[Kharon]

But dear Wombat; and it is a great big duckling But. Let us take a look at what was omitted by the operator, the CASA and the ATSB. The root objective and the reasons why it is essential that 'full' inclusive training be given, particularly at CPL level for a precautionary search and landing. It is an essential building block for future thinking and operational integrity. Lets take a look at the valuable lessons not gained.

And so, Master Wombat – today we will conduct a navigation exercise; as prelude to the CP licence test. I am going to brief on, then observe the precautionary search and landing as an essential test item. It is not a tick-a-box exercise, it may, one day, in the bush save you and the C210 loaded with passengers or cargo.

So today we will be simulating some bad weather ahead and there is no viable escape path back to anything other than this ALA (Name and diagram). Item one, with the forecast wind/temperature today – which runway direction do you think will suit us best? It is an uphill run to the North and downhill to the South, the high ground close in, rising toward the North West. Item two; lets open the AFM, and see what the book says about landing and take off performance with today's conditions, applied to this ALA.

Item next – Short field Landing. The 'art' in conducting a 'good' short field in not in floating in and then beating 20 landings out of the brakes. The true art is in knowledge of and practice in speed and flight path management. It takes some practice to nail down the speed, the profile and land on a 'chalk line' without 'rough' handling. At CPL level it would make you smile all day to absolutely 'nail it'. That is skill true enough; but it is a skill based in grounded knowledge of 'how' the limitations of the aircraft performance will affect, under ambient conditions the outcome. For example; (test question) what is the lowest height, considering the terrain/conditions, from which you would attempt an overshoot, today, When; Why, and for a Choc Frog, what 'clearance' (give or take) could you expect over the terrain? Fair question for a CPL candidate...

Understand, the simple pre flight pencil and paper exercises open the doorway to understanding and promote situational awareness; it is also a part of forming a professional attitude and 'habit' to and understanding of 'performance data'; and, why it is so important to be 'aware' of it and the limitations that imposes. Anyway - briefing complete, full bottle on what we have to work with (not to mention what we have not got) and off we go.

So we arrive at our 'decision point' and divert back to our 'alternate' (just in case) option, and guess what the wind has changed. Are we now at a higher risk status? NO! The pre flight exercise 'on the books' has given us a clear picture of all the limitations and options; sure, a little rough in finite detail but we are 'aware' of the implications of an increased downwind/ crosswind and how this and the approach/ overshoot (if required) and departure gradients will affect how we set about doing what we are expected to do. That is, get in and get out in one piece, without damaging anything.

Apologies for the ramble; but that inept 64 page ATSB report defined so many things wrong with the ATSB, and the CASA approach to training and the operators poor training regime and the instructors inattention to basic airmanship and training logic; gave me the screaming ab-dabs.

That's it – much better with that off my chest.

Toot toot...

[Peetwo]

AO-2022-034: Final report released?? -   

Ref: https://www.atsb.gov.au/publications/inv...o-2022-034

Findings

ATSB investigation report findings focus on safety factors (that is, events and conditions that increase risk). Safety factors include ‘contributing factors’ and ‘other factors that increased risk’ (that is, factors that did not meet the definition of a contributing factor for this occurrence but were still considered important to include in the report for the purpose of increasing awareness and enhancing safety). In addition ‘other findings’ may be included to provide important information about topics other than safety factors. 

These findings should not be read as apportioning blame or liability to any particular organisation or individual.

---

From the evidence available, the following findings are made with respect to the birdstrike and in-flight break-up involving a Bell 206L1 LongRanger, registered VH-ZMF, near Maroota, NSW, on 9 July 2022

Contributing factors

• Sun position and pilot workload at the control zone boundary likely resulted in the pilot not identifying a potential airborne collision risk.
  
• ]While cruising at about 700 ft AMSL, the aircraft struck a wedgetail eagle just below the left windscreen.
  
• The pilot was likely startled by the birdstrike resulting in an abrupt control input, which led to the main rotor blades contacting the tail boom and subsequent in-flight break-up.
  

Although the prelim report for this fatal accident investigation was 69 days in non-compliance with the ICAO Annex 13 30 day rule, the final report today was produced in a record time of 10 months and 3 days. The final report grew from a 6 page prelim report to 16 pages, which probably reflects that other than the normal investigative stages (DIP, Commissioners etc), there was not too much more to add. So chocfrog to Popinjay and crew for this one...

Next a new short investigation... : https://www.atsb.gov.au/publications/inv...o-2023-023

 

Runway incursion involving Diamond Aircraft DA40, registration VH-ERE, at Sunshine Coast Airport, Queensland on 7 May 2023

Summary

The ATSB has commenced an investigation into a runway incursion which resulted in a Boeing 737 conducting a missed approach at the Sunshine Coast Airport, Queensland on 7 May 2023.

The pilot of a Diamond DA40 entered runway 31 without a clearance. ATC subsequently instructed the Boeing 737 on approach to go-around. As part of the investigation, the ATSB will examine the circumstances leading to the runway incursion and determine contributing factors.

The investigation will include interviewing the flight crew, air traffic controller, and other relevant personnel, examining available recorded data, reviewing relevant procedures and collecting other evidence as required.

A final report will be published at the conclusion of the investigation. Should a critical safety issue be identified at any time during the investigation, the ATSB will immediately notify operators and regulators so appropriate and timely safety action can be taken.

Hmm...pardon my ignorance but isn't this incident just a reflection of how the system is supposed to work...      

MTF...P2 

[Gentle]

Ummm…pardon my arrogance…but this exactly what the ATSB should be investigating…

Runway incursions like this worry people….I seem to remember some place in the Canary Islands, another one in Italy etc

Just because the situation was resolved presumably In this case by the controller sending the landing B737 round doesn’t mean we don’t want to know how such a serious runway incursion occurred in the first place….my experience, should take about a day, not the three years…

Just because certain incidents are serious ie Loss of Separation. Runway Incursion, etc doesn’t mean it takes a long time to work out the why it happened. Invariably Human Error…. Now trying to work out why the Human Error occurred is far more interesting but I don’t think ATSB should go there, despite their fumbling attempts that have been invariably wrong…

I have seen totally different outcomes by different investigators on the same incident / accident when investigators try and  ‘divine”/‘snapshot” the mental model of the controller / pilot at the time of same….interesting how the unconscious cognitive biases of investigators can complicate matters…

It’s a group / cluster of these type of seemingly human error aerodrome control incidents of aircraft landing / taking off / lining up etc that has the FAA / NTSB seriously concerned at the moment, but to their credit they acknowledge them and are proactively addressing them….unlike another country, sigh!

P2 comment: Fair call Gentle and I totally agree with your assessment. I guess it was my cynicism for the motives of the ATSB conducting short investigations ATM (refer:  Proof of ATSB delays and ICAO Annex 13 non-compliance?? (IE. Have they decided to investigate because on the other side of the world:   "FAA / NTSB seriously concerned at the moment, but to their credit they acknowledge them and are proactively addressing them…."  Ref: From the land of the Aviation Safety grownups!!)

[Peetwo]

Latest flurry of Popinjay activity to complete bollocks ATSB AAIs??

Via Popinjay HQ, this week's DTS Stewie Macleod:

Aerodrome operators urged to review use of non-standard surfaces for aircraft movement areas after prop strike incident



The propeller blade of a Beech 1900D regional airliner sheared off after it was struck by matting that had been installed to prevent stone damage to propeller blades at a gravel aerodrome.

The Australian Transport Safety Bureau investigation report from the incident notes that on 17 November 2022, the flight crew of the Beech 1900D, operated by Penjet, refuelled and then boarded passengers at Fortnum Aerodrome, in WA’s Murchison region, for a flight to Perth.

The runway, taxiways, and parking area at Fortnum are gravel. At the time of the incident, there were designated parking areas with pieces of conveyor belt matting fixed to the ground, intended to allow engines to be operated with minimal propeller damage from loose gravel.

“As the flight crew was conducting pre-take-off checks, the end of the conveyer belt matting under the left propeller was drawn into the propeller arc, resulting in a sheared propeller blade and vibration damage to the aircraft,” ATSB Director Transport Safety Stuart Macleod said.

The aerodrome manager, who witnessed the event, detailed that the propeller picked up a corner of the matting and one propeller blade was ejected about 50 to 100 m in the air.

In addition to the detached propeller blade, another propeller blade snapped approximately 250 mm from the blade tip, and the left engine propeller governor control arm fractured.

There was also buckling to the left engine firewall and cracking to the nacelle structure adjacent to the engine mount.

Since the incident, the aerodrome operator has removed the strips from the apron.

“The installation of the matting was a non-standard method to prevent propeller damage, and was not subject to any installation specifications or inspection requirements,” said Mr Macleod.

“As this occurrence demonstrates, the consequences of a propeller strike can be serious, and operators of aircraft and aerodromes are advised to review the use of any non-standard surfaces for aircraft movement areas.”

Read the report: Propeller strike due to foreign object debris involving Beech 1900D, registered VH-NYA, at Fortnum Aerodrome, WA on 17 November 2022

And:

Nut loosened over time before R44 drive belt tensioning motor failed during flight



Personnel involved in maintenance and operations of R44 helicopters should be aware of the risks posed by the failure of the drive belt tensioning motor, as demonstrated by an incident at Hamilton Island in January.

On 8 January 2023, the pilot of an R44 was on approach to Hamilton Island Airport, Queensland, when they noticed a persistent clutch warning light.

The pilot carried out the clutch warning light emergency procedure, and landed at the airport.

Ground crew found the clutch actuator electric drive motor had separated from the gearmotor assembly, and fallen between the drive belts and the right-hand fan shroud.

“A subsequent Australian Transport Safety Bureau investigation found that during assembly of the gearmotor, the required thread adhesive was either not applied, or applied in a manner that did not prevent the loosening of the electric motor retaining nut,” ATSB Director Transport Safety Stuart Macleod said.

“Consequently, over time, normal aircraft vibrations loosened the retaining nut, resulting in the clutch actuator electric motor separating from the gearmotor assembly in flight.”

Robinson Helicopter Company advised the ATSB they are working with the component manufacturer to rectify identified quality issues with the gearmotor assembly.

Robinson said it is also considering updating the procedures for the inspection of the clutch actuator assembly.

“This incident is a reminder to R44 maintainers and operators to be aware of the risks posed by the failure of this component, specifically the risk of a loose component interfering with the v-belts and impacting rotor drive,” Mr Macleod said.

“The ATSB encourages pilots and maintenance engineers to physically check the security of the R44 clutch gearmotor assembly on a regular basis.”

Additionally, Mr Macleod emphasised that any discovered defects should be rectified, and reported to the Civil Aviation Safety Authority, and the manufacturer.

Read the report: Drive belt tensioning motor failure involving Robinson R44 helicopter, VH-ZUJ, at Hamilton Island Airport, Queensland, on 8 January 2023

This one is attributed to Godlike.. :

Forced landing accident following catastrophic engine failure highlights aircraft maintenance, type familiarity lessons



The Lycoming O-360 engine of a four-seat MS.893A Rallye light aircraft which failed during a ferry flight from Moruya to Archerfield, resulting in a forced landing and serious injuries to the pilot, had not been overhauled in more than two decades.

The ATSB’s investigation report from the 6 November 2020 accident details that the pilot experienced a catastrophic engine failure when they were about 37 km from their destination. With their forward visibility reduced due to engine oil over the windscreen and smoke created by escaping oil on the exhaust system, the pilot force landed in a paddock, with the aircraft striking trees.

Witnesses found the unconscious pilot had been thrown from the aircraft and moved them to safety before the aircraft was consumed by a post-impact fire.

“The ATSB’s investigation found the separation of the number 2 piston connecting rod initiated a catastrophic mechanical failure of the engine,” ATSB Director Transport Safety Dr Stuart Godley said.

The engine had not been overhauled since 1997, and had had limited usage for an extended period, possibly with no specific engine preservation done while in storage.

“Had the engine been overhauled at the manufacturer’s recommended calendar time, the connecting rod journal bearings would have been replaced with post-modification bearings,” Dr Godley said.

“This accident highlights the need for owners and maintainers to be cognisant of the manufacturer’s service information, to ensure the serviceability of engine and airframe systems are maintained to the highest standards.”

In addition, the pilot had been ferrying the aircraft on behalf of the owner and had limited aircraft type experience and knowledge of its performance capabilities.

“The pilot was unaware of the aircraft’s slow speed performance capability, a full understanding of which capability may have been beneficial when responding to the engine failure and forced landing,” Dr Godley said.

The investigation also found that the aircraft was not fitted with a fixed or portable emergency locator transmitter, and that the pilot did not leave a flight note with a responsible person.

“Fortunately the forced landing occurred in a populated area and there were witnesses to the accident who were able to render assistance and call emergency services,” Dr Godley said.

Read the report: Engine failure and collision with terrain involving S.E.D.E. Morane-Saulnier MS.893A, VH-UQI, 22 km south-west of Archerfield Airport, Queensland, on 6 November 2020

Publication Date
02/06/2023

MTF...P2 

[Peetwo]

AO-2023-024: Popinjay decides to investigate...

Via Popinjay HQ:

Collision with terrain involving Magni M16C Tandem gyroplane, registered G1850, while avoiding Extra EA 300L, VH-IOG at Lake Macquarie Airport, New South Wales on 12 May 2023

Summary

The ATSB is investigating a collision with terrain involving a Magni M16C Tandem gyroplane, registered G1850, at Lake Macquarie Airport, New South Wales, on 12 May 2023.

A Magni M16C Tandem gyroplane, with an instructor pilot and student pilot on-board, commenced take-off from runway 07. As the gyroplane became airborne, the instructor pilot saw an Extra EA 300L aircraft, registered VH-IOG, with a pilot and passenger on-board, backtracking towards them on runway 07. The instructor pilot took evasive action to avoid a collision, and the gyroplane subsequently collided with terrain resulting in substantial damage. The instructor pilot received serious injuries while the student pilot had minor injuries. The pilot and passenger on-board VH-IOG were uninjured and there was no damage to the aircraft.

The evidence collection phase of the investigation will include collection of relevant information, including recorded data, weather observations, pilot and witness reports, and radio calls.
A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.

Not sure why Popinjay took so long to decide to investigate (> than 3 weeks) but doesn't this investigation go against his previous policy of not investigating accidents involving recreational aircraft? Perhaps it had something to do with the owner/operator of the Extra 300??



MTF...P2 

[Peetwo]

AO-2022-035 (Short) & AO-2022-052 (Short): Two more from the list completed -   

Courtesy of this week's (attributed to) DTS Stewie (stating the Ducking obvious) Macleod...  :

737 issued incorrect runway arrival clearance after undetected verbal slip

Back to top

• During scheduled passenger flight from Brisbane to Sydney, airliner was cleared for standard arrival for runway 34L at Sydney, which was operating runway 16L at the time.
  
• Error was not detected initially by flight crew, despite ATIS indicating 34L was not operating. It was also not detected by crew or controller during read-back or hear-back.
  
• Sydney Approach controller identified discrepancy and corrected clearance; aircraft landed 16L without incident.
  
• Incident is a reminder that verbal slips can happen at any time, and that pilots and controllers should seek verification when there is confusion or misunderstanding.
  

A mistakenly-issued standard instrument approach arrival clearance for the incorrect runway at Sydney Airport highlights the importance of pilots and air traffic controllers being alert to verbal slips and seeking verification when there is confusion.

On 19 October 2022, after a Virgin Australia Boeing 737-800 reached top of descent on a scheduled passenger flight from Brisbane to Sydney, the flight crew contacted air traffic control, advising they were maintaining flight level 340.

The enroute controller provided the flight crew a clearance to conduct a standard instrument arrival for a landing on runway 34L in Sydney. The flight crew then read back this clearance to the controller, including runway 34L.

This was despite runway 16L being operational at Sydney at the time, and information available to the crew via the automatic terminal information service (ATIS) indicating runways 16L and 16R were in operation for arrivals and departures.

The ATSB’s investigation of the incident found the incorrect clearance was verbally communicated, and not identified, likely due to momentary interference of related, coinciding information about the assigned flight level (FL 340) and the runway (34L).

“This error was not identified by the enroute air traffic controller or the flight crew during the read-back or hear-back,” ATSB Director Transport Safety Stuart Macleod said.

“However, the information entered into the air traffic management system was correct, and when the crew transferred to Sydney Approach, the approach controller identified the error and rectified it well before an undesirable state for landing had the opportunity to develop.”

Once the approach controller had established the correct runway clearance, the crew performed an uneventful landing on runway 16L.

Mr Macleod said the incident is a reminder to pilots and air traffic controllers that verbal slips can happen at any time, and are less likely to be detected when there is a high degree of similarity between the presentation of simultaneous, related information, while performing a familiar and repetitive action.

“Slips in verbal communication can pose a threat to safe operations if the content of the message is inaccurate, and then not identified during the read-back or hear back process.

“In this case, the read-back and hear-back procedure was the opportunity for both parties to detect the error before it propagated further.”

Read the report: Air traffic control error involving Boeing 737, VH-YFT, near Armidale, New South Wales on 19 October 2022

Publication Date
06/06/2023

 
BRB member's OBS on this:  

Of course, ATCs issue a completely conflicting STAR, yet the lessons are for pilots to hear better! ?. Nicely worded to protect our beloved AsA!

Next:

Flight crew declares fuel MAYDAY to receive priority landing at Perth to maintain required reserve fuel

Back to top

[size=1]



Higher than planned fuel burn and longer than anticipated arrival delays meant the crew of a Boeing 737 operating a passenger service from Brisbane to Perth were required to declare a fuel MAYDAY to avoid landing below fuel reserves.

On 18 July 2022, the Qantas Airways Boeing 737-838 was operating flight QF933 from Brisbane to Perth with 174 people on board, including two flight crew.

During the cruise, the flight crew descended from 34,000 ft to 28,000 ft due to turbulence and to take advantage of lesser headwinds, but identified they were using more fuel than planned.

“As the aircraft reached the decision point, the flight crew were aware the aircraft had used 600—700 kg more fuel than planned, but there was still sufficient fuel to continue to Perth,” ATSB Director Transport Safety Stuart Macleod said.

“However, advice then came from air traffic control (ATC) that delays at Perth were longer than the promulgated estimate of 10 minutes.”

Given this new information, the flight crew determined they would be unable to accept the ATC delay without landing in Perth below fuel reserves (sufficient fuel, as required by the Civil Aviation Safety Regulations, to allow up to 30 minutes flying at holding speed, at 1,500 ft above the aerodrome elevation).

ATC advised the flight crew that the order of aircraft in the arrival sequence could not be changed unless they declared a fuel MAYDAY.

“This left the flight crew with no other option than to declare a fuel MAYDAY to receive priority landing,” Mr Macleod said.

After declaring the fuel MAYDAY, the aircraft was given priority for the approach, and landed in Perth without incident, and with the required reserve fuel intact.

The ATSB investigation report from the incident notes that sophisticated flight planning and monitoring systems allow fuel usage and aircraft movement to be accurately determined, and that the ATSB independently verified that the aircraft had departed Brisbane with the required fuel on board.
“Decisions by flight crew and air traffic controllers can result in higher-than-planned fuel usage, reducing available airborne options,” Mr Macleod said.

“Where flight crew find that they may not have required fuel reserve, it is vital – as in this case – that flight crew alert air traffic control and, if necessary, declare a fuel MAYDAY, to ensure the aircraft receives priority during the approach, preventing an unsafe situation from developing.”
Read the report: Fuel Mayday declaration involving Boeing 737-838, VH-VZO, abeam Wave Rock, Western Australia on 18 July 2022

Publication Date
08/06/2023

Hmmm...elements of the Mildura Fog Duck-Up and QF28 revisited?? But my question is...where is the ATSB analysis of the QF fuel policy?? Is this yet another case of CASA and ATSB capture by the Red Rat?? - 

MTF...P2 

[Peetwo]

Fatal midair crash Caboolture - RIP! 

Via the ABC:

1,049 views  Streamed live 74 minutes ago  #ABCNews #ABCNewsAustralia

Police Minister Mark Ryan and Queensland police's Superintedent Paul Ready say two people have died in a collision between two light aircraft at Caboolture Airfield, north of Brisbane Subscribe: http://ab.co/1svxLVE Read more here: https://rb.gy/3t4ok

ABC News provides around the clock coverage of news events as they break in Australia and abroad, including the latest coronavirus pandemic updates. It's news when you want it, from Australia's most trusted news organisation.

For more from ABC News, click here: https://ab.co/2kxYCZY
Watch more ABC News content ad-free on ABC iview: https://ab.co/2OB7Mk1

MTF...P2 

[Peetwo]

Popinjay to the rescue - Will investigate midair...this time?? 

Fatal midair crash Caboolture - RIP! 

Via the ABC:

1,049 views  Streamed live 74 minutes ago  #ABCNews #ABCNewsAustralia

Police Minister Mark Ryan and Queensland police's Superintedent Paul Ready say two people have died in a collision between two light aircraft at Caboolture Airfield, north of Brisbane Subscribe: http://ab.co/1svxLVE Read more here: https://rb.gy/3t4ok

ABC News provides around the clock coverage of news events as they break in Australia and abroad, including the latest coronavirus pandemic updates. It's news when you want it, from Australia's most trusted news organisation.

For more from ABC News, click here: https://ab.co/2kxYCZY
Watch more ABC News content ad-free on ABC iview: https://ab.co/2OB7Mk1

Via PJ HQ:

Caboolture aircraft collision
The ATSB has launched a transport safety investigation into a collision between two single-engine light aircraft at Caboolture Airport, Queensland on Friday.

It was reported that the collision occurred shortly after 10:30 am local time, when a Jabiru J430 was taking off from one runway while a Piper Pawnee was landing on a crossing runway.

Tragically, both occupants of the Jabiru were fatally injured. The Pawnee pilot was uninjured.
Investigators from the ATSB’s Brisbane office arrived on site this afternoon, while additional investigators from Canberra will be on-site tomorrow morning.

Investigators will begin gathering evidence by mapping the accident site, examining the aircraft wreckage, interviewing the surviving pilot and witnesses, and collecting relevant recorded information such as any CCTV footage and flight tracking data.

The ATSB asks anyone who witnessed the accident, or may have video footage of either aircraft at any phase of their flights, to make contact via the witness form on our website: atsb.gov.au/witness at their earliest opportunity.

The ATSB anticipates publishing a preliminary report, which will detail factual information established during the investigation’s initial evidence collection phase, in approximately 6-8 weeks (P2 - In contravention to ICAO Annex 13).

The ATSB will publish a final report, detailing contributing factors and any identified safety issues, at the conclusion of the investigation.

However, should any critical safety issues be identified at any stage during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate safety action can be taken.

Date
28/07/2023

Also from PJ HQ:

Runway excursion involving Piper PA-31-350 VH-XMM at Essendon Airport, Victoria on 21 July 2023

Summary

The ATSB is investigating a runway excursion involving a Piper PA-31-350, registered VH-XMM, at Essendon Airport, Victoria, on 21 July 2023. 

During the take-off roll, the aircraft reportedly struck and damaged 4 lights on the runway edge, resulting in minor damage to the aircraft. The pilot subsequently rejected the take-off. 

The evidence collection phase of the investigation will involve interviewing the pilot, retrieving and reviewing recorded data, and the collection of other relevant evidence.

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

Plus attributed to this week's DTS Dr Godlike:

R22 accident highlights risks of dark night flight, hazards of accidents in remote locations



A helicopter accident in Arnhem Land highlights the risks to VFR pilots of flying after last light, and the potentially fatal consequences of survivable accidents in remote locations, an ATSB investigation report details.[/size]

The pilot of a Robinson Helicopter Company R22 had been part of a multi-vehicle animal mustering operation in the Arafura Swamp, south of Ramingining, Northern Territory, on 14 November 2022.

After the mustering had concluded for the day, members of the mustering operation began departing the swamp and it was expected the pilot would depart shortly to pick up another member of the group, before continuing to the camp.

However, when other members of the mustering operation arrived at camp, the pilot and helicopter were not there.

Realising that the pilot was missing and becoming increasingly concerned about the pilot’s welfare, the mustering group subsequently commenced a search using land vehicles, before organising an aerial search the following morning.

The wreckage of the helicopter was subsequently located at about 1300 on 15 November, about 6 km from the mustering camp. The pilot was found deceased outside the aircraft, and the helicopter was destroyed.

The pilot held a Commercial Pilot Licence (Helicopter), but was not qualified for flight in non-visual conditions, and the helicopter was not equipped for night flight.

On the evening of 14 November last light occurred at 1858. Considering the location of the accident site, the pilot probably flew easterly from the camp, facing away from the setting sun. There was no ground-based lighting in the area, and cloudy conditions associated with a nearby storm may have also reduced visibility.

“The ATSB investigation found that the accident flight occurred after nautical twilight and in dark night conditions. The pilot likely became spatially disoriented, leading to a collision with terrain,” said ATSB Director Transport Safety Dr Stuart Godley.

ATSB research and investigation reports regularly refer to the dangers of flying after last light without the appropriate qualifications and equipment to do so.

“Dark night conditions provide no useable external visual cues and in these environments all VFR pilots, including those with endorsement to operate under the night VFR, will experience an increased risk of spatial disorientation,” said Dr Godley.

“The ATSB encourages all VFR pilots to take note of the tragic consequences associated with dark night flight in this accident.

“Landing 10 minutes before last night provides reliable method for VFR pilots to ensure they have the necessary visual cues.”

A pathologist’s report found that the injuries sustained by the pilot in the collision were probably not fatal, and that the pilot probably succumbed to environmental exposure.

After the collision, it is likely the pilot manoeuvred out of the seat belt, outside of the damaged helicopter which was laying on its side. With injuries reducing the pilot’s mobility, the pilot likely planned to wait for rescue. The day time conditions were hot and humid.   

While the helicopter was equipped with a manually activated personal locator beacon, the beacon was secured to the inside of the helicopter, and the pilot was probably unable to access it once outside the helicopter after the collision.

The ATSB found that the combination of the personal locator beacon not being activated and authorities not being notified when the aircraft was missing resulted in a delay to the pilot being located before succumbing to environmental exposure after sustaining survivable injuries in the accident.

Dr Godley noted that the investigation highlights how remote locations can present an increased risk of fatal consequences from otherwise survivable accidents.

“Pilots operating in remote locations should carefully consider the use and location of equipment such as a personal locator beacon, to maximise the likelihood it will be accessible to them in the event of an accident,” he said.

Read the ATSB’s report: Collision with terrain involving Robinson Helicopter Company R22 Beta, VH-LOS, 36 km south of Ramingining, Northern Territory, on 14 November 2022

MTF...P2  

[Peetwo]

Short investigation: AO-2023-031 Preliminary Report

Last week PJ's DTS was Kerri Hughes and for some reason she was tasked with putting out another bollocks pre-prepared media release highlighting a short investigation into R22 fatal mustering accident..  

Preliminary report details known sequence of events in Limbunya Station R22 helicopter accident



The ATSB has released a preliminary report detailing evidence gathered to date in its investigation of a fatal mustering accident, which occurred approximately 550 km south of Darwin in June.

The preliminary report, which contains no analysis or findings, notes two pilots were taking part in mustering operations at Limbunya Station, in the Northern Territory’s Victoria River region, on the morning of 27 June 2023.

Both pilots were using Robinson R22 helicopters to conduct the aerial work, which started that day at around 0700 local time.

At about 0930, one pilot set down at a collection of fuel drums to refuel, then departed.

The second pilot advised via radio that they had done the same at about 0945.

Approximately 15 minutes after that, the first pilot contacted the head musterer to ask whether they had heard from the second pilot. The head musterer advised they had not.

After a short aerial search, the first pilot located the wreckage of the second helicopter at about 1015.

The helicopter was destroyed, and the pilot had sustained fatal injuries.

The ATSB deployed investigators to examine the accident site and wreckage.

“As well as on-site work, the investigation has so far included the collection of meteorological data, and pilot and aircraft records,” ATSB Director Transport Safety Kerri Hughes said.

“Investigators have also conducted interviews and liaised with the Northern Territory Police Force.”

As it progresses, the ATSB’s investigation will include further review and analysis of the meteorological data, wreckage information, and instruments and components gathered from the accident site.

“Electronic data from the accident pilot’s mobile phone, the aircraft’s maintenance history, and any similar occurrences will also be reviewed,” Ms Hughes added.

A final report will be released at the conclusion of the investigation.

“Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so appropriate and timely safety action can be taken,” Ms Hughes concluded.

Read the report: Collision with terrain involving Robinson Helicopter R22 Beta, VH-PSC, 29 km south-east of Limbunya Station, Northern Territory, on 27 June 2023

Publication Date
31/08/2023

Not sure why this short investigation is considered significant enough to have a Media Release accompanying it??

"..The preliminary report, which contains no analysis or findings.."

Especially when you consider the prelim report is not much more than an interim factual statement (see above) that is 35 days past it's ICAO Annex 13 compliance due date...

MTF...P2 

[Peetwo]

Popinjay to the rescue: Caboolture midair prelim report released?? 

Via PJ HQ another pre-prepared (absent media) press release -  :

ATSB releases preliminary report from on-going Caboolture mid-air collision investigation



A preliminary report details factual information established as part of the ATSB’s ongoing investigation into a mid-air collision at Caboolture airfield on the morning of 28 July.

The report does not contain findings but outlines the accident’s sequence of events. It details that a Piper PA-25 glider tug aircraft, with a single pilot on board having just launched a glider, was returning to land from the west on Caboolture’s runway 06, while a Jabiru J430 light aircraft, with a pilot and passenger on board, was preparing to take-off to the south-east from the intersecting runway 11.

A third aircraft, a Cessna 172 was taxiing at the airfield, with a solo student pilot on board, prior to departing on a solo navigation flight.

Caboolture is an ‘aircraft landing area’, which is an airfield that has not been certified by the Civil Aviation Safety Authority. In addition, it is located within class G non-controlled airspace, where pilots make and monitor radio positional broadcasts on a designated common traffic advisory frequency (CTAF) to ensure separation from other aircraft.

Several witnesses monitoring the CTAF recounted hearing the Piper pilot broadcast that they were commencing a final approach to runway 06 and that they would be ‘holding short’, indicating they would not cross the intersection with runway 11/29.

The pilot of the Cessna, meanwhile, reported having turned down the aircraft radio volume to conduct engine run-ups near the intersection of the two runways and had not subsequently restored normal volume. As a result, the pilot did not hear any transmissions from the pilot of the Piper PA-25, and was not aware of the aircraft approaching on runway 06.

Just prior to the Piper touching down, the Cessna taxied across runway 06 ahead of the Piper. The pilot of the Piper initiated a go-around, broadcasting their intention to do so, according to witnesses.
As the Piper began climbing while maintaining the runway 06 heading, the Jabiru lifted off from the intersecting runway 11.

About 5–10 seconds later, while both aircraft were climbing on crossing tracks, the pilot of the Jabiru commenced a left turn, likely in an attempt to avoid a collision.

The two aircraft collided above runway 06, just north-east of the intersection with runway 11, at a height of about 200–300 feet. The Piper PA-25 remained flyable and landed soon afterwards, while the Jabiru J430 collided with the ground near the end of runway 06. Both occupants of the Jabiru aircraft were fatally injured.

“Thanks to CCTV footage, some recorded radio calls, witness accounts, and an examination of the accident site, ATSB investigators have been able to build an understanding of this tragic accident’s sequence of events,” said ATSB Chief Commissioner Angus Mitchell.

“However, I would caution against making any assumptions as to the contributing factors to this accident, and I would note that aviation systems have multiple layers of defence in place to prevent accidents,” he continued.

“Not all radio calls at Caboolture were recorded and our analysis of witnesses recollections of radio calls is continuing, so we are still building our understanding of the nature of the calls made, and giving consideration to a range of other potential factors.”

As the investigation continues, investigators will continue their analysis of aircraft flight paths, with particular attention given to potential visibility restrictions –trees between the intersecting runways partially obscure visibility.

They will also further review aircraft, pilot, aerodrome and operator documentation, analyse procedures at non-controlled aerodromes with intersecting runways, and further examine of aircraft components and other items recovered from the accident site, including two data recording devices from the Jabiru.

A final report, which will include analysis and detail the ATSB’s findings, 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 and timely safety action can be taken,” Mr Mitchell concluded.

Read the preliminary report: Mid-air collision involving Jabiru J430, VH-EDJ, and Piper PA-25-235, VH-SPA, at Caboolture Airfield, Queensland on 28 July 2023

Publication Date
08/09/2023

PDF version: https://www.atsb.gov.au/sites/default/fi...nary_1.pdf

The occurrence

On the morning of 28 July 2023, the pilot of a Piper PA-25, registered VH-SPA and operated by Caboolture Gliding Club, took off from runway 061 at Caboolture Airfield, Queensland, with a glider in tow. It was a clear day with light winds. This was the pilot’s second flight of the day, having previously completed one prior glider aerotow in VH-SPA. After the glider was released, the pilot of VH-SPA entered the circuit for runway 06, with the intention of landing so that the aircraft could be used to tow a third glider into the air.

Caboolture Airfield was located within class G (non-controlled) airspace, and had a designated common traffic advisory frequency (CTAF) on which pilots made positional broadcasts when operating within the vicinity of the airport. To date no recordings of radio transmissions from any aircraft on the ground at Caboolture around the time of the accident have been identified (see Recorded data). Witness recollections of radio transmissions are being collated and analysed by the ATSB.

Some transmissions from aircraft in flight were recorded. While in the circuit, the pilot of VH-SPA made several radio calls on the CTAF, the last of which was at about 1030:19 and was partially recorded. According to several witnesses who heard the transmission, the pilot announced that VH-SPA was commencing a final approach to runway 06 and stated that the aircraft would be ‘holding short’, indicating that it would not be crossing the intersection with runway 11/29.

At about 1030:44, while VH-SPA was on final approach, the pilot of a Jabiru J430, registered VH-EDJ, began take-off on runway 11. The pilot and passenger were conducting a private flight to Dirranbandi Airport, Queensland.

Also at that time, a Cessna 172, registered VH-EVR, was being taxied at the airfield by a solo student pilot. The pilot of VH-EVR later reported having turned the radio volume down to conduct engine run-ups near the intersection of the two runways and had not restored normal volume upon completion. As a result, the pilot of VH-EVR did not hear any transmissions from the pilot of VH-SPA, and was not aware of the aircraft approaching runway 06.

At 1030:49, just prior to VH-SPA touching down on runway 06, VH-EVR crossed runway 06 ahead of VH-SPA in a north-west direction. The pilot of VH-SPA initiated a go-around, and made an associated radio call (according to several witnesses) which was not recorded.

At 1030:55, VH-SPA began climbing while maintaining a runway 06 heading as VH-EDJ lifted off runway 11 before the runway intersection. About 5–10 seconds later, while the aircraft were climbing on crossing tracks, the pilot of VH-EDJ commenced a left turn, likely in an attempt to avoid a collision.

At 1031:11, the two aircraft collided on similar tracks above runway 06, just north-east of the 06/11 intersection, at a height of about 200–300 feet (Figure 1)

Figure 1: Approximate tracks of VH-EDJ and VH-SPA based on video footage


The leading edge of the inboard left wing of VH-SPA struck VH-EDJ’s right wing at the outboard trailing edge, resulting in separation of the right wing tip and part of the right aileron. VH-EDJ rolled to the right while rapidly losing altitude. VH-EDJ collided with terrain in a nose-down, rightwing-down attitude near the end of runway 06. The pilot and passenger were fatally injured.

VH-SPA sustained damage to its left wing in the collision but remained flyable and the pilot was uninjured. The pilot circled the airfield to direct people towards the accident site. The aircraft landed on runway 11 without further incident.

No idea why Popinjay feels the need to step in and interpret these reports for us, instead of letting the report speak for itself?? However at least this prelim is only 12 days in non-compliance with the ICAO Annex 13 30 day to publish rule...  

MTF...P2 

[Peetwo]

AD-2022-001: Safety risks from rotor wash at hospital helicopter landing sites - Final report 



On Wednesday Dr (Lies, damn lies and statistics) Godlike, this week's attributable to DTS, issued this presser in relation to the release of AD-2022-001 data and analysis final report... :

ATSB issues safety advisory after series of rotor wash injuries at hospital helicopter landing sites



The Australian Transport Safety Bureau has issued a safety advisory after a number of occurrences in which pedestrians were injured by rotor wash around hospital helicopter landing sites.

The notice advises medical transport operators and hospital helicopter landing site operators to engage with one another and ensure local procedures are sufficient to mitigate the risk of rotor wash associated with larger helicopters, such as the Leonardo Helicopters (AgustaWestland) AW139.

It stems from an ATSB Aviation Data and Analysis Report analysis of a series of incidents over the last five years, which considered the common factors, existing regulatory guidelines, and ways to mitigate the effects of rotor wash.

“Of the 18 helicopter rotor wash incidents reported to the ATSB in the last five years, nine occurred at hospital landing sites,” ATSB Director Transport Safety Dr Stuart Godley said.

“Six of those nine occurrences resulted in injuries to pedestrians who were within approximately 30 m of the landing site, and flight crew were not aware of the presence of pedestrians in all cases.

“In fact, in most instances, flight crew were not aware any incident had occurred at the time.”

Significantly, there were no reported occurrences of rotor wash related injuries at hospital HLS prior to the notable increase in the utilisation of AW139 for medical transport operations from 2017.

If the recommended rotor wash exclusion area for the AW139 had been applied at each HLS, it would have reduced the risk of the pedestrians being injured.

The ATSB’s report notes a range of key factors contribute to the effects of rotor wash, including the weight and size of the helicopter, the main rotor size, disc loading, prevailing winds, and flightpath.
“The flightpath is the only element that can be managed by the pilot in accordance with the operator’s procedures,” Dr Godley said.

“But as these occurrences demonstrate, pilots may be unaware of the presence of pedestrians in the vicinity, and therefore be unable to adjust their flightpath accordingly.

“As such, hospital landing site owners and helicopter owners should ensure pedestrians are not affected by rotor wash, by implementing appropriate risk controls for their landing sites, in addition to the helicopter operating procedures.”

Risk controls may include physical barriers, warning devices such as sirens, lights, high visibility warning signs, painted lines on nearby public thoroughfare to alert pedestrians to the rotor wash danger area, an inspection schedule for the landing site facility and surrounding area, and establishing a closed-loop reporting system.

Read the Safety Advisory Notice: Safety at hospital helicopter landing sites

Read the Aviation Data and Analysis Report: Downwash incidents at helicopter landing sites

Publication Date
27/09/2023

Here is the safety advisory notice:



From pg 7 of the report:

Australia

The Civil Aviation Safety Authority (CASA) does not regulate the design or operation of HLSs if
they are not an integral element of an aerodrome certified under Part 139 of the Civil Aviation
Safety Regulations (CASR) 1998. As hospital HLSs are not located at Part 139 certified
aerodromes, CASA does not regulate their design or operation...

I would suggest that even at a Part 139 certified aerodrome CASA's oversight is limited to providing advice only and not enforcing standards - reference Airport public self-serving safety risk mitigation obfuscation - Oz style?

And while PJ's crew have got the tools out on safety risk mitigation at hospital HLS, maybe they should extend their concern to potentially more serious issues in the grey area of design, planning, regulatory jurisdiction and safety oversight - remember this?? HOT OFF THE PRESS! via the EMAC (Evans Head Memorial Aerodrome Committee) 

..Well done class; all correct – now then, for Choc Frog; one last question. How would you like to be a patient flying in a helicopter to hospital, at low level <500' around about tea time or breakfast time through a 1.5 kilometre ‘launch zone for hundreds of flying foxes? For a bonus point, how many Fruit Bats to kill a Chopper?. Give up, can’t guess, well wait a while and the answer will become clear – the route to the emergency ward through the Fruit Bat launch zone is ‘approved’. Consequences? Wuzzat - Never heard of ‘em. The local airport development plan has - but 'what-the -hell'..

Still not sure why Popinjay's head crew feel the need to big note themselves in bogus media disengaged press releases?? However, all in all not a bad effort from the research boffins at Popinjay HQ...  

MTF...P2 

[Peetwo]

AO-2022-046 (Occurrence Investigation) - Final Report

From DTS for this week Dr Godlike...

Islander forced landing accident likely the result of fuel starvation



A twin piston-engined charter aircraft’s forced landing on an island in the Torres Strait was likely the result of fuel starvation, an Australian Transport Safety Bureau final report details.

On 3 October 2022, a Torres Strait Air Britten-Norman BN-2 Islander with a pilot and six passengers on board was operating a flight from Saibai Island to Horn Island.

While in the cruise at about 6,000 ft, the aircraft’s engines began to surge. The pilot diverted towards Kubin Airport on Moa Island, but was unable to reach the runway and was forced to land on a road.

During the landing the aircraft impacted the ground heavily, with the rear fuselage and tail breaking away, but fortunately, there were no reported injuries.

The ATSB’s subsequent transport safety investigation found the dual engine speed fluctuations and associated power loss was probably the result of fuel starvation.

“Fuel records from earlier flights showed the pilot was using the wing tip tanks when fuel remained in the aircraft’s main tanks, which was not in accordance with the flight manual,” ATSB Director Transport Safety Dr Stuart Godley said.

“In addition, the configuration and location of the aircraft’s fuel controls and gauges were probably not conducive to rapid and accurate interpretation, with the main tank gauges and cocks located overhead the windscreen centre post and the wing tip tank contents indicators on the right side of the cockpit.”

The ATSB considered that both of these factors increased the likelihood of the wing tip tanks being inadvertently selected during part or all of the round trip, leading to the exhaustion of the wing tip tanks.

Dr Godley noted accidents involving fuel mismanagement are an ongoing safety concern to the ATSB.
“Pilots are reminded of the importance of understanding an aircraft’s fuel supply system and being familiar and proficient in its use,” he said.

“Adhering to procedures, maintaining an accurate fuel record, and ensuring appropriate tank selections are made for the phase of flight will lessen the likelihood of fuel starvation.”

Dr Godley noted that prior to the accident, in June 2022, Britten-Norman released service letter 145, which detailed an optional modification for Islander aircraft with wing tip tanks.

“The service letter details an optional modification that centralises the fuel system controls, specifically relocating the wing tip tank indicators to the overhead panel adjacent to the main tank fuel indicators, with the fuel selection switches mounted between the indicators,” he said.

“We would encourage Islander aircraft operators to consider actioning this service letter for their aircraft.”

Read the report: Fuel starvation and forced landing involving Pilatus Britten-Norman Islander BN2A, registration VH-WQA, Moa Island, Queensland on 3 October 2022

Publication Date
05/10/2023

'Tongue in cheek comment': Again no idea why Dr Godlike needs to put in his 2 bob's worth but I do wonder about how many fuel starvation events have occurred with C208 LCRPT operations in the Torres Strait?? -    

Ref: Su_Spence to the rescue on Torres airfield embargo?? - Yeah right! 



MTF...P2 

[Kharon]

Clock, compass, flight plan, map and pen...

A scribble, signifying SFA. Just idle speculation here; the sort of casual discussion you'd have over a beer. Godley's glib waffle skims over the surface of the above event, but I wonder if there are not some 'deeper' elements associated being dismissed. But, this is only a casual, stray thought or two notion.

Deep within my tech library are a few of the old style 'lever arch' binders, covered in dust, they contain old flight plans, from back in the day when 'operational control' and full reporting was mandatory, I dug out and dusted off some of the early ones to check if memory served. Some of the aircraft flown had interesting fuel systems; nacelle tanks, pod tanks, tip tanks, even a nose tank in one venerable favourite (no names). I digress. The reverse side of the plans (almost without exception) are covered in 'notes' – calculation etc. and a 'fuel table' – Mains – ON 0100 – OFF 0135; 165 minutes / Aux ON 0135 – OFF 0230 – 10 mins – Nacelle tank transfer _ Left main + 60/ X feed 30. Just a record (accurate enough - in shorthand) to keep track of where, how much and how long; lest the noise cease. On the 'plan side' the note 'TX' is mostly aligned with a position report; report due @ 0232 so tanks change, position report and back to sleep. No (gods sent) GPS to assist, so the 'focus' was very much on paying attention to weather, track, fix, speed and time; which spun back to being very fuel aware. 'Situational awareness' they call it now.

I loved the first Omega system I ever used; Ground speed/ Wind etc. all without the slightest effort; wonderful; then the GPS even better, magical stuff. All there on screen, 75% reduction in the 'what if' equation, particularly at night on long legs, with a bit of weather around. Brilliant bit of gear. However, I wonder, is there a downside to this luxury? Just a small one, it could be successfully argued that the 'luxury' allows more time to pay attention to 'other' things like, switching tanks, or turning off the auto pilot to check the trim, or even looking ahead at the weather and contemplating 'what if' it gets worse and fuel available for any diversion? GPS can't do that for you. Sure it will take you to a diversion, but that is all it will do 'Go To' Kickatinalong – easy as. Just added 30 nms to the journey – fuel sufficient? You need to know, really, you do. Even a 'post it' note stuck on the dash – change tanks before lunch @ 0100 hrs....Mind you, running a tank 'dry' was an art form, guile, cunning and an intimate knowledge of the fuel system and engine 'personality' was a prerequisite.

Of course this is all stone age stuff; modern gear solves a lot of these 'matters aeronautical' – I just wonder if there is not a penalty in 'situational awareness' due to the lack of 'effort' (for wont of better) needed to keep things right side up. Don't know, just saying – Stray thoughts with second coffee.

Toot – toot.....

[Peetwo]

Popinjay to the rescue?? - Gundaroo Cirrus Fatal to be investigated - 

Via PJ HQ:

Gundaroo aircraft accident

The ATSB has launched a transport safety investigation into a fatal accident involving a Cirrus light aircraft at Gundaroo, north of Canberra, on Friday afternoon.

Transport safety investigators from the ATSB’s Canberra office were expected to arrive at the scene on Friday evening to conduct an initial assessment of the accident site.

Over coming days, investigators with experience in aircraft operations and maintenance will conduct a range of evidence-gathering activities on site including site mapping, wreckage examination, and recovery of aircraft components for further examination at the ATSB’s technical facilities in Canberra.

Investigators will also seek to interview any witnesses and involved parties, and collect relevant recorded information including flight tracking data, as well as pilot and aircraft maintenance records, and weather information.

The ATSB asks anyone who may have witnessed the accident, or may have video footage of the aircraft in any phase of its flight, to make contact via the witness form on our website: atsb.gov.au/witness at their earliest opportunity.

The ATSB anticipates publishing a preliminary report, which will detail factual information established during the investigation’s initial evidence collection phase, in approximately 6-8 weeks.

The ATSB will publish a final report, detailing contributing factors and any identified safety issues, at the conclusion of the investigation.

However, should any critical safety issues be identified at any stage during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate safety action can be taken.

Date 06/10/2023

Plus from MSM:

Investigation commences after fatal light aircraft crash outside Gundaroo, north of Canberra

Key points:

• NSW Police say they are still confirming how many people were on board the plane when it crashed just before 3:00pm
  
• Australian Transport Safety Bureau investigators will arrive at the scene on Friday evening and will prepare a report
  
• It appears the Cirrus light aircraft took off from Canberra Airport about 2:30pm on Friday
  

Emergency services are at the scene of a fatal light aircraft crash at Gundaroo, a small town north of Canberra.

NSW Police said they received a report that a plane had crashed and caught alight just before 3:00pm today.

The Rural Fire Service (RFS) has extinguished the fire and a crime scene has been established.

Police said they were still conducting inquiries and confirming how many people were on board at the time.

It appears the plane took off from Canberra Airport about 2:30pm.

NSW Police superintendent Cath Bradbury said she believed a local resident had called emergency services after seeing flames in the vicinity of the crash.

"When police arrived with RFS services there was a small grass fire and obviously a catastrophic crash of a small light aircraft," she said.

"The RFS extinguished the plane — unfortunately there are no survivors.

"Police will be working here through the night."

Superintendent Bradbury said there were "minimal witnesses" to the crash.

Australian Transport Safety Bureau (ATSB) chief commissioner Angus Mitchell said investigators were expected to arrive at the scene of the Cirrus light aircraft crash on Friday evening.



"Over coming days, investigators with experience in aircraft operations and maintenance will conduct a range of evidence-gathering activities on site including site mapping, wreckage examination, and recovery of aircraft components for further examination at the ATSB's technical facilities in Canberra," he said.

"Investigators will also seek to interview any witnesses and involved parties, and collect relevant recorded information including flight tracking data, as well as pilot and aircraft maintenance records, and weather information."

The ATSB is calling on anyone who may have witnessed the accident or who has footage to contact the bureau via its website.

The ATSB said it would publish a report on the crash within six to eight weeks.

In a statement, Air Services Australia said its Joint Rescue Coordination Centre was "aware of the incident".

Hmm...PJ didn't take long to decide to investigate this one?? Nine thousand feet to crash in sixty seconds suggests a catastrophic failure? Pardon my ignorance, I'm not sure if it is possible but I wonder if the parachute was inadvertently deployed??

'K' (add-in) The radio silence is noteworthy.  

MTF...P2 

[Kharon]

Out loud thinks...Gundaroo Cirrus..

Item 1: -BoM Graphic Area Forecast – Freezing levels :-

Area 'C' into 'A'. Fzl 5000' – 6000' – 8000' – 10,000'.


Item 2: -BoM Graphic Area Forecast – Cloud:-CU/SC -

Without getting too technical; a quick study of the forecast suggests a high probability  of in-flight icing. Lots of CU, lots of 'mixing' indicated by the wide range of freezing levels prescribed. To me, this indicates possibility of icing from just after departure to landing, along with turbulence and some areas of reduced forward visibility. In short, not a pleasant sort of day – routine enough for those running turbines or pistons with ice protection; but would I have taken off and set out for a 'look-see' in a single with little more protection than a heated pitot? Probably yes; provided the back door was wide open and the welcome mat out. The key factor would be performance margin available if I get iced up. How much ice can I manage, can I lose it, and if the build up continues (on descent), where can I go?

Much to consider; IFR without ice protection – route selection and 'what-if' options  would/should be a prime consideration. From the data we can see, seems the aircraft had a steady climb to altitude, seems reasonable to speculate that this was achieved without a significant ice build up; 02:36 to 02:45 (ish) nine minutes to TOC (1885' to 9,000+/- = 7000' gained : 9 minutes)– from the ADS-B data, routine stuff.

But; the 'speed' line begs some consideration, as does the mean freezing level. Hard to arrive at any conclusion from the crude 'graph' – HERE - . But, it tells a part of the story worth a thought or two..




At 02: 36 (ish) climb speed <100.
At 02: 37 (ish) climb speed <110.
At 02: 38 (ish) climb speed <125.
At 02: 39 (ish) climb speed =100.
At 02: 40 (ish) climb speed <120.
At 02: 41 (ish) 8,000 speed >130.
At 02: 42 (ish) 8,000 speed <100.
At 02: 43 (ish) >8,000 speed <100.
At 02: 44(ish) 8,500  speed <100.

Yes;yes,  really rough numbers, scientifically indefensible I realise; but, it seems a brick wall was hit at about the 8000' level; cloud up to 10,000, the concentration of potential 'airframe ice' would be at that height; as the vertical component of the CU (lapse rates) would be easing off as stability (balance) was reached. Probably a mix of super cooled and ice particles; perfect for the real stuff on the ice cold airframe.

What occurred between 02:45 and 02:47 is well  beyond my remit or knowledge; and speculation beyond that point would be foolhardy and best left to the investigator (IMO). But, without much doubt, the wheels came off at 8,000 and airframe ice involvement is a racing certainty.

I shall now retire back to knitting and await the report – (and wait and wait).. ATSB IIC ain't got a lot to work with on this one; apart from the obvious eliminations. 'Nuff said, probably too much.

Toot – toot.

[P7_TOM]

Spin resistant - ??

In the way of quiet contemplation, thinking aloud and prompting sensible discussion with those who may be able to answer some 'practical' questions related to the Cirrus event. Lots of 'theory' around, much speculation, but little of a practical nature. Never flown a Cirrus; not ever even sat in one; but, there is 'data' out there and much information, all freely available. This has raised some questions which I cannot answer; for instance:-

Laminar flow wing; stall and centre of pressure; and the leading edge 'cuff' with regard to behaviour in icing conditions, resistance to spin and the need for a parachute for USA certification. These items raise the question of tackling clearly defined icing conditions.

Speed fluctuations? – hand flown climb will; or, 'may' define a constant speed read out (CLIAS) maintained; with environmentally created fluctuations in the 'rate of climb'. The ADSB data indicates something different. It suggests the AP was maintaining an 'attitude' rather than an airspeed. The fluctuations in speed suggest a dogged determination to achieved the selected height, rather than a focus on essential speed control. I did say 'Suggests ,,, I have no knowledge of the 'type' or capability' or of the equipment fitted to the event aircraft. However, I feel it is a valid point for discussion.

Item last – why persist with a climb to 10,000' with the forecast as presented? Personally I would have opted for the lowest safe, taken the 'rough ride' and avoided any and mostly all possibility of sticking any ice on the airframe. I could, if provoked, cite many thousands of hours (and tales) spent in un pressurised, no de or anti ice twins on long haul night freight where that lesson was learned very early in the piece; and believe me, one upset, in serious ice is enough, not to mention the additional costs incurred carting half a ton of ice cubes along for the ride...So I am curious about the determined, apparently habitual climb to A100 against the forecast. No axe to grind and although I would question the general wisdom; given the weather, but, the notion of taking a look at the actual and making an informed command decision would garner 100 % support.

This particular event is a head scratcher; help is at hand though. I will take up the matter with a very experienced Cirrus pilot and see if we can winnow some wheat out of the chaff. MTF. No envy for the investigators; this will be a tough one.

[Peetwo]

Merriton aircraft accident - ATSB to investigate?? - 

To begin, kudos for once, the ATSB put out the following short factual statement in response to the tragic, fatal crash of a C172 at Merriton SA:

Merriton aircraft accident

Back to top

The ATSB has launched a transport safety investigation into an accident involving a Cessna light aircraft at Merriton, SA on Sunday afternoon.

The ATSB is preparing to deploy a team of transport safety investigators with aircraft operations, maintenance and engineering expertise to the accident site on Monday.

Once on site they will conduct a range of evidence-gathering activities including site mapping, wreckage examination, and recovery of aircraft components for further examination at the ATSB’s technical facilities in Canberra.

The ATSB asks anyone who may have witnessed the accident, or may have video footage of the aircraft in any phase of its flight, to make contact via the witness form on our website: atsb.gov.au/witness at their earliest opportunity.

Date 08/10/2023

 
Note no DTS for this week; or Popinjay input and opinion on this tragedy, that in itself is a huge positive, maybe someone has finally got a rope around PJ and his executive/middle management minions??   

Next from the ATSB aviation investigation page today:  

Summary

The ATSB is investigating a wirestrike and collision with terrain involving a Cessna 172, registered VH-RSB, near Merriton, South Australia on 8 October 2023.
It was reported that, during a private flight, the aircraft impacted terrain and was destroyed by fire. Initial evidence is consistent with the aircraft having struck a powerline while landing on private property. The pilot and passenger were fatally injured, and one person on the ground was injured during the rescue.
An ATSB investigation team was deployed to the accident site. As part of the investigation, ATSB investigators will examine the aircraft wreckage and other information from the accident site, interview any witnesses, examine maintenance records, and collect other relevant information.

Although the factors involved in this accident are yet to be established, the ATSB encourages pilots who land and take off from private property to read Avoidable Accidents No. 2 Wirestrikes involving known wires: A manageable aerial agricultural hazard. It includes valuable guidance to help manage the risk of wirestrike for all types of low-level operations.

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

MTF...P2 

[P7_TOM]

Frustrating and Tedious.

The frustration stems from not being able to source the data; not the 'happy-clappy' stuff; but the results of test flight and performance data. The little Cirrus is a good little rocket, no doubt about it – provided the recommendations and factory data is applied, it will 'perform design function' quite nicely. Yes, this is the however bit:-

Strictly related to the 'Gundaroo' event; critical elements in no specific order:-

Centre of Gravity – much depends on the estimated location of this datum; as does the estimated TOW. No point in guesstimating it; ATSB will do their best on that. It matters though; the weight and the C of G location could (and I did say could/ maybe) have some bearing on events subsequent. For consideration.

Resistance to Spin; certification and flight tests results for same. These are proving to be deuced difficult to locate, access and consider. Given the paucity of evidence for ATSB to work with, we can only hope that resources, time and money will be invested taking a long, educated read of the data. Why? Well; there are questions which need answers.

For instance; given the known data that there are some 'situations' in which the Cirrus is unable to affect a spin recovery; this led to certification as 'resistant' to spin and the CAPS were developed to alleviate this small area of 'difficulty'.

For instance; the 'wing cuff' was an 'add-on' to assist the laminar wing when critical angles were approaching. Good idea; cheap, cheerful and it works. Bravo – However; trying to find data related to flight test of the performance of 'the cuff' in icing conditions, at a critical speed/angle of attack., on climb, possibly through icing layers,  is proving to be a bit like Hen's teeth – bloody tough to find.

Now the 'If's' part: with great scope for 'Yeah-but'. The perennial problems of thinking aloud: consider some of the data available.

Met forecast – short odds on icing in one form or another.
Increased 'work load' on the lift/ drag ratio and airflow;
Add ice to the cuffed wing section;
Add ice to the aircraft weight;
add in an aft C of G;
consider the spin 'limitations' on the aircraft and;
consider the chances of a 'flat-spin'.

Still leaves a lot of questions unanswered I know this; but we must begin somewhere and these are obvious questions to be seriously considered and eliminated – even if just to clear away some 'grey' areas. Something went terribly wrong; can't do too much about that which is history; but we must at least try to prevent a repeat performance.

[Kharon]

Sad day; great loss; and no ATSB investigation:-

First details from the – ABC -  and the  - Australian..

[Earl Lank]

Vale my mate 'Swervin' Mervyn Mudge. 

BASI would be turning over in it's grave.