Of metaphors, both mixed and muddled.
Well, not really metaphors; but it is a close descriptor to the jumble of 'information' and analysis the 'Essendon DFO' event has created. That the aircraft collided with one of the buildings is beyond doubt. The ATSB have produced two reports; one into the flight path and etc. One into the legal aspects of where the buildings are located. Both (IMO) inconclusive muddled word pools. There are two clearly separate stories here, each should be considered and analysed as 'stand alone' items, for clarity.
“How often have I said to you that when you have eliminated the impossible, whatever remains, however improbable, must be the truth?”
The first element of the event is the aircraft and the flight path; take the DFO building out of the picture for a moment and ask – could control have been regained before a collision with terrain occurred? From almost the moment power was applied, the aircraft began diverging from the centre line. The subsequent events and the radio calls leave the impression that there was something amiss within the cockpit. When taken in conjunction with the events at Mt Hotham; it is reasonable to consider and investigate if there was some form of medical condition existing; perhaps undetected or even undeclared. The first event perhaps a clear warning that all was not well; the second event in a more critical environment. The glib assertion that 'full left rudder trim' was the radical cause is a nonsense; post, pre-flight, pre-take off checklists almost eradicate the possibility; over 20 knots IAS the error would be become apparent and quickly rectified. The shocking lack of detailed examination in the ATSB report begs many questions. Questions which should begin from the application of take-off power; through the track along the runway, into the radio calls and on through to the collision event. Hood's hasty appearance 'on-site', potential for contamination of site and quick pronouncement of 'rudder trim & pilot error' leave a faint, but unmistakable odour and cast a shadow over the probity of subsequent investigation. It all leaves a major question unanswered – Pilot error v Pilot incapacitation, - never fully answered, but quickly used to distract from the notion that the buildings have no right to be there under the existing runway classification.
“There are works which wait, and which one does not understand for a long time; the reason is that they bring answers to questions which have not yet been raised; for the question often arrives a terribly long time after the answer.”
Consider the cynical, buried line in the manual – Aircraft operators must determine the suitability of the aerodrome for their operation (paraphrased). In short all responsibility rests with the air operator – you use it – your risk – (hope you noted the reduced margins for the insurance company). Which leaves us with two questions.– Had the building not been there, could a control recovery have been affected? Two schools of thought on that. But secondly should the DFO and the Dan Murphy edifice have ever been allowed to be built within the safety (ICAO promulgated) margins? Chicken and egg job that – if treated together; simple enough if separated, as it stands the margins are blurred together, muddled and obfuscated..
The aerial shot provided by the ATSB on the front cover of their 'report' is deceptive. Shots taken along the runways would present a much clearer, accurate picture of the impingement of a 'wall of concrete' up close and personal on both runways. Irrespective of the DFO event those building have not been proven to be ICAO 'black letter' legal; there is enough evidence of 'sharp' practice and liberty taken to demand a serious inquiry. The citing of 'grandfather' clauses is slippery and hard to justify if one tracks back through ICAO data. For example the 'approved' use of a 180 mt wide 'strip' notification (overlooked) has never been 'attributed' or substantiated or even verified; it seems to have morphed as fact and been ratified – but its origins cannot be determined; certainly not under the ICAO grandfather guidance material. So where did it come from and how did it become not only 'accepted' but 'missed; during the many approval checks required before building and operational approval? But, to me the big question is why were the buildings located where they are. The highway gives you a clue; the hope of the developers is 'if you build it – they will come'. But how will they get there? The shortest, least expensive 'access' road leads to the exact spot – take look at the overhead shots – build anywhere else and the costs and headaches escalate. So slip in a reduced runway strip width and Bob's your uncle, bonus all round. All good until – something goes wrong. The gods were smiling that day – a hour later and ten foot lower – the carnage would shock the nation.
Not good enough; not by a country mile it ain't; made worse by the avoidance of responsibility and shunning of probity...
Hitch - in a nut shell:-
The ATSB looks like it has been down a rabbit hole the size of the Grand Canyon in its efforts to find out why a DFO was built so close to a runway at Essendon. After five years of investigation and compiling a 146-page report, the ATSB has laid out all its findings, but tellingly has made no recommendations. Here's my summary as I see it. The DFO was built so close to runway 26 because CASA told them the OLS could be based on a 180-m wide runway strip, as was the width of the runway that had been published for a number of years. However, no-one can remember why the runway width was ever set at 180 m and no records can be found. Had the required 300-m width been enforced at that time, the DFO would have had to have been set back further, unless an exemption was granted. What all this tells me is that somehow, some way, the system failed to raise a red flag at a crucial time in the approval process. The runway width is still set at 180 m despite it being less than standards required because of the grandfathering provisions of Part 139. It's important to note that this grandfathering happened during the course of this investigation, and now shores up the legitimacy of the runway width. Despite sifting through the minutiae of Australian and international airport standards, the ATSB has been unable to flag any changes that could prevent such a thing happening again. And you can be assured that sometime in the future, one of the operators of the Commonwealth leased airports will want to build something closer to a runway than the standards allow. At that time, we will see if any lessons have been learned from the Essendon DFO.
Toot – toot..
Well, not really metaphors; but it is a close descriptor to the jumble of 'information' and analysis the 'Essendon DFO' event has created. That the aircraft collided with one of the buildings is beyond doubt. The ATSB have produced two reports; one into the flight path and etc. One into the legal aspects of where the buildings are located. Both (IMO) inconclusive muddled word pools. There are two clearly separate stories here, each should be considered and analysed as 'stand alone' items, for clarity.
“How often have I said to you that when you have eliminated the impossible, whatever remains, however improbable, must be the truth?”
The first element of the event is the aircraft and the flight path; take the DFO building out of the picture for a moment and ask – could control have been regained before a collision with terrain occurred? From almost the moment power was applied, the aircraft began diverging from the centre line. The subsequent events and the radio calls leave the impression that there was something amiss within the cockpit. When taken in conjunction with the events at Mt Hotham; it is reasonable to consider and investigate if there was some form of medical condition existing; perhaps undetected or even undeclared. The first event perhaps a clear warning that all was not well; the second event in a more critical environment. The glib assertion that 'full left rudder trim' was the radical cause is a nonsense; post, pre-flight, pre-take off checklists almost eradicate the possibility; over 20 knots IAS the error would be become apparent and quickly rectified. The shocking lack of detailed examination in the ATSB report begs many questions. Questions which should begin from the application of take-off power; through the track along the runway, into the radio calls and on through to the collision event. Hood's hasty appearance 'on-site', potential for contamination of site and quick pronouncement of 'rudder trim & pilot error' leave a faint, but unmistakable odour and cast a shadow over the probity of subsequent investigation. It all leaves a major question unanswered – Pilot error v Pilot incapacitation, - never fully answered, but quickly used to distract from the notion that the buildings have no right to be there under the existing runway classification.
“There are works which wait, and which one does not understand for a long time; the reason is that they bring answers to questions which have not yet been raised; for the question often arrives a terribly long time after the answer.”
Consider the cynical, buried line in the manual – Aircraft operators must determine the suitability of the aerodrome for their operation (paraphrased). In short all responsibility rests with the air operator – you use it – your risk – (hope you noted the reduced margins for the insurance company). Which leaves us with two questions.– Had the building not been there, could a control recovery have been affected? Two schools of thought on that. But secondly should the DFO and the Dan Murphy edifice have ever been allowed to be built within the safety (ICAO promulgated) margins? Chicken and egg job that – if treated together; simple enough if separated, as it stands the margins are blurred together, muddled and obfuscated..
The aerial shot provided by the ATSB on the front cover of their 'report' is deceptive. Shots taken along the runways would present a much clearer, accurate picture of the impingement of a 'wall of concrete' up close and personal on both runways. Irrespective of the DFO event those building have not been proven to be ICAO 'black letter' legal; there is enough evidence of 'sharp' practice and liberty taken to demand a serious inquiry. The citing of 'grandfather' clauses is slippery and hard to justify if one tracks back through ICAO data. For example the 'approved' use of a 180 mt wide 'strip' notification (overlooked) has never been 'attributed' or substantiated or even verified; it seems to have morphed as fact and been ratified – but its origins cannot be determined; certainly not under the ICAO grandfather guidance material. So where did it come from and how did it become not only 'accepted' but 'missed; during the many approval checks required before building and operational approval? But, to me the big question is why were the buildings located where they are. The highway gives you a clue; the hope of the developers is 'if you build it – they will come'. But how will they get there? The shortest, least expensive 'access' road leads to the exact spot – take look at the overhead shots – build anywhere else and the costs and headaches escalate. So slip in a reduced runway strip width and Bob's your uncle, bonus all round. All good until – something goes wrong. The gods were smiling that day – a hour later and ten foot lower – the carnage would shock the nation.
Not good enough; not by a country mile it ain't; made worse by the avoidance of responsibility and shunning of probity...
Hitch - in a nut shell:-
The ATSB looks like it has been down a rabbit hole the size of the Grand Canyon in its efforts to find out why a DFO was built so close to a runway at Essendon. After five years of investigation and compiling a 146-page report, the ATSB has laid out all its findings, but tellingly has made no recommendations. Here's my summary as I see it. The DFO was built so close to runway 26 because CASA told them the OLS could be based on a 180-m wide runway strip, as was the width of the runway that had been published for a number of years. However, no-one can remember why the runway width was ever set at 180 m and no records can be found. Had the required 300-m width been enforced at that time, the DFO would have had to have been set back further, unless an exemption was granted. What all this tells me is that somehow, some way, the system failed to raise a red flag at a crucial time in the approval process. The runway width is still set at 180 m despite it being less than standards required because of the grandfathering provisions of Part 139. It's important to note that this grandfathering happened during the course of this investigation, and now shores up the legitimacy of the runway width. Despite sifting through the minutiae of Australian and international airport standards, the ATSB has been unable to flag any changes that could prevent such a thing happening again. And you can be assured that sometime in the future, one of the operators of the Commonwealth leased airports will want to build something closer to a runway than the standards allow. At that time, we will see if any lessons have been learned from the Essendon DFO.
Toot – toot..