“Aviation in itself is not inherently dangerous.
"But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect."
AG Lamplugh coined that phrase a while ago and it has robustly withstood the test of time; supported by dozens of prime examples proving the point. The stand out example is the continuously increasing list of fatal events, involving aircraft continuing operations into marginal conditions; often misidentified as 'inadvertent' which implies an 'unintentional' act. This is a misnomer in 85% of cases examined. Any discussion or examination of the last three events dismiss the notion of anything 'unintentional' occurring. It begs the question - how much blame can we lay on the altar of 'pilot error'? 'Tis a fair question and must be examined if for no other reason than to examine 'motive' or 'why' despite the body count, the rules, the advice and prior examples we continue to read reports, such as the Tasmanian event.
Three basic elements involved, the pilot, the weather and the landscape. Ancillary players the Operating company, the BoM, the CASA, the ATSB and finally (alas) the Coroner.
“This thing, what is it in itself, in its own constitution? What is its substance and material?”
One of the blessings of holding an instrument rating is the setting of cast iron boundaries - “Minima” not Visual = TOGO/power up/ climb to safety and reassess. It is a 'cash and no bullshit' defined 'safe minimum'. Same thing as a defined LSALT – and yes, it does seem like an overkill, unless you are covered in ice, with OEI; when absolute 'safety' may be compromised, the buffer reduced but it provides a fighting chance for survival. So much for IFR in IMC. VFR into marginal conditions is a different animal – very. In fact it is a known, acknowledged killer; often misnamed – 'inadvertent' – Bollocks. No such thing – unless on an instrument approach, at night from cloud into rain; think circling at minima... (What ? Banned? Bloody right too).
There is a mountain of 'data' relating to the Par-Avion event in SW Tasmania. The Coroner has had his say and the papers filed away in the basement. The basic lesson is the same old, battered, oft abused mantra – don't push your luck. Is this enough? No: it bloody well is not; not by a long shot it ain't....Let's begin at the beginning.
“From me you shall hear the whole truth; not, I can assure you, gentlemen, in flowery language... decked out with fine words and phrases; no, what you will hear will be a straightforward speech in the first words that occur to me, confident as I am in the justice of my cause; and I do not want any of you to expect anything different.”
The aircraft, a serviceable, reliable BN2 a.k.a. A 'Bongo'. Enter the pilot; a reasonably 'seasoned' pilot, familiar with both aircraft, the route and the terrain; just another day at the office on the way to bigger and better things. Walking beside the pilot is the ever present Murphy of dubious reputation and cunning. Item one – access the computer; grab a forecast, submit preloaded standard plan. Total time about six minutes. On to the daily inspection, fire up and launch. What is wrong with this montage? Two items scream for attention; to wit, the format of the forecast and the translation of that document into 'operational thinking'. Buried within the coded message were subtle hints that perhaps matters meteorological were not as easy as imagined; had the forecast been 'translated' correctly; the words 'orographic uplift' would come to mind and noted as a caution. I'd bet good money that our pilot answered a question of the Met exam about this and other 'stuff', probably even read about some of the very real, not mentioned risks in the forecast. Why? Well pilots are supposed to 'know' it and be able to read it into the script, through the 'shorthand' report as delivered by the BoM.
May we label this as Pilot error 1? Perhaps this error may be farmed out to 'other' parties. IMO it is a forgivable transgression. Pilot exams are treated as 'part' of the bull-dust associated with licencing. A pass in 'Met' implies only one thing – that on the day sufficient knowledge was available to achieve a PASS. There is little incentive to add to or actively use the knowledge provided in an environment where the words “Oh, it's just some CASA stuff; do this, pass that, then file and forget. Then, the pilot is faced with the BoM forecast; codes and legal requirements, data for all but no real 'feel' for what may be over the horizon; indeed I've spoken to many who get a forecast to stay legal – but put little faith in the accuracy; BoM are bound to +/- 70% margin for error, and tend to go 'worse case' based on previous models. What the pilot wasn't given, nor could disseminate from the text provided was: the words to go with the music; for example:-
"On the night of 7 December 2018, Tasmania was under a very moist north-easterly airstream, with dew point temperatures in excess of sea surface temperature thus sea fog, coastal mist and very low cloud were expected to develop around the coastal areas of Tasmania. A surface trough moving over the south west in the morning of 8 December 2018 was expected to extend low cloud over southern Tasmania during the morning."
"Conditions on the morning of 8 December 2018 were characterised by coastal sea fog and mist, low orographic cloud developing and the passage of a mid-level cloud band with light rain and Viirga.[11]."
There is also hearsay that the forecast issued was 'unusual'. Missing the almost daily division of the island into two separate areas. There is an unconfirmed, but persistent story floating about that claims the BoM computer upgrade and a late forecaster contributed to the 'crap' forecast issued. It is noteworthy that ATSB failed, during their last minute change to a 'systemic' investigation do not mention the strange forecast, how it came into being or the possible influence it had on decision making.
No matter – off we go; into the valley of death. (Rode the 600).
So, airborne and it seems we have selected the 'right' route; the quick glance for 'tells' on the unusual forecast has produced a sense of security; a false one as it turned out. Relaxed and confident the pilot finds time to take and text photographs – and probably a 'conversation' of some sort. Crime or indicative of attitude? I wonder what a 'CASA flight ops' inspector would have made of it – had they survived? Would I dare do it during a check flight – don't reckon I would; however.... Pilot error 2? – Subjective....
And so we toddle along until the 'saddle' – well, you know the rest. The trap springs closed; cloud, bricks above and below. What to do? Well, consider two elements; one a lapsed IFR and a low level rating. Then, consider the climb rate of the empty Bongo; then consider the altitude estimates before during and after the event. The golden rules of weather and mountain flying had been abandoned; the back door was allowed to slam shut. Were there other options? I can see three which would have given a fair chance of survival. Clearly, the pilot could not see the fast approaching brickwork – in cloud perhaps? We shall never know. I count that as error three.
Well, so much for speculation and armchair analysis. I can't find it in my heart to blame the pilot; not entirely, there are traps for young players and I don't believe that there was any 'fool-hardiness' involved. Fooled by forecast, lulled by experience, with all the holes in that famous cheese neatly lining up – perhaps. But enough. There is the investigation, ATSB, CASA and the Coroner to consider.
'Well, sir,' said the captain, 'better speak plain, I believe, even at the risk of offence. I don't like this cruise; I don't like the men; and I don't like my officer. That's short and sweet.”
Where to begin is a puzzle – chicken and egg variety; not to mention 'history' and the internal battles being waged – at the expense of a fair 'no blame' analysis. No matter how supportive of the ATSB and CASA you may be; there are elements within the 'official' dealings which, not only highlight the dysfunctional and the duplicitous, but the endless quest to avoid any and all responsibility for even producing a fair, reasoned and unbiased report into a recurrent safety matter; to wit - VFR into IMC and the increasing blood bill.
P2's posts, - analysis and - comment on these antics, read carefully provide an insight. I know! It takes time and thought, but this is not Witter or farce-book or that other unmentionable forum. There are elements within the ATSB and Coroner reports which demand consideration. For example (and there are many) the Coroners rejection of the first ATSB effort, his anger over witness statements withheld in a previous case; the MoU in place and the way it was used; the pogrom against Par-Avion despite CASA being 'comfortable' with the operation and the standards. Then there is the naivety, clearly visible which is trying to lay blame on the 'documents' provided to pilots related to operations in South West Tasmania. I will leave the 'homework' up to the reader: but, we are offering Choc Frogs to anyone who can, without equivocation, fluff or nonsense answer two questions:-
^ Translate the Safety Recommendation issued by ATSB to CASA to plain English with motive analysis.
"The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority amend its acquittal process for repeat safety findings to ensure it is effective in ensuring that all previous findings of a similar nature are also appropriately assessed prior to the current and all associated safety findings being acquitted.
^^ Explain why a 'routine' investigation was upgraded to a 'systemic' investigation and yet dismally failed to meet all the requirements of either; but felt free to go after the operator and the Regional CASA office.
"Systemic investigations can involve in the field activity, and a range of ATSB and possibly external resources. They have a broad scope and involve a significant effort collecting evidence across many areas. The breadth of the investigation will often cover multiple organisations. Occurrences and sets of transport safety occurrences investigated normally involve very complex systems and processes."
There is (once gain) no clear, definitive solution or advice or reasoning provided, in this ATSB report; for a no blame outfit, they sure like to throw it about – in a sneaky way. CASA have no case to answer; bar the 'dumbing down' of flight crew who have so much 'other stuff' to contend with that the basics are often simply a matter of 'tick, flick and forget; too much gravy, not enough spuds and meat. This Coroner, like many before him has been 'frustrated'. These are not, in the main, silly people: they see a lot of the darker side of this life and carry a very real responsibility. The history of previous Coroner dealings with ATSB in another matter added to this latest effort would make a stone idol cranky. ATSB are degenerating from a laughing stock into an operational, legal and investigative pariah; time to pull up their sock methinks – or sod off and shut up. Not good enough, not for the money and power granted; nowhere near good enough. Shame on them.
“If someone is able to show me that what I think or do is not right, I will happily change, for I seek the truth, by which no one was ever truly harmed. It is the person who continues in his self-deception and ignorance who is harmed.”
Phew! Quite the ramble; but seriously, read P2's posts – its all there. WTD ATSB think they are about is beyond any sensible rational. Unless of course you weigh into the 'operational' v 'legal' brawl - the Tote is open on that one for any brave enough to take a punt.
Having said all that, I've quite run out of puff; there were 'other' matters to deal with; but thirst, hunger and wet boots clamour for attention. Boots off first or raid the fridge and grab a sausage roll on the way back to boot park. Silly question really.
Selah... _ _ _?
"But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect."
AG Lamplugh coined that phrase a while ago and it has robustly withstood the test of time; supported by dozens of prime examples proving the point. The stand out example is the continuously increasing list of fatal events, involving aircraft continuing operations into marginal conditions; often misidentified as 'inadvertent' which implies an 'unintentional' act. This is a misnomer in 85% of cases examined. Any discussion or examination of the last three events dismiss the notion of anything 'unintentional' occurring. It begs the question - how much blame can we lay on the altar of 'pilot error'? 'Tis a fair question and must be examined if for no other reason than to examine 'motive' or 'why' despite the body count, the rules, the advice and prior examples we continue to read reports, such as the Tasmanian event.
Three basic elements involved, the pilot, the weather and the landscape. Ancillary players the Operating company, the BoM, the CASA, the ATSB and finally (alas) the Coroner.
“This thing, what is it in itself, in its own constitution? What is its substance and material?”
One of the blessings of holding an instrument rating is the setting of cast iron boundaries - “Minima” not Visual = TOGO/power up/ climb to safety and reassess. It is a 'cash and no bullshit' defined 'safe minimum'. Same thing as a defined LSALT – and yes, it does seem like an overkill, unless you are covered in ice, with OEI; when absolute 'safety' may be compromised, the buffer reduced but it provides a fighting chance for survival. So much for IFR in IMC. VFR into marginal conditions is a different animal – very. In fact it is a known, acknowledged killer; often misnamed – 'inadvertent' – Bollocks. No such thing – unless on an instrument approach, at night from cloud into rain; think circling at minima... (What ? Banned? Bloody right too).
There is a mountain of 'data' relating to the Par-Avion event in SW Tasmania. The Coroner has had his say and the papers filed away in the basement. The basic lesson is the same old, battered, oft abused mantra – don't push your luck. Is this enough? No: it bloody well is not; not by a long shot it ain't....Let's begin at the beginning.
“From me you shall hear the whole truth; not, I can assure you, gentlemen, in flowery language... decked out with fine words and phrases; no, what you will hear will be a straightforward speech in the first words that occur to me, confident as I am in the justice of my cause; and I do not want any of you to expect anything different.”
The aircraft, a serviceable, reliable BN2 a.k.a. A 'Bongo'. Enter the pilot; a reasonably 'seasoned' pilot, familiar with both aircraft, the route and the terrain; just another day at the office on the way to bigger and better things. Walking beside the pilot is the ever present Murphy of dubious reputation and cunning. Item one – access the computer; grab a forecast, submit preloaded standard plan. Total time about six minutes. On to the daily inspection, fire up and launch. What is wrong with this montage? Two items scream for attention; to wit, the format of the forecast and the translation of that document into 'operational thinking'. Buried within the coded message were subtle hints that perhaps matters meteorological were not as easy as imagined; had the forecast been 'translated' correctly; the words 'orographic uplift' would come to mind and noted as a caution. I'd bet good money that our pilot answered a question of the Met exam about this and other 'stuff', probably even read about some of the very real, not mentioned risks in the forecast. Why? Well pilots are supposed to 'know' it and be able to read it into the script, through the 'shorthand' report as delivered by the BoM.
May we label this as Pilot error 1? Perhaps this error may be farmed out to 'other' parties. IMO it is a forgivable transgression. Pilot exams are treated as 'part' of the bull-dust associated with licencing. A pass in 'Met' implies only one thing – that on the day sufficient knowledge was available to achieve a PASS. There is little incentive to add to or actively use the knowledge provided in an environment where the words “Oh, it's just some CASA stuff; do this, pass that, then file and forget. Then, the pilot is faced with the BoM forecast; codes and legal requirements, data for all but no real 'feel' for what may be over the horizon; indeed I've spoken to many who get a forecast to stay legal – but put little faith in the accuracy; BoM are bound to +/- 70% margin for error, and tend to go 'worse case' based on previous models. What the pilot wasn't given, nor could disseminate from the text provided was: the words to go with the music; for example:-
"On the night of 7 December 2018, Tasmania was under a very moist north-easterly airstream, with dew point temperatures in excess of sea surface temperature thus sea fog, coastal mist and very low cloud were expected to develop around the coastal areas of Tasmania. A surface trough moving over the south west in the morning of 8 December 2018 was expected to extend low cloud over southern Tasmania during the morning."
"Conditions on the morning of 8 December 2018 were characterised by coastal sea fog and mist, low orographic cloud developing and the passage of a mid-level cloud band with light rain and Viirga.[11]."
There is also hearsay that the forecast issued was 'unusual'. Missing the almost daily division of the island into two separate areas. There is an unconfirmed, but persistent story floating about that claims the BoM computer upgrade and a late forecaster contributed to the 'crap' forecast issued. It is noteworthy that ATSB failed, during their last minute change to a 'systemic' investigation do not mention the strange forecast, how it came into being or the possible influence it had on decision making.
No matter – off we go; into the valley of death. (Rode the 600).
So, airborne and it seems we have selected the 'right' route; the quick glance for 'tells' on the unusual forecast has produced a sense of security; a false one as it turned out. Relaxed and confident the pilot finds time to take and text photographs – and probably a 'conversation' of some sort. Crime or indicative of attitude? I wonder what a 'CASA flight ops' inspector would have made of it – had they survived? Would I dare do it during a check flight – don't reckon I would; however.... Pilot error 2? – Subjective....
And so we toddle along until the 'saddle' – well, you know the rest. The trap springs closed; cloud, bricks above and below. What to do? Well, consider two elements; one a lapsed IFR and a low level rating. Then, consider the climb rate of the empty Bongo; then consider the altitude estimates before during and after the event. The golden rules of weather and mountain flying had been abandoned; the back door was allowed to slam shut. Were there other options? I can see three which would have given a fair chance of survival. Clearly, the pilot could not see the fast approaching brickwork – in cloud perhaps? We shall never know. I count that as error three.
Well, so much for speculation and armchair analysis. I can't find it in my heart to blame the pilot; not entirely, there are traps for young players and I don't believe that there was any 'fool-hardiness' involved. Fooled by forecast, lulled by experience, with all the holes in that famous cheese neatly lining up – perhaps. But enough. There is the investigation, ATSB, CASA and the Coroner to consider.
'Well, sir,' said the captain, 'better speak plain, I believe, even at the risk of offence. I don't like this cruise; I don't like the men; and I don't like my officer. That's short and sweet.”
Where to begin is a puzzle – chicken and egg variety; not to mention 'history' and the internal battles being waged – at the expense of a fair 'no blame' analysis. No matter how supportive of the ATSB and CASA you may be; there are elements within the 'official' dealings which, not only highlight the dysfunctional and the duplicitous, but the endless quest to avoid any and all responsibility for even producing a fair, reasoned and unbiased report into a recurrent safety matter; to wit - VFR into IMC and the increasing blood bill.
P2's posts, - analysis and - comment on these antics, read carefully provide an insight. I know! It takes time and thought, but this is not Witter or farce-book or that other unmentionable forum. There are elements within the ATSB and Coroner reports which demand consideration. For example (and there are many) the Coroners rejection of the first ATSB effort, his anger over witness statements withheld in a previous case; the MoU in place and the way it was used; the pogrom against Par-Avion despite CASA being 'comfortable' with the operation and the standards. Then there is the naivety, clearly visible which is trying to lay blame on the 'documents' provided to pilots related to operations in South West Tasmania. I will leave the 'homework' up to the reader: but, we are offering Choc Frogs to anyone who can, without equivocation, fluff or nonsense answer two questions:-
^ Translate the Safety Recommendation issued by ATSB to CASA to plain English with motive analysis.
"The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority amend its acquittal process for repeat safety findings to ensure it is effective in ensuring that all previous findings of a similar nature are also appropriately assessed prior to the current and all associated safety findings being acquitted.
^^ Explain why a 'routine' investigation was upgraded to a 'systemic' investigation and yet dismally failed to meet all the requirements of either; but felt free to go after the operator and the Regional CASA office.
"Systemic investigations can involve in the field activity, and a range of ATSB and possibly external resources. They have a broad scope and involve a significant effort collecting evidence across many areas. The breadth of the investigation will often cover multiple organisations. Occurrences and sets of transport safety occurrences investigated normally involve very complex systems and processes."
There is (once gain) no clear, definitive solution or advice or reasoning provided, in this ATSB report; for a no blame outfit, they sure like to throw it about – in a sneaky way. CASA have no case to answer; bar the 'dumbing down' of flight crew who have so much 'other stuff' to contend with that the basics are often simply a matter of 'tick, flick and forget; too much gravy, not enough spuds and meat. This Coroner, like many before him has been 'frustrated'. These are not, in the main, silly people: they see a lot of the darker side of this life and carry a very real responsibility. The history of previous Coroner dealings with ATSB in another matter added to this latest effort would make a stone idol cranky. ATSB are degenerating from a laughing stock into an operational, legal and investigative pariah; time to pull up their sock methinks – or sod off and shut up. Not good enough, not for the money and power granted; nowhere near good enough. Shame on them.
“If someone is able to show me that what I think or do is not right, I will happily change, for I seek the truth, by which no one was ever truly harmed. It is the person who continues in his self-deception and ignorance who is harmed.”
Phew! Quite the ramble; but seriously, read P2's posts – its all there. WTD ATSB think they are about is beyond any sensible rational. Unless of course you weigh into the 'operational' v 'legal' brawl - the Tote is open on that one for any brave enough to take a punt.
Having said all that, I've quite run out of puff; there were 'other' matters to deal with; but thirst, hunger and wet boots clamour for attention. Boots off first or raid the fridge and grab a sausage roll on the way back to boot park. Silly question really.
Selah... _ _ _?