[Peetwo]

HVH snow-job report swallowed by MSM - 

Some media reports from the Oz that IMO suggest how HVH & co cleverly manipulate the MSM to slowly but surely reinforce 'the pilot did it' propaganda:

Pilot error caused deadly crash
ROBIN IRONSIDE
The fiery crash which killed five people when a light plane plunged into a DFO building last year has been blamed on pilot error.

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The long-awaited report into last year’s horrific Essendon plane crash has found pilot error most probably caused the tragedy and not any sort of mechanical defect.

Five people, including pilot Max Quartermain were killed, when the Beechcraft King Air B200 crashed into the DFO Building near Essendon Airport on February 21, 2017.

The four passengers Russell Munsch, Greg De Haven, Glenn Garland and John Washburn, were American tourists heading to King Island for a day of golf.

The Australian Transport Safety Bureau report on the crash said the pilot did not detect the aircraft’s rudder trim was in the full nose-left position prior to take-off.

“The position of the rudder trim resulted in a loss of directional control and had a significant impact on the aircraft’s climb performance in the latter part of the flight,” the report said.

The aircraft was only in the air for nine seconds before the crash, when it was observed to veer sharply left and was unable to avoid the DFO building.

Another contributing factor was the fact the aircraft was 240kg above its maximum take-off weight of 5670kg.

The report went on to say the pilot and operator did not have an appropriate flight check system in place for the aircraft.

“Although this did not contribute to this accident, it increased the risk of incorrect checklists being used, incorrect application of the aircraft’s checklists and checks related to supplemental equipment not being performed,” said the report.

Why the rudder trim was in the full nose-left position was not completely apparent in the report, which noted that the ATSB “could not exclude the possibility the rudder trim had been manipulated by unknown persons prior to the flight”.

“However the aircraft had been stored in a secure hangar until the previous afternoon,” said the report.

“After this, the aircraft was parked outside the hangar within the confines of the airport.”

Former airline captain and RAAF fighter pilot Byron Bailey said the findings were devastating.

“The thing is, (the rudder trim) is never touched,” said Mr Bailey.

“For it to be wound in the full left position is very unusual.

“Normally the only time you would use the rudder trim would be in an engine failure situation. This guy wouldn’t have known what was going on.”

He said it highlighted the need for proper pre-flight checks and not taking anything for granted.

The report said a review of witness observations and air traffic control audio recordings found no evidence to suggest that the before takeoff (run-up) checks had been completed by the pilot.

A separate report is being prepared by the ATSB into the approval of the DFO building adjacent to Essendon Airport.

However the report said the “presence of the building struck by the aircraft was unlikely to have increased the severity of the outcome of this accident”.

The widows of the four passengers killed will release a statement through their Australian lawyer later today.

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Pilot boasted no need for checks

ROBYN IRONSIDE
A pilot who boasted he did not need checklists, failed to spot an incorrectly positioned control, resulting in a crash that killed five.

A pilot who once boasted that he did not need pre-flight checklists, failed to spot an incorrectly positioned control in his aircraft, resulting in a crash that killed him and four American tourists near Essendon Airport in Melbourne.

Lawsuits seeking millions of dollars in damages will be filed in the wake of the final Australian Transport Safety Bureau report on the crash, on February 21 last year.

Max Quartermain, 67, was at the controls of the Beechcraft King Air B200 on a flight from Essendon to King Island off Tasmania’s northwest coast.

Shortly after a longer than normal takeoff roll, the aircraft was seen to veer sharply to the left as Quartermain repeatedly radioed “mayday”.

After just 10 seconds of flight, the plane crashed into the DFO shopping centre on nearby Bulla Road and burst into flames.

The ATSB report found that the rudder trim of the Beechcraft King Air B200 was in the full nose-left position prior to takeoff, ­causing a loss of directional control that affected the aircraft’s climb.

The report also found the aircraft was 240kg over the maximum takeoff weight, and a tripped “impact switch” for the cockpit voice recorder had not been reset.

ATSB chief commissioner Greg Hood said the rudder-trim position should have been picked up in any of five standard pre-flight checks for the B200.

“There were opportunities in the checklist that existed for the pilot to ensure that the rudder trim was set to neutral, prior to takeoff,” Mr Hood said.

Statements provided by people who had flown with or knew Quartermain indicated he was not always in the habit of consulting checklists during pre-flight ­inspections.

On one occasion, a passenger said he had to prompt Quartermain to close the main cabin door of the aircraft just before takeoff.

Another pilot said Quartermain had indicated he did not believe in checklists.

The report also quoted previous correspondence between the ATSB and Quartermain in which he suggested “you don’t need to use a checklist because you are doing it every day”.

In late 2015, following a near miss over Mount Hotham, the Civil Aviation Safety Authority identified Quartermain did not have an approved flight-check system for the B200.

He was also ordered to undergo an instrument-proficiency check, which he failed on the first attempt but passed three weeks later.

Yesterday, Gordon Legal partner Paul Henderson, who is representing the widows of Quartermain’s passengers, said he had recommended they make a claim under the Civil Aviation Carrier’s Liability Act and take a negligence action against the pilot’s ­estate.

Mr Henderson said claims made under the act were capped at a maximum of $725,000, but the negligence action meant there was an opportunity to gain “true compensation” for the widows of Glenn Garland, 67, Greg DeHaven, 70, Russell Munsch, 62, and John Washburn, 67.

“They’re experiencing a range of emotions from frustration to a great sense of sadness and a great sense of loss and, to some degree, anger,” he said.

Lawsuits would be filed in the next 60 days, Mr Henderson said.

A statement from Quartermain’s daughter Melissa said she and her brother were having a “very difficult time coming to terms with losing our dad”.

“We love him dearly and he is missed enormously,” she wrote.

“We will always remember him as the wonderfully loving and proud father, and adoring Papa to his three grandchildren.

“Our lives will never be the same without him.”

& a Sandy comment :

The claim that the pilot did not use check lists should be assessed against the background of common practice in flight training. We do not normally teach flying using a physical check list, it is normal to follow a ‘learnt by rote’ check list for the critical stages of flight. It might be a valid argument to say that having to pull out a written check list or handle a physical tab system which displays a sequence of written instructions is creating a distraction from the actual task of, for example, noting engine parameters or looking outside to determine the proper operation moving control surfaces. Different story in more complex aircraft with two pilots. 

In many experienced eyes the ATSB, an independent body as of 2009 by then Minister Albanese, has fallen well short in its reports and the too easy ‘blame the pilot’ mentality  undermines the the most important element, how to prevent this from happening in the future. In addition the explanation for how the rudder trim would be wound over to one side and left there (extremely unusual) might bear further investigation as would be the question why the rudder force could not be overcome. 

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Checklists indispensable to safety
BYRON BAILEY
This incident shows how vital it is for ­pilots to take time to action checklists fully.

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I have often thought single-pilot multi-engine charter flying is the most demanding sphere of civil aviation. The pilot can be responsible for flight planning, fuel load, passenger and baggage, often with time pressure, as well as safely flying the aircraft.

But there is no excuse for missing vital cockpit checklists that ensure the safety of the flight.

The KingAir checklists specify in the before-engine start cockpit set up, that the three control surface trims of pitch (electric switch on the control column yoke) and manual aileron and rudder trim wheels be checked through the full range and be returned to the neutral takeoff settings. The trim wheels are highly visible just behind the throttle quadrant and very obvious markings indicate the neutral position.

The taxi checklist also requires the pilot to verify the trims are set for takeoff.

On the takeoff roll, it would have been apparent quite early as aerodynamic forces increased as the speed built up that the aircraft was wanting to deviate to the left.

This would have needed increasing right rudder to keep straight — so why did the pilot not abort takeoff before the rotation point? It would have been increasingly obvious there was a problem.

Simulator training emphasises the need to stop for any problem before 80 knots. The aircraft apparently rotated after a ground roll of 700m, which still left plenty of room to stop. At this stage, the pilot would have had his hands full: full right rudder and aileron just to try to keep straight and unable to retract the landing gear. As well as missing a required pre-takeoff visual check of the rudder trim position, the pilot continued while having control difficulties when all training would demand a discontinuation.

Engine fire/failure and loss of directional control are safety ­issues that are not taken into the air before the vital speed V1, which occurs just before rotation and there is no choice but to abort the takeoff.

There is a widespread opinion among general aviation pilots that checklists are too long-winded, thus increasing the likelihood of missing an item, but this incident shows how vital it is for ­pilots to take time to action checklists fully and undergo takeoff emergencies simulator training.

Byron Bailey is a former RAAF fighter pilot and Emirates 777 captain.

Come on Bailey you should know better than to swallow that HVH bollocks...

Yet to find a dissenting media report? Which means that (at this point in time) the HVH weasel worded confection of half baked hypotheses and factually incomplete assumptions, that are  contained within yet another dodgy ATSB final report will remain unchallenged by any decent investigative journalist; or independent aviation accident investigative expert? 

This means that much like in the PelAir cover-up; the Mildura fog duck-up; the Lockhart River tragedy etc..etc; that once again the aviation safety bureaucracy have managed to Hoodwink the Minister/Govt while effectively obfuscating all responsibility and potential liability for this accident...  

However it is yet to be seen whether the ICAO, the FAA and/or the NTSB will be quite so convinced that there is nothing more to this tragic accident than an incompetent and therefore negligent pilot:

Quote from Oz Aviation article yesterday (my bold): 

ATSB raises questions about building approvals process for shopping centre

The ASTB said the building the aircraft struck did not increase the severity of the consequences of this accident.

“In the absence of that building, the aircraft’s flight path would probably have resulted in an uncontrolled collision with a busy freeway, with the potential for increased ground casualties,” the report said. P2 - Still shaking my head over that unprofessional bollocks statement...

However, the ATSB said its investigation did identify that two of the four buildings within the retail precinct “exceeded the obstacle limitation surface (OLS) for Essendon Airport”. “While those exeedances had been approved by the Civil Aviation Safety Authority, the ATSB identified several issues relating to the building approval process for the precinct,” the report said.

“It is beyond the scope of this investigation to consider in detail the issues identified with the Bulla Road Precinct building approval processes.

“These issues will be addressed in the current ATSB Safety Issues investigation ‘The approval process for the Bulla Road Precinct Retail Outlet Centre AI-2018-010’.”
The ATSB final report noted the OLS for the departure runway was not infringed and VH-ZCR did not collide with those buildings.

Essendon Airport chief executive Chris Cowan said it was clear from the final ATSB report “the operation or conditions at Essendon Fields Airport played no role in this terrible crash”.

“The report confirms that the presence of the DFO building struck by the aircraft did not increase the severity or the consequences of this accident. This building is not subject to further investigation,” Cowan said in a statement.

“The ATSB is conducting a separate investigation into the approval process of two other buildings at Essendon Fields DFO. We note those buildings were approved by CASA prior to construction. Those two buildings did not contribute to this accident.”

Committee views
Essendon Airport accident
4.44      As the investigations continue into the tragedy that occurred at Essendon Airport in February 2017, the committee observes that such a terrible event may trigger reinvigorated discussions at all levels of government on broader airport land use planning and development issues, to improve the safety for all those who engage with airports.
4.45      The recently announced ATSB investigation into the building approval process for buildings around Essendon Airport, resulting from the Essendon crash, will play an important role in progressing discussions about aviation safety in relation to urban development. As previously noted, the findings of this investigation should be carefully considered in the context of legislative changes to airport planning laws.
4.46      The committee hopes that the important work of NASAG goes some way to addressing the concerns of stakeholders about building and structures near runways, and the impact these have on safe aircraft operation.
4.47      It appears to the committee that the encroachment of developments, be they residential or commercial, on and near airport land presents significant safety concerns. It is essential that safety on and around airports is given proper consideration at all times, without being overridden by commercial pressures.
4.48      The committee is of the view that a holistic approach should be taken to airport planning, and this should be reflected in the MP process. It should be incumbent on all airport lessees, developers and planners to do more than the bare minimum to adhere to airport planning legislation and frameworks, in order to give proper consideration to broader safety considerations.

The following extract is from the now decade old 2008 ICAO audit report:

And from the ICAO 2017 audit report: http://auntypru.com/wp-content/uploads/2...t_full.pdf

AGA:
Ensure that the State has a coordinated mechanism to ensure full and effective implementation of the obstacle limitation surfaces (OLS) at aerodromes, including arrangements to prohibit any building developments which could create an obstacle to aircraft operations.

http://www.auntypru.com/forum/thread-143...ml#pid9296

P2 comment: It is worth keeping in mind, that this more than decade old ICAO identified SSI (serious safety issue), would presumably have been known by the present CASA CEO Carmody when he gave evidence as the Deputy CEO to Byron in the Senate RRAT committee inquiry into the administration of CASA. Hansard extract 2 July 2008 public hearing: 

S10926_pdf.pdf Size: 714.02 KB  Downloads: 1

Senator O’BRIEN—I understand ICAO conducted an audit of our aviation circumstances

earlier this year involving, obviously, CASA as the regulator. And I have seen a story which
suggests that deficiencies in air safety in Australia have been uncovered in that audit. Is that so?

Mr Byron—I am not aware of deficiencies in air safety. Certainly, the write-up of the audit
process is ongoing, and I might have to defer to Mr Carmody, who handles this part of the
organisation, just to give the latest update. But from my recollection of the debriefing, naturally there were some issues that we need to attend to. The only one that was of significant note that I really need to think about is the ongoing training of our largely new workforce. A lot of them come to us qualified; we need to continue our efforts to give them technical training, and we are working on a workforce capability program for that now. But my understanding is that, in terms of the key elements of the audit that related to legislation, oversight and airworthiness directives, we scored quite high in the draft stages.

Mr Carmody—Senator, I can respond in a little more detail if you wish.

Senator O’BRIEN—Yes, please.

Mr Carmody—The final report is not out yet; it is not out till the end of the year.

Senator O’BRIEN—And there is a draft between now and then as well, isn’t there?

Mr Carmody—Yes, there is a draft. In fact, we go back and forth and talk about the draft and those sorts of things with ICAO. We have reviewed our score against the critical elements in the ICAO standard and we think we have come out of it quite well—very well, in fact. There is one area we did not come out particularly well. I think we were still above the global average, but we are not as far ahead as we would like to be. In all other areas, we did quite well P2 - Why does that comment sound so familiar?? 

Senator O’BRIEN—So which area were you not satisfied with?

Mr Carmody—The area we are not satisfied with is technical personnel qualification and
training. What we needed to be able to demonstrate more clearly was a linkage between our human resources systems and the training that is undertaken in our field offices, and be able to indicate more clearly than we could to ICAO the qualifications of personnel and some of those things. That is my understanding, Senator, and I think we are working very hard on that now. We are also looking at some technical training aspects that came out of that. But, as I said, I think we were still equal to or above the global average on that score, and we were well above on the rest.

Senator O’BRIEN—Where does the global average sit? What sorts of nations are you talking about being at the average level, given that we have a fairly high standard, I would have thought?

Mr Carmody—I could find some data, but, off the cuff, for example, we are ahead of New
Zealand in a range of areas. I do not know about the United States, I am sorry. We are ahead of Canada in some areas. Our ratings were between eight and nine out of 10 on the critical elements and five out of 10 on the training personnel element. So, overall, we think we have done quite well—and the global average was low on that training personnel qualification area. That is clearly a focus for ICAO to build on as they go around the world, so they are pressing everybody on exactly the same points.

CHAIR—Does Dr Aleck have any additional information on that?

Mr Carmody—No, he does not. P2 - Hmm..that's a peculiar response -  There is a chart that I do not have with me that I would like get hold of. I might be able to get hold of it and come back with a more detailed response later, to make sure those numbers are exactly right.

Senator O’BRIEN—So were they talking about training within CASA or training generally?

Mr Carmody—Training within CASA. It lists technical training of qualified personnel and
how much technical training we are doing, and as I indicated we are not as far ahead as we would like to be.

Senator O’BRIEN—So, in the context of a major staff turnover, we now find ourselves with
a training deficiency. Is that how I should understand the circumstances?

Mr Carmody—I think that some of the things we were not able to demonstrate were, for
example, our diploma in aviation safety, which had not started—it starts this year. There are actually a range of things that we were not actually in a position to demonstrate because they were not in play, but, certainly, we did not come out as well as we would like to. I would not characterise it quite as seriously as you have, Senator, but it is important.

Senator O’BRIEN—Have these criteria been applied in the past?

Mr Carmody—I am presuming—

Senator O’BRIEN—Sorry, you were not there.

Mr Carmody—that ICAO uses the same methodology. I do not know.

 
This also means that Carmody would have been fully cognisant of this ICAO identified SSI when he gave evidence in the May 2017 Budget Estimates:

       
&..



He would also have been cognisant of the November 2017 ICAO report finding...

...Ensure that the State has a coordinated mechanism to ensure full and effective implementation of the obstacle limitation surfaces (OLS) at aerodromes, including arrangements to prohibit any building developments which could create an obstacle to aircraft operations...

  ...yet CASA did not provide any input to the following QON submitted and subsequently answered by the Dept:

Portfolio Question Number 201
Question - Senator PATRICK: Are you looking at public safety zones around Sydney Airport? 
Mr McRandle: We're looking at public safety zones generally across Australian airports as part of the National Airports Safeguarding Framework. A consultation process commenced a little over a week ago with the community around public safety zones. It will include all airports. Queensland has already incorporated the public safety zone approach to their airports. There are others around Australia that haven't adopted it. 
Senator PATRICK: That's on your website, is it? 
Mr McRandle: It is on our website. 
Ms Spence: We can send the link to the secretariat if that would help? 
Senator PATRICK: That might be helpful, and I'm happy to help advertise that.
Answer The National Airports Safeguarding Advisory Group is seeking comments on a draft new Guideline I— Managing the Risk in Public Safety Zones at the Ends of Runways. The draft guideline is available on the Department of Infrastructure, Regional Development and Cities’ website at: https://infrastructure.gov.au/aviation/environmental/airport_safeguarding/nasf/public_consultation_nasf.aspx.

Nor did Carmody and/or CASA provide any insight/input, on the identified ICAO SSI (x2), when the Senate RRAT committee were conducting their Airports Amendment Bill 2016 inquiry - https://www.aph.gov.au/Parliamentary_Bus...ndmentBill . This was despite the inquiry report being subsequently delayed by request by the then minister Chester (because of the YMEN DFO accident occurring) and the subsequent duplicate finding from the November ICAO audit (see above)...  


MTF...P2