Recent RA-Aus fatal accident history

[John Brandon]

You may find the latest update of the document 'Recent RA-Aus fatal accident history' at

 

http://flysafe.raa.asn.au/safety/intro2.html of interest, particularly the following extract.

 

So, what are the reasons?

 

RA-Aus introduced human factors (HF) training in 2008 and from August that year all student pilots were studying HF in their training and all existing Pilot Certificate holders were required to complete an HF course, or just an examination, by August 2010. In the 28 months since January 2011, 17 accidents have killed 23 persons. On top of that it was only extremely good fortune that the October 2011 controlled flight collision with an operating Ferris wheel at Old Bar did not add members of the public at large to the toll.

 

HF training is not designed to worsen the safety record, so there must be something wrong in the RA-Aus HF training syllabus, or lacking in its implementation or in the quality assurance outcome, of both the association's HF training for student piots and the 2010 HF 'examination' of the, then existing, certificated pilots.

 

In addition, there are concerns whether it is appropriate for the RA-Aus board to persist in its long standing opposition to the dissemination of information concerning the occurrence of a serious accident, and the later distribution of the RA-Aus accident investigation team's report. The current situation is that the occurrences are never mentioned in the website news section or the monthly journal 'Sport Pilot'; not even when the member concerned is well known to, and well respected by, the broad membership. The unpublished policy is that it is left to the membership to learn of the event via the public media's uninformed reports and the internet forums' sometimes grossly speculative reporting, and thus the membership learn nothing of real value from the accident, except, when necessary but very occasionally, an aircraft airworthiness directive might be issued as a result of the investigation. Certainly, this negative attitude is doing absolutely nothing to improve safety outcomes and the governance of the Association is neglectful of member safety — including those members who need to be protected from their own wilful actions.

 

Paragraph B.7 in the statement of purpose section of the RA-Aus constitution is a reminder to all ordinary members and all board members. It states: "To set promote and maintain standards of safety for recreational aircraft by the specification and dissemination of information concerning standards of airworthiness for aircraft, standards of workshops and standards of knowledge for pilots and in particular, to specify, impose and enforce standards of skill and competence reactive to all stages of flying operations and to require any Member to meet such standards to the satisfaction of the Association before authorising such Member to engage in flight operations or any stage or aspect thereof and to grant, issue authorise, modify, cancel, suspend or revoke under the rules of the Association for the time being in force certificates and authorisations relating to aircraft, aerodromes, flying instructing and flying schools and to the skill and qualifications of pilots, instructors, navigators, drivers, mechanics and all persons managing, flying, driving, constructing, repairing or otherwise engaged in connection with recreational aircraft or recreational activities and to do all things relating thereto as may be deemed expedient and to make reports and recommendations to any clubs, authorities or persons concerning the same."

 

I leave it to the reader's own experience to judge whether the requirements of paragraph B.7 are currently being fulfilled and, as B.7 contains the constitution's sole reference to 'safety' (and 'aircraft safety' at that), does the constitution as drafted really express any concern with theongoing safety of all the membership and their passengers? Why doesn't the constitution require dissemination to the membership of RA-Aus serious accident events, investigation progress and the very valuable RA-Aus investigator reports summarising the facts and the investigator'sconclusions? Accident investigator's reports were last published in the AUF website in 2004. The following are previously published examples of AUF investigators reports, without the photographs.

 

• Capella 3 November 2002 combination of factors.
   
   
  
• Chinook 31 May 2003 pilot lack of capability.
   
   
  
• RANS Coyote 5 July 2003 unauthorised low flying.
   
   
  
• Drifter 22 February 2003 'get-home-itis' – flight into IMC.
   
   
  
• Airborne Edge X 19 December 2002 combination of factors.
   
   
  
• Harrier 23 March 2002 wing divergence due to aileron flutter in dive.
   
   
  
• Bantam B22S 22 February 2005 EFATO turn back.
   
   
  
• Corby Starlet 4 October 2003 misjudged forced landing.
   
   
  
• Drifter 30 July 2003 mustering, no low-level training.
   
   
  

 

 

 

 

[Guest Crezzi]

You may find the latest update of the document 'Recent RA-Aus fatal accident history' at http://flysafe.raa.asn.au/safety/intro2.html of interest, particularly the following extract.

Very interesting - thanks for posting John.

 

The statistics appear to show a drop in fatal accidents during the period 2008-2010 after HF was introduced so could it be argued that it did have a benefit at the time but the message has now been forgotten ?

 

I'm interested to know what training RAAus pilots did/received as part of the HF requirement so I've created a poll here http://www.recreationalflying.com/threads/how-did-you-get-your-raaus-human-factors-endorsement.63025/

 

Whilst I have always been critical of RAAus' inability / unwillingness to disseminate accident information, I strongly suspect that the underlying causes of the fatal accidents since those published on the website wouldn't actually have any new causes in them.

 

Maybe knowing the facts surrounding recent accidents would have a greater educational benefit but, IMO, the lessons are already there if we choose to learn from them.

 

Cheers

 

John

 

 

[104chocks]

Why did they cease to publish in 2004 - if the job is too much for them to manage then pass the summary details on to the ATSB for them to host and publish on their website - currently you are in an information dark void - ASRA are in the same dark void too.

 

You can view recent accident reports below for GA, ultralight, gyrocopters, airliners, Twins below - other countries manage to do this

 

UK

 

http://www.aaib.gov.uk/publications/bulletins/april_2013.cfm

 

NZ

 

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

 

USA

 

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

 

South Africa - see menu on left

 

http://www.caa.co.za/

 

Why stay in the dark - raise the standards and publish.

 

Steve

 

 

[kaz3g]

I just tried the links to the sample reports, John, and they don't seem to be working.

 

Would be good to read them.

 

Thanks for all you do

 

Kaz

 

 

[XP503]

Yes all accidents should be investigated and their reports publicized! Can't open the links John

 

 

[John Brandon]

Yes all accidents should be investigated and their reports publicized! Can't open the links John

You will have to go to the full document at http://flysafe.raa.asn.au/safety/intro2.html to access the reports.

 

 

[John Brandon]

Very interesting - thanks for posting John.The statistics appear to show a drop in fatal accidents during the period 2008-2010 after HF was introduced so could it be argued that it did have a benefit at the time but the message has now been forgotten ?

Perhaps, but you will recall that the then existing Pilot Certificate holders were not required to have completed an HF course, or just an "examination" until August 2010.

 

John

 

 

[Bruce Tuncks]

Here's the risks we recreational pilots run in life and in flying:

 

Risk of dying in a RAAus plane = one in a thousand

 

Risk of dying from all caused ( male in his 60's ) = ten in a thousand.

 

Risk of dying from all causes if 5 kg overweight ( male in 60's) = 12 in a thousand

 

So it is twice as dangerous to be 5kg overweight as it is to fly our planes. So we need PANTRY checks instead of ramp checks.

 

I'm not really joking. Of course I am risking a charge of heresy.

 

regards, Bruce

 

 

[turboplanner]

It's OK, you're off the hook, you didn't accuse us Christians......

 

 

[facthunter]

Heresy or heresay? Human factors IS a factor in most accidents .Nev

 

 

[John Brandon]

Here's the risks we recreational pilots run in life and in flying:Risk of dying in a RAAus plane = one in a thousand

Risk of dying from all caused ( male in his 60's ) = ten in a thousand.

 

Risk of dying from all causes if 5 kg overweight ( male in 60's) = 12 in a thousand

 

So it is twice as dangerous to be 5kg overweight as it is to fly our planes. So we need PANTRY checks instead of ramp checks.

 

I'm not really joking. Of course I am risking a charge of heresy.

 

regards, Bruce

You appear to be a person who accepts that fatalities in aviation are inevitable and so produce a general list of the probabilities of dying. You obviously haven't read the ' Recent RA-Aus fatal accident history' document I referred to in my post. If you had you would see that the heading of the opening section is a quote from Mark Twain - 'Lies, damned lies and statistics' and the first paragraph might describe your attitude to aviation safety and, of course, your own. Unfortunately this attitude is not rare in RA-Aus circles.

 

1.1 'Lies, damned lies and statistics'

 

We seem to have heard of more fatal accidents in recent years. Why are these accidents occurring? Are sport and recreational pilots and/or aircraft less safe than they were in the 1990s?

 

Any person believing that fatalities are inevitable in sport and recreational aviation and examining the fatal accident statistics (an annual average of 3.6 p.a. during the five years 2008-2012) may conclude that the RA-Aus membership — being representative of powered, fixed-wing, sport and recreational aviation — has, perhaps, been achieving near-reasonable safety results, after taking into account the fading away of the older ultralight types and the continuing introduction of faster, heavier, more complex and less docile aircraft; together with a marked reduction in the average years of experience of the RA-Aus pilot base. The latter is because of the accelerated intake, and training, of new pilot members in recent years — although there is a very high turnover in newer members.

 

Such cold, bare statistics may be of some value, but they fail to reflect the heartache and economic difficulties within the families that result from serious and fatal accidents. What is perhaps even more distressing to all of us is that so many future accidents will still be considered as so-called 'pilot error'* or 'human error'.

 

Generally, a shortcoming in knowledge, awareness and task management plus misjudgement and/or unwise decision-making or poor planning, and perhaps neglect plus complacency ("we won't bother with doing the checks again, we'll be OK!) figure prominently as causal factors in those accidents. Accidents also happen when we attempt to operate in circumstances beyond our experience and/or ability. Quite often, just two or three misjudgements, possibly not that significant in themselves, combine to lead on to a heap of wreckage. And, of course, there are those very few occasions where pilot incapacitation was thought to be the cause.

 

For those older members be aware that our abilities (including judgemental ability) and both the speed and appropriateness of our reactions does continue to deteriorate as we age, but we tend to deny it to ourselves and to others. (Speaking as an octogenerian who has been able to observe the ageing process on myself and acquaintances for quite a number of years.)

 

We — the sport and recreational pilot community — must do all we can to bring the number of all such accidents to zero. Fatalities are not inevitable, even an engine failure over heavily forested terrain is survivable and, possibly, some forms of pilot incapacitation accidents could be avoided if pilots follow the pre-flight safety and legality check procedures or appropriate aircraft maintenance in the case of carbon monoxide poisoning. Of course there are events that an individual pilot might have little control over such as a bird strike at a critical time or being struck by an overtaking aircraft on final approach, but again, there may be aspects of situational awareness involved.

 

So, the only statistic that sport and recreational aviation should be striving for is 'zero'; no fatal accidents and no crippling injuries.

 

 

[turboplanner]

There appears to me to be a definite link from training standard to behavioural standard to results with the current elevated levels John.

 

One possible cause is that RAA has left itself open by not having a management level above instructors.

 

Although this then makes instructors responsible for the behaviour of their students until they move out of the instructor's area, not too many understand this, and there are a few who stand by and spectate on bad behaviour, making comments such as "you can only teach them so much" and not realising that they have an obligation to ground the miscreant.

 

 

[TK58]

John,

 

I couldn't agree more with your views on this. In my understanding the purpose of introducing HF training/certification was to address (and reduce) the number of incidents - serious or otherwise - by ensuring all RA-Aus pilots have an understanding of their own role in the safety of the aircraft they pilot. The numbers suggest that aim hasn't been achieved. There could be any number of reasons, the syllabus being among them. It could also be that the public perception is true and there are too many cowboys in RA-Aus aircraft. Whatever the causes, we'll never know for sure unless the Board of RA-Aus - our representatives - get off their asses and take a serious look at the issue. If things continue as they are, there is a growing risk that someone (CASA, insurers, lawyers, Minister - pick one or more) will step in and shut the whole show down, grounding us all.

 

As for the current stance on reporting of incidents, it's a joke. There should be no reason a basic statement of facts can't be published. I am campaigning to be elected to the Board (as a SQ rep) and if successful this is one of the things I'll be pushing hard for. Have a look at how other similar bodies (e.g. ASRA) handle this issue. It can be done and it should.

 

 

[boingk]

Good work mate, you've certainly got my vote.

 

- boingk

 

 

[Guest Crezzi]

Although this then makes instructors responsible for the behaviour of their students until they move out of the instructor's area, not too many understand this, and there are a few who stand by and spectate on bad behaviour, making comments such as "you can only teach them so much" and not realising that they have an obligation to ground the miscreant.

RAAus instructors could decline to train a student or refuse to hire a pilot certificate holder a school plane but they have no power to "ground" anyone.

 

Cheers

 

John

 

 

[motzartmerv]

Anyone who thinks Human factors training is going to stop fatal accidents in any form of aviation has there hand firmly fastened to their nether regions. You can't teach or test airmanship. Its either in the culture, or its not. Unfortunately, more often it seems "not".

 

I understand and accept the idea of the syllabus, but think it falls very short of the mark. The time/energy/ and funds would be far better spent on having propper accident investigations. Where are all the facts to suport ANYthing other than speculation and conjecture in any of the fatal RAA accidents? I am yet to see a clear explination post thorough examination yet. The sting accident at golbourn while very much in the fore did not have a detailed investigation as the basis for any of the coronors evidence.

 

How can we say with any certainty what is causing the increase in fatal accidents when we dont have any real evidence as to the individual accident causes? Should have done propper checks, better planning etc, where is the evidence to suport these ideas?. Is inadequite pre flight checks a factor in a high percentage of fatal RAA accidents??I don't know... Does poor planning feature highly in RAA fatals? Possibly but who knows for sure?

 

Not to take away from comments made earlier, but I dont see any evidence, cold hard facts to suport anything other than conjecture based politics . Personally, i think airmenship has gone the way of the dog in light aviation in general. I have nothing other than personel observation to back my theory, but when I see a training plane with an instructor taxi past me and through a holding point, cross a runway as the call is given without stopping, then 20 minutes later watch that same instructor land on the runway only 2 or 3 hundred meters behind another aeroplane, I have to say, its no wonder airmanship is a dyeing art, people accept the reality they are presented with. What hope does that particular student have of gaining a solid foundation of airmenship and safety as the footing to build his flying skills on??..

 

We can preach "8 hours bottle to throttle, 0.02 BAC, know your medications, dont take drugs n fly, have plenty sleep...bla bla bla.. but at the end of the day its only an ass covering syllabus and in my view is a redundant requirement if airmenship is "demonstrated and encouraged as part of every lesson and interaction between students, Instructors, pilots, RAA staff, managment etc.. ALWAYS....

 

 

[turboplanner]

RAAus instructors could decline to train a student or refuse to hire a pilot certificate holder a school plane but they have no power to "ground" anyone.

RAA is self administering, but hasn't got around to setting up a full management system.

 

If a pilot's Certificate is suspended for 3 months, six months, twelve months, or life he is very quickly grounded.

 

With road vehicles, you receive training then when you are licenced you are audited and managed by Police, and additionally by Road Authorities if you drive a truck.

 

I administered 30 race tracks in Victoria, and drivers were audited and managed from the time they arrived at the tracks by 30 Chief Stewards, and their cars were checked for safety by three or four machine examiners at each race meeting, for an operation which arguably carries the same risk factor as flying. We started with about the same number of fatalities per year as recreational aviation is having today, and pulled this down to zero, and have maintained zero fatalities for nearly fifty years.

 

In General Aviation there is a management level above instructors - Flying Operations Inspectors (FOI) who audit and manage the behaviour of GA Pilots.

 

However, in RAA that upper level does not exist to ensure safety, so the CFI's are the front line when someone wants to blame someone.

 

 

[facthunter]

I think FOI's normally deal with the standards of organisations that do the training or charter etc rather than at the level of the average pilot. Nev

 

 

[damkia]

Heresy or heresay? Human factors IS THE factor in most accidents .Nev

Modified...

You (general, not personally!!!) may not be able to do much about a random undetectable mechanical fault, but there are things you can doto manage the remainder of your risk profile. It starts from the time you get up in the morning thinking about flying....

 

Most accidents involve human error at some point along the line, even if that is a failure to check everything yourself before flying. Very, very few are actually random failures, with most of those failures being able to be managed if previously prepared for (constant eye on the ground looking for landing areas, nearest alternates, etc...).

 

 

[turboplanner]

I think FOI's normally deal with the standards of organisations that do the training or charter etc rather than at the level of the average pilot. Nev

In your case yes, but you behave yourself.

 

 

[eightyknots]

.....

I have nothing other than personel observation to back my theory, but when I see a training plane with an instructor taxi past me and through a holding point, cross a runway as the call is given without stopping, then 20 minutes later watch that same instructor land on the runway only 2 or 3 hundred meters behind another aeroplane, I have to say, its no wonder airmanship is a dyeing art, people accept the reality they are presented with. What hope does that particular student have of gaining a solid foundation of airmenship and safety as the footing to build his flying skills on??

 

......

I think you're an honesst man Mozart but these actions from an instructor seem too unreal to be real.

 

(I thought only ag pilots did this sort of thing? )

 

 

[motzartmerv]

Nope, I pull not your leg. I wish I was..:(

 

 

[damkia]

This is what RA-Aus management should be aspiring to......

 

http://www.eaa.org/news/2013/2013-04-25_NTSB-chair-kudos-to-EAA-on-homebuilt-safety.asp

 

 

[Bruce Tuncks]

John, there was nothing I said that indicated that I reckon aviation accidents are inevitable. Personally, I have a great regard for proper maintenance and also human factors training. Please don't say I hold certain views unless I have stated them.

 

Here's a view you can criticise me for: I reckon there is a terrible deficiency in RAAus training with regard to engine-failure. In the sudden eerie quiet of their first real engine failure, many so-called experienced pilots panic and crash. They were untrained babes in the wood when the engine really stopped. This in another heresy of mine.

 

Getting back to what you said about my posting, you appear have said that deaths due to avoidable lifestyle factors ( like being overweight ) are inevitable and should be disregarded, even though these deaths take out twice as many PILOTS as aviation accidents.

 

Is that what you really meant?

 

... Bruce

 

 

[motzartmerv]

Bruce, efato fatals and accidents are a big problem industry wide, not just in the raa. There's many an experienced ga pilot spun in after an efato. Airline pilots, military pilots, all have documented cases of the same problem. It's sad but true, it duz still kill pilots today, efato and failures at alititude.