First this week’s SBG:
Oh, I love a ducked up country,
a land of counter claims
a land of government agencies,
that listen carefully to complains,
a purpose of avoiding all the blame.
A land of broken aeroplanes,
Of pilot’s widows grieving,
awaiting someone to explain
Why their loved ones went away
and won’t come home this Christmas day…Anon…
There comes a time (in all good establishments) when the Landlord calls “Time gentlemen please.” It means its time to pay your slate; drink up and go away. It is not only my opinion which believes it is only minutes now until a responsible government calls ‘Time’ on the ATSB; anything less would not only be a travesty, but could (indeed should) result in some serious embarrassment to the incumbent minister. The basic purpose of the ATSB, in simple terms is to ‘investigate’ accidents, determine the facts and present, in some form, a probable cause and where possible suggest ‘ways and means’ to prevent a repeat, through analysis and advice to industry. Before we continue, I ask you take a careful read through the following report into a fatal event at Lockhart River before we continue this discussion.. – HERE -:::
Can anyone see the great travesty contained within the opening stanzas? The deception? – A layman wouldn’t, a politician certainly could not; indeed they would probably think it was money well spent. BOLLOCKS. It is an exhibition of total, complete, utter and abject failure to perform design function. The ‘travesty’? Oh, sorry I meant to explain; an error which I will immediately correct. There are three separate ‘lessons’ of great value to ‘safety’ which ATSB have completely overlooked. These should have been the focus of the ‘investigation’ summary, in order to drive home to industry exactly ‘why’ certain ‘practices’ should never be contemplated, let alone used in marginal weather flying operations. Australia has a significant number of fatal events, every year, due to these elements. Had the ATSB had the wit, expertise and fully understood their basic function; then the opportunity to ‘hammer home’ a safety lesson would have been taken. Alas. Enough back light; now for the spotlight…
“The pilot conducted the first approach consistent with the recommended (3°) constant descent profile, and the aircraft kept descending through the minimum descent altitude (MDA) of 730 ft and passed the missed approach point (MAPt). At about 400 ft, the pilot commenced a missed approach.”
After conducting the missed approach, the pilot immediately commenced a second RNAV GNSS approach to runway 30.
During this approach, the pilot commenced descent from 3,500 ft about 2.7 NM prior to the intermediate fix (or 12.7 NM prior to the MAPt). The descent was flown at about a normal 3° flight path, although about 1,000 ft below the recommended descent profile. While continuing on this descent profile, the aircraft descended below the MDA. It then kept descending until it collided with terrain 6.4 km (3.5 NM) short of the runway. The pilot and 4 passengers were fatally injured, and the aircraft was destroyed.
“I know that two and two make four – and should be glad to prove it too if I could – though I must say if by any sort of process I could convert 2 and 2 into five it would give me much greater pleasure.”
Why? Under the CASR – this is a criminal act: no if, but or maybe. This was deliberate breach of not only the regulations, but of solid good aeronautical sense. Its bloody dangerous. We’ve all done it – pinched 50 or even a hundred feet on a ‘sketchy’ visual call – multi crew – but single pilot under the IFR? This statement from the ATSB reveals much about how little they ‘understand’ of flight operations. Great at ‘bird strikes’ but; my Mamma can see the wisdom in avoiding, where possible ‘close encounters’ with the avian species – no brainer really. But, in tricky weather to opt for a very ‘dodgy’ approach? It begs the question – why would an IFR qualified pilot deliberately continue as scripted? We know he did. Even so – take a very close look at this picture provided by the ATSB (magnify and enhance if you can – its worth the effort). Look very close indeed – at where cowling meets wing – can you see it? The perennial ‘sucker trap’. Light and shadow – murk up above, terrain and a horizon below that. This is a very good picture of how VFR pilots get lured into IMC and how junior IFR pilots will deviate from the published procedure – the majority ‘learn’ how this trap can and often is ‘sprung’. But every once in awhile it snaps shut – 5 dead. End of.
“Contrariwise,’ continued Tweedledee, ‘if it was so, it might be; and if it were so, it would be; but as it isn’t, it ain’t. That’s logic.”
That picture and any others available should have been be made into a briefing on the tricks and traps of how light, cloud and rain can deceive. The picture also demonstrates exactly and precisely the right circumstances which will create spatial disorientation. These are the real, valuable lessons from this fatal event. ATSB have waffled on for reams and failed, utterly, to provide in any way shape or form anything of ‘safety’ value to industry. Yet its all there – waiting to be used as a salient lesson and of benefit to the Coroner. This report, an elegant pile of ‘stuff and nonsense’ has neither intrinsic or practical value to anyone – except to the Popinjay’s aspirations to empire.
“If you have built castles in the air, your work need not be lost; that is where they should be. Now put the foundations under them.”
Next we must ask – what persuaded this pilot to throw away any form of ‘single engine’ overshoot safety margin by going around 330 feet below the overshoot gradient, this has not been explained – not even in terms of basic OEI ‘performance’. From 730′ at the operating weight – the loss of an engine on go-around would have been ‘interesting’ but survivable – from 400′ – not so much. It is always one of the ‘challenges’ airline training pilots face, to ensure that a ‘disciplined’ attitude to SOP is adhered to; with a multi crew scenario ‘minima’ is ‘rock solid’ to ensure that the ‘worst case’ on an OEI go around does not end up a smoking pile on a mountain side somewhere, due lack of climb performance to achieve the gradient required.
Rant over – but this ATSB report is nothing more than desktop generated, cheap window dressing; padded, fluffed up and fit only for the political audience – it ain’t worth a ‘squirt’ as a ‘safety’ document; it is simply a waste of time, money and effort providing little of value to the industry the ATSB is supposed to serve.
P2 – “Godley justifies continuing because we now have 2 fatal s involving bird-strikes in less than a year. Yet we have two complex midair collisions killing 6 people in 2 years and we have nothing to see here?? – FDS!” (Spot on mate).
Sandy – “I m sure you understand that being Glen’s representative its most important that you assess his case in detail. I, and many others, would be happy to answer any questions you may have, by way of information of how the system has been working.”
Subtle enough, concise and to the point – and a great example of a slight ‘understatement’ – just a bit. But how else is the message delivered to be presented? How, when we are left with ‘bloody fools’ like McCormack who skull Kava down and wonder why they’re rendered ‘sedated’; and, still on the tax payer payroll ? It will take a very intelligent, brave, honest, well supported, very sure of the ground beneath politician to call out CASA. But; if such a ‘Statesman’ (generic) emerged from the ranks and dared to invite ‘all’ industry complaints to a ‘no holds barred’ inquiry; there would be a story which would, in no uncertain terms; shock the nation. Buckley is but the merest pinnacle of a very large iceberg. A ‘smart’ minister would, if properly advised, get well out in front of the Buckley case; for in a very short while the Pascoe case will be released – transcripts and all. Standing alone; these are but ‘tales’ which can be and are ruthlessly portrayed as nothing to fret about. But they are; and if there was ever a platform, delivered by a politician of any stripe to examine the ‘dark side’ of the ways CASA operates; well, lets just say there would be some serious changes made, all to the benefit of the nation, the budget and political credibility. It is worth some serious consideration – first in, best dressed methinks.
But enough – DT seems Hell bent on destroying Sunday peace and harmony – more visitors – and I could do with a quiet day, been a long week – alas. All started with ‘can you build me a cupboard here’ – no problem except it was to be fastened to a wall. You guessed it – first I had to build the ‘wall’. 160 metres of 4×2 Stud was all it took, the drop saw on overtime. The cat came along (routine now) when you are cutting a 5.6 metre into 600 mm ‘noggins’ you really don’t expect to see a cat sitting, calm and peaceful on the next mark to go under the saw blade – do ya? ‘Wanna move” say’s I – a languid stretch precedes an elegant dismount and an amble to park on the next length into the saw. Never sure whether to laugh or throw something at it. No matter, there is a breeze, Flying foxes and a clear sky: I believe we may ‘go a roving’ – away dogs! the orchard gate awaits.
Also from the forum: