[Peetwo]

AO-2017-061: Another PC'd report? - 

After reading the ATSB safety watch media blurb related to the tragic last flight of Cessna 172 VH-FYN...

'Personal minimums' checklists can help pilots to manage risks

Pilots should avoid deteriorating weather by conducting thorough pre-flight planning, a new ATSB report notes.
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A Cessna 172 was flying from Queensland to New South Wales when it entered an area of reduced visibility, including low cloud, fog and drizzle. The aircraft diverted off the initial track and was last seen disappearing into cloud heading inland. A short time later, the aircraft collided with terrain and the pilot was fatally injured.

The ATSB found that the decision to depart on the flight had placed the pilot at risk of encountering conditions of reduced visibility. On entering those conditions, the pilot likely became spatially disoriented, resulting in a loss of control and a collision with terrain. The ATSB also found that the pilot was likely under some degree of self-imposed pressure to continue with the flight, despite the inclement weather conditions.

Weather-related accidents remain one of the most significant causes of fatal accidents in general aviation.

“The ATSB’s safety messages from this investigation are clear: visual flight rules pilots should conduct thorough pre-flight planning to avoid the possibility of flying into bad weather. They should also make alternate plans in case weather deteriorates, and make timely decisions about diverting or turning back,” said ATSB Executive Director Transport Safety Mr Nat Nagy.

“If visual flight rules pilots do find themselves in deteriorating weather and become disoriented or lost, they should seek whatever help is available including contacting air traffic control. This simple action has averted potential disaster in many instances.”

Weather-related accidents remain one of the most significant causes of fatal accidents in general aviation. Inflight decision-making is one of the ATSB’s SafetyWatch priorities, particularly regarding pilots flying with reduced visual reference.

Among the advice that SafetyWatch provides, the use of ‘personal minimums’ checklists is key. VFR pilots should use a checklist to help control and manage flight risks by identifying risk factors that include marginal weather conditions and only fly in environments that do not exceed their capabilities.

This report highlights an ongoing safety issue in aviation. Check out our SafetyWatch page, Inflight decision making, for more information on this important subject.

Read the investigation report: VFR into IMC and loss of control involving Cessna 172, VH-FYN, 13 km NNW of Ballina, NSW, on 16 June 2017

 ...your first thought is not another needless VMC into IMC CFIT accident...  

However then you read the 'safety analysis' section of the report under the subheading 'Decision to depart Southport' where it says:

...The reason for the flight on 16 June 2017 was to deliver the aircraft to a maintenance facility, as the aircraft’s maintenance release was due to expire the following day. The pilot initially had the aircraft maintenance booked for Tuesday 13 June 2017. The pilot then rescheduled the booking twice that week based on the forecast weather conditions. The final booking was scheduled for Friday 16 June 2017. During the course of that week, the pilot had downloaded weather forecasts through his National Aeronautical Information Processing System (NAIPS) account a number of times. Additionally, the pilot had been in contact with the maintenance provider in Ballina to check the weather conditions and reschedule the bookings. The last call the pilot made to the maintenance provider was on Wednesday 14 June 2017. During that call, the maintenance provider told the pilot he could get a special flight permit to allow him to fly the aircraft to Ballina after the expiration of the maintenance release. Instead, the pilot confirmed the booking for Friday...

     
Naturally this led me to the 'findings' section where I discovered, much like the 'safety watch' media blurb, that there was no mention of the above record inside of the 'contributing factors':

Findings

From the evidence available, the following findings are made with respect to the collision with terrain involving Cessna 172, VH-FYN 13 km north-north-west of Ballina, NSW, on 16 June 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factors

• The pilot departed Southport, Queensland for Ballina, New South Wales under the Visual Flight Rules with a forecast likelihood of low cloud, fog and showers of rain that reduced conditions below that required for visual flight.
  
• It is likely the pilot encountered conditions of reduced visual cues and became spatially disorientated which led to a loss of control and collision with terrain.
  

    
I guess that part of the of the report, which IMO should normally fall under contributing organisational factors, would have detracted from the 'safety watch' message that team Hooded Canary wanted to convey.

That and the fact that archaic CASA rules that say that an aircraft that is airworthy one day suddenly becomes a ticking safety bomb that could threaten the lives of the Australian public the next could be somewhat embarrassing for the Patron Saint of Australian Aviation Safety and by association our totally captured DPM dummy McDo'Naught...  
  
Addendum: AOPA response to AO-2017-061 

BAD REGULATIONS AND FATAL AIRCRAFT ACCIDENTS
March 15, 2019 By Benjamin Morgan

AOPA AUSTRALIA EXECUTIVE DIRECTOR BENJAMIN MORGAN DELVES INTO THE LOSS OF CESSNA VH-FYN
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This week the Australian Transport Safety Bureau (ATSB) released its final report and a warning to pilots about the dangers of continued flight into terrain (CFIT) following the fatal crash of a Cessna 172M (VH-FYN) near Ballina NSW in 2017.

Click to read the full report.

On the surface, the ATSB report reads like so many others, where the pilot in question departed in deteriorating reduced visual conditions, resulting in VFR flight into IMC; by a pilot who was not current on instruments, culminating in a senseless, tragic and entirely avoidable CFIT accident.

And, it’s the word ‘avoidable’ that has been ringing in my head since the day news broke of this accident, and what has angered me after reading the ATSB’s final report.

The sole objective of an aviation accident investigation is to prevent future accidents from happening by clearly identifying the cause or the reason why, so that improvements to aviation safety can be made.  To achieve this, the Australian aviation industry relies on the independence and objectivity of the ATSB to undertake detailed and forensic examinations of all the facts and factors that play a role in the accident chain of events.  More importantly, we rely on the ATSB to make independent recommendations.

But what happens when the ATSB loses its way and produces a report that’s glaringly deficient and fails to embrace the actual cause and need for change?

The simple and inconvenient truth is that the loss of VH-FYM was directly attributable to CASA’s inflexible aircraft maintenance regulations and the inability for aircraft owners or pilots to obtain a simple over the phone approval to ferry an aircraft for the purpose of maintenance.  Had such a facility been in place, the pilot would not have been under any pressure to undertake the accident flight.

Instead of issuing warnings to pilots about continued flight into terrain, the ATSB would be best served issuing a warning to government about bad regulation that has proven to kill pilots, with a call for immediate change.

A totally avoidable accident, yet one that will repeat because the ATSB is failing to play its impartial and independent role in helping improve aviation regulations to drive better safety outcomes for everyone.

  
"..More importantly, we rely on the ATSB to make independent recommendations.."
 
But Ben since Beaker brought in the BASR (beyond all sensible reason AAI philosophy), the ATSB don't make safety recommendations (especially to the regulator), unless they absolutely have to for international diplomacy or political reasons - see from page 3 here: https://auntypru.com/wp-content/uploads/...opin_2.pdf    
  
MTF...P2