It is an old drum; but a good one.
It's worth taking a moment to read 'Cloudee's' post on the UP _HERE_.
"A coroner examining the 2018 death of a young pilot says he cannot find anyone at fault following her fatal crash at a mountain range in remote southern Tasmania — but slammed Australia's air safety investigator for its "worthless" investigation of the tragedy."
I wonder; now this could just be a one-off bark by a Coroner having a bad case of flatulence on the day. On the other hand, it could, just, maybe, be the opening stanza of something much more valuable. There is long, long line up of Coroner remarks and open dissatisfaction related to aviation deaths. Victoria has had it's fair share lately and will keep the Coroners enclave busy for a while yet.
We all do it, in the pub after work; during a break or at the end of a shift; discuss the latest item of interest and voice our opinion. I imagine that within the realms of the Coroner, with certain restrictions, there may be a similar amount of general 'discussion' - perhaps not related to specifics - but to 'general' common features. Items like the ATSB reports for example. I know I get fed up reading the ATSB reports, when they finally emerge from the sheltered workshop. Trying to convert those reports into something of value toward prevention of a repeat is essentially a waste of time and effort. It must be frustrating for the Coroners; there is long history of their recommendations and input being dismissed or denigrated by the aviation authorities (and that is a historical fact).
Take the Essendon DFO event for a classic, ranked up there with Lockhart River, or even as far back as the Seaview event. How is the Coroner to make a decision without 'all' the facts being presented in the report. How does a Coroner deal with that which is not mentioned, particularly when much is swept under the carpet. The Coroner can only deal with that which is presented or can be determined; but what of the background 'noise'; that which is not investigated and yet may have some relevance.
Questions - for instance; why was Hood, not a qualified investigator on the Essendon scene in record time; did he contaminate the 'scene'? Was his first encounter with burned bodies traumatic to the extent that his judgement was impaired? How extensive was the examination of the pilots medical history and general background post event? Does the Coroner realise that at ingrained habit of all multi engine pilots in the King Air class of aircraft is keep a hand on the power levers throughout the take off; apart from the five or six second it takes to retract the undercarriage? Or even why an experienced pilot would not spot an out of trim condition before the speed indicator was off the peg? To me it seems that these and other items (like the Mayday call-outs) are relevant to the Coroner's thinking. Not mentioned. - But I digress.
The case in point is the event in Tasmania; yet another CFIT. This type of accident is way up on this list of 'repeat' events; nearly all fatal. ATSB are now waving the ADSB flag as a 'cure-all'. Of course this is 100% proof snake oil; ADSB would be of no value to either the Essendon or the Tasmanian pilots; non whatsoever. (MTF on this).
Aye well; this Coroner may just have has indigestion - the mini rant soon forgotten and glossed over; his report about as much use as the ATSB's in preventing a repeat performance where low cloud and high terrain meet the unfortunate. How many has this killed in the last few years and what has ATSB done to reduce the toll?
"Similarly, the Coroner cannot determine civil liability, although the Coroner’s finding may be relied upon in subsequent civil proceedings and/or insurance claims."
Toot - toot...;
It's worth taking a moment to read 'Cloudee's' post on the UP _HERE_.
"A coroner examining the 2018 death of a young pilot says he cannot find anyone at fault following her fatal crash at a mountain range in remote southern Tasmania — but slammed Australia's air safety investigator for its "worthless" investigation of the tragedy."
I wonder; now this could just be a one-off bark by a Coroner having a bad case of flatulence on the day. On the other hand, it could, just, maybe, be the opening stanza of something much more valuable. There is long, long line up of Coroner remarks and open dissatisfaction related to aviation deaths. Victoria has had it's fair share lately and will keep the Coroners enclave busy for a while yet.
We all do it, in the pub after work; during a break or at the end of a shift; discuss the latest item of interest and voice our opinion. I imagine that within the realms of the Coroner, with certain restrictions, there may be a similar amount of general 'discussion' - perhaps not related to specifics - but to 'general' common features. Items like the ATSB reports for example. I know I get fed up reading the ATSB reports, when they finally emerge from the sheltered workshop. Trying to convert those reports into something of value toward prevention of a repeat is essentially a waste of time and effort. It must be frustrating for the Coroners; there is long history of their recommendations and input being dismissed or denigrated by the aviation authorities (and that is a historical fact).
Take the Essendon DFO event for a classic, ranked up there with Lockhart River, or even as far back as the Seaview event. How is the Coroner to make a decision without 'all' the facts being presented in the report. How does a Coroner deal with that which is not mentioned, particularly when much is swept under the carpet. The Coroner can only deal with that which is presented or can be determined; but what of the background 'noise'; that which is not investigated and yet may have some relevance.
Questions - for instance; why was Hood, not a qualified investigator on the Essendon scene in record time; did he contaminate the 'scene'? Was his first encounter with burned bodies traumatic to the extent that his judgement was impaired? How extensive was the examination of the pilots medical history and general background post event? Does the Coroner realise that at ingrained habit of all multi engine pilots in the King Air class of aircraft is keep a hand on the power levers throughout the take off; apart from the five or six second it takes to retract the undercarriage? Or even why an experienced pilot would not spot an out of trim condition before the speed indicator was off the peg? To me it seems that these and other items (like the Mayday call-outs) are relevant to the Coroner's thinking. Not mentioned. - But I digress.
The case in point is the event in Tasmania; yet another CFIT. This type of accident is way up on this list of 'repeat' events; nearly all fatal. ATSB are now waving the ADSB flag as a 'cure-all'. Of course this is 100% proof snake oil; ADSB would be of no value to either the Essendon or the Tasmanian pilots; non whatsoever. (MTF on this).
Aye well; this Coroner may just have has indigestion - the mini rant soon forgotten and glossed over; his report about as much use as the ATSB's in preventing a repeat performance where low cloud and high terrain meet the unfortunate. How many has this killed in the last few years and what has ATSB done to reduce the toll?
"Similarly, the Coroner cannot determine civil liability, although the Coroner’s finding may be relied upon in subsequent civil proceedings and/or insurance claims."
Toot - toot...;