Missing plane from Gympie yesterday

[dan3111]

Sometimes the ATSB get asked to recover any lost glass panel flight data and if they do they put the report on there web site, which there has been a few RAA reports on there . The 258 jab looked to have a glass panel .

 

Dan

 

 

[Old Koreelah]

Thanks for that info Andy. Official procedures change at glacial pace, so it's a credit to our new RAAus team that they have established a good working relationship with investigating authorities so that common sense prevails. As a result, some recent accidents were quickly followed by advisories which quite likely saved lives.

 

 

[Teckair]

I live a bit East of the probable track that flight would have been. On that morning. I looked out of the window at the rain squalls and cloud and said to myself you would't want to be flying anywhere in that. I have had a few frights in bad weather and I am now more cautious than some.

 

 

[turboplanner]

Yes Fh the discussion on this site is caring and analytical and the conclusions often stand up.

 

Yes Andy, the RAA work is to be commended.

 

The problem is that Police will not release their Brief to the Coroner, and the coroner has a different set of objective to those wanting to learn from an incident.

 

 

[facthunter]

I feel we have progress. Investigation produces information that helps make things safer for all of us. THAT has to be the aim and purpose. Nev

 

 

[Teckair]

Some people put a Artificial Horizon in their plane in case they might need it one day. I think if you don't have one you remove the temptation to push on when you shouldn't. Of course different if you are current IFR and have the correct equiped plane.

 

 

[Keenaviator]

The problem is that Police will not release their Brief to the Coroner, and the coroner has a different set of objective to those wanting to learn from an incident.

In the past 35 years I have produced many inquest briefs for Coroners (Magistrates officiating coronial inquest). The brief is basically a collection of statements, photos, plans, a detailed summary and conclusion made/obtained by the police investigator. The coroner is immediately informed of a reportable death and a case number is issued. Preliminary reports are submitted immediately (form 83's) and within a few days the investigator is given a date within a month or two, depending on the complexity of the investigation, to have the final inquest brief completed and submitted.

 

If safety issues arise out of an investigation the member includes these in the conclusion. The coroner may or may not take further action or give directives. I would not want to be the person ignoring a coroner's direction.

 

 

[turboplanner]

In the past 35 years I have produced many inquest briefs for Coroners (Magistrates officiating coronial inquest). The brief is basically a collection of statements, photos, plans, a detailed summary and conclusion made/obtained by the police investigator. The coroner is immediately informed of a reportable death and a case number is issued. Preliminary reports are submitted immediately (form 83's) and within a few days the investigator is given a date within a month or two, depending on the complexity of the investigation, to have the final inquest brief completed and submitted.If safety issues arise out of an investigation the member includes these in the conclusion. The coroner may or may not take further action or give directives. I would not want to be the person ignoring a coroner's direction.

I agree with everything you have said. Perhaps I should have said "Police effectively cannot....."

 

The public can only learn from the Coroner's report, if they can find it. Maybe I've been looking in the wrong places, but I've been waiting for nearly a decade for one to come out involving three incompatible semi trailer brake couplings, some which lock the trailer brakes on when connected, some which release the trailer brakes when connected.

 

 

[Jaba-who]

Keen Aviator said "I would not want to be the person ignoring a coroner's direction"

 

Coroners seem to be ignored all the time.

 

The problem of the coroners reports seems to be that they are not bound by any real world limitations. So its no wonder they get either ignored or eventually lost.

 

If a coroner makes a recommendation that is actually against the law, as it stands, then they appear to have no idea of the complexities in how that law came to exist or what effect following their recommendations would have.

 

In mind was the one where an experimental Exec 162 had a tail rotor failure with subsequent death of the owner builder.

 

The coroners direction was that home builders of helicopters should not be allowed do tail rotor maintenance!

 

Well that's just stupid because the maintenance is not beyond a builder. It's done successfully by other builders and the law as it stands allowing maintenance on tail rotors exists as part of a far wider spectrum of allowing maintenance on all parts of the machine; provided the builder fits the criteria for eg CASA I/A 33/13 . To allow someone with a narrow agenda to make directions that have ramifications against personal freedom etc & to start to cherry pick what can and can't be done would cause chaos.

 

In the medical field I have seen lots of coroners recommendations that are totally ignored because they make no medical sense and that to follow them would cause more problems than it solves. Often the conclusions have only relevance in a very narrow set of circumstances.

 

 

[Downunder]

Ah, the old procedure to mitigate the risk becomes more risky than the original risk itself situation......

 

Been there, done that!

 

 

[Jaba-who]

Ah, the old procedure to mitigate the risk becomes more risky than the original risk itself situation......Been there, done that!

Yep been there done that too. Deal with it on an almost daily basis.

 

We have had equipment introduced to prevent a rare side effect or risk but which is then a unable to perform the original task which is required. But I digress.

 

 

[Guest Andys@coffs]

Yes Fh the discussion on this site is caring and analytical and the conclusions often stand up.Yes Andy, the RAA work is to be commended.

 

The problem is that Police will not release their Brief to the Coroner, and the coroner has a different set of objective to those wanting to learn from an incident.

We can learn from the incident by being involved and providing that the information is deidentified we can look to change culture and aircraft specifics as required ahead of formal coronial inquest release if essential.

 

Furthermore a coroners sole purpose in life is to try and prevent repeatable accidents/hazards and if we felt that the issue was extreme and we needed to immediately advise members of an otherwise unknown risk and the message is more acceptable/believable with details from the incident then it would very much surprise me if the coroner wouldn't allow....but at the end of the day it is their decision not ours.

 

We don't have, for example, a specific section in the magazine called "Accident investigative outcomes" but if you carefully read the Opps and Tech managers pages you will get the info if there is info to be gleaned from the incident de-identified and passed on.

 

While making no correlation between general RAAus processes and this specific incident, it is the case, as you know, that human failure factors fairly highly in accident outcomes and as such no Directive will come out regarding Aircraft and if the incident, for example was don't fly so slow that a wing stalls then given that in general that specific subject has almost certainly been well covered in pilot training and reviews then I wouldn't expect too much from Jill and/or team, just like your Dr doesn't regularly remind you that failing to breath can be detrimental to continued life....

 

It is a continuing fallacy that RAAus members don't get to hear safety related outcomes from accidents/incidents involving a fatality, they get the info if its there to be had and is unique or a trend is determined to be developing, they just get it without linkages to the specific incident.

 

Andy

 

 

[Teckair]

It is a continuing fallacy that RAAus members don't get to hear safety related outcomes from accidents/incidents involving a fatality, they get the info if its there to be had and is unique or a trend is determined to be developing, they just get it without linkages to the specific incident.Andy

Maybe but I would like to know why accidents occur not just things RAAus think we need to know. If it is pilot error we can still learn from others mistakes.

 

 

[Guest Andys@coffs]

Maybe but I would like to know why accidents occur not just things RAAus think we need to know. If it is pilot error we can still learn from others mistakes.

Then let me know how we can go about that while still fitting in with the state based statutory authorities rules.. We believe we have the best available with the limited context we can use.

 

So lets for argument say that it has been noted that a number of recent fatalities are related to pilots working low levels over their own productive properties (fences...dams.....stock related etc) and Jill then in her Ops manual in the mag goes into details about risks of low level flying over your own property without appropriate training and endorsements and that she has seen first hand the devastation and loss etc etc .....Perhaps it could be argued that if she had said Pilots X,Y and Z died because they did this the message might have more impact, but within the constraints available to us she has still spoken loudly and strongly about the risks of low level flying without appropriate training...... What more is that you want in this example?

 

We still haven't given up on being potentially included in the ATSB umbrella legislation that would allow us to investigate and eport in our own right.....but that in my opinion isn't something that will happen overnight..... As said previously we are building relationships and trust, an essential prerequisite in my opinion.....

 

Andy.

 

P.S I have just finished reviewing an upcoming Sport Pilot issue for May and I commend the Ops column "Pilot Talk" to you from this issue, it exactly addresses the point Im trying to make...I believe it will be sent late April/early May so coming soon......

 

The first few paragraphs are:-

 

There have been a number of fatal accidents

 

involving RA-Aus aircraft this year.

 

These have included a homebuilt aircraft

 

which collided with terrain at Sublime Point

 

near Wollongong and a mid-air collision between

 

a Thruster and a Drifter resulting in a

 

dual fatality near Townsville. Our condolences

 

and thoughts are with the families and friends

 

of the pilots involved.

 

On the list of fatal accidents from last year

 

were a collision with terrain as a result of a pilot

 

taking photographs at low level, a collision with

 

terrain due to fog or medical incapacitation

 

and a collision with terrain (see the pattern?)

 

while low flying.

 

Our investigation into one accident revealed

 

evidence the pilot deliberately entered cloud,

 

and that it was a regular occurrence for him,

 

despite the fact his aircraft was not equipped

 

with the appropriate instruments. This comment

 

is made with full acknowledgement that

 

other members of the pilot’s aero club had already

 

raised their concerns with him. All our pilots

 

are trained, know the rules and are aware

 

of the circumstances of poor decision making.

 

The saddest part of any pilot’s poor decision

 

making is when those left behind have to ask

 

why?

 

 

[turboplanner]

It is a difficult area to deal with Andy, you really do have to leave out the words which might identify the incident. In some cases that will work, in other cases it just gets watered down and looks like propaganda to some people. The best outcome is to get within the ATSB umbrella and be able to call a spade a spade.

 

 

[johnm]

yes good idea Turbo

 

................... where there is a fair chance it was an error - leave out the details that identify the person, plane, place and accident location. We need to hear things we can all learn from

 

 

[Jaba-who]

The problem of leaving out identifying factors is that many times even a mention of the necessary facts identifies the accident. ( to someone)

 

So some accidents have to be hidden if you don't want somebody identified.

 

I don't know what the answer to that scenario is because if we are going to learn and prevent a future accident we have to highlight why it happened.

 

 

[dan3111]

It is a difficult area to deal with Andy, you really do have to leave out the words which might identify the incident. In some cases that will work, in other cases it just gets watered down and looks like propaganda to some people. The best outcome is to get within the ATSB umbrella and be able to call a spade a spade.

It is a hard thing to to get the message throw to people and some cases you will never ever get throw to :( . There a saying ( he Didn,t know what he Didn,t know ) that sums up a lot of crashes that Didn,t have to happen. The old days you did 50knots and a head wind stop you in your tracks . I Think moden aircraft are a lot faster and climb well and engines are more reliable . But down side to moden aircraft hit things faster and harder . Cheers dan

 

 

[dazza 38]

I hope you mean through to people.

 

 

[Yenn]

Some of the accident causes are so much a No No that there is no way that they can be stopped. When we have pilots putting their brains away we cann only expect accidents. The casee of pilots deliberately flying into cloud are a good example. Apart from the fact that it is easy to get disoriented, the main reason for not flying in cloud is the fact that there may be a legal IFR flight there. It is to avoid these flights that we have to maintain a set clearance from clouds. I certainly don't fancy flying close to cloud and suddenly finding something big coming straight at me, especially when those fast aircraft have poor visibility.

 

 

[Pearo]

I flew over this area today. Its hard not to feel a little sadness as you go by. It also hits home about how vulnerable you are when you are in the air.

 

 

[Guest ozzie]

To stop unqualified pilots from flying into cloud is pretty easy. Remove the instrumentation that allows them to do it.

 

ASI ALTI and a bit of string is good enough for RAAus aircraft. Any more and you are GA.

 

 

[turboplanner]

To stop unqualified pilots from flying into cloud is pretty easy. Remove the instrumentation that allows them to do it.ASI ALTI and a bit of string is good enough for RAAus aircraft. Any more and you are GA.

Let's not get carried away.

Flying into cloud is one of the biggest killers in GA flying too.

 

 

[planedriver]

Even a simple photocell unit on the panel might not go astray, if things start to go a bit dark, do an about face and yet your arse back to base, and see the family again.

 

 

[Teckair]

Even a simple photocell unit on the panel might not go astray, if things start to go a bit dark, do an about face and yet your **** back to base, and see the family again.

Once things go a bit dark it is too late.