Jacobs Well incident 5th April 2020

[BLA82]

MODERATOR'S COMMENT:

This comment was reported to Moderators for being rude and nasty. The way BLA82 expressed his disagreement with OneTrack did not advance the discussion.

 

It is perfectly OK to disagree with other people, but firstly, do it politely, and secondly, put something down that supports the reasons for your disagreement. By doing so, you advance the discussion. In this case a simple "Are you sure about that?" posed to OneTrack would have elicited the response as given in Post #142.

 

So, argue your case fervently. Attack the content. Play the ball, not the man.

 

Old Man Emu

Well I will put it out publicly I don't apologise for what I said nor do I take it back as the comment that I responded to was disrespectful and a disgracefull thing to say when family and friends of the victim could see it. I find it more disappointing that as a moderator you would spend more time justifying the fact the conversation should be advanced and to whom who reported it I must say you are just as bad. I have been a member of this forum for over 10 yrs and the way it has changed where people get reported for sticking up for what's right is sad.

Please tell me how stating the survivability % of a burns victim who is still undergoing treatment is justified or relevant?????

[FlyBoy1960]

The person you are referencing was at lunchtime, still in a Coma !

 

The survivability comments were completely unnecessary, completely irrelevant, completely cold and unsympathetic and should have been deleted immediately.

 

I can tell you that both families have read what is on this website.

[old man emu]

Please tell me how stating the survivability % of a burns victim who is still undergoing treatment is justified or relevant?????

 

I'd say the original comment by OneTrack was relevant as an aside in the discussion. That's about all they were in that context.

 

Let me say, that having just gone through this whole thread, I suspect that BLA82 and FlyBoy1960 are acquaintances of the survivor, and probably the pilot. Both these members are obviously grieving the loss and injury and are at the same time giving some support to the families. Their vigorous defence of the good name of the pilot, and hopes for the recovery of the passenger show real comradeship. Perhaps the vigour of the defence lead to the short, sharp comment the tone of which was complained of.

 

This incident has been fodder to the armchair analysts, as every other reported incident seems to be. The sorry thing is that as much as we pour out our thoughts around the time of an incident, there never seems to be reference to final reports which are where we learn if a mistake caused the incident.

 

At Post #32, The Administrator called for this topic to close down, but it wasn't. Perhaps from now on we could restrict posting in this thread to reports on the condition of the survivor, and in due course, reference to the report of the investigation into the incident. Once the Coronal Inquest has been commenced, all the evidence comes into the public domain.

[FlyBoy1960]

Once the Coronal Inquest has been commenced, all the evidence comes into the public domain.

 

Not true, most of the evidence used at a coronal inquest is not made public. Things that are talked about in the coronal inquest our public unless the coroner prohibits publication of such evidence. All of the reports that are referenced in a coroner's inquest are not public and on the Internet or anything like that so for example if the police prepare the 500 page report of a particular accident then that report will not go up into public domain, it will be referred to during the inquest but it will not be made public.

 

It is only the coroner's summary which is normally made public. All of the evidence, police reports, pathology is normally kept private

[BLA82]

I'd say the original comment by OneTrack was relevant as an aside in the discussion. That's about all they were in that context.

 

Let me say, that having just gone through this whole thread, I suspect that BLA82 and FlyBoy1960 are acquaintances of the survivor, and probably the pilot. Both these members are obviously grieving the loss and injury and are at the same time giving some support to the families. Their vigorous defence of the good name of the pilot, and hopes for the recovery of the passenger show real comradeship. Perhaps the vigour of the defence lead to the short, sharp comment the tone of which was complained of.

 

This incident has been fodder to the armchair analysts, as every other reported incident seems to be. The sorry thing is that as much as we pour out our thoughts around the time of an incident, there never seems to be reference to final reports which are where we learn if a mistake caused the incident.

 

At Post #32, The Administrator called for this topic to close down, but it wasn't. Perhaps from now on we could restrict posting in this thread to reports on the condition of the survivor, and in due course, reference to the report of the investigation into the incident. Once the Coronal Inquest has been commenced, all the evidence comes into the public domain.

 

Not true, I have no link to any of the crash victims, I am even unsure of their names. Seriously mate if you think that comment was justified you are just as bad as the original poster.

[old man emu]

I'd say the original comment by OneTrack was relevant as an aside in the discussion.That's about all they were in that context.

 

I used "aside" with the meaning something that departs from the main subject. Someone mentioned burn injuries. OneTrack commented on a way of assessing the degree of injury. Was he correct in the facts of his statement or not? I don't know.

 

Their vigorous defence of the good name of the pilot, and hopes for the recovery of the passenger show real comradeship.

 

I don't know how I could be much fairer to BLA82 and FlyBoy1960 than that.

 

As for the public nature of Inquest materials, if you have the money you can get the whole transcript and Brief.

 

http://www.coroners.justice.nsw.gov.au/Documents/Form24-Application%20for%20Access%20to%20Coronial%20Documents.pdf

[FlyBoy1960]

Its different in other states

[Mike Gearon]

The person you are referencing was at lunchtime, still in a Coma !

 

The survivability comments were completely unnecessary, completely irrelevant, completely cold and unsympathetic and should have been deleted immediately.

 

I can tell you that both families have read what is on this website.

This is quite disturbing. I’m really sorry for any comments I’ve made when simply trying to understand how this could have happened in order to avoid it. We all fly for the joy of it. Only reason to get back in the plane, line up and push the throttle forward.

 

The moderator here has an awful job. Who’d want it? You’re damned if you do and damned if you don’t with regard to intervention.

 

As mentioned previously I’m a new pilot and new to forum. I’ll tread very lightly around the incident reports in future with respect for the families. I’ll unwatch this particular thread as my first ever such action here. It’s either that or stop reading the forum and I’m sure it’s a better move to keep reading the rest of it. There is so much that’s both fun and educational/ safety related and I’ve not found a better forum to date.

[Bruce Tuncks]

Here's a true story which may throw some light on the aviation expertise of the typical coroner.

There was a glider which crashed following a cable break at altitude. The crash had little to do with the cable break, it was the result of a spin.

Now the coroner may well have had experience with crane accidents, so even though he was told better, he mandated crane-type cables for future glider launches.

It cost the GFA lots to appeal this coroner's ill-founded decision.

[turboplanner]

Here's a true story which may throw some light on the aviation expertise of the typical coroner.

There was a glider which crashed following a cable break at altitude. The crash had little to do with the cable break, it was the result of a spin.

Now the coroner may well have had experience with crane accidents, so even though he was told better, he mandated crane-type cables for future glider launches.

It cost the GFA lots to appeal this coroner's ill-founded decision.

That's the weakness in the Coronial system compared with the ATSB.

On the one hand, the ATSB has world aviation experts to draw on, and are very skilled at developing all links in the chain, which is particularly required in the case of airline crashes.

On the other hand, a Coroner's skills are getting at the cause of death, but he/she must handle the whole spectrum of deaths from those involving technical or operational failures to those who may have overdosed on drugs or had a medical episode.

So there's no point expecting an ATSB type analyisis from a Coroner, although in some cases the evidence provided does lead them down that path,

[NT5224]

Hi folks

 

I have pretty much read through much of this thread in one sitting.

 

First, deepest sympathies to the families of those affected by the Heck field incident. It was another tragic incident, and like many other tragic incidents before, I hope we will all come to understand why it happened in the fullness of time.

 

I was aware of this incident when it first occurred and although I did not read the thread, it did cross my mind why that particular flight had gone ahead when we were all being urged to lockdown.

 

While One-Tracks comment on the Baux scale might have been mildly insensitive, there was absolutely no malice in it, and I for one found it very valuable. I have since gone online to read about it further. It’s worth a glance, particularly with so many of us over fifty and practicing an activity where fire is an inherent risk.

 

I’m sure the families of those affected will be getting the very best medical advice already and possibly already come across the Baux scale if they have been seeking to gather information on burns treatment.

 

It’s heartbraking each time we lose a brother/ sister aviator to another accident and we can only wish that the surviving crew member makes a rapid and full recovery.

 

My question is, given the amount of forensic examination we put into understanding why accidents occur ( and that as somebody earlier wrote) “no new ways have been found to crash a plane since the 1930’s”, why do these accidents keep happening?

 

Surely we need to start focusing ensuring that flightcrew are adapting practices to avoid making these known mistakes. Are we as a community doing enough in that respect and how can we improve?

 

It’s all very well wailing about what went wrong after each individual incident, but if we can’t find a way to change practice within the community, then what’s the point?

 

Cheers

 

Alan

[turboplanner]

My question is, given the amount of forensic examination we put into understanding why accidents occur ( and that as somebody earlier wrote) “no new ways have been found to crash a plane since the 1930’s”, why do these accidents keep happening?

I can tell you in one word; behaviour.

 

The Behaviour segment fits in the mix with Medical, Skill(qualification), Currency, Mechanical, Design, Meteorology, Flight Planningetc,

None of the Behaviour crashes would be repeating if the Behaviour was being self-managed.

The fact that they do means that a percentage of pilots need to be managed.

 

I'm mentioned a number of times that we haven't killed any drivers in speedway racing in Victoria for over 50 years.

That's because they are supervised and there's a structured management system which doesn't hold back the slef-managed types, but weeds out the people who can't.

 

When was the ast time you heard from the RAA or any other Self Administering Organisation about this subject?

[facthunter]

Car and bike crashes individually, happen over a short elapsed time. An Air incident or accident may be the outcome of a build up of circumstances the sequence and combination of which causes the accident. Behaviour is basic in human factors considerations. and has been very much apart of investigations for a long time and I really don't think that has changed. It's much easier to regulate motorsport events because they are at specific localities require approvals scrutineers and marshalls and many competitors personalities and performance history are well known. to supporters sponsors, regulators and rule makers. You can black flag people and stop races. Aviation is different although an airshow or race is less so. Much aviation is committed in isolated places by individuals who are not so easily supervised. Could easily be some foreign Pilot who thinks Inland Australia is the flying Wild West. (as Has Happened). Nev

[M61A1]

Yep....Aside from the SAO title and use of petroleum fuel there are virtually no similarities between the two.

If RAAus was holding competitive events we might have some similarities, but we have more in common with weekend tourists.

[turboplanner]

Car and bike crashes individually, happen over a short elapsed time. An Air incident or accident may be the outcome of a build up of circumstances the sequence and combination of which causes the accident. Behaviour is basic in human factors considerations. and has been very much apart of investigations for a long time and I really don't think that has changed. It's much easier to regulate motorsport events because they are at specific localities require approvals scrutineers and marshalls and many competitors personalities and performance history are well known. to supporters sponsors, regulators and rule makers. You can black flag people and stop races. Aviation is different although an airshow or race is less so. Much aviation is committed in isolated places by individuals who are not so easily supervised. Could easily be some foreign Pilot who thinks Inland Australia is the flying Wild West. (as Has Happened). Nev

If we are looking at Recreational Flying only, I put some figures together a few years ago which showed about the same number of participants congregating at about the same number of locations. You might think that there's no way of supervising pilots who fly from their own strips on farms, but when you do the analysis, they fly in to the above touch points, so when you combine the club members and the visitors, Pilots are coming in to these touch points about the same number of times per year. At their departure points and arrival points there is the opportunity for hands on administration.

[old man emu]

If there is a death in NSW due to the operation of a VH- registered aircraft, the NTSB will carry out its investigation, using its specialist skills. It's report is provided to the Coroner, under subpoena, to form part of the Inquest material. In the case of RAAus operations, the NTSB usually hands the technical investigation over to the RAAus. In all cases the preparation of the Brief required by the Coroner is the responsibility of the poor copper who was the initial responder. It used to be that the poor Plod had no experience with aircraft, so was working in the dark. I believe that procedures have been developed in the past few years to handle these incidents.

 

The Coroner's tasks in dealing with the types of deaths within its purview are to:

1. Confirm the identity of the deceased.
   
2. Determine the time, date and place of death.
   
3. If possible, determine the cause of death.
   
4. Determine if any other person or persons were responsible for the death.
   

The Coroner may make recommendations for changes that might eliminate or reduce factors that appear to have lead to the death, but the Coroner CANNOT direct that changes be made.

[facthunter]

Coroners do a fairly good job under the circumstances but are NOT generally aviation experts or even well versed in it's practices or Laws. NTSB is across ALL transport, NOT just aviation as ATSB was. It's ability to investigate is influenced by FUNDS and the limited high standard info provided by CVR's and Flight Data Recorders. which are NOT utilised in U/L s or light end VH aircraft. Many accidents don't get investigated, Like single occupant aerobatics incidents. Also the time elapsing before reports become available diminishes their value as regards timely modification of rules and practices. The principle purpose of air incident/accident investigation is supposed to be to PREVENT similar events occurring in the future..Nev

[FlyBoy1960]

If there is a death in NSW due to the operation of a VH- registered aircraft, the NTSB will carry out its investigation, using its specialist skills. It's report is provided to the Coroner, under subpoena, to form part of the Inquest material. In the case of RAAus operations, the NTSB ...................................

 

I think you mean ATSB not NTSB

[M61A1]

The principle purpose of air incident/accident investigation is supposed to be to PREVENT similar events occurring in the future..

It seems to have made a difference to RPT, but nothing really noticable in other flying. The same stuff keeps happening, except they call "Pilot Error", Human Factors Related" now.

[old man emu]

I think you mean ATSB not NTSB

 

Yep. ATSB. Hard to think of the correct initialism with grandkid's cartoons booming from the TV in the next room.

[facthunter]

M61A1,There may well be no improvement in U/L's etc. I really don't know but I don't think it's much either way. They had a great year with no deaths then a shocker the next in heavies in the recent past. . I'm not confident there's a great leap forward there either, but air travel is statistically very safe.. As we see that CAN change quickly. The lengthy grounding of the Boeing Max series is historic but there's been other issues with designs from time to time. Rudder jambing on earlier 737s and several DC-10 issues to name just a few "Pilot error" is an unfortunate term that has masked a lot of design and training issues in the past and I caution against just blindly accepting it again in an unqualified way Yes Pilots DO make errors but some procedures and designs set them up to happen more than they should, and we don't get far by just saying the Pilot made an error, and other pilots telling themselves Well HE did, but I wouldn't do that and we don't get anywhere. Nev

[johnm]

let him who is without sin cast the first stone

[M61A1]

M61A1,There may well be no improvement in U/L's etc. I really don't know but I don't think it's much either way. They had a great year with no deaths then a shocker the next in heavies in the recent past. . I'm not confident there's a great leap forward there either, but air travel is statistically very safe.. As we see that CAN change quickly. The lengthy grounding of the Boeing Max series is historic but there's been other issues with designs from time to time. Rudder jambing on earlier 737s and several DC-10 issues to name just a few "Pilot error" is an unfortunate term that has masked a lot of design and training issues in the past and I caution against just blindly accepting it again in an unqualified way Yes Pilots DO make errors but some procedures and designs set them up to happen more than they should, and we don't get far by just saying the Pilot made an error, and other pilots telling themselves Well HE did, but I wouldn't do that and we don't get anywhere. Nev

That's pretty much exactly the point. They've done a lot of investigations, coroners have made tonnes of recommendations and made a lot of rules and changes over the years without a significant result.

The facts are that in the western world over 80% of crashes are caused by the crew and that hasn't changed in decades neither have the reasons they crash.

HF is supposed to get to the root causes of decisions made not just say they screwed up.

The way I see HF applied here in Australia is just used as another term for pilot error when at the end of the investigation you see the cause as "Human Factors Related". HF in it's current form is a pointless exercise.

Companies carry out HF training, implement their SMS and quality systems without a second thought to the fact that their admin intensive system contradicts every principal of HF by making a more complex system with distractions at every turn.

 

let him who is without sin cast the first stone

 

I'm casting stones at administrators here, not pilots and crew.

[Blueadventures]

Hi folks

 

I have pretty much read through much of this thread in one sitting.

 

First, deepest sympathies to the families of those affected by the Heck field incident. It was another tragic incident, and like many other tragic incidents before, I hope we will all come to understand why it happened in the fullness of time.

 

I was aware of this incident when it first occurred and although I did not read the thread, it did cross my mind why that particular flight had gone ahead when we were all being urged to lockdown.

 

While One-Tracks comment on the Baux scale might have been mildly insensitive, there was absolutely no malice in it, and I for one found it very valuable. I have since gone online to read about it further. It’s worth a glance, particularly with so many of us over fifty and practicing an activity where fire is an inherent risk.

 

I’m sure the families of those affected will be getting the very best medical advice already and possibly already come across the Baux scale if they have been seeking to gather information on burns treatment.

 

It’s heartbraking each time we lose a brother/ sister aviator to another accident and we can only wish that the surviving crew member makes a rapid and full recovery.

 

My question is, given the amount of forensic examination we put into understanding why accidents occur ( and that as somebody earlier wrote) “no new ways have been found to crash a plane since the 1930’s”, why do these accidents keep happening?

 

Surely we need to start focusing ensuring that flightcrew are adapting practices to avoid making these known mistakes. Are we as a community doing enough in that respect and how can we improve?

 

It’s all very well wailing about what went wrong after each individual incident, but if we can’t find a way to change practice within the community, then what’s the point?

 

Cheers

 

Alan

Alan my view from some personal experince is that some people just do not take notice. As an example in a past life as a diver we recovered a teens body from fast flowing water and before we had our dive equipment packed up some were back into the water. Therefore my opinion considering other similar situations is that education and even first hand, being there education does not work for some people.

[facthunter]

My view is that the Human FACTORS training has frequently been bastardised to suit companies cost aims and inadequately taught in most other circumstances I've had anything to do with excluding the "live in 2 day one" I did in the early days of it's introduction in this Country. Blokes who muttered and carried on about only commonsense and "know it all already cause they've been around since Pontius was a pilot" etc usually were the ones who came out looking stupid as they rushed in where angels fear to tread. It included cockpit resource management also for multicrew situations as well but not limited to that.. It is considered by most authorities in the "Aircraft" world to be the single best most cost effective adjunct to training there is to advance air safety.. Pity it hasn't been done well and it's not like a pill you swallow and that's it. Tick ME off. It is an ongoing feature of all training.. Nev