Old Bar Ferris Wheel Incident

[David Isaac]

Correct me if I'm wrong, but blaming the ferris wheel is a bit like blaming the tree that you backed into with the car isn't it?(No offence intended by this comment)

Oh you are a funny boy Tomo.

The point is that the Ferris Wheel appears to have been within the splay. That means for the runway to be used in a liability exempt manner, the threshold must be displaced to ensure a clear splay. If the pilot asked permission to land, which he MUST to legally operate into an ALA he should have been advised of the Ferris Wheel and the displaced threshold, otherwise the runway should have been closed.

 

This adds another whole dimension to the consequence of this accident.

 

 

[kjfab]

Well said David,As a further thought, I know there has been a fair bit of Morgan criticism as a result of the ATSB revelations but in reality how many others out there are flaunting the rules???

Unfortunately kit aircraft are only ever as good as the builder either has the inclination for them to be or as poor as the lack of skill in assembly. There are plenty of GA aircraft out there that I would not fly due shonky maintenance by LAMEs of dubious reputation. All sorts of short cuts have been taken in the past by all sorts of people. So in fairness to this situation making an issue of these Morgan discrepancies and singling out Morgan in the obvious knowledge that many of us have about shonky practices across the industry is perhaps a bit harsh.

 

The ATSB report clearly shows some unprofessional practices by Morgan, but I will speculatively guarantee there will never be another Morgan Factory Build aircraft with the defects the ATSB report revealed at this accident investigation because Morgan Aeroworks will have rectified their practices. What about all the other shonky practices out there in RAA and GA land, and products with alleged defects in manufacture, are they going to have a little private wake-up call over the investigation revelations in this accident????? How lucky were we not to have had a fatality as a result of this accident. How lucky have Jabiru been that one of their engine failures hasn't killed anyone yet.

 

This report will be a wake-up call for Morgan and for the rest of the industry who do SIMILAR things, we know this is NOT isolated to Morgan. In all reality everyone who has a Morgan is going to go over their aircraft and fix the things that have been highlighted or other things they may have done to their aircraft in their own assembly.

 

Every time there is an accident like this it will expose the aircraft involved to a fairly high level of scrutiny.

 

I'll bet there are few people out there who have put kits together and also factory build aircraft at the moment thinking " …there but for the grace of God go I ...".

 

Lets make sure we collectively take this on board as a lesson to all and not let it turn into a destruction of RAA and Australian Manufacturing. We know the problem, so does Gary Morgan, let us just collectively learn, fix the problem, and move on.

[kjfab]

Hi David i have been keeping an eye on this thread for some time and reading your post it is one of the most intelligent comments I have read, this problem is not isolated to Morgan aircraft I would be interested if a report of this magnitude was made with any other manufacture Australian or import how many problems would be unturned. I purchased a Morgan Sierra based on the fact that it was Australian product and I AM extremely proud of the product that Garry and co have produced and will stand by my decision. I would not like to see any Australian manufacturer go to the wall over an isedent like this. At the end of the day it like the Spanish inquisition it looks like someone needs a scape goat for a very public accident that was not caused by a problem of the aircraft.

 

 

[kgwilson]

I still stand by my initial post #53 more than 2 months ago. We have had a preliminary report, that is all. As I see it there have been many holier than thou posts made, it seems by those who have never made a mistake or perhaps are not human. Thank you David Isaac for keeping an objective perspective to this thread.

 

 

[Guest davidh10]

Alan,I think constructive discussion is good value given that there are some very unusual factors that impacted on the pilots actions that day and I think my position of sympathy for Paul is understood.

There are some very valuable points on this accident, none any less significant than the ALA issues. So in relation to the ALA and putting any piloting errors aside, please allow me to put up some interesting information.

 

Below is the image from the CASA ALA publication for single engined centre thrustline aircraft not exceeding 2000Kgs. This would be about the limit for Old Bar and the dimensions appropriate for Old Bar. Note the runway and runway strip dimensions and the 5% (1:20) splay requirements.

 

The ATSB report stated that the Ferris wheel was 34 metres East of the runway centre line and 161 metres from the threshold and that the gross height of the Ferris Wheel was 20 metres AGL. I know that the elevation at the base of the Ferris wheel was approximately 1 to 2 metres conservatively below the elevation of the runway, so lets say the Ferris wheel was 18 metres above the runway elevation.

 

Now the consideration is this : Is a 18 metre high obstacle 34 metres from the centre line and 161 metres out from the threshold within the splay?

 

Someone do the maths and advise us please. I believe it is in the splay, therefore an obstruction and therefore a very foolish place to place it. EDIT: I have redone the calcs; at 1 in 20 in a distance of 161 metres it is 8.05 metres, add that to the edge of the flyover area which is 30 metres from the centre line and you have 38 metres ... so the Ferris Wheel IS in the splay and worse, it protudes approximately 10 metres into the vertical clearance requirement of the slope on the splay which is required to be clear of objects above a 5% slope. Why was this little gem of information missing from the ATSB preliminary report??? So maybe the organisers have a case to answer after all.

This is all good as an exercise, but I seem to recall, from the ATSB preliminary report, that the information, referenced by the pilot, about the Old Bar ALA said that it did not comply with the standards.

 

In fact, quite a few unregistered ALAs are non-compliant by reason of obstacles.

 

There also seemed to be a difference of opinion between the pilot and the ATSB over whether there was any obstacle information in the directory. Obviously it would not have noted the ferris wheel as that was temporary, but it may have had the trees that also protruded into the transition surface. (I don't have a Country Airstrips Directory to look up).

 

 

[David Isaac]

....... but I seem to recall, from the ATSB preliminary report, that the information, referenced by the pilot, about the Old Bar ALA said that it did not comply with the standards.

Hi David, actually the ATSB preliminary report stated

Special local procedures for use at Old Bar were published online and in airfield guides. That included advice that the airstrip satisfied the requirements of Civil Aviation Advisory Publication 92-1 (1) - Guidelines for Aeroplane Landing Areas, with the exception of the transitional surfaces.

so there is a published warning that the transitional surfaces may not satisfy the ALA requirements, but given the pilot had operated out of Old Bar before he would have been aware of that; the report also said

The local council reported that the airstrip has never been formally surveyed for obstructions. However, a number of trees to the south of the airstrip that were under the approach path and to the south-eastern side of the airstrip exhibited evidence of pollarding to ensure that they did not pose a hazard to aircraft operations.The airstrip is not a public airstrip and prior permission for its use is required from the Old Bar Heritage Airstrip Committee. The caretaker of the strip indicated that the pilot of the Sierra had not sought permission to use the airstrip that day.

This indicates that pollarding had taken place but there may have still been a few trees other than the Ferris Wheel, but by my estimates the Ferris wheel was potentially a 10 metre obstruction. However, the report alleges that no permission was sought ...

 

In fact, quite a few unregistered ALAs are non-compliant by reason of obstacles.

That is correct and even if an ALA meets the requirements of Civil Aviation Advisory Publication 92-1 (1) - Guidelines for Aeroplane Landing Areas, it does NOT mean that it is suitable for all aircraft even of a similar type. The Pilot must determine that the performance of the aircraft will allow operation within the dimensions of the ALA. E.G. a 600 metre ALA at 4,000' elevation may be ok for a C182, but not suitable for a C172. EDIT: For clarity sake, the Sierra should be able to easily operate into and out of OLd Bar, so at least that is not at question here.

 

There also seemed to be a difference of opinion between the pilot and the ATSB over whether there was any obstacle information in the directory. Obviously it would not have noted the Ferris wheel as that was temporary, but it may have had the trees that also protruded into the transition surface. (I don't have a Country Airstrips Directory to look up).

Correct, except I am of the opinion there were no trees protruding into the splay due to the stated evidence of pollarding by Council. What the ATSB report actually said was

The pilot advised the investigation that before leaving Taree Airport, he had consulted the ‘Country Airstrip Guide’ entry for the Old Bar Airstrip and determined that there were no obstacles in the area around the airstrip and that the runway length was sufficient for the flight. He also indicated that he had checked the NOTAMS and determined that there were no problems in conducting the flight. The pilot did not report accessing any weather information prior to leaving home, and did not contact the caretaker of the airstrip to obtain an assessment of the local conditions or for permission to use the strip.4

Perhaps a more relevant question that will probably remain unanswered is whether anyone who used Old Bar airstrip that day obtained permission and whether or not on seeking permission there was a warning about the obstruction of the Ferris Wheel. It is my humble opinion that those who regularly use Old Bar rarely seek permission each time, and of course they do that at their own risk. It is not actually a legal risk, it is a potential insurance risk where should an accident occur it may jeopardise a claim.No matter which way you cut it, the Ferris Wheel appears to be in the splay and the decision to place it there without a displaced threshold marked on the ground or a warning issued to pilots, was in my opinion a significant shortcoming. Its placement arguably contributed to the accident because if it wasn't there, there would not have been an accident.

 

 

[turboplanner]

Correct me if I'm wrong, but blaming the ferris wheel is a bit like blaming the tree that you backed into with the car isn't it?(No offence intended by this comment)

Without wishing to pollard your comment Tomo, this would be an exception in that for most of the year that ferris wheel would not be there, just appearing at the festival.

 

The temporary obstacle would be mentioned when getting permission from the airfield operator, but festival organiser and the ferris wheel operator may still have had a duty of care not to obstruct the splay.........unless those marker cones were there.

 

 

[turboplanner]

It is my humble opinion that those who regularly use Old Bar probably rarely seek permission each time, and of course they do that at their own risk. It is not actually a legal risk, it is a potential insurance risk where should an accident occur it may jeopardise a claim.

A person has a duty of care to follow regulations and practices which ensure safety. In the transport industry use used to ignore Australian Standards where they didn't suit the application. They had no standing under prescriptive legislation, but now can be pulled out in a public liability case and used against us - a much more powerful impact on our daily lives, and I don't disregard any of them.

 

There may or may not be any public liability claim on this incident, but in one of the cases I was involved in a driver sued the fire marshal who saved his life.

 

When he crashed a huge fireball engulfed that car and the fire marshal, knowing the foam truck was just seconds behind him aimed the fire extinguisher around his head to prevent flames going into his lungs. He couldn't get out of the car because he'd fitted a cheap harness with plastic components which welded together. His lawyer asked the question: Where is the correct location to aim a fire extinguisher? The correct answer is: "At the seat of the flames" and that was one of the reasons our insurance company settled out of court for $800,000.00 for the loss of three fingers.

 

 

[David Isaac]

True Tubz,

 

Court arguments often use 'Standards' as reference bench marks in both supporting and defending issues of liability.

 

It is a complicated legal world for us mere mortals (pilots). Every aspect of flying is a risk versus mitigation exercise even when we possibly aren't even aware of it. Everything is fine and dandy until something goes wrong and we are often left gob smacked by the final outcomes, the analysis of which always has the benefit of retrospective consideration, something we don't have the benefit of at the time of an incident.

 

It is also interesting that part of the subject matter that the ATSB will be further investigating and quoting from the ATSB report is:

 

• assessment of the festival activities and supporting risk assessments• assessment of the council approval processes for the festival

• examination of the aviation activities associated with the festival.

The outcome on these investigations will come in the final report.Some very interesting lessons for all involved, including every contributor to this thread me thinks.

 

 

[Guest davidh10]

Assessment of risk is not trivial. It is a continual learning process.

 

Don't know if anyone watched Aircrash Investigations last night,but it was a good case in point. Just focusing on the relevance..

 

• The aircraft had reported similar problems with the radar altimeter in flights in several days leading up to the accident.
   
   
  
• The aircraft had a long history of radar altimeter issues.
   
   
  
• The whole fleet of same model of aircraft had as its most numerous maintenance issue, problems with the radar altimeter.
   
   
  
• Boeing had been consulted and could not isolate the cause of the issues either.
   
   
  

 

 

The pilot and co-pilot both have radar altimeters fed by separate radar units (redundancy). The Auto-throttle has as one of its inputs, the feed from the radar altimeter, but only reads from the Pilot's altimeter (not even realised by investigators for a while). During the landing flare, the Auto-throttle, using the radar-altimeter input of height AGL, moves the throttles to flight idle for landing.

 

On the accident flight, the pilot's radar altimeter was reading "-8" and was continually giving altitude alarms. The pilot cancelled the alarms and treated the issue as a nuisance rather than as a problem. After all, he was used to seeing this problem and he still had the co-pilot's radar altimeter as well as the barometric altimeter to provide real information.

 

Boeing, although aware of hundreds of reports of this issue occurring in flight and having the aircraft engines reduced to flight-idle during a flight, did not consider it to be a safety issue, because there were enough other indications that the pilot could recognise and correct for the problem.

 

What made this situation different was that at this aerodrome, contrary to normal practice, the ATC instructed flights to follow a path requiring them to intercept the ILS from above, rather than below. This mean't that rather than just flying into the ILS glide slope, the aircraft had to drop altitude very quickly to catch the glide slope from above, while it was also decreasing in altitude below them. The practise was well known at this aerodrome and was done to get the traffic in quicker.

 

The cause of the accident was that in selecting an autopilot descent rate of 1,400'/min to try and catch the glide slope, the throttle reduction to flight idle was interpreted as being in response to that input, rather than the faulty radar altimeter trying to land the aircraft at 2,000'. Complications were that there was a co-pilot in training and they were slow / late with their pre-landing checks. A situation exacerbated by the ATC's required approach, with caused high workload.

 

Essentially, the flight crew didn't realise they were in trouble until the stick shaker activated at 460' AGL and by then it was too late for any action to have saved the aircraft. The crew should have noticed other warnings, like the airspeed decay or the landing configuration indication, but for some reason didn't.

 

The point is that the risk had been assessed as acceptable, but not taking into account the co-incidence of events that masked the problem on that day.

 

That show and threads like this one continually expose us to different scenarios and allow us to all continually re-assess risk or recognise a risk where we did not do so previously, in our own flying activities.

 

 

[David Isaac]

Folks this whole scenario gets even more interesting.

 

I am no lawyer and this is simply my opinion but I am even more convinced that the scrutiny of the pilot and the criticism of Morgan is potentially a side show and ‘Scape Goat’ to the real causal factors of this accident.

 

I have been reliably informed that Morgan Aeroworks were invited to attend the Old Bar Festival by the Airfield Committee, which is clearly permission to use the airstrip. Morgan Aeroworks are familiar and regular users of the Old Bar airstrip. The threshold was not displaced to account for the positioning of the Ferris Wheel obstructing the 5% slope and 5% splay and no warnings were issued that the splay was obstructed by the Ferris Wheel.

 

Further general invitations were on the Festival web site stating:

 

“Old Bar Heritage Listed Airstrip Committee celebrates each year by having a fun fly in and would like to encourage all aviators to participate.”

 

In normal circumstances a late go around at Old Bar as was carried out by the pilot at the time would have been achieved without impact although somewhat tenuous.

 

The ATSB report stated that a risk assessment had been carried out on the placement of the Ferris Wheel. Clearly this assessment presents significant difficulties as it did not take into consideration the published Old Bar airfield guides that included advice that the airstrip satisfied the requirements of Civil Aviation Advisory Publication 92-1 (1) - Guidelines for Aeroplane Landing Areas, with the exception of the transitional surfaces (light poles of the playing fields etc). The airfield slope, splay and gradient dimensions detailed by the Civil Aviation Advisory Publication 92-1 (1) - Guidelines for Aeroplane Landing Areas are there to mitigate risks in such circumstances as happened to this pilot. The Ferris wheel placement meant that it was sticking up some 10 metres into the splay (by my estimation) a splay which is meant to be clear of obstructions.

 

I am also advised that complaints were lodged about the Ferris Wheel placement at some time (heresay). The weather at Old Bar both this year and last year significantly limited the number of aircraft in attendance (fact) and had more been in attendance who knows what may have happened or what additional complaints would have been lodged (speculation on my part).

 

Sure there were issues that were revealed by the ATSB (by the way I have been advised that the serial number issue was the simple typo of transcribing a “S” as a “5” as in “5200” instead of “S200”) and these need to be dealt with as separate issues; but perhaps we and RA Aus should be getting behind the real causal issues of this accident and separating them from the other side show issues.

 

Just my thoughts and observations folks; I don’t believe in kicking a man when he is down.

 

 

[fly_tornado]

Interesting theory David, the "speculation" makes it plausible.

 

You do have to feel sorry for Paul, if he had just flown into the trees this incident wouldn't have been newsworthy and he wouldn't be under such scrutiny.

 

 

[facthunter]

There are plenty of reasons why you couldn't guarantee a satisfactory climb gradient being achieved. Adverse wind shear, turbulence, wind change, less than full power being applied/ available, carb heat on, climb speed too fast/slow. etc. Regardless of any eventual legal issues/ outcomes, the siting of the Ferris wheel is stupid really.

 

What has happened here illustrates that you can't believe any thing you read either. ( without qualification). If the error relating to the registration number is as David says, how different is the import of that to the impression originally conveyed in the report. The "interim" report certainly got plenty of exposure ( to the detriment of the RAAus). Will any clarification/ correction get the same. (Of course not). Nev

 

 

[turboplanner]

I have been reliably informed that Morgan Aeroworks were invited to attend the Old Bar Festival by the Airfield Committee, which is clearly permission to use the airstrip. The threshold was not displaced to account for the positioning of the Ferris Wheel obstructing the 5% slope and 5% splay and no warnings were issued that the splay was obstructed by the Ferris Wheel.

 

Further general invitations were on the Festival web site stating:

 

“Old Bar Heritage Listed Airstrip Committee celebrates each year by having a fun fly in and would like to encourage all aviators to participate.”

 

In normal circumstances a late go around at Old Bar as was carried out by the pilot at the time would have been achieved without impact although somewhat tenuous.

 

The ATSB report stated that a risk assessment had been carried out on the placement of the Ferris Wheel. Clearly this assessment presents significant difficulties as it did not take into consideration the published Old Bar airfield guides that included advice that the airstrip satisfied the requirements of Civil Aviation Advisory Publication 92-1 (1) - Guidelines for Aeroplane Landing Areas, with the exception of the transitional surfaces (light poles of the playing fields etc). The airfield slope, splay and gradient dimensions detailed by the Civil Aviation Advisory Publication 92-1 (1) - Guidelines for Aeroplane Landing Areas are there to mitigate risks in such circumstances as happened to this pilot. The Ferris wheel placement meant that it was sticking up some 10 metres into the splay (by my estimation) a splay which is meant to be clear of obstructions.

 

I am also advised that complaints were lodged about the Ferris Wheel placement at some time (heresay).

What a valuable resource this site, and the speculation on it is.

 

If you are correct this could produce an amazing turnaround.

 

If you divide the incident up into: Manufacturer::::Training::::Pilot::::::Public Liability, and just look at public liability where the deep pockets are required, and I stress this is more speculation and not legal advice:

 

(a) the pilot and manufacturer may be able to claim that there would have been no incident if the ferris wheel placement and notification had not been negligent, so the standard of manufacture and the actions of the pilot were not negligent, given that no one can guarantee he couldn't have climbed out through the trees.

 

(b) the pilot and manufacturer may even be able to claim their out of pockets.

 

One of the disadvantages of Public Liability Insurance is that you can't use your own lawyer, the Insurance Company uses theirs, and they decide the strategy, but what an interesting development!

 

 

[turboplanner]

The "interim" report certainly got plenty of exposure ( to the detriment of the RAAus). Will any clarification/ correction get the same. (Of course not). Nev

What do you think Recflying is for Nev - you are reaching thousands today against dozens in the old Club days of say the sixties, you just don't get a Club Tie.

 

 

[fly_tornado]

No wonder the RAA board disapprove of this site...

 

 

[fly_tornado]

Of course, we haven't even considered possible carbon monoxide poisoning on the pilot and passenger!

 

 

[Guernsey]

No wonder the RAA board disapprove of this site...

I tend to agree with you generally however, some Board Members are also members of this forum.

 

Alan.

 

 

[dazza 38]

I have only had dealings with the ATSB once.That was when they were called in when A8-127 Crashed in Guyra in 1993.They where a fairly quiet bunch of guys.But they where great to work with as well.They will look at all the scenarios, they are not out there to hang people from my limited experience with them.They are paid to find a course of a accident/incident and they will look at it from every angle.That is why it takes along time for final reports to come out.IMO the ATSB do not and have not got on very well with CASA at times.ATSB have made alot of recommendations that have for whatever reason has fallin on deaf ears. All they want from my experience, is to A-find a course and B- recommend changes to try and prevent the same accident from happening again.They are very professional.

 

David has brought up some valuable information here.Good stuff.Its great because you have looked outside the little picture and have found information to help Paul.Great stuff mate.They would have already looked at that by now as well.What happens is that people get frustrated because they have not heard anything, we are all very worried about Paul.The poor bloke has been through the ringer.Apart from the accident he has to read all of this.It must be realy stressing him out, sorry for any stress that I have caused you mate.This is, as others have mentioned is different because the pilot is not de-identified. No accident is cut and dry.(well the one I was invloved with was, that is why the jets flew a few days after the incident). We knew what to look for, we just had to find it,in the case I was involved with. This one is different. I said that I would move on from this thread, I just had to say what I have said.Mistakes where made.Humans makes mistakes.Its apart of being human.Things will be OK I think.Lets just wait and see.Cheers Guys

 

 

[turboplanner]

No wonder the RAA board disapprove of this site...

Why would RAA disapprove of this site providing a platform which would correct any information detrimental (meaning bad) to the RAA?

 

 

[David Isaac]

No wonder the RAA board disapprove of this site...

Except that RAA received an unfettered battering on PPrune.

At least on this site we can rally the troupes so to speak and people are reasonably minded and there is little if any vitriol.

 

So whilst this site may make undesireable things public, it also goes to a measure of transparency and we are able to get the positive lessons and rectifications out there in the public domain which ultimately benefits RAA.

 

 

[fly_tornado]

I suspect back in the old days the doings of the old boys club was all done behind closed doors... life was a lot simpler back then, when no one questioned the powers that be.

 

 

[Tomo]

No wonder the RAA board disapprove of this site...

Do they?? A resource that has attracted hundreds, thousands to be an RAA member... the mind boggles. If there's nothing to hide, there's nothing to be worried about.

 

Once something is on the net, there's no stopping it going anywhere... the ATSB would be very aware of that, what about PPRune...

 

 

[fly_tornado]

As a rank and file member the net is a boon but if you run the RAA not such a good idea. This accident has shattered the illusion that RAA #24 aircraft are safer than #19, which is giving the RAA a bad reputation.

 

This might be the end of #24 self regulation.

 

 

[David Isaac]

Ahhh ... the old accountability thing again, what we used to hide in the closet in earlier days is now not possible because there are cameras in the closet and they are connected to the internet . It is a real bugga when you have to be held accountable isn't it.

 

More power to accountability. Those who don't like it should get out of management and governance, because if they don't get out, accountability will eventually drive them out.