Well; We don't know!
P7 - “I have now wandered far from my intended track – it was to Gympie in Qld I was headed. I know the 'gliders' are punctilious in their notifications of operations; it is reasonable to assume these were in NOTAMS and available pre flight; we know that the airfield is clearly marked as having gliding operations, we also know that a quick phone call or radio call would have provided advice of glider traffic operations, where the best thermals were and how many craft they had airborne now and in the near future. What we don't know is how much information, warning and alerting the power aircraft pilot not only had, but gave. We also don't know if there was a brain fart; was this a spur of the moment thing, to try and find a glider and watch it work, take pictures?. The ATSB have grudgingly deigned to review the GPS data – WTF for? It will only show that the two aircraft tracked toward each other and collided. What we need to know is WHY and what part of the system failed; then we need that failure eradicated. That is the basic function of the ATSB – define the how and the why and the best course of preventing a repeat.”
And, neither will the Coroner.
In fact, no one, bar the two dead pilots knows the why and how of the Gympie mid-air. But, eventually a Coroner will need to 'examine' the event and make some form of ruling which, in turn, will trigger the insurers response. To arrive at any sort of rational conclusion, the Coroner must rely, in one form or another, on 'expert' advice from the investigating agency. With aviation events, this is, almost without exception, the ATSB report. Now, each 'jurisdiction' (bar the Commonwealth) has its own coronial legislation, with subtle differences. But, no matter the nuances, they must rely on 'subject matter' expert testimony. Here is where the difficulties of the ATSB 'can't be bothered' response to the Gympie mid-air creates difficulties for not only the Coroner, but for all involved. Quite apart from it being reprehensible behaviour (and it is) from an expensive tax payer funded 'autonomy'. ATSB is in place and funded solely to present and provide independent, expert analysis and probable cause: additional funding available – 'on request' no questions asked. The outright refusal, on very (very) shaky grounds, to not 'investigate' the Gympie mid air fatal has far reaching consequences. Not only to overall aviation safety, but for the legal proceeding which will follow behind the Coroners rulings.
I can almost hear the howls of derision from the legal eagles; but in lay terms, the ATSB is creating a legal minefield, which can only lead to long, drawn out, expensive legal action further down the 'event aftermath' road. In a nutshell (with apologises to the eagles) it goes something like this. The Coroners findings involves two elements, the 'cause' of death and the 'manner' of death.
So, Charlie is carrying a couple of bags of cement along a scaffold gangway – three stories up. He is last seen falling off the gangway, lands and is pronounced dead at the scene. The 'cause' of death would be identified as injuries sustained at the end of the fall. But the 'manner' of death would be 'how' that 'fall' came about. A moments thought will reveal not only the implications and liabilities, but the scramble to avoid legal action following the investigation. The builder will need to show the compliance with 'code' for scaffold, as will the scaffold company which assembled it, as will the site manager, Charlie's boss, etc. all roped in to the liability hunt; all hanging on for the Coroner's ruling on 'the manner' of death, not the cause. Is the Coroner an expert in any related field to this event? Nah and even if – then, probably, a change of Coroner would be required. Ergo - Independent investigation is an essential element; by independent experts in the field, with substantive protection under the law...
You can see how the 'liability' chain exists; the builder must provide a scaffold – was it there – Yes. Did the builder erect the scaffold – No, contracted out to an 'expert' certified company; did they install it correctly? The 'eagles' would have a field day with that – beginning with was the Scaff contractor a mate and job done at a rate? Were the riggers used qualified and supervised? Was the safety inspection done – who by? You see where this all leads – the Coroner can only make a 'safe' (read sound) decision based against a completely independent, no skin in the game – expert. Meanwhile, poor old Charlie's widow is wondering if the insurance will come through and praying Charlie didn't have a beer at lunch time and gets all the blame – 'drunk and in charge of a pair of boots' M'lud.
There must be unbiased, independent and honesty presented in Coroner's reports, no frills or, 'spin', or 'bias', or agenda (see Tasmanian fatal) - provided to the Coroner and, by extension, to the insurance legal sharks. ATSB has that job; they have no financial restrictions attached when it comes to accident investigations; they have rock solid protection under the TSI Act; all they are lacking is some independence (see MoU) expertise (see reports) and integrity in the management department – been shy of that the last few years – and it shows.
Toot – toot...
P7 - “I have now wandered far from my intended track – it was to Gympie in Qld I was headed. I know the 'gliders' are punctilious in their notifications of operations; it is reasonable to assume these were in NOTAMS and available pre flight; we know that the airfield is clearly marked as having gliding operations, we also know that a quick phone call or radio call would have provided advice of glider traffic operations, where the best thermals were and how many craft they had airborne now and in the near future. What we don't know is how much information, warning and alerting the power aircraft pilot not only had, but gave. We also don't know if there was a brain fart; was this a spur of the moment thing, to try and find a glider and watch it work, take pictures?. The ATSB have grudgingly deigned to review the GPS data – WTF for? It will only show that the two aircraft tracked toward each other and collided. What we need to know is WHY and what part of the system failed; then we need that failure eradicated. That is the basic function of the ATSB – define the how and the why and the best course of preventing a repeat.”
And, neither will the Coroner.
In fact, no one, bar the two dead pilots knows the why and how of the Gympie mid-air. But, eventually a Coroner will need to 'examine' the event and make some form of ruling which, in turn, will trigger the insurers response. To arrive at any sort of rational conclusion, the Coroner must rely, in one form or another, on 'expert' advice from the investigating agency. With aviation events, this is, almost without exception, the ATSB report. Now, each 'jurisdiction' (bar the Commonwealth) has its own coronial legislation, with subtle differences. But, no matter the nuances, they must rely on 'subject matter' expert testimony. Here is where the difficulties of the ATSB 'can't be bothered' response to the Gympie mid-air creates difficulties for not only the Coroner, but for all involved. Quite apart from it being reprehensible behaviour (and it is) from an expensive tax payer funded 'autonomy'. ATSB is in place and funded solely to present and provide independent, expert analysis and probable cause: additional funding available – 'on request' no questions asked. The outright refusal, on very (very) shaky grounds, to not 'investigate' the Gympie mid air fatal has far reaching consequences. Not only to overall aviation safety, but for the legal proceeding which will follow behind the Coroners rulings.
I can almost hear the howls of derision from the legal eagles; but in lay terms, the ATSB is creating a legal minefield, which can only lead to long, drawn out, expensive legal action further down the 'event aftermath' road. In a nutshell (with apologises to the eagles) it goes something like this. The Coroners findings involves two elements, the 'cause' of death and the 'manner' of death.
So, Charlie is carrying a couple of bags of cement along a scaffold gangway – three stories up. He is last seen falling off the gangway, lands and is pronounced dead at the scene. The 'cause' of death would be identified as injuries sustained at the end of the fall. But the 'manner' of death would be 'how' that 'fall' came about. A moments thought will reveal not only the implications and liabilities, but the scramble to avoid legal action following the investigation. The builder will need to show the compliance with 'code' for scaffold, as will the scaffold company which assembled it, as will the site manager, Charlie's boss, etc. all roped in to the liability hunt; all hanging on for the Coroner's ruling on 'the manner' of death, not the cause. Is the Coroner an expert in any related field to this event? Nah and even if – then, probably, a change of Coroner would be required. Ergo - Independent investigation is an essential element; by independent experts in the field, with substantive protection under the law...
You can see how the 'liability' chain exists; the builder must provide a scaffold – was it there – Yes. Did the builder erect the scaffold – No, contracted out to an 'expert' certified company; did they install it correctly? The 'eagles' would have a field day with that – beginning with was the Scaff contractor a mate and job done at a rate? Were the riggers used qualified and supervised? Was the safety inspection done – who by? You see where this all leads – the Coroner can only make a 'safe' (read sound) decision based against a completely independent, no skin in the game – expert. Meanwhile, poor old Charlie's widow is wondering if the insurance will come through and praying Charlie didn't have a beer at lunch time and gets all the blame – 'drunk and in charge of a pair of boots' M'lud.
There must be unbiased, independent and honesty presented in Coroner's reports, no frills or, 'spin', or 'bias', or agenda (see Tasmanian fatal) - provided to the Coroner and, by extension, to the insurance legal sharks. ATSB has that job; they have no financial restrictions attached when it comes to accident investigations; they have rock solid protection under the TSI Act; all they are lacking is some independence (see MoU) expertise (see reports) and integrity in the management department – been shy of that the last few years – and it shows.
Toot – toot...