Accident Reports

[barandbrew]

Where can I access the results of RAA investgations on accidents. There has been many fatal accidents but only a few reported in the Mag.

 

 

[Guest pelorus32]

Lee Ungerman discussed this at Natfly. From this month you will start seeing accident reports in the magazine. I gather that there has been some doubt at RAAus as to the best way of handling what is a sensitive issue. It is also not helped by the fact that as Lee explained RAAus have no statutory rights when investigating accidents - the site "belongs" to the police and the coroner controls the release of information.

 

For those reasons it's much more difficult than it is for ATSB.

 

Anyway we are told that you will start seeing some older ones from this month on.

 

Regards

 

Mike

 

 

[Kaz]

Have you tried the RAA site http://www.auf.asn.au/accidentreports/index.html

 

It hasn't been updated for a while but there are some interesting reports there.

 

 

[Guest Fred Bear]

The ATSB one for GA you can find here:

 

http://www.atsb.gov.au/publications/investigation_reports/index.aspx?mode=avi

 

 

[Guest TOSGcentral]

Hmmm! So this old one comes up again?

 

 

It is 35 years ago since I was head hunted to Australia and was then invited to a GFA National Gliding School. One of the subjects was Accidents and reporting.

 

 

At that time GFA were expressing the same ‘cultural cringe’ as has been mentioned on this present thread – we cannot do anything because of the powers that be, coroners, police and all the rest of what is actually irrelevant crud in realistic flight safety terms!

 

 

Yet if you read the current RAA magazine there is a full accident report that was apparently conducted by RAA – so they can be very hands on but choose to remain silent for a couple of years because of the powers that be etc etc!

 

 

I expressed my opinion at that NGS and recounted what the British Gliding Association had been doing for years very successfully.

 

 

The process is very simple – the responsible controlling body (that anyway should normally get the initial report in parallel with the others) proeduces a responsible appraisal made on what happened with no comment on why it happened and everything is de-identified. That simple report is posted promptly to the membership via the ‘Official Journal’ – the magazine.

 

 

From this the members have a clue on the extent of accidents and incident frequency but more importantly what kinds of occurrences – eg a growing spate of turn back incidents (Ops and also potentially airworthiness from poor engine maintenance). There has been happenings when something apparently reasonably harmless but a bit scary has alerted people to a growing fatigue problem before it eventually killed!

 

 

From this you can pick up emerging trends very early and start doing something about it. You can only do this if you have reports and you do not get reports because the members will not report. This is either because they think it is a waste of time (because they seldom see anything in print) or because they think they can just get away with it unless someone has been killed, seriously injured or the situation makes the newspapers.

 

 

Now here are some hard facts Sportsfans! I run the Thruster Support Group and I can tell you flatly that there have been dozens of accidents, some very major, that have gone totally unreported, and some were reported and never investigated or published to the membership. That is just one ultralight type. I know of many other cases on other aircraft types as well. How many would you like?

 

 

I have done my own ‘trend research’ and look after the people that I presume to aid. That is not a paid job – it is a commitment to flight safety at a practical level!

 

 

We have the wrong ‘culture’ and attitudes to accident reporting – it becomes a negative when it has to be turned into a positive! The members will not report because it seems to go nowhere and RAA will not publish because they do not have the staff and it would be extremely less than politically expedient to put the actual volume in the (now on the newsstands) magazine!

 

 

And yet, for those with long memories, we did have two ex officio AUF officers who did a monthly report on what they got – in exactly the same way as I have outlined above and published it in the magazine. No flak, no drama, no legal cases – but at least some information. For some reason that closed down and the replacement we currently have is dwindling rapidly in size!

 

 

But – in absolute fairness to RAA – they can only publish what they are told. Perhaps both sides of the fence could find a means of making it worthwhile to communicate?

 

 

Aye

 

 

Tony

 

 

[Guest brentc]

I well known CFI once told me: "I have a nil reported accident history"

 

That's the type of culture that you are no doubt referring to.

 

 

[eastmeg2]

I spotted the April edition of the RAAus mag in the news stand today and had a quick flick through. Mine has not arrived in the mail yet.

 

It had a report on a fatal accident at the Oaks last year, but still nothing on the fatality involving a top of the line 4 stroke RAAus registered trike fitted with a BRS chute in Jan06. That accident was one I found very disturbing and we're still waiting on a report 15 months later.

 

Rgds,

 

Glen

 

 

[Guest Fred Bear]

It had a report on a fatal accident at the Oaks last year

I thought that was a year before last??? Maybe it was referring to the motorglider further down near Narellan?

 

 

[Yenn]

I am all for reporting in the magazine. The reports can be de-identified if that is the word, but any report is a good guide for other pilots and as such helps to keep us all safe.

 

 

[bushpilot]

..... but still nothing on the fatality involving a top of the line 4 stroke RAAus registered trike fitted with a BRS chute in Jan06. That accident was one I found very disturbing and we're still waiting on a report 15 months later.

I haven't heard anything about this particular one; but as a triker I think I need to...

 

I agree with all the comments here; full and timely information sharing on the circumstances - cause and affect - is critical to educating pilots in all categories..

 

Chris

 

 

[Guest TOSGcentral]

I want to chase this one a little further. Bushpilot (and others) it is unlikely (and unreasonable) to expect to get too much actual cause/fault etc out of an early report until an investigation has been done.

 

 

The important thing is that a brief report comes out that there has been an occurrence and roughly what it was. From this you may pick up a trend which could be in Ops or could be in Airworthiness, could be peculiar to a new type, or an old type starting to fatigue.

 

 

I will give you a few examples:

 

 

A few years ago, and within a few months of each other, there were two major crashes with Gazelles on first solos. Now that may have only been two events but it was a major wake-up gong! You just do not get major crashes on first solos – they are normally as safe as houses as so much work goes into preparation. On top of that the Gazelle is so docile it is very hard to get into trouble with.

 

 

So that situation invited a good look at what was happening with instructor standards!

 

 

Something similar, but in a different area, happened many years ago with the Thrusters. A few pilots did report sternpost cracking and failure and this resulted in a mandatory AUF AD for 50 hourly inspections (that is still in force). Although relatively minor in itself the consequences of a total sternpost separation does lead to total loss of directional control on the ground – and that can be very serious indeed.

 

 

That fact that a handful of Thruster pilots did make airworthiness reports indicated that it was a potential weakness on ALL Thrusters and not an isolated incidence. The entire Thruster community thus benefited and became a bit safer.

 

 

I once had a most unusual happening when taxiing a T500. There was a sharp ‘crack’ that caused me to stop immediately and have a good look around. Despite my experience I saw nothing untoward and continued. However on the next routine pre-flight inspection my student found a rudder cable half melted through – which sort of stopped things while I made a new cable.

 

 

We had not been struck by lightning but had experienced a major static discharge. I still put in an incident report although there was nothing anyone could do or forecast about such a rare event. The reason that I did so was to underline the importance of the pre flight inspection before EVERY flight – not just a look around in the morning!

 

 

That is what a healthy reporting system can give you.

 

 

Tony

 

 

[Guest joe]

Tony (& others), reporting systems would work if you were able to take the human factor out. i work near a large industrial organisation that has a clean sheet so far as their OH&S accident reporting goes because they never call the QAS (ambulance) when an accident/incident occures, they instead transport their injured workers to a health facility, thus appearing safe as ambulances are not recorded as attending.

 

So accident reporting fraud occurs in all industries, arguably with a greater impact in aviation. so what does one do (a student for example) when he/she experiences a reportable incident; the details of which could be of benifit to the wider flying community; & the CFI wants to keep it hushed up? ... they move on

 

 

[bushpilot]

I want to chase this one a little further. Bushpilot (and others) it is unlikely (and unreasonable) to expect to get too much actual cause/fault etc out of an early report until an investigation has been done.

Agreed. But what is not unreasonable to expect is timely and full reporting; some of these ASI's drag on for ever... and even when reported, you have to know where and when to go looking for the reports..

 

The RA-Aus should be bringing all relevant reports and outcomes (that they are made aware of) to members notice, in the interest of spreading the lessons that come from most accidents / incidents; not waiting for months after issuance of a report to add it to their website.

 

So important is this aspect of our flying, that the RA-Aus, and other 2 and 3-axis representative bodies, could compile a group list of email addresses of their members - and send email notices announcing the release of each new report, together with a link to the report source. This should include GA reporting as well.

 

I was a member of the HGFA for many years (and a Safety Officer for several) and found them to be quite proactive in encouraging incident reporting and publishing summaries of all A & I reports made available to them.

 

In summary, the attempts to spread the knowledge to date mainly revolve around references in association and industry magazines - which means the usual delays in receipt, compilation and publishing. Now, with most people having access to the internet, accessibility and speed of dissemination can be far more effective, if used properly.

 

Just my thoughts.

 

Cheers

 

 

[Guest TOSGcentral]

Good question and points well made Joe.

 

 

The answer resides in the form of environment you have (culture if you like), how that is controlled and by whom!

 

 

In your example your student can do very little except try to cause a major upheaval and probably be crushed by the results.

 

 

It would be a very different story if the CFI involved (I appreciate that this is probably a hypothetical example we are discussing – but is far from uncommon) was constrained by Movement structure such that he knew he would not get away with it and his ratings were on the line as a result, so would perforce have reported it despite not wanting to.

 

 

But it goes beyond that. We have to engender a culture where we encourage good quality reporting and hence safety feedback to all, via control systems that the membership may be practically involved in and thus gain from. The human factor you refer to is important and has to be treated head on! We have to have a movement where it really is ‘one for all and all for one’ and the members believe that their contribution is valid to make that happen plus materially assist in retaining the credibility of their movement so that they may also retain the freedoms the movement has won!

 

 

Peer Group Pressure is increasingly being mentioned as a force in our movement at airfield level. That can only exist if there is an effective structure for it to exist in! Without that it comes down to force of personality (which an individual may not have) or actual threats of reprisal (which an individual may not want to do).

 

 

A couple of examples: Quite a few years ago, at a major ultralight fly-in at Watts, a visiting Drifter pilot commenced full spins from around 1000’ agl and recovering at around 400-500’ agl. He was doing this right over the only row of houses for bloody miles, the owners of which were conducting a campaign to have our fledgling airfield closed down! So I had several forms of motivation running and was waiting for him when he landed.

 

 

A student could not have done what I then did, but I certainly could and made it clear that I would enforce my view one way or another while pointing out how many actual Laws he had broken. Suffice to say he was gone as soon as he refuelled and has never been back. That is one form of ‘peer group pressure’.

 

 

Another was again a visiting Drifter pilot that put on a hopeless display of Airmanship in circuit work and I sort of left my own students and wandered over for a chat with him. I asked for his views on circuit work and we had a little discussion that was most amicable and solved the problem. We parted on friendly terms and we have never had a problem with him again when he has returned (quite often) – he simply did not realise.

 

 

What is often (conveniently) overlooked is that you cannot hush things up by not reporting them – either at airfield or National level! There are eyes everywhere and it is not simply a case of peer group pressure within our own movement – recreational airfields may have representatives of many other movements or interest groups. The word soon gets around and we are thus diminished even more, not simply because of lack of present control, nor lack of reporting – but apparent disinterest in any of it. However it does work the other way.

 

 

At another major Watts (GA) fly-in a strange Drifter appeared (OK I may not like Drifters much, appreciate that they are actually fine aircraft, but I am certainly not picking on them).

 

 

This was one of the early 95.10 Maxair Drifters, but still with two seats, unregistered and no markings. It was being flown by a very senior and qualified commercial GA flying instructor who coincidently was not a member of AUF nor ever had been. He worked at a very major Qld school where the CFI openly despises ultralights – but eagerly takes our member’s money for GA conversions. The piss-poor Airmanship display that went on repeatedly defied description. I finally broke when we had a near collision (20’ separation) at the threshold of 30L as he landed over another ultralight starting take-off and had managed to engineer this magnificent situation by flying a 300’ tight circuit that kept him totally out of sight of the other pilot!.

 

 

I did not bother with the pilot but went straight for his boss. The interchange was acrimonious to say the least! It terminated by a flat statement from myself – the pilot and aircraft were to be off Watts by the following morning or a formal, detailed complaint was going into CASA along with photographs. The pilot and aircraft left that afternoon! Another form of peer group pressure.

 

 

OK I reported none of the above. I had resolved them at source and reporting was a waste of time anyway. Been there and done that also! Here are some examples where reports were submitted by myself or others:

 

 

(a) Prop fell off a Skyfox and killed the pilot. Nothing much done about it.

 

(b) Same school as above – Owner ordered by supervising LAME to get a prop rebalanced. This was not done and the crankcase split in the air with a student on board. But the school continued

 

© Same school as above – at least four major prangs with Skyfox aircraft. Mainly operational causes. School not known to have been responsibly examined. Situation resolved at source by taking the owner behind a hangar and giving him a thorough flogging. School voluntarily closed down!

 

(d) CFI/PE/L2 commercial operator with several airworthiness problems already under his belt was convicted, in two separate court cases brought by CASA and jailed for criminal operational misuse of aircraft. AUF retained him as a member and merely removed his instructor ratings.

 

(e) CFI/PE/L2 commercial operator commissioned myself to fly in his trainer a distance of about 150 nm. Aircraft failed pre-flight on 9 points including a broken main boom that had been inadequately repaired because the cause had not been identified – nothing done despite a detailed report.

 

(f) Same as above. An allegedly rebuilt T300 produced 2.5 A4 pages of faults including elevator cables sawing into fuel lines, non compliance with mandatory ADs, illegal just as it stood, aileron system worn beyond tolerance, non compliant 95.25 components, that were obvious, falsified UACR – nothing done despite two detailed reports.

 

(g) Same as above. The individual was criminally convicted (at the hands of CASA) for operational misuse of an ultralight. This, on top of the Airworthiness issues reported, saw him still with his full ratings two years later!

 

 

That is sufficient for the time being. I have prior stated that I would start opening up unless something responsible was done about the control structure of this organisation and have now started doing so. I have extensive records, a good memory and always couch my comments in terms where they can be refuted in equal detail. So do not go up my ribs for ‘bagging RAA’ – we have to deal with what we have got and the record does speak for itself – if you begin to become acquainted with it!

 

 

I am going to cease here, but there is a lot more yet to come.

 

 

I will close by saying that accident, incident and airworthiness reporting is not in itself the issue. The real issue is an environment where the members see that it is worthwhile reporting and we have the manpower/funding/media and structure in which this can happen.

 

 

Aye

 

 

Tony

 

 

[Guest pelorus32]

...don't know much about history...

 

I'm not new to aviation but I am very new to RAAus and I don't know much about the history.

 

I do have a real wish to be part of a safe operating environment. Friends and colleagues getting killed is very, very gut wrenching as some of you well know.

 

I do know a little about cultural change. I know about the power of one person quietly and clearly articulating why something is wrong, unacceptable or better not done. I know that if each member on this website influenced one other person who flies an RAAus aircraft to "fly safer" in some way then that's 20% of the total membership of RAAus that we have touched. If we continue to influence that person so that the behaviour becomes embedded we have a different culture emerging. That is a minority capable of far reaching change - simply because that minority would be motivated and have something they cared about. That minority becomes in effect the dominant culture. Violating at one end, or acting thoughtlessly or without knowledge at the other end, becomes increasing uncomfortable for those that do it. They in turn have to change their behaviour.

 

We can do that in many different ways: by affirming someone's decision not to fly in doubtful conditions. By voicing a clear view when someone does something dangerous. By quietly pointing out a fault in an aircraft and asking for it to be fixed before we fly it. By making the safe choice ourselves and being resistant to influence to do the unsafe. And on it goes...think of situations where, without song and dance, you could have influenced someone towards the safe view of a situation rather than the unsafe. Turn your back on the aircraft doing a low, fast pass; say to whoever is next to you that you think it is unsafe. If you can, say the same to the person who did it.

 

I do not believe that the people who run our organisation are supportive of an unsafe culture. I do not believe that. Indeed quite the reverse. But it is always the case that there are many ways to achieve an outcome and it is natural that there will be diversity of opinion on the best way to get there.

 

If I had to describe the qualities that I aspire to as a pilot I'd say things like:

 

Conservative in my actions but not timid;

 

Careful but not over-cautious;

 

Alert but not fretful;

 

Decisive but not impulsive;

 

Inquisitive;

 

Observant;

 

Chronically uneasy but not anxious (thanks James Reason);

 

Communicative but not dominating;

 

Attentive to others;

 

Courteous;

 

Adept and current both in stick and rudder and in management of the a/c;

 

....

 

My bottom line is that I can't change all of the ills of the world, or even our little part of it. I can however stand up and be counted.

 

I am sorry if this sounds like a homily, it's not meant to be one. However, if I were to be entirely selfish, I have a vital interest in returning home safe at night. I now have an even more vital interest that my 15 year old daughter who has just begun learning to fly also returns home safe at night.

 

Kind regards

 

Mike

 

 

[Ben Longden]

Well said Mike.

 

Ben

 

 

[Guest TOSGcentral]

I respect Pelorus32s words very much. Perhaps there is more practical perspective in philosophy rather than politics – although we ultimately have to deal with both.

 

 

Try these few lines – written long before aviation was invented. Maybe, within these, is the foundations there for what accident reporting is really all about?

 

 

 

All mankind is of one author, and is one volume; when one man dies, one chapter is not torn out of the book, but translated into a better language; and every chapter must be so translated...As therefore the bell that rings to a sermon, calls not upon the preacher only, but upon the congregation to come: so this bell calls us all: but how much more me, who am brought so near the door by this sickness....No man is an island, entire of itself...any man's death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee."

 

 

This is a quotation from John Donne (1572-1631). It appears in Devotions Upon Emergent Occasions, Meditation XVII:

 

 

[facthunter]

Accident reports.

 

My position on this matter .

 

I believe it is law that any person observing an accident or unsafe operation of an aircraft, is required to report it, however, this is not enforced. The principle is there and forms are provided in our organisation, so I presume they should be utilised, on many occasions they probably aren't.

 

We then deny our members the best opportunity to benefit from the experiences of others, without having to find out the hard way, themselves.

 

How would you feel, if you as an owner of an aircraft of a certain type, had a narrow escape due to something breaking or jamming then found out that that particular fault was known to the manufacturer/agent etc for some time? Unimpressed to say the least, I would imagine, & rightly so. Apply this thinking to non-reporting. You can't justify it .It's just not professional.

 

The sort of things that result from experience in service reports:-

 

Structural modifications ..... Specific inspections ...Handling modifications (design changes or operating envelope changes) Changes to the life of components..Changes to flying training techniques, where a type may exhibit certain habits,etc.

 

The knowledge disseminated throughout the organisation to individuals raises the standard, however I have some concern as to the form & the forum for this information to be published in. There would have to be constraints in a magazine freely available at the newsagents & a report along the lines of ....Thruster 503..

 

On take off the A/c experienced engine failure from an unknown cause at about 200 ft and bent the undercarriage on landing. The pilot was uninjured. (not much of an example, but you get the gist of it) Doesn't do much for you does it?

 

Clearly there is a lot to be gained & a lot to be done in this area. Nev...

 

 

[Guest pelorus32]

G'day Nev,

 

I don't disagree with you - I had drifted from the original question to one about a safety culture. For mine the whole set of issues about reporting/non-reporting will tend to go away when the safety culture is in place. Until then it will be a battle.

 

We need reporting of accidents/incidents; we need publication of factual summaries and then probable cause (as our US mates would have it). We also need to understand what has been learned in the other areas of aviation about no-fault reporting and confidential reporting. Both of these things have their place and we shouldn't just go about making mistakes when others have already found the solution.

 

Lots more to be said here no doubt...

 

Regards

 

Mike

 

Regards

 

Mike

 

 

[barandbrew]

This has turned into a good thread, and confirms my orginal question that we need ,correct timley information on accidents particulary fatal ones, so we can hopefully avoid the same situation ourselves

 

 

[Guest Crezzi]

I'm still a member of the BMAA (UK equivalent to the RAA). Four times a year their magazine includes an excellent accident summary as a seperate A5 pamphlet. Although their mag is only available to members (not in newsagents), doing the same thing here would solve the problem of making the information available to the wider public.

 

The accident reports are mostly user submitted with pertinent comments and observations from the BMAA Tech officer. They are made anonymous Eg Airfield XXXX. Although I'm sure that there are UK accidents which go unreported, it doesn't seem to be as prevelent as here. I think there is more peer pressure and many people fly from airfields with instructors / schools who insist on reports being submitted.

 

The summary also includes more serious / fatal accidents including those investigated by AAIB (equivalent to ATSB) but only after their report has been completed.

 

I'm not a lawyer but I'm not sure what law in Aus would prevent doing a similar thing here ?

 

John

 

 

[TechMan]

This has turned into a good thread, and confirms my orginal question that we need ,correct timley information on accidents particulary fatal ones, so we can hopefully avoid the same situation ourselves

Can you perhaps give us your thoughts on what 'timely' would be and what you would want to see in these said reports? I take it, substantiated facts would not be required in these reports, as perhaps they have not been determined as yet.

 

Would you be looking for an overview of the accident? Ie, engine stopped, aircraft crashed, pilots on board deceased?

 

Whilst I know that experienced crash investigations will form some sort of theories early on in the piece and then go and try to prove those theories incorrect, which theory should be in the report?

 

We all want to know what happened so there is a process that gets followed, even perhaps if it was not done so in previous events prior to the current Ops team.

 

I personally can't see any benefit in producing a report indicating that the aircraft was flying from A to B in a supposed normal attitude, the aircraft entered a spiral condition and crashed into trees killing the occupant(s). Reason - unknown.

 

I can bet the minds out there reading this will already have formulated some sort of theory as to what might have happened.

 

Whilst it is a touchy subject, and one that people will argue over for years to come, information will be broadcast with factual information once it has been established.

 

Chris

 

 

[Guest pelorus32]

Hi Chris,

 

for me there are two reasons I would want to know about something in a "timely" way (more on the timely in a minute). The first is if there had been a couple of accidents in a similar type of aircraft and this one looked similar. In that case I might see something like:

 

"The Goodplane MkIII departed from normal attitude during the turn onto final and impacted the ground in a steep nosedown attitude. Whilst no cause has been determined RAAus is aware of two other apparently similar accidents with the Goodplane MkIII in the recent months and wishes to draw this to members' attention."

 

Now I am aware that cause is still up in the air, I'm also aware of potential liability issues around statements about an a/c type. But a statement of this sort will sharpen pilots' and instructors' minds sufficiently to ensure that they take notice of this aircraft in particular configurations and situations. This may ensure that you only have 3 events on which to base a finding rather than 4 or more.

 

The second case is one where there was a failure of some sort. So for instance the notification might say:

 

"A recent accident occurred with a Goodplane MkIII powered by a Goodengine MkII. Whilst the accident investigation is continuing RAAus wish members to be aware that it appears that the Goodengine MkII suffered a crankshaft failure which resulted in catastrophic engine failure. The cause of this failure has not yet been determined."

 

Now it may be that there have been other such failures of the Goodengine MkII in Europe for instance. Which you might also mention. But if I am an operator and I have been a bit fast and loose with maintenance, or I am overdue for an overhaul then I might be encouraged to get on with it and if I have the crankshaft out then I might have a really good look at it - doing whatever the engineers do to check for cracks etc.

 

What does timely mean? Well in both those cases within 2 weeks. Why? Well we are not arriving at determined findings - rather we are passing on objective observations and the sooner the better. My experience is that I will hear three different versions of events anyway within that period of time. Therefore I might as well hear one that has some semblance of being close to the facts.

 

You might need your lawyers to write you a nice disclaimer about not making findings and certainly not making negative claims about a certain aircraft. That's for the lawyers.

 

I think that a threshold question that might arise with some of these issues is this: If, before a finding is made, you have serious safety concerns - though unproven yet - or you have info that you think operators and maintainers need, then why wouldn't you disseminate the info, or mandate specific checks or in extreme cases ground the aircraft pending further info?

 

I think a good model of information dissemination is the one that has gone on around the BAC Strikemaster fatal at Bathurst. We were made aware of information in an incremental fashion from very early on in the investigation. That allowed other operators and indeed the punting public to form an educated view on what they should do.

 

Long answer.

 

Regards

 

Mike

 

 

[barandbrew]

Chris

 

I have read in newspapers and watched reports on TV of fatal ultralight accidents on many occacasions but very few of the official reports have been published that I can find. I would believe that there would be an official RAA report to every incident? I asked the question where can I revue these reports and the answers given so far would make me believe that there is no such facility. If there is then please advise me how to access it as that would answer my question. Correct timely information can only be given as soon as possible after a decission on an accident has been made ,however if professional opion is that the cause was because of strut bolt failure then a notice to opperators to check this area should be made ASAP.

 

John

 

 

[bushpilot]

My point on timeliness is this:

 

* In some intances reporting of an accident can be a matter of 'life or death' (beyond whatever has been suffered as a direct result of the accident) for other pilots that might encounter similar circumstances - whether they be conditions, state of the a/c, pilot judgement, or whatever.

 

* Waiting for a full investigation followed by a quasi-inquest, then reporting, can sometimes mean a year or more of delay in getting vital information out.

 

* The investigating agency should be bound, in normal circumstances, to issue an "interim finding" as soon as the basic facts and circumstances are understood This could be qualified as necessary, if for instance exhaustive metallurgy and static loading tests on components are required. This qualification might say something like: "The port-side wing appears to have folded upwards at 90o from its normal orientation, at a point about 900mm in from the wing tip, prior to impact. Tests will be carried out in an attempt to ascertain the cause of this failure."

 

* This and other known information could act as a guide to other pilots / owners to check for any problem in the area in question (on type).

 

Cheers,