Thread: ATSB reports
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Old 16th Nov 2013, 05:30
  #48 (permalink)  
Join Date: Apr 2007
Location: Go west young man
Posts: 1,732
Linking the links i.e. accident(s) causal chains (back to reason)!

Having now read the report (AO-2011-102), scrolled through numerous media articles and video coverage, including the ABC 7:30 report (Report on ABC helicopter crash urges overhaul of regulations), I'm quite disturbed by some very interesting parallels coupled with some déjà vu(flashbacks) to episodes in the Senate Inquiry and previous Senate Estimates.

{Note: The 7:30 vid is well worth watching but warning you'll have to put up with large sections of Beaker fumbling along mi..mi..mi-ing. However it is not quite as bad as his appearances at the Senate inquiry/Estimates or the 'head buried in the sand' interview on 4 corners..see here- 4C Beaker interview}

So for a setting the scene here's a quote from the 7:30 Report transcript(my bold):
PHILIPPA MCDONALD: The crash and subsequent fire was so intense that Air Transport Safety investigators feared they'd never determine exactly what happened. But an intense two-year forensic investigation uncovered far more than ever anticipated, with vital information provided by the United States Army Aeromedical Research Laboratory.

MARTIN DOLAN: One of the key things they did for us was to feed into some modelling of human perception the flight data that we had for this flight which showed that the sort of increasing bank associated with this helicopter and this accident would probably until very late in the stage not have been detectable without visual reference or without reference to instruments.

PHILIPPA MCDONALD: Investigators believe the pilot experienced what's called spatial disorientation. In the dark of night, with no visible horizon, he couldn't recognise the chopper's spiralling descent in time to recover.

Fellow chopper pilot and friend, David Wilson, knows how spatial disorientation can unhinge the senses.

DAVID WILSON, CHANNEL NINE PILOT: I don't think there'd be a pilot out there today who couldn't say he has never suffered from spatial disorientation. It's a matter of firstly recognising it and then doing something about it because it fights all your senses. You think you're sitting bolt upright, whereas you're actually leaning at 45 degrees.

PHILIPPA MCDONALD: Gary Ticehurst was considered one of the nation's best helicopter pilots and was qualified to fly under the conditions that night. But the Australian Transport Safety Bureau says this tragedy shows aviation regulations need to be tightened.

MARTIN DOLAN: We're saying we're not sure that flight in dark-night conditions, that the standards of safety are necessarily at the level they should be and we're asking the Civil Aviation Safety Authority to take a close look at that.

PHILIPPA MCDONALD: The Civil Aviation Safety Authority says things will change. In future, all helicopters flying at night with passengers will have to be fitted with an autopilot or have a two-pilot crew.
This is where the neurons started pinging around, so I then referred to the report and in particular Appendix F – Accidents involving night VFR operations. In table F1 (halfway down the page) there was this entry:

17 Oct 2003
Bell 407 helicopter, VH-HTD, aerial work (emergency medical services) en route from Mackay to Hamilton Island, Qld. Loss of control en route. Dark night conditions. 3 POB, all fatally injured.

It was then that it all started to gel and drew my attention to a recent post from PAIN post #34 , that linked to some working notes and this is where it gets interesting , from the PAIN notes:
1) CFIW: East of Cape Hillsborough, QLD, Bell 407, VH-HTD; 17 October 2003.
Report - R20050002.
Issue date 14 March 2005.
Recommendation R20050002
As a result of the investigation, safety recommendations were issued to the Civil Aviation Safety Authority recommending: a review of the night VFR requirements, an assessment of the benefits of additional flight equipment for helicopters operating under night VFR and a review of the operator classification and/or minimum safety standards for helicopter EMS

ATSB Safety Recommendation.
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review it's operators classification and/or it's minimum safety standards required for helicopter Emergency Medical Services operations. This review should consider increasing; (1) the minimum pilot qualifications, experience and recency requirements, (2)
operational procedures and (3) minimum equipment for conduct of such operations at night.
Ok so if you then download the 2003 ATSB report (link above) and put that report alongside the AO-2011-102 report you will see some remarkable parallels..especially in the areas that deal with spatial disorientation and in the Safety Actions/Recommendations section (pg 71 onwards from 2003 report).

{Hmm..kind of makes you wonder why the ATSBeaker needed to rely on the United States Army Aeromedical Research Laboratory when they had already done the hard work back in 2003.}

On a final note here is a quote from the PAIN working notes from Coroner Henessy's findings/recommendations:
16. The Coroner supports CASR draft regulations point 61 and 133 becoming final.
17. That beacons, both visual and radio, be placed on prominent and appropriate high points along routes commonly utilised by aero-medical retrieval teams, including Cape Hillsborough.
18. The Coroner supports the ATSB recommendations 20030213,and promulgation of information to pilots; 20040052, assessment of safety benefits of requiring a standby altitude indicator with independent power source in single pilot night VFR; 20040053, assessment of safety benefits of requiring an autopilot or stabilisation augmentation system in single pilot VFR; and R20050002, review operator classification and minimum safety standards for helicopter EMS operations.

Starting to join the dots?? More to follow..Sarcs (K2)


CASA SRs for AO-2011-102: AO-2011-102-SI-02 , AO-2011-102-SI-03

CASA SRs for air200304282: R20040053,R20050002, R20010195, R20030213.

Note: With the courage of their convictions and experience, you will note that the bureau of old issued R20030213 within a month of the accident.. compare that to ATSBeaker...27 months was it??

Last edited by Sarcs; 16th Nov 2013 at 22:20. Reason: Addendum: SR Links
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