[Peetwo]

Joining the dots & dashes on the DFO cover-up?

...ATSB has now gained a world wide reputation of being an ‘arse covering’ glove puppet, a catamite to those who hold sway. Look back to Lockhart River, look back to the Pel-Air debacle, take a close look at MH 370. Then take a very close look at the Hood credentials to run the ATSB. When you’ve done with that, take a very close look at NASAG and the DoIT involvement in the selling off of aerodromes. I say there is more chance of an ‘error’ to be found there, than in Quartermain’s pre take off preparations...

So glad that the BRB are taking up the cause on what I believe to the most disgusting ATSB Final Report cover-up to date (that includes the 1st and 2nd iteration of PelAir investigations).

...For a start, with two healthy engines and an old lady flying the aircraft, it would have been, with a simple rudder out of trim condition, easily ‘flyable’ for the short period it would take to correct the error. It would climb like a homesick angel, despite the ‘sideslip’ mumbo-jumbo Hood dragged out of his sorry arse. This incident began on the runway – the take off path clearly defines this; the rest is history. We need to know what, exactly was going on in that cockpit. Something had gone awry – but what and why?...

This brings me to another huge aberration with this bollocks report - first a reference from a 'Search 4 IP: 

The HVH YMEN DFO faery tale grows...    


Reference P7 Accidents - Domestic post: http://www.auntypru.com/forum/thread-103...ml#pid9398 

..I note, with some amusement, that the ‘experts’ on the UP are finally catching on. Shan’t bother you all with the posts – but, to further elaborate the abysmal ATSB performance in support of only the gods know what; a quote directly from the Be20 bible.

“The engine driven fuel pump (high pressure) is mounted on the accessory case in conjunction with the fuel control unit (FCU). Failure of this pump results in an immediate flame-out.” The primary boost pump (low pressure) is also engine driven and is mounted on the drive pad on the aft accessory section of the engine. This pump operates when the gas generator (N1) is turning and provides sufficient fuel for start, take-off all flight conditions except operation with hot aviation gasoline above 20, 000 feet altitude, and operation with cross-feed.

The minister should be asking his experts to clearly define what actually happened that day, at Essendon. They could, in turn, ask the ATSB what the hell they are playing at. Better yet, he could bring in the IIC and ask him; on oath, (in camera) if he can – hand on heart – provide a little more ‘fact’ than the Hood faery story. I’d expect some folk in the USA would value anything a little better than the current Wild Ass Guess (WAG) which claims, without any convincing supporting data or proof, 100% Pilot error. 

The simple truth minister is the ATSB management have NFI; the ‘tin-kickers’ might; but there is not enough evidence here to support any claim other than supposition. The bloody aircraft hit a building and burned, killing 5; that is fact – after that – well, you pay your money and take your chances...

Not exactly sure why but the last time I looked the mods over on the UP are still mulling over whether to approve Grogmonster's NTSB report attachment...

Grogmonster:

Some frightening similarities here people. Not Rudder Trim !!!!
Attachments Pending Approval
[img=16x0]https://www.pprune.org/images/attach/pdf.gif[/img]
 
NTSB report on Wichita Crash.pdf

---

Lead Balloon: 

Pending approval, here’s some of the report:

The airline transport pilot was departing for a repositioning flight. During the initial climb, the pilot declared an emergency and stated that the airplane "lost the left engine." The airplane climbed to about 120 ft above ground level, and witnesses reported seeing it in a left turn with the landing gear extended. The airplane continued turning left and descended into a building on the airfield. A postimpact fired ensued and consumed a majority of the airplane.

Postaccident examinations of the airplane, engines, and propellers did not reveal any anomalies that would have precluded normal operation. Neither propeller was feathered before impact. Both engines exhibited multiple internal damage signatures consistent with engine operation at impact. Engine performance calculations using the preimpact propeller blade angles (derived from witness marks on the preload plates) and sound spectrum analysis revealed that the left engine was likely producing low to moderate power and that the right engine was likely producing moderate to high power when the airplane struck the building. A sudden, uncommanded engine power loss without flameout can result from a fuel control unit failure or a loose compressor discharge pressure (P3) line; thermal damage prevented a full assessment of the fuel control units and P3 lines. Although the left engine was producing some power at the time of the accident, the investigation could not rule out the possibility that a sudden left engine power loss, consistent with the pilot's report, occurred.
A sideslip thrust and rudder study determined that, during the last second of the flight, the airplane had a nose-left sideslip angle of 29°. It is likely that the pilot applied substantial left rudder input at the end of the flight. Because the airplane's rudder boost system was destroyed, the investigation could not determine if the system was on or working properly during the accident flight. Based on the available evidence, it is likely that the pilot failed to maintain lateral control of the airplane after he reported a problem with the left engine. The evidence also indicates that the pilot did not follow the emergency procedures for an engine failure during takeoff, which included retracting the landing gear and feathering the propeller.

Anyway for the benefit of those IOS and BRB members interested, here is some links for the quoted NTSB final report into the 30 October 2014 B200 fatal accident at Wichita, Kansas (Report No. - CEN15FA034): 

1. https://www.ntsb.gov/_layouts/ntsb.aviat...4112&key=1
   
2. https://aviation-safety.net/database/rec...20141030-0
   
3. http://www.kathrynsreport.com/2016/02/be...g-air.html
   

NTSB Identification: CEN15FA034
14 CFR Part 91: General Aviation
Accident occurred Thursday, October 30, 2014 in Wichita, KS
Probable Cause Approval Date: 03/01/2016
Aircraft: RAYTHEON AIRCRAFT COMPANY B200, registration: N52SZ
Injuries: 4 Fatal, 2 Serious, 4 Minor.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The airline transport pilot was departing for a repositioning flight. During the initial climb, the pilot declared an emergency and stated that the airplane "lost the left engine." The airplane climbed to about 120 ft above ground level, and witnesses reported seeing it in a left turn with the landing gear extended. The airplane continued turning left and descended into a building on the airfield. A postimpact fired ensued and consumed a majority of the airplane. 

Postaccident examinations of the airplane, engines, and propellers did not reveal any anomalies that would have precluded normal operation. Neither propeller was feathered before impact. Both engines exhibited multiple internal damage signatures consistent with engine operation at impact. Engine performance calculations using the preimpact propeller blade angles (derived from witness marks on the preload plates) and sound spectrum analysis revealed that the left engine was likely producing low to moderate power and that the right engine was likely producing moderate to high power when the airplane struck the building. A sudden, uncommanded engine power loss without flameout can result from a fuel control unit failure or a loose compressor discharge pressure (P3) line; thermal damage prevented a full assessment of the fuel control units and P3 lines. Although the left engine was producing some power at the time of the accident, the investigation could not rule out the possibility that a sudden left engine power loss, consistent with the pilot's report, occurred.

A sideslip thrust and rudder study determined that, during the last second of the flight, the airplane had a nose-left sideslip angle of 29°. It is likely that the pilot applied substantial left rudder input at the end of the flight. Because the airplane's rudder boost system was destroyed, the investigation could not determine if the system was on or working properly during the accident flight. Based on the available evidence, it is likely that the pilot failed to maintain lateral control of the airplane after he reported a problem with the left engine. The evidence also indicates that the pilot did not follow the emergency procedures for an engine failure during takeoff, which included retracting the landing gear and feathering the propeller.

Although the pilot had a history of anxiety and depression, which he was treating with medication that he had not reported to the Federal Aviation Administration, analysis of the pilot's autopsy and medical records found no evidence suggesting that either his medical conditions or the drugs he was taking to treat them contributed to his inability to safely control the airplane in an emergency situation.


The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

• The pilot's failure to maintain lateral control of the airplane after a reduction in left engine power and his application of inappropriate rudder input. Contributing to the accident was the pilot's failure to follow the emergency procedures for an engine failure during takeoff. Also contributing to the accident was the left engine power reduction for reasons that could not be determined because a postaccident examination did not reveal any anomalies that would have precluded normal operation and thermal damage precluded a complete examination.
  

 
The first and most obvious question is why was this final report not listed in the ATSB's 'related occurrences' section of the VH-ZCR final report -   

Probably because it didn't fit the HVH faery tale:

Related occurrences

A review of the ATSB’s occurrence database and the United States’ National Transportation Safety Board’s (NTSB) online database identified three potentially similar accidents that involved an aircraft taking off with the rudder trim not correctly set.

  
After reviewing the NTSB accident reports, phots and video footage, IMO there is absolutely no debating the remarkable similarities in the two accidents. What makes it worse is that I suspect that the ATSB investigation team have actually referred to the NTSB report as some of the investigatory methodology is remarkably similar.

Example: 

..The NTSB conducted a sideslip thrust and rudder study based on information from the surveillance videos. This study evaluated the relationships between the airplane's sideslip angle, thrust differential, and rudder deflection. Calculations made using multiple rudder deflection angles showed that full right rudder deflection would have resulted in a sideslip angle near 0°, a neutral rudder would have resulted in an airplane sideslip angle between 14° and 19°, and a full left rudder deflection would have resulted in an airplane sideslip angle between 28° and 35° airplane nose left. Calculation of the airplane's sideslip angle as captured in the image of the airplane during the last second of flight showed that the airplane had a 29° nose-left sideslip, which would have required the application of a substantial left rudder input...

---

https://www.atsb.gov.au/publications/inv...-2017-024/

...Following witness observations of a significant left yaw, the ATSB attempted to define the aircraft’s sideslip and roll angles at different points along the flight path using video footage from CCTV and a vehicle dashboard camera. Still images were extracted from the CCTV and dashboard camera footage, and the location of the aircraft was determined using ADS-B data at points A through G (Figure 16). ZCR’s track was determined at each point using ADS-B data...

...Analysis of the roof impact marks indicated that:

• the aircraft had a heading angle of about 86 ⁰ (T)
  
  
• the ground track was about 114 ⁰ (T)
  
  
• the aircraft was at a sideslip angle of about 28⁰ left of track
  
  
• the aircraft was slightly left-wing and nose-low with a shallow angle of descent at the initial roof impact
  
  
• after the initial impact, the aircraft rotated left on its vertical axis until the fuselage was about parallel with the rear parapet wall of the building...
  

P2 comment - I note in the case of the Wichita accident that on 26 October 2016 Flight Safety International filed a lawsuit against 12 different companies associated with the King Air crash: http://www.kathrynsreport.com/2016/10/be...g-air.html

FlightSafety files lawsuit over 2014 King Air crash 

WICHITA, Kan. FlightSafety International has filed a lawsuit, naming more than 12 companies (19 defendants total) it says contributed to the October 2014 fatal crash of a Beechcraft King Air near Wichita's Mid Continent Airport, now known as Dwight D. Eisenhower National Airport.

On Oct. 30, 2014, a Beechcraft B200 Super King Air crashed into a flight safety training center building near the airport, killing the pilot and three people inside the training center.

Among the defendants in the lawsuit are Textron Aviation, Yingling Aircraft, Beechcraft Corporation, Hartzell Propeller, Inc., Pratt and Whitney Engine Services, Inc. and the plane's previous owner.

Investigators say the pilot failed to maintain control of the King Air after a reduction in power to its left engine.

Source:  http://www.kwch.com 

After once again reading the Wichita accident report - https://www.ntsb.gov/about/employment/_l...034&akey=1 - and in particular under the 'Medical and Pathological' section :

MEDICAL AND PATHOLOGICAL INFORMATION 

This 53-year-old pilot had been an air traffic controller for more than 20 years at ICT and retired in 2013. Since his first medical certification in 1980, the pilot had reported thyroid disease, hernias, and recurrent symptomatic kidney stones to the FAA. Beginning in 1997, he had episodes of anxiety and depression, which required intermittent treatment with medication. During the first episode, he was unable to work for a certain time. A second episode began in October 2013 and continued through the accident date. He did not report his recurrent anxiety or his use of buspirone and escitalopram to the FAA. However, he visited his primary care physician about 1 month before the accident and was noted to be stable on the medications. In addition, the pilot had a procedure to treat kidney stones in 2013 that he did not report to the FAA. 

On November 3, 2014, the Regional Forensic Science Center, Sedgwick County, Kansas, performed an autopsy on the pilot. The cause of death was determined to be thermal injuries and smoke inhalation and the manner of death was determined to be an accident. According to the autopsy report, a thin plastic medical catheter was identified in the pilot's pelvis, but it was not further described in the report. The Regional Forensic Science Center also conducted toxicology testing of the pilot's heart blood, which identified carboxyhemoglobin at 39 percent, but no other tested for substances were found.

Toxicology testing performed by the Bioaeronautical Research Laboratory at the FAA's Civil Aerospace Medical Institute identified buspirone and citalopram and its metabolite n-desmethylcitalopram in the pilot's heart blood and urine. In addition, the carboxyhemoglobin was 35 percent; no ethanol, cyanide, or any other tested for substances were identified. Buspirone, also named BuSpar, is an anxiolytic prescription medication. Buspirone is different from other anxiolytics in that it has little, if any, typical anti-anxiety side effects, such as sedation and physical impairment, but it does carry a warning, "May impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." Citalopram is a prescription antidepressant, also named Celexa, which carries a warning, "May impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)."

From the ATSB YMEN DFO accident report:

Medical and pathological information  The pilot held a Class 1 Aviation Medical Certificate that was valid until 20 May 2017. The pilot was required to wear distance vision correction and have available reading correction while exercising the privileges of his licence. The pilot’s CASA medical records indicated that he was diagnosed with Type 2 diabetes in 2007. At the time of the accident, the pilot was reportedly on multiple oral medications to manage his diabetes and was considered to have met the CASA requirements for maintaining his medical certificate.

The records also showed that, as part of the pilot’s annual medical requirements, an echocardiogram was performed in 2016, which revealed an abnormal mitral valve. This was repaired in July of that year, with a post-operative follow-up identifying nil issues. CASA subsequently reviewed the pilot’s medical history and he was advised on 4 February 2017 that he could continue exercising the privileges of his licence, but should cease flying if there was a change in his treatment or condition.

The pilot’s post-mortem examination established that the pilot succumbed to injuries sustained during the impact sequence. Mild to moderate coronary artery atherosclerosis22 was noted, along with signs of mitral valve annuloplasty.23 There was no evidence, however, of any significant natural disease which may have caused or contributed to the accident. Further, the toxicology results did not identify any substance that could have impaired the pilot’s performance or that were not noted in the pilot’s CASA medical records. While post-mortem results for the passengers were not provided to the ATSB at the time of writing, given the injuries sustained by the pilot and the results of his post-mortem, the accident was not survivable. The pilot’s family described him as being fit for his age and indicated that he regularly exercised.

Plus the quote on that bizarre, abnormal Mayday call: 

MAYDAY call

The MAYDAY call broadcast by the pilot of ZCR shortly after take-off was reviewed by the ATSB. No additional information regarding the nature of the emergency was identified. In addition, the ATSB’s assessment of the pilot’s speech characteristics was unable to provide any further information.

Not sure why there is no analysis material/documentation highlighting the methodology used in the ATSB assessment of the pilot's speech characteristics but even as a layman I would have thought there was considerable significance in the pilot giving a non-standard Mayday call -  i.e x7 Mayday's, instead of x3, without any information in regards to the nature of the emergency - at the most critical point of the accident flight (remembering pilots are consistently trained in an emergency situation to prioritise - aviate, navigate, communicate).    

Keeping the Wichita accident report and the non-standard Mayday call in mind, I can't help but think that the YMEN DFO accident pilot Max Quartermain may not have suffered a physical incapacitation but rather a mental incapacitation (like the Wichita pilot obviously did), some sort of cognitive block which did not allow him to react or assess and then act appropriately (ANC) to the abnormal/emergency situation he found himself in - just saying...  


MTF...P2