[Peetwo]

Update 17/03/17: Widow condemns CASA as 'incompetent' & 'dysfunctional' -

Reference posts:

Next I note that NSW Deputy Coroner today handed down his findings on the tragic 2013 Dromader fire fighting accident near Ulladulla. From AAP via the Oz:

Pilot died after 'inadequate' inspection

• Jodie Stephens
  
• Australian Associated Press
  
• 4:32PM March 13, 2017
  

A waterbombing pilot fighting a NSW blaze was killed after his plane's wing broke off mid-flight as a result of cracking and corrosion that was missed during an "inadequate" inspection months earlier, an inquest has found.

David Black, 43, died when his M18 Dromader aircraft crashed in an isolated and mountainous area of the Budawang National Park, in the state's south, on October 24, 2013.

The experienced pilot was preparing to attack a bushfire when the left wing of his aircraft suddenly broke off, causing the aircraft's rapid descent, Deputy State Coroner Derek Lee wrote in his inquest findings released on Monday.

Mr Black left behind his wife of 12 years, Julie, and three young children.

"David and Julie had worked together as a team, industriously, to reach a stage in life where their business was successful, their family was nurtured and cared for, and they were simply able to enjoy life," Mr Lee wrote.

"To lose David in sudden circumstances is heart-rending."

The plane Mr Black was flying was owned by his company, Rebel Ag, which provided aerial support to the NSW Rural Fire Service.

It was tested and inspected just over two months earlier by two companies, Aviation NDT and Beal Aircraft Maintenance, but Mr Lee said the work was inadequately done.

He wrote in his findings that testing by Aviation NDT used an unauthorised method and did not comply with the mandatory requirements of the Civil Aviation Safety Authority.

Further, the plane's wings were not removed during a visual inspection by Beal Aircraft Maintenance, meaning that corrosion and cracking on one of the left wing's attachment lugs was not detected.

By the time Mr Black crashed in October, the Australian Transport Safety Bureau found that cracking on the inner surface of the lug had reached a critical length of 10.4 millimetres and at least 32 secondary micro cracks were also identified.

The engineer behind the visual inspection, Donald Beal, told the inquest the manufacturer's service bulletin did not mandate removal of the wings, so he didn't see any need to remove them.

Mr Beal also said there was ambiguity about what visual inspections actually involved, Mr Lee recalled in his findings.

At the NSW Coroner's Court on Monday, Mr Lee recommended that CASA consider issuing a directive that wings be removed during inspections of M18 Dromader planes.

He also recommended they consider a different way of calculating fatigue damage, which did not just rely on flight hours but also looked at other factors that age an aircraft, such as its speed and the weight of loads that it carries.

A CASA spokesman said they would consider the recommendations carefully.

Update to NSW Deputy Coroner report.

Firefighting plane that crashed killing pilot had maintenance issues, inquest finds
ABC Online
 - ‎1 hour ago‎

The Sydney court heard Mr Black's plane was inspected on the 8th of August, 2013, using an alternative, less sensitive procedure that was not approved by the Civil Aviation Safety Authority (CASA). In his report, the Coroner asked: "Was the August 2013 ...

---

Safety inspection failed to detect fatal corosion in plane's wing
dailytelegraph.com.au
 - ‎5 hours ago‎

State Coroner Derek Lee found on Monday that an inspection of the plane conducted 11 weeks prior to the crash used an unauthorised method and did not comply with the mandatory requirements of the Civil Aviation Safety Authority. Cracking and corrosion ...

Courtesy the Oz today:

Solo mum keeps business afloat

Julie Black has been flying solo for the past 3½ years in more ways than one.

..After the accident, Ms Black had to replace the Dromaders with Air Tractors, and find a chief pilot, as well as juggling the raising of her children. “The business is still going. It is still employing people and maintaining services to our clients,” she says.

Ms Black vowed to never put pilots in Dromaders again and has since bought four Air Tractors for spraying.

“It has been extremely hard when you are used to working with someone in a partnership for 17 years, and been able to tag-team between work life and home life,’’ she says.

“When you have lost that 50 per cent and you are now 100 per cent on your own … all our decision making was done ­together.

“Now I lie in bed and night and wonder if I have made the right ­decision and what would David have thought about whatever the issue is at hand.’’

‘Incompetent’ CASA slammed

...Ms Black said the inquest by the deputy State Coroner Derek Lee showed the crash involving a Polish-built M18 Dromader was a textbook example of the Swiss cheese theory of accidents. This theory postulates that holes develop because of human error and dysfunction, and eventually they link up to cause serious accidents.

“In this accident when you go back and you look at all the holes that were lining up over a matter of 13 years, this aircraft was doomed. Had we known that we obviously would never have flown it,” Ms Black said. “When you go back through the ATSB report you can see the holes developing right back to 2000. In just about every single one of those holes CASA is involved. How CASA originally said you could use a flawed testing system (the eddy current technique) is unbelievable. It was contrary to what both the manufacturer and the FAA had mandated as the correct testing method.”

Ms Black’s solicitor, Mark Gray-Spencer of GSG Legal, said the evidence presented to the inquest clearly showed CASA failed to identify the fact that the maintenance company, Beal Aircraft Maintenance, and its non-­destructive testing company, Aviation NDT Services, was using the wrong method to test the attachments on the Dromader wings.

“Aviation NDT used an eddy current technique to test the wing attachments which was contrary to what both the manufacturer and the FAA said should be used. Both had advised that Magnetic Particle Testing had to be used,” Mr Gray-Spencer said.
“Six weeks after the approval from CASA for the eddy current technique was sent to Neil Joiner (of Aviation NDT Services), CASA issued an airworthiness directive (AD) stating that you had to use magnetic particle testing. This was inconsistent with the eddy current technique approval. The maintenance organisation should have looked at the AD and realised their procedure was not OK.”

An AD is a legislative instrument issued under federal law.

“For 13 years, from the issuing of the AD until the accident, the wrong testing was used,” he said...

And here is Pinocchio Gobson with the totally predictable zero care, zero responsibility, "we're looking into it" bollocks statement:
   
“CASA has been looking carefully at the Coroner’s report and recommendations. There are a range of issues to be considered and CASA is working through these methodically. We appreciate issues raised by the family are important.”

- That is word-weasel bureaucratese for.. "this will be O&O'd till we can quietly shuffle the report in to the infamous CASA shelf-ware out-tray"  -  

P2 comment: Gutsy lady Ms Black! - Welcome to the ranks of the IOS...


MTF...P2

Ps "K" this may have to be moved to the 'Closing the safety loop' thread...

A complimentary round trip ticket.

P2 – “And here is Pinocchio Gobson with the totally predictable zero care, zero responsibility, "we're looking into it" bollocks statement:
 
“CASA has been looking carefully at the Coroner’s report and recommendations. There are a range of issues to be considered and CASA is working through these methodically. We appreciate issues raised by the family are important.”

- That is word-weasel bureaucratese for.. "this will be O&O'd till we can quietly shuffle the report in to the infamous CASA shelf-ware out-tray"  -  

P2 comment: Gutsy lady Ms Black! - Welcome to the ranks of the IOS...

Welcome indeed. One of the reasons people can sit at home watching horrific stories of carnage, destruction, tragedy, fire or even aircraft accidents on the TV while eating their dinner is that it ain’t ‘personal’. Nowadays, folk rush off to ‘counselling’ after they’ve had a splinter removed from their arse and tell everyone who will listen about the trauma and how they intend the sue the council because the park bench surface was not ‘safe’. Why? Well it’s now ‘personal’. It’s the same with ‘CASA contact’; until the filthy spectre has tapped you on the shoulder; it ain’t personal. But when it does……Problem is that from the minister down, no one, except those affected ‘get it’. The vast majority of aircrew and engineers have never had the dubious pleasure of dealing with CASA other than in the routine way of medicals and such. DAME’s, Chief pilots, etc. all have had ‘the experience’ even then that’s a mixed bag: and, the 'go along to get along' syndrome has resulted in some truly awful aberrations; I digress. See Thorny’s post – HERE – for just a small part of the problem.  

P2 - “Ps "K" this may have to be moved to the 'Closing the safety loop' thread...

It probably should be mate; but you know as well as I the CASA response to coronial recommendations; they are treated as opinion. What did we examine when we did the analysis; some thirty or so cases? We selected just a few to provide a range and for all the good that hard work has done, we could have stayed in the pub; (practiced your darts).

HITCH - (Oz Flying)– “Only by the reaction to these truths can we judge the commitment of the Federal Government. However, we need to lift our chins and plod on; we have more hope of reform with the advisory group than we would have without them.”

Hitch and probably the GAAG understand the truth of it; but, what else can they do? The ‘CASA’ experts who have royally buggered the system and wasted hundreds of millions while getting paid handsomely to do so now expect ‘help’ from industry experts, who are not only doing it all ‘for love’ but taking time, resource and energy away from their own interests. Do they have to cooperate? Well I suppose they do; but its not the first time and it most certainly will not be the last time an industry advisory panel has laboured – in vain. History children, history. Not too far back – Pel_Air?, Forsyth? Ring any bells?

FWIW, I reckon the minister and CASA are taking the Mickey – again; same old tune, same old result. One may fervently hope for the best but it always most sensible to expect and prepare for the worst.

We wish Mrs Black well and any small support we can offer. The first part of this story is tragic and life changing; the second part is in the lap of the gods. Personally, I would not abandon all hope just yet, but I wouldn’t be holding my breath either.

Toot toot.