[Kharon]

P2 - Q&A.

• 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.

10 days. ATSB don't mention that as being a Minimum Equipment List (MEL) item. It probably is - but

• 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.

I could see it as being a 'get you home' item, even stretched out to a couple of days to allow for parts to be delivered. I wonder if the order to operate 'both' in Manual mode was issued. I can see a potentially 'unsafe' scenario or two developing there – there are times when 'split throttles' can create a distraction. Only a minor issue I admit but it speaks of a corporate mind set; a need to generate income and a chief pilot unable to impose his will on that mind set. A lack of parts, or the money to buy 'em is not a CP problem. Fix it or ground it is not a bad maxim. CP 's are paid to weather the storms of management bombast and have the full backing of CASA to do so. It is not a matter of can we keep it flying – it is a matter of should we – on risk analysis. I know we've all done it, nursed a sick aircraft about the place to get a job done – but only because we know that on return to base – it will be fixed.

2) Given the practice flight was operated 'private', supposedly because; a) the carriage of the observer would be defined as carrying a passenger 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? 

Is the practice of OEI operations 'legal' with a 'passenger' inboard, no matter how well that 'passenger' is qualified? Then there is the small matter of being 'qualified' (officially) to simulate 'emergency' high risk operation? It takes us back to 'management' attitude and CP compliance with management dictates. As to the complete, black letter law 'legality' of that operation – I'd suggest asking CASA to explain. In fact, I'd add it a long list of 'please explain' questions for CASA to answer. 

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..."

When there is a potential for 'confusion' which can be simply eradicated, there is little excuse for not doing so. The difference in torque settings between the three and four blade propellers is great – 150 and 350 – a 200 ft/lb difference. A pre flight briefing should always include 'words' to indicate the how and data related. Simulation will be through the power lever to a zero thrust setting of no less than XYZ. I even mark it down on the TOLD card – lest I forget. (I also always have a paw on the quadrant and boots on rudder pedals – just in case). 

One further item intrigues me:- semantics I know, but nonetheless FWIW:-

While the pre-check briefing was not witnessed by anyone other than the participants, surveillance data and radio transmissions indicated the accident flight was conducted as per the briefed flight exercises, except that no single-engine go around was performed on arrival at Renmark.

If you intended to simulate an EFATO at a height of 400' or so; then why by-pass the operationally perfect situation of initiating an overshoot from an instrument approach minima? Not visual, go around, wallop – engine out. Minima at Renmark is (or was) 730'. An overshoot on one engine from that height provides obstacle clearance, a flight path, a 'real' scenario and a high work load – quite safely. Why bugger about at 300' with an artificial 'take-off' (not) when a much better, safer alternative means of testing is available? Just saying. 

But back to P2's remarks -

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?

IMO, every scrap of paper should be collected and examined. This was a very messy operation, from top to bottom. This report highlights much that is 'wrong' within the system, from the MoU between ATSB and CASA, the CASA management of the company and of the company itself. How many more similar events, like Lockhart, Seaview and Pel_Air must we see, before someone gets a grip?

Toot - toot.

[P7_TOM]

I'll have two bobs worth of that please.

'K' - “If you intended to simulate an EFATO at a height of 400' or so; then why by-pass the operationally perfect situation of initiating an overshoot from an instrument approach minima? Not visual, go around, wallop – engine out. Minima at Renmark is (or was) 730'. An overshoot on one engine from that height provides obstacle clearance, a flight path, a 'real' scenario; and, a high work load – quite safely. Why bugger about at 300' with an artificial 'take-off' (not) when a much better, safer alternative means of testing is available? Just saying.”


Just out of idle curiosity I took a look at the Renmark DAP. Then a look at the Adelaide area – for a suitable place to play at flight testing. Kingscoat seems closer with lower minima, higher circling – but, fewer restrictions. Don't know the local 'do's and don't s but it seemed a better operational choice. But that's a personal, prima facie choice only.

Renmark – (YREN) 
Minima - Lnav 730'
Circle 800'
No circle SW of 36/07
10 nm  MSA 1700'.
Lots of inconvenient aerials about the place etc.

An engine out just after take off (low) would present some problems and demand some thought out, briefed and discussed solutions – with inclement weather around;or, (more to the point) operating under the IFR. The operation was to be IFR which assumes (for test purposes) IMC conditions; that means, to me at least, that OCH and OEI gradients must be considered – for the continued operation case. This notion of simulating an engine out at 3/400 feet seems to be neither fish nor fowl. It proves or tests nothing, pointless really. It also places the aircraft in a 'vulnerable' (IFR) situation (take off minima). The flight path described is at least 400' below the IFR minima; that which ensures obstacle clearance in the event of a missed approach. Furthermore, it robs the aircraft of valuable distance to run. i.e.  – 10 miles (MSA) minus the distance from the Mapt, plus the runway, plus the distance to climb to 400'. In order to achieve the mandated 1700' within the 10 nm radius, with OEI, even a well maintained aircraft with an experienced crew would have their work cut out. I am assuming the check flight was under the IFR here. But you do see where the holes in the cheese are. Yet CASA not only sanctioned this unrealistic check flight, but failed to examine the IFR compliance safety case. -ATSB probably never heard of it. Oh, and where is the fatigue analysis?

The idea of failing an engine at the minima, and executing a missed approach is (a) much more demanding and (b) provides a 'real' test of practical operation – under the IFR, with built in safety margins. So why was this crew allowed to operate in this half arsed, imaginative scenario? It proved nothing of any value to the pilot, the examiner or the CASA. CASA need to get real, sort out what they want to see; or butt the duck out.

Yo Ho Ho and a bottle of Rum.

There, my two bob spent as pleased me best.

[P7_TOM]

There's them as whats done it

ATSB - “During the landing at Mount Gambier, the aircraft touched down with the landing gear retracted, with the propellers contacting the runway twice before the pilot initiated a go‑around. During the go-around, the left engine failed. The aircraft then landed without further incident.”

And them as is going to do it. Amen.

[P7_TOM]

Preliminary report – AO-2020-017. - HERE. C404 fatal at Lockhart River.

Too early yet to draw anything like a final conclusion; but there is, IMO a safety message within to be delivered. We have had several accidents involving visual flight only into instrument conditions. This one speaks of a one of the most challenging and demanding aspects of 'instrument flying' – single pilot - in weather – and in particular, in 'stream weather', when does IFR  change into VFR? I reckon it's worth a paragraph (or two).

When there are two on deck, one flies 'on the clocks' – the other looks outside. When there is only only one bloke – he has to do both jobs. The secret of success is the essence of simplicity- stay on the dials until minima – take a look and decide. Go Around or continue to land. In a perfect world that is the 'letter perfect' way of managing the whole thing; of course, real life ain't that simple.

The heart of the problem lays where a break in the weather happens; visual – see the ground and the weather ahead – but not the blasted runway or lights. What to do?  Jink into the clear area, find a friendly landmark and scoot in – or continue on the approach path and risk being jammed by the weather. Or not. You pays your money and takes your chances.

Another problem noted is that of 'disorientation'; coming off instruments to pick your way through the weather and stay 'visual' is a gift to the disorientation syndrome. On the clocks, Up is Up, down is down left is left etc – but a cloud layer particularly a low one may not be 'level' – light plays tricks and when combined, at speed, up close and personal – the seeds are sown.

I'm not, not for one minute saying this is the cause of this accident. However, the photographs provided IMO graphically demonstrate how switching between instrument flight and visual flight is a tempting, often necessary temptation. Only experience can make that decision – would I have gone for the IFR/VFR option? Dunno, wasn't there; but I would have been aware of the risks – on both sides of the coin. There, but for the grace of Karma go you and I. But can remember (never to forget) one late afternoon at a very remote location flying into what I can only describe as being like a dirty goldfish bowl. The air was green – bush fire smoke, dust and the late afternoon light – weird;  even the aircraft seemed to wonder WTF. I could see the runway – right where it should be – but the distance seemed somehow 'distorted'. Bugger this says I – locked onto the approach and even then, I flew on the clocks till I was certain them big white markers wuz where they should be; power off – safe home. The FO and I had two beers before we talked about it, then we talked about it for ages.

Old fool rambles on – but even sitting here, cosy, with a beer at my elbow – I can still remember the 'queerness' of it – FWIW. Another Ale will remove memory from mind, best get onto it.

[Peetwo]

Hooded Canary catching up on AAI backlog? 

The ATCB has recently released two interesting final reports, one of which took 2.5 years to complete. Both reports were accompanied with Hooded Canary pressers -  :    

Maximum take-off weight exceeded following cargo loading irregularity


An Airbus A330 departed Sydney with the aircraft’s maximum take-off weight exceeded by 494 kg following a loading irregularity, an ATSB investigation details.

On 17 December 2017, a Qantas A330-300 was being loaded with freight in preparation for an international passenger flight from Sydney to Beijing, China. After landing in Beijing, the airline’s freight agent identified that the aircraft had been loaded incorrectly. As a result, the aircraft had departed Sydney 875 kg above the weight listed in the revised load sheet, and 494 kg above the aircraft's maximum take-off weight.

The ATSB found that an operational requirement for additional holding fuel resulted in the operating flight crew issuing a revised load instruction to carry less cargo. However, this instruction was not actioned and led to a 2,005 kg pallet of freight remaining on board the aircraft, instead of being replaced with a lighter unit weighing 1,130 kg.

The required cargo variation was not actioned by the load supervisor, as electronic messages associated with the revised loading instruction were acknowledged without being correctly interpreted. That action was probably influenced by the supervisor’s experience that load changes were accompanied by verbal advice, which did not occur on this occasion.

The ATSB’s investigation into the incident highlights the importance of communication between all parties responsible for aircraft loading. Planning and loading of freight in the high-capacity passenger sector is often conducted under significant time pressure, where delays can lead to scheduling issues.

Effective communication between all parties responsible for aircraft loading can assist in reducing errors, the investigation notes.

As a result of this, and other freight loading occurrences, Qantas have introduced handheld scanning devices that automate much of the freight confirmation and mobile communication process using printed barcode and scanning technology. The scanners were implemented at most domestic and international Qantas ports by June 2019.

Read the investigation report AO-2018-003: Aircraft loading-related occurrence involving Airbus A330-303, VH-QPD, Sydney Airport, NSW, on 17 December 2017

Hmm...not exactly sure why the HC mob continued with this investigation, although a relatively significant load weight exceedance and an obvious causal chain of events/actions (or non-actions) that led to this exceedance, surely this occurrence didn't warrant the carriage of full blown ATCB investigation?      

Warbird accident highlights the inherent risks of low-level aerobatics in high-performance aircraft


The pilot of a Yakovlev YAK 9 warbird which entered a low altitude spin before impacting the ground had not previously conducted aerobatics in the aircraft and so was unlikely to be aware of its unique handling characteristics, an ATSB investigation into the accident has found.

The investigation report details that the pilot, prior to undertaking a planned instructional flight with an instructor in the YAK 9* later that afternoon, took off from Latrobe Regional Airport, Victoria shortly after 2:20pm on 7 September 2018 for a local private flight.

Data from the nearby East Sale RAAF Base air traffic control radar showed the aircraft tracked first to the south-west, maintaining runway heading, before turning north-west. North of the town of Moe, at an altitude of about 2,800 feet above sea level, the pilot began to conduct what witnesses on the ground described as aerobatic manoeuvers.

The pilot was endorsed for aerobatic manoeuvres completed by 3,000 feet above ground level but had not previously conducted aerobatics in the YAK 9.

With limited experience and recency in flying the YAK 9, the pilot was likely unaware of the aircraft’s unique handling characteristics during aerobatic manoeuvres or spin recovery.

One witness described observing the aircraft perform what appeared to be a roll followed by a loop. The aircraft came out of the bottom of the loop and made an abrupt left turn before spiralling towards the ground. Video taken by another witness showed the aircraft in a spinning, steep nose‑down attitude prior to disappearing from view.

The aircraft was found to have impacted the ground in a paddock about 3 km north of Moe, in a flat, slightly right‑wing and nose-low attitude consistent with an aircraft established in, or recovering from, a spin. The pilot was fatally injured and the aircraft destroyed.

ATSB Transport Safety Director Stuart Macleod said the accident highlights the risks inherent with performing low-level aerobatics in high performance aircraft.

“High‑performance aircraft like the YAK 9 transition into a fully developed spin quicker and more forcefully than a typical light training aircraft. It is essential to have sufficient altitude to effectively recover from a spin,” he said.

“Experienced YAK 9 pilots stated that, depending on pilot experience, 5,000 to 7,000 feet is required to safely recover the aircraft from a developed spin.

The report notes, unlike in most other warbird aircraft, as the airspeed increases during a high-speed dive recovery, in the YAK 9 the effort required to pull back on the control stick reduces.
 
“This investigation reinforces to pilots performing low-level aerobatics the importance of observing minimum approved operating heights, commensurate with their ability and qualifications, and to engage in regular flight reviews and instruction.”
 
The investigation report notes the pilot had conducted aerobatics in a number of warbird aircraft but only had between five and six hours of flying experience in the YAK 9, and that the accident flight was the pilot’s first in the aircraft in three months.

“With limited experience and recency in flying the YAK 9, the pilot was likely unaware of the aircraft’s unique handling characteristics during aerobatic manoeuvres or spin recovery,” Mr Macleod said.  

The ATSB investigation also identified a number of safety issues that while they did not directly contribute to the accident flight, increased risk.

For example, the aircraft’s canopy had been opened intentionally in flight the previous day, resulting in the loss of documentation from the aircraft including the aircraft checklist, flight manual and maintenance release.

“Pilots need to ensure that careful preparation and planning is undertaken prior to each flight and that all documentation, checklists and required manuals are appropriately stored and accessible within the aircraft,” Mr Macleod said.

In addition, post-accident examination of the aircraft identified incomplete maintenance practices, including inadequate airframe anti‑corrosion measures and insecure primary flight controls and seat fasteners.

* The YAK-9 was a Russian-designed single-seat fighter aircraft used during the Second World War, similar in performance to the Spitfire and P-51 Mustang. The accident aircraft, a YAK-9 UM, was a replica of the original design, built in the 1990s and fitted with two seats and an American-built, rather than Russian, engine.


Read the investigation report AO-2018-061: Loss of control and collision with terrain involving YAK-9UM, VH-YIX, 19 km west-north-west of Latrobe Regional Airport, Victoria, on 7 September 2018

A few disconnections and points of interest in this investigation report, for example:

"..The instructor and the pilot discussed the absence of the checklist and other required documents. The instructor reported that they agreed that the aircraft should not be flown, but taxiing would be acceptable...The aircraft was taxied along to the run-up bay. The witnesses observed that the rear canopy of the aircraft was open and that the pilot appeared to conduct routine engine checks. A short time later, the aircraft entered runway 21, the pilot applied power and commenced to take-off.

The instructor, who was walking across the tarmac from the aero club, recalled observing the take-off roll of the YAK 9 and noted that the aircraft used more than double the normal length of runway before it lifted off. The instructor then noticed that the rear canopy was not secure.

He attempted to contact the pilot from within the aero club by radio to advise him that the rear canopy was not secure. The instructor made several broadcasts but did not receive a response from the pilot..."

Then this from this week's Hooded Canary 'Transport Safety Director' Stuart Macleod...

ATSB Transport Safety Director Stuart Macleod said the accident highlights the risks inherent with performing low-level aerobatics in high performance aircraft.


“High‑performance aircraft like the YAK 9 transition into a fully developed spin quicker and more forcefully than a typical light training aircraft. It is essential to have sufficient altitude to effectively recover from a spin,” he said.

“Experienced YAK 9 pilots stated that, depending on pilot experience, 5,000 to 7,000 feet is required to safely recover the aircraft from a developed spin.

The report notes, unlike in most other warbird aircraft, as the airspeed increases during a high-speed dive recovery, in the YAK 9 the effort required to pull back on the control stick reduces.
 
“This investigation reinforces to pilots performing low-level aerobatics the importance of observing minimum approved operating heights, commensurate with their ability and qualifications, and to engage in regular flight reviews and instruction.” 
 
The investigation report notes the pilot had conducted aerobatics in a number of warbird aircraft but only had between five and six hours of flying experience in the YAK 9, and that the accident flight was the pilot’s first in the aircraft in three months.

“With limited experience and recency in flying the YAK 9, the pilot was likely unaware of the aircraft’s unique handling characteristics during aerobatic manoeuvres or spin recovery,” Mr Macleod said. 

Earth to Macleod, do you really think it appropriate to use this particular unfortunate pilot's more than likely intended last flight accident to highlight obvious operational deficiencies and intentional illegalities as safety risk issues? 

I also find it passing strange that this week's Transport Safety Director Macleod makes this obs:

“This investigation reinforces to pilots performing low-level aerobatics the importance of observing minimum approved operating heights, commensurate with their ability and qualifications, and to engage in regular flight reviews and instruction.”

Yet in the ATSB RossAir presser for Executive Director Transport Safety Nat Nagy a similar observation wasn't made..

“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. 

..despite the fact that the CASA approved simulated OEI was conducted at approximately 4,600 ft below the Cessna AFM and 2600 feet below the company OPs Manual recommended topdeck levels for that kind of operation.

MTF...P2 

[Peetwo]

Four and a half years for this?? 

Via, this week's (and last week's) Director Transport Safety,  Stewie Macleod:

Floatplane accident highlights go-around considerations



A Cessna Caravan floatplane operating a scenic charter flight over the Great Barrier Reef clipped trees and impacted dense scrubland while attempting to go-around after an aborted water landing, a new ATSB investigation report details.

The aircraft, with a pilot and 10 passengers on board, was attempting a landing at Whitsunday Island’s Chance Bay on 28 January 2016 when it bounced three times on the water’s surface, after the pilot reported holding off the landing in order to fly through an observed wind gust. After the second bounce, with the aircraft nearing the beach, the pilot increased engine power and initiated a go-around. A more pronounced third bounce, which occurred almost immediately after the second, resulted in the aircraft rebounding about 30 to 50 feet above the water.

While increasing power, the pilot perceived that the engine torque was indicating red, suggesting an engine over-torque for the selected propeller configuration. Noticing that the climb performance was less than expected with the flaps at the 30 degree setting, the pilot stopped increasing power and reduced the flap to 20 degrees.

As it climbed straight ahead towards a saddle, the aircraft’s climb performance was still below the pilot’s expectations. Assessing that the aircraft would not clear the surrounding rising terrain, the pilot turned right. However, during the turn the aircraft clipped trees before coming to rest in dense scrub about 150 metres from the eastern end of the main beach, near the top of a ridge.

Variable water conditions and the possibility of sharing the landing area with marine vessels means that every water landing has the potential to be markedly different.

The pilot promptly advised the passengers to exit and move away from the aircraft. Some of the passengers suffered minor injuries in the accident, but all were able to leave the aircraft quickly. There was no post-impact fire, but the aircraft was substantially damaged.

The ATSB’s investigation found that the aircraft’s initial contacts with the water were past the pilot’s nominated decision point and beyond the northern boundary of the water landing area. This, combined with the delay in initiating the go-around, reduced the options and margins available for a safe outcome.

“Variable water conditions and the possibility of sharing the landing area with marine vessels means that every water landing has the potential to be markedly different,” ATSB Director Transport Safety Stuart Macleod said.

“In this case, despite the perceptions of over-torque, the pilot initiated a go-around without using all available power and the optimal speed, turned towards higher terrain, and placed the aircraft in a down-wind situation, which ultimately resulted in the collision with terrain.”

Mr Macleod said a go-around is standard practice and is typically a safe option whenever landing conditions are not satisfactory.

“However, it is important that pilots consider aircraft performance and local conditions when planning an exit route, including conducting mental rehearsals of standard procedures.”

The investigation also found that the engine operating limitations detailed in the float manufacturer’s pilot operating handbook supplement were not consistent with other guidance, and may have influenced the power level applied by the pilot during the go-around.

The investigation also noted that the aircraft was equipped with lap-sash seatbelts, which have been demonstrated to reduce injury, while the use of emergency beacons and satellite phone facilitated a timely response to the accident.

Read the investigation report AO-2016-007: Collision with terrain involving Cessna 208 Seaplane, VH-WTY, 11 km NE of Hamilton Island Airport, Queensland

MTF...P2 

[Kharon]

A soupçon of sympathy.

Believe it or not, I do occasionally feel some sympathy for the 'authority'. The report into this 'accident' brought about a head shake in answer to a question which has always remained unanswered. To wit – how do you prevent stupidity? I get the same feeling whenever we see a fatal VFR into IMC without an escape path being defined prior to entry; and, half a dozen other similar events which end up with someone else having to examine the wreckage, move the bodies, explain to the families and begin the whole process of investigating another completely avoidable 'accident'. I always think that 'accident' is a misnomer:-

“an event that happens by chance or that is without apparent or deliberate cause”

The Bristell (LoC) event – HERE - defies the dictionary definition. The aircraft was deliberately – for whatever reasons – placed in harms way several times. Had the event occurred over a built up area, once again, there could have been lives lost, property and infrastructure damaged etc. Hence, my 'sympathy' for the regulator who must find a way to prevent this type of behaviour. But how? Wannabe an aerobatics star – fine; get qualified on an aircraft fit for purpose; get the advanced training, do the practice, learn the rules and responsibilities; do more practice then get qualified – off you go, fill your boots. But until you do all that don't push your luck too far. Lest it push back.

"Aviation in itself is not inherently dangerous. But to an even greater degree

than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect."

ATSB - “The avionics system fitted to the accident aircraft had data storage capability and also backup storage capability by way of a secure digital (SD) card which could be fitted to the avionics system. An SD card was not fitted as standard equipment when Bristell aircraft were delivered to operators from new. Further, the operator was not aware (bollocks) of the additional memory card storage capability and had not installed SD cards in any of their Bristell fleet.

ATSB -”The Bristell light sport aircraft (LSA) operating instructions prohibit excessive angles of bank, aerobatics and intentional spins. This was clearly defined and the information relating to spin avoidance was also presented by way of a placard in the cockpit.

The data recorded that at about 1230, while the aircraft was overhead the built-up area shown in Figure 2, it was operated significantly outside of its allowable flight envelope. This included banking to 94° while manoeuvring between 600-1,300 ft above a populated area.

At 1319, the recording captured a 91° roll to the left followed by a pitch down to 40°. The data also recorded a climbing right turn to 91° angle of bank at 1323, followed by a pitch down to 38° then a rolling left pull out turn. Whilst pulling out, the instrumentation system recorded a peak normal acceleration of 4.4 G. That loading exceeded the aircraft’s positive load limit of 4 G.

From 1340, there was significant variation in the magnitude of pitch, roll and load factor, consistent with additional aerobatic manoeuvring during the final minute of the flight (Figure 9).At 1340:36, while the aircraft was operating at:
• about 90 kt indicated airspeed
• a pitch-down angle of about 50°
• high angle of attack and positive load factor it abruptly pitched down to 90° and rolled significantly to the left. That behaviour was consistent with the aircraft experiencing an accelerated aerodynamic stall.6

Subsequent variation in the recorded parameters indicated that the aircraft then entered a counter-clockwise upright spin at a rotation rate of about one full turn every 1.5 seconds and a vertical descent rate of over 3,000 ft/min at the time of impact. The engine power level remained at a constant high setting prior to the spin entry.6Ac

“Stupidity cannot be cured. Stupidity is the only universal capital crime; the sentence is death. There is no appeal, and execution is carried out automatically and without pity.”

The analysis above speaks well for the integrity of the airframe and the robust margins provided within the certification data; hard to blame the 'aircraft' this time. Not one for making things 'mandatory' – however,

ATSB - “The avionics system fitted to the accident aircraft had data storage capability and also backup storage capability by way of a secure digital (SD) card which could be fitted to the avionics system. An SD card was not fitted as standard equipment when Bristell aircraft were delivered to operators from new. Further, the operator was not aware of the additional memory card storage capability and had not installed SD cards in any of their Bristell fleet.”

If the avionics have this capability, there can be no excuse for not utilising it. Mighty handy for operational analysis – it won't bother honest folk.

Toot – toot...

[P7_TOM]

My tuppence worth --

ATSB - “The data recorded that at about 1230, while the aircraft was overhead the built-up area shown in Figure 2, it was operated significantly outside of its allowable flight envelope.”

“K” - “The analysis above speaks well for the integrity of the airframe and the robust margins provided within the certification data; hard to blame the 'aircraft' this time”.

Have to agree; the words 'significantly outside of it's allowable flight envelope' – not once, but repeatedly and they survived the impact, speaks well of the airframe and the design limitations. For what the aircraft is and considering the 'purpose' for which it was intended, I'd have to say well done Bristell. Even in 'skilled' trained hands, the antics described in the ATSB report would test any airframe not built for 'aerobatics' and even then – >60 bank and spins at low level demand serious training, constant practice and even then, they are still high risk category operations. Deliberately putting the aircraft into that part of the envelope; or indeed flying the aircraft in the manner described, over built up area, with a 'passenger' inboard is reckless, undisciplined and irresponsible. Three of the major crimes a pilot can commit right there; not to mention abuse of an airframe not intended for such treatment (unforgivable).

The potential for this type of behaviour in a pilot should have been spotted early in the piece and either 'cured' or further training denied. I'm not saying that on the odd occasion  a little bit of 'madness' is unacceptable – we've all done it – and enjoyed it (immensely) still do – but always in the right place, with a suitable machine. Occasionally, as any professional will tell you, there is a requirement to 'push' the aircraft to a limit – it happens, rarely but it is there. Knowing the limitations of both man and machine is an important tool in any type of flight environment. Keeping the whole show together, without breaking anything or hurting anyone is very much part of a professional life. Some would say the pilot of the Bristell has learned a hard lesson; IMO he should not be allowed anywhere near an aircraft ever again.

I kicked off wanting to say what a good little aircraft this is; and wandered (old age is real). The airframe was brutalised, outside of design and certification limits and stayed together to the point of impact, no fire (luck) and they 'walked away'. Bravo Bristell; the final act of grace was survive ability after a crash impact. Nice one.

[Kharon]

Just a stray thought (or two).

The little Bristell did very well, agreed, no fire was a bonus gift. I feel that within it's 'designated' primary role, as a 'private' aircraft there can be little quarrel about its usefulness or value. However, as a dedicated ab initio 'training' aircraft, you have to wonder. In the horse (and dog) world there is an unspoken rule which has stood the test of time; old horse with a young rider – or vice versa – as applicable. It works (mostly). Student pilots approaching a first licence standard can and do get themselves 'jammed' into a corner; the potential for error leading to a change of pants 'event' is at it's greatest then. This is where the aircraft must be utterly docile and have a significant 'buffer' against fumble. Once the student gains experience then they can fly on the raggedy edge till the cows come home. But until that time, aircraft which are sensitive in some areas of the flight envelope should be left in the barn.

Last bit; self discipline. IMO this is one of the hallmarks of the 'pro' – be it a PPL or an ATPL; the ability to manage oneself in all manner of situations or circumstance, when alone in a cockpit, in a potentially dangerous situation is essential. It is almost an 'inherent' in built ability 'to keep your head' and manage. On the ground the 'pro' may be a different animal; but not in the air. I too have trouble reconciling the event pilot's behaviour with that of a pro pilot. Don't matter what type of licence is held, to deliberately operate an aircraft in that manner demonstrates that 'the right stuff' is not present. There is a world of difference between the mind set which has a 'bit of fun' on a clear day and the flight description provided by ATSB. A fine line? Yes it is, but real pilots understand that.

Ah, happy daze; Chandelle's, wing overs, steep turns, stalls, spins: - all the fun of the fair in a clear sky; then 'aero's. First encounter with aerobatics teaches that strict personal discipline is an essential element, it also teaches that a half hour on 'Google' reading about 'how to do it' is about as much use as a chocolate fire wall. I like to see the 'kids' having fun, flying and learning the do's and do nots – Ah, but now I ramble. 

Just saying.......

[Peetwo]

R44 fatal accident Broome - RIP! 

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Ref: https://twitter.com/atsbgovau/status/127...2099708930

ATSB
@atsbgovau

The ATSB will investigate the collision with terrain of a Robinson R44 at Bilingurr, Broome, on Saturday afternoon. Transport safety investigators with experience in aircraft operations and maintenance will deploy to the accident site.

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Broome helicopter crash pilot identified as tourism company founder Troy Thomas

The founder of an award-winning tourism company has been identified as the pilot and one of two people killed in a helicopter crash in Broome.

Key points:

• Troy Thomas was at the controls of the helicopter when it crashed
  
  
• He died along with a 12-year-old girl, two others were critically injured
  
  
• Mr Thomas has been remembered as a "devoted husband and father" and a "beautiful soul"
  

Troy Thomas, 40, and a 12-year-old girl died when the Robinson R44 helicopter crashed on Antheous Way, Bilingurr, a northern suburb of Broome, just after 2:30pm on Saturday.

A woman in her 20s and another 12-year-old child were critically injured in the crash and have been flown to Perth for medical treatment.

Witnesses reported hearing a loud bang and the sound of the helicopter prior to the crash, while sirens from the large-scale emergency response could be heard across Broome.


Troy Thomas was at the controls of the helicopter when it crashed in Broome.(Supplied: Facebook)


An RFDS plane transported the injured woman and child to Perth.(ABC News)

Mr Thomas started the award-winning Horizontal Falls Seaplane Adventures company in 2006, but sold it last year to tourism group Journey Beyond.

He was retained for one year as a manager, so was still working with the company at the time of his death.
He accepted an award on behalf of the company at the Australian Tourism Awards in March.

Friends, including sports commentator and former West Coast Eagles player Karl Langdon, took to social media to express their grief.

Small community left 'struggling'

Kimberley District Inspector Gene Pears said the crash and the deaths were having a significant impact on the local community.

"It's not a great day for Broome," he said.

"There were many witnesses to the crash, some may have heard something, some may have seen something.


Inspector Pears says the local community is reeling from the crash.(ABC News)

"We're interviewing witnesses at the moment, but this will be really tragic for people here in a small community, so many people would be affected, many people would be struggling.

"Please seek professional help and talk to each other and look after each other as Broome people do really well."


Police remain on the scene of the fatal crash.(ABC News)

Inspector Pears said as is the case in most country towns, the first responders would have known those involved in the crash.

He said while the investigation was still in its preliminary stages, it was understood the helicopter crashed shortly after take-off.

He said the crash site was being secured by police while they waited for officers from the Australian Transport Safety Bureau (ATSB) to arrive.


Flowers left near the scene of the helicopter crash.(ABC News)

Tourism industry 'in mourning'

The WA branch of the Australian Tourism Export Council commented about Mr Thomas's death on social media.

"The Tourism Industry is in mourning today with the very sad news of the tragic death of Troy Thomas in Broome," it said.

"Troy was the founder of the award winning Horizontal Falls Adventure Company, a devoted husband and father, son, brother and friend to many … a beautiful soul who will be missed, but whose legacy will remain as a trailblazer for tourism in Western Australia.

"Our sincere condolences to Troy's family and friends, and to the family of the little girl who also did not survive the helicopter crash."

WA Tourism Minister Paul Papalia said he was deeply saddened by Mr Thomas's death.

"The Western Australian tourism industry has lost a valued leader and a good friend," Mr Papalia said in a statement.

Natasha Mahar, chief executive of marketing body Australia's North West, said Mr Thomas was an iconic figure for tourism in the region and worked tirelessly to put Horizontal Falls on the map.

"He really was a character of the Kimberley and he put all his hard work and effort into really making people happy and making their day and giving them an experience that they wouldn't ordinarily find anywhere else in the world," she said.

The ATSB said it was bringing in investigators from WA and interstate to examine the wreckage and the crash site.

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AE-2020-008 :  Technical Assistance to RAAus - Collision with terrain involving BRM Aero Bristell, 24-8555, Kanangra-Boyd National Park, NSW, on 16 December 2019

Summary

On 16 December 2019, a BRM Aero Bristell aircraft, recreational registration 24-8555, collided with terrain in Kanangra-Boyd National Park, near Oberon, New South Wales. The pilot was fatally injured.

In response, Recreational Aviation Australia (RAAus) commenced an investigation into the occurrence and requested technical assistance from the ATSB in the recovery of flight data from two instrumentation units – a Dynon SV-D1000 and Garmin aera 795; both of which were subsequently provided by NSW Police.[/size]

The ATSB successfully downloaded data from both devices, including flight path information and aircraft operational parameters. Figures 1 and 2 summarise this information.

Both instrumentation units were returned to NSW Police on 23 June 2020 and a technical report and all recovered data provided to RAAus on 24 June 2020.

With the completion of this work, the ATSB has concluded its involvement in the investigation of this accident. Any further enquiries in relation to the investigation should be directed to Recreational Aviation Australia.

The information contained in this update is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

Figure 1: Flight paths from Garmin and Dynon units

[b]Source: Google Earth, GPS points by ATSB[/b]
[b]Figure 2: Selected flight parameters[/b]

Source: ATSB

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Why do I get the feeling that the Hooded Canary's aviary was glad to see the back of that particular accident, especially when you consider what the tail end of the GPS vertical profile pictorial appears to show -    

Hmm...a quick referral to the RAAus bollocks 'Accident and defect summaries' page 8:

16/12/2019: Fatal Accident involving RAAus member. RAAus accident consultants are assisting police in determining the causal factors that led to the accident.

Simply put unless the NSW Coroner's office decides to examine further, that'll be the last we hear about that particular fatal LSA (Light Sports Aircraft) accident -   


 MTF...P2 

[Kharon]

Snap !-

Strange and wondrous are the ways of coincidence; not to mention how operational 'logic' eventually surfaces. The Beaver accident in Jerusalem Bay is a case in point. Two items of interest have surfaced; one being the widespread lack of faith in the ATSB's investigation, coincident with the somewhat 'tardy' investigation of CO levels (from the engine exhaust) as a possible cause. 

Lead Balloon, on the UP – HERE – touches on a very relevant safety issue; which has been around, unattended, for many years now. Most who have flown GA aircraft have seen the 'card' type CO detector stuck on the dash – LB mentions the dubious 'reliability' of these cards. It begs the question; if there is known reliability doubt, why has there been no positive steps taken toward education and awareness? Why have the ATSB not investigated the possibility and published the results? Should it been demonstrated that the ' CO card' is of little value, then steps must be taken to eliminate the possibility of accident due to CO. Maintenance of the aircraft exhaust system should eliminate the possibility – however – as we all know – Murphy is an ever present passenger.

FW47 weighed in and beat us to posting the link to  AOPA (USA) – HERE -: this article  is worth the time to read through. But, read it carefully the 'cause' of the CO intake is buried in the somewhat 'dramatic' text; although that may be forgiven as the article is scripted to 'drive home' a valid point.

Exhaust systems are the primary safeguard – the warning system a backup. Daily pre flight inspection in single engine involves opening the cowls – nothing hanging, nothing dripping and the exhaust firmly attached. Lesson one; day one. 

Is there a 'statistical' need to mandate a warning system? – probably not. But, if I ever owned a single engine aircraft (unlikely in the extreme) I'd spend the dollars – just to be sure – to be sure.

Toot – toot.

[Peetwo]

Via the Hooded Canary HQ aviary:

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Weather, aircraft performance and operating procedures among areas of focus for on-going C-130 large air tanker accident investigation



Key points:

• ATSB has released an interim report from its on-going investigation into large air tanker accident
  
  
• Interim report does not contain findings, but details accident’s sequence of events
  
  
• Weather, aircraft performance and operating procedures among areas of focus
  

 
Weather and environmental influences, aircraft performance and handling, and operating policies and procedures are among the areas of ongoing focus as the Australian Transport Safety Bureau (ATSB) continues its investigation into the collision with terrain of a C-130 large air tanker.  


Three aircrew were fatally injured when the aircraft impacted rising terrain after conducting a fire retardant drop to protect property at Peak View, north of Cooma, NSW on 23 January 2020.

“The interim report does not contain findings nor identify safety issues, which will be contained in the final report. However, it does detail the extensive evidence gathered to date, which has helped ATSB investigators develop a detailed picture of this tragic accident’s sequence of events,” said ATSB Chief Commissioner Greg Hood.

“To-date, the ATSB has interviewed other pilots and key personnel from the aircraft operator, NSW Rural Fire Service personnel involved in aviation operations, witnesses, C-130 and other aerial firefighting pilots, and key personnel in overseas aerial firefighting operations.”

In addition, while the aircraft’s cockpit voice recorder was inoperative, the investigation team drew upon ADS-B transponder data (used for air traffic control and surveillance); data recorded by the aircraft’s SkyTrac tracking system (used for monitoring by the NSW Rural Fire Service); and video of the accident taken by firefighters on the ground, to develop an understanding of the aircraft’s flight path.

Analysis of the witness video confirmed that the aircraft initially established a positive rate of climb and was banking to the left following the retardant drop, the report details.

After climbing for about 10 seconds the aircraft was then observed to roll from a left bank to a slight right bank. A maximum height of about 330 feet above ground level was reached before the aircraft was observed descending. A further seven seconds later, the aircraft was observed at a very low height above the ground, in a left bank, before it collided with the ground. 

In the video the aircraft is intermittently obscured by smoke, however, it is unclear if the aircraft flew behind the smoke or entered smoke, Mr Hood noted.

The report also notes that at the time of the retardant drop, the aircraft’s recorded ground speed (determined from ADS-B and SkyTrac data) was 144 knots, while prior to the impact, the groundspeed had increased slightly to a maximum of 151 knots.

Mr Hood said the ATSB’s examination of the accident site and recovered wreckage established no evidence of structural failure or pre-existing damage to the aircraft.

“All major sections of the aircraft’s structure were identified. No pre-existing airframe issues were identified, and there was no evidence of an in‑flight break-up or pre-impact structural damage,” Mr Hood said.

“All four engines and 16 propeller blades were located on-site, and a subsequent teardown inspection of the engines indicated they were rotating at impact.”

Due to the extent of damage, the elevator, aileron and rudder trim settings could not be established. However, on-site measurements of the flap screw jacks indicated the flaps were set at 50 per cent at impact, consistent with the expected setting following a retardant drop.

The aircraft was originally tasked to conduct retardant drops at the Adaminaby fire ground. However, after conducting a number of circuits over the fire ground, the crew determined that conditions were too windy and smoky to conduct a drop. Instead, the Cooma Fire Control Centre re-tasked the C-130 to conduct a retardant drop to protect property at Peak View, about 58 km to the east of Adaminaby.

Following the accident, the ATSB received multiple witness reports of the weather conditions at Peak View.
“Witnesses all consistently reported very strong winds from the north-west,” Mr Hood said.

“One resident noted that, although the prevailing wind was from the north-west, the direction and strength at ground level were also being influenced by the local terrain.”

A private weather station, about 1.3 km from the accident site, had recorded winds from the west of 15-16 knots, with a peak gust from the north-west of 43 knots.

Mr Hood said a Bureau of Meteorology analysis of the weather conditions on the day of the accident indicated that a cold front was approaching the accident location, with hot and strong north to north-westerly winds ahead of the front.

“The Bureau of Meteorology considered the conditions on the day were favourable for mountain wave development, and satellite imagery of cloud formations confirmed their presence in the general area of the accident,” he said.

“However, from the data available they were unable to determine the severity of mountain wave activity.”

The interim report also notes that the flight crew were appropriately licenced and endorsed, held valid medical certificates, and that there no indications they were fatigued. However, there was insufficient information available to the ATSB about the crew members’ sleep and non-duty activities to estimate fatigue levels with confidence.

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

Read the interim report AO-2020-007: Collision with terrain involving Lockheed EC130Q, N134CG, 50 km north-east of Cooma-Snowy Mountains Airport (near Peak View), NSW, on 23 January 2020

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MTF...P2 

[Kharon]

It had to happen -

The ATSB published this 'milk and water' report October 1, 2020.

A 'LL'  post on the UP – actually worth reading – and; spot on to boot.

LL - Interesting that isn't addressed in the report. Its not just QF 737s that only have the tiller on the LHS and at a critical point, particularly after a relatively high speed exit off the runway, the Captain has to take control of the aircraft. Another point not mentioned is functional blindness. The PIC didn't "see" rwy 06 because he wasn't expecting to see it, he also didn't "see" the aircraft lined up on 06. If you want a good example of functional blindness then just remember the bloke in the gorilla suit walking through the basketball passing competition. Most airline pilots would be familiar with this.

LL -”There is a lot more going on with this incident than is obvious to anyone not familiar with jet operations. The briefing; probably overly detailed and the Captain has already made up his mind how they are getting from the runway to the terminal. J2 is like the Haymarket roundabout in Melbourne and it should have been altered to be a 90 degree exit off the runway well before this. Look at the photo of the view to the terminal off J2, your eyeline goes to the terminal. Brand new FO is always going to be less situationally aware as they are still slightly behind the aircraft. Captains deal with that situation in different ways. Some will assume that because they have been cleared to line then they are fully up to speed, others will take it into account and slow the operation down. Despite all the briefings, all the HF training all the ICAO recommendations you cannot know what mental model the other pilot is operating to until it starts to manifest itself. There is only 19 seconds from entering J2 to crossing the stop bars, in that time there is a fair bit of activity going on in the flight deck including a change of rolls. Not a lot of time for the FO to comprehend that the Captain's idea of what is going to happen is different to his/hers.



LL - “I'm not critical of the report but I am not surprised that this occurred. The best safety action was Perth Airport getting rid of J2.

Concur - A good summary which leaves one wondering – once again – why the ATSB are using soft soap in place of 'operational expertise'.

Choc Frog – nicely summarized. 

Toot – toot.

[P7_TOM]

The basics of good airmanship and aerodynamics have not changed since the Wright Brothers. The lessons have been taught many times - …..........

"Out of a clear blue sky" -

[P7_TOM]

Al Fentanyl  (UP) - "My opinion only". - Choc Frog.

"Having once started a takeoff roll with full left rudder trim wound in, after a series of OEI approaches, I can make the following observations:

"The trim was visually checked by both pilots, the square white indicator at the end of travel looks - at a glance - very much like the square white indicator at the centre of travel."

"Through about 50kt, the aircraft was drifting left and could not be managed with the full strength of the pilots leg input which is considerable. This is well before take-off speed and I believe it highly unlikely that the incident pilot was in the same situation and still allowed the aircraft to accelerate to take-off speed. In fact I doubt whether he could have physically held it on the runway strip long enough to even get to take-off speed."

"The situation was only examined in a SIM. It was not trialled in a real aircraft. I have also tried it in the same SIM and found it relatively easy to hold direction, very much different to the aircraft."

Alas, dear Al, not just your humble opinion. It stands as the opinion of the many B200 qualified pilots Aunt Pru can reach out to. I was, just 15 minutes ago, sitting with just under 8000 collective hours command experience in the peerless King Air. We sat together to discuss the results of a 'survey' we did through the PAIN network of 'qualified' experienced pilots on the aircraft type. I will not regurgitate the 'data'; it is sufficient to say that your opinion is mirrored by about 100 Be20 pilots. I can't begin to count the hours on type, nor was the question asked. I have about 2000 hours on type and have held a C&T qualification for same. I have never, not ever once seen any other reaction to a 'full rudder trim' scenario - bar 'coals off' : brakes on; and, the WTD is going on question.

After landing: item 5 – Trim - SET

Before take off – item 5 Trim tabs - SET

A professional pilot does not (or should not) need any additional 'ex- checklist' (mnemonics). Post flight check list calls for trim reset; pre flight checks call up trim check. There are a few (several few) honest enough to own up to having forgotten the humble rudder trim reset after landing; yours truly included (long story). I and my fellow sinners spotted the sin at about 40 knots- many at even even less speed.

However; and here's the rub: in any normal flight configuration the rudder trim off-set is so slight, depending on the airframe operated; that even when the promulgated 'reset to zero'  is neglected; through two separate check lists – it is very much a 'something – nothing'. Full rudder trim is a very serious amount of trim to leave on – even after an asymmetric approach and landing event (been there – done that).

For the ATSB boss to declare that 'full' rudder trim was 'on' prior to take off is not only risible; unrealistic and 90% not probable, leaves one wondering Why? – Is it a cock-up/ flawed investigation; or, a cover up to protect the DoIT and it's murky dealings in the great airport asset sell off (rip-off); protection for big money developers; and, of those they bind 'close'? There is as yet no reply or response to the inquiry into the 'development' program for Essendon. Not from anyone; not a single word. I wonder why. 

There are two lines of inquiry the American interests could examine. The California code for tall building about airports is one; the other could be for the FAA data base related to 'out of trim' events for the Be20 which resulted in fatal 'mysterious' accident. Be a short list I'd reckon......

[Kharon]

Exploring a dark, mysterious realm.

Death and the reason why. A chance remark which sets the mind to work and sparks the dreaded curiosity bump into action. There we were, stood about the dart board, the Essendon collision with a large building being 'discussed' (again) there was some speculation about the medical condition of the pilot; could there have been some 'medical' trigger – partial or full on etc?

The chap who raised the topic cited the Mt. Hotham flight which preceded to the Essendon event. Was there some kind of medical event at Hotham? It was a fair question, tough to answer and yet like it or not it is part of the tapestry of the Essendon event.

Now, the pilot's medical condition is known; “but where's the autopsy?' says another bloke. Good question, as yet unanswered. That was the bit which got the wheels spinning.

There are two (IMO) serious questions which should be answered: why the ATSB do not provide a 'most probable cause' and why ATSB rely on CASA, through the MoU, to allocate 'blame'. The NTSB nearly always present a 'most probable cause' often citing autopsy results. As in the percentage of Carbon Monoxide present, for example.

So, to my puzzle, who may order an autopsy; who is made privy to the results; who pays the not inconsiderable charges; how much 'material' is required to provide a definitive explanation as to the cause of death; and, how much damage caused by fire  can be separated from a fundamental cause? Would the burning mask a serious heart attack or stroke?. I just don't know – but I know some people who may. Time to scratch the curiosity itch methinks.

Was the Hotham incident indicative of a deeper problem; were the multiple 'mayday' calls a clue; and, last, but by no means least, could someone please explain how the aircraft managed to become airborne against a 'full left trim' setting, you would needs the legs of Hercules to manage that trick and the brains of a rice pudding to not abort or correct. Sorry too much, but the ATSB is not the NTSB and the many questions begging answers have not been addressed. Gods alone know what the USA folk must think – probably unprintable anyway.

Aye, a speculative twiddle – but many are still wondering WTD really happened at Essendon and what the ATSB is playing at.

Toot – toot..

[Kharon]

Mount Hotham - revisited.

'We' got lucky and managed to contact some fairly well qualified folk, who spared the time to entertain our bumbling questions. A sincere thank you to those for their unstinting help and the time gifted.

I'll keep it short: curiosity about 'Coroners' and autopsy was satisfied; the most interesting from our PoV was what can and cannot be determined from autopsy. I'll spare the grisly details, but much depends on the 'state' of the body provided; for example, with major trauma to the head there's not too much left of use to the analysis; however the organs contained within the body have a much better chance of telling the story. Endit...

Back to the Essendon event and the reason we bothered busy folks. There are many cases where a heart attack has been passed off as nothing more than heartburn; other serious events have been passed off as related to 'other' causes. Many reasons for doing this – particularly when a Class 1 medical examination has been passed within the preceding half year. So, one of our questions was – is it possible to be undergoing some kind of performance affecting 'event' and be unaware? “Yes” was the collective answer.

Anyway – long story short; our wise owls all agreed the the Mount Hotham incident was a key element in the Essendon event. What occurred at Hotham was a 'passing strange' event. An experienced pilot, in a familiar aircraft, conducting a routine instrument approach got into a serious tangle. I can't for the moment put my hand on the graphic (P2?) , but the flight path and conduct of the operation was 'peculiar' to say the least. Automation and equipment abnormality may have been in the mix; but, there were several other 'safer' ways of sorting things out available, other than the options taken.

Despite the glib, IMO erroneous opinion of the ATSB PR department; there are parallels with the Essendon event – there were (again) other 'safer' options available to the pilot, yet of all the choices available; the decision to continue the take off was, on balance, with 20/20 hindsight, the least viable. Why?

It seems that there is little chance of useful information being gathered from the brain; there is a good chance that the rest may provide some answers. It seems that there are many things which can and do affect decision making and performance.

If Max had a medical event which affected his performance then it would be unfair to lay all the blame at his feet. Equally, CASA in issuing a medical certificate cannot be held to account, the boxes were ticked, medical issued – end of..

So we are left with two separate incidents which question the performance of an experienced, capable pilot. One, a narrowly escaped mid-air collision or ground strike; the next not so lucky.

FWIW there seems to be only two questions demanding answers; 1 what caused two serious departures from 'routine' operation; and, 2 Why is that abomination at Essendon still standing?

There, curiosity bump scratched – but to quote the infamous John McCormack – it is all “passing strange”.

She gave me for my pains a world of sighs.
She swore, in faith, ’twas strange, ’twas passing strange,
'Twas pitiful, ’twas wondrous pitiful.

Toot – toot..????

[Cap'n Wannabe]

A medical event, from my own personal experience..

I jumped out of the shower at home and noticed I was getting a headache. Nothing too serious, but strong enough for me to swallow a couple of Neurophen. I got dressed, and went out to the car with my then girlfriend. We started driving, and about 5 minutes later, I started thinking of a couple of friends of mine, and something they'd done recently. Except....the friends didn't exist. Nor did whatever it was they'd done. I started to tell the gf about the friends. But.....what I was saying, while coherent and making perfect sense, didn't match the thought that was going through my head. I was talking about completely different people. Who also didn't exist. She had no idea who I was talking about, and told me. This brought on a little confusion on my part, as I struggled to understand firstly why I was thinking about people who did not exist, but also why I was telling her about different people who also didn't exist. Still, I shrugged it off and continued driving.
All was going ok for about another 10 minutes or so, then I almost rear-ended someone. Didn't give that much thought either...it can happen, after all. But then it happened again. My reactions were slowing, but I didn't quite realise. A discussion with my gf ensued, and she convinced me to pull over and let her drive.
At this point, we were still going to our original destination. Given she wasn't a local, she asked me to direct her. I missed a street we were supposed to turn down, but again, thought nothing of it. It was easy to get her back onto the road we needed to be on, although it seemed to take a bit longer than usual for me to tell her where to turn. A little more confusion set in....why was it taking so long?
After about another 5 minutes or so, she pulled into a service station and called 000. I was having a lot of difficulty speaking by now, and was showing some facial droop. She asked the operator where the nearest hospital was, but not knowing where she was, it fell upon me to tell her. Which I did, but not without great difficulty. I then managed to guide her to the hospital, where we went into the Emergency Department.
From there, I can remember everything up to the point where I fell asleep (or did they knock me out?) after being checked in.

So, what is the point of all this?
A medical event doesn't just turn out the lights. It can creep up on you, and you don't even realise it's happening. You don't realise your decision-making process is suffering. You don't realise you're losing functionality....until it's too late.
Six months prior to mine, I had passed a Class 1 with no problem...

[Peetwo]

ATSB AO-2020-059 update?? - 



Not sure why but the Hooded Canary's aviary has sailed well past the ICAO Annex 13 preliminary reporting requirements of 30 days:
 

What are a State’s reporting obligations during and after an aircraft accident investigation?
 
Under Annex 13 to the Chicago Convention, States in charge of an investigation must submit a Preliminary Report to ICAO within thirty days of the date of the accident, unless the Accident/Incident Data Report has been sent by that time. Preliminary Reports may be marked as confidential or remain public at the investigating State’s discretion. 

Maybe there is some legitimate excuse?? However I find the delay extremely suspect given that the fatal accident involved yet another Soar flight training aircraft and remembering that same company/flight school was so enthusiastically promoted (in November 2018) by a certain Minister (current Acting PM)?

Hmm...but maybe the MSM are finally joining the dots and making the connections?

Via Yahoo News:

No plane faults found in NSW crash probe

Luke Costin
Tue, 12 January 2021, 4:18 pm AEDT

Investigators probing a fatal crash involving a financially-troubled flight school will examine maintenance history and the experience of those on board.

A student pilot and her instructor were killed when their two-seat light aircraft slammed into a small dam in central NSW on November 4, 2020.

The flight was a final check before the Soar Aviation student underwent a commercial pilot licence test later that month.

A crash investigation update released on Tuesday said the engine had fuel supply at the time of the crash at Carcoar, south of Orange.

Weather reports also indicated no cloud, good visibility and light winds.

"On-site examination of the aircraft's flight controls, engine and structure did not identify any pre-existing faults or failures," the Australian Transport Safety Bureau's Kerri Hughes said in a statement.

Ms Hughes said the ATSB would now analyse the pilot's personal electronic devices, the aircraft's maintenance history, weight and balance, and performance.

Planning for the flight and the pilots' qualifications, experience and medical information will also be examined before the final report, expected in late 2021.

Soar Aviation, which entered administration on December 29, no longer has a working phone number listed on its website.

Comment was sought via email and via its administrators, who held a creditors meeting this week.

The ATSB's initial investigations had uncovered that the crashed aircraft was flying in a pattern consistent with a touch-and-go at a landing area near Carcoar before it crashed.

It had earlier departed Bankstown Airport and landed at Orange, where a witness saw the instructor consulting flight charts.

Two orbits of the airstrip near Carcoar were completed before the crash.

No eyewitnesses saw the aircraft but a witness heard sounds consistent with it approaching and then leaving the area.

Less than 10 seconds later, the witness heard the plane hit the bank of the small dam, which was on rising terrain about 600 metres beyond the runway.

MTF...P2 

[P7_TOM]

Ahem!

And, I do apologise for interrupting here – but, it seems 'passing strange'

“The ATSB's initial investigations had uncovered that the crashed aircraft was flying in a pattern consistent with a touch-and-go at a landing area near Carcoar before it crashed.”

That aircraft is pointing which way?

The reciprocal of '07' is (070+180)=250°. It may have finished up pointing a tad South of that – rough calculation 210 :: ish.

So what is the 'picture' trying to say'?  Was the aircraft trying to reach runway 07 and land on 25. The 'Met' data indicated 'light wind' so a downwind landing with an emergency was a playable lay.



“Less than 10 seconds later, the witness heard the plane hit the bank of the small dam, which was on rising terrain about 600 metres beyond the runway.”

Runway 07? WTD – to be that low at 600 meters from the threshold of runway 25 speaks of something going wrong. Once again an experienced instructor an almost 'commercial' pilot and in fine weather, on a calm day, they bump into a dam? Bullshit.. and BOLLOCKS.......

“A student pilot and her instructor were killed when their two-seat light aircraft slammed into a small dam in central NSW on November 4, 2020.” - Costin.


But - WHY????????

Nowhere near good enough, quick enough, informative enough; or, even accurate enough from the Hooded bird cage -  is it. Time to muck out the bird gage methinks.