Questions? - without Notice.

[Kharon]

Bismiilah.

Pprune is an excellent forum, no doubt. However, even on Pprune the YLHR tragedy continues and will continue to ask questions; some the consistency of iron, an unyielding, though fragile base metal; some will try to bar real answers relying the scant evidence provided (at the time). Read Barnes.

There will always be the unanswered questions, asked until answered- of the incumbent Minister about the event; why?. Simply because it is intriguing. So much cheese, so many holes and it appears, so many bums hanging out in the blame game. Fascinating, for those with strong stomachs a love of truth and a genuine interest in ensuring that IT never happens again, Ever.

Should have been cut, dried and put away; years ago. But why does it continue to raise it's head?.

The 'Bard” (or a dozen others) could perhaps assist me here, but for clarity:

Why are the families of the tragedy still seeking 'real' answers?.
Why is the industry questioning the actions of all parties concerned?.

The answer is simple, It was Rum then, and remains so to this day.

Frank -A. Postulated a silly (for fun) conspiracy theory, the USAN would not cause an accident of this nature, but as with all questions, the answer needs be made to the questioner.

There are lots of YLHR questions not satisfactorily answered, particularly for the 'families'.

Remember May 5 – sure we do.

Selah.

[pinkpanda]

Kharon, I to followed the 7th Fleet thread with much interest and must admit to being disappointed when it was shut down by a CASA lover, geez you'd think that at least some sites could be sacred.

I have a close friend who is a family member of one of the victims killed in the Lockhart accident, they strongly believe there was so many unanswered questions that came out of the coroner's inquest. These questions deserve to be explored.

The worst part is I work for a company that has a lot of the very same safety culture issues that Transair displayed. What does CASA do about it? Nothing we're only Airwork and I'm only a backender, so what would I know? Trouble is I need the job!

[Sarcs]

In the previous thread:
alphacentauri

The GPWS tests I alluded to in the above post were after the incident.



Those flights, one in a Metro and one in a Conquest, were they properly conducted? The coroner didn't seem to think the first Metro flight was:


"In response to concerns the ATSB raised abut this possibility CASA commissioned Mr Bryant, an experienced pilot and aviation consultant, to conduct a test flight in a Metro aircraft equipped with GPWS to fly the runway twelve RNAV GNSS approach to Lockhart River using the advisory stabilised slope as published and additionally using the "step down" approach, flying not below minimum safe altitude at each step in the approach. Mr Bryant found that using the stabilised slope method of approach and with the aircraft configured appropriately, at normal speeds, no GPWS alerts were activated. There is however some doubt as to whether, when undertaking this test, the aircraft flew over the highest ground under the approach path.

Further, flying a stabilised approach at high speeds caused GPWS alerts to be activated. So too did the use of the step down approach where at 5.3 nautical miles to waypoint LHRWM, at 2,060 ft, a "terrain terrain" hard warning occurred and at 4.6 nautical miles to that waypoint a further "terrain terrain" hard warning occurred.

I was concerned that the letter sent by CASA to the ATSB advising of the results of its test flights was not as frank as one would expect communications between collaborating safety agencies to be. Neither of the reservations referred to above were mentioned. I was therefore relieved to hear that the agencies will undertake further examination of this issue to determine whether a problem in fact exists."

However CASA again didn't involve them in the second Conquest flight!

As K mentioned in an earlier thread, the Coroner had some serious reservations about the regulator vs investigator relationship:


“Finally, I wish to return to the concerns I expressed earlier about the working relationship between CASA and the ATSB. In this and previous inquests I have detected a degree of animosity that I consider inimical to a productive, collaborative focus on air safety. CASA’s submissions in this inquest suggest there was a danger of the ATSB’s recommendations being ignored and I continue to detect a defensive and less than fulsome response to some of them. I am aware that others in the aviation industry share these concerns, although I anticipate the CEO’s of the two agencies will disavow them.”


However the two flights conducted were somewhat irrelevant, as the ATSB engaged Honeywell to conduct a some what more 'scientific' approach and used an appropriate simulator with a GPWS, see Appendix F : http://www.atsb.gov.au/media/3148359/aair200501977_appendices.pdf

Those findings showed that there would have been several 'hard warnings' from the GPWS for the aircraft's config!

These findings, however, were discounted by the regulator why?


alphacentauri:
The aircraft used to validate the original procedure was a Navajo, to the best of my knowledge it was not equipped with GPWS. There was and is still no requirement in the certification process to assess GPWS warnings, although it is brought to CASA's attention if one is found to alarm during a flight test. Further investigation usually results until the regulator is satisfied for publication.



This outdated attitude doesn't make it right though!

Because there wasn't a requirement to test GPWS on instrument approaches. There still is no requirement to do this, however the procedures are now flown using a GPWS fitted Conquest.

Which still didn't excuse not pulling the approach for four long years after the accident!:ugh::=

[601]

The basic concept of these approaches is flawed.

This was pointed out to CASA at the Brisbane Convention Centre when CASA (or whatever name they had then) first briefed the industry on this type of proposed approach.

The concept of a constant changing waypoint for distance instead of one, i.e. airport, was and still is, stupid.

It is the largest hole in the cheese.

[Sarcs]

Agree 601 it was a hole, just not sure if it was the biggest hole!:cool:

[alphacentauri]

Which still didn't excuse not pulling the approach for four long years after the accident!:ugh::=

And in 4 long years, how many incidents/accidents occured on that approach? None! Yep sounds like the approach was unsafe to me (sarcasm, not intended to be offensive just keeping it light hearted)

Where in the investigation and susequent reporting was it ever found that the approach was unsafe? Why was there a reason to withdraw it? I am sorry but just because it gives pilots the heebi jeebies, isn't excuse enough to withdraw an approach.

OK, so the common theme here seems to be that pilots don't like the current RNAV approach methodolgy. In some ways I agree, but we are constrained by the current RNAV database coding. The only option we have is to withdraw them all until we can find an alternative solution. But that isn't suitable either for 2 reasons a) watch the bitching start when we withdraw them and b) in 3 years there will be hardly any ground based navaids left to design procedures to.

Why is this only an issue here? I don't hear the same complaints coming from the rest of world. Bear in mind that, as far as I know, we are the only country to publish a descent profile table on our RNAV approaches. They don't do it in the US. Is that the answer? remove the DIST/ALT scale?

Not being aggressive, just presenting another side to the argument. I understand there are issues, but presented solutions are often far and few between.

Alpha

[rmcdonal]

Seems as if the GPWS alerts only went off if the aircraft was flown at an excessive rate of decent. Not a fault with the approach its self which provided the required terrain clearance when flown in accordance with the AIP.

[Sarcs]

And in 4 long years, how many incidents/accidents occured on that approach?

Not sure if that's true now AC, besides the LHR accident itself and the one's not reported, there are these two:

ATSB Occurrence No: 200502286
On 10 May 2005, the ATSB received a report from
an operator stating that:
We cannot conduct the Lockhart River
Runway 12 RNAV approach without the
GPWS (Ground Proximity Warning System)
announcing ‘Terrain Terrain Pull Up Pull Up’.
This happens in both our Hawker 800XP and
Kingair 350. The occurrence is always just
after passing LHRWF [the final approach fix]
inbound.
The operator also reported that, in all instances,
the aircraft was on the constant angle approach
path and, in most cases, with the autopilot
coupled to the flight management system.
2
and this:

ATSB Occurrence No: 200703363
On 29 May 2007, the crew of a Beechcraft B300
Super Kingair reported that a Lockhart River
Runway 12 RNAV (GNSS) non-precision approach
was being conducted, via the LHRWD waypoint, in
instrument meteorological conditions (IMC), with
the flight management system coupled to the
autopilot:
At a point 5nm from the MAPT [LHRWM] the
Enhanced Ground Proximity and Warning

System (EGPWS)
3 gave aural and visual
alerts of ‘Terrain Terrain Pull Up Pull Up’
which lasted for 1 cycle of approximately 3
seconds. No amber or red terrain indications
appeared on the EGPWS display. At the time
of the warning, the airspeed was 130 KIAS
and a rate of decent of 700 fpm in IMC at an
altitude of 2150 ft. The RADALT indicated
approximately 1600 ft just prior to the event
and decreased to 1000 ft during the event.
The crew responded to the alert, established a
positive rate of climb and conducted a missed
approach. The crew then made a second attempt
via the LHRWG entry waypoint and reported:
During the second approach, in the same
configuration and, at the same position as
the first approach, the same alerts were
produced by the EGPWS.
The terrain map showed only blue and green
terrain and the aircraft was again accurately
on both azimuth and glide path. The flying
pilot noted the RADALT height reduce from
1600' to 1000' over a period of less than 1
second before returning to 1600'. The alert
continued for 1 cycle before ceasing. The
aircraft was confirmed on FMS glide path
and a decision to continue was made…


If you talked to most local pilots if the prevailing winds favoured RW12 (and lets face it they do for 80% of the year) and you were in IMC, they would prefer to go offshore and let down to LSALT and then come back in, rather than shoot that approach i.e. because then you avoided the tiger country and the Mech Turb!

[Sarcs]

With all due respect rmcdonal, neither of the reported incidents were unstable approaches:The operator also reported that, in all instances, the aircraft was on the constant angle approach
path and, in most cases, with the autopilot coupled to the flight management system

On 29 May 2007, the crew of a Beechcraft B300
Super Kingair reported that a Lockhart River
Runway 12 RNAV (GNSS) non-precision approach
was being conducted, via the LHRWD waypoint, in
instrument meteorological conditions (IMC), with
the flight management system coupled to the
autopilot:



At the time of the warning, the airspeed was 130 KIAS
and a rate of decent of 700 fpm in IMC at an
altitude of 2150 ft.


None of the above sounds like an unstable approach to me!

[alphacentauri]

I can't defend/nor explain the GPWS warnings. I can only say that they don't happen all the time.

I can defend the approach, because I was involved in the ATSB review of the approach from an independent view point. The approach was compliant with the criteria of time and was given the seal of approval. There was nothing wrong with it and there was never anything found in the investigation to point at it being unsafe.

That's really all I have to offer you.

I am defending the approach because numerous times since the accident people have got on here beating the war drums trying to blame everything on the approach. Alot of times these people are far from informed on approach design and verification involved in publishing one. Maybe they pick on the approach because its the only thing they can pick on, and feel qualified to comment on. To persue other avenues means enevitably concentrating on the cockpit environment.

But we dare not point the finger at those who cannot defend themselves.

And its that point that keeps these questions coming back. The argument seems to be that there has to be some reason, other than the aircrew, for this accident to occur.

Does there? Really? What if there isn't?

[Oktas8]

It would seem that there are only three options available to fix the false GPWS alarm problem, other than re-equipping with EGPWS.
1 - remove the approach;
2 - raise MDA or make the approach angle quite a lot steeper;
3 - realign the whole approach to avoid the offending terrain (which might in turn force a higher MDA).

These options are either operationally undesirable or quite expensive. Perhaps the operators who use the approach should present their case to Airservices, with reference to Airservices' own charter.

If change is really necessary, convince someone that the safety case for change is stronger than the she'll-be-right case for none.

[Sarcs]

O8 it was changed mate, at the end of 09!:ok: Sorry couldn't help myself...

[Sarcs]

And its that point that keeps these questions coming back. The argument seems to be that there has to be some reason, other than the aircrew, for this accident to occur.



I don't think you will get much argument on here that the poorly trained, ill disciplined crew were very much causal to this accident, or if you like one of the holes in the reason model.

Does there? Really? What if there isn't? But what if there is?

[blackhand]

or if you like one of the holes in the reason model.
I think not, a ******** flew the aircraft into a hill.
No invoking of Mr Reasons theories will alter this.

[Frank Arouet]

Re the pulling of the other thread, I neither posted it in jest or otherwise, it was a legitimate query, but the outrage from old mate Mick was profound and direct and confirms the loudest noise comes from those with the vested interest to silence it. Also to those with access to confirmed information.

Shame, shame, shame on the PPRune PM system.

I have the same medical priveleges of half the posters on this thread which may, or may not, make me a practising professional pilot, but I believe Mr ironbar is mostly selling hair restorer on street corners these days. (or a consultant to some pigs trough space).

The Families are simply wanting of some closure to the LHR matter, I'm not exacerbating their grief, but believe there are many avenues that have not been fully explored. Indeed left open.

[rmcdonal]

With all due respect rmcdonal, neither of the reported incidents were unstable approaches
I didn't say they were unstable, GPWS alerts are based on speed and timing (Closure rate) and as such the faster you fly the more likely you are to receive a warning. As per your initial post Further, flying a stabilised approach at high speeds caused GPWS alerts to be activated. So too did the use of the step down approach where at 5.3 nautical miles to waypoint LHRWM, at 2,060 ft, a "terrain terrain" hard warning occurred and at 4.6 nautical miles to that waypoint a further "terrain terrain" hard warning occurred..

It would not have surprised me however if the database coding for the GPWS at that airport was poor resulting in a higher number of spurious Warnings.

[Kharon]

AC - I can defend the approach, because I was involved in the ATSB review of the approach from an independent view point. The approach was compliant with the criteria of time and was given the seal of approval. There was nothing wrong with it and there was never anything found in the investigation to point at it being unsafe.


Furry muff, if I was to comment it would only be on the repeated phrase “at the time”. I don't, personally, believe the approach, or the rush to PANS OPS approval was as 'sound' as it could be. But; did the approach kill anyone – I doubt it, so lets say, on balance the approach whilst 'questionable' is not guilty.

The thing that intrigues me about the “TA” approach is why any potential or perceived threats were not investigated as part of the 'proving' flight process, why there was no SOP for the port written up and trained for. A close approach over high ground in mechanical turbulence is routine but for RPT ops it must be additionally covered because the aircraft is obliged to go; rain, hail or shine.

AC- But we dare not point the finger at those who cannot defend themselves.


I think in honesty we must, there is little doubt about the quality of the crew on the day. But, pragmatically we must ask how they were allowed to continue to operate in that fashion. That sort of behaviour does not sprout overnight, normalised deficiencies are a killer. A half way competent C&T pilot would have beaten them out of the habits acquired through home made SOP and operating practice. Anyway – I digress.

The questions raised by reading through the Coroner, ATSB and others leaves some serious doubts (and bad tastes) not so much about the accident it's self but the aftermath. It's a pity we haven't got an aviation polly with balls big enough and brains to match the assembly, to ask some questions. The Senate report the Minister signed off after YLHR was a bigger fairy story than the last white paper.

One thing is certain sure though – I'd hate to see it happen ever again. History of course has and does repeat it's self.

[Sarcs]

It would not have surprised me however if the database coding for the GPWS at that airport was poor resulting in a higher number of spurious Warnings.

Good point rmcdonal, maybe that was the problem with South Pap as it wasn't depicted as a spot height on the original LHR plate. It only had a contour of 1500', which I always thought meant it was not properly surveyed (alphacentauri can correct me if I'm wrong).

So in terms of the database for the GPWS South Pap wouldn't have been depicted, hence the occasional hard warning from the RADALT, ah the penny drops!

[004wercras]

Interesting thread and one that should be promoted, seems to me that the LHR mistakes and questions should be probed and prodded so it doesn't happen again!

As Will once wrote, "time shall unfold what plighted cunning hides...
Who cover faults, at last shame them derides."

It's about time we got some credibility back into this industry and got rid of the deniability and fear of liability. Otherwise there will be more smoking holes in the landscape!

[Up-into-the-air]

Exactly 004

[Clearedtoreenter]

The basic concept of these approaches is flawed.

+1 to that. They are an ergonomic disaster area. Far too easy to mistake a waypoint and go down too early, especially with some of the earlier GPS units, single IFR pilot, high terrain .....and the holes begin to line up. The system is flawed.

[Kharon]

Spent a very interesting day with some fellah's and the YLHR documents, half expected to be bored rigid; and, it is 'dry' until you start to see what's going on. Join the dots and see the hidden pictures.

I'll say this, not for a million dollars, a pension, a bag of sweeties, a night with you're sister and a free holiday in Europe would I have been Coroner Barnes. What a superb effort he put in; he could see smell and almost touch the hidden problems. Top marks, I guess these folk ain't doing the job because they're any where near dopey.

He just couldn't beat the dichotomy created the two warring bodies, both trying so hard to 'cover' the more sensitive parts of their piers anatomies. (Wood from trees).

I reckon that a honest, independent inquiry could uncover 2 essential truths.

The most probable and ranking causes of the accident.

The reasons for the extraordinary lengths gone to by the protagonists to avoid, conceal and obfuscate these vital details and witnesses.

Kudos to Mr. Barnes ? Absolutely.

The approach design whilst interestin' is not where the story lays. The`ATSB survey and the CASA response was a much better read, but a sidebar to the headlines.

Steam off.

[Iron Bar]

While the discussion regarding GPS approach construction and the ground prox' functionality is most valid. To the 7th fleet conspiracy theorists I will say this.

Occam's razor 

the maxim that assumptions introduced to explain a thing must not be multiplied beyond necessity.

(Why manufacture a complicated answer when the simple one is sufficient)


The unfortunate circumstances surrounding this accident are clear and available for all to read and learn from. I certainly have.

From the ATSB report

3.2.1 Contributing factors relating to occurrence events and individual actions

• The crew commenced the Lockhart River Runway 12 RNAV (GNSS)
approach, even though the crew were aware that the copilot did not have
the appropriate endorsement and had limited experience to conduct this
type of instrument approach.

• The descent speeds, approach speeds and rate of descent were greater than those specified for the aircraft in the Transair Operations Manual. The
speeds and rate of descent also exceeded those appropriate for establishing
a stabilised approach.

• During the approach, the aircraft descended below the segment minimum safe altitude for the aircraft’s position on the approach.

• The aircraft’s high rate of descent, and the descent below the segment
minimum safe altitude, were not detected and/or corrected by the crew
before the aircraft collided with terrain.

• The accident was almost certainly the result of controlled flight into
terrain.


To perpetuate this alternate "theory" is harmful and embarrassing.

Now, back to my Rogaine vending van.

[Kharon]

PP - The worst part is I work for a company that has a lot of the very same safety culture issues that Transair displayed. What does CASA do about it.

Sadly, probably the same as they did last time and every other time before “Not our fault M' lud, no Sir; and, we will go to extraordinary lengths to prove it” quoth the sock puppet.

It's a tried and tested approach, why change a system that works – just fine. Just ignore the bodies folks nothing to see here, your jovial, robust authority will now check your WAC chart date.

Aye - “If the Lord the power would give us, to see ourselves as others see us.

No mention of the ICAO or FAA words were there, are we on?. Merde - Click.

[waren9]

Good point rmcdonal, maybe that was the problem with South Pap as it wasn't depicted as a spot height on the original LHR plate. It only had a contour of 1500', which I always thought meant it was not properly surveyed (alphacentauri can correct me if I'm wrong).

So in terms of the database for the GPWS South Pap wouldn't have been depicted, hence the occasional hard warning from the RADALT, ah the penny drops!

Sarcs

Jeppesen advise that not all spot heights are necessarily depicted on approach plates.

[Sarcs]

Wazza I was aware of that, maybe it had something to do with the fact that the approach was overlayed over the South Pap spot height.

However having checked the other LHR plates (amendment 15 JUN 07) prior to the RW 12 RNAV GNSS changing, at the end of 2009, the contour of 1500' was depicted for South Pap but not the spot height on all the LHR plates.

Once the new plates came out, all of a sudden, South Pap was depicted as a spot height of 1330' (from memory), hence I reasoned that maybe it had been properly surveyed in the interim!

Anyway Waza just food for thought, now back to the blokes with the blinkers on......Mick old mate, if back in your day when you were fanging around the corner on the ol' checkerboard in your Tristar....would CP have accepted that you just had a CFIT accident while turning onto final at Kai Tak?:=

No Swires (or whoever owned it back then) would want to know how a Rogue Cowboy Captain was allowed to escape all their fuzzy little systems. Do you think your HOFO would have said to the big bosses... " Old Mate Mick always thought he'd come to grief one day"....sheesh:ugh: