Lockhart River Coroners Findings (Merged) [Archive]

Brian Abraham

18th Aug 2007, 06:21

Just read the Coroners report on the Lochart River accident and wonder what his comments have to say about the regulatory authorities. Are things really as bad as he hints, and more importantly what is/are the problem/s?

CASA had senior, expert legal representation who I’m sure would not have made such a sustained attack on the integrity of the ATSB investigation report without explicit instructions. In my view, these protestations are symptomatic of serious, ongoing animosity between the two organisations that needs redressing. I shall return to the issue in the recommendation section of these findings.

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

Seems to be a total disconnect with CASA's view of aviation safety and reality when the they put forth "CASA submitted that responsibility for the crash started and ended in the cockpit; that there was nothing that any other individual or organisation could have done to prevent the crash." The sort of statement you would expect to see written by a know nothing tabloid journalist, not a body entrusted with the regulation and safety of the industry. I'm sure they have even met James Reason, or is that an unreasonable assumption?

WELLCONCERNED

18th Aug 2007, 10:45

I'm really surprised that no-one has reacted to the coroner's findings on Lockhart.

Putting aside the expected 'prime suspects', why wasn't CASA singled out for specific condemnation - and legal action......

To infinity & beyond

18th Aug 2007, 10:50

http://www.pprune.org/forums/showthread.php?t=288413

Frank Burden

18th Aug 2007, 23:18

Interesting that this thread has been moved to D&G General Aviation & Questions the place for students, instructors and charter guys rather than being left on D & G Reporting Points Airline and RPT issues in Australia and enZed. I thought this Aerotropics flight operated by Transair was RPT.

Interesting that people promote Reason and come up with one major cause for the accident. No aviation safety regulator has the hand of God to stop accidents. Look at the road kills around Australia.

Interesting that no one is considering the responsibilities of the operator. He owned and operated the company. The containment of risk was his primary responsibility.

Interesting that no one is being reflective on the pilot in command responsibilities.

Interesting that none of the 'informed' members of the industry had the gumption to put their concerns formally before the accident.
Interesting that the ATSB report in relation to the pilots actions was discredited by the Coroner. Where is the professional analysis of the report in the context of the Coroner's findings.

Possibly the moderator has got it right, this thread lacks sufficient depth to remain on the D&G Reporting Points site.:(

Brian Abraham

19th Aug 2007, 02:28

Frank Burden - I have to whole heartedly agree with you

Possibly the moderator has got it right, this thread lacks sufficient depth to remain on the D&G Reporting Points site.

Maybe because of post #9 :p

Page 53 of the Coroners report (bolding mine)

Primary responsibly for the incident must rest with the captain of the aircraft, a highly experienced and competent pilot. He knew that the approach he was planning to undertake into Lockhart River on 7 May was inconsistent with official regulations and Transair’s policies. He must have also known that his departure from it was fraught with risk. The contribution of the co-pilot, if any, can not be known. CASA submitted that responsibility for the crash started and ended in the cockpit; that there was nothing that any other individual or organisation could have done to prevent the crash. I don’t accept that. There is no evidence that Captain Hotchin was suicidal or that he habitually disregarded his safety of that of his passengers. It is necessary therefore to consider the context in which the actions occurred and the external influences that may have impacted on his behaviour. That is what the ATSB report and these findings have attempted to do.
I have also found that Transair failed to adequately monitor its pilots and to take steps to ensure that they were all complying with its policies. In my view the evidence establishes that its safety management system (My comment - that includes CASA) and the performance of key personnel was sub-optimal.
I have highlighted what I consider to be a number of deficiencies in CASA’s surveillance and audit of Transair and its departure from its own procedures. I have made recommendations about how some of those issues could be addressed, as has the ATSB.
That does not mean that CASA is to blame for the crash. There is no compelling evidence that if it had scrupulously followed all of its procedures and processes, the deficiencies that led to the crash would have been obviated, although it is impossible to avoid the conclusion that the risk may have been reduced.

PLovett

19th Aug 2007, 07:18

Having read parts of the Coroner's Report I feel that some of his conculsions are based on legalities rather than practicalities.

For example he appears to dismiss the First Officer's ability to influence the approach as he was not qualified to conduct a GPS NPA. I don't find this credible. I am not qualified to do a GPS approach but I can sure read and interpret the approach plate as I am sure most IFR qualified pilots can do.

The Coroner also seems to be saying that the Captain was attempting to get visual based on comments made to an inquest concerning a previous fatal crash. This is despite the fact that the Lockart River R12 approach is over high ground. If the approach had been made from the opposite direction then the comment may have had more validity.

The prospect of a lack of situational awareness is given scant attention.

However, the Coroner's conclusions, quoted by Brian Abraham, would appear correct. The handling pilot's performance in the past and apparently on the day was less than professional. It was a crash waiting to happen. The CASA oversight program is a joke. It gives lip service to compliance of the regulations by only doing paper audits. They serve to absolve CASA of any responsibility for when things go pear shaped, they most certainly do not detect actual non-compliance. The company is now no longer but it also appears to have been less than satisfactory in its running of its operations. The chickens appear to have come home to roost.

Will aviation learn from this crash. Probably not. It most certainly learnt nothing from Seaview, Monarch and Whyalla. Why should this one be any different? Let's just blame someone else.:mad:

Sunfish

19th Aug 2007, 07:55

A simple question for the more knowledgeable and experienced here....

I note previous threads, some years old, about the standards and behaviours of certain North Queensland CASA staff (only known by their nicknames, such as "Pinocchio"), all of whom have apparently now departed in the face of the "New Broom" - BB.

May I ask if certain of these gentlemen were responsible for auditing Transair?

das Uber Soldat

19th Aug 2007, 08:34

OK I'm going to get absolutely burned alive here however, was I the only person that was surprised by the shear volume of spelling, grammatical and formatting errors in what is supposed to be a rather important and official report? Sorry for the drift and just delete this if its too out of line.

TWOTBAGS

19th Aug 2007, 08:48

Good Question Fishy,

As an RPT operator in FNQ we were supervised by the Brisbane “RPT/High Capacity” FOI’s not by TSV staff.

We were however ramp checked by TSV staff who demonstrated their complete lack of knowledge of turbine aircraft on more than one occasion.:mad: :\

Licences, Medicals, Loadsheets, manuals…… no problem;). Turbine aircraft and higher caliber systems….. forget it:ugh::{

I would be very surprised if they (TSV) had inspection accreditation of the Transair group. :E

Under Dog

19th Aug 2007, 08:51

Page 37 of the Coroners Report States that the pilots had not been "Cleared to Line".Please Excuse me if Im abit naive but I've never worked for a company in charter or RPT (and thats been a few)that have not conducted a rigorous check to line with plenty of paper work filled out at the end of it.
If this is the case then certain people with in the company and CASA do have a very serious case to answer.

Regards The Dog

tail wheel

19th Aug 2007, 08:58

To the contrary Mr Burden, I find nothing trivial about Australia’s worst scheduled air service accident in 30 years.

The thread was started in this forum and a parallel thread started later in Reporting Points, was merged with this thread. I’m happy to move the thread to Reporting Points if you think it will make one iota difference to the lessons we should learn from this tragic event?

I too read the Coroner’s Report and am mystified that certain important regulatory and operational issues upon which one would expect the Coroner to investigate or at least comment, fail to rate a mention in the Report.

Seven people perished in the June 1993 Monarch Airlines Piper Chieftain crash at Young, NSW, nine people perished in the October 1994 Seaview Commander 690B disappearance enroute to Lord Howe and eight people perished in the May 2000 Whyalla Airlines Piper Chieftain disappearance into Spencer Gulf, all three accidents being extensively investigated (including numerous and extensive formal inquiries) and important lessons were learned.

And yet fifteen people tragically and needlessly died at Lockhart River in the worst air disaster in thirty years and we are to learn nothing except the cause was “pilot error” and CASA and the ATSB don’t always cooperate?

No Mr Burden, the Lockhart River accident was not trivial. I’m not sure I could make the same comment regarding the Coroner’s findings. Indeed, one could be excused for feeling the legal profession and perhaps even certain politicians got the report they sought.

ForkTailedDrKiller

19th Aug 2007, 08:58

I can assure you that CASA's TL office have recently taken some huge strides towards cleaning up the cowboy GA operators in NQ - NOT.:bored::bored::bored:

Dr :cool:

tail wheel

19th Aug 2007, 09:01

FTDK. Are you referring to those employed within the CASA FNQ offices, or FNQ GA operators in general?

Aside from the odd immovable geriatric, I agree almost all CASA FNQ staff have changed in the past few years.

Surveillance of the AOC holder involved in the Lockhart River accident emanated from the CASA Airline Office in Brisbane - not the CASA offices at TL or CS.

TWOTBAGS

19th Aug 2007, 09:11

Tail Wheel

Check you PMs, your right on!:ok::E

PA39

19th Aug 2007, 10:27

A chain of events which ended with the deaths of innocent parties. There is a lot in this. I won't point a finger at anyone specific, rather a group of people, organisations, regulators and individuals who should have known better! If each party allows irregularities to go uncorrected then disaster is the ultimate outcome. It could have all been avoided.

Mainframe

19th Aug 2007, 10:42

Tailwheel

You are correct.

When the circumstances of the inquiries into Monarch, Seaview and Whyalla are compared to flight HC675 at Lockhart River,
one can be excused for contemplating that something is not quite right.

When one digs deeper and investigates how this inquest has been stage managed,
the sheer co-incidence of counsel assisting with a vested commercial interest in things CASA,
with tentacles reaching into the upper echelons of CASA, conveniently recently retired, and other matters of public interest,
one cannot feel a little disturbed.

The accident and fatality rate in FNQ was and is out of proportion to the rest of Australia, despite an attempt by ATSB to dismiss that.

There is no doubt that the TL & CS CASA offices may have somehow failed,
not looking where they should have,
and looking and harassing where they shouldn't have.

Yes, there is no doubt that were human factors attributable to the crew that caused this tragedy.

What is overlooked is the lack of effective surveillance that created the climate that permitted the culture to grow and flourish.

The causes for the lack of effective surveillance result from several areas,
some similarities to Seaview with mates rates deals,
and the failure of the NQAO to conduct surveillance on another jurisdictions turf.

There is more substance for a Royal Commission into flight HC675 than there was for Seaview, but the wagons were circled early in the investigation.

There is no political will for an RC, the Federal Govt cannot afford the exposure in a lead up to an election.

We have all witnessed a whitewash of Watergate dimensions.

Its over, and swept under the carpet.

There have been further career casualties as a result, but they too have been kept relatively quiet.

What more can I say?

Air Ace

19th Aug 2007, 18:46

Recommending charges against the operator may well have also necessitated the Coroner taking a far more detailed look at the role played by CASA staff?

Fifteen people needlessly die; no lessons to be learned to avoid similar disasters in the future; and justice has not seen to be done by the families who lost loved ones.

Diatryma

20th Aug 2007, 03:39

Frankly I dont give a STUFF whether the operator is charged or not. That won't make one iota of difference to safety.

How many more operators are there out there like this one? Could CASA answer that question? I think not. It would seem they have no idea.

How many more accidents like this have to happen before something is done to improve CASA? They appear to be toothless and useless as far as giving the travelling public any confidence at all in their safety.

Then we have a Coroners hearing in which counsel assisting has (seemingly) a close relationship with CASA. I was not in the least suprised by this outcome. Extremely disappointed - but not suprised.

I don't think the families will be letting it go at that though. Stay tuned!

Di :mad:

PA39

20th Aug 2007, 05:23

:rolleyes:I learned very early in my career not to "buck the system" nor will you ever "beat the establishment". There will always be too many aces held in the wrong palms.
The beat goes on.

tail wheel

20th Aug 2007, 07:11

Anger over crash ruling

Courier Mail
August 18 – 19, 2007.

Angry scenes erupted outside a Brisbane Courthouse yesterday after the State Coroner delivered his inquest findings into the Lockhart River plane crash in which 15 people died.

It was the nations worst air disaster in almost 40 years, the two man flight crew and their 13 passengers died when the Transair operated aircraft slammed into a hillside about 11 kms northwest of the Lockhart River aerodrome on May 7, 2005.

Among the dead were David Banks 55, Frank Billy 21, Fred Bowie 25, Mardie Bowie 30, Robert Brady 35, Edward Green 35, Kenneth Hurst 55, Gordon Kris 37, Noel lewis 48, Paul Norris 34, Arden Sonter 44, Sally Urquhart 28 and Helen Woosup 25.

During the delivery of his lengthy findings, State Coroner Michael Barnes upset some family members by saying he would not make anyone a scapegoat for the crash, despite identifying failings by Transair and levelling criticisms at the Civil Aviation Safety Authority.

“With all due respect to those families, the making of scape goats in that manner is not part of my function,” he said.

“I find that CASA could have done more to insist that Transair improve certain aspects of its operations but I do not believe the evidence supports a finding that they could reasonably have stopped it from operating or prevented the crash.”

Outside the court, Trad Thornton – the fiancée of Constable Sally Urquhart – said he thought the scapegoat comment was “absolutely ridiculous”.

“We’re looking for answers and were hoping that Mr Barnes would make numerous recommendations to stop something like this from happening again,” he said.

Constable Urquhart’s father, Shane, said that CASA had got away scott-free and described the inquest outcome asa “whole waste of time”.

Mr Barnes made four recommendations, including that CASA expedite the introduction of mandatory crew resource management training.

He also called for CASA to reconsider the introduction of measures to ensure the efficiency of training and checking organisations for air transport operations.

He also asked the Federal Minister for Transport address “a degree of animosity” between CASA abd the Australian Transport Safety Bureau.

Tmbstory

20th Aug 2007, 07:53

I would suggest that the Regulator & the Industry take a long hard look at the value of " Stabilised Approaches " as against any type of "scud running" in RPT operations.

Torres

20th Aug 2007, 09:17

Oh, I see. Thanks.

I thought that was what the Coroner was expected to consider? :confused:

TwoHundred

20th Aug 2007, 11:05

So where to now?

The pilot was at fault, he is dead.

The operator is clearly negligent, he has disappeared overseas.
Don't blame him, if my loved ones had perished on that plane, I would hunt the bastard down and put him out of his f:mad:cken misery.

CASA were negligent, what the hell will they do now that will make a difference? I can tell you.....F:mad:CK ALL.

Attention Regulators. How about doing something that makes a
f:mad:cking difference. What will be done to ensure that this doesn't happen again? What have we learned from this that we can implement to improve the safety of the travelling public?

The weather at LHR was a factor. So why doesn't it have an AWIS with a ceiliometer?? Oh that's right because its expensive.

If you have tried this approach in a strong SE wind you will know about the horrendous turbulence. Is there a warning on the approach plate of this? Nah that would be to sensible, let the suckers find out for themselves.

What f:mad:cken idiot designed the approach in the first place? Probably the same one who penned the CKN NDB to go directly over the highest hill in the area. What the f:mad:ck do you expect to happen??

A TRAGIC UNNECESSARY LOSS OF LIFE.:{

200

Under Dog

20th Aug 2007, 21:54

So True" TWO HUNDRED"

Fifteen lives can be lost and no one is made accountable,but If for some reason you ripped of the TAX office you would find yourself in Gaol very quickly.So the old rule applies that money is worth more than life.

Regards The Dog

Diatryma

21st Aug 2007, 03:12

CRIKEY!!!

(from Crikey.com)
CASA couldn't stop Transair, so what good are they?

Date: Monday, 20 August 2007

Ben Sandilands writes:

It would have been appropriate for air sickness bags to have been handed out to the relatives of those killed in the Lockhart River air crash when Queensland coroner Michael Barnes reported his finding on the disaster on Friday afternoon.
Barnes blamed the deaths of 13 passengers and both pilots on 7 May 2005 on the actions of the senior pilot Brett Hotchin and the defunct regional carrier Transair.

An astonishing revelation really. Just as the Australian Transport Safety Bureau made clinically clear in its ferocious report into the accident published in April.

Also astonishing is the finding that CASA could not have prevented the crash.

If it couldn’t prevent even a tin pot airline serving Aboriginal and Torres Strait Islander communities from crashing, why is CASA being trusted with the safety regulation of big Australian airlines?

Can someone, perhaps the Minister of Transport Mark Vaile, discover at what threshold of air transport activity CASA becomes effective?

Before the Coroner sat, CASA had admitted knowing that Transair was deficient in key operational matters. It knew that pilot Brett Hotchins was dangerous.

Yet it told the public nothing about what it knew, knowledge that might have informed decisions about whether to fly on its services. Its oversight of its operations was so ineffective it let Transair masquerade as a safe airline and fly 13 unsuspecting passengers to their deaths.

What else isn’t CASA telling us? How many dead people will it take for the government to address the core issues of culture and competency and resources in air transport safety regulation for all Australians, black, white, outback, city, in large jets or small turbo-props?

Surely Ian Harvey QC, the counsel assisting the coroner must have tried his utmost to focus the inquest on issues that go to the core of public safety in the air?

After all, he came to the inquiry with impeccable credentials in terms of insights into aviation and CASA, having earned $475,436 from appearing for the safety regulator between July 1, 2002 and June 30, 2006.

Di :(

squawk6969

21st Aug 2007, 08:03

Di

Maybe I am naive and out of the loop here, but does the last part of that story suggest......A CONFLICT OF INTEREST there?:uhoh:

If so that needs running up a flag pole!

SQ

Air Ace

21st Aug 2007, 08:11

"....does the last part of that story suggest......A CONFLICT OF INTEREST there?"

Of course not Squawk! He achieved exactly what his client expected!

Diatryma

21st Aug 2007, 11:25

Squawk,

Spot on mate.

You too AA.

The coroner really should have had someone assisting who had no connection with any of the parties involved - just to remove any doubt.

Di

megle2

21st Aug 2007, 12:30

I actually went to the Brisbane Coroners Court for a number of days and watched procedings.
During my time there I only saw two others who were not involved as legal advisors, press ect.
One I understand was an ex Transair pilot viewing procedings from another room via video. That was on the day the Chief Pilot was in the box. The other, who knows.
I was impressed with the Coroner. His report was well written and reflected what I witnessed.
Its a pity that basically nobody from the industry bothered to attend.

Mainframe

24th Aug 2007, 12:02

Lest we forget,

17. Senate questions over CASA crash and burn
Ben Sandilands writes:

There is a very bad smell hanging over conduct of CASA in relation to safety oversight of Transair, the now defunct remote community airline that killed 15 people in the Lockhart River crash of 7 May 2005.

Crikey has examined more than 100 serious and detailed questions raised in the Senate by Senators Kerry O’Brien and Jan McLucas before and after the Australian Transport Safety Bureau released its scathing final report into the disaster on 4 April.

Every single one of them received a pro forma brush off response from Senator David Johnston representing the Minister for Transport, Mark Vaile, with each response including these paragraphs:

The accident is also currently being examined in an inquest by the Queensland Coroner's Office.

Both CASA and the ATSB are assisting the Coroner. The coronial inquest provides the most appropriate forum for detailed and objective consideration of CASA’s oversight of Transair.

Together, the ATSB report, the coronial proceedings, and the evidence CASA has provided to the Senate on several occasions, ensure that the public interest in the issues raised by the accident is fully addressed.

These formula answers were being churned out by Senator Johnston and put on the parliamentary record right up to day the Queensland Coroner, Michael Barnes, delivered his report on 17 August.

Clearly the Minister’s confidence in "detailed and objective" consideration is misplaced and he must be as disappointed in the Coroner as everyone else.

The Coroner, ably assisted by none other than Ian Harvey QC, who often represents the safety regulator in legal matters, scarcely touches upon voluminous matters of concern to the relatives of the victims.

Or the wider interests of air travellers exposed to CASA’s failings in relation to its safety obligations to remote and predominantly Aboriginal community air services which remain unresolved.

The Senate, in however much time it has left, is the only place in which these answers can be pursued.

Some of the questions are very pertinent and technical, and were clearly framed after receiving detailed advice about the specific actions and inactions that must have transpired between CASA and Transair over a period of time.

Is it all too hard for the Minister and the safety regulator to confront the truth, that between 1999 and the fatal day, all of the processes and checks the CASA claimed to have in place where sometimes not performed, or continually bungled?

Or is it a case that the airline and its victims are dead, and best forgotten?

Diatryma

27th Aug 2007, 00:52

Lockhart River Inquest lawyer replies

Date: Friday, 24 August 2007

Ian Harvey QC, counsel to the Coroner in the Lockhart River Inquest, writes (http://www.crikey.com.au/Politics/20070824-Ian-Harvey.html):

The good fortune of Crikey’s readership in having the intrepid Ben Sandilands as its aviation writer has been demonstrated once more with his in-depth reporting of the recently concluded Lockhart River Inquest.
With more than 45 years in journalism, Ben Sandilands is an internationally respected travel writer who over the years has produced incisive articles on a range of aviation topics for "prominent media". He no doubt has earned 100’s of thousands of dollars over recent years writing for "syndication arms" and "leading newspapers" around the world.

Surely with such a wealth of experience in addition to pouring over transcripts of Parliamentary Committee proceedings, he must have tried his utmost to come to grips with almost 2000 pages of transcript, some 170 exhibits and an array of other documents produced at the inquest to inform himself on the core issues on aviation safety that were examined.

With these "impeccable credentials" in terms of insights into aviation and an understanding of the aetiology of accidents, I only wish that Ben Sandilands could apply those skills to all aviation matters in the passionate pursuit - that we all share - of ensuring public safety in aviation. Indeed one accident comes specifically to mind.

It is almost the 20th anniversary of a controlled flight into terrain accident by a Fokker F27 aircraft of Burma Airways on approach to Pagan. All 49 people on board the aircraft were killed. The reasons for the accident have never really been explained. A journalist colleague of Ben Sandilands was actually awaiting the arrival of the aircraft at Pagan.
Fate was kind to him but without the impeccable credentials of a Ben Sandilands I don’t think he conducted any kind of forensic investigation of why a perfectly good aircraft flew into a mountain. I mean, if getting information out of Australian aviation authorities is hard, imagine the frustrating difficulty of extracting anything from the Burmese government.
However, with the international reputation and respect that Mr Sandilands commands, I am sure he could get to the real reasons for that accident.

Oh, and why, I can hear Ben Sandilands ask, do I specifically mention a CFIT accident of twenty years ago? I suppose it’s just that my father and step-mother were two of four Australians on board that flight.

WHAT'S THIS ALL ABOUT? Surely this is not actually Ian Harvey writing this? What's he trying to say? You would think he might have taken the opportunity to defend his reputation rather than slagging off at the journalist?

Di :sad:

404 Titan

27th Aug 2007, 04:54

Maybe he is a little closer to the facts than the Journalist?

Creampuff

27th Aug 2007, 05:10

Di

Perhaps that's Ian's way of saying that he's the last person on the planet who has any interest in covering up the real causes of CFIT accidents (I use 'accidents' in the counter-intuitive, ICAO sense).

You did notice the bit about his father and step-mother having died in an as-yet unexplained CFIT accident, didn't you?

And won't the coroner be impressed at the insult to his intelligence! The truth was there to be discovered, but that tricky lawyer managed to cover it up.

Mainframe

27th Aug 2007, 22:09

This is my last post on this subject.

Undisputed fact:

CFIT due to deviation from SOP’s (established from evidence).

i.e. not utilising stabilised approach, one crew member not qualified for the approach, both crew members not completed CRM course as per Ops Manual Sect C.

Substantiated history of non compliance in various areas.

OK, yes, Pilot Error, close the case.

Coroner’s duty:

Establish cause of death of victims.
Who was killed
When did it happen
Where did it happen
How did it happen
Why did it happen
Make recommendations to mitigate re- occurrence
Coroner’s duty completed.

But wait! What created the culture that it was ok to not comply?

Why was the operator reasonably sure that it was ok not to ensure it followed its Ops Manual?

Why was a pilot rostered for a flight without all the boxes in the C & T being ticked and signed off?

Shouldn’t the non compliances have been picked up in a normal everyday CASA audit?

Ben Sandilands merely pointed out the more than 100 questions asked in the Senate (and thus available on Hansard) about the diligence of the regulator,
and the evasive and possibly untruthful answers given as to the role of the regulator.

The senate was assured that not only had CASA conducted an audit on the operator,
CASA actually stated that it was a “Fulsome Audit”. (Hansard)

Subsequently ATSB established just how deficient that “fulsome audit” was, and listed the numerous deficient areas.

On the basis of Hansard and ATSB, there may be evidence to suggest that the regulator didn’t in fact regulate the particular operator in a diligent and impartial manner,

and thus maybe a contributory factor in the accident that had to happen, eventually happening.

The appointment of a CASA loyal Counsel Assisting caused consternation and objections were raised by families of the deceased.

Those objections were over ruled.

Outcome: Pilot Error, case closed on Australia’s worst aviation tragedy in 30 + years.

This tragedy eclipsed Seaview, Monarch and Whyalla, but was simply better stage managed.

The damage control was very effective, but it was noted that while there were some animosities between CASA and the ATSB, there were no contributory deficiencies.

Lest We Forget

Diatryma

27th Aug 2007, 23:38

Excellent post Mainframe.

It is now highly likely that that is the end of the matter as far as aviation safety in Australia is concerned. Nothing will change. We must now wait for the next major accident, or perhaps another 2 or 3 - or 10 - before perhaps something is done to improve CASA's effectiveness.

The only other hope is action taken by the relatives left behind. This may take many forms, and may require assistance from our friends the lawyers and journalists - and may or may not have any effect.

Perhaps the fact that there is a looming federal election can be used to apply pressure?

At the end of the day it seems "Best We Forget" rather than "Lest We Forget".

Di :{

PLovett

28th Aug 2007, 01:38

This tragedy eclipsed Seaview, Monarch and Whyalla, but was simply better stage managed.

Of course it was better stage managed. They have learnt from those previous tragedies how to manage the fall out thus protecting their lords and masters. :mad:

Pity they still have to learn how to protect the flying public. :ugh:

Brian Abraham

28th Aug 2007, 02:00

Not an excellent post at all Mainframe - absolutely outstanding and on the mark. :ok: Coming from Whyalla I travelled regularly on Whyalla Airlines, knew the operators family going back to the late 50's and knew some of the families of the deceased. What I find galling is I went to a companies CEO, ATSB and CASA with concerns as to how business was done in a certain company and was anyone interested? Hello!!! All the failings found in the Lockhart case were exactly the failings I brought up, indeed, it could be said with some measure of truth that Transair was the more professional of the two. The professionals within CASA and the ATSB must cry in their beers at night, certainly Don Anderson must surely be rolling in his grave. Sadly we can already write the script for the next accident - take the Lockhart report and just change the names. I wonder who will be next to lose in this game of Russian Roulette - you or me?

Torres

28th Aug 2007, 09:47

"...certainly Don Anderson must surely be rolling in his grave.."

Certainly he would. But there are few left who remember the professional integrity and competence which existed in The Department in Don's days........

:mad:

Diatryma

28th Aug 2007, 23:02

Hey Brian - did Whyalla Airlines ever get anything by way of compensation from Lycoming? I know the passenger's relatives got an "out of court" settlement. But I'd heard that Whyalla got something back for the aircraft, and was wondering if they got anything for the loss of their business?

Di

Mainframe

29th Aug 2007, 04:46

Di, and Brian Abraham.

It seems we are among those who can't see the King's new clothes.

I did not wish to continue on this thread through sheer disgust,
but today's response by BB fails to address my question,

WHAT CREATED THE CULTURE THAT IT WAS OK NOT TO COMPLY?

BB, a lot of people, in and out of CASA, knew that a special relationship may have been in place between the regulator and the operator.

We know the name, you know the name, and he has conveniently retired.

A Royal Commission, or a Judicial Inquiry, may just find the evidence needed.

One does not need to be a Rhodes Scholar to deduce that knowledge of a lenient surveillance regime,
and not the dreaded "FULSOME AUDIT" as reported in Hansard, can lead to substandard operating practices.

In simple terms, if your mate is the policeman with the radar gun,
do you really need to worry about exceeding the speed limit in your mate's jurisdiction?

For those who haven't seen today's response, here it is.

August 2007

From CEO Bruce Byron

CASA is carefully studying the Queensland Coroner's report into the May 2005 Lockhart River accident. In a 54 page report Coroner Michael Barnes concludes that primary responsibility for the Metroliner accident in Far North Queensland must rest with the Captain of the aircraft. The report says:

"He knew that the approach he was planning to undertake into Lockhart River on 7 May was inconsistent with official regulations and Transair's policies. He must have also known that his departure from it was fraught with risk."

In examining the question of why the aircraft departed from standard published approach procedures, the Coroner states:

"It seems likely that when descending below the minimum safe altitude of 2060 feet, Mr Hotchin was relying upon a perception of terrain visibility that he hoped would continue and improve as he got lower. Further, it seems he formed the equally false perception that he was closer to Lockhart River in the approach that he was attempting than he actually was. It is impossible for me to accept that Captain Hotchin would have flown at the vertical speed he did with the nose pitched down as steeply as it was had he not seen the ground at some point. The force with which the plane crashed into the mountain indicates he lost visual contact before impact. The most likely explanation for his continuing with this flight path after losing sight of the ground is the attitude...of having made a decision, pressing on regardless."

The views expressed by the Coroner mirror the conclusions I came to when I studied the first Lockhart River accident factual report, which was released in late 2005. This report contained information from the flight data recorder and after some careful analysis over several days it led me to believe that the aircraft was being flown with a deliberate high rate of descent, with the aim of gaining or maintaining visual contact with the ground. I know this same view is held by a range of industry people with extensive experience and expertise. I believe that to aviation people with a background in training and checking in this class of aircraft this is a logical conclusion. Of course, no-one can prove this conclusion as the information from the cockpit voice recorder was not available - but there is a high probability it is the correct scenario.

Having decided this scenario was the likely explanation behind the accident, I was confident stating earlier this year that it was not possible to make a direct link between the actions of CASA and the failures that took place on the flight deck of the Metroliner. While there have been various attempts to make a direct connection between CASA and the mistakes made by the crew, the Coroner's report does not support them. The Coroner says CASA should not be blamed for the crash. The report states:

"There is no compelling evidence that if it (CASA) had scrupulously followed all of its procedures and processes, the deficiencies that led to the crash would have been obviated, although it is impossible to avoid the conclusion that the risk may have been reduced. I find that CASA could have done more to insist that Transair improved certain aspects of its operations but I do not believe that the evidence supports a finding that they could reasonably have stopped it from operating or prevented the crash."

I agree with the Coroner's key message - that CASA could not have prevented the accident but never-the-less must always be committed to supporting the aviation industry's safe operations. CASA has a duty to make sure everything possible is done to influence, assist and direct the aviation industry to deliver the best safety outcomes. The Coroner quite rightly pointed to shortcomings in the way CASA operated in the past and has recommended changes in a number of areas. I do not shy away from accepting that in the past CASA should have been doing a better job in areas such as industry oversight. That is why I have been leading a change program across CASA for the last three years, which is putting more inspectors on the tarmac and increasing surveillance of passenger carrying operations and using risk analysis to drive activities.

I have directed that the Coroner's recommendations be assessed and implemented as soon as possible, recognising that some of these improvements are already underway. The recommendations included expediting the introduction of mandatory crew resource management training, consideration of firm guidelines for CASA staff who approve appointments of key personnel in aviation organisations such as chief pilot and reconsideration of measures to ensure the efficiency of training and checking in air transport operations. CASA will also co-operate fully with the implementation of the Coroner's fourth recommendation, which calls for the Federal Transport Minister to appoint an external consultant to examine the relationship between CASA and the Australian Transport Safety Bureau. The Minister, Mark Vaile, has announced he will adopt this recommendation.

For people in the aviation industry I believe it is very important to take careful note of the findings of the Lockhart River accident Coronial report. There are stark lessons for pilots and indeed anyone in a position of responsibility in the industry. These lessons are best summed up by this statement in the report:

"...had the pilots adhered to the accepted aviation procedures and well published guidelines, the crash would not have occurred."

WHY DID THEY BELIEVE IT WAS OK NOT TO COMPLY??

A mate had the radar gun?

Jabawocky

29th Aug 2007, 05:29

Mainframe I understand you wanting to cease the dialogue, but I see you can't so easily. Its as you say a disgusting whitewash.

You keep asking WHY DID THEY BELIEVE IT WAS OK NOT TO COMPLY?? is this a rhetorical question? I think we all know the answer, because once some lazy or slack or cowboy attitudes and behaviours start, they then become practised a bit, and then become normal, and then become an unofficial SOP!

Why did it ge that far?........your mate has the radar gun! You have hit the nail on the head.

Why is it in aviation and many other professions that the whistle blower is often haunted out of the industry or worse, and nothing is done about stopping Cowboys. I watched Australian Story this week and it was about a Dr McLaren in Canberra hospital, and the had Neurosurgeon who was plainly incapable of performing at the level required. Nothing was done for years and years although everybody knew and would talk about it amongst themselves. Dr McLaren blew the whistle and he became the one who suffered.

Seems that same practice is very healthy in GA and maybe a little in the airlines although SIM checks etc help correct any issues before they become serious.

BB says he is aware of the need for change and has been embarking on it, but I wonder when I hear of CASA trying to prosecute a private guy for missing an inspection date for an AD by a couple of days and flying the plane (job was done a few days later no defects) when surely they are meant to be focussing on the commercial and RPT issues. Sure write a letter saying you are a naughty boy etc, wrap over the knuckles but why waste the resources on such a thing when there are bigger more important things to do. Yes this was in NQ.

Mainframe, do you think the Leopard has not changed its spots yet?

J

Chimbu chuckles

29th Aug 2007, 05:51

Further, it seems he formed the equally false perception that he was closer to Lockhart River in the approach that he was attempting than he actually was.

Yeah...because the design of the approach makes it inevitable:ugh:

Mainframe

29th Aug 2007, 06:06

Jabawocky

Some replies:

Yes, it is a rhetorical question, and one that should have been asked at the inquest as part of the "WHY" (1 of Coroner's 5 thingies).

Yes, the Leopard is changing its spots, BB inherited the problems and the culture,
and he is committed to rectifying them all.

He has quite correctly stated that he is actually doing that.

I am confident that he will instill some integrity back into the culture, but until some accountability is also included, it will be just window dressing.

CASA itself did not contribute to the tragedy, but perhaps someone formerly employed by CASA may have.

as for your comments on NQAO, there are some slow learners still there.

Keep watching NQ office, the culture change is not yet complete, but eventually will be.

Some of the changes are already obvious but there is still resistance to change and that too will be resolved.

Yes, I am disgusted at what used to happen, and what has happened,
but I am willing to concede that although BB cant accept responsibility for the past,
he can and will accept responsibility for fixing it and keeping it fixed.

Change will be complete when we see criminal charges handed out instead of backdoor exits with golden Handshakes for the miscreants.

Brian Abraham

29th Aug 2007, 06:38

WHY DID THEY BELIEVE IT WAS OK NOT TO COMPLY

Because of ineffectual auditing and the fact that the defacto and illegal SOP’s had worked for so long.

The operator I referred to earlier effectively took no notice of what was written in AIP, CAO, CAR, or anything else. Operations were conducted IMC below LSALT (supposed to be VFR), made up instrument approaches because you didn’t have the fuel to fly a legal approach (you’re VFR remember), no alternates provided for although ALL operations required one, TAFs and Area reports not deemed by the organisation to be necessary although AIP required same. I could go on but you get the salient drift. I was seduced I must admit by the operating ethos that “this is how we do things around here”, as were all employees, although everyone, almost to a fault, said on joining “what the hell is going on here”. I woke up, figuratively speaking, when the operator had a non aviation accident in which two people were killed, quite a few badly injured, and the non availability of a states resource for a fortnight, putting a great many people out of work and businesses incurring financial loss. They attempted to lay all the blame at the feet of the lowest guy on the totem pole, but a Royal Commission found otherwise. A book authored by Andrew Hopkins summed it up

“the accident was quite preventable. It was caused by a series of organisational failures; the failure to respond to clear warning signs, communication problems, lack of attention to major hazards, superficial auditing and a failure to learn from previous experience.”

All those points could have also been written about the aviation operations. This a company with extremely deep pockets and not a GA operator trying to eke out an existance. In attempting change I was of course cast in the role of “bad boy”. The operator was of the opinion that because they had never suffered an accident in 30 years of its aviation operation, and having received industry awards for their safety record, everything must be OK. Mind you, there had been quite a number of close, and I mean BLOODY CLOSE calls in that time. How about a CFIT miss by 35 to 40 feet. Operating IMC when supposed to be VFR will do that. You won’t find any reports on those sort of events of course, because unless you were involved, or good friends with the person involved, you wouldn’t find out. Only things that ever got reported were mechanical failures, chip lights, engine failures etc etc.

Having gone to the ATSB and CASA the best answer (verbal - nothing in print) I got, unless I misunderstood the answer, was "because its a private operation and doesn't have an AOC we can't do anything." Go figure.

Di - To answer your question, I know not I'm afraid.

Tmbstory

29th Aug 2007, 20:07

Some of us do.
It was a far better organisation than what it is today.

Integrity & competence are the key phrases, we hope that common sense returns to our industry.

Are the basic standards today, any better than 40 years ago & if not then why not.

ROARING RIMAU

29th Aug 2007, 21:38

Chimbu says "Yeah...because the design of the approach makes it inevitable":ugh:

It looks like you have been beating your head against the wall too often Chimbu, or are you always beating something else.

If you go way below the minimum altitude on ANY published approach the inevitable will happen.

I think it's called CFIT.

Airservices are advertising for procedure designers, why don't you apply and solve all the problems in aviation.:zzz:

Diatryma

29th Aug 2007, 23:04

From BB:

CASA could not have prevented the accident

Well I guess that says it all. This tells me there are more than likely operators out there who are operating in the same manner - likely to have major accidents in the future - and CASA believes there is nothing they can do about it.

Disgracefull.

Di :rolleyes:

Brian Abraham

30th Aug 2007, 04:32

ROARING RIMAU - I'm afraid I have to agree with Chimbus observation, as do many others. Read the Lockhart River thread in its entirety and you will find much discussion on GPS approach design.
http://www.pprune.org/forums/showthread.php?t=270575&highlight=Lockhart+River

Air Ace

30th Aug 2007, 05:24

Chuck. If the design of the approach makes a false perception inevitable, why is it that only one aircraft, over a long period of time, ended up with CFIT?

No doubt that approach has been flown hundreds of times by many aircraft and pilots; only one accident?

I don’t think there is any dispute the design of the approach could be significantly improved, however it was not fundamentally flawed and if the Transair Metro pilot had flown the approach in accordance with the existing approach parameters, the outcome would have been very different.

The primary question must remain in the operator’s culture which permitted the event to occur and why that culture was not detected by CASA over a prolonged series of rigorous audits?

Diatryma

30th Aug 2007, 06:20

Air Ace,

Yea - I think you might have a point. Generally speaking "inevitable" is probably a bit strong a term in most cases. Perhaps "more likely" would be better.

However with all the other factors which came into the equation in this accident, "inevitable" could well be closer to the mark. The approach design issues might have been the final hole to line up in the Swiss Cheese!

Di

Chimbu chuckles

30th Aug 2007, 09:56

Inevitable simply means something WILL happen sooner or later...and it did.

Inevitable does not mean something will happen regularly or sooner rather than later...and guess what? If the INCREDIBLY fecking stupid, idiotic, negligent, dangerous GPSNPA approach design is not addressed sooner rather than later it is INEVITABLE that a similar accident will happen again.

Scenario 1.

A cowboy metro captain flies an approach at speeds and rates of descent that are off scale for ANY IAL procedure.

Scenario 2.

An relatvely experienced captain flying a VERY poorly designed approach is 'helped' by a well intentioned but non qualified copilot and becomes convinced that he is on the final 5nm approach segment to the MAP, rather than the preceeding 5nm segment to the Foxtrot waypoint, and therefore high..he increases RoD to salvage the approach and crashes into terrain.

If you were the regulatory authority that approved the GPSNPA design (let alone completely confusing waypoint naming protocol) and promulgation what scenario would you prefer was in the public domain?

Roaring Rimau, can I make my position any more clear for thickheads like you?

:mad:

Jabawocky

30th Aug 2007, 11:53

CC

from a thickheads perspective, I fly VFR (so no formal training yet I can work it out)....I studied the approach plate and others back when the prnag happened....I came quickly to the conclusion CC came to and many many others, even investigators have. The "distance to" is the issue.

It is easy to get confused with the segments when a lot is happening in a dynamic situation, and you might only mess it once in a thousand, and even then you may get lucky......but you might not. I think Di sums it up.

So to ROARING RIMAU have a read back thru two years of thread....and tell me and others we do not have a point. Its a significant factor, along with a few others. This guy clearly flew HOT and took short cuts etc, so maybe this day he was a bit too slick and also got his segments wrong.....swiss cheese!

J

NOtimTAMs

30th Aug 2007, 12:48

CC - Wait a sec

Re: Scenario Two - for this op., 2 pilots were required and both were required to be qualified on the procedure to be used. Co-pilot wasn't qualified , thus shouldn't have flown the GNSS approach in any case. Also, annunciator should show APP mode at/just before FAF - if you're not seeing that, you're either not in the place you think you are or the GPS thingy (or the space segment thingies) have chucked a wobbly and you shouldn't descend further in any case - another back up. If wx too bad for NDB APPCH and GNSS not possible due above limitations, then divert if fuel not critical....is that hard?

Should the design be made simpler so that rulebreakers can "get away" with it? Dunno.

As Ace said, there's thousands of these approaches flown, and if you do them often, you get quite familiar with them, including the waypoint naming (which i think is better than the random US/FAA naming of GPS waypoints). PIC's have fecked up ILS, LLZ/DME, VOR/DME APPCH, GPS Arrivals and visual arrivals, too....does that prove those accidents were inevitable due to design of the procedure?

ROARING RIMAU

31st Aug 2007, 00:01

What is the POOR PART OF THE DESIGN of the Lockhart GNSS approach that is not part of the internationally accredited DESIGN CRITERIA?

Just because you don't like them doesn't mean they are unsafe.

I bet your passengers are glad that you don't fly GNSS approaches, because clearly it is inevitable that you will have a CFIT flying one to your own rules.

If you get your landings wrong the instructor doesn't sign you off for solo.

If you fail your GNSS rating/renewal, the ATO doesn't sign you off.

If you don't fly the procedure as published, you kill all of your passengers and yourself.

The main issue with the approach was the way that JEPPESEN doesn't depict the initial segment that can cause confusion to undisciplined or untrained crews.

AsA DAP depicts the entire approach.

Jabawocky

31st Aug 2007, 04:58

Hey RR

I bet your passengers are glad that you don't fly GNSS approaches, because clearly it is inevitable that you will have a CFIT flying one to your own rules.

I bet CC will be along soon to set the record straight:ooh:. I might fetch a beer and a snack, this could get entertaining!:E

and
If you get your landings wrong the instructor doesn't sign you off for solo.

If you fail your GNSS rating/renewal, the ATO doesn't sign you off.

If you don't fly the procedure as published, you kill all of your passengers and yourself.

Reckon we all agree with you on that!:ok:

J

ForkTailedDrKiller

31st Aug 2007, 06:17

It is very rare that I find myself on the opposite side of a debate from CC. However, that is the case on this occassion.

I have flown the YLHR GPSRNAV Appr in question on several occassions and do not see a problem with it or any other Ozzie GPSRNAV Appr.

BUT - I have a moving map on the GNS430 which make situational awareness much easier than older generatation approach capable GPS units.

I can see how a mistake could be made in relation to where you are on the descent, and I guess if if one flies the approach with the same disregard for the rules that appear to be evident in this case - the outcome is probably a forgone conclusion - eventually!

Dr :cool:

Brian Abraham

31st Aug 2007, 07:31

On the aircraft I used to fly I had the benefit of map mode on the EHSI (being fed by a Trimble 2101) and the flight manual only allowed a GPSNPA to be flown in coupled mode - no hand flying even with flight director bars. It beats me how the guys fly the approach (on evidence quite successfully) with only the raw data 2101 presentation, and hand flying it at that. I'm afraid as I said before, I agree with CC, if only because of the work load involved, and the attention that is needed to "place" yourself in the correct segment of the approach. Easy with the map mode, but raw data? I suspect, but don't know if, this was one aspect which required our "coupled only" certification.

We are all entitled to our point of view, eg;

If you get your landings wrong the instructor doesn't sign you off for solo.

Quite right, and how many highly experienced aviators have found them selves sitting in the grass/over run/wreckage following a landing gone wrong wishing they could relive the previous five minutes. We all stuff it up at times, even the good Doctor, who didn't know whether it sucked or it blew (knows now but ;)), and that includes misreading/misunderstanding approach charts. Cargo 747 at KL for one. Or do some of you people never make mistakes - honest ones that is? Call me thick if you will, plenty of people do. :p

ForkTailedDrKiller

31st Aug 2007, 07:52

"We all stuff it up at times, even the good Doctor, who didn't know whether it sucked or it blew (knows now but ;))"

.... but ignorance of "suck" or "blow" is unlikely to end one's life cycle!

ahhhhhh, well in an aviation sense anyway!

Dr :cool:

Chimbu chuckles

31st Aug 2007, 08:26

RR I am GPSNPA qualified and I do fly them...as published...but I have been instrument rated for over 20 years and have held Instrument C&Ting approvals, including Initial Issue captain/copilot and am very aware of the potential problems with the approach design...and have seen how innexperienced IFR pilots get confused.

The GPSNPA is an unreasonably complicated approach and what makes it so is the Foxtrot waypoint half way down finals. If the FAF waypoint was at say 9nm/2500agl and the MAP waypoint was, say, 2.0nm/600agl, or even 1.5nm/450agl ir would be VERY much more difficult to lose situational awareness and descend early.

It shouldn't need a high end moving map to safely fly a GPSNPA...It should be easy enough even with something like my KLN90b etc.

Whomever wrote into the TSO that a waypoint should be stuck where the foxtrot waypoint is clearly has next to no IFR experience. Then someone componded that by a less than simple waypoint naming protocol.

GPS is a highly accurate navigation system and it should have been reasonable to expect as simple as possible an approach to make best use of the technology...but we got something as complicated as possible...it's almost as if the same technogeeks that design Airbus aircraft wrote the GPSNPA TSO. GPSNPA are a human factors nightmare...just because most people manage to work around the inherant problems doesn't make them any less a problem.

There should be no more than 3 waypoints on a GPSNPA...IAF, FAF and MAF. The FAF waypoint should be up around 2400'agl and 8nm from the runway. If I was designing them there would be a dist/alt scale across the bottom WITH a 3x profile printed next to it that if followed would result in a safe constant descent to the MAP waypoint. The pilot could then load the approach read the chart profile and put the plate aside and merely fly the aircraft rather than constantly looking at the approach plate to check where he was in the approach...no distance counter marching down from 5nm to 0nm several times in the course of flying the approach. THAT is the potential confusion and it is potentially deadly....and it serves no usefull purpose.

I think it is HIGHLY likely that in the heat of the moment the co-pilot offered missleading advice on their position in the approach...however well intentioned. Had the approach been designed along the lines of every other approach with DME (of some description) then even if the copilot gave missleading advice the captain would instantly recognise it as such and discount it.

Yes the copilot in this case was not qualified to actively participate in the approach...but human nature suggests a captain would be more likely to try and keep a 2 crew interaction going in the most high workload part of the sector...most pilots in this situation would consider it good CRM...it is not a hugh stretch to suggest the captain had developed some degree of trust in the young man and thought he was more than capable of reading the chart and recognising the waypoint names well enough to be of help.

We'll of course never know for sure but is it more or less likely that this is what happened or that the captain just decided on the spur of the moment that a dirty dive to VMC was called for in an area he knew to have terrain considerations?

I just do not accept that the captain, whatever his perceived professional faults, was that stupid...suicidal or confused?

It is easy to say that if the FO was qualified to fly the approach the accident may not have happened...equally it is reasonable to suggest innexperience may have caused him to be similarly confused and still misslead the captain with well intentioned but deadly advice.

Had the approach been designed with proper Human Factors taken into account there is MUCH less likelyhood ANYONE would have been confused and if ONE person was it is MUCH less likely the other would have been too and flown into the ground as a result.

The design of these approaches is a hole in the cheese that DOES NOT NEED TO EXIST.

In my view this is a design fault that is even more a potential trap for single pilot operations...it shouldn't need FTDK's high end moving map to fly safely.

Interestingly Air Niugini BANNED non EFIS (big moving map nav display) aircraft from flying these approaches...I say again BANNED them.

Why?

Because Air Niugini pilots spend their entire working lives in and around terrain, bad weather and truly crap ATC and the check and training system has been teaching profiles and demanding a very high standard of situational awareness for DECADES...they have never had a CFIT even though the PX operation suffers EVERY SINGLE RISK factor for CFIT...all in spades.

Chimbu chuckles

31st Aug 2007, 08:35

It is of course equally possible that the captain became confused about his exact position with no input from the FO at all...same result for the same reasons.

These approaches are a human factors **** up.

ForkTailedDrKiller

31st Aug 2007, 11:44

"It is very rare that I find myself on the opposite side of a debate from CC. However, that is the case on this occassion."

Naah! On second thoughts I take it all back. Just had another look at RNAV Rwy 12 YLHR - maybe it is a crap approach made relatively easy in terms of situational awareness by the use of a moving map display.

I always fly them like an Localiser Appr and set the aircraft as I would to fly a 3 degree glidepath from the indicated top of descent point. Why is that not LHRWF rather than 1.7 nm from LHRWF?

In the case of YLHR I gotta work a bit at getting down in the BE35 cause its 3.49 degrees not the usual 3 degrees.

Why in this Appr is it 5 nm from LHRWI to LHRWF and then 7 nm from LHRWF to LHRWM?

Dr :cool:

OZBUSDRIVER

31st Aug 2007, 14:10

I am still learning this. In most all NPA in Australia that I have looked at, Why isn't there a waypoint AT the point where the descent begins? I checked OS NPA and they ALWAYS seem to have a fix or waypoint at the beginning of the descent.

Except for ILS and LLZ approaches we always begin a descent AFTER passing an aid. Why is a NPA different? Is there a reason for it to be this way?

Chimbu chuckles

31st Aug 2007, 15:05

ForkTailedDrKiller

31st Aug 2007, 20:28

CC - I have never flown YLHR RNAV Rwy 12 to minima. I think the lowest I have broken out is about 1600' at around 4 nm from the threshold, and of course there is plenty of runway length available to get a Bonanza down anyway.

I have flown the NDB to the circling minima and circled onto 12 - by day.

Dr :cool:

bretski

31st Aug 2007, 23:58

Flown the Metro for many years. Flown the approach. I agree with CC.:ok:

It is a booby trapped approach.

Of interest or this may come as no surprise to some particularly former Eastland Air pilots :E

http://www.pprune.org/forums/showthread.php?t=289980

ROARING RIMAU

1st Sep 2007, 00:06

As I have not flown the approach in question I went and pulled up the plate on AsA's website (nice feature btw:ok:) and had a quick peruse...and I gotta say I have rarely seen a more boobytrapped approach.

What a load of crap. What boobytraps?

GPSNPA have their faults generally speaking but this particular approach is virtually unflyable as published.

Rubbish, it is flown regularly. Transair only crashed ONCE and did this approach lots of time. CASA flew it recently and reported it as FLYABLE and meeting the criteria.

RAAF conducted an independent check of the approach and it meets the criteria. See the coroner's report.

1/. To have any chance maintaining the published profile(s) you're descending at 400'/nm..at 120KIAS that is 800'/min just for starters. You'd need to fly the entire approach FULLY configured in something like a Metro to have any chance.

Read the profile. 3.5 degrees APCH PATH. Well within Descent Gradient criteria.

2/. If the weather is right on the minima you're to too high to land straight in. At 3nm the profile is 1375'....that is 475' higher than you would be on a normal approach. Even in my Bonanza with gear down and full flap I would need 700'/min all the way to touchdown or >1000'/min down to <500' and then something approaching a normal RoD after that....and I don't fly ANY approach configured that way...well I used to fly the Kathmandu VOR/DME Rwy 02 configured except for final landing flap....from memory the profile for that approach was 400'/nm too but you arrived at a usable MAP and a 10000' runway.

At 2nm/1040' you're still 440' high...no possibility of landing on 12 and you're also 350' below the circling minima.

Who says you have to be able to land from the Missed Approach Point? It is purely a point, if at which you are not visual with your landing environment, you CONDUCT THE PUBLISHED MISSED APPROACH.

If you understand where you will be at the bottom of the approach, before you start it, then there are no surprises. DO YOUR APPROACH PLANNING PROPERLY.

3/. You'd need something like 4nm vis to be able to see the landing environment.. Much rain and you just won't...even if you can vaguely make out the landing threshold through light rain on the windscreen you will need best part of 1000'/min all the way to roundout to make it.

The required vis is 5.0KM due to the high MDA required by the terrain environment.

If the vis is forecast or reported at less than 5KM you are not allowed to do the approach. REF AIP.

Can anybody say "stabilised approach?"

If you fly the published APCH PATH you will have a STABILISED APPROACH all the way to 50ft above the threshold.

That is what all the CFIT studies have advocated and why AsA design the procedures that way.

It is steep but within the criteria.

Airlines demote/sack people for flying as per above.:ugh:

If I was the CP of a multi crew turbine RPT operation my crews would be banned from flying the runway approach in IMC, period.

It would be;

1/. Captains only approach,
2/. Flown to the circling minima only,
3/. Company profile based on arriving at the circling minima at 2nm..that's 3xdist+800'....all the way from tip over...that keeps you well above all limiting steps, gives a shallower descent flown configured for circling and gives you 1 min level to the MAP to assess the circling area.
4/. If visual over the runway and assured of maintaining visual reference circle left descending to be 1000' established on downwind and a normal 'min weather' circuit from there.

Nice and calm and above all controlled.

Captains route training would be 5 trips (2 at night) with a minimum of three such approaches flown to simulated minimas (minimum 1 at night) (real if the weather is such) under the care and feeding of a training captain and two such approaches flown as recurrent ICUS every 6 mths. FO route training would involve supporting a training captain as he flies the circling approach to simulated minimas 5 times (2 at night).

Any captain reported attempting to fly the runway approach in anger would be busted back to FO for 12mths without even 4 seconds worth of discussion on the matter.

The rwy approach to 30 is no better:ugh:

There is just NO other way, in my view, to fly that approach with weather anywhere near minimas.

Circling Approaches in near minima conditions increase the possibility of CFITs.

Several major airlines do not allow their crews to conduct circling approaches in some weather conditions.

Your attitude shows that you will say anything to have a go at the authorities but will not directly approach them. Your attitude is also not the way that many other RESPECTED operators allow their crews to operate.

Put your concerns to CASA and stop corrupting the minds of those on PPRUNE with your crap about RNAV (GNSS) approaches.

Fly the published approach after a thorough brief and you will not be putting the lives of yourself and your passengers in jeopardy.:=

ROARING RIMAU

1st Sep 2007, 00:13

OZBUSDRIVER says:

"I am still learning this. In most all NPA in Australia that I have looked at, Why isn't there a waypoint AT the point where the descent begins? I checked OS NPA and they ALWAYS seem to have a fix or waypoint at the beginning of the descent."

I am yet to see a descent fix for any approach at 120nm from the airfield.

If you are cruising at FL390 that is about where you start descent. If you are a decent captain, and ATC don't stuff you around at low level, then you should be able to continue descent into the approach.

"Except for ILS and LLZ approaches we always begin a descent AFTER passing an aid. Why is a NPA different? Is there a reason for it to be this way?"

Maybe it is because the RNAV(GNSS) NPA does not have NAVAIDS!!!!!

A VOR approach from straight in does not commence at a NAVAID.

There is no reason for NPAs to be any other way.

Yup

1st Sep 2007, 00:15

Looking through the ATSB reports today and found this incident. This happened on the 29 May 2007 in a B300. Incident No: 200703363

Quote "During a runway 12 RNAV approach to Lockhart River in IMC, the aircraft's EGPWS activated a momentary terrain warning. The crew carried out a missed approach and elected to carry out the approach again. During the second approach, at the same position as in the first approach, the EGPWS activated momentarily before returning to normal. The crew established visual reference and landed safely.
The investigation is continuing."

OZBUSDRIVER

1st Sep 2007, 05:17

ROARING RIMAU, Thats not what I meant. TOPD is an arbitary point dependant on your own aircraft's performance Yes? I am talking about the PUBLISHED approach. At this point you must be at X speed and Z height and commence the descent at Y rate to arrive at the MAP with this much vis and threshold or environs visual to continue the approach or go missed. NDB and VOR procedures have you passing the aid to then commence a procedure. A fixed point to do a specific thing. I feel an NPA still requires a point where the descent commences. IAF or FAF, whatever!

I understand that positioning over an aid places you within the protected zone down to the MDA. A precision approach gives a glideslope so doesn't require a point to begin the descent, or does it? You have to have a knowledge of the height you must be at to intercept that glideslope without being too high or too low. Vectoring gives me an intercept from below the glideslope so I wait until I intercept to begin approach.

NPA plate has you flying along at a height above the LSA for the sector then you must chose your own descent point to arrive at the FAF at the stipulated height in approach config. Wouldn't it be easier to have this point stipulated so as you fly the last sector before this point you have configured yourself for approach you have leveled off at the correct altitude to start the procedure You pass the point and start descent for the approach
. Wouldn't this be easier than trying to judge the point yourself?

EDIT-I am learning this so please be gentle:ok:

Jabawocky

1st Sep 2007, 08:49

Jusiceseeker, welcome. I had no direc connection with this accident althought a couple of indirrect ones. I would welcome any input you may have.

I do believe Chimbu Chuckles has rasied very valid points and in particular the possible input of the F/O which I had not considered in such a way. Did any investigation reports explore that possibility?

Cheers

J

Chimbu chuckles

1st Sep 2007, 09:08

Rimau the approach plate is here.

http://www.airservices.gov.au/publications/current/dap/LHRGN01-101.pdf

The descent profile keeps you approx 500 higher than what would be considered nominal all the way down. I never suggested you should be able to land straight in from the MAP...that is clearly impossible in this case, and many others, but even if you got visual at 3nm or 3.6 you would be too high to make a landing on 12 without excessive sink rates on short final.

Looking at the plate I would suggest about the only way to land straight in is if you got visual back around 5nm, where you would be 2100' (still 600' higher than a 'normal' approach profile), and then visually ducked under the profile...terrain permitting of course...which it seems it maybe doesn't.

If the cloudbase was 1600' you would get visual at 3.6nm...500' higher than a nominal altitude for a straight in approach.

If the cloudbase is at the circling minima, 1390', you will see nothing until 3nm...where you will be 490' high on approach for a straight in.

If the cloudbase is at the straight in minima you will see nothing until it is FAR too late to land straight in and you will be 350' below the circling minima.

If you turned final at 3 or 4nm in a Metro on a cloudless blue day 500' high would you,

a/. stuff the nose down and land or,
b/. Go around?

This is the classic non stabilised approach and this IAL procedure sets you up for it right from the get go...hence it is boobytrapped.

If you cannot land off a straight in using normal rates of descent and manouvers then you are limited to the circling manouver. To suggest a gentle circling manouver from overhead the landing threshold is more dangerous than poking the nose down to salvage a landing from 500' higher than nominal beggers belief...you clearly have not flown many circling approaches, I have flown 100s.

I don't give a flying fig who has flown this approach in sunny, calm conditions and pronounced it wonderfull...get them out there when the weather is on the minima in low cloud and rain and ask them again.

As to my 'constant' attacks on the regulator or this IAL procedure?

Believe me I have told them to their face...usually the answer has been "Well Chuck yes, you're right, but...."

Classic groupthink...google the term if you're unfamiliar.