Old Bar "Dreamcatcher" report leaked

[turboplanner]

I think Pylon's solution is good for the Council and that means good for the Club. Someone could still have an failure after takeoff and attempt a turnback. This decision removes all chance. Both the Shire and the Club had a duty of care to stop operations once the splay had been compromised.

 

In the prescriptive days the Council would have had an active officer. These days the Council may mot have aviation expertise in which case it would be in the interest of the Club to provide advice to the Council on all aviation aspects. That also allows the Council to be comfortable that the risk management is being addressed. Some preventative action would also be to ensure a "shortfield only" note appears in the ERSA

 

 

[David Isaac]

Well if you shut it down you remove all risk and don't have to shoulder any responsibility. So if you want to fly in to the festival tough, they will lose a very small amount of attendance and have again marginalized a select group of the community. There is no reason why it could not be kept operating if the splays are in place. If you want to remove all risk then close the bloody streets as well FFS.

 

Rant rant rant rant ......

 

can you tell i am not impressed, they are so conservative now they might as well be CASA, but even CASA would let the field operate if the splays were in place.

 

 

[turboplanner]

At the Ouyen Vanilla Slice Festival they shut down the main street and one or two others and you can't even drive in and get your vanilla slice.

 

 

[facthunter]

After all that they never fixed the "wheel" problem. A displaced threshold would leave hardly any strip. It shouldn't have been within the splay. "the wheel". The rest of the report is as has been said what one would expect. Information detected in the course of an investigation, but which couldn't be ignored. (Like a ramp check) It's there when you find it. Nev

 

 

[bexrbetter]

At the Ouyen Vanilla Slice Festival they shut down the main street and one or two others and you can't even drive in and get your vanilla slice.

You should try explaining "Snot Block" to the Chinese, they look at you very strangely as "ewww, gross...." - then go back to eating their rabbits head, duck's tongue and turtle stomach.

 

 

[Oscar]

Well if you shut it down you remove all risk and don't have to shoulder any responsibility. So if you want to fly in to the festival tough, they will lose a very small amount of attendance and have again marginalized a select group of the community. There is no reason why it could not be kept operating if the splays are in place. If you want to remove all risk then close the bloody streets as well FFS.Rant rant rant rant ......

 

can you tell i am not impressed, they are so conservative now they might as well be CASA, but even CASA would let the field operate if the splays were in place.

My bolding.

 

However - if this result doesn't tell us just how precariously we are perched on the edge of community acceptability, then we are deluding ourselves. It's no great jump from being excluded for a particular event to being excluded from an area entirely by the removal of an airfield because the bloody local Council can get a bucket-load of rates from selling the land. It's no use feeling umbraged, what is needed is positive action to make 'Recreational Aviation' a desired part of local community living. Unless the local community values our presence, we cannot expect their support.

 

 

[David Isaac]

Unfortunately we are seen as 'rich boys' because we fly aircraft. The average person has no idea that an average 4WD costs more to own and operate than a small aircraft. After all wasn't recreational aviation supposed to make aviation in Australia affordable.

 

Unfortunately I doubt we will ever be seen as a 'valued presence', when we are no less valuable than any other sector.

 

Closing the airfield to this event is a huge mistake and I will wager a decision made more on political grounds than one of safety especially since the cause of the accident was readily identified and can be easily relocated.

 

My fear is the airfield committee succumbing to this event will be the thin edge of the wedge. The airfield is heritage listed and an important part of this event at Old Bar. The committee should have got some balls and acknowledged the mistake, fix it and move on.

 

The placement of the Ferris Wheel within the airfield splays was was one of the most profoundly stupid acts imaginable. If the Ferris a Wheel had not been placed where it was in the splays, this thread would not exist and neither would the ATSB report and all the politicking that resulted.

 

 

[Oscar]

David, I agree with all that you have said - but the result has been that we are the easiest group to be sacrificed. That is the situation that we need to address.

 

 

[turboplanner]

David that's the old "if only" we all indulge in after an accident; "if only the person hadn't been drinking", "if only the train hadn't been there at that time", "if only the ferris wheel hadn't been there and so on".

 

This case will be used as a negligence bible for years; and example of how out of control recreational aviation is.

 

I took my money away from an airfield where an instructor had me do a landing where a tractor with mower was cutting grass with one wheel on the runway in the touchdown area.

 

Sure it was profoundly stupid, but Oscar is on the money. Normal Council reaction would be to recoil and sell the land, eliminating the PL risk and making a profit, and I wouldn't rule that out once this report is absorbed and printed in the mass media.

 

Better to take the medicine.

 

 

[Paul Cox]

And that is the hard thing with aviation,,,we all make mistakes ,sometimes it's a real hard ,cruel ,even fatal lesson,,,,others get to sit down and quietly reflect on what went wrong , and learn from it!Even Morgans have suffered not because their aircraft was at fault but in the aftermath it was found to bit a bit of a sh1tbox.

The pilot was posting here , inspite of his stuff up I'd hope he's still flying ,at the end of the day it's just a crash that thankfully everyone got to go home from ,,,,,,if/when I have one I hope I'm as successful !

 

Matty

Thanks Matty

 

Still flying albeit a lot wiser now.

 

 

[David Isaac]

Tubz, Old Bar airfield is heritage listed, it can't be sold. But they could potentially stop it being used.

 

 

[David Isaac]

Recreational aviation being out of control had NOTHING to do with this accident. It was a Committee of GA pilots and Taree Council who allowed the Ferris wheel to be placed in the splays FFS. MOVE THE BLOODY THING AND THE ACCIDENT WOULD NOT HAVE HAPPENED. yes I was yelling.

 

 

[Camel]

David, I agree with all that you have said - but the result has been that we are the easiest group to be sacrificed. That is the situation that we need to address.

The RAA members, management and board need to stick together, they did it in the past. An ex CASA man was at RAA and was useless in my opinion yet he was treated like royalty being ex CASA. Some hard working dedicated RAA people have been defamed by political BS and weak glory seekers. Not many GA flying schools left, GA has been very expensive and now people join RAA as a affordable option, CASA want to make RAA answer more to Casa so they can justify their job, sitting around drinking coffee trying to make life hard for those who seek enjoyment. Hanging around Natfly letting everyone know who is in charge !

 

If you knew all the facts, you would be thoughly ashamed of CASA and the ATSB, also RAA has not done all it could have done in fact I was surprised how it was handled.

 

We are not being sacrificed as much as we are getting shafted, we need to unite and make Casa accountable for their actions. The ATSB needs to explain WHY it investigated the Old Bar accident, they SERIOUSLY lacked knowledge on how the RAA operated and know that the Ferris wheel did not need to be where it was and know that it was a danger ! They know that the pilot was a GA pilot and doing a RAA conversion and was basically required to do at least five hours and did way over this, he could have done a GA AFR and this would have had no case to blame his training. To be honest most GA pilots who convert to RAA have some very bad habits i.e flare to high, land three point and land sideways or crabbed besides using the pedals as foot rests, unaware of Adverse Yaw.

 

CASA employ ex RAA people to be familiar with how it operates !

 

I also wonder how many instructors want to do GA conversions now ? I seriously think this is a serious problem ! it is better to teach someone from scratch than change someone's habits of many years ? The old Bar accident blaming his training is an ATTACK on RAA ! Read the ops manual on GA conversions and see for yourself ! http://www.raa.asn.au/wp-content/uploads/2012/02/Section-2.13-Conversion-of-General-Aviation-or-Glider-Pilots.pdf

 

If you pass someone who meets the standard and has an accident you are blamed ! Give me an example of a similar case, does a school teacher get blamed for his student turning to crime ? for failing future exams ? Driving instructors students meeting an accident ? I know an instructor now deceased who explained how a student he would not pass, got passed by another and was fighting a court case against the widow because he was killed by his own carelessness.

 

When people learn to fly they take on a dangerous sport, they are taught what is dangerous and still flirt with danger and disregard or forget rules ! Is this the instructors problem ?

 

All sports aviation bodies need to stick together ! All it's members need to unite !

 

 

[graham brown]

The problem with a sh1t fight is that everyone gets covered with sh1t!

 

This has happened with this incident.

 

I agree; work together to improve ourselves and our sport.

 

Also don't let anyone impose crap on us.

 

 

[David Isaac]

...... Better to take the medicine.

What, ..... Take The thin edge of the wedge ... and that will change the outcome. Not bloody likely. The focus is on the wrong thing.

Wake up everybody, a whole bunch of people were involved in placing a Ferris Wheel in the splays of an aerodrome. Splays are put in place for safety margins to provide a safe area for aircraft when things go wrong, when mistakes are made or where weather may cause drift. The people that made that decision are responsible for this accident. The pilot skill here only explains why the aircraft was where it was, but the aircraft was entitled to be where it was except some bloody idiot put a Ferris wheel right within the splay.

 

So now what are they going to do ... Instead of making sure the splays are clear during the next event they are going to stop flying. FFS .

 

HELLO HELLO IS ANYONE OUT THERE.

 

Am I the only one who can see the profound stupidity here?

 

 

[dazza 38]

I would have sued who ever was responsible for placing the Ferris wheel in that particular location in the first place.( within the splay)

 

 

[David Isaac]

You bet your pretty face Dazz, so would have I.

 

The pilot skill here is and always was irrelevant, the aircraft was within the splay and collided with an object deliberately placed within the splay. The ATSB report clearly shows the Ferris Wheel was within the splay and shows pollarded trees below the Ferris Wheel.

 

Additionally there was no advice on the airfield web page warning of the obstruction of the Ferris Wheel. The only warning on the web page was the playing field lights being within the splay and that warning has always been there for Old Bar.

 

 

[turboplanner]

David, you are 100% correct in saying that if the ferris wheel had not been placed in the legal splay of that runway the crash could not have of occurred.

 

Therefore I agree, if this was a fatality the people you mention would be starting to sell assets, having realised what defending themselves was going to cost.

 

If you have a beef with the Old Bar committee, and the Council and the agreed decision on closing the field for the event, that's fine. I'm looking at the bigger picture which involves other Councils as well.

 

Advice on the airfield web page, displaced threshold (which I think we agree would have closed the runway), and better still runway closure markers were all in my opinion critical omissions which would now be biting committee members, council officers and councillors if the accident had been a fatal.

 

It's also correct to say that if the pilot had used the duty runway like the Diamond did it would not have happened, and this becomes a contributing factor.

 

And that opens the issue up to question the aircraft's flightpath.

 

It doesn't matter what you think, it doesn't matter whether people band together, it doesn't matter whether or not GA or RA are involved, after a major event like this it all comes down to rules, regulations, laws, specifications, standards, and compliance with these.

 

There are degrees of contribution to the event.

 

Since what I wrote in another place seems to have had a more calming result, I'll repeat it here:

 

"This is bigger than Ben Hur. I've read it once, need to read it a few times, but many areas are impacted. What we do have, since no one was badly injured, is a unique chance to look at what the situation might have been if they were, then start ticking the duty of care boxes, and taking urgent action to reform and put in place checks and balances without possibly facing extinction if the insurance wasn't paid out. As it is there's breathing space to do this. As you say there are absolutely no surprises, but look how long it's been since the crash and then look at what changes have been introduced..............."

 

 

[turboplanner]

If you knew all the facts, you would be thoroughly ashamed of CASA and the ATSB, also RAA has not done all it could have done in fact I was surprised how it was handled.

I agree, and the Minister, and the Shadow Minister, I've watched Australian aviation degenerate from one of the safest in the world, with a clear learning, operation and compliance regime to a dogs breakfast, but when you get 300 out of a 10,000 member organisation bothering to vote, you know its just going to keep drifting downward like a leaf on the wind.

 

The ATSB needs to explain WHY it investigated the Old Bar accident

And when it explains why it singled out this one, where no one was seriously injured, it needs to explain why it hasn't been investigating serious "teaching" accidents involving fatalities.

And I, rightly or wrongly drew a conclusion that some of this report contained shrapnel aimed at CASA, instead of concentrating on specifics of the case itself.

 

they SERIOUSLY lacked knowledge on how the RAA operated

They don't have to know that if they stick to the facts and find out what should have been done and what should not have been done.

However, now we all know how RAA operated

 

They know that the pilot was a GA pilot and doing a RAA conversion and was basically required to do at least five hours and did way over this

Before I comment on the next few lines, I'm one of these hybrid pilots, and Paul, in comments on pilots I was once in a near identical situation to you where I faced trees in an aircraft that ran out of clearance climb at 60 kts.

This pilot was 23 years away from recency. The Instructor has a duty of care to ensure he is current in ALL aspects of his duties. I returned to flying after a similar absence, and had forgotten all my checks, had to deal with radio calls from Martians, couldn't line an LSA55 up with the runway in three attempts, had to learn hand eye control again (other than the basics of roughly getting it right).

 

So I would suggest the training syllabus is referring to a GA pilot who is current, in which case the manual needs to be corrected following the example in this incident.

 

To be honest most GA pilots who convert to RAA have some very bad habits i.e flare to high, land three point and land sideways or crabbed besides using the pedals as foot rests, unaware of Adverse Yaw.

I agree, and I had some of these, and my instructor retrained my and that took a lot longer than five hours.

An instructor is there to train a pilot to the required standards, and if the pilot can't meet them, fail him/her.

 

The instructor has the duty of care to do this

 

it is better to teach someone from scratch than change someone's habits of many years ?

Yes it is because there is no "unlearning" and double messages going into the pilot's brain.

I am particularly critical of CASA, and its predecessors' handling of radio phraseology over and over again, so virtually no two pilots of varying ages uses the same phrase, and in an emergency are most likely to revert to the first one they learnt.

 

However, if you think about it, what;s so different from Endorsement training for a specific aircraft - it's all income

 

The old Bar accident blaming his training is an ATTACK on RAA ! Read the ops manual on GA conversions and see for yourself!If you pass someone who meets the standard and has an accident you are blamed !

On the pilot's actions on that day, I would place very little responsibility on him, but a lot on his trainers in terms of duty of care.

 

Your comments relate to the prescriptive era where parliament passed regulations and if you complied with those regulations it was someone else's fault

 

So for example a weights and measures man would come around to look at your cranes, and would give you a certificate of safety.

 

Doesn't happen now, so Duty of Care rests with all those who are involved in making something happen, or approving something to happen.

 

The Instructor has a duty of care only to sign off a pilot who meets the standards.

 

The RAA has a duty of care not to provide wrongful advice

 

CASA has a duty of care to ensure their instrument is operating safely

 

The Minister has a duty of care to ensure his instrument is ensuring safe operation

 

If you pass someone who meets the standard you have a defence against being blamed but it depends on what happens on the day

 

Give me an example of a similar case, does a school teacher get blamed for his student turning to crime ? for failing future exams ?Driving instructors students meeting an accident ?

I know an instructor now deceased who explained how a student he would not pass, got passed by another and was fighting a court case against the widow because he was killed by his own carelessness.

 

When people learn to fly they take on a dangerous sport, they are taught what is dangerous and still flirt with danger and disregard or forget rules ! Is this the instructors problem ?

When you are a self administrating body you have to cater for all of these things no one else is going to put their hand up, and governments have walked away.

 

So there are quite a few activities which no longer exist, and some, like water slide sports where maybe 2% have survived.

 

What I found with RAA is that there appears to be no structure above the level of CFI taking responsibility for the ongoing training and management of the people they turn from pedestrians, cyclists and car drivers to pilots.

 

That's why I was so adamant that a Safety Management System was absolutely urgent, particularly since RAA had been instructed to have one operating since 2010.

 

An SMS deals with this sort of thing and allows an orderly setting up of safety layers.

 

 

[dodo]

I have doubts about the check-box style of safety which an SMS can encourage.

 

In this investigation, everyone with paperwork filed seems to have been accepted by ATSB.

 

To summarise the ATSB perspective on CASA and RA: RA audits of the FTF have been properly done, but the FTF used ticks rather than a 1-2-3 system, and further scrutiny of the FTF is an accepted safety response from RA.

 

The emphasis was on planned processes (the audits) been done as planned: the effectiveness or relevance of the process was not considered.

 

If the FTF had complied with the letter of the RA syllabus paperwork, the FTF would likely have been off the hook, too!

 

How does that work?

 

But the diffusion of responsibility for having that obstacle there never is resolved by the report or even identified as a major contributor.

 

We had an ALA with no real binding effect (guidelines), no real NOTAM capability, and a committee that didn't care enough to place a requested NOTAM, the festival dodging the risks and benefits of having aircraft around, no one responsible, not any of the committees, not CASA .... but the ATSB fluffed off in the wilderness of what paperwork was filed (or not filed).

 

Checkbox safety doesn't work

 

dodo

 

PS The Ferris wheel operator seems to have done his best - he did comply with the standards (I went and read one lot, and they have a lot of good stuff about setup and operation, but nothing about placing obstacles in the air - just about making sure they don't fall, and if they do, don't hit anyone on the ground). I note the ATSB doesn't refer to those (non-transportation) standards. I imagine the ferris wheel operator probably wasn't covered by insurance under the circumstances, despite his (or her) honest efforts.

 

 

[Head in the clouds]

I haven't had time yet to read the report but solely based on the comments in this thread, a couple of points to ponder -

 

The ferris wheel operator would have put it where he was told, so he wouldn't have to know anything about the aviation requirement, and may not have even been aware of the presence of an airfield BUT surely people in the aviation community would have noticed a big obstacle on their turf (the splays). So why didn't anyone speak up? Where's the duty of care from other pilots and/or the airfield operator?

 

All this reminds me of a situation that developed at one of the first Inglewood (IIRC) fly-ins in the late 1980s. A hot air balloon operator set up doing short tethered flights to about 30ft alongside the runway at about the mid-length point. He was about 50ft clear of the markers, so was well outside any position that would ordinarily be considered a safety risk.

 

However, as plane after plane took off to go for local flights almost every one of them drifted off the centreline and came alarmingly close to the balloon. Quite a number of us in turn remarked "someone's going to hit that balloon, sooner or later", and yet not one of us did anything about it for a long while because, objectively, the balloon seemed to be well off the runway.

 

Then I went for a fly and did exactly the same thing as many of the others had done. As I approached the balloon it loomed large and attracted my attention, object fixation took over and I inadvertently turned toward the 'obstacle'. It wasn't a cross-wind drift or anything like that, but a (now) well documented phenomena.

 

When I completed my flight a few of us went and had a chat about it with the balloonist and he was a bit upset that all these 'loony' pilots were flying so close to his balloon, and pax, and he was also annoyed that we suggested he move further away because he would have a number of deeply embedded star-pickets and a safety barrier to move. He packed up but I don't remember him going to the effort of re-establishing further away.

 

I'm not saying that O.F. was the cause of the dreamcatcher episode as I understand that the pilot didn't see the wheel, but we bunch of pilots at Inglewood seeing a potential danger and doing nothing about it has stayed fresh in my mind all these years.

 

.

 

 

[turboplanner]

Dodo, I believe your observations are correct.

 

In the early days after governments walked away from many activities, companies thought it would be easy and did develop check box systems which they dutifully ticked and ignored.

 

However they found themselves sued and awarded against because they didn't have a duty to tick boxes, they had a duty to ensure safety.

 

In my opinion CASA has a lot to answer for in (a) blurring the situation with ever changing and ever increasing rules, then trying to ensure compliance by making them strict liability, but to simply carrying out duty of care.

 

If ATSB is giving credence to boxes being ticked instead of duty being carried out then I agree with you, they are off the mark and won't be doing what they are set up to do.

 

 

[Camel]

Quote,

 

"On the pilot's actions on that day, I would place very little responsibility on him, but a lot on his trainers in terms of duty of care.

 

Your comments relate to the prescriptive era where parliament passed regulations and if you complied with those regulations it was someone else's fault

 

So for example a weights and measures man would come around to look at your cranes, and would give you a certificate of safety.

 

Doesn't happen now, so Duty of Care rests with all those who are involved in making something happen, or approving something to happen.

 

The Instructor has a duty of care only to sign off a pilot who meets the standards.

 

The RAA has a duty of care not to provide wrongful advice

 

CASA has a duty of care to ensure their instrument is operating safely

 

The Minister has a duty of care to ensure his instrument is ensuring safe operation

 

If you pass someone who meets the standard you have a defence against being blamed but it depends on what happens on the day."

 

Turbo I don't fully agree with what you say above, yes we all have a duty of care, I'm sure no instructor wants their student to meet an accident.

 

I'm saying if they meet the standard and the instructor is happy they are safe and ready to fly unassisted then he has shown his duty of care to make the pilot safe, when a student pilot is given a certificate he is told now go and learn to fly.

 

After 150 hours I nearly met with a serious accident but my training saved me. At about 100 hours I also had a close call but a friend who knew my instructor commented on my recovery saying he taught you well, before that I probably was dangerous and not knowing it. An instructor can train you for the worst but the pilot has to apply it by decisions and perform. I have had 3 HGFA instructors, 3 AUF, 5 GA and for AFR. So which one shall I blame for not being perfect.

 

 

[turboplanner]

You're ahead of me Camel, one of my CFI's died when he failed to make an EFATO, another of my CFI's died when he failed to overcome wind shear, and one of my Instructors died when he became disorientated at low level over water during and official search and rescue, so I'm wondering where I'm going to finish up.

 

What I said may have seemed harsh, but once governments stepped away from prescriptive legislation the only way we would avoid public liability exposure was to self administer.

 

The usual bunch of defendants is "all the people who created the situation where this could happen", and instructors fit into this category; before you trained the person to become a pilot, he was on the ground unable to crash an aircraft.

 

So it's a fundamental thing; RAA just haven't put a safety system in place to remove the responsibility for those people from your back.

 

 

[facthunter]

An instructor trains and assesses a person at a particular point in time. The training may be over a significant period of time, but at some point he/she (the student) is considered competent, by some one qualified to make the decision .

 

Clever experienced pilots are good at doing the right thing on the day and reverting to cowboy tactics afterwards. They fool no-one but themselves, long term.

 

I am not suggesting that this relates directly to what happened here, but blaming EVERYTHING that may be done wrong by a particular pilot into the future on an instructor or system is not realistic. Humans are not programmable fully and there is the unpredictable and often "why did I do that? I was trained to NEVER do that"..Response afterwards, possible.

 

Some times the training may be deficient, which is not acceptable at all, and no-one pretends that as newly qualified you are a COMPETENT pilot in the full sense of the word anymore than a recently qualified apprentice is a master tradesman.

 

The "New" pilot should be guided by mentors and advice and hopefully will not be exposed to a situation beyond his/her capability till more experience is obtained. This is the luck/ experience balance. In a sense your experience completes something the training allowed you to commence. That is the way it works. The assessment is a matter of judgement. Is the pilot SAFE? rather than an ace.

 

What he did achieve was to go around and keep control of the aircraft when he realised the remaining runway was not sufficient. The aircraft was being flown at a slow speed and not performing well but it was controlled at all times and would have required a lot of concentration. The unexpected contact with the ferris wheel turned a non event into a potential catastrophe. Nev