Atsb Report Into Old Bar Incident

[Guest DWB]

http://www.atsb.gov.au/media/3525311/ao2011126_prelim.pdf

[Guest DWB]

I hadn't read it when I posted it. Have read it now & almost wish I hadn't but that wouldn't change anything.

 

 

[Guest David C]

I urge everyone to read it .. Makes for some very interesting reading ... I'll let you all make up your own minds on this one ..

 

Dave C

 

 

[Guest Michael Coates]

My o My.... wow, there are going to be a few people in trouble for this one. Aircraft serial numbers on the data plate not matching the registration information, ribs manufactured that aren't held in place by rivets, stunt flying, formation takeoff without suitable radio calls. This is going to keep someone busy for a long time... Perhaps then they will stop annoying me!

 

 

[Guest ozzie]

The Final Report will be interesting.

 

160mts out, left of C/L and < 20mts. AGL. Surprised he didn't find a power line earlier.

 

: Examination of the aviation activity associated with the festival: Way to go!

 

Ya just gotta shake ya head and wonder.

 

(Might duck over to prune, bound to be 400+ expert posts on this by now.)

 

 

[metalman]

The pilots problems are one thing, the issues with the factory built aircraft are real scary, the engineers I use for automotive stuff would laugh me out of the business if I presented a vehicle with zip ties holding the fuel system together, let alone the rivets , the joy stick, the brake lines, and what else , I wonder if the whole lot will be inspected for shoddy practices?

 

 

[cficare]

this will be a 'ripper'....its like a swiss cheese!!

 

if CASA want to move in on RAA...this will provide the reason.

 

 

[cficare]

evidently the a/c in question has'returned to the skies'!!!

 

 

[Spin]

Well no real surprises in relation to the incident itself, the video would be interesting to see though. That aircraft however.....!

 

I'm not familiar with the process, a homebuilt aircraft would need to be signed off by an approved person, not so? How does it work with a factory built, who has oversight there?

 

 

[Guest DWB]

How does it work with a factory built, who has oversight there?

Spin I would presume that once a type certificate is issued it would then come down to quality control at the factory & a dedicated authorised person within the factory to sign off...........maybe? Given this is the preliminary report, I hate to think what will be in the final report. It beggars belief that so many things were wrong, although most were not presumably contributing factors. Just really got caught with their pants down! Miight have to invest in a fallout shelter.

 

 

[Guest Michael Coates]

factory built LSA approved aircraft are covered under different building approvals including the ASTM standards in the USA. It is pretty easy for a factory to declare that they meet or exceed the standards during the building of an aircraft. The ASTM standards actually provide for a very thorough and accomplished building process if the standards up followed correctly. Should somebody not want to follow the standards then there is really very little chance they get caught out. Regardless of the factory and category the aircraft must be inspected by a CASA approved person before it can be registered, this is an independent aircraft inspection and whoever did this inspection would probably have already been speaking to CASA weeks ago about these problems. Photographs are in many cases really difficult to judge by but when you see a fuel filter which is not approved for aviation use, cable ties on fuel hose carrying pressure, power cables strapped to fuel hose and following alongside and the classic control stick holes not in the right place welded up and then drilled again you really have to start wondering about the quality of the manufacturer. This could be very easily blamed on an amateur builder and I have seen aircraft like this being produced by amateurs, they are not expected to have the same standards of finish that are required by a factory built aircraft and disease problems which get picked up during the aircraft inspection by the CASA approved person. This whole thing sounds Shonky to me! There would not be a CASA appointed inspector pass this aircraft in 1 million years, how is it that the said pilot can get a pilot's licence using information from a flying school which does not exist ? surely the RAA have to have better management and standards in place to pick this sort of thing up, unfortunately they don't. At the moment there are heap of LSA and factory built aircraft flying the skies where the RAA don't even have the most basic records on file. We have been requested to supply information to several aircraft which we know have already been sent through before and the RAA have misplaced or lost the documents. Unfortunately with this problem and many others currently surfacing the RAA cannot demonstrate they have the ability to manage our market segment correctly.... they keep blaming manpower issues but it really does seem to go deeper than that.

 

 

[Old Koreelah]

What was that old quote about the freedoms we enjoy today being dependent on everyone doing the right thing...

 

or

 

"The price of freedom is eternal vigilance." - Thomas Jefferson

 

The costs (in time, maintenance, inspections and money) of us operating in RAAus land are tiny- but likely to increase as a result of this.

 

 

[Spin]

Sadly I think you're 100% right, at the very least RA are going to have to scramble to convince CASA that they are able to manage things down the line. Part of the problem is CASA too have to be seen to be doing something, there are enough people waiting to catch them asleep on the job.

 

The worst part of this is there are people around who had to have some level of awareness of the quality of work being produced in the factory and yet all you ever seem to hear is gushing praise:eek:. I know I was previously berated for daring to question the advertised stall speed of the Sierra (22kts!) Sadly I had always quite liked the look of the aircraft and by all accounts it is pleasant to fly - but this level of corner cutting throws it all into question - ie. just how comprehensive was the flight testing, the structural engineering etc?

 

 

[dazza 38]

Apparently the school was/is Legit.ATSB where looking in the wrong place for the information.It has all been sorted out now.

 

 

[Spin]

I don't know about that Dazza; I also read the whitewash exercise elsewhere and I would be interested to read what the final report has to say, the prelim report is pretty carefully worded and I suspect the authors knew exactly what inference would be drawn in reading it. I guess you also saw the "it was Garry's own plane" therefore not representative of what else is produced in the factory comment? Funny, I've seen previous ads where the fact that it was the builders personal plane was used as a selling point.

 

 

[Guest Darren Masters]

evidently the a/c in question has'returned to the skies'!!!

With cable-ties?

 

 

[metalman]

With cable-ties?

I too was wondering that, I also wonder how much damaged stuff has been "straightened " and put back in the aircraft!

 

 

[Guest Darren Masters]

Sadly I think you're 100% right, at the very least RA are going to have to scramble to convince CASA that they are able to manage things down the line. Part of the problem is CASA too have to be seen to be doing something, there are enough people waiting to catch them asleep on the job.The worst part of this is there are people around who had to have some level of awareness of the quality of work being produced in the factory and yet all you ever seem to hear is gushing praise:eek:. I know I was previously berated for daring to question the advertised stall speed of the Sierra (22kts!) Sadly I had always quite liked the look of the aircraft and by all accounts it is pleasant to fly - but this level of corner cutting throws it all into question - ie. just how comprehensive was the flight testing, the structural engineering etc?

Sorry mate but disagree (personally) with the 'it's pleasant to fly' comment. I have flown many aircraft (from GA/aerobatic to ultralight). I fly my microlight here in NZ in crosswinds you probably would not EVER consider taking some aircraft in. Why? Because I like to stay intouch with winds/cross winds and I know that my aircraft (as simple as the design is will handle it). Flying the Cheetah and Sierra I was not the slightest impressed. I went up several times with the manufacturer and with owners and I think it was the only aircraft I could 'not get a hang of'. It's twitchy (majorly). I don't think it was 'just me'. Anyway, my two cents and my comment on another forum here in NZ:

 

I very much doubt that this tool has touched down '20m into the strip, same as the first one' as he claims and very much doubt that it was at 60kts. 

 

I regards to the photos, in figure 2...yes I can see three (3) holes have been drilled. Fourth time lucky in this case. My question is, has that push-rod been bent to connect with the stick? Seems it has.

 

Electrical wiring near the fuel line...do the math.

 

Brake line in the fuselage without a grommet or any other means of passing through the fuselage is absolutely pathetic!

 

Being factory-built it does raise some serious concerns about the build process and the aircafts integrity. I knew the manufacturer personally (having flown from his former base airfield) and I decline to comment on 'issues' in the past. I will say, though, that this incident and pending investigation is likely a blessing.

[Guest Darren Masters]

This has seriously opened a can of worms for GM. There will be many directives come of this. I'm positive of that...

 

 

[Spin]

Sorry mate but disagree (personally) with the 'it's pleasant to fly' comment. I have flown many aircraft (from GA/aerobatic to ultralight). I fly my microlight here in NZ in crosswinds you probably would not EVER consider taking some aircraft in. Why? Because I like to stay intouch with winds/cross winds and I know that my aircraft (as simple as the design is will handle it). Flying the Cheetah and Sierra I was not the slightest impressed. I went up several times with the manufacturer and with owners and I think it was the only aircraft I could 'not get a hang of'. It's twitchy (majorly). I don't think it was 'just me'. Anyway, my two cents and my comment on another forum here in NZ:

You have the advantage on me, I have never even had a close look at one, was merely quoting what had been said on numerous occasions elsewhere. I suppose I should really know better after all this time in legal and associated fields, the truth is a fairly elusive little sucker.

 

Edit: I guess I should clarify, more than anything else I am disappointed ..... disappointed that what looked from the outside like an Aussie good news story, has been exposed as something akin to the Dodgy Brothers Circus.

 

 

[Guest Darren Masters]

You have the advantage on me, I have never even had a close look at one, was merely quoting what had been said on numerous occasions elsewhere. I suppose I should really know better after all this time in legal and associated fields, the truth is a fairly elusive little sucker.Edit: I guess I should clarify, more than anything else I am disappointed ..... disappointed that what looked from the outside like an Aussie good news story, has been exposed as something akin to the Dodgy Brothers Circus.

Just to clarify, hope no offence was taken the aircraft was not suitable for myself to fly. Just found it way too touchy. "Ah, you get used to that" was what the manufacturer told me. I later flew another which he said he had stiffened the controls and I found it just as bad. The cable ties...no comment. Maybe it's been going on a while...

 

 

[dazza 38]

Its not looking good for the people involved.Also as spin has previously mention.I as well had some serious doubts about some of the book fiqures.Especialy the Stall speed fiqure. The Savage Cub crusier I used to fly stalls at around 33 Knots.It has VG's fitted.They where quoting a fiqure for their A/c well below that. Sounds dodgy to me.But I have never flown one.

 

 

[Guest Darren Masters]

Its not looking good for the people involved.Also as spin has previously mention.I as well had some serious doubts about some of the book fiqures.Especialy the Stall speed fiqure. The Savage Cub crusier I used to fly stalls at around 33 Knots.It has VG's fitted.They where quoting a fiqure for their A/c well below that. Sounds dodgy to me.But I have never flown one.

Dazza, there were always many doubts about the quoted stall...

 

 

[David Isaac]

I don't know about that Dazza; I also read the whitewash exercise elsewhere and I would be interested to read what the final report has to say, the prelim report is pretty carefully worded and I suspect the authors knew exactly what inference would be drawn in reading it. I guess you also saw the "it was Garry's own plane" therefore not representative of what else is produced in the factory comment? Funny, I've seen previous ads where the fact that it was the builders personal plane was used as a selling point.

twitchy all right, I have had a go, would be a handful on landing until you got used to it ... that flying tail is the culprit me thinks. But it was like flying a little sports car. Not bad to fly just twitchy, but so are a lot of other aircraft.

 

 

[David Isaac]

What started out as an accident that in reality was the result of a failed go around attempt was a very unfortunate and no doubt terrifying experience for the pilot. The fact no one was injured is nothing short of remarkable.

 

What many would not be aware of is that had the Ferris Wheel not been in the position it was, the Sierra could have likely impacted with the trees immediately behind the Ferris wheel. If that had occurred we may well have had a tragic outcome. EDIT: I have since checked on Google and street view and have realised the trees that I thought from personal knowledge of the site were behind the Ferris wheel are actually one and it exhibits signs of pollarding as well. So it is likely the aircraft would have been safe if the Ferris Wheel was not in that particular position provided the aircraft wasn't stalled in the process.

 

Many are also not aware that the elevation of the ground on which the Ferris Wheel was erected is several feet below the airfield elevation (possibly 1 to 2 metres). If we consider the factual evidence in the ATSB report, the Sierra appears to have impacted the Ferris wheel about 3 metres from the Ferris Wheels highest point. The Ferris wheel was stated as standing 20 metres above the ground and as being 167 metres from the runway threshold and 34 metres to the East of the runway centre line. A quick deduction of numbers indicates how low the Sierra was at the point of impact 167 metres out from the threshold. The impact was obviously aggravated by the nose high attitude of the Sierra in such circumstances where the pilot is quoted as saying that he did not see the Ferris wheel until after impact. I noted one of the ATSB considerations was to investigate the cabin ergonomics of the Sierra, however, many aircraft have nose high attitudes at low speed and high power and this has to be managed by the pilot. Try looking over the nose of a C180/185 at max climb angle speed.

 

However, what has come about as a result of an ongoing and thorough investigation into this event by the ATSB has in my opinion far greater consequences for the administration, education and surveillance activities of RA Aus and the quality of training for Flight Training Facilities and compliance for ‘Factory Certified’ aircraft manufacturers.

 

I actually feel very sorry for the pilot (Paul), I am of the personal view that he has unwittingly been drawn into a situation of unfortunate circumstances. His accident has effectively opened a can of worms as the ATSB investigation has exposed 'other' issues that will have reaching consequences.

 

I am of the view that two of the most likely consequences of this investigation will be a thorough examination into the quality of the training the pilot received (this is a separate issue to any FTF registration issues and this is likely regardless of who trained any pilot in this kind of accident scenario); and the actions / practices of the manufacturer of a certified aircraft.

 

What worries me more than anything is what appears to be ‘sanitising’ attempts by some to minimise or trivialise the ‘Factual Information’ (ATSB words, not mine) in the ATSB preliminary report. The defects that were subsequently discovered in this aircraft are serious issues that need looking into from a public safety point of view. Such practises have the potential to badly damage the reputation of RA Aus Certified aircraft in general. This is particularly relevant in this investigation because this Sierra is a 24 registered ‘Factory Certified Aircraft’ that according to the regulations has a ‘Special Certificate of Airworthiness’. Questions need to be asked in this area.

 

A suggestion was made elsewhere that this was the manufacturers personal aircraft and that it was being used for development and was not representative of a factory built unit … . Whilst that has not been established and I make no representations regarding that suggestion, this aircraft was a factory certified aircraft with 24 prefix registration and it was up until the accident used for ‘ab-initio’ training which is widely known in the Taree, Kempsie Port MacQuarie area. It is not permitted to modify and use for development an aircraft that is ‘Factory Certified’ and used for training purposes. Any modification to a certified aircraft invalidates its certification the moment you do unapproved modifications. The rules for the development of certified types are very clearly laid down and for development purposes you are only allowed to build two examples of your development aircraft during the pre-approval developmental stage.

 

There are other worrying aspects to this incident … revelations in the ATSB preliminary report of statements allegations stunt flying by a pilot who has already been grounded by RA Aus for similar recent activities.

 

Hopefully this accident will be the catalyst for the RA Aus to sort out the unprofessional work from the professional work in the whole RAA industry, not just these ones exposed in the ATSB report.