RAA accident investigation results

[Bandit12]

Hi All

 

The other day I was browsing through ATSB's accident and investigation reports, as I like to do every now and then. I find it quite informative, and while some reports leave a little to be desired, I believe the fact that the information is publicly available is a great resource for all pilots.

 

Many times I have read on these forums of people's displeasure about the fact that reports are never made public by RAA. I wonder if it isn't time for the members to start a collective push for a similar system to be developed by RAA and made publicly accessible, similar to the ATSB site. Like all things, without a member push, the committee will not discuss and vote on it. With so many new committee members taking up roles at the moment, this is a great opportunity for ideas like this to be floated and to gauge support.

 

Cheers

 

Shane

 

 

[Guest Crezzi]

Some RAAus reports are published - see http://www.raa.asn.au/accidentreports/index.html

 

Unfortunately not have been "selected" for publication in the past 6 & half years

 

Good Luck :hittinghead:

 

John

 

 

[68volksy]

I don't think this sort of thing could be properly achieved by RA-Aus. Properly investigating an accident takes a huge amount of resources and a great deal of time - and even then there are many questions that go unanswered. Plus to do it properly you need a record-keeping system that is well-documented and reliable.

 

I think it's one of those cost-cutting choices you make when stepping from GA to RA-Aus.

 

 

[turboplanner]

Bandit, the State and Territory Police investigate the accidents and prepare a brief for the Coroner, so for the equivalent of an Interim report you would have to contact Police in each State and Territory and make an agreement for them to send us a copy of their brief to the Coroner. Good luck with that hurdle.

 

When the brief is received by the State/Territory Coroner is goes into queue which can be several years long, and the Coroner's job is only to find the cause of death.

 

I've been looking for a couple of case results for years but haven't broken the code to find out when the cases are published or how to get a copy.

 

If a Coroner's report is found it's not likely to contain information we'd like for prevention of future accidents but just the direct cause of death, ie hitting the ground.

 

ATSB has the precedent of direct investigation from the earliest days when no one knew much about "flying machines", has the legal framework of Federal Government and the benefit of the pioneers of Aviation who wanted to make flying safer.

 

So it's not just a matter of campaigning.

 

Perhaps if we paid an extra say $200.00 per year, to ATSB, we would then get the full reports which have been so valuable in the past.

 

 

[68volksy]

Hi Turbo,

 

I managed to chase up a Coroners report by ringing the coroners office handling the hearing for an accident a couple of years back. They were quite helpful and emailed it to me.

 

I wish they were easier to get or someone reported a summary of the findings as the one i was after was extremely scathing of a certain aircraft retailer. I'll certainly never go near the individual in the future after reading the Coroners findings and summary of the hearing. If it came out as an ATSB report and mentioned Cessna they'd be shut down overnight...

 

 

[turboplanner]

I've read a few reports on Speedway deaths where relatives, friends were close enough to it to keep on the wheel of the office after the hearing, and the reports there have all been particularly good. The hardest part is to be able to judge the time of the Hearing and the time of the report.

 

 

[Bandit12]

Perhaps if there was enough interest, the Board could approach the ATSB to see what would be involved in them investigating accidents. I'm sure it wouldn't be cheap, howeverI am sure that it would be difficult to argue the benefits of a proper accident process and the resulting information that could be shared.

 

Alternatively they could surely create something themselves, even if it can't definitively establish a causal relationship. Even associated and possibly contributing factors, and stats on incidents by type would surely be useful.

 

 

[turboplanner]

Bandit, look no further than this site for that. We've had some excellent threads. While the family will be looking for a closure decision, in many ways our discussions don't need the definitive cause, because as we discuss matters and get off the track many scenarios emerge, often producing several lessons out of a single accident.

 

What we do miss is the very detailed ATSB stories (which don't seem to be as detailed now as they were in Macarthur Job's day) which delve into the pilot's known attitudes, and previous discretions where he got away by the skin of his teeth, and finish with a this one got him theme, so we can all correct our little tendencies early.

 

 

[Guest davidh10]

RAA actually do get involved in quite a few accidents, but as advisors to the state police. As such they are not at liberty to release details that are essentially evidence in a police investigation.

 

I sent an email to our past Ops Manager about this topic and received a good response. He had plans to improve the reporting and detail, but said there were many hurdles. He was pleased that more members were using the incident reporting process, as that was a good improvement.

 

For accidents where people are seriously injured, however, the issues are legal. ATSB has a special status conferred by legislation such that their findings cannot be used to conduct either prosecutions or civil actions.

 

As I see it, the only way forward would be for ATSB to conduct the investigation, co-opting trained RAA Accident Investigators and then for ATSB to publish the reports.

 

When our new ops Manager has been appointed and has settled in, I'll write again and make this suggestion in more detail.

 

I suspect the strategy may get lost in the change of incumbent.

 

 

[Bandit12]

Turbs, this site is fantastic for discussion. What I like are figures, especially raw figures. And I hate to say that I am a bit of a fan of statistics. I'm just wrapping up a study of nearly 650 participants for attitudes towards inclusive education, and have been thinking about looking into the human factors side of aviation (another pet interest) for a while. I can find plenty of useful stuff to study through the ATSB, but little of the same depth in RAA.

 

 

[turboplanner]

Turbs, this site is fantastic for discussion. What I like are figures, especially raw figures. And I hate to say that I am a bit of a fan of statistics. I'm just wrapping up a study of nearly 650 participants for attitudes towards inclusive education, and have been thinking about looking into the human factors side of aviation (another pet interest) for a while. I can find plenty of useful stuff to study through the ATSB, but little of the same depth in RAA.

If you're patient, you'll find it here coming off the keyboards in posts. It won't be admitted, but you can classify it yourself. I recall one where a guy severely criticised an aircraft, and it sounded believable until months later someone else came out with the story, and it was a Human Factors classic. When you took a closer look at the original guys posts (which of course you can quickly search), he was a flying HF case. RAA seems to have a much bigger polarisation than GA with quite a big group adamant that HF was thought up by morons to tie them up in red tape (while continuing to be involved in a healthy number of HF incidents) and an equal group taking it very seriously.

 

Davidh, you put your finger on it when you mentioned the ATSB exemption legislation. It won't be possible to match that with something as lightweight as a voluntary Association, and although RAA do provide expert advice WHEN CALLED IN they can't tell us about it, so the way forward is for ATSB to take on Recreational accidents, and I would suggest the only impediments to that would be for us to agree to it, and for the cost to be covered for the Commonwealth.

 

Currently the investigation costs are totally paid for by the States and Territories (Police), so theoretically the cost would be no greater if transferred to the Commonwealth.

 

Practically, the politics would start with the States and Territories under reporting their costs, and the Commonwealth baulking until a fairer cost arrangement was achieved.

 

 

[Guest davidh10]

... RAA seems to have a much bigger polarisation than GA with quite a big group adamant that HF was thought up by morons to tie them up in red tape (while continuing to be involved in a healthy number of HF incidents) and an equal group taking it very seriously....

Unfortunately we don't get to hear just how many RAA fatal accidents had HF as a significant contributing factor, as to post information about that can be debatable and nobody wants to be debating it in court. Actually being able to expose cases could help convince the doubters.

With some improvements, the RAA incident / accident reporting procedure could result in some analysis that would prove more educative than the current "Pilot Notes" in the magazine, however it may have to be on the new web site, both for space considerations, but also as a knowledge base for all pilots. I suggested that to Mick and it was on his radar.

 

People may think that only inexperienced pilots suffer from HF, but that is not the case. Everyone is subject to HF, to a degree. The more you learn from others, the more you can recognise it in yourself and avoid circumstances that contribute to risk unnecessarily.

 

 

[Gnarly Gnu]

Bandit12 try to get hold of Kitplanes magazine, there is a long running series of highly detailed statistics comparing the accident rates of many different LSA aircraft brands.

 

 

[turboplanner]

With some improvements, the RAA incident / accident reporting procedure could result in some analysis that would prove more educative than the current "Pilot Notes" in the magazine, however it may have to be on the new web site, both for space considerations, but also as a knowledge base for all pilots. I suggested that to Mick and it was on his radar.

You're right. Just reporting that "on landing a Jabiru ran into a fence tells us nothing, and non fatal accidents are under the control of RAA, so this would be the area to push.

 

And yes, HF affects anyone. The recent Cherokee 180 crash may well have been caused at Essendon when the pilot decided to depart at 4 pm for a flight which which would have an ETA shortly before last light. I certainly wouldn't think of leaving that time of day for that town. He was a 1000 hour pilot, so we should be paying more attention to this subject, and the minor accidents are a lot more pleasant than a fatal.

 

 

[68volksy]

I think some legislative changes definitely need to be made. RA-Aus (and to some extent the GA experimental category) has been allowed to run on a very long leash for the past few years. If we were to look at the accidents over the past few years (especially the fatal ones) I think we'd find the balance of aircraft involved tilting very heavily towards the high-performance end of the RA-Aus spectrum. It would be interesting to compare the accident rate of high-end RA-Aus to low-end GA and the causes of those accidents. There's 100 years worth of data on GA aircraft and accidents - if the RA-Aus statistics aren't at least as good as (in theory they should be better) the GA statistics then changes need to be made. It's so damn simple in my view it shows nothing but utter arrogance in the RA-Aus community that comparisons such as this are not being done and cannot be done.

 

End of rant - normal viewing can now commence.

 

 

[Bandit12]

My thoughts exactly Volksy - there are no valid excuses for RA-Aus to not maintain and make available for public access a database of accidents, and whatever reasons have been established. Surely if CASA can do it, it can't be that hard!

 

 

[turboplanner]

I think some legislative changes definitely need to be made. RA-Aus (and to some extent the GA experimental category) has been allowed to run on a very long leash for the past few years. If we were to look at the accidents over the past few years (especially the fatal ones) I think we'd find the balance of aircraft involved tilting very heavily towards the high-performance end of the RA-Aus spectrum. It would be interesting to compare the accident rate of high-end RA-Aus to low-end GA and the causes of those accidents. There's 100 years worth of data on GA aircraft and accidents - if the RA-Aus statistics aren't at least as good as (in theory they should be better) the GA statistics then changes need to be made. It's so damn simple in my view it shows nothing but utter arrogance in the RA-Aus community that comparisons such as this are not being done and cannot be done.End of rant - normal viewing can now commence.

I'd add a word of caution Volksy, I've put a few figures together now and again, and each time RA is roughly equal to GA in the recreational area (ie PPL, not CPL)

 

Furthermore, the number of fatalities burnt into my mind, particularly airframe failures in flight seems to be at the light end of RA.

 

Don't forget that a number of accidents we've debated have been GA aircraft.

 

That having been said, we are at a disadvantage in not having correct statistics as an incentive for safety, and that having been said, we've covered those reasons in at least three threads. eg Bandit's post................

 

 

[68volksy]

Hi TP,

 

I'd find it hard to believe that you had access to the full number of RA accidents given the lack of investigations? We can pick some up from news reports and on this forum but there'd be many out there unreported or not caught by the news cameras. Talking to a guy from the ATSB the other day and he said they're getting very concerned about the RA-Aus accidents as they're getting at least one request a week over the past 12 months to assist police with an investigation.

 

To prove/disprove my point I might ask if anyone here can tell me how many fatal accidents or serious injuries have occurred in RA-Aus registered aircraft over the past 12-24 months? I'm after the official number (if there is an official number). Should be a pretty simple one to start with?

 

 

[turboplanner]

(a) I don't have access to official figures but very few fatalities get past google/Recflying etc.

 

(b) The ATSB guy might have been smoking you because the Police call RAA for expert advice on RA accidents.

 

 

[68volksy]

The ATSB guy was involved in the training of the Police aviation investigators and is a very reliable source. I always find it funny when they say "RA-Aus will investigate" as from my understanding they have no training or expertise in accident investigation. The NSW Police only have 1 or 2 trained investigators who have found themselves with quite a heavy workload of late by the sound of it.

 

 

[68volksy]

Hi Bandit,

 

If you're a fan of the statistics you have probably already found the ATSB summary report for the past 10 years:

 

http://www.atsb.gov.au/publications/2011/ar2011020.aspx

 

A good summary of operations. The Private/Business years 2006-2008 which had fatal accidents in the double digits are a little frightening however it's good to see only 3 fatal accidents occurred during 2010.

 

 

[Tex]

Talking to a guy from the ATSB the other day and he said they're getting very concerned about the RA-Aus accidents as they're getting at least one request a week over the past 12 months to assist police with an investigation.

The NSW police aviation investigators are investigating 1 new RAA accident per week?

 

 

[Guest rocketdriver]

I wonder if a confidential reporting system might help ... i'm thinking of a self reporting thing (Like I did perhaps with my landing mishap at Leongatha) but where the pilot's report form is deidentified and separate from anything else. As long as we could be confident of no adverse personal result, might that not work .. at least in part ....?

 

Cheers

 

RD

 

 

[turboplanner]

RAA provide expert advice when called on by police, and in some reports you'll notice they in turn call in ATSB, say for example for a metallurical analysis.

 

 

[turboplanner]

I wonder if a confidential reporting system might help ... i'm thinking of a self reporting thing (Like I did perhaps with my landing mishap at Leongatha) but where the pilot's report form is deidentified and separate from anything else. As long as we could be confident of no adverse personal result, might that not work .. at least in part ....?Cheers

RD

Non fatal accidents should be well within the capacity of RAA, and unless I'mm mistaken they are the ones the Ops guys look into. I've suggested before that they, and narrow escapes provide some if the best intelligence for training, so the rest of us can learn a lesson - for example putting the restriction marker cones out on your own club field.