Aircraft crash north of Melbourne

[Jeff Gordon]

(Please note this thread serves as a learning tool of discussion regarding the accident listed at:

 

http://www.recreationalflying.com/threads/plane-crash-north-of-melbourne.28077/ -Ian)

 

He was roughly 14 Nm off track to the north.Last light at Horsham on Monday was 5:57 pm EST

The area aroumd Horsham is wide open wheat country

Perhaps they were flying under cloud with land rising underneath them, then continued in the dark for the last half hour of the flight. A very difficult situation and decision for the pilot to press on or not to press on, or to make a precautionary landing before last light. The pressure on the pilot would be immense, particularly if you factor in the psychological effects of a scheduled "mission" on operations that are planned in advance but terribly weather dependent.

 

 

[nong]

The honeymoon might be over for Angel Flight.

 

Were the passengers given the information they needed to assess the level of risk to which they were being exposed?

 

Were they with a private pilot operating outside a structure that could impose discipline and guide the operation?

 

Were the passengers under the impression that Angel Flight provided an equivalent operational standard to that provided by, for example, the RFDS? Does it?

 

Considering that Angel Flight uses the electronic media to promote and offer what appears to be some sort of air transport service......

 

- Does it have and is it required to have an an AOC and does it have operational standards equivalent to those required of a charter operator?

 

If reports are correct, how does Angel Flight explain carrying possibly poorly informed passengers after last light in dodgy weather in a Cherokee 180?

 

Does Angel Flight take the position that it merely "facilitates" pilots getting together with passengers in the way that a travel agent might claim?

 

Should be interesting.

 

 

[Spin]

Honeymoon? Maybe go back n read #26 (in the previous thread), the choice for most of these people is no choice, they either rely on charity or they forgo treatment.

 

 

[Jeff Gordon]

Right on Turbo...I'd take the bus anyday...and read a nice book....what' a few more hours when you have the rest of your life to live. The second tragedy here is that a great and well meaning orgnisation may get their wings clipped because of one incident.

 

 

[dunlopdangler]

do u really reckon that right Spin??.............or should 'well meaning amatuers'...disguise themselves as a 'professional organisation'?

you should remember cfi..(and nong) that there are quite a few well meaning professionals as well in an amatuer and well run and well meaning organisation such as AF doing great work helping vulnerable people in some of their darkest periods in their lives. Everything that AF does, it does with a paramount emphasis on safety. This accident will only reinforce the resolve of everyone concerned to keep the high standard that is expected. Instead of knocking...put your hand up (and also into your hip pocket and help as well) Even the professionals can get it wrong sometimes as there has also been tragic accidents within RFDS and other air ambulance operators. Even one accident in over 11,000 missions is one too many!!

 

 

[Spin]

do u really reckon that right Spin??.............or should 'well meaning amatuers'...disguise themselves as a 'professional organisation'?

Not sure I follow exactly where you're going with that cfi, bit cryptic for this time of morning. Just for the record though, no I don't think that well meaning amateurs (read charity) should need to disguise themselves as a quasi airline. I'm afraid Monday morning quarterbacking, as our trans Pacific cousins say, is a pet hate and trying to overlay AOC's and the associated cr@p over the top of what has never pretended to be anything other than a charity to help rural patients, is the surest way of bringing the whole enterprise to a screeching halt. Safer, oh certainly, after all aircraft that stay on the ground don't crash, but not exactly helpful to a patient out bush.

 

To put my comment in context, I was not referring to this specific incident, but the Angel flight concept as a whole, hence my use of "most... patients" in my original post. On the face of it the pilot here appears to have worked himself into a tight corner thanks to decisions made earlier in the day - and to have paid the ultimate price for it. Certainly a human factors lesson in there for all of us.

 

 

[Jeff Gordon]

This is the thread I will be watching now that the condolences have gone out. As a group of interested pilots and as the facts come to light, we can all learn from this accident. For instance I learnt from the PPRuNe site that the pilot left EN at 4pm headed North via Kilmore, hence was travelling over known territory and the reason why he was North of a direct track to Nhill. Another report was of a long scar on the land, which could lead one to believe a shallow entry, so my original comments still remain. See #1.

 

 

[Guernsey]

Speculation! Speculation! Speculation!

 

It was a news item....let's wait for the FACTS before speculating.

 

Alan.

 

 

[djpacro]

"The Law in Australia Relating to Negligence of Aircrew and Engineers" by Tony Pyne - presentation to the Melbourne Branch of the Royal Aeronautical Society in 1990. Back then Tony was a partner with Phillips Fox. For a time he was one of the independent Directors on the CASA (or its predessor) Board. Pilot and all round nice guy.

 

If anyone is interested I can send the 1.3Mb pdf. 17 pages - a pretty good reference on this topic.

 

Most aircrew and engineers recognise and accept the high standard required of them and the disastrous potential of their errors. This paper highlights what will inevitably happen to those who fail to do so.

[kaz3g]

 

 

The manufacturer eventually conceded and settled out of court. But this was a case where money changed hands - it was not a gratuitous service like Angel Flight. The test for a gratuitous service is remains gross negligence.

 

 

 

Please note this amateur legal advice is provided gratuitously with a disclaimer "What would I know, I'm not a lawyer?"

 

 

The case of (McAlister) Donoghue (a pauper) v Stevenson [1932] All ER Rep 1; [1932] AC 562 House of Lords is well known to all students of law as a leading decision by the then Master of the Rolls, Lord Denning.

 

 

 

CASA gives a useful summary at http://www.casa.gov.au/wcmswr/_assets/main/fsa/2006/jun/64-65.pdf

 

 

 

Note the question of whether a duty of care exists is to be determined according to the 'reasonable person' test:

 

 

 

You must take reasonable care to avoid acts or omissions which you can reasonably foresee would be likely to injure your neighbour. Who, then, in law is my neighbour? The answer seems to be - persons who are so closely and directly affected by my act that I ought reasonably to have them in contemplation as being so affected when I am directing my mind to the acts or omissions which are called in question.

 

 

 

But what of volunteers?

 

 

 

In most states, there is a sequal to the usual 'good samaritan' legislation designed to protect persons who assist in emergencies. In Victoria, for example, volunteer members of community organisations are immune from claims of negligence occasioned either by by act or omission when doing community work within the scope of their community organisation's activities.

 

 

 

The clear objective of the Acts in Victoria, Western Australia and South Australia is to ensure that where a plaintiff alleges negligence by a volunteer, the volunteer is protected from personal liability but the organisation for which they are volunteering may still be liable. NSW and Qld have complicated it a bit but I'm not going to attempt to cover their efforts here.

 

 

 

"Gross" negligence in connection with "gratuitous services"' seems to be a feature of US legislation and does not apply in statutes here as best as I can determine without more work.

 

 

 

kaz

 

 

[kaz3g]

"The Law in Australia Relating to Negligence of Aircrew and Engineers" by Tony Pyne - presentation to the Melbourne Branch of the Royal Aeronautical Society in 1990. Back then Tony was a partner with Phillips Fox. For a time he was one of the independent Directors on the CASA (or its predessor) Board. Pilot and all round nice guy.If anyone is interested I can send the 1.3Mb pdf. 17 pages - a pretty good reference on this topic.

Yes please :-)

 

kaz

 

 

[Jeff Gordon]

Has anyone heard any preliminary report on this incident? I noticed that the ABC made an announcement re the Chopper Crash at Lake Eyre on todays midday news.

 

 

[FlyingVizsla]

Horsham Angel Flight crash is still "pending" with final report due August 2012. ASTB is offering assistance to the RAAus & NSW police with the Curl Curl beach crash.

 

Status Reports are here: http://www.atsb.gov.au/publications/safety-investigation-reports.aspx?mode=Aviation

 

Sue

 

 

[68volksy]

Preliminary report now released. Looks like it could be an open/shut case of pilot error...

 

http://www.atsb.gov.au/publications/investigation_reports/2011/aair/ao-2011-100.aspx

 

 

[Gnarly Gnu]

Hmm... Geoscience gives a sunset time of 17:57 for 15/08/2011 at Wallup / Horsham.

 

Update: sorry, was in 1st comment.

 

 

[Jeff Gordon]

That's the first news of a landing in Bendigo that I have read. The Pilot was possibly being cautious in this regard due to his initial weather report. But something must have changed his mind (in Bendigo) to make him want to press on with the flight. It would be very interesting to find out what happened in Bendigo as the stop there opens another whole lot of questions. Did they stop and exit the plane, did they speak to anyone or download more weather information, did they take on fuel or similar?

 

 

[motzartmerv]

Its terribly sad.. blokes trying to do the right thing, and help someone out.. but even angels can't save you from this sort of thing..

 

When will the message get across??...

 

 

[turboplanner]

Jeff, the prune guys seem to have some information that he stopped at Bendigo to get an update on weather, and a passenger made a phone call to Nhill to check conditions there.

 

If that is correct, the first opportunity to call it quits was at Essendon when it was obvious the flight was due to arrive at around last light (He was NVFR endorsed), and the second opportunity was at Bendigo when the weather appears to have become an obvious issue.

 

I think, and it's only my thoughts from knowing the country, that the 500 acre paddocks and long distances between houses robbed him of the lights, which would normally give some form of horizon, that he would have been used to in the closer settled north east. Nhill had landing lights so that wasn't a problem, and if he'd tracked via the Western Highway that could have provided a stream of car and truck lights, but to get there he had to cross a lot of very dark country.

 

Motz, in reference to when will the message get across, I, after reading all the accident reports, have actually pushed on to the point where I opted to land at an airfield to reassess the weather report. There was no danger, but it is so easy to trap yourself into doing it.

 

This is a Human Factors issue where safe decisions are compromised, often paddock by paddock. How often to do hear people talking about scud running, and know they were just a simple change of wind from not returning?

 

 

[FlyingVizsla]

Jeff, the prune guys seem to have some information that he stopped at Bendigo to get an update on weather, and a passenger made a phone call to Nhill to check conditions there.

The preliminary report here http://www.atsb.gov.au/media/3467455/ao2011100_prelim.pdf has GPS plots, wreckage spread and a lot more information. The Bendigo stop - "While on the ground at Bendigo, the pilot logged on to the National Aeronautical Information Processing System (NAIPS), from which it was possible to access the most up-to-date aviation weather forecasts and reports. One of the passengers telephoned a family member at Nhill for an assessment of the weather there. On the basis of this assessment, the pilot decided to continue the flight and POJ departed Bendigo for Nhill at approximately 1711 (Figure 1)."

Sue

 

 

[Bandit12]

An interesting read. I noticed that there was no mention of NVFR currency either (real currency, not just 3 take offs and landings in the previous 90 days). Flying when the weather conditions are borderline is bad enough during the day, when you can make a judgement to undertake a precautionary landing if you had to. At night, that option is not quite as easy.

 

It really highlights the impact that outside pressures can make. I imagine that most people would not have chosen to fly that route at that time of the day/night, under those weather conditions, just for fun. But throw into the account that it was to transport a parent and sick child, and people will consider doing just that.

 

 

[Jeff Gordon]

Thanks, this is very interesting FV. The Preliminary Report on this very sad incident is certainly a very salutory lesson to all pilots in so many ways. I am not NVFR rated, but I guess when you get the rating there would be strong lessons about the type of weather and terrain you should be flying over. I am not following this thread for any morbid reasons but to implant in myself and other pilots the sort of safety boundaries that we need to place around us. This looks like a series of decisions by an experienced pilot, that compounded and produced the outcome of flying into terrain. The GPS trail from EN to Bendigo suggests dodging weather during the first part of the flight and right wing low on impact could indicate lack of orientation from a non instrument rated pilot in difficult flying conditions.

 

 

[turboplanner]

Then again would you have a passenger (if unlicensed) phone a friend (if unlicensed) for a weather assessment?

 

Given that you were Pilot in Command?

 

Given that the weather issue was big enough to use Kilmore Gap, and big enough to warrant an on-ground re-check?

 

The timeline from Bendigo probably tells most of the story. NVFR is just Night Visual Flight Rules, not Instrument Flight Rules so you must have reference to the ground at all times.

 

 

[Guest davidh10]

Then again would you have a passenger (if unlicensed) phone a friend (if unlicensed) for a weather assessment?Given that you were Pilot in Command?

...

Depends on the information returned...

The PIC MUST have weather info from an authorised source on which to base his decision to fly, but may take into account other factors. For instance, if the authorised source indicated marginal conditions at the destination, but ok where you were, he may decide to "have a go" with an alternate (or two) and the option of turning back as part of the plan. On the other hand id the "fone a friend" feedback was "it's crap weather at the other end", the PIC may well decide not to even give it a go. I wouldn't however depend on unskilled observers to be my reason to fly when other information from authorised sources was indicating contrary or uncertain conditions.

 

 

[Steve Donald]

Oh hec this subject can get messy, AF picks up what the FED GOV fails to do for AUSTRALIAN TAXPAYERS fails to do for them, whilst spending the $ on illegals without thought of their own people who provided the funds in the first place, as for DUTY OF CARE THE LAW AND LITIGATION, where does mercy flights come in, in the last 10 years i know of 2 unqualified flights to a major town as mercy flights which were not challenged lives saved, but now we seem to focus on law and accountability rather than outcomes, i know if i needed urgent help i wouldn't care if i was flown by Micky mouse in a drifter to get help. oh boy what holes we seem to dig ourselves.

 

 

[Guest davidh10]

... i know if i needed urgent help i wouldn't care if i was flown by Micky mouse in a drifter to get help. oh boy what holes we seem to dig ourselves.

I see a few issues with what you have indicated that you would accept:-

 

1. If you need "urgent medical help", then there is the ambulance service and that includes air ambulance. AF is strictly for "non-urgent" cases. AF specifies that all clients must have back-up plans in case of flight cancellation, bad weather etc..
    
    
   
2. I'd be very concerned if Mickey Mouse was the pilot. I'd like to think that the organisation has qualified the pilot not just in terms of viewing qualifications attained, but by having knowledge of the pilot's performance history. In a situation where you fly with an organisation that has an AOC, the organisation will monitor its pilots and remediate any undesirable performance detected. I don't know how AF can do that. I'd also like to think that I was getting the best qualified pilot available for the flight, given that different pilots may have widely differing levels of qualifications.
    
    
   
3. I'd have no problem with a Drifter, either, but only provided it was properly maintained and "airworthy". I've got some chance of assessing that, but the majority of AF clients will not. Note that AF specifies that the "airworthiness of the aircraft is the PIC's responsibility. Another reason I'd be concerned about "Mickey Mouse being the pilot.
    
    
   

 

 

I think that one of the byproducts of the way in which this service is provided is that to assess the safety of using the service the AF client would seem to have to rely on:-

 

• The individual pilot to ensure the airworthiness of the aircraft.
   
   
  
• The individual pilot's personal standards in terms of safety and minima. This also substitutes for an organisation's operating procedures.
   
   
  
• That the choice of pilot / aircraft, selected through AF, is appropriate to the circumstances of the flight.
   
   
  
• Whoever did the pilot's last BFR for whether the pilots skills are current and up to standard.
   
   
  
• CASA to ensure that the pilot has a current license and endorsements.
   
   
  

 

 

I can see some challenges in operating in a total outsourced environment which limits oversight of performance and adherence, as well as pushing the total responsibility for safety to every individual pilot. Doing anything else, however may require AF to have an AOC along with attendant costs and duties. I suspect this is what is meant by ATSB when they say they will be "examining the use of private flights for the transfer of passengers for non-emergency medical reasons".

 

As a pilot, you come to know that there are some other pilots out there who you would choose not to fly with and some aircraft that are registered, but that you would choose not to fly in. I wonder how AF makes the former decision? We know they don't make the latter decision, as that is left up to the PIC.

 

I don't think that anyone wants to see AF curtailed, but this accident has perhaps drawn attention to the way in which things are organised and maybe there will be some suggestions for improvement as a result of the examination, which this accident has triggered.