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“It’s an ugly, dangerous business, Watson”. AP Forum version

I played around with the idea of redrafting and shaping the ATSB carefully edited placebo into a real report into a real fatal accident which claimed the lives of three experienced pilots. A routine assessment flight with a dual purpose – (a) to re-quantify a pilot on type for line operations and; (b) to qualify a pilot as a ‘check-pilot’ on type. But, it is far too serious an event to mess about with. In fact, it is almost too serious a matter for the Coroner to be handling alone.

Let us, just for the moment put aside the many peripheral issues attendant; there are many. But, in primus, the accident itself must be closely examined before anything else. Much depends on the Coroner. Anyone who does not know nor is aware of the undercurrents surrounding this event; or, a layman reading the ASTSB report could be forgiven for concluding one thing – pilot error – writ large. But was it? Really? What would a jury of qualified check and training pilots have to say about the event. No matter how well legally qualified a Coroner is, he simply cannot, not could possibly have the same depth and understanding of the situation as his jury would. ‘Pilot-error’ is an easy verdict; ATSB would have you believe it is so and the ‘paperwork’ is nicely arranged to lead a stranger to that conclusion. The ‘balance of probability’ is a strange and wonderful area into which ‘we’ must now stray.

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“There comes a time when one must take a position that is neither safe, nor politic, nor popular, but he must take it because conscience tells him it is right.” ― Martin Luther King Jr., A Testament of Hope: The Essential Writings and Speeches

Consider this; having spoken (at length) with experienced simulator operators about the Conquest (C441) aircraft it can be said that with an engine set at ‘flight idle’ there is around about an 8 to 10 second window after which rudder control become ineffective; the use of aileron is, in this situation a known killer (technical). There are three qualified multi engine pilots on board who are very, very well aware of this fact. There were three qualified, competent men on board who fully understood that the ‘zero thrust’ setting was the only ‘safe’ option. ATSB are asking a jury to believe that three men, fully aware of the limitations and protocols would sit there, like stunned mullets, while the aircraft slipped away from being controlled – and did nothing. Ask yourself – on balance of probability, could this have happened? Is it likely? Three experienced men, a clear day, at least 600 feet to play with, two serviceable engines – and they ‘lost it’. Oh, I think not.

“Conquest Simulator in America. They highlighted a lot of the weaknesses in the Conquests systems and indicated that the aircraft I was flying was not set up correctly and similar problems are encountered on a lot of high time Conquests as was all of Rossair’s fleet”.

IMO, much higher on the list of ‘probability’ – Murphy’s Law, once again prevailed. Something went wrong. It could be as simple as a fuel computer decided to quit without notice; or, any one of several systems decided now was the time to develop a problem. Who would know – ATSB, despite the very chequered maintenance history and the attendant ‘money’ problems associated with engine/ airframe maintenance seem to have by-passed several matters which could; just maybe, have created an in flight problem. There is anecdotal evidence that the aircraft’s engine were ‘in and out’ of rig and generally messed about with. No blame but, things can and do get ‘overlooked’ when time and money problems are on the table. The old rule of the Sea – if it can go wrong it will at the most inconvenient moment. On balance, without evidence to the contrary, can we ‘safely’ rule out a mechanical failure? No, we dare not – not without proof positive. 

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“Through pride we are ever deceiving ourselves. But deep down below the surface of the average conscience a still, small voice says to us, something is out of tune.” ― Carl Gustav Jung

Aye, something is ‘out of tune’ Well out IMO. Once you get past the slippery ATSB editorial analysis; there are lots of peripheral questions which are not answered. Like why would Ross Air take away a pilots home computer – claiming it was for the ATSB. Keep it a while “in a secure” lock up (did they have one?) when ATSB were surprised that they did not have it? Curious – it gets even more curious when you dig into the tale a little deeper; not my story. But it is one the which the Coroner should be obliged to evaluate. Not mark you that anything any Coroner has said in the past twenty years has made the slightest difference – but try they must.

From Up – ‘Duck Pilot’ : This accident should never of happened, CASA’s processes failed Steve and both of the two pilots who were tragically killed in this accident. The processes should never have allowed this training environment to occur.

Then this:-

Anon: ”Stephen Guerin at one stage was a Chief pilot of Rossair before CASA inspector.”

Anon: –Paul Daw was a Chief pilot of Air Charter which merged with Rossair, before CASA inspector.

Which brings us to Rumour and speculation. There is ‘allegedly’ a couple of ‘E-mails’ floating about the place which shed a new light on the ‘why’ of CASA’s failure to get it right (again). An example paralleling the Pel-Air fiasco – it seems they knew all about the ‘problems’ within Ross Air; or so I’m told. Then there’s the pitiful AFAP response – are they so dependant on their CASA members loot that they dare not become involved in anything related to pilots operating aircraft?

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“There is no witness so dreadful, no accuser so terrible as the conscience that dwells in the heart of every man.” ― Polybius

Oh; there’s lots of peripheral stuff – was any of it contributory to the accident event? Who knows. One thing stands out like the proverbial dog’s bollocks. The quality of the operations manual, the CASA sanctioned discontinuities and general confusion within those manuals left the aircrew essentially without clearly defined guidance, instruction and SOP. Back to the shades of Pel-Air.

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“They’re certainly entitled to think that, and they’re entitled to full respect for their opinions,” said Atticus, “but before I can live with other folks I’ve got to live with myself. The one thing that doesn’t abide by majority rule is a person’s conscience.” ― Harper Lee, To Kill a Mockingbird

An essentially tarted up ATSB report which can and probably will lead a Coroner up the garden path of ‘safety’; CASA covering it’s sorry arse; operator gone with the wind – is everybody happy? Oh, yes M’lud – de ducking lighted we is..

That is enough ramble for me; I just don’t believe the ATSB scenario. But; it matters not. I’m signing off here – the dogs can hear vehicles approaching – P7 and a couple of BRB heavies – come to drink my Ale and discuss matters aeronautical. Can’t wait – Skype and all is OK but not the same as the real thing, sat in my stable. No where near the same. Must be P7 first – dogs exeunt stage right doing about 20 knots (he smuggles treats in for ’em).

If you wake at midnight, and hear a horse’s feet,
Don’t go drawing back the blind, or looking in the street;
Them that ask no questions isn’t told a lie.
Watch the wall, my darling, while the Gentlemen go by!