[Kharon]

Two men dead; and a time line to meet...

Is this the best our once-upon-a-time  world best ATSB can manage???? - With the clock ticking – a 'report' of some sort needed to be generated. - THIS – pathetic effort is all the ATSB could manage? Seriously

Report status – Pending – Investigation status – Highest injury level – Fatal.

“No eyewitnesses observed the aircraft land and subsequently take-off from runway 07 at Coombing Park, although one witness heard the aircraft approaching from that direction. The witness described the aircraft engine as sounding normal prior to the sound fading, consistent with the aircraft flying away. However, after no more than 10 seconds later, at about 1709, the witness heard the aircraft colliding with terrain.”

What a fatuous, arse covering little missive the 'report' is.

”However,  However, after no more than 10 seconds later, at about 1709, the witness heard the aircraft colliding with terrain.” at about 1709, the witness heard the aircraft colliding with terrain.”

This dross has not even been edited out - “after no more than 10 seconds later”,

This piss poor use of the English language is allowed to pass through, without challenge, to the world audience? WTD then do our peers and betters make of the quality of any ATSB report? Then this pearl:-

“at about 1709, the witness heard the aircraft colliding with terrain.”

The bloody 'arrow' (see the picture) pointing to runway 07 indicates the aircraft North of the airstrip – it also indicates that the runway 25 threshold was – where?


ATSB - “About 2 hours later, the wreckage was found with both occupants fatally injured and the aircraft destroyed. The aircraft had impacted the bank of a small dam, located on rising terrain about 600 m beyond the end of runway 07 (which end) and about 30° to the left of the runway centre-line” - for which runway?  (Go Figure 2).

So they take off heading 070 – all normal – ten seconds later – crunch; two dead. The aircraft 600 meters 'beyond' ( North or South) the end of the 07. That aircraft, according to the ATSB picture is North of runway 07.

This is a pitiful example of the slack Hooded Canary operation. Compare it to any report provided by ATSB, back in the day, before they became CASA's PR 'boy'.

Shame; two men dead; and all ATSB can conjure up is a desktop picture and a report which 'meets' the time line.

Disgusting, shiftless, lazy and an insult to every 'tin-kicker' on this small planet. Nearly as unpalatable as the AF 'statistical' farrago.  Maybe the Hooded Canary could just go back to his proper job; boot - licker, footstool and catamite to whosoever owned him. Disgraceful, disgusting and an insult to those left behind.

Toot – FLUSH – toot.

[Cap'n Wannabe]

OK...I've been asked to put up some pictures from Google Maps of the Soar crash site.  The thing is, I don't know which dam the Bristell came to grief at (P2 - I believe the a/c was an Aquila not a Bristell).  I've narrowed it down to two possible locations, based on the shape of the dam from the ATSB photo, the distance from both the threshold of RWY 25, and roughly the centre of RWY 07/25 (I'm not sure if that's where the ATSB would take measurements from, but AFAIK the location isn't specified..), and the direction to the RWY 07 threshold.

Overall image showing the two possible sites


Distance of Dam 1 from centre of RWY 07/25 approx 600m


Distance of Dam 1 from RWY 25 Threshold approx 450m


Distance of Dam 2 from RWY 25 Threshold approx 600m


Direction of Dam 1 from RWY 07 Threshold


Direction of Dam 2 from RWY 07 Threshold


Other things to note:
Dam 1 is 60m South of the Mid Western Highway, and 330m West of Fell Timber Road
There is a group of buildings approx 900m to the North East, and another approx 900m to the East of Dam 1, and a further group of buildings approx 600m North.  All three groups of buildings include a house and some sheds.

Dam 2 is 430m West of Mt Macquarie Road, and 425m East of Fell Timber Road.
There is a group of buildings approx 220m to the North East, and another approx 500m to the North of Dam 2.

Dam 1 lies within the downwind leg of the RWY 07 circuit, whereas Dam 2 is just outside the crosswind leg.

So....questions..
600m beyond the end of RWY 07?  As Kharon has asked...which end?  If it is the landing end, there is no dam that fits that criteria.  Dam 1 is approx 600m from the mid-point of RWY07/25, and Dam 2 is approx 600m from the upwind end of RWY 07.  There are no other dams that fit the shape or direction within a bulls roar of the airfield.
Why did it take 2 hours for the wreckage to be located?  There are buildings and roads located within 1km of the crash site...surely somebody must've seen or heard something and wondered what the hell just happened.  Well, someone did, but...
Engine failure?  Looking at the map, plenty of space to conduct a forced landing, especially to the North and North East..

P2 - Not to mention the highway itself?? Excellent Stuff CW and I do wonder about the pic of the crashed aircraft which looks very similar to an aircraft that has suffered an uncontrolled flat spin into terrain??


Ref: https://www.flightsafetyaustralia.com/20...n-warning/

[P7_TOM]

Choc frog for CW.

Good work, not too shabby at all.

The graphics beg questions the ATSB have not answered,

“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.

November 04/ 2020 was the incident date. Last update January 12, 2021.

So, it is not a long stretch to imagine that the ATSB report was not 'a report' but more of a box tick; put together by the PR department office boy; or, even the tea lady. For it bears little resemblance to a NTSB 'bare bones' 30 day report. Two men died; we have no idea why or even where; but here's a published report which keeps ATSB out of the ever deepening 'Do-Do' for another short while. What a bloody shambles.

There are some questions which should be answered, even in the sketch provided.

Who – took two hours to reach the wreck? Was it any of the many locals> Was it the rescue or police and ambulance services? Was it farmer Brown on his tractor? Were the men killed immediately on impact; or, were they a fighting chance of survival given proper, rapid attention? Did either man make a phone call – was the telephone 'tracked' to locate the wreckage? There is a long list of questions which would assist the interested parties to determine exactly what happened, where and why. Particularly why it took so long to get assistance and medical crew to the crash site.

Then there is the 'aircraft' in-situ. What, why, when and how would be a welcome gift to those left behind; even a hint of where the aircraft was in relation to the airfield and the circuit; for that dreadful ATSB 'picture' and the stupid little arrow provide no sensible clue to any ducking thing.

Pic 1.

Silly question boy; to which you well know the answer; ale with you Sir; yes please and wipe that grin off -

[Peetwo]

Via the Oz:

---

Airspace changes ‘would have stopped fatal crash’


Matthew and Jeffrey Hills in the cockpit a week before their Mooney M20J four-seater crashed into a hill in Dorrigo National Park, west of Coffs Harbour, in 2019.

ROBYN IRONSIDE
AVIATION WRITER
@ironsider

9:28PM JANUARY 20, 2021
13 COMMENTS

A fatal plane crash in northern NSW could have been avoided if long-awaited changes to Australia’s airspace had been made, veteran aviator Dick Smith says.

The final report by the Australian Transport Safety Bureau on the September 20, 2019, crash found a trainee air traffic controller sent a Mooney M20J plane into deteriorating weather that ultimately resulted in a crash 26km west of Coffs Harbour Airport. Both men on board, pilot Jeffrey Hills, 59, and his 25-year-old son, Matthew, were killed.

The report revealed the pilot had sought clearance to continue flying at 6500 feet in Class C airspace, but was refused, despite no limiting weather factors.

Airspace near busy airports is generally classified as Class C, which means all aircraft must seek clearance before transiting.

With no clearance provided, Hills was sent to a lower altitude in Class D airspace where there was an increased risk of encountering poor weather.

As conditions deteriorated below those required for visual flight, the Mooney descended into a hilly area and crashed.

Mr Smith said the crash would not have occurred if the agency responsible for air traffic control, Airservices Australia, had followed a ministerial directive issued in 2004. That directive, which is current, instructed Airservices to provide an approach radar control service where Class C airspace existed or reclassify to Class E. “They have not done either,” Mr Smith said. “Airservices have not given the controller the correct tools to do their job so it’s just easier to stop planes coming into the airspace.”


The wreckage of the Mooney M20J.

If the changes had been made, the Mooney would have simply continued on its journey at 6500 feet above mountains and weather, and on to its destination.

The report highlighted that Airservices did plan to reclassify the Class C airspace above Coffs Harbour to Class E, which meant pilots flying under visual rules would not have to seek clearance to transit. However, the time­frame for the reclassification was not available, the report said.

Mr Smith said it was dis­appointing the ATSB pointed the finger at a trainee traffic controller rather than tackling Air­services’ failings. “I’d like to see the report redone using guidance from overseas airspace experts.”

The report also revealed the pilot was not carrying appropriate navigation equipment and had “most probably not obtained weather forecasts”.

Hills Sr had not undergone a flight review or proficiency check since 2010, which meant he did not have a current licence. “This probably led to a deterioration in the knowledge and skills required for safe flight management and decision-making,” the report said.

ATSB chief commissioner Greg Hood said the crash illustrated the significant influence air traffic control could have on the conduct of a flight, and was another reminder of the risks for pilots without an instrument rating flying into non-visual conditions.

---

MTF...P2

[P7_TOM]

The 'question'.

Silly ol' me; I had to ask, did the Mooney pilot 'file' a flight plan? Well, it seemed to me a little bit 'odd'. Now, its been at least 50 years since I filed a VFR flight plan; back then you had to; full SAR, full reporting, operational control and a mandatory 'chat' with the weather man. We had the magic flight service system and we used WAC charts and 'whizz-wheels' and all kinds of stuff; and, we paid attention. Two minutes (from memory) to an estimated position was all the latitude allowed. I liked the old FSU system – its an old man's prerogative.

McLimit - “Inbound IFR aircraft do not just 'pop up.' That's not how an ATC system works. They are known about well in advance through co-ordination from the previous controller. The Tower also gets a departure message from the AFTN network”.

But; in this modern world of GPS wonder boxes and little in the way of a 'flight plan' a nutted out one , I wonder. For example; I'm going from a secondary airport to an airfield close to a control zone; drop off the passengers and toddle off to the Control zone field for fuel, lunch and a wee-wee (old age pre planning). Why would I not put a flight plan into the system; just to let the tower control know, early in the day, that my arrival – at/ about 1300 LMT was going to happen. They may not bake me a cake, but at least they'd know I was 'imminent'. So 30 odd from the boundary – with the ATIS, I politely ask for 'clearance' and guess what – I may need to 'hold at' XYZ for a couple or even three while the 'sequence' sorts out; but sooner or later, with patience from all who understand the situation I get my fuel, lunch and wee-wee.

The Australian system is, what it is – for weal or woe. It ain't the USA, it ain't Europe and it most certainly is not some of the third world systems. My question was – did the Mooney pilot file a plan? I would have VFR or not – I expect to enter controlled airspace; and, it is only polite (good manners or airmanship) to let 'em know you are coming. Not to understand the 'system' from the ATCO point of view is (IMO) unprofessional. Cuss all you like; they are even more rigidly hidebound than the aircrew; no, not kidding.

I can't see how this 'go in silence' mode of operation is supposed to work; ATC have a system, a sequence (and rules which are terrifying). Different countries have a 'different' approach to 'traffic'. Across this globe; I have had an apology from an approach controller a Heath Row for holding me 12 minutes on a Friday evening about 1815 o'clock; been held for 86 minutes at some foreign hell hole (no names) and then kept in the terminal for two hours; had Sydney send me out to sea one evening 90 miles without a whisper of explanation; or complaint. Re-payed in full next day mind you – best speed three mile final take first exit (1030 AM local). All part of 'normal operating' and a thing a pilot must, repeat, must simply get used to – end of...

Hah! No matter once the 'Electric blue idiot' gets his multi million dollar system in all will be well. When is that supposed to happen again? When the 'courage' straps wear off? Time for a minister to ask the right questions methinks; before we needlessly kill off the few remaining viable aircraft and crew...................

All too busy sheeting home 'blame' rather than address the problems ATCO and aircrew have been stuck with for far too long; private operations included.

[P7_TOM]

Back to the Beaver.

It took a while: but I did catch up.

Cedrik - “Beavers are an unforgiving aircraft when stalled with a heavy load.
A climb out with flap being retracted after take off which would have been considerable to get out of the water at that load. Leaving the flap movement lever in the up position is a bad habit after retracting flap.”

“If the aircraft still had climb flap or more out and a steep turn attempted then if flap was pumped to tighten the turn radius (Common practice in a Beaver) with the flap movement lever in the up position then the aircraft would have departed from controlled flight abruptly.”

“The Beaver in normal configuration has two levers, one controlled the direction of movement, the other pumps the hydraulic pump for flap movement either being up or down depending on where the smaller lever is positioned.”

Spot on: finally, someone who has actually operated the 'Beaver' presents a possible reason for the inexplicable. As the old saying goes - “there's them as has done it and them what's gonna do it”. Seems like a 100 years ago, but I can still hear the voice and words of the fellah who introduced me to the aircraft; as he pointed out what would happen, low, slow and heavy, should you get thing out of sequence.

Did the ATSB mention the relative positions of these two important levers? Can't remember and life is too short to waste ploughing through their dribble again.

[P7_TOM]

An insignificant Penny drops; with a loud clang.

I note. with some interest that some of the 'experienced' thinking pilots are taking a long hard look at the 'Beaver' fatal event. Despite the claims of some of a 'job well done' by ATSB, it is becoming apparent that it was not.

It is so very easy and so very, very wrong to grab the first easy; or, even the second 'most likely' cause; draft a report supporting that (those) supposition(s) and toddle off to the pub. However; once there is enough 'fluff' stuck on top of the icing – and the word 'bull-pooh' is creeping about the periphery of the ATSB 'investigation' perhaps its time to revisit the 'investigation'.

Starting with the time taken to produce a very shallow analysis; with gross error in 'procedure' which essentially provides one allegation – 'pilot error'. Well; that ain't good enough; then to belatedly 'discover' a slightly elevated CO level and blame that all on a few small holes in a fire wall; then to 'realise' that there was 27 minutes of 'taxi' prior to take off and then admit that CO test was not initially brought into the equation; then have the arrogant audacity to claim the rubbish produced as a 'final' report: it beggars the imagination.

“Is it credible?” asks Wingnuts. No good Sir it is not. It should be enough to demand Hood's resignation for producing not only this load of gobbledegook; but those which precede it – Essendon for one at the top of a long, long list. Fantasy and innuendo may pass as fact in his world; we deal in the world of hard fact, criminal liability and trying to prevent an event, particularly a fatal one, ever happening again. ATSB is fast arriving at the point of becoming irrelevant. No where near good enough is it, particularly at the cost of providing a report a junior, wet behind the ears, fresh out of a sausage factory, wannabee pilot could draft over a KFC meal and a beer.

Disgusting;;; ? You bet.

[P7_TOM]

One for the Tin Foil hat troops?

Or; not. The horses mouth says all was as it should be on touch down. The, a 'gust' picked up the arse of the aircraft; the rest demonstrated in one picture.

Strong Southerly – buildings of epic proportions – vortex analysis  - non existent.

If, and it is a very definitely testable IF; these big buildings up close and personal with  an active runway are creating 'vortex' or 'shear' – then surely there is a 'safety' case to examine. Maybe they is; maybe they isn't. But, surely a 'safety authority' could spare the time to either refute or acknowledge that there may be a possibility that tall buildings close to runways do; or, do not present a hazard. It would be really nice to know why; your perfect landing ended up in the ditch with foreseen, forecast local wind-shear or 'vortex' (as advised) being present and part of your landing plan - when the wind was from a certain quarter. Just ask the bloke flying this one – bet he'd have liked a warning.



This ain't a simple 'whoopsee' – to be written off as 'bugger'. ATSB need to take a close look and believe the pilot's explanation. Before someone gets hurt – again...

[Cap'n Wannabe]

From the other Aunty:

Pilot dies in light plane crash in north Queensland

A 74-year-old male pilot has died in a light airplane crash in north Queensland.

Emergency services were called to the scene 90 kilometres south of Charters Towers around 12:30pm after receiving reports a plane had failed to return to its destination in Bowen.

Police said the pilot was the sole occupant of the plane.

He was pronounced dead at the scene.

Aerial assets have been sent to the scene.

The Forensic Crash Unit are assisting the Australian Transport Safety Bureau with its investigation.

And from The Guardian:

Queensland plane crash: five dead in Lockhart River after light plane crashes on landing

Government charter plane wreckage found by police 5km south of township on Cape York


Five people on a government charter flight died when their light plane crashed trying to land near the Cape York community of Lockhart River in far north Queensland.

Queensland police confirmed the 10-seat plane had attempted to land two times at Lockhart River in wild weather about 9.30am on Wednesday, before crashing into sand dunes during its third attempt.

“We know there were five people on board. At this time, we’re trying to contact their next of kin to advise those people personally of the tragedy that’s occurred,” acting chief superintendent Chris Hodgman told reporters.

“Nobody has survived that crash.”

The wreckage was found on a beach about 5km to the east of the Lockhart River airstrip. Hodgman would not speculate on the cause of the accident.

“We know the weather conditions are pretty rough up there at the moment, but we are investigating on behalf of the state coroner at the moment, so I won’t be making any comment in regards to any causal factors,” he said.

Hodgman confirmed all the victims were from Cairns but said out of respect for the families no further comment would be made regarding their identities at this time.

The plane, a Cessna 404 twin-engine piston aircraft, was found on the beach about 1.20pm.

The Australian Transport Safety Bureau said it was investigating the crash and a preliminary report would be released in about a month.

“ATSB transport safety investigators with experience in aircraft operations, aircraft maintenance and aeronautical engineering are preparing to deploy to the accident site,” a statement said.

“The investigation’s final report can be expected to be released in about 18 months.”

Perth-based charter company Aerohire has confirmed it was their aircraft.

The Cape York area, mostly populated by remote Indigenous communities, is in a region where the Bureau of Meteorology has warned of high winds and flooding rains due to a tropical low that is expected to develop into a cyclone over the Coral Sea at the weekend.

Such charter flights are commonplace for government service delivery to remote communities.

[Peetwo]

Ref: https://auntypru.com/sbg-29-03-20-if-you...today-etc/

A Soar point for Mick Mack?? 

Via the Hooded Canary's Aviary:

---

Solo training flight stall-spin accident highlights the potential consequences of deviating from safety-critical procedures and regulations



Key points:

• Student pilot initiated a low-level go-around;
  
  
• Aircraft deviated from the runway centreline, stalled and commenced a spin, before impacting the ground;
  
  
• Student pilot had very limited experience in the Bristell aircraft type;
  
  
• Flying school’s flight dispatch procedures were not followed.
  

 
The student pilot of a Bristell aircraft that stalled and commenced a spin before colliding with the ground was not authorised to conduct the flight and did not have the necessary qualifications and skills to safely operate the aircraft, an ATSB investigation has found.

The student pilot had departed Melbourne’s Moorabbin Airport on the morning of 12 December 2019 to conduct a series of circuits in the Bristell in what was their first solo flight in the aircraft type.

Just after crossing the runway threshold for the first touch-and-go landing, witnesses observed the aircraft suddenly pitch up. The left wing then dropped, bank angle increased to the point where the aircraft became inverted, and the aircraft entered the first half rotation of a spin entry. The aircraft’s nose then dropped before it impacted the ground adjacent to a taxiway in a steep inverted attitude.

The student pilot was severely injured in the accident, and the aircraft was substantially damaged.

The ATSB’s investigation found that the pilot commenced a go‑around at low level when the aircraft deviated from the runway centreline in a crosswind (the crosswind component was subsequently calculated to be about 13 kt, within aircraft performance limitations).

During the go‑around, the aircraft aerodynamically stalled and commenced a spin.

“The ATSB identified that the student pilot did not have the necessary qualifications and skills to safely operate the Bristell aircraft solo,” said ATSB Director Transport Safety Stuart Macleod.

“The student had undertaken only one supervised training flight in the Bristell, and that flight, which was curtailed due to deteriorating weather conditions, did not include any go-arounds, crosswind landings or stall training.

“Consequently, the student pilot’s familiarity with the Bristell was very limited.”

All the student’s previous flying had been undertaken in the Aeropakt A-32 Vixxen, a lower-performance aircraft with a different configuration and handling characteristics compared to the Bristell.

“The Bristell exhibits different handling characteristics to the other aircraft type the student pilot had previously operated,” said Mr Macleod.

“Specifically, instructors reported that the Bristell is less docile and has a stronger tendency to pitch up when engine power is applied for a go-around.

“Instructors also reported that the Bristell has less elevator authority to counter the nose-up effect and a greater tendency to drop a wing during a stall.”

Even though the student pilot believed they were instructed, and authorised, to conduct a solo flight in the Bristell, the ATSB found that the student pilot did not follow the operator’s solo flight dispatch procedures, including not endorsing the aircraft’s maintenance release, and not undertaking the required solo flight briefing and sign out procedure with a flight instructor.

“Familiarity with an aircraft’s specific systems, controls, handling and limitations is essential for safe flight,” said Mr Macleod.

“That is why safety-critical procedures and regulations are in place to ensure that pilots have the required level of skill and experience to safely operate an aircraft.

“The outcome of this accident, which could just as easily have been fatal, illustrates the potential consequences of deviating from safety-critical procedures and regulations.”

Subsequent to the accident, the flying school operator, Soar Aviation, advised the ATSB that they had revised procedures to ensure an aircraft could not be taken by a student for a solo flight, either deliberately or inadvertently.

The flying school ceased operations in December 2020.

Read the report: Loss of control and collision with terrain involving BRM Aero Bristell S-LSA aircraft, VH-YVF, Moorabbin Airport, Victoria on 12 December 2019

---

MTF...P2 

ps: 



pps:

[Kharon]

Cats may have nine lives - human kind has only one.

From the ATSB - HERE - a good report into a bad accident. Another fatal - VFR into IMC identified as probable cause.

The report is worth a careful read - the opportunities to 'walk away' were many and ignored; the percentage chances of a 'win' slim to none.

I wonder, with the resources and publishing power ATSB has if a 'compendium' of VFR into IMC incidents and accidents could not be compiled and distributed, covering the last  decade of these so avoidable accidents. The cynic in me says preaching to the converted  won't help; but if it saves just one fatal, the effort would be worth work.

Oh, I don't know - but this latest ATSB report clearly defines at least four 'get out of jail free' cards, which were discarded. Sad, tragic even, but nonetheless real for all that.

Toot - toot.

[Cap'n Wannabe]

From the other Aunty..

Pilot dies in light plane crash north of Brisbane


The plane came down on mudflats near Bribie Island.(ABC News)

The pilot of a light plane that crashed near Bribie Island in south-east Queensland this morning has died, the Civil Aviation Safety Authority (CASA) has confirmed.

Queensland Fire and Emergency Services said the light plane was found on the western side of the Pumicestone Passage.

The light plane is sitting upside down in mudflats and emergency services are at the scene.


The pilot was the only person aboard, CASA says.(ABC News)

Civil Aviation Safety Authority spokesman Peter Gibson described the plane crash as a tragic accident.

He said witnesses saw the plane descending rapidly at about 9.30am before it crashed into the mangroves.


The pilot was the only person aboard, CASA says.(ABC News)

The pilot has been confirmed dead and was the only person on board.

Mr Gibson said the plane was "kit built" and likely to be used in aerobatics.

An operation to recover the wreck is underway, with more than six Queensland Fire and Rescue trucks on scene.

'K' add on - You have got to admire the emergency services. Thanks fellah's is inadequate -

[Cap'n Wannabe]

And this from Channel Nine..

Pilot killed in light plane crash north of Brisbane

A pilot has been killed in a light plane crash in remote wetlands north of Brisbane.
Authorities originally received a distress signal from the aircraft around 10am today just off Bribie Island before the aircraft was detected descending rapidly.
Wreckage of the aircraft was found around 11am on the banks of the Pumicestone Passage with the body of a single passenger, the aircraft's pilot.



Rescue crews have now been winched down onto the mudflats to attempt to retrieve the man's body and the aircraft's wreckage.
Wet weather conditions and a rising tide have made retrieval efforts challenging.
Investigations are continuing into what caused the crash.

There's a little more in the video, but I don't know how to link that here..

[Kharon]

From the ATSB - HERE - the bare bones of a nightmare; an in-flight breakup of the airframe. The report mentions sharp eyes in a training chopper spotting pieces separating - . Nasty one this, lets hope ATSB crack on with the investigation and provide an accurate report of some value in a timely manner.

All the services did very well indeed to gather the wreck and remove it in what must have been 'difficult' conditions, to say the least. Well done.

Toot-toot.

[Peetwo]

Final report: AO-2020-002 

Via the OZ: 

---

Heavy rain ignored in QantasLink runway overrun



The pilots of a QantasLink flight that overran a runway by 70m failed to factor in the effect of heavy rain on the landing at Newman Airport in Western Australia.

An Australian Transport Safety Bureau report on the incident on January 9, 2020, found there were no injuries to the 93 passengers and crew on board the Fokker 100 but loose gravel damaged the landing gear.

According to the report, 88mm had fallen on Newman when the QantasLink plane left Perth for the 105-minute flight.

Despite assessing the weather as a threat, the flight crew did not identify the potential effect of the rain on the stopping distance.

“Their focus was primarily on the wind and the visibility,” said the report.

“Despite the forecast for heavy rain obtained before the flight and the aerodrome weather information service providing observations of heavy rain occurring, there was no consideration of the effect of the rainfall on the runway state or the braking performance.”

As a result, when the plane touched down, the brakes did not work as expected and flight crew experienced “aquaplaning” or a sensation of sliding over the runway.



The captain asked the first officer for help in applying the brakes as the Fokker failed to decelerate.

“The aircraft stopped 70m beyond the end of the runway inside the runway end safety area,” the report said.

“An inspection of the aircraft found that the loose gravel had damaged some of the landing gear components.”

The ATSB investigation found neither the operator (Qantas subsidiary) Network Aviation nor the Civil Aviation Safety Authority had published guidance to allow the crew to recognise the conditions as a hazard to the operation.

Network Aviation chief pilot Rick Heaton said the issue was quickly rectified.

“A few weeks after the incident, we introduced new restrictions for landing on runways like they have in Newman in very wet conditions,” Captain Heaton said.

“If these conditions were repeated, the aircraft would divert to another airport.”

Captain Heaton said pilot training had also been updated to include additional strategies to manage similar situations.

Since the incident, CASA had also published guidance, reflecting research from the US that found landing on ungrooved runways in moderate rain had the potential to significantly affect braking performance.

The ATSB also found that the runway had been identified as in need of maintenance to ensure an adequate level of surface friction but that work had not been carried out.

ATSB director of transport safety Stuart Macleod said they encouraged operators and pilots to review the latest guidance and tools available in relation to maintaining safety on runways, and the factors that caused runway overruns.

“In wet weather, additional conservatism is encouraged when calculating the required landing distances,” Mr Macleod said.

---

REF: https://www.atsb.gov.au/publications/inv...-2020-002/


While reviewing the ATSB aviation investigation page I noted the following initiated investigation: https://www.atsb.gov.au/publications/inv...-2021-034/

The ATSB has commenced a transport safety investigation into an uncommanded engine power reduction involving the Beechcraft King Air 200C, VH-VAH, at Essendon Airport, Vic., 19 August 2021.

At about 50 ft on take-off, a partial power loss from the number one engine resulted in a momentary loss of directional control and a failure to achieve climb performance. The pilot restored climb power and continued the take-off. The pilot later reported the number one engine throttle friction was not set correctly. The investigation is continuing.

The evidence collection phase of the investigation will include interviewing the crew, a review and examination of operational manuals, maintenance records and the gathering of any other relevant evidence. 

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

Q1) Pardon my ignorance but since when have the donks on a B200 been numbered (ie No 1. engine and presumably No 2 engine?)??

Quote: "..The pilot restored climb power and continued the take-off. The pilot later reported the number one engine throttle friction was not set correctly. The investigation is continuing.." Q2) Why is the investigation continuing? Surely the finite resources of the ATSB would be better spent investigating accidents/incidents where the cause is not already known - My 2 bob's worth...

MTF...P2 

[Peetwo]

Gunnedah NOTAM GOTCHA??

Via the ATSB: 

Attempted take-off from closed runway highlights the importance of checking NOTAMs



Key points

• A pilot attempted to take-off from a closed runway at Gunnedah after failing to check the local NOTAM in pre-flight planning;
  

• At the time of the incident no works safety officer was on-site, and there was no ground-based closed runway signage in place;
  

• Airport operator was not aware of recent updates to Manual of Standards for Aerodromes, as email address registered with CASA was not being monitored.
  

A twin-turboprop aircraft sustained substantial damage when attempting to take-off from a runway that had been closed for repair works, an Australian Transport Safety Bureau investigation details.

The Fairchild Industries SA226-T Merlin had landed at Gunnedah, northern NSW on the afternoon of 19 August 2020, and was parked there overnight. 

The following morning, in line with a NOTAM published the previous day closing the runway from 0700 to enable runway repair works, a work crew had excavated two holes from the runway pavement (measuring 3 m wide by 5 m long and about 30 cm deep).

That afternoon, at about 1230 while the work crew was off-site from the airport during their lunchbreak, the Fairchild pilot commenced a take-off run on the runway for a flight to the Gold Coast.

As the aircraft accelerated, the pilot saw the two rectangular holes excavated from the runway pavement. The pilot attempted to avoid the holes, but they were struck by the aircraft’s left main landing gear.

“The aircraft sustained damage to its left main landing gear assembly, which resulted in it collapsing, and the left propellor striking the ground,” ATSB Director Transport Safety Dr Stuart Godley explained. 

“The aircraft veered off the runway and came to rest outside the flight strip.”

The pilot – the sole occupant on board the aircraft – was uninjured.

“The ATSB investigation found that during pre-flight planning, the pilot had not checked for relevant NOTAMs, including one stating that Gunnedah Airport was closed due to works in progress,” Dr Godley said.

NOTAMs are accessible via the National Aeronautical Information Processing System (NAIPS) web portal and contain information concerning the establishment, condition, or change in any aeronautical facility, service, procedure, or hazard.

“An essential component of pre-flight planning is to check all NOTAMs relevant to the planned flight,” Dr Godley said. 

The investigation also found that while the work crew was away on their lunch break there was no works safety officer on site. Further, while a white cross had been placed at the main windsock, visible to aircraft arriving overhead, there were no ground-visible unserviceability markings on the runway. 

Both measures are required by the Civil Aviation Safety Regulations Part 139 Manual of Standards (MOS) for Aerodromes.

“Aerodrome works staff were not aware of updated MOS requirements that had come into effect seven days earlier, and had interpreted the superseded MOS to not require unserviceability markings if the whole aerodrome was closed,” Dr Godley said.

The Gunnedah Airport operator had not received notification of the updated MOS because the email included on CASA’s mailing list was for a member of staff who had left the operator. No autoreply, forwarding, or ‘hard bounce’ was in place on the email address, so CASA was not aware the email had not been received.

“To ensure receipt of correspondence that may affect safety of aircraft operations, aerodrome operators should ensure CASA is provided up to date contact details, particularly following changes to staff,” Dr Godley concluded.

Read the report: AO-2020-056 Take-off from a closed runway involving Fairchild Industries SA226-T, VH-LDQ, Gunnedah Airport, New South Wales, on 20 August 2020

And via the Yaffa: 

ATSB highlights NOTAMs in Merlin Accident Report
27 October 2021

The Australian Transport Safety Bureau (ATSB) has highlighted the importance of checking NOTAMs after a Fairchild Merlin was damaged attempting to take off from a closed runway.

SA226-T Merlin VH-LDQ was damaged at Gunnedah in August last year when the main undercarriage hit runway works in the take-off roll. The left gear leg collapsed and the aircraft veered off the runway. The pilot, the only person on board, was uninjured.

According to the ATSB report released yesterday, the airport had been closed for runway works, but the pilot failed to check the NOTAMs before attempting to depart for the Gold Coast.

The ATSB also found the airport operators had not adequately marked the airport as closed because they didn't have the current Manual of Standards.

"The ATSB investigation found that during pre-flight planning, the pilot had not checked for relevant NOTAMs, including one stating that Gunnedah Airport was closed due to works in progress,” ATSB Director Transport Safety Dr Stuart Godley expained.

“An essential component of pre-flight planning is to check all NOTAMs relevant to the planned flight."
The investigation also found that while the work crew was away on their lunch break there was no works safety officer on site. Also, although a white cross had been placed at the main windsock to alert aircraft arriving overhead, there were no unserviceability markings on the runway that could be seen from the ground.

Both measures are required by the Civil Aviation Safety Regulations Part 139 Manual of Standards (MOS) for Aerodromes.

“Aerodrome works staff were not aware of updated MOS requirements that had come into effect seven days earlier, and had interpreted the superseded MOS to not require unserviceability markings if the whole aerodrome was closed,” Dr Godley said.

The full report is on the ATSB website.

MTD...P2 

[Peetwo]

Stewie MacLeod back in favour as last week's ATSB Director of Transport Safety - 

Via the ATSB:

Forced landing short of the runway followed engine failure due to ice ingestion during flight in icing conditions



Key points:

• Flight was planned and conducted through forecast icing conditions;
  
• Ice accumulated on the aircraft, leading to engine failure;
  
• Unable to restart the engine, the pilot conducted a glide toward Moruya Airport for an attempted landing, but collided with terrain nearby;
  

The forced landing of a turbine-powered Cessna 210 about 560 metres short of the runway threshold following an engine failure from flight in icing conditions highlights the importance of proper pre-flight planning, according to an ATSB investigation.

The US-registered Cessna P210N Silver Eagle, a pressurised Cessna P210N re-engined with a Rolls-Royce M250 turbine, had departed Sydney’s Bankstown Airport for a private flight under instrument flight rules to Hobart’s Cambridge Airport on 19 December 2019. The pilot and a single passenger were onboard.

The flight was planned and conducted through forecast icing conditions although the aircraft was not certified or equipped for flight in known icing. It entered icing conditions about half an hour into the flight, shortly after reaching the cruise altitude of about 18,000 ft.

“Flight through icing conditions for an extended period resulted in significant accumulation of ice on the airframe,” ATSB Director Transport Safety Stuart Macleod said.

The pilot continued to operate in icing conditions for an extended period of time before exiting those conditions and descending to 16,000 ft. Subsequently, the pilot deactivated the propeller de-ice and engine ice-protection systems, which in turn led to a flameout from ice ingestion.

“Attempts to restart the engine were unsuccessful, most probably because of a phenomenon known as rotor lock – where rapid and differential cooling of the engine’s components temporarily prevents it from rotating,” Mr Macleod explained.

Without engine power, the pilot conducted a glide approach towards Moruya Airport on the New South Wales South Coast.

“While the pilot was able to get near the airport, the subsequent manoeuvring compromised the ability to remain visual with the airport and assess the glide approach, resulting in the aircraft being too low to reach the most appropriate runway,” Mr Macleod said.

“Subsequent distraction led to a misjudged approach to the remaining runway options.”

The aircraft impacted terrain about 560 m north of the runway threshold, and was destroyed. The pilot was seriously injured, and the passenger sustained minor injuries.

“This investigation highlights that thorough knowledge of an aircraft’s limitations and systems, in combination with an understanding of hazardous weather and aviation meteorological products, is critical to safe and effective flight operations,” said Mr Macleod.

“Icing conditions can be extremely hazardous to aircraft. Every icing encounter, to some extent, is unique and unpredictable.”

Mr Macleod stressed that pilots should carefully evaluate all available relevant meteorological information when determining whether icing conditions are likely along the planned flight path.

“Where the aircraft is not certified or equipped to operate in icing conditions, any ice-protection systems on the airframe, propeller, or engine should be regarded as a means to provide time to exit unexpected icing conditions, not to continue to operate in those conditions.”

In addition, the ATSB investigation emphasises that practice and proficiency in simulated forced landings and power-off approaches can improve the likelihood of successfully managing emergency situations.

“Although forced landings can occur in a variety of circumstances, in general, pilots should focus on remaining visual with the intended landing area in order to accurately assess the aircraft’s performance in glide, and reach key decision points to refine the course of action,” Mr Macleod said.

The investigation also identified a number of other factors associated with pre‑flight preparation and the operation of the aircraft and its systems.

Finally, the ATSB also found that the seatbelts and shoulder harnesses worn by the pilot and passenger probably reduced the extent of their injuries, and the prompt attendance of nearby paramedics further reduced their risk.

Read the report: Engine failure and collision with terrain involving Cessna P210N, N210BA Near Moruya Airport, New South Wales, on 19 December 2019

Being a former approved ASETPA pilot (PC12/C208B), beside the fact the pilot was flogging along in an aircraft uncertified for flight in icing conditions, one of the things that I found most disturbing about this accident report was the figure 3 flight track depiction:



I wonder if the pilot received a 'please explain' from CASA?   

MTF...P2 

[P7_TOM]

As requested and required, a few of our 'older' associates read and considered the report from ATSB - (above) with a view toward prevention of a repeat performance. One of the more interesting elements discussed was 'Australian Ice' as opposed to it's northern hemisphere counter part.

In essence, it is the same stuff and it's affects on aircraft performance identical, no matter where you pick it up. A known killer, the world over. The difference lays in 'where' it is encountered; and in what season the operation is conducted.

Mid November in Australia is almost 'summer' while in the northern hemisphere it is late Autumn - verging on winter. So, for example a turbine engine and airframe operating in Oz can base performance expectations on ISA + 10° C at MSL; in the USA ISA -5° C is a fair expectation (ballpark). Freezing levels respectively 15 ° C apart, which places the 'alert zone' considerably lower in the northern lands; which is an advantage to performance and an earlier escape from the icing layer. Mind you, I've had ice accretion in temperatures as high as +5 and as low as -25, it all depends on what weather type you are operating in, and where. Our man in the 210 would be somewhere near enough 'max power' at F180 and was dragging some ice around with him; between 'cloud layers'. Can anyone spot the danger areas in this scenario? There are just a few large red flags waving.

Options - climb out of the icing. In theory worth a shot - provided the horsepower available will carry the aircraft through a climb with an iced airframe, already performance degraded (no de-ice boots); and, that there is guarantee of clear air above a 'layered' sky; and, that the ice accumulation does not impact on TAS which leads to a fuel/range problem. - So, having accumulated some ice on the initial climb - and 'topping' the cloud not an option, the next option is 'down' - back through the icing layers - down low enough to shake off the ice. You know there is ice down there - probably have some idea of where you began to pick it up - so why not leave the 'heat' on until you are below that level? So, you descend and arrive at a lower level with double the original ice - and a reduced TAS/range problem, at least until until the ice obligingly disappears. But will it? Here we meet Murphy - always present. 

But what of the airframe performance? Ice weighs - ice disturbs the airflow - ice costs speed and fuel - ice tends to cling in areas not visible - in short, carting ice about the place is at the high end of the risk scale.

One of the more potential serious risks in 'warm' lands is the height at which the arbitrary 'Freezing level' is found. Often toward the top end of turbine power available; but the 'freezing level' ain't the problem is it. The FL simply defines what? The problem area is the icing layers above that - the red zone - where layers merge and mix; where convective currents spread cooled water particles which are quite happy to turn into ice with a small nudge from an airframe. Ice has a habit of 'building' which affects airflow, and allows more area to be presented, degrading speed which allows even more build up - and so begins the chain of events which lead to the hole in that famous cheese reserved for those who failed to have a clear plan and focus on the insidious 'ice-man' who rides with Murphy. 

The slick answer is 'if you get into ice - get out of it' - The sensible, thinking pilot's answer should be .................? Handing over..

[Peetwo]

New CC Gus fronts media for C210 inflight structural failure FR release -   

Via the ATSB:

ATSB recommends manufacturer takes further safety action following Cessna 210 wing separation during low-level survey operation



Key points:

• During a low-level geophysical survey flight, an overstress fracture due to a fatigue crack in a Cessna 210’s wing carry-through spar structure resulted in the separation of the right wing;
  

• Relevant Cessna 210 aircraft have since been subject to eddy inspection requirements to assess for fatigue and the application of a corrosion preventative coating, however the ATSB is recommending further safety action be taken;
  

• Cyclic loads induced by the low-level survey flight profile are significantly greater than those associated with the higher-level flight profile originally intended for the aircraft type.
  

The Australian Transport Safety Bureau has made a formal recommendation to the manufacturer of the Cessna 210 aircraft to further address the risk of fatigue cracking within the aircraft’s carry-through structure.

The safety recommendation forms part of the ATSB’s final report from its investigation into the 26 May 2019 collision with terrain of a Cessna T210M which was conducting low-level geophysical survey work about 25 km north‑east of Mount Isa, Queensland.

The aircraft, with a pilot and observer on-board, was operating at a height of 193 ft above ground level and a speed of 147 kt when its right wing separated in flight, leading to a rapid loss of control. The aircraft collided with the ground, and both crewmembers were fatally injured.

Relevant components of the aircraft were subject to detailed examination at the ATSB’s technical facilities in Canberra where it was found that relatively minor corrosion near a highly-stressed location on the lower surface of the wing spar carry-through had progressed into the aluminium alloy structure, initiating a fatigue crack. The crack propagated to a critical size resulting in an overstress fracture of the remaining wing carry-through structure material and separation of the right wing.

This information was immediately communicated to the aircraft manufacturer, Textron Aviation (which now owns Cessna), and Australian and US aviation regulators, and resulted in a number of initial safety actions.

These included Textron issuing service bulletins to owners of relevant Cessna 210 and Cessna 177 aircraft on 24 June 2019 requiring a one-off inspection of the carry‑through structure and communication of inspection findings to the manufacturer, and a US Federal Aviation Administration (FAA) Airworthiness Directive issued on 21 February 2020 requiring the visual and eddy current inspections of the carry-through spar lower cap along with the application of a corrosion preventative coating of certain model Cessna 210 aircraft.



At the time of finalising the ATSB’s investigation report, the FAA and Textron Aviation had received 1,119 reports from Cessna 210 owners/operators who had undertaken the visual and eddy current inspections of the carry-through spar on their aircraft. Of these, 499 reported corrosion and 68 carry‑through structures were removed from service.

Textron has advised the ATSB that it would be undertaking a fatigue analysis of the C210 wing spar carry-through in its original configuration to determine whether a modified inspection program or life limit is necessary. Textron has also advised the ATSB that it is working on a certification program to install a new spar in the C210 with an updated configuration and material.

“The ATSB acknowledges the significant safety actions taken to date by the manufacturer and regulators as a result of this accident and the ATSB’s investigation, and notes that these measures have addressed the short-term risk of further similar failures,” said ATSB Chief Commissioner Angus Mitchell.

“Further, the ATSB welcomes Textron’s ongoing efforts to address the risk of cracking in wing spar carry-through structure of Cessna 210 aircraft used for low-level geophysical survey operations. However, the ATSB remains concerned by the indefinite nature of the manufacturer’s proposed analysis and certification program and recommends that further action be taken to address this safety issue.”

In 1992, Cessna had introduced a continued airworthiness program for the Cessna 210 which included repetitive eddy current inspection for cracking of the carry-through structure. This flight-hours based inspection was more stringent for aircraft being used for low-level surveys.

Eddy current inspection is a form of non-destructive testing which can detect flaws in the internal consistency of certain types of metals.

However, following an assessment of historical data in 2011, Cessna replaced this inspection with a visual corrosion inspection, on a three-yearly frequency for all operation types, irrespective of hours flown.

“Had the previous flight-hour based eddy current inspection schedule remained in place, it is almost certain that the fatigue crack within the wing spar carry-through would have been detected before this accident occurred,” Mr Mitchell said.

The accident aircraft had accumulated 6,241 flight hours in the six years leading up to the accident, and had been operated exclusively as a geophysical survey aircraft during that time. In total the aircraft had accumulated 12,175 flight hours.

As part of the investigation the ATSB, in cooperation with the operator, undertook data gathering using an instrumented Cessna 210N to determine in-flight loads associated with the geophysical survey flight profile. Data from 95 flights over a period of 10 weeks during autumn in 2020 was sampled and analysed.

“The ATSB’s analysis showed that cyclic loads induced by the low-level survey flight profile were significantly greater than those associated with the higher-level flight profile originally intended for the aircraft type, and this probably increased the risk of a fatigue-related structural failure,” Mr Mitchell said.

“Even when flying within operational limits, if an aircraft is operated in a flight profile for which it was not originally intended, its structure can fatigue more rapidly.

“The ATSB cautions all geophysical survey aircraft operators that the terrain following flight profile may significantly increase aircraft fatigue damage accumulation.”

The investigation also determined that the airframe and system modifications incorporated into the accident aircraft did not significantly increase the fatigue damage accumulated by the wing spar carry-through structure.

Read the final report: AO-2019-026 In-flight break-up involving Cessna T210M, VH-SUX 25 km north east of Mount Isa Airport, Queensland on 26 May 2019

MTF...P2 

ps Dear Gus...About time the nearly 4 year Essendon DFO approval process investigation FR was finally published - HINT..HINT?? Ref: https://www.atsb.gov.au/publications/inv...-2018-010/

[P7_TOM]

Oh: My wing fell off - I wonder why?

“The ATSB’s analysis showed that cyclic loads induced by the low-level survey flight profile were significantly greater than those associated with the higher-level flight profile originally intended for the aircraft type, and this probably increased the risk of a fatigue-related structural failure,” Mr Mitchell said. Oh, so Troo dat!



Well; duck me! - Finally, 'someone' has at least, although somewhat belatedly,  recognised that the airframe was not designed, built and certified to sustain the insistent pounding of high speed cruise in low level turbulence, particularly in Australia.

When young (and hungry for hours) after one particular survey (frontal research and thunderstorm survey) I did ask that question. I also asked the same question after some low level survey operations 'down in the valleys' for a forestry gig. Silence the stern reply. So I did the unthinkable; I examined the certification data.

Not Cessna's fault. Not one of the 200 series or even the 300 series, (nor the Partenavia) were ever subjected to 'testing' the hammering the airframe gets on low level survey; particularly - most particularly - when a quote has been given and accepted based on a 'time' frame. Not one of the aircraft I ever used had manufacturers specification for time spent operating in 'uncomfortable' conditions..Yet the 'push' to complete a 'run' within budget and time frame was, and remains, a big part of the profitless 'prosperity' to be gained from such ventures.

You do see the problem; me, I walked away with no idea of what residual damage the airframe had sustained. Metal does have a memory - and even within a tough old bird, like a 210, there are limits, that holds true.

So, why do CASA 'approve' operations which, had the homework been properly done, allow, despite the 'data' attached to design, test flight and certification standards the continued operation of air frames which, with just a little more 'pounding' outside of certification data continue to operate 'in the grey zone'?

I thought CASA were supposed to be a 'safety' oriented crew. The specification are there. the design philosophy is there, the test flight data is there, the engineering specifications are there, the 'holes' in the cheese are very clearly apparent.

No good blaming the maker - they were honest to certification demands. The big question is why there is not a mandated log on "G" and a CASA engineering codicil related to just how much, and for how long can the airframe sustain integrity operating in conditions for which it's certification data has neither been tested, approved or validated with 'time in service' data?

Nice aircraft - but designed, tested, certified and built for the repeated low level hammering? No CASA it was not - do your bloody homework FCOL. Hint - Ag aircraft can and do this type of work all day every day - a 210 is for 'cruise' operations - not being belted about at high speed at low level. CASA purblind ignorance on display - once again. No surprise there, hardly a 'professional' feeding at the GA trough. Rank amateurs rule = OK. Bull Pooh....