Taupo Seneca crash report on TV news tonight...

[MOR]

NZ TV news is reporting that the Christian Aviation Seneca that crashed last February was a CFIT (which the TAIC report confirms).

A lot of people were saying at the time that "once the report came out, many of us would have to eat our words". It now appears that the reverse is true.

Sadly, the report also notes the presence of cannabis in the bloodstream of the pilot. Dave Brown was strongly denying on TV that his son ever took drugs, and that the presence of cannabis was as a result of "passive smoking". However, the report discounts that possibility.

So here's my thing. I would be the last person in the world to ever agree that any pilot should take an illegal drug, however I can't help thinking that this will now be seized upon and used to impose drug testing on the NZ pilot community, even though the report clearly states that the use (or not) of cannabis was not a factor in the accident. That was obviously the intent of the CAA spokesman interviewed for the piece.

Is anyone, apart from me, concerned about this? I am not concerned from the point of view of any personal involvement with drugs. My problem is that pilots are now being perceived as unprofessional and in need of supervision in this regard. when was the last time your doctor underwent a drug test at work?

Discuss...

[QF Quoll]

I wonder if they ever thought of checking the blood samples of the ANZ DC 10 Erebus crew regarding a CFIT.:hmm:

[pakeha-boy]

MOR.....I believe everybody in our choosen field should be concerned.This is another example of pilots who do not deserve the priviledge of flying aircraft.

You may remember a while back,there was discussion of another accident involving a pilot who tested positive for drugs.This seems an all too familiar subject,and it is just pathetic.

I say again,...We as pilots are held to a higher standard than most,the reasons being obvious.The public hearing of this situaton and the supposed drug use, will only make your and my ability to make a living in aviation that much harder,and will most certainly degrade our image as professionals!!!!!

I have previous dealings in these issues,and have been on the recieving end of pilots who have used drugs,and it has cost me a buisness and several lawsuits.Believe me,it has not been a holiday.

Thanks for the post MOR.......arohanui

[pakeha-boy]

QF.Quoll....not to be disrespectfull,but concerning the Erebus crash.....you need to read the book "Impact Erebus"...I believe it would shed light on your comments.....If you cant get it,PM me,I would be more than happy to send it to you to read......only if you send it back.......I have friends in the mongrel mob if you dont.....

[prospector]

pakeha-boy,

I would think the type (fixed card) and the position of the instrument (lower left panel) of the ADF, and the fact that it did not comply with the requirement that all nav instruments be duplicated if being used as prime navigation aid (NDB Approach) would be more likely to have been the prime cause of this accident rather than the finding of cannabis in the blood stream.(Is it possible to have had the reading found from third party smoke?) This is of course unacceptable, but he had carried out the flight prior to the accident without any apparent problems, including two missed approaches at Keri Keri. That a fixed card ADF, which whilst it may be acceptable for under the hood basic training, in VMC, should be approved for actual IFR, and approaches for real, in this day and age I find quite remarkable.

Prospector

[belowMDA]

prospector, at some point we have to draw the line as to what is safe and what is not. The regulatory autorities around the world still alow fixed card ADF to be used for IFR flight, certainly for part 135 operations. Had there over the last 30-40 years been an appreciable number of accidents directly attributed to Fixed card ADF use then I think this would no longer be the case. It is all fine and well condemning the use of this technology (maybe you use it, maybe not) however, it is tried an tested and still acceptable for commercial operations.
As an aside, I personally found fixed cards easier to use than RMI's but there you go.

I don't want to get into the drug thing too much, but HAD he been using cannabis then the vast majority of my sympathy for him goes out the window. How many pilots out there are STUPID enough to take drugs and risk their lives and careers, not to mention the innocent lives of others. I sincerely hope they are few and far between.

regards
below.....

[pakeha-boy]

Prospector....

With all due respect,I do not believe the prime reason for this accident was cannabis,did it contribute??? to believe it did not,I find hard to believe.

In the early 80,s,I co-owned an operation in Alaska.We had a C-206,3 C207,s and 2 Twin otters.Several of these A/C had fixed card ADFs,this was the era and their use was the thing of he day.

One of my pilots,crashed the C-206,killing himself and several others.The autopsy showed THC and others drugs classified as "illegal".At the hearing,evidence presented confirmed he was a casual user.Before all of this,he did a fine job,always at work,considered a good stick.

The lawsuit that followed cost me my buisness,my certificate,and the flying jobs of 6 pilots.Am I biasd???,bloody oath I am.I dont make the rules,I just follow them.

MOR,s original post asked if we are concerned,for one, I am,I stand by my post.Was drug use the root cause?, probably not,but I have seen and been through enough to know that it did not help!!!!

you have a nice day mate.........PB

[MOR]

Prospector

Nobody is saying that cannabis use played an active part in the accident - not the report, and certainly not me. I also believe the fixed-card ADF is a red herring - you are either competent in it's use or not, if you aren't, you shouldn't use it. Part of the problem no doubt stems from the pilots lack of recent use of this ADF, but that doesn't excuse anything - the first rule of IFR (especially an approach) is that you should at all times know where you are, cross-checking with whatever you have available. If at any time you become uncertain of your position, you MUST execute a missed approach and climb to MSA.This is basic stuff.

Pilots (especially Part 135 pilots) naturally want to complete the approach, and many will live with the vague uneasiness they feel about an approach when they are not 100% sure about their position or tracking. 99% of the time they get away with it... but occasionally they run out of luck. It is a stupid way to operate. However, it is a way of operating that is common in the charter world.

In this case, the pilot didn't know where he was with any certainty, and even if the ADF was inoperative, the picture would have been wrong. He pressed on at low level whilst IMC, and paid the price.

Sadly, there is NO EXCUSE for CFIT.

However my main concern remains the drugs issue. I agree with pakeha boy, pilots who use drugs don't deserve to have licences. When you receive your first CPL, it is an expression of trust in your ability and judgement by the government and by extension, the travelling public. They have a right to expect you to abstain from drugs of any kind that could affect your performance as a pilot.

Now having said that, it is clear in this case that the cannabis is unlikely to have had any role in the accident (which is also true of Hamilton Island). Regarding "passive" or second-hand cannabis smoke, the report discounts that possibility due to the amount of cannabis in the bloodstream (too much for passive smoking).

I'm concerned about where we go from here. The standing of the profession of airline pilot has been significantly eroded in recent years, and it looks like it may get a whole lot worse now.

[prospector]

MOR,

I agree with what you have written, I have had no first hand dealing with cannabis, but it would appear that passive accumulation was not likely.

However, a little off the prime question you raised but still relevant I believe, is the following taken from the accident report.
-------------------------------------------------------------------------------------------------
Aircraft instrumentation requirements
1.8.6 Civil Aviation Rule 135.3538 stated in part that operators were to ensure that an aircraft was
equipped .with the number of instruments and equipment to ensure that the failure of any
independent system required for either communication or navigation purposes, or both, will not
result in the inability to communicate or navigate safely as required for the route being flown..
1.8.7 The Civil Aviation Authority (CAA) advised that for an IFR flight the Rule required aircraft to
have a second independent navigation system available should the primary system fail.
Therefore, for an NDB approach the aircraft should have 2 independent ADF installations.
However, CAA conceded that there was still ongoing discussions with industry representatives
and operators about the intention of the Rule, many of whom did not meet the requirements of
the Rule.
1.8.8 Areas of discussion included alternative navigation equipment, for example GPS, to enable an
aircraft to be climbed to a safe altitude should equipment fail during an instrument approach and
either, conduct another approach using that equipment or being able to divert to an alternative
destination. The ACNZ.s planned phasing out of NDBs around New Zealand and the cost of
installing new equipment that could soon become obsolete also needs to be considered.
-----------------------------------------------------------------------------------------------------
Rule 135.3538. It was not being complied with. And it would appear with the knowledge and approval of CAA, ongoing discussions about a rule that was already in force?? ACNZ planned phasing out of NDB's, installing equipment that could soon be obsolete? The aircraft was imported in 1986, Christian Aviation had ownership from 1988, would CAA concede there have been ongoing discussions with industry representatives for some 20 years? and all this time NDB approaches were being carried out not in compliance with the rules? and no action from the regulator?
-------------------------------------------------------------------------------------------------------
"Pilots (especially Part 135 pilots) naturally want to complete the approach, and many will live with the vague uneasiness they feel about an approach when they are not 100% sure about their position or tracking. 99% of the time they get away with it... but occasionally they run out of luck. It is a stupid way to operate. However, it is a way of operating that is common in the charter world."
-------------------------------------------------------------------------------------------------------
Strong statement, very hard to crosscheck with anything on the NDB approach if you have only one needle, that surely is why the rule states two required?. If this way of operating is common in the charter world, and one would presume you speak from experience, then surely it is time CAA did something about it? or does it not fit into their definition of Affordable Safety.

Prospector

[MOR]

Prospector

I quite agree with you.

You could take the view that a "second independent navigation system available should the primary system fail" could mean a VOR receiver used at the alternate, in other words the pilot could have diverted to Rotorua and carried out a VOR/DME approach there. However it is a slightly frivolous view.

My own belief is that the CAA are criminally negligent (in the moral sense) for not either enforcing the rules, or ensuring that ACNZ provide naviads more in keeping with the 21st century. But then, the CAA take a very hands-off approach to safety in any case.

Having said that, there was nothing stopping Christian Aviation from equipping both it's aircraft and it's pilots more appropriately for the charter task - for example getting the aircraft GPS installation approved for IFR approaches, providing a second RMI to complement the RBI, and making sure the pilot was approved to carry out GPS approaches.

Yes, I do speak from experience in charter work, a time in my life that I am very glad is over. Operators will all tell you that they are very safety-conscious, and in their hearts most want to be, but the fact is that it is a competitive industry with small margins and high expectations from the customer. Few operators can afford to equip their aircraft with all the toys, those that can often don't want to as "we have always managed with an ADF, why spend the money?"

Most will bend the rules to "get in", it is virtually an industry-standard attitude that the CAA is doing nothing to stop.

[stillalbatross]

At the end of the day you have to say was this accident in this crapheap old aircraft any different to similar cfit accidents occurring 30 or 40 years ago when they had the same light twin aircraft operating SPIFR with borderline-in-todays-world autopilot and nav systems having the same accidents?

Answer NO.

When you look at automotive safety and the areas it has improved to reduce fatalities overall or shipping safety and the areas it has improved to reduce fatalities overall it is criminal that aviation has the same accidents occurring decade after decade after decade after decade. SPIFR in commercial ops should only take place in an aircraft with a minimum of a competent deicing system, gpws and a nav and autopilot system that can competently fly an approach/missed approach hands off.

The public don't deserve any less, neither do those operating the aircraft. Obviously the public will have to pay for the extra cost and the size of the charter industry may go down but the level of safety will increase tenfold.

There are a considerable number of people on this forum who would say "I cut my teeth in SPIFR" or "Best training I ever had" But a great deal of them also wouldn't put their kids on a SPIFR charter if it was shaping up to be a nasty day to go flying.

It isn't the greatest analogy but if stagecoach imported a bunch of those buses that hack around the Kashmir with no brakes, overloaded by a factor of 3 and put them on runs around Auckland charging 20% of what they charge for a bus fare now Joe Public would have a fit at the poor safety and casualty rate.

But Joe Public doesn't know aviation quite so well, relies on the industry and CAA to police it and set a level for his safety and that still isn't occurring.

In theory I am just as safe in SPIFR as I am flying a link service to the same small town with it's non precision approach and limited aids. Obviously since there have in the past been over 30 SPIFR fatal accidents while the link services have had 0 this is not occurring.

Something is therefore wrong.

However as SPIFR deaths will continue to occur with monotonous regularity
it will at least provide for lively debate on the forum.

[flyingkiwi]

I said it before and i will say it again, having been based in Taupo on the commuters and before that flying GA twins IFR into Taupo, that approach is dangerous, those of us that flew into there all the time knew the Bravo approach did strange things and the scariest of these was to give false inbound indications especially taking you East of the centerline. You could have 50 RMIs on board and you would have no idea that you were been fed false information. We advised CAA and they did nothing like usual.

Fixed card vs RMI, its safe its legal and its easy, i did over 100 fix card approaches in AP on the Bravo, albiet keeping myself slightly west of the inbound, i was scared of that hill.

Im saddened about the cannabis use but dont think it was a causual factor.

[MOR]

What a load of twaddle.

An approach doesn't "do" anything, and any refractive effect would be obvious when the approach was being calibrated.

There is no way you can get that far off-track with an apparently correct indication, he was at least 24 degrees off-track... have a look at the track plot in the accident report. Besides, the ADF had a trapped reading that was roughly correct (32 degrees right of the aircraft heading), so if that was what the instrument was reading at the time of impact, it is clear that the ADF or NDB was not the problem, as testing confirmed. Subsequent airborne testing of the NDB installation the next day found no problems.

So it wasn't the approach itself, or the ADF.

I am also intrigued as to why you would think the CAA has anything all to gain by ignoring your reports... it isn't their navaid.

What you are saying is that the CAA deliberately refused to investigate a safety-related issue, which is unlikely, even for them.

[QF Quoll]

Don't like this military vs cilvilian IFR training procedures; this needs a good Dept of Civil Aviation balanced opinion. Providing of course the Department is balanced....

[cjam]

I've just read the taic report, found it a bit interesting that they said he descended in accordance with the profile and the steps...they made specific mention of the five mile step but didn't mention that there is a step of not below 3600ft until 8 miles, by the time he got there he had already descended through the step by 600 feet. Overloaded? He had been flying for three hours with two missed approaches and was in a cockpit that required a different scan than he was used to and until that day hadn't done a fixed card approach since 2002, With all that I reckon it wouldn't take much else to make me overloaded. If I was starting to get sick or had not got a good nights sleep the night before I reckon it might overload me. Does anyone else think it could be that simple?
Another thing I found interesting is that with the AWIB reporting the cloud as BKN 4000 and wind favouring rwy17 he would have had a certain picture, he got the real story about the weather while joining the arc and opted to carry on then circle for 35. I think thats exactly what I would have done as well, when briefing the approach though, his mindset would have been getting visual on the arc, for me in the past this has adversly affected my attitude to the approach, it has caught me out when conditions are worse than expected, does anyone else get that?

[pakeha-boy]

Flyingkiwi....a question....why would anyone contemplate evening thinking about doing an NDB app with the knowledge or thinking that the signal strength was questionable?......

I, like you have done many NDB apps,none under the premise that this was a "hit and hope" operation....

apologies if I have misread your post.........PB

[mattyj]

Come on MOR, don't you remember basic IFR instruments and navaids?

Coastal effect?

ADF roll on..the effect of cloud and hills on the approach..and the common frequency of electrical storms..

Hardly a 100% guaranteed approach aid.

[prospector]

cjam,

Yes, I do believe it is very likely that it was that simple. There is nothing wrong with a fixed card if it is all you are using, but to jump from one system to another, with periods of months in between is a big ask. And to have the instrument in the bottom left hand of the panel certainly would not help.

Prospector

[MOR]

mattyj

Come on MOR, don't you remember basic IFR instruments and navaids?

Coastal effect?

ADF roll on..the effect of cloud and hills on the approach..and the common frequency of electrical storms..

1. Coastal effect - no, it's a lake with a convoluted coastline.
2. Cloud - I assume you are joking.
3. Hills - maybe, but then it would show up during navaid calibration, wouldn't it? The approaches are designed to take this into account (same with coastal effect), and that is the reason that you often see offset final approaches on NDB approaches - to allow sufficient tolerance.
4. Electrical storms - well there weren't any in this case, but if you had ever flown around thunderstorms, you would know that the effect on an ADF needle is to make it swing around (pointing towards the TS). The movements are erratic, and any pilot that relies on an ADF during electrical weather needs their head read. Go somewhere with a real approach.

Not sure what you mean by ADF roll on, if you mean dip, it is only relevant when turning. Doesn't apply on a final approach.

It isn't a 100% navaid (whatever that means), but it is a perfectly acceptable aid if used within its limits.

It wasn't so long ago that we were doing approaches into NSN using an AM broadcast station... not even an NDB. I still have the approach plates...

[Capt. On Heat]

Someone has to back you up FlyingKiwi. I was scared of that hill too. When I first started doing regular GA flights to Taupo our company senior pilots filled me in on that damn Bravo approach and the concerns many pilots before me had with it. Yeah it's certified and been checked etc etc but I was (and still am) of the opinion that SOMETIMES when god knows what conditions there are and the moons align you can recieve some frightening indications in that area. Only ever flew it IFR if I had a GPS to back up. Did it VMC several times and tried to fly that approach as accurately as I could for personal curiousity I suppose. Gave a FAIR track on MOST occaisions but several times (to varying degrees) it put me (what I would class as) significantly to the East of track and more correct indications did not start to occur until 3-4 nm from the aid. Once was almost over the lower slopes of the Mount.
Not saying this WAS the cause-but I'd say it may well have played a part, significant or minor. Perhaps it was merely compounded by other factors in the report and discussed. At the end of the day it was (and will no doubt remain) an accident without a known cause/causes.
Prospect- Some aircraft I used flew to AP had two ADF's and they showed the same thing.

MOR as for the 032 trapped RB indication-that's hardly definitive! The aeroplane came to an awful sudden stop and the surely every ADF needle you've ever seen hasn't pointed consistly (except in a sim!) I think you're being a bit harsh on FlyingKiwi. An opinion from fellow aviators of experiences they have had is not twaddle. You cannot experience everything yourself and considering the experiences as well as the mistakes of others is a must for any pilot n'est pas? ;)


Cjam- Had to recheck that radar plot in the report. Cannot believe naught was made of it in the report.

[cjam]

It's not only that they didn't mention it in the report that I found strange, it's that they actually said the profile was in accordance with the steps or some such thing. Weird. In my mind it says quite a lot, it says that things weren't going right in the verticle plane as well as the horizontal one.
If the profile was spot on but tracking was consistantly out I might think that there was something wrong with the signal as others have suggested, but the fact that the a/c was 600ft below a step on the inbound suggests to me that SA was going or gone.
I don't think a CFIT accident has ever occured where the pilot/s haven't lost SA, therefore it seems an important point to me.

[MOR]

Capt. On Heat

MOR as for the 032 trapped RB indication-that's hardly definitive! The aeroplane came to an awful sudden stop and the surely every ADF needle you've ever seen hasn't pointed consistly (except in a sim!)

No it isn't definitive, but it is awfully telling that given the aircraft heading, the offset of the needle on the RBI is not that far from what it SHOULD have been reading from that position. In other words, it wasn't (in all probability) sitting straight ahead, or on any sensible wind correction angle. As you say, the aircraft did come to a very sudden stop, for that reason the trapped reading is likely very close to what it was indicating at impact. The point is, why would you continue with that much deflection on the needle? You are either way off track (in which case you execute a missed approach), or you are on track but your ADF is telling you lies for whatever reason (in which case you execute a missed approach).

cjam

It's not only that they didn't mention it in the report that I found strange, it's that they actually said the profile was in accordance with the steps or some such thing. Weird. In my mind it says quite a lot, it says that things weren't going right in the verticle plane as well as the horizontal one.

It could just be a simple misunderstanding. He may have been "cutting the corner" a bit in descending below 3600' before 8D, but he never descended below 2700', which is the FAF altitude. I don't think you can say he lost SA in the vertical plane.

You are right though, the approach was never "in accordance with the steps".

[pakeha-boy]

mattyj......not to sound obnoxious....but you post reveals your lack of "approach" exprience.....

True,the NDB is regarded as the "worst" of all the apps that one can make,but let me remind you that many International" high volume airports,ie PANC/CYVR to name a few, use the the NDB as a viable app.

I have flown into Taupo,and the above mentioned airports,if flown correctly the app has a positve outcome!!!!
Let me remind you there in no app that is 100%,why you have a notion that there is,let me know.I consistantly do RNAV APPS,using IRS/GPS,considered the most accurate of apps,never considered 100%.

The CAT3 A/B APPS,that I.m qualified to do,allow me after the alert height,in zero/zero vis,to continue the app,under the premise,that if I feel all parameters are met,I can continue the landing.

All approach types have parameters,it is up to the individual who is executing that app to stay within the confines of its accuracy.......WAIMARIE

[Wombat35]

Hello all,

This thread opens about every can I can think of and before it heads off in the direction of irrelevance, I thought I would put in my two cent worth about what I can do, as professional pilot, to stop it from happening to more of our mates.

My aim is not to interact with the MOR and others, rather to discuss with pilots in NZ who may be in a similar situation faced with similar pressures both social and commercial about what you can do to minimise your risk and more importantly why it matters.

Who the hell am I?
It doesn’t matter however, I have been lucky to have received good training in accident awareness and risk management and I have been flying for over 20 years. I also actively fly out of AR as an instructor.

As I see it the, accident is another case of no one clear cause so it a good example of an application of the ‘Reason model’. For those of you who have never heard of this or the ‘Swiss cheese’ accident theory, basically after an accident, all the factors are identified so that a chain can be established, from this a cause can generally be attributed. As professional pilot’s, I would suggest that you learn about this theory as through practical application it has stopped me from doing stuff that may whilst being insignificant at the time, may have contributed in turning an accident into an incident or prevented an incident in the first place.

Why minimise risk?

I try and look at this in reverse, what can I do to maximise my safety? My aim is to always insert more slices, or reduce the hole size to give me every opportunity to survive.
Before each flight I try and identify what will be the biggest hole/s and what can I do to reduce the size to as small as possible.

As a practical example let take currency. If I haven’t done a particular type of flight for a while the currency hole is going to be large. Now that it’s identified I minimised the size with time. I take the time to review the brief/manual and take the time to do things slowly so that I’m organised and have though of as many contingencies as possible.

As for social pressures, we all want to enjoy our life that’s why we do this, however we do not want to become an empty glass on the bar, we have a responsibility to ourselves and our passengers. As for illegal drugs, god knows I’d like to however, NO. Not because they are illegal, rather I don’t know how they would affect the size of the whole.

For alcohol at lease there have been studies done and guidelines as to how long an amount takes before it leaves your system. You can use that guideline to minimise the size of the hole.
In this particular accident what could have been done to minimise the risk?
Ask your self about drugs….

Being under the influence, secondary smoke or whatever might not be an important factor however it determines the size of the hole in that slice of cheese.
State of mind is another slice, as is the location of the instruments, weather, airfield, type of approach. Minimising the risk starts then take shape. What would you have done to minimise the risk of this flight. How risky do you think it would have been to undertake?

Well, war and peace is complete :zzz: , sorry about all the slices and holes :confused: , however if it gives you a tool to use to stay alive (and I think it is a great tool) then it’s worth a minute or two to think about :ok: .
Cheers
Wombat35

[mattyj]

MOR I'm starting to get pissed off with your argument method..its very arrogant and patronising. Sure you have experience most of would kill for but I was trying to remember some common limitations of the NDB from my IFR theory of 5 years ago. Now you have forced me to get out my old notes (from a respectable training organisation)

- Night effect
-Coastal refraction (including ANY large body of water and known to be a problem with the old 24 approach into Wangarei..ask any old Friendship pilot)
-Terrain effect
-Mountain effect (you should research that one..it seems to be particulary relevant to the accident)
-Thunderstorm effect (while looking for Steve we spoke to Air Charter Taupo who said large black clouds had rolled over around midday and sudden 180 degree wind shifts HAD occured)
-Quadrantal Error
-Super Refraction or Tunneling (what I was referring to when I said clouds..not really a problem but also requires an inversion)

Thats just from my old notes..I'm not claiming any of them where a factor that day or if any of them are relevant to the accident, just that there are errors and inaccuracies documented..thats all.

[mattyj]

..Oh and Pakeha Boy..I am not trying to conceal my lack of experience..I admit..I have a lack of experience...

..but I kept my notes which were written by those more experienced than either of us I assume.

[MOR]

Wombat35

There is one big problem with the "swiss cheese" theory... it's full of holes... ;)

Sorry, couldn't resist...

mattyj

There is a big difference between theory and the real world. All you have is the theory.

What you will find in the real world, is that you will very rarely see any of the effects you list from your textbook, to the extent that they could make an approach unsafe - that is why non-precision approaches are regularly calibrated. You will also find that whilst your textbook authors may know about radio aids, they may not know much about actually using them.

None of the effects you list are relevant to this accident, certainly NOT mountain effect (see point above about calibration).

There are errors and inaccuracies with any navaid, you learn what they are and you adjust accordingly. I could tell you horror stories about GPS departures out of Paris CDG, or some interesting deviations on a Cat II ILS at Heathrow when at 90 feet AGL... no navaid is foolproof (other than your eyes).

Finally, for reasons I don't quite understand, you mention two effects that you say are relevant to the accident, then later say that you are not claiming that any of them are relevant. Anyway, the two effects aren't relevant in the slightest - mountain effect, as calibration would pick that up; and thunderstorm effect, because a simple passage of a trough does not cause electrical storm activity. The report notes that there were no CBs anywhere near the area... "dark" clouds and a wind shift doesn't equal thunderstorm.

You can get as pissy as you like, but in the end it is very immature to dismiss those who have actually spent their working lives using these systems. Better not act quite so truculent when trying (again) for that first job... :rolleyes:

[Luke SkyToddler]

Going back to MOR's original post which I think is a bloody interesting point, I'll cut and paste it since we're onto page 2 here

I would be the last person in the world to ever agree that any pilot should take an illegal drug, however I can't help thinking that this will now be seized upon and used to impose drug testing on the NZ pilot community, even though the report clearly states that the use (or not) of cannabis was not a factor in the accident. That was obviously the intent of the CAA spokesman interviewed for the piece.

Is anyone, apart from me, concerned about this? I am not concerned from the point of view of any personal involvement with drugs. My problem is that pilots are now being perceived as unprofessional and in need of supervision in this regard. when was the last time your doctor underwent a drug test at work?

It's unclear whether you are coming out for or against drug testing here? I think we agree that anyone who tries to fly while under the influence of alcohol or illegal drugs has no place in this profession, and I personally have no problem with drug testing on that basis, they can bring it on all day and if they find any pilot who's under the influence of marijuana or booze or anything worse then hit the road jack and don't come back.

However the hot potato in this report is that while the guy had detectable levels of cannabis in him, it was 'not considered to be a contributing factor' to the accident.

Clearly this means that the CAA must have some cutoff level / guideline amount of cannabis above which pilots are considered to be under the influence?

I think we have a right to know what that level actually is, how they came up with the figure, and then does there need to be a punishment for people who test positive but below that level? I'm of the opinion that as long as it's illegal, any pilot who engages in illegal drug taking, even while on a lengthy spell off duty with plenty of time for it to clear their system, is showing extreme foolhardiness and disregard for their future career. However given that they're technically not endangering anyone in their aircraft, is it a crime against aviation?

What worries me is that the tests now are soooo good, does anyone remember that greyhound a few years ago that was disqualified from a race because it tested positive for opium, which was subsequently found to have come from a few poppy seeds on top of a filled roll which it had eaten a week beforehand? I wouldn't fancy that happening to me :eek:

[prospector]

MOR,

"no navaid is foolproof (other than your eyes)."

Erebus???

[MOR]

Luke ST

I don't have a problem with drug testing per se, but it opens up what used to be regarded as an honourable profession, to all sorts of intrusive testing.

We all know that many professionals use drugs or booze to alter their mental state. However, most know when to stop - most surgeons, for example, would not contemplate operating on somebody whilst intoxicated with anything. The major difference between a pilot and a surgeon - other than 14 years of training - is that a surgeon can only kill one person at a time, whereas we can kill hundreds.

My argument is that in countries where testing happens, there are virtually no positives. The only possible conclusion is that the vast majority of pilots are trustworthy.

My other argument is that testing would be a knee-jerk reaction by the PC brigade, and would achieve virtually nothing, whilst costing somebody a lot of money.

That being the case, I fail to see the need for testing and would oppose it, although if it was imposed I would submit to it.

To me, it's very much like the airport security stupidity after 9/11 - shutting the door well after the horse had bolted.

Prospector

My point would be that using the Mk 1 eyeball assumes you have visual reference. The Erebus crew apparently didn't. Of course they were misled in other ways as well.

[pakeha-boy]

Luke ST.....drug testing in the Major Airlines,as you know,is standard stuff,I myself get tested 3-4 times per year,and it is supposedly random.Each test is different,sometimes blood,sometimes urine.The poppy seed issue is now a non issue but a valid point.

I worked as an instructor for JAL, in there 747 programme.Any time we reported for work,we were required to "blow-the-bag".I am unaware of anybody testing positive,but this was a front line measure designed to stop the obvious.

The aviation community world wide has been digging this hole for themelves,for many years,and the day is fast approaching where everybody,even you mattyj,will have to submit to a drug test before flying.We only have ourselves to blame.It is a case of a very few spoiling it for the rest of us.

I have a mate sitting in jail in Miami as I write,5 YRS in the Fed Penn,for trying to fly an A/C whilst intoxicated,many of you may remember this case,ie AWA pilots.....if that doesnt bring home the bacon...... ,nothing will.....
porangi

[stillalbatross]

MOR,

Afraid I have to disagree with you there. If you look at Whangarei it was an unsafe single NDB approach (or borderline under ICAO regs) and after calibration one day CAD decided that it was outside tolerances and stuck in a second NDB making it a twin NDB approach. Now you don't have to be too sharp to figure out that with a twin NDB approach it doesn't matter what the instruments are saying so long as you plonk the needles over one another. Basically CAA had given up on that NDB in that position supplying accurate enough data.

As Aust ditches it's NDBs in favour of GPS approaches we, and some other 3rd world countries, are being offered their redundant NDBs and some VORs but to take them would be to admit we don't have a respectable level of safety in the area of non precision approaches. Far better we have approaches that lead to accidents that kill people.

10 years ago CAD could have jumped on the "GPS approach" bandwagon with CASA but then we wouldn't have been in charge and the whole kiwi-battler/tall poppy/aren't we wonderful/we know everything kiwi psyche wouldn't allow us to have the aussies dictate the technology introduction.

So here we are :sad:

[MOR]

stillalbatross

Not sure which comment of mine you are disagreeing with... however concerning Whangarei, I'm not surprised there were some issues, you are crossing two coastlines on that approach. However, adding another NDB should fix it because now you have two independent sources of tracking data, if the Whangarei beacon starts doing it's little dance, you have the Springfield beacon to back it up. Safe as houses... ;)

However I have to agree with you about the attitude of the CAA. If the NDB isn't performing properly, better to bin the thing and do something else. We should be embracing the latest technology, GPS is getting cheaper by the minute and I really don't see why we aren't going that way more.

I can't agree, though, that it is the navaids that cause the accidents. The pilot is the one who decides if the information he is getting is adequate to complete the approach. If you have a nice, steady needle on an NDB approach, it is a perfectly acceptable aid. If the needle is swinging about more than +/- 5 degrees, go somewhere else - it really is that simple. If more pilots rejected approaches when the data was questionable, there would be a better case for replacing them with something better. Of course, part of the problem is that operators don't want to spend money equipping their aircraft or pilots for the newer technology.

Some here seem to think that this accident is down to a possibly-overloaded pilot misinterpreting an ADF presentation that he hadn't seriously used in two years. I don't accept that. He would have known what an RBI was supposed to look like, and if he was uncomfortable with it's use, he could have gone elsewhere. A professional pilot is expected to be able to exercise that level of judgement. Even flying a nice jet with all the toys, I have sometimes rejected an approach when something about it made me uneasy (flying into Innsbruck in fohn conditions, for example). You have to make these calls sometimes, and I have never had much difficulty justifying my actions.

In this case - although we will never know for sure - I think the pilot made a basic tracking error. I don't think he was overloaded as his radio comms gave no hint that he was under stress. His vertical profile was a little sloppy, but he was maintaining the correct height (more or less) for the FAF. To me, the telling point is that he said he was at the FAF - so he had situational awareness in two planes, it was only the tracking that was incorrect. If I had to guess (and it can only ever be a guess), I would say he intercepted, or was trying to intercept, the wrong track.

Have to agree with your last para too.

[prospector]

stillalbatross,
In an earlier post in this thread you said
----------------------------------------------------------------------------------------------------
"At the end of the day you have to say was this accident in this crapheap old aircraft any different to similar cfit accidents occurring 30 or 40 years ago when they had the same light twin aircraft operating SPIFR with borderline-in-todays-world autopilot and nav systems having the same accidents?

Answer NO."
-----------------------------------------------------------------------------------------------------

Can you detail any of these CFIT accidents from 30 or 40 years ago??
I can recall a couple of SPIFR accidents but they were certainly not CFIT.

40 years ago the NDB approach to Whangarei was based on the beacon out at Marsden Point, also the only DME's in the country were 200mgs units, only NAC had the equipment to utilise them. The vast majority of approaches carried out were NDB, apart from Auckland. Even at Wellington, the PRA shut down down at 2300M, night approaches there after that time were Twin NDB.
No such thing as PAL either, night flying only AA WN or CH available. But I still cant recall any SPIFR CFIT accidents, were you referring to NZ or further afield?

Prospector

[tinpis]

Um 40+ years ago...?
That doesnt include the cat and duck method used by Fletchers thru the early morning fog at Rukuhia before Bill the grumpy old sod of a controller came on. :)

[prospector]

Tinpis,

Take a long time to log any IMC time climbing thru ground fog, could spoil your day if there was a low layer of stratus above tho.

Prospector

[tinpis]

:} I do recall a well known chap ( RW) breaking out of the clag over Raglan harbour at 9000' feet or so.
But he was in a Beaver.

[prospector]

Wombat 35,
Would you agree that all you are saying can be relayed by the very simple first commandment.
"Thou shalt not make a stuff up or the ground will arise and smite thee"

Prospector

[steinycans]

Im no IFR flier but i read somewhere alternators emit radio waves on a similar frequency to NDB's.
Is there a possibility that the ADF reciever became unshielded during the earlier part of the approach (due perhaps to a loose connection) and became shielded again prompting the guy to turn onto a more-or-less runway heading (without sufficient time to figure out the problem*)?
Also, what effect would unshielding the ADF reciever have on quadrantal error? If the effect was so great that the needle was stuck on the nose, the pilot would have no reason to question it, given what i would assume would be a negligable expected drift angle (again - not ifr so i dont know).
1.12.7 Says several components were removed for detailed inspection however the only result mentioned that i can find is the RB display and the gps holding no useful infomation.

Just a thought.

*impact occured 1m 8s after turning

[prospector]

steinycans,
From the accident report.

2.22 The ADF installation in the aircraft was found to be satisfactory. The condition of the .Y.
channel connector cable probably resulted from the sudden and very forceful impact. Had the
circuitry been compromised before the impact the pilot should have seen the ADF pointer align
itself with the fore and aft axis of the aircraft . in this case probably pointing directly forward as
the beacon was to the front of the aircraft. However, the pilot was likely receiving correct ADF
information as he was able to fly around the arc and start the turn inbound at about the right
position. Also the ADF needle was pointing about 30º to the right of aircraft heading, towards
the NDB, at the time of impact.
2.23 Nevertheless, it was possible, albeit unlikely, that as ZK-FMW turned inbound from the arc, the
cable connection became momentarily loose and made contact again just before impact. This
could be an explanation for the steady divergence away from the inbound track, because with
such a connector fault the ADF needle would point directly ahead of the aircraft. After nearly 3
minutes on the steady but diverging heading the pilot may have become concerned and turned
right to fly the inbound heading. However, if that had been the case and the pilot had become
concerned about the ADF information being presented to him, he should have immediately
initiated a climb to a safe altitude and advised UNICOM or ATS. The last radio transmission
gave no indication that the pilot had any cause for concern.
2.24 The concept of duplicated and independent navigation systems is laudable and should be
practised where possible and practicable. However, further discussion was required, and is
being undertaken, to ensure that unnecessary additional costs are not incurred by Part 135
operators, especially where a withdrawal of an NDB is planned and practicable alternatives may
be available. For ZK-FMW it is unlikely that a second ADF would have indicated anything
different from what the pilot saw as he flew inbound on the approach.
---------------------------------------------------------------------------------------------------
It is given as a possible explanation for the approach as flown. It is possible, but no one will ever know for certain.

You wll note that 2.24 states that the concept of a duplicated and independent system is laudable and should be practised where possible and practicable. You will perhaps also note that this was a mandatory requirement according to the regs for some years previous. It also states that it is unlikely that a second ADF would have indicated anything different. Who Knows??
Prospector

[mattyj]

Have a look at the track he flew after turning inbound on the radar plot..dead straight correctly allowing for drift, but just 20 degrees left of inbound..which was about 150 instead of 170...could he have mistakenly bugged 152? This was the inbound at KK that he had just missed twice before continuing on to AP. Mindset or something. It looks fishy that the track he held was straight but incorrect..
..and while I'm looking at the radar plot..just how far off the correct inbound must you get before control helps you out..a little bit more proactive and 3 lives might have been saved.:ugh:

[MOR]

"Just" 20 degrees left? Five degrees off track is missed approach territory!

could he have mistakenly bugged 152?

According to the report, he had bugged 158 and had the CDI on 170, both of which make sense for the approach.

just how far off the correct inbound must you get before control helps you out..a little bit more proactive and 3 lives might have been saved.

No... he wasn't receiving a positive control service, he wasn't flying in controlled airspace, and he was monitoring Unicom. As the report says, the controller, who had no responsibility for the flight, would have had insufficient time to contact the unicom operator and alert the flight. In any case, at the range the controller would have been using on his display, it is unlikely that he would have even seen the deviation - his screen would not have had any approach overlays on it for Taupo. you can't blame the controller.

You should really visit a control room and see how difficult it would be (as should every pilot).

[Waka Rider]

mattyj the pilot was a sound fella and sometimes these things just happen. To get through SPIFR you need bit of luck and survival judgement regardless of the levels of regulation. I personally would be alot happier if AP had a radar approach operator and tower controller its quite likely that SB would still be around. But under the user pays system it just will not happen. AP needs it I believe.As MOR makes the point its hard to hit a hill above MSA. Its great to apply models like SHELL and REASON and PPP. But sometimes luck and survival kick in. Please can some one remind me where KK is?

[stillalbatross]

mattyj the pilot was a sound fella and sometimes these things just happen. To get through SPIFR you need bit of luck and survival judgement regardless of the levels of regulation.

So what you're saying is that people need to die in SPIFR in NZ to remind us of the luck and survival judgement required. Only in NZ or some other 3rd world country could a statement like this ring so true.

There should be another air transport ops non-schuduled fatal crash in the next 4 to 6 months if we can just maintain some level of consistency. Prospector, I'll dig up a few more cfit/SPIFR accidents for you over the coming weeks if you like. Some branch of CAD did a bit of a study on it a while back as we have one of the worst accident records in the 1st world (but we look good next to Nigeria). We don't have the worst weather or terrain but we certainly think we're alot better than we really are, or we wouldn't be killing our passengers with such regularity.

[MOR]

To get through SPIFR you need bit of luck and survival judgement regardless of the levels of regulation.

Luck and survival judgement are NOT required. What IS required is some self-discipline on the part of supposedly professional pilots.

Nobody forces you to descend below MSA or make a particular approach. That is YOUR decision, and if you do descend below MSA without visual reference, or carry out an approach which you are less than happy with, there is only one person to blame - YOU.

Why do you think we plan alternates?

You can, AT ANY TIME, mentally say "go around" and select a safer alternative.

we certainly think we're alot better than we really are, or we wouldn't be killing our passengers with such regularity.

Precisely. It isn't the navaids' fault, it isn't the weathers' fault, it is down to the poor decision-making and an entrenched "must get in" attitude of many pilots, an attitude that pervades the industry. None of these people would be dead if the pilot had made the correct decision (except where mechanical failure played a part).

I have lost count of the number of times I have sat in aero club bars and been entertained by pilots bragging about how the got in when the weather was 8/8ths on the deck, or the crosswind was 45 kts, or how they knew that if they descended below minima they would go visual, so that's what they did. It is like a badge of office to a lot of them.

Only when you solve the attitude problem, will you solve the CFIT problem.

[Waka Rider]

still a bird a certain degree of realism is required. To stop the kill rate with SPIFR will require amazing amounts of money spent in training.I do not think the government and the industry want too do. Why does NZ still have third rate navaids and a lack of radar? Surely a place like AP, RO, NR, PM, TG and many others deserve an ILS. At least Abudja has radar ( when the operator turns up in the morning) and an ILS. I am no ace but we do a large amount of NPA's each time I know that the cockpit workload goes through the roof compared with an ILS. Workload and SA follow together when my workload increases above certain levels it does affect my SA. That is why regulators required EGPWS, TCAS, windshear detection so when pilots like myself and yourself make mistakes their is a safety net. Airbus even design there aircraft to not even allow the pilot to fly the aircraft beyond certain roll rates and attitudes. Why are aircraft in NZ able to perform commercial operations into unattended aerodromes without precision approaches and no EGPWS or to add TCAS. All are aids to the pilots to help with workload and SA. Honestly if the Ansett DHC-8 guys had the simulator training for their type ratings to go through procedures (manual lowering of the gear) and PM had an ILS that hull probably would not have been lost. Personally I cannot see why in NZ we should kill so many people. But with the lack of investment and infastructure we have commercial operations combined with parachute, private ops with high terrain near the airfield without any radar and an ILS. All the ingredients are there so when someone makes a mistake their is no net to help protect peoples lives. Definately MOR you have a point with the attitude many people have. I have noticed the smaller the aircraft the bigger the ego of the pilot back home. Why doesn't the airline attitude of upmost paramount safety at all times and the abililty to say NO not filter through to grass levels? Hopefully the New Zealand government and the CAA take note of Nigeria's efforts to improve their system. Nigeria are already at least one step ahead of NZ they recognise they have a problem and are not afraid to ask for help to solve it.

[prospector]

stillalbatross,

The only CFIT accidents I can find for the 60's and70's in New Zealand are DC3, AYZ Kaimai Range 3 July 63. F27 NFC Manakau Harbour, 17 Feb 79. There were of course the two training accidents that were Semi controlled into terrain, TEAL Electra at Whenuapai 27 March 65, and the ANZ DC8 at Mangere 4 July 1966.
There were a number of third level scheduled airlines operating SPIFR services in this period, Air North (Ex Geyserland Airways) Air Central, Napier.And I believe Capitol Air Services, Wellington. Bellair out of Whakatane, and Company operations SPIFR, Owensair out of Tauranga, Pinex out of Ardmore. I am sure I have missed some, but there was plenty of SPIFR operations during this period, but I cant recall any CFIT accidents. An example of a day in the life of an Air North Pilot on the Northern run;
RO-AA-KO-AA-RO-GS-RO-AA-RO, and then for a change a day on the Southern run;
RO-GS-NR-PM-AP-RO-AP-PM-NR-GS-RO. made for an interesting day if the weather was inclement, and we had no DME available.
To keep the night time current, we had a newspaper run AA-WN-RO out of AA 0100 Sun mornings.

Prospector

[nike]

..and while I'm looking at the radar plot..just how far off the correct inbound must you get before control helps you out..a little bit more proactive and 3 lives might have been saved

MattyJ, I can't believe you actually wrote that!! What a complete :mad: !

Just because you've stated a lack of knowlegde and experience doesn't give you the right to mouth off at all and sundry.

[nike]

MATTYJ,

I'm not big on PM's.....


I don't get it..please explain your post..don't hold back, I won't be offended:D
..I think that if you can see an aircraft off course on the screen it is poor form to let them continue just because you're not required under the rules to intervene. Assuming the pilot has information dialled up on standby and is listening, whats so bad about coming to a pilots aid who has stuffed up?
Anyway read the other posts..I'm not the only one who thinks so


I took offence to your post because you were refering to the specifics of this particular radar plot and not the concept you have now portrayed in your PM and in such, you insinuated that ATC were not doing their job. That was not the case at all. There is no way that you should be expecting ATC to monitor an aircraft outside of controlled airspace. It is OUTSIDE CONTROLLED AIRSPACE.

And even in this PM you come across as if you think that the Controller had nothing else to do but sit there and watch the events unfold before him/her with no regard.

You could have chosen to write about the possibility of ATC spotting any deviation and whether or not they have the ability to make contact with aircraft outside of their airspace, rather than clumsily mashing out a half arsed remark with no regard for the individual(s) you were slandering.

Maybe my harshness was the result of reading several of your posts in a short time frame and getting frustrated at your readiness to pass judgement without restraint.

Obviously the responses you are going to get are directly related to what you post. So take your time and try to get across your point(s) clearly. After a while of reading the various threads on this website you'll see how most debates/arguements come down to interpretation by the other parties and therefore it is important to avoid statements that can lead to mis-understandings.

regards/

[MOR]

Anyway read the other posts..I'm not the only one who thinks so

The only people that think so are those that know precisely nothing about flying under IFR... :rolleyes:

[haughtney1]

Waka, I have to agree with you mate..this whole affair looks like a clusterf**k from start to finish.
The problem as I see it is partly cultural...the " she'll be right factor" partly commercial, and partly systemic.
Like a few of you on here Ive done my bit of SPIFR work in NZ, in my case flying a clapped out 30yr old Cheiftain around at night, at the time it was all very normal to nibble at minima to get in, fudge load sheets, paperwork etc to get the job done, basically things that now make me glad Im nowhere near that part of the industry anymore.
It now seems to me that the NZ GA scene has descended to third world levels, and when you look at this objectively what other conclusion can anyone come to? Is the CAA offering any leadership? Has the industry offered anything more than mouth music and uncomfortable shuffling of feet? The can of worms is getting opened wider and wider.
The thing that scares me about all this that there still appears that NOTHING is being done, heads in the sand, another report, letters to the editor etc etc.
I have ZERO confidence in the industries ability to resolve this, very little confidence in the CAA's ability/willingness to address these problems, and Im waiting for the next accident to happen:uhoh:

[6080ft]

With all this talk of the aicraft being on the radar controllers screen, and certain people thinking it would be easy for the controller to contact the pilot, I am wondering how accurate the radar coverage is at the alt and area the aircraft was at.
I also wonder what is the minimum radar vectoring alt in the Taupo area?

The radar controller can not be expected to monitor an aircraft that has left controlled airspace. When the aircraft has left controlled airspace why would the radar controller continue to monitor it? No doubt that controller on the day had TG, RO and HN under his control, which is more than enough to keep them busy. 125.3 is bloody busy these days.

6080ft