[Peetwo]

For the record - off the Senate Estimates thread:

...I read the ‘factual part of the ATSB report into the Mt Gambier accident with some horror; particularly the following paragraph:-

ATSB : At 1003, as YTM passed over the top of runway 36 in a westerly direction, the pilot made a CTAF broadcast ‘lining up for 36’, indicating that he intended to land on runway 36. Witnesses reported that the pilot then conducted a go around after initially touching down on runway 36, and witnesses reported then seeing the aircraft climb back into cloud. The pilot then broadcast on the CTAF ‘going around for runway 24’. After another two low-level turns over the airport, in which the aircraft was captured emerging from the cloud on closed-circuit television (CCTV) at low altitude, the aircraft landed on runway 29 at about 1008.


...And yet, the accident pilot persisted; ducking and weaving around low cloud, whizzing about in low visibility, looking for a sighting of a runway end, eventually landing on R29. I wonder if he realised it was not R 24.

We will never know the reason ‘why’, not really. We can surmise, speculate and reason away all we like; but we will never truly know ‘why’. P2 raised another puzzle; why didn’t he go for a Piddle? He certainly had time. Why didn’t he take off to the East, where the weather conditions were reported better? Why the rush? But the big question is why not cancel. “Sorry folks; but the weather is unsuitable, even the airlines are waiting; we can wait until it improves; or we can go to the Pub”.  

But, the greatest mystery of all is what the hell is ATSB playing at laying all this at the feet of Angel Flight? Did the pilot contact AF for advice? No. Was he pressured or instructed by AF to act in the manner ATSB describe? No. Then WTD is AF doing in the Dock? Individual criminal negligence is on the table here; not the way AF or any CSF do business. It begs a question or two don’t it. There are many causal links in the accident chain – unexamined. Why? While you’re at it, ask why only AF is in the gun, not all CSF operations...

Devil's advocate: Hmm...despite the obvious illegalities involved (see P7 post above) in the maneuverings of the pilot on approach and final landing, followed by the departure into obvious non-VMC conditions, I am somewhat perplexed by the figure 2 to 3 track and aircraft maneuvering depictions??





Note in figure 2 that there would have presumably been much scud running and even at times penetration of cloud, yet never does the pilot's maneuverings approach any where near uncontrolled, reckless AOB or pitch movements suggestive of a VFR pilot panicking because he has inadvertently entered IMC. 

Now refer to figure 3 and it is the same thing, where except for an initial slight veering to the left of the centreline, followed by a couple of minor deviations to the right, the pilot then appears to make a decision to initiate a turn back to the airfield and sets up standard rate 1 turn to the left until 5 second panel 13, where the pilot IMO inexplicably loses control. Although there is no panel 14 it would appear that in less than 10 seconds the aircraft has gone from being in a standard rate turn and maintaining 200 ft agl (ie controlled flight), to pitching at least 30 degrees nose down and rolling slightly to the right. IMO this would introduce the possibility of a catastrophic event. However nowhere in the report (that I can find) was the possibility/hypothesis even remotely explored. 

Pilot information

The pilot obtained a Private Pilot (Aeroplane) Licence in December 2014, and held the appropriate aircraft endorsements required to operate YTM. His logbook showed a total aeronautical experience of approximately 530 hours. In the 90 days prior to the accident flight, he had conducted the three take-offs and landings required by Civil Aviation Safety Regulation (CASR) 61.395 to permit the carriage of passengers. At the time of the accident, he held a valid Class 2 Aviation Medical Certificate renewed on 6 June 2017. This included a requirement for reading vision correction to be available while exercising the privileges of the licence.

The pilot commenced training for a Night Visual Flight Rules (VFR) rating in December 2015; this included about 3.5 hours recorded as instrument flight time. The pilot completed a total of 12 hours of training in flight under night VFR between December 2015 and May 2016, however he did not obtain this qualification. The pilot did not hold an instrument rating and his logbook recorded a total of 7 hours of instrument flight time, the latest of which was 0.1 hours in simulated flight conditions during an aeroplane flight review on 29 November 2016.

The ATSB assessed whether the pilot may have been experiencing a level of fatigue known to have an effect on performance. Consideration was made of the pilot’s sleep obtained, time awake at the time of the occurrence, time on task, potential workload and environmental factors. Based on the available evidence, the pilot was very unlikely to have been experiencing a level of fatigue known to affect performance.

Medical and pathological information

The pilot’s medical records, post mortem examination and toxicological analysis identified no acute or pre-existing medical conditions that may have contributed to the accident.

The forensic examination of the pilot doesn't indicate any serious research into the pilot's flight experience and/or logged flights. I would have thought that given the flagrant disregard for the rules surrounding legal VFR flight that there would have been at least a thorough investigation into past flights conducted by this pilot into and out of Mount Gambier (what was obviously a local airport for him). Could it be that there was a pattern of deviance that for this pilot had become very much normalised? 

Hmm...much MTF me thinks?? - P2 

ps Also in regards to the disturbing and unbelievable waffle/weasel worded confection offered up by Dr Chelsea (Godlike) Manning as expert evidence at the Senate public hearing, I note the following off the Dock's self-flagellating linkedin page:

About

I have worked in transport safety for over two decades, mostly in aviation. With a human factors psychology background, I have applied analytical skills at the ATSB to aviation safety investigations, research and analysis of safety data. My role as Director at the ATSB now also incorporates rail safety as well as aviation. As Director I oversee transport safety investigations of incidents and accidents, safety studies (research), and the overall data strategy at the ATSB. Prior to the ATSB I worked in the safety department of Qantas in both safety analysis and human factors roles. This was from an original grounding of road safety research from a human factors psychology perspective at Monash University Accident Research Centre (including a PhD) and then at the University of Sydney.

---

Australian Transport Safety Bureau
Total Duration15 yrs

Director Transport Safety
Dates EmployedJun 2017 – Present
Employment Duration2 yrs 4 mos
Canberra, Australia

Director Transport Safety
Dates Employed Oct 2004 – Present
Employment Duration 15 yrs
Canberra, Australia

Assistant General Manager
Dates Employed 2004 – Jun 2017
Employment Duration 13 yrs
Canberra, Australia

Previously:
Senior Transport Safety Investigator
Manager Research
Manager Reporting and Analysis

Currently:
Assistant General Manager, Reporting, Short Investigations and Research

15 years??    - So that would mean he was involved in/or on the periphery of the Lockhart River tragedy; he was there for the PelAir cover-up and the Beaker adoption of the 'beyond all reason' investigative philosophy; he was there for the MH370 cock-up/cover-up etc..etc..etc - Hmm and Chelsea is not conflicted? FDS!

Fair Call – However:-

P2 –“Note in figure 2 that there would have presumably been much scud running and even at times penetration of cloud, yet never does the pilot's manoeuvrings approach any where near uncontrolled, reckless AOB or pitch movements suggestive of a VFR pilot panicking because he has inadvertently entered IMC.”

Devils advocate right back atchya. Noted. Discuss; – the aircraft was certified for IFR. Feasible that there was a serviceable auto pilot on board and no doubt GPS. ATSB don’t think it worthwhile to mention how the aircraft was equipped. I can easily see someone at one of the ‘confidence’ benchmarks (500 hours), underestimating the inherent ‘risks’, overestimating their ability, backed up by auto flight and GPS accuracy taking a punt. Those patterns are very, very neat. There are two small clues to this being at least a start point for discussion:-

(1) “ATSB – Witnesses reported that the pilot then conducted a go around after initially touching down on runway 36, and witnesses reported then seeing the aircraft climb back into cloud.

Why? If it had been me, and I’d touched down after an approach like that (unlikely) there’d be no-way I’d go around, back into the murk. More likely I’d be behind the shed having a smoke, trying to sooth agitated nerve endings.

(2) “ATSB - The pilot then broadcast on the CTAF ‘going around for runway 24’. After another two low-level turns over the airport, in which the aircraft was captured emerging from the cloud on closed-circuit television (CCTV) at low altitude, the aircraft landed on runway 29 at about 1008.

Now he’s called for R24 and landed R29. IMO that is a clue to some sort of geographical disorientation – switched on bloke would have called the change – had he been aware of it.

Just saying…. There’s room for speculation on the approach pattern. The departure (as depicted) does appear to indicate a very small time period between what appears to be a controlled, descending left turn and the accident site. Hard to tell from the awful schematic, but; 200 feet a minute (FpM) descent rate is only 3.33 FpS. 600 FpM is 10 feet per second. 1200 FpM is 20 feet per second. So, ten seconds at 1200 FpM = 200 feet. That brings a descent angle of about 60˚+/-. Good-Oh, ATSB reckon 30˚from vertical.

ATSB – “Ground scars and evidence from the wreckage indicated that the aircraft impacted the ground nose down in an inverted attitude, approximately 30° from vertical, and that the engine was producing power at the time of impact.”

For the sake of discussion only: what if the trusty Auto Pilot gave up the ghost, in cloud? Is there enough time lapse for the pilot to not recognise an attitude change, become disoriented and loose control? You can imagine it happening – stressed pilot, believes the AP is running the show, peering out of the window, looking for breaks in weather – then the ‘Oh- crap’ moment when reality dawns – too late.

So glad ATSB didn’t bother to interrupt their hysterical investigator's ‘Air time’ to bother looking into possible causes; after all as she stated in her TV 15 moments of fame, we will be investigating Angel Flight (submission to CASA following) – and they did. I cheered when Rex Patrick pulled the Soppy, so Sympatico Hood up when he dared to blame the Senate for forcing them to look at ‘operators’ rather than flight crew – as they did in the disgraceful Pel-Air investigation. The crazy thing, which clearly demonstrates just how sycophantic ATSB under Hood has become is that they have gone after not once, but twice the wrong Fox. Pel-Air operator deserved a hammering; AF don’t. The Pel--Air pilot got flogged; all of the Mt Gambier pilot’s aberrations have become Angel Flight’s; who, by the way ain't an 'operator'.................

Hood needs to sort his carts and horses out methinks. Aye well, we shall hear what the Senate Committee think of it all in due course. Let’s hope they are not baffled by the Bullshit in another awful report; one of the many we have read lately; or not, depending whether the PR crew and Spin Doctors have finished applying the polish. A No Confidence call in the ATSB would be well justified and supported.

Toot – toot.