Par Avion BN-2 Accident South West Tasmania

[Rotorwork]

Reports filtered through yesterday 8th of December that a Par Avion Islander was missing in Tasmania’s South West National Park on it’s way to Melaleuca with only the pilot on board. 

 

During the day search aircraft failed to find the Islander due to poor weather in the area. 

 

The Westpac Rescue helicopter had  dropped 3 Police search crew & an Ambulance paramedic into the South West National Park area around 5.00pm.They have direction finding equipment to locate the beacon”.

 

Sadly an early morning report from ABC

 

 

Wreckage of missing plane found in Tasmania, pilot presumed dead

 

WWW.ABC.NET.AU

 

Search and rescue police say the plane's sole occupant, the pilot, could not have survived the crash.

 

Thoughts are with the pilots family, friends, rescue personnel, Shannon & all at Par Avion 

 

RW

 

 

[facthunter]

 Weather in that area noted for rapid changes and spectacular rugged topography. It used to record annual rainfall in the region of 190 inches in the old measurement. Multiply by 25 to get MM's . Sad outcome . It's not your normal bit of countryside by any means, and an air service is the only way to get some places.  Nev

 

 

[Marty_d]

Sh*t, I was camping with the family this weekend and didn't know about this.  

 

We were in Dover Saturday afternoon/night and I remember hearing a couple of choppers nearby, then today saw what I assume was Rotorlift's Bell 230 (sounded like a Huey) go over Franklin about 2pm.

 

The Par Avion Islanders usually go about 2 or 3 km north of our place on their track down to the south-west, almost a daily occurrence.  Sometimes I see two of them passing reasonably close together.

 

This is a tragedy for the pilot's family, I guess the only silver lining is that it wasn't a full flight.  

 

 

[dsam]

I did an enjoyable day visit as a passenger with Par Avion down to Melaleuka a couple years ago, travelling on a fine day. As a frequent Tassie visitor, I know very well how the weather down that way can become suddenly challenging. 

 

Condolences to the family, friends, and colleagues of the pilot - very sad.

 

 

[fly_tornado]

article on the pilot

 

 

'I love my job': Crash pilot dream ends in tragedy in Tasmania

 

WWW.ABC.NET.AU

 

The pilot killed in the crash in Tasmania's south-west wilderness has been identified as Nikita Walker, police announce.

 

 

[nomadpete]

I look up every day when they track right over our place. Usually two runs a day. As you said, Marty, there is often a pair travelling within sight of each other (never too close though). I'd judge the cloud base by their height and visualise their view of the tiger country that they were traversing every day. Its rugged country. Although I've never met any of the pilots, it feels like I've lost a friend.

 

Sincerest condolences to all affected by this tragedy.

 

 

[poteroo]

It's not unheard of for pilots to admit to flying just a little closer to the limit when by themselves, and especially so if the flight is to pickup pax who are known to be waiting at a remote location. Publicly, we all deny any 'commercial pressure', but it's part of a charter pilots career.  Anyone who has flown charter in the tropic monsoon season, or in mountainous terrain, quickly learns when to turn back. Most of us rode our luck and made it home, but many of my peers didn't.  I feel for her family and friends. RIP

 

 

[onetrack]

This is a particularly sad event. But it must make the instructor who taught her, wonder what went wrong in his training of her, and whether he should have concentrated more on her weaknesses in navigation, or concentration, or general flying skills.

 

To run into cumulogranitus just 100M below the peak of the mountain range is the most basic and most unforgiveable flying error you can get.

 

I was under the impression that you are always taught to ensure that there's lots of air between you and the highest known points of terra firma along your route.

 

In every case I have read about, where a CFIT into high ground occurred, there were serious deficiencies in the PIC's navigation and flying skills that were never addressed - or their training was deficient.

 

I understand the flying conditions were more than likely pretty atrocious, and mountain rotor turbulence could have played a substantial part in the reason or reasons for this crash.

 

However, one would expect, it would have been hammered into her, to be particularly alert to the phenomenon - even more so, in the area she was flying into, which is well known for some of the worst types of these events.

 

The sobering part is, if she had had a full complement of pax, we could have been looking at possibly Australias worst air disaster since Lockhart River.

 

I trust the investigators find something of value in the wreckage, to determine the reasons behind this tragedy - but by the sound of it, they are going to be struggling to find any mechanical evidence of any value.

 

ATSB - Mountain Wave turbulence

 

 

[dsam]

Excluding severe mountain wave factors, CFIT is a sad & puzzling outcome to me. These days, for the price of an iPad & EFB software, every aircraft & pilot in Australia has excellent terrain & weather awareness at their fingertips.  With this modern equipment, and competent planning & airmanship, CFIT in mountainous areas should be a thing of the past.  I can only imagine that other factors must be involved (eg. loss of engine thrust, or unseen airframe icing...).

 

 

[facthunter]

You could not rule it out unless all OAT's were above freezing where the plane was operating  at. Unlike Carb ice it is directly related to visible moisture and actual OAT (temperature)  for the types of planes we are referring to because they are not fast where some heating effect is present. Ice accumulation can be rapid and the only way to counteract it is to fly clear of cloud and descend where possible to a warmer level. The props ice up and vibrate making the instruments impossible to read and the airframe loses aerodynamic efficiency and your stall speed can become quite high due to the altered airfoil shape and  added weight. Supercooled rain drops can form ice very rapidly. Nev

 

 

[Garfly]

But CFIT can also happen in plain sight; as when attempting a 180 escape in a valley and misjudging the max rate turn.

 

https://www.news.com.au/national/breaking-news/raaf-remembers-worst-peacetime-crash/news-story/af10948a903da81c02f3dc23d381ae4a

 

And I think what Poteroo tells us (in Post #7 above) about the everyday realities of charter work in tough terrain also needs to be kept in mind.

 

This Aviation Safety Digest from 1971 holds many lessons along these lines - as relevant today as then:

 

https://www.atsb.gov.au/media/5774770/asd_73_mar_71.pdf

 

 

[dsam]

Yes, human factors comes into play (remote stranded passengers), as does “airmanship” (perhaps an antiquated term these days) - but I’m an old guy with an appreciation of powerful modern tech + old lessons learned by other’s mistakes.

 

Garfly, your last ATSB 1971 link may well be closest to the mark on such airmanship:

 

“The probable cause of the accident was that the pilot persisted with such determination or confidence in his attempts to reach his destination in the face of deteriorating weather conditions, that he did not ensure he could safely discontinue the approach at any time and still maintain visual reference to the significant terrain.”

 

May we all heed the lessons of those who have challenged avoidable disasters and paid the ultimate price. 

 

 

[dsam]

Today I had a chat to my Tassie friend who was driving in the nearby general area that fateful day. In his opinion, airframe icing that day was unlikely - cool but not freezing. No doubt, BoM records will be more definitive about conditions at 4500 ft and the authorities will certainly be checking the facts on this in their investigations. 

 

 

[turboplanner]

This is a particularly sad event. But it must make the instructor who taught her, wonder what went wrong in his training of her, and whether he should have concentrated more on her weaknesses in navigation, or concentration, or general flying skills.

To run into cumulogranitus just 100M below the peak of the mountain range is the most basic and most unforgiveable flying error you can get.

 

I was under the impression that you are always taught to ensure that there's lots of air between you and the highest known points of terra firma along your route.

 

In every case I have read about, where a CFIT into high ground occurred, there were serious deficiencies in the PIC's navigation and flying skills that were never addressed - or their training was deficient.

 

I understand the flying conditions were more than likely pretty atrocious, and mountain rotor turbulence could have played a substantial part in the reason or reasons for this crash.

 

However, one would expect, it would have been hammered into her, to be particularly alert to the phenomenon - even more so, in the area she was flying into, which is well known for some of the worst types of these events.

 

The sobering part is, if she had had a full complement of pax, we could have been looking at possibly Australias worst air disaster since Lockhart River.

 

I trust the investigators find something of value in the wreckage, to determine the reasons behind this tragedy - but by the sound of it, they are going to be struggling to find any mechanical evidence of any value.

 

ATSB - Mountain Wave turbulence

In the IFR flight planning the LSALT path is much wider, providing a greater safety margin for being blown off course, but there are quite a few historic cases where disasters have occurred after ad hoc mid-flight  changes have been made due to icing, weather etc. and it's exponentially harder to notice the odd peak sticking up above the others in a bouncing cockpit compared to sitting at a desk with a ruler and WAC Chart,, so even if that wasn't the cause, it's a worthwhile revision subject.

 

 

[facthunter]

 The IFR procedure is different really. There was practically NO IFR flying in PNG though I've had to resort to it a couple of times,  having to cross the Ranges later in the day when the clouds have built up. (as they do) Normally you rely on the VFR rules and stay with the ceiling and visibility restrictions and can fly between the peaks.. and all works out OK.  if you are careful and have some experience.  In mountainous areas becoming Non VMC has serious ramifications and often they are catastrophic for the people involved. It's not different to flying an IFR level complying with a stated and properly established  LSALT and having to divert or becoming  ICED up or losing an engine and not able to maintain  the level . Flying into a valley with a cloud overlay (Ceiling) is an area where you must leave an escape route. ie Be able to do a 180 without hitting the valley sides , stalling in the turn or entering the cloud.. This is part of that type of flying training which  is essential and encourages you to fly near one side of the valley to have the room to turn . etc  as an example or don't go there.  I've had friends who appeared to be very safe pilots, end up flying into cliffs in IMC when conditions deteriorated, often trying to climb up through the cloud and get on top.. Nev

 

 

[Marty_d]

Coroner's findings out for this crash.  They're not happy with the ATSB report.

 

https://www.abc.net.au/news/2022-08-25/coroner-inquest-pilot-nikita-walker-tasmania-crash/101370152

[onetrack]

Not happy is the understatement of the week. A veritable savaging is a better description. The ATSB had better sit up and take notice, this is pretty appalling on every level, that they would spend so much money on producing something described as "worthless" by a very senior legal investigator. Perhaps the ATSB needs to be thoroughly investigated as regards its procedures, investigators level of skills and training, and whether there is any measurable benefit in the results they produce?

[Thruster88]

Read the ATSB report. I wonder about the cost of the ATSB report versus the Coroner's report and there worth for  pilots and the general public. The coroner appears to have little knowledge of aviation.  

 

https://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-078/ 

[turboplanner]

2 hours ago, Thruster88 said:

Read the ATSB report. I wonder about the cost of the ATSB report versus the Coroner's report and there worth for  pilots and the general public. The coroner appears to have little knowledge of aviation.  

 

https://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-078/ 

As we know the Coroner has a different job to the ATSB.

The Coroner is trying to find out the cause of death of the deceased.

The ATSB are trying to find out the cause of the crash which happened to injure or kill a person or people.

There are subtle differences.

 

Sometimes a Coroner can cross over into looking at the cause of the accident.

 An employee was using a hydraulic truck tailgate to load pallets, got caught between the tailgate and floor. He pressed the stop button but it didn't work and he was killed. At the inquest the tailgate manufacturer said the stop button the driver was using was known to fail and the remote control for that model had been changed. The problem was there was no way for a driver to tell whether he had the now one or the old one. The Coroner came to a transport industry conference, and told us the story. He said he had recomended a recall of the remotes, and new ones issued with a colored button so all drivers knew they were operating the new fail-safe version.

 

On another occasion a race car at a speedway in SA flipped several times and the driver was killed. The President of the car class Association did a TV News interview the next night blasting the track promoter for failing to grade the track and footage was shown of an ambulance going to the scene and sure enough the Ambulance was rocking noticeably. It's never a good idea to announce a decision before a Judge or Coroner has made it, but this Coroner was very patient and very thorough. At the end he announced that the cause of the driver's death was a racing incident where his car flipped sideways multiple times before hitting the gound. He said the roughness or otherwise of the track played no part in the driver's death because the car had been airborne from before the rough section to after the rough section.

 

 

 

 

[Blueadventures]

3 hours ago, Thruster88 said:

Read the ATSB report. I wonder about the cost of the ATSB report versus the Coroner's report and there worth for  pilots and the general public. The coroner appears to have little knowledge of aviation.  

 

https://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-078/ 

The ATSB report would be only one piece of evidence that I would expect the Coroner would have requested and heard before making the determination.  

[onetrack]

The bottom line is that there needs to be something worthwhile come out of a Coronial Inquest and an ATSB report that ensures there's minimal chance of a similar repeat event. We're still getting regular CFIT's under VFR flying.

 

We have to remember this pilot could have been carrying 9 passengers - and in that case, this could have been a level of 10 fatalities, which would have reverberated around the nation for decades.

 

This statement by the Coroner is puzzling to me.

 

"Why she flew into the Western Portal is not something the evidence enables me to determine with any real certainty".

 

It's pretty obvious even to Blind Freddy, she left VMC whilst operating under VFR, blundered around in cloud, and ran into a mountain top she couldn't see.

This goes against all her training and instruction, and for someone consistently lauded as a "competent and professional pilot", indicates a major deficiency in her level of piloting judgement.

 

This crash also reflects badly on the aviation company and its policies and training, and employee selection, and I see nothing in the Coroners report that completely clears the aviation company from any deficiencies in those areas.

We repeatedly see pilots taking serious risks under VFR, and for someone tasked with the major responsibility of a lot of other peoples lives during a planned flight, then it behoves the company operating those flights to make sure that risk-taking and risk-taking employees, are eliminated from operating in areas where they can place others lives at serious risk of injury or death.

 

In the construction, mining and building industries, directors of companies are now personally responsible for deaths where there has been a failure to initiate and follow good OH&S procedures.

In this aviation crash case, I would have expected the Coroner to examine the entire situation to see where the companies OH&S policies were adequate to prevent the crash, and whether there were adequate procedures to address risk-taking behaviour by employees.

 

In every industry, unnecessary risk-taking by employees, carried out by employees who are readily prepared to indulge in risk-taking behaviour, and to not observe established safety procedures, is the major cause of injuries and fatalities.

This is compounded by company directors and managers who fail to implement adequate safety policies and procedures in their company operations.

 

https://www.findlaw.com.au/articles/242/ohs-infringements-8211-directors-held-personally-l.aspx

[cooperplace]

On 26/08/2022 at 3:53 AM, Thruster88 said:

Read the ATSB report. I wonder about the cost of the ATSB report versus the Coroner's report and there worth for  pilots and the general public. The coroner appears to have little knowledge of aviation.  

 

https://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-078/ 

it's not the coroner's job to have knowledge of flying. As a judge -or equivalent- they rely on expert witnesses. The first thing an expert witness does is state their name and qualifications/expertise. Neither is available in the ATSB report so it's not surprising they got a well-deserved savaging.

[Jerry_Atrick]

On 25/08/2022 at 10:14 PM, turboplanner said:

As we know the Coroner has a different job to the ATSB.

The Coroner is trying to find out the cause of death of the deceased.

The ATSB are trying to find out the cause of the crash which happened to injure or kill a person or people.

There are subtle differences.

I couldn't agree more.. however, if the coroner is trying to find the cause of a death caused by an aeroplane accident, then surely finding the cause of the aeroplane accident is going to be a critical factor in finding the cause of death, is it not?

 

On 26/08/2022 at 2:30 AM, onetrack said:

It's pretty obvious even to Blind Freddy, she left VMC whilst operating under VFR, blundered around in cloud, and ran into a mountain top she couldn't see.

This goes against all her training and instruction, and for someone consistently lauded as a "competent and professional pilot", indicates a major deficiency in her level of piloting judgement.

Could not agree more.. but there is one thing we all miss in this.. and that is human factors - something which wasn't taught even when I did my ATPL theory (well, nothing like it is today), which, admittedly, was a flippin long time ago.

 

As a young an inexperienced pilot, I could not understand why people flew into terrain, barring some inforeseen emergency or weather event. However, as an older and more experienced pilot, I did find myself afflicted by pressonitis - twice - you would have thought I learned the first time..

 

Both times were purely self-inflicted, but the second time, there was an external influence. The first time, which has been published in Aussie Flying and Pilot (UK), was where I ended up so frustrated, I pushed on regardless.. and the only thing that saved me from driving a burning hole in the ground was that I may not get the rental back in time for the next renter - not the fact that I would have left my partner and two primary school-aged children behind. Diving home from the airfield was when I realised that.. and writing about it now still sends shivers down my spine.

 

The second time, I took a look at the weather and even though it was well below my now VFR only minima, I thought it looks good enough.. and I pressed on. I won't go into the reason why, but it blinded rational thought.. and I knew it did, but still pressed on. The reality was, I didn't want to dissapoint some people who were very important to me - my family. Imagine how disappointed they would have been if I drilled a smoking hole in the luscious British countryside (as it was then.. looks a bit brown at the moment).

 

I am well trained, have had all manner of safety requirements drilled into me, and am normally of fairly strong will. Sometimes, the holes in the Swiss Cheese aliign well before the flight starts.

 

I have no idea how the airline the pilot flew for operates, nor what commercial pressure the pilot was under. But I do know that sometimes we put ourselves under pressure and mixing that with confirmation bias can lead to a deadly cocktail. The second time I found myself in a pickle over pressonitis, I ended up luckily sandwiched between two layers of strataform cloud, about 200' vertically separated. In the UK, you can normally rely on the military for vectors to a close by airfield, but the closest had been sold off, and was a housing estate.. the nearest was about 100nm away. I made a beeline out to a sparesly shipped part of the English channel, wedged between these two layers until I breached French airspace, were, amazingly, the clouds gave way to clear blue skies. I tracked the Freench side of EGLL (line between French and English airspace), until clouds thinned on the British side of the line. In the drama I forgot to ask ATC to relay to the destination airfield that I was turning back. Not only that, but do you think I had a lifejacket on and the life raft ready to be deployed? My partner waited at the destintion airfield until an hour after I was scheduled to arrive and without a word, raced to my son's departing to Europe on a school holdiay - the event I was prepared to die to miss, apparently. My partner was in tears, in the full knowledge I had perished.. But, if I had, no ATSB, AAIB, NTSB, Coronial Enquiry could have really established anything.. because they don't know what was going through my head at the time. And while you may judge, you don't know, either.

 

These are two occasions in flying that I do not deserve to have survivied. But, as aligned as the holes in the Swiss Cheese were, they weren't perfectly aligned.

 

Having trained in Australia, UK, US, Canada, and Germany, I can say Australia is as good, if not better than those. I am sure the pilot would normally implement her training - from the reports, there is no reason not to suggest otherwise. Also, there is no reason to suggest that had she made it to pick up her passengers, she would have conducted the flight in a way that would have resulted in their demise. We don't know what happened on that flight and we never will. That is the reality of most of pilot error accidents. I will not say it is pilot fault until I can read their minds.

 

May she rest in peach and all those affected receive my sincerest condolences.