Coroners Recommendations

[youngmic]

Gentlemen, and Ladies,

 

I do apologise, I am not aware of any official findings on these accidents outside of the Coroners report on the Sting.

 

My understanding of the accidents may well be wrong, regarding the Sting accident my comments were based on the Coroners report of a broken crankshaft so I would assume that was the case.

 

Regarding the Sportstar my comments were based on local hear say, and thus may well be short of the mark, I again apologise to anyone offended and for bringing the forum into disrepute. I should have researched a little more and not assumed that with the passage of time what has become local knowledge has not in fact been established formally.

 

Riley, I have made an error in commenting on the Sportstar accident I therefore will not meet your request for further comment on the matter nor will I reveal what I know on the matter.

 

All that said the potential "Achilles Heel" I referred to is still, I believe a valid point, and the failure mode to which I commented is not unheard of on other types. It may of course have absolutely nothing to do with either of these accidents and I posed the question on the basis of collective and personal learning on the matter.

 

Consider the principles of auto rotation.

 

A prop on a 912 liberated from the crankshaft regardless of pitch (unless feathered) has what to stop it from uncontrolled wind milling, this to me is significant question. Hence posing the question.

 

 

[Guest brentc]

For those that haven't been around here for very long, we all lost a valued forum member in the SportStar crash in WA, so in respect of everyone here we should maybe wait until something official comes through for that one.

 

 

[Guest TOSGcentral]

I have some disquiet about aspects of this coronial business – but perhaps more disquiet about attitudes which pre-suppose that ‘official’ inquiries and/or investigations are some kind of word of God! That may not be the case at all!

 

In the Accident & Incident forums the concepts of ‘speculation’ and ‘taste for the feelings of family and friends of victims’ have been well canvassed and I believe are well understood – so I have no intent to stir up that aspect. On the other hand informed opinion may be contributory to preventing the same thing from happening again.

 

Also I have no intent to attempt to comment on any aspects of the Sting double fatal, any specific information from the Coroner’s report, or make any opinion on the conduct of the Coroner. But I do wish to draw some parallels in both specific and general senses associated with ‘Official Inquiries’.

 

EXAMPLE #1. A few years ago a front lift strut attachment bracket on a Thruster let go, the wing came off and both occupants were fatally injured on impact. This to my knowledge was the first time anyone had ever been killed in a Thruster during the types quarter century of service, other than one factory test pilot in the early days. Here are quite a few facts about that circumstance (I am using insider information but that is exactly what official inquiries are supposed to uncover)

 

• The inquiry took some time and in that time everyone felt that they were muzzled as the matter was sub judice so no public comments could be made – either informed or speculative in nature.
   
   
  
• RAAus responded promptly and sanely. The then current Tech Manager raised a mandatory inspection notice ‘Before Next Flight’ of the lift strut attachment brackets and a procedure how to do the inspection. That was perfectly satisfactory in all aspects and was a requirement within a couple of days.
   
   
  
• Over 4000 of these brackets have been flying, up to a period of 25 years and hundreds of thousands of hours – with no prior failures bar one which was only minor fatigue cracking just beginning to appear. Subsequent to this crash one bracket on a UK T600 (which has a similar bracket arrangement). The UK investigation (which was also most prompt) established that the aircraft had been tied down over the winter and the fatigue cracking just starting to appear was a product of repeated cyclic stresses from exposure to wind vis a vis the mode of tying down.
   
   
  
• Back in Australia the situation progressed quite rapidly, including an informal parallel inquiry by TOSG on a self preservation motivation - and a few things emerged.
   
   
  
• The failed bracket was examined and was (I believe) done so jointly by RAAus and a CASA metal analysis lab. What had happened was not in doubt – why it had happened was something else.
   
   
  
• Concurrently TOSG received several independent reports from private individuals who had local knowledge of the aircraft’s former operation. What they had to say fitted exactly with the fatigue damage that I had been made privy to ‘off the record’. But it appears that this information was never disclosed to the official inquiry – or if it was then it was ignored.
   
   
  
• When the Coroner’s findings were brought down the requirement was a total shocker and had no bearing on much reality at all! Sit quietly Sportsfans and just read the following.
   
   
  
• Basically the Coroner, in effect, overruled the previous RAAus Airworthiness Directive, forced them to make a new one to meet the findings and grounded EVERY Thruster in the country pending compliance with the findings!
   
   
  
• With ‘every’ Thruster in the country you are talking several hundred machines. More significantly you are talking nearly 60 different types and models. Now grasp the stupidity that manifested itself in several different ways.
   
   
  
• The Coroner appears to have latched onto one point. The failed bracket had the design changed slightly from spot welded to seam welded. There was also an overt tight bend radius between the half cup of the bracket and the lug. The thinking seems to have been that the sealed lug was a water trap that would cause corrosion and fatigue would manifest itself along the overtight bend radius of the lug. No consideration seems to have been given to the fatigue failure allegedly penetrating from the outside inwards, not from internal corrosion penetrating outwards!
   
   
  
• Neither was any consideration given to the Thruster range. That the early ones were all seam welded as are the much later T600s and all without failures! Damn, I own the Thruster prototype that is now 27 years old – its seam welded wing brackets are as good as they were originally made. These brackets are wildly over-engineered and you would fail the entire wing before you broke one!
   
   
  
• Virtually all the records of the Thruster types are now either not in existence or are not in the public domain. TOSG has spent 13 years painstakingly piecing back together their design and airframe type recording so that information is available publicly. I have just sent measurements to the UK Thruster factory so that some new parts may be made for an old type as they did not have the drawings any longer! Yet not once was TOSG asked for any opinion, any data or any testimony. 30 mins in the witness box and I could have forced an entirely different outcome to what became a sorry business!
   
   
  
• The Coroner decided that the manufacturing design had been changed from the original 95.25 certification (that must have been done by opinion because there is not hard data left in either CASA or RAAus). TOSG has the data but we were not asked and did not even know the inquiry was in progress until after it was finished.
   
   
  
• The Coroner was correct – the design had been changed slightly so the brackets were no longer compliant 95.25 but there was no testimony given, to my knowledge, on how strong they actually where. Equally the early Thrusters were all 95.10 or the later T600s are built to a much higher overseas requirement – yet all of them got bagged en-mass.
   
   
  
• It took me only about a week of research to establish that the bracket batching and design had changed in about mid 1993 and as I knew how many Thrusters had been produced since we were probably looking at only about 50 plus any that had been retrofitted with the new brackets for maintenance, rebuild or repair. Rod Hewitt Cook’s initial AD still stood firm – just inspect your aircraft but now change it if it was 95.25 and had the ‘defective’ bracket to meet the Coroner’s ruling.
   
   
  
• Bit of a problem there though! The Thruster factory were not about to start producing brackets and supplied none! It was not a case of nipping down to the Ford dealer for a new car part – the Thruster brackets were ‘batch made’ and individual brackets were drilled in at initial assembly by the factory. Batches were different re drill holes. Replacements had to be hand made straight off the original ‘defective’ brackets or you would start putting oval holes in main wing spars! It was a very involved process to sort out so that an average ultralight owner could do the task at home with confidence.
   
   
  
• TOSG solved it by commissioning a CAR35 Engineering Order so owners can get both replacement brackets for ‘defective’ brackets or can pick up exchange brackets vis a vis accident damage etc. TOSG will never recoup the outlay to do this project there is simply not enough mark up so that prices stay low enough to encourage people not to do ‘back yard jobs’ on important primary structure!
   
   
  

 

 

So much for ‘Official Inquiries’ and how technically good they actually may be while muzzling or ignoring the people who actually use the aircraft and work on them – or are simply around them and see what happens to them!

 

The actual futility of the Coroner's findings and rulings resides in the following. The Coroner specifed the four main lift strut pick up brackets for attention. There are four of these. BUT there are also four other almost identical brackets on the wing that take the primary structure flying wires to brace the wing spars inboard. There was no mention of these yet they would be equally subject to corrosion/fatigue as the brackets that were targeted.

 

Perhaps the Coroner did not know enough (yet can make far reaching findings), or relied on 'expert advice' from others who also did not know enough?

 

 

Now try a different scenario:

 

EXAMPLE #2. About a year ago a tailplane began coming off a Thruster TST in a big way whilst in flight. By any reasonable assumption both the occupants should have died. Some skilled flying, experience on type and Lady Fate being distracted for a couple of minutes saved them. The aircraft was extensively damaged in the crash landing but injuries were minor – such as they were.

 

So there was no ‘Offical Inquiry’ – No CASA, no police taking over the investigation and no Coroner with consequent ‘findings’ to be enforced!

 

What happened was very quick and very simple.

 

TOSG made immediate contact with the RAAus Tech Office. Within 24 hours TOSG had detail inspected five different Thrusters with the same type of tailplane and found nothing.

 

RAAus put out an alert straight away to owners which at this stage had to be general in nature.

 

RAAus and TOSG between them formulated an inspection procedure, TOSG initiated manufacture of tail unit bushes (no longer available) ‘just in case’ and designed a tail unit bracing wire cable tensioning and checking system that had been never done by the original 95.25 requirements or the factory in the aircraft maintenance and operating manuals.

 

Further aircraft were inspected over the next week both in Oz and UK – no problems. All indications were that this was a on-off incident and not a general problem – but which alerting and future inspection procedures would contain entirely.

 

Within two weeks of the crash RAAus Tech had issued a comprehensive account and detailed inspection procedure that was illustrated – put it on the web site and sent a copy to each registered Thruster owner.

 

We have had no reported failures, or even impending failures, since and the whole matter was put to bed quietly and professionally with no drama, very quickly

 

Bit of a difference is there not between an ‘Official Enquiry’ and when people can have control over their own lives? Perhaps we should look at how we conduct enquiries, how fast this is done and by whom it is done?

 

Aye

 

Tony.

 

 

[turboplanner]

Good points Tony, there seems to be a vacuum prior to Coronial Inquiries where information on when a case will be coming up is not available. I've been waiting for three years for a truck fatality case to be heard in Victoria and phone about every six months only to be told the case is still being prepared. My evidence pin points the exact cause of death, and points to the need for a specification change, but the weakness is there doesn't seem to be a case index, there's no follow up from the Coroner's Office (Victoria). At the same time as this is going on, over eager theorists with no direct knowledge of the case often manage to get into the Inquiry, which can quickly get off the track as these people throw in Red Herrings.

 

One way of correcting this to a degree is to stay in contact with the direct relatives of the deceased, but it would be a lot better if the system was brought up to date with a databased pending Case List so direct formal contact can be made with the Coroners Office at the key time.

 

I'm still kicking myself over a case a few years ago where a truck driver was killed when he tanker rolled over on a corner, ad a newspaper reported he was speeding.

 

The location was right where I worked, so I walked over and had a look the following day, finding tyre marks on the road consistent with a mechanical turntable lockup, which took control away from the driver and resulted in the roll over.

 

Iphoned the police officer investigating the case gave him my information, and told him that Cummins had agreed to provide a Computer Simulation, which would provide virtually the exact speed, since there was quite a long uphill climb to the corner, and all the other factors were known. His response was "We have our computers too", but the finding was excessive speed, based on a motorists calibrated eyeball.

 

 

[Riley]

Youngmic

 

Due to a change of ISP, I've been offline for a week and have only just now gained access to your post of 13th Feb. Like yourself and everyone else on these forums, I'll be happy as Larry if the ultimate report on the WA crash can specifically identify the reasons (broken crank/gearbox or whatever) for the loss of the machine and two good men. In the interim, your response to my concerns is accepted with thanks.

 

cheers riley

 

 

[Guest peterf]

GPS Track

 

Hi Guys,

 

I only just found out about this report. I may have missed this in the comments but a couple of things immediately come to mind. I was wanting to know what the plane was doing before the engine failed and what it did afterwards.

 

So how did the police delete the GPS track? That would have been very useful information to see what happened in the last part of the flight before the crash.

 

My Garmin keeps track information even with no batteries. I don't know which Garmin was used in the Sting. Are there some Garmins that will delete the track information when "inadvertently" powered down?

 

At 4000' you would think the Sting would have shown up as a paint on Sydney Radar (does Canberra have its own radar?). I wonder why they weren't interested in getting the path of the Sting?

 

Also, someone mentioned that oil ended up in the static line which caused the altimeter to freeze at around 4000'. The String I've flown in has the pitot/static out under the right wing. It's a long way from the engine to the static and at 100Kts or so, it must have been a pretty impressive explosion to get oil that far out. Did the Sting have a different static pickup at a different location?

 

Anyway, I was just curious.

 

-Peter

 

 

[Guest peterf]

Static

 

So reading between the lines they had compromised static pressure due to the oil, didn't realise and stalled on short final. One extra (and unexpected) complication on top of the engine failure, finding a landable field, strong wind and turbulence. I guess it's something to keep in mind. Shame we don't have their track to confirm.

 

-Peter

 

 

[Guest TOSGcentral]

Excuse me! Hello out there! For many years I have been brought up to believe that an ASI system on a simple aircraft (like an ultralight) was simple!

 

 

You have the ASI instrument itself that has two outlets – pitot and static. The pitot is connected to the pitot head by a simple plastic tube. The static may or may not be connected to a static head by a similar tube but is frequently left open on ‘cockpit static’.

 

 

Now kindly tell me how this very basic air driven system has anything to do with the engine or oil or much of anything else? Particularly to the extent of people dying because their systems are not understood or are too complicted for their maintenance ability and they think they may be stalling?

 

 

[Guest basscheffers]

Engine explodes, oil goes everywhere, including static vent or line?

 

Could happen, but pretty far fetched. But then again, the causes of air accidents often look far-fetched because of the great care usually taken in design, build operation and maintenance...

 

 

[Guest peterf]

Hi Guys,

 

The comment was made before that:

 

The altimeter comment is due to oil being found in the altimiter tube. They figured that the oil blocked the tube and kept the pressure constant.

 

The Sting I do know does have the ASI static coming from the static vent. I don't know about the one that crashed; I'm assuming it would be similar. The report doesn't give much in the way of useful facts; have to do a lot of assuming.

 

Try putting some water in your static line and go for a fly - lots of fun. I had it happen once; I noticed my descent speed was at least 10Kts faster than expected (advantage of flying lots of hours in the same plane). Decided to ignore instruments and did a straight-in flap-less glide approach. I didn't want to start banking as I wasn't sure of my speed. The plane was trimmed for around 60Kts, so flew in conservatively and landed. After stopping the ASI was reading 20+Kts. I'm guessing that if I had other more important things on my mind, I probably wouldn't have given the ASI value a second thought.

 

There was an airliner that crashed because they left tape over the static vents after washing the plane.

 

-Peter

 

 

[Guest Maj Millard]

Yes I can see oil flowing back along the fusulage and blocking the static vent, but have trouble believing the engine exploded throwing oil out to the pitot tube.

 

In an aircraft that slick, deadstick in turbulance or wind, with crew under some stress, I can see very clearly how incorrect airspeed info, could be a factor in the final scenero............

 

 

[motzartmerv]

A blocked static vent would have also played havoc with the ALT and VSI would it not?

 

I find it difficult to believe also that the pitot could have been fouled by oil, but, stranger things have happened.

 

With all that was going on, a failure of the ASI would easily have been the final straw, very sad, wateva happened it would seem these guys had it right, right up until the final stages..

 

 

[Guest peterf]

This seems a bit extreme, but interesting.

 

From Fulfilling a Dream: My Sonerai IIL

 

April 17, 1988

 

...

 

But look at the altimeter! It's switching back and forth like an angry cat's tail ... and the airspeed says I'm doing 90 knots ... pull up ... No! Now it says I'm going 0 knots. The first inkling of distrust in these instruments begins to creep in. I really don't believe I'm going 0 knots

 

As I continue to roller-coaster around the pattern, I figure out the problem.

 

Water

 

in the static line (which runs fore and aft in the bottom of the fuselage) sloshes back and forth, making the altimeter and airspeed indicator respond to attitude and acceleration as well as altitude and airspeed.

 

 

...

 

-Peter

 

 

[Guest peterf]

Or this Cirrus SR20 (and a bit about the SR22):

 

On August 9, 2004, Jeff Ippoliti had his SR22 washed and some avionics maintenance performed. On August 10, 2004, Ippoliti departed into low IMC and began getting erratic readings from his pitot-static instruments. He pulled the parachute and walked away from the wreckage, which was examined by the FAA:

 

"Examination of the static system of the airplane revealed approximately 1 teaspoon of water was found between the static port openings and the alternate static air valve; the water was retained for analysis. ... Prior to the wash the pitot tube and two static ports were reportedly covered with yellow vinyl tape (Patco's #150-P 2). Testing of the water sample retained from the static system of the airplane, revealed it contained 3.2 mg/L of fluoride, which is common in tap water."

 

The NTSB report implies that had Ippoliti activated the alternate static source, he would have recovered normal airspeed and altimeter readings. Who among us can say that we would manage the emergency more successfully, however? So let's credit the parachute with at least this one life.

 

 

[palmettoe]

yahoo xair group

 

By members, pilots, smelling a rat and calling it in...

Nice to be a new member here, thanks for the invite. Very interesting (discussion?) on the above site, some of you may want to take a look, thanks again, John

 

 

[motzartmerv]

Not exactly sure what ya saying mate???...do you have a link to the site??

 

 

[Guest TOSGcentral]

Some of the comments coming out of this thread are a tad depressing, not for what is being said but via a reflection of the world base that the viewpoints are coming from.

 

 

What happened to the days where we were taught, and then in turn taught and checked ourselves, not being instrument dependent?

 

 

That known normal attitude and RPM WILL give a certain airspeed and you do not need an ASI all the time to demonstrate that. You certainly do not have to ‘switchback around a circuit’ chasing a defective instrument!

 

 

If you have lost the donk and thus RPM then our emergency landing training and checking should demonstrate that the pilot is able to maintain control of the machine and recognise an impending stall by instinctive glide attitude and control feel plus other cues.

 

 

That works very well (or did) on basic aircraft. So we may say now that viewpoints being expressed are reflecting aircraft that our basic training and airworthiness practices have not been evolved to deal with but we now have the aircraft!

 

 

There is a famous saying “Those who refuse to learn the lessons of the past condemn themselves to repeat those lessonsâ€. None of this is rocket science, we have a century of flight experience to draw from! So how many people do we allow to die before we start reinventing the operational training and airworthiness wheels?

 

 

Or is that in fact what more than one Coroner is now tapping us on the shoulder and making us do? Bearing in mind that they are not aviation people usually and are dependent upon expert advice given to them – some of which may not be friendly towards ourselves.

 

 

[Guest Maj Millard]

Yes a blocked static vent or pitot should affect Alt,Vsi, and airspeed if they are all hooked up correctly. Basically you are looking out the window, and flying by the seat of you're pants at that point...........................

 

 

[Guest ozzie]

anyone ever heard of 'sensory overload'?

 

no amount of emergency training will help if you don't understand how the brain operates under times of extreme stress.

 

Ozzie

 

 

[Guest TOSGcentral]

Aye Ozzie, but of what do you actually speak?

 

 

My concept of emergency training was to force the individual through the emotive and mental distraction overload into automatically doing something that would keep them alive and their machine perhaps not too badly damaged – if at all!

 

 

But the emergency training remains specific to groups of aircraft types etc. Open the gate too wide and what form of training do you give?

 

 

I suppose, from what I see, the new Human Factors training of a couple of hours and a small written paper will resolve all that and we do not require the specific training – or can substantially discount it?

 

 

I would probably attribute more credence if ever something practical had been done in mandatory instructor training in the human factors area – like the Scanning, Processing, Controlling which controls all workload and particularly the effectiveness of the individual instructor in exercise delivery and thus the retention by the student.

 

 

Hey, do not mind me – I am just traditional and this crap was hammered out by the universities decades ago. Not really relevant – requires thinking about these days and that is not something that is really required at the basic levels any longer – too much else to do!

 

 

[Guest ozzie]

It may not be in a emergency situation. it is simply the ability of the brain to be able to keep up with the amount of processing it has to do in a fast paced situation. a individual may be loaded right up just driving in peak hour. now the phone rings. to handle the added task something has to give so they slow down and "stop" driving.

 

sensory overload can be just a short term switch off when it cannot cope with the speed of incoming information.

 

 

[Guest ozzie]

Now think about the other side of the event . sensory overload also effects recall.

 

 

[Guest Maj Millard]

.....Prioroties must be set, you must fly the aeroplane first, and make it home for tea that night as best you can............................

 

 

[Guest ozzie]

you mean the order of aviate, navigate, communicate.

 

 

 

[Guest Maj Millard]

What have you got there Oz, some old B2 gut-rudder gear, with killer 2 shot capwells ?..and french Paraboots even....Holy Shix......................