Texas Qld

[Keenaviator]

Wouldn't a police report or standard coroner's report just state cause of death as impact trauma due to aircraft accident and leave it at that? i wouldn't think those reports would investigate to the level to help us understand root cause on the accidents themselves? I could be wrong, i have never seen one, but my impression was unless an aviation-related party investigates, that the info provided is mostly about what happened and when and to whom and the result at a pretty basic level? in other words, probalby nothing we wouldn't already know or have guessed.

I think you are confusing the police/coroner's report with the pathologist's. The police conduct a full investigation of the accident/circumstances resulting in the Coroner making a 'finding' as to the cause of death. If factors such as road design, vehicle design issues etc are noteworthy the the Coroner can make recommendations.

 

 

[Diddy Pilot]

Many years ago in a past life I worked for BASI (Bureau of Air Safety Investigation), I am not completely familiar with what may have changed since creation of ATSB or RAAus. However back then all accidents and incidents reported were managed to collect the necessary learnings to make flying safer for everyone. We even requested that bird strikes were reported, or via CAIR (Confidential Aviation Incident Reporting) we sought the details of mistakes or errors which when viewed across the whole spectrum might lead to a training need.

 

Our focus was to investigate the factors which may have contributed to an accident, we did not investigate to apportion blame. What is the maintenance history - could this have contributed or detected something, does this type of aircraft require a safety check. Environment - what were the weather conditions, was this near an airfield / traffic which may have impacted on where the craft was etc. Human Factors - what was the pilot doing, experience etc what training have they received, why might they have made certain decisions. Plus of course many other aspects which might be particular to an individual event. Police and coroner reports if they existed were made available to assist.

 

The conclusion of our investigations may involve recommendations which were made publicly available, in some cases this lead to actions by CAA (CASA or AA) implementing mandated requirements. This was done to improve safety.

 

I would hope that this focus on improving safety has transferred across to the ATSB (certainly some of the older hands there have come from BASI). As such RAAus does not need to be intrinsicly involved in investigation, but certainly as a representative body within the aviation industry should be a primary stakeholder when an investigation involves a RAA registered craft or personnel. The relevant conclusions/ recommendations should then be communicated back to members.

 

 

[ave8rr]

I would hope that this focus on improving safety has transferred across to the ATSB (certainly some of the older hands there have come from BASI). As such RAAus does not need to be intrinsicly involved in investigation, but certainly as a representative body within the aviation industry should be a primary stakeholder when an investigation involves a RAA registered craft or personnel. The relevant conclusions/ recommendations should then be communicated back to members.

Diddy Pilot, the problem is that ATSB do not investigate RAAus accidents except on the odd occasion.

They (ATSB) will help with some matters in respect to an accident. This may be as small as checking an instrument or GPS track etc. What we want is RAAus to attend all accidents and report a summary to the members with in 30 days as would be the case IF ATSB was carrying out the investigation.

 

 

[Guest Crezzi]

As has been pointed out previously RAAus do have trained accident investigators (in addition to the Ops & Assistant Ops managers). I very much doubt that they decline any request from the police to assist with a recreational aircraft accident but they have no rights to do so otherwise.

 

The problem is their understanding that the report of the investigation is only for the police to submit to the coroner and cannot be published. I'm not a lawyer so cannot comment on whether this is true and whether such restrictions also prevent them from disseminating a summary to members.

 

At one time RAAus did seem to publish summaries of serious accidents (presumably after the coronial inquest). There were some on the old website (with the most recent being from 2005) but the practice seems to have stopped and I can't find even those old ones on the new site. That page included a statement the quote to the effect that RAAus didn't publish accident reports because they are just a repetition of the same old pilot errors.

 

Whilst I don't agree that this is adequate justification for not publishing the details of Australian accidents it is, nevertheless, absolutely true that pilots simply don't find new ways of killing themselves.

 

The information we need to to avoid the same outcomes isall already there in the reports from countries which do publish them (such as UK, USA and NZ).

 

We all just have to try & learn it

 

http://www.aaib.gov.uk

 

http://www.ntsb.gov/aviationquery/index.aspx

 

http://www.caa.govt.nz/safety_info/fatal_accident_reports.htm

 

Cheers

 

John

 

 

[turboplanner]

Many years ago in a past life I worked for BASI (Bureau of Air Safety Investigation), I am not completely familiar with what may have changed since creation of ATSB or RAAus. However back then all accidents and incidents reported were managed to collect the necessary learnings to make flying safer for everyone. We even requested that bird strikes were reported, or via CAIR (Confidential Aviation Incident Reporting) we sought the details of mistakes or errors which when viewed across the whole spectrum might lead to a training need.Our focus was to investigate the factors which may have contributed to an accident, we did not investigate to apportion blame. What is the maintenance history - could this have contributed or detected something, does this type of aircraft require a safety check. Environment - what were the weather conditions, was this near an airfield / traffic which may have impacted on where the craft was etc. Human Factors - what was the pilot doing, experience etc what training have they received, why might they have made certain decisions. Plus of course many other aspects which might be particular to an individual event. Police and coroner reports if they existed were made available to assist.

 

The conclusion of our investigations may involve recommendations which were made publicly available, in some cases this lead to actions by CAA (CASA or AA) implementing mandated requirements. This was done to improve safety.

 

I would hope that this focus on improving safety has transferred across to the ATSB (certainly some of the older hands there have come from BASI). As such RAAus does not need to be intrinsicly involved in investigation, but certainly as a representative body within the aviation industry should be a primary stakeholder when an investigation involves a RAA registered craft or personnel. The relevant conclusions/ recommendations should then be communicated back to members.

Unfortunately Diddy, after your time the professionalism, sense of responsibility and even common decency went right down the plug hole, and the years of care that you and your predecessors put in has been lost.

 

Occasionally i look at some of the old Aviation Safety Digests and despair that today we are losing pilot after pilot and condemning their families to ongoing misery, just because the infrastructure isn't there to make sure they do simple things like not letting an aircraft stall or spin into the ground just because an engine stops.

 

The situation we are in today is avoidable and utterly disgraceful, and a lot of people in the industry have blood on their hands.