VH-PGW ATSB report

[Jabawocky]

Expected release Q1 0f 2012

Update to Q2 of 2012

Almost 2013.

Any ideas?

[Old Akro]

I think the delay is scandalous. I think it reveals that the ATSB has no real interest in improving safety. I think it is a demonstration of a number of areas of the public service where (for whatever reason) the government departments are simply not doing what we are paying them to do.

I made a post asking about the delay in the report of the Angel Flight Cherokee near Horsham (15 months and counting). In response someone suggested that the reason was the beating the ATSB are getting in a senate committee over the Pel-Air report.

If you scroll there the released reports of the last 3 or 6 months, I think 3 things are apparent:
1. Reports seem to be released in groups only once or twice a month, usually most reports come out in the last days of the month. I wonder if they sit on someone's desk for approval?
2. The list of incomplete or pending reports is growing. They are not keeping up with the workload.
3. Most reports that are being released are minor in nature. There doesn't seem to be any reports of substance that might contain lessons that have been released in ages - maybe even since Norfolk Island.

I don't know what happened to the credo of "frank and fearless advice".

[Jabawocky]

Agreed Akro...sadly!

The Cherokee crash, as tragic as it is, is mostly a repeat of the same things for the umteenth time. Just like the dragon. I am trying to be realistic here. From a few early details, an initial study of what happened, I think we can group all these types of accidents, regardless of the loss of life, and say...nothing new here.

The PGW and for that matter the the Norfolk ditching are somewhat more worthy of spending time and money on. FFS they did not and still have not pulled the recorders. :ugh:

Benalla and Lockhart are reports I am starting to wonder about given some things were not thoroughly explored.

Without harping on, if you accept the botching up of the Whyalla report, which will forever be a huge embarrassment to the bureau, as being a litmus test, there does indeed raise doubt over the rest of the reports.

It seems to me that the mundane ones get churned through easily, the kinds of things like airliners getting too close, plenty of easy to diagnose data available, but for anything else....where some really clever stuff is needed, it is a coin toss.

Don't for one minute assume I think I am in any way an accident investigator of worth, but I do wonder if the few really good ones we have are always on the ball due to other pressures.

And it does seem ironic that the priorities of what is looked at closely and what is not, what is actually reported in detail, are becoming less than consistent. Like as if there are greater forces at play. Agendas to meet.

Maybe this is less of a mystery to some, but it is not looking like a logical well executed service to industry and the public. Budgets are tight, sure, but where the money is spent is what puzzles me most.

[Kharon]

So close on the heels of the aftermath of the on going, slightly embarassing Pel Air enquiry; I wonder if they dare? Canley Vale closely followed by Hempel. Woo hoo – bring on the New Year, I've got my Christmas present.

Fee-fi-fo-fum,
I smell the blood of an Englishman,
Be he live, or be he dead
I'll grind his bones to make my bread. http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/thumbs.gif

Amend to suit -

[Sunfish]

Why do you need a report?

Following on from the Pel AIr/ Norflk Island performance:

1. The ATSB has no safety recommendations.

2. CASA says its all the pilots fault.

Case closed.

[Old Akro]

Sunfish,
You might have missed #3 that CASA inspectors have had a number of longstanding unspecified concerns about the procedures and safety of the operator that were not communicated to the operator, but will be leaked to the press.

[gobbledock]

Old Akro,
If you scroll there the released reports of the last 3 or 6 months, I think 3 things are apparent:

1. Reports seem to be released in groups only once or twice a month, usually most reports come out in the last days of the month. I wonder if they sit on someone's desk for approval?Corect. Usually at the end of the month to 'prove' that work has and is being carried out at the ATSB. It's an old smoke n mirror trick and is meant to make the taxpayer feel warm and fluffy, that his money is being robustly and well spent. And yes, reports often have to be given the green light first by the Minister, the Beaker, and a few other filtering levels and even discussed with the operator prior to going public. A final investigation report for instance could take 12 months to complete, but it could then sit in the sweaty palms of some postulating trough dwellers for another 12 months before getting the final ok. You know, the lawyers have to disect each word and ensure no that government entity is included in any of the blame. Can't have government or the Minister looking bad can we? It wasn't as bad as this 4 years ago.
Team Beaker = FAIL

2. The list of incomplete or pending reports is growing. They are not keeping up with the workload.Nothing new in that statement brother. A growing aviation environment, coupled with the fact that our current one is slipping to a standard that even raises ICAO's and FAA's eyebrows means the fronline Investigators work is growing due to increasing incidents and accidents. Of course funding is growing, but only enough to satisfy management's hunger for huge salaries, bonuses and trips abroad, and for filling back offices with more mid-level management. The frontline always misses out. It wasn't as bad as this 4 years ago.
Team Beaker = FAIL

3. Most reports that are being released are minor in nature. There doesn't seem to be any reports of substance that might contain lessons that have been released in ages - maybe even since Norfolk Island. Another bureaucratic ploy - spin, smoke n mirrors and polishing the turd 101.
Releasing a bunch of low level investigations puffs up the numbers on paper and makes it look like they are keeping up with the workload and managing sufficiently. But it is a carefully scripted stage show. The true facts always come out, and they do when you look at stats on how long it takes to produce a high level report, how many of those reports make it to public within a reasonable time frame, and the quality and accuracy of the report. The decline commenced 4 years ago, blind Freddy can see that. Again, protecting governments, gravy trains and one's own spotty botty takes precedence over real facts, lessons learned and the truth.
Team Beaker = FAIL

Aagh Jaba san,
Benalla and Lockhart are reports I am starting to wonder about given some things were not thoroughly explored.Praise the Lord my scholared non-tautological friend! You have seen the light!You have smelt the pooh! AMEN!!
Seriously, correct Jaba. If you take a look at those previous investigation reports (prior to Team Beaker) you will see, I guess for better words, some interesting reporting. However, if you look primarily at Lockhart through the eyes of government and the Regulator you will see that some of the findings and reporting match perfectly with their devious, fact spinning, deflecting methodology.
Don't let facts stand in the way of a good story type of mischief. CASA was scrutinized over Lockhart, and concerns were raised and pointed in their direction regarding approach plates and 'inspector oversight' by way of surveillance and audit, but of course they escaped, 'scott-free', as usual. Keeping in mind the 'James Reason' Tasmanian cheese model you will no doubt recall that there is virtually always a number of causal factors. And that is precisely what occurred at Locakhart.
And one of the clever ploys they adopted as part of the post accident ruse? Adopting SMS. Now SMS in itself is an interestig discussuion point which doesn't belong here, but SMS, when used incorrectly, is a great tool for ensuring the government remains at arms length from any blame when something goes tits up! They can say - Safety is your responsibility. It is all your fault.

[Sunfish]

The "safety management system" I remember from my Exxon/esso days was designed to:

(a) ensure any troublemakers with a genuin concern for safety were identified and removed.

(b) ensure any accident or incident could be successfully blamed on a low level employee/victim.

(c) ensure that the company and senior management escaped any responsibility via plausible deniability, usually proven by the existence of lovely manuals and an internal reporting scheme.

The actual intent of the scheme was the exact reverse of the published purpose to whit forcing employees to cut corners to save money and ensuring they wore the blame for the resulting incidents and accidents.

[Up-into-the-air]

The initial report from atsb says:

The investigation is continuing and will include:

1. An ongoing examination of operational issues including pilot training and checking

2. Continued analysis of recorded radar data and voice transmissions

3. An ongoing human factors review.

It is anticipated that the final investigation report will be released to the public in the first quarter of calendar year 2012.

Item 3 did not occur with the Norfolk Island "investigation" by atsb, it will be interesting to see if it has happened with PGW.

and if not, WHY NOT

[Up-into-the-air]

Since 15th June 2010, there are 98 un-completed investigations. The oldest appears to be PGW and a general report on R22 belt systems from 2009.

The completed column over the same period shows around 215 reports "completed", of all incidents, so over that period, only 2/3 have a "completed" sticker and we know the extent of some of these such as the Westwind ditching at Norfolk and the problems inherent in this with the Senate inquiry.

[Old Akro]

Its a bit worse than it looks because many of the 215 "completed" reports are small investigations or records of assisting other bodies.

[Up-into-the-air]

As I said "completed" and if you take out all the "easy" reports, atsb is not doing much at all.

The attitude in the Norfolk one, where there appears to a be too cosy a relationship with casa strikes me as a real problem for long term air safety.

Maybe the FAA was right in their assessment some years ago, with the un-answered compliance notices. I can repost the link if you are un-aware of this.

[Jabawocky]

Next Thursday, :hmm: great timing :hmm:

This thread will be 16 pages long by the time they get back to fix up all the errors we find here on pprune.

My guess is the company, the senior management and many of the crew will be ducking and weaving and hoping the ATSB don't do a good job. Sorry, ex company and management will be.

Just a long shot. But if I am anywhere near accurate in my suspicions the CASA will be likewise hoping the ATSB do a poor job, otherwise it will be Lockhart, Archerfield/Straddie, Norfolk, Botany, Bankstown.......... Surely it is just coincidence.

Stop calling me Shirley

[bentleg]

ATSB Final Report (http://www.atsb.gov.au/media/4058105/ao-2010-043_final.pdf)has issued

Have to feel for the pilot a bit. Took the "normal" descent profile but when he found he had to hold his altitude he couldn't do it. Very sad.

[Old Akro]

131 weeks to write 56 pages.

[strim]

The PA31 is one of the worst single engine performers in the light twin category.

1" of manifold pressure, couple of degrees of bank, position of dead enging cowl flap, even the condition of the paint and props all contribute to the difference between climb, level flight and descent.

Any endorsement process that didn't ram this into the candidate to the point where they had a healthy fear of the machine certainly shouldn't qualify as "not a bad endorsement".

Nothing alerts a pilot more to the limitations of this aircraft OEI, than the VSI whilst holding Vyse and opening the cowl flap.

I feel this pilot may have slipped through the cracks. Cracks that CASA let grow for far too long.

I also feel that this pilot, the organisation he worked for and the culture of GA, probably all saw the endorsement process as a box ticking exercise in order to get a job, not a process whereby you learn things that may one day save your life. If only he'd been trained properly, by a proper aviator who saw the bigger picture and took the time to prepare this young man to operate this aircraft safely. Unfortunately he's now another statistic; another young pilot who didn't make it through GA.

Light twin drivers take note.

[Jabawocky]

strim

It would seem most of the nails have been hit on the head. And CASA will once again have a lot to answer for.

The operator, the CP, the C&T folk....everybody involved in this outfit will no doubt be ducking for cover. Remember the court cases when they were shut down.

This will not end here. I can see Justice Seeker getting wound up big time.

This poor pilot made all sorts of poor decisions, we have done them over in previous posts. Not much new has come out here. The system that allowed this to happen is another matter.

Why is it CASA will chase a PVT operator almost to jail over a Beech rudder pedal inspection two days over due, yet this kind of outfit gets away with years of non conformance, plus a Metro and Mojave crash......and numerous other "incidents of serious natures" and nothing happens.

They should have been working closely to achieve an outcome, not doing an audit and saying fix this, and not seeing it through.

And not that it changes much, but does anyone else find the ATSB's summation of the engine anomaly a little bit.....like.....errr.....Bull****?

About time compulsory EMS fitment and PROPER education in what they are telling you. Not the crap printed in CPL texts and CASA exams :mad:

[kimwestt]

G'day,
From the mid eighties, and for years and years "the Operator" concerned tried to have a formalised Check and Training org put into place. The CASA continually replied that because it (C&T) for under 5700 kg wasn't in the regs, it would therefore not be approved by CASA, and if the Operator were to include that in their COM, well the COM would not be recognised. On that matter, the operator wrote to the then Minister, asking for an explanation as to why they (the Operator) were being denied the opportunity to improve safety.
As I understand, the Operator still awaits a reply.
In reference to "working closely", you obviously are not "Bankstownised".
At an Audit conducted by Casa on the Operator, at the opening meeting, the then CASA Area Manager stated, and I quote :-
"We are not here to help you, assist you, or advise you. We are here to audit you and prosecute you. You had better watch out".
To say that there was a stunned silence at the end of that diatribe would be an understatement.
The company went very close, at that time, to ask the CASA team to leave the premises. In fact, subsequently, that team leader was declared "persona non grata" on those premises.
The non conformance issues you mention were very real, yet it seems that the main players in the saga have almost escaped attention.
Why have these persons been let off the hook?
And yes, I agree with you, the ATSB report leaves a lot to be desired.
Why was this report written in the way it has been?
Why were several warnings by senior pilots to both CASA and the company ignored?
There should be more to this report.
:mad:

[Jabawocky]

kim,

you are correct, I am not in the slight bit interested in going to Bankstown, although I should have flown there and back yesterday instead of going via an airline, as the YBBN holding is beyond the joke...but back to topic.

As for all the goings on with the operator have no axe to grind, but from the previous threads, the court transcripts of them being shut down there seems to me to be two sides to the story and both are bad.

CASA and whoever the persons concerned are I have no idea, but clearly they were not doing their job, despite what they were actually doing. The operator it seems from what I can tell was also not doing their job.

It seems to me that the ATSB again have not done a very good job, and it seems like all three organisations should be shut down. So far only one has!

I am really disappointed, actually completely pissed off at the ATSB report. Sure focus on all the lack of training and all the things done poorly. I would take a lot of convincing that the operator was doing a good job. There is no way all the bad stuff that happened to them over the last several years was just "unlucky". The message I get is there was a lot of sub standard stuff going on and many of the young pilots would not have known any better.

CASA clearly has not been doing a "GOOD" job. They were obviously doing a job. But when you measure QUALITY by assessing the OUTCOME.... FAIL!!!

[OZBUSDRIVER]

My sentiments exactly...

WRT ATSB report... I am a bit incredulous. Faster than single engine climb speed and you cannot maintain altitude??? Is this in the context that any faster than Vyse is a waste of limited available power...meaning you are going downhill?

[Obidiah]

I will be interested to see what the CASA puts out in regard to the recommended additional OEI guidance material for engine handling.

The final report is,.. well a report, thorough in some areas wanting in others, no doubt the condition of the wreckage made it very difficult.

But the thoroughness seems focused on audit outcomes and C&T processes, relevant yes, but I really wanted to learn and understand more about the mechanical issues at play. Particularly in light of the history of so many in flight engine issues recorded in the last 4 years, including surging.

Uneven fuel distribution, perhaps, after all they did find one faulty injector, although undetermined as to what when it failed (pre/post crash) but I am not really buying it. FCU issue/fault seems more plausible, but you would possibly still have even distribution, just not the correct A/F ratios. No history on the FCU given in the report, or I missed it.

This report might well be grist to the mill for the likes of John Deakin and co. as had it just been a plugged injector blocking and un blocking and the A/C had (maybe it did??) a more comprehensive EIS the pilot may have seen it for what it was and elected to just reduce power on the R/H and return gracefully. Somewhat supposition though.

I cannot help but feel that the aircraft themselves should be subject to some form of compliance process other than just a CAO statement that it must achieve 1% gradient to 5000’. The pilots get grilled over and over again on performance, but what about the aircrafts performance.

Perhaps a phase in of a structured ongoing audit process on commercial low performance twins where they physically demonstrate the ability to achieve book figures. Those that fall short have a MTOW penalty imposed and an amended MTOW inserted into the AFM. Perhaps a two tier requirement non pax and pax services.

If I were a pax on board I would like to know that the young hour building pilot up front of a low performance twin had at least an aircraft that will afford him a modicum of performance on one.

[Up-into-the-air]

I have read the report by atsb - Agree with Jabs - "FAIL"

Lets have a look at some of what is missing in the atsb report:


Maintenance Issues
The "surging engine";
The effect of the regulator


And from Obidah:

Uneven fuel distribution, perhaps, after all they did find one faulty injector, although undetermined as to what when it failed (pre/post crash) but I am not really buying it. FCU issue/fault seems more plausible, but you would possibly still have even distribution, just not the correct A/F ratios. No history on the FCU given in the report, or I missed it.

Well, the history that atsb reports should have identified maintenance problems, yet no reccomendations.

The reference by atsb to casa is as follows:

CASA audit and surveillance

No organisational or systemic issue was identified in respect of CASA’s surveillance that might adversely affect the future safety of aviation operations.

However, during the investigation CASA advised that, in September 2010, it had commenced a Certificate Management Team approach to its audit and surveillance activities.

This change was intended to improve the evaluation capability across CASA, allow the more effective assignment of resources, increase knowledge sharing, clarify defined roles and responsibilities, and foster standardisation and consistency.

Yet the AOC is removed by casa.

Do we have yet another failure by casa to surveil, and an attempt to "cover up" the fact by "executing" the AOC holder in the AAT??

PLEASE EXPLAIN Mr. casa and Mrs casa [sorry - atsb]

[Jabawocky]

Obid,

Funny you should say this.This report might well be grist to the mill for the likes of John Deakin and co. as had it just been a plugged injector blocking and un blocking and the A/C had (maybe it did??) a more comprehensive EIS the pilot may have seen it for what it was and elected to just reduce power on the R/H and return gracefully. Somewhat supposition though.

Well I was wondering if I should post the private correspondence I had over night with the very folk you mention. But seeing you make mention here goes, and to be fair I will post my email to the guys last night after I read the report.

Is this another ATSB report like the Whyalla report?

OK, not a bunch of fare paying pax, but a flight nurse, and an under trained pilot are dead.

Initial problem a “surging prop”

ATSB accept Lycomings response being surging from a fuel distribution problem.

Cause of the engine surging
The engine manufacturer advised that the surging identified by the spectral analysis of radio transmissions during the accident flight was ‘consistent with uneven fuel distribution to the cylinders’. The propeller manufacturer advised that it had ‘yet to find a causal factor in surging that was clearly identified as being from the propeller or governor, especially for a report of a large RPM excursion’.

I am perplexed at how this could be, in the climb with a TC engine surely full rich, the partial plugging of an injector would mean no noticeable power surging (if EMS equipped a rising EGT, TIT, and CHT on the affected cylinders) and not sufficient power loss that RPM variations occurred. If the injectors to one or more cylinders were such that they went excessively LOP and or beyond operational flows, it would have vibrated liked paint can mixer.

I find that hard to believe. Maybe I have a lot to learn.

In this case the PIC handled the whole event poorly, very poor on a number of fronts, and should not have shut it down completely and not descended at all until overhead YSBK. That aside….have the ATSB cocked this up like MZK?

Another good case for charter ops to have a fully functioning EMS and pilots educated to use and understand it.


And here is John Deakins reply, and I must say he has a few very interesting observations about what to do in such an emergency. If only I could learn half of what he has forgotten.Your analysis is "spot on."

CASA (typo should be ATSB)discounts the effect of the landing gear warning horn (one throttle back, gear not down). From personal experience, I can tell you that can have a MAJOR effect on the human brain, and if loud enough, the noise alone can be utterly incapacitating. And I do mean incapacitating. I cannot help wondering if he'd just advanced the throttle on the feathered engine to get rid of the horn, the whole thing might have been avoided.

There's no mention at all of any ACTUAL shutdowns performed during training or proficiency checks, and a passing reference to the Chief Pilot not being an instructor, and therefore not authorized to conduct such training. The young pilot may not have been aware of what that horn was, or how to get rid of it.

Of course, there was apparently no reason to shut the engine down in the first place for the minor surging alone.

The surging sounds more like a problem with the prop governor or the flow of oil to/from the prop. Lycoming was willing to blame it on "something, anything else" to avoid liability.

They said that not having the correct bank angle probably would cost 20 to 30 feet per minute difference. I'd dispute that strongly, this alone might have had 200 to 500 fpm difference. The manual also suggests 5 degrees as optimum, which is not correct. That's a certification allowance for CONTROL at Vmc.

The whole report strikes me as self-serving for CASA. They have set forth massive requirements for Airmen of all levels, and specified paperwork and forms to be completed to show compliance. Many "Manuals", and other documents, most requiring some repetitive action within close time frames. They go into loving detail for all this, for 68 pages. It goes on and on, and it means nothing, distracting from the "real mission," which is to get there, safely.

Disgusting.

Best...
John Deakin
Advanced Pilot Seminars


So along with that one and a few others, who likewise are struggling to see what value there was in this report, as it was not helpful in preventing further crashes, it was more like a police report to a coroner, which makes me think, whose job are they doing here?

A pilot and a flight nurse lost their lives here...surely they deserve better than this???

There was this comment from from Walter Atkinson, John Deakins associate at APS, who understands my position on all commercial ops having an EMS and pilots specifically trained how to understand what they display and not just stare and blinking numbers and bars.
The presence of an engine monitor would have confirmed this and given the pilot useful info about a confusing situation. When are the Aussies gonna figure this EMS issue out?


Seems they share the same frustration.

‘consistent with uneven fuel distribution to the cylinders’.

Poor fuel distribution my arse, supply maybe :ugh: If the wreckage was that bad, that they could at best come up with that conclusion, they should not have been making any. Lycoming :ugh: I think the prop people are the only sensible ones in this bit.

Rant over for now....not happy Jaba is going home from the office to cool down. Merry Christmas Y'all.

[Old Akro]

I have printed the report but not yet read it. On first glance, I suspect that the ATSB has side stepped the more difficult issues that might have delivered some lessons.

Top in my mind, is that I can't imagine a pilot who has been dealing with an issue for several minutes and has a descent rate that knows is a problem is not going to push the throttle forward at some point. You might start out trying to be nice to the engines, but at some point I struggle to believe that desperation won't kick in and you'll push everything forward. I'm expecting to see some gaping gaps in logic from the ATSB here.

I disagree with the EMS bit. It wouldn't have changed a thing. The experience of the engine surging is going to over-ride what any instrument says. Either you can deal with the engine misbehaving to gain whatever residual power it will produce or you wont. EGT's can't help assess that.

We tend to think of aircraft fuel injection as more complex than it is. It is what the car racing guys call "piss & dribble". The injector is a brass fitting with a hole in it. It continuously sprays fuel into the inlet manifold at the back of the inlet valve. I'm going to read the ATSB analysis of this with interest.

[Tidbinbilla]

Thread edited to bring back onto topic :O

[Horatio Leafblower]

I was in Bankstown yesterday and heard a rumour ATSB could only find one LAME in Australia with enough knowledge of a Mojave engine to properly supervise the tear-down.

...the same guy who built it :ugh:

We operate similar aeroplanes and the Chief Pilot yesterday took the ATSB report, made a copy for every pilot in the company, and went through all the salient points asking for the crew's imput on where we might be making the same mistakes.

How many other Chief Pilots have picked it up and done the same?

[Jabawocky]

Leafie,

I know a guy in Adelaide who would have been ideal for the ATSB to use. They did not look too hard did they? :ugh:

Akro....I concur with the first line. Much is missed.

As for the EMS bit, I and many others strongly disagree with you. Having said that, pilots who are not trained properly on how to understand their EMS may well be a "Deer in the headlights" and I would say that is 95%.

If the ATSB report of the No6 injector being completely blocked happened in flight, what was the obstruction material? Had there ben any fuel system work done recently? Surging engine RPM does not seem likely from a blocked injector. And yes, an EMS that displayed all the typical parameters such as fuel pressure and flow, EGT/TIT/CHT, oil data, accurate tacho, would have made understanding the problem far easier and allowed for better decisions to be made. Assuming they were understood. If it were partially blocked, that would have stood out like a sore thumb on an EMS. Fully or almost fully blocked that also would have stood out, but the engine would have been shaking itself off the mounts almost.They don't feel smooth on 5.

Your description of the fuel injection is completely accurate :ok: And not very easy to completely block unless someone introduces lint or sealant in recent times. Unlike a car.

Reading the report makes you ask more questions than were answered.

[Horatio Leafblower]

Here is another thought....

...I just pulled out my PA31 manual and it stipulates 49.0" MAP as the maximum value up to 15,000'. In fact I am trying to remember the last time I saw a Chieftain pulling anything above 44.0".

It is common practice to "dial back" the max MAP on Chieftain engines to protect them from over-boosting by the pilots.

Who, then, is going to be protecting the pilots and the passengers from the under-boosting?

What is the maximum MAP set up on OGW or IGW or the other remaining Luft-tex Mojaves, or for that matter their Chieftains? :suspect:

[Old Akro]

I've just finished reading the report and I'm a bit dumbfounded. I regularly either write or supervise engineering reports for both clients and as court reports. Overall, I think the ATSB document fails as an engineering report and I would question whether the author has sufficient technical understanding for the job. I find it interesting that it has a range of human factors texts cited in full Harvard referencing discipline. However there is no reference to technical and measurement equipment used, its calibration, not a discussion on the limits of accuracy.

This is not a technical document.. It fails any basic test as an engineering report.

Furthermore, the references to surging RPM and engine roughness through "uneven fuel distribution"are prima facie contradictory. I am concerned that the author does not understand the operation of a CSU. If the statement that the RH engine was exceeding the maximum permissible RPM is correct, then this points to a CSU issue, not an engine issue. The engine should not be able to make the propeller go faster than redline. This also fits the history of that aeroplane (which is glossed over by the ATSB). I might come back and side with John Deakins a little, because if an engine monitor showed normal EGT's it would have allowed the pilot to immediately deduct a propeller issue. Although the standard equipment TIT should be adequate for this. A single non firing cylinder should cause an overall drop in TIT.

The reports inclusion of un-named pilots opinion of the PGW pilots flying ability makes me as mad as hell. This is nothing better than reporting on gossip and has no place in a professional report. If the ATSB saw value in collecting opinions of the pilots ability beyond that of those tasked with doing so by the CASA regulations (ie Chief Pilot, ATO, etc) then the correct way is to conduct structured interviews, disclose the position of the interviewees, append the list of questions and cite quotations from individuals and / or conclusions while keeping the identity of those question confidential. This is easy, routine and practiced by the market research industry daily. Frankly, it makes the ATSB look like hack amateurs in my opinion.

In my opinion, the report also seems to indulge in gratuitous criticism of the operator and its operating discipline that is not germane to the accident. If this is an accident investigation, lets stick to the accident. If its a witch hunt, then lets call it that.

Here is my hypothesis & take home lessons.
1. It looks like PGW lost a lot of height before the engine was feathered and the pilot was trying to diagnose the issue. I'm not sure that I've really seen this discussed, but it sounds real. Its possibly a reminder that in some situations you might be better to go straight to feathering an engine rather than diagnose it.
2. The pilot did not immediately go to VYSE and I think this might be a reminder that regardless of altitude or descent profile, that this is the best practice.
3. It looks like the pilot has tried to fly a normal descent profile back to Bankstown. I can absolutely see how one could be suckered into this. In part its an attempt to manage stress and make things closer to normal and potentially a fear of arriving too high. There is a joke about forced landings in Pitts that you choose the landing spot by throwing a brick out and following it down. I think this is a reminder that you need to plan to be way high. Its better to land at an airport fast & high and run off, than not land at an airport.
4. The pilot tried to follow the directions of ATC. Once we have a problem, the pilot should be assertive in telling ATC what he needs. I'm disappointed there is no discussion in the report of whether ATC might not have played a more supportive role. The stuff about not making a PAN call is bureaucratic mis-direction. The controller knew it was an emergency. Some of the US radio transcripts of emergencies we read in magazines show the controllers taking an active role in coaching or supporting the pilots. Should we encourage that here? Would the outcome have been different if PGW had not been directed to descend from 5,000ft to 2,500ft, but instead have been allowed to continue at the pilots discretion?
5. Trying partial power asymmetric is not something I have experienced in my training. "Fire, Fix or Feather" is drummed into us. Is there a role for trying a partial power setting first?
6. There but for the grace of god.... I'm not sure how well I'd stand up to the personal scrutiny that the ATSB gives pilots. I'd like to think I wouldn't make the same errors as this guy. But he seemed a pretty good diligent pilot and in quiet moments, I'm not really sure how much better I might have done. Which is why we deserve decent ATSB reports.

[Obidiah]

Akro

If the statement that the RH engine was exceeding the maximum permissible RPM is correct, then this points to a CSU issue, not an engine issue

I wouldn't be to quick to draw that conclusion, it is not unusual for an engine surging toward full power in flight to briefly exceed the governors ability to catch it at red line, mass inertia and all that. The report did not state the magnitude of the exceedence due to the sprectral measuring apparently topping out at 2600 RPM.

The exceedence may have been only a 100 RPM, enough to generate the comment in the report but not enough to consider abnormal. Difficult to make conclusive statements.

I have no idea as to the natural limitations of the spectral analysis equipment in the circumstances, but I for one would like to know how large the exceedance was.

Can't help but wonder if the ATSB was shaken to the core over the Whyalla report that ever since they have shyed away from technical analysis of pistons. So many of us backyard experts quick to internationally embarrass them if they get it wrong. Humans are nothing if not predictable.

I hope that from all this the training environments are encouraged to remove the "bogey man" mentality surrounding OEI training and encourage a more thorough and relaxed familiaristion to this regime of flight.

[Jabawocky]

Looks like we are all pretty much on the same page. You have summed up my thoughts very well Akro. Thank you for articulating your post so well.

Now how will things change? :hmm:

[Old Akro]

I don't see why ATC could not have given a clearance direct to Bankstown with decent at the pilots discretion. Like all accidents, there are a number of factors at play here, any one of which could change the outcome. PGW needed what possibly may have been as little as an extra 500ft to have made the airport. You've got to wonder if there had been no requirement to descend to 2,500 ft whether it might have made the difference. The controller directed PGW to give up altitude it had no opportunity to regain for the sake of operational expediency. I'm not blaming the controller or saying it would have prevented the accident. Its just another piece of Swiss cheese that the report is deficient in not having examined.

Secondly, I said publish the questions, not the answers. Absolutely standard practice for qualitative research. Interview technique 101. It demonstrates an objective framework and allows peer review without compromising the confidentiality of the participants. Once again, not being across these techniques would question the authors qualification for the task.

[Old Akro]

Obidiah

I get your point. An aerobatic aircraft going vertically down will not exceed the propeller RPM, so I based my judgement that a CSU will controll RPM under duress on that experience. I think your point is that transient fluctuations in engine RPM might cause the CSU to "overshoot".

My response is it might have been nice to have seen a paragraph discussing this point in the report. A discussion that this was considered in the report would eliminate our (my) speculation. Its a lightweight report that should not have taken 131 weeks.

[Roger Greendeck]

I am surprised that the ATSB ave discounted the role of the type rating training in the accident and have not even mentioned the ongoing training in the factors. If I am understanding their logic this is because the pilot had flown a lot of hours post training.

It is not my intention to be critical of the pilot as I know my ability to deal with in flight malfunctions is largely based on high quality training that I have received, not my innate skill. But I can't escape the conclusion that the aircraft ultimately crashed because of the way the malfunction was handled. If OEI operations was not taught well on the type rating, and/or was not well trained during subsequent ICUS flying, and not checked properly during the company's regular checks on the pilot, then when does the ATSB think that he would have attained this knowledge during the hours he accumulated? It certainly would not have developed all by itself during the almost 800 hours on type where both engines were working or the 1,700 hours multi where both engines were working.

[Lookleft]

HL that would have to be a very enlightened CP to have done this:

We operate similar aeroplanes and the Chief Pilot yesterday took the ATSB report, made a copy for every pilot in the company, and went through all the salient points asking for the crew's imput on where we might be making the same mistakes.

Unfortunately too many people do not read anything to do with flight safety even a report that is thin on some aspects of the flight. The reduction in standards of flight safety information coming from CASA and the ATSB certainly doesn't help. Posting on Prune is only preaching to the converted. Even if this report was the most stunning breakthrough in accident investigation it would not reach the hands of most of the people who would benefit most and that is the majority of GA M/E pilots. I don't even consider that its apathy or a "Gen Y" thing. The message needs to be taken to where the pilots work and that requires some sort of adequately resourced education group be it private or government. Unfortunately there is probably no money in it for private enterprise and there is no interest from government in really making a difference to GA safety.:sad:

[The Green Goblin]

I found the report disgusting.

I could have written a better report in a fortnight of what happened.

Basically the cause of the accident goes right to the heart of the culture of general aviation and CASA in Australia.

Insufficient training.

Operating in an often reckless manner from operational pressure in aircraft that are dubiously maintained.

Should a mojave be operating single Pilot doing the work it was doing? I think a Kingair or PC12 would be the prefered option.

To me, the fact the gear warning horn was blaring throughout the entire accident sequence suggest Willow was so loaded up, he had nowhere to go (mentally). He would have been operating at his peak processing ability. He found himself in a situation, probably was second guessing his actions (no pan call), and dreading the return to base to be told there was nothing wrong with his ship. Or to be picked apart for his actions. (from the report he had been put through the ringer on a air return due to pitch lever movement).

The fact he didn't lower any flap prior to the accident re-enforces my opinion of his processing ability.

Another hole in the cheese was when he heard a reassuring voice on the other end of the radio telling him to descend, and he complied.

I think ATC should clear you to your diversion airport with the instruction to descend at will. Or at least 'when ready'.

Imagine his family reading that report. Going from the son who saved the kids at the school and being called a hero, to an incompetent operator with a dubious history (from his so called peers) and selected comments from his training file to support the case. I'm surprised they didn't throw in the accident he had in Kununurra hitting a tree with an airvan wing. That would have made the report really spicy!

I wouldn't wipe my arse with that report.

[Old Akro]

Lookleft - are you suggesting we need something like "Aviation Safety Digest" ? I'll step quickly away from the line of fire now!!!

Seriously, I was hoping to get some insight into the accident and lessons from this report, but its so superficial that I think it has little value.

The ill-fated pilot had done a bunch of check flights. They are summarised on pages 12-13. This raises the question of the efficacy of the CASA dictated check flight regime. This report had the opportunity to look at the check flight syllabus, but didn't.

An element of this accident is the diagnosis of a mechanical problem. 30-ish years ago when I learned to fly, most pilots had a strong mechanical bent. We poked around aeroplanes & workshops. This has largely changed now and mechanical aptitude is no longer as highly valued in pilots. This is the way of the world, but it does raise a question of whether fault diagnosis should become part of the training. That might have made an interesting discussion point in the report too!

[Lookleft]

I'm not even sure that would be enough anymore Akro, who reads stuff anymore and if its an electronic copy it has to compete with Angry Birds and You Tube for attention!

The safety message has to be taken to those who will benefit most from it. As you stated:

most pilots had a strong mechanical bent. We poked around aeroplanes &
workshops. This has largely changed now and mechanical aptitude is no longer as highly valued in pilots.

Its not even valued by the manufacturer when you look at the manuals that are supplied by the bigger manufacturers. Unfortunately even the format of the report highlights the general trend of keeping knowledge superficial.

[puff]

Interesting enough the question is being asked of with the surge should he have shut down, if you have read other reports you may remember a baron that crashed into Darwin that had a partial engine failure, he thought it was providing power so kept it running. It wouldn't perform on one and crashed, he was heavily critised for poor training and not understanding the amount of drag caused by a windmilling prop!

I'm not sure about his training but my MECIR training actually included situations like single engine g/a, climb to LSALT, discussion of what now in this situation, plus 2-3 other what ifs with a what then question mark, all whilst still hand flying on one, all discussions included maintaining height until as long as safely required.

Engineering analysis alone, crap report aside I think the big issues were in the report, and I guess known at the time were,
1. Lack of assertiveness with ATC
2. Lack of knowledge of the a/c (horn blaring in background and how to silence it) - perhaps back to his crap endorsement
3. Lack of discipline in handling of the engine failure, all things aside with this you can't deny it was mishandled.

Lets face it in all stages of GA pilots set their own standards, in GA it's not like the airlines were you are thrown in the sim and demanded to perform. Even in the airlines so guys are in the books brushing up weeks before a cyclic, others do a swat study the day before to cover the basics to get through it.

Sadly those guys that chase the 'easy' ATO for an endorsement or renewal are doing themself an injustice, it should always be a learning experience not a tick and flick exercise.

[LeadSled]

The stuff about not making a PAN call is bureaucratic mis-direction. The controller knew it was an emergency.OldAcro,
Sadly, in compliance land, compliance is everything, including pedantic compliance with "standard radio procedures". Initiative, enterprise and common sense is actively discouraged. It might lead to creating a liability, you know.

Cast your mind back to the last major loss of life at YSSY --- a Kingair that crashed on the seawall around the 34 (now 34L) threshold -- everybody died.

Despite the engine failure advised, the controller did not clear the aircraft No.1 because the pilot did not broadcast a Mayday or otherwise formally declare an emergency. It's all in the BASI report. Had he not been cleared No2 behind a B727, in all likelihood the aircraft would have made it.

Go even further back to the night the TAA B727 on takeoff hit the taxing CPA DC-8. Once again, pedantic and slavish Australian (and non-ICAO) "radio procedures" played a big part in the accident.

Or the Garuda DC-10 ( I think it was a 10) that nearly hit a domestic over Perth --- once again, failed "radio procedures" ---- but if the poor bleeding controller doesn't deviate --- he or she doesn't loose their jobs.

It's a long sad history of Australian "radio procedures" versus effective communications.

Tootle pip!!

[Old Akro]

Puff

I think I found the Baron incident that you refer to. it's report 200000624. Unfortunately the ATSB do not publish the full report - only the synopsis.

In that case he had a dead engine, pure & simple and I think the simply "dead leg, dead engine, confirm with throttle" routine would have identified that.

In this case the engine was unquestionably delivering power. The engine was surging and probable the aircraft was yawing in response to the surges. As the engine surged it would have gone out of sync, so there would have been constantly changing beating as well. The question no one will be able to answer is whether there was a low power setting that would have stabilised the engine and delivered more power than the zero thrust setting.

In the early stages of the incident (before the RH engine was feathered) the desecnt rate was up to 1600 fpm without any corresponding speed increase. This suggests that the desecnt rate was caused by the drag of the mis behaving RH engine / yawing aircraft rather than poor airspeed / attitude control by the pilot.

I think shutting down the RH engine was a good decision. Whether or not it was the perfect decision can be debated for some time. Its interesting to note that my Seneca II POH does not have any reference to action for a mis behaving CSU. This would make me wonder if the Mojave POH is similarly deficient. Another thing the ATSB might have considered but did not.

[ForkTailedDrKiller]

In the early stages of the incident (before the RH engine was feathered) the desecnt rate was up to 1600 fpm without any corresponding speed increase. This suggests that the desecnt rate was caused by the drag of the mis behaving RH engine / yawing aircraft rather than poor airspeed / attitude control by the pilot.

Gear up, flaps up, one engine on cruise power, the other engine surging, descent rate of 1600 fpm without any corresponding speed increase - due to drag/yawing caused by surging engine??

Sorry, but I find that hard to believe.

Dr :8

PS: Yes, I am endorsed on the PA31.

[Old Akro]

Ok. What then? Unless the ATSB derived data is wrong I struggle to see another explanation.

[Bladeangle]

Mojo POH emerg actions for engine failure during climb...
1.airspeed 101kts
2.directional control, maintain
3.power op engine, max continuous
4.inop engine, identify and verify
5.inop engine, complete engine securing procedure.
Land as soon as possible at nearest suitable airport.

Actions for engine roughness...
1.emerg fuel pumps on
2.engine instruments, scan for cause
3.mixture, adjust as required
4.alternate air, on
5.cowl flaps, adjust for proper CHT
6.magnetos, check

He appears to have actioned as per the POH for failure in climb. Just possibly not the correct airspeed and descended. Might have also been a different story if he didnt have 900 (650kg) odd litres of fuel on board.

They are an awsome ifr aircraft to fly normal ops, but Im not confident they will not maintain height at mtow 1 inop. They feel and perform a little differently to the chieftain.

[Obidiah]

Ok. What then?


The way I read the sequence it was 0753:00 and no gear horn 130 KIAS/1000 fpm some thrust from the surging engine

By 0754:35 it was 140 KIAS 900 fpm and gear horn blaring and speed RoD reducing.

In the 1.5 minutes in between these we see transitions up to 160 KIAS and 1600 fpm but not simultaneously.

I got the feeling that these time stamp snap shots were showing the power coming off the surging engine with the trottle being closed (and drag significantly increasing) then feathering occuring and speed increasing and RoD decreasing.

I imagine during this time he had his head down in the cockpit while holding a nose down profile and hand flying.

Who knows where the trim was, and with all that was going on around him coupled with some tasks he was trying to get accomplished it suprises me little that speed and RoD were all over the place for 90 seconds.

Just a shame he didn't get back to Vyse after it was all done.

But hey I wasn't there, we don't know if while all this was going on he didn't spill a hot coffee on his crutch further compounding the issues.

In this day and age surely it must be possible to have a cheap rugged basic data recording device in these things. Certainly would make it easier to garner information later.

[Trent 972]

Obidiah, I think you may have made an incorrect assumption when you said 130 KIASThe way I read the sequence it was 0753:00 and no gear horn 130 KIAS/1000 fpm some thrust from the surging engine
The report describes the speed as "Derived airspeed: 130 kts"
I think perhaps that the speed was 'derived' from the radar recorded groundspeed and adjusted for the 'wind' at the time.
If that is the case, and the 'derived airspeed' was a TAS of 130 knots, therefore the IAS (@ 7000 feet) would be about 110 knots.
After AW reported shutting down an engine @ 07.53.33 his 'derived airspeed' was 120 knots (@ 6100 feet), that would make his IAS roundabouts 105 knots. (much closer to blue line than some people here seem to think)
If I am incorrect about how the 'derived airspeed' in the report was calculated, then everything I have written above is BS of course.

Increased RoD during the turn back to BWU would most likely have been the cause of the higher descent rate without a consequent speed increase.

edit.
Reading this report makes we weep for the families of the victims.
It seems to me that AW gave it a 'good shot' considering the situation he was in and with the tools he had at hand.
I hope that a lot of the 'younguns' in GA read the report and take away some lessons to enhance their own skills and decision making processes.

[Old Akro]

Trent

Thanks. I think that adds perspective to the debate. I agree that I have sympathy for the families and I'm pretty upset that they didn't get the ATSB report that they deserved.

The pilot of PGW did many things right and he seems a good, reasonable pilot if not a superhero. A lot of the initial conjecture about fuel issues or shutting down the wrong engine have been disproven. In theory, an engine failure around 15nm out from Bankstown should not have had this result. As a light twin pilot I'd like to understand this accident and learn from it. The ATSB report does not help this.

[Up-into-the-air]

Just my two penneth:

I also have had a look at the PA31-350 POH and concur with the data above. I have 1400 hours twin time, with 150 odd in PA31-350's and rest in PA30-160.

In both aircraft, it is essential to do the troubleshooting routine.

It is essential to ID the engine.

I have had two reductions of power and "Panic" is not an option, but it is a real issue.

A decision has to be made quickly and a "blaring" gear horn would not help.

Flying the "numbers" is essential ie. Vyse and 5 degrees bank.

The old adage of height is your friend cannot be understated.

The real issue of "Why the surging" has not been answered by atsb, neither the human factors involved.

[Old Akro]

The ATSB preliminary report publishes a number of position details. It used groundspeed. The final ATSB published position reports using a "derived airspeed". Out of a combined (approx) 35 data points there are 9 in common between the 2 reports. This reveals that the ATSB have given PGW tailwind components of 7 - 23 knots both climbing away from Bankstown, in the turnaround and on descent back towards Bankstown. Its looking like the ATSB have messed up the whole airspeed element.

[DeRated]

More than anything else in this 'report' - I would have expected some in-depth engineering discussion!

".... and the number six nozzle from the right engine was completely blocked."

Well, it takes a solid object to block the size of the 'piss and dribble' nozzle, so what was it? Considering the nozzle is shielded by metal from the fire, it should be possible to analyse the foreign object.

Not done....... which is the crux of the whole event and the ATSB didn't go there.

For an object this large to have got through the fuel pump - WHAT is left in the fuel pump - and hence a blockage to fuel supply to all injectors, causing the surging/overspeed (which a CSU can't capture quickly enough).

No discussion, no examination apart from.......

"The ATSB was unable to determine whether the erratic nozzle spray patterns and blockage of the number six nozzle were due to pre-impact contamination."

The blockage couldn't happen after the engine was feathered, or after the accident.


Five paragraphs only on the Engine and ancillary systems - when this is what caused the sequence of actions which culminated in the accident.

C'mon........:mad:

[Trent 972]

Several posters and the 'report', have made reference to the "blaring gear horn".
Recognition of the aural Stall Warning on AF447 was investigated and is the subject of further investigation by EASA.
Quoting from Flightglobal AF447 inquiry grapples with stall-warning enigma (http://www.flightglobal.com/news/articles/af447-inquiry-grapples-with-stall-warning-enigma-373857/)
It cites cognitive research suggesting that visual, rather than auditory, information is prioritised by pilots coping with high workloads.

"Piloting, calling heavily on visual activity, could lead pilots to a type of auditory insensitivity to the appearance of aural warnings that are rare and in contradiction with cockpit information," the analysis says

Perhaps the warning horn was not as distracting as some may think, as in the case of AF447, where the crew did not comment on the repetitive "stall stall" warning.
The human brain is an amazing thing.

[Obidiah]

Trent 972

My apology on KIAS

I assumed it was corrected data for KIAS, TAS seems more likely now you mention it. Would've been handy if the report had made it a little clearer.

Up into the Air

Be careful on the 5 to the live notion as it is somewhat of an OWT.

Detail can be found in the FAR23 certification standards, which is where it was born from. 5 degrees is a certification requirement.

Reality is for low performance twins it is typically less.

John C Eckalber's book "Flying High Performance Singles and Twins" gives detailed explanation on this as well as methods for calculating the optimum angle for each type.

Apparently research has shown that for every degree off optimum the loss is about 30 fpm and the typical light twins zero side slip angle is around 2 degrees.

How we as pilots will ever be able to fly that acurately in a real assymetric scenario baffles me, but there it is. Perhaps as I mentioned earlier we just need more quality time with one feathered.

[Old Akro]

I assumed it was corrected data for KIAS, TAS seems more likely now you mention it. Would've been handy if the report had made it a little clearer.

The report doesn't define "Derived Airspeed" at all, which frankly is a novice mistake. I agree that I think its meant to be KTAS. However, it makes no sense.

1. According to the prelim & final report the Bankstown METAR was 340 deg @ 4 kts and the METAR for Richmond was calm. However at the final fix 6nm from YSBK at 500 ft they are using an 11 knot tailwind component.

2. No met data for winds aloft has been tabled. The Prelim report quotes speed as Groundspeed derived from TXP returns. There are not many data points that correlate between the 2 reports, but there are 9. Just before TOC over Richmond flying pretty much North, the ATSB calculations show a 19 kt tailwind. 4 minutes later having turned through slightly more than 180 degrees at the same altitude (after having climbed further, then descended) they are using a 16 kt tailwind. How does this work?

I don't think any of the "derived airspeeds"can be relied upon at all. Which completely undermines their conclusion that the pilot was not managing airspeed.

This is a seriously flawed report

[Jabawocky]

Obid said
Be careful on the 5 to the live notion as it is somewhat of an OWT.

Detail can be found in the FAR23 certification standards, which is where it was born from. 5 degrees is a certification requirement.

Reality is for low performance twins it is typically less.

John C Eckalber's book "Flying High Performance Singles and Twins" gives detailed explanation on this as well as methods for calculating the optimum angle for each type.

Apparently research has shown that for every degree off optimum the loss is about 30 fpm and the typical light twins zero side slip angle is around 2 degrees.

How we as pilots will ever be able to fly that acurately in a real assymetric scenario baffles me, but there it is. Perhaps as I mentioned earlier we just need more quality time with one feathered.

Indeed, and John Deakin makes special mention of that point, and in subsequent emails we have had. It may well be the extra ROD is attributable to these things. Again ATSB have not exactly explored this either, as an educational piece for others to learn from in the future.

The report is a disgrace.

Just like MZK, more recently the Norfolk dip. Why are we wasting taxpayers money on reports if they are not yielding any safety benefit.

When I started this thread I hoped for better than this. To say it is underwhelming is an understatement.

I doubt there is anyone there who really understands a piston engine, let alone how to fly a piston twin. The biggest insult is I believe I could have done a far better job. That is seriously sad.

A sad way to end 2012.

[Trent 972]

Hi Jaba. Merry Christmas to you and yours. :ok:
It may well be the extra ROD is attributable to these things
I'm only a mug playing a guessing game, but I assume the RoD came from the Mode C radar data and is independent of the airspeed.
My understanding is that the altitude readout is given in increments of 100 feet on a controllers display and I don't know if the raw data that is recorded is more accurate.
I see little problem in believing that within those parameters, the RoD data is probably quite accurate.

[Old Akro]

This incident should not have needed the optimising tricks like banking to the good engine. It didn't need to maintain altitude. It just needed a descent rate that was 100 ft/min less than it had. An average descent rate of 500 ft/min for the 14 minutes of flight after the incident would have happily gotten them to the pub that night.

I'm interested that all radio transmissions have been modified in their wording for the report. There is also a discrepancy in the language between the preliminary & final reports. I don't understand why they would not append radio transcripts. If there had been an initial instruction to descend to 5,000 ft, followed by a further instruction to descend to 2,500 ft, then this whole incident takes on a completely different flavour. I raise this because of the ambiguous wording used in the report coupled with a difference in wording between the 2 reports.

For instance, the preliminary report says "ATC instructed the pilot to descend to 2,500 ft". The final report does not cite the ATC transmission, but says "The pilot read back an ATC clearance to descend to 2,500 ft". There is a fair difference between being cleared & being instructed. Which was it?

[Jabawocky]

Trent, and likewise yourself :ok:

I just tidied up my post, I was referring to Obids post not Akro's. More about the bank angles, drag and RoD.

Agreed on the mode C info.

[Trent 972]

O A, that last post is gold.
The lesson in this report for drivers of this kind of aircraft is - They are built to achieve the required standard, nothing else.
You stack the cards in your favour, short of hurting anyone else.
If there is any doubt, then you haven't stacked enough cards in your favour, start restacking.
If it all turns to sh!t, you go down fighting.
This report says to me that a few less than optimum decisions were made, however AW went down fighting.
In my mind, that makes him heroic.

[VH-MLE]

Cast your mind back to the last major loss of life at YSSY --- a Kingair that crashed on the seawall around the 34 (now 34L) threshold -- everybody died.

Despite the engine failure advised, the controller did not clear the aircraft No.1 because the pilot did not broadcast a Mayday or otherwise formally declare an emergency. It's all in the BASI report. Had he not been cleared No2 behind a B727, in all likelihood the aircraft would have made it.

Go even further back to the night the TAA B727 on takeoff hit the taxing CPA DC-8. Once again, pedantic and slavish Australian (and non-ICAO) "radio procedures" played a big part in the accident.

Or the Garuda DC-10 ( I think it was a 10) that nearly hit a domestic over Perth --- once again, failed "radio procedures" ---- but if the poor bleeding controller doesn't deviate --- he or she doesn't loose their jobs.

It's a long sad history of Australian "radio procedures" versus effective communications.

As usual coming from you, what complete and utter nonsense!! You appear to have no qualms or conscience in manipulating whatever incidents occur in this industry to suit your own personal agenda(s) and I think that that is quite disgraceful!!!

Please explain how you reach your conclusions in the first two examples?? I am unaware of the Garuda "domestic" that you refer to - please elaborate so that I can compare your version of fact with reality.

Cheers.

VH-MLE

[Old Akro]

This report says to me that a few less than optimum decisions were made, however AW went down fighting.
In my mind, that makes him heroic.

I didn't know him at all. But it seems to me that he made a reasonable fist of it. He didn't make the dumb mistakes that the posts at the time speculated. He could have done better, but we're still debating how the Captain of the Titanic could have done better too.

The aeroplane should have brought him home on one engine. Its why we fly twins. I'd like to understand why not and the ATSB has failed us in this regard. Was there an issue with the other engine? Did he follow ATC instruction to descend too literally? There are many unanswered questions.

This has been a good thread with proper debate. Its brought out a range of issues that the ATSB did not. Its improved my understanding and provided food for thought. I think this is pprune at its best.

Merry Christmas. Lets toast missing friends and pray we don't get tested in the way PGW's pilot did.

[The Green Goblin]

Did he follow ATC instruction to descend too literally?

He did take it literally as it was intended. It was an instruction to descend. Had there been the words 'when ready, or 'at your discretion, descend', IMO it is unlikely the accident would have happened.

Ultimately though it should have been Willow who said, 'pan pan, pan pan, pan pan, PGW, PGW, PGW, engine failure, tracking present position direct bankstown, driftdown procedures 2 POB.

GG

[Jack Ranga]

Jabman,

Any chance JD will reconstruct the accident report for us? I rely on his & his mates knowledge :ok:

So weak & gutless political correctness has made it into what should be something that saves other pilots lives (accident reports).

I'm not in a position to judge, wasn't there but I do have a feeling the culture of IFR aircraft descending OCTA into BK had a fair bit to do with this :{

[Jabawocky]

JR

Not likely, JD has retired from that well appreciated writing role. Mind you he was rather motivated in offering his comments, and when I asked permission to publicaly upload our conversation, I even offered anonymous posting, he was quite adament that attribution be included, so included it was.

I dont think he cares about ruffling feathers down here :}

[Horatio Leafblower]

I have never flown a Mojave, and I don't have a POH/AFM, BUT

- What is max MAP?
- What is max continuous MAP?
- What MAP could Airtex's Mojaves achieve on T/O? Had they been adjusted "to protect them from ******* pilots"? :suspect:

I have a good reason for asking... Hey Chad, do yourself a favour and check the MAP on IGW on T/O. :uhoh:

[LeadSled]

MLE,
What agenda might that be, other than having long and very publicly advocated the importance of effective communication, as opposed to the Australian approach to pedantic rote "radio procedures" at the expense of effective communications.

Amongst international crews, Australia is a byword for stilted, inflexible and pedantic "radio procedures", if you don't understand this, it can only be your own lack of relevant experience. If you don't understand the problem, you are probably part it, and unlikely to be part of the solution.

I am not blaming individual controllers, they get it in the neck if they deviate --- but "the system", including Airservices, in latter days CASA, and CivilAir are all at the heart of the problem.

The objections to the formal acceptance of ICAO SARPs on the subject (Annex 10, Vol.2 and associated docs.) was fierce.

Fortunately, the combined approach of Qantas, Ansett, AIPA, AOPA and ASAC carried the day, when it came to the adoption of ICAO compliance.

Although at least now we pay lip service to ICAO SARPs, there is still a world of difference between radio comms here and just about everywhere else I have ( and other international operators) experience.

As to the B727/DC-8 and Kingair accidents, I suggest you re-acquaint yourself with the reports of the accidents ,as to the Garuda incident, go have a look, but I remember it all too well, having been there that day, and caught some of it on frequency.

Tootle pip!!

PS: I have just recalled another very serious incident, that highlighted the dangers of "same words, different meanings" , when the Continental DC-10 got all too close to an executive jet in oceanic north east of Sydney.

If you are in ignorance of all the history, the answer is in your hands.

PS2: I was also on YSSY at the time the Kingair crashed, it is etched on my memory. To this day, every time I visit my solicitor, I can see a significant part of that Kingair sitting in his bookshelf, as testimony the the post accident legal battle. The PIC of the Kingair was a distant relative of mine, believe me, I was very close to the whole investigation.

[ForkTailedDrKiller]

Ultimately though it should have been Willow who said, 'pan pan, pan pan, pan pan, PGW, PGW, PGW, engine failure, tracking present position direct bankstown, driftdown procedures 2 POB.

Absolutely!

You can tiptoe around it all you like, but in the end it comes down to that!

Dr :8

[Jabawocky]

Quote:
Ultimately though it should have been Willow who said, 'pan pan, pan pan, pan pan, PGW, PGW, PGW, engine failure, tracking present position direct bankstown, driftdown procedures 2 POB.
Absolutely!

You can tiptoe around it all you like, but in the end it comes down to that!

Dr

+1

no argument from me.

[Up-into-the-air]

Is it not Aviate Navigate Communicate??

[dhavillandpilot]

HorTio leaf lower perhaps you need to look in a hangar at bankstown Igw won't be flying again it is now a Christmas tree.

All those that are armchair pulling the ATSB report to pieces. Perhaps you should all reflect it could just as easily have been you in a similar aircraft.

Having had one propellor failure, one total jet engine failure, and a total single engine failure the words my first instructor stan mobs taught me wa

There by the grace of god go I, this was after the c320 crashed on the go.f course at bk.

I would suggest some humility

[Jabawocky]

Humility is fine DH, but we the taxpayer, and aviators, employees, passengers deserve a whole heap better than the report presented.

Humility my arse, two more dead, and even though the PIC left a lot to be desired, the whole system here has let down not just the two deceased, but everyone else as well.

If they were your family, you would want better, not just for closure, but for the hope their death was not in vain.

Many of us are not happy and we never knew the folk concerned.

It simply is not good enough.

[Horatio Leafblower]

HorTio leaf lower perhaps you need to look in a hangar at bankstown Igw won't be flying again it is now a Christmas tree

Yeah yeah whatever I try to avoid the place.

[VH-MLE]

Unfortunately, it would seem your agenda is to denigrate the Australian aviation system and its associated bodies and staff at every opportunity. That is well and truly apparent in many of your posts.

As for the B200 accident and B727/DC8 event at Sydney, please point out exactly where you think faults in Australian radio phraseology had any bearing on either occurrence because I have just re-read each report in fine detail and cannot find even the slightest piece of evidence to support any part of your sensationalist claims (NOTE: I recommend you re-read both reports from beginning to counter that seemingly increasingly faulty memory of yours).

With regards to Garuda incidents in Perth, there have unfortunately been several serious ones over the years and the one you allude to doesn’t spring to mind. Given your very well documented history of misinformation and distortion, please provide more detail so that I can review for myself your assertion.

VH-MLE

ps. Have a Happy Christmas and I while I acknowledge your strong views on GA in Australia, I hope 2013 enables you to have a more balanced perspective on aviation matters…

[VH-MLE]

Dear LeadSled,

I hope you had a very happy Christmas.

However, continuing on with your earlier assertions (that the accidents/incidents you raised in earlier posts could/would have been avoided if the not for radio phraseologies in place at the time) you have failed to justify how this was the case - please advise me how you can justify your position on this when it is clearly contrary to the evidence available.

In the interim and regarding the poor communication processes you seem to believe exists in Australia, I invite you, as a basic example, to listen (via Youtube) to a few "JFK Tower" exchanges with other aircraft (both international and domestic) and dare to tell me afterwards that their communication style is both "effective" and internationally standardised.

I'm sure after that you'll agree with me that compared to your beloved FAA air traffic system, the Australia system isn't so bad after all...

Once again, I'm waiting for you to provide specific details of how "failed radio procedures" led to both the B200 and B727/DC8 events you refer to and also how the Garuda aircraft "nearly hit a domestic over Perth".

Over to you...

VH-MLE

[bentleg]

provide specific details of how "failed radio procedures" led to both the B200 and B727/DC8 events

Thread drift however I want to comment on VH-AAV as I knew the pilot.

With the B200 event the 727 had touched down by the time Kerry (the pilot of VH-AAV Kingair) had declared his landing would not be normal. Like PGW if he had declared a PAN at the outset, the result may have been different. In both cases the pilots expected to fly OK on one engine (which did not happen) and that it was not a PAN situation. I do not blame this accident (or PGW) on failed radio procedures.

[Jack Ranga]

Dare I say it! Perhaps we could learn something from the RAAF here? A PAN is declared on an engine failure regardless of how the aircraft is performing, regardless of how many engines the aircraft has. It's not left to pilot discretion.

[MACH082]

There is no discretion about it.

The regulations clearly state that when shutting down an engine in any multi engine aeroplane, (except intentional for training purposes) requires the declaration of pan pan.

Safe flying folks.

[bentleg]

The regulations clearly state that when shutting down an engine in any multi engine aeroplane, (except intentional for training purposes) requires the declaration of pan pan.


If that's the case maybe the radio procedures did fail! I'd like to read the regulation, can you point me to it please?

[Old Akro]

One of the factors here is (I think) that (rightly or wrongly) there is a belief that if you declare a PAN or mayday that you'll spend the next week dealing with CASA paperwork. I think there is also an image thing that professional pilots understate the circumstances and sound cool. If you look no further than "Sully" Sullenberger as a role model, he transmitted neither a PAN or MAYDAY call but there has been nothing but praise for his handling of his incident.

I still question whether this would have made a difference. The controller knew it was an emergency and had called for emergency services at Bankstown.

I do agree with Jack Ranga that the better thing would have been to declare a PAN and reject the instruction to descend.

[LeadSled]

Unfortunately, it would seem your agenda is to denigrate the Australian aviation system and its associated bodies and staff at every opportunity. That is well and truly apparent in many of your posts.
MLE,
If you actually read what I say, and not what you think I say, you will understand I have long criticized the Australian approach to rote "radio procedures", as opposed to effective communications. And those unions that have stood in the way of reform.

Indeed, the whole reason for the very existence of the AIPA, was the refusal of AFAP, across many issues, to except modernization and reform. To name but a few: F/E on all aircraft with more than 100 seats, no "glass cockpits", no intersection takeoffs, no derated /flexi thrust takeoff power --- and many more. AFAP was standing in the way of us operating our B767 the way Boeing designed them. Remember the nonsense of F/E in Ansett B767.

A good starting point would be to compare ICAO recommended phraseologies with the page after page of same in the AIP. Also consider the CASA proposal, not yet dead, to make the AIP phraseologies legally enforceable, on pain of strict liability penalties.

As to the B727/DC-8 --- why was the DC-8 still on the runway?

Because the clearance was something like: "Take next taxiway right, backtrack, call ground xxx.x"

This is exactly what the DC-8 did --- followed the clearance in internationally accepted/ICAO terms, at the next taxiway, they did a 180 and backtracked on the runway.

In internationally accepted/ICAO terms, you can only backtrack on a runway, not a taxiway. The frequency change instruction should have been something like "when clear, call ground xxx.x". With the DC-8 in ground, it did not hear the takeoff clearance for the B727.

I well recall the ATC standards mob in DCA being referred to as the "Airstapo", their penchant for disciplining individual controllers who had exercised initiative was hardly a secret.

As to the Kingair, it was clear the aircraft was in trouble, the controller knew the aircraft had an engine failure and was having performance problems, but initiative was forcefully discouraged, the Kingair was not cleared No1, because it did not declare a formal emergency.

As to the close go between an executive jet and a Continental DC-10. Australia phraseology at the time was "cruise (say) FL350" instead of "climb to/Climb to and maintain FL350".

In ICAO and US terminology, "Cruise 350" was a clearance for a cruise climb, to cruise at anywhere between 350 and the minimum level for the airway, and included a clearance to descend when ready to the IAP for the filed destination".

As Murphy's law dictates, the two aircraft were extremely close to being at the same point and height at the same time.

Just as we see with ATSB now, how the investigation report dealt with this was a masterpiece of bureaucratic obfuscation to conceal the Australian "regulatory" contribution to the near hit.

If one was able to go back into the records of the AFAP/Overseas Branch Tec Sub Committee of the day, you would find we were well aware of the problem of "same words, different meanings" in Qantas, and had written to the powers that be, (particularly "cruise" v. "maintain") and been completely ignored, until the inevitable.

As to regarding BASI/ATSB reports as "the whole truth and nothing but the truth" and being a wholly reliable source for all the details, warts and all, of an accident or incident ---- how would you describe the recent reports of the Norfolk ditching or the Canley Vale fatal. Do they tell the whole story. If you think they do, why are we having the Senate RRAT inquiry.

All reports of serious incidents and accidents, especially if a foreign aircraft is involved, are politically influenced ---- there were three "investigations" into the B727/DC-8 accident --- did you know that??

Rest assured, I shall continue to criticise associations/unions and individuals who stand in the way of advancements in cost/benefit justified risk reduction, or much needed reforms, or associations that promote "changes" that are for the benefit of the associations, particularly commercial benefit , and not aviation in general, for whatever reason.

That goes double when I hear that "cultural differences" (pig headed parochialism) prevent practices that are entirely successful elsewhere, particularly in the NZ/US/CA/UK, "working in Australia". Such views usually emanating from dolts who have no relevant experience outside Australia's very small aviation pond.

Tootle pip!!

[Fly_by_wire]

If you look no further than "Sully" Sullenberger as a role model, he transmitted neither a PAN or MAYDAY call but there has been nothing but praise for his handling of his incident.

Gotta call BS on that one.. (His mayday call was garbled)

From the NTSB report:
At 1527:33, the captain reported the emergency situation to the LGA departure controller, stating, "mayday mayday mayday this is Cactus fifteen thirty nine hit birds, we've lost thrust in both engines, we're turning back towards LaGuardia"

[flighthappens]

Jack Ranga Dare I say it! Perhaps we could learn something from the RAAF here? A PAN is declared on an engine failure regardless of how the aircraft is performing, regardless of how many engines the aircraft has. It's not left to pilot discretion.

Absolutely. Something is seriously wrong with my aircraft I want priority... dont leave it to the bloke/blokette in atc to make the call.

[Old Akro]

US Airways Flight 1549 Full Cockpit Recording - YouTube

Flybywire. I'll accept that the NTSB is correct, but I had seen it reported that he did not make a MAYDAY call and I certainly cannot make out a distinguishable MAYDAY call from the cockpit recording. Its all in about the first 12 seconds of the youtube video. A garbled section is at the 4 second mark, but it doesn't seem long enough to contain the word Mayday once, let alone 3 times.

On this basis, I'll continue to contend that the controller acted primarily out of an comprehension of the situation rather than hearing a declaration of MAYDAY.

[Old Akro]

Flighthappens. I agree. But I can't help thinking that the ATSB would have done well to examine the psychological reaction to receiving and obeying a direction from ATC to descend in a state of duress, rather than the waffle it had on the psychological effect of a gear warning horn. It would appear that the ATSB have discounted this topic completely. Also, if you look at the difference in reporting of the controllers radio calls between the preliminary report and the final report plus the lack of any transcripts, I think that leaves them open to the suspicion of changing the radio dialogue to suit their desired conclusion.

The official NTSB transcript is here ;http://dms.ntsb.gov/public%2F47000-47499%2F47230%2F420526.pdf

But I have found a number of blogs accusing the NTSB of adding the mayday call. Listening to the recording, I have sympathy with this view.

Wouldn't it have been nice for the ATSB to have done a similar transcript for PGW in the 131 weeks it took to write the report?

[VH-MLE]

LeadSled says “Go even further back to the night the TAA B727 on takeoff hit the taxing CPA DC-8. Once again, pedantic and slavish Australian (and non-ICAO) "radio procedures" played a big part in the accident. “ and “As to the B727/DC-8 --- why was the DC-8 still on the runway?

Because the clearance was something like: "Take next taxiway right, backtrack, call ground xxx.x"

This is exactly what the DC-8 did --- followed the clearance in internationally accepted/ICAO terms, at the next taxiway, they did a 180 and backtracked on the runway.”

You are incorrect – the instruction was “take next taxiway right – call on 121.7” – nothing confusing about that and to say that “pedantic and slavish Australian (and non-ICAO) "radio procedures" played a big part in the accident” is nonsense.

Regarding the tragic B200 accident at Sydney, the B727 was never a factor in that accident (there were, however, a number of factors involved that you conveniently fail to mention and that appear on pages 28-29 of the accident report. They include: environmental conditions - 39 deg C plus sun glare, overweight ops by approx 128kg, a likely reduced power take-off technique used by the company, a company policy of not using the auto feather system even though it was fitted to this aircraft, using a hand microphone to transmit and turning toward the "dead" engine”. Therefore given the above factors do you still agree with your statement that “had he not been cleared No2 behind a B727, in all likelihood the aircraft would have made it”? In my opinion this sort of distortion and misinformation from you just backs up my claims that you endeavour to denigrate the Australian system at every opportunity.

Regarding the ATSB report into the Norfolk ditching – I do agree that there has been an apparent fundamental shift here and agree with the Senate inquiry as this report is way off what I would have expected from the ATSB. However, that report has little to do with the 2 events you have raised.

Lastly, I have absolutely no issue with your comment “Rest assured, I shall continue to criticise associations/unions and individuals who stand in the way of advancements in cost/benefit justified risk reduction, or much needed reforms, or associations that promote "changes" that are for the benefit of the associations, particularly commercial benefit , and not aviation in general, for whatever reason” however what I do have an issue with is the amount of distortion and misinformation you throw around with gay abandon to try and make your point.

My apologies to others for the thread hijack here but LeadSled needs to be exposed for his misinformation.

VH-MLE

[Tidbinbilla]

Yes, well let's get back on topic, shall we? This thread has drifted far enough.

[Jack Ranga]

What was this thread about again?

[VH-MLE]

Yes Jack,

You're 100% correct, I do apologise for my posts however ultimately I had to draw a line in the sand as far as LeadSled's bull**it is concerned.

Back to the tragedy of VH-PGW...

VH-MLE

[Deaf]

Listening to the recording, I have sympathy with this view.

Heard the tape of a Mayday call I made, "mayday mayday mayday" sounds like a short word, rest of it was a bit clearer.

[Jack Ranga]

MLE,

Don't apologise! It's good to see fact disproving conjecture & personal opinion :ok:

[Lumps]

Turbocharger failure and the incorrect engine shut down? Wouldn't be the first mishandled turbocharger failure in PA31s, and would explain a few things...

How come the ATSB were forced to revisit their wonky Whyalla report yet PGWs report is still in its original ignorant and incurious form?

[Old Akro]

The ATSB report was a crock. One of my favourite failings of the report was that they changed the radio transcript between the draft and final report. Another is that they used groundspeed (from radar returns) plus the forecast wind to estimate airspeed. But, they used made the same adjustment both flying away from Bankstown and returning to Bankstown. I forget the wind direction, but they (for example) gave it a headwind in both directions. Then they used this flawed arithmetic to criticise the pilots airspeed control!!

Its not at all clear that the pilot shut down the wrong engine. The engine he left operating was still operating, but failed to allow the aircraft to maintain altitude. It was never investigated whether the operating engine was capable of producing full power.

A factor that was never highlighted in the report is that the pilot complied with ATC descent requests. These descent requests were the standard profile that ATC use for its own convenience to descent IFR aircraft below the Sydney steps. So, the pilot did not find out that the aircraft would not maintain altitude until it was too late and his fate was sealed. For me a massive lesson is that ATC are not necessarily going to have your best interests at heart in an emergency. If the pilot had refused to comply with the ATC descent requests and maintained altitude, there would have been a happier outcome.

[Lead Balloon]

I'm appalled to note that I'm unsurprised to note another ATSB 'report' that is a mixture of fiction and inept bungling.

[LeiYingLo]

If the pilot had refused to comply with the ATC descent requests and maintained altitude, there would have been a happier outcome.

Which is what any competent twin pilot knows to do and would've done in the first place.

[Lumps]

Which is what any competent twin pilot knows to do and would've done in the first place.

Simplistic answer that doesn't help.

Akro et al, Furious agreement gents, but I didn't mean to revive this thread for repetition.

Even with the ATC descents it should have maintained height at 2500ft on one... unless the one that was going was only putting out a bit over 200hp in its naturally aspirated form

- in the tests following the accident was the scenario and performance of one engine shut down and one operating without turbocharger evaluated?

- with this in mind was the turbocharging system on the 'good' or operating engine really closely examined? Or was it assumed that the bad engine was the one that the pilot shut down, and this was the one that got most attention? (perhaps the ATSB investigators are time poor and are under some form of pressure to get results under time constraints, leading to unconscious bias or assumptions that suit their own situation, so to speak)

- maybe it all was done by ATSB, but in reports of yesteryear a hypothesis would be proposed and the proven or disproven with the available evidence (or insufficient evidence, which no doubt is what happened here, but at least mention that in its relation to the hypothesis!)

- for those of us that want to know, I'd argue all of us that have lives invested in aviation, what is the avenue to get reports re-examined?

[Old Akro]

Which is what any competent twin pilot knows to do and would've done in the first place.

The pilot was young. He was under great stress. He received what was essentially was an instruction from ATC. He needed to descend anyway. I don't condemn him for complying or blindly trusting that the instruction was in his best interests rather than traffic management expediency.

The issue is that the ATSB have a massive blind spot about this and other issues which firstly, denies the ability to understand the truth of the situation and secondly to learn from the experience.

It was a scandalously shabby report.

[Adamastor]

The first transmission from ATC to the pilot was maintain 5000’ which the pilot accepted but then either chose not, or was unable, to do. They descended below that assigned level and were then issued further descent.

ATC then specifically asked the pilot whether they were capable of maintaining altitude and advised that if they were unable, that YSRI aerodrome was 2nm away. They got another non-committal response, the aircraft overflew YSRI, and the rest is tragic history.

Your assertion that a controller would deliberately put an IFER (in-flight emergency response) aircraft in increased danger because it suited their airspace layout or traffic management is disgusting.

[thorn bird]

Adamaster,
is your assertion the pilot should have landed at YSRI? I passed over RIC shortly after the event. The runway was obscured by Fog.

There is nothing in the ATSB report about organisational, operational and bullying issues with the operators chief pilot, reported to CASA but ignored.

I have experienced an engine failure in the type aircraft and had no problem maintaining height for a considerable distance, over 60 NM.

Listen to the voice of the young pilot on the tapes, he is cool, calm, in control and endeavouring to find solutions to his problem, he flew his aircraft under control to the very end.

I knew this young man very well, he was well trained and very well aware of the limitations of the aircraft he was flying.

You arm chair experts are quick with your condemnation, but you were not there on the day, nor is there anyway to establish what actually occurred.

Suffice it to say, any SAFETY issues that may have been learnt went out the window to protect a vindictive incompetent regulator.

[Adamastor]

Thorn_bird, I can see that this was a difficult accident to deal with for both of us.

Is your assertion the pilot should have landed at YSRI?

No, it is not.

There is nothing in the ATSB report about organisational, operational and bullying issues with the operators chief pilot, reported to CASA but ignored.

Agreed.

I knew this young man very well, he was well trained…

I knew him too. It was a tragic loss, and yes, it is still raw.

You arm chair experts are quick with your condemnation…

The only person I was attempting to ‘condemn’ was Old Akro for stating that the ATC deliberately placed a stricken aircraft in further harm’s way for something as trivial as airspace layout or ‘traffic management expediency’. Attempting to lay blame after a tragedy is a natural response, but that was uncalled for and simply not true.

Suffice it to say, any SAFETY issues that may have been learnt went out the window to protect a vindictive incompetent regulator.

I learnt plenty from this one (and would gladly give it all back in a heartbeat), but I agree that other valuable lessons were lost in the haze. Safe flying.

[Lumps]

I have experienced an engine failure in the type aircraft and had no problem maintaining height for a considerable distance, over 60 NM.

Exactly! So what happened here then?

The whole ATC instructions may be nothing but a misdirection in analysing this. Maybe it didn't help, but seems very possible it was not the root cause of why the aircraft could not maintain height.

The analysis of the power plants was skimpy, to put it politely. Who does the ATSB use to look into these engines? An overhaul shop, experienced piston engine expert, or a staff member that once took his lawnmower apart and then got it going again.

[Jabawocky]

Lumps,

I had a discussion with some ATSB folk in Canberra a few years ago, he declared they had no piston engine specialists, all turbine. Much like CASA.

They still believed the Whyalla report was factual despite the data and coronial inquiry proving it was full of crap.

So who knows? :hmm:

[Lumps]

Jabawocky - as Carl Sagan said 'extraordinary claims require extraordinary evidence', maybe ATSB would enhance their relevance by employing an expert, on a case by case basis!

[Old Akro]

The only person I was attempting to ‘condemn’ was Old Akro for stating that the ATC deliberately placed a stricken aircraft in further harm’s way for something as trivial as airspace layout or ‘traffic management expediency’. Attempting to lay blame after a tragedy is a natural response, but that was uncalled for and simply not true.

Firstly, thats not what I said and you have maliciously twisted what I said.

Secondly, I was told that hypothesis by a controller with knowledge of the people involved.

Thirdly, the preliminary and final reports differ in the radio transmission "transcript" specifically relating to the altitude directions from the controller. No transcript was appended, which in itself is a departure from proper practice, which prevents anyone from accessing primary data. I would like to know why the ATSB changed the reported radio transmissions between the preliminary report and the final report.

Thirdly, if you graph the descent rates based (you have done that so you are properly informed- right?) the descent rates are not consistent with an aircraft unable to maintain altitude. They airspeed and initial rate of descent are consistent with a descent to a target altitude. According to the tabled data the initial descent was at a speed well above VYSE and had a descent rate in excess of 1200 ft/min. However, in latter part of the flight when the aircraft reached the assigned altitude the airspeed reduced to about VYSE and the rate of descent reduced to 320 ft/min.

It seems clear that (for reasons that were not investigated) that PGW could not maintain altitude on one engine. But, the descent rate on one engine was low enough that it still could have returned to Bankstown safely from the position and altitude where the first engine was shut down.

In my opinion, The altitude loss that prejudiced the aircraft's ability to reach Bankstown most was the initial 2,600ft descent to 5,000ft which occurred at 1200 ft/min. The preliminary report suggests that this was at ATC direction. The final report removes this reference. Who knows?? Very, very sloppy work from the ATSB. If the aircraft had maintained the rate of descent of the middle section of the flight (around 740 ft/min @ approx 140 kt GS) - let alone the rate of descent after the pilot reached the instructed altitude of 2500 ft (320 ft/ min), then the aircraft would have made the airport.

The ATSB criticisms the pilot for poor airspeed control, but they base this criticism on airspeed derived from groundspeed, derived from radar returns. And they got the math wrong and applied the wrong wind vector. The criticism that the pilot did not maintain proper airspeed is based on erroneous data.

Fourthly, the aircraft did reach 2,500 ft approx 2nm before the 2500 ft control step. Could be a co-incidence.

My beef is with the incident report. The people who lost their lives and the aviation industry in general deserved a thorough objective investigation. But we didn't get it.

a) It is a very poor, sub standard report with incomplete investigation, what appears to be changed evidence with calculation errors.
b) A proper, objective report should have considered all potential causes and this report completely glossed over the potential factor that a young, scared, overwhelmed pilot complied with an ATC descent direction that he should have rejected.
c) The pilot was blamed based on flawed airspeed data.