[Kharon]

P7 - You seem to have omitted that the Pitot Static heating failed at the time of the fire – seen your report on this ancient tale – I liked the log book entry – laconic, - to say the least. Later - 

[P7_TOM]

ATSB – Albany – Report.

The ATSB report into the in flight breakup of a C210 is – HERE - . It is brief, but to the point.

"The ATSB found that for reasons that were not established, abnormal operation of the aircraft produced high levels of unusual aerodynamic loading on the right wing that exceeded the strength of the wing and initiated an in-flight break-up and impact with terrain.

"The aircraft did not have a pre-existing structural deficiency or damage that would have contributed to the in-flight break-up and the local meteorological conditions were not conducive to inadvertent aircraft overstress.

"The ATSB found that the presence of methyl amphetamine in the pilot’s system increased the risk of operational misjudgements and aircraft mishandling, and pilot incapacitation. This did not necessarily contribute to the accident.

"The pilot had worked for a number of organisations which had the required risk controls for problematic alcohol and other drug (AOD) use in place. There was no data that indicated a systemic problem with problematic AOD use in Australian aviation.

Recently an airline pilot was reported with an addiction to Oxycodone.  

“Although oxycodone brings relief for many people suffering from traumatic pain, the dangers of the drug are becoming more clear than ever. Due to the euphoric effects of oxycodone, many people abuse the drug despite the risks. Those who begin abusing oxycodone on a regular basis are likely to develop a dependence on and/or an addiction to the drug. Oxycodone is extremely addictive because it is derived from opiates, making it similar to morphine and heroin.”

I did a light- quick & nasty – search on the net to try and get an idea of what ‘aviation’ may face – statistics and facts – which, to one not familiar with the size and scope of the problem was quite alarming. I have friends who have struggled through ‘addiction’ with their children and seen the damage done – to all. It never occurred for minute that there may be problem among the pilot fraternity, yet the research indicates the use of ‘drug’ s in not restricted to anyone particular group of society. “Booze’ has always been a pilots mate and occasional enemy – the DAMP system of random checks seems to be effective enough; I myself moan and groan – but, alas it is a necessary evil. Mind you, the chances of getting caught out on the road to the airport are greater – particularly during the holiday period, when the local Bobbies are on the roads, rather than at the family BBQ.

But, I am familiar with the effects of ‘Booze’ and can object to working with someone clearly ‘suffering’; although I’ve never had to do it. But, being older and never exposed to ‘drug related’ symptoms, how am I to know what’s what? There is a strong defence mechanism – the DAME being the first brick in the wall; DAMP the second and of course your own native common sense.

But I wonder – is there a case for a screen test at every medical? It’s a hellish problem for Avmed – the whole world up in arms, cussing and spitting; damning CASA for being a tyrant etc. However, you can’t fly if you are unwell, you can’t fly three sheets to the wind and legless – so why should the potential for drug use escape the list? Blood testing is part of every medical, so why not extend it to an extra test – to be sure, to be sure. The other sider of the coin is the Avmed induced paranoia of loss of licence for having a wart on your Willy. Right -

Coat - Tin hat – Taxi!

[Peetwo]

ATSB – Albany – Report.

The ATSB report into the in flight breakup of a C210 is – HERE - . It is brief, but to the point.

"The ATSB found that for reasons that were not established, abnormal operation of the aircraft produced high levels of unusual aerodynamic loading on the right wing that exceeded the strength of the wing and initiated an in-flight break-up and impact with terrain.

"The aircraft did not have a pre-existing structural deficiency or damage that would have contributed to the in-flight break-up and the local meteorological conditions were not conducive to inadvertent aircraft overstress.

"The ATSB found that the presence of methyl amphetamine in the pilot’s system increased the risk of operational misjudgements and aircraft mishandling, and pilot incapacitation. This did not necessarily contribute to the accident.

"The pilot had worked for a number of organisations which had the required risk controls for problematic alcohol and other drug (AOD) use in place. There was no data that indicated a systemic problem with problematic AOD use in Australian aviation.

MAY 16, 2019
AVIATION



Ice blamed for fatal plunge
[/url]
A pilot high on ice has been blamed for the wing failure that sent his plane into a fatal plunge.
By ROBYN IRONSIDE

A pilot who was high on ice flew his light plane in such a way that the right wing broke off, resulting in the aircraft plunging to the ground and killing him.



The Australian Transport Safety Bureau has published its final report on the crash near Albany in Western Australia on October 24, 2017, which claimed the life of local firefighter Sam Ferns.

The 40-year-old, who had relocated to Albany from Victoria, owned the Cessna 210B he was flying and had about 6500 hours of flying experience.

On the morning of the crash, Mr Ferns was planning to fly to Bunbury for training and assessment activities ahead of the upcoming aerial firefighting season.

After takeoff he made a radio transmission outlining his flight plan.

Witnesses observed nothing abnormal as the Cessna did some local flying as Mr Ferns took pictures of coastal scenery, which were sent to a friend.

But about 30 minutes later, 30km northwest of Albany, a loud crack from the aircraft was heard by several people. They described the noise as being like a gunshot or a thunder clap.

Shortly after the aircraft was seen in a nosedive, with the engine roaring. An aerial search later found the wreckage of the Cessna in dense bushland in the Mount Lindesay National Park. The body of the pilot was inside the wreck.

The ATSB report issued on Thursday revealed toxicology tests found a concentration of methylamphetamine in Mr Ferns’ liver that was “sufficiently high enough for the pilot to be significantly affected by the drug”.

“It is possible that the pilot was very markedly affected and there was potential for lethal effects of the drug, most commonly as a result of effects on cardiac function,” said the report.

In the absence of any other explanation for the in-flight breakup of the Cessna, the ATSB concluded that “the aircraft was operated outside of the relevant airspeed or handling limitations to the point of failure of the right wing”.

The report went on to explore the issue of alcohol and drugs on pilot performance, quoting Civil Aviation Safety Authority tests which returned positive results in just 0.09 per cent of cases.

The ATSB could find no history of alcohol or drug abuse in relation to Mr Ferns, apart from a low-level drink driving offence in 2010.

The report said since 2006 there had been just four fatal crashes in Australia in which the pilot was under the influence of drugs or alcohol; two serious incidents where the pilot became unconscious during flight and one accident involving a wire-strike by a drunk pilot.

No safety issues were identified as a result of the investigation but the ATSB said there were opportunities for aviation organisations to collect more data, and to enhance risk controls for problematic alcohol or drug use.

Recently an airline pilot was reported with an addiction to [url=https://www.addictioncenter.com/opiates/oxycodone/symptoms-signs/]Oxycodone.  

“Although oxycodone brings relief for many people suffering from traumatic pain, the dangers of the drug are becoming more clear than ever. Due to the euphoric effects of oxycodone, many people abuse the drug despite the risks. Those who begin abusing oxycodone on a regular basis are likely to develop a dependence on and/or an addiction to the drug. Oxycodone is extremely addictive because it is derived from opiates, making it similar to morphine and heroin.”

I did a light- quick & nasty – search on the net to try and get an idea of what ‘aviation’ may face – statistics and facts – which, to one not familiar with the size and scope of the problem was quite alarming. I have friends who have struggled through ‘addiction’ with their children and seen the damage done – to all. It never occurred for minute that there may be problem among the pilot fraternity, yet the research indicates the use of ‘drug’ s in not restricted to anyone particular group of society. “Booze’ has always been a pilots mate and occasional enemy – the DAMP system of random checks seems to be effective enough; I myself moan and groan – but, alas it is a necessary evil. Mind you, the chances of getting caught out on the road to the airport are greater – particularly during the holiday period, when the local Bobbies are on the roads, rather than at the family BBQ.

But, I am familiar with the effects of ‘Booze’ and can object to working with someone clearly ‘suffering’; although I’ve never had to do it. But, being older and never exposed to ‘drug related’ symptoms, how am I to know what’s what? There is a strong defence mechanism – the DAME being the first brick in the wall; DAMP the second and of course your own native common sense.

But I wonder – is there a case for a screen test at every medical? It’s a hellish problem for Avmed – the whole world up in arms, cussing and spitting; damning CASA for being a tyrant etc. However, you can’t fly if you are unwell, you can’t fly three sheets to the wind and legless – so why should the potential for drug use escape the list? Blood testing is part of every medical, so why not extend it to an extra test – to be sure, to be sure. The other sider of the coin is the Avmed induced paranoia of loss of licence for having a wart on your Willy. Right -

Coat - Tin hat – Taxi!

P2 addition: Here is a link for the AAT dismissal decision for Whitehall v CASA. 

BACKGROUND

1. The issue in this matter is whether Mr Nathaniel Whitehall, the applicant, meets the medical standard for the issue of a Class 1 medical certificate to enable him to fly as a pilot on a commercial passenger aircraft. If he does not, the issue is whether the extent to which he fails to meet those standards is likely to endanger the safety of air navigation and whether any conditions could be imposed upon a medical certificate which would ameliorate any threat posed to air safety.
   
2. The applicant sought review of two decisions of the  Civil Aviation Safety Authority  (CASA), the respondent in these proceedings:
   • (a) the decision (Class 2 decision) by a delegate of the respondent dated 14 December 2017 to suspend the applicant’s Class 2 medical certificate pursuant to reg 67.240 of the Civil Aviation Safety Regulations 1998 (the CASR). This is the subject of proceedings 2018/0199.
     
   • (b) the decision (Class 1 decision) by a delegate of the respondent dated 29 January 2018 to refuse to issue the applicant with a Class 1 medical certificate pursuant to reg 67.180(7) of the CASR. This is the subject of proceedings 2018/0474.
     
3. The application to review the Class 2 decision was dismissed by consent because the license that would have resulted from it had expired by the effluxion of time. The issues in relation to each license were in any event the same. That leaves only the Class 1 decision for review.
   
   

---

CONCLUSION

105.In order to obtain the Class 1 licence, the applicant has to meet the criteria set out in para 10 above. He has failed to do so. He has a medically significant condition that is safety relevant because it reduces his ability “to exercise a privilege conferred or to be conferred or to perform a duty imposed or to be imposed by a licence that he or she holds or has applied for”. We are satisfied, accepting the evidence of all of the doctors but in particular Dr Atherton, that he has a severe opioid dependence and moderately severe benzodiazepine dependence. We accept the evidence that the rate of relapse from both disorders is extremely high.
106.We are satisfied that he used and possibly continues to use over the counter or prescribed medication that causes him to experience side effects likely to affect him to an extent that is safety relevant. Given our hesitation in accepting his evidence we are not satisfied his addiction has ceased.
107.We are satisfied that he engaged in problematic use of substances within the meaning given by s 1.1 of Annexure 1, Personnel Licensing, to the Convention on International Civil Aviation. The evidence indicates that there is a likelihood that he still engages in such problematic use.
108.We are satisfied that there is a personal history, problematic use of opioids and benzodiazepines and that his abstinence from problematic use of them has not been certified by an appropriate specialist medical practitioner and he has not provided evidence that he has undertaken or successfully completed an appropriate course of therapy.

The Tribunal affirms the reviewable decision dated 29 January 2018 in application 2018/0474.

I certify that the preceding 108 (one hundred and eight) paragraphs are a true copy of the reasons for the decision herein of Deputy President Ian Hanger AM QC, and Member Dr Stephen Lewinsky

[P7_TOM]

Re the above post.

Going to weigh into this – on the side of Avmed – (shock – horror). I know, but fair’s fair. Here’s a fellah who, like myself is ‘drug’ dependent. For me it is a simple, no harm, no foul, accepted remedy. I take my anti-cholesterol and Aspirin (religiously), everyday at the same time (give or take). It is an essential part of staying fit – not to mention the exercise.

It is an acknowledged fact: this fellah (above) had a ‘problem’ – this fellah had been prescribed a ‘treatment’. This was acknowledged and accepted by AvMed – prescribed pain relief for a condition – all up front, all honest and no restriction imposed by AvMed. Fair call I’d say.

Where the wheel comes off is when any measure of dishonesty comes into bat. Had the prescribed dose been ‘tested’ and found consistent with the prescribed dose; then, I believe, AvMed would have had no problem – 100 Mg per day (or whatever) to assist in ‘management’ of the condition – no problem. But once you are caught out, claiming 100 mg a day and ‘sneaking off’ to get more – then CASA have a problem if they discover this. It is that simple. Had this fellah disclosed that an increased dose was required – to alleviate the condition – and worked through the hoops, then, perhaps AvMed could have been able to honestly assess the ‘risk’, taken expert advice and not been forced into the AAT.

Modern medicine is stunning; but old fashioned honesty has also been around for a long time. Pilots should not need to live in fear of ‘the regulator’ – given the range and scope of the modern options for managing ‘a condition’. Perhaps it’s time to revisit the sometimes hidebound, arcane dogma AvMed must live under. Maybe change (or modify) ‘the culture’ they are forced to work within. Be shut of the old WWII ‘pilot’ requirements and move into the modern medical era. Then, perhaps – just maybe – pilots would be able to – even dare – to tell the DAME that ‘something’ ain’t right; continue to work and get early treatment. My Vet reckons early is good, earlier is better.

Just the ramblings of an old fool – but would have an early ‘catch’ of the problem above not been a better result – all around? Sure AvMed is a pain – the old school vets wanted you back to flying duties a.s.a.p. AvMed seem to want to ground you and send you off to a specialist for breaking wind twice – instead of the routine thrice before first coffee. But; at the end of the shift – how would you know whether you are fit to fly (or at risk)? (Chronic flatulence aside).

Get it sorted – soonest – then tell the truth. Cheaper, quicker, easier and better all around. Telling fibs only fuels the CASA paranoia – makes it harder for everyone.

Speech over – "another round here" – then we begin the post election BRB/IOS joint action campaign. Gods help the new no policy miniscule – whoever it is.

[Peetwo]

Update: ATSB O&O investigation AO-2017-057.

Ref: Adelaide Advertiser:

Renmark Rossair crash investigation blows out to two and a half years because of absence of flight recorder

Mitch Mott, The Advertiser
May 30, 2019 8:30pm
Subscriber only
May 30, 2017: Three killed in plane crash disaster
May 2018: Victims’ families remember loved ones
May 2018: Lead investigator quits, delaying report
May 2019: Widow says they’ve been treated like ‘worthless entities’

A plane that crashed at Renmark killing three pilots did not have a black box, delaying the aviation safety watchdog’s investigation by more than a year and a half.

On the second anniversary of the Rossair plane tragedy, the Australian Transport Safety Bureau says the final report is still six months away.

The investigation has been beset by multiple delays, including the chief investigator quitting, leaving the families of the three men craving answers about what happened in the seconds between the plane taking off from Renmark Aerodrome and it crashing into the ground.

Paul Daw.Stephen Guerin.

Experienced pilots Paul Daw, 65, Stephen Guerin, 56, and Martin Scott, 48, were in a nine-seat Rossair aircraft when it crashed into scrubland 4km from Renmark Aerodrome on May 30, 2017.

The trio had been completing a re-evaluation test for Mr Daw with Mr Guerin, a Civil Aviation Safety Authority officer, observing the older man.

The plane was only in the air for between 60 and 90 seconds before it careened into the ground nose first, killing all three men instantly.

The report, which was initially slated to take 12 months, has stretched out to two and a half years.

The final report is now due in the fourth quarter of 2019.
Crash victim Martin Scott, his partner Terri Hutchinson and their son Andy. Mr Scott was killed when a Rossair training flight crashed after take off in Renmark. Picture: Terri Hutchinson

Mr Scott’s long time partner and fiancee Terri Hutchinson, 51, said the overwhelming question for her was “how could this happen with three experienced pilots on board”?

“I don’t think you ever come to terms with a loss of such magnitude, however the delay in providing answers has played a heavy toll on any attempt we make to try to move forward with our lives.”

Both Ms Hutchinson and Mr Scott’s father Joe believe that the accident was entirely preventable.

“Nothing will bring Martin back; however, it is extremely important to us that lessons are learned so that no one else should have to deal with such a terrible tragedy,” Ms Hutchinson said.

The ATSB said the investigation had been complicated by the lack of on-board recorders including a black box. Picture: Dylan Coker

An ATSB spokesman said the Bureau was still examining the evidence to ensure that the final report was “objective” and “factually correct”.

“One complexity with this investigation is the accident aircraft’s lack of any flight data recorder or cockpit voice recorder,” he said.

“The accident aircraft was not required to be fitted with either a flight data or cockpit voice recorder, but the lack of on-board recorders adds to the complexity of the investigation, as the ATSB works to rule in and rule out contributing factors to this accident on the basis of the available indirect evidence.”

The Civil Aviation Safety Authority regulations dictate that a plane weighing less than 5700kg needs a black box recorder if it is pressurised, carries more than 11 people or is turbine powered by more than one engine.


The wreckage of the plane as seen from above. Picture: 7 News Adelaide

In the aftermath of the accident Ms Hutchinson moved back to the United Kingdom with her son Andy, now aged 11.

They have settled in the quaint seaside village of Cullercoats, in the country’s northeast. But as the pair heal on the other side of the world from the scene of the crash, Mr Scott has never been far from their minds.

“Neither Andy or I have been able to look at photos or videos since Martin died as things are still too raw and painful; I’m sure we’ll get there one day and thankfully we have each other,” she said.

Andy has taken after his father, inheriting a love of all things aviation.

“For his eleventh birthday he received a trial flight in a two-seater aeroplane which he got to fly by himself,” Ms Hutchinson said.

“I know many people would be concerned about flying in our circumstances, however I take the pragmatic approach and tell myself how rare aviation accidents actually are.

“There would be no point in trying to stop him anyway. It is definitely in his blood.”


Martin Scott, Terri Hutchinson and their son Andy, who has inherited his father’s love of aviation. Picture: Terri Hutchinson

Ms Hutchinson said it took a year to decided to leave Australia for the country where both she and Mr Scott had been born.

“This decision was to take me a year to make as I seemed to be in a fog up until that time,” she said.

“I think that year was probably the worst of my life. I just couldn’t believe that this could happen to such a confident, happy, fearless person like Martin.”

MTF...P2  

[Peetwo]

Busy week in the Hooded Canary avery?? -   

First with an update to the tragic C210 crash near Mount Isa on May 26 -   

Investigation update: 7 June 2019
The information contained in this investigation update is derived from the initial investigation of the occurrence. Readers are cautioned that there is the possibility that new evidence may become available that alters the circumstances as depicted in the report.

What happened

At 1407 Eastern Standard Time[1] on 26 May 2019, a Cessna Aircraft Company 210M, registered VH-SUX and operated by Thomson Aviation, departed Mount Isa Airport for an aerial geological survey flight. There were two pilots on board, one operating the aircraft and the other observing the flight to familiarise himself with the survey area. The survey was to be conducted at a target height of about 200 ft above ground level along parallel east and west lines, spaced about 90 m apart.

The evidence indicated that about 1 hour and 40 minutes into the flight, as the aircraft tracked west along the sixth survey line, the right wing separated, resulting in a rapid loss of control and subsequent collision with terrain. The pilots were fatally injured and the aircraft was destroyed.

Wreckage and site information

The accident site was located about 25 km north-east of Mount Isa Airport in flat, arid scrub land (Figure 1). The wreckage trail was on an approximate east to west heading, in line with the expected survey flight path. The right wing was the first major component in the wreckage trail and was located about 130 m from the main wreckage. The aircraft impacted terrain about 90 m from the right wing, coming to rest a further 40 m away. All major aircraft components were accounted for at the site.

Figure 1: Accident site overview looking east

Source: ATSB

On-site examination of the wreckage indicated the right wing and part of the carry-through spar[2] had separated from the aircraft (Figure 2). Preliminary examination of the spar identified that it had fractured through an area of pre-existing fatigue cracking. The fracture was located inboard of the wing attachment lugs.

The carry-through structure was removed for detailed examination.

Figure 2: Right wing viewed from inboard end showing section of carry-through structure

Source: ATSB

Initial findings

Technical examination of the carry-through structure was conducted at the ATSB’s Canberra facilities. This examination confirmed that the fatigue cracking reduced the structural integrity of the carry‑through to the point where operational loads produced an overstress fracture of the remaining material. The fracture location was approximately 290 mm inboard of the right wing fuselage attachment lugs and coincident with a change in section thickness of the lower flange (Figures 3, 4 and 5). Characteristic features identified across the fracture surfaces confirmed that the fatigue cracking had initiated from the underside surface, growing across the lower flange and penetrating vertically into the structure.

Figure 3: The approximate location of fracture

Source: Cessna, modified by the ATSB

Figure 4: Carry-through structure, as received at the ATSB’s facilities

Source: ATSB

Figure 5: Close view of the outboard portion of the fracture surface (fatigue cracking has initiated on the underside surface)


Source: ATSB

Aircraft details

The Cessna Aircraft Company (Cessna) 210M is a high cantilever wing, piston-engine aircraft with a three-blade variable-pitch propeller and retractable tricycle landing gear (Figure 6). The aircraft is normally fitted with six seats. The accident aircraft (serial number 21061042) was manufactured in the United States in 1976 where it operated until 2013. It was imported to Australia and registered as VH-SUX in June 2013. At that time, the aircraft was modified for geological survey work, which included the removal of the passenger seats and the installation of specialised equipment.

Figure 6: VH-SUX


Source: Operator

The aircraft also had Supplemental Type Certificates for the installation of integral wing tip fuel tanks and a non-standard engine and propeller installation.

VH-SUX accumulated about 6,000 flight hours in the 6 years it was on the Australian register. It was operated exclusively as a geological survey aircraft during that time. The aircraft had 12,174 flight hours total time in service at the time of the accident.

Operation

The flight was one of a number of flights undertaken for the purpose of a geological survey to the north and north-east of Mount Isa.

The survey was conducted in a grid pattern, with closely spaced east and west lines along with more widely spaced north and south lines flown for data verification purposes. The flight profile closely followed the topography of the survey area at a speed of about 140-150 kt with procedure turns flown at each end of a survey line.

Each flight typically lasted for about 5 hours with multiple flights required to complete each survey. Two flights were normally flown each day in accordance with allowable environmental and daylight conditions, each flight on a given day being operated by a different pilot.

The aircraft typically departed with full fuel, resulting in it operating at close to the maximum allowable take-off weight.

Safety action

On 31 May 2019, the ATSB notified the Civil Aviation Safety Authority, the US National Transportation Safety Board, the aircraft manufacturer and operator of the initial finding of fatigue cracking within the wing spar carry-through structure.

The ATSB is working closely with those organisations to ensure the continued safe operation of the aircraft type.

Further investigation

The investigation is continuing and will include:

• a metallurgical examination of the wing carry-through structure and associated parts
  
  
• further examination and assessment of the aircraft wreckage
  
  
• examination of the maintenance procedures and inspections associated with the wing spar carry-through structure
  
  
• factors that may have contributed to the development of fatigue cracking
  
  
• the operational history of the aircraft from 1976 until 2013.
  

---

& from LMH:






Fatigue Failure caused Wing Separation in C210 Crash
7 June 2019
Comments 0 Comments
    
The Australian Transport Safety Bureau (ATSB) today said that fatigue cracking in the wing carry-through spa was responsible for in-flight wing separation on a Cessna 210 near Mount Isa.

VH-SUX was on a geological survey flight with two people on board when it crashed near Mount Isa on 26 May this year. Both people were killed in the crash.
"Evidence at the accident site indicated that the aircraft’s right wing had separated while in flight, resulting in a rapid loss of control and subsequent collision with terrain," the ATSB said.

"Subsequent technical examination confirmed the aircraft’s wing spar had fractured due to fatigue cracking, which reduced the spar’s structural integrity to the point where operational loads produced an overstress fracture."

ATSB Executive Director Nat Nagy said that the ATSB had notified the relevant National Aviation Authorities.

“The ATSB has notified the Civil Aviation Safety Authority, the US National Transportation Safety Board, the aircraft manufacturer and operator of the initial finding of fatigue cracking with the wing spar carry-through structure,” Nagy said.

"The ATSB is working closely with those parties to ensure the continued safe operation of the the aircraft type."

Fatigue cracking is most often related to the age of a metal component and happens when a small crack grows to the point that the cross-section of a component is reduced to the point where it can't carry the load imposed.

The fear of fatigue in older aircraft was one of the driving factors behind the controversial Cessna Supplemental Inspection Documents (SIDs) programs that were to have been completed for charter and aerial work by the end of July 2016. The SIDs required non-destructive testing and inspections for both primary and secondary aircraft structural components.

The ATSB has moved to differentiate this accident from two other fatal accidents involving C210s in WA and NT. Both of those accidents were attributed to over-stressing of the wings in flight.

Read more at http://www.australianflying.com.au/lates...BVye0hw.99

 
And on the Yak tragedy near South Stradboke island, which appear to have some disturbing parallels to the Barry Hempel and Andrew Lovell accident   :

The ATSB is investigating a collision with water involving a Yakovlev Yak-52, registered VH-PAE, near South Stradbroke Island, Queensland, on 5 June 2019.

The pilot and passenger had departed Southport Airport on a 30-minute scenic flight of the Gold Coast area. The aircraft did not return at the scheduled time and was reported missing. A search was commenced, with aircraft parts subsequently found on South Stradbroke Island. As at midday 6 June the search was continuing.

As part of the investigation the ATSB will liaise with the Queensland Police Service and interview involved parties and witnesses. The ATSB will also examine the recovered aircraft wreckage and collect other relevant evidence and information.

Any witnesses are asked to call the ATSB on 1800 020 616 or complete the ATSB’s online form www.atsb.gov.au/witness

A report will be released at the conclusion of the investigation. However, should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate action can be taken.

---

Pilot Marcel van Hattem confirmed dead as wreckage of missing plane located
By Jennifer Huxley and Kate McKenna
Updated yesterday at 10:56am




PHOTO: Marcel van Hattem and his Yak 52 at Southport Airport. (Facebook: Marcel van Hattem)

RELATED STORY: Debris spotted in search for Soviet-era plane missing off Gold Coast

Emergency authorities have found the body of pilot Marcel van Hattem in the wreckage of his light plane, discovered in waters off South Stradbroke Island on the Gold Coast on Thursday afternoon.

Key points:

• Pilot Marcel van Hattem had taken Trista Applebee on a joy flight for her birthday when they went missing
  
• Police divers found Mr van Hattem's body and are still searching for Ms Applebee
  
• Southport Flying Club president Neil Aitkenhead said Mr van Hattem was a very experienced pilot
  

Police said they were still looking for his 31-year-old female passenger Trista Applebee and the remainder of the plane's wreckage.

The Yak 52 Soviet-era plane was reported missing on the Gold Coast on Wednesday.

Ms Applebee had been on a joy flight for her birthday at the time, police said.

Ms Applebee and Mr van Hattem, 52, a Dutch-national, were both Gold Coast residents.

Mr van Hattem took off from the Southport Flying Club around 10am on Wednesday on a half-hour scenic flight over South Stradbroke Island, but never returned.

"It's actually her birthday today," Officer in Charge of the Gold Coast Water Police, Senior Sergeant Jay Notaro said on Thursday morning.

"The pilot was known to her and was providing that flight for her as part of her birthday celebrations."

He said authorities were having difficulties reaching the family of the pilot.

It is the same model plane that crashed in a similar location in 2008, claiming two lives.

Mr van Hattem's friend Deborah Toussaint told the ABC he had two teenage sons.

VIDEO: Deborah Toussaint flew with Marcel van Hattem just a few weeks ago and even took the controls of the plane. (Supplied)(ABC News)



"[He] took me for a joy ride in his plane only weeks ago … he was such a generous and beautiful man … he knew what he was doing and he was an excellent pilot," she said.


"I feel for his boys who are not here in Australia."


The search is continuing with the assistance of Polair and the Westpac Lifesaver Rescue Helicopter, jet skis, all-terrain vehicles, police vessels and volunteer marine rescue groups.


Senior Sergeant Notaro said police were also using underwater sonar equipment in the search for the plane.

"A lot of that debris has been within the waves and the conditions are quite tricky and that's what's hampering our efforts," he said.

"There's always hope and we're acting upon that hope right now, trying to get some answers for both the families involved.

"Anyone who locates any debris is asked not to touch it and called police link immediately.

"I'm calling upon any witnesses who may have seen this plane between the hours of 10.00am and 11.00am yesterday in the proximity of the coastline of South Stradbroke Island."


PHOTO: Police divers in the water assisting in the search. (ABC News)



Pilot regular at airstrip and 'very experienced'


Southport Flying Club president Neil Aitkenhead said Mr van Hattem was a regular at the airstrip and "very experienced".


"It's always bad news to hear and until we know more, there's not a lot we can do," he said.

Mr Aitkenhead said the conditions had been "perfect" for flying and the aircraft was "very reliable, solid and Russian-built".

The Yak 52 is a Soviet-era training aircraft often used for aerobatics and scenic flights.

  
Next a rare (for the ATSB) actual interim report/update, on the anniversary of the crash of VH-EWE -    

Updated: 7 June 2019

The investigation into the collision with terrain involving Cessna 172S, VH-EWE, near Moorabbin Airport, Victoria, on 8 June 2018 is continuing.

The investigation is currently in the examination and analysis phase, which includes the examination of retained aircraft and engine components, maintenance documentation, the pilot’s experience, fuel records, and available electronic data.

During this phase, the available evidence is reviewed and evaluated to determine its relevance, validity, credibility, and relationship to other evidence and to the occurrence. Evidence can be vague, incomplete and or contradictory. This may prompt the collection of more evidence, which in turn needs to be analysed and examined – potentially adding to the length of an investigation.

Once the evidence analysis phase is complete, a final report will be drafted and undergo a rigorous internal review to ensure the report findings adequately and accurately reflect the analysis of available evidence. Final investigation reports also undergo other technical and administrative reviews to ensure they meet national and international standards for transport safety investigations.

Following the completion of the internal review, a draft of the final report will be sent to all directly involved parties for their comment before the report is finalised and published

Currently, the anticipated completion and publication date of the final report is during the fourth quarter of 2019. However, should any safety issues be identified during any phase of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.

And finally an actual final report...   - 

Loss of control and collision with terrain involving Cirrus SR22, VH-PDC, Orange Airport, NSW, on 15 May 2018

What happened

On 15 May 2018, at 1903 Eastern Standard Time, a Cirrus SR22 aircraft, registered VH‑PDC, collided with terrain at Orange Airport, New South Wales. The accident was a night training flight with one pilot (aircraft owner) and one flight instructor on board. The pilot and instructor were seriously injured and the aircraft destroyed.

What the ATSB found

The ATSB found that the pilot, who was conducting his first night training flight, likely became spatially disorientated during a go-around manoeuvre, which resulted in a loss of control at low level and collision with terrain.

The flight instructor did not intervene to take control of the aircraft during the go-around manoeuvre, because she was not aware the pilot had become spatially disorientated and was accustomed to directing the pilot to correct control problems. Inconsistent with Civil Aviation Safety Authority guidance, the instructor, who had previously instructed the pilot for his private instrument rating, did not provide a night flying demonstration before directing the pilot around the circuit.

Safety message

It is important for flight instructors to provide a demonstration when introducing a pilot to a new flight sequence or new flight environment. Time spent demonstrating the key points of a new sequence or environment will usually improve the learning process by ensuring that the development of a new skill is supported and preceded by knowledge and understanding from experience.

The flight instructor reported that for the delivery of future initial night flying training, she would conduct either a separate session of daytime flying training circuits prior to night, or deliver the training as day-into-night circuit training. She also commented that, prior to teaching night flying, flying training organisations should consider conducting refresher training in unusual attitude recoveries, irrespective of a pilot’s level of experience and qualifications.

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Disorientation caused Cirrus Crash: ATSB
6 June 2019
Comments 0 Comments
    
The Australian Transport Safety Bureau (ATSB) has found that spatial disorientation contributed to the crash of a Cirrus SR22 at Orange last year.
A pilot and instructor were on board VH-PDC conducting night training at Orange in May 2018 when the aircraft crashed during a go-around attempt. The aircraft was destroyed and both the occupants were seriously injured.

The ATSB investigation report released today found that during the go-around the pilot became spatially disoriented, which resulted in a loss of control. According to the report, the instructor was not aware the pilot had become disoriented and so continued to direct the pilot rather than intervene.

During the go-around, the aircraft pitched up in response to power and began to roll to the left. Because the pilot–who had a private instrument rating–lost sight of the runway lights and the night was pitch black, he became disoriented.

"When full power was applied, the aircraft pitched up," the report states. "As the pilot was attempting to transition his scan onto the instruments, the instructor, whose attention was on the attitude indicator, directed him repeatedly to level the wings – 'wings level'.

"The pilot observed the runway lights disappear off to the right and felt the aircraft was in a roll as he was trying to focus his attention on the attitude indicator."

Although the pilot reported trying to correct the aircraft, it struck a fence and came to rest upside down. The time from the decision to go-around to impact was only seven seconds.

The instructor reported that she did not take control in this situation because the side-stick in the SR22 made it difficult to do so, and also because the during the previous night circuit the pilot had responded well to direction. She also said that by the time she understood the pilot was disoriented there was no time left to avoid the crash.

The incident also prompted the ATSB to issue a warning to would-be rescuers about the risk involved with ballistic recovery systems (airframe parachutes). In this instance, the Cirrus Airframe Parachute System (CAPS) rocket fired uncommanded nine minutes after the crash.

"The post-impact deployment of the aircraft’s parachute recovery system highlights an important safety message for emergency personnel and others who attend aviation accidents, to be aware of the potential dangers of an unactivated rocket-deployed parachute systems," the ATSB warned.

"The mishandling or misidentification of these systems could be fatal."

The full investigation report and ballistic recovery system warning can be found on the ATSB website.

Read more at http://www.australianflying.com.au/lates...krC6gkK.99

On the last in case you missed it here is the ATSB spectacular video footage of the CAP rocket firing off from the burning wreckage of the Cirrus...  

 

MTF...P2 

[Peetwo]

Vortex sleepy pilot investigation completed -   

Remember this? 

Ironsider follow up to snoozing pilot incident - 

via the Oz today:

Pilot fell asleep at wheel
ROBYN IRONSIDE
Two investigations are under way into a freight flight that overflew its destination because the pilot was asleep

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Freight pilot’s 40 winks propels two safety investigations

Two investigations are under way into a freight flight that overflew its destination by almost 50km because the pilot was asleep.

The Civil Aviation Safety Authority is investigating the fatigu­e management practices of flight operator Vortex Air.

The Australian Transport Safety Bureau is also investigat­ing the incident, which it classified as “pilot incapacitation”.

The flight left Devonport in Tasmania at 6.20am on November 8, to make the 250km trip to King Island. It was the first flight of the day for the Piper PA-31-350 Navajo Chieftain, which can carry up to 700kg of freight.

The Australian understands the pilot reported for duty despite having had little or no sleep the prev­ious night due to a personal crisis. He was the only person on board and, according to the ATSB investigation summary, fell asleep during the cruise part of the one-hour flight.

It’s thought a radio call may have woken him after the aircraft overflew King Island Airport by 46km. The Piper landed safely just after 7.20am, then went on to do six further flights that day.

The ATSB investigation was launched in response to “addit­ion­al information” received by the bureau in the past week but a spokesman was unable to provide any further details.

As part of the investigation, the pilot would be interviewed and operational procedures reviewed, the ATSB summary said.

A CASA spokesman said its investigation would focus on the fatigue risk-management practices of Vortex Air to ensure it met Australian standards.

Vortex managing director Colin Tucker refused to comment yesterday on the incident.

Devonport Airport general manager Dave Race said Vortex Air was a reputable and safe operator that conducted regular flights, carrying freight and passengers to King Island, which boasts three golf courses.

King Island Council Mayor David Munday also described Vortex as a “professional” airline.

Research undertaken by the ATSB on pilot incapacitation incide­nts in Australia between 2010 and 2014 found they were rare in the general aviation sector.

There are only two reported cases of pilots falling asleep on the job. In one case, the pilot of a Cessna 210 Centurion awoke to find he had entered controlled airspace twice without clearance while flying from Port Macquarie on the NSW mid-north coast to Bankstown in Sydney. In the second, a passenger awoke the pilot of a Gippsland GA-8 who nodded off doing locust spotting over farmland in Ardlethan, NSW.

This today from the ATSB:

Acute fatigue leads to pilot incapacitation

A pilot was experiencing acute levels of fatigue before falling asleep during an early morning freight flight from Devonport to King Island, an ATSB investigation has confirmed.



The Piper PA-31-350 aircraft had reached top of descent into King Island when the pilot, who was the only person on board, started to feel tired and quickly fell asleep. After several unsuccessful attempts by ATC and other pilots in the area to contact the pilot, he awoke and advised ATC operations were normal and that he was turning back to King Island.

While on autopilot the aircraft had overflown the island by approximately 78 km to the north-west.

The aircraft landed without further incident. However, after talking with the operator, the pilot then flew from King Island to Moorabbin to complete his shift.

The ATSB found that the pilot had been awake for about 24 hours and had been unable to sleep during a scheduled rest period before the incident flight. Analysis confirmed the pilot’s fatigue was at a level known to effect performance, while further analysis showed that even if the pilot had been able to sleep during his rest period he still would have been fatigued to a level known to affect performance.

In addition, the pilot had not modified his sleep pattern in preparation for the planned night shift, contributing to his fatigue.

The ATSB found that the pilot had been awake for about 24 hours and had been unable to sleep during a scheduled rest period before the incident flight.

“This investigation highlights the need for pilots to assess their level of fatigue before and during their flight,” said ATSB Executive Director, Transport Safety, Mr Nat Nagy.

“Before commencing night operations pilots are encouraged to modify their usual sleep routines to ensure they are adequately rested.”
The ATSB also calls on operators to consider the risks of allowing a pilot to continue operating directly after a fatigue-related incident without corrective management.

“Just as it is the pilot’s responsibility to use rest periods to get adequate sleep and to remove themselves from duty if they feel fatigued, it is also incumbent on operators to implement policies and create an organisational culture where flight crew can report fatigue and remove themselves from duty in a supportive environment,” Mr Nagy said.

Information on fatigue management is available from the Civil Aviation Safety Authority and ATSBwebsites.

Read the investigation report AO-2018-075: Pilot incapacitation involving Piper PA-31, VH-TWU, near King Island, Tasmania, on 8 November 2018

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& fm Ironsider, via the Oz:

Pilot who fell asleep at controls was allo



A Piper PA-31 Navajo aircraft. Aviation

• ROBYN IRONSIDE
  AVIATION WRITER
  @ironsider
  
• 2 HOURS AGO JUNE 25, 2019
  
• NO COMMENTS
  

A pilot who fell asleep while operating a cargo flight in Tasmania had been awake for 24-hours prior to the incident.
An Australian Transport Safety Bureau report into the incident, which occurred on November 8 last year, found the pilot was “acutely fatigued to a level affecting performance”.

Despite his lack of sleep, the pilot flew from Moorabbin in Victoria to Devonport, Tasmania, had a three-hour break, then headed off again to fly to King Island.

During the flight he nodded off, waking up to find he was almost 80km past his destination.

From 7.25am to 7.33am, air traffic control tried to contact the pilot without a response.

The ATSB report said at 7.33am a transmission was received from the pilot who advised that operations were normal.


An investigation has been launched into an incident in which a pilot fell asleep during a one-hour charter flight, resulting in the aircraft overflying its destination by 46km. The 6.21am Vortex Air flight from Devonport to King Island on November 8

He landed the Piper PA-31 at King Island at 7.55am and contacted his supervisor and air traffic control in Melbourne to discuss what happened. 

Despite the in-flight nap, the pilot was allowed to finish his shift, flying from King Island back to Moorabbin. 

The ATSB investigation found the pilot recalled not feeling fatigued before the morning flight which was his first after five days off.

During the three hour break at Devonport, the pilot said he rested but didn’t sleep.

“From the information reported by the pilot, it was determined that at the time of the occurrence, the pilot had been awake for about 24-hours,” said the report.

“Using the information obtained at interview and the pilot’s roster, fatigue analysis was conducted, which identified that the pilot was acutely fatigues to a level known to affect performance.”

The report took aim at operator, Vortex Air, pointing out that “despite knowing the circumstances of the incident, no measures were put in place to ensure the pilot was fit to continue the shift”.

“This resulted in the pilot continuing to fly the aircraft while still being fatigued to a level known to affect performance,” said the report.

Vortex Air managing director Colin Tucker said he spoke to the pilot on the ground that morning, and he assured him he was fine to fly.

He described the incident as a “tiny blip” that had caused considerable damage to the company despite its “exemplary safety record”.

“We’ve been flying for 15-years and it damages your brand. It’s a competitive air space we fly in,” Mr Tucker said.

He said the pilot was badly affected by publicity surrounding the incident but had returned to flying and was doing well.

“If you’ve been on leave for five days before a shift, there’s nothing as an organisation we could’ve done,” said Mr Tucker, adding the pilot was aware of his roster before he went on leave.

Changes had since been made to the rostering system to provide more notice for pilots but Mr Tucker said occasionally last minute changes were necessary.

Well this must be some kind of all time record for the Hooded Canary led ATSB i.e 7 months and 18 days to complete an aviation occurrence investigation?? - Yeah right...  

My cynical but best guess is that given there was apparently a regulator investigation run in parallel, that Fort Fumble are getting ready to drop the Big E-enforcement bomb on this Vortex mob and needed the Hooded Canary mob to be out of the picture...  

Q/What is it with all the YMMB connections (CASA Southern Region) of late? Hmm...I see some very big dots and dashes appearing before my eyes...  


MTF...P2 

[Kharon]

Very short update from ATSB re the latest YAK accident; the fall out and CASA response could be interesting.

[Peetwo]

Very short update from ATSB re the latest YAK accident; the fall out and CASA response could be interesting.

And courtesy Ironsider and the Oz:

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Graphic wreckage of fatal Queensland plane crash



The Australian Transport Safety Bureau has released a confronting image of the remains of a light aircraft that crashed off southeast Queensland last month, killing the pilot and passenger.

A preliminary report on the crash of the Yakovlev Yak-52 said the wreckage was indicative of a high speed impact.

Private pilot Marcel van Hattem was taking friend Trista Applebee for a 30-minute joyflight on the morning of June 5 ahead of her 32nd birthday the following day.

When they failed to return to Southport airfield after the designated time, a second passenger waiting for a turn, raised the alarm with members of the Southport Flying Club.

Just after 1pm, Airservices Australia was contacted by club members, and within an hour the Australian Maritime Safety Authority initiated search and rescue operations.

Later that afternoon part of a propeller was found on the eastern side of South Stradbroke Island.

More wreckage was found in the following days, including the left side of the fuselage, part of the right wing and propeller pieces, along with the bodies of the pilot and passenger.

The report said Mr van Hattem held a private pilot licence and a class 2 aviation medical certificate, and had received both aerobatic and spinning endorsements in January.

His logbook indicated he had 490-hours of flying experience, including 38-hours in the Yak-52 registered VH-PAE.

Records show the aircraft had undergone maintenance five days before the crash, and had accumulated 1164 hours of total time in service.

The report did not reach any conclusions on why the plane crashed with investigators to look further into recovered aircraft components, maintenance records, pilot experience, weather conditions and witness reports.

The ATSB acknowledged the assistance of the Queensland Police Service, and said the final report should be completed in the first quarter of next year.

[Peetwo]

ATSB Mount Gambier Angel Flight report out -   

Has the Hooded Canary buried Angel Flight? You be the judge, via the ATCB:

ATSB investigation highlights risks of community service flights


Source: Mount Gambier Airport
An Australian Transport Safety Bureau investigation has found that community service flights conducted on behalf of Angel Flight Australia have a fatal accident rate per flight that is seven times higher than for other private flights.

That was a key finding of the first analysis to be undertaken in Australia to determine the relative safety of Angel Flight compared to other private flying operations, after a second fatal accident involving the charity in the past decade.

The analysis was conducted as part of the ATSB’s investigation into the collision with terrain of a SOCATA TB-10 Tobago light aircraft near Mount Gambier Airport, South Australia, on 28 June 2017. The aircraft had departed Mount Gambier in poor weather bound for Adelaide, transporting a young person to a medical treatment appointment on behalf of Angel Flight, accompanied by a family member.

Shortly after take-off the aircraft entered low-level cloud (estimated to be about 200 feet above ground level), and the pilot, who was not qualified to fly in other than visual conditions, probably became spatially disorientated, resulting in a loss of control of the aircraft.

Our analysis of the circumstances of this tragic accident highlights that passengers on Angel Flight community service flights, and indeed their volunteer pilots, are being exposed to much higher levels of risk

About 70 seconds after take-off, the aircraft collided with the ground. Both passengers and the volunteer pilot were fatally injured, and the aircraft was destroyed.

“The ATSB considers that the conduct of community service flights, where volunteer pilots flying private aircraft to transport those less fortunate requiring medical treatment from regional and rural Australia, demonstrates a laudable concern for others,” ATSB Chief Commissioner Greg Hood said.

“However, our analysis of the circumstances of this tragic accident highlights that passengers on Angel Flight community service flights, and indeed their volunteer pilots, are being exposed to much higher levels of risk compared with other types of aviation operations.”

Community service flights operating on behalf of Angel Flight do so as private flights, which the Civil Aviation Safety Authority (CASA) defines as “flying for pleasure, sport or recreation, or personal transport not associated with a business or profession”.

However, the ATSB investigation showed that the rate of safety occurrences, which can be pre-cursors of fatal accidents, was substantially higher for passenger carrying Angel Flight operations than other private operations. This is almost certainly due to pilots operating community service flights on behalf of Angel Flight being exposed to additional operational risk factors.


Source: South Australia Police

These include the potential for pilots to experience perceived or self-imposed pressures to take on what Angel Flight described as ‘missions’ to fly ill, unrelated passengers (rather than family  or friends) at pre-determined times and locations to meet scheduled medical appointments, rather than at times chosen by the pilot.

“Angel Flight did not pressure pilots to fly in conditions beyond their capability, but some circumstances can lead a pilot to feel pressure anyway, such as the responsibility to fly unrelated ill passengers to meet medical deadlines. This can lead to degraded decision making under high-pressure situations, like when confronted with poor weather,” Commissioner Hood said.

On the morning of the Mount Gambier accident two regional airliner flights into Mount Gambier were delayed due to the poor weather, Commissioner Hood noted.

The ATSB’s analysis determined pilots flying on behalf of Angel Flight were more likely to make operational errors when compared to other private operations, particularly associated with flight preparation and navigation, airspace, runway events, and communications breakdowns.
 
“The community could reasonably expect that community service flights would have a level of safety at least commensurate with other private operations, if not higher. However, this investigation has shown that those conducted for Angel Flight are actually less safe than other private operations, let alone charter and scheduled airline flying,” Commissioner Hood said.

Earlier ATSB research has already established that private flying has a fatal accident rate per flight that is eight times higher than commercial charter operations and 27 times higher than low-capacity scheduled airline flying. Further, there have been no fatalities involving a high capacity airliner in Australia in more than 40 years.

“Given the factors identified for the accident at Mount Gambier and previously with another Angel Flight fatal accident in 2011, supported by the differences identified in the analysis of safety occurrences and consistent with findings from investigations of similar organisations in the United States, the ATSB considers that measures must be undertaken to improve existing risk controls,” Commissioner Hood said.

The ATSB commends Angel Flight for initiating some pro-active action on a number of the investigation’s identified safety issues, including developing an online safety course, planning a pilot mentoring program, and implementing a safety management system. The ATSB will continue to monitor the implementation of these and other controls to ensure pilots receive sufficient support and guidance to deal with the additional risks faced by private pilots when conducting a flight on behalf of Angel Flight.

However, the ATSB has issued a formal safety recommendation to Angel Flight Australia, recommending that it consider paying for commercial flights where they are available to transport its passengers.

“This ATSB investigation showed that commercial passenger flight options are available for nearly two-thirds of the private flights organised by Angel Flight,” Commissioner Hood said.

Angel Flight could purchase tickets on commercial flights for two passengers for a comparable cost to the organisation to what they normally reimburse for the fuel costs of privately-operated flights. Taking into account other passenger needs, 30 to 40 per cent of flights could be done using existing commercial flights.

“As a charity established to transport rural and regional people with limited financial means to medical appointments, the ATSB considers that Angel Flight could and should include the fact that commercial passenger flights have a lower safety risk to passengers than private operations as a factor when they are organising flights.”

Commissioner Hood noted that on the day of the Mount Gambier accident, suitable and cost-comparative airline flights were available.
In response to a separate safety issue raised by the ATSB’s investigation, CASA has taken proactive safety action by ensuring community services flights can now be identified separately to other private operations, which will better enable it to identify risks in the sector into the future.

“The ATSB is supportive of the community service flight sector, however, based upon the analysis conducted, it is essential that the controls for risk are strengthened to prevent further accidents,” Commissioner Hood said.

Read the investigation report AO-2017-068: Collision with terrain involving SOCATA TB-10 Tobago, VH-YTM, near Mount Gambier Airport, South Australia, on 28 June 2017 

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And via Oz Flying:






Angel Flight should be using Public Transport: ATSB
13 August 2019

The Australian Transport Safety Bureau (ATSB) has recommended that Angel Flight clients should be placed on regular public transport (RPT) flights rather allow private pilots to fly missions.

The conclusion was part of an investigation report released this morning into the 2017 crash of a TB10 Tobago at Mount Gambier on an Angel Flight mission.

According to the ATSB, the pilot of VH-YTM was ferrying passengers from Mount Gambier to Adelaide in June 2017 when he took off into low cloud and poor visibility. The aircraft reached a maximum altitude of only 300 feet before it descended and struck terrain about a minute after take-off. All three on board were killed. The flight was VFR and the ATSB considered the pilot did not have IFR proficiency.

" ... the pilot took off in low-level cloud without proficiency for flight in instrument meteorological conditions," the report states. "Shortly after take-off, the pilot likely lost visual cues and probably became spatially disorientated, resulting in loss of control of the aircraft and collision with terrain."

Cameras at Mount Gambier airport and GPS tracks showed the pilot conducted a series of non-standard turns during his initial approach to the airport and that conditions were marginal.

Among its findings, the ATSB stated that Angel Flight's incident rate was "considerably more" than other private operations, that Angel Flight didn't have controls in place to address operational risks involved in community service flights and that CASA didn't have a system in place to differentiate between community service flights and normal operations.

"The ATSB found two aspects in particular likely contributed to this higher rate," the ATSB explained. "These were the potential for some pilots to experience perceived or self-induced pressure by taking on the responsibility to fly ill, unknown passengers, at scheduled times to meet predetermined medical appointments, often with an expected same day return; and the required operation to unfamiliar locations, and limited familiarity with procedures in controlled airspace (associated with larger aerodromes)."

The ATSB also slammed Angel Flight for not having placed the passengers on commercial RPT.

"It was identified that Angel Flight did not consider the safety benefits of commercial flights when suitable flights were available, the report states.

"While Angel Flight arranged and paid for commercial flights (18% of all flights) for capital city transfers, or when private pilots cancelled, it was estimated that nearly two-thirds of the private flights conducted for Angel Flight had a commercial regular public transport option available, which offered considerable safety benefits when compared to private operations.

In a media statement accompanying the reports, ATSB Chief Commissioner Greg Hood said that Angel Flight should use RPT as a first resort.
"The ATSB has issued a formal safety recommendation to Angel Flight Australia, recommending that it consider paying for commercial flights where they are available to transport its passengers," Hood said.

“This ATSB investigation showed that commercial passenger flight options are available for nearly two-thirds of the private flights organised by Angel Flight.

"Angel Flight could purchase tickets on commercial flights for two passengers for a comparable cost to the organisation to what they normally reimburse for the fuel costs of privately-operated flights. Taking into account other passenger needs, 30 to 40% of flights could be done using existing commercial flights.

Angel Flight responded to the safety concerns raised in the investigation by saying it considered it inappropriate for the ATSB to criticise them for not abandoning the model for which they were constituted.

"Angel Flight only consider[s] the use of regular passenger transport in two circumstances: if a private pilot is unavailable or cancels at short notice and flights are available, or if the flights are capital city to capital city.

"They are not, and are not required to be, considered other than as a back-up and for long distance compassionate flights."

In March this year, CASA instituted new restrictions on pilots conducting community service flights, which is currently the subject of legal action between Angel Flight and the regulator. The matter has also been listed for disallowance motions in both the Senate and the House of Representatives.

Read more at http://www.australianflying.com.au/lates...toxGB4V.99

Hmm...I find it passing strange that despite the ATSB stating on all active investigations similar words to the effect...

..should any safety issues be identified during any phase of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue...

 
 ...that the ATSB in this case waited till the final report release day to issue a very rare safety recommendation directly to Angel Flight:

Safety issue description

Angel Flight did not consider the safety benefits of commercial passenger flights when suitable flights were available.

Response to safety issue from Angel Flight: Angel Flight consider it inappropriate for [the ATSB] to criticise the charity for not abandoning the model for which it was constituted. Angel Flight only consider the use of regular passenger transport in two circumstances: if a private pilot is unavailable or cancels at short notice and flights are available, or if the flights are capital city to capital city. They are not, and are not required to be, considered other than as a back-up and for long distance compassionate flights.

ATSB comment: The ATSB acknowledges that Angel Flight uses commercial passenger transport for some flights it organises. This ATSB investigation showed that commercial passenger flight options are available for a considerable percentage of the private flights organised by Angel Flight. As a charity established to transport people without the means to medical appointments, the ATSB considers that Angel Flight could and should include the fact that commercial passenger flights have a lower safety risk to passengers than private operations as a factor when it is organising flights.

The ATSB is issuing the following recommendation.

Recommendation

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Action organisation: Angel Flight Australia

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Action number: AO-2017-069-SR-015

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Date: 13 August 2019

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Action status: Released

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The Australian Transport Safety Bureau recommends that Angel Flight Australia takes action to enable it to consider the safety benefits of using commercial flights where they are available to transport its passengers.

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Current issue status: Safety action pending

So despite conducting an exhaustive 2+year investigation the Hooded Canary only now considers the Angel Flight response/action to the initial identified safety issue as unsatisfactory and therefore requiring the issuing of a safety recommendation - yeah right. Note that the initial identified safety issue is also dated 13 August 2019 (see HERE) but given the Angel Flight response obviously that is not possible. 

Still reading but at this stage this report IMO is the biggest bureaucratic stitch up since the PelAir ditching and there will be definitely MTF...

[Cap'n Wannabe]

Angel Flight's response to the ATSB report:

ANGEL FLIGHT RESPONSE TO ATSB REPORT 13 august 2019

ANGEL FLIGHT IS AUSTRALIA’S LARGEST AND LONGEST-SERVING CHARITY FACILITATING COMMUNITY BENEFIT FLYING

Angel Flight has co-ordinated free flights for more than 100,000 disadvantaged rural Australians, whose only other option to attend city hospitals for specialist treatment is ground transport – often taking days each way, at times with the driver/ patients being very elderly or accompanying very young children, on dangerous outback roads. These people cannot afford commercial air travel, which is more often than not, unavailable from their hometowns. Angel Flight recognises, publicly and privately with the affected people, the consequences of tragic fatal accidents, wherever and in whatever circumstances they occur, and is (and has always been) committed to safety and welfare as its priority.

THE ATSB REPORT INTO THE ACCIDENT AT MT GAMBIER ON 20 JUNE 2017

RECOMMENDATIONS

The ATSB offered no safety recommendations to pilots flying light aircraft in bad weather.

The safety recommendation made was for the charity to book people on airlines for travel: this does not adequately factor in cost (particularly where two or more people are travelling, which is often the case); nor does it properly factor in the infrequent scheduling or non-existence of airline flights into country regions across Australia; the
inconvenience and difficulties faced by the elderly and families with young children at major city airports, and the associated ground travel; and appears to work on the assumption that city specialists and hospitals will gear their appointment times around airline timetables. Angel Flight does use airline flights where practicable and necessary, and will continue to utilise these services.

The rules implemented by CASA were not directed to the cause of the 2017 accident, or any other accident in the community benefit sector, and the ATSB has not given any support for those rules, save and except for that requiring pilots to write community benefit flights up in their log books, and note that fact on flight plans: the only flow-on from those rules is one of policing data – the very same data has been given by the charity to the ATSB.

It is regrettable, that the Bureau made no relevant safety recommendations, nor gave any guidance whatsoever, to pilots flying in poor weather conditions – the cause of the accident: it would have been of benefit to the flying community had the ATSB focussed on these aspects of the accident.

The safety message raised – induction training and safety management systems, together with a pilot mentoring programme, had already been implemented by the charity prior to the ATSB report and recommendations. Angel Flight takes, and has taken, a very serious and proactive approach to improving safety, and will continue to do so. Angel Flight will continue to urge CASA to improve its Human Factors training in the pre-licencing stage of training, in addition to the refresher courses now offered.

THE DATA

The charity engaged two senior expert statisticians and an analyst, all of whom concluded that the accident rate was not significantly different from the rate for other private flying across Australia.  The ATSB also chose to compare only the passenger-carrying sectors of flights coordinated by the charity –it disregarded the flights, also coordinated by the charity, where the aircraft flew from home base to the city collection points, the return trips back to base, and the positioning flights to collect passengers from their own home towns: it did, however, include those flights when reporting ‘occurrences’ against the charity flights. There was, and is, no reason for this failure. To
remove up to two-thirds of the coordinated flights in order to make statistical conclusions is unjustifiable. Moreover, when comparing the data with private flights generally, it did not exclude the non-passenger flights for that group – all flights were counted in the general private sector, but not in the charity sector.

Angel Flight has coordinated more than 46,000 flights for the purpose of travelling to, returning from and carrying rural Australians to the city for non-emergency medical appointments. The ATSB has excluded more than half of these flights when assessing accident rates, with the result being to substantially increase the alleged statistical accident rates.

THE EXACERBATION OF THE DATA ERRORS

The ATSB has not adopted its own protocols (and those followed in the US) of counting flight hours for general aviation accidents - instead it counted only flight numbers. An example of that methodology, further invalidating the findings, is (a common route), where the pilot departs home base in Tyabb, flies to Essendon to collect passengers, flies from Essendon to Hay, then returns to Tyabb (three sectors) – this is counted as one flight by the ATSB for its statistical purposes. The flight time for this route in a Cessna 182 would be at least 3.5 hours yet the ATSB gives it is given the same status as a 6-minute touch-and-go circuit at Essendon. To disregard both the actual flight numbers, and the flight hours, compounds the errors (and unreliability) of the findings to an extraordinary degree.

OCCURRENCES

The ATSB also looked at ‘Occurrences’ in controlled airspace (in comparison with private flights generally, most of which occur in uncontrolled space, and therefore are not reported). The ATSB acknowledged that they have no data from flights OCTA, so they did not take that fact into account.  The investigators also included in the occurrence data (adverse to the charity), instances where the admitted and conclusive report findings included ATC errors; errors of other aircraft causing safety breaches (not the fault of the charity flight); the proper reporting by the charity-organised flights where others had caused danger (including, for example, a pilot reporting a model aircraft illegally
on a flight path, causing the authorised charity aircraft to take evasive action: this was included as a ‘negative’ occurrence against the charity; and diversions to other airports in the interests of safety.

This cannot be regarded as valid in the collection of statistical data, and nor was it found to be so by the experts.

OTHER FINDINGS

The ATSB, amongst its findings, noted that Angel Flight was planning a mentoring program: this is incorrect, and known to the ATSB – the charity implemented its pilot mentoring programme more than a year ago. It was required to stop because CASA introduced rules which imposed restrictions on who could accompany a pilot, as was made very clear by the written advice of a senior CASA executive that “another pilot can accompany a pilot on a CSF as operating crew, so long as the other pilot qualifies to be a co-pilot of the aircraft and has such duties in relation to the CSF”: this clearly precludes pilots from being on board for mentoring, familiarisation, and observation of Angel Flight’s processes and safety culture.

FUTHER OVERLOOKED FACTS

It has not been acknowledged that all volunteers operating their own (CASA-approved and maintained) aircraft for the purpose of these community benefit flights, are CASA-licensed, CASA trained, and CASA-tested on a one or two-yearly basis. Angel Flight has ensured that the volunteer pilot qualifications are not less than as permitted by the Civil Aviation Safety Regulations, and for the entire period leading to the investigation (14 years), these pilots have had substantially more than the required experience for passenger-carrying private flights in Australia. The new Rules decreed by CASA would have had no bearing on the accident under investigation, and this has been acknowledged by CASA. The pilot under investigation had greater experience than that required by either the former or the current Rules.

Angel Flight has been urging CASA for a substantial time, to re-visit and strengthen the training of its pilots in the human factors area prior to issuing licences. With the additional safety, risk management and induction training that Angel Flight has already implemented, the addition of CASA training would be beneficial for all pilots in this and other general aviation environments.

This message has been authorised by Angel Flight Australia.

[Kharon]

Yes, I learned about ‘flying from that.

Hitch – “Visual flight into instrument weather has been resulting in tragedy after tragedy for as long as there have been aeroplanes and bad weather.

True enough – and, as a short precursor to a serious problem, not a bad place to begin a discussion of basic tenets. The question (IMO) is where lays the radical ‘base of error’?

Must we look at human nature – now there’s a puzzle that has confounded both fools and wise folk for millennia. Is it just too hard to quantify? Gods know many have tried to put that particular genie into neatly labelled bottles – and failed; spectacularly. You need look no further than the carnage on roads (worldwide) to realise you simply cannot make a prediction on how any individual will, or will not respond to a given set of circumstance, mind set or even their own and the ‘safety’ of others; well not on a global scale anyway. So, where do we look for a balanced solution to the VFR pilot straying into solid instrument conditions?

Hitch – “And there will be a lot more of it given that it is often the result of a poor decision and pilots are probably going to continue to make poor decisions.”

But is it really that simple? Deciding what to have for breakfast may, or may not be a poor or good decision; the consequences insignificant in the great scheme of things. Deciding to push a small, low performance airframe into high performance weather is an animal of an entirely different colour. I think we can set the psychology aside for a moment (only a moment) and take look at the ‘temptations’; what are they? What creates them – what motives? The modern era has laid many traps: precision navigation tools which can get you to tin can in the middle of the Sahara at midnight, coupled with an auto pilot which performs beautifully for example. This false security is aided and abetted by weather forecast which, despite the science supporting is still, to this day, regarded as purely a guide (+/- 70%).

Even so, we need to understand what possessed the Mt Gambier pilot to believe he could take off into a clear, visible, active and present danger situation.

Back in the day Mack Job published wise articles; retrospective for sure, after the fact; but nonetheless valuable for that. Cautionary tales which were not only read by countless pilots, young and old, when published, but kept and re-read many times. The cautionary tales were written to take you along on the experience; made you think and had real credibility, to all stripes of pilots. A collective, shared experience. You had no need to gain this experience yourself, it was gifted to you. Thus, in my own case least, my first encounter with the known killers, ice, storm, darkness, failing engines etc. was met with at least some previous knowledge of the pitfalls and traps for young players. The ‘experience’ was gained second hand, but it came from the horse’s mouth; so to speak.

The juxtaposition is equally compelling; IMC these days is predicted with some semblance of accuracy – give or take; it is freely available to all – no charge. Not perfect but a good place to begin deliberations - pre departure. No amount of paper can ensure that a pilot will ‘comprehend’ the implications contained within a ‘briefing’ - particularly those who are not familiar with the subtle, cut and dried, abbreviated, often cryptic acronyms. “Looks a bit crook, we’ll go and take a look”. Famous last words?– Yes; in some cases, but not in all. Many more take the punt than do not – and are often proven correct. Often, enough get through and feed the legend that with guile, cunning and a back door, the dire predictions of the BoM are ‘useful’ - but padded. This feeding of the legend is dangerous. Ask any experienced Australian instrument pilot how many approaches they’ve been obliged to fly to published minima and not ‘gotten in’; then ask how many approached they gave away and diverted; then ask how many times they ‘got in’ second try. Believe me, they will remember each and every one; for there will not be many.

So, what’s to be done?

Only my opinion, but I believe there are a couple of things which may be done that would be of great assistance. We need to begin at the beginning – and acknowledge that there will be instances where a VFR Pilot will get ‘trapped’. For it happens and will probably continue to happen.

In the grand scale of expensive ‘safety initiatives’, it would cost ATSB/CASA very little to collate and publish the collection of ‘I learned about flying’ and other educational articles contained in the old ‘Crash Comic’. Make it a mandatory, examinable text for the issue of a PPL, bring the stark reality of the dangers into sharp focus, early in the piece. Education 101.

Secondly, I’d like to see an analysis of the results of an inadvertent entry to IMC, in terms of ‘what happens’. For example – the percentage of ‘spins’, the percentage of significant height loss, the percentage of steep turn/stall/ spin, the percentage of CFIT. From this data training programs could be modified to ensure that when an aircraft is caught out, the PIC has the basic skills to reverse a track, or divert while being aware of the terrain below v cloud base/ turbulence/visibility equation. I don’t know how flying at an ab intio level is taught these days; but I and many of my peers were taught to confirm, on instruments, the ‘attitude’ we were to fly, from lesson one. The transition to IF became simply an extension of first flight, not an entirely new method of operating. – Training 101.

Lastly, I would like to see more emphasis placed on ‘practical’ meteorology. By this I mean the ability to ‘read’ an area or terminal report as a static depiction of a dynamic situation as it will affect the flight path. From this ‘escape’ plans can be developed. An overlay if you like: there on the GPS is the flight path – but in your mind is a picture of the weather situation developing during the flight time. So if the ETA at Kickatinalong becomes the same as the front, the back door is consciously kept open. The BoM (bless ‘em) cannot do this for you, it is part and parcel of a pilot’s tool kit, a skill developed only through education and with conscious practice. Situational awareness 101.

Without a Ouija board we cannot tell what the Mt Gambier pilot was thinking or how he came to make the decisions he did. What we can define is what he should have been thinking; it is probably time for the right thinking to be taught and reinforced, from day one, lesson one.

Was the fatal accident Angel Flights problem? I don’t think so. Has ATSB taken steps to prevent a reoccurrence? Have CASA taken a long hard look at the problem and designed an enhanced safety training program? You know the answer as well as I do.

Aye well, my two bob, spent as pleased me best; a small punt on the ‘Blame game’ race to the bottom.

Toot – toot.

[thorn bird]

Sober valid thoughts K,

a great deal of merit in what you annunciate.

These types of accidents have been happening since the Wright brothers and defy whatever attempts are made to find a fix. Back when Methuselah was a pup and I was instructing abinitio pilots, when an opportunity presented itself and could be safely done, I'd fly them into cloud and let them experience just how quick spatial disorientation occurs. Guess these days I'd be sitting in a jail cell pondering what heinous crime I'd committed against the MOS, never to instruct again.

But I can't help pondering the cause and effect of Australia's unique tranche of gobbledygook our regulator provides us that increases the cost of operating an aircraft to over double the cost of the same aircraft in the USA.

In the USA gaining an instrument rating is a fairly simple, affordable exercise. Maintaining it is also a straight forward affordable exercise. In this modern IT world almost anyone can afford a computer based flight sim to polish up those skills, my eight year old grandson can fly an ILS better than I can but has never put his hands on a control yoke of an  actual aircraft. At an airline I worked for the sim technician could fly the damned thing like it was on rails, yet had never had a flying lesson, self taught skills honed by practice.

In the USA over 80% of private pilots hold an instrument rating. In Australia very few do.

Could it therefore be said that over-regulation stifles participation by making it prohibitively expensive and therefore effectively makes it less safe?

Practice makes perfect.

[P7_TOM]

Mooney missing;

The Australian Maritime Safety Authority said in a statement it was aware of the overdue Mooney M20 aircraft and had tasked the Westpac Rescue Helicopter and a search-and-rescue jet with the search

Not much to add at this time: the post below from Prune sums it up, in a nutshell.

Clearedtoreenter:- “Be that as it may. The tragedy here is that 2 more people are dead and another family is devastated. We have no idea why this has occurred and we should not speculate in this case. However, in the context of thread drift, because we have no idea at this stage if this is what has happened yet again here, why do Visual Flight Rules into Instrument Meteorological Conditions continue to occur in this country? Those accidents are almost always fatal and too many good pilots and their passengers continue to be lost."

"Not many pilots here have instrument qualifications in Australia and maybe the 2 hours they did on instruments during training many moons ago is just is not enough when the chips are down?"

Fair comment I’d say.

[Kharon]

A two coffee read.

It has taken nearly 34 months to provide the ATSB report into:-


Collision with terrain following an engine power loss involving Cessna 172M, VH WTQ, 12 NM (22 km) north-west of Agnes Water, Queensland on 10 January 2017

It is a ‘long’ read and some of the details (below) are worthy of note. ATSB have made some serious efforts to establish why the engine failed when it did. That primary mystery remains unresolved, not from lack of effort on the ATSB part; I can’t think of much else they could have done. Even a simulation would not be able to duplicate the exact circumstances to determine if some weird ‘air-lock’ due to un-porting of a fuel feed had occurred would not provide definitive answers to the puzzle (IMO). So why the engine failed, when it did will remain unexplained. However, there are some salutary lessons to be learned from the detailed investigation.

There are some things which (again IMO) could have been done better by the operator. For example, the beach inspection protocols. Anyone who has flown ‘in-the-bush’ the real thing, knows how difficult it is to even spot (stationary) livestock on an ALA from much above 3/400 ft; below that objects become much clearer, so there is an identified ‘requirement’ to get ‘low and slow’. How low and how slow is difficult to define – in terms which could be realistically transposed into SOP.

ATSB. - The pilot of the accident flight reported that he normally conducted airborne inspections of Middle Island ALA at 150–200 ft. A review of the GPS data identified 19 previous inspections of Middle Island ALA, all of which were conducted by the pilot of the accident flight. The lowest altitudes recorded during these inspections were generally below 100 ft with a median value of about 60 ft (see Review of airborne inspections at Middle Island ALA ). Given the relatively constant descents and straight flight paths involved in these inspections, the GPS data was probably within the GPS manufacturer’s expected level of accuracy.

ATSB. - Overall, the ATSB concluded that the altitude at the time of the engine power loss was probably between 40 and 80 ft and therefore probably close to the GPS-based altitude of 60 ft.

ATSB. - The inspections were generally flown at 50–100 ft AMSL while flying at normal cruise speed towards an area of water at the end of the beach, with no planned consideration of what to do in the event of an emergency.

Valid points – there was a requirement for almost a 180˚ reversal around the headland to land into wind. Ref Fig 2. With 150 or 160 feet on the clock, would there have been a better outcome? With a little less speed and a handful of flap, could the outcome have been less damaging? I wonder, had there been a little less ‘thrill’ for passengers and a little more conservative thinking been applied, could the whole accident have been avoided. I don’t know; would I be flat chat, flapless, at 60 feet over a beach, with a reversal to follow – I don’t think so. This is the sort of ‘stuff’ that needs to written into an Ops Manual – company SOP. Murphey is everyman’s co-pilot and anything that can be done to keep his mucky paws out of the equation should be done.


Engine mystery.

The engine sustained a sudden and total power loss. The engine/propeller speed immediately reduced and then gradually decreased for the remainder of the flight (see Audio analysis of the engine/propeller speed).

ATSB - Despite a detailed inspection of the engine and related systems, the ATSB was unable to identify the reason for the loss of engine power.

ATSB - During the period immediately prior to the engine power loss, the indicated fuel quantity was about one quarter full on the left tank gauge and slightly above half full on the right tank gauge.

ATSB - Based on an hour meter reading documented in maintenance worksheets on 12 November 2015, the flight time documented on the maintenance releases underestimated the actual flight time by 62.2 hours (or about 40 per cent) during the period from the periodic inspection on 1 May 2015 to the next periodic inspection on 12 November 2015.

ATSB - There were multiple days on which flights were recorded on the aircraft’s GPS unit and/or the pilot of the accident flight had included flights in VH-WTQ in his logbook, but there was no certification on the maintenance release stating that a daily inspection or flights had been conducted (see Appendix A).

ATSB - Prior to the sudden engine power loss at 1037:34, the only anomaly in the engine/propeller sound during the flight occurred at 1036:13, when there was a momentary reduction of engine/propeller speed before it recovered to its normal setting. This occurred during a rapid though brief pitch-down manoeuvre. The brief reduction in power appeared to be consistent with what would expected with the normal operation of the carburettor in such a manoeuvre and would have had no long-term effect.

The Go-Pro puzzle.

ATSB - Given the high degree of potential importance as evidence, an extensive search of the accident site for the GoPro cameras was conducted by the ATSB, police and state emergency service volunteers. That search did not locate either of the missing cameras.

ATSB - The reason why there was no memory card in the black-handled GoPro camera could not be determined, and the yellow-handled camera was never located

All food for serious thought; not the slightest bit of comfort for those grieving or hurt, but that is not the ATSB’s role. Despite the delay in the report being released, it is not too shabby an effort to define what went wrong. The only criticism I would gently make is that there is no advice provided, to prevent a reoccurrence; or, guidelines for Chief pilot’s to work with to set some minimum guidelines for pilots who need to make low level strip inspections.

Anyway, FWIW that’s all I can glean from the ATSB report, which is almost, but not quite up to world standard.

Toot - toot.

[Cap'n Wannabe]

Just a note...the prec search & landing technique I was taught was thus:

Fly the upwind leg parallel to the runway, off to the side, with 1 stage flap and gear down, flying at 500 feet and 75 knots (depending on the aircraft - in a Cessna 172, that sounds about right).
Continue in that configuration and fly a 500 foot circuit.
After turning final, once again, offset from the runway (but closer), descend to 250 feet and fly a second pass then climb back to 500 feet for another circuit.
After turning final again, descend to 50 feet just off the centreline, fly a third pass, then climb back to 500 feet for another circuit, whereupon you perform a short field landing.

The first pass is to inspect the general condition of the field, the second is to time the length of the proposed runway, and the third is for closer inspection.

[P7_TOM]

Missed the (above) CW post (busy scribbling) : nevertheless, it raises some interesting points. Clearly, the prescription offered has been SOP for an operator. Perhaps not an operator who ‘routinely’ needs to make a ‘strip inspection’ when (importantly for this event) a ‘strip report’ is not provided. Scheduled services, such as ‘mail runs’ require that should a strip report not be available, then the pilot is required to conduct an assessment – prior to landing. SOP, (how to) writ in stone. Fair and reasonable stuff.

While I doubt the ‘practical’ value in the procedure described; it is at least a ‘SOP’ based on previous, though limited experience of ALA operations.

The operation being examined differs in one respect – it was a beach landing. This, believe it or not, is not a task for the ‘inexperienced’. In fact, I’d go as far as to say it is a unique ‘skill set’ which demands careful and extensive training. There is a need to ‘get down’ close and personal with ‘the beach’ for things may have changed; such as the slope of the beach, or even the reliability of the surface. To see the changes, one must get a little lower than 500’ and, importantly, one must be able to ‘read’ those changes as they can affect to landing.

Specialised operations require, no demand, clearly defined SOP and training. No doubt the accident pilot was experienced in such operations; but, was the operation conducted within the restraints of ‘sensible’ stated operating policy? It leaves two questions begging answers.

Did CASA approve/ accept the ‘operating policy? Was the accident pilot in compliance with that policy? You may even ask, “was there a policy?” If not, why not? Where was our watch-dog?

Cheers CW. Thought provoking appreciated.

P9 – “ATSB - During the period immediately prior to the engine power loss, the indicated fuel quantity was about one quarter full on the left tank gauge and slightly above half full on the right tank gauge.”

Not being ‘familiar’ with the type, that statement of fact puzzles me. Assumptions are in order here. (i) the operators stated policy on re-fuel seems to indicate that there would be an almost equal quantity of fuel in each tank. (ii) The stated operational policy was to operate with a ‘fuel feed’ from both tanks. (iii) It would, from dim, distant memory seem sensible to manage the fuel supply in such a way as to ‘balance’, within the limitations of the fuel gauges, the quantity in each tank: just common sense.

Why was the quarter tank discrepancy mentioned in the ATSB report?

Sure, it was based on the best information available to ATSB; and, in all probability, has bugger all to do with the engine quitting – but it is a part of the ‘mystery’.

Too many decades have gone by since my days in single engine Cessna aircraft for memory reliability; however, I can’t recall any warning about an ‘unbalanced’ fuel load leading to engine failure.  But, it seems to be out of ‘consistency’ with either operating practice or normal system function. No idea, except it sticks out; awkward like. No doubt ATSB covered it off, just seemed “passing strange” to my addled old head.

Yes boy, shut up and sup up is a good ideal; adopted instanter.  Cheers.

[Peetwo]

A two coffee read.

It has taken nearly 34 months to provide the ATSB report into:-


Collision with terrain following an engine power loss involving Cessna 172M, VH WTQ, 12 NM (22 km) north-west of Agnes Water, Queensland on 10 January 2017

It is a ‘long’ read and some of the details (below) are worthy of note. ATSB have made some serious efforts to establish why the engine failed when it did. That primary mystery remains unresolved, not from lack of effort on the ATSB part; I can’t think of much else they could have done. Even a simulation would not be able to duplicate the exact circumstances to determine if some weird ‘air-lock’ due to un-porting of a fuel feed had occurred would not provide definitive answers to the puzzle (IMO). So why the engine failed, when it did will remain unexplained. However, there are some salutary lessons to be learned from the detailed investigation.

There are some things which (again IMO) could have been done better by the operator. For example, the beach inspection protocols. Anyone who has flown ‘in-the-bush’ the real thing, knows how difficult it is to even spot (stationary) livestock on an ALA from much above 3/400 ft; below that objects become much clearer, so there is an identified ‘requirement’ to get ‘low and slow’. How low and how slow is difficult to define – in terms which could be realistically transposed into SOP.

ATSB. - The pilot of the accident flight reported that he normally conducted airborne inspections of Middle Island ALA at 150–200 ft. A review of the GPS data identified 19 previous inspections of Middle Island ALA, all of which were conducted by the pilot of the accident flight. The lowest altitudes recorded during these inspections were generally below 100 ft with a median value of about 60 ft (see Review of airborne inspections at Middle Island ALA ). Given the relatively constant descents and straight flight paths involved in these inspections, the GPS data was probably within the GPS manufacturer’s expected level of accuracy.

ATSB. - Overall, the ATSB concluded that the altitude at the time of the engine power loss was probably between 40 and 80 ft and therefore probably close to the GPS-based altitude of 60 ft.

ATSB. - The inspections were generally flown at 50–100 ft AMSL while flying at normal cruise speed towards an area of water at the end of the beach, with no planned consideration of what to do in the event of an emergency.

Valid points – there was a requirement for almost a 180˚ reversal around the headland to land into wind. Ref Fig 2. With 150 or 160 feet on the clock, would there have been a better outcome? With a little less speed and a handful of flap, could the outcome have been less damaging? I wonder, had there been a little less ‘thrill’ for passengers and a little more conservative thinking been applied, could the whole accident have been avoided. I don’t know; would I be flat chat, flapless, at 60 feet over a beach, with a reversal to follow – I don’t think so. This is the sort of ‘stuff’ that needs to written into an Ops Manual – company SOP. Murphey is everyman’s co-pilot and anything that can be done to keep his mucky paws out of the equation should be done.


Engine mystery.

The engine sustained a sudden and total power loss. The engine/propeller speed immediately reduced and then gradually decreased for the remainder of the flight (see Audio analysis of the engine/propeller speed).

ATSB - Despite a detailed inspection of the engine and related systems, the ATSB was unable to identify the reason for the loss of engine power.

ATSB - During the period immediately prior to the engine power loss, the indicated fuel quantity was about one quarter full on the left tank gauge and slightly above half full on the right tank gauge.

ATSB - Based on an hour meter reading documented in maintenance worksheets on 12 November 2015, the flight time documented on the maintenance releases underestimated the actual flight time by 62.2 hours (or about 40 per cent) during the period from the periodic inspection on 1 May 2015 to the next periodic inspection on 12 November 2015.

ATSB - There were multiple days on which flights were recorded on the aircraft’s GPS unit and/or the pilot of the accident flight had included flights in VH-WTQ in his logbook, but there was no certification on the maintenance release stating that a daily inspection or flights had been conducted (see Appendix A).

ATSB - Prior to the sudden engine power loss at 1037:34, the only anomaly in the engine/propeller sound during the flight occurred at 1036:13, when there was a momentary reduction of engine/propeller speed before it recovered to its normal setting. This occurred during a rapid though brief pitch-down manoeuvre. The brief reduction in power appeared to be consistent with what would expected with the normal operation of the carburettor in such a manoeuvre and would have had no long-term effect.

The Go-Pro puzzle.

ATSB - Given the high degree of potential importance as evidence, an extensive search of the accident site for the GoPro cameras was conducted by the ATSB, police and state emergency service volunteers. That search did not locate either of the missing cameras.

ATSB - The reason why there was no memory card in the black-handled GoPro camera could not be determined, and the yellow-handled camera was never located

All food for serious thought; not the slightest bit of comfort for those grieving or hurt, but that is not the ATSB’s role. Despite the delay in the report being released, it is not too shabby an effort to define what went wrong. The only criticism I would gently make is that there is no advice provided, to prevent a reoccurrence; or, guidelines for Chief pilot’s to work with to set some minimum guidelines for pilots who need to make low level strip inspections.

Anyway, FWIW that’s all I can glean from the ATSB report, which is almost, but not quite up to world standard.

Toot - toot.

Just a note...the prec search & landing technique I was taught was thus:

Fly the upwind leg parallel to the runway, off to the side, with 1 stage flap and gear down, flying at 500 feet and 75 knots (depending on the aircraft - in a Cessna 172, that sounds about right).
Continue in that configuration and fly a 500 foot circuit.
After turning final, once again, offset from the runway (but closer), descend to 250 feet and fly a second pass then climb back to 500 feet for another circuit.
After turning final again, descend to 50 feet just off the centreline, fly a third pass, then climb back to 500 feet for another circuit, whereupon you perform a short field landing.

The first pass is to inspect the general condition of the field, the second is to time the length of the proposed runway, and the third is for closer inspection.

Missed the (above) CW post (busy scribbling) : nevertheless, it raises some interesting points. Clearly, the prescription offered has been SOP for an operator. Perhaps not an operator who ‘routinely’ needs to make a ‘strip inspection’ when (importantly for this event) a ‘strip report’ is not provided. Scheduled services, such as ‘mail runs’ require that should a strip report not be available, then the pilot is required to conduct an assessment – prior to landing. SOP, (how to) writ in stone. Fair and reasonable stuff.

While I doubt the ‘practical’ value in the procedure described; it is at least a ‘SOP’ based on previous, though limited experience of ALA operations.

The operation being examined differs in one respect – it was a beach landing. This, believe it or not, is not a task for the ‘inexperienced’. In fact, I’d go as far as to say it is a unique ‘skill set’ which demands careful and extensive training. There is a need to ‘get down’ close and personal with ‘the beach’ for things may have changed; such as the slope of the beach, or even the reliability of the surface. To see the changes, one must get a little lower than 500’ and, importantly, one must be able to ‘read’ those changes as they can affect to landing.

Specialised operations require, no demand, clearly defined SOP and training. No doubt the accident pilot was experienced in such operations; but, was the operation conducted within the restraints of ‘sensible’ stated operating policy? It leaves two questions begging answers.

Did CASA approve/ accept the ‘operating policy? Was the accident pilot in compliance with that policy? You may even ask, “was there a policy?” If not, why not? Where was our watch-dog?

Cheers CW. Thought provoking appreciated.

P9 – “ATSB - During the period immediately prior to the engine power loss, the indicated fuel quantity was about one quarter full on the left tank gauge and slightly above half full on the right tank gauge.”

Not being ‘familiar’ with the type, that statement of fact puzzles me. Assumptions are in order here. (i) the operators stated policy on re-fuel seems to indicate that there would be an almost equal quantity of fuel in each tank. (ii) The stated operational policy was to operate with a ‘fuel feed’ from both tanks. (iii) It would, from dim, distant memory seem sensible to manage the fuel supply in such a way as to ‘balance’, within the limitations of the fuel gauges, the quantity in each tank: just common sense.

Why was the quarter tank discrepancy mentioned in the ATSB report?

Sure, it was based on the best information available to ATSB; and, in all probability, has bugger all to do with the engine quitting – but it is a part of the ‘mystery’.

Too many decades have gone by since my days in single engine Cessna aircraft for memory reliability; however, I can’t recall any warning about an ‘unbalanced’ fuel load leading to engine failure.  But, it seems to be out of ‘consistency’ with either operating practice or normal system function. No idea, except it sticks out; awkward like. No doubt ATSB covered it off, just seemed “passing strange” to my addled old head.

Yes boy, shut up and sup up is a good ideal; adopted instanter.  Cheers.

Update: Via Ironsider yesterday in the Oz.

---

CASA urged to mandate upper torso restraints

Operators of light aircraft could be ordered to fit upper torso restraints to passenger seats after an investigation into a fatal charter flight crash at Agnes Water in January 2017.

A British backpacker was killed in the crash, and three other people including the pilot suffered serious injuries when the Cessna 172 suddenly lost engine power while conducting a low-level beach inspection.

A 2½-year investigation by the Australian Transport Safety Bureau was unable to explain the sudden loss of engine power but identified a number of problems with the operator’s activities.

These included a lack of training or procedures to manage the risk of engine failure at low height. Other issues identified by the ATSB were poor documentation of flight hours, unsecured baggage, no life jackets on board and the conduct of near-aerobatic manoeuvres during passenger charter flights with limited controls in place.

Shortly after the crash, the Civil Aviaton Safety Authority cancelled the licence of pilot Les Woodall, and that of charter operator Bruce Rhoades, as well as the air operator’s certificate for Wyndham Aviation.

Mr Woodall launched legal action against CASA and was allowed to reapply for his licence, then last year, the terminally ill Mr Rhoades mounted a public campaign to clear his name, accusing the regulator of a substandard investigation.

He passed away last month without seeing the ATSB’s final report on the crash.

Although the loss of engine power was a mystery, the report found that had the Cessna’s seats been fitted with upper torso restraints in addition to compulsory lap belts, passengers’ injuries would have likely been less severe.

“As a consequence, the ATSB recommends that CASA consider mandating the fitment of upper torso restraints for all seats in small aeroplanes and helicopters,” said ATSB chief commissioner Greg Hood.

“The recommendation is particularly aimed at those aircraft being used for air transport operations.”

CASA was considering the recommendation.

---

For those interested here are the SRs issued by the ATCB and addressed to CASA:

Regulatory surveillance – scoping of surveillance : events https://www.atsb.gov.au/publications/inv...005-si-08/

Safety issue description

The Civil Aviation Safety Authority’s procedures and guidance for scoping a surveillance event included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

Response by the Civil Aviation Safety Authority:

In August 2019, in response to the draft ATSB report, the Civil Aviation Safety Authority (CASA) stated:

CASA, as a regulator, has the ability to help ensure that an operator complies with aviation safety regulations and operations manual procedures through ongoing surveillance. Both CASA’s records and the draft [ATSB] report indicate that CASA had identified issues with the operator which were addressed (at least in terms of operations manual procedures).

However, the effectiveness of CASA’s system of regulatory surveillance and auditing in ensuring safety is based on the assumption that operators are genuinely interested in, and meaningfully committed to, compliance. What appears to have occurred in this case is that Wyndham Aviation had developed a culture of wilful, or at least habitual, non-compliance with both the safety regulations and the requirements of the Wyndham Aviation operations manual.

CASA has a robust entry control and oversight system which is continually under review and in this case additional or different oversight is unlikely to have significantly impacted the attitudes and behaviours of the operator.

ATSB comment:

The ATSB notes that CASA has advised that it continually reviews its entry control and oversight system. However, the ATSB is concerned that CASA has not outlined any specific safety action to address this safety issue, nor has it undertaken any apparent safety action to effectively address a similar safety issue released in November 2017 (AO-2014-190-SI-14). Accordingly, the ATSB issues the following recommendation.

Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority undertake further work to improve its procedures and guidance for scoping surveillance activities to formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

Requirements for upper torso restraints in small aircraft : https://www.atsb.gov.au/publications/inv...005-si-06/

Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority consider mandating the fitment of upper torso restraints (UTRs) for all seats in small aeroplanes and helicopters, particularly for those aircraft (a) being used for air transport operations and/or (b) for those aircraft where the aircraft manufacturer has issued a mandatory service bulletin to fit UTRs for all seats (or such restraints are readily available and relatively easy to install).

ATSB safety advisory notice to all operators of small aeroplanes and helicopters
Action number: AO-2017-005-SAN-028

The Australian Transport Safety Bureau strongly encourages operators and owners of small aeroplanes manufactured before December 1986 and helicopters manufactured before September 1992 to fit upper torso restraints to all seats in their aircraft (if they are not already fitted).

MTF...P2 

[P7_TOM]

Placebo or real fix?

The fitting of torso restraints is probably not too bad an idea; why not mandate air bags while you’re at it. Of course a much better notion would be to prevent this type of accident ever happening.

I’ve been to some trouble today to get some ‘real’ information, from those who know of what they speak, about ALA inspection SOP, beach landings and ‘sudden’ engine failure of the type this pilot experienced. For, therein lays the real cause of death.

In short; the engine type requires but three elements; in the right proportion to keep operating – unless there is a gross loss of lubricant i.e. oil. A seizure due to oil (lack thereof) is easily discernible; no evidence that lubrication was an issue. Which leaves us with the ‘three amico’s’ – air, spark and fuel. Aircraft engines of this type are really ‘basic’. The more basic, the better; less to go wrong, less to mishandle, less weight and more reliability, due to the straightforward, no frills design. Plenty of air available, filtered to prevent nasty stuff getting in and doing damage. Fuel supply is simplicity – gravity feed to a simple carburettor, heating available to prevent or cure carby ice, not too much else to worry about there; and, last ‘spark’ two sets of spark plugs, two sources of ‘juice’ each magneto capable of keeping the spark where it should be, as and when required. Basically a simple engine with the known problems covered. Gods know hour many reliable, trouble free hours of operations, in all climes, these engines have provided. Fantastic reliability statistics – provide proper care and attention to maintenance is provided. So why did this particular donkey keel over at a crucial time of a dangerous situation? I, for one would like to know.

ATSB have done what they may – but; to be unable to answer the basic question leaves many more unanswered. Like – can this ‘failure’ occur again; at short notice with no prior warning? I’d reckon there would be many folk who like to know that answer. Can my tested, tried, true, well maintained engine quit without warning, at any tick of the clock? 
Sorry ATSB; “Dunno” is nowhere near good enough.

DG - "I reckon a few of us could hazard a pretty good guess what caused that engine to quit. But as you say, we shouldn't have to. It's supposed to be their job, not ours. But with 129 pages in the report, you'd think they could have spared a paragraph to discuss how the carby float bowl ended up dry. I'll just leave that there."  Choc Frog.

Now, to the ATSB provided photographs. The last one in the sequence (#4) shows exactly where you would not want an engine failure. So why was the aircraft in that position at all. Fig. #3 and #4 graphically illustrate how to perfectly box yourself in. There is no safe exit, no wriggle room and while it may all seem like ‘derring-do’ and jolly good fun - it ain’t.





Rather than see some wishy-washy, feel good twaddle about ‘torso restraints’ being mooted; how about CASA make certain that every operator who conducts ALA operations has a sound procedure in place, with either ‘strip reports’ or pilot assessment procedure - which allows for ‘an out’. CASA probably have not got that type of expertise on tap – but plenty in the industry have and can back it with rock solid, real life experience. Prevention being much better than cure and a lot more helpful than ducking ‘torso restraints’ (a.k.a. shoulder straps).

Rather than a pathetic “we don’t know” –  how about ATSB gets off it’s collective arse and works out why a reliable, millions of operational hours, bog standard engine quit. These engines just do not pack it in for no reason; I’m sure every user of the engine, world wide, would love to know “Why”.

If this report had taken a half year, I’d say what’s the hold up. But 30 odd months to reach no conclusion – bloody well taking the Mickey ain’t it. 

Lord – the engine quit, the pilot crashed – takes 10 seconds to write. We knew that, on the day. Is ‘torso restraint’ the real answer to a rather large ‘safety question’.  I think not.

[P7_TOM]

Further discussion.

Not being required at the Houseboat compound; I did some scratching around – (if “K” can’t make a garden seat in a day by now. Etc.) with regard to the ‘brace position’ and the benefit of shoulder harness. Wow! Experts to the left of me, Exponents of both arguments on the other. There has been a lot, a serious lot, of research done into ‘accident’ and the results of that research comes out at about 50/50 (give or take). It all seems to be dependant on a ‘given’ set of circumstances. In one case, the road safety analysis; it is a lay down misère for shoulder harness. But for aircraft accidents, the ‘Brace” position seems to carry some weight.

Of course ‘weight’ is the big denominator. Two shoulder harness additions in the back seats of a single engine whatever is something nothing; two or three hundred in a commercial jet is a significant penalty, for many valid practical reasons.

But, to me the big, as yet unanswered question is – who, in a crash scenario like the one we see at Middle Island, would stand the better chance of survival? The bloke who was briefed to adopt the ‘brace’ position before impact: or, the fellah who was upright and dependent on the ‘torso restraint’.

It is a valid question; one which insurance companies need to ask. No one minds the pennies to fit shoulder harness to ‘light’ aircraft: provided that the (ATSB favourite) statistical analysis of accident casualty and death can be used to demonstrate that ‘torso restraint’ is the ‘best practice’ way to go forward.

“Brace” has a huge scientific following. ‘Torso restraint’ is backed by the motor vehicle industry insurance. Perhaps ‘horses’ for courses’ is a good ideology. Average car crash speed is? Average aircraft crash speed is?

The Cessna which crashed (basically LOC - again) at Middle Island landed at about ‘fast car accident’ speed. It crashed, because ‘something’ caused the engine to quit; sudden and unexpected.

I ask only a few simple question: were the passengers briefed, pre flight, on ‘Brace’ – if not why not? Were the passengers ‘advised’ to ‘Brace’ before impact? Was there time, due to the low altitude for them to (a) don torso restraint; or, (b) adopt the ‘Brace’ position?

“In the unlikely event of a sudden engine failure” etc.

You see it is all well and good to say – retrospectively – this or that should have happened – or been fitted as part of standard equipment. It sounds good; but why was this possible scenario not addressed years ago?

Of course, had the aircraft engine just not given up the ghost when it did; matters may have worked out differently. The real cause of death was collision with terrain, the reason why this occurred is that the engine failed.

ATSB simply ‘don’t know’. I suggest they find out – quick smart; lots of potential failures, world wide, out there. Non with the placebo of ‘torso restraints’ fitted to alleviate the burden of hitting the Earth, very hard -- at speed. F=Ma always.

This leads us to the nub. CASA crucified the operator: yet ‘accepted’ their Emergency procedures; does that therefore make ‘em complicit? ATSB cannot define the radical cause and we are fobbed off with some fantasy that ‘torso restraints’ would have saved the whole thing. BOLLOCKS.

That CASA would tolerate and accept/approve the ALA inspection protocol is either gross negligence or plain ignorance. That ATSB would dare to state that they could not define ‘why’ the engine failed is a gross dereliction of sworn duty.

Not to worry – torso restraints – mandated will solve it. And, well it might; for the useless minister is living in a fantasy; a protected bubble of unadulterated Pony-Pooh. (And loving it).

Are we being conned? Are these clowns taking the Mickey Bliss?

I’ll have another Ale, quiet like, while all the C172 operators, mechanics and pilots have a little think about the ATSB conclusions and the CASA response.