Remembering my little mate

[nomadpete]

In Ross's case, I believe the post crash fire had prevented a meaningful investigation into the cause of power loss.. We will never know what the cause was.

 

 

[motzartmerv]

Yes Pete. It was not in good shape that’s for sure.

 

Have you seen the size of circuit board they used to catch the Lockerbie bomber ? The size of a 5 cent piece. 

my point is you don’t know what you will find, and I would argue leaving the engine in the ground where it came to rest is leaving potential causes out in the paddock.

Recall how CASA reacted a few years ago to an engine manufacturer, on the strength of no fatal accidents.

 

Here is a fatal accident with a question mark over the engine, and its left in the paddock? 

I just feel pretty let down to be honest. It’s been years, and nothing has come of it. 

 

 

[kgwilson]

The reality in this case is that there is no public interest in establishing the cause unlike any commercial aircraft crash, so little or no funding is allocated. The result is that all is eventually forgotten except for those close to the person. A sad but true indictment on our society.

 

 

[turboplanner]

I went looking for the original report on this site, but couldn't find it.

 

It would help an awful lot if Thread titles could be edited to correct mistakes, and include the location, Aircraft and Date, and be easily searchable.

 

I also went looking for the Coroner's report and found it within a couple of minutes.

 

In this case you'll note that the Coroner flies recreational aircraft and also has a PPL.

 

Here's the report: https://www.courts.qld.gov.au/__data/assets/pdf_file/0003/578010/nif-millard-r-20180723.pdf

 

 

[NotSoSuperSonic]

The reality in this case is that there is no public interest in establishing the cause unlike any commercial aircraft crash, so little or no funding is allocated. The result is that all is eventually forgotten except for those close to the person. A sad but true indictment on our society.

 

If the aviation community wants to be respected and considered true aviators , then the level of public interest, low or not, shouldn't be used as an excuse for not investigating accidents and incidents correctly and thoroughly. Most cases seem to indicate an attitude of "Don't go looking too hard and chasing the real facts, in case you might find something you don't want to be found". Also, it doesn't cost a great deal to carry an effective investigation, so the availability of formal funding shouldn't really play a part either.  If you can carry out basic troubleshooting, etc., you have the foundation skill set to carry out/play a part in an investigation. Long story short, it can be down to having the right Attitude and Approach. Cheers

 

 

[NotSoSuperSonic]

I went looking for the original report on this site, but couldn't find it.

 

It would help an awful lot if Thread titles could be edited to correct mistakes, and include the location, Aircraft and Date, and be easily searchable.

 

I also went looking for the Coroner's report and found it within a couple of minutes.

 

In this case you'll note that the Coroner flies recreational aircraft and also has a PPL.

 

Here's the report: https://www.courts.qld.gov.au/__data/assets/pdf_file/0003/578010/nif-millard-r-20180723.pdf

 

Same Investigator and Coroner as the Young and Friend accident that occurred in February 2015. I personally don't believe that that accident was investigated to the level that it should have been. If it had, Mr Millard may still be alive.  Cheers

 

 

[facthunter]

What people want is quick and appropriate info coming out . You can't have quick and "anything good" guaranteed. COST is a factor you can't just wish away and as always someone has to pay. Who's offering? We already whinge about every extra dollar we are asked to pay.  Investigation relies on Data and there's no CVR's or Flight data collected on U/L's and Australia is a big place and the cost of getting people and any equipment to some places is more than significant. IF the organisation shoulders it  cash wise people will revolt and if it runs it's own,  it can't ,as it's under the jurisdiction of the police in our case. If it goes to a coroner that is lengthy and will over ride anything else that comes out. In this matter you have to realise you are limited by resources and what you can reasonably expect in the circumstances and that often you will not get a conclusive answer as to exactly why the accident occurred.  I don't see any  structural "dark forces" involved in this to any extent but sometimes the events that get attention could have  a dramatic aspect rather than an outcome that benefits the users of airspace.  IF we have management involved in ownership/sale  of planes one could definately need to make sure an arms length situation was observed at all times . That's why NTSB  separate from CASA does investigations but they do ALL transport, not just aviation, which was once the  case. Nev

 

 

[motzartmerv]

Nothing good happens quickly for sure, but the coroners report in this case is 18 months Nev. 

 

The NTSB is the American version of our ATSB, and has a sizeable budget, and of course they can’t investigate every accident. 

But a fatal accident involving an engine failure of a major brand, installed in thousands of aircraft in Australia should surely warrant some further investigation?

 

How expensive could it be to pull an engine out of the ground and strip it?

 

I have had engines removed and stripped in half a day! 

 

Secondly, there are potential learning outcomes being over looked regarding the actions post the engine failure which all pilots could benefit from of handled correctly. The non technical skills aspects and dare I say, failures, are major factors in almost all serious and fatal accidents in this class. 

If we as the pilot body just accept the reality of the situation and say ‘ it is how it is’ then nothing will ever change.

 

Saying we ‘may never know’ is far from an acceptable reason to not look for the answer !! 

 

 

[turboplanner]

What people want is quick and appropriate info coming out . You can't have quick and "anything good" guaranteed. COST is a factor you can't just wish away and as always someone has to pay. Who's offering? We already whinge about every extra dollar we are asked to pay.  Investigation relies on Data and there's no CVR's or Flight data collected on U/L's and Australia is a big place and the cost of getting people and any equipment to some places is more than significant. IF the organisation shoulders it  cash wise people will revolt and if it runs it's own,  it can't ,as it's under the jurisdiction of the police in our case. If it goes to a coroner that is lengthy and will over ride anything else that comes out. In this matter you have to realise you are limited by resources and what you can reasonably expect in the circumstances and that often you will not get a conclusive answer as to exactly why the accident occurred.  I don't see any  structural "dark forces" involved in this to any extent but sometimes the events that get attention could have  a dramatic aspect rather than an outcome that benefits the users of airspace.  IF we have management involved in ownership/sale  of planes one could definately need to make sure an arms length situation was observed at all times . That's why NTSB  separate from CASA does investigations but they do ALL transport, not just aviation, which was once the  case. Nev

 

What's your opinion of the Coroner's report for Ross Millard which I linked above and here again:     

 

https://www.courts.qld.gov.au/__data/assets/pdf_file/0003/578010/nif-millard-r-20180723.pdf

 

 

[facthunter]

I recall reading that report and considering other material and comments at the time.. I also probably posted here.. I have also interacted and met with Ross a couple of times, always amicably, and discussed mutual issues.. He was not a person reluctant to come forward with strong view,s and his relationship with U/L's was real and not based on theory alone.. He flew as well as fixed.

 

  On the Coronial report, I have NO difficulty with it and the unusual situation of having U/L pilotage experience, while not overemphasised, was helpful giving more validity to the comments made.. On a ratings scale which I'm not overqualifed to make, I would put it well above what one might be  provided with and expect generally in average circumstances.. Coroners aren't Aviation experts and need to have unbiased  relevant technical knowledge provided to get to the truth in these matters  and with this one , we pretty much got there. . IF you require a definite answer to cause of the engine's failure, you may not ever get one and we can speculate but I'm not into that here, nor did the Coroner in the report. Nev

 

 

[facthunter]

 Merv, you can look for the engines issues as was done with the Goulburn incident where the crankshaft was found defective.  I'm surprised it was not done but engines will fail and we should cope with it. Do you have any reason to think some extra prior investigation might have helped here? We are trained to handle engine failures. THAT can be learned from this matter and pilots may take note of a couple of related issues .

 

 (1) Maintaining control of the Plane is the prime necessity. You always crash more  Badly when you lose control.

 

(2)  Have a plan before every take off and STICK to it. Brief yourself even if it seems like a silly idea. Forewarned is forearmed.

 

            Every Commercial take off caters for engine failures at all stages of  ground roll and initial climbout and it's FULLY briefed with appropriate speeds and procedures/actions.. Reaction times must be a minimum consistent with positive and effective control . You do as you've been trained to do..

 

  Partial engine failure. At low levels you don't have  MUCH time to troubleshoot.  You can't count on the engine providing anything, so don't (count on it). .

 

  Refer  Both (1) and (2) Nev

 

 

[motzartmerv]

Yes Nev. we all know the textbook responses, and if I could stress a point it would be that the textbook doesn’t always work. It didn’t in this case, Ross knew better than most what happens when you don’t control the acft POST EFATO. I actually interviewed Ross on camera for over an hour, discussing exactly this scenario ( only months before his accident )His understanding and knowledge of the problems was very strong, and he had some very hard and fast rules of thumb and rote disciplines, particularly when testing aircraft. And he still got bitten.

 

I have 2 issues.

 

1. The engine failure was not investigated . A coroner doesn’t have tk explain what happened, only what the cause and manner of death was. The ‘speculation ‘by the Raa investigations  he mentioned was not accepted, nor should it be.

 

2. The theme mentioned in the report regarding ‘ normal procedures and syllabus items’ post engine failure was not a fair reflection of the situation and is a massive issue that should be looked into. The Raa can’t just keep saying “ that’s not how we teach our pilots “ 

 

it obviously IS how we train our pilots, because it keeps happening. The whole matter needs a thorough rethink, we can do better, but we never will if we keep pussy footing around the subjects and using throw away lines in corners court like “ the pilot flew contrary to the training syllabus” In a just culture the ‘system’ is looked at first!! Something I have NEVER seen happen in any investigation into a mates death in an RAA machine. For which I’m afraid the list is starting to get too long!!  

 

 

Rant over 

 

 

 

[facthunter]

That's OK, Motz. Don't worry about being concerned about  too many deaths in planes which seem unnecessary. I share that concern, as you know. I'm also in a position of having lost too many good friends and acquaintances  in air incidents. I believe the syllabus is tick boxes  too much and somewhat dumbed down to sell it cheaply and make out it's easier than it is to swell the numbers. I don't quite know how this applies to Ross though. He's far from a newly trained novice.  He's gone and all we can do is try to glean something from it that is helpful to those still here. Nev

 

 

[motzartmerv]

You are right, it doesn’t apply to Ross, but was raised by the RAA in the coroners report. In my view, a hand washing exercise. “ we didn’t teach him that” 

 

 

[facthunter]

Looked to be more defensive than helpful..  I took no notice of it because it contributed little. We don't know what went on during the investigation though as distinct from the documented hearing . Nev

 

 

[kgwilson]

It doesn't matter how experienced a person is, mistakes can always be made. The Coroners report alluded to the differences in characteristics of the 2 Lightwing models and in the few seconds Ross had he may have instinctively flown this aircraft like his own. I don't think he'd have had time to think about trying not to bend someone elses aircraft

 

 

[turboplanner]

1. The engine failure was not investigated . A coroner doesn’t have tk explain what happened, only what the cause and manner of death was. The ‘speculation ‘by the Raa investigations  he mentioned was not accepted, nor should it be.

 

Several people have mentioned that in more than one fatality.

 

It may happen with RPT aircraft where investigators have the finance to try to rule out a recurring problem.

 

But they also have a very formal maintenance regime, with qualified specialists at every level so on a per mission basis they have a lot less failures.

 

I can't see that ever being feasible in RA because:

 

1. The owners are allowed to maintain their own engines, and the RAA training is rudimentary.  

 

    Under that situation you would expect a lot of engines to be in something less than factory condition.

 

2. RAA cater for that in setting the 45 knot stall speed, on the assumption that a pilot who has an engine failure can glide to the ground and make contact with the ground, structures, trees etc at no more than 72.45 km/hr

 

That's the basis on which RA pilots have the right to fly.

 

3. It's not financially feasible based on current standards in Australia.

 

I know that's a bitter pill to swallow, particularly for the relatives, but fatalities in car accidents and many other fields are all processed by the State Coroners on the same basis; the investigation is done by Police to their policy standards and they had a brief to the coroner, and the public only see the Coroner's report.

 

One of the regrets of my life is not pushing hard enough with the cause of death of a semi trailer driver in one of the first B Doubles in Australia. It happened near where I walked so I walked over and looked at the scene. The B Double had been travelling along Melbourne's Monash Freeway, and after climbing a grade made a left turn on to the Princes Highway. Half way through the turn there were skid marks on the road which indicated to me a mechanical failure, or instant loss of traction. The Prime Mover was a 6x2 (one rear axle driving instead of two), to save fuel.The newspapers had reported the truck was speeding. I phoned the Police MCU and offered to help. I had access to the Cummins VMS system in the US which, using the engine data, truck specifications, trailer load etc. could provide the fastest possible speed at the point of rollover. Given the grade and low power of the truck that wasn't going to be fast. The cop said "I don't need that, we've got our machines too, we have a witness who saw the trucks speeding." 

 

The witness was facing the truck head on. I later found out the driver had a perfect record which included driving semis in Europe.

 

My point in writing this, is there is a framework for each case, and it has limits which are tighter than we would want, but that's what we live with.

 

4. So we are left with; he had a partial engine failure, and he didn't  make it to the forced landing, and why that was, we don't know.

 

2. The theme mentioned in the report regarding ‘ normal procedures and syllabus items’ post engine failure was not a fair reflection of the situation and is a massive issue that should be looked into. The Raa can’t just keep saying “ that’s not how we teach our pilots “ 

 

it obviously IS how we train our pilots, because it keeps happening. The whole matter needs a thorough rethink, we can do better, but we never will if we keep pussy footing around the subjects and using throw away lines in corners court like “ the pilot flew contrary to the training syllabus”

 

I agree with you that too many pilots have died never even getting close to a glide let alone touching the ground at 45 knots, and while that is the basic cornerstone of why RA pilots are allowed to fly, and while that may well be covered in the syllabus, there's clearly a disconnect betwen RAA policy and the Pilot.

 

The Coroner's job doesn't extend to wet nursing an industry, but woiuldn't you think a bell would go off in RAA, and someone would think "our training needs an urgent shake up here".

 

RAA are frequently called in to provide specialised assistance to Police, but the findings and Police Brief are not for any release other than to the Coroner. Hence, we don't get an RAA report on what they found and what they did, but is it too much to expect them to database these findings and take action, in this case to improve Forced Landing performance?

 

 

 

In a just culture the ‘system’ is looked at first!! Something I have NEVER seen happen in any investigation into a mates death in an RAA machine. For which I’m afraid the list is starting to get too long!!  

 

I think you have to at least step up to LAME maintenance for that. Take a look at what a retired coffee shop owner or Accountant has to do to qualify for L2.

 

 

[Kyle Communications]

My experience with LAME built aircraft and LAME maintenance......I never let them touch my aircraft....sure there are a couple I can trust but the rest?....sorry

 

Ross was one of the trusted ones

 

Having had a few beers and a few steaks with Ross at the Breakfast Creek pub a few times when he used to come to the big smoke and many long ph calls and knowing what he was like I think he got caught by a very different handling aircraft than his own with the desire to try not to bend his mates aircraft. The report states the conversation and direction of fuel was different this I think maybe be the loss of power. It has caught many a person out. I was totally shocked with his death at the time and still think about him often. RIP fella 

 

 

[turboplanner]

My experience with LAME built aircraft and LAME maintenance......I never let them touch my aircraft....sure there are a couple I can trust but the rest?....sorry

 

So much for Australia's commercial aviation industry then, I'm sure they would be interested in how they can improve.

 

 

[Yenn]

The coroners report does not really tell us anything new.

 

RAAus want to be able to keep administering ultra light flying, so their agenda is to deflect criticism from themselves and a sure way to do that is to lay the blame on pilot incompetence. Then they have to ensure that they cannot be responsible for the lack of competence. Easy in this case. Ross trained before RAAus existed.

 

CASA has given powers to RAAus to run recreational flying, so that they are not held responsible. That way they have no need to look into the accident.

 

Just make sure that if you have an accident, that its cause will be obvious to Blind Freddy, otherwise it will be pilot error.

 

 

[farri]

"No one has found a new way of crashing an aircraft!" I don`t remember who made that statement, but it was made on this forum, a while back, and as I recall, it was Ross and Me, who said more than once on here, " you will never stop the accidents."

 

  A lot has been said on here about training, so! just a bit of history in an attempt to make my point... When I started flying Ultralights there were no twin seat Ultralight aircraft approved for training, if you wanted to fly, you taught yourself or you went looking for an instructor but the instructor couldn`t legally be in the aircraft so it was no better than teaching yourself! accidents were occurring and it was found that the majority of the accidents involved GA pilots who had been trained to fly but not trained to fly Ultralights! then came the certification of the Drifter and the Thruster and those of us who were capable, went on to start, twin seat instruction! if a GA pilot wanted to fly an Ultralight, they had to be instructed by an Ultralight instructor! but the accidents continued to occur.

 

Back then, once a student achieved their A.U.F. pilot certificate, they could fly any Ultralight, within the A.U.F. system! accidents, fatal and non fatal, continued to occur, so! the endorsement system began, but! the accidents continued, so! the Low performance and High performance endorsements were brought in and the accidents continued to occur.

 

Time went on and the A.U.F. became the R.A.A ,or if you prefer, R.A-Aus, and the time of the L.S.A. had arrived! a lot of instructors, like myself, retired from instructing and as a result a substantial amount of A.U.F/R.A.A flight training schools closed ( and are still closing) so now those second rate instructors, as some thought, were out of the system, but guess what? the instruction was deemed to have been improved but accidents continued to occur and as we all know, are still occurring,  regardless! of the training or the thoroughness and findings of the investigation of the previous accident.

 

 Of those I instructed, only one crashed his plane and was fatally injured! Why? because he chose to come down to powerline height and as a result he hit it! several others had engine failure in their own aircraft but all managed to landed safely.

 

 Ross may have started off like me but he became a very experienced pilot who knew what he was doing and regardless of anything that is said, here, or elsewhere, by whoever, there will never, ever, be any proof, that had he, or anyone else, in a similar accident, landed straight ahead or 30 degrees either side, would still be here with us.

 

Human Factors are the biggest cause of accidents and didn`t all of us R.A.A pilots have to do and pass a Human Factors exam?

 

Franco,

 

Ps, I prefer to remember Ross as the A.U.F/R.A.A pilot, who did what he thought was the right to do on the day. 

 

 

[turboplanner]

OK this thread has deteriorated into crap - let's forget it.

 

 

[farri]

OK this thread has deteriorated into crap - let's forget it.

 

Yes!  and you`ve been a fair contributor to the crap, so don`t both replying!!!

 

 

[facthunter]

There's a lot of things you (only) learn when you start  as an instructor (very rapid then)  and keep doing when ever you are instructing. The student won't learn if you don't allow them to get into a position where it's OBVIOUSLY going wrong. Then, The "rabbit out of a hat" skill is needed.  but the easy path to a licence or any kind of ticket /permit/certificate is not doing the pupil any favours if there's  serious gaps in the essential experience/knowledgebase.  Learning by your mistakes is possible with a large luck factor working for you but far better if the Instructor gives you the full wringing out  treatment, while you doing the training.. Nev

 

 

[facthunter]

If we fixate on the engine being the cause, I think we miss the point. Engines DO fail or partially fail. We all know that, no matter who works on them. In some circumstance there's more chance of a fault than with others. You have some choice in this matter but there are NO guarantees..

 

   This was a test flight and Ross correctly declined to take a passenger, who was the owner.

 

 I have tried to NOT speculate on this and the Coroner did a good job in covering aspects he regarded as significant and maybe contributory, so I will leave it at that.

 

 I know (Personally) one person who turned back and crashed. I will paraphrase the comments as accurately as I can. " I was always taught never to turn back. I understood the dangers, but when it happened I DID turn back . I don't know "why" I did it..

 

  We can ( and have) discussed all aspects of turning back and whether you sometimes CAN and some times will not do it safely. We know if you muck up the turn back you are in far worse circumstances than landing into wind more or less straight ahead.

 

  WE also know that maintaining control in this situation  is critical (Not much speed or height.{ Energy}).

 

  Nev