[Kharon]

Ironsider, via the Oz:

Seventh crash extends horror run, pressure on investigators

ROBYN IRONSIDE
AVIATION WRITER
@ironsider

5:06PM MARCH 12, 2020


ATSB transport safety investigators examine the wreckage of a Piper Seminole near Mangaolore Airport, Victoria last month. Picture: ATSB

The crash of a charter flight at Lockhart River this week, killing all five men on board, was Australia’s seventh fatal plane crash this year.

Just 10 weeks into 2020, 18 people have lost their lives in aviation incidents, compared with 21 deaths for the whole of 2019.

Wednesday’s crash followed on from last month’s mid-air collision at Mangalore in Victoria that killed four people, including two flight training instructors and two student pilots, and the January 23 tragedy involving a C-130 bomber that claimed the lives of three Americans.

Two brothers died in the crash of a Wittman Tailwind in Tooloom National Park on January 12, and a Brisbane couple lost their lives when a Cessna 182 crashed in Moreton Bay on January 22. There have also been two single fatality crashes involving sports aircraft.

The tragic spate of accidents has not only raised concerns about safety standards within the aviation industry but placed significant pressure on the agency responsible for crash investigations, the Australian Transport Safety Bureau.

As well as examining five of the fatal plane crashes, the ATSB has another 145 “active” investigations under way, the bulk of which are aviation incidents, along with 41 marine and rail accidents.

An ATSB spokesman said the higher than typical number of incidents this year had placed an increased load on their 60 transport safety investigators, but they were managing.

“The agency will work to prioritise its investigatory workload within its current staffing and budgetary resourcing,” he said.

“The ATSB has not sought additional resources from government at this time, nor does it anticipate doing so.”

But former Civil Aviation Safety Authority chairman and veteran pilot Dick Smith said the amount of time being taken to complete each investigation was not helping to improve safety.

“They take so long to come out with their answers instead of very urgently within the first two weeks saying ‘here is the problem, we want it addressed’,” Mr Smith said.

“What they do is they don’t address it. They’ll take two years to bring out a report and by that time it’s forgotten by the media.”

With a worrying number of crashes involving “collisions with terrain” often in bad weather, it seemed imperative to look at ways of increasing instrument-rated pilots, he said.

“CASA and the ATSB tell pilots ‘don’t fly into cloud’ instead of saying ‘let’s get more pilots instrument-rated’,” Mr Smith said.

“Unfortunately CASA has made it so difficult and so expensive for a private pilot to gain an instrument rating, people don’t get one.”

He said as few as 18 per cent of private pilots were instrument rated in Australia, compared to 70 per cent in the US.

“As a result, most people fly around without an instrument rating and then fly into a mountain,” said Mr Smith.

“But the ATSB and CASA tell us the fatalities are just an unfortunate anomaly even though we’ve got less people flying then before.”

A CASA spokesman confirmed the number of crashes in the year to date was higher than the trend for the previous five years.

But he said there was “no obvious correlation between the seven fatal accidents as they covered a variety of different activities and aviation sectors, including charter air transport, aerial firefighting, flight training, private training and sport aviation”.

“In line with normal procedures, CASA is reviewing all safety and regulatory matters regarding the Victorian midair collision, the NSW firefighting collision with terrain and Wednesday’s Cessna 404 accident in Lockhart River,” the spokesman said.

The ATSB spokesman said they were confident the identification and communication of critical safety issues was not being delayed due to the workload.

“The ATSB stresses that raising awareness of safety issues is not dependent on the publication of an investigation’s final report,” he said.

The last time the ATSB sought additional funding from the government was in 2016-17.

MTF...P2 

An unforgettable line.

“The ATSB stresses that raising awareness of safety issues is not dependent on the publication of an investigation’s final report,” he said.

If the minister, government and industry are going to let that statement pass without comment – its time to take a long, hard look at what ATSB is about.


The ATSB spokesman said they were confident the identification and communication of critical safety issues was not being delayed due to the workload.

Clever bit of legerdemain right there – ‘critical’ being subjective and nebulous.

Disgraceful and worrying? Just a bit.

[Peetwo]

Have they no shame?

Pointless political posturing, poncing about and generally pathetic. Colour me cranky.

“The ATSB stresses that raising awareness of safety issues is not dependent on the publication of an investigation’s final report,” he said.

Like the dew on the mountain,
    Like the foam on the river,
Like the bubble on the fountain,
    Thou art gone, and for ever!

Is that it; for those left behind after any sort of fatal accident? I’m no psychologist, but I’ve seen enough of the aftermath sudden death causes. Particularly when an ‘accident’ snatches a partner, comrade or loved one from a family and friends. I’ve no idea why finding out the cause of death is so very important; but I do know it matters. They call it ‘closure’ these days. I’m not certain that is not anything else other than an escape clause for those who have accepted the death and can walk away from it. It seems that unless its directly connected to ‘you’ the period of ‘mourning’ is a variable thing. I have been to over a dozen funerals now – pilots I worked with or knew – all related to air accident. Other funerals have been a little more personal – But. Of those where the cause of death was known whilst I miss the company of Grand parents, I can easily live with the loss, happy memories of a good innings, the natural way of life.

There are however some losses to which no easy explanation can be used to assuage the sadness. Mostly because of the delay in a final ATSB report being published and the unsatisfactory answers provided. We even depersonalise the event – the Brazillia, Botany Bay, Canley Vale, Essendon, Pel Air, Ross Air, Lockhart River – there is quite a list. But when you know the blokes, had a beer with ‘em, shared a laugh and a flight deck – one needs to know exactly what happened and why. When the final report is eventually released and the first thought is ‘bullshit’ – it is then you start to doubt the probity of an ATSB carefully massaged 'final report'.

For those left behind, the interminable wait for a report to define ‘what happened’ is the stuff of nightmare. When that report avoids painting an accurate picture; then what use is it to anyone except those who seek to cover over the simple fact that the culture and system of aviation safety oversight, Australian, style is one of the radical causes of accident and the ATSB will go to any length to divert attention from that root cause. Since Seaview, any careful study will reveal the desperate struggle to avoid responsibility, in any form for the minister or CASA.

Pel Air was a classic example, the treatment of Karen Casey typical, the cost of avoiding the simple fact that CASA had approved (accepted) some fairly thin operational safety margins disappeared in the smoke and mirrors. All the recommendations of a Senate committee and an independent review, in total almost 140 have been carefully obfuscated and quietly put to death.

For those operational types, waiting on a report to see what they may do to prevent a reoccurrence the extensive delay is dangerous. Could someone please list the positive changes made to prevent any one of the latest round of fatal accidents. Aye; thought so.

Toot – toot.

Not that anything ever changes regardless of whether they wait for accident reports. Those reports could be produced in 6 days or 6 years and safety issues would still be ignored. Just have to look at the plethora of Coroners recommendations....

Speaking of delays and following on from this post :- 

While trolling the Hooded Canary's ATCB website, I happened to come across the following interesting and somewhat disturbing FOI disclosure log entry which I gather was the original released documents from the AFAP FOI request (article above) :  FOI 19-20(1) documents

All emails, letters and other communications between the ATSB and external parties – including but not limited to DIPs – pertaining to the release of ATSB investigation AI-2018-010: The approval processes for the Bulla Road Precinct Retail Outlet Centre from 1 November 2018 to present day.

 
Extract from the released documents:..

...From that we can deduce that AI-2018-010:


...a) has been suspended at the DRAFT report/DIP and/or Final Report approval process for nearly 16 months; and
b) that the Victorian Coroner is now (since November 2018) a directly interested party to this investigation.

"...An ATSB spokesman said the report had been delayed by detailed feedback from directly involved parties that prompted more discussion..."

This begs the question is the Coroner's inquest and subsequent parallel findings the reason why this report has been severely O&O'd?

...As a 'passing strange' coincidence, less than 5 days after I made that post and a day after making some further inquiries on social media, yet again without any fanfare or public acknowledgement AI-2018-010 was discretely updated...

 ..Last update 12 March 2020..

...with you guessed it yet another delay:

Anticipated completion: 2nd Quarter 2020

Hmm...no comment - 

MTF...P2 

[Peetwo]

O&O: Under the cover of COVID-19? (complete the post -   )

Following on from the above post yet another example coming out of the Hooded Canary's avery, from 0tto L off the UP: https://www.pprune.org/pacific-general-a...st10734067

---

From the ATSB website today (bolding is mine): https://www.atsb.gov.au/publications...r/ao-2017-118/

Update published: 31 March 2020
The ATSB investigation into the collision with water involving a de Havilland Canada DHC-2 Beaver aircraft, VH‑NOO, at Jerusalem Bay, Hawkesbury River, NSW, on 31 December 2017 is continuing.

The ATSB external review process commenced on 20 December 2019 and provided directly involved parties (DIPs) the opportunity to comment on the draft investigation report and present any evidence in support of their comments for incorporation into the final report. During the report review process period, some additional evidence was obtained by the ATSB that requires further research and analysis to ascertain its relevance and influence on the accident.

This has required an extension to the intended timeframe that the ATSB will be able to complete the final report. The ATSB intends to complete this analysis and provide DIPs with the opportunity to consider and provide comment on the new information if deemed relevant.

The additional work is anticipated to be completed in the second quarter of 2020.

Plus LB response post: 

The additional work is anticipated to be completed in the second quarter of 2020.

That means some time maybe in 2021.

Three and a half to four years. Six dead.

About par for ATSB.

MTF...P2 

[Kharon]

I thought it an April Fool's spoof. 

“Based on a review of the available evidence, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues. Additionally, in the context that the investigation examined a time period associated with the early implementation of an SMS, it was also assessed that there was minimal safety learning that was relevant to current safety management practices. Consequently, the ATSB has discontinued this investigation.”

It is not.

The event occurred October 2017.

Report released March. 2020.

Cost – unknown.

Benefit to industry – Zero.

The event.

“As part of the occurrence investigation into the In-flight upset, inadvertent pitch disconnect, and continued operation with serious damage involving ATR 72, VH-FVR.”

Opinion: Please carefully consider those events; in operational terms and then tell me what any of that has to do with SMS. Piss poor operation of an aircraft; dreadful crew coordination, seriously flawed inspection and continued operation of an aircraft with a seriously damaged tail section? It is bullshit; pure, undiluted, cynical, irresponsible crapola.

(AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in over sighting the operator's systems.

Disgraceful and dangerous.

[thorn bird]

"also explored the role of the regulator in over sighting the operator's systems."

In other words, "Dear Saint Carmody, did your outfit oversight the operator?"

Answer "yes"

"Thank you, obviously no case to answer here, is that okay?"

[Peetwo]

Q/ Is the ATSB Tweeper a white hat? 

It would seem that the person (currently) in charge of the ATSB Twitter handle has either had a very early start; or is working from home. The following Tweep was sent at 6:36 am this morning: https://twitter.com/atsbgovau/status/124...7354635264

ATSB
@atsbgovau

A great article which looks at VFR into IMC accidents and spatial disorientation. Worth the read

Vertical Magazine
@verticalmag

Why do #helicopter crashes like Kobe Bryant’s keep happening? Read our feature story here:

https://www.verticalmag.com/features/hel...nt-safety/

He/she is right, it is worth the 2 coffee read. 

However one (still) wonders about the apparent disparity between those on the front line and those in the executive of both the ATSB and CASA, when you consider the factual evidence presented and then seemingly disregarded by the likes of Dr Godlike and Dr (I've lost my marbles) Aleck:

     

MTF...P2 

Ps Standby for a rerun of "Return of the Jedi" - 

[ventus45]

Good article.
Due to Covid-19 Self Isolating Lockdown - found something (perhaps) useful to do.
Converted it to a pdf file (minus adds).
https://www.mediafire.com/file/8ejdva3pw...t.pdf/file

[Peetwo]

AOPA Oz jumps on the Angel Flight Sky Wagon - 

Thanks for that "V", well done that man -    

Hope you don't mind "V" but I've raised an AP library link for your PDF version: https://auntypru.com/wp-content/uploads/...Bryant.pdf

Hmm...the NTSB 3D flight path depiction has some very real similarities to the final flight path of the tragic Huey accident off Anna Bay? ref: https://www.atsb.gov.au/publications/inv...-2019-050/



I also note that BM from AOPA Oz has also seen the irony in the Angel Flight announcement of continued and increased free humanitarian services (see: https://auntypru.com/sbg-5-04-2020-irony...he-stupid/ ) - 

---

 Ref: https://www.facebook.com/AOPAaustralia/p...=3&theater

---

MTF...P2 

[ventus45]

P2" All good - glad to do it - distribute as you wish.

[P7_TOM]

“Thanks for that "V", well done that man -

Second the motion. Choc frog awarded.

Interesting reading, a nicely construed argument and much of it 'spot-on'. But it does provide food for thought and room for discussion about a subject which has been around a long, long time. Now, don't get me wrong here, but I have a modicum of IFR experience and an equal association with the weather which requires it. The article, for me at least, brings up some questions which IMO have never been properly addressed. I bring up the following for discussion purposes only (BRB verboten) : I ain't saying they are 'the' answer but, based on experience I can vouchsafe their validity. Tin hat on, taxi waiting.

IFR flight has little to do with holding 'a rating'; it is a 'mind-set'. IFR flight is not some 'add on' which allows brief encounters with 'weather'. If one is preparing for operations in IMC or even under the IFR, then the approach to the flight must be in accordance with the  'rules' set down – it is IFR all the way, irrespective of weather. IFR operations deny trust in visual conditions, no matter how good they are. Sector LSALT for a Gin clear night approach is not a number to flirt with. Airline and commercial operating pilots, the world over may well breathe a sigh of relief when they are clear of cloud and the field becomes 'visual'. “Cleared visual approach” a welcome blessing at the end of a long tough sector. But no one buggers about with the 'rules' and starts ducking and weaving around weather below a safe height. A night circling approach to a remote field with rain and/or patches of low cloud about is about as spooky as it can get – 400' AGL then 'Woof' the aerodrome vanishes. What to do? There's only one smart thing to do.

Now then; I take umbrage with this 'inadvertent' flight into IMC line of argument. In the circling situation above, entering cloud may well be 'inadvertent' – you can't always see the stuff.  But, for a VFR 'mind-set' there can be little excuse. There is the forecast – there, in front of you is the reality. The crap weather can be seen. So, there are options; turn back, take an  alternate track, take a look-see and decide - with a viable escape plan; land somewhere and wait; or persist with the back door wide open. What you cannot do is take a VFR 'mind-set' into IMC. You cannot mess about in cloud at low level. Bit like being partially pregnant – not possible. I've often asked folk two questions which seem to trouble 'em. (I) What is the sector LSALT on this track? (ii) If I put the hood on you now, can you climb to that height? Often, when the mood strikes I'll ask what is the freezing level here today? To an IFR mind, the questions are already answered; most VFR minds are so lost puzzling out the answers, that when they attempt to fly the aircraft (AP fail)– it all turns to custard.

I have always liked the term 'situational awareness'. A true understanding of the current and approaching 'situation' and how to manage the possibilities and even probabilities has always seemed a good idea to me. Don't always get it right – but do I try hard to cover the bases; well, as many as I can see. When the weather is liquid and lousy, we fly. How one proposes to manage the flight is a personal decision; but, if you propose to chance your luck and start flirting with rising terrain and lowering cloud, it's best to make up your mind about how-where - and what - before the Palm trees start gently cleaning the windscreen.

Flying is a head game of the first water.

There, mini ramble over – just a personal thought, shared. 

“Yes please” - I can't abide a half full glass – not natural.

Happy Easter and 'be careful out there'.

[Kharon]

Fraught with peril – however....

I reckon P7's post above merits a little further 'discussion'. Pilots qualified for flight in 'Visual Meteorological Conditions; (VMC) bashing rudely into the tops of hills and other stuff which won't move an inch has claimed a fairly significant number of lives over the years – quite a lot in fact. Why, is a fairly good question which could use an answer.

Following along the P7 line, there is one item which is IMO of primary interest. Pilots qualified for flight under the Instrument Flight Rules (IFR) DO NOT no matter where they hail from, start pissing about in cloud/ weather below a height which may be called 'safe'.

Lowest Safe Altitude (LSALT) as used in IFR is a glass floor – the lowest 'safe height' above solid objects is calculated for a variety of situations; there are many of these encountered on a routine flight under the IFR. For example – an instrument approach at a regional aerodrome will provide a 'minimum' descent altitude – if, at that height the runaway cannot be seen, then an overshoot becomes necessary. The 'escape' path factors in such things as minimum terrain clearance at a calculated climb rate. To avoid bumping into rocks and trees and stuff. However, if the climb gradient requires – say a minimum of 300 feet per mile, and the aircraft One Engine Inoperative (OEI) cannot meet that gradient, then the minimum height must be adjusted upwards – to ensure an avoidance of  a Controlled Flight Into Terrain (CFIT).In short IFR pilots must always be cognisant of the lowest 'safe' height to which they may descend – and escape.

One of the most important lessons IFR pilots must keep tucked away is the time, distance and gradient calculation – it may well be 'sub-conscious' – but, an appreciation of how far, at what speed, at what rate of climb do I need to avoid an obstacle. Picture this – it's raining cats and dogs – it is a short runway – and it is dark with a minimum cloud base; there are hills on the departure track. All the IFR pilot has to avoid hitting anything is the written performance of the aircraft and an instrument panel. Once the undercarriage is up the aircraft disappears into the murk. From there on, it's all 'by the numbers'.

It is great fun and good aircraft handling practice to 'scud run'. We've all done it; particularly when we know the area and the local conditions very well. Slipping through the high passes, cutting around a mountain top – Hell's bells, nothing would move in PNG,  Fiji etc if pilots were not 'trained' to do so. That training includes 'cut-off' points and escape routes; well known, practised and drummed into the new fellah. But what of the average mutt? The non professional, the untrained, confronted by low cloud, high terrain, rain and turbulence; or any on the other combinations the weather can produce? What for them?

I've flown with fellah's who knew; intimately, the local topography and weather patterns and never been worried once. I have trained pilots who did not – and never had a scare ('cept once - for another day). I guess the message is starting to emerge – if IFR pilots don't go poking about in cloud, below a 'safe height' then why do VFR pilots persist in doing it? The statistics are crystal clear.

Situational awareness is (second the P7 opinion) the key to this on going problem. That and never, ever loosing sight of the terrain below a 'safe' height (10 foot is as good a miss as any). I've no quarrel with 'pushing on' – provided the back door is open; no problem with a little judicious 'scud running', provided all factors have been considered. There's little wrong with picking your way around showers and rain, the kids in the NT do all day during the 'wet' season – been done that way for decades. But; (second P7's notion) there is no such bloody thing as 'inadvertent' unless it's a night circling approach, in the rain. Which brings us to a point for debate.

Is deliberate entry into IMC, with full knowledge of the risks, without the skill or equipment to climb to a 'safe' height' culpable, a crime? Perhaps a couple questions could be asked of those intending to do so.  Can your aircraft meet the climb requirement to avoid the highest obstacle on this track, from here? What is the climb gradient required? How many miles are needed to reach that height? Do you have that performance available? What is the freezing level? If you intend to enter the weather conditions ahead – what is your escape plan? Should the Auto pilot fail can you safely extricate the aircraft from IMC to a safe place?

But, for mine, the big question is – why? Why persist into IMC without an escape plan and the skills or equipment to finalise that plan. Why? 

When thing's (matters of the Earth) return to normal – I'll bring this up at a BRB as a serious question for discussion – if P7 don't do it first: either way we shall see what the 'collective' opinion is.

Toot – toot.

[Peetwo]

Hooded Canary releases Mangalore mid-air prelim report - 

Via HC central yesterday:

Warning: Bucket may be required for the Hooded Canary segments -   

The Australian Transport Safety Bureau has released the preliminary report from its ongoing investigation into the mid-air collision involving a Piper Seminole and a Beech Travel Air aircraft south of Mangalore Airport in Victoria on 19 February 2020.

The preliminary report details basic factual information established in the investigation’s early evidence collection phase, and outlines the collision’s sequence of events using a number of sources including ADS-B transponder data and information from an iPad with an electronic flight bag app installed. The report also outlines weather information at the time and notes that there was no recording of the Common Traffic Advisory Frequency (CTAF) frequency.

The Travel Air aircraft, registration VH-AEM, had departed Tyabb Airport for a return Instrument Flight Rules (IFR) training flight to Shepparton via Mangalore with an instructor and student pilot on board at 10:55 am. Meanwhile the Seminole, registration VH-JQF, advised Air Traffic Control (ATC) at 11:11 am they were taxiing for departure from Mangalore for a round-trip IFR flight via Essendon and Shepparton. An authorising testing officer and pilot were on board.

Six minutes later, the Travel Air began its descent from 6,000 ft for airwork at Mangalore between 4,000 ft and ground level. ATC advised the Travel Air of the departing Seminole from Mangalore. The Seminole then made a departure call, advising ATC of a planned climb to 7,000 ft. ATC passed details of the Travel Air’s intended airwork to the Seminole.

The two aircraft collided at 11:24 am approximately 8 km south of Mangalore Airport at an altitude of about 4,100 ft. The Seminole travelled for about half a kilometre to the east before impacting an open field, while the Travel Air  continued north and impacted a lightly wooded area 1.4 km from the collision point. Debris was found in area ranging from 1.6 km to the north-north-east and about 200m to the west of the Hume Highway. The two pilots on board each aircraft were fatally injured.

Examination of the recovered radios, weather conditions at the time of the accident, as well as recorded area frequency calls and recollections of CTAF radio broadcasts will be the focus as the investigation moves forward.

ATSB Chief Commissioner Greg Hood noted preliminary reports do not contain findings, identify contributing factors or outline safety issues and actions, which will be detailed in an investigation’s final and any interim reports.

“Examination of the recovered radios, weather conditions at the time of the accident, as well as recorded area frequency calls and recollections of CTAF radio broadcasts will be a focus as the investigation moves forward,” Mr Hood said. 

“Other areas for investigation include air traffic services actions, procedures and practices, traffic density in and around Mangalore Airport and classification of its airspace, and Class G* and CTAF operational and communication processes and procedures at the airport. Visibility from both aircraft will also be examined.”

A final report is expected to be completed next year.

“However, should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate safety action can be taken,” Mr Hood said.

* In class G airspace, air traffic controllers provide traffic information to IFR aircraft about other conflicting IFR and observed VFR flights, but do not provide separation services.

Read the preliminary report AO-2020-012: Mid-air collision involving Piper PA-44-180 Seminole, VH-JQF, and Beech D95A Travel Air, VH-AEM, near Mangalore, Victoria, on 19 February 2020

Not sure exactly why the Hooded Canary feels the need to put his 2 bob's worth in? Why can't he just leave it to his experts? Perhaps HC is just trying to justify his existence and bloated (nearly 500k) base salary but I do wonder if there isn't some hidden (singing Canary) message behind this?

For a more damning assessment of the ATSB's findings so far IMO you can't go past the 'Advance' post off the UP -   

  US vs Australian airspace

---

In the USA ALL IFR aircraft are separated by ATC.

Dick Smith has been trying to bring Australian safety standards up for at least 30 years by insisting on the same ATC separation here.
The ATSB report confirms what this forum has known for some time => both aircraft were visible to ATC via ADS-B tracking.
Airservices have a flow chart that demonstrates the workload of providing separation is LESS than the workload of only providing traffic.
WHY?
Each task requires ATC considering the trajectory of every aircraft in the sector.

To separate aircraft, the ATC makes a decision and issues an instruction.

If the ATC passes traffic then the pilot may respond with his decision to change altitude or track or otherwise avoid the conflict.

BUT then the ATC has to assess this change to determine if a different conflict will occur and perhaps pass further traffic.

So let us stop accepting the nonsense argument that it costs more to provide separation compared to traffic information - it does not.

What is the total cost of this accident going to be?

Almost two decades ago Dick organised a trip by both Airservices and CASA staff to the United States with flights arranged to demonstrate the ease of use and safety of Class E airspace.

A very experienced US ATC from the Southern California Terminal Radar Control Unit addressed the team and pointed out how easy it was to provide separation and how safe the result.

John and Martha King of King schools tried very hard to educate the team on why US airspace is as safe as Australian airspace in terms of collisions per flight hour but has so much greater traffic density and thus greater actual safety.

A lot of very experienced pilots and controllers in this country know Dick was right back then and he is proven right again by this accident.

CAN WE LEARN FROM IT THIS TIME???

MTF...P2 

[Kharon]

(PWP and cranky).

The 'accidents' we had to have.

A Pipistrel crashed and burned; quite recently. One killed, one badly mauled by the old enemy – fire. Now the culprit is alleged 'engine failure' – an accident happened. Could have been any engine on any aircraft. An unpredictable occurrence, part of the risk matrix, bus, truck, car and even lawn mower motors occasionally quit – without notice – results directly in relation and proportionate to circumstances. Unavoidable.

But what of those accidents which were clearly and inexcusably preventable? How do we come to terms with those? Essendon – entirely preventable. The bloody DFO building should never, not ever been allowed. Six dead, with a potential for many, many more.  And yet?

Now four dead in an entirely preventable mid-air collision -

Old Akro (legend) "By definition, IFR aircraft can not separate themselves visually and giving them traffic does NOT solve the problem. IFR aircraft are frequently constrained to fly one flight path and one only - they have no choice; consider an instrument approach for example."

Advance (Choc frog candidate) - “Get on to Worksafe, the Victorian Police, the AFP, your local MPs and point out that the Airservices organisation responsible for separating aircraft had the means to do so but did not; that the CASA OAR organisation charged with implementing international best practice in airspace administration has failed to do so.

Thing that really bunches my panties is the incredible difference in the 'take' between the highway death of four Coppers and the mid air collision between two aircraft. Same ducking body count. The world, his wife and every bleeding heart halfwit on morning TV is wittering on about an explainable road accident, of which we have many. Yet non of these talking heads seem to be in the slightest concerned that a major infrastructure, aircraft separation system has a gaping hole in it; several holes in fact. An allegedly 'fail safe' public transport system has failed four pilots.  No one apart from the responsible ATCO' (bless 'em) and those few remaining flying public transport aircraft, within that deeply flawed monopoly system seem to give a toss that this event occurred despite many, many warnings, issued by experts to several governments that Australia has got airspace wrong.

Four Bobbies killed in the line of duty – a national outpouring, gnashing of teeth and much wailing; furry muff. BUT. Four dead in a mid-air – page three for 12 hours and forgotten. In this day and age of whiz-bang technology the mid air collision should never have been even a remote possibility – and yet, there it is. Done, dusted and waiting down the three years required for ATSB to eventually finish smoothing it all away, under the ever hungry bipartisan carpet.

Will these accidents spur government to come to grips with real 'air safety'? No reason it should – it never has in the past, despite millions spent on gaining the right answers –only  to be obfuscated, manipulated and diluted to a fare thee well. Sickening waste.

Shame, shame on the lot of ya. Disgusting don't cover it, but 'twill suffice for now.

Toot – Aye, Full steam – Toot.

[Choppagirl]

"A final report is expected to be completed next year"

Please don't make me laugh! ATSB have only just completed the investigation into the Rossair crash and will be publishing on Thursday. It's only taken them 2 years and 11 months!

It's an absolute disgrace.

[P7_TOM]

CG -


“ATSB have only just completed the investigation into the Rossair crash and will be publishing on Thursday”.

There are three short price favourites on 'K's' tote for the result of this report.

@ 5/2 odds on; is the BRB/IOS favourite. (Surreal McCoy). Which we have been keeping quiet. I, personally would not bet on any other result. Forget your expectations, but consider that which may be done in the Sim and that which an aircraft will tolerate. Think 'Braz'.

@ 4/2 odds on; (Negative Loss). Never a clear winner – but everyone comes out clean with little loss of face, responsibility or need to change the race strategy.

@2/1 odds on (Undetermined). Always a sporting chance – the mystery of safety and the mystique of managing the same always a good chance to 'place' with prospects of doing better.

'K” does this sort of thing better than I – however; just for sport – give us your tip for the result – it has been a three year marathon and the finishing line is close. Where would you, in your best, clinical, analytic mode: (considering recent ATSB form) place your betting choc frogs? - You know you want to.

Deep breath; consider all (carefully) separate expectation of professionalism, consider the politics, the players and the track record of those 'investigating'. Finally, consider the implications of the veritable 'truth' ever seeing daylight.

Tote is open; 'K' will take your choc frogs and drink vouchers; so be careful in choice and moderate in expectations.

You'll never walk alone – unless I've fallen over a bar stool – (happened once, never heard the end of it). Chin up, brace and let the chips fall where they may.

“Two here please: and, yes the lady drinks pints – tonight”.

[Peetwo]

Proper AAI vs 'Lies, damned lies and Dr Godlike' -   

While we wait for the running of the nearly 3 year Hooded Canary Rossair cover-up report, note the following off the Accidents OS thread...  

Jan 30, 2019, in Canada.

Beechcraft B200 accident. Well worth a read through.  -  HERE

Please note, today's date April 30, 2020. Not too shabby a turn around time for a very good, professional, valuable report. Nicely done Canada.

UP thread with Centaurus summary - 

Canadian accident King Air-200 loses both AH's in IMC and crashes

---

https://www.tsb.gc.ca/eng/rapports-r.../a19w0015.html


This accident report on a King Air 200 is from Transport Safety Board Canada.

The copilots AH was u/s after engine start. Normally the MEL would preclude flight. The captain assumed the copilots AH could eventually come good with time and elected to continue with the flight. The first officer was unhappy about the captain's decision. After takeoff it was obvious the F/O's AH was inoperative and he again told the captain who reassured the F/O the AH would come good eventually. In fact the AH was unserviceable.

During en route cruise in IMC the captains AH also failed. The autopilot disconnected. The captain attempted to fly on partial panel in IMC.but soon became disorientated

The aircraft went into a steep spiral dive and broke clear of IMC at 2000 ft agl. The captain was unable to recover in time and the aircraft crashed at 400 knots.

Note the following from the Canuck TSB report: 

This report concludes the Transportation Safety Board of Canada’s investigation into this occurrence. The Board authorized the release of this report on 18 March 2020. It was officially released on 27 April 2020.

That is 1 year, 1 month and 13 days to complete a reasonably complex investigation - 

Now compare that to this mostly desktop, simple 3 year, 7 month, 16 day investigation into the cause of drum stock fuel contaminants near Cloncurry aerodrome in September 2016...  : https://www.atsb.gov.au/publications/inv...-2016-144/   

This is an extract from the bollocks media presser that accompanied that report...

 

...Mr Macleod noted that the investigation established that no contaminants were found in any aircraft exposed to the fuel.


“Filtration during the refuelling process appears to be effective in preventing these contaminants from reaching the aircraft and there was no evidence that the sealant dissolved in the fuel.”

The report notes it is possible that the sealant may break down into small enough pieces to pass through a fuel transfer pump’s micronic pre-filter and reach the aircraft’s fuel tank, and from there pass through the aircraft’s fuel filtration system and enter the engine.

“However, if that was to occur, the particles would be in minor quantities and too small to affect engine operation,” Mr Macleod said.

“As long as fuel is filtered as required under the regulations, and in accordance with best practice, harmful contaminants should not be able to reach the aircraft.”  - FDS!   

On another matter, I note that the almost inevitable smokescreen to the Rossair FR was wafted out yesterday by the ATCB's real boss Dr God-like, when he released his much anticipated latest round of pointless, bollocks aviation occurrence stats for the last decade...  : 

ATSB releases Aviation Occurrence Statistics report



The Australian Transport Safety Bureau has released its latest Aviation Occurrence Statistics report, covering the 10-year period from 2010 to 2019.

“Each year, thousands of safety occurrences involving Australian aircraft and foreign‑registered aircraft operating in Australia are reported to the ATSB,” said Dr Stuart Godley, ATSB Director Transport Safety.

“This report is part of a series that aims to provide information and statistical data to the aviation industry, manufacturers and policy makers, as well as to the travelling and general public, about these aviation safety occurrences. In particular, the data can be used to determine what can be learned to improve transport safety in the aviation sector.”

This latest Aviation Occurrence Statistics report notes that there have been no fatalities in scheduled commercial air transport in Australia since 2005, while that over the 10-year 2010-2019 period, the number of general aviation fatalities and fatal accidents decreased, and the number of fatalities and fatal accidents within the recreation aviation sector remained relatively constant.

The study uses information over the 10-year period from 2010–2019 to provide an insight into current and possible future trends in aviation safety.

The study uses information over the 10-year period from 2010–2019 to provide an insight into current and possible future trends in aviation safety, Dr Godley explained.

“For example, since 2016, remotely piloted aircraft have surpassed helicopters to become the second most common aircraft type involved in an accident. Further, the number of manned aircraft experiencing near encounters with an RPA also increased significantly over the study period.”

Dr Godley also noted that for the first time, statistics in this report have been organised around the type of aircraft activity being conducted, rather than the operational regulation.

“An activity type reflects the activity the aircraft was engaged in, while an operation type reflects the legal regulation that the aircraft was flown under,” he said.

“For instance, all ferry flights are now recorded under the same activity irrespective of whether the ferry flight was a positioning flight for a commercial air transport passenger flight or an aerial work flight.”

The report incorporates interactive web versions of all tables and graphs to allow the user to display aviation occurrence data in the format of their choice.



Read the report AR-2020-014: Aviation Occurrence Statistics 2010 to 2019
Related: Aviation statistics

Hmm...doesn't this line smack of sheer hypocrisy?? 

“For instance, all ferry flights are now recorded under the same activity irrespective of whether the ferry flight was a positioning flight for a commercial air transport passenger flight or an aerial work flight.”

From Hansard for 04/09/19 :

Senator PATRICK: Okay, we don't have to take that on notice now. We know the answer is zero, and we got to the end of the entire investigation without talking to any Angel Flight pilots about pressure. I want to go back to the statistics. I'm reading this as saying that, if you include the prepositioning flights, Angel Flight comes up at 1.5 accidents per 10,000 flights, and you've got the other flights coming up at much higher numbers.

Dr Godley : Sorry, could you say that again?

Senator PATRICK: Looking at page 69, if you include the prepositioning flights and postpositioning flights—

Dr Godley : So you're just talking about the subset of accidents now?

Senator PATRICK: Yes.

Dr Godley : And that was Senator Brockman's point, yes.

Senator PATRICK: Was it a discretionary choice, or some choice you made, in respect of not including prepositioning flights, or is there some standard by which that is the requirement for these investigations?

Dr Godley : If you look at the current definition of a community service flight that CASA put out—

Senator PATRICK: No—

Dr Godley : it's about passengers.

Senator PATRICK: That definition actually came out two years after this accident occurred.

Dr Godley : But it is consistent with that—

Senator PATRICK: It's semantics. The reality is that the flights start—the pressure starts—from the moment they first get out onto the tarmac at their original location. They know they need to get to wherever they need to get to to pick up the passenger. Probably the last sector has less pressure on it. It just seems totally against all reasonableness to cut out those flights. I am just wondering what—

Dr Godley : As we said, we did—

Senator PATRICK: In terms of international standards, are there any international standards that suggest that the way you are doing it is the way that it should be done?

Dr Godley : There is no international standard, but, as I said before, we made our conclusions—

---

From the report: https://www.atsb.gov.au/publications/2020/ar-2020-014/

Background to change


In 2013, recommendations by the Tenth Session of the Statistics Division of the International Civil Aviation Organization (ICAO) were adopted by the ICAO Council and a new edition of the Reference Manual on the ICAO Statistics Program was published. Included within the manual was a new ICAO Classification of Civil Aviation Activities.

The Australian Bureau of Infrastructure, Transport and Regional Economics (BITRE) adopted ICAO’s new classification in 2014 and began collecting statistics in their General Aviation Activity Survey (which the ATSB uses to calculate rate data presented in this report) to reflect this change.

In 2019 the ATSB adopted the new activity classification to better align with BITRE and ICAO. The ATSB conducted a multi‑year project to reclassify over 320,000 occurrences and events within the ATSB occurrence database to include the new activity classification. As a result, the ATSB’s occurrence data now closely aligns with BITRE’s classification and therefore reduces most of the uncertainty associated with combining the databases. These changes mean the ATSB will be able to present more accurate, higher resolution rate data (the best measure for comparison between activities) for more activities than previously.

---

Senator PATRICK: So you made a choice?

Dr Godley : based on all incidents. When you look at prepositioning flights as well as passenger flights, it's still higher for all those together. But there is a difference between prepositioning flights and passenger flights, so the risk is not the same; the risk is slightly higher. It is higher when there are passengers on board.

Hmm...Dr G brings a whole new perspective to the line...'lies, damned lies and statistics' - 

MTF...P2   

ps 11:30 EST - still waiting "K" 

[Peetwo]

Proper AAI vs 'Lies, damned lies and Dr Godlike' -   

While we wait for the running of the nearly 3 year Hooded Canary Rossair cover-up report, note the following off the Accidents OS thread...  

Jan 30, 2019, in Canada.

Beechcraft B200 accident. Well worth a read through.  -  HERE

Please note, today's date April 30, 2020. Not too shabby a turn around time for a very good, professional, valuable report. Nicely done Canada.

UP thread with Centaurus summary - 

Canadian accident King Air-200 loses both AH's in IMC and crashes

---

https://www.tsb.gc.ca/eng/rapports-r.../a19w0015.html


This accident report on a King Air 200 is from Transport Safety Board Canada.

The copilots AH was u/s after engine start. Normally the MEL would preclude flight. The captain assumed the copilots AH could eventually come good with time and elected to continue with the flight. The first officer was unhappy about the captain's decision. After takeoff it was obvious the F/O's AH was inoperative and he again told the captain who reassured the F/O the AH would come good eventually. In fact the AH was unserviceable.

During en route cruise in IMC the captains AH also failed. The autopilot disconnected. The captain attempted to fly on partial panel in IMC.but soon became disorientated

The aircraft went into a steep spiral dive and broke clear of IMC at 2000 ft agl. The captain was unable to recover in time and the aircraft crashed at 400 knots.

Note the following from the Canuck TSB report: 

This report concludes the Transportation Safety Board of Canada’s investigation into this occurrence. The Board authorized the release of this report on 18 March 2020. It was officially released on 27 April 2020.

That is 1 year, 1 month and 13 days to complete a reasonably complex investigation - 

Now compare that to this mostly desktop, simple 3 year, 7 month, 16 day investigation into the cause of drum stock fuel contaminants near Cloncurry aerodrome in September 2016...  : https://www.atsb.gov.au/publications/inv...-2016-144/   

This is an extract from the bollocks media presser that accompanied that report...

 

...Mr Macleod noted that the investigation established that no contaminants were found in any aircraft exposed to the fuel.


“Filtration during the refuelling process appears to be effective in preventing these contaminants from reaching the aircraft and there was no evidence that the sealant dissolved in the fuel.”

The report notes it is possible that the sealant may break down into small enough pieces to pass through a fuel transfer pump’s micronic pre-filter and reach the aircraft’s fuel tank, and from there pass through the aircraft’s fuel filtration system and enter the engine.

“However, if that was to occur, the particles would be in minor quantities and too small to affect engine operation,” Mr Macleod said.

“As long as fuel is filtered as required under the regulations, and in accordance with best practice, harmful contaminants should not be able to reach the aircraft.”  - FDS!   

On another matter, I note that the almost inevitable smokescreen to the Rossair FR was wafted out yesterday by the ATCB's real boss Dr God-like, when he released his much anticipated latest round of pointless, bollocks aviation occurrence stats for the last decade...  : 

ATSB releases Aviation Occurrence Statistics report



The Australian Transport Safety Bureau has released its latest Aviation Occurrence Statistics report, covering the 10-year period from 2010 to 2019.

“Each year, thousands of safety occurrences involving Australian aircraft and foreign‑registered aircraft operating in Australia are reported to the ATSB,” said Dr Stuart Godley, ATSB Director Transport Safety.

“This report is part of a series that aims to provide information and statistical data to the aviation industry, manufacturers and policy makers, as well as to the travelling and general public, about these aviation safety occurrences. In particular, the data can be used to determine what can be learned to improve transport safety in the aviation sector.”

This latest Aviation Occurrence Statistics report notes that there have been no fatalities in scheduled commercial air transport in Australia since 2005, while that over the 10-year 2010-2019 period, the number of general aviation fatalities and fatal accidents decreased, and the number of fatalities and fatal accidents within the recreation aviation sector remained relatively constant.

The study uses information over the 10-year period from 2010–2019 to provide an insight into current and possible future trends in aviation safety.

The study uses information over the 10-year period from 2010–2019 to provide an insight into current and possible future trends in aviation safety, Dr Godley explained.

“For example, since 2016, remotely piloted aircraft have surpassed helicopters to become the second most common aircraft type involved in an accident. Further, the number of manned aircraft experiencing near encounters with an RPA also increased significantly over the study period.”

Dr Godley also noted that for the first time, statistics in this report have been organised around the type of aircraft activity being conducted, rather than the operational regulation.

“An activity type reflects the activity the aircraft was engaged in, while an operation type reflects the legal regulation that the aircraft was flown under,” he said.

“For instance, all ferry flights are now recorded under the same activity irrespective of whether the ferry flight was a positioning flight for a commercial air transport passenger flight or an aerial work flight.”

The report incorporates interactive web versions of all tables and graphs to allow the user to display aviation occurrence data in the format of their choice.



Read the report AR-2020-014: Aviation Occurrence Statistics 2010 to 2019
Related: Aviation statistics

Hmm...doesn't this line smack of sheer hypocrisy?? 

“For instance, all ferry flights are now recorded under the same activity irrespective of whether the ferry flight was a positioning flight for a commercial air transport passenger flight or an aerial work flight.”

From Hansard for 04/09/19 :

Senator PATRICK: Okay, we don't have to take that on notice now. We know the answer is zero, and we got to the end of the entire investigation without talking to any Angel Flight pilots about pressure. I want to go back to the statistics. I'm reading this as saying that, if you include the prepositioning flights, Angel Flight comes up at 1.5 accidents per 10,000 flights, and you've got the other flights coming up at much higher numbers.

Dr Godley : Sorry, could you say that again?

Senator PATRICK: Looking at page 69, if you include the prepositioning flights and postpositioning flights—

Dr Godley : So you're just talking about the subset of accidents now?

Senator PATRICK: Yes.

Dr Godley : And that was Senator Brockman's point, yes.

Senator PATRICK: Was it a discretionary choice, or some choice you made, in respect of not including prepositioning flights, or is there some standard by which that is the requirement for these investigations?

Dr Godley : If you look at the current definition of a community service flight that CASA put out—

Senator PATRICK: No—

Dr Godley : it's about passengers.

Senator PATRICK: That definition actually came out two years after this accident occurred.

Dr Godley : But it is consistent with that—

Senator PATRICK: It's semantics. The reality is that the flights start—the pressure starts—from the moment they first get out onto the tarmac at their original location. They know they need to get to wherever they need to get to to pick up the passenger. Probably the last sector has less pressure on it. It just seems totally against all reasonableness to cut out those flights. I am just wondering what—

Dr Godley : As we said, we did—

Senator PATRICK: In terms of international standards, are there any international standards that suggest that the way you are doing it is the way that it should be done?

Dr Godley : There is no international standard, but, as I said before, we made our conclusions—

---

From the report: https://www.atsb.gov.au/publications/2020/ar-2020-014/

Background to change


In 2013, recommendations by the Tenth Session of the Statistics Division of the International Civil Aviation Organization (ICAO) were adopted by the ICAO Council and a new edition of the Reference Manual on the ICAO Statistics Program was published. Included within the manual was a new ICAO Classification of Civil Aviation Activities.

The Australian Bureau of Infrastructure, Transport and Regional Economics (BITRE) adopted ICAO’s new classification in 2014 and began collecting statistics in their General Aviation Activity Survey (which the ATSB uses to calculate rate data presented in this report) to reflect this change.

In 2019 the ATSB adopted the new activity classification to better align with BITRE and ICAO. The ATSB conducted a multi‑year project to reclassify over 320,000 occurrences and events within the ATSB occurrence database to include the new activity classification. As a result, the ATSB’s occurrence data now closely aligns with BITRE’s classification and therefore reduces most of the uncertainty associated with combining the databases. These changes mean the ATSB will be able to present more accurate, higher resolution rate data (the best measure for comparison between activities) for more activities than previously.

---

Senator PATRICK: So you made a choice?

Dr Godley : based on all incidents. When you look at prepositioning flights as well as passenger flights, it's still higher for all those together. But there is a difference between prepositioning flights and passenger flights, so the risk is not the same; the risk is slightly higher. It is higher when there are passengers on board.

Hmm...Dr G brings a whole new perspective to the line...'lies, damned lies and statistics' - 

MTF...P2   

ps 11:30 EST - still waiting "K" 

Renmark C441 Rossair accident report finally released - 

Only took 1067 days but finally here it is...  

Via the ATCB:

Accident highlights risks inherent in simulated engine failures after take-off



A twin-engine Cessna 441 Conquest collided with the ground shortly after take-off following a simulated engine failure at about 400 feet when the aircraft did not achieve the expected single-engine climb performance or target airspeed.

An ATSB investigation into the 30 May 2017 accident, near Renmark, South Australia, which resulted in the deaths of the three pilots on board, found the lack of expected performance was likely due to the method of simulating the engine failure, pilot control inputs or a combination of both. The investigation also established that normal power on both engines was not restored when the expected single engine performance and target airspeed were not attained.

“That was probably because the degraded aircraft performance, or the associated risk, were not recognised by the pilots occupying the control seats,” said ATSB Executive Director Transport Safety Nat Nagy.

“Consequently, about 40 seconds after commencing the simulated engine failure exercise, the aircraft experienced an asymmetric loss of control, and impacted the ground about four kilometres west of Renmark Airport.”

If one engine inoperative training sequences are conducted close to the ground, then effective risk controls need to be in place to prevent a loss of control, as recovery at low height will probably not be possible.

The aircraft, operated by Adelaide-based Rossair, was conducting a check flight on the Cessna 441 for Rossair’s chief pilot by a Civil Aviation Safety Authority (CASA) flight operations inspector (FOI). In turn, the chief pilot was conducting a check of an experienced Cessna 441 pilot who was rejoining Rossair after a period away from the company. The inductee pilot was the pilot flying and was seated in the aircraft’s front left control seat, the chief pilot was seated in the front right seat, and the CASA FOI was observing and assessing the flight from the first passenger seat directly behind the left-hand pilot seat.

They were operating a return flight from Adelaide Airport via Renmark, with a number of flight exercises planned as part of the inductee’s check flight, including the simulated engine failure after take-off on departure from Renmark.

“Conducting the engine failure exercise after the actual take-off meant that there was insufficient height to recover from the loss of control before the aircraft impacted the ground,” said Mr Nagy.

Noting that there is no Cessna Conquest simulator in Australia, the investigation highlights that one engine inoperative training should follow the manufacturer’s guidance and, where it is possible, be conducted in an aircraft simulator.

Mr Nagy said if one engine inoperative (OEI) training sequences are conducted close to the ground, then effective risk controls need to be in place to prevent a loss of control, as recovery at low height will probably not be possible.

“These risk controls can include defined OEI performance criteria that, if not met, require immediate restoration of normal power; use of the appropriate handling techniques to correctly simulate the engine failure and ensuring that aircraft drag is minimised/OEI performance is maximised; and ensuring that the involved pilots have the appropriate recency and skill to conduct the exercise and that any detrimental external factors, such as high workload or pressure, are minimised.”

The investigation also identified a number of safety factors, although they did not necessarily contribute to the accident flight. These included:

• The operator’s training and checking manual procedure for simulating an engine failure in a turboprop aircraft was inappropriate and increased the risk of asymmetric control loss;
  
  
• The CASA flying operations inspector was not in a control seat and was unable to share the headset system used by the inductee and chief pilot;
  
  
• The inductee and chief pilot, while meeting recency requirements, had limited recent experience in the Cessna 441;
  
  
• The chief pilot and other key operational managers within Rossair were experiencing high levels of workload and pressure; and
  
  
• CASA’s method of oversighting Rossair increased the risk that organisational issues would not be identified and addressed.
  

Mr Nagy also noted a lack of recorded data from the aircraft reduced the amount and type of evidence available to investigators about handling aspects and cockpit communications, as the aircraft was not fitted with a cockpit voice recorder or flight data recorder, and nor was it required to be.

“This limited the extent to which potential factors contributing to the accident could be analysed.”

Read the investigation report AO-2017-057: Loss of control and collision with terrain involving Cessna 441, VH-XMJ, near Renmark Airport, South Australia on 30 May 2017

[Kharon]

Ross Air Conquest accident.

There are 81 pages in the just released report from ATSB into this accident. Most of it seems reasoned and reasonable – considering the lack of 'finite' data. There is quite a bit both the IIC and we don't know. But you have to start somewhere. My favourite is a 'skip -read' – skipping the padding and fluff and just reading the bits that catch the eye. These are most helpful as when you worry 'em and toss 'em about, questions turn up and a deeper read is needed to find those answers. This report is worth a 'careful' long read; the investigators were not given too much to begin with and left with much to puzzle out. That said, it is too early to weigh and measure a report which has been subjected to some very careful editing. 

What we don't know is a greater number than 'proven' fact. There are questions which have not been fully answered; it seems the investigators have gone to some trouble to find satisfactory explanations to those awkward questions. No point in speculating, not until the report has been digested (in full). Anyway – below is my 'grab-bag' from a first read – there are questions within which require careful consideration. Engaging brain before opening gob is always a good start point. ('aircraft' not that horrible USA airplane ). No matter- FWIW:-

ATSB - “The aircraft maintained the runway heading until reaching a height of between 300-400 ft above the ground (see the section titled Recorded flight data). At that point the aircraft began veering to the right of the extended runway centre line (Figures 1 and 15). The aircraft continued to climb to about 600 ft above the ground (700 ft altitude), and held this height for about 30 seconds, followed by a descent to about 500 ft (Figures 2 and 13). The information ceased 5 seconds later, which was about 60 seconds after take-off

ATSB - “Manual mode refers to the engine power output being directly controlled by the power lever position rather than by a signal sent to the engine by the electronic engine control unit (EEC). The power system is designed so that fuel scheduling is lower in manual mode than it is in normal (automatic) mode. Higher power lever positions are therefore required to maintain engine power when in manual mode compared to normal mode. This means that if a fault is detected in the EEC and the engine operation automatically reverts to manual mode the engine will have a reduction in power for that particular power lever setting. If that occurs the power can be restored by advancing the power lever as required. ('K' Consider near Vmca speed recovery).

ATSB - “The VMCA published in the Cessna 441 pilots operating handbook (POH) was 91 kt indicated airspeed. The POH further stated that:The airplane must reach the air minimum control speed (VMCA) before full control deflections are able to counteract the roll and yaw tendencies associated with one engine inoperative and full power operation on the other engine. VMCA with wing flaps in take-off position is indicated by a red radial on the airspeed indicator. VMCA with wing flaps in the UP position and the airplane in an en-route climb configuration will be buffet limited and occur at a higher speed. In addition to the published VMCA the POH also listed an ‘intentional one engine inoperative’ indicated airspeed of 98 kt with advice that:Although the airplane is controllable at the air minimum control speed, the airplane performance is less than optimum. A more suitable speed with wing flaps positioned in take-off is 98 KIAS [kt indicated airspeed]. This speed is identical to the normal rotation speed, thus the pilot can direct more of this attention to determining and securing the inoperative engine than to achieving a speed not  normally associated with take-off. This speed also provides additional safety for controllability and allows easier maintenance of altitude during the period of gear retraction and securing the inoperative engine.  (Worth checking the speed diagram - questions there)

ATSB - “This procedure directly referenced related guidance in the POH, applicable to the demonstration of VMCA, which stated:One engine inoperative procedures should be practised in anticipation of an emergency. This practice should be conducted at a safe altitude (5000 ft AGL), with full power on both engines, and should be started at a safe speed of at least 98 KIAS. As recovery ability is gained with practice, the starting speed may be lowered in small increments until the feel of the airplane in emergency conductions is well known. It should be noted that as the speed is reduced, directional control becomes more difficult. Emphasis should be placed on stopping the initial large yaw angles by the IMMEDIATE application of rudder supplements by banking slightly away from the yaw. Practice should be continued until: (1) an instinctive corrective reaction is developed and the corrective procedure is automatic, and (2) airspeed, altitude and heading can be maintained easily while the airplane is being prepared for a climb. The POH did not contain any procedure relating to simulation of an engine failure during the actual take-off phase.

Food for thought there. - MTF after the midnight oil is burned.

Toot – toot.

[Peetwo]

So why the delay? -

Slowly working my way through the full report, I do understand that there was a considerable lack of hard facts and recorded information which makes the job of the IIC particularly complex because the investigators have to delve into the area of high probabilities against subject matter expert opinion and experience.

Referring back to the prelim report - https://www.atsb.gov.au/publications/inv..._2_content - the FR is basically an expanded version of the prelim report. 


Which is why I still can't get my head around why this high profile investigation could possibly take nearly 3 years to complete...  

With that question in mind I just had to skip forward (sorry "K") to the 'safety issues and actions' section which I believe starts to go the cause of such considerable delay - read and absorb:

Safety issues and actions

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action taken by the Civil Aviation Safety Authority in response to this occurrence.

Following the accident, CASA issued temporary management instruction (TMI) 2017-004 to provide interim instructions to CASA officers tasked to conduct in-aircraft activity as a CASA employee. These instructions were issued with the caveat that CASA did not know the contributing factors to this accident. The instruction’s intent was to generally provide higher risk protection around operations involving CASA flying operations inspectors (FOIs).

The operating requirements differed, based on whether the CASA FOI was occupying a control or non-control seat in the aircraft. For key personnel and check pilot assessments when the FOI was in a position other than a control seat, the TMI required:

• Emergencies were not to be simulated below 1000 ft above ground level and initiated at VYSE + 10 kt.
• The assessment could only be conducted if the non-control seat was in the immediate vicinity of the operating crew, suitable communication existed and a pre-flight briefing was conducted.
• The CASA FOI had to have evidence of each person at the controls meeting the requirements of Civil Aviation Safety Regulation 1998 Regulation 61.385 – General pilot competency requirements in relation to the manoeuvres intended to be conducted and recover from the above manoeuvres in the event of mishandling. For example, a person who does not regularly (and recently) operate the aircraft may be unable to demonstrate the general competency requirements to the satisfaction of a CASA officer.
• The FOI had to have evidence that the person under check had been trained and considered competent / recommended by someone other than themselves. The time between the competency recommendation and the assessment flight could be no more than 28 days.

The temporary management instruction published on the CASA website expired in June 2018. This was reissued as an amended internal document in June 2018 and November 2019, with an expiry of May 2020. One additional relevant inclusion in the amended versions was a requirement for CASA officers to ensure the requirements of the new CASA exemption 58/18 - Carriage of passengers on proficiency check and flight test flight instrument (updated to 58/19 in May 2019).

As of April 2020, the TMI conditions had not been incorporated into regulation.

Remember that the above TMI was initiated within months of the accident occurring - now note the expiry of the TMI and the comment down the bottom:

This was reissued as an amended internal document in June 2018 and November 2019, with an expiry of May 2020...

...As of April 2020, the TMI conditions had not been incorporated into regulation.

MTF...P2 

[Choppagirl]

Quite disappointed in the media reaction - "Crash tragedy pilots flying too low during emergency simulation"

I provided them with the following but it seems to have been ignored.

In most accidents there are a number of events which occur which lead to the outcome. It appears that this one was no different and ended with the deaths of three highly experienced pilots in a completely preventable disaster.

We will never know conclusively exactly what led to this occurrence due to a lack of recorded data, despite the Australian Safety Regulator (CASA) having received prior recommendations from the accident investigators (ATSB) to mandate for the installation of lightweight recorders in aircraft such as this one.

In particular this report highlights the casual and informal way in which CASA conducted their safety regulation of a company which they knew had little regard for the extreme workload, stress levels and commercial pressure which was placed upon their staff members. This economic focus led to an unwillingness to provide any more than the minimum training required by regulations less stringent than those required in some other parts of the world. Despite a number of safety events which had been reported to CASA, no audit was ever undertaken to assess the systemic cultural inadequacies prevalent within the company; this was completely contrary to their own guidelines.

A particular focus of this investigation is the simulated engine failure which was conducted shortly after take-off. CASA themselves admit that simulations can be more dangerous than the real event, yet it was performed at a much lower altitude than recommended by the aircraft manufacturer and in other jurisdictions such as Europe. In addition, both of the flying pilots were under assessment. One pilot was undergoing a proficiency check, which was being conducted by the Chief Pilot. Simultaneously, the Chief Pilot was undergoing assessment of his ability to conduct such checks. This was by a CASA inspector who had no method of adequate communication with either pilot.

In short, this was another needless accident which has left families and friends devastated by the loss of their loved ones. Recommendations from Investigators and Coroners continue to be ignored. Consequently, it is only a matter of time before we see yet another tragic accident because valuable lessons appear to be routinely disregarded by the body responsible for aviation safety in Australia.