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 12-19-2021, 09:57 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 03-08-2022, 10:05 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 07-01-2022, 08:44 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Sandy Reith - 07-02-2022, 01:16 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Kharon - 07-02-2022, 07:40 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Wombat - 07-02-2022, 08:49 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 08-26-2022, 04:57 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by P7_TOM - 08-28-2022, 07:00 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 09-01-2022, 11:50 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 10-21-2022, 10:23 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 10-22-2022, 09:14 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 10-29-2022, 10:05 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Kharon - 10-30-2022, 07:14 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 12-19-2022, 09:33 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 03-02-2023, 07:22 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 03-24-2023, 05:52 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 05-13-2023, 10:35 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Kharon - 05-27-2023, 05:53 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 06-11-2023, 10:58 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 10-31-2023, 08:11 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 11-01-2023, 08:22 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 11-02-2023, 06:16 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 11-04-2023, 04:51 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by ventus45 - 11-04-2023, 05:33 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 11-09-2023, 08:28 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Kharon - 01-23-2024, 07:14 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Kharon - 01-30-2024, 11:16 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 03-18-2024, 05:00 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 03-28-2024, 08:13 AM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Kharon - 03-29-2024, 06:38 PM
RE: Closing the safety loop - Coroners, ATSB & CASA - by Peetwo - 10-31-2024, 07:07 PM



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