RA-Aus Not Investigating Accidents.

[APenNameAndThatA]

Others might have covered this before. RA-Aus said today that they were not investigating the accident "for a myriad of reasons". As was clear from both the first and the second communications I saw from RA-Aus about this, the only reason they are not investigating is that they won't be paid. I'm not saying that that's the wrong stance. I am less happy with the stalking horses they use. Maybe to get things done you need to mislead, maybe you don't. They their attempt to mislead would have failed, because if their true motivation is obvious to me, it will be obvious to others too. If there are any really sophisticated operators at RA-Aus, they don't get them to do their communications. 🙄

Edited December 19, 2022 by APenNameAndThatA

[facthunter]

They really CAN'T investigate for the same reason CASA doesn't and even moreso. It's not at arms length with either CASA  to whom they owe their very existence or any donors/sponsors to RAAus and some of the decision makers in RAAus may be selling aviation stuff..  Conflict of Interests it's Called.  Nev

Edited December 19, 2022 by facthunter

[turboplanner]

49 minutes ago, APenNameAndThatA said:

Others might have covered this before. RA-Aus said today that they were not investigating the accident "for a myriad of reasons". As was clear from both the first and the second communications I saw from RA-Aus about this, the only reason they are not investigating is that they won't be paid. I'm not saying that that's the wrong stance. I am less happy with the stalking horses they use. Maybe to get things done you need to mislead, maybe you don't. They their attempt to mislead would have failed, because if their true motivation is obvious to me, it will be obvious to others too. If there are any really sophisticated operators at RA-Aus, they don't get them to do their communications. 🙄

If this is related to recent accidents there's a lot on the process which is reasonably straightforward.

 

1. For an accident within any of the Self Administering organisations of which RAA is one and you'll find the others listed in the recent threads, if someone is killed, the State Police investigate and prepare a report for the Coroner. 

The police may call on the SAO to provide technical assistance, but the brief belongs to the Police/Coroner chain.

Where someone is injured, the process may well be the same, you would have to ask Police in your state.

Where no one is injured, RAA have the process which leads to the reports you read in the monthly magazine. Personally I've found those reports generally very good, but a few realled needed to be bumped up to senior management, or someone in senior management who flies should check the list before it is published; relatively easy to fix.

Both Police and ATSB have legal processes neither the SAO nor us can interfere with and go off half cocked on a serious accident.

They could conduct their own investigations where the Police and ATSB boundaries aren't crossed, and we did look at rough costs per year per member and they would be significant, just to get a little more information. A slight upgrade to the reports we see now would be plenty.

 

[old man emu]

I've posted extensively elsewhere on the role of the Coroner where a death occurs from an aircraft impact. In those posts, I've indicated the how the information the Coroner needs is gathered, and Turbo has reiterated my words. However, Turbo raised a point that is often overlooked:

14 hours ago, turboplanner said:

Where someone is injured, the process may well be the same, you would have to ask Police in your state.

Injury resulting from an aircraft impact is an overlooked area of the criminal law. The Law in NSW (Crimes Act Section 52) does deal with causing death or injury due to the operation of motor vehicles or boats, but aircraft are not included. I suppose one could examine the offence created by Section 54:

Causing grievous bodily harm

Whosoever by any unlawful or  negligent act , or omission, causes grievous bodily harm to any person,

 

However, there is probably a lack of awareness that this Section might apply to an aircraft impact. The thought process is likely to be that if the crash didn't kill you, then no sweat, because we all know that aeroplanes always simply plummet from the skies without human intervention.

 

Notice the words "negligent act" and "omission". That brings maintenance organisations into play.

[F10]

It is not a satisfactory situation, the NTSB won't investigate RA fatal crashes, but possibly understandable. Be that as it may, I am sure that there are enough members of RAAus, who have experience/expertise in flight safety, accident investigation and technical/engineering experience/qualifications, to investigate accidents. After all, we all have a vital interest, in learning about what caused an accident. Clearly if you don't know the why's, you can't come up with the don'ts.

 

I suggest a better approach might be, to build up a team of investigators amongst RAAus members, with maybe applicants to be vetted and approved (legitimized) by the NTSB, to go and conduct professional investigations. Would this approach not be better? Hopefully coupled with this, some form of subsidy or Federal support could possibly provide funding. Because yes, what I want to really avoid is the appointment of an accident investigation team, driving up membership costs. Membership costs and aircraft rego costs, seem to constantly happily increase, without this added incentive.

 

But in summary, I think the ATSB should be approached with the possibility of official support, for the standing up of an RAAus investigation team, to address this unsat' situation of no investigation. 

[turboplanner]

11 minutes ago, F10 said:

It is not a satisfactory situation, the NTSB won't investigate RA fatal crashes, but possibly understandable. Be that as it may, I am sure that there are enough members of RAAus, who have experience/expertise in flight safety, accident investigation and technical/engineering experience/qualifications, to investigate accidents. After all, we all have a vital interest, in learning about what caused an accident. Clearly if you don't know the why's, you can't come up with the don'ts.

 

I suggest a better approach might be, to build up a team of investigators amongst RAAus members, with maybe applicants to be vetted and approved (legitimized) by the NTSB, to go and conduct professional investigations. Would this approach not be better? Hopefully coupled with this, some form of subsidy or Federal support could possibly provide funding. Because yes, what I want to really avoid is the appointment of an accident investigation team, driving up membership costs. Membership costs and aircraft rego costs, seem to constantly happily increase, without this added incentive.

 

But in summary, I think the ATSB should be approached with the possibility of official support, for the standing up of an RAAus investigation team, to address this unsat' situation of no investigation. 

We have covered this in a lot of detail, albeit in threads where probably no one will ever find it. What you are suggesting is the legal equivalent of putting a team of motorists together to go to the scene of a road accident which the police are investigation and try to investigate while they have the vehicle, the people and the scene locked down. There are protocols to be considered first. 

[F10]

Firstly, if done properly, like sanctioned by the NTSB, or RAAus, this would be a bit more than a "team of motorists". Secondly, I'm sure the police would be happy to have the help of people who know about aircraft. The whole point would be to appoint a team who would have "legal" authority, to photograph the wreck, cockpit switch positions, advise of any dangerous aircraft components (ballistic parachutes, carbon fibers) etc, to name but a very few considerations, police may not be familiar with. I would not be surprised if some highly qualified potential investigators are also RAAus members. How "legal" do you need it? Is the NTSB "legal"?

[Blueadventures]

38 minutes ago, F10 said:

It is not a satisfactory situation, the NTSB won't investigate RA fatal crashes, but possibly understandable. Be that as it may, I am sure that there are enough members of RAAus, who have experience/expertise in flight safety, accident investigation and technical/engineering experience/qualifications, to investigate accidents. After all, we all have a vital interest, in learning about what caused an accident. Clearly if you don't know the why's, you can't come up with the don'ts.

 

I suggest a better approach might be, to build up a team of investigators amongst RAAus members, with maybe applicants to be vetted and approved (legitimized) by the NTSB, to go and conduct professional investigations. Would this approach not be better? Hopefully coupled with this, some form of subsidy or Federal support could possibly provide funding. Because yes, what I want to really avoid is the appointment of an accident investigation team, driving up membership costs. Membership costs and aircraft rego costs, seem to constantly happily increase, without this added incentive.

 

But in summary, I think the ATSB should be approached with the possibility of official support, for the standing up of an RAAus investigation team, to address this unsat' situation of no investigation. 

They could invite RAAus to undertake an investigators course.   When I did mine back then there were Rail, ATC, Airline, Marine and Aviation including two from Dubi airport.  Maybe RAAus has partaken in a course over the years.

[turboplanner]

1 hour ago, F10 said:

Firstly, if done properly, like sanctioned by the NTSB, or RAAus, this would be a bit more than a "team of motorists". Secondly, I'm sure the police would be happy to have the help of people who know about aircraft. The whole point would be to appoint a team who would have "legal" authority, to photograph the wreck, cockpit switch positions, advise of any dangerous aircraft components (ballistic parachutes, carbon fibers) etc, to name but a very few considerations, police may not be familiar with. I would not be surprised if some highly qualified potential investigators are also RAAus members. How "legal" do you need it? Is the NTSB "legal"?

Firstly, RAA have been called on by Police for many years, so the relationship already exists

Secondly, what I forgot to mention,  RAA is no longer an Incorporated Association; the members voted for a Limited Company, so can no longer just vote to form a group for anything, members pay a subscription for services from the Company. As I mentioned on one of the other forums, Police call in RAA Ltd personnel when they need them in an investigation, as does every other SAAO.

 

The system isn't broken as the title implies, just some people don't understand how it works.

[Garfly]

6 hours ago, F10 said:

... But in summary, I think the ATSB should be approached with the possibility of official support, for the standing up of an RAAus investigation team, to address this unsat' situation of no investigation. 

It's not as if nothing along these lines has ever been thought of, or that no procedures are, in fact, in place.  To start with, a few excerpts from the RAAus website:

 

"Fatal Accident Investigation Process

 

RAAus has developed an emergency response plan to ensure serious and fatal accidents are managed ...

 

... First and foremost is the fact that RAAus is not able to attend any accident scene without the express permission or invitation from local authorities, usually the police who are despatched to the accident scene. In some cases RAAus is not invited and instead the ATSB may investigate or a third party may be invited to work with police.

It is always RAAus' preference that the ATSB investigates RAAus accidents due to their increased resources and investigative capabilities, however when they elect to not investigate, RAAus offers technical assistance to the police in order to provide aviation expertise by trained aviation accident consultants ....

 

• Who are RAAus Accident Consultants (ACs)?

  Accident Consultants (ACs) are typically RAAus employees who are requested to assist at accident sites.  ACs who are employees of RAAus are required to complete the ATSB Accident Investigation Training, or an equivalent course, to formalise their qualifications.  RAAus is also supported by other subject matter experts and the ATSB.

• Role of the RAAus Accident Consultant

  Due to the specialist nature of aviation accident investigations, the police may request assistance from RAAus as Subject Matter Experts (SME) and in a specialist advisory role. This is the only way RAAus can attend an accident scene. RAAus has no authority or power to enter an aircraft accident without an express invitation from the police or local authorities. 

  An RAAus Accident Consultant (AC) is only there to assist the police in their investigation and to gather the facts and present them to the police. Under no circumstances are staff expected to lead the investigation. RAAus ACs do not have any jurisdiction under the Transport Safety Investigation (TSI) Act 2003.

  The role is intended to provide the police based Investigating Officer (IO) of any aviation related hazards and specific industry or aviation knowledge to assist them in their investigation. 

  When an AC is dispatched to an accident, incident or other emergency site they are to abide by RAAus AC policies, procedures and checklists.

• Processes and Procedures

   

  ....  Regardless of who provides the notification, RAAus’ first action is to check our database for the aircraft file to determine whether a ballistic parachute system is fitted or if any other dangers exist. This is provided as advice to first responders to ensure they are aware of potential hazards when conducting onsite rescue efforts ...

   

  ... The ATSB may elect to investigate a RAAus accident, in which case RAAus presence is simply to provide RAAus operations subject matter expertise. ATSB assesses the safety value of ATSB attendance at an accident and generally the investigation is conducted by police with assistance by RAAus. The ATSB may provide invaluable technical and analytical support to RAAus later in the process ...

  ... One major point of difference between ATSB and RAAus processes however is the Transport Safety Investigation (TSI) Act 2003. If the ATSB conducts an investigation, the TSI Act provides the ATSB with legal responsibility for the investigation, which while conducted with cooperation of local police, results in the ATSB publishing a report on their website. The ATSB is protected under the TSI Act from any civil or legal action by anyone associated with the fatality.

  RAAus however, is not protected from legal or civil action at all by the TSI Act, resulting in RAAus only being able to provide a report for the police and Coroner and only providing relevant and general safety information to members.

  Once the on-site portion of the investigation is completed, which typically takes 24 - 48 hours, investigators will also continue to work with the local police, interviewing relevant people, reviewing the pilot logbook and aircraft maintenance logs and if required, arrange for the ATSB to conduct a technical analysis and data extraction of any onboard GPS, Engine Flight Information Systems (EFIS), video footage or other assessments. Any ATSB technical assistance typically results in the production of a report regarding this assistance by ATSB, which is published on the ATSB website in due course.

  On return to the office, the investigators will continue to work on the investigation, assessing a variety of relevant factors including human factors, environmental, mechanical and operational considerations. Components like the engine, propeller and airframe may be torn down and assessed by an engineer, including metallurgical, fabric or fibreglass and carbon fibre analysis may be conducted and fuel may be subjected to testing. If the accident involved a student, a review of relevant training records will be conducted.

  RAAus has an internal commitment to the production of a report for the police and Coroner within 6 months of the accident and an immediate commitment to our members to provide any relevant safety information as soon as possible ... "

 

 

https://members.raa.asn.au/safety/fatal-accident-investigation-process/

 

 

 

 

 

 

Edited December 20, 2022 by Garfly

[facthunter]

That's all clear enough AND logical. Spells out what RAAus Can't do.  Nev

[pmccarthy]

But that is what RAA did before they stopped doing it.

[facthunter]

Maybe they just clarified what they do. Nev

[APenNameAndThatA]

On 19/12/2022 at 2:46 PM, facthunter said:

They really CAN'T investigate for the same reason CASA doesn't and even moreso. It's not at arms length with either CASA  to whom they owe their very existence or any donors/sponsors to RAAus and some of the decision makers in RAAus may be selling aviation stuff..  Conflict of Interests it's Called.  Nev

I agree with you. And if RA-Aus was more sophisticated, that’s the reason RA-Aus would have stated. Just to restate: the logical reason you gave is not RA-Aus’s reason, otherwise they would have said so. 🤦‍♂️🤦‍♂️🤦‍♂️🤦‍♂️🤦‍♂️🤦‍♂️🤦‍♂️🤦‍♂️🤦‍♂️🤦‍♂️. If only they had spoken to you first. 

[facthunter]

I thought they had alluded to it but I'm surprised they didn't just point out the fundamental problem . Perhaps they didn't want to lose sponsors or have restrictions on being involved with profit making aspects of light aviation.  Nev

[Garfly]

You have to cut RAAus a bit of slack here since much of the horse-trading would, necessarily, be happening behind the scenes.  What matters is not winning the argument but winning the day.  And RAAus has made it clear that a good outcome for them would be the government deciding to properly fund the ATSB to do its job; the whole of it, and that includes us.  After all, most of the lessons learned from RA accidents are perfectly applicable to the GA scene.  In NZ and other jurisdictions, the arbitrary distinction would seem absurd.  I wouldn't be surprised if the ATSB quite agrees with RAAus.  They may welcome just such an extended role if only they had the financial wherewithal.  No other outfit has the expertise, arms-length-status nor the legal protections that they do.  But who knows? It's hard to say what goes on in bureaucratic backrooms, but equally, it's hardly fair to judge RAAus' strategy without knowing.

 

Be that as it may, the organisation has put its position publicly and clearly, most recently in this ABC report on the Nullarbor tragedy:

 

" ... Esperance Detectives took on the case after the Australian Transport Safety Bureau (ATSB) declined to investigate, saying it typically did not investigate recreational aircraft accidents.

Recreational Aviation Australia (RAA) criticised the move, saying it wrote to the Minister for Transport Catherine King in November raising concerns about the ATSB's inability to conduct investigations due to limited funding.

"We have seen at least five fatal accidents in the past 12 months and many in the years prior where the ATSB has chosen to not investigate," RAA chief executive Matt Bouttell wrote in the letter.

"This equates to a significant cost to the Australian people through awaiting State Coroners to arrive at findings that often result in diminished safety outcomes due to a lack of subject matter expertise during the investigation and evidence-gathering phase.

Mr Boutell told the ABC that RAA has provided police with technical support in the past, but it has no legislative powers to conduct fatal accident investigations.

"We have previously provided police with on-site support at accidents, including performing analysis around the circumstances of the accident however, in recent times it's become clear that due to the lack of legislative protections, we cannot keep 'propping up' the ATSB by doing so," he said."

"We have therefore said enough is enough, and that the Government should fund the ATSB for the purpose it is established for." 

 

https://www.abc.net.au/news/2022-12-20/pilot-in-nullarbor-crash-identified-as-43-year-old-perth-father/101793432

 

 

 

 

 

Edited December 23, 2022 by Garfly

[facthunter]

I think I have already indicated I find the current RAAus stand on this appropriate and well articulated. .  Nev

[Garfly]

 

 

Yeah, I wouldn't have thought otherwise, Nev. 

I should have included a quote to make it clear who and what I was reacting to.

In this case:

 

APenNameAndThatA said:

 

"I agree with you. And if RA-Aus was more sophisticated, that’s the reason RA-Aus would have stated. Just to restate: the logical reason you gave is not RA-Aus’s reason, otherwise they would have said so. 🤦‍♂️🤦‍♂️🤦‍♂️🤦‍♂️🤦‍♂️🤦‍♂️🤦‍♂️🤦‍♂️🤦‍♂️🤦‍♂️. If only they had spoken to you first. "

 

 

 

 

 

Edited December 23, 2022 by Garfly

[turboplanner]

This is the link to the Constutution of Recreational Aviation Australia Limited, and under "powers" you will notice that it doesn't have any powers to investigate accidents.    https://www.raa.asn.au/storage/raaus-constitution.pdf

 

ATSB do not investigate RAA accidents, generally, but to be precise, now and again decide to investigate a specific accident.

However, in general there should have been no expectation that ATSB would investigate the W.A accident.

 

Police investigate RAA accidents, and provide a brief to the Coroner, which is what is happening in the W.A case.

 

So no surprises there.

 

The comments by the Recreational Aviation Australia Limited are interesting, but ATSB and W.A. Police have both provided answers which confirmed the normal process is happening.

 

There is another process which hasn't been mentioned and that is if someone decides to sue someone else for breach of duty of care where the responsibility is decided in Court but so far there has been no indication that will happen with the W.A case.

 

 

 

[Blueadventures]

My belief is that RAAus should be in a position to identify contributing factors of incidents and accidents (or up skill to have such ability) in a manner that does not hinder or hamper the investigation by the lead investigator (Police) and pass the findings of primary and secondary contributing factors to members to enhance safety.

Edited December 23, 2022 by Blueadventures

[pmccarthy]

The ATSB is responsible for a wide range of safety, not just aviation. It applies limited funds to cases that might enhance safety learnings. It does not investigate all GA accidents or fatalities. It has discretion to decide what is worth investigating for the possible learning outcomes.

[APenNameAndThatA]

4 hours ago, Garfly said:

You have to cut RAAus a bit of slack here since much of the horse-trading would, necessarily, be happening behind the scenes.  What matters is not winning the argument but winning the day.  And RAAus has made it clear that a good outcome for them would be the government deciding to properly fund the ATSB to do its job; the whole of it, and that includes us.  After all, most of the lessons learned from RA accidents are perfectly applicable to the GA scene.  In NZ and other jurisdictions, the arbitrary distinction would seem absurd.  I wouldn't be surprised if the ATSB quite agrees with RAAus.  They may welcome just such an extended role if only they had the financial wherewithal.  No other outfit has the expertise, arms-length-status nor the legal protections that they do.  But who knows? It's hard to say what goes on in bureaucratic backrooms, but equally, it's hardly fair to judge RAAus' strategy without knowing.

 

Be that as it may, the organisation has put its position publicly and clearly, most recently in this ABC report on the Nullarbor tragedy:

 

" ... Esperance Detectives took on the case after the Australian Transport Safety Bureau (ATSB) declined to investigate, saying it typically did not investigate recreational aircraft accidents.

Recreational Aviation Australia (RAA) criticised the move, saying it wrote to the Minister for Transport Catherine King in November raising concerns about the ATSB's inability to conduct investigations due to limited funding.

"We have seen at least five fatal accidents in the past 12 months and many in the years prior where the ATSB has chosen to not investigate," RAA chief executive Matt Bouttell wrote in the letter.

"This equates to a significant cost to the Australian people through awaiting State Coroners to arrive at findings that often result in diminished safety outcomes due to a lack of subject matter expertise during the investigation and evidence-gathering phase.

Mr Boutell told the ABC that RAA has provided police with technical support in the past, but it has no legislative powers to conduct fatal accident investigations.

"We have previously provided police with on-site support at accidents, including performing analysis around the circumstances of the accident however, in recent times it's become clear that due to the lack of legislative protections, we cannot keep 'propping up' the ATSB by doing so," he said."

"We have therefore said enough is enough, and that the Government should fund the ATSB for the purpose it is established for." 

 

https://www.abc.net.au/news/2022-12-20/pilot-in-nullarbor-crash-identified-as-43-year-old-perth-father/101793432

 

 

 

 

 

Fair point. 

[old man emu]

Don't bite my head off for saying this, but from the very early information provided in this thread, it sounds to me like the aeroplane could have best been described as "piece 'o' crap". This should have been obvious to the pilot before commencing the flight way back at the start. If a person decides to fly an obviously sick aeroplane, then, in my opinion, that puts any subsequent incident into the category of "Pilot Error". Why do it? Sure, it would have been expensive to crate up the aeroplane and put it on a truck. However, buy doing that, a life would have been saved and an aeroplane not destroyed at great cost to the purchaser. Penny wise, pound foolish.

 

In this particular case, as in all similar losses of life, I empathise with those who are left to grieve. 

[Yenn]

While RAAus do not have safety as part of their constitution, they have been very vocal in pushing the safety barrow. They keep telling us what we should or should not do and by taking that stance I believe they should be finding out what happened at any accident involving their aircraft.

[jackc]

I am sorry, but RAAus needs to lift their game a bit.   They can harp on all they like about safety, maybe their methodology in the delivery of the message needs to change?  

In this threads case, pilot made poor decision  by the looks of it. His logbook hours, experience, endorsements etc mean NOTHING.   His licence did not save him.   Circumstances on the day went against him 🙂. 

I feel sad for those left behind 😞.  He probably should never have started the trip, if the plane was not right. Too late now 😞