ATSB criticised for refusing to investigate Gympie plane crash that killed two pilots

[jackc]

The FAA’s FAR Part 103 regime is looking better all the time, No Licence and NO rego and just go flying……hang the consequences and just take all responsibility:-). 

[turboplanner]

Just now, jackc said:

The FAA’s FAR Part 103 regime is looking better all the time, No Licence and NO rego and just go flying……hang the consequences and just take all responsibility:-). 

You probably produced about 10 nodding heads  within CASA and RAA there.

[jackc]

1 minute ago, turboplanner said:

As an investigator, what does that tell you.

NO functioning radio(s) because of faults, on differing frequencies? Or possibly one radio not ‘on’ or being used.  NO EC devices or transponder fitted or in use. And poor ‘see and avoid’ ?

Wonder IF this incident would have occurred IF Sky Echo units were fitted and ON in both aircraft? 

[turboplanner]

17 minutes ago, jackc said:

NO functioning radio(s) because of faults, on differing frequencies? Or possibly one radio not ‘on’ or being used.  NO EC devices or transponder fitted or in use. And poor ‘see and avoid’ ?

Wonder IF this incident would have occurred IF Sky Echo units were fitted and ON in both aircraft? 

Yep, that’s about it. 
RAA Ltd would probably conclude the same. 
ATSB might well have concluded the same.

 

 

[facthunter]

In a collision, you can't rule out incapacitation of the occupant, due to the forces involved, either.  Nev

[turboplanner]

38 minutes ago, facthunter said:

In a collision, you can't rule out incapacitation of the occupant, due to the forces involved, either.  Nev

In this case the Coroner will pick that up, so that avenue is covered.

[Blueadventures]

1 hour ago, turboplanner said:

This thread started with a report that a family criticised ATSB for not investigating the Gympie collision.

The family will be getting an answer from a Coroner's investigation in this case.

Investigations right back from the Department of Civil Aviation were done to provide information which might prevent future repeated incidents.

If you think about it, if there were no radio transmissions and if neither aircaft were in prohibited airspace, what could you investigate?

 

I reckon the Coroner will not be impressed that ATSB have not provided an investigation as an expert opinion report containing information will not be available to him.   Just my opinion from experience.

[turboplanner]

10 minutes ago, Blueadventures said:

I reckon the Coroner will not be impressed that ATSB have not provided an investigation as an expert opinion report containing information will not be available to him.   Just my opinion from experience.

The default position with Recreational Aviation Australia is that Police investigate at the scene, and call in RAA for any specialist needs, and on one occasion I can remember RAA in turn called in ATSB for some specialist work.

The Police produce a brief for the Coroner who primarily is looking for the cause of death, and the Coroner makes the decision.

 

I presume the same default exists for the other SAAOs but I'm not sure:

Australian Ballooning Federation

Australian Parachute Federation

Australian Skydiving Association

Australian Sport Rotorcraft Association

Australian Warbirds Association Ltd

Gliding Federation of Australia

Sports Aviation Federation of Australia

 

Don't underestimate RAA's work and skills over the years; they have been good.

 

What teaches us lessons best is the cause of the accident, which is why ATSB's investigations in GA are usually more detailed and useful.

[jackc]

22 minutes ago, turboplanner said:

 

 

Don't underestimate RAA's work and skills over the years; they have been good.

 

 

Better remind the RAAus CEO about the history, his recent attitude requires reprogramming…..

[turboplanner]

3 minutes ago, jackc said:

Better remind the RAAus CEO about the history, his recent attitude requires reprogramming…..

RAA Ltd is a company.

I recommended RAA stay as an Incorporated Association because that's what Incorporations were set up for, but the majority were swept along by the rgetoric and opted for a Company.

The Company now operates at arms length from the members, as it has every right to.

Company employees can make statements, but members no longer have the right to intrude; that's what they voted for.

[jackc]

Arms length all right, until it wants rego money, certificate and membership money OR it wants to change regulations, enforce regulations.  No such thing as an arms length regulator?  I would allege the structure of the organisation is incorrect and should possibly go back to what it was?

[turboplanner]

11 minutes ago, jackc said:

Arms length all right, until it wants rego money, certificate and membership money OR it wants to change regulations, enforce regulations.  No such thing as an arms length regulator?  I would allege the structure of the organisation is incorrect and should possibly go back to what it was?

I would agree with you, and over time new blood will come in.

 

[Thruster88]

The ATSB could, should have done a quick investigation just so this accident is on the record. No need to examine the wreckage, nothing to learn there. Just the ADS-B or flarm data if any and the CTAF comms which would be recorded since Gympie has landing fees..

[turboplanner]

45 minutes ago, Thruster88 said:

The ATSB could, should have done a quick investigation just so this accident is on the record. No need to examine the wreckage, nothing to learn there. Just the ADS-B or flarm data if any and the CTAF comms which would be recorded since Gympie has landing fees..

I understand your thoughts, but the accident involves two Sport Aviation Self-Administering Organisations.

I'd suggest that both should have addressed this by either investigating or advising why they were not investigating.

 

From memory, CASA gave RAA some added responsibilities in the 2010 deed of agreement and they have never been rescinded. We covered it on this site one or two years later. If someone wants the details they could search this site.

[440032]

I would think that CASA could not direct a sport org to do accident investigations - that's out of their scope.

CASA does not do accident investigations so can't make someone else do it.

[turboplanner]

49 minutes ago, 440032 said:

I would think that CASA could not direct a sport org to do accident investigations - that's out of their scope.

CASA does not do accident investigations so can't make someone else do it.

We don't have to speculate. The tasks CASA gave RAA will be on the historic record.

[facthunter]

ATSB is independent of the CASA (as it MUST be). Similarly RAAus being dependent on CASA for survival can hardly be critical of CASA, (or it's  own sponsors or financial interests they may have) It's involved as an administrator and more and would have interests to protect. (Just as CASA does).. Investigation has to be at arm's length to be trusted. . Nev

[bull]

On 05/12/2022 at 11:38 AM, turboplanner said:

 

Really?

 

 

[old man emu]

On 07/12/2022 at 10:09 AM, facthunter said:

Investigation has to be at arm's length to be trusted

While the integrity of the investigators is essential, they have to have an organisation to give them all those thongs we could lump together under the title "Business Administration". You can't expect the person who goes out to the site of an incident to investigate for causes to also have to worry if there is enough paper and tone in the office printer, or if there is an office to have a printer in. I can see no conflict of interest in aviation investigators being included in the business administration duties of the people who do it for CASA. However, you must remember that the ATSB investigates incidents in all areas of transportation where the Commonwealth has jurisdiction. So it is a separate organisation from CASA. Also, if a death results from a transport incident, the information discovered during the investigation must be given to the Coroner. 

 

The office of coroner was established by Richard I in 1194. It was a very high ranking office in the judiciary. Amongst its initial roles was to determine if the person who died was a Norman, and then to determine a cause of death. If the cause indicated foul play, then the coronial inquest turned into murder investigation. However, if the person was not a Norman, that is a Brit, the coroner was no interested any more. Obviously these responses were based on protecting the conquerors from the conquered, as was seen during WWII when the boss of the SS, Reinhard Heydrich was mortally wounded in Prague on 27 May 1942 as a result of Operation Anthropoid. Nazi intelligence falsely linked the Czech and Slovak soldiers and resistance partisans to the villages of Lidice and Ležáky. Both villages were razed; the men and boys age 14 and above were shot, and most of the women and children were deported and murdered in Nazi concentration camps.

 

The word itself is ancient. The term relates to when the deceased was entrusted to the coronator, that is to a necrofore who prepared the corpse according to custom and, among other things, put a small laurel or myrtle wreath (Lat. corona) on his head so that he might be accepted in glory in the afterlife.

 

Necrofore: a grave digger.

[Old Koreelah]

On 4/12/2022 at 9:02 PM, pmccarthy said:

ATSB has a limited budget and in future will not investigate all GA fatals unless the investigation is likely to lead to insights that prevent future serious accidents ie multiple fatals.

How do they know which accidents, when investigated, will yield useful insights? What super wisdom or experience do they possess that allows them to decide that one crash is unworthy of their talents but another is? Seems they’d need to decide, without investigating, what the most likely cause was.

 

That’s a bit like pure science v applied. Much of the innovation that built our modern world is the result of pure science: dedicated people following lines of enquiry that interested them, rather than projects designed to boost the profits of their sponsors.

[turboplanner]

On 09/12/2022 at 8:41 AM, old man emu said:

While the integrity of the investigators is essential, they have to have an organisation to give them all those thongs we could lump together under the title "Business Administration". You can't expect the person who goes out to the site of an incident to investigate for causes to also have to worry if there is enough paper and tone in the office printer, or if there is an office to have a printer in. I can see no conflict of interest in aviation investigators being included in the business administration duties of the people who do it for CASA. However, you must remember that the ATSB investigates incidents in all areas of transportation where the Commonwealth has jurisdiction. So it is a separate organisation from CASA. Also, if a death results from a transport incident, the information discovered during the investigation must be given to the Coroner. 

 

The office of coroner was established by Richard I in 1194. It was a very high ranking office in the judiciary. Amongst its initial roles was to determine if the person who died was a Norman, and then to determine a cause of death. If the cause indicated foul play, then the coronial inquest turned into murder investigation. However, if the person was not a Norman, that is a Brit, the coroner was no interested any more. Obviously these responses were based on protecting the conquerors from the conquered, as was seen during WWII when the boss of the SS, Reinhard Heydrich was mortally wounded in Prague on 27 May 1942 as a result of Operation Anthropoid. Nazi intelligence falsely linked the Czech and Slovak soldiers and resistance partisans to the villages of Lidice and Ležáky. Both villages were razed; the men and boys age 14 and above were shot, and most of the women and children were deported and murdered in Nazi concentration camps.

 

The word itself is ancient. The term relates to when the deceased was entrusted to the coronator, that is to a necrofore who prepared the corpse according to custom and, among other things, put a small laurel or myrtle wreath (Lat. corona) on his head so that he might be accepted in glory in the afterlife.

 

Necrofore: a grave digger.

In this case the family quite rightly are grieving and want answers. They mistakenly went down the path of thinking ATSB would be the investigator when both the bodies involved in this collision were Self Administering Organizations where the normal practice is for the Coroner to investigate the cause of death, and that process would be under way.

 

ATSAB investigates GA aircraft crashes, for cause of the accident and even then doesn't automatically investigate every one.

 

The SAOs can decide to investigate accidents or just provide assitance related to the SAO experience to Police who request it for their brief to the Coroner.

 

This case is a lesson to those who boast about breaking the rules, or flying without licence.certificate, registration etc, who may be perfectly happy that accidents aren't investigated, but almost always their relatives are not.

 

RAA Ltd has made its comments on cutting back on investigatons.

 

OME has explained the Coronial process.

 

Which leaves RAA and GFA members wanting to know what actually caused accidents so they can avoid them.

In the absence of that we'll just see more people buying the latest $50 Chinese item that supposedly protects the pilot from having to do what he is supposed to do.

 

Calling for an arms length investigation body was fine in the prescriptive era before 1985 when taxpayers were paying for the sport of recreational flying, but that came to an end when the Self Administered Sports Aircraft section of flying was established about 25 years ago.

 

That changed the responsibility for safe flying from the government to the participants.  Arms length investigation might be nice, but it was expensive. Now members had to pay and they had to do it themselves. Unfortunately the results haven't been pretty; most just took the CASA exceptions and sat there flying as if the government was still responsible for risk, not them. Even today many are underinsured by millions. 

 

I've previously mentioned what Speedway racing did to transition into self administration and self responsibility, and its searchable on this site. It cost us and our insurers millions of dollars, so we learnt fast, and the claims dropped away to the point where we were asked to inspect US tracks every year.

 

Recreational Aviation Australia Inc. had the correct structure for this self-administration responsibility, but never really understod why the change had come, and never completed setting up the Constitution, instead voting for a Limited Company, or putting it another way since only a minute pecentage of Members voted, didn't vote to stay as they were and update for full Self Administration.

 

One example, which I've quoted a few times did. Sporting Shooters Association of Australia has ranges all over Australia and reasonably forseeable risks are many, so they all have  to be addessed.

 

And they've done it as an Incorporated Association, not as a Limited Company - so the members still control day by day changes and activity.

 

Disclaimer: the following is just for a loose relationship with flying; if you want any information about SSAA you should not use this, but go direct to SSAA, because here is could be incorrect, out of date or out of context.

 

Because several people got hung up on comparing speedway with flying, comparing shooting with flying also has major differences, but this information is about principles.  For example there's no point in saying "But you can't have Range Officers at every airfield." No you can't but you have to find a working model that achieves the same result.

 

SSAA Self Administration

The Sporting Shooters Association of Australia Inc, is an incorporated association designed for the self- administration era.

 

Safety Course

SSAA provides a detailed course addressing safety issues.

 

Link relating to operating rules at a specific Range

https://ssaavic.com.au/wp-content/uploads/2016/08/SV-Range-Rules-SSAA-February-2018-Version-5.pdf

 

Commentary on link: disclaimer this is not necessarily the latest version, and I haven’t addressed all of it, just made some equivalent comments on what a Recreational Flying policy for today’s era might look like. Comments match the paragraph numbers in the link.

In some of the comments I’ve paraphrased showing aircraft or flying equivalents

 

Conditions of Entry

Ear protection

Eye protection

Closed toe shoes

No excessively open shirt tops or singlets

Minimum age 12   #1

12-17 yo require adult supervisor and consent from guardian  #1

No prohibited person allowed to be on range

Range officer must be present

Risk of lead dust rules

 

1.2       Victoria Police Range Standards (prescriptive legislation crossover same as CASA)

            Victoria Police rifle regulations

2          Legally owned firearms

2.3       Attendance confirmed 

2.8       Range Rule violations must be reported

2.11     Red Flag = Range Open

2.16     Controlled use of Clubrooms  #1

2.18     Procedure for unsafe firearm

2.19     Some firearms prohibited

3.1       Firearms loaded only on firing line

3.2       Specific safety instruction

3.3       Must have approval to use that range that day

3.6       Specific instructions for use

3.8       Specific area for operations

3.9       Beat ups (aircraft) prohibited  (Behaviour control)

3.10     No low flying, into cloud etc

3.11     Authorised person checks safe to leave area

3.12     Behaviour to and from range

3.15     Not permitted to walk away from operable aircraft

3.16     Only Duty Range   handle any firearm belonging to another shooter

4.1       Area made safe – comply

4.2       Emergency procedures

5.1       Alcohol & Drugs not permitted

5.4       No smoking on firing line

 

Other rules

Shooing alone

Range Officers

Holsters

Safe Handling Area

Malfunctions

 

12        Targets

12.1     Approve targets

13        Ammunition

14        Emergency procedure

14.1     Accident/Incident reporting

15        Responsible person

16        Range officer policy

18        Specific Rules – Ranges

 

All shooters must be covered by a current Public Liability insurance policy.

 

#1        Most public liability claims are not for the central activity.

 

SSAA Constitution

 

https://ssaavic.com.au/wp-content/uploads/2021/02/SSAA-Victoria-Constitution-24-Sept-2020.pdf

 

Comments

3.1 Liability of Members is limited

 

47 Power to discipline Members

·         Penaties Caution, Reprimand, Suspension, Expulsion

·         47.2.1

·         47.2.2

 

47.3 Natural Justice, Panel for Review

47.5 Power to extend Inquiry (Review panel can investigate beyond what was provided)

 

 

SUMMARY

This combination of Rules and Constitution has worked very well for SSAA, made possible by being one of the many Incorporated Associations which were developed by the States and Territories for Self Adminitrative Sports and Recreation bodies.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[aro]

You can bet if someone is shot at a firing range it won't be SSAA investigating it. Likewise, if someone dies in speedway it will be the Coroner investigating. Speedway participants will be witnesses, not investigators.

 

The problem with expecting RAA or GFA to investigate is that you have multiple organizations involved. RAA and GFA obviously, but the rules to avoid collisions are administered by CASA so they are involved too. Do you think RAA can realistically conclude that CASA is responsible for the accident - even if they find that everyone was following CASA rules, and the accident could just as easily involved 2 GA aircraft?

 

In reality, I think ATSB investigate too many accidents. It doesn't generally produce anything useful, other than satisfy a ghoulish fascination with what happened. Can you find an ATSB investigation that produced a meaningful change to prevent future accidents? As they say, it is very unusual to invent a new way to crash.  For private operations, there should be an initial assessment, and then only do an investigation if it appears that the causes are not understood, or part of a wider pattern.

 

Aircraft have been colliding for 100 years. We know why, and we know what to do to prevent it. CASA have been watering down the rules around uncontrolled airfields for as long as I have been flying. It might be useful to investigate and decide whether that contributed. If it is established e.g. that the RAA pilot was not following rules, maybe you would want to do an investigation to see whether that was systemic in RAA in GA in general. Otherwise, there is probably not much new to learn.

[turboplanner]

1 hour ago, aro said:

You can bet if someone is shot at a firing range it won't be SSAA investigating it. Likewise, if someone dies in speedway it will be the Coroner investigating. Speedway participants will be witnesses, not investigators.

 

The problem with expecting RAA or GFA to investigate is that you have multiple organizations involved. RAA and GFA obviously, but the rules to avoid collisions are administered by CASA so they are involved too. Do you think RAA can realistically conclude that CASA is responsible for the accident - even if they find that everyone was following CASA rules, and the accident could just as easily involved 2 GA aircraft?

Words in Italics are what I said:

 

"The SAOs can decide to investigate accidents" - in the case of accidents where Police are not involved.   So for example a near miss where one of the airctaft comes down, and the lesson is separation, or an aircraft hit an object below 500 feet etc. Many more accidents happen than fatals.

 

"or just provide assitance related to the SAO experience to Police who request it for their brief to the Coroner."

That's the current situation, but possibly could be extended if there were lessons that the Coroners line of responsibility, i.e. cause of death didn't touch on, but where what happened is very important in avoiding a repeat. Under the current regimes this is not going to happen, and would need consultation with the Coroners offices and an agreed process which does not infringe on the Coroners findings. - similar to the way RAA and Police work together under long established guidelines.

 

1 hour ago, aro said:

 For private operations, there should be an initial assessment, and then only do an investigation if it appears that the causes are not understood, or part of a wider pattern.

See the paragraph below; the first thing is to identify all the reasonably forseeable risks. Then the procedure for avoiding them. Then the rules. Then any necessary investigations.  "We couldn't afford it" doesn't carry any weight in a PL case, but what you're saying is true, so there is still latitude for not having an investigation if the cause is already known, or if the accident won't provide any new information, because an SAO is not operating to the parameters of ATSB. 

1 hour ago, aro said:

 

CASA have been watering down the rules around uncontrolled airfields for as long as I have been flying.

Most of that which I've seen is shedding of legal liability to property owners, AOC holders, Instructors, Pilot and Maintenance people.

Not surprisingly, in the various Industries and Sports Activities governments haven't made that obvious, possibly to avoid outrage from the people who now have to spend the money.  I think you'll find the SAOs needed to  replace those rules. They are required to come up with a way to eliminate all reasonably forseeable risks. We've gone from the fun of getting away with it, avoiding a fine to the aircraft a crumpled mess on the ground, the passenger a quadriplegic and us shelling out around $11 million to support him for the rest of his life.

[aro]

10 minutes ago, turboplanner said:

I think you'll find the SAOs needed to  replace those rules.

RAA, GFA etc fly in the same airspace as everyone else. They are bound by the same rules as GA. RAA are not free to make their own rules in that area.

[turboplanner]

11 minutes ago, aro said:

RAA, GFA etc fly in the same airspace as everyone else. They are bound by the same rules as GA. RAA are not free to make their own rules in that area.

I pointed that out earlier in the SSAA comparison,  SAOs fly to dual rules just as  shooters operate on one set of SSAA rules plus Police Rules.

No one has suggested making rules that duplicate CASA rules.