Western Australia Ultralight Fatality

[ave8rr]

Any further news on the fatal ultralight accident in WA yesterday?

 

News advises that RAA and Police are investigating.

 

 

[mAgNeToDrOp]

my blood ran cold when I saw that :(

 

Condolences to the family:

 

http://www.abc.net.au/news/2013-06-17/man-dies-in-ultralight-crash-in-mid-west/4757702

 

 

[Hongie]

We have a member from Dongara, where the pilot was from... I selfishly hope it was not him.

 

 

[ayavner]

what sort of ultralight, i wonder? Sad news... :(

 

 

[damkia]

Firstly, condolences to the family and friends of the gentleman involved.

 

My question is do RA-Aus actually have anyone that is capable of doing a "proper" investigation of incidents, ie has formal recognised training in incident investigation that would be consistent with a coronial inquiry as an "Expert witness"?

 

 

[paulh]

Another tragedy, dreadful news.

 

this is why I think CASA will be pushing RAAus harder to get much better in relation to safety matters, and quickly. Of course with generic reporting of the aircraft as an "ultralight" the aircraft may not necessarily be RAAus registered. In the bigger scheme of things however, doesn't really matter who it was registered with, another fellow aviator gone.

 

 

[Guest Crezzi]

My question is do RA-Aus actually have anyone that is capable of doing a "proper" investigation of incidents, ie has formal recognised training in incident investigation that would be consistent with a coronial inquiry as an "Expert witness"?

Yes

 

 

[jamel]

"My question is do RA-Aus actually have anyone that is capable of doing a "proper" investigation of incidents, ie has formal recognised training in incident investigation that would be consistent with a coronial inquiry as an "Expert witness"?

 

Yes

"Will they do anything? Of course not! Some nice policeman who most likely doesn't know a rudder from an elevator will prepare a report for a coroner who wouldn't know a stall from a flare who then will most likely find that the poor gentleman died from a severe impact.

 

My condolences to his family, they are unlikely to get any closure from the process.

 

 

[Blue Drifter]

My Condolences to the family as well.

 

But are the RA Aus ever going to tell us what happened so some one else might not make the same mistake.

 

 

[Guest Crezzi]

Will they do anything?

This has been discussed frequently on these forums - they can only become involved if the rozzers invite them.

 

 

[seb7701]

"...some nice policeman who most likely doesn't know a rudder from an elevator will prepare a report for a coroner who wouldn't know a stall from a flare who then will most likely find that the poor gentleman dies from a severe impact."

Spoken like a true example of someone with 'all the gear and no idea...'.

 

I think you will find that investigating organisations require a certain level of expertise when it comes to incident investigation and do not simple throw the crayons to the nearest persons and ask them to do something believable with them. Such comments certainly don't do justice to the vast expertise contained within the ranks of many of our RAA members either.

 

Coroners, whilst I can see what you may be thinking, do have a level of understanding either from experience or from explanations contained within a report, in order to formulate a finding and/or recommendations

 

I suggest you read some coroners findings and familiarise yourself with the process and see if you find any examples where the family members were left longing for a level of expertise in the report.

 

Just my 2 cents....

 

 

[damkia]

My question is do RA-Aus actually have anyone that is capable of doing a "proper" investigation of incidents, ie has formal recognised training in incident investigation that would be consistent with a coronial inquiry as an "Expert witness"?

Yes

Who would that be, and what are the qualifications?

We have had a few changes in the senior management, and I think this deserves more that a one word reply...

 

A tech officer (or whoever else) does not automatically have the expertise required for investigation of incidents by virtue of their inherent tech knowledge.

 

 

[jamel]

Spoken like a true example of someone with 'all the gear and no idea...'.I think you will find that investigating organisations require a certain level of expertise when it comes to incident investigation and do not simple throw the crayons to the nearest persons and ask them to do something believable with them. Such comments certainly don't do justice to the vast expertise contained within the ranks of many of our RAA members either.

Coroners, whilst I can see what you may be thinking, do have a level of understanding either from experience or from explanations contained within a report, in order to formulate a finding and/or recommendations

 

I suggest you read some coroners findings and familiarise yourself with the process and see if you find any examples where the family members were left longing for a level of expertise in the report.

 

Just my 2 cents....

OK I will bite! Apart from the Goulborn

 

and Mildura inquests can you point me in the direction of any other worthwhile investigations into quite a few fatalities in the last few years?,

 

 

[facthunter]

You don't get many inquests although Lee Ungermann went to plenty of them . having a ferris wheel seems to help ( because of the sensation.) and people involved although no fatalities.

 

The costs of investigating these matters would be prohibitive. You have vast distances involved and you have to get there quickly. I don't believe it will ever happen to any real, extent. That doesn't mean that something better than what we have now should be available, certainly in some instances, where more than basic statements can be made. Perhaps better reporting of incidents/accidents might happen. At the moment a lot are not reported ( I feel).. Nev

 

 

[Guest Crezzi]

Who would that be, and what are the qualifications?

Its been discussed before - a number of people have undergone training and become RAAus accident investigators. I imagine this included the Operations managers as well as non-staff members but, as I'm not one of them, I can't provide any details.

 

Judging by the various coroners reports its not unusual for the RAAus Ops manager to be called at inquests

 

John

 

 

[jamel]

You don't get many inquests although Lee Ungermann went to plenty of them . having a ferris wheel seems to help ( because of the sensation.) and people involved although no fatalities.The costs of investigating these matters would be prohibitive. You have vast distances involved and you have to get there quickly. I don't believe it will ever happen to any real, extent. That doesn't mean that something better than what we have now should be available, certainly in some instances, where more than basic statements can be made. Perhaps better reporting of incidents/accidents might happen. At the moment a lot are not reported ( I feel).. Nev

Nev, I guess we all know the risks, no one is holding a gun to my head to make me fly RAA , part of the deal is that there is very little in the way of accident investigation, if we fly rAA we have to accept that!

Let's hope the new SMS goes a way towards helping avoid these happenings.

 

 

[facthunter]

I am in full agreement that information is valuable for learning from other's mistakes without having to make them yourself, and I have lost quite a few good friends too. I have spent a lot of effort over my flying career involved with investigations and am very safety conscious. I guess if we don't lift our game we don't get to fly. I'm not sure we are much worse than a lot of GA but there you go. IF you give them an opportunity to catch you out on basics then don't be surprised if things go pear shaped for you. Nev

 

 

[Guest Andys@coffs]

the thing that needs to be learned is not how it all went wrong, but how others/we can learn and recall and APPLY the lessons that others died to teach.......I cant help but think there is very little new to be learned and that the learning part is merely one link in the chain and its probably not even the weak link

 

Andy

 

 

[seb7701]

OK I will bite! Apart from the Goulbornand Mildura inquests can you point me in the direction of any other worthwhile investigations into quite a few fatalities in the last few years?,

It's not a matter of biting. My issue was with the ill-informed criticism of the investigation processes.

 

As for other 'worthwhile investigations', they are ALL worthwhile, particularly if your loved ones are involved.

 

If you are suggesting that because there were only two inquests into several fatalities that investigations are not being thoroughly completed, you might want to take a look at the Coroner's Act for the relevant jurisdiction.

 

An inquest is not required if a matter is sufficiently investigated to a coroner's / family member's satisfaction. There are plenty of lessons to be learned simply from coroner's findings without an inquest.

 

I certainly concur with the suggestion hat RAA needs to source the findings once released and highlight things we could do better to help the prevention of reoccurrences.

 

 

[DWF]

From the Sport Aviation Self Administration Handbook 2010:

 

"As part of the RAAOs’ Industry Risk Profile, the supply of and proficiency in safety data and information is key. Therefore RAAOs are to ensure that appropriate safety data and information management processes exist and provide CASA with a safety profile of their sector via six monthly reports.

 

This is to include:

 

• Accident and incident occurrences, including frequency and severity

 

• Accident and incident investigation and findings

 

• Records that safety analysis has been communicated to members."

 

Does RA-Aus do any of this?

 

I have not seen any evidence of the third item - "safety analysis [being] communicated to members".

 

DWF

 

 

[mAgNeToDrOp]

Another report, video also showing the aircraft and naming the Pilot.

[Guest Maj Millard]

Looks like a Colyaer Martin 3 LSA, possibly 24-5474 which was advertised for sale last October in the Mag...........Maj...

 

 

[Riley]

"My question is do RA-Aus actually have anyone that is capable of doing a "proper" investigation of incidents, ie has formal recognised training in incident investigation that would be consistent with a coronial inquiry as an "Expert witness"?

"

Will they do anything? Of course not! Some nice policeman who most likely doesn't know a rudder from an elevator will prepare a report for a coroner who wouldn't know a stall from a flare who then will most likely find that the poor gentleman died from a severe impact.

 

My condolences to his family, they are unlikely to get any closure from the process.

 

Perhaps a bit emotive jamel. Some of the doomsayers would crap themselves to learn that we, in WA, have at least one dedicated and experienced current RAA-GAA pilot/aircraft owner/career copper (who obviously is multi-experienced in forensic everything), and...guess what....he's been CASA-schooled in the requirements of aircraft accident investigation and reporting! So there already exists a modicum of ability within RAA ranks to at least participate in (if not conduct) the establishment of reports re: these unfortunate fatalities. With RAA being so far behind the 8-Ball in so many respects at present, only the good Lord knows how long it might be before the system is modified to allow us to be involved in our own house-keeping. Despite all of the above, I too offer sincere condolences to the Pilot's family and friends.

 

 

[turboplanner]

From the Sport Aviation Self Administration Handbook 2010:"As part of the RAAOs’ Industry Risk Profile, the supply of and proficiency in safety data and information is key. Therefore RAAOs are to ensure that appropriate safety data and information management processes exist and provide CASA with a safety profile of their sector via six monthly reports.

 

This is to include:

 

• Accident and incident occurrences, including frequency and severity

 

• Accident and incident investigation and findings

 

• Records that safety analysis has been communicated to members."

 

Does RA-Aus do any of this?

 

I have not seen any evidence of the third item - "safety analysis [being] communicated to members".

 

DWF

 

What DWF found here could be the answer to getting aviation-based investigations of RA aircraft crashes.

 

As we know, the present situation is that Sate and Federal Police control the investigation and prepare a brief for the Coroner, whose primary responsibility is to determine the cause of death, not necessarily the cause of the crash, which might be outside his/her legal parameters.

 

Recreational Aviation Australia's expert may be called in to provide specialist advice to the investigating police, but they, except in rare cases, will not release any details of that brief.

 

So the result is a cone of silence relating to the crash, and no learning sequence for us, which could prevent a similar incident, which ironically is one of the duties of the Coroner.

 

From time to time on this site, some people have posted anecdotal information that "RAA was offered the opporunity for ATSB to investigate all fatalities but didn't pick it up"

 

What DWF found is an IMPERATIVE from CASA, probably part of the Deed, which RAA is in default on, so something has to be done and fast.

 

Except in this case it's a catch 22 - Recreational Aviation Australia Inc. does not have the legal powers that ATSB has.

 

Given the very high cost of getting ATSB to investigate RAA fatalities, my preference would be for the Federal Government to provide the investigative and reporting powers that ATSB has.

 

Recreational Aviation Australia Inc investigators, with their specialist knowledge of Ultralight aircraft dynamics and performance could then investigate at crash sites and publicly report aviation based lessons to be learned from the fatality.

 

Because RAA are in default of CASA requirements, there is an urgency, but it is also a golden opportunity.

 

 

[Phil Perry]

Having discussed a lot of previous cases on this, and indeed other forums, I can only conclude the following, with my total lack of knowledge of the manner in which RAA was set up in the first instance.

 

In the UK, we have the A.A.I.B. the Air Accident Investigation Branch, which is separate specialist department of the CAA, and world renown for it's superb quality of service to the aviation industry and private aviation. They always investigate ANY and EVERY FATAL accident involving an UK registered aircraft, however big or small. I'm not really certain how this is all funded, but as you probably all realise, the entire land mass of Britain fits neatly TWICE into an area smaller than the state of Victoria, so they don't really have to travel very far ( relatively) in any particular direction to carry out their work.

 

Australia is ABSOLUTELY VAST by comparison, ( APPROX 32 TIMES THE SIZE OF THE UK ? ) with pilots flying in all corners of the continent AND IN THE MIDDLE TOO. . . ., which must cause an enormous headache in itself with regard to transport / time /cost logistics, and also the collection of a specialist investigation team for the accident, depending upon whether it's a trike or a Boeing 777. I would suggest that this is one reason, though perhaps not a primary one, but a hugely important consideration nonetheless. And since the ATSB also investigate OTHER transport accidents, Trains, buses, ships running into docks, etc. . . It isn't hard to see that they are probably a bit busy without a special unit dedicated to aviation incidents.

 

Australia has obviously grown up into aviation over the past 50 years or so in a slightly different manner, with differing Governmental priorities. . . from what I've been reading over the last few months from obviously very knowledgeable members who seem to have a grasp on how your system works. . . . ( I still don't )

 

In the UK, the Police always attend an air accident, and are, usually along with first responder paramedics,. . .. but have absolutely NOTHING to do with any sort of investigation of cause whatsoever, and our coroner can only complete a case when advised of the probable cause by the A.A.I.B. and no other organisation. Only then can the families of the deceased get any closure.

 

However, in some cases, due to the workload, these results quite often take up to a couple of years before the final result is published, but PUBLISHED it ALWAYS is. . . . in most of the available aviation journals, so that HOPEFULLY, someone else won't make the same mistake, should a mistake or error have been cited as the primary cause.

 

I don't have a lot of time lately to research stuff like this, but I will try to find out how the accident investigation branch are specifically funded, and if I can find this information I will post it here. This discussion seems to be an ongoing subject, and I find it most interesting.

 

Phil