[Kharon]

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.

[Choppagirl]

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....

[P7_TOM]

'Bristol City'.

Loosely translates in the Cockney rhyming slang vernacular to 'titty'. Ergo – a 'right Bristol' may be construed into a right royal – selected noun - . e.g. “Micheal made a right Bristol of himself last night”. And he continues, unerringly to do so – with or without 'expert' advice. For example:-

David J Pilkington • a day ago
BRM's spin test report seems like a reasonable set of data (I have limited knowledge of the type so there may be a question of additional test points required) and there is EASA guidance on flight test programmes for LSAs which is relevant here. I haven't seen the stall flight test report but I don't doubt that it would also show compliance and I would guess that BRM would be able to demonstrate both aspects to CASA. Intererestingly, the ASTM allows for an additional 60 deg of roll from a stall, with no tendency to spin, in a 30 deg banked turn. Notwithstanding that (some?) instructors who know it well have described adverse behaviour at the stall. It is important to separate the two separate issues: 1. compliance with ASTM requirements (and the manufacturer just has to show it, the rules do not require a regulatory body to find compliance although the FAA was folllowing the Cessna 162 very closely); 2. suitability as an ab initio trainer especially in the context of CASA adding those incipient spin requirements into Part 61.

There is a whole different area of 'expertise' not being mentioned – that of the longevity of reliability of these LSA, from an air-frame life and maintenance repair limitations. These vital questions were not addressed by either CASA or their new best mates at RAOz. This all ties back to a considered approach to the aircraft being 'fit for purpose'. By that I mean the long term effects on the aircraft from constant hard use in training. Maybe the LSA can last for decades – maybe not – we simply don't know. Neither CASA nor RaOz have examined this fairly important consideration.

The 'fit for intended purpose' exercise should have been done long before the forensic analysis of 'suitability' for purpose. A careful, educated read of the flight test data may have raised some 'safety' eyebrows. Stalls and spins are not only a required training exercise, but vital weapon in a pilot's arsenal – as is the ability to read and comprehend exactly what the Aircraft Flight Manual (AFM) sets down 'in stone'.

Between CASA and RaOz there should have been at least one rule set mandating exactly which fight sequences could be taught in the type to ab intio student pilots. Perhaps even a requirement to pass an examination of weight and balance control, including a comprehensive knowledge of C of G and %MAC limitations as applicable to operations.

Back in the day – we used to say “If you want a MU 2 – buy a paddock and wait". It seems, to my ancient creaking brain that perhaps we should bring it back into vogue – just substitute LSA.


But, the final straw on the dear old camel's back – RaOz to investigate and provide a report to CASA. Un ducking believable. The potential for a commercial conflict of interest alone, enough to scare blue lights out of any reasonable, thinking man; without a RaOz acolyte whispering in the ministerial ear hole. Seriously worrying stuff, hard to fathom and swallow. Ale is not, therefore I shall take the easy road, have another and try not to worry too much about all the mother's sons 'bashing' about the place and occasionally bashing into it. Lambs to the slaughter. Amen.

[Cap'n Wannabe]

From the other Aunty..

Light plane crashes at Jacobs Well on Gold Coast, killing one man and injuring another



A man is dead and another is in hospital in a serious condition after a light plane crash at Jacobs Well on the Gold Coast this morning.

It is believed the plane took off from Heck Field airstrip at Jacobs Well, then lost power at very low altitude.

As the plane made a right turn, it clipped an overhead telephone cable and crashed 25 metres from the intersection of Stapylton Jacobs Well Road and Cabbage Tree Point Road near the Heck Field airstrip.

The plane caught fire and the passenger escaped with significant burns but the pilot was killed.

Emergency services were called to the incident at 9:24am.

The man who died and the man who was injured were members of the Gold Coast Sports Flying Club.

A syndicate of four people owned the privately owned recreational aircraft.

The surviving man was taken to the Royal Brisbane and Women's Hospital.

[Peetwo]

From the other Aunty..

Light plane crashes at Jacobs Well on Gold Coast, killing one man and injuring another



A man is dead and another is in hospital in a serious condition after a light plane crash at Jacobs Well on the Gold Coast this morning.

It is believed the plane took off from Heck Field airstrip at Jacobs Well, then lost power at very low altitude.

As the plane made a right turn, it clipped an overhead telephone cable and crashed 25 metres from the intersection of Stapylton Jacobs Well Road and Cabbage Tree Point Road near the Heck Field airstrip.

The plane caught fire and the passenger escaped with significant burns but the pilot was killed.

Emergency services were called to the incident at 9:24am.

The man who died and the man who was injured were members of the Gold Coast Sports Flying Club.

A syndicate of four people owned the privately owned recreational aircraft.

The surviving man was taken to the Royal Brisbane and Women's Hospital.

I note that other than about 3 posts on the UP related thread (posted on the day of the accident) and the above ABC coverage there has been bugger all mention of this tragic accident?? 

I also note that the accident has only today been recorded on the RAAus A&D summaries page but is yet to be recorded on the ATSB accident occurrence database??

Here is the very brief summary: "...Fatal Accident involving RAAus members. RAAus accident consultants are assisting police in determining the causal factors that led to the accident..."

Hmm...that kind of reads like the police will be the only ones investigating this fatal accident...

MTF...P2 

[Kharon]

Once again – wait for answers.

“It is believed the plane took off from Heck Field airstrip at Jacobs Well, then lost power at very low altitude.”

Being a fatal and in Qld, it's probably fair enough for the police to investigate; they were involved and did well with the Hempel fiasco; more recently the latest Lockhart accident. They seem to be pretty good at 'investigation' but I wonder at their frustration levels, after they've finished their work.

This one is going to be tough, trying to work out why the engine lost power after a fire must be difficult. If something internally has packed up, the engineers will find that quickly enough; but if it has been one of the basic two (air/ fuel) then there are difficulties. No doubt some form of conclusion will be reached. But what then?

A detailed report should follow. That report must be fully and freely available to all. There are valid reasons for a speedy, comprehensive analysis. Unless the aircraft engine was a 'one-off' then many others will be in service. There have been several LSA Recreational fatalities recently – there has not been too much published which reflects the reasons why . RA Oz provide only a summary, ATSB seem hamstrung; and, the general population have no salient details from which a safety plan can be developed - to minimise or prevent a repeat of a similar accident.

Fatal Accident involving RAAus members. RAAus accident consultants are assisting police in determining the causal factors that led to the accident..."

P2 - Hmm...that kind of reads like the police will be the only ones investigating this fatal accident.

Perhaps it is time the 'official' investigators were called in; at least the Police are accountable and have proven to be reliable. Full, open disclosure of the accident is essential to safety; a two line 'summary' is not only worthless, but dangerous. Not good enough is it.

Toot – toot...

[thorn bird]

I fear you are right K....left to the police, who of course have wide ranging expertise in accident investigation.

For motor vehicles.

Just replacing one bunch of amateurs for another.

[P7_TOM]

Lesser of the two Weevils.

TB - “Just replacing one bunch of amateurs for another.”

Ah, yes – but.

"Fatal Accident involving RAAus members. RAAus accident consultants are assisting police in determining the causal factors that led to the accident..."

It begs a question; RA Oz insurance 'consultants'? At least the Police are independent of and may be clearly seen by a Coroner as unbiased and impartial. The police are also trained to extract information, details and to sort 'wheat from chaff'. Read the RA Oz statement again and think about the coroners inquest. Credibility matters as does a conflict of interest. RA Oz is a commercial operation, vested interests, rice bowls and members to protect.

Any investigation must be seen free and clear of even a hint of bias. The only real way to ensure this is for the ATSB to be called in to every fatal, with Police assistance. Chain of evidence and impartial investigation removed from and above reproach. If the ATSB were funded and operated as the NTSB, then Police assistance while welcome would be part of establishing, beyond reasonable doubt, the integrity and probity of the report. Not only that, the report would be drafted by trained professionals and published.

Anything that moves in Qld is a 'vehicle'. Even had a mate booked DUI riding his horse home from the pub through the State forest one night. But, having lost one of their own in an accident at Lockhart, you can understand their interest and they have an air wing. Quite reasonable for the QP to be involved – keeps it all honest.

[Kharon]

Gossip - Strictly unconfirmed.

The recent fatal accident at Heck's Field, (Jacobs Well) has got my curiosity bump active. The lack of 'posts' on the UP adding to the itch. Usually, amongst the usual clutter there are some details mentioned, at least aircraft type; nothing? I caught a whisper on the breeze that it was a Pipistrel – mark and model unknown.

I tracked down an article in 'Plane and Pilot' – HERE – which discusses one variant, and may be of some interest.

“Perhaps the biggest design consideration of any powered aircraft is the engine, and Pipistrel from the start conceived the Panthera as being somewhat engine agnostic. Tine conceived an aircraft could accommodate many types of “power eggs”—piston, electric, hybrid and turbine units—all of which would meet up with the firewall without requiring major surgery. When the project started, Pipistrel’s engineers were thinking of a 2+2. Then their thoughts turned to a full four-seater built around the six- cylinder 220/330hp Rotax that was then undergoing tests. This unit promised low fuel consumption on mogas and reduced weight in comparison to the existing American aero engines. However, for financial and strategic reasons, Rotax abandoned the project, forcing the engineers at Pipistrel to rethink. In 2009, they settled on the relatively modern 210 hp Lycoming IO-390. Lycoming promised to modify and certify this engine with “iE-2” (Electronic Fuel Injected FADEC), allowing it to run on mogas. But at the start of 2014, Lycoming announced that it was abandoning the project, obliging Pipistrel to plan for certification with the 260 hp Lycoming IO-540, a dinosaur of an engine but bullet-proof—and capable of using motor fuel. Nevertheless, if there’s sufficient demand from clients, Pipistrel will propose an IO-390 STC.”

As this was a fatal and engine failure may be involved, the ATSB are obliged to enter the investigation, but who will carry the burden of the report to the Coroner? How much of the Qld Police and RA Oz qualified (ATSB approved) investigation team input will make through to the final report is of some interest. A curious side bar is the liability and legal intricacies of the RA Oz 'consultant' investigators position, when push comes to shove. There is potential trap inside the workings of that particular arrangement which could do with a little judicious digging. MTF on that topic. We must hope the local 'Plod' can keep it all straight. A fatal and an engine failure must demand proper, holistic, impartial investigation and a detailed, published report.

That's it – whispers on the wind – nothing substantial.

Toot – toot.

[Peetwo]

Heck Field fatal accident update -   

Not too much to add to either confirm or deny the above "K" sourced gossip. The RA Oz A&D summary does confirm that the aircraft was a Pipistrel (Model: Virus SW 100) that was powered by the seemingly popular Rotax 912 (ULS). Interestingly enough that particular Rotax engine features 18 times in the 1st two A&D pages, obviously the occurrences are not always engine related and in different RA Oz airframes. 

For those interested, this is the ASN webpage for the collated detail for the Pipistrel accident (so far):  https://aviation-safety.net/wikibase/234764

And this is the ASN database for all recorded Pipistrel occurrences (45 since 2007): https://aviation-safety.net/wikibase/type/PIVI 

Still puzzling over why the ATSB have not made an entry acknowledging the fatal accident at Heck Field on their aviation occurrence database?? So I guess any chance of the ATSB investigating this particular accident are slim to none. I do note however that in between catching up with their rail occurrence investigations(?? see: https://www.atsb.gov.au/ ) that there was an interesting entry yesterday that involved an RA Oz request for assistance for a fatal accident that occurred in October last year:SUMMARY

Summary

On 20 October 2019, an I.C.P. Savannah aircraft, recreational registration 19-7429, collided with terrain near the Emkaytee aerodrome, Northern Territory. The pilot was fatally injured.

In response to this accident, Recreational Aviation Australia (RAAus) commenced an investigation. As part of its investigation, RAAus requested technical assistance from the ATSB.

The ATSB initiated an investigation under the Transport Safety Investigation Act 2003 and assisted RAAus by downloading flight data from the aircraft’s Dynon Electronic Flight Instrument System (EFIS) The Dynon EFIS was successfully downloaded. However, the data logging functionality of the device was not enabled. No flight data was retrieved from the device.

With the completion of the examinations and data recovery, the ATSB has concluded its involvement in the investigation of this accident. Any enquiries relating to the accident investigations should be directed to RAAus at: www.raa.asn.au 

This was the entry for that accident off the RA Oz A&D summary pages: ref - page 8

Fatal Accident involving RAAus member. RAAus accident consultants are assisting police in determining the causal factors that led to the accident.

That aircraft was also powered by a Rotax 912 ULS - 

MTF...P2 

[P7_TOM]

FWIW:-

"Recreational Aviation Australia (RAAus) wishes to advise members that a Pipistrel Virus SW100 aircraft, registration number 24-8190, was involved in an accident on Sunday 5 April 2020 at Heck Field (Jacobs Well) in Queensland."


"One occupant of the aircraft was sadly killed in the accident and the other is in serious condition in hospital suffering from burns due to a post-impact fire. RAAus extends its deepest sympathies to family, friends and the aviation community."



"The aircraft took off from Heck Field airport, Qld that morning to conduct circuits. The aircraft impacted an NBN line and trees approximately 800m to the east of the runway and caught fire. RAAus accident investigators are working with Queensland Police and preparing a written report for the coroner."



"RAAus provides specialised subject matter expertise to assist Police when investigating accidents of this nature. Areas of investigation typically include environmental, mechanical and operational factors. At this stage there are no indications of an immediate safety issue relative to the aircraft type and RAAus will advise members if any safety related issues are identified."

Only members ? A fatal crash and a fire? Perhaps more than just 'their members' may be interested, as the RA Oz death toll mounts.

[Kharon]

The what the Heck accident (cont)..

Heck Field near Jacobs Well. Home of the salubrious Gold Coast Sports Flying Club. Recently a Pipistrel (Virus) took off from there, crashed and burned, killing one, seriously injuring another.

That's it – the rest just whispers on the wind – nothing substantial. The silence surrounding this accident is deafening. Even on the UP there are only two posts after the initialising report. Fascinating – when you look back at some of the comment count on other, similar events. You have to wonder why. Two comments against the usual two pages (give or take).

One whisper is a thing which one simply files as 'interesting'. But when that 'whisper' is repeated from different sources, then it becomes worth a question. Still operating strictly within the gossip file here, but it has my curiosity bump active. FWIW – the question begging an answer is - 'are substantial funds being spent on heavy duty lawyers, relating to this event? A simple Yes or No will suffice.

If rumour is true then it raises other questions, like Why?. If rumour turns out to be rubbish, then the remaining curiosities and silence are still matters of interest. They will remain so until an investigation into a fatal accident reaches a satisfactory conclusion, supported by a semi independent ATSB report. We had an almost hysterical response to the Angel Flight fatal – Senate committee and everything else thrown at it; Buckley's flight school attempts down the tubes without so much as a satisfactory explanation – but anything RA Oz goes dark. Why is there so little interest in the statistics for LSA operations from the masters of numbers at ATSB?

There has been a fatal – yet another LSA involved. There has been a fire – yet another LSA. An engine failure is suspected – it is a Rotax model which has featured in many incidents. RA Oz deem that the results of 'their' investigation should be passed on to only their members. Is this good enough for a first world aviation community?

Billions have been spent to develop 'safety management systems' (SMS) designed to prevent aircraft crashing, burning and killing folks. A big part of that system is open, transpt reporting, impartial investigation; followed by published reporting of the facts. It is an essential ingredient of preventing a repeat performance. So WTD is going on (or not) and why?

Toot – toot.

[Kharon]

"a quarter less five, and Jesus saves”.

“The ATSB examined the aircraft’s engine, its components and fuel system, but was unable to determine the reason for the reported engine power loss. The investigation also found that when control of the aircraft was lost, there was insufficient height to recover.”

Ducking Stellar, abso-bloody-lutely first class, brilliant insight, certain to bring international acclaim, awards and set the new benchmark for investigative excellence.

ABC -

[Kharon]

DP – Pilko - Your outline of the accident omitted what I believe to be the most important statement of advice to others in that ATSB report: “Taking positive action and ensuring that control is maintained has a much better survivability potential than when control of the aircraft is lost.” My opinion is that is an understatement! Bob Hoover's quote springs to mind “If you’re faced with a forced landing, fly the thing as far into the crash as possible.”


Advice; after the event, not from the ATSB who were 'unable' to determine why and engine failed, an aircraft crashed into a street, burned and killed the pilot. Lucky body count I reckon; like Essendon, it could have been a whole lot worse.

When you have done with the ATSB non report, consider asking the ATSB to provide the detailed report on the 'investigation' they conducted on the 'engine failure' related to this accident.

I just don't believe that a reasonable cause could not be determined. They came up with the same thing for the – Agnes Water - accident. Two fatal accidents – related to noted engine failure and ATSB were 'unable to determine' the cause? Twice -

It would IMO be most helpful to the Senate Inquiry and indeed industry, to see an unedited, original version (all of it) to the investigations conducted. Then ask why, despite resource, time, money and expertise – no cause of engine failure could be determined - twice.

It is bullshit.

Find some time and listen to AI episode 22.  -  HERE.

There was however a serious amount of resource expended, seeking to lay 'criminal' charges. Even if you don't have the time – go to the 36 minute marker and listen. See how the professionals set about 'charges' being laid and their response to 'parallel investigation'.

Toot – toot.

[Peetwo]

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

MTF...P2 

[Kharon]

“I don't know. It's a mystery”

Thinking aloud here, rather than speculation. I keep being drawn back to P23 – Fig. 13. of the ATSB report. Can't put a finger on it, but every time I look at it, a half dozen questions pop up to which a definitive answer eludes me.

One item is a constant irritation, best get that off my chest before I venture into the realms of mystery. – This use of 400' AGL as some sort of a magic number – it ain't. The height you need is Obstacle Clearance Height – OCH. Here's a couple of check flight question; if an engine fails just after take off, in today's conditions, what rate of climb and climb gradient can you expect? How far from the runway end must you travel to reach an OCH of 700'? The answers nearly always surprise the victim. Setting an arbitrary 'safe height' of 400' AGL is a nonsense, a myth perpetrated by CASA into some form of a safe zone. It ain't, not by a country mile. Rant over; but it annoys me. Back to business.

P 19 – ATSB - Part A detailed that engine failure simulation for training purposes was to occur above 3,000 ft above ground level unless specifically required during the approach and landing phase. Part C permitted the simulation of engine failure ‘After attaining the higher of 400’ or acceleration altitude’. The reference to ‘acceleration altitude’ was not applicable to the Cessna 441. BOLLOCKS.

P27 – 30.- ATSB. “While the manual of standards does not specify a height at which these activities should be conducted, CAAP guidance stated that they should not be conducted below 400 ft above ground level. The requirement of managing an engine failure during an instrument departure or after take-off, could be interpreted as meaning that these activities should to be conducted at low altitude. However, there was no direct comment in any CASA guidance that this is required.

Look at Fig. 13 again. At 20 seconds, the speed was 130KIAS, then reduced to 120 KIAS (SEBROC) at the 30 second mark. By the 35 second mark the speed is below 120 KIAS and reducing. Yet the altitude remains constant during the speed decay - why? One of two things should have happened..i.. an acceleration segment to regain the lost speed and trim the aircraft or: ..ii.. the check pilot should have returned power to both engines. Neither of these things happened; nor was whatever caused the loss of performance identified. I'm curious as to why, two experienced men would sit and watch the speed wash off while trying to maintain an altitude; they had two serviceable engines, daylight, height to spare and a lightly loaded, clean configuration aircraft.


ATSB - P20 – Fig. 12. “N.B. Normal power on the failed engine is to be restored should the Flight Crew member flying experience difficulty in maintaining control of the aircraft”

P 62. - ATSB - A review of the ATSB occurrence database identified that there were three accidents during asymmetric training/checking flights in the last 10 years, with this accident being the only one with a fatal outcome.

Yes, but why? Hundreds of pilots qualified on the aircraft; gods alone know how many 'simulated' engine failure scenario's have been safely and competently executed, the aircraft is a tried and tested performer with a long safety record behind it. There were two experienced men at the controls. So what went so horribly wrong. After (almost) three years of 'investigation' ATSB should be able to come up with something more real than a subliminal hint that it was pilot error. I say it would take a nanosecond for either pilot to grab a fistful of power levers and get the Garret's singing their familiar song, at cobbed throttle. That never happened. Why?

End of ramble, but there are questions begging answers, lots of. Perhaps the answers lay within the mysteries of CASA 'approval' of C&T systems and the convoluted rubbish Part 61 demands. We shall see; meanwhile I remain slightly bemused by the ATSB report which, once again,essentially fails to identify the radical, while hinting at the surreal. Aye well; more puzzling to follow.

Toot – toot.

[P7_TOM]

More 'Q' than 'A'.

While we are in question mode; there are a couple of additional points which, to me at least don't seem quite 'kosher' (Halal seeing as its Ramadan). Those crucial few seconds between a good, solid speed buffer above VMC and the loss of control. Neither of the crew were exactly 'new' to multi engine aircraft, nor turbine engines. The experience levels suggest much familiarity with the 'essentials' of managing an Engine Failure on Take Off (EFATO); the basics would have been drilled into them, the reaction almost instinctive. 

Had this even been a couple of new chums; to gain a Check/Training tick and enough multi time to be progressed onto a turbine type; there would have been a significant amount of training and practice on asymmetric operations. In short, to operate this class of aircraft, you need to know your stuff, be able to recognise the danger areas and, importantly, be able to and have demonstrated prevention of a dangerous combination or at very least, be able to 'dig your way out' of the hole. My point is simple. How come in just a few seconds, two experienced, sane, sensible qualified pilots managed to loose so much speed, in so short a time, to the point where complete control was lost. 

There is nothing in the ATSB report to convince me that it was 'pilot error'. Sorry too much; but, I just don't believe it. From 600 feet, with a what? 98 – 120 = 22KIAS above VMCA my granny could have shoved some power on and 'danced it out of the Daisy patch.

So what went wrong? I can identify half a dozen possible causes; but not one that experienced pilots would not recognise and be able to deal with. There is little mentioned by ATSB of the potential 'system' failures; there is no mention made of the 'trim' settings, there is no information on the power and condition levers final settings; there is no detail of the EEC system/ power lever relationship. In fact, after three years and a severe editing  this bloody report is so gender neutral, it is unsure of what it is unsure of. We are no wiser now than we were three years ago.  How do we prevent a reoccurrence from the ATSB report? We cannot is the short answer; we should be able to after a three year 'study'.

The excerpts from the Operations Manual are of deep concern. They carry the whiff of FOI interference with sound, tested operational practice. The wording has been messed about with to satisfy some whims or the dictates of more than one FOI. There is a lack of continuity, clarity and classification. That which is enshrined in Part A MUST be parallel with and reflect that contained in Part C. In fact anything in Part A but a reference to where to find the information in Part C should be torn out. I have read some seriously conflicted, CASA approved, operator paid for rubbish in several COM. The pug marks of FOI personal ignorance, arrogance and bias writ large across the pages. Which is why of course, the COM is usually used to keep the office door open.

No Ale for me tonight. I have been given two Sections of the ATSB report to read and digest, under threat of no darts if I slide off the hook. I would dearly love to get hold of the Ross Air Company Operations Manuals, from a decade ago to the latest version. What tale would that study tell, I wonder?

Right: back to the grindstone then; at least until dinner time – after that, all bets are off.

[Kharon]

The Bullshit factor.

One of several major shortcomings within the CASA FOI system may be found within the approval of operational material. There are countless anecdotes which relate to 'type specialists' in disagreement with experienced operators of an aircraft type. Some risible comments have been writ into a training system or manual, simply to 'satisfy' the FOI. Those who have experienced and understand this have no need of further explanation. It is a real existing problem which CASA must address should they wish to eliminate what I believe is a serious, concealed safety issue. That of an attitude toward 'CASA bullshit'. You can hear it a dozen times a week. “Nah, we don't do that, its just some CASA bullshit”. The problem being that as that approach becomes 'the norm' – often real safety issues within that area are treated in the same manner. You do see the problem, disregard for published material becomes a normalised deviance. Most chief pilots and check pilots in GA will confirm this. Airline training comes as a shock to a lot of GA pilots, when 'by the book and only the book' becomes the new norm.

ATSB - “The ATSB sought information from CASA regarding the circumstances under which the incorrect procedure was approved for use by the operator. Despite this request, no information was provided by CASA. Consequently, the ATSB was unable to determine whether the approval of incorrect information was an isolated human error or symptomatic of a systemic deficiency with the approval process.

Right there a classic. There is a great deal of difference between 'reading' a Flight Manual (AFM) and 'studying' it. In order to 'teach' (or pontificate) an aircraft type one must seriously study the relevant manuals. The end product should be a pilot who not only knows and understands not only the entire operational envelope, but how to keep the operation within safe, legal parameters. Take a simple thing like the following.

ATSB - Additionally, the likely power setting was less than the AIRSTART lever position detailed in the POH and had the potential to allow the aircraft’s right fuel computer to trip from the normal automated mode to the manual mode. If that occurred it could have affected that engine’s power level and/or been a distraction to the crew. As switching of the fuel computer from normal to manual was not recorded, it was not possible to determine if this occurred.

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.

The workings, limitations and potential traps of this system should be acknowledged; a system to prevent inadvertent activation during abnormal operation must be prescribed and built into a C&T system ambit. Awareness of this possibility, through an 'approved' method of simulating an EFATO must be acknowledged. The CASA approved Ross Air system presented in both Part A and C of the operating manual fail to mention, let alone alert crew to this possibility, particularly in the simulated engine failure case. It may well be 'something-nothing' but, if the manufacturer has gone to the length of covering a possible 'loop hole' then either CASA or the operator should have picked it up and made it part of the 'approved' training system. If it can go wrong, etc.. 

ATSB - “Despite guidance in the CAAP to follow flight manual/POH recommended methods, on this occasion the exercise was conducted in accordance with the more general CAAP procedure at minimum practice height of 400 ft above the ground. The same procedure was also reflected in Part C of the company operations manual and, as such, had been approved by CASA. Practically, conducting the exercise in that manner resulted in it being conducted at a much lower safety height and via a different engine failure simulation method than detailed in the POH. That in turn reduced the overall safety margin for the activity.

Reverse bullshit this time – just because CASA say its OK don't necessarily make it so. A quick look through the performance charts and a read of the manufacturer notes would inform both regulator and pilot that they were on the raggedy edge of performance. One needs to be careful relying on the 'legal' weight of both the AFM and POH. The POH has 'legal grunt' only when it is included in the type certification data. Then there are parts of the AFM which carry serious legal weight and others which do not Depends on the manufacturer and the certifying authority (sort of – its complicated). However, IMO a case to answer is parked very squarely at the CASA front door. Parts of the CASA approved COM present operation out side of the POH; despite the CAAP and CASA approval. It is debatable as the 'Limitations' section of the AFM do not elaborate. But, for a classic example, take trip back in time to the Pel-Air 'approved' system – the more things change, the more they stay the same eh?

But stop and think for moment. What is the real purpose of asymmetric training? It is to develop and foster the 'drills' and methods for avoiding the inherent dangers. It is to promote early recognition of a danger area and initiate the actions taken to extricate the aircraft from a developing situation. Should the 'real deal' happen, once in a lifetime, the response and management from the crew should be almost 'routine'. This is essential in the lighter, FAR 23 certified aircraft. It is a difficult task when there is certified single engine performance; let alone in an aircraft with a single engine performance which will take you to the scene of the accident.

There's far too much bullshit floating about the place satisfying a perceived method of compliance. As most of this is treated with contempt and covertly undermined anyway, perhaps a reality check is needed. Beginning with making sure operations are conducted within the AFM specified limitations, acknowledged and not subject to the vagaries of individual, subjective preference.

I would very much like to know the trim settings of the accident aircraft. ATSB found them for the Essendon King Air crash in record time; but no mention made in this report. Its a curiosity; but then, almost everything in this gender neutral report generates questions. No matter we shall plod on.

Stand corrected. Sorry, missed the data; mea culpa and anyone who wants to borrow my phone may do – to ring anyone who gives a monkey's.


ATSB P.36 – Rudder trim.


The rudder trim actuator screw jack was found in a slightly over extended position which equated to a full nose-left trim position. The actuator displayed evidence of having been alternately driven toward the retracted and extended positions by impact forces. The ATSB could not determine the extent to which impact forces affected the screw jack’s pre-impact position.


The rudder trim indicator was found in the full nose left position. Although it is possible that impact forces may have affected the position of the indicator, it was considered that crushing, evident in the cockpit area probably captured the indicator in its pre-impact position.


On balance, the evidence supported the rudder trim being in the full nose-left position at impact. That position was consistent with pilot response to a simulated failure of the right engine.


Toot – toot.

[P7_TOM]

P7 -”From 600 feet, with a what? 98 – 120 = 22KIAS above VMCA my granny could have shoved some power on and 'danced it out of the Daisy patch”.

Typo correction: Vmca is specified at 91 KIAS in the POH – P.14 of the ATSB thing explains the intentional OEI speed of 98 KIAS. There's a fair bit of 'huff and puff' and explanatory notes there, which fuddled my typing. I am trying to establish exactly what the Vmca specified in the limitations section of the Type certification data is. A Vr set at 98 KIAS makes good sense; the ATSB have defined a Vmca 'range' - which is an 'interesting' concept refer Fig 13. 

I have obtained a copy of a generic check list (Thanks-  you know who) I must say that on a single read through, the check process for the 'electronic' fuel scheduling system and associated bits and bob's are complicated. Probably not so when you do it every day – but from a cold start; they need some careful reading. But, it leads to more operational questions which IMO should have been answered; just for the sake of completeness. For example:- Was a full, first flight systems check carried out by the operating crew – it should be part of a proficiency check, particularly when multiple, intentional simulated engine out operations are to be conducted as part of a C&T operation? The answer lays in the time between fire up and (tempted) but let's say 'take off' instead.

For example:- (the notes are of interest)....

ELECTRONIC FUEL CONTROL HIGH-POWER MONITOR CHECK
When operating in normal mode, this check is to be performed before engine starting on the first flight of the day or after performance of an maintenance, periodic inspection or adjustment involving the engine control system.

1. Power Levers - GRND IDLE.
2. Condition Levers - TAKEOFF, CLIMB AND LANDING.
3. Power Levers - FLIGHT IDLE.

NOTE
The FUEL COMP OFF lights should illuminate, indicating the high-power monitor is operating properly. If the light(s) does not illuminate, a problem in the airplane power lever rigging and/or the fuel control computer monitoring circuit is indicated. All flights should be conducted in manual mode until the problem is corrected. Refer to Manual Mode Operations in Section 3 of the POH.


4. Condition Levers - START AND TAXI.
5. Fuel Computer Switches - CYCLE from ON to OFF to ON. Check that FUEL COMP OFF lights extinguish when the fuel computer switches are positioned to


MANUAL MODE FUEL CONTROL CHECK
1. Condition Levers - ADVANCE to attain approximately 75% RPM.
2. Fuel Computer Switches - OFF. Verify illumination of FUEL COMP OFF annunciator lights and engine speeds initially decrease then increase and stabilise at 85% ±10% RPM.

NOTE
If engine speeds decrease below 55% RPM, return the fuel computer switches to ON. Increase RPM to 85% using the condition levers and repeat the manual mode check.

3. Power Levers - ADVANCE slightly. Verify engine speed increases with power lever movement. Retard power levers to GRND IDLE.
4. Condition Levers - START AND TAXI.
5. Fuel Computer Switches - ON (Guards Down). Verify engine speeds decrease and FUEL COMP OFF annunciator lights go out.

MANUAL MODE OVERSPEED GOVERNOR CHECK
This check is intended for daily use and is a combination of the Overspeed Governor Check and the Manual Mode Fuel Control Check. Before performing the check, set the parking brake, ensure the propeller start locks are engaged and the area ahead of the airplane is clear.

1. Condition Levers - ADVANCE to attain approximately 75% RPM.
2. Fuel Computer Switches - OFF. Verify illumination of FUEL COMP OFF annunciator lights and engine speeds initially decrease then increase and stabilise at 85% ±10% RPM.
3. Power Levers - ADVANCE slightly. Verify engine speed increases with power lever movement. - ADVANCE until further motion causes no increase in fuel flows or RPMs. Engine speeds should be 103.5 to 105.5% RPM except on airplanes incorporating SK441-79. Engine speeds should be 104.5 to 105.5 RPM on airplanes incorporating SK441-79.

CAUTION
Ensure that the propellers have not "jumped" their start locks.

Do not allow engine speeds to exceed 106.0% RPM.

If overspeed limits are exceeded beyond the following times, refer to the applicable engine maintenance manual. a. Time in excess of 30 seconds to stabilise at 103.5% to 105.5% RPM. b. Time in excess of 5 seconds at 105.5% to 106.0% RPM. c. Anytime in excess of 106.0% RPM.

4. Power Levers - GRND IDLE.
5. Condition Levers - START AND TAXI.
6. Fuel Computer Switches - ON (Guards Down) Verify engine speeds decrease and FUEL COMP OFF annunciator lights go out.

Having read through it, twice now, I can see why there may be some room for speculation about 'why' the flight turned to tragedy in short order. A shortfall of scheduled fuel on the operating side may explain the 'shot duck' nature of the accident time line.

It is my firm belief that mankind could do no better than be sat in a quiet stable, with a full glass at his elbow and a cigar in hand. All is highly conducive to lucid thought and rational discussion, especially when there's no one around.... MTF.
Ssshhh..

[Peetwo]

P2 OBS: Dots, dashes and passing strange disconnections??? -   

While the BRB continue to mull over the IMO obvious (for whatever reason??) top-cover edited version of the final report, I intend to go off on a slightly different toot...

Ref: https://www.atsb.gov.au/media/5777738/ao..._final.pdf

Throughout the report there are several references to a pratice flight conducted a week before the accident flight - initial  reference from page 21:

...In preparation for the occurrence check flight, a practice flight covering similar sequences was conducted in XMJ the week before with the chief pilot and inductee pilot. That flight also had an observer on board with extensive Cessna 441 check pilot experience. The practice flight was not conducted as a training flight, but rather a private flight with two licenced and experienced pilots on board, preparing for their respective roles during the CASA check flight.

The observer advised that during the practice flight, the engine failure was simulated by the chief pilot reducing the power lever but not all the way to the flight idle stop. He further recalled that once the inductee pilot completed the initial response actions, the chief pilot partially advanced the power lever. The observer stated that, based on his experience, zero thrust in the occurrence aircraft was about 150 ft.lbs of torque and lower than other company Cessna 441 aircraft. He also recalled that the chief pilot set a power lever position at or slightly above that torque value during the simulation...

Page 26:

In assessing personal competency under this regulation, CASA recommended that ‘pilots should seek advice and consider refresher training or practice before commencing an operation they haven’t carried out for a while’. Although the pilot is already licenced and current on the class of aircraft, training for general competency can only be given by a pilot who holds an instructor rating and appropriate training endorsements.

The check flight briefing (see the section titled Check flight sequences) prepared for the flight had a series of questions at the end of the briefing for the inductee pilot to answer, consistent with the areas of competency identified above. Additionally, the practice flight conducted by the two pilots the week prior was an opportunity to practice the handling skills in this aircraft rather than other aircraft flown by each of the pilots...

Page 34:

...The chief pilot completed two flights as a check pilot in the year since being judged ready for assessment (Cessna 441 fleet manager’s OPC and a line check) and the practice test flight the week prior...

Page 35:

...Other than during the practice flight the week prior, the inductee pilot had not managed an engine failure in the Cessna 441 in over two and a half years, and the chief pilot had not had the opportunity to set an engine failure in almost a year. It is unclear from the chief pilot’s training records if he had ever been required to demonstrate a recovery from a mishandled engine failure after take-off in a Cessna 441.

The Cessna 441 check pilot observer who was present on the practice flight the week before described that flight as ‘messy’, with the inductee pilot appearing to be ‘rusty’. Specifically he recalled that the inductee:

•had to make reference to the checklist as he was unfamiliar with the memory items and wastherefore ‘well behind’ the aircraft
•adopted a steep pitch attitude that resulted in a lower than normal climb airspeed.

The observer further advised that there were also omissions by the chief pilot during the flight including that the:

•pre-flight briefing did not cover the procedure for transferring control of the aircraft between the two pilots
•incorrect use of the engine anti-ice system was not identified.

He also stated that the practice engine failure simulation after take-off from Renmark was ‘quite safe’ and that he debriefed both pilots on his observations...

..The inductee pilot had limited recent experience in the Cessna 441, and the chief pilot had an extended time period between being training and being tested as a check pilot on this aircraft. While both pilots performed the same exercise during a practice flight the week before, it is probable that these two factors led to a degradation in the skills required to safely perform and monitor the simulated engine failure exercise...

P2 questions? 

1) To begin I wonder if there is a Flight Radar 24 &/or GPS record of the 'practice flight' from the week before? If so it would be interesting to see if the flight profile did indeed mimic the accident flight profile?
2) Given the practice flight was operated 'private', supposedly because; a) the carriage of the observer would be defined as carrying a pax and; b) the Chief Pilot didn't yet have CASA approval to conduct an OPC as a 'Check Pilot' on the C441, wouldn't that necessarily deem any simulated/practice asymmetric (OEI) as illegal, despite the fact the observer had extensive Cessna 441 check pilot experience? 
  
Quote: "..The observer stated that, based on his experience, zero thrust in the occurrence aircraft was about 150 ft.lbs of torque and lower than other company Cessna 441 aircraft. He also recalled that the chief pilot set a power lever position at or slightly above that torque value during the simulation..."

Now note the following from page 7:

Part 1 of the aircraft’s Log Book Statement specified that the aircraft was to be maintained in accordance with the AE Charter Services system of maintenance and all applicable airworthiness directives. The following summarises the maintenance activities conducted on XMJ leading up to the accident.

• On 31 August 2016 a number of parts, including both the left and right engines were removed for use on other company aircraft. These engines were reinstalled on 24 November 2016 and had operated for 385.2 hours on XMJ since this time.
• On 30 April 2017, the installed fuel control unit (FCU) from the aircraft’s left engine was replaced by an FCU borrowed from a third party maintenance organisation.
• On 4 May 2017, the aircraft was erroneously released to service prior to in-flight FCU set-ups having occurred, with an endorsement in the deferred defect list that the left engine had to be operated in manual mode until the FCU set-up had been completed but could continue in service until no later than 14 May 2017 without the set-up being completed.
• The Rossair chief pilot raised a concern on 8 May 2017 about the aircraft being released into service without the in-flight set-ups being completed, as the aircraft was more difficult than normal to operate with one engine in manual mode. Further maintenance work was performed on the aircraft, and, on 10 May, the aircraft was released into service, with both engines operating in normal (automatic) mode.
• The aircraft subsequently flew 28 flights, totalling 32.6 hours with no reported issues.
• On 26 May 2017, the original FCU that was removed on the 30 April 2017 was reinstalled onto the left engine of XMJ following removal, cleaning and reinstallation of the FCU’s manual mode control valve.
• A certification regarding a wing de-icing system unserviceability was made on 26 May 2017. It stated ‘No action was carried out at this time. Aircraft unavailable due to flying requirements. Customer notified.’ There was no entry in the defect field of the current maintenance release Part 3.
• Between 26 May and 30 May, the aircraft flew 6.9 hours without reported issue, including 4.5 hours across five sectors on the morning of the accident.

So the observer had prior experience conducting simulated/practice OEI in the accident aircraft to the extent that he/she could remember to the ft/lb what was required to be set in order to achieve zero thrust.  
3) Was the observer's experience with the accident aircraft before or after any of the listed maintenance to the engines (and in particular the LH engine)?

In relation to the above, I note the following from page 49 of the report:

 The self-recommendation made by the chief pilot on his training records was for CASA to assess him in checking other check pilots, that is, just the Cessna 441 fleet manager, rather than checking all line pilots. Following that recommendation, a CASA FOI (who was on the accident flight) observed the Cessna 441 check pilot’s OPC, which was conducted by the chief pilot in the right-hand seat.

The OPC of the Fleet Manager, conducted by the CP and observed by the accident flight FOI, occurred in May 2016:
4) Did the FOI have de-brief notes on that flight? If so did he make mention of the procedure and possibly the setting of zero thrust of the Chief Pilot? I also wonder if there was a Flight Radar 24 record for that flight?

5) I wonder if it would be worth requesting through FOI (or Senate order) a copy of the ATSB interview transcript of the practice flight observer who had extensive check pilot experience on the C441?

Much MTF...P2