Coroners Recommendations

[markendee]

Let it go

 

 

[John Brandon]

Some remarks in this thread decrying the performance of Magistrate Mary Jerram's recent coronial task are ill-founded and need correction, lest that NSW State Coroner — and her colleagues — opinion of RA-Aus members is further eroded.

 

Her opinion of one member is clearly expressed in her inquest findings dated 4 February 2009: "Very little if any of his (Michael Coates) two days oral evidence could be accepted other than his own admission as to his deceptive, or fraudulent dealings with RA Aus in relation to the registration of aircraft and use of unregistered aircraft, his ‘re-registering’ of an unregistered plane, his

 

continued use of Czech registration in Australia in contravention of requirements, and

 

his wrongful use of the serial number of an aircraft in Australia, on an aircraft in the

 

USA. He compounded the litany of dishonesty ..."

 

The coroner's task is quite clearly defined:

 

"Coronial findings and recommendations (NSW)."

 

"The coroner's court is not bound by the rules of evidence but may inform itself in any way it considers appropriate. The coroner's court may order a person to attend the court to give evidence or to produce something. If the person fails to attend the court may issue a warrant."

 

"The coroner holding an inquest concerning the death or suspected death of a person shall, at its conclusion or termination, record in writing his or her findings as to whether the person died and, if so:

 

(a) the person’s identity;

 

(b) the date and place of the person’s death;

 

© the manner and cause of the person’s death;

 

(d) and refer the matter to the Director of Public Prosecutions if the inquest reveals that a known person has committed a serious criminal offence in connection with the death."

 

"Also the coroner is bound to protect lives and well being by

 

(a) bringing to the notice of relevant authorities any practices, policies or laws which could be changed to prevent similar deaths in the future, and

 

(b) exposing other matters of public importance."

 

If you read the findings CAREFULLY you will see that the coroner has done exactly what is specified. It must be clear to all reasonable persons, pilots or otherwise, that the prime cause of the deaths was the catastrophic crankshaft failure. No crankshaft failure then no deaths. Everything else followed from that. Perhaps the pilots may have saved themselves if they had acted differently; who knows, certainly not me — or the coroner — or anyone else who wasn't in that cockpit.

 

The coroner wasn't required to speculate as to the prime cause of the crankweb failure; all she could say was that "One could be forgiven for doubting whether any maintenance or servicing was ever

 

performed on the aircraft while owned by Coates. His record keeping was so appalling and

 

to the extent that it existed at all, inaccurate, that we will never know."

 

These forums have quite a large readership and I would be surprised if anything stated in them, which could be offensive to a section of Australian society, is not soon disseminated. Can I suggest that authors in this thread review any posts where criticism of the coroner is unfounded bearing in mind the coroner's brief outlined above?

 

One other thing. Please do not delude yourselves that we have a good safety record. We had a good year last year but 15 people died in RA-Aus aircraft during the 24 months of 2008-9 which is rather horrific. Be very wary about any statistics produced comparing GA to RA-Aus, they are generally nonsensical. The only indisputable statistic is the number of coffins. Nowadays we usually produce two coffins per fatal accident and we are averagin 4.5 fatal accidents per year. See http://www.raa.asn.au/safety/intro2.html#fatal_accidents

 

cheers

 

John Brandon

 

 

[rick-p]

Hi John,

 

All you have said I feel is correct, to a point, but there is so much more.

 

You and I both know that it wasn't the engine failure itself, on it's own that was the cause of death of the pilot and passenger, it was just a factor in a chain of events that led to their deaths.

 

On the other hand we don't know why the aircraft impacted the ground in the manner it did which such resulted in the death of the 2 occupants.

 

To attempt to ascertain this without a full and precise physical investigation of all facts and circumstances which would include a full airframe and mechanical examination is not possible and any comment would only be conjecture regardless of the credentials of the theorist.

 

In the report under recomendations the Coroner stated that "the inquest has been concerned with the manner of death that is how the deaths happend".

 

Yes the engine failed but that in itself didn't cause it to fall out of the sky, did it?

 

It was still flying to the point where it actually crashed.

 

It hadn't broken up mid air.

 

The engine failed and it was flown into the ground, why?

 

Isn't that what the Coroner should be attempting to determine ie the manner of deaths, how the deaths happend or more properly why?

 

As said hereinbefore the engine failure was just part of the sequence of events which led to the very sad demise of these people.

 

If you read the report closely then you will see that the Coroner and I do not mean any disrespect to her, had a mind set that "ultra lights" in general were flimsy, unsafe ill-maintained toys, not real aircraft, with non proven engines, which really does fly in the face of the truth.

 

Bad publicity breeds contempt.

 

Pilot error, or however you call it, in all forms of aviation is the biggest killer of all not aircraft failure, whether it be mechanical or airframe.

 

In the present matter one must ask themself why the pilot did not deploy the BRS (the same by any other name), the answer is obvious he believed that they would get on the ground safely.

 

Yes, I know conjecture but a reasonable assumption.

 

This is exactly what a lot of the Coroner's report is made up of, that is assumptions, but not always reasonable because of an ill-conceived view in the matter of "ultra lights'.

 

The point I'm attempting to make here is that the Coroner's findings in my view would have best served the spirit of the legislation and the public at large if it had just been found that the engine failed for whatever reason and due to the then ensuing events, which such were not capable of being determined accurately by the Court without the producton of solid facts and circumstances, the pilot and passenger met their demise when there aircraft impacted the ground.

 

It was never proved to be a maintenance issue and there was no referal to the DPP.

 

There is no real point in getting too emotional over the report because as you quoted in your post the Coroner's court is not bound by the rules of evidence but may inform itself in any manner it considers appropriate which in turn means that any finding of that court may be subject to a level of scrutiny above that of the traditional Courts, if it is felt warranted in all the circumstances.

 

Like everyone else who submits posts in these forums we are all entitled to our opinion and to have our say and the above is my opinion which such is I feel informed.

 

Regards,

 

Rick-p

 

 

[turboplanner]

Thanks Rick, the RAA had the responsibility of investigating the accident, so we really need to see their report if we are to learn anything about this incident in order to improve our safety.

 

Unfortunately, when I double checked the RAA website, the only Accident Reports I found were those posted above, so there's an immediate improvement the RAA could make to improve safety advice.

 

 

[facthunter]

Timing of report.

 

While the matter is the subject of a coronial investigation, no doubt any comment would be inappropriate. That time has passed. I do not know what force at law the Coroner's determination carries and what processes are available for a review.. Rick-P do you have a view on this? I have a feeling that you are stuck with it , which to me would be very concerning situation. I feel that the process is a flawed one insomuch as it can produce skewed outcomes. Nev.

 

 

[turboplanner]

I went chasing the Investigation report, and asked Mick Poole if I could post some details of the discussion we had and he has agreed.

 

Firstly, I said the RAA had the responsibility of conducting the Accident Investigation, and was wrong on this.

 

The Police conduct the investigation with assistance from the RAA, and hence the investigation and relevant documentation is under the control of the Investigating Police Officer.

 

There is an Accident Report of approximately 53 pages, so this will reassure those who thought the Coroner’s comments were all that was involved.

 

While the RAA is keen to get details out, the Police determine what is released, and Mick is checking so see what can be made available, and hopefully may be able to provide information in due course.

 

In the meantime, given that Investigation data based on evidence does exist, we probably should not muddy the water by speculating our own opinions until we see what really happened.

 

 

[Guest Maj Millard]

Would anybody know what the deadstick, stall speed of the Sting would be, two-up, plus fuel, and with possibly a 3 blade, in-flight adjustable prop stuck in course pitch ??.............or even for that matter, the safe approach speed in that condition ?

 

 

[skybum]

Engine was over stressed by previous owner, either unknowing or worse? No MP gauge fitted so no true indication of how much power was being produced. Big difference from adjustable to constant speed. A contributing factor. The cause of death was the aircraft breaking up during the forced landing and not protecting the occupants. We will all have to wait for the full report to discover if the field was suitable for a forced landing....something we are all trained for....indeed, something the PF of fifty years experience should have an understanding about the basics.

 

I would like to know the mechanics behind the crash. Did the fuse break up after hitting a solid object or, started breaking up after an undercarriage collapse? As pointed out previously, the pilots believed they were under control of the situation by not deploying the BRS. It appears the aircraft broke up very early in the event. Considerable energy required to cause death instantly. Unexpected result for sure.

 

Should it be a recommendation that rather than attempting a landing on anything other than flat terrain it should be mandated that the BRS be deployed. Should BRS be a standard fitment on Sting aircraft? How strong in impact are our aircraft?

 

That's the reason for the mandated stall speeds. Slower crash, better survivability. Why did these guys die? It matters not why the engine stopped, it matters heaps that the aircraft didn't do it's job. It matters heaps to us and our training system if the landing was botched. We learn on the blood of other's mistakes. That's just the way it is in aviation.

 

I hope there is a very clear reason why these guys didn't walk away from the wreck.

 

 

[turboplanner]

Skybum, please read my post #56, You've covered a wide area of issues and assumptions not necessarily involved in this fatality. The situation at the moment is that RAA are requesting approval to release details of the Police report. I think we all agree that we'd like to see it and learn from it, but until we get it we shouldn't cause confusion over things which may not have happened, or which haven't been published, eg who legally owned the engine when the damage occurred.

 

 

[Guest Maj Millard]

Yes it will be interesting to see the actual police report. Obviosly it would take a fair bit of speed/impact to break a carbon structure, which could be initiated by a gear failure, or an inherent structual weakness. We await the report and the possible lessons therein. Actually Kevlar is a better material for impact resistance, hence why they use it in ice impact panels on the sides of some aircraft structures, near the props.....................

 

 

[Yenn]

"(d) and refer the matter to the Director of Public Prosecutions if the inquest reveals that a known person has committed a serious criminal offence in connection with the death."

 

I find this a bit odd. It implies that the coroner can decide if someone has committed an offence, but I think in reality it is up o the courts to make that decision.

 

In the Townsville case I alluded to the coroner said the policeman caused the death, but the court decided that he was innocent.

 

 

[youngmic]

912 Achilles heel??

 

 

Following the sad loss last year of 2 members in WA following a gearbox/crankshaft failure behind a 912 which resulted in a seemingly inexplicably hard impact, I began to wonder.

 

 

Now looking at the Sting accident I am again wondering, maybe someone who has a good working knowledge of the 912 or any gearbox equipped Rotax engines might care to comment.

 

 

Question.

 

 

In the event of a crankshaft failure, particularly close to the gearbox or a gearbox failure itself, what would stop the prop from a high RPM wind milling state?

 

 

Perhaps the ability to semi feather or full coarse pitch if the installed system is still operating or capable of manual full coarse may mitigate it??

 

 

Those who fly fixed shaft turbo props, Garrett’s etc. or even free shafts in Beta will know all to well the huge drag penalty of a discing prop with no power, for those that don't the free shaft PT6 in turbo Porters gives a dramatic but somewhat exaggerated example during the let down following parachute drops.

 

 

Could it be possible that in the case of the Sportstar in WA and the Sting accident referred to here, that both aircraft had a runaway prop condition requiring an exaggerated nose down attitude to maintain flying speed??

 

 

Could this in turn have created handling difficulties that resulted in hard impact arrivals.

 

 

I know that there have been many cases around the world, including Australia where a runaway prop on a turbine has resulted in destroyed aircraft and fatalities.

 

 

Anyone care to comment?

 

 

M

 

 

[68volksy]

A simple question...

 

There are many statements floating around and people standing on soapboxes preaching the glorious stregth of carbon fibre and other newer synthetic materials.

 

I have always assumed that Carbon Fibre can be created to many different thicknesses and strengths similar to steel, alloy and aluminium.

 

Therefore the statement that "Carbon Fibre is stronger than steel" is utterly incorrect without the qualifier "of the same weight". Is this assumption of mine correct? Is anyone going to tell me that one strand of carbon fibre is stronger than a 16 metre wide strand of steel?

 

My point is that Carbon Fibre is only stronger if it is made to be stronger. I am aware that making it is a very expensive and complicated process. Otherwise due to its light weight every aircraft in existence would have a full carbon fibre roll cage, similar to Formula 1 racing cars. I've seen those things stop dead from 200km/hr with the drivers walking away.

 

 

[Guest basscheffers]

Don't forget that stronger does not equal better!

 

You need a combination of strenght and designed weaknesses, also know as crumpling zones. The reaseon those F1 drivers walk away is because while their tub is strong as anything, there is weaker material in front that slows the deceleration.

 

The same applies to aeroplanes; if you make a plastic fantastic that is just is strong the whole way around, YOU will be the crumpling zone. Some say that makes metal aircraft safer because it does buckle, but again it needs to buckle in the right places; if it buckles the yoke right through you stomach, it is no good either.

 

Safety is in design, regardless of materials.

 

 

[68volksy]

Are there any aircraft deisgned in such a way? I think the new sportstar comes with a rollover hoop? If you've ever been beside a formula 1 car you will note that you do not need much room to install the crumple zones you talk of.

 

Are there many aircraft out there that have been designed with a decent crash structure? I know the new Boomerang has a 12g tested roll cage.

 

 

[facthunter]

Windmilling prop.

 

youngmic...The fine pitch stops would limit the overspeed tendencies of the propeller. The usual design feature is to make sure that the prop will not overspeed in full fine( inflight) at a fair margin above stall speed, either with the throttle closed, or with a drivetrain disconnect Altitude complicates this because the speed that affects shaft speed is TAS, however this is not a factor in this case, and I only mention it in passing.

 

Having removeable pitch stops to enable in-flight reverse thrust, would over-ride the "in flight safety speed" concept, and I hope we NEVER see that feature used in the aircraft we operate. Nev..

 

 

[Guest basscheffers]

I am not too familiar with them, but I understand with a CSU, if the engine fails and oil pressure drops, it goes to coarse, simply due to lack of presure.

 

Any such feature on an electric prop such as this? I would imagine not. So in case of a massive failure, if you don't have electrics to the prop, does it stay where it is?

 

And what would create greater windmilling drag, a coarse or fine prop?

 

 

[facthunter]

Corse or fine.

 

Fine will create more drag with the tendency to overspeed and destroy the engine being a distinct possibility. IF the prop goes supersonic the noise is considerable and the drag is enormous. The cure is to slow the plane down quickly. As to where the prop will go as a result of failure of the pitch control mechanism, usually the centifugal forces applying to the leading and trailing parts of the propellor blades, will try to force it into fine pitch, hence the safety feature of having "fine pitch limit stops" set at a point where continued flight is possible (at a lower speed), if the pitch control mechanism fails. Nev..

 

 

[poteroo]

Following a gearbox or crankshaft failure, isn't it likely there would be no propellor rotation due to power? A 'stopped' prop causes far less drag than a spinning prop in fine pitch - and so the glide should be flatter.

 

A windmilling prop in fine pitch does give you lots of 'barndoor' effect, and this necessitates a steeper angle of descent, followed by a very low and positive roundout to land. You just cannot allow the IAS to decay as you get onto a very short 'final'

 

I'd like to learn more about how this particular forced landing was executed, and what lessons we can learn from it to better teach our students.

 

poteroo

 

 

[facthunter]

true.

 

I think this engine was "jammed", and the prop therefore not rotating. It is generally agreed that a stopped prop causes less drag than one rotating with the engine not delivering power. Freewheeling (discorrected) at a moderate rate of revolutions, would not produce much drag, either, in my view. Nev.

 

 

[Riley]

2008 WA Sportstar Fatal Crash

 

YoungMic

 

You asked for comments on your linking the Sting/Sportstar crashes to a failed gearbox/broken crankshaft on the R912 engines. As far as I'm aware, the investigation report on the WA loss of lives/machinery in Dec 08 hasn't yet been made public. Therefore I gotta ask .. is your 'freewheeling propellor hypothetical' just that or is there a factual report available which identifies a broken gearbox/crank as the cause of the WA accident? It is only fair that statements made in the public domain which allude to a specific failure must either be substantiated or withdrawn. Over to you.

 

 

[Guest Maj Millard]

With my 912 experience I would suggest the the prop would probabily not be turning in the Sting in Question, with a broken crankshaft I mean. Don't know what pitch it was in of course, but if they were at 4 grand in cruise, one would expect it to be coursed out a bit.

 

Having designed one successfull aircraft, I can tell you that it is not always easy to design in good crashworthyness, especially when you're flat out trying to keep it light, so that it will fly in the first place. But it should be something that you must try to incorporate.

 

Some aircraft types come with good inherent crashworthiness. IE. all metal aircraft and welded chromolly fuselages generally do well (Cessna,Lightwing etc). The Jabaru with it's (i'm guessing) standard fiberglass structure, seems to do ok as demonstrated by a few off-runway excursions, where people generally walk away only minor injuries. Many of the older aluminum tube aircraft were fine, unless you got speared by a bit of broken aluminum tube.

 

Crumple zones do work, and are very important in a crash. As stated previously by a forum member 'with a completely stiff structure, you do indeed become the crumple zone at impact.'

 

 

[Gibbo]

As to the reason for the initial engine failure, this months RaAus mag could have the answer.

 

Prop certification and 4 cly engines producing torque vibrations from the firing of the piston.

 

Gibbo

 

PS. Another benefit of Mr Diesels invention of the compression ignition system.

 

 

[Riley]

WA Sportstar double fatality 2007.

 

Gentlemen

 

In a post a couple of days back Youngmic unequivocally stated that the two deaths in the WA Sportstar crash in Dec 2007 were a direct result of a R912 gearbox/crankshaft breakage. As both of the deceased were my personal friends and fellow club members, I have been monitoring this tragedy with a great amount of concern. Since posting my original query to Youngmic's statement, over the past two days I have checked with both the RAA representative for WA and immediate next-of-kin of the deceased regarding the status of an accident report. As of close of business today neither the RAA nor the respective families have either released or had access to any report which, as yet, identifies gearbox/crankshaft failure (or any other area) as the root cause of the crash.

 

In these forums we go to great lengths to hold the media's feet to the fire for erroneous reporting. It appears, in this instance, we are doing it to ourselves. As such, in fairness to the families, RA Aus, (and, I guess, Rotax) it seems Youngmic needs to front up and either fish or cut bait. If left unsubstantiated (or not retracted) this allegation has the potential to reduce Rec Flying forums to the level of Pprune. I'm not stirring just for the sake of stirring but I ask again of the poster "Do you have access to an offical report which identifies the circumstances leading up to the the crash in the Julimar Forrest or is your evaluation just a hunch?" Either way you need to respond. Standing by.

 

 

[turboplanner]

Youngmic:

 

"Following the sad loss last year of 2 members in WA following a gearbox/crankshaft failure behind a 912 which resulted in a seemingly inexplicably hard impact, I began to wonder."

 

 

 

Riley:

 

"In a post a couple of days back Youngmic unequivocally stated

 

that the two deaths in the WA Sportstar crash in Dec 2007 were a direct result of a R912 gearbox/crankshaft breakage."

 

Maybe you are being a bit hard on him Riley, but this does show how a fertile imagination and lack of sensitivity can cause hurt to others.

 

We would be a lot better off if some posters did some research, or contacted manufacturers to get the facts before bugling their own theories.

 

Riley, perhaps you can put pressure on to get the Police to release the accident report. It seems that we in RAA are at a disadvantage over the more open CASA system which has two effects:

 

1. It minimises unfounded speculation

 

2. It gives us a set of facts we can all learn from