What actually happened
Special InvestigationReport79-1
This Accident Investigation Report prepared by the Dept while appearing to be extensive and detailedin its investigation of this accident is in fact deficient in its pursuit of the subject matter to its logical extensionof the ramifications of the total assessment of all the facts.
The Dept have touched on the matter of pilot strength when they investigated control system failure caused by pilot input loads but choseto not detail in a similarmanner the requirements of FAR 23-143(c) which limit the force requiredto be exerted by a pilot on a temporary basis not to exceed 75 pounds
This report also omits to detail any reference to the fact that the position of the trim tab actuator was in a position that indicated that the trim tab travelwas other than that certified in Australia
This report omits to admit to the fact that the Dept failed to obtain flight test reports as required by ANO 101-22 prior to certifying the Autopilot/Electric Trim system.
This report omits to detail that the Trim Tab Travel Range was excessive to that required to comply with FAR23-689(f) which establishes total trim capacity requiredfor an aircraft.
This report fails totally to address the fact that the Electric Trim System was never flight tested correctly as required.
This report by not completely investigating all aspects of the Electric Trim System was able to minimize the design and certification deficiencies to enable the claim of pilot error to be raised by stating
“However,the more likely explanation is that the command trim switch was activated unknowingly.”
This cannot be supported by any supported by any evidence as the coroner found at the inquest.
The CAUSE as listed in this report is incorrect and misleading and would be more accurateif listed similar to the following.-
Cause
The cause of the accidentwas that the aircraftbecame grossly out of trim at a heightwhich did not permit time for the crew to affect recovery.The trim system design allowed control forces to be generated that exceeded pilot control force limits to be exceeded by a substantial amount. The manner in which the out of trim conditionoccurred has not been determined and the possibility of a trim system malfunction cannot be eliminated
All this was only achieved after many numerous legal orders were obtained as the Department did everything they could to stall and delay proceedings.
I think their tactic was to maximize the delaying tactics hoping that I would tire of the whole process and just go away.
I had to get a court order to get them to let me get copies All the documents were laid out on a conference table in a boardroomin no logical order.I then had to identify he relevant documents that I required to be copied. It ended up taking a full days work to sort out.
In the end I ended up accepting an offer as I had been made aware that if I didn’t,Legal Aid would withdraw their support and I would be on my own from a financial point of view if I didn’t accept what was on offer. So reluctantly I accepted and at the end of 1993 after repaying the workers compensation costs and paying my legal costs I received what was left.
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Last edited by 6317alan; 22nd Aug 2017 at 06:06.