Accident causes, training and Raa Aus responses

[Dieselten]

However much we may feel we could have prevented this accident, the fact remains that ultimately the pilot-in-command made the decision to undertake the flight. Perhaps some people did advise him not to do so. The investigators may discover if this occurred. Perhaps he chose to ignore that advice - if it was given. His passenger, also an experienced pilot, may have also suggested the flight not take place due to impending loss of light. We will never know. But the PIC made the decision to fly, and events then took their turn.

 

There are always lessons to be learned from fatalities. On this occasion I think it hammers home the critical importance of the Human Factors which we deal with on a daily basis as aviators. We may look askance at Human Factors during our training and grudgingly pass the RAA Human Factors exam, but they are an inescapable part of every flight we undertake. Clearly, decision-making is involved in this accident and, sadly, that rests solely with the PIC.

 

I understand the frustration, bewilderment and anger expressed by a number of posters on this thread. Instructors especially take these events very hard because they do their utmost to impart to pilots a good set of values and to instil good and prudent judgement. But the reality is an instructor just gives the student two things; a set of skills with which to handle the aircraft (and themselves) and confidence. Once a pilot proceeds beyond the status of student they shoulder responsibility for their own safety.

 

They can, if they so choose, ask for an instructor's advice - and no instructor will think any the less of any pilot of any experience level who does so. But once committed to a flight, the PIC is solely responsible for the outcome. His judgement and his alone determines the success or otherwise of the flight. On this occasion the price for making a poor decision has been very harsh indeed.

 

 

[Guest davidh10]

Andy, would you dismantle the wing for the night and move the pod to a better protected spot, tie it to a car etc

I'll also answer this as I was planning a group flight to Temora, last year for the Warbirds Downunder event. About 4 or 6 trikes would have been in the group. With poor weather in the surrounding days, my evaluation at 04:00 on the morning of departure, after studying the weather reports, pressure charts etc, was to call it off and drive.

While we could have flown up to Temora, being chased by a front with embeded thunderstorms, the prospect of having my trike tied down in the open with forecast 35kn winds on the ground at Temora was a significant factor in my decision to drive. With a couple of phone calls, the group ended up car-pooling.

 

If I was caught away from home in such circumstances, I'd consider pulling the slats out and folding the wing, but only as a last resort, since without a clean area to do so, and the wing covers, you could get a lot of dirt and possibly mud into the fabric. Finding a partially sheltered area to tie it down would be preferable.

 

 

[brilin_air]

We were talking to the some CASA people at Natfly and asking about the checks that were happening and what they were actually doing. The weather forcast came up and we were told that we had to be able to get the weather forcast where we were, this could be on the phone or a computer and it would be fine, BUT it was suggested that the weather be moved to a file in the computer that you take with you or printed as a copy that could be read incase there was no phone or internet service available.

 

Brian

 

 

[Guest davidh10]

We were talking to the some CASA people at Natfly and asking about the checks that were happening and what they were actually doing. The weather forcast came up and we were told that we had to be able to get the weather forcast where we were, this could be on the phone or a computer and it would be fine, BUT it was suggested that the weather be moved to a file in the computer that you take with you or printed as a copy that could be read incase there was no phone or internet service available.Brian

Correct. You may have it on an electronic device, but it must be local to the device and not dependent on network connectivity. I carry it on my phone and had cause to reference it in flight a week ago, as it happens, to check last light, as the ambient light didn't accord with my recollection from the download... I'd mentally added 11 hours instead of 10, so my flight was rather short.

 

 

[Guest Andys@coffs]

Ian

 

As David said, there are ways of reducing the risk by effectively removing the flying surface by pulling the profile battens and fully or partially folding the wing. The wing is the only issue, once thats done then winds that would damage/move the pod and folded wing are going to do a lot of damage to everything else around.....

 

Anyway,as identified my specualtion was off base...although I wonder, like many accidents if its likely a heap of elements coming together....perhaps the impending front may well have been the straw that did the camel in.....

 

Andy

 

 

[PapaFox]

Didn't the front come through Friday night/Saturday morning though? Saturday evening had no significant Wx. Clear sky, full moon, not much wind.

 

 

[Admin]

Didn't the front come through Friday night/Saturday morning though? Saturday evening had no significant Wx. Clear sky, full moon, not much wind.

You're right there PF, easy to forget which day was which at NatFly

 

 

[Bluey]

As with any accident more than one factor was responsible for the end result. I'm sure this accident is no different. The decision to leave so late in the day was just the start. I'm sure that the ensuing investigation will reveal other disturbing occurrences. The culture of risk taking by some in our hobby is not surprising and will never be irradicated given the nature of the individual's that attracts them to flying in the first place. Only the collective action of the rest of us working together can make some individuals think twice about some of their actions.

 

We've all heard of stories of people taking extreme risks and getting away with it. I can remember one story that occurred recently where a couple of pilots on a long cross country flight fighting adverse weather conditions decided to push on to their destination. They arrived well after dark and couldn't see the runway. Luckily, their friends who had arrived earlier were able to organise a car to illuminate the runway with it's head lights and the pair landed safely. The weather was shocking the rest of trip and no other flying was possible. On the last day, a number of aircraft decided to depart in horrible weather. A few returned soon after leaving (smart move). About three aircraft continued on despite the extreme weather. Two made it back to home base (only just) one had to outland and then rolled on take off and luckily wasn't injured (the aircraft had to be recovered). The others who stayed behind ended up having friends at home needing to rescue them with trailers. This was a big deal and showed the value and loyalty of friendship as the return drive from where the stranded pilots were situated was more than 15 hours! The point being while a few may have been horrified by all this no one really said hey, it's not worth it. I recall speaking to one of the pilots who made it home a few weeks later and asking him what he thought of that horrible trip. His reply was along the lines of what horrible trip! It was a great success!

 

We all have built in "risk thermostats" that determine what levels of risk we are willing to take. some of us have thermostats set low and take fewer risks others have it set high and take greater risks. It is just the way we are all genetically pre-programmed.

 

I don't know what the solution to all this is? It may well be more regulation to keep better tabs on our activities. It may well be more reporting of bad behaviour with disciplinary action possibly resulting. The risk taking will not stop by some unless they get caught and disciplined for it. one thing is certain, it will be cheaper if we can self regulate and maybe save a few lives in the process. The research is pretty clear on this, risk takers respond most to criticism from their piers than from some bureaucrat telling them that what they are doing is dangerous and they need to alter their actions.

 

Bluey.

 

 

[turboplanner]

Good thought, but not in this case. I believe the female concerned was imploring a departure from about 16:00 local time, however the male had some objective at NatFly, that was as yet unsatisfied, and thus delayed departure. On this basis you could well conclude that at the time of departure, they knew that the flight would not be completed before last light.

Temora airport to Cootamundra airport is just 29 km. You would be virtually looking at your destination field shortly after take off. Many people would be within their own training area in a similar situation, so it's unlikely not carrying a weather report with them is significant.

 

I agree with you Motz, the culture of the governing body, whether HGFA or RAA needs a look here.

 

You cannot run an organization and just walk away from human behaviour, because that plays a major part in statistics - way more than mechanical failure, and way more than weather per se.

 

If you are the sort of person who says "How can I prevent this happening to me?" rather than "It can't happen to me!" then the lesson from this one is not to short cut going through your Performance and Operations calculations, even for a 29 Nm trip.

 

I wouldn't necessarily agree that the spate of fatalities over the last 18 months is here to stay and getting worse - we went for quite a time without any prior to that, but I agree with Motz that the CAUSES have been an indicator that someone has got training and airfield management culture back to front.

 

 

[frank marriott]

Thanks Ozzie

 

CAR 233 (h) answers my query

 

FrankM

 

 

[Guest Howard Hughes]

CAR 239 refers...

 

239 Planning of flight by pilot in command

(1)Before beginning a flight, the pilot in command shall study all available information appropriate to the intended operation, and, in the cases of flights away from the vicinity of an aerodrome and all I.F.R. flights, shall make a careful study of:

 

(a) current weather reports and forecasts for the route to be followed and at aerodromes to be used;

 

(b) the airways facilities available on the route to be followed and the condition of those facilities;

 

© the condition of aerodromes to be used and their suitability for the aircraft to be used; and

 

(d) the air traffic control rules and procedure appertaining to the particular flight;

 

and the pilot shall plan the flight in relation to the information obtained.

 

(2)When meteorological conditions at the aerodromes of intended landing are forecast to be less than the minima specified by CASA, the pilot in command shall make provision for an alternative course of action and shall arrange for the aircraft to carry the necessary additional fuel.

 

Penalty: 25 penalty units.

 

(3) An offence against subregulation (2) is an offence of strict liability.

 

Note For strict liability, see section 6.1 of the Criminal Code.

No requirement in there to carry weather and/or NOTAM's, however it may go some way to proving that you have 'studied the necessary information' if you do have a hard/soft copy.

Source = "comlaw.com.au - Civil Aviation Regulations 1988, updated 27 June 2011".

 

 

[Guest Howard Hughes]

Lots of good information in the Visual Flight Guide (VFG).

 

 

[brilin_air]

The culture of people that take risks will not be changed by regulation as they are already doing their thing and not taking any notice of rules and regulation, the best way that I can see to help avoid any further carnage to people and machines is peer pressure to do the right thing and be around for another day, We are all friends in aviation and should not be frightened to question someone in what they are doing if it does not seem right to us, the person being questioned might just have an extra think about what they are about to do or have just done and we might just learn something ourselves that could save us from making a mistake.

 

Ther is no such thing as a dumb question.

 

Brian

 

 

[Powerin]

Temora airport to Cootamundra airport is just 29 km. You would be virtually looking at your destination field shortly after take off. Many people would be within their own training area in a similar situation, so it's unlikely not carrying a weather report with them is significant.

Flying around earlier in the afternoon (about 4pm) there was a significant smoke/haze layer up to about 3000ft in most directions as there was quite a bit of burning off going on in the wider area. It may have cleared later, but if it continued into the evening it would have made the horizon hard to see. However, full moon was Saturday morning, and I recall as I was driving home seeing the moon rise not long after sunset. It was red, indicating smoke haze, but also should have helped in identifying the horizon.

 

 

[nong]

Some aviation bureau (for their own unrelated purposes) decided we should study HUMAN FACTORS. The premise was dodgy. Study of such stuff has not prevented stress factors applying in the real world.

 

The proof of my statement is in the pudding, incident wise.

 

Anyway, a full moon with a clear sky can be tempting.....

 

Hmm. Lets see. A visible horizon. Unlikely to encounter fog. Runway lights at home base. A road to follow. A warm bed (deadly).

 

Against this, the law. Well, we all make judgements about our compliance. I would bet that none of you are blindly obedient zombies. Mostly obedient? Yes.

 

Was passenger an informed co-adventurer? If not, no go. Aircraft anti-collision and ground guidance lighting. No lights, no go. Ability to change radio frequencies in the dark, also a show stopper.

 

And what about highly trained airline pilots who hold the stick full back to recover from a stall. Yes, there's yet another one in the latest FLIGHT SAFETY. Over 50 dead.

 

Humans are amazing!

 

 

[Guest davidh10]

Some aviation bureau (for their own unrelated purposes) decided we should study HUMAN FACTORS. The premise was dodgy. Study of such stuff has not prevented stress factors applying in the real world....

No amount of rules or training will prevent people deciding to take undue risks. The study of HF is just to alert people to some of the causes of risks that we might otherwise overlook. The exam is of no greater value than ticking the box. The value can only be of use if each individual believes it can help them to identify situations in which they may inadvertently either, do the wrong thing, or omit to do something necessary. Having that belief, the safety conscious pilot will continue self educating by reading, listening, discussing and asking questions. That is one of the values of these forums, amongst other resources.

I agree with Motzartmerv. It is the culture, of which we are all a part, that is more powerful than rules and regulations. Despite that each individual has their own risk tolerance and what to some of us is an unwise risk may be an acceptable risk to others.

 

One of the significant points in this case, is that it seems that one of the occupants was not comfortable with the late flight, but chose for whatever reason to fly anyway! One has to wonder, that if one of them had declined to fly, would they have both stayed the night and flown home the next day? (rhetorical question)

 

 

[alf jessup]

No amount of rules or training will prevent people deciding to take undue risks. One of the significant points in this case, is that it seems that one of the occupants was not comfortable with the late flight, but chose for whatever reason to fly anyway! One has to wonder, that if one of them had declined to fly, would they have both stayed the night and flown home the next day? (rhetorical question)

The question remains David that they were only a little over a 3/4 hr to a 1hr drive from their hanger at Cootamundra and they had friends at the hanger waiting for them and also their car was there.

 

I am sure if they decided not to fly back they could have called the friends to come get them and both head back in the morning for one to retrieve the trike and fly back and the other to drive back.

 

Hindsight is a good thing and I am sure as it turned out if they had that chance again knowing what was to happen to them they would have done it differently but they can't as it is now history.

 

What we as fellow aviators MUST do is learn from others unfortunate outcomes in aviation, if we don't some of us aviatiors will eventually end up the same way. (never coming back home)

 

Life is a treasured gift why just throw it away for no need.

 

Alf

 

 

[Gnarly Gnu]

Thoughts are with the Family and friends. Frankly, ive had a gut full. Im not here to point fingers at deceased people. But I am going to point fingers at the rest of us.

I don't get this - it reads like you are sympathetic with the pilot that caused this accident but angry with everyone else... or am I misunderstanding you?

 

 

[motzartmerv]

Gnarly. I thought I was pretty clear. Read some of the other threads that have been started in response to this incident and my comments. I'm not pointing fingers at the deceased because he's had the biggest finger of them all pointed at him already. And while I reserved my feelings towards him an his actions out of respect for his family I dint spare my feelings towards all of us. Myself included. While I have not ha a great deal of influence over this particular pilot I have been I a position to have made some impact On his attitude. Clearly my influence had little or no effect. While I am pointing the finger at the culture I have 3 fingers pointing back at myself.

 

I hope this has cleared it up for you.

 

 

[poteroo]

One of the hardest decisions that you make as PIC is to divert early, and land with power and light. But it sure beats being up there - wishing you were down here!

 

 

[Tomo]

BUT it was suggested that the weather be moved to a file in the computer that you take with you or printed as a copy that could be read incase there was no phone or internet service available.

Naips on your smart phone can save the weather report (my iPhone you can anyway)

 

Good old pen and paper is fairly simple method also. (copy it) But a weather report in regards to this accident is a bit off track! And don't forget, having a weather report won't save your life. It'll help of course, but it's the PIC at the end of the day.

 

 

[Powerin]

Clearly my influence had little or no effect.

Motz,

 

You have had an influence on me. Even though we've never met. From all you've written in forums and even on chat (believe it or not) you've been someone whose opinion I respect. As a student I have taken a lot you've said here to heart...either by reinforcing things I've learnt, or stuff my own instructor didn't tell me. When you talk aviation you talk safety and promote that culture.

 

If a guy like you can't instil a culture of aviation safety in those around you, well, I'm not sure anyone could. What else can you do?

 

Cheers,

 

Peter

 

 

[kaz3g]

CAR 233 (h)and

 

AWB 00-017 issue 2

 

as a valid CPL holder you'd know, or at least know how to find it.....

Hi Ossie

 

CAR 233(h) says you must have with you the latest editions of charts, info and instructions published in the AIP. AWB 00-017 is about electronic flight bags but we haven't really got that far advanced, yet. and AIP GEN 0.1 9.1 says we must have access to ERC, WAC, VNC, VTC and ERSA relevant to the flight for VFR.

 

CAR 239 requires the PIC to make a careful study of (a) current weather reports and forecasts for the route...and plan the flight in relation to the information obtained.

 

So my take on it is that you don't need a hard copy weather report with you but you must be able to evidence the fact that you studied it.

 

I personally print a copy of weather and notams off NAIPS before heading off any distance if possible but always have it as a download on my laptop (or on my iPad now). I also have all the current charts in electronic form but carry hard copies and use them as well.

 

Kaz

 

 

[turboplanner]

Pow makes a good point Motz.

 

In teaching you can only get a percentage of them across the line; even Jesus Christ only got a percentage.

 

If the reports are true this individual was getting a very strong message from the co pilot and an official before he made his decision to go.

 

 

[farri]

Have I missed it or what?..All this discussion on who and what should have been done or wasn`t done!...Does anyone here know the exact cause of the Trike accident?

 

Frank