[Peetwo]

When we've got GT who needs the ATSB?-

Reference from 'Accidents - Domestic' thread:

Second coffee speculative.

“When Hansard do their thing we will take a closer look at just who is responsible for what; but CASA have made it clear they are, so far as they are concerned – off the hook.”

Can anyone spot the pattern emerging?  The CASA has identified one of the very real causal chain links and are moving the spotlight away from that area. Senator Back (bless) has very nearly tumbled to it; close but, no cigar.

Carmody spells out the CASA concerns – the operational area approved, “the box”, was the amount of airspace allocated too restrictive? Now, to be fair we cannot blame the CASA for this; well not for all of it.  Say you were flying the display aircraft and CASA gave you an area to work within – for crowd safety reason. You look at the sketch (map or whatever) and note that you only have room to turn onto a base leg which will place you on say (for sake of a number) on a half final; it’s far too tight. So you then negotiate an alternative; minimum height, speed and distance required for a ‘stable’ approach; CASA can make an exception to allow this. It is called command discretion, or operational control. I doubt that the CASA officer issuing the ‘permit’ knows the aircraft performance requirements, probably not even type rated; part of his job is to ensure crowd safety, which requires a ‘safety area’ to be defined and enforced. If the space is too small, ultimately it is the pilots responsibility to ensure an extension, exemption, or cancel if a suitable compromise cannot be achieved. I’d bet my hat this never happened.

But, it is fairly human to simply accept the boundaries imposed, particularly CASA enforced ones.. I am starting to think the Mallard accident was, very much, a Human Factors classic. You can see the picture; dead keen to participate; delays in approval, licence and rating hassles, organisers needing to do there thing; a hundred minor details to sort out; and the subconscious anxiety. To ‘stuff it up’ by getting outside the steel rules and loosing the hard won approval and, possibly, landing in hot water with CASA would weigh on the mind. Particularly for an ‘inexperienced’, newly fledged display pilot.

I wonder if the ATSB will examine how much ‘practice’ was done to ensure that the aircraft could be operated within the approved area? Normally, with any sort of medium weight multi engine aircraft a three mile final approach leg from 1500 feet is a ‘routine’ breeze; two miles from 1000 feet is a very acceptable stroll in the park; and a one mile final from500 feet is routinely doable- student pilots do it all day long; but much less distance than that is approaching the ‘risky’ if the aircraft is not configured and stable.

This all leaves us with a mosaic, a jigsaw puzzle to fit together. One piece which must be acknowledged is the ‘fear’ of CASA reprisal and punishment for getting ‘outside’ of the black and white law as specified. Perhaps CASA would not have penalised, punished or prosecuted had the aircraft strayed from the mandated area; the option to ‘go around’ and return for a second shot was always available – as was abandoning the exercise. Why did the pilot persist is the question we need answered, the answer to that question remains in the Swan. But if we can remove even one of the ‘causal chain’ elements perhaps this accident will not be repeated.

Aye, ‘tis a pretty puzzle; I’ll leave the closing remarks to the CASA - CEO/DAS.

Toot toot.

Better late than never, yesterday the ATSB released their preliminary report into the Swan River 'Sky Works' Mallard fatal accident:

Preliminary

On 26 January 2017, the pilot of a Grumman American Aviation Corp G-73 amphibian aircraft, registered VH‑CQA (CQA), was participating in an air display as part of the City of Perth Australia Day Skyworks event. On board were the pilot and a passenger. The weather was fine with a recorded wind of about 20 km/hr from the south-west and a temperature of about 39 °C.

The pilot of CQA was flying ‘in company’ with a Cessna Caravan amphibian and conducted a series of circuits that included low-level fly-pasts of the Langley Park foreshore (Figure 1). After the second fly-past, the pilot of CQA commenced a third circuit, while the Caravan departed the area.

Figure 1: CQA air display flight track, showing the first fly-past in yellow, the second in magenta and the third in red

Source: OzRunways Pty. Ltd., modified by the ATSB

As part of the third circuit, the pilot of CQA flew in an easterly direction, parallel with the South Perth foreshore, before commencing a left turn. This would have facilitated a third pass in a westerly direction along the Langley Park foreshore. During the left turn, CQA rolled left and pitched nose down, consistent with an aerodynamic stall[1] (Figure 2). The aircraft collided with the water and broke up. The pilot and passenger were fatally injured.

Figure 2: CQA just prior to the collision with water (looking north)

Source: Mike Graham

The ATSB completed the on-site phase of its investigation on 4 February 2017. No pre-existing aircraft defects, which may have contributed to the collision with water, were identified. The ATSB has retained several items and components from the aircraft for further examination. This includes a fuel totaliser, a navigation unit and a mobile phone.

The investigation is continuing and will include:

• examination of numerous witness reports and images and a significant quantity of video footage taken on the day by members of the public, media outlets and so on
  
• review of the aircraft’s maintenance records, operational records for recent flights and pilot training records
  
• review of the meteorological conditions at the time
  
• an examination of aircraft performance and other operational factors
  
• further examination of the recorded flight radar, radio and Global Positioning System data
  
• review of the planning, approval and oversight of the air display, including a focus on safety and risk management practices.
  

Should any critical safety issues emerge during the course of the investigation, the ATSB will immediately bring those issues to the attention of the relevant authorities or organisations. This will allow those authorities and organisations to consider safety action to address the safety issues. Details of such safety issues and any safety action in response will be published on the ATSB website at www.atsb.gov.au.
 
______________
The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.
 
__________

1. Aerodynamic stall: occurs when the airflow separates from the wing’s upper surface and becomes turbulent. A stall occurs at high angles of attack, typically 16˚ to 18˚, and results in reduced lift.
   

 
Initial
Updated: 30 January 2017
The ATSB has deployed two additional specialists to investigate the collision with water involving Grumman American Aviation Corp G-73, registered VH-CQA, on 26 January 2017.

A Licensed Aircraft Maintenance Engineer (LAME) and a Human Factors specialist have arrived from Canberra to join the ATSB team in Perth.

The investigation will continue in detail, seeking information and data on meteorological conditions on the day, as well as examining pilot and maintenance documentation.

The ATSB will also seek recorded radar and radio information from AirServices Australia.

The ATSB has assisted the WA Department of Transport (Marine) recover the wreckage to enable the investigation to continue. The investigation may take up to a year to complete.

The ATSB is grateful to the many witnesses who have provided written, photographic and video evidence of the aircraft immediately prior to, during and after the accident. Investigators will contact witnesses as soon as they are able. 
 
Published: 27 January 2017


The ATSB is investigation the collision with water involving Grumman American Aviation Corp G-73, registered VH-CQA, 10 km WSW of Perth Airport, Western Australia on 26 January 2017.

While overflying the Swan River near the Perth CBD, the aircraft crashed into water destroying the aircraft and resulting in fatal injuries to the pilot and one passenger.

The ATSB deployed two investigators who arrived at the accident site during the afternoon of Thursday 26 January 2017. Over the next few days they will examine the accident site, interview witnesses, and collect maintenance and pilot records, and air traffic control recorded data.

The investigators are seeking witness reports and video recordings that might assist the investigation. Witnesses are requested to contact the ATSB on 1800 020 616 or email ATSBinfo@atsb.gov.au.
 
General details

General details Date: 26 Jan 2017
 
Investigation status:
Active
 
Time: 17:08 WST
 
Investigation type: Occurrence Investigation
 
Location   (show map): Swan River, Perth
 
Occurrence type: Collision with terrain
 
State: Western Australia
 
Occurrence class:
Operational
 
Release date: 08 Mar 2017
 
Occurrence category: Accident
 
Report status: Pending
 
Highest injury level: Fatal
 
Expected completion: Jan 2018 
 
Aircraft details

Aircraft details/Aircraft manufacturer: Grumman American Aviation Corp
 
Aircraft model: G-73 Mallard (amphibious)
 
Aircraft registration: VH-CQA
 
Type of operation: Aerial Work
 
Damage to aircraft: Destroyed 
 
 


Last update 08 March 2017

The release of the ATSB prelim report was followed closely by a review from resident WA AAI expert and media commentator GT in PerthNow... :

What caused the Swan River seaplane crash on Australia Day
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/article/921fcf883480b34f15f1f7c0c700dba9?esi=true&t_template=s3/chronicle-tg_tlc_storyheader/index&t_product=PerthNow&td_device=desktop[/img]Geoffrey Thomas, PerthNow
March 8, 2017 9:55pm
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/article/921fcf883480b34f15f1f7c0c700dba9?esi=true&t_template=s3/chronicle-tg_tlc_storymeta/index&t_product=PerthNow&td_device=desktop[/img]
AUSTRALIA'S crash investigator says that the Grumman G-73 Mallard that crashed into the Swan River in front of thousands of spectators celebrating Australia Day suffered an aerodynamic stall.

Father-of-three Peter Lynch, 52, and Endah Cakrawati, 30, died when the twin-engine Mallard stalled during a tight turn and plunged nose first into the river.

Mr Lynch had owned the plane since 2011 and had spent more than 120 hours at the controls.

But as a newcomer to Perth, he had never before attempted to land it on the river.
He has expressed concerns about the flying display he was take part in because of the lack of wind and the heat which would have impacted the plane’s performance.

Those conditions required a higher speed and in this case deployment of the aircraft’s flaps which increase the wing’s lift.

However the flaps were not activated.

The ATSB said that the wind was about 20 km/hr from the south-west and the temperature was about 39 °C.
The sequence of the Swan River crash. Pictures: Twitter / Vicki Clark

When the plane crashed it was travelling north-east so the 20km/hr south-west wind would have worsened the situation by affectively reducing his over-the-wing-speed by 20km/hr.

The ATSB said it found no pre-existing aircraft defects, which may have contributed to the collision with water.

However the ATSB has retained several items and components from the aircraft for further examination.

These include a fuel totaliser, a navigation unit and a mobile phone.

Hmm...wonder how much GT charges for top cover 'the pilot did it' investigative reports? Maybe Hoody can farm out some of his outstanding backlog of AAI's to GT - for a small fee of course...

MTF...P2