[Peetwo]

..TM raises one of the major items the ATSB hesitates to approach.   Remember who approves/ accepts procedures and checklists.  For students a critical area; who knows,  had the GA been executed as per the manufacturer procedures used during certification the accident would. perhaps, never have occurred.  But I forget, the average CASA FOI knows truck loads more that the manufacturer and their test pilots, sorry my bad...

..Bravo TM, spot on and damn right.   But of course ATSB ain't going to step up to mark and say it is very wrong to teach a homemade, but approved system for a critical flight sequence – the fellah was sick don'tcha know.   Well, that's Avmed back in the spotlight.  

What a cluster of ducks.  

Indeed so here we have another classic ATSB report that when put to a cursory review by peers in the industry is found desperately wanting and suspiciously edited for Political correctness...

From the report:

Operational information

Go-around procedure

A go-around may be initiated by a pilot when an aircraft is on an approach to land. A go-around is intended to change an aircraft’s flight profile from descending in an approach or landing configuration to a climb in a climbing configuration. A go-around procedure is considered a normal procedure and, although it is not often required, it should not result in increased risk.

The operator was unable to provide the ATSB with the go-around procedure that was in use at the time; however, the procedure that was effective from November 2013 is shown in Figure 5. This procedure was consistent with that published by Cessna.

Figure 5: Go-around procedure
(see report)
Source: Aircraft operator

The flying school taught students that when their aircraft was descending through a height of 300 ft above ground level on approach to land, the pilot should initiate a go-around unless the:

• aircraft was within 10 kt of the correct airspeed

• aircraft was established on the extended runway centre-line

• approach profile was aligned with the visual approach slope indicator

• aircraft was configured to land.

Flap settings

The aircraft’s wing flaps were found to have probably been in the fully-extended, 40° position at impact. The instructor who approved the student pilot for night solo circuits that night reported that the student had been trained and observed to conduct landings at night with a maximum of 20° flap extension.

It was further reported that students were trained to use full flap extension in certain circumstances, including short-field landings and practice forced landings during the day.

Practice forced landings would include a go-around from the full flap extension configuration. According to the flying school’s integrated training syllabus, practice forced landings were not conducted at night.


At 40° flap extension, the aircraft can be flown at a particular airspeed with a lower nose attitude than when conducting the same manoeuvre with a lesser degree of flaps, or with flaps retracted.

Cessna advised that a go-around from a trimmed approach with 40° flap extension would require about 20 kg of forward control yoke force to maintain 55 kt. About 25 kg of forward control yoke force is required at 20° flap extension in the same scenario. Cessna also advised that on the night, the aircraft’s climb performance at 40° flap extension would have been about half that expected if the flaps had been fully retracted.

It was reported that the pilot was trained to retract the flaps in 10° stages during the go-around, removing the force required on the control yoke. 

 
Although only cursory the investigators have examined the Operators FCOM etc. to establish what the cadet trainee had been taught for a SE GA (as per above). However as TM points these procedures were contrary to the procedures as outlined in the manufacturer's AOM. In any normal AAI that should automatically make it into at least the contributory factors section of the report. So let us have a look:  

Findings

From the evidence available, the following findings are made with respect to the loss of control and collision with terrain involving Cessna Aircraft Company 182R, registered VH-AUT, which occurred near Hamilton Airport, Victoria on 23 September 2013. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factors

• Following a go-around during night circuit consolidation training the aircraft departed controlled flight and collided with terrain.

Other factors that increased risk

• The pilot had an undiagnosed heart anomaly that predisposed him to a cardiac event and incapacitation.

• For reasons that could not be conclusively determined, the Civil Aviation Safety Authority was unaware of the student's prior treatment for attention deficit hyperactivity disorder, preventing its consideration and management of any ongoing safety risk associated with the condition.

Other findings

• Post-mortem examination was unable to completely exclude the possibility that the accident was precipitated by a cardiac event.

   
FFS...nothing, not a dicky bird - instead the Beakerised TL/Reviewers/GM & Commissioners go off on some wild goose chase about some pilot medical issues that may/or may not remotely have contributed to the accident...

As a result the media jumps all over the medical condition part alone and before you know it...

Report finds trainee pilot killed in plane crash near Hamilton had undisclosed heart condition


Updated Fri at 1:08pmFri 8 May 2015, 1:08pm


An investigation into a fatal plane crash in Hamilton, in south-west Victoria, has revealed the pilot's medical condition may have led to the incident.

A 20-year-old trainee pilot from New South Wales was killed when the single-engine Cessna 182 crashed into a paddock north of Hamilton in 2013.

A report by the Australian Transport Safety Bureau found the pilot had an undisclosed congenital heart anomaly "capable of causing incapacitation" and that may have "contributed to the development of the accident".

The report recommends a "shared responsibility" between pilots, doctors and the Civil Aviation Safety Authority in reporting, assessing and managing medical conditions.

 
Wonder what it will be this time next week..

"Trainee Pilot flagrantly ignored authorities by not reporting known medical conditions..blah..blah.."

MTF...P2